Horizontal or Vertical Incision? Anterior or Posterior approach?

[DakotaDocMartin]

Dr. Palmer made an approximately 12" horizontal incision for my BHR, made a posterior approach and spread the piriformis, gamelli, and obturator muscles (external rotators) instead of cutting them as has been done in the past.  I'm completely amazed at how little trauma the surgery did to me.  Obviously, this method is far superior in that no muscles need to be reattached.

I'm interested if the majority of BHR surgeries are now done that way.  Horizontal incision with a posterior approach and spread the muscles?

UPDATE: I had my wife measure the incision and it's actually 9.25" instead of 12"  :o

[Lopsided]

Doc, twelve inch incision! You must have a fat a***. My surgeon did a posterior with an eight inch diagonal incision.

You are right, amazingly little trauma or discomfort. Some surgeons believe that a bigger incision is better as it gives them better access, and cutting along the muscle heals much better than cutting across.

D.

[lkallok]

My incision starts out horizontal then bends around the hip to vertical. I haven't measured it but I estimate it's about 12 to 14 inches long (by the way, I'm pretty lean!) I asked him which muscles were cut and he told me the piriformis and superior and inferior gemellus. I think each surgeon develops their own approach. Other than the hematoma I have under the incision, I am doing great with very little pain and good mobility. This is my second BHR and it is much easier than the first on my right hip.

[John C]

My posterior incision was only 4" (standard for Dr. Gross), but I know that a number of muscles were cut and reattached. I had heard that the direct anterior approach allowed the surgeon to spread the muscles rather than cutting, but this is the first that I have heard about a posterior approach allowing this. Do you know if there are any videos showing this technique, or detailed written descriptions of it that we could look at?

[Tin Soldier]

6", curved like a shark bite (I'm fairly small), posterier, no muscles were cut, just spread.

[FlbrkMike]

Posterior approach, on both sides.  I haven't measured the incisions but I'd estimate 7" - 8", smiley shaped, diagonal in direction when standing up.  I'm a fairly large person - 5"11" and about 225.  The doc said that I have very hard and dense bones, esecially the acetabular side, which is good in the long run but makes it hard to work with.

[John C]

I am curious if we have a confusion in terms here. Surgeons sometimes use terms that are unclear to us layman. For example, when they say they are "separating", "dividing", or "releasing" something, that means that they are essentially cutting it in two, as opposed to spreading it. Since this is often done with a cautery (burning) device instead of a scalpel, the terms "separating", "dividing", or "releasing" are often used instead of "cutting". In the standard posterior approach, some of the smaller rotator muscles are separated/ divided / released in order to allow the femur to be dislocated. In all of the articles that I have read, and videos that I have watched of numerous surgeons, this separation/ division/ releasing means cutting the muscles or tendons free in some way, and then hopefully reattaching them after the joint has been resurfaced and reduced. I had always thought that this is the approach that Dr Pritchett has used for many years, and I would find it interesting if he has developed a posterior approach that did not involve separating /dividing/ releasing(cutting) any muscles or tendons.
If anyone has the opportunity, it would be interesting to confirm with Dr Pritchett or other surgeons that there is now a posterior approach that does not involve separating, dividing, or releasing any muscles or tendons.

[DakotaDocMartin]

I specifically asked Dr. Palmer which muscles that he "cut" and reattached and I was told that he did not cut off any of them.  He split and spread them lengthwise.  So, they didn't require a reattachment as was done in the past.  From what I had read and the videos I had watched prior to the surgery, I fully expected that the small external rotators would be severed and reattached.

Apparently, that's no longer always the method used.

[Dayton96]

I've been thrown by the doctor speak too.  I guess after all is said and done, my question is:

If my tendons or muscles are cut/separated/divided/released, is there ever a complete recovery of the tendons/muscles that have been affected, or will there always be a weakness there that might fail later on in life while I'm on a run or playing tennis?

[John C]

This one continues to be confusing for me. I emailed Dr Gross's office to see if they were aware of a posterior approach option that did not involve cutting the rotators. Dr. Gross replied:“It is impossible to do a posterior approach without cutting the short rotators. There is something wrong with this description”. If Dr. Palmer has developed such an approach, it would be worth getting the word out into the resurfacing community. Maybe Pat could ask him to submit a short article to the web-site describing the new approach? I am going to have to get my other hip done in a year or two, and if there is a revolutionary approach out there, I would love to see the word spread about it.

As far as Dayton96s concerns: My understanding is that the body does a pretty phenomenal job of healing muscle tissue that has been well repaired. If the muscle tissue has been gradually worked and strengthened, by the time we are three to six months out, it should be pretty sound. I do remember reading somewhere that the body continues to break down the initial scar tissue and replace it with more functional tissue for two to three years out. If you build the muscles back up, and keep them in shape, I think that the chances of them failing are similar to anyone "pulling" or straining a muscle; but I do not think we need to be concerned with them "failing" after a reasonable healing time.

[DakotaDocMartin]

If Dr. Palmer has developed such an approach, it would be worth getting the word out into the resurfacing community.

As far as I know, Dr. Palmer didn't develop a new approach.  I know that he trained in Canada so maybe it was developed there.  I'll be seeing him this coming Tuesday so I'll try to remember to ask him about it.

[resurface1]

Dr. Snyder - May 6, 2010 - more of a lateral [slightly anterior] incision near the IT Band -  4" wound that healed very well.  Most structures were dissected - no muscles are cut.  This is the advantage of the approach. Some capsular ligaments are cut in order to dislocate the hip. The anterior / lateral approach is much more demanding on the surgeon.

[DakotaDocMartin]

UPDATE: I had my wife measure the incision and it's actually 9.25" instead of 12"  :o

[Lopsided]

UPDATE: I had my wife measure the incision and it's actually 9.25" instead of 12"  :o

This can mean at least one of:

• The scar is healing up at one inch per week.
• You should never measure up your own hind side, especially after surgery.
• Having your wife and family around makes recovery easier.

[DakotaDocMartin]

Up until today, I was relying upon someone eyeballing the incision.  It looked a lot smaller in the mirror to me so I had my wife measure it with a tape measure. 

The incision used to have a bend in it and now it's straight across.  So, maybe as the swelling went down it actually shrunk. 

It's looking really good anyway. :)

[imgetinold]

Mine is a Dr. Gross typical 4".  It is kind of diagonal.

My understanding is (from somewhere in this forum?) that Dr. Gross spreads most muscles, and only cuts/reattaches one of the small external rotators.

[JEMacpherson]

My 5" incision by Dr. Pritchett is posterior just in front of my right butt check on a sort-of vertical angle - very clean looking.

[Rob6297]

My incision is horizontal and about 8 inches or so in length.  I had the posterior approach by Dr. Su.

[mslendzion]

Anterior approach, vertical incision 5 inches down the front of my leg.

[B.I.L.L.]

11" vertical