Anterior vs. Posterior...Same Claims on Nerve Damage Avoidance???

[MikeinNeb]

The anterior approach is an extremely uncommon approach used for hip resurfacing.  There are only a handful of surgeons in the United States capable of performing hip resurfacing through this approach.  The anterior approach offers the advantage of decreased soft tissue dissection and a smaller incision.  The typical incision for anterior approach hip resurfacing is 5-6 inches.  One potential complication of posterior approach hip resurfacing is sciatic nerve palsy which results in numbness and a drop foot.  This complication is not seen with anterior approach because of the difference in leg positioning for the exposure.  Anterior approach hip resurfacing is performed with the use of x-rays in the operating room.  This ensures that the cap is centered precisely on the femur and the cup is positioned correctly in the pelvis.  The longevity and survival of hip resurfacing has been shown to be directly related to implant position, so this is a considerable advantage of performing the surgery through the anterior approach.



Dr. Yerasimides’ view on Hip Resurfacing

OK. What gives?  I had a response in my first post that said it was the anterior approach that risked more nerve damage. (foot drop.) And I know I've read that same viewpoint on the anterior approach in other posts.

So which one is correct, or at least less wrong?

[Lori Cee]

I'm not sure but it almost seems to me that whatever option the surgeon chooses he has reasons for believing that the option he chooses is the least risk.   All surgeries carry risks, I think it's just that the type of risks differ.  I've heard pros and cons for both approaches, so I'd probably look for the best surgeon I could find first rather than how they do it.  The reasons for each approach all seem logical so I'd make sure that you find someone that you trust and who is highly experienced and then trust them to do the surgery that they do best that they have had their high success rates with.

[katekosar]

My thinking exactly, LC.  Dr. Brooks here in Cleveland does the anterior/lateral approach.  I am sold on Dr. Brooks.  Therefore, whatever he does is okay with me.  He could quite frankly use a mallet and a chisel, as long as he gets it right.   :o  I'll leave the professional stuff to the professional, and concentrate on the things that are within my control.

For an OCD type person, this is a real leap of faith.  But to do other than to rely completely on the doctor's professional expertise would make me nuts and paranoid to boot.

Kate

[obxpelican]

In the 3 years I've lurked/posted on various hip forums I will have to say that the Anterior approach does tend to have nerve damage issues at a somewhat alarming rate.

I'm personally not sold on that technique and I would not go for on my next go around.


Chuck

[phillwad]

MikeinNeb

I am no expert but I went and had a bunch of questions and found that the Dr had a bunch of answers - he did not seem put off by me asking and was able to "go deep' on the techy stuff.  Now I having been reading and posting for the last few weeks I have a bunch more questions for my follow-up. 

Like katekosar I went with the doctor who made me feel he really understood what the options were and the risks.

Length of the scar, recovery time were minor, at my age I am looking for something that will work for the next 30 years not to get back and ride my bike in the next 30 days

Cheers - Phill

[obxpelican]

Before going with a procedure like the anterior make sure to go to the surface hippy yahoo group and research it by searching "drop foot" and "anterior" or "nerve damage" and "anterior".

I think Pat has some failure posts on this forum too.

Chuck

[Dayton96]

Mike,

I think you are right to be cautious.  I took a look at Dr. Yerasimides web site.  His website states he has completed 1400 hip replacements since August 2006 and that he had one fellowship during 2005-2006 that was somehow connected with Dr. Joel Matta.  The web site also says he does hip resurfacing, but does not say how many he has done.  Dr. Yerasimides is quoted as saying that one reason he does not like the posterior approach, is because the incision is "typically 12-16 inches."

I had a hip resurface with Dr. Gross, who used a posterior approach, and my incision was about 4 inches long.  Like Chuck, I found the same negative comments about the anterior approach.  I even had an appointment up at the Cleveland Clinic with Dr. Brooks, who uses the anterior approach with a BHR.  While Dr. Brooks has outstanding credentials and has probably done over a 1000 hip resurfacings by now, when I later tried to pin down his assistant as to how many complications they had related to nerve damage, etc, he was pretty vague.  That experience with Dr. Brooks' office, along with what I read on this site and the Yahoo surface hippy site, convinced me to stick with the posterior approach.

At the very least, I would ask Dr. Yerasimides how many hip resurfacings he has done on his own.  I would ask him what his statistics (revisions, nerve damage, infection rate, etc) are, specifically for hip resurfacings (Careful here, I found some surgeons wanted to keep including their hip replacement surgeries in the statistics).  I would ask him for  a list of former hip resurfacing patients (again, make sure they are resurfacings, not hip replacements).  I would then call those folks and ask how they liked their surgery.

Good luck,

Mac             

[Lopsided]

Dr. Yerasimides is quoted as saying that one reason he does not like the posterior approach, is because the incision is "typically 12-16 inches."

I don't think there would have been enough room on my cheek to make a 16" incision without ripping the entire rump off.

Don't rush into surgery unless you are sure about the surgeon.

[newdog]

I don't think there would have been enough room on my cheek to make a 16" incision without ripping the entire rump off.

lop,

You would have to get the other side done so the other cheek would match!  ;D

You crack me up!!

[moe]

If I add both of mine up it's about 12".  ;D

[einreb]

So which one is correct, or at least less wrong?

huh, now I'm confused too... and I've been poking around this stuff for years.

The reference to 16" scars is a little peculiar.  His use of an xray to check position has nothing to do with the approach... lots of oddly worded stuff.

Looks like he has a bunch of experience with that approach for THR's and he's applying his knowledge to how he does his resurfacing.

[John C]

A couple of thoughts to clarify (or confuse) some of the issues here.
Always be sure to clarify whether the approach is antero-lateral, or direct anterior. Both of these are sometimes referred to as "anterior"  approaches, though they are quite different. Dr. Matta was a strong proponent of the direct anterior approach, so I am sure that Dr Yerasimides is using that as well. I believe that Dr. Brooks is referring to the antero-lateral; very different.
As pointed out, using x-rays during surgery is not a factor of approach, and many doctors are using it with their approach of choice, including posterior.
Scar lengths certainly vary from surgeon to surgeon, but I think that it is unfair to characterize the posterior approach as using a 12-16" incision. I think that up to 12" is not uncommon, but Dr. Gross's normal incision is 4" with a posterior incision.
Different approaches pass near different nerves. It is true that the posterior approach is more likely to affect the sciatic nerve than the anterior approach, because it passes nearer to that nerve. The anterior approach passes near to other nerves which can be affected. I believe that sciatic nerve injury is rare for experienced surgeons using the posterior approach. It seems that, at least on this forum, we are hearing about more nerve problems from the anterior approach, though it would not likely affect the sciatic nerve.
Not trying to say anyone is right or wrong here; just hoping to clarify some wordings that may be confusing.

[phillwad]

I am my 6 week post op with Dr Brooks next week and I am going to chat with him about his "approach" as I have another one to get done soon.  Here is a link to Dr Brooks' discussion on different approaches here on this site

http://www.surfacehippy.info/surgicalapproachesbrooks.php

Looking at my scar it is about 8 inches and I can not see it when I stand in front of the mirror, it is just around the corner

Cheers - Phill

[Anniee]

This is a very confusing subject! I read the article by Dr. Brooks and then the "operative report" from my surgery last week (Dr. Gross gives a copy), trying to figure out the difference between these different approaches.  Dr. Gross calls it a minimally invasive posterior approach, but my incision is on the outside of my thigh towards the back, not on my behind!   The details in my report do not really fit any of the scenarios described by Dr. Brooks, and certainly not his description of a posterior approach, so my conclusion is that Dr. Gross uses his own version of a posterior approach, which seems to be more from the side than from the back.

Also, my incision is only about 4 inches long, so it probably would fit on most people's rumps, if that is where it was located!

[John C]

Dr Gross does use a smaller incision than most, but the location is the standard for what is referred to as posterior. The name comes from its location relative to the other options; antero-lateral which comes in more from the side, and direct anterior which comes in from straight in front. There is no approach that comes in from straight behind, because there is too much tissue in the way, and it would not give good exposure to the acetabulum.
They each involve trade-offs, so there is no "right" answer. As most surgeons will tell you, pick your surgeon, and let him worry about the approach that works best for him.

[newdog]

John C ,

Thanks for the answer. I too was a little confused about location because mine are also between the side and the "bottom" of the rump.