Prior to that, the Birmingham surgeon performed the more traditional posterior hip replacement for 15 years. The difference astounds him.
Direct anterior hip replacement produces less pain, less bleeding, less chance of dislocation and a faster return to normal activities. The procedure works well no matter what the reason for the replacement, whether from trauma, osteoarthritis, avascular necrosis or other disease.
“The posterior procedure requires muscle cutting where a large incision is made on the backside of the hip,” Buggs says. “Muscles and soft tissue in the back are cut. If you cut that muscle, it has to heal--and it hurts. Also, postoperatively, there is an increase incidence of dislocation when a person, for instance, is sitting down in a chair, leaning over to tie his shoes, or trying to climb stairs.”
“By contrast, the anterior approach is a muscle-sparing procedure,” he says. “You go between the muscles from the front. It’s as if you have a sandwich and you are separating the pieces of bread. That’s how you separate the muscle.” Also, the anterior approach uses a smaller incision, 4 inches to the posterior’s 10 to 12. He estimates dislocations with anterior are less than one percent, even with patients returning to normal, even strenuous, activities much sooner.
The pain compared to the muscle-cutting procedure is minimum. “Patients are hurting less after the surgery than they were before the surgery,” he says. “Family members and people in the community often don’t even know that they have an artificial hip because they’re not limping and they’re not in pain.” Many require no pain medication afterward, either.
According to Buggs, physicians in California already are treating this as a one-day procedure. While that’s not the norm in Birmingham, he says, “I’ve done the surgical procedure in the morning, then visited in the afternoon for post-op rounds and found them walking in the halls.”
He enjoys sharing recovery stories about his patients. “I had an 87-year-old grandma who was able to fly from Birmingham to Las Vegas to a family reunion three weeks after her hip surgery because she could sit in an airplane,” he says. “Normally that would not be a possibility.” He has also seen hikers and tennis players return to these activities in as little as two weeks.
The procedure is ideal for hip fractures of the elderly. “They can get out of bed and start walking again faster,” he says. Also, caregivers “don’t have to worry about, say, a patient with Alzheimer’s doing the wrong thing, such as turning over in in bed incorrectly and dislocating.”
Despite the advantages, Buggs estimates only about 200 surgeons in the United States, including about ten in Alabama with four in Birmingham, offer anterior hip replacements. Why aren’t the numbers higher?
“With some procedures in orthopedics you can read a book, see a DVD and pretty much do the procedure without much error,” Buggs says. “You cannot do this procedure that way. It’s a much more difficult procedure to learn. It takes a certain number of cases to be proficient.” Once learned, however, it takes about the same amount of time to perform. “I can do it in about an hour to an hour and a half,” he says.
Also, the surgical tools are different. “You cannot use the same instrumentation because you’re doing this surgery in a small area—four to six inches—and you’re putting in a total artificial hip,” Buggs says. “You have to have special instrumentation to be able to do that. When we started it at Princeton, we had to actually develop and design our own instrumentation.”
Eventually, though, he believes the advantages of the anterior hip replacement procedure will win out. “My prediction is that in the next 10 to 15 years, this is going to be the surgical procedure to replace hips,” he says. “They’re going to see my 87-year-old grandma flying out to Los Vegas. They’re going to see my 55-year-old man playing tennis two weeks after surgery. Surgeons are going to see the results of these patients.”
