IвЂ™ve also seen a number of patients who were treated with the anterior approach by other doctors and developed complications associated with a non-recognized fracture that became apparent during the post-operative course.

If a fracture occurs during an anterior approach, it is much more difficult to fix and often requires a separate incision. No matter how carefully a surgery is performed, when you do enough procedures, at some point the femur will fracture. With the mini posterior approach, I can choose the best stem for the patient, not the procedure.ДЄs a revision surgeon, I also carefully consider every next step and вЂњwhat ifвЂќ as I construct an implant. I am building a construct in a patientвЂ™s body that hopefully will last 20 years or more and I donвЂ™t want the approach to determine which type of stem I use. Reconstructing through a mini posterior approach, I am able to use the Exeter stem for some patients. The Exeter stem is the gold standard in the industry, has a 45-year track record and remains the most commonly used implant in the world. A вЂњcementedвЂќ stem is fixed within the bone of the upper femur by bone cement, which is a time-tested acrylic grout and for some people with specific types of bone or anatomy, it is the preferred choice.

A вЂњpress fitвЂќ stem achieves its initial stability by being tightly wedged into the bone of the upper femur in the hope that with time, bone will grow into or onto the stem. When approaching the hip anteriorly, I would choose a вЂњpress fitвЂќ stem rather than a вЂњcementedвЂќ Exeter stem. Time will tell.ДЄnother reason I discontinued use of the anterior approach is I felt limited as to what type of femoral stem I could use.

The surgical community has hope that this new crop of short stems will do well. How these stems will perform over the years remains to be seen, as with all new prosthetics being devised. This can result with the end of the hip stem pressing against the inside of the femoral cortex and cause pain. Because femoral exposure is more challenging, many stems are not placed down the middle of the femoral canal. Because of this, most of the major orthopedic manufacturing companies now are producing new, shorter stems which are much easier to place. Regardless, the positioning of standard-length, time-tested stems is more difficult when approaching anteriorly. As a result, many surgeons will use a special table to aid in this technique. However, there is increased blood loss associated with the anterior approach and more patients develop symptomatic anemia, increasing the likelihood of a transfusion.Д®xposing the femur for reconstruction is more difficult with the anterior approach. In fact, I find in my practice that having to transfuse someone after surgery is rare. Also, the need for a blood transfusion is minimized. In my experience, recovery is more consistent because patients feel better and stronger more quickly. With the mini-posterior approach, there is significantly less bleeding which reduces post-operative anemia. Simply, I couldnвЂ™t continue to use a procedure that I could not trust to deliver every time. I stoppedВ performing this procedure because in my experience there are no advantages to the surgery, rather a number of potential disadvantages. Recently, a patient asked me why I no longer use theВ anterior approachВ for total hip replacement. As a surgeon with a specialty practice in hip and knee replacement surgery, patients rely on my expertise.

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