Total hip replacement is one of the most commonly performed orthopedic procedures in the U.S., but debate continues around the best surgical approach.
During a recent presentation hosted by Becker’s Healthcare and Cardinal Health, Keith Berend, MD, orthopedic surgeon at JIS Orthopedics in New Albany, Ohio, outlined why the anterior approach is gaining traction based on its historical context, comparative benefits and implementation strategies.
Here are four key takeaways from the session.
1. Fewer complications, faster recovery
Dr. Berend emphasized that the anterior approach to hip replacement was already established in 1949 but has gained popularity due to improved outcomes in early recovery.
Multiple randomized controlled trials and meta-analyses show that patients experience less pain, reduced narcotic use and improved function within the first three months post-surgery compared to the posterior approach.
“We have patients that are trying to recover quickly, patients that need to get back to work,” Dr. Berend said. “Patients want the benefit of the operation and they want to have it very quickly. At three months there was overall less narcotic consumption because of less pain severity, improved hip function and no difference in the rates of complications.”
2. Decreased risks with the right tools
While the overall complication rate is similar between approaches, the anterior method has a higher rate of intraoperative fractures and lateral femoral cutaneous nerve issues. Meanwhile, posterior approaches have greater risks of dislocation and infection.
Dr. Berend stressed that many anterior-specific complications are linked to implant selection and surgical technique — not the approach itself. He recommended using metaphyseal-filling, three-dimensional stem designs to reduce fracture risk and emphasized the importance of surgical visibility and proper femoral exposure.
3. The importance of training and education
For surgeons new to the anterior approach, Dr. Berend advised starting with ideal candidates that feature flexibility with minimal deformity and good bone quality. It’s important providers only perform one anterior case per day at first.
For Dr. Berend, his learning curve involved 40 cases that took about six months to get to half of his cases being anterior and half through a less invasive direct lateral approach. He underscored the need for team-based training and mentorship through implant manufacturers or organizations like the Anterior Hip Foundation.
“There’s no reason you can’t do an anterior approach once you’re facile with the approach and your team importantly is facile with the approach,” Dr. Berend said. “Your team should be very comfortable setting up and performing this operation after about six months or 30 to 40 cases.”
4. ‘The best approach for patients’
A key concern with the anterior approach is the risk of wound healing complications, particularly in obese patients. Dr. Berend clarified that these issues are due more to compromised blood supply than to soft tissue coverage.
He concluded that with proper technique, training and implant selection, the anterior approach can be safely and effectively used in nearly all total hip arthroplasty cases.
“We’re not reinventing the wheel, we’re simply utilizing a well-established, well-known anatomical approach to the hip,” Dr. Berend said. “It’s the best approach for patients and the only approach that you can do without cutting any muscle, repairing any tendons and without having to limit the patient’s activity postoperatively.”
