The anterior approach with a bikini incision
The anterior approach is a technique for total hip replacement in which the surgeon reaches the joint from the front, through the natural space between the muscles. The muscle fibres are neither cut nor stitched; they are moved aside. The bikini incision is horizontal and follows the natural crease of the skin.
What a hip replacement is
A joint replacement means replacing a damaged joint with an artificial one. In the hip both parts are replaced: the head of the femur and the socket in the pelvis.
A metal cup is placed into the socket, and inside it sits a liner: polyethylene, ceramic or another material. A stem is placed into the femur, and a new spherical head is fixed onto it. These two surfaces glide over each other just as they do in a healthy joint.
The aim of the operation is not "a new leg". The aim is to take the pain away and restore movement. For most patients it is precisely the disappearance of pain that changes their life.
Comparing the approaches: posterior, lateral, anterior
All three approaches are used widely around the world and all three give good results in the hands of an experienced surgeon. The difference lies in where the surgeon comes to the joint from and which tissues lie on the way.
Three approaches, described honestly
| Approach | Route to the joint | Strengths | What it involves |
|---|---|---|---|
| Posterior | From the back of the buttock | The most widespread and best studied. Good visibility, useful in complex and revision cases. Most surgeons train in it. | The short muscles of the posterior group are cut and then stitched back. In the early period the patient is given positional restrictions. |
| Lateral | From the side of the thigh | Good stability, low dislocation risk. Technically reliable. | The gluteus medius is partly damaged, which in some patients causes limping in the early period. |
| Anterior | From the front of the thigh, between the muscles | Muscle is not cut but moved aside. Positional restrictions are usually not applied. X-ray control and a leg length check are possible during the operation. | Technically more demanding and requires special training. It is not suitable for every patient. The learning curve is longer. |
No approach is inherently "the best". The most important factor is the surgeon’s experience in the particular technique. I choose the anterior approach because it is what I train in, what I research and where I have the most experience.
Why I choose the anterior approach
The mechanism is simple: on the front of the body there is a natural space between two muscles where a surgeon can pass without cutting muscle. It is called the intermuscular and internervous space.
Muscle is not cut
What is not cut does not need to heal. This is the main reason the early period usually goes more easily.
Less blood loss
Passing through a natural space means less muscle tissue is damaged. That reduces blood loss during the operation.
Without positional restrictions
After a posterior approach the patient is often forbidden certain leg positions. After the anterior approach such restrictions are usually not applied, which makes everyday life significantly simpler.
Operating with the patient on their back
The operation is performed with the patient lying supine. This allows X-ray control during the procedure and a check of implant position and leg length symmetry.
This is an explanation of the mechanism, not a promise of an outcome. The individual result depends on age, the state of the joint, other conditions and rehabilitation.
The bikini incision: how it differs from a vertical one
The anterior approach can be performed through two kinds of incision: vertical, along the axis of the leg, or horizontal, following the natural groin crease. The second one is called the bikini incision.
Where the scar sits
The bikini incision falls into a natural skin crease and hides under clothing. A vertical incision is more visible.
The direction of the skin crease
A horizontal incision follows the natural tension lines of the skin. This reduces the force acting on the scar while it heals.
Healing
An incision made along the crease usually heals better. That said, healing quality is individual and depends on skin type, age, weight and other conditions such as diabetes.
Cosmetic result
For most patients the scar becomes less noticeable over time. This is not the main aim of the operation, but for many patients it matters.
The type of incision is chosen individually. In selected cases a vertical incision is safer, and then that is what is done.
The protocol: five steps
These are the five points that apply to every case in my practice. They are connected to each other and work together.
- Preoperative digital templatingBefore the operation, special software is used on the X-ray to plan the implant size, position and leg length in advance. This reduces uncertainty in theatre and helps keep the legs symmetrical.
- Getting moving within a few hoursMost patients stand up on the day of surgery and take their first steps with a walking aid. Early mobilisation reduces the risk of thrombosis, pneumonia and pressure sores.
- No drains or dressing changes in standard casesWith a modern approach a drain is no longer placed in most cases. The wound is closed so that the patient does not need daily dressing changes. This makes care at home simpler.
- Discharge usually within two days at mostOnce a patient walks independently, manages stairs and controls the pain with tablets, there is no point in staying in hospital. A home environment supports recovery.
- Independent movement in about two weeksA significant share of patients move without walking aids by this point. This is the usual course, not a promise; the timing is individual.
Who this method is not suitable for
This section deliberately stands before the risks. A surgeon who says their method suits everybody is not telling you the truth.
Significant obesity, especially with a large volume of fatty tissue on the front abdominal wall. The anterior approach then becomes technically harder and the risk of wound complications rises.
Severe deformity of the joint, marked dysplasia, or previous operations that changed the anatomy significantly.
Certain types of femoral fracture, where another approach gives safer visibility.
Some revision operations, where wider access is required.
The condition of the skin in the groin area: inflammation, a rash or infection at the site of the incision.
If the anterior approach is not the best choice in your case, I will tell you so directly at the consultation and explain which method would be safer.
Risks and complications, honestly
Hip replacement is today one of the most studied and predictable operations in orthopaedics. That does not mean there is no risk. Every surgical procedure carries risk.
Infection
Rare, but the most serious complication. Antibiotic prophylaxis, a sterile protocol and preoperative preparation are used to prevent it. The risk is higher with diabetes, obesity and smoking.
Venous thrombosis
Anticoagulants, compression stockings and, most importantly, early mobilisation are used to prevent it.
Nerve injury
The most characteristic one for the anterior approach is irritation of the lateral femoral cutaneous nerve, which causes numbness or burning on the outer thigh. It is usually temporary, though in some cases it remains.
Fracture during surgery
While the implant is being placed, a crack or fracture of the bone is possible, especially with osteoporosis. If it happens, it is dealt with during the same operation.
Leg length difference
A small difference is common and usually unnoticeable. Templating and X-ray control during the operation exist precisely to keep it to a minimum.
Dislocation and wear of the implant
Dislocation after the anterior approach is rare. Wear is a natural process, and over time a revision operation may become necessary.
The probability of a complication is individual and depends on age, other conditions, weight and smoking. We discuss your personal risks at the consultation. No surgeon can give you a guarantee of the result.
Choosing the implant and how long it lasts
The implant is chosen individually, according to age, bone quality, activity level and the anatomy of the joint. The type of fixation matters too, cemented or uncemented, as does the material of the bearing couple.
Data on the service life of modern implants exists in international registries and is published. For a large share of patients an implant lasts decades, though the specific figure depends on activity, weight, age and the state of the bone.
The younger and more active the patient, the more realistic it is that a revision operation will be needed during their lifetime. That is exactly why an orthopaedic surgeon does not rush a very young patient into surgery.
Specific figures for service life are individual, and promising them would be dishonest. At the consultation I will show you which implant is planned in your case and why.
Questions and answers
How long does the operation take?
The procedure itself usually lasts one to two hours. Preparation and waking up are added to that, so the total time spent in the operating suite is longer. The duration depends on the state of the joint and the particulars of the anatomy.
What kind of anaesthesia is used?
Most often spinal anaesthesia, frequently together with sedation. This means the lower body has no sensation while the patient is calm and often asleep. The final choice is made by the anaesthetist after talking to you and reviewing your tests.
Can I walk through a metal detector with a hip replacement?
Yes. A hip implant may set off a metal detector at an airport. In international practice a special card is no longer required; it is enough to tell the security officer. MRI is also possible, but you must tell the radiologist about the implant in advance.
Does every patient get a bikini incision?
No. The type of incision is chosen individually according to anatomy, weight, the condition of the skin and any deformity of the joint. In selected cases a vertical incision is safer, and then that is what is done. Safety comes before cosmetics.
Why is there no drain and no dressing change?
Current evidence shows that a drain brings no benefit in most cases, while it increases discomfort and hinders early mobilisation. Modern wound closure technique and a special dressing allow the patient to get through the first days without daily dressing changes. This applies to standard cases, not to everyone.
Can I get a second opinion?
Of course. A hip replacement is elective surgery and the decision is yours. Getting a second opinion is a normal and sensible step. If you need it, I will give you my assessment and the templating in writing.
Have a question about your own case?
At the consultation we look at your X-ray together and I tell you what stage the joint is at and what the next step is. Seeing a surgeon does not mean surgery.
Updated: · Author: Mikheil Mikeladze, MD