I initially looked at switching to the anterior approach (going into the hip from the front rather than the side or back of the hip) because the PAs (physician assistants), nurses, and physical therapists in my hospital all told me that they felt that the patients who had anterior approaches were having significantly less pain and were able to rehabilitate faster.

I have a partner who was one of the first people in the Seattle area to do anterior approach THR and the hospital staff could watch the difference in how the patients recovered after their surgery.

Anterior Approach

Finally one day I asked our head PA how she would want her total hip done and she said definitely by the anterior approach. At that point I knew I had to learn more about it and whether it was reasonable for a surgeon that has always done THR through a posterior approach to change to a dramatically different technique and still be confident that my patients would benefit.

I first observed the technique in the operating room and then studied the anatomy of the anterior approach. The first obvious benefit is that the approach to the hip from the front is anatomically easy and does not involve cutting any major structures to get to the hip. You simply spread the interval between two muscles and you are down onto the hip capsule.

When you go in from the back you have to divide the gluteus maximus (butt) muscle and split part of the ilio-tibial band on the side of the hip and then cut several small tendons off the back of the hip.

The thing that stops a lot of surgeons from doing this approach is that it is so different from what they are used to. The other thing that stops them is the special technique that is necessary to place the stem into the femur (upper thigh bone). When you approach the hip from the back, it is fairly easy to place the stem of the implant into the femur.

From the anterior approach most surgeons use a special table called a fracture table that allows you to position the leg in a very specific way. In my case, all of the operating room staff and my assistants were used to doing this approach and that made my job a lot easier.

Once I decided that I wanted to learn this technique, I went to a lab where you can practice on cadavers. I was surprised at how easy the approach was and how well I could get good exposure of the socket and the femur to do the surgery. Once I had the exposure, the actual placement of the implants was exactly what I had been doing from the posterior approach.

I have now been doing all of my hips using the anterior approach, and although the first few that I did made me a little anxious, after about 10 hips I knew that I would never go back. For me to switch, I had to feel that it was an advantage to my patients and that I could do as good or better job implanting the components. I have definitely found both to be true.

I have found that my patients have less pain and are ready to leave the hospital sooner. After an anterior hip there are no hip position precautions like there are after a posterior approach. This means no pillows between the legs and you can bend over as far as you want.

My patients who have had one hip done through the posterior approach and one through the anterior approach tell me that not having to follow specific hip position precautions is one of the biggest positive differences that they noticed and they feel that it helped them recovery more quickly.

From my standpoint as a surgeon, I love the approach because I don’t have to cut any major structures to get to the hip, and also when it is done through the anterior approach it is easy to use fluoroscopy (real time x-ray) to check the position of the hip components while you are putting them in. This allows the cup position to be optimal and allows the surgeon to check the leg length to be sure it is the same as the other leg.

I am very happy that I was pushed to learn this new approach to THR. Total hip replacement surgery is one of the most rewarding surgeries that we do. No matter how it is done, as long as it is done well, patients have wonderful results. This is exactly why many surgeons don’t feel the need to change. They are doing an operation with excellent results and they don’t want to take a chance on having problems while learning a new way of doing it.

Fortunately for me, I was able to see a good surgeon and support staff doing this procedure and it convinced me to change.

My last thoughts for anyone reading this who is contemplating having their hip replaced is to know that the most important thing for a successful hip replacement is having a good surgeon and a hospital that does hip replacement surgery routinely. I do think the anterior approach has advantages over the posterior approach for both the patient and the surgeon and that’s why I switched.

Ulnar nerve entrapment at the elbow, also known as cubital tunnel syndrome is a condition where the ulnar nerve in your arm becomes irritated or compressed. This nerve is one of the three important arm nerves that travel from your neck all the way down into your hand. Constriction can occur in a number of places along this path, and depending on the site of irritation or compression, this pressure causes numbness, elbow pain, hand and wrist discomfort, or finger pain. When the ulnar nerve is compressed at the elbow, it is called, Cubital Tunnel Syndrome.   This condition is now also commonly called “cell phone elbow”.

Causes of Cubital Tunnel Syndrome

The ulnar nerve gives you feeling in your little finger and half of your ring finger. Additionally, it controls the muscles of the hand that allow you to pick stuff up and do other fine movements. It also controls bigger muscles of the forearm that allow you to grip objects.  The exact cause of cubital tunnel syndrome is not completely understood, but it is believed that the ulnar nerve is susceptible to compression at the elbow because it passes through a narrow space where there is not much tissue for protection.

Keeping your elbow bent for long periods of time (like when you hold a cell phone to your ear) may cause ulnar nerve irritation and symptoms.   Other common reasons for this condition include:

• -A direct blow to the inside of the elbow or “hitting the funny bone”
• -Fluid buildup in the elbow that leads to swelling and nerve compression
• -Irritation when the nerve slides in and out of place with bending
• -Pressure on the nerve from prolonged leaning on your elbow
• -Sleeping with your elbow bent

Home Remedies for Cubital Tunnel Syndrome

The simplest thing you can do is to lay down your cell phone and avoid other activities that require you to bend your arm for long periods of time. Also, make sure your computer chair is not too low, and do not rest your elbow on the armrest a lot. Keep your elbow straight when sleeping, if possible, by wrapping a towel around your elbow region or wear an elbow pad backwards.

What the Doctor May Do at Your Visit

If the orthopedic specialist suspects you have cubital tunnel syndrome, he may order special X-rays to see if bony deformities are the cause of the problem.  Additionally, he may order electrical nerve conduction studies to determine how well your ulnar nerve is working and to identify exactly where the compression site is located.

Nonsurgical Treatment

Sometimes, non-steroidal anti-inflammatory medicines can alleviate your symptoms. The orthopedic specialist will want to decrease the swelling around the nerve with these medications. Also, he may inject a “steroid”, like cortisone around the ulnar nerve area of compression. It is not uncommon for the doctor to recommend a brace or splint for you to wear at night to keep your elbow straight. Finally, there are certain nerve gliding exercises that may help your nerve slide through the cubital tunnel so that symptoms can improve or resolve completely. These special exercises help keep the wrist and forearm from getting stiff and sore.

Surgical Treatment

For some people, nonsurgical measures are not enough to relieve the symptoms of cubital tunnel syndrome. In these cases, the orthopedic specialist recommends surgery to take the pressure off the ulnar nerve. Also, surgery is indicated for those who have severe nerve compression or muscle wasting due to the condition. The surgical procedures available include:

Endoscopic or Open Cubital Tunnel Release:  In this surgery, the ligament “roof” of the cubital tunnel is divided. This allows for an increased tunnel space and a decreased nerve pressure.   This procedure minimizes the dissection around the nerve and allows for the quickest recovery.  Dr. Weil is one of the only surgeons in the northwest performing Endoscopic Cubital Tunnel Ulnar Nerve Decompression surgery.  This method is the least invasive and allows for the fastest recovery of all ulnar nerve decompression surgeries.  Dr. Weil was highlighted on King 5 news Health Link for his treatment of cubital tunnel syndrome.

Ulnar Nerve Anterior Transposition:  With this procedure, the nerve is moved from the cubital tunnel and placed in front of that region. Ulnar nerve anterior transposition allows the nerve to lie under the skin and fat but on the muscle, within the muscle, or under the muscle. Placement will depend on your particular problem and the surgeon’s choice.

Medical Epicondylectomy:  One great option to release the ulnar nerve is to remove part of a bony section called the medial epicondyle. This technique prevents the nerve from becoming caught on one of the bony ridges so that it can adequately stretch with bending motions.

Surgical Recovery

If you must undergo a surgical procedure, the orthopedic specialist may put you in a splint following the surgery. For the endoscopic technique no splint is required, for the transposition technique, you may have to wear it as long as 6 weeks. Also, your doctor may recommend that go to physical therapy to learn exercises that will help you regain strength and motion in your arm.