The Mako robotic system is not locked into one surgical approach. It can be used with both the anterior (front of the hip) and posterior (back of the hip) approach, and your surgeon will choose based on their training, your anatomy, and your specific situation. In practice, the posterior (posterolateral) approach is used more frequently with Mako, but the anterior approach is a well-established option too.
Why Mako Works With Either Approach
The Mako system is a planning and guidance tool, not a specific surgical technique. Before your surgery, a CT scan of your hip creates a detailed 3D model of your bones. Your surgeon uses this model to plan exactly where the implant components should sit, accounting for your natural hip center, leg length, and offset. That plan then guides a robotic arm during surgery, keeping the surgeon within precise boundaries while they prepare the bone.
This CT-based planning step is the same regardless of where the incision goes. A randomized controlled trial published in The Bone & Joint Journal found that Mako-assisted surgery was more accurate than conventional methods at restoring the natural hip center, preserving combined offset, correcting leg length differences, and placing the socket component in the desired position. Those precision advantages come from the robotic guidance system itself, not from the direction of the incision.
The Posterior Approach Is More Common With Mako
The posterolateral approach, where the surgeon accesses the hip from behind, is the most widely used path for Mako-assisted hip replacements. In one large study of over 2,000 consecutive robotic-assisted hip replacements performed between 2017 and 2020, roughly three out of four (1,542 of 2,040) used the posterolateral approach, while about one in four (497) used the direct anterior approach.
This reflects broader trends in orthopedic surgery. Many surgeons trained on the posterior approach long before Mako became available, and the system integrates smoothly with that technique. The posterior approach provides excellent visibility of the hip joint and is familiar territory for most hip surgeons.
One traditional concern with the posterior approach has been a slightly higher dislocation risk compared to the anterior approach, because the muscles behind the hip are cut during surgery. A study of over 2,500 posterolateral hip replacements (both manual and Mako-assisted) found a dislocation rate of just 0.4% for both groups, with no significant difference between the robotic and manual techniques.
The Anterior Approach With Mako
The direct anterior approach enters the hip from the front, working between muscles rather than cutting through them. This muscle-sparing quality is its main appeal: it can mean less post-operative pain and a faster early recovery for some patients. A systematic review found that 76% of robotic-assisted hip replacements in the published literature used the Mako system, making it the dominant platform for both approaches.
Combining Mako with the anterior approach did show a notable 75% reduction in reoperations compared to manual anterior hip replacements. However, the robotic-assisted anterior procedures took longer in the operating room, and patient-reported outcomes like pain scores and functional recovery were not significantly different between robotic and manual techniques. In other words, the precision benefits of the robot may help avoid repeat surgeries, but patients don’t necessarily feel a dramatic difference day to day.
Do Outcomes Differ Between the Two Approaches?
When Mako is in the picture, the gap between anterior and posterior outcomes narrows considerably. A direct comparison of robotic-assisted anterior versus posterolateral hip replacements found no significant difference in dislocation rates, reoperation rates, or revision rates at two years. Reoperation-free survival was 97.8% for the anterior group and 98.6% for the posterolateral group, a difference that was not statistically meaningful. After adjusting for age, sex, and BMI, the two approaches performed essentially the same.
This is an important finding because it suggests the robotic system’s precision in placing components helps level the playing field. Accurate cup positioning, which is one of Mako’s core strengths, plays a major role in preventing dislocations regardless of which direction the surgeon approaches from.
What Actually Determines Your Approach
Since Mako works well with both approaches, the choice usually comes down to your surgeon’s experience and preference. A surgeon who has performed hundreds of posterior hip replacements with Mako will likely get better results sticking with that technique than switching to the anterior approach, and vice versa. Surgeon volume and familiarity with an approach matter more than the approach itself.
Your body type can also play a role. The anterior approach can be more technically challenging in patients with a higher BMI or very muscular thighs. Some hip deformities or prior surgeries may also favor one approach over the other. If you have a strong preference, it’s worth asking your surgeon which approach they use most often and how many Mako cases they’ve performed with that technique. The combination of a high-volume surgeon and robotic guidance is what drives the best results, not the direction of the incision alone.