The Rottinger approach for total hip arthroplasty: technique and review of the literature

Abstract

The surgical approach utilized in total hip arthroplasty has been identified as a factor that may affect surgical outcomes. There have been many different approaches and modifications used since the procedure was popularized by Sir John Charnley. The popular approaches today can be grouped by their relationship to the trochanter (anterior or posterior), patient position, leg position for dislocation/femoral preparation, and treatment of the abductors and short external rotators. The Rottinger approach is an anterior approach which utilizes the muscle interval between the tensor fascia lata and abductor musculature. The abductor attachments are preserved and the femur is prepared in extension, adduction, and external rotation. This approach has been shown in literature to be safe with some studies showing improved outcomes both in terms of reduced complications and better function than other standard approaches.

Fig. 1

A split let peg board is used to allow for the operative extremity to be placed in extension, adduction, and external rotation for femoral preparation

Fig. 2

A picture of the split leg peg board attachment to the OR bed. By dropping the lower part of the bed (bed attached to the blue foam), the operative leg is allowed to be adducted, extended, and externally rotated for femoral preparation

Fig. 3

Patient positioned on the OR bed. Notice the distal part of the OR bed has been dropped and the patient’s legs are both resting on the single leg portion of the peg board. By dropping the bed there is now room for the operative extremity to be placed in the needed position for femoral preparation. The leg is placed in a sterile bag during the operation when it is placed in the extended, adducted, and externally rotated position

Fig. 4

The incision will be made connecting the three black dots marked. The main bony landmarks are the ASIS and the superior/anterior corner of the greater trochanter. For orientation for all pictures: This is a left hip with the picture being taken from anterior. Left is proximal and right is distal. All pictures that follow are taken of the same hip in the same orientation

Fig. 5

After the deep fascia is split the interval between the abductors and tensor fascia lata is developed. Blood vessels are reliably found marking the distal aspect of this interval (isolated by right angle clamp) and are either tied or cauterized

Fig. 6

The muscle interval has been divided and a curved retractor (top) placed over the femoral neck exposing the rectus femoris covering the joint capsule

Fig. 7

Another curved retractor and Bennet retractor have been placed along the inferior femoral neck and the rectus has been cleared showing a clean view of the anterior hip capsule

Fig. 8

The leg is placed in a Fig. 4 position in order to dissect along the femoral neck to expose the lesser trochanter

Fig. 9

The view of the proximal femur after the femoral neck cut has been made. The leg has been dropped off the bed posteriorly in the sterile bag in the full extended, adducted, and externally rotated position

Fig. 10

View of the acetabulum. Curved retractors have been placed over the anterior and posterior walls and a blunt cobra retractor has been placed in the acetabular teardrop for orientation. The femur is being retracted in the posterior direction (top of picture)

Fig. 11

The position of the leg during acetabular preparation. A large roll is placed in the groin to abduct the extremity and the leg is allowed to fall into external rotation

Fig. 12

Femoral reaming is being done with standard, straight reamers. This approach allows for safe and adequate femoral exposure. The surgeon is not limited to special reamers and broaches

Fig. 13

Closure of the hip capsule

Fig. 14

The gluteus medius is shown above. It has been well preserved throughout the procedure