Surgical approach in primary total hip arthroplasty: anatomy, technique and clinical outcomes

Abstract

Total hip arthroplasty (THA) has revolutionized the treatment of hip arthritis. A number of surgical approaches to the hip joint exist, each with unique advantages and disadvantages. The most commonly used approaches include the direct anterior, direct lateral and posterior approaches. A number of technical intricacies allow safe and efficient femoral and acetabular reconstruction when using each approach. Hip dislocation, abductor insufficiency, fracture and nerve injury are complications of THA, although their relative risk varies by approach. Numerous clinical trials have sought to elicit differences in patient-reported outcomes, complication rates and return to function among the surgical approaches. This review outlines some of the technical pearls of performing a THA through either a direct anterior, direct lateral or posterior approach. A literature review outlines the impact of surgical approach on clinical outcomes and clinically relevant complication rates.

Fig. 1

Example of the specialized table (Hana fracture table, Mizuho OSI) used during a direct anterior approach. Boots attached to lever arms allow traction and free positioning of the leg during each procedure. A perineal post provides counter-traction, and a motorized lift allows improved femoral exposure.

Fig. 2

The skin incision used for the direct anterior approach to the hip.

Fig. 3

Once the hip joint capsule is exposed, a capsulotomy is performed along the long axis for the femoral neck. Heavy braided suture tags are often used to assist in retracting the joint capsule to expose the femoral neck and identify the capsule for closure.

Fig. 4

After femoral neck osteotomy, the femoral head is removed using a corkscrew. The femoral head often requires manipulation to ensure the corkscrew is positioned eccentrically in the femoral head.

Fig. 5

Example of retractor placement during implantation of the acetabular component. Note the use of an offset inserter handle to minimize soft tissue trauma during insertion.

Fig. 6

(A) An offset femoral broach handle permits easier access to the proximal femur during preparation. (B) A bone hook assists with anterior displacement of the femur and can be secured in position using a sterile bracket.

Fig. 7

The skin incision used for the direct lateral approach to the hip.

Fig. 8

(A) The gluteus medius muscle fibres and associated tendinous insertion on the greater trochanter. (B) A tenotomy is performed through this tendinous insertion, leaving a cuff of tissue for repair during closure.

Fig. 9

Visualization of the acetabulum using a direct lateral approach following careful retractor placement.

Fig. 10

The skin incision used for a posterior approach to the hip. A curvilinear incision or, alternatively, a straight incision with the hip flexed 90° can be used.

Fig. 11

Exposure of the short external rotators during a posterior approach.

Fig. 12

Retractor placement and acetabular exposure using a posterior approach. The tagging suture helps retract the short external rotators, draping them over the sciatic nerve.

Fig. 13

Exposure of the proximal femur using a posterior approach. Note the position of the operative limb, held in position by a surgical assistant. Hohmann retractors or bone skids can help elevate the proximal femur during preparation.