Surgical Approaches for Total Hip Arthroplasty

Abstract

Total hip arthroplasty (THA) has become one of the most reliable and patient-requested surgical interventions in all medicine. The procedure can be performed using a variety of surgical approaches, but the posterior approach, direct lateral approach, and direct anterior approach are by far the most common across the globe. This article highlights the history and technique for each of these common approaches. A review of outcomes and complications for each approach are also provided. Each approach has its own unique advantages and disadvantages, but all can be safely and successful utilized for THA. Strong, convincing, high-quality studies comparing the different approaches are lacking at this time. Surgeons are therefore recommended to choose whichever approach they are most comfortable and experienced using. Though not described here, THA can also be done using the anterolateral approach (also known as the Watson Jones approach) as well as the two-incision approach. In addition, recently, some surgeons are utilizing the so-called direct superior approach for THA. While these approaches are far less commonly utilized, they are recognized as viable alternatives to traditional approaches.

Keywords: Direct anterior approach; Hardinge approach; Moore approach; Orthopaedics; Smith-Petersen approach; Southern approach; Surgery; Surgical technique; arthroplasty; direct lateral approach; hip; osteotomy; posterior approach; replacement; total hip arthroplasty; transgluteal approach.

Figure 1

Peroperative photographs showing (a) The pelvis is stabilized with a padded peg-board and four padded posts. (b) The PA incision starts approximately 5 cm distal to greater trochanter. (c) The fascia lata and ITB are incised longitudinally and proximally to split along the fibers of gluteus maximus. (d) Deep dissection identifies the piriformis and short external rotators (SERs). (e) Retractors maximize visualization of the acetabulum. (f) After cup placement, the leg is internally rotated, flexed, and adducted

Figure 2

Peroperative photographs showing (a) A bump is placed under the pelvis at the level of the anterior superior iliac spine. (b) The incision is started 2–4 cm proximal to the anterior-middle third of GT and extended distally in line with the femur to a point 4–6 cm distal to GT. (c) The anterior and posterior border of gluteus medius are identified. (d) Blunt dissection is used to split the muscle in line with its fibers. (e) The leg is placed in extreme adduction and external rotation to allow the surgeon excellent visualization of femoral version

Figure 3

Peroperative photographs showing (a) An arm board is placed distally on the contralateral side of the table. (b) The DA incision begins approximately 3 cm lateral and 3 cm distal to ASIS. (c) The fascia overlying TFL is incised longitudinally in line with the muscle's fibers. (d) Blunt retractors are placed intracapsular around the femoral. (e) Extraction of the “napkin ring” formed by the double osteotomy allows for removal of the femoral head with a corkscrew. (f) Acetabular exposure is accomplished with three or four retractors: Lighted retractor on the anterior acetabular rim, blunt curved retractor placed just distal to the transverse acetabular ligament, and sharp Hohman placed behind the posterolateral acetabular rim. (g) A hook is placed from lateral to medial just distal to GT. This is attached to a sterile arm that applies tension to the femur during capsular release (h) Femoral preparation and broaching using offset handles