Understanding Hip Surgical Approaches: A Review With Clinical and Imaging Correlation

Abstract

Hip surgery is evolving rapidly, with an increasing diversity of techniques across arthroplasty and arthroscopy. This diversity presents challenges not only to radiologists interpreting postoperative imaging but also to general clinicians assessing surgical outcomes. A clear understanding of the various surgical approaches, their anatomical pathways, and associated complications is essential for multidisciplinary care. This review summarizes the key surgical access routes used in hip procedures, outlines their technical features, and highlights relevant postoperative findings, including potential nerve and soft tissue complications. The goal is to provide clinicians, surgeons, and imaging specialists with a unified understanding of modern hip surgical access and its implications for patient evaluation.

Keywords: arthroplasty; arthroscopy; clinical correlation; hip approaches; postoperative imaging.

Figure 1. Illustration of posterior hip approach

(A) Coronal T1-weighted image depicting the extent of the lateral skin incision. Gluteus minimus and medius tendons are preserved. (B) Axial T2-weighted diagram showing dissection of the lateral gluteus maximus near the gluteal tuberosity (white arrowhead) and tenotomy of the short external rotators, in this case the obturator internus–gemelli complex (black arrowhead). Image Credit: Original artwork by Juan Pablo Muñoz, corresponding author GMed: gluteus medius; GMin: gluteus minimus

Figure 2. Posterior approach: postoperative MRI

(A) Axial T2-weighted image showing hypointense scar in the subcutaneous tissue (white arrowhead). (B) Coronal MAVRIC (multi-acquisition variable resonance image combination) sequence demonstrates preserved abductor tendons (black arrowheads). Image Credit: Juan Pablo Muñoz, corresponding author

Figure 3. Illustration of lateral hip approach

(A) Axial T2-weighted image showing gluteus medius split (white arrowhead). (B) Gluteus minimus tenotomy (black arrowhead) and skin incision extending above and below the greater trochanter. (C) SGN shown at risk in this approach. Image Credit: Original artwork by Juan Pablo Muñoz, corresponding author GMed: gluteus medius; GMin: gluteus minimus; SGN: superior gluteal nerve

Figure 4. Lateral approach: postoperative MRI

(A) Axial T2-weighted image shows subcutaneous scar tract (white arrowhead). (B) Coronal T1-weighted image shows a scar at the myotendinous junction of the gluteus minimus (black arrowhead) and scar along the gluteus medius dissection plane. Image Credit: Juan Pablo Muñoz, corresponding author

Figure 5. Illustration of the anterior approach (Smith-Petersen interval)

(A) Axial T2-weighted diagram showing the interval between sartorius and tensor fascia lata (TFL), exposing the rectus femoris. Lateral femoral cutaneous nerve (white arrowhead); femoral nerve (black arrowhead). (B) Coronal T1-weighted diagram showing proximal detachment of the rectus femoris and the course of the lateral femoral cutaneous nerve (white arrowhead). Image Credit: Original artwork by Juan Pablo Muñoz, corresponding author TFL: tensor fascia lata; RF: rectus femoris; SRT: sartorius; ASIS: anterior superior iliac spine

Figure 6. Anterior approach (Smith-Petersen interval): pre- and postoperative findings

(A) Preoperative axial proton density fat-saturated (PDFS) image. (B) Postoperative axial short tau inversion recovery (STIR) with slice encoding for metal artifact correction (SEMAC). Postoperative thickening of TFL fascia (white arrow) and thickening of the rectus femoris tendon (black arrow) from partial release. Access is anterior to the TFL (distinct from the anterolateral Watson-Jones interval). Image Credit: Juan Pablo Muñoz, corresponding author

Figure 7. Illustration of the anterolateral muscle-sparing approach (Watson-Jones interval)

(A) Axial T2-weighted diagram showing access between tensor fascia lata and gluteus medius. Lateral femoral cutaneous nerve (white arrowhead); femoral nerve (black arrowhead). (B) Coronal T1-weighted diagram showing access between gluteus medius, minimus, and tensor fascia lata (curved arrows). Nerves are displaced medially. Femoral nerve is protected if dissection remains lateral to sartorius. Image Credit: Original artwork by Juan Pablo Muñoz, corresponding author GMed: gluteus medius; TFL: tensor fascia lata; RF: rectus femoris

Figure 8. Hip joint compartments and arthroscopic portals

(A) Coronal T1-weighted fat-saturated arthrogram showing central (white dotted line) and peripheral (black dotted line) compartments. Articular surfaces are only visible with traction. (B) Reformatted sagittal CT with portal overlays showing common outside-in arthroscopic portals. Image Credit: Juan Pablo Muñoz, corresponding author ASIS: anterior superior iliac spine; ANT: anterior portal; ANT.LAT: anterolateral portal; MID.ANT: mid-anterior portal; DIST.ANT: distal anterior portal

Figure 9. Outside-in arthroscopy (early postoperative MRI)

Axial PDFS images (A) at the femoral head level and (B) above the greater trochanter show a trans-gluteal portal with TFL penetration (black arrow) and capsular lobulation at the suture plane (white arrows). Anterolateral portal path varies due to fluoroscopic placement. Image Credit: Juan Pablo Muñoz, corresponding author PDFS: proton density fat-saturated; TFL: tensor fasciae latae

Figure 10. Outside-in arthroscopy (portal tract evolution)

(A) Early postoperative axial PDFS image shows anterolateral portal tract as high signal through TFL and gluteus medius, extending to the joint capsule (white arrowhead). (B) Late postoperative axial T2-weighted MRI shows tract replaced by hypointense scar tissue (black arrowhead). Image Credit: Juan Pablo Muñoz, corresponding author PDFS: proton density fat-saturated; TFL: tensor fasciae latae

Figure 11. Nerve anatomy around the hip (greater trochanter level)

Superior gluteal nerve shown in Figure 3. Image Credit: Juan Pablo Muñoz, corresponding author LFCN: lateral femoral cutaneous nerve; FN: femoral nerve; SN: sciatic nerve; PN: pudendal nerve; TFL: tensor fascia lata; SR: sartorius; INT.O: obturator internus; IP: iliopsoas

Figure 12. Normal anteromedial portal scar adjacent to LFCN

Axial T2-weighted images, proximal to distal, showing linear scar tissue (black arrowhead) along the anteromedial portal tract adjacent to the intact LFCN (white arrowhead). No disruption noted. Patient was asymptomatic. Image Credit: Juan Pablo Muñoz, corresponding author LFCN: lateral femoral cutaneous nerve

Figure 13. LFCN neuropathy due to portal injury

Axial PD fat-saturated images, proximal to distal, showing scar (black arrowhead) contacting the LFCN (white arrowhead) with nerve thickening and high signal. Patient reported dysesthesia over the lateral thigh. Compare the LFCN signal and diameter between slices. Image Credit: Juan Pablo Muñoz, corresponding author LFCN: lateral femoral cutaneous nerve; PD: proton density

Figure 14. LFCN neuropathy with meralgia paresthetica symptoms.

(A) Longitudinal ultrasound with power Doppler shows segmental thickening of the LFCN (white arrowhead). (B) Corresponding diagram. No vascular flow noted, supporting neural origin. Image Credit: Juan Pablo Muñoz, corresponding author LFCN: lateral femoral cutaneous nerve

Figure 15. Tensor fascia lata denervation after arthroscopy

(A) Postoperative axial PDFS image following outside-in arthroscopy shows a portal access scar traversing the TFL (black arrowhead) and gluteus medius (white asterisk), with diffuse TFL edema consistent with subacute denervation secondary to superior gluteal nerve branch injury. (B) Coronal PDFS image demonstrates full-thickness TFL involvement (black arrowhead), characteristic of denervation. Image Credit: Juan Pablo Muñoz, corresponding author PDFS: proton density fat-saturated; TFL: tensor fascia lata

Figure 16. Capsular dehiscence after arthroscopy

(A) Sagittal PDFS preoperative image shows a thin, intact capsule (white arrowhead). (B) One-year postoperative image shows lobulated contour at the suture site, consistent with dehiscence (black arrowhead). Image Credit: Juan Pablo Muñoz, corresponding author PDFS: proton density fat-saturated

Figure 17. Abductor insufficiency

(A) Axial T2-weighted MRI showing diffuse gluteus minimus atrophy (white arrowhead) and anterior gluteus medius atrophy (black arrowhead). (B) Coronal MAVRIC sequence in another patient shows gluteus medius (black arrowhead) and gluteus minimus (white arrowhead) atrophy following lateral approach. Image Credit: Juan Pablo Muñoz, corresponding author MAVRIC: multi-acquisition variable resonance image combination

Figure 18. SuperPATH hybrid technique

(A) Sagittal T1 and (B) Axial T2 diagrams depicting skin incision posterior to the greater trochanter (white dashed arrow), gluteus maximus (GMax) blunt dissection, gluteus minimus (GMin) and medius (GMed) anterior retraction and rotators posterior retraction; superior access to the joint capsule (white arrow). Image Credit: Original artwork by Juan Pablo Muñoz, corresponding author

Figure 19. MAKO Robotic-Arm Assisted Surgery System (Stryker, Mahwah, NJ, USA)

Preoperative CT-based planning. (A) Standing and sitting pelvic tilt, cup inclination, and version are loaded into the navigation system to ensure proper placement. (B) Pelvic array (reformatted and superimposed sagittal CT slices): three iliac pins (white arrowheads), placed posterior to the ASIS, anchor the pelvic array (white bracket) in place to provide spatial orientation for acetabular reaming, regardless of the patient's position. Image Credit: Juan Pablo Muñoz, corresponding author ASIS: anterior superior iliac spine