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REPLACEMENT
MICHAEL L. PARKS, MD, and WILLIAM MACAULAY, MD
This review describes the most popular surgical approaches used for total hip arthroplasty. The surgical anatomy of
each approach is explored in depth and the neurovascular structures that are at risk are noted. Particular attention is
directed to comparison of heterotopic ossification, dislocation rates, and abductor weakness, common complications
that vary with surgical approach. The authors provide technical pearls for extending surgical exposure of the hip joint
and optimizing visualization to greatly aid the surgeon performing total hip arthroplasty.
KEY WORDS: surgical approach, total hip arthroplasty, dislocation, heterotopic ossification
The concept of low friction arthroplasty introduced by vous plane between the rectus femoris (femoral nerve) and
Sir John Charnley popularized primary total hip arthro- gluteus medius (superior gluteal nerve) to gain access to
plasty in the early 1960s. Over the ensuing three decades, it the hip joint.
has become one of the most successful orthopaedic recon- The patient is placed supine on the operating table. A
structive procedures, with an estimated 200,000 cases folded sheet is placed under the operative hemipelvis to
performed each year in the United States alone. push the involved side forward. The skin incision as
Total hip arthroplasty requires complete visualization of originally described begins at the middle of the iliac crest
the acetabulum and proximal femur. Recognition of the and curves anteriorly to the anterior superior iliac spine
surrounding landmarks is crucial for the correct orienta- and ends 10 to 12 cm distally and laterally. The lateral
tion and implantation of the prosthetic components. The femoral cutaneous nerve exits the deep fascia close to the
ultimate goal is to achieve adequate surgical exposure intermuscular interval between the tensor fasciae latae and
while minimizing complications. Charnley was uncompro- the sartorius. It must be protected and retracted medially
mising in his belief that a transtrochanteric approach was to preserve sensation to the lateral thigh. The superficial
fundamental in obtaining the wide exposure necessary for fasciae and attachments of the tensor fasciae latae and
total hip arthroplasty. However, in the years following his gluteus medius muscles are detached from the iliac crest.
introduction of this procedure, multiple surgical ap- The tensor fasciae latae and gluteus medius are then
proaches have been used. Today, the most commonly subperiostially elevated from the lateral wing of the ilium.
performed methods for total hip arthroplasty include the Small nutrient vessels supplying these muscles may be
anterior (Smith-Petersen), anterolateral (Watson-Jones), encountered and should be packed or cauterized to obtain
muscle splitting lateral (Hardinge), transtrochanteric lat- hemostasis. Distally, the dissection is carried through the
eral (Charnley), and posterior approaches (Moore, Gib- deep fascia of the thigh to expose the interval between the
son).
tensor fascia lata laterally and the sartorius and rectus
femoris medially. The ascending branch of the lateral
SURGICAL APPROACHES FOR TOTAL HIP femoral circumflex artery is encountered in this interval at
REPLACEMENT 2 to 3 cm from the hip capsule and must be ligated. The
anterior capsule is then directly visualized by placing a
Anterior Approach (Smith Petersen) cobra retractor over the anterior acetabular rim. The
Several authors have advocated the anterior approach, capsule is then transversely incised with a knife to reveal
including Smith-Petersen, 1Bost et al, 2 and Cubbins, 3Suther- the underlying femoral head. The femoral head is then
land and Rowe,4 Fahey, 5 and Luck. 6 This approach devel- dislocated anteriorly after sectioning the ligamentum teres
ops the superficial muscular internervous plane between with curved scissors, and the femoral neck is osteotomized
the sartorius (femoral nerve) and the tensor fasciae latae with an oscillating saw. The femoral head is removed using
(superior gluteal nerve) and the deep muscular interner- a corkscrew and a hip skid. After removing the femoral
head, a complete capsulotomy is performed, and acetabu-
lar exposure is optimized with retractors placed anterome-
From Division of Hip and Knee Surgery, The Department of Orthopaedic dially at 5 o'clock and posterolaterally at 7 o'clock.
Surgery, New York Presbyterian Hospital at Columbia University, New Keggi et al 7,8 have reported excellent results with 1,000
York, NY. total hips using a modified anterior approach. In this
Address reprint requeststo Michael L. Parks, MD, New York Presbyte- series, the anterior approach utilized is performed through
rian Hospital, 622 W. 168th Street, PH 1lth Floor, New York, NY 10032.
Copyright © 2000 by W.B. Saunders Company a curved transverse skin incision beginning at the anterior
1048-6666/00/1002-0003510.00/0 border of the tensor fasciae latae just inferior to the anterior
doi:l 0.1053/io.2000.5890 superior iliac spine and ending distally at the anterior
C D
Karapelou
: ~-~1i~4 •
Fig 2. Direct lateral approach to the hip. (A) The anterior
one-third of the gluteus medius and vastus lateralis is split
longitudinally. (B) Deep dissection with elevation of the gluteus
medius and vastus sharply from the anterior femoral surface.
(C) The location of the superior gluteal nerve and the safe zone
for surgical dissection (shaded).
- - .. , - .,~ _. .. . . , ::-
" ... : .
capsule was then pierced, and the cut was made after Posterolateral Approach
ensuring that the location of the Gigli saw was located
The most commonly used position for total hip replace-
deep to the posterosuperior surface of the trochanter. The
ment today is the posterolateral approach. It is technically
osteotomy site then exited through the vastus ridge (Fig 3).
This technique may be expedited by using an oscillating simpler than the other approaches. We prefer to position
saw after exposure of the vastus ridge and anterior femoral the patients in the lateral position on a custom-designed
capsulotomy. The cut begins at the vastus ridge and is hip table (Medricon, Garwood, NJ). This table has multiple
angled 45 ° to exit at the superior margin of the femoral adjustable features that allow stable neutral positioning of
neck. The posterior capsule and external rotators may be the pelvis reduce any uncertainty in the positioning of the
released as needed. Detachment of the trochanter in the acetabular components. After skin preparation and drap-
lateral exposure allows dislocation by simple adduction. ing, the trochanter is marked superiorly, inferiorly, anteri-
Care should be taken to ensure that the trochanteric orly, and posteriorly. A longitudinal skin incision is cen-
fragment is large enough and shaped appropriately to tered one-third over the trochanter, one-third below it, and
facilitate repair. Repair of the trochanter has been de- a proximal curvilinear portion, above the trochanter, paral-
scribed by a variety of techniques including wire knots lels the fibers of the gluteus maximus. The tensor and
and the commonly used Dall-Miles cable grip system. gluteal fascia are incised in line with the skin incision
There are several disadvantages to using the trochan- directly over the trochanter. Sharp incision is used for the
teric osteotomy in total hip arthroplasty. Rates of trochan- tensor fasciae latae and fascial envelope of the gluteus
teric nonunion have reportedly ranged from 5 to 32%. 1.,2° maximus. The fibers of the gluteus maximus are, however,
Trochanteric migration of more than 3 cm has been shown bluntly divided after the fascial incision is made. The
to correlate to poor abductor power. In a series of 100 total gluteal sling is located and divided along its superior half
hips done using a transtrochanteric approach, Menon et using the electrocautery.
al 2° noted a 9% incidence of trochanteric migration of more The posterior border of the gluteus medius is identified
than 3 cm. Additionally, broken wires, trochanteric bursi- and retracted carefully using a 90 ° angled thin Hohrnann (a
tis, and ectopic bone formation have been reported as "thin bent" retractor). An Aufranc retractor is then swept
frequent complications. Many surgeons have noted the under the fat and areolar tissue and superficial to the
potential for increased intraoperative time and blood loss external rotators to lie directly under the femoral neck. The
because of the time needed to repair the trochanteric piriformis tendon and conjoined tendons of the gemelii
osteotomy site. In addition, another significant disadvan- and obturator externus are identified and divided with the
tage is delayed rehabilitation because of delayed weight- electrocautery from their insertion on the greater trochan-
bearing postoperatively (usually 6 weeks). ter and tagged with nonabsorbable braided suture. Placing