OPERATIVE APPROACHES FOR TOTAL HIP

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
Sir John Charnley popularized primary total hip arthro-
plasty in the early 1960s. Over the ensuing three decades, it
has become one of the most successful orthopaedic recon-
structive procedures, with an estimated 200,000 cases
performed each year in the United States alone.
Total hip arthroplasty requires complete visualization of
the acetabulum and proximal femur. Recognition of the
surrounding landmarks is crucial for the correct orienta-
tion and implantation of the prosthetic components. The
ultimate goal is to achieve adequate surgical exposure
while minimizing complications. Charnley was uncompro-
mising in his belief that a transtrochanteric approach was
fundamental in obtaining the wide exposure necessary for
total hip arthroplasty. However, in the years following his
introduction of this procedure, multiple surgical ap-
proaches have been used. Today, the most commonly
performed methods for total hip arthroplasty include the
anterior (Smith-Petersen), anterolateral (Watson-Jones),
muscle splitting lateral (Hardinge), transtrochanteric lat-
eral (Charnley), and posterior approaches (Moore, Gib-
son).
SURGICAL APPROACHES FOR TOTAL HIP
REPLACEMENT
Anterior Approach (Smith Petersen)
Several authors have advocated the anterior approach,
including Smith-Petersen, 1Bost et al, 2 and Cubbins, 3Suther-
land and Rowe,4 Fahey, 5 and Luck. 6 This approach devel-
ops the superficial muscular internervous plane between
the sartorius (femoral nerve) and the tensor fasciae latae
(superior gluteal nerve) and the deep muscular interner-
From Division of Hip and Knee Surgery, The Department of Orthopaedic
Surgery, New York Presbyterian Hospital at Columbia University, New
York, NY.
Address reprint requeststo Michael L. Parks, MD, New York Presbyte-
rian Hospital, 622 W. 168th Street, PH 1lth Floor, New York, NY 10032.
Copyright © 2000 by W.B. Saunders Company
1048-6666/00/1002-0003510.00/0
doi:l 0.1053/io.2000.5890
vous plane between the rectus femoris (femoral nerve) and
gluteus medius (superior gluteal nerve) to gain access to
the hip joint.
The patient is placed supine on the operating table. A
folded sheet is placed under the operative hemipelvis to
push the involved side forward. The skin incision as
originally described begins at the middle of the iliac crest
and curves anteriorly to the anterior superior iliac spine
and ends 10 to 12 cm distally and laterally. The lateral
femoral cutaneous nerve exits the deep fascia close to the
intermuscular interval between the tensor fasciae latae and
the sartorius. It must be protected and retracted medially
to preserve sensation to the lateral thigh. The superficial
fasciae and attachments of the tensor fasciae latae and
gluteus medius muscles are detached from the iliac crest.
The tensor fasciae latae and gluteus medius are then
subperiostially elevated from the lateral wing of the ilium.
Small nutrient vessels supplying these muscles may be
encountered and should be packed or cauterized to obtain
hemostasis. Distally, the dissection is carried through the
deep fascia of the thigh to expose the interval between the
tensor fascia lata laterally and the sartorius and rectus
femoris medially. The ascending branch of the lateral
femoral circumflex artery is encountered in this interval at
2 to 3 cm from the hip capsule and must be ligated. The
anterior capsule is then directly visualized by placing a
cobra retractor over the anterior acetabular rim. The
capsule is then transversely incised with a knife to reveal
the underlying femoral head. The femoral head is then
dislocated anteriorly after sectioning the ligamentum teres
with curved scissors, and the femoral neck is osteotomized
with an oscillating saw. The femoral head is removed using
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-
dially at 5 o'clock and posterolaterally at 7 o'clock.
Keggi et al 7,8 have reported excellent results with 1,000
total hips using a modified anterior approach. In this
series, the anterior approach utilized is performed through
a curved transverse skin incision beginning at the anterior
border of the tensor fasciae latae just inferior to the anterior
superior iliac spine and ending distally at the anterior

1 06 Operative Techniquesin Orthopaedics, Vol 10, No 2 (April), 2000: pp 106-114

border of the greater trochanter. The approach used by
Keggi et al differs from the classic description primarily in
that the fibers of the anterior border of the tensor fasciae
latae muscle are longitudinally split in the direction of the
muscle fibers. Keggi et al. find the logic in this muscle
interval from the confluence laterally of the tensor fasciae
latae with the fasciae latae and medially with the sartori-
ous which takes origin from the anterior superior iliac
spine and inserts distally onto the proximal tibia. This
dissection follows an "internervous line," as the medially
retracted muscle is supplied by the femoral nerve and an
upper lumbar root, and the laterally retracted muscle is
supplied by the superior gluteal nerve. The classic Smith-
Petersen ~ approach is an expansion of this exposure in
which the gluteus medius, gluteus minimus, and tensor
fasciae latae are freed from their origins on the iliac crest.
The major advantage of the modified anterior approach
described by Keggi et al is that the abductors are not
disturbed during the dissection. A major disadvantage of
this approach, however, is in proximal femoral exposure.
Although excellent visualization of the acetabulum is
achieved, the proximal femur may be obscured by over-
hang of the abductors. Poor exposure may necessitate
further capsular release from the femur and release of the
tensor fascia lata and sartorius from their origin on the
ilium or osteotomy of the greater trochanter for the most
difficult exposures. These maneuvers greatly increase the
amount of soft tissue trauma necessary to complete the
procedure.
The lateral femoral cutaneous nerve and femoral nerve
are at risk with an anterior approach. The lateral femoral
cutaneous nerve is at risk with the detachment of the
abductors around the area of the anterior superior iliac
spine. The lateral femoral cutaneous nerve can also be
injured in proximal dissection of the intermuscular interval
between the sartorius and the tensor fasciae latae as it
pierces the fascia of the thigh. Numbness of the thigh and
"meralgia paresthetica" are common complaints from this
approach. In addition, the femoral nerve lies almost di-
rectly anterior to the hip joint and may be injured during
retraction anteriorly when exposing the acetabulum. Care
should be taken when using Hohmann retractors to keep
them close to bone and avoid the anterior neurovascular
structures.
Anterolateral Approach (Watson-Jones)
Originally described by Watson-Jones,9 the anterolateral
approach to the femur provides good exposure to the hip
joint and proximal femur without osteotomy of the trochan-
ter. This approach exploits the intermuscular plane be-
tween the tensor fasciae latae and the gluteus medius. The
patient is placed in the supine position on the operating
table near the edge of the table. A table with a movable
segment (kidney rest) to allow the skin of the buttock to
hang free will facilitate access to the incision site and
draping. The incision begins 2.5 cm posterior and distal to
the anterosuperior iliac spine and curves distally and
posteriorly to the tip of the greater trochanter and extends
to the lateral surface of the femoral shaft 5 cm distal to the
base of the trochanter (Fig 1A). The interval between the
gluteus medius and tensor fasciae latae is identified and
OPERATIVEAPPROACHES FOR TOTALHIP REPLACEMENT
divided (Fig 1B). This is often most easily accomplished at
a point midway between the anterior spine and the greater
trochanter at a point before the confluence of the tensor
fasciae latae and its fascial insertion. The size and direction
of the muscle fibers can be used to separate these two
muscles. The dissection is carried proximally to locate and
expose the inferior branch of the superior gluteal nerve,
which innervates the tensor fasciae latae. Distally, the
origin of the vastus lateralis and the vastus ridge are
identified. Using electrocautery, the muscle is reflected up
along I to 2 cm from its origin. Blunt dissection is then used
to expose the capsule and slip a retractor over the anterior
wall of the acetabulum. The capsule is then incised longitu-
dinally along the anterosuperior margin of the femoral
neck. A complete capsulotomy is sometimes necessary for
full exposure (Fig 1C). The femoral head then is dislocated
anteriorly. Femoral dislocation is accomplished by traction,
external rotation, and adduction of the extremity. An
oscillating saw is used for the femoral neck osteotomy, and
the exposure is complete after placement of Hohmann
retractors anteriorly, posteriorly, and inferiorly.
Femoral exposure is gained by external rotation of the
leg. A wide retractor with points is used to elevate the
femoral neck. The abductor mass of the gluteus medius
and minimus is protected with a second small retractor. A
blunt Aufranc retractor is then hooked under the iliopsoas
tendon.
A frequent complication of the anterolateral approach is
damage to the femoral shaft and malpositioning of the
femoral component. 1° During femoral canal preparation,
the broaches must be placed as lateral as possible to
prevent canal perforation and varus positioning of the
implant. In lateralizing the broaches, however, unavoid-
able damage to the abductors is experienced because of
their anterior location. Difficult cases may necessitate a
wider surgical exposure. Expansion of the femoral expo-
sure is facilitated by detaching the anterior fibers of the
gluteus medius and the entire gluteus minimus tendon
from the trochanter. A trochanteric osteotomy may also be
used to reflect the anterosuperior part of the greater
trochanter proximally with the tendinous insertion of the
gluteus medius muscle." By taking a wafer of bone, this
preserves the gluteus medius and allows for its easy
reattachment after prosthetic implantation. As in the ante-
rior approach, these maneuvers designed to augment
extensile exposure significantly increase the amount of soft
tissue trauma associated with the anterolateral approach.
Two neurovascular structures are at risk with the Watson-
Jones exposure. The branch of the superior gluteal nerve
that supplies the tensor fasciae latae is found at the interval
between the gluteus medius and tensor fascia latae. This
nerve may be damaged when exposing the joint capsule. In
addition, as with the anterior approach (Smith-Petersen)
during acetabular exposure and reaming, injury to the
femoral neurovascular structures anteriorly may occur if
care is not exercised when placing pointed Hohmann
retractors (Fig 1D). Because the femoral nerve is the most
lateral structure in the bundle, it may be injured by direct
penetration of retractors and by traction used to gain
acetabular exposure. Also, the femoral artery and vein may
107
B /

Fig 1. Anterolateral approach to the hip, (A) Skin incision for

anterolateral approach. (B) The anatomic plane is exposed by
retracting the gluteus medius posteriorly and the tensor fascia
latae anteriorly. (C) The hip joint is exposed anteriorly by a
T-shaped incision that is later repaired, Alternatively, a com-
plete capsulectomy may be performed. (D) Acetabular prepara-
tion is augmented by careful retractor placement anteriorly to
avoid neurovascular structures.

C D

Karapelou

108 PARKS AND MACAULAY

be perforated by placing retractors anteriorly into the
substance of the iliopsoas.
Direct Lateral or Transgluteal Approach (Hardinge)
The direct lateral approach bisects the thick periosteum
covering the greater trochanter and preserves the continu-
ity of the conjoined tendinous attachment of the gluteus
minimus and medius proximally and the vastus lateralis
distally. Hardinge :2 popularized this approach. Its advan-
tage is that it avoids the need for osteotomy of the greater
trochanter while allowing access to the anterior and poste-
rior hip joint because of the location of the midlateral
incision. Access to the proximal femur for reaming is
improved with this approach as compared with the ante-
rior and anterolateral approaches.
The patient is placed in the supine position near the edge
of the operating table. This position allows the gluteal fat to
hang freely and fall away from the operative incision site
and also aides in draping. A straight incision is made in the
midline along the shaft of the femur beginning 5 cm
proximal to the tip of the greater trochanter and ending 5
or 6 cm below it. There is no internervous or intermuscular
plane. The gluteus medius and vastus lateralis are split
distally from their points of innervation. The tensor fasciae
latae is exposed and incised to extend the full surgical
incision length. The gluteus maximus is divided along its
aponeurosis, with care taken not to injure its muscle belly.
A self-retaining Charnley retractor is placed after clear
identification of the sciatic nerve. The greater trochanter is
then easily visualized in the center of the wound. Occasion-
ally, bursal tissue overlying the trochanter must be excised.
At this point, the anterior portion of the greater trochanter
and the common insertions of the gluteus medius and
vastus lateralis can easily be identified. The gluteus me-
dius is divided along the junction of the anterior two-thirds
and the posterior one-third beginning at the tip of the
greater trochanter (Fig 2A). The posterior one-third re-
mains attached to the trochanter. An anterior flap is
developed composed of the anterior portion of the gluteus
minimus, the underlying gluteus minimus, and the ante-
rior segment of the vastus lateralis (Fig 2B). Care is made to
avoid extension of the dissection further than 5 cm above
the greater trochanter to avoid injury to the superior
gluteal nerve (Fig 2C).
Sharp dissection is used to detach these muscles from
the greater trochanter. The dissection is carried forward
anteriorly with the bony contour onto the femoral neck.
The gluteus minimus tendon is exposed and sharply
detached from its insertion on the anterior greater trochan-
ter. The capsule is exposed and incised with a T-shaped
capsulotomy. The femoral neck is then osteotomized and
extracted using a cork screw and hip skid. The exposure is
then optimized by circumferential placement of retractors.
A modified Hardinge approach has also been popular-
ized in the United States. ~3 This teclmique divides the
abductors at the junction of the anterior one-third and
posterior two-thirds. Although less abductor mechanism is
involved, greater care must be taken to avoid injuring the
tendon that remains during femoral preparation.
Moskal and Mann ~4reported their results using a modi-
fied direct lateral approach in 453 consecutive primary and
revision total hip arthroplasties. They note several advan-
OPERATIVE APPROACHES FOR TOTAL HIP REPLACEMENT
tages of the approach including its wide exposure and
improved access to the femur when compared with the
anterior and anterolateral approaches. This approach obvi-
ates the need for trochanteric osteotomy and its associated
complications of nonunion, bursitis, pain, and wire break-
age. However, a major postoperative complication was
postoperative limp, with an incidence of 18%. The overall
incidence of heterotopic ossification was 47%, with a
slightly higher incidence in the revision group. No patients
in this series, however, developed bridging calcification.
Mulliken et al is reported on 712 total hip arthroplasties
performed using a modified direct lateral approach at a
minimum 2-year follow-up (average, 3.6 years). He noted a
0.3% dislocation rate and 3% incidence of severe hetero-
topic ossification [Brooker 16grade III or IV].
Jacobs and Buxton 17 dissected 10 cadaveric specimens
and studied the superior gluteal nerve and its branches
bilaterally. They identified two patterns of neural branch-
ing. The most common pattern was a "spray pattern" in
which the main trunk divides within 1 to 2 cm of the
superior border of the piriformis muscle into numerous
branches fanned out along the intermuscular plane be-
tween the gluteus medius and the gluteus minimus. A
second pattern, the "transverse trunk pattern," was found
in patients in which the majority of the branching was
peripheral. From these studies, a safe zone for the superior
gluteal nerve was established which encompasses a band
of the gluteus medius muscle approximately 5 cm wide
immediately adjacent to the greater trochanter. The supe-
rior gluteal nerve is less likely to be damaged if surgical
dissection is confined to this area (Fig 2)Y ,l~
In addition, the femoral nerve, artery, and vein are
vulnerable to anteriorly placed retractors as in the Smith-
Petersen and Watson-Jones approaches. The transverse
branch of the lateral femoral circumflex artery may also be
injured during mobilization of the vastus lateralis.
Lateral Transtrochanteric Approach
Charnley's m introduction of the low friction arthroplasty
in 1962 popularized the trochanteric osteotomy. He cited
the excellent exposure and the improved biomechanics of
the abductor mechanism through the advancement of the
greater trochanter through distal reattachment. Using this
technique, the surgeon achieves a complete visualization
of the anterior and posterior aspects of the hip and a full
view of the acetabulum.
The patient is positioned in a lateral position, and the
approach is performed through a straight lateral incision
as described for the direct lateral approach. The tensor
fasciae latae is divided to expose the gluteus medius and
vastus lateralis. The fascial incision is straight, beginning at
the tip of the trochanter and extending distally 2 to 3 cm
below its tip. Proximally, the incision is curved to parallel
the fibers of the gluteus maximus. Blunt dissection is used
to identify the interval between the tensor fasciae latae and
the gluteus medius. The anterior capsule is exposed and
stretched by externally rotation of the femur. The electrocau-
tery is then used to divide the anterior capsule and to
expose the summit of the vastus ridge. The classic trochan-
teric osteotomy as described by Charnley was performed
by passing a cholecystectomy clamp posteriorly from the
anterosuperior exposed surface of the femoral neck. The
109
 C •

: ~-~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).

110 PARKS AND MACAULAY

 .! -;. :
• _ - . • . . .-. .. ..,- . ,. ...:

- - .. , - .,~ _. .. . . , ::-

Fig 3. The anterior exposure of the interval

between the tensor fascia latae and gluteus
medius and inferior vastus ridge provide
reference for osteotomy of the greater tro-
chanter.

" ... : .

". , " . ". :~.; , i ..,''~': '" % "

" " ' " " • 2 -

. " " • " .:' ": . . . . . " . . . . . ~ , ~ '~"~ :i':

capsule was then pierced, and the cut was made after
ensuring that the location of the Gigli saw was located
deep to the posterosuperior surface of the trochanter. The
osteotomy site then exited through the vastus ridge (Fig 3).
This technique may be expedited by using an oscillating
saw after exposure of the vastus ridge and anterior femoral
capsulotomy. The cut begins at the vastus ridge and is
angled 45 ° to exit at the superior margin of the femoral
neck. The posterior capsule and external rotators may be
released as needed. Detachment of the trochanter in the
lateral exposure allows dislocation by simple adduction.
Care should be taken to ensure that the trochanteric
fragment is large enough and shaped appropriately to
facilitate repair. Repair of the trochanter has been de-
scribed by a variety of techniques including wire knots
and the commonly used Dall-Miles cable grip system.
There are several disadvantages to using the trochan-
teric osteotomy in total hip arthroplasty. Rates of trochan-
teric nonunion have reportedly ranged from 5 to 32%. 1.,2°
Trochanteric migration of more than 3 cm has been shown
to correlate to poor abductor power. In a series of 100 total
hips done using a transtrochanteric approach, Menon et
al 2° noted a 9% incidence of trochanteric migration of more
than 3 cm. Additionally, broken wires, trochanteric bursi-
tis, and ectopic bone formation have been reported as
frequent complications. Many surgeons have noted the
potential for increased intraoperative time and blood loss
because of the time needed to repair the trochanteric
osteotomy site. In addition, another significant disadvan-
tage is delayed rehabilitation because of delayed weight-
bearing postoperatively (usually 6 weeks).
Posterolateral Approach
The most commonly used position for total hip replace-
ment today is the posterolateral approach. It is technically
simpler than the other approaches. We prefer to position
the patients in the lateral position on a custom-designed
hip table (Medricon, Garwood, NJ). This table has multiple
adjustable features that allow stable neutral positioning of
the pelvis reduce any uncertainty in the positioning of the
acetabular components. After skin preparation and drap-
ing, the trochanter is marked superiorly, inferiorly, anteri-
orly, and posteriorly. A longitudinal skin incision is cen-
tered one-third over the trochanter, one-third below it, and
a proximal curvilinear portion, above the trochanter, paral-
lels the fibers of the gluteus maximus. The tensor and
gluteal fascia are incised in line with the skin incision
directly over the trochanter. Sharp incision is used for the
tensor fasciae latae and fascial envelope of the gluteus
maximus. The fibers of the gluteus maximus are, however,
bluntly divided after the fascial incision is made. The
gluteal sling is located and divided along its superior half
using the electrocautery.
The posterior border of the gluteus medius is identified
and retracted carefully using a 90 ° angled thin Hohrnann (a
"thin bent" retractor). An Aufranc retractor is then swept
under the fat and areolar tissue and superficial to the
external rotators to lie directly under the femoral neck. The
piriformis tendon and conjoined tendons of the gemelii
and obturator externus are identified and divided with the
electrocautery from their insertion on the greater trochan-
ter and tagged with nonabsorbable braided suture. Placing

OPERATIVE APPROACHES FOR TOTAL HIP REPLACEMENT 111

the leg in gentle internal rotation aides in the dissection by TABLE 2. Comparison of THR HO Incidence by Surgical
placing the external rotators and capsule on gentle stretch. Approach
The external rotators are then tagged and placed posteri-
HO Total
orly to form a protective sling around the exposed sciatic Author Approach Incidence (%)
nerve.
A periostal elevator is then used to bluntly divide the Horowitz et aP 3 Direct lateral 45
Transtrochanteric 20
remaining gluteus minimus from the capsule, and the thin Bischoff et a125 Posterior 30
bent Hohmann retractor is replaced to protect the abductor Anterolateral 77
mass. A trapezoidal posterior capsular flap is then created. Moskal & Mann TM Direct lateral 47

The capsule is incised in line with the longitudinal poste-

rior border of the trochanter. A superior line parallels the
course of the piriformis tendon extending from the greater thrifts, and the handling of the soft tissues at the time of
trochanter to the acetabular labrum. An inferior incision is surgery. Pai 24 compared three variations of the lateral
similarly made at the superior border of the quadratus approach in 264 patients; the direct lateral approach, the
femoris with care taken to avoid the sciatic nerve posteri- transtrochanteric approach, and the Liverpool approach,
orly. The corners of this flap are tagged with No. 2 which employed the detachment of a wafer of trochanteric
nonabsorbable sutures and retracted posteriorly with the bone with the detachment of the gluteal flap. He found a
short external rotators. A long-handled knife is then used 52% incidence of HO, with the most severe occurrences
to divide the superior capsule beneath the abductor mass. being associated with the detachment of a wafer of trochan-
The hip is then gently dislocated using longitudinal trac- teric bone to augment exposure. Bischoff et a125 evaluated
tion and internal rotation. At this point, the quadratus 112 consecutive total hip arthroplasties in similarly matched
femoris is identified at the base of the femoral neck. Using groups using postero- and anterolateral approaches. The
the electrocautery, this muscle is divided 2 to 3 mm from its posterior approach was found to have a significantly lower
insertion on the femur with care to leave a small cuff of incidence of HO (Table 2).
tissue for later repair. Bleeding is often encountered during
the dissection, and branches of the medial femoral circum- Dislocation
flex artery should be anticipated and ligated. The Aufranc The anterior and anterolateral approaches have been found
retractor is then replaced at the inferior border of the lesser to have lower rates of dislocation when compared with the
trochanter. After osteotomizing the fully exposed femoral posterior approaches. The direct lateral approach offers
neck, exposure is complete. The leg may be placed in excellent access to the proximal femur but has the advan-
gentle flexion and internal rotation. This allows complete tage of maintaining the short external rotators and has a
acetabular exposure after placement of anterior and poste- lower incidence of dislocation as compared with the
rior retractors. posterior approach (Table 3). Six weeks should be allowed
The major advantage of the posterior approach is its for posterior wound healing and for the formation of a
technical ease when compared with other methods of pseudocapsule. At this time, hip precautions are lifted.
exposure for the hip joint. The major disadvantage of this Two recent reviews have, however, reported infrequent
approach has been its unacceptably high rate of disloca- dislocations with complete repair of the native posterior
tion. Rates have been reported as high as 9.5%. 21,22Many structures (Fig 4). Hedley 2~ performed 259 consecutive
surgeons, however, believer that the shorter operating time total hip arthroplasties with complete repair of a capsulo-
and decreased blood loss with the posterolateral approach muscular flap. They reported only 2 (0.76%) dislocations.
outweigh the disadvantage of a higher risk of dislocation Pellicci et a127 reported a 0% dislocation rate in 395
(Table 1).~ consecutive primary total hip replacements performed
with an enhanced posterior soft tissue repair.
COMPLICATIONS
Abductor Strength and Recovery
Heterotopic Ossification The direct lateral approach offers the widest exposure of all
Heterotopic ossification (HO) is a frequent complication of the nontranstrochanteric approaches to the hip. Its major
total hip arthroplasty. The incidence has been reported to
be as high as 80%. 24 Although the etiology is unknown,
several factors have been associated with HO formation TABLE 3. Comparison of THR Dislocation Rate by Surgical
including prolonged surgical time, the subtype of osteoar- Approach
Author Approach Dislocation Rate (%)
TABLE 1. Comparison of THR Operative Time and Blood Charnley 19 Transtrochanteric 0.80
Loss By Surgical Approach Eftekhar29 Transtrochanteric 0.50
Pellicci et al 3° Transtrochanteric 0.47
Time Blood Loss Robinson et a122 Posterior 7.50
Author Approach (h) (mL) Woo & Morrey 31 Anterolateral 2.30
Posterior 5.80
Horowitz et aP3 Direct lateral 2.2 (1.5-3) 1101 (565-1873) Vicar & Coleman 32 Anterior/Transtrochanteric 2.20
Transtrochanteric 2 (1.4-3) 1227 (610-1712) Posterior 9.50
Robinson et a122 Transtrochanteric 2.03 687 McCollum & Gray 23 Posterolateral 1.14
Posterior 1.8 606 Pellicci et a 1 2 7 Posterolateral 0.00
Mallory et a 1 3 3 Anterolateral 0.79
Abbreviation:THR, total hip replacement.

112 PARKSAND MACAULAY

Fig 4. Complete repair of hip capsule, exter-
nal rotators, and quadratus femoris muscle
after implanting acetabular and femoral com-
ponents.
d i s a d v a n t a g e is the increased incidence of p o s t o p e r a t i v e
a b d u c t o r limp in a d d i t i o n to heterotopic ossification. Ab-
d u c t o r w e a k n e s s m a y be c a u s e d b y d e t a c h m e n t of the
g l u t e u s m e d i u s or b y injury to the s u p e r i o r gluteal nerve.
A n a t o m i c studies of the course of the s u p e r i o r gluteal
n e r v e h a v e s h o w n a safe z o n e of 3 to 5 c m from the tip of
the greater trochanter. It is essential, h o w e v e r , to p e r f o r m
m e t i c u l o u s a n a t o m i c dissection and r e a t t a c h m e n t of the
g l u t e u s m e d i u s a n d g l u t e u s m i n i m u s if a b d u c t o r w e a k n e s s
is to be a v o i d e d . The g l u t e u s m i n i m u s is first repaired to its
insertion on the anterior femur. The repair is c o m p l e t e d
using drill holes if there is inadequate tendinous s t u m p
remaining. The gluteus medius and vastus lateralis are superfi-
cial to the minimus and are repaired next. With repair and
reattachment of the abductors and by keeping surgical dissec-
tion within the "safe zone," the incidence of postoperative limp
has been r e p o r t e d to be no h i g h e r with the direct lateral
a p p r o a c h w h e n c o m p a r e d with other approaches.M,28
CONCLUSION
M a n y acceptable surgical a p p r o a c h e s are available for
p e r f o r m i n g a total hip arthroplasty. O n e c a n n o t overesti-
m a t e the i m p o r t a n c e of repetition to p r o v i d e reproducible,
efficient c o m p l e t i o n of this operative procedure. N e v e r t h e -
less, each s u r g e o n s h o u l d be a w a r e of the classic criticisms
of his preferred a p p r o a c h a n d try to m i n i m i z e the possible
complications. In o u r experience, the posterolateral ap-
p r o a c h is r a p i d l y p e r f o r m e d , a n d formal repair of the short
external rotators and posterior capsules brings the disloca-
tion rate d o w n into an acceptable range. Importantly, m o r e
OPERATIVE APPROACHES FOR TOTAL HIP REPLACEMENT
than 90% of patients are w a l k i n g w i t h o u t a perceptible
limp by 6 w e e k s postoperatively.
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