European Journal of Orthopaedic Surgery & Traumatology (2018) 28:771–779

https://doi.org/10.1007/s00590-018-2158-2

EXPERT’S OPINION • HIP - ARTHROPLASTY

Minimally invasive total hip arthroplasty using Hueter’s direct anterior

approach
Pascal Moreau1

Received: 5 December 2017 / Accepted: 8 December 2017 / Published online: 6 March 2018
© Springer-Verlag France SAS, part of Springer Nature 2018

Abstract
For many years the Hueter anterior approach has been performed exclusively in Paris. Robert and Jean Judet described it
for the first time in 1950 in relation to total hip arthroplasty. They started using an orthopaedic surgery table in 1985. The
approach was only taught within the capital’s orthopaedic units and was relatively unknown before. In the last 10 years there
has been widespread renewed interest in this approach which preserves the muscles. The technique is described in detail
with its tricks and risks. It appeals to the surgeon in its minimally invasive form and provides particulary effective treatment
for the patient.

Keywords  Total hip arthroplasty · Hueter anterior approach · Rapid recovery · Minimally invasive technique

Introduction
For many years the Hueter anterior approach has been per-
formed almost exclusively in Paris. Robert and Jean Judet
described it for the first time in 1950 in relation to total hip
arthroplasty (THA) [1]; they started using an orthopaedic
surgery table in 1985 [2]. The approach was only taught
within the capital’s orthopaedic units and was relatively
unknown beyond. In the last 10 years there has been wide-
spread renewed interest in this approach which preserves the
muscles. It appeals to the surgeon in its minimally invasive
form and provides particularly effective treatment for the
patient [3].
My personal experience dates back to 2004. At the time,
minimally invasive procedures for prosthetic hip and knee
surgery had been an ongoing discussion for 2 years. Berger’s
[4] double-incision approach for the hip and the quadriceps-
sparing knee technique were being practiced. However,
minimally invasive surgery and minimal incision surgery
are often confused. This happened to me. I performed hip
arthroplasty using a posterior approach and chose, as oth-
ers did, to reduce the length of my incision. The depth of
the approach was essentially the same. I made it through
* Pascal Moreau
moreau.pascal5@wanadoo.fr
1
Polyclinique Montier la Celle,
10120 Saint André les Vergers, France
the gluteus maximus and sectioned the short external rota-
tor muscles while preserving, in most cases, the piriformis
tendon then made an incision at the top of the crural com-
partment to achieve haemostasis of the posterior circumflex
pedicle. However, I realized quite quickly that this surgery
had restricted access and was quite difficult with little benefit
for the patient.
I then met Frédéric Laude in Paris. He fitted the same
prosthesis as I did and had been performing the minimally
invasive anterior approach for a long time. He spoke with
ease about it, and his technique was practised. I discovered a
new set-up, the traction table, manipulation and much more.
Yet, what stood out was the quality and the speed at which
the patients treated in his department recovered. At the time,
France still had thresholds for minimum required lengths of
stay for patients in hospital, called the “bornes basses” so
I had the opportunity to see treated patients at Day 1, Day
2 and even Day 3. I saw patients up and dressed, walking,
with or even without a stick, and going up and down stairs
with no difficulty. It was what impressed me the most when
visiting the department. I was witnessing for the first time
the outcome of non-traumatic surgery.
My activity was already centred on hip arthroplasty so
my only alternative was to change my surgical technique to
achieve this perfection.

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772 European Journal of Orthopaedic Surgery & Traumatology (2018) 28:771–779

Operative technique

Planning

With more than 6000 THA behind me, I still plan each oper-
ation. This is all the more important when operating using
the anterior approach, as the operating field is narrow and
there are few anatomical landmarks. The lesser trochanter,
for example, is not visible and sometimes not palpable.
Other landmarks must be found.
Planning starts by choosing the diameter and the position
of the cup which will then define the centre of rotation of
the hip (Fig. 1). I identify the depth of reaming against the
quadrilateral blade that remains visible at all times, in order
to avoid anterior overlap of the prosthetic cup. I then choose
the tilt and estimate external overlap against the outer edge
of the acetabulum that is always visible or palpable. I iden-
tify possible osteophytes that require removal.
On the femoral side (Fig. 2) the lesser trochanter is no
longer in the operating field. On the plan, I identify the ideal
position of the stem, the size, offset and penetration against
the upper edge of the neck at the level of the cervical oste- Fig. 2  Planning: identify the level of the cervical osteotomy
otomy—my constant landmark. Finally, I identify the level
of the cutting marks and positioning at 45°. I check the level
against the lesser trochanter and consider it a viable land- the pudendal nerve when using an orthopaedic surgery table.
mark, if it is close to the cut. This debate needs closing once and for all.
An orthopaedic surgery table is not a traction table and
Set‑up must never be used to enforce a position. It only assists in
maintaining positions achieved by surgical release. Begin
I use a classic orthopaedic surgical table, with extension with the lower limb in neutral rotation, in slight flexum to
if required, to which the two feet are attached. This should relax the anterior area in slight tension.
allow for less pelvic inclination—a source of malposition I use a mechanical arm (Flexible pneumatic arm GAS-
of the cup. Pelvic support is comfortable and sufficient TON, Medacta International, Switzerland) (Fig. 4) which
(Fig. 3). Some colleagues have described compression of allows me to maintain the retractors forward and to dispense

Fig. 1  Planning: choose the diameter and the position of the cup Fig. 3  Set-up: pelvic support is comfortable

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European Journal of Orthopaedic Surgery & Traumatology (2018) 28:771–779 773

The tensor aponeurosis is reached and incised in the axis

of the scar, exposing the tensor muscle fibres, angled in the
same direction. The tensor muscle is then separated from
the aponeurosis at the front (Fig. 5) and loaded with a spe-
cific autostatic retractor (AMIS instrumentation, Medacta
International, Switzerland). The fibres of the rectus femoris
(Fig. 6) are visible and are facing the same way. The aponeu-
rosis of the rectus femoris is incised, and this releases the
muscles which are loaded with the autostatic retractor.
This space is defined, at the top, by the rectus femoris
reflected tendon, at the bottom by the insertion of the vastus
lateralis muscle, in front by the rectus femoris and behind by
the tensor, both loaded with the autostatic retractor.
In depth there is the fascia innominate. Just above the
bulge of the vastus lateralis, you will find the anterior cir-
cumflex pedicle going across the incision. This fascia is
incised carefully to preserve the pedicle. The pedicle is

Fig. 4  Flexible pneumatic arm allows to exempt from assistant

with another assistant. The assistance of only one person is

necessary.

Anaesthesia

General anaesthetic with administration of curare is my first

choice and has been for some time now. The incision is short
and sections neither tendon nor muscle. Adequate muscle
relaxation is therefore essential. The anaesthetists I have
worked with have needed convincing before they agree to Fig. 5  Opening tensor aponeurosis
reject a spinal anaesthesia I considered to be inconsistent and
insufficient. Efficiency of spinal anaesthesia is too dependent
on the practitioner, the choice of product and the technique.
Also, urinary catheterization is practically compulsory and
is not in the best interests of male patients in particular.

Approach

The incision is centred on the tip of the greater trochanter;

two fingerbreadths back from the anterior superior iliac
spine. The iliac spine is an important landmark as it is
always accessible. The incision mustn’t be performed fur-
ther back as it could be the wrong zone or further forward
as it could cause damage to the femoral cutaneous nerve.
The incision will be inclined downwards towards the head
of the fibula. The length will vary according to the surgeon’s
experience and the patient’s morphology; it is not greatly
significant, whereas the approach according to the depth is. Fig. 6  Fibres of the rectus femoris are visible

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Fig. 7  Section after ligation of the anterior circumflex artery
Fig. 8  Exposure of the capsule
exposed, ligated and sectioned (Fig. 7). You then find fatty
tissues that line the front of the anterior joint capsule. This
will be excised and will expose the capsule, from which
above is the reflected tendon of the rectus femoris, below
the vastus lateralis, in front the psoas muscle and behind the
gluteus minimus (Fig. 8). A Hohmann retractor is placed
between the psoas and the anterior capsule. Another is
placed between the superior joint capsule and the gluteus
minimus. Capsulotomy starts at the bottom by removing the
capsule from the intertrochanteric line. In order to extend the
capsule, ask the scrub nurse to rotate externally. The inci-
sion is completed by drawing a U with a posterior pedicle
[5]. The foam spacers are inserted intra-articularly, and this
exposes the femoral neck efficiently. The scrub nurse pro-
vides internal and external rotation to provide you with clear
reference points before cutting the neck. The junction neck/
greater trochanter is visible, or at least palpable. Select the
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European Journal of Orthopaedic Surgery & Traumatology (2018) 28:771–779
Fig. 9  Separation of the neck osteotomy
Fig. 10  Extraction of the femoral head
desired inclination and anteversion. It is easier to separate
the osteotomy line when the limb is under tension (Fig. 9).
The head is tilted, loaded with a lag screw and extracted
(Fig. 10) after freeing capsular adherences and also remov-
ing the autostatic retractor that could injure the muscles.
Acetabular stage
Use your finger to palpate the anterior capsule that will
be retracted with the anterior arm of a modified Charnley
spacer (AMIS instrumentation, Medacta International,
Switzerland). Use the capsular pedicle shred at the rear to
load the posterior arm of the Charnley. The display is good
and in axis. The bulge is excised before freeing the outer
edge of the bony acetabulum to make it visible or palpable.
The quadrilateral blade is exposed. Identify the transverse
ligament. Reaming will start in depth as planned and will
European Journal of Orthopaedic Surgery & Traumatology (2018) 28:771–779 775
grow taking care to stay well centred. The choice of cup size
will take into account the need to leave a secure margin at
the front with the anterior horn, in order to avoid anterior
overlap which is a source of conflict with the psoas. The
implant needs to be placed with the least anteversion possi-
ble. The inclination is a matter of experience identifying two
landmarks, which are the external edge and the transverse
ligament. After impaction, bone contact and presence of an
anterior bony overlap must be checked. If required remove
the osteophytes.
Femoral stage
The femoral stage is often the most complex when lacking
experience. It is essential to expose the femur. Start by put-
ting the limb under tension and rotate externally. The patella
needs to be rotated to 90°. If this is not achieved, it is usually
because of the following two hindrances:
• Excessive tension of the inferior joint capsule can be
detected perfectly with the finger. In this case incise the
capsule in contact with the bone towards the lesser tro-
chanter.
• The greater trochanter is blocked behind the acetabulum.
The aim is then to raise the greater trochanter in the ace-
tabulum. The capsule is incised externally just in front of
the greater trochanter (Fig. 11), and a Hohmann type spacer
is used to rise the femur. This is most often sufficient and
you may continue and put the limb in extension and adduc-
tion. If it is not adequate you will need to free the medial
face of the greater trochanter and get the capsule across the
greater trochanter. Once again, never try and force positions
with the orthopaedic table. It is almost never necessary to
either free the posterior capsule or section the short external
Fig. 11  Great trochanter is in front of the acetabulum
rotator muscles. The strict minimum should be performed.
The femur is then prepared in the usual manner. Identify the
upper edge of the neck and choose the size of the prosthesis
which will reach the level planned. Reduce with a short neck
then test the position and external rotation of the foot to 90°.
If the choice of implants is as planned, there is no great risk
of error. The trial implants are then exchanged with the final
implants after thorough cleaning.
Closure and post‑operative management
Clean and apply analgesia infiltration. Closure is rapid, ten-
sor aponeurosis, subcutaneous tissue and skin with or with-
out drainage.
Post-operative management is usually quite simple. The
patients can get up the following morning after removing
the Redon drain (young patients can get up that same night);
they can bear their total weight on the limb and are free to
leave their room and walk down the hall.
The second day they can go up and down stairs. Instruc-
tions are repeated, and 90% of patients can leave the hospital
by the end of the morning. In fact, the only restriction is
to avoid movements associated with extension and external
rotation. Everything else is allowed. Physiotherapy is not
permitted the first week and then will only be prescribed to
patients who deem it necessary.
Discussion
Our experience
I am not particularly in favour of ambulatory treatment. I fit
five hip or knee prosthesis a day, 3 days a week. I like con-
sistency in patient care. My patients don’t request or push
for ambulatory care. I aim to see a well-informed, confident
patient leave the hospital. Furthermore, the first night post-
operatively can be difficult and pain and anxiety are best
managed within a care facility.
Hueter’s anterior approach using minimally invasive sur-
gery has enabled my patients to recover faster and return
to normal daily activities sooner. Patients should, however,
be warned to avoid subjecting their hip to excessive stress
before osteointegration has occurred and stem stability relies
on press-fit only. This may be even more relevant when short
cementless stems are used.
Since 2011, I have opted to use short cemented stems
(AMIStem-C, Medacta International, Switzerland) with
a cementless cup (­ Versafitcup® CC Trio, Medacta Inter-
national, Switzerland) and a ceramic on ceramic bearing
couple. I prefer fitting a short cemented stem to a cement-
less straight stem. A short stem is easier to fit with the
least debridement [6]. The minimally invasive spirit is thus
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maintained. I use 32–36 diameter heads to ensure better ana-
tomical recovery and stability [7].
I was always very cautious when using the technique,
while I was inexperienced and selected my patients carefully.
Other colleagues chose to treat all patients using the anterior
approach and encountered complications due to the learning
curve. It is a notion that I dislike and is unnecessary. Total
hip arthroplasty must remain an operation with simple post-
operative care, and it is communally considered this way. A
surgeon must take responsibility and train himself correctly
before offering this technique.
Indications and contraindications: the ideal patient was
a slender man or woman, with no osteoporosis and a rea-
sonably long femoral neck. A long femoral neck generally
offers greater ease when exposing the femur and improved
flexibility of the capsule.
Ninety-five per cent of our primary THAs are done using
the anterior approach. Indications for posterior approach are
maintained for patients that are difficult or with a risk:
• Patients with an abdominal apron and a risk of macera-
tion of the scar.
• Acetabular protrusion when the hip is very stiff.
• Serious osteoporosis, although this is rare today.
• Very elderly male or female patients [8] as the advan-
tages of the anterior approach don’t outweigh the risks.
I also don’t believe in using the anterior approach on
fractures of the femoral neck on elderly women when
still inexperienced, as the operation needs to be quick
and without risk.
• However, there is a big advantage to the anterior
approach in obese women with a flexible hip unlike obese
men. The fatty tissue is not as thick at the front.
• Revisions of prosthesis except in the rare cases when
I’ve changed cementless femoral stems that were inserted
using an anterior approach and haven’t integrated.
Literature review
The literature is actually quite poor despite a ten-year revival
of the direct anterior approach. Authors frequently compare
their early experience with the anterior approach to series
of patients operated on with their usual technique [9, 10].
The operation lasts longer, bleeding is more important, and
the global benefit is considered very small. However, hos-
pitalization is shorter, recovery and discarding walking aids
are accelerated, and care centres are used less frequently
[11–18].
I particularly appreciated Philippe Lapresle article [19],
and I appreciated meeting him. At the end of his career
and with his great experience, he remains modest and very
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European Journal of Orthopaedic Surgery & Traumatology (2018) 28:771–779
enthusiastic. His description of the procedure is systema-
tized and realistic.
The analysis of the literature and our own experience can
highlight the following points:
Advantages
Rapid recovery
Ninety per cent of patients are out by D2. They don’t require
walking aids after 15 days and can drive their cars after only
8 days. They can go home without having to stay in a care
centre. Even people who live alone, go home more and more
frequently. They feel better than they did preoperatively,
more rapidly. There is no risk of dislocation and patients
feel confident. Those who work can return to their jobs very
quickly. Certain craftsmen and independent professionals
only take a long weekend break.
Patients suffer less pain and therefore need less analge-
sics [20]. The most surprised are the patients who recall a
previous hip operation performed using a posterior approach
and who are then treated with the anterior approach. I’ve let
patients out at D1 without consequences. I’ve also performed
bilateral operations on young patients who have recuperated
just as well as those who underwent unilateral treatment.
Time off work is much shorter: in 2012 my patients
ceased working for an average of 39 days when the regional
reference is 72 days (figures supplied by the French Health
Care). More recent data are not available.
Joint stability and near absence of dislocation
Dislocation is essentially due to a excessive cup anteversion.
The only forbidden movement following surgery is exten-
sion combined with external rotation. I advise my patients
to be careful for 3 weeks, and then they can do as they like.
They can get into a car and drive without a problem, even
the second day after the operation.
Convenience for the anaesthetist
The supine position and being able to use a laryngeal mask
are significant points. Any advantage concerning bleeding
needs yet to be proven. In my personal experience I have
required transfusions extremely rarely.
Inconveniences
The novelty
The basic problem is that everything is new when you
are starting out: the approach, the set-up, the orthopaedic
European Journal of Orthopaedic Surgery & Traumatology (2018) 28:771–779 777
table, the equipment and even the prosthesis. You need
real collaboration from the whole team.
• The anaesthetists It is not easy to convince the anaes-
thetist to start giving general anaesthetics again. You
need to discuss the issue without imposing your opin-
ion, while insisting there is no choice in the matter.
When you start out you need to take your time at each
stage. An incomplete rachianaesthesia or of limited
duration will create peroperative problems.
• The nurses You need to discuss a new way of working
as the scrub nurse has an active role. You will need to
take the time to show how the orthopaedic table works
and point out the important features. The scrub nurse
has great responsibility during the operation, and this
is not always appreciated in some operating rooms. It
is easier to work with the same nurses in the operating
room when on the learning curve, but this is not always
possible when the facility uses temporary staff. This is
why certain surgeons do not use an orthopaedic table.
In this situation, you will need another assistant. In a
private facility this has a cost. In public facilities the
lack of staff grade doctors, junior doctors and nurses is
starting to cause problems.
The risk of femoral fracture [21]
This risk rests essentially on the quality of the approach
and understanding how to free the joint capsule. It also
depends on the bone stock.
Fracture of the femur can be located in two different
places:
• The trochanterian area This fracture occurs when the
femur remains in depth and isn’t positioned up in the
cup. Forced external rotation with extension causes the
fracture.
• The calcar and diaphysis It is most commonly caused
by incorrect preparation of the femur due to inadequate
exposure. The main risk factors are using a femoral
prosthesis without cement and Dorr’s type A.
This is a serious complication that may compromise
post-operative management. Osteosynthesis is complicated
due to the set-up. Fracture of the greater trochanter is a
priori stable and doesn’t require treatment. Fracture of the
calcar or the femur, however, requires wiring in the best
cases and sometimes more serious treatment. Care must
be taken to avoid this risk, and the best solution is to select
the right patient when inexperienced.
Limb length discrepancy
This is the second reason certain surgeons choose to operate
without an orthopaedic table; they can assess the length of
the leg and compare it to the other one. In practice I have
avoided the problem by planning in an accurate and reliable
manner. Planning defines certain items and when they are
respected the sources of error are avoidable. The approach is
stable, and, as with the posterior approach, it is unnecessary
to extend to gain stability. My own experience has shown
me that I insert long necks very rarely. In fact, I find that
my planning is mostly accurate, and therefore, I reduce the
trial prosthesis with a short neck. If I have standard piston
action and the prosthesis is stable in neutral extension with
90° external rotation of the foot, I leave things as they are.
Otherwise, I reduce the final prosthesis with a medium neck.
This enables a 3-mm extension. It is almost impossible to
reduce when extension is excessive.
I do not believe direct anterior approach without an ortho-
paedic table is an alternative as the position of the pelvis can
easily be modified. Landmarks can be difficult to guarantee,
and mistakes can occur, as in posterior approach in supine
position.
I rarely use a double mobility cup. I select this implant
only when I’m concerned with primary stability in very
elderly women suffering from osteoporosis. I then use a
tripod fixation. These implants are frequently hemispheric
and are therefore difficult to insert from the front, with risk
of anterior conflict with the psoas. Reduction in the trial
prosthesis is often difficult as is dislocation before inserting
the final implants.
Malposition of the implants [21]
When it concerns the cup, it may be excessive verticaliza-
tion and caused by incorrect landmarks and exposure. To
ensure the implant is horizontal, the transversal ligament
and the external edge of the cup must be visible. The other
cause may be excessive anteversion. This is more difficult
to deal with as the landmarks are unreliable and depend on
the position of the pelvis. In fact, the anatomical direction
should be defined preoperatively in order to apply the least
anteversion possible without letting the cup overlap the bony
wall in front. The cup must be impacted while pulling your
hand down. The consequence of this malposition is instabil-
ity in external rotation.
Anterior conflict [22] is a very well-known complication
when using the data, whatever the approach. It seems to
occur more frequently using the direct anterior approach.
The cup actually needs to be buried by reaming to the quad-
rilateral blade and you need to choose the smallest cup with
the least anteversion possible.
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Fig. 12  Avoid nerve damage: the foot is only in external rotation and
not at the floor
When it concerns the femur, the femoral stem needs to
be in varus. The principal landmark is the difference in
size between the size planned preoperatively and the one
chosen peroperative. Going off course can also complicate
the operation. Using fluoroscopy can be useful, but I do
not recommend it systematically.
Nerve damage [23, 24]
It consists mainly in dysesthesia in the cutaneous femoral
nerve area. Apart from very rare hyperaesthesia, sensory
damage is not troublesome. I have never observed in my
experience damage to the either the sciatica nerve or the
inguinal ligament or to the pudendal nerve. This is cer-
tainly due to my concept of the orthopaedic table. I never
use the hand traction system. The only time I use traction
is when I’m about to cut the neck and it never lasts more
than a minute at the most. At the end I raise the greater
trochanter into the cup and from then onwards barely lower
the limb (Fig. 12).
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European Journal of Orthopaedic Surgery & Traumatology (2018) 28:771–779
Conclusion
This operation is a step-by-step process. It is an accumu-
lation of details that need to be known and anticipated.
When they are mastered, the speed and the quality of the
result are unequalled.
Compliance with ethical standards 
Conflict of interest  The author has a contract as medical advisor to
Medacta International, Switzerland.
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