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Approaches for Primary Total Hip Replacement

Article  in  Hip International: the Journal of Clinical and Experimental Research on Hip Pathology and Therapy · June 2014
DOI: 10.5301/hipint.5000163 · Source: PubMed

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Hip Int 2014 ; 00 ( 00 ): 000 - 000 DOI: 10.5301/hipint.5000163

REVIEW

Approaches for primary total hip replacement

Thomas Ilchmann

Birshofklinik Hirslanden, Münchenstein - Switzerland

In total hip replacement surgeons can choose from a various number of approaches, from posterior,
lateral or direct anterior. Excellent results can be achieved with all approaches and there is no evidence
for the use of a specific approach. Minimally invasive operating techniques might further contribute
to that success. Early rehabilitation and functional outcome can be improved by the introduction of
evidence based clinical pathways irrespective to the used approach.

Keywords: Hip replacement, Approach, Comparison, Complication, Outcome

Accepted: May 16, 2014

INTRODUCTION APPROACHES

It is well established that total hip replacement is one Posterior approach

of the most frequent and most successful operations in
orthopaedic surgery. Thus the reliability of the procedure
is of major socio-economic importance. The operation
should be effective in terms of pain relief and should
come along with a preferably short hospital stay and fast
recovery. The overall function of the hip and patient sat-
isfaction should be high, aiming for a high percentage of
patients with a “forgotten joint replacement” as soon as
possible (1).
Posterior, lateral and direct anterior approaches are es-
tablished for total hip replacement (Fig. 1). The opera-
tions can be performed in supine or in lateral position on
standard or on trauma tables. More recently minimal in-
vasive operating techniques (MIS) have been developed
for all possible approaches in assumption that muscular
damage is reduced and postoperative recovery is thus
facilitated (Tab. I). The various different approaches and
their variants which surgeons can choose from raises
the question which is most appropriate for total hip re-
placement.
The patient has to be placed in a lateral position (2). The m.
gluteus maximus is bluntly split and the short external rota-
tors need to be detached to get access to the femoral joint
capsule. The surgeon needs to be aware of the location of
the sciatic nerve. Refixation of the short external rotators
after implant placement reduces the risk of dislocation.
Using the posterior approach makes it more difficult to
control implant orientation and perioperative radiographic
examination in lateral position is less feasible as compared
to operations in supine position. However, the abductor
and flexor muscles are not touched.
The posterior approach can be extended both for exposure
of the acetabulum and the femur and thus is suitable for
most indications in primary and revision hip arthroplasty.
Lateral and anterolateral approach
The patient can be placed in a lateral or in a supine position.
Various techniques are described to elevate the muscular

© 2014 Wichtig Publishing - ISSN 1120-7000 1

Approaches for primary hip replacement

The sciatic nerve can be irritated by retractors when ele-

vating the femur, thus caution needs to be taken. Further-
more, the femoral nerve and the femoral vessels are at
risk by retractors placed on the anterior rim of the acetab-
ulum (5) and extensive splitting of the m. gluteus medius
can damage the superior gluteal nerve (6). In the supine
position implant orientation might be better reproducible
and the use of the intensifier is facilitated. As a part of the
abductor muscles is detached and the femoral reamers
have to pass and thus might damage the insertion of the
m. gluteus medius, it might be difficult to achieve early
weight bearing.
The lateral approach can be extended and gives good
exposure to both the acetabulum and femur, thus being
suitable for primary and revision operations.

Anterior approach
Fig. 1 - The posterior, lateral, anterolateral and anterior approach. The direct anterior approach has been well established
Each approach has specific muscle groups that have to be mobil-
for arthrotomies and periacetabular osteotomies (7) and
ised and for each approach specific neurovascular structures are
at risk. recently has become more popular in hip replacement.
The patient is placed in supine position on a standard
table or on a fracture table (8). M. Sartorius, m. rectus
TABLE I - THE MOST FREQUENTLY USED APPROACHES IN
femoris and m. iliopsoas on one side and m. tensor fas-
HIP REPLACEMENT
ciae latae on the other side are mobilised and held back
Anatomic Authors MIS authors by retractors. The femoral nerve and vessels are at risk
dissection if retractors are placed on the anterior rim of the acetab-
Posterior Split of Langenbeck, Wenz, Sculco, ulum and the lateral branches of the femoral nerve are
m. gluteus Kocher, Roth, at risk when using caudal retractors. During preparation
maximus Moore Nakamura and reaming parts of the m. tensor fasciae latae might
Lateral Split of Bauer, Berger, be damaged.
m. gluteus Hardinge, Higuchi The exposure of the acetabulum is good and it can be ex-
medius Learmonth
tended for acetabuar revisions but the posterior column
Anterolateral Interval between Watson Röttinger, can not be reconstructed. The femoral preparation is more
m. gluteus medius Jones, Jerosch,
difficult and femoral revisions with osteotomies can not be
and m. tensor McKee Pfeil
fasciae latae Farrar performed using this approach.
Anterior Interval between Smith- Lesur, Keggi,
m. tensor fasciae Peterson, Matta, Comparison of the various approaches
latae and Hüter, Judet Rachbauer
m. sartorius Hip replacement is a successful procedure proven for
all approaches but there are some specific differences
(Tab. II). The dislocation rate might be higher for the pos-
bridge of the ventral portion of the gluteal muscles and the terior approach (9, 10) however, the risk of dislocation is
m. vastus lateralis (3). In the anterolateral approach the m. multifactorial and thus the used approach is only one of
vastus lateralis, in some variants, does not need to be de- many aspects (11).
tached (4). The lateral and the anterolateral approaches, In the lateral approach the splitting of the m. gluteus me-
with their variants, are often used synonymously. dius might damage the superior gluteal nerve (6) and fatty

2 © 2014 Wichtig Publishing - ISSN 1120-7000

Ilchmann
TABLE II - POTENTIAL ADVANTAGES (+) AND DISADVAN-
TAGES (-) OF THE DESCRIBED APPROACHES
Risk of Risk of Dislocations Implant
muscle nerval orientation
damage damage
Anterior + - + +/-
Lateral - +/- +/- +
Posterior +/- + - +/-
degeneration of the m. gluteus medius and minimus have
been shown in MRI studies but long lasting functional defi-
cits are rarely found (12). The posterior approach gives less
damage of the abductor muscles as compared to the later-
al approach however a functional difference is not proven
in clinical trials (13).
In the anterior approach the n. cutaneous femoris latera-
lis is at risk and numbness of the anterolateral tight might
occur. However, performing a more lateral and distal skin
incision of the tensor fascia might reduce this problem
(14). To access the hip joint capsule using the anterior
approach a real intermuscular and interneural plane is
passed, thus the muscular damage is reduced as shown
in MRI studies and with muscle damage markers (12, 15).
Using the anterior approach facilitates early mobilisation
and reduces hospital stay compared to the posterior ap-
proach (16), but a long-lasting functional benefit is not
proven.
As the direct anterior approach only recently has been
popularised for hip replacement there is a lack of studies
with larger patient populations and with long-term results.
Minimal invasive hip replacement
There are many studies comparing standard and MIS
procedures with posterior, lateral and anterior approach-
es. They have shown that according to MRI images
there is less muscle damage (12) and a lower increase
in markers for muscle necrosis and inflammation (15)
as compared to standard procedures. Several studies
have shown that MIS is accompanied by improved early
function and facilitated rehabilitation (17). This might af-
fect the length of hospital stay and time of recovery. In
the mid- and long-term no functional advantages have
been shown when using MIS compared to standard ap-
proaches (18, 19).
© 2014 Wichtig Publishing - ISSN 1120-7000
TABLE III - POTENTIAL ADVANTAGES (+) AND DISADVAN-
TAGES (-) OF MIS APPROACHES AS COM-
PARED TO STANDARD APPROACHES
Learning Early Special Long- Psychology
curve recovery implants term
results
Standard + - + + -
MIS - + - - +
Curved instruments and short stems have been developed
to facilitate preparation and implantation which might con-
tribute to the reduction of complications (20).
However, there is a risk that the quality of cementing and
primary fixation of uncemented implants is affected by MIS
approaches and it is not yet established that the long-term
fixation is not compromised by the use of MIS techniques
and implants.
Increasing knowledge in anatomy and blood supply of the
hip has contributed to reduce the surgical trauma in all ap-
proaches and there is a lack of definition of what is con-
sidered a MIS hip replacement. The length of skin incision
is mainly cosmetic but might lead to a psychological bias.
However, the aim of MIS should be a muscle preserving pro-
cedure although even so called standard procedures can
be done carefully without considerable traumatisation of the
soft tissue.
A multimodal and interdisciplinary pathway for joint replace-
ment including anaesthesia, pain and blood management, a
better awareness of the psychology of the patient and sub-
specialisation leading to a higher case load have contributed
to enhanced early recovery and better outcome, indepen-
dent from the used approach (21). A longer lasting effect of
MIS procedures could not be proven yet but as standard hip
replacement already shows good results there is a ceiling ef-
fect when assessing the outcome with classical instruments
(1) and more detailed analysis is necessary (Tab. III).
Using a new approach
Each approach is accompanied by a learning curve and
case-load might affect the complication rate. Sticking to
one specific approach leads to a higher experience what
means knowing the anatomical aspects in detail, intro-
ducing muscle sparing techniques, optimising surgical
instruments and avoiding specific complications.
3
Approaches for primary hip replacement
The introduction of a new approach has a learning curve
for all people involved in the process. Intraoperatively there
might be more complications like nerve damage, peripros-
thetic fractures, dislocations and infections. Problems in
implant positioning, orientation and fixation can compro-
mise long-term outcome. A change of the approach used
as standard also means a change of the postoperative
care, especially in the prevention of dislocations.
The introduction of a minimal invasive approach might be
even more complex and have a flatter learning curve since
it is technically more difficult and can lead to more com-
plications (22). Intraoperative views are more limited thus
new didactic tools like cadaver workshops, practice on
REFERENCES
1. Behrend H, Giesinger K, Giesinger JM, Kuster MS. The
“forgotten joint” as the ultimate goal in joint arthroplasty:
validation of a new patient-reported outcome measure.
J Arthroplasty. 2012;27(3):430-436, e1.
2. Gibson A. Posterior exposure of the hip joint. J Bone Joint
Surg Br. 1950;32(2):183-186.
3. Bauer R, Kerschbaumer F, Poisel S, Oberthaler W. The trans-
gluteal approach to the hip joint. Arch Orthop Trauma Surg.
1979;95(1-2):47-49.
4. Soni RK. An anterolateral approach to the hip joint. Acta Or-
thop Scand. 1997;68(5):490-494.
5. Weale AE, Newman P, Ferguson IT, Bannister GC. Nerve
injury after posterior and direct lateral approaches for hip
replacement. A clinical and electrophysiological study. J
Bone Joint Surg Br. 1996;78(6):899-902.
6. Ramesh M, O’Byrne JM, McCarthy N, Jarvis A, Mahaling-
ham K, Cashman WF. Damage to the superior gluteal nerve
after the Hardinge approach to the hip. J Bone Joint Surg Br.
1996;78(6):903-906.
7. Smith-Petersen MN. THE CLASSIC: Evolution of Mould
Arthroplasty of the Hip Joint. Clin Orthop Relat Res. 2006;
453:17-21.
8. Matta JM, Shahrdar C, Ferguson T. Single-incision anterior
approach for total hip arthroplasty on an orthopaedic table.
Clin Orthop Relat Res. 2005;441(441):115-124.
9. Hailer NP, Weiss RJ, Stark A, Kärrholm J. The risk of revi-
sion due to dislocation after total hip arthroplasty depends
on surgical approach, femoral head size, sex, and primary
diagnosis. An analysis of 78,098 operations in the Swed-
ish Hip Arthroplasty Register. Acta Orthop. 2012;83(5):
442-448.
4 © 2014 Wichtig Publishing - ISSN 1120-7000
plastic bones and visitations would be useful. But the in-
troduction of MIS techniques can facilitated to do changes
in peri- and postoperative care and help to introduce new
concepts like enhanced recovery.
Financial Support: None.
Conflict of Interest: None.
Address for correspondence:
PD Dr. med. Thomas Ilchmann, PhD
Birshofklinik Hirslanden
Reinacherstr. 28
4142 Münchenstein, Switzerland
thomas.ilchmann@hirslanden.ch
10. Jameson SS, Mason J, Baker P, et al. A Comparison of Sur-
gical Approaches for Primary Hip Arthroplasty: A Cohort
Study of Patient Reported Outcome Measures (PROMs) and
Early Revision Using Linked National Databases. J Arthro-
plasty. 2013.
11. Brooks PJ. Dislocation following total hip replacement:
causes and cures. Bone Joint J. 2013;95(11)(Suppl A):67-69.
12. Bremer AK, Kalberer F, Pfirrmann CW, Dora C. Soft-
tissue changes in hip abductor muscles and tendons after
total hip replacement: comparison between the direct an-
terior and the transgluteal approaches. J Bone Joint Surg
Br. 2011;93(7):886-889.
13. Downing ND, Clark DI, Hutchinson JW, Colclough K, Howard
PW. Hip abductor strength following total hip arthroplasty: a
prospective comparison of the posterior and lateral approach
in 100 patients. Acta Orthop Scand. 2001;72(3):215-220.
14. Ropars M, Morandi X, Huten D, Thomazeau H, Berton E,
Darnault P. Anatomical study of the lateral femoral cutane-
ous nerve with special reference to minimally invasive ante-
rior approach for total hip replacement. Surg Radiol Anat.
2009;31(3):199-204.
15. Bergin PF, Doppelt JD, Kephart CJ, et al. Comparison of
minimally invasive direct anterior versus posterior total hip
arthroplasty based on inflammation and muscle damage
markers. J Bone Joint Surg Am. 2011;93(15):1392-1398.
16. Martin CT, Pugely AJ, Gao Y, Clark CR. A comparison of
hospital length of stay and short-term morbidity between
the anterior and the posterior approaches to total hip arthro-
plasty. J Arthroplasty. 2013;28(5):849-854.
17. Nakata K, Nishikawa M, Yamamoto K, Hirota S, Yoshikawa
H. A clinical comparative study of the direct anterior with
mini-posterior approach: two consecutive series. J Arthro-
plasty. 2009;24(5):698-704.
Ilchmann
18. Dorr LD, Maheshwari AV, Long WT, Wan Z, Sirianni LE. Early
pain relief and function after posterior minimally invasive
and conventional total hip arthroplasty. A prospective, ran-
domized, blinded study. J Bone Joint Surg Am. 2007;89(6):
1153-1160.
19. Goosen JH, Kollen BJ, Castelein RM, Kuipers BM,
Verheyen CC. Minimally invasive versus classic proce-
dures in total hip arthroplasty: a double-blind random-
ized controlled trial. Clin Orthop Relat Res. 2011;469(1):
200-208.
© 2014 Wichtig Publishing - ISSN 1120-7000
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20. Molli RG, Lombardi AV Jr, Berend KR, Adams JB, Sneller
MA. A short tapered stem reduces intraoperative complica-
tions in primary total hip arthroplasty. Clin Orthop Relat Res.
2012;470(2):450-461.
21. Kehlet H, Dahl JB. Anaesthesia, surgery, and challenges in
postoperative recovery. Lancet. 2003;362(9399):1921-1928.
22. Spaans AJ, van den Hout JA, Bolder SB. High complication
rate in the early experience of minimally invasive total hip
arthroplasty by the direct anterior approach. Acta Orthop.
2012;83(4):342-346.
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