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■ tips & techniques

Small Incision Total Hip Replacement

by the Lateral Approach Using
Standard Instruments
Victor M. Ilizaliturri, Jr, MD; Pedro A. Chaidez, MD; Fernando S. Valero, MD; Jose M. Aguilera, MD

Small incisions in total hip replacement should be

easily extensile to provide further exposure when
needed without compromising the safety of the surgical
approach or the skin.

P rimary total hip replace-

ment (THR) is performed
by different approaches. The
traditional transtrochanteric
approach described by
Charnley1 is not commonly
used today in primary surgery
and has been substituted for
less invasive approaches.2
The posterior approach is
popular in THR. Favored by
many surgeons, it provides
anatomic dissection and less
traumatic access to the hip.
Higher dislocation rates have
been reported with this
approach, mainly due to inex-
perienced surgeons or treat-
ment of the posterior capsule
and external rotators.3,4
Posterior approach tech-
niques by short skin incisions
ranging from 8-10 cm have
been described for primary
THR.5,6 Less blood loss and
reduced need for blood trans- 1
Figure 1: The greater trochanter is
outlined; the center line shows the
position for the skin incision.
Figure 2: Incision through the
subcutaneous fatty tissue.
Photograph shows dissection of the
fatty tissue from the fascia to
improve skin mobility.

From the Joint Reconstruction

Service, Orthopedics Institute,
National Rehabilitation Center,
Mexico City, Mexico.
Reprint requests: Victor M.
Ilizaliturri, Jr, MD, Amores 942-21,
Col Del Valle, Mexico City, 03100,
Mexico. 2

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■ tips & techniques

fusion have been important tion of the greater trochanter

features of the procedure7
along with reduced hospital
stay and cost.8
The direct lateral approach
is a frequently used procedure.
Low dislocation rates and the
ability to place adequately ori-
ented prosthetic components
with an acceptable level and
severity of limp and hetero-
topic bone formation have
been reported.9-11 Clinical
starting 2 cm above the tip of
the greater trochanter and
extended distally 5-8 cm
below (Figure 1). The subcuta-
neous fatty tissue is sectioned
as the skin incision. The ili-
otibial band is incised 1-2 cm
longer than the skin incision
proximally and distally.
Adequate dissection of fatty
tissue from the iliotibial band
is recommended to increase

3 The direct lateral approach results in low

dislocation rates and the ability to place
adequately oriented prosthetic components.

results are similar when the skin mobility (Figure 2). A

posterior approach and the
direct lateral approaches are
compared; this has encour-
aged the use of the latter.12
The article presents a short
skin incision technique using a
modified direct lateral
approach with standard instru-
ments for THR.
SURGICAL TECHNIQUE
4
With the patient positioned
in lateral decubitus on the
unaffected side, prepping is
done in the standard fashion.
The greater trochanter is the
main skin landmark, and a
longitudinal incision is made
parallel to the long axis of the
femur centered at the mid por-
Charnley retractor is placed on
the anterior and posterior
edges of the iliotibial band
incision and moderate tension
is applied so that longitudinal
exposure is not affected
(Figure 3).
The trochantheric bursa is
resected until the gluteus
medius and vastus lateralis
fibers are easily identifiable. A
“hockey stick” incision is
made at the union of the ante-
rior and mid fibers of the glu-
teus medius starting approxi-
mately 2 cm proximally and
anteriorly of the tip of the
greater trochanter (Figure 4).
The superior gluteal nerve lies
at least 3 cm above the tip of

Figure 3: With the iliotibial fascia incised, the Charnley retractor holds the
anterior and posterior edges of the cut in the fascia. The bursa has been
partially resected and the gluteus medius and vastus lateralis are exposed
along with their insertion on the greater trochanter. Figure 4: “Hockey-stick”
incision through the anterior third of the gluteus medius and the vastus
lateralis. Figure 5: Anterior displacement of the muscle flap (MF), the middle
and posterior thirds of the gluteus medius (GM) attached to the greater
trochanter (GT), insertion of the gluteus minimus (GMi), and the hip capsule
5 (HC) are exposed.

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the greater trochanter.13 The Charnley retractor can be

incision of the gluteus medius
is directed posteriorly and
inferiorly toward its distal
insertion in the greater
trochanter and then directed
distally over the prominence
of the greater trochanter and in
between the vastus lateralis
fibers at 3 cm.
Electrocautery is used ini-
tially, but blunt dissection is
performed through the deep
fibers of the gluteus medius to
avoid damage to the superior
gluteal nerve. The anterior
muscle flap, including the glu-
teus medius and vastus later-
alis, is displaced anteriorly
(Figure 5). Rectus femoralis
and gluteus minimus fibers are
detached and displaced off the
hip capsule and greater
trochanter. After the joint cap-
sule is exposed, a Hohmann
retractor is placed under the
posterior flap of the gluteus
medius (still attached to the
greater trochanter) and the ten-
don of gluteus minimus. Both
are elevated to expose the
superior aspect of the hip cap-
sule. The anterior hip capsule
is resected, exposing the neck,
femoral head, and acetabular
rim.
The hip can be dislocated,
or a high neck cut close to the
femoral head can be done in
situ (Figure 6). After the
femoral head is resected, the
removed if mobilization of the
leg is obstructed. A proximal
femur elevator is placed under
the greater trochanter and
directed posteriorly. External
rotation along with medial
capsular release exposes the
medial aspect of the femoral
neck (the leg is flexed and
externally rotated). The space
created by the absence of the
femoral head allows for palpa-
tion of the lesser trochanter.
This is used as a landmark for
the final neck resection 6
according to the preoperative
plan (Figure 7). Medial capsu-
lar release is important to
obtain adequate external rota-
tion, which is mandatory for
femoral preparation. The hip
is further flexed and externally
rotated so that the proximal
end of the femur is “pushed
out” of the incision by the
proximal femur elevator. Two
Hohmann retractors are used.
The first is placed above the
lesser trochanter and the ante-
rior edge of the incision is dis-
placed forward, and the sec- 7
ond is placed under the poste-
rior neck, which pushes the
superior edge of the incision
down and helps elevate the
proximal femur. Proper neck
resection can be performed.
Straight access to the femoral
canal is possible at this step,
and femoral preparation is per-

Figure 6: Anterior dislocation of the femoral head through a complete anterior

capsulectomy. Figure 7: A proximal femur elevator is placed posteriorly under
the greater trochanter, the proximal femur is “pushed out” of the joint by flexion
and external rotation, a proximal Hohmann retractor helps elevate the proximal
femur and an anterior Hohmann retractor exposes the medial aspect of the
femur. Intraoperative photograph shows a high neck osteotomy and a second
cut to adjust the osteotomy level, according to the location of the lesser
trochanter and preoperative plan. Figure 8: Flexion and external rotation of the
extremity are important to allow for straight access to the medullar canal.
8

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9 10
Figure 9: Acetabular exposure. Two Charnley pins are placed on the iliac bone 1 cm proximal to the lateral acetabular rim. An anterior Hohmann retractor provides
anterior acetabular exposure, and a large bone hook is used to pull the proximal femur posteriorly. Figure 10: Acetabular preparation and component implantation.

11 12
Figure 11: Femoral component insertion and head reduction trials are performed. Figure 12: Soft-tissue repair.

formed in the standard fashion
(Figure 8).
Acetabular exposure begins
by removing the previously
described retractors. The leg is
placed in the original position
and the anterior muscle flap is
identified and displaced anteri-
orly with a Richardson retrac-
tor. This helps locate the poste-
rior gluteus medius flap, which
is retracted posteriorly and
superiorly with another
Richardson retractor. The
remaining anterior capsular
attachments to the acetabular
rim and the acetabular labrum
are now resected; the lateral
rim is clearly identified along
with 1 cm of the adjacent iliac
bone. Two anterior and poste-
rior pin retractors are placed
on the iliac bone proximal to
the acetabular rim and perpen-
dicular to the pelvis. The pos-
terior Richardson retractor is
removed. The anterior rim of
the acetabulum is located and
a blunt Hohmann retractor is
placed over the anterior rim.
The anterior Richardson
retractor is removed. The
proximal femur is pulled back
with a bone hook (Figure 9).
Exposure of the inferior
acetabulum is performed, and
a blunt curved acetabular
retractor can be placed under
the acetabular notch. Full
acetabular exposure should be
obtained at this point, and
acetabular preparation is per-
formed. After bone prepara-
tion is complete, the compo-
nents are implanted in a stan-
dard fashion (Figures 10 and
11). Careful soft-tissue repair
is performed with reattach-
ment of the gluteus minimus
to the insertion of the gluteus
medius and full repair of the
anterior muscle flap (Figure
12). A subcutaneous skin
suture is used (Figure 13).
RESULTS
From January 2002 to
March 2003, 40 patients (31
women and 9 men) were oper-
ated on at our institution using
the small incision lateral
approach for THR. Average
age of the women was 60
years (range: 34–79 years).
Average age of the men was
58 years (range: 33-75 years).
Average body mass index was
28.19 (range: 25.39-34.15).
Patient diagnoses included:
osteoarthritis (n=29), develop-
mental dysplasia of the hip
(Crowe 1) (n=3), femoral neck
fracture (n=2), ankylosing
spondylitis (n=2), rheumatoid
arthritis (n=3), and avascular
necrosis of the hip (n=1).

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4ilizaliturri.qxd 4/6/04 4:08 PM
The skin incision measure-
ment averaged 8.2⫾1.04 cm
(range: 7-10 cm). Average
bleeding was 584⫾244.4 mL
(range: 250-1000 mL).
Sixteen (42%) patients did not
require a blood transfusion.
Transfusion criteria at our
institution includes a hemo-
globin value ⬍10. The preop-
erative hemoglobin value of
the series averaged 13.2⫾1
(range: 10.9-14.7).
Twenty-six uncemented, 9
hybrid (uncemented cup), and
5 total cemented hip implants
were used. Third generation
cementing techniques were
used for cemented stem
implantation (11 stems).
Average acetabular inclination
was 42° (range: 36°-50°).
Average length of hospital
stay was 2.31 days. Five
patients were discharged the
next day, 16 the second day,
and 17 the third day postoper-
atively. Two patients were dis-
charged ⬎10 days postopera-
tively; one due to a pulmonary
embolism (with a cemented
stem) and the other with
rheumatoid arthritis who
stayed because of a physical
therapy program. These two
patients were not considered
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Page 381
Figure 13: Postoperative photograph of the left hip after
small incision THR. Figure 14: Typical skin abrasions on
the distal incision.
13
in the average hospital stay of
the series.
One pulmonary embolism
occurred and 19 patients had
small skin abrasions that
healed with no complications
(Figure 14). No dislocations or
infections occurred. Three
cases began as small incision
procedures and were convert-
ed to a standard procedure
(⬎10-cm incision length).
They are not included in the
series.
DISCUSSION
Minimally invasive THR is
an attractive alternative for
surgeons and patients. The
technique described was used
for a small incision THR by
the lateral approach. In our
series, the procedure was
highly reproducible. Implants
were oriented correctly and
the approach proved to be eas-
ily extensile when more expo-
sure was needed.
No dislocations or infec-
tions were reported. Pulmonary
embolism occurred, but it was
not related to the surgical expo-
sure and may have been related
to the pressurized cementation
of the femoral canal. All
patients in the series followed
Section Editor: Steven F. Harwin, MD
14
the same prophylaxis protocol
for deep venous thrombosis,
which included low molecular
weight heparin, 30 mg starting
12 hours postoperatively and
taken every 12 hours for 21
days. Long compressive stock-
ings and early mobilization
were also used.
Skin abrasions were ob-
served at the distal margin of
the incision and occurred dur-
ing preparation or implantation
of the cup because of impinge-
ment of straight instruments
against the distal portion of the
incision. Modified curved
reamers and cup impactors
may be necessary to avoid
these skin lesions.
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■ tips & techniques
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