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Anterior Approach for Total

Hip Arthroplasty: Beyond
the Minimally Invasive Technique
BY ROBERT KENNON, MD, JOHN KEGGI, MD, LAURINE E. ZATORSKI, RN, AND KRISTAPS J. KEGGI, MD

Introduction Surgical Technique

A
revision total hip arthroplasty presents a greater The surgical technique for primary total hip arthroplasty has
challenge than a primary procedure regardless of the been described in detail previously1-5, and this article deals with
approach used. The same direct anterior approach its adaptation to revision surgery. As with the technique for pri-
developed by the senior author for primary total hip ar-
throplasty through mini-incisions can be readily extended
proximally and distally for use in complex revision surgeries,
including reconstruction with an acetabular cage, stem revi-
sions, and even total femoral replacements. We routinely use
it for all of our revision surgeries.
The single-incision technique previously described is
usually all that is required for revision of the acetabular compo-
nent or for a liner exchange (Fig. 1)1-5. However, for more com-
plex acetabular work, such as grafting or use of acetabular cages,
the approach can be extended proximally in a fashion similar to
a Smith-Peterson approach (Fig. 2). The incision curves proxi-
mally along the anterior superior iliac spine and posterolaterally
back along the ilium (Fig. 3). If necessary, the origins of the sar-
torius and tensor fascia lata muscles can be elevated and de-
tached from the anterior superior iliac spine, but this is very
rarely necessary. Further exposure can be obtained by partially
detaching the origins of the gluteus medius and minimus mus-
cles from the outer wing of the ilium by blunt dissection.
Occasionally, it is necessary to expose the femoral shaft
distally for procedures such as insertion of a long-stemmed re-
vision implant, windowing of the shaft for cement removal,
fracture fixation, or even total femoral replacement. The skin
incision is extended distally along the lateral aspect of the
thigh, and the fascia lata split is extended. The vastus lateralis
is split longitudinally with subperiosteal dissection used to ac-
cess the femoral shaft. With these extensions proximally and
distally, full access to the acetabulum and the entire femur can
be readily obtained (Fig. 4).
It is useful to review the technique of the anterior ap-
proach and its use in primary total hip arthroplasty since the
revision technique builds upon the same surgical approach.
For some revision surgeries, such as acetabular cup exchange
or partial exchange of modular parts, the one, two, or three Fig. 1

mini-incision technique is directly applicable without need for
further modification. In both primary and revision total hip
arthroplasty, the goals are to minimize soft-tissue dissection,
decrease perioperative complications, and accelerate soft-tissue
rehabilitation.
Since the late 1970s, Yale orthopaedic residents have been taught
this minimally invasive anterior approach using one, two, or three mini-
incisions without fluoroscopy, special operating tables, or special
retractors. The small single anterior incision is usually sufficient for
revision of the acetabulum only.
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Fig. 2
The same direct anterior approach developed by the senior author for primary total hip arthroplasty through mini-incisions can be readily extended
proximally and distally for use in complex revision surgeries, including acetabular cages, stem revisions, and even total femoral replacements.

Fig. 3
The approach can be extended proximally in a fashion similar to a Smith-Peterson approach. Distally, the fascia lata split is extended, and the vas-
tus lateralis is split longitudinally with subperiosteal dissection used to access the femoral shaft.

Fig. 4
With these extensions proximally and distally, full access to the acetabulum and the entire femur can be readily obtained.
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mary total hip arthroplasty, the patient is placed in the supine
position with a small sandbag or intravenous fluid bag under
the ipsilateral buttock to facilitate femoral access. Although not
used in our series, fluoroscopy can be easily employed in this
position with a radiolucent table if necessary or desired.
The incision is made from a point just distal to the ante-
rior superior iliac spine to the anterior border of the greater
trochanter. The incision is curved with its convexity in a lat-
eral direction. The average incision in a thin patient is approx-
imately 5 to 8 cm if only the acetabular component is to be
revised. Otherwise, it may be extended proximally or distally
as necessary.
The tensor fascia lata muscle is split along its anterior
margin. A strip of muscle is left medially to protect the lateral
femoral cutaneous nerve and to facilitate closure.
The anterior capsule of the hip is identified by blunt dis-
section. Cobra retractors are placed on the superior and infe-
rior aspects of the capsule. They retract the tensor fascia lata
with the abductor muscles laterally and the rectus femoris
with the sartorius medially. The anterior capsule and/or scar
tissue is excised, and the prosthesis is visualized. The cobra re-
tractors are then placed within the hip capsule on the superior
and inferior borders of the neck of the femoral component.
Insufficient removal of the femoral neck makes it difficult
to rasp the femoral shaft and can lead to varus placement of the
component within the proximal aspect of the femur. This does
not mean that the femoral neck should be removed down to the
level of the lesser trochanter. The femoral cuts can be at differ-
ent levels on the basis of the femoral neck anatomy. The base of
the calcar should be preserved if possible, since this is a solid os-
Fig. 5
We have begun to use a table-mounted self-retractor system (Arthro-Tract; Omni-Tract Surgical, St. Paul, Minnesota) in place of the Homan and co-
bra retractors, with excellent results.
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seous structure and contributes to the stability of the compo-
nents regardless of whether they are cemented or uncemented.
For hips with well-fixed femoral components, in which
only the acetabular component (or liner) is being revised, the
femoral head is carefully removed (if modular), and then the
stem can usually be retracted laterally out of the way, provid-
ing sufficient space for the acetabular revision.
The acetabular exposure is best achieved by the inser-
tion of a sharp-tipped cobra retractor under the osseous rim
of the inferomedial aspect of the acetabulum. This allows re-
traction of the anteromedial tissues (rectus femoris, sartorius,
fat, and skin). A second cobra retractor placed on the lateral
aspect of the ilium just proximal to the acetabulum retracts
the tensor fascia lata. If necessary, a third retractor can be in-
serted carefully over the rim of the pelvis anteriorly for further
soft-tissue retraction and exposure of the anterior acetabular
rim and any anterior or medial osteophytes. Recently, we have
regularly begun to use a table-mounted self-retractor system
(Arthro-Tract; Omni-Tract Surgical, St. Paul, Minnesota) in
place of the Homan and cobra retractors, with excellent results
(Fig. 5). Besides decreasing the need for surgical assistants, it
has been our impression that blood loss and soft-tissue injury
has been decreased with this system.
If necessary, a mini-incision or stab wound is made just
distal to the main anterior incision in the same fashion as with
a primary total hip arthroplasty in large muscular or obese pa-
tients. Through this stab wound, acetabular reamers and ace-
tabular inserters can be inserted in a retrograde manner to
allow reaming and prosthetic placement through the short an-
terior incision with the acetabulum exposed by the standard
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TABLE I Demographic Data on Patients Managed with Revision Total Hip Arthroplasty

Cemented Femoral Noncemented Femoral Acetabular

Component* Component* Cup Only
No. of procedures
Total 97 252 119
In patients with bilateral arthroplasty 0 8 2
Age (yr)
Average 75.8 64.3 67.6
Range 53-92 25-85 23-89
Standard deviation 8 13.7 11.5
Male 36 143 77
Female 61 109 42
Avg. height (in [cm]) 65 (165) 66.6 (169) 67 (170)
Weight (lb [kg])
Average 158 (72) 172.6 (78) 165 (75)
Range 105-245 (48-111) 85-300 (39-136) 122-245 (55-111)
Standard deviation 31.7 (14.4) 40.5 (18.4) 46.3 (21.0)

*Principal procedure with or without acetabular replacement.

cobra retractors. We have used this additional incision in
obese patients and patients with large muscles. At the end of
the procedure, it is used for suction drains.
By using multiple short incisions, we have been able to
do total hip arthroplasties with or without cement and hybrid
procedures in obese and/or very muscular patients without
making long skin incisions, undermining thick layers of fat, or
cutting muscles unnecessarily. Our outcomes in this subset of
large patients have also been excellent, and we do not hesitate
to perform total hip arthroplasties or revisions in these
weight-challenged patients6.
If the femoral component is being revised, it can usually
be removed with a tamp or punch. Distal extension of the an-
terior incision allows a femoral osteotomy (typically an oval
window just below the stem) to be made in order to facilitate
cement removal. We frequently have found that a proximal
stab wound (just posterior to the tensor fascia lata and identi-
cal to the second mini-incision utilized for femoral prepara-
tion in a primary total hip arthroplasty) is helpful for the
passage of straight reamers in preparing the femoral canal.
After the proper neck length, head size, and stem size
have been determined by means of trial prostheses, a perma-

TABLE II Intraoperative Parameters for Revision Total Hip Arthroplasty

Cemented Femoral Noncemented Acetabular

Component* Femoral Component* Cup Only
Total no. of procedures 97 252 119
Operating time (min)
Average 113.6 131.9 52.4
Range 26-280 54-288 31-129
Standard deviation 50.9 48.5 35
Intraop. est. blood loss (U)
Average 1.23 1.4 0.79
Range 0-6 0-8 0-6
Standard Deviation 1.24 1.18 2.1
Postop. est. blood loss (U)
Average 1.78 1.51 1.7
Range 0-12 0-20 0-8
Standard deviation 2.3 2.07 1.9

*Principal procedure with or without acetabular replacement.


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nent prosthesis of the selected size is inserted into the femur.
Either a cemented or a cementless device is chosen depending
on the patient’s age, bone quality, and activity level.
The wound is irrigated and débrided. All sites of bleed-
ing are once more inspected and cauterized if necessary. A
suction drain is placed in the posterior aspect of the hip. If a
distal stab wound was utilized for the passage of acetabular
reamers, it may be used to pass a suction drain with use of a
tonsil forceps. A single continuous absorbable suture is used
to approximate the tensor fascia lata. The subdermal layers
and skin are closed in standard fashion. This simple closure
technique greatly reduces the operating time.
We use aspirin for routine thromboembolic prophylaxis.
Low-molecular-weight heparin, adjusted-dose warfarin, and
adjusted-dose unfractionated heparin have been used in high-
risk patients.
Results
computerized database was instituted in 1983 to follow
A the senior surgeon’s arthroplasty patients, and to date it
includes data on approximately 3500 total hip replacements. A
previous retrospective review of the cases of these patients
over a recent ten-year period was performed to identify the
operative times, blood loss, and complication rates encoun-
tered with primary total hip arthroplasty. A retrospective re-
view of all consecutive revision arthroplasties by the senior
author during the same ten-year period yielded 468 revisions.
This included only cases in which the acetabular and/or femo-
ral components were revised, and did not include liner ex-
changes, explorations, or open reduction and internal fixation
without component exchange. These procedures were catego-
rized as follows: ninety-seven were cemented femoral revi-
sions, 252 were noncemented femoral revisions, and 119 were
acetabular cup revisions only. Table I presents the demo-
graphic data on the patients, Table II provides a summary of
important intraoperative parameters measured during these
procedures, and Table III lists the principal diagnoses accord-
ing to the category of arthroplasty.
Within the first six months after surgery, complications
TABLE III Principal Diagnoses for Revision Total Hip Arthroplasty
Cemented Femoral
Component*
No. of procedures
Total
In patients with bilateral arthroplasty
Failed acetabular cup or liner
Failed cemented stem
Failed uncemented stem
Failed endoprosthesis
Other
*Principal procedure with or without acetabular replacement.
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included dislocations, fractures, lateral femoral cutaneous
nerve damage (there were no lasting femoral or sciatic nerve
injuries in this series), clinically important hematomas, infec-
tion, thromboembolic events, cerebrovascular injuries, myo-
cardial infarctions, and a single death. Table IV summarizes
these complications.
Discussion
number of surgical approaches for total hip arthroplasty
A have been advocated over the past forty years7-14. Charnley
originally advocated the transtrochanteric approach, which is
only rarely used today15, and the most frequently used tech-
niques at present for both primary and revision surgery are
the posterolateral and anterolateral approaches.
The modified anterior approach described by the senior
author (K.J.K.) has been utilized in more than 7000 hip re-
placements at our institution over the past thirty years. The
technique was first presented in a scientific exhibit at the an-
nual meeting of the American Academy of Orthopaedic Sur-
geons in 1979 in Las Vegas, Nevada16. This approach utilizes
the interval between the tensor fascia lata and the sartorius,
and it is more medial than the anterolateral approach used by
a number of authors. It has a number of advantages in both
primary and revision settings: it does not release or distort the
abductor mechanism, it easily allows bilateral arthroplasty
(28% of 2132 primary total hip replacements in our previous
series were in patients who had a bilateral procedure17,18) with-
out changing the position of the patient or redraping, it allows
excellent anatomical visualization of the femur and acetabu-
lum, and, finally, it requires a relatively small anterior inci-
sion—with or without accessory stab wound incisions—that
reduces soft-tissue dissection, operative time, and blood loss.
This leads to a low prevalence of complications. An additional
advantage of the supine position, although very rarely needed,
is the rapid access that it provides to the previously prepared
and draped abdomen in the event of a surgical emergency.
In our series of 468 consecutive revision total hip ar-
throplasties performed over a decade, there were no known
lasting injuries of the sciatic or femoral nerve. The anterior
Noncemented Acetabular
Femoral Component* Cup Only
97 252 119
0 8 2
– – 119
34 130 –
26 99 –
30 6 –
7 17 0
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TABLE IV Complications After 468 Revision Total Hip Arthroplasties

Cemented Femoral Noncemented Acetabular

Component* Femoral Component* Cup Only†
Total no. of procedures 97 252 119
Dislocations 3 8 3
Closed reduction required 2 5 2
Open reduction required 1 3 1
Infections (perioperative) 2 8 2
Hematoma 2 4 1
Shaft fracture requiring cerclage 3 11 NA
Greater trochanter fracture or fissure requiring additional fixation 3 10 NA
Lesser trochanter fracture or fissure 4 5 NA
Calcar fracture or fissure 3 18 NA
Acetabular fracture 1 1 3
Femoral cutaneous nerve injuries (residual after 6 mo) 0 0 0
Sciatic nerve injuries (residual after 6 mo) 0 0 0
Pulmonary embolism 1 0 0
Deep venous thrombosis 1 1 0
Nonfatal {myocardial infarction or cerebrovascular accident 2 3 0
Death (myocardial infarction) 0 1 0
Lost to follow-up before 6 mo 1 0 3

*Principal procedure with or without acetabular replacement. †NA = not applicable.

approach largely avoids these structures, which can often
cause problems and increase the duration of the operation
when a posterior approach is used. There is also substantially
less scar tissue to contend with when approaching anteriorly.
An additional feature in this large series is that clinically
important thromboembolic disease was noted in only three
(0.6%) of 468 revision arthroplasties. Patients in this series
routinely received low-dose aspirin (650 mg/day) for prophy-
laxis unless they were at high risk. Although patients were not
routinely screened for pulmonary emboli or deep venous
thrombosis, two were found to have deep venous thromboses
and one had a single (non-fatal) pulmonary embolus after the
patients were noted to be symptomatic. The prevalence of
deep venous thrombosis has been documented to be between
5% and 60% in several large series of total hip arthroplasty pa-
tients managed with a variety of prophylactic regimens19-22. A
major contributory factor in the pathogenesis of thromboem-
bolic disease is intraoperative distortion of the femoral vein
due to retraction and leg positioning, which has been shown
to be particularly pronounced with positioning in the poste-
rior approach23. Numerous studies have compared different
prophylactic regimens with very little differences; we believe
that the low prevalence of thromboembolic disease in our se-
ries was due primarily to the short operative times and the in-
traoperative positioning afforded by the anterior approach.
In conclusion, the modified anterior approach to the hip
described by the senior author has been used by us in both pri-
mary and revision total hip arthroplasties with excellent results.
Since a large database to track these patients was created over
twenty years ago, many operations have been performed with
low recorded rates of complications, short operative times, and
low blood loss. A well-placed total hip replacement is the goal.
While a smaller skin incision is desirable for cosmetic reasons
and decreased healing time, what goes on beneath the skin is far
more important. We believe that the benefits of the low blood
loss and low complication rate are, at least in part, due to the
muscle-sparing nature of this approach, which keeps soft-tissue
trauma to a minimum and leads to faster postoperative mobili-
zation and rehabilitation. We continue to use this adaptable an-
terior approach for all of our primary and revision total hip
replacements and have found it to be advantageous during a
long experience with arthroplasties.

NOTE: The illustrations in Figures 1 through 4 were drawn by Victoria Skomal Wilchinsky.
Corresponding author:
Robert Kennon, MD
Keggi Orthopaedic Foundation, 1201 West Main Street, Waterbury, CT
06708. E-mail address: keggi@snet.net
The authors did not receive grants or outside funding in support of their
research or preparation of this manuscript. One or more of the authors
received payments or other benefits or a commitment or agreement to
provide such benefits from a commercial entity (Apex Surgical Inc. and
OTI Inc.). In addition, a commercial entity (Apex Surgical Inc., OTI Inc.,
Wright Medical Inc., and Smith-Nephew-Richards Inc.) paid or directed,
or agreed to pay or direct, benefits to a research fund, foundation, educa-
tional institution, or other charitable or nonprofit organization with
which the authors are affiliated or associated.
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