Approach

 

Options

 

Direct Lateral - transgluteal

Postero-lateral (AKA posterior) - release short external rotators

Direct Anterior

 

Results

 

Gait / outcomes

 

Meermans et al Bone Joint J 2017

- systematic review of 42 studies comparing Direct Anterior / Posterior / Lateral

- better outcomes in Direct Anterior in first 6 weeks

- no difference in outcome scores after 6 weeks

- no difference in three approaches on gait analysis or length of stay

 

Peng et al BMC Musculoskeletal Disorders 2020

- meta-analysis of 7 RCTS and 600 patients

- Direct Anterior versus Posterior

- reduced pain and improved function with Direct Anterior at 6 weeks

- no difference at 3,6 or 12 months

 

Dislocation

 

Koster et al J Orthop Trauma Rehab 2023

- meta-analysis of 11 studies and 2,000 patients

- dislocation rates

- posterolateral 1.4% / anterior 0.4% / lateral 0%

 

Steenbergen et al Hip Int 2023

- Dutch registry of 270,000 THA

- posterior 1.4% / anterior 0.4% / lateral 0.6%

 

Revision

 

Australian Joint Registry 2023 7 years % revision

  Anterior Posterior Lateral
Revision overall 3.1 3.3 3.5
Revision for loosening 1.0 0.4 0.6
Revision for fracture 0.8 0.7 0.6
Revision for infection 0.6 1.0 1.0
Revision for dislocation 0.3 0.9 0.8

 

Direct Anterior

 

Advantages

- muscle sparing - early mobilization in first 6 - 12 weeks

- ease of intra-operative image for component position

 

Disadvantage

- learning curve

- LFCN injury

- femoral nerve injury with anterior retractor

- femoral exposure more difficult / risk of intra-operative fracture

 

Complications

 

Huang et al Orthop Surg 2021

- meta-analysis of Anterior versus Lateral approach

- 13 studies and 25,000 THA

- reduced prosthesis malposition / LLD / Trendelenberg gait with anterior approach

- increased dislocation / periprosthetic fracture / loosening with anterior approach

 

Technique

 

AO Surgery Reference Direct Anterior

 

Vumedi Direct Anterior video

 

Smith-Petersen Approach

- supine +/- traction table

- vertical incision from ASIS over TFL

- identify and protect LFCN

- develop plane between TFL and sartorius

- identify and coagulate lateral femoral circumflex vessels

- plane between rectus femoris and gluteus medius

- femoral osteotomy and remove head

 

Acetabulum

- externally rotate leg

- check position with intra-operative images

 

Femur

- extension / adduction / external rotation

- use bone hook to elevate femur

- check offset with intra-operative images

 

Direct Lateral / Hardinge

 

Advantage

- reduced dislocation rate

 

Disadvantage

- divide abductors - abductor weakness / Trendelenberg gait

 

Complications

 

Mjaaland et al CORR 2019

- RCT of direct lateral versus anterior THA in 160 patients

- incidence trendelenberg gait at 2 years

- 16% with direct lateral

- 1% with direct anterior

 

Technique

 

AO Surgery Reference Direct Lateral

 

Vumedi Direct Lateral video

 

Hardinge approach

- patient in lateral decubitus

- incision centered on greater trochanter

- split fascia and gluteus maximus

- release anterior 1/3 of gluteus medius and gluteus minimus

- limit superior muscle split to protect superior gluteal nerve

- release anterior vastus lateralis and cauterize ascending medial circumflex

- T capsulotomy

- dislocate femoral head by external rotation

- place foot in foot bag

 

Postero-lateral

 

Hip posterior approachPosterior approach

 

Disadvantage

- ? increased dislocation rate

 

Complications

 

Dimentberg et al Arch Orthop Trauma Surg 2023

- 2,200 THA with posterior approach

- 1% dislocation rate with tendon to bone short external rotator repair

 

Anderson et al J Arthroplasty 2023

- 2,900 THA with posterior approach and guidance

- 0.4% dislocation rate

 

Technique

 

AO Surgery Reference Posterior Approach

 

Vumedi Posterior Approach video

 

- lateral decubitus

- incision centered on greater trochanter

- split fascia

- identify short external rotators

- open interval between G medius and piriformis

- place stay sutures in short external rotators and release insertion

- open capsule

- dislocate hip via internal rotation