Surgical Approaches

Hip replacements are carried out through one of several different surgical approaches. Over the decades, surgical approaches have been developed that go in through the front of the hip (anterior), between the front and side of the hip (anterolateral), the side of the hip (lateral, or transtrochanteric), and through the buttock (posterior). There are advantages and disadvantages to each, and there is a great deal of controversy among hip surgeons as to which is the "best." All surgeons have a favored surgical approach, and while there are often spirited debates at academic conferences and meetings, it is a testament to the success of the procedure that all of them generally produce good results.

Posterior Surgical Approach

The posterior approach, or Southern approach, is the most commonly used surgical approach for hip replacements in the United States today, although as more interest has been generated in recent years in minimally invasive techniques other approaches are increasingly being used. The patient is positioned on his or her side for this surgery, in what is called the lateral decubitus position.

This approach uses a large, curved incision centered over the buttock. It is usually the largest incision of all of the surgical approaches for any given patient, and requires splitting of the gluteus maximus muscle. The short external rotator muscles are completely detached from the femur, and the hip is dislocated. The femur is twisted around to the front of the patient and rotated inward expose the socket (acetabulum) and femur.

This surgical approach has the advantage of a very large exposure and visualization, but the disadvantage of significant muscle disruption. There is also a higher risk of blood clots because of twisting the vessels.

Some surgeons have recently been utilizing smaller incisions for the posterior approach, often using instruments designed to allow less surgical dissection, but the interval and muscles involved remain the same.

It is more difficult to perform bilateral (e.g., both right and left) hip replacements at the same time with this approach, as it requires repositioning during surgery and placing the patient on the freshly operated side. (In contrast, with an anterior approach, both hips may be replaced more easily during the same surgery, if necessary.) Many patients also note that the posterior incision is on the cheek of the buttocks and may be irritated by sitting.

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Anterolateral Approach

This approach, also known as a Watson-Jones approach, typically uses a straight incision over the side of the hip, with the patient positioned on his side in a similar fashion as the posterior approach. The surgical approach goes straight down to the femur, but it does require stripping of the gluteus medius muscle from the femur to expose the hip joint. From there, it usually is not necessary to detach the short external rotator muscles, but the remainder of the procedure is similar to the other surgical approaches.

The anterolateral approach is thought by many surgeons to afford a lower dislocation rate than the posterior approach, but a frequent criticism of the approach is that many patients limp for a prolonged period of time while the muscles heal (gluteus medius and gluteus minimus).

Transtrochanteric Approach

When Sir Charnley first began doing hip replacements, he utilized this approach to enter the hip from the side, cut a portion of the femur away to expose the hip joint (trochanteric osteotomy), and then wire the bone back together with the muscles still attached at the end of the case. The approach is very similar to the anterolateral approach except that it involves cutting a portion of the bone (the osteotomy). However, it fell out of favor over the past several decades because of problems associated with reattaching the section of cut bone. It is mentioned for historical interest here, given that it is not commonly used any longer in most places.

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