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Updated: Jul 19 2023

THA Approaches

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https://upload.orthobullets.com/topic/12116/images/approaches_to_hip_1500.jpg
  • Introduction
    • Surgical approach may be dictated by
      • surgeon preference
      • prior incisions
      • obesity
      • risk for dislocation
      • implant selection
      • degree of deformity
    • Standard approaches
      • direct anterior
      • anterolateral
      • direct lateral
      • posterolateral
    • Extensile approaches
      • trochanteric osteotomy
    • "Minimally invasive" approaches
  • Direct Anterior Approach
    • Overview
      • increasingly popular approach with good long-term results
      • uses interval between tensor fascia lata and sartorious
    • Advantages
      • decreased dislocation rate when compared to posterior approach in numerous studies
      • abductor mechanism not violated (compared to anterolateral exposure)
        • No difference in gait biomechanics at 3 months compared to other approaches
      • unsupported advantages include
        • decreased muscle damage
        • decreased pain
        • quicker recovery
    • Disadvantages
      • steep learning curve
        • complication rates decrease after 100+ procedures
      • surgical site infection rates increased in obese patients with large abdominal panni
      • femoral exposure can be challenging
        • may require a special operating room table for increased exposure
      • lateral femoral cutaneous nerve paresthesias
      • intraoperative fracture rate thought to be higher
  • Anterolateral Approach
    • Overview
      • less commonly used approach for arthroplasty secondary to violation of abductor mechanism and post-operative limp
      • uses interval between tensor fascia lata and gluteus medius
    • Advantages
      • lower dislocation rate than posterior approach
    • Disadvantages
      • violates abductor mechanism
        • may lead to postoperative limp
  • Direct Lateral Approach
    • Overview
      • less commonly used approach for arthroplasty secondary to violation of abductor mechanism and postsa-operative limp
      • no true interval
        • splits gluteus medius and vastus lateralis
    • Advantages
      • lower dislocation rate than posterior approach
      • allows access to both anterior and posterior hip joint without osteotomy
    • Disadvantages
      • violates abductor mechanism
        • may lead to postoperative limp
      • heterotopic ossification is common
  • Posterolateral Approach
    • Overview
      • most common approach for primary and revision arthroplasty
      • no true interval
    • Advantages
      • abductor mechanism not violated
      • excellent exposure of both femur and acetabulum
      • easily converted to more extensile exposures both proximally and distally
    • Disadvantages
      • dislocation rates may be higher than anterior exposures
      • risk reduced with repair of capsule and short external rotators
  • Extensile Approaches
    • Trochanteric osteotomy
      • overview
        • 3 types
          • standard trochanteric osteotomy
          • trochanteric slide
          • extended trochanteric osteotomy
        • useful for difficult primary and revision hip arthroplasty
      • advantages
        • excellent acetabular exposure
        • useful for component removal
      • disadvantages
        • complications include
          • non-union
          • heterotopic ossification
          • trochanteric bursitis
          • abductor weakness
        • extended trochanteric osteotomy requires diaphyseal engaging stem
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