THA Approaches - Recon - Orthobullets

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 may 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