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 Anterior retractor can result in femoral nerve injury 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 fracture of the osteotomy fragment is the most common complication extended trochanteric osteotomy requires diaphyseal engaging stem