12 Anterolateral Approach to Total Hip Arthroplasty

10.1055/b-0040-174135

12 Anterolateral Approach to Total Hip Arthroplasty

Stephen Maraccio

Summary

The antero-lateral approach to the hip is one of several approaches used in total hip arthroplasty, including the direct anterior, posterior, and direct lateral. This approach is common, as it emphasizes exposure of the acetabulum with adequate clearance of the femoral shaft for reaming purposes. Popularized by Watson–Jones in the early 1980s, this approach utilizes an intermuscular plane between the tensor fascia lata and gluteus medius. The greatest benefit is a wide exposure of the acetabulum, which is accomplished by detaching the abductor mechanism, allowing for the proper adduction of the hip for greatest acetabular visualization. This chapter will explore the antero-lateral approach to the hip in the setting of total hip arthroplasty.

12.1 Preop

Surgical table. Surgeon-specific flat table or the Jackson trauma table.
Patient position. Place the position supine on the table with the body shifted toward the operative side of the bed, with the buttock of the affected side almost hanging over the edge of the table.
Hip positioners. Adequate gel or towel bump can be placed under the affected side.
Patient exam. A detailed motor exam is critical prior to operating to serve as a “baseline” for postop examination. Perform a detailed motorsensory exam of the bilateral lower extremities prior to beginning.

12.2 Approach

In the supine position with the affected hip bumped, palpate the anterior superior iliac spine (ASIS, may be difficult to palpate in obese patients). Mark the outline of the ASIS.
Palpate and mark the greater trochanter, femoral shaft, and the vastus lateralis ridge, a rough line that marks the fusion site of the greater trochanter to the lateral femoral shaft (difficult to palpate in obese patients).
With the leg flexed to approximately 30 degrees and adducted, make an approximately 10–15 cm incision that begins at the tip of the greater trochanter, extending down the center of the femoral shaft. Dissect to fascia lata with adequate bleeding control using electrocautery.

12.3 Superficial Dissection

Incise the fascia lata to enter the deeper bursa. Develop a plane within the fascia lata both proximally and distally in line with the fibers.

Be aware of the superior gluteal nerve, which enters the tensor fascia lata proximally, near its origin at the iliac crest. It is vital to be aware that carrying your dissection too proximally puts the superior gluteal nerve at risk of damage.
Extend your incision through the tensor fascia distally until the vastus lateralis is exposed. Elevate the flap anteriorly to locate interval between tensor fascia lata and the gluteus medius. This can be performed by blunt dissection.

There will be a collection of blood vessels located within the interval between the gluteus medius and the tensor fascia—these can be ligated.
Once this interval is developed, place a retractor (right-angle or cobra) deep to the abductors to retract them laterally and proximally, thus exposing the hip capsule.
Externally rotate the hip to stretch the joint capsule and expose the origin of the vastus lateralis. This should be incised at its origin, which can then be reflected inferiorly. This should expose the anterior joint capsule.
Bluntly dissect proximally along the joint capsule along the acetabulum to separate the anterior fat pad from the capsule itself (fat pad facilitates the postoperative healing of capsule—work to preserve it).