The anterolateral approach to the hip, also known as the modified Hardinge approach, is a well-established surgical approach to the hip for performing total hip arthroplasty.

This approach provides excellent exposure of the acetabulum and proximal femur for reconstructive purposes.

Preoperative gait and abductor muscle assessment should be performed before surgery to anticipate abductor insufficiency that may require repair using this approach.

Careful takedown and repair of the abductor musculature is critical to optimize postoperative function and hip biomechanics and mitigate the risk of hip instability.

The senior author favors a course of protected weight bearing postoperatively to facilitate healing of the abductor repair.

Lateral decubitus or supine—surgeon preference

Two hip bolsters for lateral decubitus position

Operative leg draped free for ease of acetabular and femoral exposure

The patient is positioned in the lateral decubitus position with the operative hip up (Figure 3.1). A hip bolster is applied posteriorly just proximal to the gluteal cleft and anteriorly on the pubic symphysis to immobilize the pelvis during surgery. Additional bolsters can be applied to the upper back and sternum for additional immobilization.

It is critical to ensure the operative leg can be moved through a full range of motion before draping to permit optimal acetabular and femoral exposure.

A 10- to 15-cm incision is made centered over the tip of the greater trochanter. Angling the incision posterior-proximal to anterior-distal can assist in accessing the femoral canal during femoral reconstruction (Figure 3.1). Typically, extending the incision proximally assists with femoral exposure, and extending distally assists with acetabular access.

Identify the fascia latae (Figure 3.2). A small split is made distally in the fascia in-line with the femoral diaphysis. Abduct the leg and sweep deep under the fascia to break up bursa adherent to the fascia. Identify the interval between tensor fascia latae and gluteus maximus and split the remaining fascia along this interval.

A Charnley retractor is often placed under the anterior and posterior fascia latae flaps to assist with exposure.

Identify and assess the gluteus medius muscle (Figure 3.3). The muscle is split proximally along its fibers as it inserts onto the greater trochanter. There is often a raphe that will split naturally with blunt dissection, and this represents an approximately 35% anterior, 65% posterior split in the muscle (Figure 3.4). Scissors can then be placed through the raphe (Figure 3.5) and replaced with retractors (Figure 3.6) to expose the gluteus minimus and capsule overlying the femoral neck.