Classically, total hip arthroplasty (THA) was performed through 20- to 30-cm incisions through various approaches. In 1970, Charnley advocated the transtrochanteric approach “the lateral exposure with elevation of the greater trochanter” (1). However, surgeons such as Muller and Harris argued that there were many advantages to performing primary THAs without a trochanteric osteotomy, including a shortened operative time, less blood loss, elimination of the need to perform a trochanteric repair, avoidance of its complications (e.g., nonunion and bursitis), and early unsupported weight bearing (2,3). The more modern alternatives to the transtrochanteric approach include anterior (Smith-Peterson), anterolateral (Watson-Jones), direct lateral (Hardinge), posterior (Moore), and the two-incision approach. There are pros and cons of each approach but with an overall similar long-term success rate.

Recently, pressures from patients, hospitals, and surgeons have driven a push for shorter hospital stays and more rapid recoveries. These factors have forged the movement toward minimally invasive surgery (MIS) and mini-incision total hip replacement. Mini-incision surgery is considered a 10-cm incision or smaller and can be performed via any approach. Minimally invasive surgery refers to less soft tissue trauma. A muscle-sparing approach can only be done with a direct anterior or anterolateral approach; however the principles of MIS (less soft tissue trauma) can be performed through any approach.

Successful MIS surgery includes a more comprehensive surgical philosophy that not only includes decreased soft tissue trauma, but also multimodal pain management, and early therapy. With comprehensive MIS we believe that patients have greater early function, shorter hospital stays, and greater satisfaction. Short-term results have been promising but long-term results have yet to be proven (4,5,6,7,8,9,10,11).

Mini-incision/MIS THA entails creating a mobile window that allows complete visualization of both the acetabulum and femur individually. Studies have reported improved cosmesis and patient satisfaction with smaller incisions (12,13).

The direct anterior approach has gotten the most publicity lately but in fact was described by Smith-Peterson in 1949 for mold arthroplasty (14). The patient is placed supine and the incision is typically 5 to 10 cm and is approximately 2 cm posterior to a line connecting the ASIS to the fibular head. The surgical dissection is in an internervous plane and is muscle sparing, proceeding between the TFL and the sartorius. The proposed benefits include less postoperative pain and a quicker return to function. The disadvantages are that it is not expansile, often requires the use of a specialized operative table, and potentially has a high complication rate especially during the learning curve. A review by Woolson et al. (15) on 247 consecutive hips by community surgeons with limited experience in the direct anterior found a major complication rate of 9% and a more than twice as long surgical time and blood loss. In 2005, Matta et al. (16) reviewed 494 consecutive direct anterior THA performed on a fracture table and had an operative complication rate of 3.4% including three ankle fractures, three greater trochanter fractures, two femoral shaft fractures, and four calcar fractures. In a randomized prospective trial Restrepo et al. (17) found that experienced surgeons had no differences in complications rates between the direct anterior and anterolateral THA. Siguier et al. (18) retrospectively reviewed 1,037 direct anterior THA and found a revision rate of 0.77% to 0.96% dislocation rate. Likewise Matta reported on 506 consecutive direct anterior THA and concluded that this approach was both safe and efficacious (19).

The posterior approach is the most commonly used approach in the United States. This approach requires the take down of the external rotators and the posterior capsule as was initially described by Moore (20). The mini-incision posterior approach is less than 10 cm with one-third of the incision proximal to the tip of the greater trochanter and two-third distal. The biggest disadvantage is the higher rate of dislocation, however, with posterior capsule repair; the rate of dislocation is less than 1% (21,22,23,24,25).

The two-incision approach combines a mini posterior for placement of the femoral component and a mini direct anterior for acetabular component placement. Although this approach is successful and safe, it is technically demanding, and is not extensile (26).

The classic anterolateral approach was described by Watson-Jones in 1936 (27). It uses a muscle-sparing intermuscular plane between the gluteus medius and the tensor fascia lata. The patient is placed in a lateral decubitus position and with the incision based on the greater trochanter. The mini-incision anterolateral starts with an incision 6 to 8 cm from the anterior tubercle of the greater trochanter toward the ASIS.
The advantages of this approach are decreased abductor weakness (compared to the direct lateral) and lower risk of dislocation (compared to the posterior approach). Bertin and Rottinger popularized this approach and they have reported excellent short-term results on the first 300 patients (28).

The difference between an anterolateral approach and a direct lateral approach is often blurred both in conversation and the literature. The direct lateral approach was initially described by Kocher and modified by Hardinge (29). The dissection involves splitting the gluteus medius and vastus lateralis. Sometimes the direct lateral approach is called anterolateral. However, the classic anterolateral is an intermuscular dissection between the tensor fascia lata and the gluteus medius. Although most anterolateral approaches dissect through the abductors, these approaches are generally more anterior to the direct lateral approach of Hardinge. The abductor splitting lateral approach has a low published dislocation rate, the surgery can be performed with one or no assistants and the sciatic nerve is avoided (30,31). The literature has been mixed, with some studies showing an increased limp and others showing no significant limp (32,33,34

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