Hip Arthroplasty Via a Traditional and Minimally Invasive Direct Lateral Approach

Stephen Petis, MD, MSc, FRCSC

Edward M. Vasarhelyi, MD, MSc, FRCSC

Dr. Vasarhelyi or an immediate family member serves as a paid consultant to or is an employee of DePuy, A Johnson & Johnson Company and Hip Innovation Technology and has received research or institutional support from DePuy, A Johnson & Johnson Company, Smith & Nephew, and Stryker. Neither Dr. Petis nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter.

This chapter is adapted from Mahmoud T, Bourne RB: Hip arthroplasty via a direct lateral approach, in Flatow E, Colvin AC, eds: Atlas of Essential Orthopaedic Procedures. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2013, pp 319-323.

PATIENT SELECTION

Indications

The direct lateral approach to the hip, also called the modified Hardinge¹ or anterolateral approach, can be used for primary and revision total hip arthroplasty (THA). This approach also can be used for the treatment of femoral neck fractures requiring hip arthroplasty. The direct lateral approach preserves the posterior hip capsule and short external rotators, thereby reducing the risk of dislocation in patients who have risk factors for postoperative instability (eg, neuromuscular disorders, dementia, alcoholism).²^,³^,⁴ Another advantage of this approach is that it avoids direct exposure of the sciatic nerve.⁵

Contraindications

The direct lateral approach may not provide adequate exposure if access to the posterior wall and/or column is required for bone grafting or removal of internal fixation devices. Procedures requiring extensive exposure of the superior acetabulum, such as reconstructions involving high hip centers and degenerative dysplasia of the hip, might result in damage to the terminal branch of the superior gluteal nerve (SGN). Therefore, an alternative surgical approach might be considered.⁶^,⁷

PREOPERATIVE IMAGING

Anterior-posterior (AP) radiographs of the pelvis and AP and lateral radiographs of the affected hip are recommended. The radiographs should be templated to determine component size and position and to ensure that leg length and offset are restored. Judet views, or CT can be used in patients with abnormal anatomy (ie, dysplasia, bone loss, subchondral cysts), however advanced imaging is generally not necessary.

VIDEO 56.1 Total Hip Arthroplasty via a Direct Lateral Approach. Tahir Mahmud, BSc (Hons), MBBS, FRCS (Tr & Orth); Robert B. Bourne, MD, FRCSC (3 min)

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Video 56.1

PROCEDURE

Room Setup/Patient Positioning

The patient is placed in the lateral decubitus position and secured to the operating table using a device with padded pubic and sacral supports. It is important to firmly secure the patient to prevent shifting of position during the procedure.² The contralateral leg must be well padded to prevent damage to the common peroneal nerve. A sterile drape bag is placed on the anterior aspect of the patient to keep the ipsilateral leg sterile upon hip dislocation (Figure 1).

Special Instruments/Equipment

A blunt Hohmann retractor with a smooth tip on the end can reduce the risk of iatrogenic injury to the neurovascular bundle when placed anteriorly along the acetabulum in the sulcus between the acetabulum and capsule anteroinferiorly. A sharp curved Hohmann retractor, which has a sharp, pointed tip, can be inserted posterior to the acetabulum between the bone and capsule to help retract the femur posteriorly during acetabular exposure. A blunt Hohmann retractor is also placed inferiorly under the transverse acetabular ligament (TAL). This retracts the inferior soft tissues thereby allowing visualization of the TAL an,d secondarily, provides additional posterior retraction of the femur.

FIGURE 1 Illustration shows the use of a sterile drape bag to keep the ipsilateral leg sterile during hip arthroplasty via a direct lateral approach.

Surgical Technique: Total Hip Arthroplasty

Surgical Approach

A skin incision is centered over the tip of the greater trochanter and runs slightly oblique from anterodistal to posteroproximal (Figure 2). The length of the incision varies from 10 to 15 cm, depending on the size of the patient, but the surgeon should not hesitate to lengthen the incision if excessive skin and soft-tissue retraction is required for adequate visualization to complete the reconstruction safely. The incision is carried down through the subcutaneous tissue and onto the fascia lata using electrocautery for hemostasis. An incision is made in the fascia lata distally using electrocautery. The surgeon can then insert a finger deep to the fascia and superficial to vastus lateralis distally and gluteus medius proximally. This fascial incision is extended proximally in the interval between the gluteus maximus and the tensor fascia muscle using electrocautery. Care should be taken to not extend the fascia lata incision too far posterior, as this will complicate anterior retraction of the gluteus maximus. A Charnley retractor can be inserted under the anterior and posterior fascia lata flaps to aid access (Figure 3). The trochanteric bursa may then be incised longitudinally.

FIGURE 2 Photograph (A) and illustration (B) show the skin incision for the direct lateral approach for hip arthroplasty. The incision is centered over the tip of the greater trochanter.

Exposing the Hip Joint

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