The posterior approach is the most commonly used approach to the hip, and is widely used in total hip arthroplasty (THA) (1). In 1874, Bernhard von Langenbeck first described the posterolateral approach in his treatment of war wounds and infections of the hip (2). Kocher (3), in 1907, modified Langenbeck’s approach by extending the incision in a caudal direction. Since then, 13 other variations of this approach have been described (4,5,6,7). Another famous variation to the posterior approach was also described by Alexander Gibson in 1950 (5). Gibson improved exposure of the hip by adding the release of two main abductors of the hip, the gluteus medius and minimus muscles.

The most famous modified version, and most commonly used today, is the approach described by Austin Talley Moore during his work with femoral prosthesis (6). The incision in this classic, utilitarian, extensile, posterior approach extends from the posterior-superior iliac spine (PSIS) to the posterior border of the greater trochanter, and then extends 10 to 13 cm distally along the axis of the femur (8). This approach offers very wide exposure to the posterior capsule, posterior acetabular wall, ischium, and greater trochanter, and can be extended to include the entire femur.

Iyer’s modification of the Moore’s approach preserves the soft tissue attachments to the posterior hip. With this technique, a portion of the greater trochanter is osteotomized and a part of the gluteus medius is split. The Iyer’s (9) modified approach to the femur may provide better exposure to the acetabulum than the classic posterior approach; however, it is associated with significant complications such as nonunion of the osteotomy site or profound abductor lurch. In this chapter, we aim to describe our technique for posterior approach to THA and the technical details of this method.

The posterior approach offers extensive and reproducible exposure of the acetabulum, femur, and posterior soft tissue stabilizer of the hip. It is utilized in vast majority of hip procedures such as primary and revision THA, hemiarthroplasty, or any other nonarthroplasty procedures (incision and drainage of hip for sepsis, removal of loose bodies, or open reduction for posterior hip dislocation) (1,8,10). There are no contraindications to this approach.

Dislocation has been, historically, the main concern with the posterior approach—up to 4% without posterior capsular repair and 1% to 2% with posterior repair (11). Cadaveric and computer models have proved that the rate of dislocation is decreased when the posterior approach is augmented with adequate soft tissue repair (12,13,14,15). Several studies have shown that with appropriate repair of the posterior capsule of short external rotators (SERs), the rate of dislocation can be reduced to as low as 1% (12,16,17,18). Early dislocation rate for the posterior approach is highest during the first 6 weeks postoperatively while the repair is in the process of healing (19). Magnetic resonance imaging (MRI) has been used to demonstrate this healing with scar formation of the SER tendons (20,21). Using this technique in 945 primary THAs, Weeden et al. (22) demonstrated a 0.85% dislocation rate at a mean of 6.4 years follow-up.

Another potential complication of the posterior approach is sciatic nerve palsy, with a range between 0.09% and 3.7% (23,24,25). In an MRI study, we were able to show that sciatic nerve palsy is actually a compressive nerve injury between the ischial tuberosity and femoral insertion of the gluteus maximus tendon during femoral preparation. Therefore, we partially release the gluteus maximus tendon during the procedure (26).

The patient is positioned in the lateral decubitus (Fig. 3.1). The pelvis is secured on the operative table in a neutral position using two padded posts over the pubic ramus and sacrum. The greater trochanter should be in line with the shoulder. We use spinal and/or epidural regional hypotensive anesthesia to reduce intraoperative bleeding. Anatomic bony landmarks are outlined over the skin. First, the PSIS

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