Posterior Approach
Timothy S. Brown
Robert T. Trousdale
Key Concepts
Lateral positioning with patient rigidly immobilized at the pelvis is critical to prevent the pelvis from tilting which can lead to malposition of the acetabular component.
Incision placement lateral over the trochanter, with approximately 2/3 distal and 1/3 proximal to the tip of the trochanter.
Clean dissection of piriformis, short external rotators with capsule imperative for proper closure.
Circumferential exposure of the acetabulum is obtained with several straight Hohmann retractors and the femur retracted anteriorly.
Exposure of the femur is obtained with a wide Hohmann and a Mueller neck retractor.
Good posterior capsular and muscular repair is a must to prevent problems with postoperative dislocation.
Sterile Instruments and Implants
Two self-retaining cerebellar retractors
Charnley retractor
Five straight Hohmann retractors
One wide Hohmann retractor
One Mueller femoral neck retractor
6.0 mm round burr
Preoperative Planning
Preoperative planning includes
Low anteroposterior (AP) pelvis radiograph for leg-length measurements and assessment of contralateral disease
AP hip and cross-table lateral of the hip for templating
Bone, Implant, and Soft Tissue Techniques
Introduction
The posterior approach to the hip has long been a standard surgical approach for primary and revision hip arthroplasty. With evolution of the miniposterior approach and the addition of a robust capsular repair, functional and clinical outcomes of the posterior approach for primary hip arthroplasty make it the most commonly used approach for total hip arthroplasty (THA) today.
 Figure 2.1 ▪ A, B. Patient positioning in lateral decubitus position for the posterior approach. |
Technique
Patient positioning (Figure 2.1A and B). Patient positioning in lateral decubitus position for the posterior approach.
Feel leg-lengths before incision in the lateral position lining up the knees and lower leg.
Skin incision (Figure 2.2).
Greater trochanter palpated with the hip in abduction and neutral rotation. The anterior superior iliac spine (ASIS) can be a reliable landmark in large patients. If the tip of the surgeon’s long finger is placed on the ASIS and the hand placed orthogonal to the patient, the extended thumb will land close to the tip of the greater trochanter.
Incision directly lateral, centered on the greater trochanter.
Approximately 5 cm distal, 3 cm proximal angled 15° posterior-proximal to anterior-distal. Increase as needed for exposure.
Fascial incision (Figure 2.3A and B). Incision through the fascia in line with the skin incision, curved posteriorly in line with the fibers of the gluteus maximus proximal.
Feel anterior soft spot in fascia at gluteus maximus insertion.
Start fascial incision there and follow skin incision.
Take care not to dive deep with the knife or cautery and injure the vastus lateralis or the gluteus medius.
Tag or mark fascia for accurate post-op repair.
Figure 2.2 ▪ Marking out the skin incision on the patient.
Figure 2.3 ▪ A, B. Incision through the fascia in line with the skin incision, curved posteriorly in line with the fibers of the gluteus maximus proximally.
Abduct hip and bluntly split gluteus maximus proximally.Related posts:
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