Understand the pertinent surgical anatomy about the hip encountered during the direct anterior approach (DAA).
Learn to expose the hip via a DAA with safe and effective retractor placement.
Avoid complications when performing hip replacement via the DAA.
![]() FIGURE 4.1 Superficial landmarks for DAA surgery. (Copyright 2016 by The Curators of the University of Missouri, a public corporation. Reprinted with permission.) |
TABLE 4.1 Deep Surgical Anatomy Musculature | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Anterior superior iliac spine (ASIS): The ASIS is a bony prominence at the anteriormost aspect of the iliac crest, which is palpable in most patients regardless of habitus; it serves as the origin for the sartorius and the medial aspect of the tensor fasciae latae.
Iliac crest: The iliac crest is a bony expansion at the superior aspect of the iliac wing extending from the ASIS anteriorly to the posterior superior iliac spine posteriorly and serving as the origin for the internal/external oblique and transversus abdominis muscle groups.
Inguinal crease: Overlying the inguinal ligament, a visible crease is present in most patients. The position can be altered by the presence of a large overhanging pannus, which can also cause skin irritation and maceration of the surgical wound. Care should be taken when placing an incision to avoid crossing this area if possible.
Pubic symphysis: The pubic tubercle and symphysis pubis can be palpated at the midline medial to the inguinal crease. The symphysis with the bilateral ASIS forms the anterior pelvic plane, which is referenced in some navigated technologies.
Greater trochanter: The greater trochanter can be palpated laterally in most patients regardless of habitus and is a common reference for incision placement.
Tensor fascia lata: Originating from the ASIS and anterior aspect of the iliac crest, the muscle belly of the tensor fascia lata is typically palpable. Longitudinal incisions should be placed overlying this muscle.
Patella: The proximal pole of the patella can be used to estimate leg length, and the lateral border of the patella can also be referenced for incision placement.
Longitudinal incision: The ASIS, greater trochanter, and inguinal crease are identified. The incision begins 1 to 3 cm distal and posterolateral to the ASIS and extends distally, centered over the palpable bulk of the tensor fascia lata and terminating after 7 to 10 cm. Care should be taken to limit proximal extension into the inguinal crease to minimize the risk of wound complications. The incision should be directed toward or lateral to the lateral pole of the patella and remain 2 to 3 cm anterior to the greater trochanter. Superficial dissection is carried through the subcutaneous tissue to the level of the tensor fascia lata.7
Bikini incision: The ASIS, greater trochanter, and inguinal crease are again identified. The incision should be made parallel to the inguinal crease for 5 to 7 cm such that one-third of the incision is medial to the ASIS and two-thirds is lateral. Although the incision was originally made in the inguinal crease, many authors advocate for an incision 2 to 3 cm distal and parallel to the crease to limit wound complications in patients with an overlying pannus. Once through the dermis, deep dissection is performed longitudinally to the tensor fascia in the lateral aspect of the incision.5,8Stay updated, free articles. Join our Telegram channel
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