total hip arthroplasty approaches a technique primer

8/4/2019 Total Hip Arthroplasty Approaches a Technique Primer

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Tot al Hip Art hropl ast yApproaches: A Tec

Pr i 111! rM chael CIII}t on, IVD

As soc i ate Pro fe s s0r~part rren t of ext hopaedics

Universit yof Colorado Heal t h Sciences Cent er

~nver, Color ado

{qba nk}11604, 11605, 11606: 1: 1: 1: 1: 1: 0: 0: 0: Pr e t es t {/ qba nk}

Copyright © Vindico Medical Education. Unauthorized reproduction of this content is prohibited.



Post er ior

The post er i or approach tot he hi p r e rra l ns t he rmst commnl y ut iii

t od a v Pos l t ioningof t he pat ient is in a side I yngposit ion wit h

exios e d , Techni que i nvol ves t he use of a si ng e i nci si on that is 6

and I ocat ed one-t hi rd proxi mil and t wo-t hi rds di st al tot he tipt rochant er. O r i e n t at ion of t he incision is frompost erior-superior

SI ide).l Upon sharp dissect ion down t hr oum the subcut aneous tissue

in which the gut eus rrax rrus is invest ed, addit ional dissect ion t

t issue is necessary. li k e t he convent ional I()cher-L.an~nbeck approac

approach is a t r a n s q ut eal (g ut eus rrax nus ) technique and invol v

gut eus rred i us and gut eus m n i rrus ant eriorl yt 0 allow ful I view

rot at or st ruct ures, incl udingt he pirifornils, superior and inferior

i n t ern usa n d qua d rat us fe rmr is. Car e s h0u I d bet a ken t 0 a v0 ida

on the sciat ic nerve, which courses t hr oum t he fiel d post eriorl y

t )pi ca I I y dis t a Ito the pi r i fo r nil s ten don and the nove r the i s ch

of the ent ire fiel d of post erior rot at ors, incl udingt he pirifornilsi n fe rio r ~ rre I I ian d the 0bt u rat 0r i n t ern us, i s fa c iii tat edt hr 0

t he quadrat us fermris and obt urat or ext ernus st ruct ures. Because

pot ent ial of the cruciat e anast ormsis I ocat ed wit hin t he quadrat

s h0u I d be t a ken i nit s ext r e rre ret r a ct ion.




Sharp dissect ion of these external rotators is pe r for rred , t ag;jngt

which allows full espos ur e oft he post erior hip capsul e fromsuperior

capsul ar recess. The adherent capsul ar g ut eus rn n i rrus rra y need t

superiorl yfor an adequat e view. The post erior capsul e is then sha

ant erior-superior corner fl ap t hat is creat ed and t a qed . The res

per n i l t s po s t e rio r dis I 0cat ion, fe rm r a I n e ck 0s teo tony and ret r acace tab u I uman t e rio r I y fo r ace tab u I a r she I I and lin e r i rl]D act ion,

canal preparat ion for ce rren t ed or ce rren t less st empl a ce rren t . ~o

acet abul umis rra i n t ained t hr cum t he pi a ce rren t of ret ract ors an

t he pubis, post erior and inferior tot he ischial t uberosit y , and

oft he ace tab u I um Sup e rio r ret r act ion, i f n e ce s s a r y , i s fa c iii tat

a sharp-point ed ret ract or int 0 t he bone superior tot he acet ab

e I e vat 0r s can ass i s twit h e I e vat i n 9 0r lift i n 9 the pro x i rra I fe nu

a I I 0wi n gsa fe e ~ 0sur e 0f the pro x i rra I fe rm r a I can a I fo r ins t r u rre n ta

st em pi a ce rren t .

Ana t 0n i l c clos ureo f the woun d fo I I 0wi n 9 i rl]D I ant a t ion i s per n i l t ted

r e -e ppr ox na t ion of t he post erior capsul ot ony, as wei as rest orat

ext ernal rot at or st ruct ures tot he int ert rochant eric crest t

qe a t er t rochant er. ~ep fascia is r ev appr o x rrat ed, as is subcut an

ski n. Clos ur e rr a y be pe r fo r rr e dove r a dee pan d / 0r s ubcuta n e0us wo

St r uet ures at Ri 5k

• Superior gut eal nerve: W t hin t he course of the gut eus rr e d i us

• Sciat ic nerve: Courses post eriorl yand over the ischiumwit h va• Cr ucia tea r t e ria I a n a s t 0rm sis: W t hi nth e subs tan ce and dee p

fe rmr i s

• I V E d i a I fe rmr a I ci r cunil e x art e r y . Con t rib uti n 9 tot he cr ucia teaencount er ed in dissect ion

• Obt urat or art erial branches: Inferior tot he acet abul um affectpi a ce rren t

• O'eat er t rochant er: At risk for fract ure at anyt i rre duringt hpart icul arl yin ost eoporot ic pat ient s

The post erior approach allows a wide and ext ensil e e spos ur e . Less

a ppr oaches, however, have been detsWti betd he except i on of t he g ut eu

rrax rrus spl it t ing no rra] or rrus cl es are cut. The pot ent ial disadvan

posterior approach rray be a hi qie r posterior dislocation rate in

con sis ten t nee d fo r po s tope rat i ve hip pr e caut ion s, whi ch has fu e le

al t ernat ive approaches.




Ant er ior -ta t er al

A variet yof ant erior-I at eral -or s i rrpl yl at eral -approaches ha

i npl e rren t ed. ll k e t he post erior approach, t he I at eral approach

pos it i on and a sin g e in ci s ion t ha tis 6 t 0 10 cm i n len g : han d I

proxi mil and t wo-t hi rds di st al tot he pal pabl e tip of t he q e a tincision is oriented l on q t ud l n a l I v ove r the ant e r i or zm d d l e third

t rochant~ride)2 The subcut aneous and deep fascia is sharpl ydivided

the incision. The rrus cul a r and internervous interval is anterior

and po s t e rio r tot he ten s0r fa sci a I a t a. Upon e ~o sur e 0f the qI e a din 9 e d ~ 0f the gut e us rrediu sis ide n t i fi e don the pro xi rra I fe

t he ant erior hip capsul e is facil it at ed t hr oum sharp dissect ion

of the gut eus rred i us fromt he q e a t er t rochant er, or al t ernat iv

w a fe r 0f bo n e fr 0m the s a rre reg 0n. \Nt had d i t ion a Ire t r a ct ion 0f t

m n i rrus fromt he deep capsul e, as well as rred i a l ret ract ion of t h

fe rmr is, a nan t e rio rca psui 0tony i s per fo r rred, w i t has ut uret a 9 p

r epa i r .




Ant erior disl ocat ion is then pe r m t ted t hr oum ext ernal rot at i

ost eot ony. The resul t ant e xio s ur e then pe r m t 5 post erior fermral

reanilngoft he acet abul um acet abul ar shell and liner l rma ct ion,

pre par a t ion fo r ce rr e nted 0 r ce rre ntie 5 sst e m p I ace rr e nt, n e ce 5 5 ita

t he leg i n t 0 a leg ba gat t he 5ide of t he be d.

Ana t 0 nil c cI 0 5 Ureo f the abo ve woun d fo I I 0wi n 9 i rl]D I ant a t ion i 5 per

r e -e ppr ox na t ion of t he ant erior capsul ot ony, as well as rest orat

gut e us r r e diu 5 e~o 5 uret hr 0 ug , t ran 5 055 eo u5 d r i I I hoi e 5 0 r r e - at

os 5e 0u5 w a fe r os teo tony fr 0m the ant e rio r q eat e r t roc han t e r. ~

re-approxi r r a t ed, as is subcut aneous tissue and ski n. Closure r r a y

a dee pan d / 0 r 5 ubcuta n eo u5 WOun d d r a in.


• Superior gut eal nerve: W t hin t he course of the gut eus rr e d i us

• Sciat ic nerve: IVbst commnl yencount ered wit h errant post erior

pi a ce rren t• Fermral nerve: Just ant erior tot he operat ive fiel d; rr a y a l so

a g :r e 5 5 i ve ret r a ct ion

• L a t era I fe rm r a I ci r cunil e x art e r y . Sup e r fi cia Ito the ant e rio rca

• Obt urat or art erial branches: Inferior tot he acet abul um affectpi a ce rren t

.O'eater trochanter: Take caution with rred i us retraction due

and capsul ere-at t a chrre n t

The ant er i or -I at er a I a ppr oach pr ovi des a g:>od vi ew of t he acet a b

pr ox rra l ferrur. Considerat ions of i rrpl ant pi a ce rren t are necessarybec

dislocation is less likely than anterior dislocation due to cont

The pr l rra r y d r a waa ck rray be i n conpl et e gut eus rred i us heal ingt 0 th

True i npl icat ions are unci ear, but t heoret ical concerns revol ve

weakness and post -operat rve Ii np,




TlIIO-lncision

A va r i e t y 0f t e chn i que s a I low tot a I hip rep I ace rren t t 0 be pe r fo r

(3- to 4-inch) incisions. This rn n i rra l l yinvasive approach invol ves

incisions, one incision near the qo i n and one incision hig, on t he

this rret hod resul t s in no disrupt ion of tendons and r e s unpt ionpost operat ive rmbil izat ion rray be accel erat ed, all owingshort er

t han 0ned a y , ass u~ s ted by s0rre s h0r t - t e r m fo~ low- up d a t a.

For t he t wo-i nci si on t echni que, t he pat i ent is pi aced ina supi ne

the advant a~ of I egl eng: h a s s e s s rren t usingfl uoroscopy. The techniq

use 0fan ant e rio r inc i s ion, the sur fa ce I and rra r k s 0f w h i ch are a

ant erior superior il iac spine and the qe a t er t rochant er. The l

cm dis t a I, rred i a I and pa r a I I e Ito t his lin e and i s d ire ct I y s upe

r e q on , as visual ized byfl uoroscopic i rraq n q This 3- to 5-cmincision,

I at eral -caudal to rredi a l -cranial direct ion, then al I ows e xio s ur

the I ate r a I ten s0r fa sci a I a t a and rred i a I5 Isia:I~ .0 rG ars emrss t e b:e tto avoid excessive t r a urra tot he I at eral fermral cut aneous nerve

this int erval, t he deeper direct head of the rect us fermris is ad

rred l a l l y , and t issue of the refl ect ed head of the rect us fermris

capsul e of t he hip joint. E x t r e rre ret ract ion of rred i a l st ruct ures

ide n t i fi cat ion can a Iso res u I tin fe rmr a I n e r ve i nj ur y ant e rio r I

caut e r i ze the pre sen ceo f bra n che s 0f the I ate r a I fe rmr a I ci r cunil

encount ered in t his pi ane. The ant erior capsul e of t he hip j oint

ant erior aspect of the fermral neck and head.




Fermral neck ost eot onyis pe r for rred t hr oum t his approach, d e cormr

j oint for access tot he acet abul um Acet abul ar I abral and ost eper fo r r re d, fa c iii tat i n 9 rea nil n 9 and pI ace r re n t 0fan ace tab u I a r 5he

A second incision is r r a d e I at erall yand superiorl yt 0 t he pal pabl

Th i 5 inc i 5ion a I so i 5 0r i en ted po5t e rio r - ca ud a Ito ant e rio r - crang ut eus mlxi m.JS rrus cl e al lows pal pat i on of t he deeper g ut eus rr e d

The int erval ant erior tot he pirifornis and post erior tot he gCare is taken to avoid pi a ce rren t of anybl unt or sharp inst r urreint erval, resul t ingin pot ent ial sciat ic nerve inj ury. Reanilngand

pe r for rred bet ween these st ruct ures, and t he broach and st emare

The procedure is then corral et ed t hr oum the init ial ant erior i n

p I ace rre n t 0f the fe rm r a 1st e m he a dan d red uct ion.

St r uetures at Ri 5k

• L a t era I fe r m r a I cut a n e 0usn e r ve : 81 co un t ere dan t e rio r I yin thereg on

• Fermral nerve: Just rred i a l tot he ant erior incision; rray a l so ba g :r e 5 5 i ve ret r a ct ion

• Sci at i c n e r ve: IVBy be a t r i 5 k d uri n 9 fe rmr a Ire a nil n 9 and ins t r ur

• L a t era I fe rmr a I ci r cunil e x art e r y. L . o cat e d 5 U per fi cia Ito the caprequires caut erizat ion on approach

• O'eat er t rochant er: Take caut ion wit h reanilng broach and st e

t hr oum t he superior incision

Init ial ent husiasmfor use oft he t wo - J n ci s i on approach has waned

rmst I ikel ydue tot he t echnicall y der rand i n q n a t ure of the techniq

con t r a i n d i cat ion 5 fo r co rl]D I e x a nat 0n y . Rece n t d a t a 5u~ 5t 5 lit tie

hi g,-vol urre t ot al j oi nt art hropl a s t y s ur je on s .




Ant erior

Thi s rn n i rra l y i nvasi ve approach i nvol ves t he use of one ant er i or

q 0in. Th e ten don s are not dis r u pt e d us i n9 t his rretho dan d res u r

postoperative rmbilization rray be accelerated, allowinga shorter

period. The ant erior technique has increased in use and appeal inthe t wo- inc i s ion a ppro a ch, the pro ce d urei s per fo r rred wi t h the pa

posi t i on a nd wi t h fl uor oscopy, a I I owi ng I eg I eng: h a s s e s s rren t . The

t he use of an ant erior approach simi ar tot hat described bySnilt

pi a ce rren t of rml dart hrop1. a~-t y . 0 IS-cm i nci si on is rrad e super i or r

i n fe rio r I ate r a lin 0rS Ie i mite)j :4 Tb B (n t ern e r v0us PI a n e i s rred i a Ito

fa sci a I a t a, I ate r a Ito the s art 0r ius nu sci e. Car e i s t a ken t 0

di ssect i on around t he course of t he I at eral fermral cut aneous n

con tin ue s down 0nth e I ate r a I a s pe ct 0f the r e ct us fe rmr i s tot

hip caps u Ie, w h ere br a n che s 0f the I ate r a I fe rmr a I ci r cunil e x art e

capsul ot ony, fermral neck ost eot onyis pe r for rred , d e cormr e ss i n q t he

a ccesst 0 the ace tab u I um Aceta bu I a r I a br a I and 0s teo ph 't ere rm

per fo r rred, fa c iii tat i n 9 rea nil n 9 and pI ace rren t 0fan ace tab u I a r she




Adequat e espos ur e tot he fe rrur can eit her be achieved byuse of a

d e s i qi e d for this purpose or by rran ua l r r a n l pul a t f on of the lower e

of special ized t abl e tract ion e qul prre n t has been rr a r k e t ed for this

5 t rat e g cpos i t ion i n 9 0 f the leg fa c iii tat e d wi tho r wi tho ut tab

5 uffi c i e n t e ~o 5 ur e fo r fe rm r a Ire a nil n 9 br 0 a chan d 5 t e m pI ace rre n t .


• L a t era I fe r m r a I cut a n e 0 usn e r ve : 81 co un t ere dan t e rio r I yin thereg on

• Fermral nerve: Just rred i a l tot he ant erior incision; rray a l so b

a g :r e 5 5 i ve ret r a ct ion

• Sci at i c n e r ve: IVBy be a t r i 5 k d uri n 9 fe rmr a Ire a nil n 9 and ins t r ur

• L a t era I fe rmr a I ci r cunil e x art e r y . 5uper fi cia Ito the cap 5 u I e ant

caut erizat ion on approach• O'eat er t rochant er: Take caut ion wit h reanilng broach and st et hr oum t he superior incision

The ant erior approach int roduces a unique advant a~ that rray d e

the nee d fo r post 0 per a t i ve hip pre caut ion s. Inc 0 n t r a 5 t , 5 0 rre I i

ant erior approach rray ex s t . as it has I it tie capacit yt 0 be ext

and st r l ppi n q nus cl e or i q n at t a chrre n t 5 or spl it t1'i6ngmJscl e tissue.


total hip arthroplasty approaches a technique primer

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