1. Modified lateral approach in total hip arthroplasty
Dr (Prof) Raju Vaishya
MS, MCh Orth (L’pool), FRCS (Eng)
Senior Consultant Joint Replacement Surgery
Indraprastha Apollo Hospitals, New Delhi

2. Approaches for THR Different approaches (with lots of variations)
Choice is based on clinical experience & training
Most popular approaches are:
-Hardinge’s antero lateral
-Moore’s posterolateral

4. Approaches for THR A) Primary: B) Revision: Transtrochanteric
I. Anterior: Smith Petersen, Somerville
II. Antero lateral: Watson Jones
III. Lateral: Hardinge, Harris, Mc Farland
IV. Postero lateral: Gibson
V. Posterior: Osborne, Moore
VI. Medial: Ludloff
B) Revision: Transtrochanteric
C) MIS: One/Two incision

5. Surgical Approaches Differ chiefly as to whether:
I) Pt is operated on in lateral or supine position
II) Trochanter is routinely osteotomised
III) Hip is dislocated anteriorly or posteriorly

6. Ideal approach Easy and comfortable to the surgeon
Provides adequate and good exposure
Not associated with any major complications
Reproducible

7. Surgical approaches
Anatomic dissections of tissue planes that use anatomic knowledge to limit the amount of dissection required to perform the procedure while avoiding nerve and vessel damage.

8. History of lateral approach
Direct lateral approach first described by McFarland and Osborne (1954)
On the basic anatomical principle that the gluteus medius & vastus lateralis muscles act in functional continuity via their fascial connection over the greater trochanter
Both were detached from the posterior border of the greater trochanter
McFarland B, Osborne G.Approach to the hip: a suggested improvement on Kocher’s method. J Bone Joint Surg 1954; 36(B): 364–7.

9. Modifications of lateral approach

10. Reflects the anterior 1/3rd of Gluteus medius
Advantages :
Better orientation of the implant
Easier insertion of cement
Easier assessment of correction of the discrepancy in leg length

11. Principles of lateral approach
Insertion of gluteus medius to GT is by a strong tendon which is wide anteriorly and follows a crescent shaped insertion
At apex of the GT the fibres of g.medius lie horizontally
Axis of shaft of femur is continuous with the anterior half of the GT which is revealed when the tendon of the anterior half of the gluteus medius is divided

12. Direct Lateral Approach(Hardinge) Incision
Greater trochanter as its
midpoint longitudinally
Extends eight cms
parallel to the
shaft of the femur along its
anterior border.

13. Direct Lateral Approach – Hardinge Cutting fascia lata
Gluteal fascia and iliotibial band are
divided along midlateral in the same
direction as the skin incision.
Tensor fascia latae is
retracted anteriorly and the gluteus
maximus posteriorly.
Any fibres of
the gluteus medius which arise from
the deep surface of the gluteal
fascia are pushed off by blunt
dissection.

14. Direct Lateral Approach – Hardinge Cutting of Vastus Lat. and Ant
Direct Lateral Approach – Hardinge Cutting of Vastus Lat.and Ant.Slip of Abductors
Tendon of g.medius is incised using a
diathermy needle curving around GT
till the apex where it is extended
proximally along and between fibres of
g.medius, not cutting across them.
Distally the incision extends to the
bone through the vastus lateralis near
the anterior surface of the
femur.
Bleeding in the vastus lateralis from
the transverse branch of
the lateral circumflex artery is
controlled by diathermy

15. Direct Lateral Approach – Hardinge After Reflecting Vastus Lat. & Ant
Direct Lateral Approach – Hardinge After Reflecting Vastus Lat.& Ant.Slip of Abductors
Small portion of the vastus
lateralis arising from the
intertrochanteric line is
separated.
Tendinous insertion of the
anterior portion of the gluteus
minimus and the ligament of
Bigelow separated from their
ridge on the anterior aspect
of the neck of the femur.

16. Direct Lateral Approach – Hardinge After Cutting Gl
Direct Lateral Approach – Hardinge After Cutting Gl. Minimus and incising the Capsule
Adduction of
thigh, the capsule of the hip
comes into view
Capsule is divided
along the circumference with a
further radial cut into the
limbus of the capsule at
the posterolateral aspect of the
head of the femur.

17. Direct Lateral Approach – Hardinge Dislocation of the Head
Dislocation of head is achieved by full adduction and external rotation of thigh.
A good view of the acetabulum and shaft of the femur is obtained with routine retraction; capsular excision is not required.

18. Modifications from Hardinge approach
The patient is placed in the lateral decubitus position (cf. supine in Hardinge approach) which would allow direct visualization of the relevant anatomy.
Pai VS. A Modified direct Lateral approach in Total Hip Arthroplasty J. Orthop Surg
2002 Jun;10(1):35-9.

19. Modifications from Hardinge approach
The superior extension of the abductor split is only 3 cm, maintaining a safe distance from the inferior branch of superior gluteal nerve.

20. Modifications from Hardinge approach
With the posterior capsule intact and the anterior capsule repaired, this modification gives soft tissue protection against dislocation.
The gluteus-vastus flap was repaired to the bone with No. 5 ethibond to prevent avulsuion of the flap from the bone.

21. Decreased dislocation
Posterior Vs Lateral approach
Analyzed 14 studies involving 13,203 primary THR
The combined dislocation rate was 3.23% for the posterior approach (3.95% without posterior repair & 2.03% with posterior repair
0.55% for the direct lateral approach.
Masonis JL, Bourne RB. Surgical approach, abductor function, and total hip
arthroplasty dislocation Clin. Orthop. Relat Res Dec;(405):46-53.

22. Decreased risk of dislocation
Risk of dislocation directly proportional to adequate capsular repair in posterior approach
Lateral approach inherently has decreased dislocation rates.

23. Excellent exposure of acetabulum
360 degrees exposure of acetabulum
Better orientation of the acetabulum

24. Advantages of lateral approach
Decreased pain post operatively
Patients who received the antero lateral approach reported less pain
Muscle-sparing nature of the antero lateral approach is the most notable factor contributing to their more rapid discharge

25. Disadvantages of posterior approach
Increased dislocation rates
Inadequate exposure
Difficult orientation of the acetabulum
Increased chances of infection due to proximity to anus

26. More advantages of lateral approach
Approach is away from anus
Decreased chances of soiling of post operative dressing
??Potentially decreased risk of infection

27. Concern regarding abductor weakness
The strength of the hip abductors, adductors, extensors, and flexors were measured at least 2 years following surgery
The strength of these muscle groups recovered to the same level as those on the non operated side
Horwitz BR, Rockowitz NL, Goll SR, Booth RE Jr, Balderston RA, Rothman RH,
Cohn JC A prospective randomized comparison of two surgical approaches to total hip arthroplasty. Clin. Orthop. Relat Res Jun;(291):

28. Concern regarding abductor weakness
The Direct lateral Vs Posterior approach compared prospectively
Isometric abductor strength was measured with the kinetic communicator device
Trendelenburg test was recorded preoperatively and at 3 and 12 months postoperatively.
No difference in hip abductor strength recovery at 3 and 12 months between the lateral approach and the posterior approach.
No difference in the Trendelenburg test between the two groups 3 and 12 months.
Downing ND, Clark DI, Hutchinson JW, Colclough K, Howard PW. Hip abductor
strength following total hip arthroplasty: a prospective comparison of the posterior and
lateral approach in 100 patients. Acta. Orthop. Scand.2001; 72(3):

29. Potential disadvantages
Inferior gluteal n. palsy– low incidence and no effect of functional outcome
Possibilty of fracture during femoral preparation – can be decreased by
- by placing hand on knee during external rotation to
dislocate head, to avoid undue torque is not being
applied to femur.
- no attempt should be made to start broaching the femur
until it is adequately mobilized
Learning curve

30. Choice of approach Lateral Posterior Abductor weakness Common Rare
Dislocation
Less
More
Cup Orientation
Better
May be difficult
Nerve Injury
Sup Gluteal
Sciatic

31. Conclusion Easier exposure Better orientation
Decreased dislocation rates
Final choice of approach depends on the surgeon’s experience & preference
(But lateral approach has some distinct advantages over the posterior approach)

32. Thank you

33. The most important quality of successful people is their willingness to change

35. Avoid disasters
Dislocation
Foot drop