Abstract
“Like other craftsmen, we have often two ways at least of doing the same job, the success of which is dependent upon the character and the integrity of the man. “Approaches” are for us both physical and psychological: in the case of the hip joint it seems clear that there is more than one good method and that, for the sake of those we train, we should keep an open mind.”
Norman A. Capener, 1950
Orientation relative to the abductor musculature and ease of access to the pathology in question should provide the compelling basis for selection of operative approaches to the hip, rather than being based solely on surgeon habit.
Approaches to primary total hip arthroplasty remain the surgeon's choice; posterior approaches provide challenges to cup orientation and anterior approaches offer more difficult access to the proximal femur. Imperatives for a decubitus position posterior approach include pelvic dissociation with need for posterior column plating, removal of retained posterior hardware, and sciatic neurolysis after prior injury. Conversely, indications for a supine anterolateral approach include an isolated acetabular revision with a well-fixed femoral stem and the need for retroperitoneal removal of an intrapelvic acetabular component. Transgluteal approaches inflict potentially the greatest damage to the abductor musculature and are best reserved for primary operative settings; stability of a femoral endoprosthesis is optimised through this approach by preserving the posterior capsular structures. The transtrochanteric approach provides unrivaled exposure to both pelvis and acetabulum from either a supine or decubitus position, and is most helpful for removal of long well-fixed femoral stems whether cemented or cementless.
