Abstract
Total hip replacement can be performed through multiple surgical approaches including anterior, anterolateral, lateral, transtrochanteric, posterolateral, posterior and the two incision technique. The overwhelming majority of hip replacement surgery today is performed through a posterolateral approach and this approach certainly has many advantages. The posterolateral approach can be extended without difficulty, it is expeditious, has reduced blood loss, there is little muscle damage and recovery is rapid. The major disadvantage of the approach that has been cited is its increased dislocation rate which has become less of a problem with the advent of larger femoral heads and dual mobility acetabular components.
The less invasive posterolateral approach is performed through an incision of 8–10 centimeters and is suitable for patients with BMI index of less than 35. Deep dissection is less radical and the gluteus maximus tendon is not released and only the upper 1/4 of the quadratus femoris insertion is released. Full visualisation of the acetabulum must be accomplished with this approach and soft tissue releases of the labrum and anterior capsule must be performed to accomplish this. Similarly exposure of the entire proximal osteotomised femoral neck must be effected so that reaming and broaching can be performed safely. Special retractors have been developed to facilitate these techniques. Ongoing review of this procedure in almost 1500 patients operated on by me has yielded excellent radiographic and functional results. Complications have included a dislocation rate of 1.2%, femoral fracture 0.3% and sciatic neuropraxia of 0.3% all but one which resolved.
Rapid recovery from total hip replacement is multifactorial with current accelerated rehabilitation programs and improved pain management playing a role as well as surgical approach. The need for external support during ambulation with the mini-posterior approach rarely is greater than 3–4 weeks in the vast majority of patients. Hip precautions are used for a 4 week period. Hospital stay is 2–3 days and could be accelerated further in young, active patients.
There are many excellent approaches to the hip each of which has its advantages and disadvantages. The anterior approach is an excellent approach but requires advanced training, experience, a specialised table, longer surgical time, more difficultly with exposure with no evidence of advantage in outcome.
