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General Orthopaedics


Current Concepts in Joint Replacement (CCJR) – Spring 2015


Revision hip approaches can be divided into posterior, anterior, transgluteal, and transtrochanteric. The approach chosen is dictated by what needs to be exposed and the approaches with which the surgeon is comfortable.

The posterior approach remains posterior to the gluteus medius and protects the hip abductors. The disadvantage of a posterior approach is post-operative dislocation.

The direct anterior approach is currently enjoying popularity as a primary technique. Surgeons experienced in the primary technique are applying it to revision surgery. The anterior approaches also protect the hip abductors. The disadvantage is poor access to the posterior acetabular column and mobilization of the femur to gain access to the femoral diaphysis.

Transgluteal approaches split the gluteus medius typically keeping the anterior portion of the medius intact with the vastus lateralis. Proximal exposure is limited by the superior gluteal nerve, which is 4 cm above the tip of the trochanter. The disadvantage of the transgluteal approach is difficult access to the posterior acetabular column and occasional abductor weakness.

The advantage of both the anterior and transgluteal approaches is a lower dislocation rate.

All three approaches are acceptable for revisions that only require acetabular rim and proximal femoral exposure. More extensive exposure requires modifications to these approaches or the use of a transtrochanteric approach.

Transtrochanteric approaches are defined by the length of the osteotomy (conventional or extended) and if the vastus lateralis remains attached to the trochanteric fragment (slide).

Distally extended osteotomies improve access to the femur.

Osteotomies without a distal attachment to the lateralis can be retracted proximally thus improving exposure of the ilium.