Great disparity appears in the literature regarding the occurrence of minor and major complications after two-incision total hip arthroplasty (THA). Advocates of twoincision THA contend that this minimally invasive surgical (MIS) technique provides faster rehabilitation with fewer restrictions and financial advantages stemming from shorter hospital stays and quicker returns to work. These advantages, however, cannot be fully realized unless the procedure can be performed within acceptable risk levels.

The operative, perioperative, and postoperative complications of a consecutive series of 200 two-incision THAs from a single surgeon were analyzed. Of the 8 femur fractures which occurred in this series, four occurred intraoperatively. All four were nondisplaced and treated with a cerclage cable through the anterior incision. The prosthesis was retained in each case. Of the four postoperative fractures, two were nondisplaced, permitting retention of the prosthesis. These were treated with a trochanteric plate with wiring above and below the lesser trochanter. The other two postoperative fractures were displaced, necessitating revision to a longer, uncemented stem and cerclage wiring.

Other complications in this series included two nondisplaced greater trochanter fractures > 2cm, 14 asymptomatic greater trochanter fractures ≤2 cm, one malpositioned cup requiring revision, one loose stem, seven cases of heterotopic ossification ≥Grade 2, four dislocations, one superficial infection, 80 lateral femoral cutaneous nerve neuropraxias (78 of which resolved within six weeks), and four femoral nerve neuropraxias (three of which resolved in 6 to 12 weeks).

In this series, two-incision THA was performed with a low incidence of major complications but a high incidence of minor complications. Despite the minor complications, most patients experienced an accelerated recovery and rehabilitation owing to reduced tissue trauma.

To help surgeons avoid complications, we recommend periodic retraining sessions where concerns and pitfalls can be addressed and recent enhancements, taught.

Superficial nerve complications, such as those encountered in high numbers in this series, can be avoided by moving the anterior incision slightly lateral and splitting the fibers of the tensor fascia lata. The risk of minor trochanteric fractures can be reduced by first lateralizing broach-only stems with a long straight 9mm reamer and/ or by using direct visualization.