Surgical Approaches in Total Hip Arthroplasty

Total hip arthroplasty (THA) employs a range of surgical approaches tailored to optimise prosthetic placement, minimise soft-tissue trauma and enhance functional recovery. Traditional techniques include the posterolateral approach, which provides wide exposure at the expense of muscle detachment, and the lateral approach, which traverses gluteal musculature and can affect abductor strength. Muscle-sparing alternatives, notably the direct anterior approach (DAA), exploit intermuscular planes to reduce dislocation risk and facilitate early mobilisation. Minimally invasive extensions of these routes, such as supercapsular percutaneously assisted and bikini-incision modifications of the DAA, strive to limit incision length and bleeding, though they require rigorous training to avoid complications such as periprosthetic fracture or nerve irritation. Comparative analysis of component orientation, blood loss, pain scores and rehabilitation trajectories underpins the global refinement of each technique, guiding patient-centred selection based on anatomy, comorbidity and activity level.

Research from Nature Portfolio

Recent randomised data have contrasted an oblique bikini-incision variant of the DAA with the conventional posterolateral approach in simultaneous bilateral THA. Patients receiving the bikini incision exhibited significantly lower post-operative haemoglobin drop and transfusion rates, alongside shorter hospital stay and more consistent component alignment. Early pain scores were reduced and functional recovery at three months superior in the bikini-incision cohort, though a higher incidence of lateral femoral cutaneous nerve dysesthesia was reported. Overall, this investigation supports the feasibility of minimally invasive anterior techniques for bilateral procedures, emphasising meticulous soft-tissue handling and careful patient selection to balance rapid recovery against sensory complications.

Surgical Approaches in Total Hip Arthroplasty publication trend

The graph below shows the total number of articles in surgical approaches in total hip arthroplasty across all publications each year (not limited to Nature Index journals).

Technical terms

Direct anterior approach (DAA): A muscle-sparing THA technique entering through the Smith-Petersen interval to preserve abductor and extensor muscles.

Posterolateral approach (PLA): A traditional THA route involving detachment of the short external rotators and posterior capsule to access the joint.

Haemoglobin drop: The postoperative reduction in circulating haemoglobin concentration, reflecting blood loss.

Length of stay (LOS): Duration of hospitalisation from surgery to discharge.

Lateral femoral cutaneous nerve dysesthesia: Sensory disturbance of the anterolateral thigh caused by stretch or compression of the lateral femoral cutaneous nerve.

References

1. Enhancing recovery: surgical techniques and rehabilitation strategies after direct anterior hip arthroplasty. Journal of Orthopaedics and Traumatology (2024).
2. Comparison of postoperative outcomes between bikini-incision via direct anterior approach and posterolateral approach in simultaneous bilateral total hip arthroplasty: a randomized controlled trial. Scientific Reports (2023).
3. A systematic review and meta-analysis of direct anterior approach versus posterior approach in total hip arthroplasty. Journal of Orthopaedic Surgery and Research (2018).
4. High complication rate in the early experience of minimally invasive total hip arthroplasty by the direct anterior approach. Acta Orthopaedica (2012).
5. Lower Dislocation Rate Following Total Hip Arthroplasty via Direct Anterior Approach than via Posterior Approach: Five-Year-Average Follow-Up Results. The Open Orthopaedics Journal (2015).
6. Comparison of supercapsular percutaneously assisted approach total hip versus conventional posterior approach for total hip arthroplasty: a prospective, randomized controlled trial. Journal of Orthopaedic Surgery and Research (2017).