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Anterolateral Approach for Primary Total Hip Replacement
Key Points
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The anterolateral approach to the hip retains the posterior capsule and external rotators, which may enhance hip stability.
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The anterolateral approach reduces hip dislocation compared with the posterior approach.
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Patients at higher risk for postoperative dislocation—such as those with spasticity, high range of motion, small socket sizes, abductor deficiencies, and compliance issues such as alcohol abuse—may benefit from an anterolateral approach.
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Repair of the anterior portion of the abductors is critical to gait recovery after an anterolateral approach to total hip arthroplasty.
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The anterolateral approach facilitates repair of partial gluteus medius/minimus tendinous avulsions in patients with hip arthritis.
The anterolateral approach to the hip for total hip replacement (THR) was described and popularized by Hardinge in 1970. It offers an extensile approach for both primary and revision THR. Traditionally, it involved a split in the anterior portion of the abductor musculature and hip capsule. Modifications have been made in the trajectory and extent of the abductor split over the past 3 decades. Exposure of the acetabulum involves retractor insertion to achieve posterior displacement of the femur. In general, advantages have traditionally been ascribed to extensibility and reduction of postoperative dislocation in primary and revision THR. Proposed disadvantages have included the potential for postoperative limp and abductor weakness.
Patient Selection
Most patients who are indicated for a total hip arthroplasty (THA) are amenable to an anterolateral surgical approach. Patients who are at higher risk for postoperative dislocation—such as femoral neck fracture, neuromuscular disorders, high range of motion (ROM), abductor tendon tears, and rotational deformities—may benefit from an anterolateral surgical approach.
Positioning
The patient is placed in the lateral decubitus position with the use of a padded pegboard. Making sure that the pelvis is perpendicular to the table is important before skin preparation and draping. Special attention should be focused on posterior stability of the pelvis because femoral retraction to achieve acetabular exposure tends to retrovert the pelvis.
An axillary roll is inserted to help protect the brachial plexus. The leg is positioned anterior to the table during femoral preparation, and leg sterility must be ensured. This may be accomplished with multiple stockinettes or a leg bag in which the distal extent of the leg may be placed during femoral preparation.
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