Different approaches have been used to perform hip joint arthroplasty. To date there is no compelling evidence in literature for any particular approach, but consensus of professional opinion favours either the posterior approach or the modified anterio-lateral approach.
Over the last few years there has been a significant amount of debate over the minimal invasive surgery (MIS). The results of surgeries using this technique has not proven to be better than the standard approaches, in fact some studies show an inferior outcome of MIS compared to standard approach. The use of computer navigation in hip arthroplasty is another controversial subject since it hasn’t shown any significant evidence of a better outcome than using standard approaches.
The common approaches to the hip joint are:
- The posterior approach accesses the joint through the back, taking the short external rotators off the femur. This approach gives excellent access to the acetabulum and preserves the hip abductors so the patient has less chance of a limp after surgery. Critics cite a higher dislocation rate, although repair of the capsule and the short external rotators negates this risk.
- The lateral approach is also commonly used for hip replacement. This approach requires elevation of the hip abductors (gluteus medius and minimus muscles) in order to access the joint. The abductors may be lifted up by osteotomy of the greater trochanter and reapplying it afterwards using wires. This approach has lesser chance of dislocation; but the patients are more likely to develop a limp after surgery, which might be permanent.
- The anterolateral approach develops the interval between the tensor fasciae latae and the gluteus medius. Recently the anterior approach utilises an interval between the Sartorius muscle and tensor fascia latae has become more popular especially with the use of a special table that allows hip extension. The advantage of this approach is a small incision and no cutting to any muscle; but it is more technically demanding and requires proper patient selection since it is very difficult to use this approach on obese or muscular patients.
I believe that the best approach is the one that the surgeon is more comfortable with as long as optimal visualisation of the joint anatomy is obtained using as minimal soft tissue dissection as possible with efficient time utilisation.