**4. Surgical approach**

Hemiarthroplasty requires different considerations than complete hip arthroplasty. In the latter, clear exposure of both the femur and the acetabulum is essential,

### *Hemiarthroplasty DOI: http://dx.doi.org/10.5772/intechopen.106400*

necessitating a very lengthy exposure. Because patients are often older and more sensitive to anesthetics and surgical procedures, hemiarthroplasty requires a quick yet successful surgery with the least amount of stress and physiological disruption. There have been several surgical methods to the hip documented [3].

Surgical approaches to the hip for hip hemiarthroplasty can be divided into three main categories: lateral approaches (LA), posterior approaches (PA), and anterior approaches (AA) [18].

According to the few national registers that collect data on surgical approaches for hemiarthroplasty, the direct lateral approach(DLA) and posterior approach(PA) are commonly used internationally. Anterior and anterolateral approaches are also used, but less often. Internationally, it appears that the choice of approach is frequently based on surgeon preference, as a result of training and experience, rather than rigid adherence to guidelines or evidence guide [32].

Posterior approaches commonly include the Moore, the Southern, the true posterior and the posterolateral approaches [18]. The division of the piriformis, and the short external rotators while preserving the hip abductor muscles are the major characteristics of this method. The approach permits the acetabulum and femur to be clearly visualized and exposed for as long as needed. There are advantages such as a lower risk of femoral shaft fracture, a shorter recovery period, a functional abductor, and reduced blood loss. The posterior technique can be used with or without the posterior joint capsule being repaired, along with additional muscle- and tendon-sparing adjustments [32].

There are two types of anterior approaches used to access the anterior part of the hip joint: direct anterior and Smith Peterson approach l. Both of them used the internervous plane in superficial dissection b/n sartorious muscle inervated by the femoral nerve and tensor facsia lata inervated by the superior gluteal nerve and in deep dissection bln gluteas medius muscle inervated by the superior gluteal nerve and rectus femoris muscle which is inerveted by the femoral nerve [18].

The major advantage of the anterior approach is that it has a lower risk of dislocation than other approaches; this advantage makes the rehabilitation program easier for the patient. There is also a minimal chance of sciatic nerve damage. The most common obstacle most surgeons face during an anterior approach is a restricted surgical field, which can result in extensive dissection of soft tissue, particularly the gluteas medius, as well as trouble reaming the femoral medulary cavity, which can result in femur fracture [32].

Lateral approaches commonly involve (partial or complete) division or retraction of the hip abductor muscles (gluteus medius and minimus) to enable access to the hip capsule. These include the Hardinge (direct lateral), the trans gluteal, and the Watson-Jones (anterolateral) approach [18].

There is solid evidence that the method affects the frequency and character of the complications. In individuals with FNF, the most commonly employed techniques are posterolateral and lateral or anterolateral. Data show that, as compared to the lateral or trans-gluteal approaches, the posterior route is linked with a significantly greater incidence of dislocation following both HA and conventional THA. When it comes to bipolar HA, the posterior approach is associated with an 8-fold increase in the risk of dislocation when compared to the lateral approach [12].

The risk of dislocation following traditional THA is also influenced by the surgical approach: documented dislocation rates are 2% for the anterolateral approach, 12% for the posterior approach, and 14% for the posterior technique without re-attachment of the posterior capsule (p 0.001) [12].

The combination of a dual-mobility cup with the posterior approach remains a reliable option, with a dislocation rate similar to that seen when conventional THA is performed via the antero lateral approach [12].
