**3. Anatomy and approach**

general goal is to have an accurate and reproducible procedure and to avoid complications. Younger and more active patients have increased functional demands during early recovery. Utilizing an intramuscular approach allows for a faster return to activities of daily living,

The various available approaches are characterized by their own distinct advantages and risks. Extensions to these approaches have been described and allow for more extensive expo-

In the USA, the most frequently used approach is the posterior approach. It provides easy access to the hip joint and minimizes the trauma to the hip abductor muscles. However, detachment of external rotator muscles and a complete capsulectomy results in an increased dislocation rate [2, 3]. Therefore, the repair of the external rotators and the capsule is of great importance in posterior THA [4]. In addition, the posterior approach is associated with an increased variance of acetabular component positioning [5–7]. Poor component positioning increases the risk of dislocation, facilitates increased polyethylene wear, and impingement [5, 8, 9]. Variations in the lateral patient position and the lack of intraoperative fluoroscopy might

The lateral approach (anterolateral) with the patient lying in a supine position is a popular approach in Europe. The posterior part of the gluteus medius insertion can be preserved. However, injury or release of its anterior portion can result in limping [11]. Fractures of the greater trochanter are more likely using the lateral approach compared to the posterior approach [12, 13]. Postoperative patient-reported limping occurs twice as often using the lateral approach compared to the anterior approach [14]. Limping may be caused by trochanteric pain, leg length discrepancy, lack of offset restoration, nerve injury, or insufficiency of

The anterior THA is unique because of its intramuscular and internervous exposure of the hip joint. A release of major muscular stabilizers is not necessary for most patients. First described by Smith-Peterson in 1949, the anterior approach became more popular in the USA over the last decade [16]. Rapid recovery, decreased dislocation rate, fluoroscopy controlled restoration of leg length, and offset as well as component position are its main

In 1881, Carl Hueter was the first surgeon to describe the anterior approach for resection of the femoral head. Smith-Peterson further developed the approach and described the extended exposure of the pelvis to perform a hip replacement. In 1978, Wagner preferred the approach for hip resurfacing procedures due to its preservation of the femoral blood supply and intermuscular dissection [17]. In 1947, the Judet table was developed and predominantly used in France. Ten years later, a special table was developed to optimize and ease the positioning of

the operated leg in order to decrease injury to muscles and bone.

reduced pain, shortened recovery, and reduced costs [1].

explain the less predictable cup positioning [10].

sure and revision procedures.

102 Total Hip Replacement - An Overview

the gluteal muscles [15].

benefits.

**2. History**

The anterior approach classically described as Smith-Peterson approach uses an incision proximal and distal to the anterior superior iliac spine (ASIS) along the tensor fasciae latae [16]. While the proximal portion of the Smith-Peterson approach facilitates exposure of the pelvis, the distal portion is used during a direct anterior THA to expose the hip joint. The groin area usually has less subcutaneous fat than the lateral thigh, and therefore an anterior approach often has a more direct access to the fascial layer. The ASIS and greater trochanter are used as bony landmarks to guide placement of the incision. The incision usually starts

**Figure 1.** Patient in a supine position on a Hana® table. The skin incision, the anterior superior iliac spine (black arrow), and greater trochanter (white arrow) are marked.

two fingerbreadths lateral and distal of the ASIS and extends distally and posteriorly in line with the tensor fasciae latae muscle [20]. A slightly more lateral position can help to avoid the lateral femoral cutaneous nerve (LFCN) that enters the thigh medially to the ASIS (**Figure 1**).

The approach uses an intermuscular plane and does not require muscle releases. Medially, the interval borders to the Sartorius muscle (innervated by the femoral nerve) and laterally to the tensor fasciae latae muscle (innervated by the superior gluteal nerve) [22]. While the original Smith-Petersen approach entered between the sartorius muscle and the tensor fasciae latae, the modern anterior approach usually stays inside the fascia of the tensor fasciae latae to minimize the risk to injure the LFCN (**Figure 2**) [22]. Care should be taken not to confuse the medial located sartorius muscle and the more lateral tensor fasciae latae. Both can usually, easily be separated by the direction of the fibers. The tensor fasciae latae muscle fibers ran toward the lateral thigh in contrast to the sartorius muscle fibers, which run medially. After skin incision, the fascia of the tensor is split followed by deep finger dissection to separate the overlying fascia and the muscle belly of the tensor fasciae latae and progress toward its medial borders.

The deep intermuscular fat tissue between tensor and rectus femoris muscle contains the ascending branch of the lateral circumflex artery just proximal to the vastus lateralis muscle. At the level of the capsule, the interval is bordered by the gluteus medius (superior gluteal nerve) and medially by the rectus femoris muscle (femoral nerve). Ligations of the branches of the circumflex vessels are necessary to prevent perioperative bleeding and postoperative hematoma formation (**Figure 3**).

**4. Surgical technique**

vastus lateralis muscle.

The procedure is performed under general or regional anesthesia. It can be performed with a standard operating table with an Omni-Tract® femur elevating system (Integra, Plainsboro, NJ, USA) or a specialized orthopedic table (Hana®, Mizuho OSI, Union City, CA, USA). The latter helps to control hip rotation, abduction, flexion, and traction of the affected extremity and facilitates exposure of the proximal femur for femoral component insertion. However, the costs, fracture risk, and limited ability to intraoperatively test the range of motion (ROM) are its main disadvantages. A number of alternative tables are currently available by other manufactures.

**Figure 3.** Image of the deep interval bordered laterally by the gluteus medius (superior gluteal nerve) and medially by the rectus femoris muscle (femoral nerve). The lateral femoral circumflex vessels (arrow) are visualized proximal to the

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The authors recommend careful templating and implant selection. The primary goal of the templating is to guide acetabular reaming toward the most appropriate reamer size. On the femoral side, depending on the type of femur, shorter implants with less sizable distal dimensions might be preferred in a Dorr Type A Femur, while compression broaching for a longer implant with a collar might be preferred for a Dorr Type C femur [23]. In addition, careful planning of the femoral neck resection can help intraoperatively to restore the leg length.

The patient is lying supine on the table with a perineal post and both legs secured with the feet in boots. The pelvis and the nonsurgical hip are placed in a neutral position. After the standard anterior approach, as described above, a T-shaped capsulotomy is performed with medial and lateral extension at the level of the intertrochanteric ridge (**Figure 4**). The capsule can be tagged and preserved for later repair. Two Hohmann retractors are now placed within the capsule around the lateral and medial femoral neck. A napkin ring double osteotomy of the femoral neck is performed to ease removal of the head (**Figure 5**). The femoral head is removed with a corkscrew extractor. Additional traction and external rotation on the operated

A Hohmann retractor is used to expose the anterior hip capsule. It is placed underneath the rectus muscle. A second blunt retractor is placed around the lateral femoral neck. The reflected head of the rectus femoris muscle is elevated and released to expose the capsule entirely. The released tendon can be marked to facilitate its identification and repair at the end of the procedure.

**Figure 2.** Incision of the fascia of the tensor fasciae latae muscle.

**Figure 3.** Image of the deep interval bordered laterally by the gluteus medius (superior gluteal nerve) and medially by the rectus femoris muscle (femoral nerve). The lateral femoral circumflex vessels (arrow) are visualized proximal to the vastus lateralis muscle.
