Lateral approach to hip (Hardinge, transgluteal)

total hip arthroplasty

has lower rate of total hip prosthetic dislocations

(The direct lateral (Hardinge) approach has been cited to have the lowest associated dislocation rate of the options provided. The metanalysis by Masonis and Bourne found a dislocation rate for 14 studies involving 13000 total hips was 1.27% for the transtrochanteric approach, 3.23% for the posterior approach (3.95% without posterior repair and 2.03% with posterior repair), 2.18% for the anterolateral approach, and 0.55% for the direct lateral approach. Eight studies involving 2455 primary total hip arthroplasties evaluated postoperative limp. However, the article also found that the incidence of postoperative limp was 4% to 20% for patients who had the lateral approach and 0% to 16% for patients who had the posterior approach. The article by Kwon et al found the lowest dislocation rate with direct lateral (0.43%) followed by anteroalateral (0.7%) and posterior with soft tissue repair (1.01%). )

longitudinal incision centered over tip of greater trochanter

split fascia lata to expose tendon of gluteus medius

longitudinal incision in fibers of gluteus medius

do not extend more than 5 cm above greater trochanter to prevent injury to superior gluteal nerve

extend incison inferior through the fibers of vastus lateralis

detach origin of gluteus minimus from anterior greater trochanter

expose anterior joint capsule and perform capsulotomy

Superior gluteal nerve

runs between gluteus medius and minimus 5 cm above greater trochanter

protect by limiting proximal incision of gluteus medius

Femoral nerve

Superior gluteal nerve

The superior gluteal nerve enters the deep surface of the gluteus medius approximately 5 cm proximal to the tip of the greater trochanter. Splitting the muscle, as in the Hardinge approach, has been reported to cause injury to this nerve if the split is carried above 5 cm. A simple tag suture can be placed at this level to prevent propogation of the split inadvertently during surgery.

No true internervous plane as the dissection splits a muscle innervated by the superior gluteal nerve

The direct lateral approach (Hardinge) splits the fibers of the gluteus medius which is innervated by the superior gluteal nerve. The anterior approach employs the interval between the sartorius/rectus femoris (femoral nerve) and TFL/gluteus medius (superior gluteal nerve). The posterior approach utilizes the interval between the gluteus maximus (inferior gluteal nerve) and the gluteus medius (superior gluteal nerve).