Review Article
Volume 4 Issue 2 - 2021
Surgical Approaches to the Hip Joint for Total Hip Arthroplasty - An Updated Review
RB Kalia1 and A Kundu2*
1Additional Professor, Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
2Senior Resident, Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
*Corresponding Author: A Kundu, Senior Resident, Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India.
Received: December 24, 2020; Published: January 27, 2021


Primary Total hip arthroplasty (THA) remains a common and successful orthopaedic surgical procedure in today’s time. There has been a constant evolution of surgical techniques and implant designing, for patients of end-stage hip arthritis undergoing THAs. The various approaches like the posterior approach (PA), direct lateral approach (DLA) or the direct anterior approach (DAA) for the hip are mostly used during THA. PA remains the most common approach for THA. PA THA to some extent being extensively used among arthroplasty surgeon has showed lesser evidences of intra-operative blood loss and lesser operative time. DLA remains the second most common approach to the hip during THA. Despite enough literature on the varied surgical approaches to hip joint during THA, the debate still continues, and there is no successful conclusion favouring one approach over the other. DAA-THA shows better shortterm functional outcomes, early post-operative recovery, better pain relief, and lesser hospitalization duration when compared to the conventional PA for THA. Increased evidences of LCNT neuropraxia remains a significant disadvantage with DAA although it does not cause any functional derangement amongst these patients. DLA and PA, both are considered not to utilise an inter-muscular interval. While short external rotators and gluteus maximus are released or splitted in PA, Gluteus maximus and medius are released during DLA. Incidence of abductor muscle weakness has been noted to be as high as 4% to 20% with DLA THA. DAA is on the other hand utilises a true inter-muscular plane. Patient selection for this approach remains an important aspect to avoid post-operative wound complications. The use of intra-operative image guidance during prosthesis placement while performing DAA THA may result in better implant positioning and lesser incidences of post-operative dislocations or limb length discrepancies (LLD).

Keywords: Direct Anterior Approach; Total Hip Arthroplasty; Posterior Approach; Direct Lateral Approach


    1. Laupacis A., et al. “The effect of elective total hip replacement on health-related quality of life”. Journal of Bone and Joint Surgery America 11 (1993): 1619-1626.
    2. Learmonth ID., et al. “The operation of the century: total hip replacement”. Lancet (London, England 9597 (2007): 1508-1519.
    3. Khanduja V. “Total Hip Arthroplasty in 2017 - Current Concepts and Recent Advances”. The Indian Journal of Orthopaedics 4 (2017): 357-358.
    4. Waddell J., et al. “Orthopaedic practice in total hip arthroplasty and total knee arthroplasty: results from the Global Orthopaedic Registry (GLORY)”. American Journal of Orthopedics 9 (2010): 5-13.
    5. Petis S., et al. “Surgical approach in primary total hip arthroplasty: anatomy, technique and clinical outcomes”. Canadian surgery and the Canadian Journal of Surgery 2 (2015): 128-139.
    6. Jia F., et al. “A comparison of clinical, radiographic and surgical outcomes of total hip arthroplasty between direct anterior and posterior approaches: a systematic review and meta-analysis”. Hip International: the Journal of Clinical and Experimental Research on Hip Pathology and Therapy (2018).
    7. Higgins BT., et al. “Anterior vs. posterior approach for total hip arthroplasty, a systematic review and meta-analysis”. The Journal of Arthroplasty 3 (2015): 419-434.
    8. Tripuraneni KR., et al. “Acetabular Abduction and Dislocations in Direct Anterior vs Posterior Total Hip Arthroplasty: A Retrospective, Matched Cohort Study”. The Journal of Arthroplasty 10 (2016): 2299-2302.
    9. Poehling-Monaghan KL., et al. “Direct anterior versus miniposterior THA with the same advanced perioperative protocols: surprising early clinical results”. Clinical Orthopaedics 2 (2015): 623-631.
    10. Yue C., et al. “Comparison of Direct Anterior and Lateral Approaches in Total Hip Arthroplasty: A Systematic Review and Meta-Analysis (PRISMA)”. Medicine50 (2015): e2126.
    11. Masterson EL., et al. “Surgical approaches in revision hip replacement”. The Journal of the American Academy of Orthopaedic Surgeons 6 (1998): 84-92.
    12. Hansen AD. “Anatomy and surgical approaches. In: Morrey BF, editor. Reconstructive Surgery of the Joints”. 2nd ed. New York: Churchill Livingstone (1996): 883-909.
    13. Von Langenbeck B. “Uber die schussverletzungen des huftgelenks”. Arch Klin Chir 16 (1874): 263.
    14. Moore AT. “The self-locking metal hip prosthesis”. Journal of Bone and Joint Surgery America 39-A (1957): 811-827.
    15. Chechik O., et al. “Surgical approach and prosthesis fixation in hip arthroplasty world wide”. Archives of Orthopaedic and Trauma Surgery 133 (2013): 1595-1600.
    16. Graves SC., et al. “Does surgical approach affect patient-reported function after primary THA?” Clinical Orthopaedics and Related Research 4 (2016): 971-981.
    17. Martin CT., et al. “A comparison of hospital length of stay and short-term morbidity between the anterior and the posterior approaches to total hip arthroplasty”. The Journal of Arthroplasty 5 (2013): 849-854.
    18. McFarland B and Osborne G. “Approach to the hip: A suggested improvement on Kocher’s method”. The Journal of Bone and Joint Surgery. British 36B (1954): 364-367.
    19. Hardinge K. “The direct lateral approach to the hip”. The Journal of Bone and Joint Surgery. British 64 (1982): 17-19.
    20. Jolles BM and Bogoch ER. “Posterior versus lateral surgical approach for total hip arthroplasty in adults with osteoarthritis”. Cochrane Database of Systematic Reviews (2003): 4.
    21. Rosenlund S., et al. “The efficacy of modified direct lateral versus posterior approach on gait function and hip muscle strength after primary total hip arthroplasty at 12months follow-up. An explorative randomised controlled trial”. Clinical Biomechanics Bristol Avon 39 (2016): 91-99.
    22. Iyer KM. “Hueter’s Anterior Approach to the Hip Joint”.
    23. Paillard P. “Hip replacement by a minimal anterior approach”. International Orthopaedics 1 (2007): S13-S15.
    24. Wang Z., et al. “A systematic review and meta-analysis of direct anterior approach versus posterior approach in total hip arthroplasty”. Journal of Orthopaedic Surgery and Research 1 (2018): 229.
    25. Christensen CP and Jacobs CA. “Comparison of Patient Function during the First Six Weeks after Direct Anterior or Posterior Total Hip Arthroplasty (THA): A Randomized Study”. The Journal of Arthroplasty 9 (2015): 94-97.
    26. Zawadsky MW., et al. “Early outcome comparison between the direct anterior approach and the mini-incision posterior approach for primary total hip arthroplasty: 150 consecutive cases”. The Journal of Arthroplasty 6 (2014): 1256-1260.
    27. Zhao H-Y., et al. “Comparison of Early Functional Recovery After Total Hip Arthroplasty Using a Direct Anterior or Posterolateral Approach: A Randomized Controlled Trial”. The Journal of Arthroplasty 11 (2017): 3421-3428.
    28. Restrepo C., et al. “Prospective randomized study of two surgical approaches for total hip arthroplasty”. The Journal of Arthroplasty 5 (2010): 671-679.
    29. Post ZD., et al. “Direct anterior approach for total hip arthroplasty: indications, technique, and results”. American Academy of Orthopaedic Surgeons 9 (2014): 595-603.
    30. Maratt JD., et al. “No Difference in Dislocation Seen in Anterior Vs Posterior Approach Total Hip Arthroplasty”. The Journal of Arthroplasty 9 (2016): 127-130.
    31. Sheth D., et al. “Anterior and Anterolateral Approaches for THA Are Associated With Lower Dislocation Risk Without Higher Revision Risk”. Clinical Orthopaedics 11 (2015): 3401-3408.
    32. Hartford JM and Bellino MJ. “The learning curve for the direct anterior approach for total hip arthroplasty: a single surgeon’s first 500 cases”. Hip International: the Journal of Clinical and Experimental Research on Hip Pathology and Therapy 5 (2017): 483-488.
    33. Kurtz SM., et al. “Future young patient demand for primary and revision joint replacement: national projections from 2010 to 2030”. Clinical Orthopaedics 10 (2009): 2606-2612.
    34. Den Daas A., et al. “Patient satisfaction in different approaches for total hip arthroplasty”. Orthopaedics and Traumatology: Surgery and Research 7 (2019): 1277-1282.
    35. Cheng TE., et al. “A Prospective Randomized Clinical Trial in Total Hip Arthroplasty-Comparing Early Results Between the Direct Anterior Approach and the Posterior Approach”. The Journal of Arthroplasty 3 (2017): 883-890.
    36. Peng L., et al. “Clinical, functional and radiographic outcomes of primary total hip arthroplasty between direct anterior approach and posterior approach: a systematic review and meta-analysis”. BMC Musculoskeletal Disorders 21 (2020): 338.
    37. Macheras GA., et al. “Nerve injuries in total hip arthroplasty with a mini invasive anterior approach”. HIP International 26 (2016): 338-343.
    38. Jacobs LG and Buxton RA. “The course of the superior gluteal nerve in the lateral approach to the hip”. Journal of Bone and Joint Surgery America 71 (1989): 1239-1243.
    39. Russo MW., et al. “Increased Complications in Obese Patients Undergoing Direct Anterior Total Hip Arthroplasty”. The Journal of Arthroplasty 8 (2015): 1384-1387.
    40. Christensen CP., et al. “Greater prevalence of wound complications requiring reoperation with direct anterior approach total hip arthroplasty”. The Journal of Arthroplasty 29 (2014): 1839-1841.
    41. Siguier T., et al. “Mini-incision anterior approach does not increase dislocation rate: A study of 1037 total hip replacements”. Clinical Orthopaedics and Related Research 426 (2004): 164-173.
    42. Matta JM., et al. “Single-incision anterior approach for total hip arthroplasty on an orthopaedic table”. Clinical Orthopaedics and Related Research 441 (2005): 115-124.
    43. Mulliken BD., et al. “A modified direct lateral approach in total hip arthroplasty: A comprehensive review”. The Journal of Arthroplasty 13 (1998): 737-747.
    44. Demos HA., et al. “Instability in primary total hip arthroplasty with the direct lateral approach”. Clinical Orthopaedics and Related Research 393 (2001): 168-180.
    45. Goldstein WM., et al. “Prevalence of dislocation after total hip arthroplasty through a posterolateral approach with partial capsulotomy and capsulorrhaphy”. The Journal of Bone and Joint Surgery American 83-A 2.1 (2001): 2-7.
    46. White RE Jr., et al. “Effect of 60. posterior capsular repair on early dislocation in primary total hip replacement”. Clinical Orthopaedics and Related Research 393 (2001): 163-167.
    47. Sierra RJ., et al. “Dislocation of primary THA done through a posterolateral approach in the 61. Elderly”. Clinical Orthopaedics and Related Research 441 (2005): 262-267.
    48. Malek IA., et al. “A comparison between the direct anterior and posterior approaches for total hip arthroplasty: The role of an ‘Enhanced Recovery’ pathway”. The Bone and Joint Journal 98-B (2016): 754-760.
    49. Masonis JL and Bourne RB. “Surgical approach, abductor function, and total hip arthroplasty dislocation”. Clinical Orthopaedics and Related Research 405 (2002): 46-53.
    50. Bergin PF., et al. “Comparison of minimally invasive direct anterior versus posterior total hip arthroplasty based on inflammation and muscle damage markers”. Journal of Bone and Joint Surgery America 93 (2011): 1392-1398.
Citation: RB Kalia and A Kundu. “Surgical Approaches to the Hip Joint for Total Hip Arthroplasty - An Updated Review”. EC Clinical and Medical Case Reports 4.2 (2021): 13-19.

PubMed Indexed Article

EC Pharmacology and Toxicology
LC-UV-MS and MS/MS Characterize Glutathione Reactivity with Different Isomers (2,2' and 2,4' vs. 4,4') of Methylene Diphenyl-Diisocyanate.

PMID: 31143884 [PubMed]

PMCID: PMC6536005

EC Pharmacology and Toxicology
Alzheimer's Pathogenesis, Metal-Mediated Redox Stress, and Potential Nanotheranostics.

PMID: 31565701 [PubMed]

PMCID: PMC6764777

EC Neurology
Differences in Rate of Cognitive Decline and Caregiver Burden between Alzheimer's Disease and Vascular Dementia: a Retrospective Study.

PMID: 27747317 [PubMed]

PMCID: PMC5065347

EC Pharmacology and Toxicology
Will Blockchain Technology Transform Healthcare and Biomedical Sciences?

PMID: 31460519 [PubMed]

PMCID: PMC6711478

EC Pharmacology and Toxicology
Is it a Prime Time for AI-powered Virtual Drug Screening?

PMID: 30215059 [PubMed]

PMCID: PMC6133253

EC Psychology and Psychiatry
Analysis of Evidence for the Combination of Pro-dopamine Regulator (KB220PAM) and Naltrexone to Prevent Opioid Use Disorder Relapse.

PMID: 30417173 [PubMed]

PMCID: PMC6226033

EC Anaesthesia
Arrest Under Anesthesia - What was the Culprit? A Case Report.

PMID: 30264037 [PubMed]

PMCID: PMC6155992

EC Orthopaedics
Distraction Implantation. A New Technique in Total Joint Arthroplasty and Direct Skeletal Attachment.

PMID: 30198026 [PubMed]

PMCID: PMC6124505

EC Pulmonology and Respiratory Medicine
Prevalence and factors associated with self-reported chronic obstructive pulmonary disease among adults aged 40-79: the National Health and Nutrition Examination Survey (NHANES) 2007-2012.

PMID: 30294723 [PubMed]

PMCID: PMC6169793

EC Dental Science
Important Dental Fiber-Reinforced Composite Molding Compound Breakthroughs

PMID: 29285526 [PubMed]

PMCID: PMC5743211

EC Microbiology
Prevalence of Intestinal Parasites Among HIV Infected and HIV Uninfected Patients Treated at the 1o De Maio Health Centre in Maputo, Mozambique

PMID: 29911204 [PubMed]

PMCID: PMC5999047

EC Microbiology
Macrophages and the Viral Dissemination Super Highway

PMID: 26949751 [PubMed]

PMCID: PMC4774560

EC Microbiology
The Microbiome, Antibiotics, and Health of the Pediatric Population.

PMID: 27390782 [PubMed]

PMCID: PMC4933318

EC Microbiology
Reactive Oxygen Species in HIV Infection

PMID: 28580453 [PubMed]

PMCID: PMC5450819

EC Microbiology
A Review of the CD4 T Cell Contribution to Lung Infection, Inflammation and Repair with a Focus on Wheeze and Asthma in the Pediatric Population

PMID: 26280024 [PubMed]

PMCID: PMC4533840

EC Neurology
Identifying Key Symptoms Differentiating Myalgic Encephalomyelitis and Chronic Fatigue Syndrome from Multiple Sclerosis

PMID: 28066845 [PubMed]

PMCID: PMC5214344

EC Pharmacology and Toxicology
Paradigm Shift is the Normal State of Pharmacology

PMID: 28936490 [PubMed]

PMCID: PMC5604476

EC Neurology
Examining those Meeting IOM Criteria Versus IOM Plus Fibromyalgia

PMID: 28713879 [PubMed]

PMCID: PMC5510658

EC Neurology
Unilateral Frontosphenoid Craniosynostosis: Case Report and a Review of the Literature

PMID: 28133641 [PubMed]

PMCID: PMC5267489

EC Ophthalmology
OCT-Angiography for Non-Invasive Monitoring of Neuronal and Vascular Structure in Mouse Retina: Implication for Characterization of Retinal Neurovascular Coupling

PMID: 29333536 [PubMed]

PMCID: PMC5766278

EC Neurology
Longer Duration of Downslope Treadmill Walking Induces Depression of H-Reflexes Measured during Standing and Walking.

PMID: 31032493 [PubMed]

PMCID: PMC6483108

EC Microbiology
Onchocerciasis in Mozambique: An Unknown Condition for Health Professionals.

PMID: 30957099 [PubMed]

PMCID: PMC6448571

EC Nutrition
Food Insecurity among Households with and without Podoconiosis in East and West Gojjam, Ethiopia.

PMID: 30101228 [PubMed]

PMCID: PMC6086333

EC Ophthalmology
REVIEW. +2 to +3 D. Reading Glasses to Prevent Myopia.

PMID: 31080964 [PubMed]

PMCID: PMC6508883

EC Gynaecology
Biomechanical Mapping of the Female Pelvic Floor: Uterine Prolapse Versus Normal Conditions.

PMID: 31093608 [PubMed]

PMCID: PMC6513001

EC Dental Science
Fiber-Reinforced Composites: A Breakthrough in Practical Clinical Applications with Advanced Wear Resistance for Dental Materials.

PMID: 31552397 [PubMed]

PMCID: PMC6758937

EC Microbiology
Neurocysticercosis in Child Bearing Women: An Overlooked Condition in Mozambique and a Potentially Missed Diagnosis in Women Presenting with Eclampsia.

PMID: 31681909 [PubMed]

PMCID: PMC6824723

EC Microbiology
Molecular Detection of Leptospira spp. in Rodents Trapped in the Mozambique Island City, Nampula Province, Mozambique.

PMID: 31681910 [PubMed]

PMCID: PMC6824726

EC Neurology
Endoplasmic Reticulum-Mitochondrial Cross-Talk in Neurodegenerative and Eye Diseases.

PMID: 31528859 [PubMed]

PMCID: PMC6746603

EC Psychology and Psychiatry
Can Chronic Consumption of Caffeine by Increasing D2/D3 Receptors Offer Benefit to Carriers of the DRD2 A1 Allele in Cocaine Abuse?

PMID: 31276119 [PubMed]

PMCID: PMC6604646

EC Anaesthesia
Real Time Locating Systems and sustainability of Perioperative Efficiency of Anesthesiologists.

PMID: 31406965 [PubMed]

PMCID: PMC6690616

EC Pharmacology and Toxicology
A Pilot STEM Curriculum Designed to Teach High School Students Concepts in Biochemical Engineering and Pharmacology.

PMID: 31517314 [PubMed]

PMCID: PMC6741290

EC Pharmacology and Toxicology
Toxic Mechanisms Underlying Motor Activity Changes Induced by a Mixture of Lead, Arsenic and Manganese.

PMID: 31633124 [PubMed]

PMCID: PMC6800226

EC Neurology
Research Volunteers' Attitudes Toward Chronic Fatigue Syndrome and Myalgic Encephalomyelitis.

PMID: 29662969 [PubMed]

PMCID: PMC5898812

EC Pharmacology and Toxicology
Hyperbaric Oxygen Therapy for Alzheimer's Disease.

PMID: 30215058 [PubMed]

PMCID: PMC6133268

News and Events

April Issue Release

We always feel pleasure to share our updates with you all. Here, notifying you that we have successfully released the April issue of respective journals and the latest articles can be viewed on the current issue pages.

Submission Deadline for upcoming Issue

Ecronicon delightfully welcomes all the authors around the globe for effective collaboration with an article submission for the upcoming issue of respective journals. Submissions are accepted on/before May 04, 2021.

Certificate of Publication

Ecronicon honors with a "Publication Certificate" to the corresponding author by including the names of co-authors as a token of appreciation for publishing the work with our respective journals.

Best Article of the Issue

Editors of respective journals will always be very much interested in electing one Best Article after each issue release. The authors of the selected article will be honored with a "Best Article of the Issue" certificate.

Certifying for Review

Ecronicon certifies the Editors for their first review done towards the assigned article of the respective journals.

Latest Articles

The latest articles will be updated immediately on the articles in press page of the respective journals.

Immediate Assistance

The prime motto of this team is to clarify all the queries without any delay or hesitation to avoid the inconvenience. For immediate assistance on your queries please don't hesitate to drop an email to