Surgical Approaches Used for Hip Replacement

Total hip replacement has become one of the most common and most successful types of orthopedic surgeries. Nearly 500,000 hip replacement surgeries are done in the United States every year. While hip replacement surgery is largely standardized, there are variations in surgical techniques.

For example, these procedures can be done with a variety of different incision locations or with a minimally invasive method. Overall, there are risks associated with each of the different surgical approaches.

A specific surgical technique may be appropriate in certain situations, but it might not be ideal for others. And offten, a person's total hip replacement could be successful regardless of which method is selected.

Be sure to ask your surgeon if you have questions about a particular surgical approach.


Posterior Hip Replacement

photo of a man with hip pain talking with his doctor
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The posterior approach for hip replacement surgery is by far the most common surgical technique used in the United States and throughout the world.

This surgical procedure is performed with a patient lying on their side, and a surgical incision made along the outside of the hip. This is described as a posterior approach because the actual hip joint is visualized from behind the thigh bone—which is the posterior aspect of the hip joint.


The most notable advantage of this surgical procedure is its versatility. In situations that are particularly challenging due to issues like bone deformity, hardware within the hip, or other complicating factors, the incision can be extended to allow for more complex surgical reconstruction.

This approach also provides excellent visualization of the hip joint. And most any implant can be inserted using a posterior approach.


The primary disadvantage of a posterior approach is that it is associated with a higher implant dislocation rate than other approaches. Long-term data has yet to be gathered, but one of the hopes with other surgical approaches is that the dislocation rate might decrease.

The other major disadvantage with this surgical approach—and one of the possible contributors to dislocation—is the fact that some muscles and tendons (the external rotators) are typically cut away from the bone during surgery for access to the hip joint before being surgically reattached.


Direct Anterior Hip Replacement

The direct anterior approach to the hip is becoming more common. This surgical procedure, which has been used for more than 100 years, has been increasing over the past decade.

The direct anterior approach is performed with a patient lying on their back, and a surgical incision is made coming down the front of the thigh.


There are several potential advantages of the direct anterior approach. The two most prominent are a low dislocation risk and early postoperative recovery.

Many surgeons feel that the risk of dislocation following anterior approach hip replacement is lower than that of a posterior approach hip replacement. While the risk with a posterior approach is only about 1 to 2%, minimizing the likelihood of dislocation is an important consideration.

The second advantage of this method is that it's associated with a faster postoperative recovery than what is seen with other methods. People undergoing direct anterior surgery also tend to have shorter hospitalization.


A disadvantage of the anterior approach is that surgical exposure of the hip structures can be more difficult, especially in people who are very muscular or have significant girth at the center of their body. It is clear that it takes time and practice for surgeons to become skilled in this approach, and a number of complications can occur.

In addition, not all implants can be easily placed using an anterior approach, and managing anatomical deformities or performing revision hip replacement is not always as straightforward with an anterior approach as it is with a posterior approach.

Lastly, the lateral femoral cutaneous nerve, a nerve that detects skin sensation, can be injured at the time of surgery. While this type of injury would not alter gait (walking) or muscle function, it can be bothersome to have a patch of numbness on the front of your thigh.


Lateral Surgical Approaches

A direct lateral or anterolateral approach is performed on the side of the hip joint. This surgical approach is often considered to be a balance between the anterior and posterior approaches.

People undergoing a lateral approach are positioned on their side, and the surgical incision is placed directly down the outside of the hip.


The advantage of this surgical method is the balance of having a versatile incision that can be used to correct deformities and insert specialized implants with lower dislocation rates following surgery than what is observed with posterior approaches.


The disadvantage of the direct lateral approach is that the abductor muscles of the hip joint have to be cut for surgical access to the hip. These muscles may heal, but impaired healing can cause a persistent limp when walking.

In addition, dissection through these muscles can cause heterotopic ossification, a type of abnormal bone growth. While heterotopic ossification can occur after any surgical procedure on the hip joint, it is more common after surgeries that are done with the direct lateral approach.


Alternative Surgical Approaches

There are also some other surgical procedures that are used for hip replacement, although they are used less often than the three most common approaches.

Alternative surgical procedures include a 2-incision procedure and the direct superior approach. Both of these surgical procedures are used to make smaller surgical incisions and to limit the amount of muscle injury at the time of surgery.

Both of the procedures rely heavily on indirect visualization. Your surgeon would use imaging guidance during your operation to assist with proper insertion of the implants. Both of these operations can be converted into other hip replacement procedures if better visualization is required at the time of surgery.

There is only limited data available about the potential benefits of these less invasive surgical procedures, but limiting damage to normal muscle tissue might promote a faster recovery.

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By Jonathan Cluett, MD
Jonathan Cluett, MD, is board-certified in orthopedic surgery. He served as assistant team physician to Chivas USA (Major League Soccer) and the United States men's and women's national soccer teams.