What is the step-wise approach to total hip arthroplasty (THA)?

From the Guidelines

A step-wise approach to total hip arthroplasty (THA) begins with preoperative planning, which includes templating the procedure using radiographs to determine implant size and position, and the administration of paracetamol in combination with NSAID or COX-2-selective inhibitors for pain management, unless contraindicated, as recommended by the most recent guideline 1.

Preoperative Planning

The patient is positioned either laterally or supine depending on the surgical approach chosen. Common approaches include the posterior (Moore), anterolateral (Watson-Jones), direct lateral (Hardinge), and direct anterior approaches, each with specific advantages and considerations for exposure and muscle preservation.

• The choice of surgical approach should depend on surgeon and patient preference, as there is inconclusive evidence in terms of postoperative pain for choosing a specific surgical approach 1.
• The use of postoperative drains is not recommended to improve pain outcomes, as pain scores were similar in both groups with and without drains 1.

Surgical Technique

After positioning, the surgeon makes the skin incision, dissects through subcutaneous tissue, and identifies the fascia lata. The approach-specific muscle dissection follows, with careful protection of neurovascular structures.

• The hip is then dislocated, and the femoral neck is cut according to preoperative measurements.
• The acetabulum is prepared by progressive reaming until healthy bleeding bone is exposed, followed by placement of the acetabular component with proper anteversion (15-20°) and inclination (40-45°) 1.
• The femoral canal is then prepared by broaching to the appropriate size, and the femoral component is inserted with proper anteversion (10-15°).

Postoperative Care

Trial components are used to assess stability, leg length, and offset before final implants are placed. The hip is reduced, and stability is checked through range of motion testing.

• Closure is performed in layers with careful attention to capsular and muscular repair depending on the approach.
• Postoperatively, patients typically begin ambulation within 24 hours with appropriate weight-bearing status and follow a rehabilitation protocol to restore function and prevent complications such as dislocation, infection, and venous thromboembolism 1.
• The administration of paracetamol in combination with NSAID or COX-2-selective inhibitors is recommended for postoperative pain management, unless contraindicated, as it has been shown to reduce morphine consumption and improve pain scores 1.

From the Research

Step-wise Approach to Total Hip Arthroplasty (THA)

The step-wise approach to THA involves several key steps, including:

• Preoperative planning, which is a necessary first step in arthroplasty, allowing the surgeon to fulfill one of the universal goals of reconstructive surgery--precision with reproducibility 2
• Choosing a surgical approach, with the most common approaches being the posterior, direct lateral, and direct anterior approaches 3, 4, 5
• Considering the advantages and disadvantages of each approach, including the risk of dislocation, abductor insufficiency, fracture, and nerve injury 3, 4, 5
• Selecting the approach based on surgeon experience and familiarity, as the pros and cons of each approach seem to equalize by 6 weeks postoperatively 4

Surgical Approaches

The main surgical approaches for THA include:

• Posterior approach, which has the lowest rates of overall complications 4
• Direct lateral approach, which has the lowest rates of dislocation 4
• Direct anterior approach, which affords the best early recovery as measured in the first 2 to 4 weeks after surgery 4
• Anterolateral approach (also known as the Watson Jones approach) and the two-incision approach, which are viable alternatives to traditional approaches 3
• Direct superior approach, which is a recently utilized approach for THA 3

Clinical Outcomes

The clinical outcomes of THA vary depending on the surgical approach used, with numerous clinical trials seeking to elicit differences in patient-reported outcomes, complication rates, and return to function among the surgical approaches 4, 5

• A systematic review of approaches for THA found that the posterior approach or posterolateral approach is optimally beneficial 6
• The choice of surgical approach depends on many factors, including the surgeon's choice, type of pathology, bone stock, age of the patient, and experience of the surgeon 6