What is the step-by-step surgical approach for total hip replacement?

Step-by-Step Surgical Approach for Total Hip Replacement

The posterior approach is recommended for total hip replacement as it has a significantly lower overall complication rate compared to other approaches, with equal dislocation rates to the anterior approach. 1

Preoperative Preparation

1. Patient Positioning

   • Position patient in lateral decubitus position with the affected hip facing upward
   • Secure patient with anterior and posterior supports
   • Ensure all bony prominences are padded

2. Skin Preparation and Draping

   • Prepare the skin with antiseptic solution from iliac crest to mid-thigh
   • Drape to create a sterile field exposing the lateral hip region

Surgical Steps

Step 1: Incision and Approach

• Make a 10-15 cm curved incision centered over the greater trochanter
• Incise and reflect the fascia lata
• Identify and protect the sciatic nerve
• Split the gluteus maximus fibers in line with the incision
• Identify the short external rotators (piriformis, gemelli, obturator internus)
• Tag and release the short external rotators from their insertion on the greater trochanter

Step 2: Capsular Exposure and Dislocation

• Expose the posterior hip capsule
• Perform a T-shaped capsulotomy
• Internally rotate the femur to expose the femoral head
• Dislocate the hip by internal rotation, adduction, and flexion
• Cut the femoral neck with an oscillating saw at the predetermined level

Step 3: Acetabular Preparation

• Place retractors to expose the acetabulum
• Remove the labrum and any osteophytes
• Ream the acetabulum sequentially to achieve appropriate size
• Test with trial components to ensure proper fit and position
• Implant the definitive acetabular component with proper anteversion (15-20°) and inclination (40-45°)
• Secure the liner to the acetabular shell

Step 4: Femoral Preparation

• Expose the proximal femur using retractors
• Identify the entry point for the femoral canal
• Prepare the femoral canal with sequential broaching
• Ensure proper anteversion (10-15°) of the femoral component
• Test with trial components for stability and leg length
• Implant the definitive femoral component (cemented or uncemented)
• Attach the appropriate femoral head component

Step 5: Reduction and Stability Testing

• Reduce the hip joint by placing the femoral head into the acetabular component
• Test for stability through range of motion:
  • Internal/external rotation in extension
  • Internal/external rotation in 90° flexion
  • Adduction in flexion to check for impingement
• Ensure appropriate leg length and offset

Step 6: Closure

• Repair the posterior capsule to the greater trochanter
• Reattach the short external rotators to their insertion points
• Close the fascia lata with strong sutures
• Close subcutaneous tissue and skin in layers
• Apply sterile dressing

Technical Considerations

• Meticulous attention to component positioning is critical to prevent complications 2
• Proper acetabular component positioning (15-20° anteversion, 40-45° inclination) helps prevent dislocation
• Femoral component anteversion (10-15°) is essential for stability
• Adequate soft tissue tension must be achieved to prevent instability 2
• Combined anteversion technique (sum of acetabular and femoral anteversion) should be 35-45°

Postoperative Management

• Implement multimodal pain management including paracetamol, NSAIDs/COX-2 inhibitors, with opioids as rescue 3
• Begin physical therapy on postoperative day 0-1 2
• Focus on early mobilization and weight-bearing exercises as tolerated 2
• Emphasize hip abductor strengthening to optimize functional outcomes 2
• Monitor for common complications:
  • Venous thromboembolism
  • Prosthetic joint infection
  • Periprosthetic fracture
  • Instability/dislocation
  • Leg length discrepancy 4

Avoiding Common Complications

• Deep infection (22.8% of complications) and periprosthetic fracture (22.4% of complications) are the most common early complications 1
• Proper component positioning reduces the risk of dislocation (posterior approach dislocation rate: 0.84%) 1
• Balance progression with protection during rehabilitation to prevent stiffness and weakness 2
• Careful soft tissue handling and meticulous hemostasis help prevent prolonged wound drainage (21.3% of complications) 1

The posterior approach is recommended as it has demonstrated the lowest overall complication rate (5.85%) compared to the anterior approach (8.5%) with equal dislocation rates 1. Proper surgical technique with attention to component positioning and soft tissue management is essential for successful outcomes.