What is the recommended surgical technique for Total Hip Replacement (THR)?

Surgical Technique for Total Hip Replacement

The posterior (posterolateral) approach is the recommended surgical technique for total hip arthroplasty, demonstrating the lowest overall complication rate (5.85%) compared to other approaches, with equivalent dislocation rates to alternative techniques. 1

Primary Surgical Approach Selection

Posterior Approach - First-Line Recommendation

• The posterior approach should be the default choice for most patients undergoing primary THR, as it demonstrates superior safety outcomes with the lowest complication rate among all common approaches 1
• This approach provides optimal visualization and access while minimizing soft tissue trauma 2
• Dislocation rates with the posterior approach are acceptably low at 0.84%, comparable to the anterior approach (1.28%, p=0.32) 1

Alternative Approaches

While multiple surgical approaches exist (anterior, direct lateral, anterolateral, northern approach), the evidence supports the following hierarchy:

• Direct lateral and anterolateral approaches are acceptable alternatives when surgeon experience and patient anatomy favor these techniques 2, 3
• The anterior approach has a significantly higher overall complication rate (8.5%) compared to the posterior approach and should be reserved for specific indications 1
• Surgeon experience and comfort with a particular approach remains important, but the posterior approach demonstrates objective superiority in complication rates 2, 3

Critical Technical Considerations

Preoperative Requirements

• Radiographic confirmation of advanced osteoarthritis (Kellgren-Lawrence grade 3 or 4) is mandatory before proceeding with surgery 4
• Patients must have failed at least 3 months of conservative treatment 4
• BMI should be optimized to <30 kg/m² preoperatively, with BMI ≥40 kg/m² representing a contraindication 4
• Smoking cessation at least 1 month before surgery is required 4
• For diabetic patients, HbA1c must be controlled to <8% preoperatively 4

Intraoperative Technical Goals

The primary surgical objectives are:

• Complete pain elimination 5
• Restoration of full range of motion 5
• Maintenance of hip stability 5
• Precise implant positioning to ensure long-term durability 5

Anesthetic Approach

• Either spinal or general anesthesia is recommended - both are equally acceptable 6
• The choice between spinal and general anesthesia does not significantly impact surgical outcomes 6

Common Pitfalls and Complications

Most Frequent Early Complications

The evidence identifies three major early complications that surgeons must actively prevent:

1. Deep infection (22.8% of all complications) - requires meticulous sterile technique and appropriate antibiotic prophylaxis 1
2. Periprosthetic fracture (22.4% of all complications) - demands careful bone preparation and implant sizing 1
3. Prolonged wound drainage (21.3% of all complications) - necessitates proper soft tissue handling and hemostasis 1

Approach-Specific Risks

• The anterior approach carries the highest risk of complications at 8.5%, primarily due to increased periprosthetic fracture risk 1
• Surgeons should avoid the anterior approach unless they have extensive specific training in this technique 1

Long-Term Outcomes and Expectations

Implant Survival

• Primary THR demonstrates excellent long-term survival: 90% at 15 years and up to 60% at 20 years 4
• Each subsequent revision surgery has considerably lower success rates - emphasizing the critical importance of optimal primary technique 5

Functional Outcomes

• The surgical approach significantly impacts complication rates, which directly affects patient recovery and long-term function 1
• Worse preoperative condition correlates with poorer surgical outcomes, reinforcing the importance of appropriate patient selection and optimization 4

Special Considerations for Revision Surgery

When revision THR is required:

• Proceed without delay in patients with severe bone loss, deformity, or ligamentous instability, as delaying surgery increases instability and bone loss 7
• Revision THR has significantly lower survival rates (82% at 10 years, 54-65% at 20 years) compared to primary surgery 7
• Most revision failures occur within the first 7 years post-revision 7