All approaches

The anterior approach (Iliofemoral or Smith-Petersen) provides the most direct access to the anterior aspect of the hip. The anterior approach is not commonly used for periprosthetic fractures of the acetabulum.

The anterior approach provides the most direct access to the anterior aspect of the hip. Many surgeons prefer this approach for reduction of femoral head and neck fractures.

The direct anterior approach can be easily extended to perform most fracture surgeries effectively, while maintaining the posterior capsule and short external rotators.

The anterolateral approach (Watson-Jones) to the proximal femur, through the interval between glutei and tensor fasciae latae provides somewhat limited access to the hip joint along with the lateral proximal femur. With well-positioned retractors and adequate soft-tissue releases, it is possible to perform open reduction of proximal periprosthetic femoral fractures or revision arthroplasty.

The Kocher-Langenbeck approach is an approach to the posterior structures of the acetabulum. It allows direct visualization of the posterior column and the retroacetabular surface. This approach can be useful for ORIF of periprosthetic acetabular, femoral fractures and revision arthroplasty.

The Kocher-Langenbeck approach can be performed either in the prone or lateral position. (The lateral position is preferred for periprosthetic fracture and revision arthroplasty).

The maintenance of knee flexion (at 90°) and hip extension throughout the procedure reduces tension on the sciatic nerve.

Scar tissue due to previous exposure might obscure typical landmarks.

The Extended Trochanteric Osteotomy (ETO) can be performed through a posterolateral or anterior approach to the hip for arthroplasty. 

This page will describe the ETO for a posterolateral approach as this tends to be the workhorse for the revision arthroplasty.

This approach is excellent for periprosthetic fractures of the proximal femur and could be used for revision arthroplasty.

The direct lateral approach releases the anterior third of gluteus medius and minimus, while preserving the posterior femoral attachment of the major part of these muscles. The proximal part of the incision is limited by the superior gluteal nerve and vessels, crossing 3-5 cm proximal to the tip of the greater trochanter. Distally, the anterior fibers of vastus lateralis are elevated from the anterior femur. The anterior attachment of the hip capsule is next released from the anterior base of the femoral neck, and an anterior longitudinal capsulotomy is opened as necessary with a proximal transverse “T”.

This approach is useful for a periprosthetic femur fracture with a stable prosthesis or a fracture distal to the prosthesis.

The major vessels and nerves are located medially/posteromedially to the femoral shaft and are not exposed using this approach.

This approach can be performed with the patient supine or in lateral decubitus.

Scar tissue due to previous exposure might obscure typical landmarks.

The posterolateral approach can be used for revision hip arthroplasty or ORIF of periprosthetic femur fractures. This can be extended into a formal Kocher-Langenbeck for treatment of periprosthetic acetabular fractures.

The approach is essentially the same as the Kocher-Langenbeck, but exposure is limited to the hip joint, respecting but not displaying the sciatic nerve. The femoral attachment of the short external rotators and hip capsule should be repaired to reduce the risk of postoperative dislocation (early descriptions of hip arthroplasty through a posterolateral approach suggested excision of the posterior hip capsule).

This approach can be used to access the entire anterior column when supplemented with a lateral window and allows excellent visualization of the quadrilateral surface. This can be directly instrumented unlike in the ilioinguinal approach.

It can be used for ORIF of periprosthetic acetabular fractures.

The trochanteric osteotomy is performed through a posterolateral approach which can be used for revision hip arthroplasty or ORIF of periprosthetic acetabulum and femur fractures. This can be extended into a formal Kocher-Langenbeck for treatment of periprosthetic acetabular fractures.

The femoral attachment of the short external rotators and hip capsule should be repaired to reduce the risk of postoperative dislocation (early descriptions of hip arthroplasty through a posterolateral approach suggested excision of the posterior hip capsule).

The Anterior Superior Iliac Spine (ASIS) osteotomy can be used for ORIF of periprosthetic acetabular fractures or revision arthroplasty.

The ilioinguinal approach provides exposure of the inner aspect of the innominate bone from the SI joint to the pubic symphysis.

This approach can be used for ORIF of periprosthetic acetabular fractures.

Care should be taken with the approach for retrograde nailing as several anatomical structures are at risk. The most important potential hazard is damage to the anterior cruciate ligament. In addition, cartilage from the weight bearing zone may be damaged if a non-anatomic approach is selected. A non-anatomic approach can also lead to a failure to reduce the fracture properly, resulting in a varus/valgus malposition of the distal main fragment. Lastly, plunging out the back of the knee is always a major risk during this procedure because of the neurovascular structures.

The anatomical landmark is the Blumensaat’s line (solid orange line) - this corresponds to the roof of the intercondylar notch.