Posterolateral minimal incision for total hip replacement: technique and early results

There presently exists in the arthroplasty community a new and heightened level of interest in minimally invasive techniques for total joint replacement. Several investigators have published their personal experience with differing techniques, all concluding that there are multiple advantages to this concept for total hip arthroplasty. The author's perception is that the advantages of minimally invasive posterolateral approach total hip arthroplasty are multiple. They include more rapid rehabilitation and more prompt return to activities of daily living. There has been a clear impression that patients experience less postoperative pain and improved satisfaction. A concomitant decrease in hospital stay has been noted. Patients undergoing the procedure today have an average length of hospital stay of 48 hours, which represents a 30% decrease in hospital stay over the last year. Other advantages include improved cosmesis and potentially reduced blood loss without increasing complication rates. Surgeons performing this procedure require familiarity with the local anatomy, because the technique is certainly more demanding than is traditional arthroplasty. It is perhaps a technique best applied by surgeons performing more than 50 total hip arthroplasties a year. The two keys to successful application of the technique are adequate surgical training and use of specialized instrumentation. It is a difficult procedure to teach, because only one person is able to access a good view of the anatomy at any one time. With respect to component positioning, there may be a tendency to vertical cup placement early in one's experience. This is avoided by proper location of the skin incision and by use of a dog legged acetabular component inserter that facilitates proper positioning of the component despite the prominence of the distal angle of the skin incision. A tendency to eccentric reaming of the acetabulum may be noted if the proximal femur is not adequately retracted anteriorly. One must beware of the potential for inadvertent levering of the acetabular reamers on the posterior aspect of there tracted femur if the operative surgeon is not performing the reaming of the acetabulum. Particularly in patients who are larger there may be a tendency toward an excessively posterior starting point in the femoral canal when broaching the femoral component. This is best avoided by careful attention at this portion of the procedure to any pressure being applied to the broach handle by the proximal corner of the skin incision. The skin incision must be lengthened at this point if the problem presents. Finally, there remains a risk for proximal skin abrasion, particularly when one is beginning to decrease, the incision length in posterolateral approach to total hip arthroplasty. The evolution of proximal femoral elevators and skin protectors has decreased this risk to an extremely low level.