Direct Anterior Approach to Hip Resurfacing Arthroplasty

Hip resurfacing arthroplasty remains an appealing option for young and active patients¹, but its use has declined because of technical challenges, risks of femoral neck notching, and adverse reactions associated with metal-on-metal bearings, raising concerns regarding long-term implant survival². Accurate preparation of the femoral head and acetabulum is critical for successful outcomes³. In the present video article, we describe a reproducible technique utilizing preoperative 3D computed tomography (CT)-based planning and patient-specific 3D-printed jigs to optimize femoral head preparation, in conjunction with a direct anterior approach that preserves tendon attachments and avoids muscle injury.

Through a standard anterolateral skin incision and fascial split, the tensor fasciae latae (TFL) is mobilized by blunt finger dissection up to the anterior superior iliac spine while maintaining its fascial origin. The superficial internervous plane is created between the TFL laterally and the sartorius medially. Dissection proceeds in the deep interval between the gluteus medius and rectus femoris, with care to preserve the ascending branches of the lateral circumflex femoral vessels. The approach continues to the hip joint capsule, which is sharply incised to allow femoral head dislocation. Femoral head preparation is guided by patient-specific 3D-printed jigs generated from preoperative CT scans. Each jig provides a reproducible entry point and trajectory for a Steinmann pin, ensuring central alignment and avoiding femoral neck notching. Sequential reaming, chamfer cuts, and trialing are performed. The acetabulum is exposed with 3 retractors (anterior and inferior Hohmann and posterior curved 2-pronged) and progressively reamed without fluoroscopy until congruent hemispherical coverage is achieved. A press-fit cup is implanted without cement, followed by cementation of the femoral component with use of a dry-field technique. Stability and leg length are reassessed, and closure is performed in layers with barbed absorbable sutures and a waterproof dressing. If intraoperative stability or leg length restoration is found to be unsatisfactory, adjustments are made prior to final implantation. This may include repositioning of the acetabular component, upsizing or adjusting the femoral component, or performing additional soft-tissue release to achieve proper balance. Cementation of the definitive implants and closure are only performed once stability and length are confirmed in all functional positions.

Conventional resurfacing techniques rely on intraoperative fluoroscopy, mechanical alignment guides, or freehand pin placement for femoral head preparation. Compared with these methods, 3D-printed patient-specific jigs minimize intraoperative fluoroscopy, standardize pin trajectory, and reduce the risk of malalignment and implant mispositioning. Similarly, total hip arthroplasty remains a well-established alternative to hip resurfacing, providing predictable pain relief and functional outcomes, although with greater bone resection and different long-term considerations.

Patient-specific jigs derived from CT-based planning provide individualized guidance that restores native femoral head-neck orientation in slight valgus, reducing the risk of femoral neck notching and improving component survival. The minimally extensile direct anterior approach minimizes soft-tissue damage while ensuring adequate exposure of both the femoral and acetabular sides.

Patients may expect early postoperative weight-bearing, decreased need for analgesia, and comparable short-term functional outcomes. Patients may expect a more extensile incision, for adequate manipulation and dislocation of the femoral head, compared with the standard Smith-Petersen approach performed for conventional total hip arthroplasty^3,4. There is limited visualization of the superolateral aspect of the femur and posterolateral aspect of the acetabulum compared with the posterior approach, which may result in longer operative time because of technical challenges. Possible complications of the procedure are femoral neck fracture, component malpositioning, and lateral femorocutaneous nerve paresthesia⁴, which itself is not associated with a limitation in function^5,6. In addition, femoral nerve palsy as a result of inaccurate placement of retractors is a dreaded complication. Other potential complications associated with this procedure include metal-on-metal reactions (when applicable), dislocation, procedure failure requiring conversion to total hip arthroplasty, superficial or deep infection, hemorrhage, and other related adverse events. In a recent study conducted at our institution but not yet published, the revision rate was 10% at a median follow-up of 17 months, with the most common reason for revision being postoperative femoral neck fracture. Additional findings included a Forgotten Joint Score of 67% at 1 year postoperatively, closely matching the 68% reported in recent total hip arthroplasty studies^8,9. The mean blood loss was 118.75 mL, and the mean length of hospital stay was 2.25 days.

The anterior approach requires meticulous dissection and hemostasis.The anterior approach is conducted with minimal exposure, requiring careful manipulation to release the capsule.The use of 3D models is essential for accurate guidewire placement and alignment and for achieving a precise fit of ceramic or metal heads.Finger dissection of the TFL up to the anterior superior iliac spine avoids detachment and preserves muscle integrity.The posterior curved 2-pronged retractor exposes the posterior acetabulum and displaces the femoral head posteriorly, creating a working space and protecting cancellous bone.Ensure meticulous drying of the femoral head before cementation to optimize fixation.During acetabulum reaming, the reamer head can be introduced first, followed by attachment of the handle, in order to maximize clearance in tight spaces.

CT = computed tomographyASIS = anterior superior iliac spine.