Modified less invasive and bloodless lateral hip approach for total arthroplasty

  • Nikolaos A. ChristodoulouEmail author
  • Konstantinos P. Dialetis
  • Georgios K. Gouzias
  • Thomas Ch. Georgas
  • Ageliki Stavrianou
Technical Note


In traditional lateral transgluteal Hardinge approach (HA), if it is extended, injury of superior gluteal nerve branches or lateral circumflex artery at the anterior part of vastus lateralis region may occur. Our modified bloodless “Thomine et al.” R (TA) hip approach is characterized apart from no extension into vastus lateralis by a) skin incision of about 18–20% of subgroin perimeter of the thigh, b) adaptable elevation and reinsertion of the anterior bloodless and mechanically not significant part of gluteus medius muscle, c) use of two 6 mm in diameter external fixator pins over the acetabular rim to protect soft tissue during surgery. The purpose of this study is to present this surgical technique and analyze the results of 64 modified TA approach cases in 55 patients (47women and 8 men) with adaptable skin incision, mean: 12 cm (range, 8–15 cm) in comparison with 97 HA cases in 88 patients (79 women and 9 men) with traditional skin incision, mean: 18 cm (range, 16–24 cm). Harris hip score and peri-operative complications were similar in both groups but peri-operative blood loss was significantly eliminated in TA group. Pre-operative Trendelenburg sign positive in 7 hips of TA group and in 13 hips of HA group was ameliorated in all cases at 3 months post-operative followup except one TA and three HA cases with mal technique in obese patients. The modified Thomine et al. lateral hip approach has the advantages of minimal blood loss and no abduction or permanent limp problems.


Hip artrhoplasty Lateral approach MIS 


Conflict of interest

No funds were received in support of this study.


  1. 1.
    Barton C, Kim PR (2009) Complications of the direct anterior approach for total hip arthroplasty. Orthop Clin North Am 40:371–375PubMedCrossRefGoogle Scholar
  2. 2.
    Bauer R, Kerschbaumer F, Poisel S (1979) The transgluteal approach to the hip joint. Arch Orthop Traumat Surg. 95:47–49CrossRefGoogle Scholar
  3. 3.
    Chen DW, Hu CC, Chang YH, Yang WE, Lee MS (2008) Comparison of clinical outcome in primary total hip arthroplasty by conventional anterolateral transgluteal or 2-incision approach. J Arthroplasty 24:528–532PubMedCrossRefGoogle Scholar
  4. 4.
    Christodoulou NA, Dialetis KP, Christodoulou AN (2010) High hip center technique using a biconical threaded Zweymuller cup in osteoarthritis secondary to congenital hip disease. Clin Orthop Relat Res. 468:1912–1919PubMedCrossRefGoogle Scholar
  5. 5.
    Dall D (1986) Exposure of the hip by anterior osteotomy of the greater trochanter:a modified anterolateral approach. J Bone Joint Surg Br 68:382–386PubMedGoogle Scholar
  6. 6.
    Dujardin F, Mure JP, Roussignol X, Lukasiewitch M, Toupin JM, Beccari R, Duparc F, Thomine JM (2007) Approach of the hip joint by anterior hemyotomy of gluteus medius. Approach of Thomine. Interact Surg 2:144–148CrossRefGoogle Scholar
  7. 7.
    Dupark F, Thomine JM, Dujardin F, Durand C, Lukaziewicz M, Muller JM, Freger P (1997) Anatomic basis of the transgluteal approach to the hip-joint by anterior hemimyotomy of the gluteus medius. Surg Radiol Anat 19:61–67CrossRefGoogle Scholar
  8. 8.
    Eyb R (1985) Clinical results following the transgluteal and anterolateral (Watson-Jones) approach to hip prosthesis implantation. Z Orthop Ihre Grenzeb 123:966–968CrossRefGoogle Scholar
  9. 9.
    Fehring TK, Mason B (2005) Catastrophic complications of minimally invasive surgery. JBJS Am 87:711–714CrossRefGoogle Scholar
  10. 10.
    Garcia Juarez JD, Bravo Bernabe PA, Garcia-Hernandez A, Davila Sheldon OE (2008) Complications on minimal access surgery for total hip arthroplasty. Acta Ortop Mex 22:145–149PubMedGoogle Scholar
  11. 11.
    Hardinge K (1982) The direct lateral approach to the hip. J Bone Joint Surg Br 64:17–19PubMedGoogle Scholar
  12. 12.
    Ηead WC, Mallory TH, Becklarich FM, Dennis DA, Emerson RH, Wapner KL (1987) Osteotomy of anterior trochanter in direct lateral approach. J Arthroplasty 2:265–273CrossRefGoogle Scholar
  13. 13.
    Hourlier H (2006) A modified, direct-lateral, minimally invasive approach to the hip. Surgical technique and preliminary results of 103 cases. Interact Surg 1:27–32CrossRefGoogle Scholar
  14. 14.
    Huo MH, Gilbert NF (2005) Complications of minimal incision total hip arthroplasty. Int Orthopaedics 16:18–20Google Scholar
  15. 15.
    Joseph B (1998) Treatment of internal rotation gait due to gluteus medius and minimus overactivity in cerebral palsy: anatomical rationale of a new surgical procedure and preliminary results in twelve hips. Clin Anat 11:22–28PubMedCrossRefGoogle Scholar
  16. 16.
    Khan T, Knowles D (2009) Damage to the superior gluteal nerve during the direct lateral approach to the hip: a cadaveric study. J Arthroplasty 22:1198–1200CrossRefGoogle Scholar
  17. 17.
    Κiyama T, Naito M, Shitama H, Shinoda T, Maeyama A (2008) Comparison of skin blood flow between mini- and standard-incision approaches during total hip arthroplasty. J Arthroplasty 23:1045–1049CrossRefGoogle Scholar
  18. 18.
    Masonis JL, Bourne RB (2002) Surgical approach, abductor function, and total arthroplasty dislocation. Clin Orthop Relat Res 405:46–53PubMedCrossRefGoogle Scholar
  19. 19.
    McGrory BJ, Finch ME, Furlong PJ, Ruterbories J (2008) Incision length correlates with patient weight, height, and gender when using a minimal-incision technique in total hip arthroplasty. J Surg Orthop Adv 17:77–81PubMedGoogle Scholar
  20. 20.
    Migaud H, Girard J, Soenen M (2007) What is the best approach for total hip replacement? Careful assessment of data reported by French promoting experts. Interact Surg 2:155–159CrossRefGoogle Scholar
  21. 21.
    Mow CS, Woolson ST, Ngarmukos SG, Park EH, Lorenz HP (2005) Comparison of scars from total hip replacements done with a standard or a mini-incision. Clin Orthop Relat Res 441:80–85PubMedCrossRefGoogle Scholar
  22. 22.
    O’Brien DA, Rorabeck CH (2005) The mini-incision direct lateral approach in primary total hip arthroplasty. Clin Orthop Relat Res 441:99–103PubMedCrossRefGoogle Scholar
  23. 23.
    Paillard H (2007) Hip replacement by a minimal anterior approach. Hip replacement by a minimal anterior approach. Int Orthop 31:13–15CrossRefGoogle Scholar
  24. 24.
    Picado Celso HF, Garcia Flavio L, Marques Wilson Jr (2007) Damage to the superior gluteal nerve after direct lateral approach to the Hip. Clin Orthop Relat Res 455:209–211PubMedCrossRefGoogle Scholar
  25. 25.
    Ploumis K, Tapsis I, Papageorgiou, Terzidis I, Pouliopoulos D, Christodoulou A (2003) Comparative study between posterior and lateral approach of total hip arthroplasty in patients with osteoarthritis. J Bone Joint Surg Br. 85:Supp. III, 225–226Google Scholar
  26. 26.
    Pospischill M, Kranzl A, Attwenger B, Knahr K (2010) Minimal invasive comparative with transgluteal approach for total hip arthroplasty. J Bone Joint Surg Am 92:328–337PubMedCrossRefGoogle Scholar
  27. 27.
    Ramesh M, O’Byrne JM, McCarthy N, Jarvis A, Mahalingham K, Cashman WF (1996) Damage to the superior gluteal nerve after the Hardinge approach to the hip. J Bone Joint Surg 78:903–906CrossRefGoogle Scholar
  28. 28.
    Siebenrock KA, Rosler KM, Gonzalez E, Ganz R (2000) Intraoperative electromyography of the superior gluteal nerve during lateral approach to the hip for arthroplasty: a prospective study of 12 patients. J Arthroplasty 15:867–870PubMedCrossRefGoogle Scholar
  29. 29.
    Soni RK (1997) An anterolateral approach to the hip joint. Acta Orthop Scand 68:490–494PubMedCrossRefGoogle Scholar
  30. 30.
    Svensson O, Skold S, Blomgren G (1990) Integrity of the gluteus medius after the transgluteal approach in total hip arthroplasty. J Arthroplasty 5:57–60PubMedCrossRefGoogle Scholar
  31. 31.
    Thomine JM, Dupark F, Dujardin F, Biga N (1999) Gluteus medius hemiotomy for transgluteal approach of the hip. Revue Chir Orthop 85:520–525Google Scholar
  32. 32.
    Wayne N, Stoewe R (2009) Primary total hip arthroplasty: a comparison of the lateral Hardinge approach to an anterior mini-invasive approach. Orthopedic Reviews. 1, No 2 doi: 10.4081/or2009.e27
  33. 33.
    Woolson ST, Mow CS, Syquia JF, Lannin JV, Schurman DJ (2004) Comparison of primary total hip replacements performed with a standard incision or a mini-incision. J Bone Joint Surg Am 86:1353–1358PubMedGoogle Scholar
  34. 34.
    Zweymuller KA, Steindl M, Schwarzinger U (2007) Good stability and minimal osteolysis with a biconical threaded cup at 10 years. Clin Orthop Relat Res 463:128–137PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Nikolaos A. Christodoulou
    • 1
    • 2
    Email author
  • Konstantinos P. Dialetis
    • 1
  • Georgios K. Gouzias
    • 1
  • Thomas Ch. Georgas
    • 1
  • Ageliki Stavrianou
    • 1
  1. 1.Orthopaedic Department of Karpenissi HospitalKarpenissiGreece
  2. 2.AthensGreece

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