Orthopedics

Review Article 

Relationship Between Functional Anatomy of the Hip and Surgical Approaches in Total Hip Arthroplasty

Michael D. Ries, MD

Abstract

Multiple surgical approaches have been used successfully for total hip arthroplasty. Minimally invasive surgery, defined by the length of the incision, has been associated with less blood loss and shorter length of stay compared with conventional total hip arthroplasty. Differences in early functional outcomes, as well as the risk of early and long-term complications, have been observed between different anatomic surgical approaches. However, no single surgical approach has been established that achieves both the shortest functional recovery and the lowest rate of complications after total hip arthroplasty. [Orthopedics. 2019; 42(4):e356–e363.]

Abstract

Multiple surgical approaches have been used successfully for total hip arthroplasty. Minimally invasive surgery, defined by the length of the incision, has been associated with less blood loss and shorter length of stay compared with conventional total hip arthroplasty. Differences in early functional outcomes, as well as the risk of early and long-term complications, have been observed between different anatomic surgical approaches. However, no single surgical approach has been established that achieves both the shortest functional recovery and the lowest rate of complications after total hip arthroplasty. [Orthopedics. 2019; 42(4):e356–e363.]

Conventional approaches to the hip for total hip arthroplasty (THA) include the posterior, anterolateral (Watson Jones), lateral (Harding), transtrochanteric, and anterior. More recent variations of these approaches, including the 2 incision, percutaneously assisted total hip arthroplasty (PATH), and direct superior, have been developed in an effort to improve functional outcomes.

Minimally invasive surgery (MIS) techniques have also been developed for THA to reduce postoperative pain and length of stay and to improve functional outcomes. Four meta-analyses and systematic reviews that compare MIS and conventional approaches and 4 that compare various anatomic surgical approaches were recently published.1–8 The findings from these meta-analyses and systematic reviews were analyzed to assess whether the functional outcomes and risk of complications were related to the specific anatomic approach used and the length of the incision.

Summary of Prior Meta-Analyses and Systematic Reviews

The studies cited in the published meta-analyses comparing MIS with conventional THA are shown in Table 1.1–4 These studies primarily compare the effects of a smaller incision on the same surgical approach. Twenty-two studies including 1822 hips were cited in the comparisons of MIS posterior and conventional posterior approaches, 6 studies including 596 hips were cited in the comparisons of MIS anterolateral and conventional anterolateral approaches, and 6 studies including 411 hips were cited in the comparisons of MIS lateral and conventional lateral approaches. No studies compared MIS direct anterior with conventional anterior approaches.

Summary of Studies Cited in Meta-Analyses Comparing Minimally Invasive Surgery With Conventional Total Hip Arthroplasty

Table 1:

Summary of Studies Cited in Meta-Analyses Comparing Minimally Invasive Surgery With Conventional Total Hip Arthroplasty

The studies cited in the published meta-analyses comparing different anatomic surgical approaches are shown in Table 2.5–8 Twenty studies including 1647 hips were cited in the comparisons of posterior and anterior approaches, 6 studies including 512 hips were cited in the comparisons of posterior and lateral approaches, 3 studies including 247 hips were cited in the comparisons of anterior and lateral approaches, and 3 studies including 245 hips were cited in the comparisons of posterior to anterolateral approaches. No studies directly compared lateral and anterolateral approaches.

Summary of Studies Cited in Meta-Analyses Comparing Different Anatomic Surgical Approaches in Total Hip Arthroplasty

Table 2:

Summary of Studies Cited in Meta-Analyses Comparing Different Anatomic Surgical Approaches in Total Hip Arthroplasty

Comparison of MIS With Conventional THA

Imamura et al1 defined MIS as an incision 10 cm or less used for THA. The authors reviewed 15 randomized and 5 quasi-randomized controlled trials, involving 1857 participants. Most studies compared similar approaches with different length incisions. Nine studies compared MIS posterior with conventional posterior, 6 compared MIS anterolateral with conventional anterolateral, 2 compared MIS anterior with conventional anterolateral, 2 compared MIS anterolateral with conventional posterior, and 1 was nonspecified. The authors found no strong evidence either for or against mini-incision (incision length 10 cm or less) compared with standard-incision THA.1

Smith et al2 also conducted a meta-analysis comparing MIS with conventional THA. The randomized and quasi-randomized controlled trials used in the Imamura meta-analysis were included, as well as single arm series. All trials irrespective of whether computer navigation systems were included in the analysis. Studies that used multiple incisions for MIS rather than a single surgical exposure were excluded. The authors included 28 studies and concluded that there was little difference in the clinical or radiological outcomes of MIS compared with conventional THA.2

Xu et al3 performed a meta-analysis of randomized controlled trials (RCTs) that compared MIS with conventional THA. Fourteen RCTs involving THA in 1174 patients met the inclusion criteria. The MIS posterior approach was found to result in less surgical time, less blood loss, and a shorter hospital length of stay.3

Berstock et al4 performed a meta-analysis and systematic review of mini posterior to conventional posterior approaches in THA. Twelve RCTs and 4 non-randomized trials comprising of 1498 THAs were included. The mini-incision posterior approach was associated with reduced operating time and hospital length of stay.4

Comparison of Different Surgical Approaches

Higgins et al5 performed a meta-analysis and systematic review of studies comparing anterior and posterior approaches in THA. Seventeen studies were included, totaling 2302 participants. At short-term follow-up, postoperative pain and function were more favorable with the anterior approach in 4 studies. Pooled estimates showed a shorter length of stay and fewer dislocations with the anterior approach.5

Miller et al6 also performed a meta-analysis of studies comparing anterior and posterior approaches in THA. A total of 13 prospective comparative studies (7 randomized) with 524 anterior and 520 posterior approaches were included. The anterior approach was associated with lower pain severity, lower narcotic use, and improved hip function compared with the posterior approach.6

Berstock et al7 performed a meta-analysis of studies comparing the anterolateral and posterior approaches in the THA. Six prospective studies (including 3 RCTs) involving 517 participants were included. The posterior approach was found to have a reduction in the risk of Trendelenburg gait and stem malposition.7

Putananon et al8 performed a systematic review and network meta-analysis of the anterior, lateral, and posterior approaches in THA. Fourteen RCTs (1017 patients) met the inclusion criteria. Harris Hip scores and visual analog scale scores were highest for the anterior approach, followed by the lateral approach. Postoperative complications were lowest for the posterior approach, followed by the lateral approach, and highest for the anterior approach.8

Findings from the prior published meta-analyses and systematic reviews indicate that MIS (defined by the length of the incision), compared with conventional THA, results in no clinically relevant functional improvement but less blood loss and shorter length of stay.1–4 However, comparisons of different anatomic approaches indicate that functional outcomes can be influenced by the type of surgical approach.5–8 The anterior approach was associated with more favorable early functional outcomes than the posterior approach, and the anterolateral approach was associated with greater limp than the posterior approach. Complications appear to be lowest with the posterior approach and highest with the anterior approach. The favorable outcomes with the direct anterior approach may be associated with the less damage to the surrounding musculature during THA.27

Relevant Surgical Anatomy

The hip is the only joint in the body with 3 muscle layers. The outer layer consists of the tensor and gluteus maximus muscles and the iliotibial (IT) band. The middle layer consists of the gluteus minimus and medius and the vastus lateralis. The deep layer consists of the short external rotators. The gluteus medius is considered the main hip abductor because it is a relatively large muscle that originates on the ilium and inserts on the greater trochanter. In 1953, Pauwels9 described the importance of the hip abductors in maintaining a level pelvis during single-leg stance using a frontal plane free body diagram, which was emphasized by Blount10 in 1956 (Figure 1). The gluteus medius and minimus, which originate on the ilium and insert on the greater trochanter, are considered the main hip abductors. Loss of hip abductors from avulsion of the muscles or the greater trochanter results in a loss in the ability to maintain a level pelvis during the stance phase of gait and a resultant Trendelenburg limp.10

Free body anteroposterior diagram of single leg stance on the right leg. The body weight that is transmitted through the pelvis is represented by a force vector (W). The abductors (A) contract to maintain the pelvis level. The body weight and abductor forces are balanced by the joint reaction force (R).

Figure 1:

Free body anteroposterior diagram of single leg stance on the right leg. The body weight that is transmitted through the pelvis is represented by a force vector (W). The abductors (A) contract to maintain the pelvis level. The body weight and abductor forces are balanced by the joint reaction force (R).

Henry11 proposed that the glutei, tensor fascia lata, and IT band functioned as a pelvic deltoid and disruption of this mechanism may result in weakened abductor function. Lees et al12 measured the cross-sectional area of the hip abductor muscles in a cadaveric study and suggested that the muscles of the pelvic deltoid act as rotators of the hip (internal rotation by tensor fasciae latae and gluteus medius and external rotation by gluteus maximus) and that the function of this group may be likened to the rotator cuff group of the shoulder, stabilizing the femoral head in the acetabulum, similar to the humeral head in the glenoid.

The physiologic cross-sectional area of a muscle can be used as a measure of muscle strength. The abductor moment or relative contribution to hip abduction created by each hip muscle can be approximated by multiplying its cross-sectional area by the moment arm. This would indicate that the gluteus medius is the main hip abductor; the tensor fascia lata would not be expected to be an important hip abductor.12

The tensor fascia lata also does not insert directly onto the femur, so its role in hip abduction might not be expected to be significant. However, Gottschalk et al13 dissected 11 cadavers to define the shape and orientation of the abductor muscles and performed electromyography testing in 10 normal subjects. The authors found that the tensor fascia lata was the main hip abductor and holds the pelvis level during stance. The important role of the tensor fascia lata in hip abduction can be shown on a lateral free body diagram of the pelvis during single-leg stance (Figure 2). Because body weight (W) is transmitted through the spine and pelvis posterior to the hip joint, the pelvis is maintained in a level position by the tensor fascia lata (T), which originates on the anterior pelvis.13,14

Free body lateral diagram of the pelvis during single leg stance shows that the body weight force vector (W) is posterior to the hip joint. The body weight force (W) is balanced by the tensor muscle (T), since it originates on the pelvis anterior to the hip joint.

Figure 2:

Free body lateral diagram of the pelvis during single leg stance shows that the body weight force vector (W) is posterior to the hip joint. The body weight force (W) is balanced by the tensor muscle (T), since it originates on the pelvis anterior to the hip joint.

The main role of the tensor facia lata (as seen on the lateral hip free body diagram; Figure 2) is to balance the posterior upper body weight force; in addition, Henry's deltoid concept suggests that its role is an important component of hip abduction. The tensor fascia lata originates along the anterior ilium and inserts into the intramuscular septum of the femur and Gerdy's tubercle at the tibia.14 The greater trochanter protrudes laterally under the IT band, which creates compression between the greater trochanter and IT band (Figure 3). Tension in the IT band during activities can be considerable, generating friction between the IT band and the greater trochanter, which likely contributes to the many IT band syndromes that have been described.15

The greater trochanter protrudes laterally under the iliotibial (IT) band, similar to the center pole of a tent (A). Although compression force on a tent pole (vertical arrow) is high, the tent roof is supported by tension in tent ropes (downward arrows) and the flaps can be opened easily. A similar analogy may be drawn to the hip in which compression between the greater trochanter and IT band is high but the surrounding muscle fibers of the gluteus maximus and tensor muscle are relatively slack (B). When the hip is viewed from the side, the center of the tent may also be represented by a circle centered over the greater trochanter, whereas the area outside the circle is under less tension. Gluteus and tensor muscle fibers, which originate on the pelvis and insert into the IT band, are oriented such that they are directed relatively centrally toward the greater trochanter (red arrows) (C). The lateral view of the muscle fibers and IT band over the hip may be represented by a circular tent viewed from above the tent, in which the tent is supported by a central pole and tension in multiple tent ropes (blue arrows). The tensile forces in the material at the entrance to the tent is also directed radially from the tent center (black arrows), which results in relatively low tensile forces at an opening in the tent (red arrows). This illustration is intended to show that shear stresses between hip muscle fibers, which attach to the IT band, are relatively low and suggests that the muscle fibers can be separated relatively atraumatically in surgery provided that the IT band over the greater trochanter is preserved (D).

Figure 3:

The greater trochanter protrudes laterally under the iliotibial (IT) band, similar to the center pole of a tent (A). Although compression force on a tent pole (vertical arrow) is high, the tent roof is supported by tension in tent ropes (downward arrows) and the flaps can be opened easily. A similar analogy may be drawn to the hip in which compression between the greater trochanter and IT band is high but the surrounding muscle fibers of the gluteus maximus and tensor muscle are relatively slack (B). When the hip is viewed from the side, the center of the tent may also be represented by a circle centered over the greater trochanter, whereas the area outside the circle is under less tension. Gluteus and tensor muscle fibers, which originate on the pelvis and insert into the IT band, are oriented such that they are directed relatively centrally toward the greater trochanter (red arrows) (C). The lateral view of the muscle fibers and IT band over the hip may be represented by a circular tent viewed from above the tent, in which the tent is supported by a central pole and tension in multiple tent ropes (blue arrows). The tensile forces in the material at the entrance to the tent is also directed radially from the tent center (black arrows), which results in relatively low tensile forces at an opening in the tent (red arrows). This illustration is intended to show that shear stresses between hip muscle fibers, which attach to the IT band, are relatively low and suggests that the muscle fibers can be separated relatively atraumatically in surgery provided that the IT band over the greater trochanter is preserved (D).

Damm et al16 measured hip joint forces and the muscle cross-sectional area in vivo in 10 patients after THA through a direct lateral approach. Hip joint forces increased postoperatively, which was associated with relative atrophy of the gluteus minimus and hypertrophy of the tensor fascia lata, suggesting that the tensor muscle compensates for weak abductors.16

The posterior and anterolateral approaches to the hip share a similar incision through the IT band over the greater trochanter and split the muscle fibers of the gluteus maximus, whereas the anterior approach avoids disruption of the IT band (Figure 4). Minimally invasive posterior and direct lateral approaches also share a similar incision through the IT band over the greater trochanter (Figure 5). Therefore, both minimally invasive and conventional posterior and anterolateral approaches include fasciotomy of the IT band, whereas the anterior approach is IT band sparing.

Lateral diagram of the hip showing the area of high compression between the iliotibial band and greater trochanter (yellow circle) and the superficial muscle dissection for the conventional posterior (P), conventional anterolateral (L), and direct anterior (DA) approaches. The posterior and anterolateral approaches extend through the iliotibial band fascia over the greater trochanter, whereas the DA does not.

Figure 4:

Lateral diagram of the hip showing the area of high compression between the iliotibial band and greater trochanter (yellow circle) and the superficial muscle dissection for the conventional posterior (P), conventional anterolateral (L), and direct anterior (DA) approaches. The posterior and anterolateral approaches extend through the iliotibial band fascia over the greater trochanter, whereas the DA does not.

Lateral diagram of the hip showing the area of high compression between the iliotibial band and greater trochanter (yellow circle) and superficial muscle dissection for mini posterior (MP), mini anterolateral (ML), and mini direct anterior (MDA) approaches. The mini posterior and mini anterolateral approaches extend through the iliotibial band fascia over the greater trochanter, whereas the MDA does not.

Figure 5:

Lateral diagram of the hip showing the area of high compression between the iliotibial band and greater trochanter (yellow circle) and superficial muscle dissection for mini posterior (MP), mini anterolateral (ML), and mini direct anterior (MDA) approaches. The mini posterior and mini anterolateral approaches extend through the iliotibial band fascia over the greater trochanter, whereas the MDA does not.

Approaches other than the direct anterior have been developed that do not violate the IT band over the greater trochanter in an effort to minimize functional impairment after THA. The 2-incision approach used a small direct anterior exposure for insertion of the acetabular component and a second posterior incision proximal to the greater trochanter for insertion of the femoral component (Figure 6).17,18 The PATH approach uses 2 incisions, with 1 proximal and the 1 distal to the greater trochanter.19 Both incisions are in line with a conventional posterior approach (Figure 7). The proximal incision splits the gluteus maximus muscle fibers but does not extend distally into the greater trochanter. The deep dissection transects the short external rotators in the same manner as the posterior approach and is used for preparation and implantation of the femoral component. The distal incision is used to insert the acetabular reamer shaft, whereas the acetabular reamer dome is placed onto the reamer shaft through the proximal incision. The direct superior approach includes the proximal exposure, similar to the PATH approach, with angled acetabular reamers to avoid the need for a second incision distal to the greater trochanter (Figure 8).20,21

Lateral diagram of the hip showing the area of high compression between the iliotibial band and greater trochanter (yellow circle), as well as superficial muscle dissection for the 2-incision approach. Neither incision extends into the iliotibial band fascia.

Figure 6:

Lateral diagram of the hip showing the area of high compression between the iliotibial band and greater trochanter (yellow circle), as well as superficial muscle dissection for the 2-incision approach. Neither incision extends into the iliotibial band fascia.

Lateral diagram of the hip showing the area of high compression between the iliotibial band and greater trochanter (yellow circle), as well as superficial muscle dissection for the percutaneous assisted total hip arthroplasty approach, which uses 2 incisions—1 proximal and 1 distal to the greater trochanter. Neither incision extends into the iliotibial band fascia.

Figure 7:

Lateral diagram of the hip showing the area of high compression between the iliotibial band and greater trochanter (yellow circle), as well as superficial muscle dissection for the percutaneous assisted total hip arthroplasty approach, which uses 2 incisions—1 proximal and 1 distal to the greater trochanter. Neither incision extends into the iliotibial band fascia.

Lateral diagram of the hip showing the area of high compression between the iliotibial band and greater trochanter (yellow circle), as well as superficial muscle dissection for the direct superior approach. A single incision is used, proximal to the greater trochanter, and does not extend into the iliotibial band fascia.

Figure 8:

Lateral diagram of the hip showing the area of high compression between the iliotibial band and greater trochanter (yellow circle), as well as superficial muscle dissection for the direct superior approach. A single incision is used, proximal to the greater trochanter, and does not extend into the iliotibial band fascia.

Results of these IT band–sparing approaches, in terms of functional recovery, have been reported to be favorable and similar to those reported for the anterior approach.17–23 However, the 2-incision approach has been associated with an unacceptable complication rate and has been abandoned by most surgeons.24,25 The direct superior and PATH approaches have been associated with a relatively low complication rate.19,20,22,23 These approaches have similarities to the posterior approach and can be extended into a traditional posterior approach, which has been associated with a low complication rate. However, comparative studies of the functional outcomes of these approaches with the direct anterior and traditional posterior are limited.26

Biomarkers of Muscle Damage

Bergin et al27 measured markers of muscle damage and soft tissue inflammation in 29 patients with a direct anterior approach and 28 with a posterior approach. The increase in the creatine kinase (CK) level in the posterior approach group was 5.5 times higher than that in the anterior approach group. The authors concluded that the anterior approach caused significantly less muscle damage than did the posterior approach. However, Rykov et al28 found no difference in CK and C-reactive protein between 46 patients randomized to either a direct anterior or a posterior approach. The authors suggested that biochemical markers may not be sufficient to differentiate between the levels of invasiveness of the different approaches.28

Poehling-Monaghan et al29 found lower elevations of CK levels in 50 patients having the direct anterior approach compared with 50 with a mini-posterior approach. However, serum markers were not correlated with early functional outcomes and the authors concluded that the reporting of serum biomarkers as a measure of physiological burden after orthopedic surgical procedures should be viewed as suspect until clear linear or threshold values are established.29

Suzuki et al30 found higher CK and erythrocyte sedimentation rate levels in 58 conventional posterior approach THAs compared with 36 mini-incision posterior approach THAs. However, Fink et al31 found no difference in serum markers of muscle damage in 50 patients treated with a minimally invasive posterior approach compared with 50 patients who had a conventional posterior approach.

De Anta-Díaz et al32 found significantly higher mean levels of interleukin-6 and -8 and CK after THA through a lateral approach in 49 patients compared with the anterior approach in 50 patients in an RCT. However, Mjaaland et al33 compared markers for muscle damage, inflammation, and pain in an RCT of 83 patients with a direct anterior approach and 80 with an anterolateral approach for THA. The direct anterior approach was associated with less pain, but higher postoperative levels of CK. The authors suggested that muscle compression caused by retraction during the direct anterior approach might result in greater muscle damage than muscle dissection during the anterolateral approach.33

These studies demonstrate no consistent trend in serum markers of muscle damage, which suggests that other methods may be needed to compare differences in muscle and tendon trauma between the various surgical approaches. Amanatullah et al34 assessed muscle damage between direct anterior and direct superior approaches using a cadaver model. The direct anterior approach was associated with substantially greater damage to the gluteus minimus muscle and tendon when compared with the direct superior approach. The tensor fascia lata and rectus femoris muscles were damaged only in the direct anterior approach. There was no difference in the amount of damage to the gluteus medius muscle and tendon, piriformis tendon, obturator internus tendon, obturator externus tendon, or quadratus femoris muscle between approaches.34

Discussion

Minimally invasive surgery for THA can be defined by the length of the incision, usually 10 cm or less.1 Specialized instruments for MIS have been developed to allow the surgery to be done though a conventional anatomic approach but with a smaller incision. Minimally invasive surgery has been advocated to reduce pain and improve functional recovery after THA. Pooled data demonstrate that MIS techniques are helpful to reduce postoperative blood loss and length of stay, but do not improve functional recovery compared with conventional exposures.1–4

Multiple approaches have been used for THA, including the posterior, anterolateral (Watson Jones), lateral (Harding), transtrochanteric, and anterior approaches. Comparisons of different anatomic approaches indicate that functional outcomes can be influenced by the type of surgical approach.5–8 The anterior approach is associated with more favorable early functional outcomes than the posterior approach.5,6 More recent modifications in exposure options since the development of MIS techniques include the 2-incision, PATH, and direct superior approaches.17–23 These approaches, as well as the direct anterior approach, avoid fasciotomy of the IT band.

The gluteus medius and minimus are considered the main hip abductors. However, the tensor fascia lata also contributes substantially to hip abduction because it originates on the anterior ilium and balances the weight of the upper body, which is transmitted through the posterior pelvis.13 Therefore, the IT band–sparing approaches may be beneficial in permitting more rapid functional recovery after THA.

The surgical approach used should be both safe and efficacious. The anterior approach has been shown to be associated with more rapid functional recovery, but also with a higher rate of complications compared with the posterior approach.8 Complications appear to be higher during the learning curve (50 to 100 cases). The risk of complications may be mitigated by appropriate patient selection for the anterior approach and surgical training in the technique. Many orthopedic residency and fellowship programs now include teaching in the anterior approach. However, the 2-incision approach, which had been advocated to have similar benefits to the direct anterior approach, has largely been abandoned as a result of an unacceptable complication rate.24,25

The direct lateral approach is associated with a higher risk of limp than the posterior approach, which is likely related to the surgical separation and repair of the abductors in the direct lateral approach.7 The posterior approach has been shown to have the lowest complication rate.8 This is typically also used for more complex cases and revisions because it is the most extensive approach.

The IT band–sparing approaches, including the direct superior and PATH, which can be extended into a traditional posterior approach, may offer favorable early recovery with a low rate of complications. However, clinical outcomes with these IT band–sparing approaches have not been studied as extensively as the direct anterior approach. The safety and efficacy of these approaches will be proven only when more clinical and functional outcome data become available on these IT band–sparing approaches.

Methods to measure functional outcomes after THA include the Harris Hip score, Short Form-12 or -36, Hip Outcome Score, Western Ontario and McMasters University Arthritis Index, Hip disability and Osteoarthritis Outcome Score, Merle d'Aubigne and Postel score, UCLA Activity Scale, Oxford Hip Score (OHS), and Japanese Orthopedic Association Hip Score.5 Gait analysis can be used to assess clinical effects of muscle function. Serum biomarkers of muscle damage and inflammation, including CK, creatine phosphokinase, C-reactive protein, erythrocyte sedimentation rate, interleukins (IL-1, IL-6, IL-8, IL-10, IL-12, IL-1β), and tumor necrosis factors, have been used to assess muscle trauma associated with different approaches after THA.27–33 However, a correlation between serum biomarker levels and measures of functional outcome after THA has not been established, so the value of data obtained from biomarker studies is limited. The direct superior approach seems to result in less muscle damage in vitro; however, evidence of its clinical efficacy and outcomes are lacking in published orthopedic literature.

Surgeons have varying levels of training and experience with the different approaches to the hip. Differences in functional outcomes observed between surgical approaches have been reported up to 90 days after THA.5,6 However, complications can result in re-operations and long-term functional impairment. No single surgical approach has been established to achieve both the shortest functional recovery and lowest rate of complications after THA.

Conclusion

Comparisons of MIS with standard length surgical approaches and comparisons of different anatomic surgical approaches used for THA indicate that functional outcomes are influenced more by the anatomic approach used than the length of the incision. Surgical approaches that avoid dissection of the IT band (IT band–sparing approaches) may permit earlier functional recovery than surgical approaches that require IT band dissection directly over the greater trochanter.

References

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Summary of Studies Cited in Meta-Analyses Comparing Minimally Invasive Surgery With Conventional Total Hip Arthroplasty

Surgical ApproachConventional Posterior (No. of Hips)Conventional Lateral (No. of Hips)Conventional Anterolateral (No. of Hips)Conventional Unspecified (No. of Hips)
Minimally invasive surgery posteriorChimento (60)1–4; Chung (120)1,4; Dorr (60)1–4; Farr (216)1,4; Hart (120)1,3,4; Kim (140)1–4; Kiyama (20)1,4; Ogonda (219)1–4; Pneumaticos (52)1; Sharma (40)1,4; Bennett (95)2; Goosen (60)2–4; Lafosse (110)2; Lawlor (219)2; Shitama (23)2–4; Woolson (135)2; Wright (84)2,4; Roy (56)3; Khan (100)4; Varela-Egocheaga (50)4; Fink (100)4; DiGioia (70)4Total (1822)Mow (32)2; Vincente (76)2; Wenz (189)2; Wohlrab (50)2Total (347)Rittmeister (152)2Total (152)
Minimally invasive surgery lateralCharles (40)1; Dutka (120)1; Sperenza (90)1–3; Szemdroi (59)2; Mazoochian (52)3; Varela (50)3Total (411)Pour (100)1Total (100)
Minimally invasive surgery anterolateralYang (110)1–3; Lafosse (100)2Total (210)Popischill (40)1–3; Leuchte (32)2Total (72)Chen (166)2; Goosen (60)2; Howell (107)2; Kubes (80)2; Pfluge (100)2; Martin (83)3Total (596)Sculco (84)2Total (84)
Minimally invasive surgery direct anteriorZhang (120)1Total (120)Rachbauer (120)1Total (120)
Minimally invasive surgery unspecifiedKhan (100)1Total (100)

Summary of Studies Cited in Meta-Analyses Comparing Different Anatomic Surgical Approaches in Total Hip Arthroplasty

Surgical ApproachLateral (No. of Hips)Anterolateral (No. of Hips)Anterior (No. of Hips)Two Incision (No. of Hips)
PosteriorBaker (50)7; Weale (44)7; Downing (100)7; Teratani (60)7; Ji (198)7,8; Witzleb (60)7,8Total (512)Meneghini (15)8; Gossen (120)8; Yang (110)8Total (245)Barrett (87)5,6,8; Rathod (22)5; Rodriguez (120)5,6; Maffiuletti (34)5; Martin (88)5; Nakata (195)5; Spaans (92)5; Sugano (72)5; Zawadsky (100)5; Bergin (57)6; Cheng (72)6,8; Christensen (51)6,8; Engdal (39)6; Hananouchi (40)6; Luo (104)6; Petis (80)6; Poehling-Monaghan (100)6; Taunton (54)6,8; Zhang (120)6; Zhao (120)6Total (1647)Meneghini (16)8; Della Valle (72)8Total (88)
LateralRestrepo (100)8; Mjaaland (63)8; Parvizi (84)8Total (247)
AnterolateralMayr (33)8Total (33)Meneghini (15)8Total (15)
Authors

The author is from Reno Orthopaedic Clinic, Reno, Nevada; and the Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California.

Dr Ries is a paid consultant for Stryker and Smith & Nephew.

Correspondence should be addressed to: Michael D. Ries, MD, Reno Orthopaedic Clinic, 555 N Arlington Ave, Reno, NV 89503 ( riesm@orthosurg.ucsf.edu).

Received: June 10, 2018
Accepted: September 12, 2018

10.3928/01477447-20190624-03

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