This document provides an overview of total hip replacement surgery from the perspective of a nursing post-grad. It discusses the common indications for surgery, including arthritis, avascular necrosis, and fractures. It then covers the main surgical approaches - posterior, anterior, and anterolateral - outlining the positioning, incisions, dissections and potential dangers for each. The document concludes by briefly mentioning the goals of surgery, how the procedure is performed, common complications, how the new hip is fixed in place, what is evaluated on post-op x-rays, and allowing for any questions.

1. Jarrad Stevens
Orthopaedic Surgeon
MBBS, ChM, PGDip, FRACS,
FAOrthA
Nursing post-grad Total
hip replacement

2. • Indications
• Anatomy
• Approaches
• Goals
• Surgery
• Complications
• Questions
Intro

3. Indications
• Severe disabling pain
• Severe functional Impairment
• Failed non-operative management

4. Indications
• Typically arthritis: OA, RA, Inflammatory
arthritis

5. Indications
• Typically arthritis: OA, RA, Inflammatory
arthritis
• AVN

6. Indications
• Typically arthritis: OA, RA, Inflammatory
arthritis
• AVN
• Fracture

7. Indications
• Typically arthritis: OA, RA, Inflammatory
arthritis
• AVN
• Fracture
• Tumour

8. Indications
• Typically arthritis: OA, RA, Inflammatory
arthritis
• AVN
• Fracture
• Tumour
• Revision

9. Indications
• Typically arthritis: OA, RA, Inflammatory
arthritis
• AVN
• Fracture
• Tumour
• Revision

10. Anatomy

11. Anatomy

12. Approaches
• Anterior
• Posterior
• Lateral

13. • Most common approach world wide
• Extensile
• Abductor sparing
• No internervous plane
Posterior Approach

14. Position: lateral decubitus
Landmarks: greater trochanter
Incision: 10-15 cm curved incision centred on posterior aspect of GT
Internervous plane: none
Dissection:
- Superficial: incise fascia lata in line with skin incision and split fibres of gluteus
maximus with blunt dissection
Posterior Approach

15. Dissection:
- Deep:
- Retract gluteus maximus
- Sciatic nerve crosses the short external
rotators encased in fatty tissue. Push
the fat posteromedially and place
retractors in the substance of gluteus
maximus
- Internal rotation (move operative field
further from sciatic nerve)
Posterior Approach

16. Dissection:
- Deep:
- Retract gluteus maximus
- Sciatic nerve crosses the short external
rotators encased in fatty tissue. Push
the fat posteromedially and place
retractors in the substance of gluteus
maximus
- Internal rotation (move operative field
further from sciatic nerve)
- Stay sutures to piriformis and obturator
internus, detach, reflect
- May take upper part of quadratus
femoris (vascular +++)
Posterior Approach

17. Dissection:
- Deep:
- Retract gluteus maximus
- Sciatic nerve crosses the short external
rotators encased in fatty tissue. Push
the fat posteromedially and place
retractors in the substance of gluteus
maximus
- Internal rotation (move operative field
further from sciatic nerve)
- Stay sutures to piriformis and obturator
internus, detach, reflect
- May take upper part of quadratus
femoris (vascular +++)
- Capsulotomy
- IR to dislocate
Posterior Approach

18. Dangers:
- Nerves:
- Sciatic nerve
- Vessels:
- Inferior gluteal artery
Posterior Approach

19. Position: supine
Landmarks: ASIS, iliac crest
Incision: Long incision; Anterior ½ iliac crest to ASIS, then vertically for 8-10 cm
Anterior Approach

20. Position: supine
Landmarks: ASIS, iliac crest
Incision: over the belly of TFL 5cm distal and 2cm lateral to ASIS: between femoral and
superior gluteal nerves
Anterior Approach

21. Dissection:
- Superficial:
- ER to make sartorius more
prominent
- Identify gap b/n TFL & sartorius (2-
3 inches below ASIS)
Anterior Approach

22. Dissection:
- Superficial:
- ER to make sartorius more
prominent
- Identify gap b/n TFL & sartorius (2-
3 inches below ASIS)
- Dissect through fat along
intermuscular interval
- Avoid LFCN
Anterior Approach

23. Dissection:
- Superficial:
- ER to make sartorius more
prominent
- Identify gap b/n TFL & sartorius (2-
3 inches below ASIS)
- Dissect through fat along
intermuscular interval
- Avoid LFCN
- Dissect deep fascia on medial side
of gluteus medius; stay within
fascial sheath to avoid LFCN
Anterior Approach

24. Dissection:
- Superficial:
- ER to make sartorius more
prominent
- Identify gap b/n TFL & sartorius (2-
3 inches below ASIS)
- Dissect through fat along
intermuscular interval
- Avoid LFCN
- Dissect deep fascia on medial side
of gluteus medius; stay within
fascial sheath to avoid LFCN
- Retract sartorius (F.N) medially and
TFL (S.G.N) laterally
- Ligate ascending branch of LFCA
Anterior Approach

25. Dissection:
- Deep:
- Identify plane b/n rectus femoris
(F.N) and gluteus medius (S.G.N)
Anterior Approach

26. Dissection:
- Deep:
- Identify plane b/n rectus femoris
and gluteus medius
- origins, then retract medially
Anterior Approach

27. Dissection:
- Deep:
- Identify plane b/n rectus femoris
and gluteus medius
- Retract gluteus medius laterally
- Hip capsule on view
- Retract iliopsoas medially
- Adduct & ER
- Capsulotomy
- ER to dislocate
Anterior Approach

28. Dangers:
- Nerves:
- Lateral femoral cutaneous nerve
- Femoral nerve
- Vessels:
- Ascending branch of the lateral femoral circumflex artery
- Higher rate of fractures
Anterior Approach

29. Position: supine or lateral decubitus
Landmarks: ASIS, GT, femoral shaft, vastus lateralis ridge
Incision: thigh flexed 30, adducted; 8-15 cm incision centred on tip of GT (crossing
posterior 1/3 of GT)
Internervous plane: none
Intermuscular plane: between tensor fascia latae and gluteus medius
Anterolateral Approach

30. Dissection:
- Superficial:
- Incise fat, clear it off the fascia lata
- Incise fascia lata at posterior border of
GT, heading proximally and anteriorly
towards ASIS, then distally and slightly
anteriorly
Anterolateral Approach

31. Dissection:
- Superficial:
- Incise fat, clear it off the fascia lata
- Incise fascia lata at posterior border of
GT, heading proximally and anteriorly
towards ASIS, then distally and slightly
anteriorly
- Retract fascia lata and TFL anteriorly
- Retract gluteus medius & minimus
posteriorly
- Locate and develop the interval b/n TFL
and gluteus medius (crossed by series of
vessels which require ligation/cautery)
- External rotation
- Identify origin of vastus lateralis, incise
it, and reflect inferiorly ~1cm
- Blunt dissection up the anterior joint
capsule, lifting off the fat pad
Anterolateral Approach

32. Dissection:
- Deep:
Involves detaching abductor mechanism
1. Trochanteric Osteotomy
Anterolateral Approach

33. Dissection:
- Deep:
Involves detaching abductor mechanism
1. Trochanteric Osteotomy
1. Partial detachment of abductor
mechanism
Anterolateral Approach

34. Dissection:
- Deep:
Involves detaching abductor mechanism
1. Trochanteric Osteotomy
1. Partial detachment of abductor
mechanism
Detach reflected head of rectus femoris
Elevate psoas tendon from capsule
Anterolateral Approach

35. Dissection:
- Deep:
Involves detaching abductor mechanism
1. Trochanteric Osteotomy
1. Partial detachment of abductor mechanism
Detach reflected head of rectus femoris
Elevate psoas tendon from capsule
Capsulotomy
Dislocate hip by ER
Anterolateral Approach

36. Dangers:
- Nerves:
- Femoral nerve
- Vessels:
- Femoral artery & vein
- Profunda femoris artery
- Femoral shaft fractures
- During external rotation to dislocate the hip
- Need adequate capsular release
Associated with Trendelenberg Gait
Anterolateral Approach

37. Goals of Surgery
• High functioning, pain free, stable joint
without infection

38. How is the surgery performed

39. Complications
• Bleeding, fracture, damage to nerve, leg
length discrepancy, dislocation

40. How is the hip fixed into place?

41. What do we look for on X-ray

42. What do we look for on X-ray

43. What do we look for on X-ray

44. What’s new

45. Questions