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Minimally invasive anterolateral total hip arthroplasty on a standard operating table using a two-tined retractor and a double offset broach handle

Tsuyoshi Nakai* and Masaaki Kakiuchi **

*Department of Orthopaedic Surgery, Itami City Hospital
** Department of Orthopaedic Surgery, Osaka Police Hospital

Address for Correspondence:
Tsuyoshi Nakai
Department of Orthopaedic Surgery, Itami City Hospital

1-100 Koyaike, Itami City, Hyogo, 664-8540, Japan
Fax     : 81-72-781-9888



An anterolateral approach is in use for minimally invasive total hip arthroplasty. This approach uses an intermuscular plane between the tensor fasciae lata and gluteus medius.  To our knowledge, although a technique has been reported in a lateral decubitus position, no report has been made in a supine position on a standard operating table.  We describe a minimally invasive total hip arthroplasty technique done through an anterolateral approach on a supine position.

J.Orthopaedics 2009;6(3)e10


minimally invasive total hip arthroplasty; supine position; anterolateral approach; instrument


Total hip arthroplasty (THA) remains one of the most successful surgeries done by orthopaedic surgeons through a variety of surgical approaches.  Recently, minimally invasive hip arthroplasties have been in popularity, done with a variety of surgical approaches (1,2,3,4).  Surgical approaches and implant positioning have been recognized as factors influencing hip arthroplasty stability.  There is some agreement that “minimally invasive approach” refers to minimizing soft tissue damage during THA.  Kim and Heinz reported anterolateral mini-incision hip replacement surgery in a lateral decubitus position which the posterior capsule intact so that posterior dislocation could be minimized (5).  However, it is still difficult to check leg length discrepancy because of a lateral decubitus position.  The purpose of this article is to describe in detail anterolateral approach using a standard operating room table on a supine position.

Technical note:
The anterolateral approach for total hip arthroplasty is performed in a supine position on a standard operating room table.  The perineum is placed at the break in the foot of the bed so that when the foot of the bed is lowered, hip extension will result.  Before draping, the nonoperative hip was placed in abduction position on the table.  This will later allow more adduction of the operative leg.  Pneumatic compression boots were applied to nonoperative leg for intraoperative deep venous thrombosis prophylaxis.  The operative leg is completely draped free into the field to allow full range of motion of the hip during the surgery.  Preoperative templating of radiographs gave an initial plan for acetabular shell size, level of neck cut, femoral stem size, and head-neck length.  The anterolateral approach is a modification of the Watson-Jones approach using the proximal portion.  An incision is made that begins 3 to 4 cm posterior to the anterior superior iliac spine.  The incision is the extended slightly obliquely in a posterior direction for 8 to 10cm.  Dissection is carried out down in the Watson-Jones interval.  This anterolateral approach to THA, which exploits the interval the tensor fasciae lata and gluteus medius muscle for both acetabular and femoral preparation, allows for primary exposure of the hip joint capsule without any muscle damage.  The tensor fasciae lata, rectus femoris, and gluteus medius are retracted, but not cut.  The anterior hip capsule can be excised.  After releasing the hip capsule, the femoral neck osteotomy, and removing the femoral head was made.  Two tined retractor can be placed outside the acetabular labrum posteriorly, but inside the hip capsule and around the posterior acetabulum.  This two-tined retractor has made of different length with 5mm and 10mm tines.  Two versions of this retractor for the left and the right hip exist (Fig).  For left side hip retractor, left side tine is 5mm, and right side tine is 10mm, which facilitate to put the retractor to the posterior acetabulum.   A blunt tipped cobra retractor can then be placed just anterior to the anterior portion of the acetabular fossa around the anteroinferior acetabular wall.  A sharp tipped Hohmann retractor can be placed anterior acetabular wall, in a position that puts it roughly perpendicular to the ilioinguinal ligament.  Thus, view and access to the acetabulum seem to be equal to any other approach for hip arthroplasty.  Cemented as well as uncemented components have been placed through this approach depending on surgeon preference.  The legs are now positioned for femoral preparation.  The nonoperative leg is placed in abduction.  The operative leg is hyperextended, slightly adducted, and externally rotated.  We use an orthpaedic table that the leg support can be broken and flexed independent of the part of the table supporting the patient’s torso.  It is important throughout the femoral portion of the procedure to keep the knee straight.  Flexing the knee will cause increased tension on the rectus femoris muscle and tends to drive the proximal portion of the femur posteriorly, decreasing the exposure.  A two pronged retractor with relatively short tines is then placed on the posteromedial calcar region.  A second two tined retractor, with relatively long tines, is then placed around the outside the greater trochanter.  It is important to place this retractor between the greater trochanter and the hip abductors, but outside the superior hip capsule.  The proximal femur is then pulled anteriorly and laterally with a small bone hook inside the calcar.  It is necessary to release superior and posterosuperior capsule at least all the way back to the posterosuperior corner of the femoral neck.  To minimize the need for elevation of the femur, we use a double offset broach handle with lateral and anterior offset (Fig).   After broaching is complete, the trial femoral neck and head can be placed.  Stability and range of motion can be completely checked easily because the operative leg is draped free.  Leg length can also be checked at the medial malleoli because both are readily palpable in the supine position.  Cemented as well as uncemented components have been placed through this approach depending on surgeon preference.

In summary, minimally invasive anterolateral total hip arthroplasty can be performing safely and precisely on a supine position on a standard operating table using a two tined retractor and double offset broach.

Fig: Two versions of retractor exist for the left and the right hip, for left side hip retractor, left side tine is 5mm, and right side tine is 10mm (lower part).
Double offset broach handle with lateral and anterior offset (upper part).

Reference :

  1. Bal BS, Haltom D, Aleto T, Barrett M.  Early complications of primary total hip replacement performed with a two-incision minimally invasive technique.  Journal of  Bone Joint Surgery (Am ) 2005; 87: 2432-2438.

  2. DiGioia AM , Plakseychuk AY, Levision TJ, Jaramaz B. Mini-incision technique for total hip arthroplasty with navigation.  Journal of Arthroplasty 2003; 18: 123-128.

  3. Wenz JF, Gurkan I, Jibodh SR. Mini-incision total hip arthroplasty: A comparative assessment of perioperative outcomes.  Orthopedics 2002; 25: 1031-1043.

  4. Wright JM, Crockett HC, Delgado S, Lyman S, Madsen M, Sculco TP. Mini-incision for total hip arthroplasty: A prospective, controlled investigation with 5-year follow-up evaluation.  Journal of Arthroplasty 2004; 19: 538-545.

  5. Kim CB, Heinz R. Anterolateral mini-incision hip replacement surgery: A modified Watson-Jones approach.  Clinical Orthopaedics and Related Res earch 2004; 429: 248-255.


This is a peer reviewed paper 

Please cite as: Tsuyoshi Nakai: Minimally invasive anterolateral total hip arthroplasty on a standard operating table using a two-tined retractor and a double offset broach handle

J.Orthopaedics 2009;6(3)e10





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