The Experts Offer Their Tips for Primary THA

    Dr. Bernard Stulberg and Dr. Richard Berger share their top 5 “moves” in the OR when performing a primary total hip arthroplasty.

    Primary total hip arthroplasty (THA) is one of the most successful orthopaedic procedures, allowing patients to regain functioning while also alleviating pain. The Lancet has even called THA “the operation of the century.” [1]

    At the ICJR’s annual Winter Hip & Knee Course, 2 surgeons experienced in THA– Bernard N. Stulberg, MD, from St. Vincent Charity Medical Center in Cleveland, Ohio, and Richard A. Berger, MD, from Rush University Medical Center in Chicago, Illinois – offered advice in the form of their top 5 “moves” in the operating room when performing a primary THA.

    Dr. Stulberg discussed 5 important points surgeons should be aware of when learning the direct anterior approach:

    • Find the right landmarks. The landmarks will seem different with the direct anterior approach, and the surgeon should not hesitate to use imaging early in the learning curve to confirm structures.
    • Understand the releases. As Dr. Stulberg explained, there are 3 releases needed to help with visualization of the capsule: inferior capsule, anterior superomedial capsule, and the saddle (the upper upsweep of the neck as it goes into the trochanter).
    • Acetabular component selection and placement. The component chosen is not as important as the placement, Dr. Stulberg said, and he will use fluoroscopy as needed to visualize structures and confirm placement of the acetabular cup.
    • Femoral component selection and placement. Until proficient with the approach, the surgeon should not change the type of stem used. What is more important is ensuring that broaching does not create an envelope the implant cannot fill; otherwise, instability will occur. Use fluoroscopy to check fit, offset, sizing, and leg length as needed.
    • Use local infiltration to reduce pain. This includes optimizing perioperative pain control and early rehabilitation to improve the patient’s experience. Dr. Stulberg is a strong believer in the use of local anesthetic agents to infiltrate the surgical wound.

    Watch Dr. Stulberg’s presentation here.

    Dr. Berger’s tips for primary THA include the following:

    • Restore hip anatomy and leg length. Dr. Berger acknowledged that this is the most basic part of THA, but also the most important. He noted that he prefers to template the contralateral hip, assuming it is more normal that the affected hip.
    • Use an anterior-style approach. Dr. Berger said an anterior-style approach – whether the Watson-Jones or Smith-Petersen approach – is an intrinsically stable approach that removes concerns about dislocation.
    • Don’t forcibly dislocate the hip. This could pull and tear structures that have not been released.
    • Ensure good visualization. If necessary, extend the length of the incision or do additional releases.
    • Have patients resume their lives immediately. This goes back to the anterior-style approach: It allows patients to back to their normal lives without restrictions. As soon as they can ambulate and meet postoperative goals, they can be discharged from the hospital. Many of Dr. Berger’s patients go home the same day as surgery.

    Watch Dr. Berger’s presentation here.


    1. Learmonth ID, Young C, Rorabeck C. The operation of the century: total hip replacement. 2007 Oct 27;370(9597):1508-19.