VIDEO VIGNETTE: Optimizing Exposure with the Direct Lateral Approach

    The surgical approach for total hip arthroplasty (THA) remains a topic of much debate in the literature and at the podium at orthopaedic meetings.

    During ICJR’s 3rd Annual Pan Pacific Orthopaedic Congress, faculty members addressed 3 approaches to THA – direct lateral, direct superior, and direct anterior – not from the standpoint of debating the pros and con of their preferred approach, but from the perspective of providing surgical pearls for surgeons who practice each approach.

    In this report, Steven J. MacDonald, MD, FRCSC from the University of Western Ontario in London, Ontario, Canada, shares his tips for improving exposure when using the direct lateral approach, which has been his preferred approach for about 20 years.

    Future reports will review presentations from the Pan Pacific Orthopaedic Congress on the direct superior and direct anterior approaches.

    Preoperative and Initial Exposure

    • Make sure the anterior and posterior bolsters are correctly positioned and firmly in place. Don’t delegate this to residents or fellows: Be there in person to ensure this is properly done. Dr. MacDonald prefers simple over multi-axis bolsters to prevent shifting during the surgery.
    • In the morbidly obese, it can be helpful to tilt the pelvis slightly posteriorly. Dr. MacDonald said that with the patient in this position, he doesn’t have to reach across a large patient when reaming the acetabulum.
    • Keep the adhesive draping as wide as possible to provide space for an extensile exposure and help with orientation during surgery.
    • Always be prepared to extend the incision. If struggling, extend the split in the iliotibial band distally and/or the fascia proximally.
    • In very tight hips and protrusion cases, be prepared to cut the femoral neck in-situ, making the first cut as high as safely possible. Then make the final cut after the femoral head has been removed.

    Acetabular Exposure

    • Proper retractor placement is key to exposing the acetabulum. Dr. MacDonald prefers a blunt retractor at 3 o’clock, a sharp retractor at about 7:30, and another blunt retractor at 6 o’clock. If necessary, he also places a sharp retractor superiorly, at about 12 o’clock.
    • If the femur is difficult to retract, usually the posterior retractor is placed too high or too low or the neck cut is too high.
    • Fully excise the labrum to expose the complete rim of the acetabulum. This circumfrential exposure aids in cup placement and orientation and reduces impingement.

    Femoral Exposure

    • Release the soft tissue in the piriformis fossa, allowing the femur to translate anteriorly.
    • Place a blunt retractor under the greater trochanter and a sharp retractor in the piriformis fossa. This gives a 360-degree view of the femur, even in obese patients.
    • Have the assistant place the femur in additional external rotation to facilitate visualization of the proximal femur.

    Click the image above to watch Dr. MacDonald’s presentation.