The direct lateral approach (DLA) to the hip joint is a versatile surgical exposure that can be used for primary and simple revision total hip arthroplasty (THA), where an extensile dissection to visualize the pelvis or femur is not needed (1,2). It is easily and quickly accomplished, gives excellent exposure both to the native acetabulum and proximal femur, and has few complications (3,4). It is particularly valuable in patients with excessive anteversion because the proximal femur is dislocated anteriorly, directing the femoral head and neck into the wound site.

The approach has been modified dramatically by many surgeons from the original description by Mr. Brian McFarland of Liverpool in 1954 (5) and then termed the “transgluteal approach to the hip joint” by Professor Bauer et al. of Austria (6). The “direct lateral approach to the hip” was popularized in the United Kingdom and worldwide by Mr. Kevin Hardinge in 1982 (7) and by Dr. Desmond Dall (8). Since these descriptions, the surgical approach has been modified for the use of smaller incisions with less dissection but does not sacrifice full exposure of the structures necessary to perform the hip replacement with precision (9,10).

 

INDICATIONS

Primary THA

Simple revision THA without need for an extensile exposure

Drainage and debridement of an infected THA early when the implants are stable and only liner and head exchange are contemplated

Resection arthroplasty of a native hip joint

 

 

CONTRAINDICATIONS

Accepted contraindications to primary THA using any surgical approach (ongoing joint sepsis, severe abductor muscle deficiency, etc.)

Previous adjacent incisions to the one contemplated, that may jeopardize wound healing

Extensive scarring involving the tissues to be dissected due to previous burns, trauma, irradiation, etc. Complex primary THA where an extensile approach is needed, for example, a Crowe type 4 arthritic hip needing THA with major acetabular and femoral exposure with possible shortening femoral osteotomy Complex revision THA with the need for an extensile exposure

Revision THA where a previous satisfactory posterior approach has been performed Resection arthroplasty needing wider exposure, with possible extended femoral osteotomy

 

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PREOPERATIVE PREPARATION

The preoperative preparation for THA using the DLA is very similar to THA using other surgical approaches.

In addition to a complete history, physical examination, appropriate imaging, and blood work studies, a fully

informed discussion should take place preoperatively concerning the risks, benefits, and expectations of the patient. As patients are mobilized early after surgery, and hospital stays are very short, preoperative weight loss and strengthening programs may be indicated. In this respect, exercises in a pool may be useful in building flexibility and physical endurance, as well as patient confidence. The patient should undergo comprehensive medical assessment as indicated to help ensure a smooth perioperative course.

As for any THA surgery, preoperative planning is essential to ensure that all appropriate implants and sizes are available for the surgery. Preoperative planning can be performed using computer-assisted methods or simple radiographs and commercially available acetate templates.

TECHNIQUE

The patient is given an anesthetic as recommended by the anesthesia team. This may be a general, spinal, epidural, or other anesthetic or combination thereof. In general, our patients generally elect to undergo spinal anesthesia with sedation ± general anesthesia. A urinary catheter is placed in most patients except the very young. Antibiotics are given prophylactically.

The DLA to the hip may be performed with the patient in the supine or lateral position. I elect to place the patient in the lateral position so that the soft tissues move away from the wound when incised, and all assistants can see the surgical procedure. The patient is positioned in the lateral decubitus position on a pegboard, and an axillary roll is placed so as not to press on the brachial plexus proximally or impede the axillary vasculature. At least four well-padded pegs are used to stabilize the pelvis and torso: one peg at the symphysis pubis, one on the chest wall just superior to the abdomen, one on the pelvis posteriorly just proximal to the anal cleft, and one adjacent to the thoracic spine. The pelvis should be aligned and secured in a direct lateral position and not flexed excessively. I prefer an arm board and two pillows to secure the upper extremities. The operative extremity is widely abducted and held with the appropriate table attachment device. The lower nonoperated limb is padded. A nonsterile U drape is placed around the operative lower extremity, lifting the buttock to attach the drape well posteriorly for wide exposure of the pelvis. Anteriorly, the drape is placed below the anterior superior iliac spine. The operative extremity is then prepared with antiseptic solution from the ankle to the chest, and the limb is draped in sterile fashion.

After a time-out to verify all aspects of the operative procedure, the incision is marked and iodine-impregnated coverings are placed over the wound.

The incision is different for patients with different body habitus. The superior pole of the greater trochanter and proximal femoral shaft are palpated. The incision is centered over the greater trochanter and is as short or long as needed for adequate exposure. In general, the incision begins just proximal and slightly posterior to the superior pole of the greater trochanter and progresses slightly anteriorly to just beyond the palpable trochanteric crest (Fig. 2-1). The fascia lata is incised along this line. The bursa overlying the greater trochanter is incised.

This exposes the gluteus medius muscle and tendon, the greater trochanter, and the proximal vastus lateralis (Fig. 2-2). A small Hohmann retractor is placed just superior to the greater trochanter through the musculotendinous junction of the gluteus medius. Distally, a similar Hohmann retractor is placed at the junction of the anterior one-fifth and posterior four-fifth of the gluteus medius several centimeters below the trochanteric line. (Note: One modification is to place the more distal retractor immediately anterior to the vastus lateralis.) An inverted gentle U is made with the electrocautery, connecting the two Hohmann retractors. The vastus-gluteal flap is then created in one of the following ways. If the bone stock is good-excellent, a sharp osteotome is used to take a sliver of bone with the flap so as to decorticate the greater trochanter of small bone chips (Fig. 2-3).

This will provide a bone-to-bone attachment during closure. The decortication starts inferiorly and superiorly where the tendon is thickest and proceeds toward the middle (where the tendon is thinnest) from above and below, proceeding medially. Once the trochanter has been traversed medially, one looks for the pericapsular fat

from below and then sharply creates the entire flap including anterior iliofemoral

 

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ligaments as one thick flap. If the bone stock is poor or the greater trochanter is small, the risk for trochanteric

fracture is higher, so no bone is taken; the flap is developed with a knife or cautery.

 

 

 

FIGURE 2-1 The skin incision is drawn on the upper thigh of the left hip. The dot represents the superior pole of the greater trochanter.

 

 

 

FIGURE 2-2 The fascia has been cut, and the greater trochanter is visualized, with insertion of the gluteus medius to the right and the vastus lateralis to the left. The right Hohmann is just anterior to the superior pole of the greater trochanter. The left Hohmann retractor marks the distal point of the vastus-gluteal flap.

 

 

 

FIGURE 2-3 The flap is marked with a suture anteriorly. The vastus-gluteal flap is developed by gently decorticating the greater trochanter anterior to the anterior tubercle. This will facilitate bone-to-bone apposition when the flap is reapproximated.

 

 

Once the flap is developed, I usually use a tagging suture for later easy identification during closure (Fig. 2-3). Large sharp Hohmann retractors are carefully placed over the anterior lip of the

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acetabulum, and a dull Hohmann is placed below the inferior hip capsule (Fig. 2-4). A small sharp Hohmann or Hibbs retractor is placed over the superior capsule. Sometimes the capsular insertion of the gluteus minimus or straight head to the rectus femoris needs to be sharply dissected off the capsule. The capsule is incised in a T fashion and either preserved or excised (I excise it for better visualization). The posterior capsule is left intact for stability. The hip joint is gently dislocated anteriorly using the Hohmann retractors around the femoral neck as guiding levers, with the assistant on the opposite side of the operating table giving slight traction then performing a flexion, adduction, and external rotation maneuver (Fig. 2-5). The limb is placed in a sterile bag anteriorly with the knee flexed 90 degrees and a few towels in the popliteal fossa for support.

I prepare the femur first. This has the advantage of noting femoral anteversion, which can be taken into account when positioning the hip. A hip skid is placed anteriorly, lifting the femoral head from the wound (Fig. 2-6). The soft tissues are sharply dissected from the anteromedial femoral neck, and a small Hohmann retractor is placed distally, beyond the lesser trochanter, which is found and marked with an electrocautery. The femoral neck is resected according to the preoperative plan, measuring superiorly from the femoral neck. This neck resection is also confirmed with the metal template after identifying the center of the femoral head visually. When the lateral portion of the osteotomy is performed, a small sharp curved Hohmann is placed immediately posterior to the greater trochanter for better visualization. The superior and lateral aspect of the osteotomy is taken laterally enough to facilitate insertion of the rasp without impinging on the greater trochanter. The proximal femoral canal is then lateralized with a reamer, and femoral rasping then proceeds as usual. Once the final rasp is inserted, the top of the rasp is marked on the greater trochanter, and the rasp is removed.

 

 

 

FIGURE 2-4 The hip capsule has been exposed. The two anterior sharp Hohmann retractors are located over the anterior lip of the acetabulum. The dull Hohmann retractor is located inferior to the hip capsule.

 

 

 

FIGURE 2-5 The arthritic femoral head is exposed.

 

 

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FIGURE 2-6 The cut femoral neck is exposed using a hip skid.

 

The acetabulum is prepared next. A large sharp Hohmann retractor is placed over the anterior lip, a Hibbs or Richardson retractor is placed superiorly, and a small sharp Hohmann retractor is placed on the inside of the retained posterior capsule, resting on the posterior acetabular lip. The capsule exterior to the acetabulum is excised to identify the periphery, and a small sharp Hohmann retractor is placed inferior to the transverse acetabular ligament (Fig. 2-7). The acetabulum should be visualized 360 degrees. The acetabulum is prepared in standard fashion, and the final components are impacted into place. I use a minimum of two supporting screws to obtain initial stabilization. The final liner is selected, or in more difficult cases, a trial liner may be used. The proximal femur is then reexposed, and the trial femoral component is placed. A trial femoral head is placed that is one size smaller than the planned one, for ease of relocation and dislocation. For example, if I am going to use a 32-mm femoral head, I trial with a 28-mm femoral head. If hip stability with range of motion is satisfactory with the smaller head size, it will be even more stable when the true size is used. I trial for flexion stability (flexion, internal rotation, and abduction) as well as extension stability (extension, external rotation, and abduction) to test for potential posterior and anterior instability or impingement, respectively. Leg lengths are assessed, comparing the location of the superior pole of the patella on operative and nonoperative limbs placed in the same position. The hip is gently dislocated with longitudinal traction and a hook, and the limb is placed in the sterile bag anteriorly.

The trial femoral component is removed, the final femoral component placed, and the hip relocated. The extremity is placed in wide abduction on a padded Mayo stand.

 

Wound closure then takes place. A reinfusion drain is placed in the deep tissues and brought out anterolaterally at least 5 cm from the wound. With the limb on a Mayo stand in abduction and slight

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internal rotation, the vastus-gluteal flap is approximated with absorbable sutures through soft tissue distally and proximally and through drill holes in the greater trochanter (Fig. 2-8). Superiorly, once the myotendinous junction of the gluteus medius is reached, no more sutures are placed superiorly to avoid tissue strangulation and resultant heterotopic ossification. The rest of the soft tissues are closed in routine fashion and a compression dressing placed, as well as an abduction pillow.

 

 

 

FIGURE 2-7 The acetabulum is exposed. The Hohmann retractor to the left is located inferior to the transverse acetabular ligament.

 

 

 

FIGURE 2-8 All components have been placed. The suture facilitates reapproximation of the vastus-gluteal flap onto the greater trochanter. The limb is placed on a high Mayo stand and slightly internally rotated for good approximation of the surfaces. Sutures will be placed through the greater trochanter into the flap.

Patients are mobilized weight bearing as tolerated with a walker or crutches the day of surgery.

 

PEARLS AND PITFALLS (SPECIAL ADVICE FOR THE ADVANCED TECHNIQUES FEATURED IN THIS SERIES)

The location of the incision is crucial to the ease of this approach. If placed too anteriorly or posteriorly, the surgeon struggles with the hip dislocation, and reaming of the acetabulum and rasping of the femur. With heavier patients, the incision is placed somewhat more proximally to avoid skin damage during rasping of the femur. In addition, with the knee bent to 90 degrees after the neck has been resected, the femur is lowered more into the sterile bag to expose the proximal femur. However, the femur should not “hang” into the sterile bag unsupported as this may stretch the sciatic nerve.

If bone stock is poor, then no bone is taken and the vastus-gluteal flap is simply sharply dissected from the anterior greater trochanter. If the hip is more difficult, for example, dysplastic, then a thicker, larger portion of the

greater trochanter that extends more posteriorly can be cut. This simulates an anterior sliding trochanteric osteotomy in the more extreme cases.

During initial exposure, occasionally, the hip abductors have a tear in them. This can be minor and constitute only a small portion of the abductor insertion on the greater trochanter, or major, leaving the greater trochanter almost bald (the so-called rotator cuff tear of the hip). This should be recognized after the fascia lata is incised and the vastus-gluteal flap modified to incorporate the tear if possible. Abductor tendon remnants should be identified and tagged with sutures and repaired at the end of the case. Reconstruction using an allograft Achilles tendon or other tissue may be needed to supplement the repair. An abduction brace may also be needed; however, protected weight bearing is not usually necessary.

Occasionally, if bone stock is very poor and there is severe protrusion or arthrofibrosis of the hip joint, the neck should be resected very proximally in situ; dislocation is then performed through the osteotomy site, and the femoral neck is then resected again at the planned location. The femoral head and proximal neck are then excised from the acetabulum prior to reaming.

Dislocations should be gentle. Longitudinal traction and superior translation with a bone hook should easily dislocate the femoral head. There should be no forceful rotation of the limb during dislocation, or the femur will fracture.

When exposing the proximal femur, the small sharp Hohmann retractor placed just posterior to the greater trochanter should be kept parallel to the floor. If the assistant's hand holding this Hohmann retractor is not kept in position, the sciatic nerve just posterior to this retractor is in jeopardy. If the assistant holding this retractor or the hip skid elevates the femur too aggressively, the sciatic nerve may be stretched.

 

When exposing the acetabulum, sharp Hohmann retractors should be carefully placed. The anterior Hohmann just anterior to the anterior inferior iliac spine should not pierce the iliopsoas tendon. If placed too far anteriorly, this retractor could impinge on the femoral nerve, vein, or artery. The posterior Hohmann retractor should be placed on the lateral lip of the acetabulum superficially, at the level of the greater trochanter. If placed too deeply, this retractor can impinge on the

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sciatic nerve. This is especially relevant in hip dysplasia, where the acetabulum is shallow and the sciatic nerve may be located more superficially.

When reaming the acetabulum, the femur is translated posteriorly. If this translation is not sufficient, the acetabulum will be reamed in too much anteversion.

The trial reduction needs to be gentle. As the posterior capsule is retained, flexion and internal rotation may be limited. This motion is not normally performed aggressively, as it may cause an avulsion fracture of the greater trochanter.

Occasionally, the hip abductors are somewhat lax. If leg lengths and offset are correct, the surgeon can advance the abductors posteriorly and distally to tighten these, with the limb in slight abduction on a Mayo stand. Rarely, the abductors are rather tight during approximation of the soft tissues to the greater trochanter. The hip is abducted more, and then, attachment usually can be accomplished.

POSTOPERATIVE MANAGEMENT

Routine antibiotic and antithrombotic methods are initiated.

Early postoperative mobilization is strongly encouraged with a walker or crutches, with progression to a cane when limp is minimal. Strengthening of the muscle girdle with elastic band resistance exercises is useful. Hip abductor exercises are included. Single leg standing for prolonged periods of time including balancing exercises

on one leg are not useful and therefore not performed. When available, the patient engages in exercises in a pool when the wound is healed and the staples have been removed. Bicycling is initiated, making sure that the seat is raised so that the knees are extended fully alternatively. The patient may engage in the use of a cross-trainer or treadmill progressively. Weights are used to strengthen the upper extremities but not the lower extremities. Impact sports are avoided. Return to normal activities is the best physical therapy.

 

 

COMPLICATIONS

Complications are rare if the surgery is performed with precision. Potential complications may include the following:

Injury to the superior gluteal nerve or vessels. This is avoided by not dissecting more than 3 to 5 cm superior to the greater trochanter, and gentle retraction of the vastus-gluteal flap (11,12,13,14,15,16,17,18).

Heterotopic ossification. This is usually not clinically significant and can be minimized by irrigating the wound of bone debris and careful nonaggressive tissue retraction.

Disruption of the flap repair. This can be avoided by careful insertion of the flap using bone sutures, and using thin bone decortication attached to the vastus-gluteal flap to get bone-to-bone healing.

Fracture of the femur or greater trochanter.

Injury to the femoral nerve, vein, or artery. This can be avoided by careful placement of retractors (19). Sciatic nerve injury.

Incorrect placement of the acetabular or femoral component resulting in instability. This can be avoided by resetting the table so that it is flat, using the instrumentation appropriately to position the implants, and careful checking of the trial reduction and range of motion to look for potential impingement.

Excessive bleeding due to aggressive dissection of the area inferior to the obturator foramen (perforating branches of the obturator artery or vein) or posterior to the femur (branches of the profunda femoris vessels).

 

 

RESULTS

Overall, the results of THA after the DLA are comparable to other surgical approaches to the hip joint (20,21,22). Indeed, gait mechanics assessed at 6 weeks postoperatively showed no differences among the anterolateral, direct lateral, and posterior approaches to the hip (23). Previously, the incidence of dislocation after the lateral approach was slightly less than that after the posterior approach; however, currently with meticulous posterior capsular repair, this complication is comparable between these approaches (20). In one series, heterotopic ossification occurred in 210 of 1,420 (14.8%) of patients who underwent hip arthroplasty using the DLA; however, only 2 of these patients underwent further surgical excision of the heterotopic bone (24). This is similar to the current author's experience for over 25 years, who has reoperated for heterotopic ossification on only one patient who had undergone bilateral single-stage total hip replacement.

Standard length versus limited incision surgery using the DLA appears to have no proven clinical advantage at 2 years of follow-up (25). There may be some slight functional improvements in

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patients who have undergone an anterior approach compared to a standard DLA for THA at 1 year postoperatively, although this is controversial (26). There are no apparent long-term studies that

demonstrate a more favorable outcome for any particular surgical approach for THA.

 

 

THE ANTEROLATERAL APPROACH TO THE HIP

The classical anterolateral approach to the hip joint, which dissects between the tensor fascia lata and the gluteus medius onto the hip capsule, was first described by Watson-Jones (27). I do not use this approach for primary total hip replacement but prefer the modified DLA to the hip joint, as described above. However, many surgeons prefer a “minimally invasive” type of anterolateral approached to the hip joint for THA (27,28,29).

Special techniques and instrumentation have been developed to adequately expose the hip joint through smaller incisions than that originally described by Watson-Jones. The outcome and potential complications are very similar to those described above for the DLA. Whatever surgical approach is chosen, the surgeon must ensure that adequate visualization of important anatomical landmarks is afforded, so that proper placement of implants is achieved. Inadequate exposure can lead to wound complications from overzealous retraction, suboptimal placements of implants, loosening of components, recurrent dislocation, and other potential complications.

ACKNOWLEDGMENTS

Photographs kindly taken by Dr. Changchun Fan, Stanford University.

 

REFERENCES

1. Jolles BM, Bogoch ER: Surgical approach for total hip arthroplasty: direct lateral or posterior? J Rheumatol 31(9): 1790-1796, 2004. Epub September 1, 2004.

    

    

2. Moskal JT, Mann JW III: A modified direct lateral approach for primary and revision total hip arthroplasty. A prospective analysis of 453 cases. J Arthroplasty 11(3): 255-266, 1996. Epub April 1, 1996.

    

    

3. Mulliken BD, Rorabeck CH, Bourne RB, et al.: A modified direct lateral approach in total hip arthroplasty: a comprehensive review. J Arthroplasty 13(7): 737-747, 1998. Epub November 5, 1998.

    

    

4. O'Brien JJ, Burnett RS, McCalden RW, et al.: Isolated liner exchange in revision total hip arthroplasty: clinical results using the direct lateral surgical approach. J Arthroplasty 19(4): 414-423, 2004. Epub June 10, 2004.

    

    

5. Mc FB: My present attitude to osteo arthritis of the hip. J Bone Joint Surg Am 36-A(3): 476-488, 1954; passim.

    

    

6. Bauer R, Kerschbaumer F, Poisel S, et al.: The transgluteal approach to the hip joint. Arch Orthop Trauma Surg 95(1-2): 47-49, 1979. Epub October 1, 1979.

    

    

7. Hardinge K: The direct lateral approach to the hip. J Bone Joint Surg Br 64(1): 17-19, 1982. Epub January 1, 1982.

    

    

8. Dall D: Exposure of the hip by anterior osteotomy of the greater trochanter. A modified anterolateral approach. J Bone Joint Surg Br 68(3): 382-386, 1986.

    

    

9. Gustke K: Surgical nuances to minimize muscle damage during the direct lateral approach in minimally

   invasive hip replacement. Instr Course Lect 57: 235-241, 2008. Epub April 11, 2008.

    

    

10. O'Brien DA, Rorabeck CH: The mini-incision direct lateral approach in primary total hip arthroplasty. Clin Orthop Relat Res 441: 99-103, 2005. Epub December 7, 2005.

     

     

11. Comstock C, Imrie S, Goodman SB: A clinical and radiographic study of the “safe area” using the direct lateral approach for total hip arthroplasty. J Arthroplasty 9(5): 527-531, 1994. Epub October 1, 1994.

     

     

12. Baker AS, Bitounis VC: Abductor function after total hip replacement. An electromyographic and clinical review. J Bone Joint Surg Br 71(1): 47-50, 1989. Epub January 1, 1989.

     

     

13. Eksioglu F, Uslu M, Gudemez E, et al.: Reliability of the safe area for the superior gluteal nerve. Clin Orthop Relat Res (412): 111-116, 2003. Epub July 3, 2003.

     

     

14. Basarir K, Ozsoy MH, Erdemli B, et al. The safe distance for the superior gluteal nerve in direct lateral approach to the hip and its relation with the femoral length: a cadaver study. Arch Orthop Trauma Surg 128(7): 645-650, 2008. Epub October 9, 2007.

     

     

15. Picado CH, Garcia FL, Marques W Jr: Damage to the superior gluteal nerve after direct lateral approach to the hip. Clin Orthop Relat Res 455: 209-211, 2007. Epub August 29, 2006.

     

     

16. Khan T, Knowles D. Damage to the superior gluteal nerve during the direct lateral approach to the hip: a cadaveric study. J Arthroplasty 22(8): 1198-1200, 2007. Epub December 15, 2007.

     

     

17. Goodman SB. Does the direct lateral approach to the hip joint jeopardize the superior gluteal nerve Clin Anat 4(2): 123-128, 1991.

     

     

18. Jacobs LG, Buxton RA. The course of the superior gluteal nerve in the lateral approach to the hip. J Bone Joint Surg Am 71(8): 1239-1243, 1989.

     

     

19. van der Linde MJ, Tonino AJ: Nerve injury after hip arthroplasty. 5/600 cases after uncemented hip replacement, anterolateral approach versus direct lateral approach. Acta Orthop Scand 68(6): 521-523, 1997. Epub February 14, 1998.

     

     

20. Masonis JL, Bourne RB. Surgical approach, abductor function, and total hip arthroplasty dislocation. Clin Orthop Relat Res (405): 46-53, 2002. Epub December 4, 2002.

     

     

21. Jolles BM, Bogoch ER: Posterior versus lateral surgical approach for total hip arthroplasty in adults with osteoarthritis. Cochrane Database Syst Rev (1): CD003828, 2004. Epub February 20, 2004.

     

     

22. Barber TC, Roger DJ, Goodman SB, et al. Early outcome of total hip arthroplasty using the direct lateral vs the posterior surgical approach. Orthopedics 19(10): 873-875, 1996. Epub October 1, 1996.

     

     

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23. Queen RM, Butler RJ, Watters TS, et al. The effect of total hip arthroplasty surgical approach on

    postoperative gait mechanics. J Arthroplasty 26(6 Suppl): 66-71, 2011. Epub June 28, 2011.

     

     

24. Harwin SF: Trochanteric heterotopic ossification after total hip arthroplasty performed using a direct lateral approach. J Arthroplasty 20(4): 467-472, 2005. Epub August 30, 2005.

     

     

25. Asayama I, Kinsey TL, Mahoney OM: Two-year experience using a limited-incision direct lateral approach in total hip arthroplasty. J Arthroplasty 21(8): 1083-1091, 2006. Epub December 13, 2006.

     

     

26. Restrepo C, Parvizi J, Pour AE, et al.: Prospective randomized study of two surgical approaches for total hip arthroplasty. J Arthroplasty 25(5): 671-679.e1, 2010. Epub April 10, 2010.

     

     

27. Bertin KC, Rottinger H: Anterolateral mini-incision hip replacement surgery: a modified Watson-Jones approach. Clin Orthop Relat Res (429): 248-255, 2004.

     

     

28. Basad E, Ishaque B, Sturz H, et al.: The anterolateral minimally invasive approach for total hip arthroplasty: technique, pitfalls, and way out. Orthop Clin North Am 40(4): 473-478, viii, 2009.

     

     

29. Vail TP, Callaghan JJ: Minimal incision total hip arthroplasty. J Am Acad Orthop Surg 15(12): 707-715, 2007.