Direct Lateral Approach for Hip Surgery

What is the Direct Lateral Approach?

Hip surgery is a common orthopaedic procedure, and there are various techniques and approaches to performing it. One of the most popular methods is the Direct Lateral Approach, also known as the Hardinge Approach. 

The Direct Lateral Approach is a surgical technique involving a lateral incision on the hip to access the joint. This minimally invasive approach allows the surgeon to avoid cutting through muscles, tendons, or ligaments, reducing the risk of damage and complications.

Who is Suitable for a Direct Lateral Approach?

The Direct Lateral Approach is suitable for most patients who require hip surgery, including those with osteoarthritis, rheumatoid arthritis, avascular necrosis, hip dysplasia, and hip fractures. However, the suitability of the approach may depend on several factors, such as the patient's age, weight, overall health, and the extent of the damage to the hip joint. The surgeon will evaluate each case individually and determine the best approach for the patient.

What are the Benefits of the Direct Lateral Approach?

The Direct Lateral Approach offers several benefits, including:

• Reduced Pain: The approach avoids cutting through muscles and soft tissues, which leads to less postoperative pain and discomfort.
• Lower Risk of Dislocation: The Direct Lateral Approach provides better stability and a lower risk of dislocation than other approaches.

Alternative Options to Direct Lateral Approach

While the Direct Lateral Approach is safe and effective, it may not suit all patients. Alternative options include:

• Anterior Approach: This approach involves making an incision at the front of the hip, allowing the surgeon to access the joint without cutting through muscles or tendons.
• Posterior Approach: This approach involves making an incision at the back of the hip, allowing the surgeon to access the joint by cutting through muscles and tendons.

What to do Before a Direct Lateral Approach Hip Surgery?

Before undergoing hip surgery, patients should take the following steps:

• Get a Comprehensive Medical Evaluation: Patients should undergo a comprehensive medical evaluation to assess their overall health, identify any pre-existing conditions, and ensure they are fit for surgery.
• Discuss Medications and Supplements: Patients should inform their surgeons of all the medications and supplements they are taking, including over-the-counter medications, herbal supplements, and vitamins. Some medications and supplements may need to be stopped or adjusted before surgery.
• Quit Smoking: Smoking can increase the risk of complications during and after surgery. Patients who smoke should quit at least four weeks before surgery.
• Prepare for Postoperative Care: Patients should arrange postoperative care, including transportation, assistance with daily activities, and follow-up appointments.

Direct Lateral Approach Hip Surgery

Here's an overview of what happens during the procedure:

• The patient is administered either general anaesthesia or a regional anaesthetic (spinal or epidural) to ensure they are completely numb and pain-free during the surgery.
• The patient is placed in a lateral decubitus position, which means they are lying on their side with the affected hip facing upwards.
• A curved incision is made over the lateral aspect of the hip, typically extending from the greater trochanter (the bony prominence on the side of the hip) towards the iliac crest (the top of the pelvic bone).
• The surgeon carefully dissects through the layers of muscle and soft tissue to gain access to the hip joint. In the direct lateral approach, the tensor fasciae latae muscle is usually spared, while the gluteus medius and minimus muscles are detached from the greater trochanter.
• The hip joint capsule is exposed, and an incision is made to open the joint capsule. This allows the surgeon to visualise the femoral head (the ball part of the hip joint) and the acetabulum (the socket part of the hip joint).
• The damaged or arthritic femoral head is removed using a bone saw or other instruments. The acetabulum is prepared by removing damaged cartilage or bone and reshaping the socket to accommodate the prosthetic implant.
• The prosthetic acetabular component (the new socket) is placed into the prepared acetabulum, often secured with screws or cement. A prosthetic femoral stem is inserted into the femur (thigh bone), and a prosthetic femoral head (the new ball) is attached to the stem.
• The new prosthetic femoral head is placed into the new acetabular socket, effectively forming the new hip joint. The surgeon checks for proper alignment, stability, and range of motion.
• The hip joint capsule is closed with sutures, and the detached muscles are reattached to their original positions. The layers of soft tissue are closed with sutures, and the skin is closed with staples, sutures, or adhesive strips.

After the Surgery

The patient is taken to the recovery room, where they are closely monitored as they wake from anaesthesia. Pain management, physical therapy, and mobility exercises are introduced as appropriate to facilitate recovery and rehabilitation.

Postoperative Care Plan

A recovery plan following the surgery is essential to ensure optimal outcomes and a return to normal activities. Although individual recovery times and protocols may vary, the following steps provide a general outline of the recovery process:

• Pain management: Pain is managed through a combination of medications, such as oral pain relievers, anti-inflammatory drugs, and possibly opioids in the initial postoperative period. The goal is to minimise discomfort while avoiding overreliance on strong pain medications.
• Mobility and weight-bearing: Early mobilisation promotes blood flow and prevents complications such as blood clots. Patients are usually encouraged to walk with a walker or crutches within a day or two of surgery. Weight-bearing restrictions will depend on the surgeon's recommendations and the type of implants used during surgery.
• Physical therapy: A physical therapist will provide patients with specific exercises to help regain strength, flexibility, and range of motion in the affected hip. This typically begins within the first few days after surgery and continues for several weeks to months. Adherence to the prescribed physical therapy program is crucial for optimal recovery.
• Assistive devices: During the early stages of recovery, patients may need to use assistive devices such as walkers, crutches, or canes to provide support and stability. Gradually, these devices will be phased out as strength and mobility improve.
• Home modifications: It's important to create a safe and accessible environment at home to facilitate recovery. This may include using raised toilet seats, shower chairs, grab bars and other assistive devices to minimise the risk of falls and provide support during daily activities.
• Wound care: Patients must keep the surgical incision clean and dry to promote healing and prevent infection. The surgeon will provide instructions for proper wound care.
• Follow-up appointments: Regular follow-up appointments with the surgeon are essential to monitor progress, address any concerns, and make necessary adjustments to the recovery plan. The frequency of these appointments will depend on individual circumstances and the surgeon's recommendations.
• Return to activities: Patients typically expect a gradual return to normal activities over several weeks to months. It's essential to follow the surgeon’s guidelines and not to overexert oneself during recovery. Driving and returning to work depends on individual progress, pain levels, and the type of work involved.
• Long-term care: After recovery, patients should continue to engage in low-impact exercises and maintain a healthy lifestyle to promote joint health and longevity. Regular check-ups with the surgeon may be necessary to monitor the hip's function and ensure the implants are performing as expected.

Hip Surgery Risks

Like all surgeries, hip replacement carries risks and potential complications. These may include:

• Infection: There is a risk of infection at the incision site or hip joint, which may require antibiotics or further treatment.
• Blood Clots: Patients may develop blood clots in the legs or lungs, which can be life-threatening if not treated promptly.
• Nerve Damage: The surgery may cause temporary or permanent damage to the nerves around the hip joint, leading to numbness, tingling, or weakness in the leg.
• Psoas tendinitis - This is the tendon in front of the hip and this can sometimes get inflamed after surgery; sometimes due to irritation by a metal socket which is more prominent in position . Many times there is no obvious reason and it responds to a steroid injection. Rarely it may require surgery to release the tendon or to reposition the socket which is a fairly big procedure.
• Dislocation: The prosthetic hip joint may dislocate if the patient moves or bends the hip in a certain way.
• Fracture: The surgery may cause a fracture in the bone around the hip joint, which may require further treatment.

What if hip replacement is Delayed?

Delaying hip surgery may lead to further damage to the hip joint, increased pain, and reduced mobility. However, there may be situations where the surgery needs to be delayed, such as if the patient is not fit for surgery due to medical reasons or if there are logistical or financial constraints. In such cases, the patient should work closely with their orthopaedic surgeon to develop a plan to manage their symptoms and delay the surgery until it is safe to proceed.