Lateral Approach (Hardinge/Transgluteal Approach) for Total Hip Replacement

Surgical Videos

Textbook Anatomy Diagram (Campbell's Operative Orthopaedics, 15th Ed. 2026)

Detailed Step-by-Step Surgical Technique

Patient Positioning

• Patient placed supine with the greater trochanter at the edge of the table
• Muscles of the buttocks freed from the table edge
• (Alternative: lateral decubitus position is also used in many centers)

Step 1: Skin Incision

• Make a posteriorly directed lazy-J incision centered over the greater trochanter
• The curve of the J opens anteriorly, typically 15-20 cm in length

Step 2: Fascia Lata Division

• Divide the fascia lata in line with the skin incision, centered over the greater trochanter

Step 3: Superficial Muscle Retraction

• Retract the tensor fasciae latae anteriorly
• Retract the gluteus maximus posteriorly
• This exposes:
  • The origin of the vastus lateralis distally
  • The insertion of the gluteus medius on the greater trochanter

Step 4: The Critical Gluteus Medius Tendon Split (Key Step)

• Incise the tendon of the gluteus medius obliquely across the greater trochanter
• Leave the posterior half attached to the trochanter (this is the "functional anchor")
• Carry the incision proximally in line with the gluteus medius fibers at the junction of middle and posterior thirds of the muscle
• Critical limit: The split must NOT extend more than 4-5 cm above the tip of the greater trochanter - beyond this risks injury to the superior gluteal nerve and artery
• Carry the incision distally and anteriorly in line with the vastus lateralis fibers down to bone along the anterolateral femur

Step 5: Exposure of Anterior Capsule

• Elevate the tendinous insertions of the anterior portions of gluteus minimus and vastus lateralis
• Abduct the thigh - this brings the anterior hip capsule into view
• Full anterior joint capsule is now exposed

Step 6: Capsulotomy

• Incise the capsule as desired (anterior capsulotomy, cruciate incision, or excision)
• The femoral head and neck are now fully accessible for femoral neck osteotomy and cup preparation

Step 7: THR Implantation

• Perform femoral neck osteotomy at the planned level
• Acetabular preparation: Reamers used to prepare the cup bed; press-fit cup inserted at ~40-45° inclination and 10-25° anteversion
• Femoral preparation: Canal broached, trial components sized, femoral stem impacted (cemented or cementless)
• Trial reduction performed to assess leg length, stability, and range of motion

Step 8: Closure (Critical - Restoring Abductor Function)

• The gluteus medius tendon is repaired with non-absorbable braided sutures back to the greater trochanter - this is the most important closure step
• Adequate repair prevents Trendelenburg gait (abductor lurch)
• Fascia lata closed, subcutaneous layer, skin

Advantages vs. Disadvantages

Frndak Modification (Modified Hardinge)

Key Anatomical Dangers

1. Superior gluteal nerve: Exits above the piriformis, runs anteriorly between gluteus medius and minimus - damaged if the split extends > 4-5 cm above the trochanter tip
2. Superior gluteal artery: Accompanies the nerve - bleeding risk
3. Femoral nerve: Protected by the anterior position of the approach (unlike the direct anterior approach)
4. Sciatic nerve: Protected posteriorly (unlike posterior approach)