Hip Direct Lateral Approach (Hardinge)

What it exposes. The Hardinge direct lateral (transgluteal) approach gives excellent access to the proximal femur and the acetabulum through the same incision. It is the workhorse exposure for primary total hip arthroplasty, hemiarthroplasty for femoral neck fractures, hip resurfacing, and simple revision THA (liner exchange, head and neck swap). Why direct lateral. Its great strength is inherent stability — the posterior soft-tissue sleeve and short external rotators are preserved, giving a lower dislocation rate (about 2 to 3 percent) than the posterior approach (5 to 7 percent), with excellent femoral exposure for stem insertion and good visualisation of the anterior and superior acetabulum. The trade-off is that it splits the abductor mechanism, putting the superior gluteal nerve at risk and carrying a higher rate of abductor weakness and limp than an abductor-sparing approach. Posterior acetabular wall access is comparatively limited. History and variants. The transgluteal route was described by McFarland and Osborne in 1954; Hardinge's 1982 modification — splitting the anterior half of gluteus medius at the musculotendinous junction and raising it in continuity with vastus lateralis as a single sleeve — is the current standard. The Dall modification detaches the anterior gluteus medius insertion completely for repair through bone tunnels, favoured by some for revision cases. Registry utilisation. Across the major national joint registries (NJR England and Wales, AOANJRR, Swedish and Norwegian), the direct lateral and posterior are consistently the two commonest approaches for primary THA — the direct lateral is widely used in the UK, Scandinavia and Australasia, while the posterior predominates in North America and the direct anterior has grown since the 2010s but remains a minority approach. Registry analyses generally show equivalent long-term implant survivorship across approaches, with surgeon and unit volume stronger predictors of revision than approach choice. Position and landmarks. The patient is in lateral decubitus with the affected hip up on a radiolucent table, the pelvis perpendicular to the floor (confirmed on a C-arm true AP — obturator foramina symmetric, coccyx over the pubic symphysis), supported at the pubis and sacrum. Pad the down-leg fibular head (peroneal nerve) and protect the axillary brachial plexus, drape the limb free from iliac crest to mid-calf, and mark the greater trochanter, anterior superior iliac spine and femoral shaft as incision landmarks.

The direct lateral approach works down through the fascia lata, splits the anterior third of tensor fascia lata, then splits gluteus medius at its musculotendinous junction and reflects a continuous abductor sleeve anteriorly with vastus lateralis to expose the capsule.

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Structures at risk

Approach-specific complications - Abductor dysfunction (5 to 20 percent): the signature trade-off of the approach, from superior gluteal nerve injury, excessive splitting or a poor repair. Prevent it by staying within the safe zone and repairing the abductor sleeve meticulously; persistent weakness is managed with physiotherapy, and revision repair or trochanteric advancement if refractory.

• Heterotopic ossification (10 to 30 percent radiographic, about 5 percent symptomatic): commoner than after the posterior approach (Foster and Hunter noted a 61 percent radiographic rate). Risk factors are male sex, diffuse idiopathic skeletal hyperostosis, previous HO and surgical delay; prophylaxis is indomethacin 25 mg three times daily for six weeks or single-dose radiation in high-risk patients, with excision reserved for symptomatic mature HO at around 12 months.
• Dislocation (about 2 to 3 percent): lower than the posterior approach and usually posterior in direction when it occurs. Prevent it by restoring offset and avoiding combined flexion, adduction and internal rotation; manage with closed reduction and reserve revision for recurrent instability.

Trendelenburg grading (to monitor abductor recovery)

Extensile options and troubleshooting. If exposure is inadequate, extend distally (more trochanter, more vastus lateralis) — never proximally, where the superior gluteal nerve lies. Bleeding from the proximal wound suggests superior gluteal artery injury: pack and apply pressure, and never clamp blindly (the nerve is immediately adjacent); if it persists, ligate under direct vision or pack overnight. Target component position is roughly 40 to 45 degrees acetabular inclination and 15 to 20 degrees anteversion, with stem anteversion of 10 to 15 degrees and offset restoration to tension the abductors. Aftercare and abductor recovery. Patients mobilise weight-bearing as tolerated from day 0 with DVT prophylaxis (for example rivaroxaban 10 mg daily for five weeks, enoxaparin, or aspirin) alongside mechanical prophylaxis. Hip precautions after the direct lateral approach are controversial; if used conservatively, avoid combined flexion, adduction and internal rotation for six weeks, and abductor strengthening is the rehabilitation priority. Temporary weakness with a Trendelenburg gait is expected for 3 to 6 months (50 to 70 percent of patients), persisting in 5 to 20 percent and leaving a permanent Trendelenburg in 3 to 5 percent. Weakness beyond six months warrants MRI (repair integrity) and EMG (nerve function). Return to driving is typically 6 to 8 weeks.

• Total hip replacement via the direct lateral (Hardinge/transgluteal) approach — the principal operation done through this exposure.
• Hemiarthroplasty for femoral neck fracture — fast, stable and familiar, with a lower dislocation rate than the posterior approach.
• Hip arthrodesis — accessed through the same lateral exposure.
• Hip resurfacing arthroplasty and simple revision THA (liner exchange, head and neck swap).

Guidelines, registries and global practice - Across the major registries (NJR England and Wales, AOANJRR, Swedish and Norwegian) the direct lateral and posterior approaches are consistently the two commonest for primary THA — the posterior predominates in North America, the direct lateral remains common in the UK, Scandinavia and Australasia, and the direct anterior has risen since the 2010s but remains a minority approach.

• No named-society guideline mandates a specific approach; selection is surgeon- and patient-specific. Where dislocation risk is the priority (cognitive impairment, neuromuscular disease, high BMI) the lower dislocation rate of the direct lateral is an advantage; where abductor preservation and gait are paramount, an abductor-sparing approach may be preferred.
• Registry analyses generally show equivalent long-term implant survivorship across approaches, with surgeon and unit volume stronger predictors of revision than approach choice.
• Abductor dysfunction and limp are foreseeable and must be specifically consented for; superior gluteal nerve injury is largely preventable by keeping the split within 5 cm of the trochanter, and the abductor repair technique should be documented.