Posterior approach to the Hip Joint

The hip joint is one of the most surgically exposed joints in the body [1]. The posterior approach is known to have a slightly higher risk of dislocations [2], whilst the anterior [3] and lateral approaches [4] allow for preservation of the posterior soft tissue envelope. I had developed a modifi cation of the Posterior Approach at a time when the regular Posterior Approach was plagued with the problem of dislocation. Hence this modifi cation was devised after cadaveric tests confi rming superiority by increasing its stability and thus prevent dislocation of the Hip joint. This is a posterior trochanter spliting approach to the Hip Joint by maintaining all the advantages of the Posterior Approach with excellent visualization of the Hip Joint. This was then used in patients with a fracture neck femur for insertion of an endoprosthesis.

The hip joint is one of the most surgically exposed joints in the body [1]. The posterior approach is known to have a slightly higher risk of dislocations [2], whilst the anterior [3] and lateral approaches [4] allow for preservation of the posterior soft tissue envelope. I had developed a modifi cation of the Posterior Approach at a time when the regular Posterior Approach was plagued with the problem of dislocation. Hence this modifi cation was devised after cadaveric tests confi rming superiority by increasing its stability and thus prevent dislocation of the Hip joint. This is a posterior trochanter spliting approach to the Hip Joint by maintaining all the advantages of the Posterior Approach with excellent visualization of the Hip Joint. This was then used in patients with a fracture neck femur for insertion of an endoprosthesis.
The detailed Clinical Technique stepwise in 11 steps is as described below: There were no dislocations nor instability noted in the followup of these patients. This approach was then described by Mark Conventry [5] in the year book of Orthopaedics, Terry Canale of Campbell's Operative Orthopaedics (1992) [6] till fi nally by my respected teacher Mr.F.H. Beddow in the Rheumatoid Arthritis Surgical Society (1990) [7]. Thereafter many people like James Shaw [8] did appreciate this approach and it was mentioned in books by John J Callaghan MD, Aaron G Rosenberg MD, Harry E Rubash in The Adult Hip (1998) [9] and Surgery of the Hip by Raymond Tonzo [10] and fi nally in Minimally Invasive Total Joint Arthroplasty (2004) [11] by William J Hozak, Martin Kirsmer, Michael Hogler, Peter M Bonutti, Franz Rachbauer, Jonathan L Scaffer, William J Donnelly. Above all Thomas Stahelin [12] of Zurich, Switzerland fi nally acknowledged the value of this approach. Deepa Iyer (2006) [13] and Robert H Cofi eld [14] of Mayo clinic (2005) in the USA did acknowledge this approach by carrying out their studies with reporting their results in the Acta Orthopaedica Belgica [15]. The main pupose of this modifi cation was to avoid            So patients will recover pretty soon unlike other approaches where they might take many weeks to recover. Not only physio but also patient and their family members work will reduce drastically if there is no damage to muscles and nerves and less chances of joint dislocation. Moreover, early recovery makes more confi dence and daily living activities will improve sooner in those patients who undergo this particular surgery.
Physiotherapy Treatment/ Physical Therapy plays a vital role in patient's recovery. Physiotherapist mainly works on reducing pain and swelling, restoring and maintaining full range of motion, improving muscle strength and endurance, muscle stretching exercises, fl exibility, balance exercises, weight bearing activities, promoting independence, other functional activities and many more.
Physiotherapy will continue for a number of weeks after the surgery. This depends on overall situation of the patient and the approach used by Orthopedic Surgeon. If the surgeon uses the modifi ed posterior approach technique, defi nitely length of the postoperative recovery phase reduces and patient can lead his normal life as soon as possible.

Clinical observations made by the physiotherapist Ritika Sharma bachelors of physiotherapy, Delhi, India
The posterior approach is the most common surgical approach used internationally for THAs as there are more than 100 described cases in literature. There is no book written on the title (Posterior Approach to the Hip Joint) only but are in chapters in books on the Hip Joint or Approaches to the Hip Joint. This book will be published eventually by CRC Press (Taylor & Francis,UK) and it has chapterwise contributions from all over the world to include China, Japan, India, UK, USA, Australia, France and Germany which shows the evolution and progress this approach has made since its Start.
1. This modifi cation helps to increase stability of the posterior aspect of the Hip Joint by trochanteric osteotomy of the greater trochanter as noted by its cadaveric tests and hence decreases the risk of dislocation of the Hip Joint.
2. There is minimal bleeding in this approach and no neurological defecit as the sciatic nerve is far away.
3. It does not interfere with the abductor mechanism as it leaves the abductor mechanism intact.
4. There is excellent visualization of all parts of the Hip Joint by this approach and hence useful in Hemiarthroplasty, Total Hip Replacement both primary and revision where there is good visulisation of the femur also.
5. Early postoperative recovery due to early mobilization with reduced length of hospital stay.
Rehabilitation protocols in the Hips operated by the lateral and anterior approaches vary considerably as follows: Hip positional precautions include no hip adduction past neutral, no hip internal rotation past neutral, and no hip fl exion more than 90 degrees for a minimum of 12 weeks until   soft tissue stabilization can be expected but hip fl exion may be increased gradually more than 90 from 6 weeks. An abduction pillow is used for the fi rst 4 weeks while resting or sleeping in bed. For the bathroom an elevated seat is preferred at all times which can be discontinued from the 3 rd month onwards. Use of assisted ambulation devices such as cane, walker, quad cane increases the confi dence of the patient. Avoid sitting in conventional fashion while driving with the hips fl exed more The emphasis should be made on quick mobiisation rather than the word dislocation.This can be used extensively in Fracture neck of femur for Hemiarthroplasty [17][18][19] rather than Primary or Revision Hip Replacement [20].
But with gradual understanding of the DAA, this appears to be a better substitute [21][22][23][24]. Rather than these modifi cations.
The DAA may appear to have a very steep and diffi cult learning curve in the beginning, but with practice and using this DAA, it appears as an excellent substitute for the Posterior Approach to the Hip Joint.
The features of DAA should be shared actively with physio/ occupational therapists to avoid the necessity for the use of a low chair for sitting purposes and avoid cross the legs in bed.
All HOD's in Orthopaedics should impart teaching on DAA to their students at all levels in training so that they are aware of the DAA.
The `word dislocation' has been looked as a unacceptable/ inadequate/ banned as constituting a risk/ not acceptable to mention associated with mainly Posterior Approach in Surgical Approaches to the Hip Joint since over 5 decades which is extremely diffi cult to overcome in literature even till today.