The Minimally Invasive Anterolateral Approach in Supine Position for Primary Total Hip Arthroplasty: Surgical Technique and a Narrative Review of Clinical Outcomes
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Abstract
The anterolateral approach has been widely adopted in total hip arthroplasty (THA), with numerous modifications described since its original introduction. Among these, the minimally invasive anterolateral (MIS-AL) approach, also referred to as the anterior-based muscle-sparing approach, has been developed to minimize soft-tissue damage by preserving the integrity of the gluteus medius muscle. This narrative review describes the surgical technique of the MIS-AL approach for primary THA performed in the supine position and provides a summary of clinical outcomes. When performed in the supine position, the MIS-AL approach offers several advantages beyond its muscle-sparing nature. It does not require a specialized operating table, allows for a simplified operating room setup, facilitates the use of intraoperative fluoroscopy, and enables simultaneous bilateral THA without the need for re-draping. In addition, available evidence suggests that this approach is associated with faster postoperative recovery and a reduced risk of postoperative dislocation, supporting the MIS-AL approach as a reliable and muscle-sparing option for primary THA.
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References
Watson-Jones R. Fractures of the neck of the femur. Br J Surg 1936;23(92):787-808. DOI: https://doi.org/10.1002/bjs.1800239213
Sculco TP. Minimally invasive total hip arthroplasty: in the affirmative. J Arthroplasty 2004;19(4):78-80. DOI: https://doi.org/10.1016/j.arth.2004.02.021
Berry DJ. “Minimally invasive” total hip arthroplasty. J Bone Joint Surg Am 2005;87(4):699-700. DOI: https://doi.org/10.2106/JBJS.E.00126
Röttinger H. The idea of “minimally invasive solution” total hip arthroplasty: history and perspective behind the modernization of surgery through the watson-jones muscle interval. In: Geller JA, McGrory BJ, editors. The anterior-based muscle-sparing approach to Total Hip Arthroplasty. Cham: Springer International Publishing; 2022. p. 1-13. DOI: https://doi.org/10.1007/978-3-031-02059-9_1
Bertin KC, Röttinger H. Anterolateral mini-incision hip replacement surgery: a modified Watson-Jones approach. Clin Orthop Relat Res 2004;(429):248-55. DOI: https://doi.org/10.1097/01.blo.0000150294.81825.8c
Lepri AC, Villano M, Matassi F, Carulli C, Innocenti M, Civinini R. “Anterolateral” approach to the hip: a systematic review of the correct definition of terms. Hip Int 2020;30(2 Suppl):13-9. DOI: https://doi.org/10.1177/1120700020966800
Takada R, Jinno T, Miyatake K, Hirao M, Yagishita K, Yoshii T, et al. Supine versus lateral position for accurate positioning of acetabular cup in total hip arthroplasty using the modified Watson-Jones approach: a randomized single-blind controlled trial. Orthop Traumatol Surg Res 2019;105(5):915-22. DOI: https://doi.org/10.1016/j.otsr.2019.05.004
Kishimura Y, Minoda Y, Mizokawa S, Sugama R, Ohta Y, Nakamura H. Cup alignment in total hip arthroplasty using the muscle-sparing modified Watson-Jones approachcomparison between lateral and supine positions. Int Orthop 2019;43(11):2477-83. DOI: https://doi.org/10.1007/s00264-019-04316-y
Viglietta E, Fenucci S, Iorio R, Parisien A, Grammatopoulos G, Kim PR, et al. “Intra-operative assessment of leg length discrepancy with anterior approach total hip replacement: a comparison between standard table, position table with and without intra-operative radiographs”. Int Orthop 2025;49(5):1065-71. DOI: https://doi.org/10.1007/s00264-025-06411-9
Blum CL, Luzzi AJ, Frederick JS, Cooper HJ, Shah RP, Tatka J, et al. Intraoperative Fluoroscopy Decreases Magnitude and Incidence of Leg-Length Discrepancy Following Total Hip Arthroplasty. Arthroplast Today 2024;30:101492. DOI: https://doi.org/10.1016/j.artd.2024.101492
Civinini R, Cozzi Lepri A, Carulli C, Matassi F, Villano M, Innocenti M. The anterior-based muscle-sparing approach to the hip: the “other” anterior approach to the hip. Int Orthop 2019;43(1):47-53. DOI: https://doi.org/10.1007/s00264-018-4190-6
Tamaki Y, Goto T, Wada K, Omichi Y, Hamada D, Sairyo K. Robotic arm-assisted total hip arthroplasty via a minimally invasive anterolateral approach in the supine position improves the precision of cup placement in patients with developmental dysplasia of the hip. J Orthop Sci 2024;29(2):559-65. DOI: https://doi.org/10.1016/j.jos.2023.01.012
Tachibana T, Katagiri H, Ogawa T, Koyano G, Jinno T. Enhancing the accuracy of cup placement in total hip arthroplasty using CT-based navigation by a trainee surgeon: a retrospective cohort study. BMC Musculoskelet Disord 2025;26(1):262. DOI: https://doi.org/10.1186/s12891-025-08493-3
Schwartz AM, Goel RK, Sweeney AP, Bradbury TL Jr. Capsular management in direct anterior total hip arthroplasty: a randomized, single-blind, controlled trial. J Arthroplasty 2021;36(8):2836-42. DOI: https://doi.org/10.1016/j.arth.2021.03.048
Vandeputte FJ, Vanbiervliet J, Sarac C, Driesen R, Corten K. Capsular resection versus capsular repair in direct anterior approach for total hip arthroplasty: a randomized controlled trial. Bone Joint J 2021;103-B(2):321-8. BJJ-2020-0529.R2. DOI: https://doi.org/10.1302/0301-620X.103B2.BJJ-2020-0529.R2
Lu Y, Wu Z, Tang X, Gu M, Hou B. Effect of articular capsule repair on postoperative dislocation after primary total hip replacement by the anterolateral approach. J Int Med Res 2019;47(10):4787-97. DOI: https://doi.org/10.1177/0300060519863526
Yano S, Hagiwara S, Iida S, Nakamura J, Kawarai Y, Ohtori S. Effects of anterior capsule repair during total hip arthroplasty using the anterolateral approach in the supine position. J Joint Surg Res 2023;1(1):163-7. DOI: https://doi.org/10.1016/j.jjoisr.2023.07.004
Müller M, Tohtz S, Springer I, Dewey M, Perka C. Randomized controlled trial of abductor muscle damage in relation to the surgical approach for primary total hip replacement: minimally invasive anterolateral versus modified direct lateral approach. Arch Orthop Trauma Surg 2011;131(2):179-89. DOI: https://doi.org/10.1007/s00402-010-1117-0
Müller M, Tohtz S, Winkler T, Dewey M, Springer I, Perka C. MRI findings of gluteus minimus muscle damage in primary total hip arthroplasty and the influence on clinical outcome. Arch Orthop Trauma Surg 2010;130(7):927-35. DOI: https://doi.org/10.1007/s00402-010-1085-4
Inaba Y, Kobayashi N, Yukizawa Y, Ishida T, Iwamoto N, Saito T. Little clinical advantage of modified Watson-Jones approach over modified mini-incision direct lateral approach in primary total hip arthroplasty. J Arthroplasty 2011;26(7):1117-22. DOI: https://doi.org/10.1016/j.arth.2011.04.002
Ukai T, Ebihara G, Watanabe M. Comparison of short-term outcomes of anterolateral supine approach and posterolateral approach for primary total hip arthroplasty: a retrospective study. J Orthop Traumatol 2021;22(1):6. DOI: https://doi.org/10.1186/s10195-021-00570-2
Ostojić M, Kordić D, Moro G, Ostojić Z. Anterolateral minimally invasive hip approach offered faster rehabilitation with lower complication rates compared to the minimally invasive posterior hip approach—a University clinic case control study of 120 cases. Arch Orthop Trauma Surg 2022;142(5):747-54. DOI: https://doi.org/10.1007/s00402-020-03719-6
Liu H, Yin L, Li J, Liu S, Tao Q, Xu J. Minimally invasive anterolateral approach versus direct anterior approach total hip arthroplasty in the supine position: a prospective study based on early postoperative outcomes. J Orthop Surg Res 2022;17(1):230. DOI: https://doi.org/10.1186/s13018-022-03126-0
Herndon CL, Drummond N, Sarpong NO, Cooper HJ, Shah RP, Geller JA. Direct anterior versus mini-anterolateral approach for primary total hip arthroplasty: early postoperative outcomes and complications. Arthroplast Today 2020;6(2):257-61. DOI: https://doi.org/10.1016/j.artd.2020.02.009
Sheth D, Cafri G, Inacio MC, Paxton EW, Namba RS. Anterior and anterolateral approaches for THA are associated with lower dislocation risk without higher revision risk. Clin Orthop Relat Res 2015;473(11):3401-8. DOI: https://doi.org/10.1007/s11999-015-4230-0
Clesham K, Sheridan GA, Greidanus NV, Masri BA, Garbuz DS, Duncan CP, et al. Minimally invasive intermuscular approaches versus conventional approaches in total hip arthroplasty: a systematic review and meta-analysis. J Arthroplasty 2022;37(8):1658-66. DOI: https://doi.org/10.1016/j.arth.2022.03.071
Kahn TL, Frandsen JJ, Blackburn BE, Anderson LA, Pelt CE, Gililland JM, et al. Anterior-based approaches to total hip arthroplasty: beyond the learning curve. J Arthroplasty 2022;37(7):S552-S5. DOI: https://doi.org/10.1016/j.arth.2022.01.042
Pan T, Mehta A, Mason MW. Outcomes of the supine anterior-based muscle-sparing approach for primary and revision hip arthroplasty. J Am Acad Orthop Surg Glob Res Rev 2022;6(2). DOI: https://doi.org/10.5435/JAAOSGlobal-D-21-00050
Rana AJ, Sturgeon CM, McGrory BJ, Frazier MV, Babikian GM. The ABLE anterior-based muscle-sparing approach: a safe and effective option for total hip arthroplasty. Arthroplast Today 2022;16:264-9.e1. DOI: https://doi.org/10.1016/j.artd.2022.06.007
Van Roekel N, Lutnick E, Pavlesen S, Henry M, Haider MN, Phillips M. Perioperative femur fractures in muscle sparing anterolateral - modified Watson-Jones approach to primary total hip arthroplasty: a retrospective cohort study. J Clin Orthop Trauma 2024;59:102828. DOI: https://doi.org/10.1016/j.jcot.2024.102828
Herndon CL, Nowell JA, Sarpong NO, Cooper HJ, Shah RP, Geller JA. Risk factors for periprosthetic femur fracture and influence of femoral fixation using the mini-anterolateral approach in primary total hip arthroplasty. J Arthroplasty 2020;35(3):774-8. DOI: https://doi.org/10.1016/j.arth.2019.10.011
Fleischman AN, Rothman RH, Parvizi J. Femoral nerve palsy following total hip arthroplasty: incidence and course of recovery. J Arthroplasty 2018;33(4):1194-9. DOI: https://doi.org/10.1016/j.arth.2017.10.050
Vajapey SP, Morris J, Lynch D, Spitzer A, Li M, Glassman AH. Nerve injuries with the direct anterior approach to total hip arthroplasty. JBJS Rev 2020;8(2):e0109. DOI: https://doi.org/10.2106/JBJS.RVW.19.00109
Takada R, Jinno T, Miyatake K, Hirao M, Kimura A, Koga D, et al. Direct anterior versus anterolateral approach in one-stage supine total hip arthroplasty. Focused on nerve injury: a prospective, randomized, controlled trial. J Orthop Sci 2018;23(5):783-7. DOI: https://doi.org/10.1016/j.jos.2018.05.005
Goulding K, Beaulé PE, Kim PR, Fazekas A. Incidence of lateral femoral cutaneous nerve neuropraxia after anterior approach hip arthroplasty. Clin Orthop Relat Res 2010;468(9):2397-404. DOI: https://doi.org/10.1007/s11999-010-1406-5
Patton RS, Runner RP, Lyons RJ, Bradbury TL. Clinical outcomes of patients with lateral femoral cutaneous nerve injury after direct anterior total hip arthroplasty. J Arthroplasty 2018;33(9):2919-26.e1. DOI: https://doi.org/10.1016/j.arth.2018.04.032
Gala L, Kim PR, Beaulé PE. Natural history of lateral femoral cutaneous nerve neuropraxia after anterior approach total hip arthroplasty. Hip Int 2019;29(2):161-5. DOI: https://doi.org/10.1177/1120700019827201
Reichert JC, Wassilew GI, von Rottkay E, Noeth U. Compared learning curves of the direct anterior and anterolateral approach for minimally invasive hip replacement. Orthop Rev (Pavia) 2022;14(3):37500. DOI: https://doi.org/10.52965/001c.37500
Kagan RP, Greber EM, Richards SM, Erickson JA, Anderson MB, Peters CL. Advantages of an anterior-based muscle-sparing approach in transitioning from a posterior approach for total hip arthroplasty: minimizing the learning curve. J Arthroplasty 2019;34(12):2962-7. DOI: https://doi.org/10.1016/j.arth.2019.07.009
Inui H, Nakasone I, Kanazawa T, Yamashita T, Tanuma Y, Saita K. Learning curve of minimally invasive anterolateral approach in supine position for total hip arthroplasty. J Joint Surg Res 2024;2(2):31-4. DOI: https://doi.org/10.1016/j.jjoisr.2024.02.001
Laffosse JM, Chiron P, Accadbled F, Molinier F, Tricoire JL, Puget J. Learning curve for a modified Watson-Jones minimally invasive approach in primary total hip replacement: analysis of complications and early results versus the standard-incision posterior approach. Acta Orthop Belg 2006;72(6):693-701.
Stubnya BG, Schulz M, Váncsa S, Szilágyi GS, Szatmári A, Bejek Z. Global trends in joint arthroplasty: a systematic review and future projections. J Clin Med 2025;14(22) DOI: https://doi.org/10.3390/jcm14228214
