Overview
The posterolateral approach provides access to the acetabulum and proximal femur and can be extended when needed. In primary total hip arthroplasty, success depends on safe exposure, a stable reconstruction, appropriate restoration of length and offset and repair of the posterior soft-tissue envelope. This guide summarizes Campbell's posterolateral exposure and cementless preparation principles; the broaching and fixation sequence must suit the selected implant (Campbell, Chapter 4).
Planning
Confirm the indication and optimize medical and wound risks before elective surgery.
Template the acetabular center, component sizes, femoral neck cut, length and offset using calibrated AP and lateral images.
Assess femoral geometry, bone quality and spinopelvic function. These may change fixation and component orientation.
Identify previous scars, hardware and deformity and prepare appropriate backup implants and extraction instruments.
Discuss instability, nerve injury, fracture, infection and leg-length inequality, including the limits of obtaining perfect equality in every reconstruction.
(Campbell, Chapter 4.)
Positioning and Exposure
Secure the patient in true lateral position. Pelvic movement during retraction can change the apparent cup orientation.
Make an incision centered over the greater trochanter with enough proximal and distal extension to permit controlled acetabular and femoral instrumentation.
Open the fascia lata and split gluteus maximus in the direction of its fibers, controlling bleeding.
Place retractors without trapping the sciatic nerve. Expose the short external rotators and tag the tendons for later repair.
Release the rotators near their femoral insertion, retaining useful length, and reflect them posteriorly to protect the nerve.
Expose and open the posterior capsule close to its femoral attachment, preserving it for repair.
(Campbell, Chapter 4, Technique 4.2.)
Dislocation and Neck Resection
Establish a reproducible reference for leg length and offset before changing the anatomy. Repeat measurements with the limb in the same position.
Dislocate by controlled flexion, adduction and internal rotation. Do not apply excessive torsion if the head is incarcerated.
If necessary, improve capsular release or remove obstructing osteophytes; an in situ neck osteotomy is an alternative when safe dislocation cannot be achieved.
Mark the planned neck cut against the lesser trochanter and templated reconstruction.
Resect with controlled saw cuts, avoiding a notch at the greater trochanter, and retain the head if graft may be needed.
(Campbell, Chapter 4, Technique 4.2.)
Acetabular Preparation
Retract the femur anteriorly to expose the full acetabular rim. Place anterior retractors against bone in the appropriate plane rather than over the iliopsoas, where the femoral nerve and vessels are vulnerable.
Remove the labrum and obstructing soft tissue with the cutting instrument kept within the acetabular boundary.
Identify the true medial wall and acetabular floor. Osteophytes can conceal the floor and lead to an excessively lateral hip center.
Begin below the expected final reamer size and deepen carefully without violating the medial wall.
Progress in controlled increments along a consistent plane, retaining as much supporting subchondral bone as possible.
Assess circumferential contact, defects and cysts. Prepare and graft defects as indicated before selecting the definitive cup.
(Campbell, Chapter 4, Technique 4.2.)
Cup Position and Fixation
Check | Reason |
|---|---|
True pelvic position | Anterior pelvic rotation during retraction can create unintended retroversion. |
Patient-specific orientation | Cup position must account for femoral version and spinopelvic motion; a static target is not universal. |
Seating and initial stability | Match reaming and press fit to the cup design and bone; excessive oversizing can prevent seating or fracture the acetabulum. |
Supplemental screws | Plan trajectory and depth with neurovascular anatomy in mind; posterior quadrants are generally safer than anterior quadrants but are not risk-free. |
Liner seating and compatibility | Confirm the correct component and secure engagement before final reduction. |
Campbell describes typical inclination and anteversion ranges for the illustrated system but explicitly adjusts the plan for spinal deformity or stiffness and combined version. Individualize these targets rather than reproducing a fixed cup angle in every patient (Chapter 4, Technique 4.3).
Femoral Preparation
Expose the proximal femur adequately and enter the canal along its true axis.
Remove lateral obstructing bone as needed to avoid varus preparation. The neck-cut aperture does not necessarily indicate the center of the canal.
Prepare with the reamers and broaches required for the selected stem, maintaining consistent axial and rotational alignment.
Advance progressively with controlled force. If a broach stops unexpectedly, reassess size, alignment and distal preparation rather than increasing impaction.
Check axial and rotational stability and the relationship of the final broach to the planned neck cut.
Use the selected trial neck and head to assess the reconstructed center and prepare for trial reduction.
(Campbell, Chapter 4, Technique 4.5.)
Trial Reduction and Final Implantation
Reduce gently and evaluate limb length and offset using the established references.
Check stability and impingement through a functional range, including positions that challenge posterior and anterior stability.
If unstable, investigate version, bony or liner impingement, offset and soft-tissue tension. Avoid correcting every problem by lengthening the limb.
Once satisfactory, insert the definitive components while reproducing the trial alignment. Inspect for an insertion-related femoral fracture.
Clean and dry the taper, use compatible head and stem components and remove debris from the articulation.
Reduce again and repeat the stability, impingement and length checks with the final implants.
(Campbell, Chapter 4.)
Posterior Repair and Closure
Repair the preserved posterior capsule and reattach the tagged short external rotators to the appropriate insertion.
Repair any additional released tendon or muscle attachment.
Close the fascia and remaining layers without undue tension.
Confirm that the reconstruction and soft-tissue repair permit the intended motion without impingement or instability.
Careful posterior soft-tissue reconstruction reduces dislocation risk; it is a planned part of the approach, not an optional substitute for correct component positioning (Campbell, Chapter 4, closure section).
Postoperative Care
Begin gait training when recovery and comfort allow, often on the day of surgery. Loading depends on component fixation, bone quality, fractures, grafts and any osteotomy. Campbell describes variation in restrictions after cementless THA and emphasizes individualization rather than a universal period of non-weight bearing.
Teach transfers, assistive-device use and the prescribed motion precautions. Although the authors describe posterior precautions, the chapter also notes evidence questioning routine precautions after uncomplicated THA. Follow the operative stability and institutional rehabilitation plan. Review the wound and reconstruction clinically and radiographically, commonly around 2 weeks in the described pathway (Campbell, Chapter 4, postoperative management).
Complications and Pitfalls
Dislocation from malposition, impingement or inadequate soft-tissue tension.
Femoral or acetabular fracture from forced dislocation, reaming, broaching or insertion.
Sciatic, femoral or vascular injury from retraction or screw placement.
Leg-length inequality, altered offset, infection, thromboembolism and heterotopic ossification.
Failure to seat or stabilize an implant and later loosening or wear.
(Campbell, Chapter 4.)
References
Harkess JW, Crockarell JR Jr. Arthroplasty of the hip. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Elsevier; 2026. Chapter 4, posterolateral exposure and acetabular preparation, pp. 221–224, Technique 4.2; cup and cementless femoral implantation, pp. 224–232, Techniques 4.3 and 4.5; closure, p. 235; postoperative care, pp. 328–330.