Surgical Approaches in THR — Posterior, Anterior, Lateral, SPAIRE

Part of The Joint Replacement Guide — Phase 4: The Operation · Article 20 of 42 · Hip

Key Points

  • Several different surgical approaches can be used to access the hip joint, each with different trade-offs.
  • No single approach has been definitively proven superior for everyone — registry data shows broadly comparable outcomes when any approach is performed well.
  • Surgeon experience and familiarity with their chosen approach matters at least as much as which approach is used.
  • Any early recovery differences between approaches tend to narrow over the following months.

Posterior Approach

The posterior approach, accessing the hip from behind, is the most widely used approach worldwide and offers excellent visualisation of the joint, making it versatile across a wide range of patient anatomies. It was historically associated with a somewhat higher dislocation risk when the short external rotator muscles and joint capsule were not repaired at the end of surgery; modern technique routinely includes careful repair of these structures, which has substantially reduced this historical difference.

Anterior (Direct Anterior) Approach

The direct anterior approach accesses the hip from the front, working between natural muscle intervals rather than detaching muscle, and has been increasingly popularised in recent years, often marketed around the idea of a faster early recovery. The evidence here is genuinely mixed: some studies do show a modest early recovery advantage in the first few weeks, but robust evidence for a meaningful long-term difference in outcomes compared with other well-performed approaches is not conclusively established. It typically requires specific instrumentation, and sometimes a specialised operating table, and carries its own learning curve for surgeons adopting it.

Lateral (Hardinge) Approach

The lateral approach accesses the hip through or around the side, and has historically been associated with a lower dislocation risk than an unrepaired posterior approach. It involves working through part of the abductor muscles at the side of the hip, and if this is not carefully repaired, it can occasionally affect abductor strength and gait afterwards. It remains a well-established, commonly used approach, particularly in certain patient groups or specific surgical circumstances.

SPAIRE Technique

SPAIRE — an acronym for “Save Piriformis And Internus, Repair Externus” — is a more recently developed modification of the posterior approach, designed to preserve more of the short external rotator muscles than the traditional posterior technique while retaining its excellent visualisation. The aim is to combine the reliability of a posterior exposure with reduced soft tissue disruption. It has a growing evidence base and is used by an increasing number of surgeons, though it remains a comparatively newer technique relative to the three approaches above.

What Actually Matters Most

National registry data broadly shows good, comparable outcomes across all of these approaches when performed well. In practice, the experience and volume a surgeon has with their usual approach is at least as important a factor as which specific approach is chosen — a surgeon who performs hundreds of posterior approach hip replacements a year is likely to achieve better, more consistent results with that approach than by switching to an unfamiliar technique. It is entirely reasonable to ask your surgeon which approach they use routinely and about their experience with it, rather than requesting a particular approach based on marketing claims alone.

In More Depth

Systematic reviews comparing surgical approaches generally find that differences in dislocation rate, pain, and function are modest once modern soft tissue repair techniques are accounted for, and that any early functional advantage seen with muscle-sparing approaches such as the direct anterior technique tends to narrow considerably by around three to six months after surgery, at which point outcomes across approaches become difficult to distinguish. This reinforces the point made above — the choice of approach is genuinely a matter of surgeon training, experience and preference more than a clear-cut clinical mandate, and patients are well served by trusting an experienced surgeon’s usual technique over pursuing a specific approach for its own sake.

This article is general information and does not replace individual clinical advice.

Sources

  • National Joint Registry — Annual Report, outcomes by surgical approach
  • Cochrane Database of Systematic Reviews — surgical approaches for total hip replacement
  • British Hip Society — surgical approach guidance

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