Direct anterior approach for total hip arthroplasty using the "bikini incision"

Objective The classic skin incision for direct anterior approach (DAA) total hip arthroplasty (THA) is usually placed over the belly of the tensor fasciae latae (TFL) muscle parallel to the axis of the lower extremity. In the "bikini incision" technique however, a more horizontal skin incision is used and placed parallel to the skin creases, which largely corresponds to the skin's tension lines to prevent hypertrophic scarring and optimize cosmetic outcomes. Indications Primary or secondary osteoarthritis, femoral neck fracture, aseptic acetabular component loosening with sufficient bone stock and without the need for proximal extension of the approach, head and/or liner exchange. Contraindications Complex primary or revision THA requiring extensile distal and/or acetabular exposure, revision with pre-existing longitudinal DAA incision, inguinal skin infection. Surgical technique The skin incision, located three fingerbreadths distal to the anterior superior iliac spine (ASIS), is orientated parallel to the groin crease. One third of the incision is medial and two thirds lateral to the ASIS. Subcutaneous dissection should only be performed in the lateral two thirds of the incision to protect the main branches of the lateral femoral cutaneous nerve (LFCN). The fascia lata is opened as far lateral over the muscle belly as possible to leave the LFCN untouched within its fascial sheet. The stepwise procedure consists of three key steps: capsular exposure, capsular release, and component insertion. The approach allows for an excellent 360 degrees exposure of the acetabulum. The femur is aligned along the incision during femoral elevation and adduction. With this technique, DAA hip arthroplasty can be performed in a less-invasive way providing best possible functional and cosmetic outcomes. Postoperative management No restrictions in ambulation or range of motion. Deep vein thrombosis prophylaxis. Results In a prospective series of 532 consecutive patients undergoing 613 primary THA with a bikini-incision in 2017, a good clinical outcome with a 2.3% incidence of wound-related problems was observed. In particular, obese patients can also benefit from the technique.