Hip – Anterolateral Approach

Modern Study Review: Hip – Anterolateral Approach (Watson-Jones)

High-Yield Summary

The Watson-Jones anterolateral approach is a classic, muscle-sparing technique for hip exposure, widely used in fracture fixation, arthroplasty, and soft tissue procedures. It provides direct access to the femoral neck and acetabulum while preserving the abductor mechanism. Although still relevant, it has been partially supplanted by minimally invasive anterior approaches that offer improved soft tissue preservation and faster recovery in modern hip arthroplasty.

Applied Anatomy & Intervals

Internervous Interval

• No true internervous plane.
• The approach exploits the interval between Tensor Fascia Latae (TFL) and Gluteus Medius, both innervated by the superior gluteal nerve.

Anatomic Landmarks

• Greater Trochanter (GT): Central reference for skin incision.
• Anterior Superior Iliac Spine (ASIS): Palpable landmark to orient incision.
• Iliotibial Band (ITB): Overlies TFL; critical for superficial dissection.

Patient Positioning & Setup

Table Type

• Standard orthopedic fracture or hip table.

Patient Position

• Lateral decubitus (most common).
• Supine position may be used depending on surgeon preference and procedure.

Specialized Equipment

• Limb positioners/supports for controlled hip rotation and abduction.
• C-arm fluoroscopy positioned for anteroposterior and lateral hip imaging.

Surgical Technique (The “Vital Steps”)

Incision & Superficial Dissection

• Make a 15 cm skin incision centered over the greater trochanter, curving slightly posterior and proximally.
• Incise subcutaneous fat to expose fascia lata.
• Incise fascia lata at the posterior margin of the greater trochanter distally.

Deep Dissection & Exposure

• Identify and develop the interval between TFL and Gluteus Maximus; incise fascia over this interval.
• Retract Gluteus Medius and Minimus proximally and laterally to expose the superior capsule margin.
• Externally rotate the leg to expose the hip capsule.
• Dissect along the femoral neck to fully expose the capsule.
• If needed, perform a trochanteric osteotomy or detach the anterior third of Gluteus Medius for improved exposure.
• Detach the reflected head of Rectus Femoris to access the capsule.
• Incise the hip capsule in an H-shaped fashion.
• Dislocate the hip anteriorly for full joint exposure.

The “Danger Zone”

Post-Operative Pearl

Early mobilization with protected weight-bearing is recommended. Avoid forced hip adduction and external rotation for 6 weeks to protect soft tissue repair and prevent femoral shaft stress.

Classic Clinical Notes

Hip – Anterolateral Approach (Watson-Jones)

• Position:
• Usually in lateral decubitus position
• May use supine position

• Incision:
• 15 cm incision centered on greater trochanter, may curve slightly posterior proximally

• Internervous Plane:
• No true plane
• Between Tensor Fascia Latae (TFL) & Gluteus Medius (superior gluteal nerve)

• Dissection:
• Incise fat to reach deep fascia
• Incise fascia latae at posterior margin of greater trochanter distally
• Identify interval between TFL & Gluteus Maximus and incise fascia
• Retract Gluteus Medius and Minimus proximally and laterally away from superior margin of capsule
• Externally rotate leg to expose joint capsule
• Dissect up femoral neck to expose capsule
• May require trochanteric osteotomy or detachment of anterior 1/3 of Gluteus Medius
• Detach reflected head of rectus femoris
• Incise hip capsule (H-shaped)
• Dislocate hip

• Dangers:
• Femoral nerve – most lateral placed structure in femoral triangle and can be stretched with overzealous retraction of anterior tissues
• Profunda femoris artery – lies on psoas muscle deep to femoral artery and can be damaged by poorly placed retractors
• Femoral artery and vein – may be damaged by incorrectly placed acetabular retractors that penetrate iliopsoas
• Femoral shaft fractures – with dislocation of hip or with forced adduction and external rotation for reaming of shaft

Last Updated on January 25, 2026 by orthonet