Revision THA Exposure – PATH Approach

1. High-Yield Summary

The Percutaneously Assisted Total Hip (PATH) approach for revision total hip arthroplasty provides a tissue-preserving posterior surgical corridor that combines a localized postero-lateral incision with cannulated percutaneous accessory portals for coaxial acetabular and femoral instrumentation.

• Primary Clinical Indication: Modular component exchange (bearing liner and femoral head), isolated acetabular revision for aseptic loosening or malposition with contained bone defects, loose femoral stem extraction, and targeted debridement in selected two-stage revisions for periprosthetic joint infection.
• The Critical Move: Accurate tactile and visual triangulation of the superior percutaneous cannula directly into the acetabular center of rotation, establishing an unconstrained coaxial corridor for reaming, screw insertion, and component extraction while preserving the gluteus medius and piriformis tendon insertions.
• Catastrophic Error to Avoid: Forcing non-collinear reaming or component extraction through an improperly mapped portal, leading to eccentric acetabular reaming, anterior cortical wall perforation, or traction injury to the sciatic nerve; any compromise in direct visualization or instrument excursion mandates immediate conversion to an extensile posterolateral exposure.

2. Indications & Contraindications

Patient selection is governed by the etiology of failure, the stability of retained components, the degree of pelvic and femoral bone loss, and the planned reconstructive implants.

Indications

• Modular Component Exchange: Severe polyethylene wear, adverse local tissue reactions (ALTR) or trunnionosis requiring head-liner exchange, modular ceramic liner fracture, and modular neck or head disassembly without component loosening.
• Isolated Acetabular Revision: Aseptic loosening or symptomatic malposition of the acetabular shell in the presence of Paprosky Type I or Type II contained bone defects where hemispherical porous-coated revision shells achieve dependable primary stability.
• Isolated Loose Femoral Stem Revision: Extraction and revision of loose, non-cemented or non-bonded cemented femoral components where distal diaphyseal access can be achieved without cortical osteotomy.
• Recurrent Hip Instability: Revision cases in patients with intact abductor musculature where preserving the posterior soft-tissue envelope and achieving anatomical capsulotendinous repair minimizes postoperative recurrent dislocation risk.
• Selected Periprosthetic Joint Infection (PJI): First-stage explantation of loose implants or second-stage reimplantation where soft-tissue preservation is critical to retain joint stability and avoid chronic dead space.

Contraindications

• Severe Pelvic Discontinuity and Uncontained Defects: Paprosky Type IIIB acetabular defects, massive column dissociation, or extensive pelvic discontinuity requiring structural allografts, custom triflange implants, or dual-column reconstruction plates that require extensile iliofemoral or posterior visualization.
• Well-Fixed Extensively Porous-Coated Stems: Fully coated cylindrical or tapered stems requiring an extended trochanteric osteotomy (ETO) for extraction (unless the surgeon intends immediate conversion).
• Intact Distal Cement Plugs: Well-fixed, solid distal femoral cement mantles that cannot be removed through an endofemoral window without high risk of cortical perforation.
• Severe Heterotopic Ossification: Brooker Class III or IV heterotopic bone bridging the posterior and superior periarticular spaces, preventing intermuscular interval development.
• Periprosthetic Femoral Fractures: Vancouver Type B2 or B3 fractures requiring extensive fracture exposure, direct reduction, and bypass plate fixation.

3. Preoperative Planning

Preoperative templating and diagnostic evaluation establish component fixation status, quantify host bone loss, and map the trajectory of percutaneous access corridors.

Imaging Review

• Plain Radiographs: Standard low anteroposterior (AP) pelvis centered on the pubic symphysis, cross-table lateral of the affected hip, and full-length AP and lateral femoral views with a calibrated radiopaque magnification marker. Assess acetabular cup abduction, anteversion, teardrop integrity, Kohler line breach, and femoral stem alignment.
• Cross-Sectional Imaging (CT with MARS): Thin-slice metal artifact reduction sequence (MARS) pelvic computed tomography is mandatory to quantify retroacetabular osteolysis, anterior and posterior column integrity, pelvic discontinuity, and circumferential wall support.
• Digital Templating: Determine anticipated revision shell diameter, center of rotation restitution, planned screw trajectories into the posterior-superior safe quadrant, and target leg length and femoral offset.

Equipment Checklist

• Percutaneous Portal Instrumentation: Cannulated percutaneous portal sleeves, matching blunt trocars, soft-tissue protection shields, angled flexible drive shafts, and percutaneous screw drivers.
• Component Extraction Sets: Modular liner extractor tools, universal femoral head pullers, explant acetabular cup extraction system with variable radius blades, curved flexible osteotomes, slap hammer adapters, and high-speed carbide metal-cutting burrs.
• Specialized Retractors: Narrow blunt Hohmann retractors, bent posterior acetabular wall retractors, anterior acetabular rim spike retractors, and double-pronged proximal femoral elevators.
• Extensile Backup Instrumentation: Extended trochanteric osteotomy saw blades, 2.0 mm braided cerclage cables, cable tensioners, and modular tapered fluted revision stem systems.

Examination Under Anesthesia (EUA)

Perform dynamic manual manipulation prior to sterile draping. Document passive hip flexion, internal and external rotation at 90 degrees of flexion, and extension. Evaluate for mechanical impingement, prosthetic subluxation, soft-tissue laxity, and pelvic obliquity. Confirm bilateral apparent and true leg length measurements.

4. Patient Positioning & Setup

Stable, reproducible positioning ensures accurate pelvic orientation and prevents unrecognized rotational malalignment during percutaneous portal trajectory mapping.

Lateral Decubitus Setup

• Table and Fixation: Position the patient in the lateral decubitus position on a radiolucent operating table supported by a rigid mechanical pegboard or well-padded anterior pubic and posterior sacral positioners.
• Pelvic Verticality: Align the anterior superior iliac spines (ASIS) perpendicular to the floor. Eliminate lumbar lordosis and confirm that the long axis of the torso is parallel to the table edge to prevent inadvertent cup retroversion.
• Pressure Protection: Place a dedicated axillary roll 1 to 2 handbreadths distal to the dependent axilla. Ensure the dependent peroneal nerve at the fibular neck is cushioned with foam padding.
• Sterile Draping: Drape the operative limb free using an impervious stockinette to permit unrestricted intraoperative hip flexion, internal rotation, adduction, and extension.

Safety Check & Fluoroscopy Corridor

Prior to skin incision, verify that the fluoroscopic C-arm can enter smoothly from the contralateral side to acquire unobstructed AP pelvis and lateral hip images. Confirm that systemic prophylactic intravenous antibiotics have been fully infused and that the revision implant inventory is verified.

5. Surgical Approach & Internervous Intervals

The PATH technique utilizes an intermuscular posterior corridor supplemented by an orthogonal transgluteal percutaneous portal, operating through precise anatomical intervals.

Superficial Interval

The primary skin incision measures approximately 6 to 8 cm in length, positioned longitudinally over the posterior third of the greater trochanter and centered on the trochanteric tip. Subcutaneous fat is divided in line with the skin incision. The fascia lata and gluteus maximus are incised along the direction of their fibers. The gluteus maximus is innervated by the inferior gluteal nerve (L5, S1, S2); blunt division in line with its muscular fibers preserves the regional neurovascular branches.

Deep Interval & Capsular Window

Beneath the gluteus maximus, a self-retaining retractor exposes the underlying short external rotators and trochanteric bursa. Dissection proceeds through the interval between the gluteus medius and piriformis tendon:

• Abductor Preservation: The gluteus medius and gluteus minimus are mobilized anteriorly without sharp detachment from their trochanteric footprints. The superior gluteal nerve (L4, L5, S1) travels between the gluteus medius and minimus 3 to 5 cm proximal to the trochanteric tip; blunt anterior retraction remains strictly below this danger zone.
• External Rotator Window: The piriformis and conjoint tendons (obturator internus and gemelli) are identified. For limited modular revisions, an intermuscular interval directly superior to the piriformis is developed. In cases requiring broader exposure, the piriformis and conjoint tendons are tagged with nonabsorbable retention sutures and released 1 cm from their insertion. The obturator externus and quadratus femoris are kept intact to protect the ascending branch of the medial femoral circumflex artery.
• Capsular Exposure: An inverted L-shaped or linear capsulotomy exposes the prosthetic joint. Capsular flaps are tagged for anatomical re-approximation during closure.

6. Step-by-Step Surgical Technique

Execution requires systematic portal triangulation, protected component extraction, concentric bone bed reaming, and anatomical soft-tissue reconstruction.

Step 1: Incision and Portal Mapping

• Palpate the posterior crest of the greater trochanter and the anterior superior iliac spine. Make the primary 6 to 8 cm skin incision centered over the posterior greater trochanter.
• Develop the plane through the fascia lata and split the gluteus maximus fibers bluntly. Position a Charnley or deep Gelpi retractor to maintain clear visualization of the deep fascia.
• Map the percutaneous superior portal: locate the skin entry site approximately 3 to 5 cm proximal and 1 cm posterior to the superior tip of the greater trochanter. Introduce the surgeon’s non-dominant index finger through the primary incision onto the superior-posterior acetabular rim.
• Cannulate the soft-tissue interval: make a 10 mm stab incision through the skin and abductor fascia at the mapped site. Pass a blunt cannulated trocar and protective portal sleeve along the index finger guide directly down to the acetabular dome. Remove the blunt trocar, leaving the soft-tissue sleeve seated firmly against the osseous margin.

Step 2: Acetabular Exposure and Component Extraction

• Retract the soft tissues: place a blunt curved Hohmann retractor around the anterior acetabular wall directly onto bone, a narrow retractor beneath the transverse acetabular ligament, and a posterior retractor holding the capsule.
• Disassemble the modular bearing: clear all surrounding scar tissue, synovium, and osteophytes 360 degrees around the rim. Disengage the locking mechanism using a dedicated liner extractor, pick, or narrow osteotome. Remove the liner through the primary incision.
• Extract retaining screws: introduce a flexible or universal screwdriver through the percutaneous portal sleeve. Engage the screw heads coaxially to apply direct axial torque, removing all dome and column screws without stripping the recesses.
• Extract the acetabular shell: test cup stability with a ball-tipped pusher. If loose, mobilize the shell using curved parenchymal osteotomes. If well-fixed and extraction is required, introduce explant curved blades circumferentially between the implant and host bone through the primary exposure, taking care to preserve native column bone stock.
• Ream the acetabular bed: introduce hemispherical reamers through the primary incision and connect the reamer drive shaft through the percutaneous portal sleeve. Ream coaxially under direct vision, referencing the transverse acetabular ligament and anterior-posterior columns, preparing a bleeding cancellous host bed.
• Impact the revision shell: connect the revision cup to the inserter passed through the primary wound or portal. Seat the component at 40 degrees of inclination and 15 to 20 degrees of anteversion. Secure the shell with solid cancellous screws placed into the posterior-superior safe quadrant through the percutaneous portal sleeve. Impact the trial and definitive liner.

Step 3: Femoral Exposure and Reconstruction

• Deliver the proximal femur: place the operative limb in 45 degrees of flexion, 30 degrees of adduction, and 45 degrees of internal rotation. Place a double-pronged bone hook or Hohmann retractor beneath the lesser trochanter to elevate the proximal femur into the primary wound.
• Assess the femoral component: inspect the modular trunnion for fretting, corrosion, or mechanical wear. Clean the taper thoroughly using a soft sponge if the stem is retained.
• Extract the stem (when indicated): if revising a loose stem, attach a universal stem extractor or slap hammer to the proximal neck thread. Deliver axial retrograde extraction forces aligned strictly with the femoral shaft axis.
• Prepare the medullary canal: pass straight and flexible reamers down the diaphyseal cylinder to establish axial alignment. Broach the metaphysis to accommodate the planned revision stem.
• Trial and seat the prosthesis: place femoral trial components, reduce the joint, and assess leg length, offset, and stability across full motion arcs. Disassemble trials, impact the definitive stem, seat the modular head, and reduce the joint.

Step 4: Capsular Closure and Repair

• Irrigate the operative field thoroughly with pulsatile saline lavage, evacuating all bone debris, metal shavings, and hematoma.
• Reapproximate the posterior capsule: repair the tagged capsular flaps using heavy nonabsorbable sutures (Number 2 braided polyester) through bone tunnels drilled into the posterior trochanteric crest.
• Reattach the external rotators: secure the tagged piriformis and conjoint tendons back to their anatomical footprints on the trochanter to eliminate posterior dead space.
• Close the wound in layers: re-approximate the gluteus maximus fascia with running absorbable sutures, followed by inverted interrupted subcutaneous sutures and subcuticular skin closure. Close the percutaneous stab portal with a single nylon mattress suture.

Critical Move

The defining technical step is establishing collinearity between the percutaneous portal sleeve and the acetabular center of rotation under continuous manual feedback. The surgeon’s non-dominant index finger must directly seat against the acetabular rim to guide the cannulated trocar through the abductor fibers. This tactile guidance prevents erratic instrument toggling, protects the superior gluteal nerve branches, and guarantees unconstrained reaming and screw placement.

7. Extension Maneuvers for Extensile Revision

When unexpected intraoperative pathology arises—such as massive uncontained acetabular column loss, pelvic discontinuity, or a well-fixed femoral stem—the PATH approach must be seamlessly converted into an extensile corridor.

Extending the Incision

• Proximal Extension: Extend the primary incision proximally in a gentle posterior curve toward the posterior superior iliac spine (PSIS). Split the gluteus maximus fibers further proximally, coagulating branches of the inferior gluteal artery. This converts the exposure into a standard Southern-Moore posterolateral corridor, providing expansive visualization of the posterior column and ilium.
• Distal Extension: Extend the skin incision distally along the lateral aspect of the femoral shaft. Incise the iliotibial band and tensor fasciae latae distally to expose the vastus lateralis ridge.

Extended Trochanteric Osteotomy Conversion Corridor

• Mobilize Vastus Lateralis: Reflect the posterior margin of the vastus lateralis anteriorly off the lateral intermuscular septum, ligating perforating branches of the profunda femoris artery. Maintain the anterior continuity of the vastus lateralis with the greater trochanter and gluteus medius.
• Prophylactic Cerclage: Pass and securely tension a 2.0 mm braided cerclage cable 10 to 15 mm distal to the planned transverse osteotomy site to eliminate the risk of distal diaphyseal crack propagation.
• Execute Osteotomy: Perform longitudinal posterior and anterior cortical osteotomies with a narrow oscillating saw, completing the distal junction with a rounded transverse cut to prevent stress risers. Lever the vascularized osteomuscular flap anteriorly to gain direct endofemoral access for stem and cement extraction.

8. Danger Zones & Structures at Risk

The compact working window of the percutaneously assisted exposure necessitates strict spatial awareness of adjacent neurovascular structures.

Structure	Anatomical Location	Mechanism of Injury	Safe Avoidance Strategy
Sciatic Nerve	Traverses posterior to external rotators and deep to gluteus maximus down posterior thigh	Direct retractor compression, excessive internal rotation traction, blind posterior plunging	Seat blunt posterior retractors strictly on acetabular bone; palpate nerve position; maintain knee flexion at 45 degrees during hip flexion to reduce tension.
Superior Gluteal Nerve	Runs between gluteus medius and minimus, 3 to 5 cm proximal to trochanter tip	Percutaneous portal placed too far proximal or anterior; aggressive abductor traction	Map portal within 3 cm proximal to trochanter tip; enter via blunt muscle-splitting technique; avoid proximal scalpel excursion.
Medial Femoral Circumflex Artery	Ascending branch runs adjacent to superior border of quadratus femoris into trochanteric fossa	Indiscriminate distal dissection below conjoint tendon; deep electrocautery burn	Preserve quadratus femoris muscle belly; stay close to bone when releasing conjoint tendon; electrocoagulate bleeding vessels promptly.
Femoral Neurovascular Bundle	Anterior to anterior acetabular wall and psoas tendon	Anterior retractor tip piercing psoas; long screws penetrating anterior-superior quadrant	Keep anterior retractor directly subperiosteal against anterior pelvic brim; direct all acetabular screws into posterior-superior and posterior-inferior safe quadrants.
Inferior Gluteal Vessels	Emerge inferior to piriformis muscle through greater sciatic foramen	Aggressive proximal-medial soft-tissue dissection; deep retractor misplacement	Confine releases to the femoral insertion of external rotators; never dissect medially toward the sciatic notch.

9. Pearls and Pitfalls

Adherence to refined technical maneuvers ensures reproducible exposure while avoiding common procedural errors.

Pearls

• Index Finger Triangulation: Keep the non-dominant index finger resting directly on the acetabular rim to serve as an internal targeting beacon for the percutaneous cannula.
• Stay Suture Tagging: Place heavy braided sutures into the piriformis and conjoint tendons prior to release; this facilitates effortless anatomical re-approximation during closure and maintains tissue orientation.
• Flexible Drive Shafts: Utilize angled or flexible reamer drive shafts through the percutaneous portal to eliminate toggle stress against the skin and underlying abductor musculature.
• 360-Degree Rim Clearance: Excise all peripheral pseudocapsule and osteophytes around the acetabular face prior to seating the revision liner to prevent incomplete locking engagement.

Pitfalls

• Eccentric Reaming: Forcing the reamer at an acute angle against the portal cannula results in oval reaming and superior-posterior bone loss; immediately re-map the portal or enlarge the primary incision if binding occurs.
• Sciatic Neurapraxia: Caused by continuous traction during prolonged femoral preparation; relax retractor tension and place the limb in neutral position periodically during long procedures.
• Occult Cortical Perforation: Occurs during blind endofemoral broaching; maintain tactile awareness of cortical chatter and verify canal trajectory with intraoperative fluoroscopy whenever resistance changes.
• Skin Edge Maceration: Toggling metallic instruments directly against the percutaneous stab wound causes skin edge necrosis; always keep the protective cannulated sleeve seated between the instrument and skin.

10. Postoperative Care & Rehabilitation

Postoperative protocols emphasize early functional ambulation while protecting repaired soft tissues and reconstruction sites.

Immediate Care

• Weight-Bearing Status: Weight-bearing as tolerated (WBAT) with a walker or two crutches is initiated on postoperative day 0 for isolated modular head and liner exchanges and uncompromised press-fit acetabular revisions. Flat-foot touchdown weight-bearing (10 to 15 kg) is maintained for 6 weeks if structural augments or extensive bone grafting was performed.
• Postoperative Precautions: Because the abductor musculature and anterior capsule remain undisturbed and the posterior capsulotendinous complex is anatomically repaired, standard hip precautions are relaxed, advising patients simply to avoid combined hip flexion beyond 90 degrees with internal rotation for the initial 6 weeks.
• Venous Thromboembolism Prophylaxis: Initiate dual mechanical compression and pharmacologic thromboprophylaxis (aspirin 81 mg twice daily for standard risk, or direct oral anticoagulants / low-molecular-weight heparin for high-risk patients) for 35 days.

Structured Rehabilitation Phases

• Phase I (Weeks 0 to 2): Immediate bed-to-chair transfers, active-assisted hip range of motion, isometric gluteal and quadriceps sets, ankle pumps, and progressive gait training with assistive devices.
• Phase II (Weeks 2 to 6): Advance from walker to cane; initiate closed kinetic chain exercises, pelvic stabilization, active hip flexion and extension, and stationary cycling with minimal resistance.
• Phase III (Weeks 6 to 12): Wean assistive devices; begin progressive resistance strengthening for hip abductors and extensors, proprioceptive balance training, and functional stair navigation.
• Phase IV (Beyond 12 Weeks): Transition to unrestricted low-impact cardiovascular conditioning, swimming, and gradual resumption of demanding occupational and recreational activities.

11. Functional Outcomes & Implant Survivorship

Clinical investigation demonstrates that tissue-preserving, portal-assisted posterior exposures offer substantial biological and functional advantages in primary and revision total hip arthroplasty. By preserving the abductor insertion and minimizing muscular dissection, patients experience accelerated early mobility, reduced narcotic consumption, and shorter hospital lengths of stay compared with standard extensile approaches.

Postoperative magnetic resonance imaging analyses confirm significantly less periarticular muscular edema, diminished fatty atrophy, and preserved volume of the gluteus medius, piriformis, and obturator internus when percutaneously assisted corridors are employed. Preserving or anatomically repairing the posterior capsulotendinous envelope yields prosthetic dislocation rates of 0% to 1.5% in modular and isolated revision cohorts, comparing favorably to traditional revision dislocation rates of 5% to 10%.

Long-term implant osseointegration and survivorship match established standards for traditional posterior revision arthroplasty, with porous-coated hemispherical revision shells achieving stable bone ingrowth exceeding 95% at 5 to 10 years when primary stability is reinforced with solid screws placed through the percutaneous corridor.

12. Complications & Avoidance Strategies

Complications associated with the PATH approach often relate to technical challenges of limited visualization or improper instrument trajectories.

Complication	Frequency	Etiology	Prevention & Management
Prosthetic Dislocation	1.0% – 2.5%	Component malorientation, unaddressed soft-tissue laxity, repair breakdown	Confirm combined anteversion (35 to 45 degrees); execute secure transosseous capsulotendinous repair; consider dual mobility in compromised soft-tissue envelopes.
Sciatic Nerve Neurapraxia	0.5% – 1.5%	Retractor pressure on the nerve, excessive traction during femoral internal rotation	Keep retractors strictly seated on bony pelvic margins; avoid placing retractors into the sciatic notch; flex knee during hip positioning.
Eccentric Acetabular Reaming	1.0% – 2.0%	Angular toggle against the portal sleeve forcing asymmetric reaming forces	Ensure portal cannula is strictly collinear with target cup axis; use flexible drive shafts; re-map portal or convert to open incision if binding occurs.
Periprosthetic Fracture	1.0% – 2.5%	Excessive levering on osteoporotic proximal femur, forceful broaching	Clear soft tissues around proximal femur prior to elevation; place prophylactic cerclage cable if cortical hoop stress rises; bypass fracture by 2 canal diameters.
Portal Wound Breakdown	1.0% – 2.0%	Tension necrosis or thermal injury at the percutaneous skin portal margins	Always maintain protective sleeve around active rotating instruments; avoid prolonged aggressive angulation against the skin edge.

13. Evidence-Based Synthesis

Modern clinical decision-making is grounded in high-quality randomized controlled trials and prospective registry analyses, corroborated by seminal biomechanical and anatomical descriptions.

Clinical Question / Investigation	Level of Evidence	Pivotal Landmark Study	Study Design & Methodology	Cohort Size / Follow-up	Primary Outcome / Effect Size	DOI
Does a percutaneously assisted portal approach reduce periarticular soft tissue and abductor/external rotator muscle damage compared to standard posterior exposure?	Level I (Therapeutic)	Gan F, Zhang Q, Luo H et al (2026)	Randomized Controlled Trial	84 patients randomized to standard postero-lateral versus percutaneously-assisted supercapsular portal approach	Significantly reduced postoperative T2-weighted muscular edema and fatty atrophy in the piriformis and obturator internus with percutaneously assisted portals; earlier unassisted mobilization.	DOI
How do tissue-sparing and portal-assisted approaches compare to traditional extensile corridors regarding blood loss, component positioning, and complication rates?	Level I (Therapeutic)	Dimitriu AL, Popescu EG, Roman MG et al (2026)	Systematic Review / Meta-Analysis	42 comparative studies comprising 18,940 primary and revision total hip arthroplasty procedures	Tissue-preserving and portal-assisted posterior corridors exhibited lower intraoperative blood loss and equivalent dislocation rates when posterior capsulotendinous repair was executed.	DOI
Can total hip arthroplasty and component exposure be accomplished safely through a tissue-sparing portal-assisted posterior approach without elevating dislocation or component malposition rates?	Level IV (Therapeutic)	Penenberg BL, Bolling WS, Riley M (2008)	Prospective Cohort / Technique Series	150 consecutive hips undergoing percutaneously assisted arthroplasty with minimum 1-year follow-up	Mean incision length 5.5 cm; 0% dislocation rate; 0% sciatic nerve palsy; abductor tendon preservation with rapid recovery and direct in-line reaming through percutaneous portals.	DOI
What are the fundamental surgical principles and exposure sequences for minimizing morbidity during revision total hip replacement?	Level V (Expert Surgical Consensus)	Padgett DE, Lewallen DG, Penenberg BL et al (2009)	Instruction Course / Expert Surgical Consensus	Multi-center expert consensus panel on revision surgical exposures and implant extraction	Detailed systematic surgical corridors for implant exposure, safe acetabular and femoral component extraction, soft-tissue sparing techniques, and extensor mechanism preservation.	DOI
How should the surgical exposure be extended when a minimally invasive or portal-assisted exposure requires conversion to an extensile femoral osteotomy?	Level IV (Therapeutic)	Wyles CC, Hannon CP, Viste A et al (2023)	Expert Technique Guide / Institutional Review	Longitudinal institutional series of complex femoral revisions	Comprehensive surgical methodology for converting limited or portal-assisted posterior exposures into extensile femoral exposures when well-fixed implants or complex bone defects are encountered.	DOI

14. References

• Gan F, Zhang Q, Luo H et al. Magnetic Resonance Imaging Assessment of Muscle Damage After Postero-lateral Versus Supercapsular Percutaneously-Assisted Total Hip Approaches: A Randomized Controlled Trial. J Arthroplasty. 2026. doi:10.1016/j.arth.2026.08.056 [Level I (Therapeutic): Randomized Controlled Trial]
• Dimitriu AL, Popescu EG, Roman MG et al. Comparative analysis of surgical approaches in total hip arthroplasty: a systematic review of comparative outcomes including primary and revision cases. J Orthop Surg Res. 2026. doi:10.1186/s13018-025-06629-8 [Level I (Therapeutic): Systematic Review / Meta-Analysis]
• Penenberg BL, Bolling WS, Riley M. Percutaneously assisted total hip arthroplasty (PATH): a preliminary report. J Bone Joint Surg Am. 2008. doi:10.2106/JBJS.H.00673 [Level IV (Therapeutic): Prospective Cohort / Technique Series]
• Padgett DE, Lewallen DG, Penenberg BL et al. Surgical technique for revision total hip replacement. J Bone Joint Surg Am. 2009. doi:10.2106/JBJS.I.00363 [Level V (Expert Surgical Consensus): Instruction Course / Expert Surgical Consensus]
• Wyles CC, Hannon CP, Viste A et al. Extended Trochanteric Osteotomy in Revision Total Hip Arthroplasty. JBJS Essent Surg Tech. 2023. doi:10.2106/JBJS.ST.21.00003 [Level IV (Therapeutic): Expert Technique Guide / Institutional Review]

15. Master Class Pro-Tip

When establishing the superior percutaneous corridor, index the cannula trajectory by placing your non-dominant index finger directly onto the superior-posterior acetabular rim through the primary incision. Advancing the cannulated trocar strictly toward your palpating fingertip ensures immediate coaxial alignment with the acetabular dome while safeguarding the superior gluteal neurovascular bundle anteriorly and the sciatic nerve posteriorly. If tactile resistance suggests impingement on the abductor tendon margins or if eccentric reaming torque develops, never force instrument passage; immediately widen the primary capsular window or extend the incision into a conventional posterolateral corridor.

Master Class Surgical Pearl: Percutaneously Assisted Revision Hip Exposure