Posterior Approach to Hip

Posterior exposure of the hip through the oblique incision of Kocher, with the gluteal muscles retracted and the short external rotators fro
Posterior exposure of the hip through the oblique incision of Kocher, with the gluteal muscles retracted and the short external rotators from piriformis to quadratus femoris released to show the posterior capsule. Image from de Boer DR, Munnik-Hagewoud R, IJpma FFA, van Driel PBAA, Ettema HB. The evolution of the posterior approach in hip surgery, Back to Langenbeck. Langenbecks Arch Surg. 2026, 411(1), 84. CC BY 4.0.
Posterior Approach to Hip, arteries of the gluteal and posterior femoral regions, gray’s anatomy plate 544
Arteries of the gluteal and posterior femoral regions, Gray’s Anatomy plate 544. Image by Henry Vandyke Carter, Wikimedia Commons, Public domain.

Indications

  • Most used approach for hip arthroplasty (Moore or Southern)
  • Total hip replacement and hemiarthroplasty
  • Revision hip arthroplasty
  • Open reduction of posterior dislocation
  • Drainage of sepsis and removal of loose bodies
  • Pedicled muscle grafting and some femoral head procedures

Position

  • Lateral decubitus with the affected side up
  • Pelvic supports hold the pelvis vertical and stable
  • Limb draped free

Landmarks and Incision

  • Palpate the greater trochanter and femoral shaft
  • Curved incision centred on the posterior trochanter, from the shaft line curving towards the PSIS
  • Hip flexion during the incision straightens the curve

Internervous Plane

  • No internervous plane
  • Gluteus maximus split in line with its fibres
  • No denervation, as the inferior gluteal nerve enters well medial to the split

Superficial Dissection

  • Fascia lata incised along the femur and continued proximally through gluteus maximus fibres
  • Retractors placed under gluteus maximus and fascia lata
  • Trochanteric bursa swept off to expose the short external rotators

Deep Dissection

  • Internal rotation tensions the short external rotators
  • Piriformis and conjoint tendon detached near their insertions and reflected posteriorly over the sciatic nerve
  • Reflected rotators act as a protective layer for the nerve
  • Proximal quadratus femoris may be released, controlling the ascending MFCA branch
  • Capsule incised, often as a tagged posterior flap
  • Dislocation by flexion, adduction and internal rotation
  • Repair of capsule and rotators to the trochanter lowers the dislocation rate

Structures at Risk

  • Sciatic nerve, lying on the short rotators and quadratus femoris
  • Inferior gluteal artery below piriformis, which retracts into the pelvis if divided
  • Medial femoral circumflex artery near quadratus femoris
  • Superior gluteal vessels if dissection strays above piriformis
  • Femoral vessels and nerve from aggressive anterior acetabular retractors

Extension

  • Distal along the posterolateral femur by elevating vastus lateralis
  • Gives whole shaft access for revision, extended trochanteric osteotomy and periprosthetic fracture fixation
  • Proximal extension limited by the superior gluteal neurovascular bundle

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.