Fig. 1. This Orthopaedic Video Theater video demonstrates a direct anterior approach using a bikini-type incision placed parallel to skin tension lines.
Published 6/26/2025
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Neil Jain, MD; Michael J. DeRogatis, MD, MS; Paul S. Issack, MD, PhD, FAAOS, FACS
Editor’s note: The following article is a review of a video available via the AAOS Orthopaedic Video Theater (OVT). AAOS Now routinely reviews OVT Plus videos, which are vetted by topic experts and offer CME. For more information, visit aaos.org/OVT.
The direct anterior approach for total hip arthroplasty has traditionally utilized a longitudinal skin incision placed perpendicular to the tension lines of the skin. Not following these anatomic creases has raised concerns regarding increased problems with wound healing and poor scar cosmesis. Recently, a bikini-type (skin-crease) incision for a direct anterior approach to the hip has been described. Incisions made at the skin and subcutaneous level are done in an oblique manner while deeper dissection is still performed longitudinally. It has been suggested that this approach leads to higher patient satisfaction and preservation of functional outcomes.
An AAOS OVT video from Nicholas Colacchio, MD, demonstrates a direct anterior approach for hip arthroplasty procedures using a bikini-type incision made in line with the hip flexion crease. Placement along anatomic skin tension lines allows movements such as hip flexion to compress the skin edges of the surgical incision and improve wound healing.
The video authors review the relevant identifiable landmarks, such as the anterior superior iliac spine, greater trochanter, and tensor fascia latae (TFL) (Fig. 1). The bikini incision is positioned in line with the hip flexion crease to allow access to the interval between the TFL and sartorius.
In carrying out the approach, the surgeons make the incision through the skin and subcutaneous fat to the fascia overlying the TFL. In their dissection through the subcutaneous fat, the authors create an interval using retractors to gently open the soft-tissue window in a craniocaudal direction in order to avoid and preserve branches of the lateral femoral cutaneous nerve. The fascia overlying the TFL is opened, and blunt dissection is used to free the underlying muscle belly medially. Next, a blunt Cobra retractor is placed in the femoral neck saddle. A second Cobra retractor is placed on the lateral side of the proximal femur just distal to the greater trochanter and proximal to insertion of the gluteus maximus tendon. Precapsular adipose tissue is excised, and a soft-tissue protector is placed distally and laterally under the TFL and medially under the sartorius and rectus femoris.
An inverted T capsulotomy is performed, starting at the base of the femoral neck along the intertrochanteric line. This is carried in line with the femoral neck up to the rim of the acetabulum and through the labrum. Suture tags are placed onto the capsule limbs for later repair. Retractors are repositioned within the hip capsule, and a femoral neck osteotomy is performed. Given the narrow surgical window, the authors recommend using a single-sided reciprocating saw and avoiding cutting too far through the posterior neck and injuring the sciatic nerve.
After the surgeons remove the femoral head with a corkscrew, they achieve acetabular exposure by releasing the superolateral hip capsule limb from a 12 to 2 o’clock position and excising the posterior labrum. For femoral exposure, the lower extremity is rotated 120 degrees, and double-pronged curved retractors are placed inferomedially along the femoral neck and superolaterally over the greater trochanter, between the hip capsule and the gluteus minimus.
Overall, this video offers a detailed and technically excellent demonstration of the steps of a direct anterior approach for hip arthroplasty using a bikini-type (skin-crease) incision. Surgeons already comfortable with performing a direct anterior total hip arthroplasty may find that this approach offers an opportunity for improved cosmesis and patient satisfaction.
Neil Jain, MD, is a postdoctoral orthopaedic surgery research fellow at St. Luke’s University Health Network in Bethlehem, Pennsylvania.
Michael J. DeRogatis, MD, MS, is an orthopaedic surgery resident at St. Luke’s University Health Network in Bethlehem, Pennsylvania.
Paul S. Issack, MD, PhD, FAAOS, FACS, is a clinical associate professor in the Department of Orthopaedic Surgery at Weill Cornell Medical College and a trauma and adult reconstruction orthopaedic surgeon at New York–Presbyterian Lower Manhattan Hospital. He is also a member of the AAOS Now Editorial Board.
Video details
Title: Bikini Incision for Direct Anterior Reconstructive Technique (DART) Total Hip Arthroplasty
Author: Nicholas Colacchio, MD
Published: February 26, 2024
Time: 9:55
Tags: Adult Reconstruction Hip, Total Hip Arthroplasty, Surgical Techniques
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