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Background  As one of the classical total hip arthroplasty (THA) approaches, the posterior approach is widely used. However, there is a lack of in-depth quantitative researches on the surgical-related injury to the hip external rotators. The purpose of this study is to quantificationally analyse the surgical injury of hip external rotators after posterior THA and explore the effect of the muscle repair on the muscle recovery using the MRI three-dimensional reconstruction technique combined with the clinical assessment.    Methods  Sixty five patients were eligible to receive a unilateral cementless THA via the posterior approach. During operation, the piriformis tendon was reattached but it was not applicable for the internal obturator muscle. We performed three-dimensional MRI reconstruction of bilateral piriformis and internal obturator muscle along with clinical assessment preoperatively, 6, 12 and 52 weeks postoperatively.    Results  Bilateral piriformis and internal obturator muscle were homogeneous preoperatively. Compared with the contralateral side, the volume atrophy and fat-muscle ratio of the piriformis on the operated side increased inconspicuously by 1.64%, 0.26% ( p  = 0.062,  p  = 0.071) at 6 weeks and 1.33%, 0.20% ( p  = 0.057,  p  = 0.058) at 12 weeks, while 7.28%, 2.09% and 15.71%, 5.14% for the internal obturator muscle ( p  < 0.01). Up to 52 weeks, the pirformis also showed significant muscle atrophy as well as fatty infiltration (increased by 7.79%, 4.21%;  p  < 0.01), and 24.18%, 11.91% for the internal obturator muscle ( p  < 0.01).    Conclusion  The THA via posterior approach significantly harms the hip external rotators and the early hip external rotation function. The effective repair could be conducive to the early postoperative recovery of the hip external rotators.    Trail registration  The study has been registered in Chinese Clinical Trial Registry (ChiCTR) before the clical trial started, the Clinical Trial Registry Number is  ChiCTR-IOR-17013007 . Registered 17 October 2017. The Trial registration is prospective registration.

Surgical injury and repair of hip external rotators in THA via posterior approach: a three-dimensional MRI-evident quantitative prospective study