[Abductor repair failure and nerve damage during hip replacement via the transgluteal approach. Why less invasive methods of joint replacement are needed, and some approaches to solving the problems]

When used for total hip replacement, the lateral approach is associated with two frequently iatrogenic, but virtually insoluble problems: limping attributable to abductor insufficiency and pain at the greater trochanter. They can result from injury to the inferior branch of the superior gluteal nerve and/or failure of the abductor repair.

These complications are due to the interruption of a voluminous abductor mass at the trochanter, which has to be done to allow undisturbed work on the femoral shaft and implantation of a straight femoral component while the leg is in the classic figure 4 position. When the lateral approach is used they cannot be avoided except by application of a technique that does not require the hip to be forced into flexion by the figure 4 position. This is possible with only slight detachment of anterior parts of the abductors, as described by Watson-Jones, and preparation of the femoral shaft as reported by Röttinger, with the hip in extension.

In comparison with the Röttinger technique, in which the surgeon manages without detaching the abductors, the technique with the slight detachment lessens the traction on the abductors and lowers the risk of nerve damage in the interval between abductor and tensor.

Whichever technique is ultimately selected, it is of decisive importance that in the case of an approach to the hip joint by way of an anterior capsulotomy with the abductors shifted in the posterior direction, the femoral shaft is prepared with the hip in extension.