A modified direct lateral approach for neck-preserving total hip arthroplasty: tips and technical notes

Tissue-sparing surgery for hip replacement aims to minimize muscle damage and conserve the femoral neck through the use of mini-prostheses. We propose a modification of the classical direct lateral access procedure that preserves the gluteus medius. Further advantages during the surgical phase include limited blood loss, visualization of the entire acetabulum, and sparing of the transverse ligament. Precise implantation is facilitated and normal biomechanics are preserved. The gluteus medius is divided longitudinally between the anterior third and posterior two-thirds to provide access to the gluteus minimus, which is detached from the femoral insertion together with a small portion of the vastus lateralis, forming a flap that exposes the underlying articular capsule. When the femoral head is revealed, a decision is made to either continue with its dislocation directly or to resect it and remove it separately to avoid damaging the gluteus medius during dislocation. Upon removal of the femoral head, with the limb flexed and slightly over-rotated, the acetabulum is completely visible. Limb length is maintained through the use of reference stitches on the gluteus minimus tendon and the proximal insertion of the vastus lateralis. In keeping with the minimally invasive philosophy, only pathological tissue is removed (marginal osteophytes, geodes, joint capsule, cartilage to the point of bleeding and pulvinar). We have performed more than 2,000 implants with this procedure since 1990. Advantages and potential critical points are discussed.