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

Abstract

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.

Better early functional outcome after short stem total hip arthroplasty? A prospective blinded randomised controlled multicentre trial comparing the Collum Femoris Preserving stem with a Zweymuller straight cementless stem total hip replacement for the treatment of primary osteoarthritis of the hip

“…Furthermore, preservation of the trochanteric region of the femur potentially enables a more gluteus-muscle-sparing approach. 13 Lastly, following the curvature of the retained native neck of femur theoretically would result in more physiological offset reconstruction.…”

A 24-year single-centre experience with Collum Femoris Preserving stem: clinical and radiological results in young and elderly population

“…This modified approach offers the advantage of sparing the posterior ⅔ of the gluteus medius, thus reducing the risk of gluteal insufficiency. 15…”

“…This modified approach offers the advantage of sparing the posterior ⅔ of the gluteus medius, thus reducing the risk of gluteal insufficiency. 15 The curvature and size of the stem were preoperatively selected in order to adapt the implant to the different centrum-collum-diaphyseal (CCD) femoral angles by using an elective radiograph of the hip with the patient positioned supine on a 30° inclined plane, in addition to a standard antero-posterior radiograph of the pelvis. The elective radiographic plane of the hip allows the best identification of the isthmus between the femoral head and neck permitting the selection of the appropriate stem curvature and size.…”

Long-term follow-up of a low profile, coated, press-fit cup: the trabeculae oriented pattern (T.O.P.) acetabular system

“…An accurate preoperative planning with component templates was developed, collegially debated, and a rescue option was prepared for every implant. Every surgery was performed through a modified Hardinge lateral approach, with the goal of minimizing muscle damage [4]. The aim of this approach is to minimize soft tissue damage and remove only pathologic tissue, in order to increase recovery and rehabilitation.…”