Direct anterior approach to the hip joint in the lateral decubitus position for joint replacement

Surgical principle and objective The direct anterior approach for total hip arthroplasty is associated with higher complication rates and difficult femoral component positioning. Performing a modified technique in the lateral position allows secure component positioning. Indications Primary hip replacement (including femoral neck fracture) and cup revision without bone deficiency. Contraindications Destruction/deformities of proximal femur or acetabulum, bone deficiency or malignancy. Surgical technique Strict lateral decubitus position. Straight anterior incision of 10–12 cm, starting 2 cm lateral to the anterior superior iliac spine. Incision of the fascia over the tensor fascia lata muscle (TFL). Lateral retraction of the TFL. Incision of the fascia and medial retraction of rectus femoris. Ligation of the ascending branch of the lateral femoral circumflex artery. Detachment of the iliocapsularis muscle from the capsule in a medial direction. Anterior capsule excision. Femoral neck osteotomy and removal of the head. Reaming of the acetabulum; insertion the acetabular component. Exposure of the femur. Incision/excision of the capsule medial to the greater trochanter for easy anteriorization of the femur. Reaming and implantation of femoral component. Postoperative management Weight bearing on day one with crutches for 4 weeks; deep vein thrombosis prophylaxis. Results In all, 138 patients (72 women, 66 men, mean age of 67 years) were followed up over 2 years. Overall complication rate was 3.6%: 3 patients (2.2%) with grade III complications required additional intervention. Acetabular cup inclination: 35–50° in 88% of patients. Neutral femoral stem position observed in 99% of patients. Mean Harris hip score improved from 61 preoperatively to 97 after 2 years. Patient satisfaction on a visual analogue scale improved from 3.7 to 9.5.