The anterolateral approach of the hip goes behind the sheath of the fascia lata tensor muscle and in front of the gluteal muscles. This is a minimally invasive approach that enables no muscles to be desinserted. The installation is performed in the lateral decubitus position, with the posterior half-table section moved out of the way to facilitate the dislocation movement.

The incision is made extending from a point located 2 cm below the trochanteric ridge to a point on the anterosuperior iliac spine (ASIS). It starts, along this line, from the anterior edge of the greater trochanter, moving toward the ASIS over a length of 8–10 cm, without going past a point located two fingers below the ASIS to preserve the vascular and nerve pedicle of the tensor fascia lata (Fig. 28.2a–c).

After careful sectioning and haemostasis of the adipose tissue, the iliotibial band is identified, tissue with strong resistance that is incised along the entire length of the approach. The limb is positioned in flexion and external rotation. A gentle dissection with scissors and by hand (Fig. 28.3a) carried out at the distal part of the wound near the trochanter enables the space between the front of the fascia lata tensor muscle and behind the medium and small gluteal muscles (gluteus medius and minus). This space leads to the plane of the capsule (Fig. 28.3b). The traps to avoid are basically perforating the aponevrosis of the fascia lata tensor muscle if the approach is too anterior, and crossing the anterior fasciculus of the gluteus medius muscle if the approach is too lateral. Generally, this space must be sought at the bottom of the incision and forwards by bypassing the fibres of the gluteus medius muscle (Fig. 28.3a).

The capsular plane can be recognised by palpating the anterior face of the neck and by exposing the capsule by means of angled retractors in an extra-capsular position above and below the neck (Fig. 28.3a, b). The capsule must have a thick, fatty and yellow appearance. If there are muscles remaining after placing a retractor, these are likely to be the fibres of the gluteus minus. Another search must be made to find the correct plane. The dissociation of the space upwards must stop above the reflected ligament of the anterior link, without reaching the anterosuperior iliac spine, to prevent a lesion of the tensor of fascia lata nerve that comes from the gluteal pedicle in the plane between the small and medium gluteal muscle. For an ideal exposure of the elements between the joint and sufficient clearance of the capsule, the capsule must be cleared correctly in the extra-capsular position before the incision is performed. The medial clearance is obtained by dissociating the capsule of the tendon of the rectus femoris muscle and by replacing the angled retractor between the capsule and the tendon (Fig. 28.3c). Towards the top, it is necessary to create a space with a raspatory between the capsule, the iliac bone and the small gluteal muscle to expose the reflected tendon of the rectus femoris muscle (Fig. 28.3c). An abdominal sheet is pushed between the space between the wing of Ilium and the gluteal muscles, to make a special space for the femoral head when exposing the acetabulum, at the top and rear above the sciatic notch.

The capsule is incised along the axis of the neck, from the intertrochanteric line up to the acetabulum, then by the longest possible medial and lateral counter incision, at the level of the inter-trochanteric line and periacetabular region, to open up the capsule like a book. The very thick capsule can be suspended on a wire and sutured at the end of the procedure. The retractors are then positioned in the intra-capsular position (Fig. 28.4a, b).

The hip is dislocated in extension –external rotation – adduction. However, dislocation is difficult as long as the ligamentum Teres is intact. In the aforementioned position, the curved scissor is passed under the femoral head and impacted over the entire length (Fig. 28.5a–d). It is also necessary to remove the osteophytes from the anterior wall of the acetabulum, notably with regard to the anteroinferior iliac spine. A Lambotte’s hook is passed under the femoral neck. While assistance is given to make the adduction movement – external rotation of the lower limb, the surgeon lifts the neck of the femur upwards (Fig. 28.5e, f).

When the hip is dislocated, the lower limb is positioned in flexion – external rotation. To do this, the leg passes from the back to the front of the table. The femoral pusher is used to help pass the femoral head under the gluteal muscles, below the acetabulum. A compression movement in the axis of the femur is used to move the femoral head backwards. The lower limb is then positioned in flexion – external rotation (Fig. 28.6a).

A long angled retractor is positioned on the posterior wall of the acetabulum in the convexity of the neck; another retractor is positioned at the level of the lower part of the anterior wall (Fig. 28.6b–d). The capsule is sectioned at the bottom, opposite the transverse ligament of the acetabulum, over its entire length, in order to facilitate the posterior translation of the femoral head.

The acetabulum exposed in this manner can be prepared. The acetabulum is reamed by using the drill guide handle. An angled handle is recommended for minimally invasive approaches. The milling tools are first positioned in the acetabulum, then the support attaches to the milling tool which makes it easier to set up the equipment. A useful piece of advice is to lock the ring, in open position, with a piece of a drain so as to be able to attach and remove the handle of the reamer easily (Fig. 28.6e).