Minimizing soft-tissue damage in direct anterior total hip arthroplasty preservation of the ascending branch of the lateral femoral circumflex artery and no-release femoral preparation

Total hip arthroplasty through the direct anterior approach has gained considerable popularity because it exploits an intermuscular interval to spare the surrounding musculature. Working between muscle planes does not, however, in itself guarantee minimal soft-tissue trauma: additional injury may occur during deep exposure, capsulotomy, retractor placement, vascular management and, above all, femoral preparation. This article describes two complementary technical principles intended to reduce such trauma — preservation of the ascending branch of the lateral femoral circumflex artery and a no-release technique for femoral preparation. The ascending branch is the dominant blood supply to the tensor fasciae latae and is traditionally ligated to improve exposure. In a consecutive series of 172 primary procedures, the vessel was deliberately preserved in 75.6% of patients, with no excessive bleeding, haematoma or infection; preservation was favoured by female sex, younger age and lower body weight. The technique relies on identifying the circumflex bundle as the distal limit of fascial dissection, leaving it within its fatty sheath, and protecting it during capsulotomy and retraction. The no-release technique addresses the femoral step, at which most additional damage arises. Using a dedicated leg positioner, controlled maximal external rotation of approximately 160–180° with slight extension, and an anterior-specific offset broach handle, the proximal femur is orientated rather than forcibly elevated, allowing femoral access without a trochanteric Hohmann retractor, hook or routine capsular release in over 95% of primary cases. Preserving the posterior and superior capsule and limiting traction maintains stability, reduces bleeding and avoids thigh pain from adductor release. The principal limitation is that vessel patency was not confirmed postoperatively and functional benefit, although biologically plausible, remains unproven. These principles are not mandatory but offer surgeons familiar with the anterior approach a reproducible framework for reducing unnecessary soft-tissue damage, extending the philosophy of the approach from muscle-sparing in theory to soft-tissue-sparing throughout the operation.