Hip

Approaches

 

Anterior

Anterolateral

Lateral

Posterior

Medial

 

Anterior Approach / Smith Peterson

 

Indications

- neonatal hip sepsis

- open reduction hip DDH

 

Techique

 

Position

- supine

- sandbag under buttock

- free drape leg

 

Landmarks

- iliac crest to ASIS / superior limb

- ASIS to lateral patella / inferior limb

 

Incision

 

Anterior half crest to ASIS  

- ASIS 10cm towards lateral patella

 

Bikini incision

- 2/3 lateral to ASIS and 1/3 medial

- 1-2cm below inguinal ligament

 

Superficial Dissection

-  between Tensor Fascia Lata (SGN) and Sartorious (FN)

-  ER leg to stretch sartorious

-  find plane 2 inches below crest

-  incise fascia over TFL to protect LFCN which runs over sartorius

-  take TFL off crest

-  divide ascending branch LCFA between the two muscles

 

Deep Dissection

- between RF and G. medius

- divide both heads of RF

- direct head to AIIS

- reflected head to acetabulum

- hip capsule is in base

 

Anterolateral Approach / Watson Jones

 

Concept

- between TFL and G. medius

 

Indications

- ORIF displaced subcapital

- THR

 

Technique

 

Position

- floppy lateral, 45o up, radiolucent table

 

Incision

- longitudinal incision, anterior to GT

 

Dissection

- plane between TFL and G medius

- TFL anterior

- G medius posterior,  sometimes detach some off GT

- find fatty tissue over capsule

- may have to elevate RF off anterior capsule

- open capsule

- flexing the hip 20-30o will detension tissues and make job much easier

 

Lateral Approach / Hardinge

 

Concept

- detach anterior 1/3 G. medius

 

Indication

- THR

- hemiarthroplasty

 

Technique

 

Incision 

- 8cm incision parallel to anterior border of femur

- slightly anterior

 

Superficial dissection

- split ITB

 

Deep dissection

 

Find anterior border of G medius

- take off anterior third

- usually a fat plane underneath

- find G minimus and take off separately

- expose capsule

 

Capsulotomy

- T shaped for hemi / THR

- Z shaped for SUFE avoiding superior neck capsule

 

Posterior / Southern / Kocher Langenbeck Approach

 

Indication

- THR

- acetabular posterior wall ORIF

 

Technique

 

Position 

- lateral

 

Incision 

- curve skin incision

- distal limb is over axis of femur

- curve over tip GT towards PSIS

- many variations

- can perform oblique incision over GT towards PSIS

 

Superficial dissection

- divide fascia

- split G. max

- there is a communicating vessel between superior & inferior gluteal arteries that crosses this plane & will bleed

- can release G. max distally to increase exposure (leave 1.5cm stump on femur for reattachment)

- wipe fat off posterior short external rotators, identify sciatic nerve

 

Cruciate anastomosis

- branches are visible over the short external rotators

- inferior gluteal artery runs along lower edge of piriformis tendon

- MCFA runs along upper border of Quadratus (has run up between obturator externus and quadratus)

- ligate these vessels in THR

 

Deep dissection

- place homan lever under G medius and minimus to expose superior joint capsule

- piriformis can be seen and palpated 

- tag piriformis / conjoint tendon / quadratus femoris with sutures

- release from GT

- take capsule in same layer

- reflect to protect sciatic nerve

 

Non arthroplasty case 

- divide short external rotators 2cm from the insertion

- preserve the anastomosis of MCFA with the gluteal vessels

- don't divide quadratus femoris

 

Medial Approach / Ludloff

 

Concept

- between Longus and Gracilis

- between Brevis and Magnus

 

Indications

- DDH open reduction

 

Technique

 

Position

- supine

- hip flexion, abduction & ER (ipsilateral foot placed onto opposite knee)

- makes adductor longus very palpable / visible

 

Landmarks

- adductor longus and pubic tubercle

 

Incision

- longitudinal / transverse incision

- begin 3cm below pubic tubercle

- continue down over adductor longus

 

Superficial dissection

- between adductor longus and gracilis (both supplied by anterior division obturator nerve)

- longus is anterior to gracilis

 

Deep dissection

- between adductor brevis (anterior division) and magnus (posterior division)

- brevis is anterior to magnus

- adductor brevis is between the two divisions of the nerve

- lesser trochanter with psoas tendon superior aspect of wound

- MFCA is medial to psoas tendon

 

Dangers

- anterior branch Obturator nerve lies between longus & brevis

- posterior branch Obturator nerve lies between brevis & magnus

- medial femoral circumflex artery passes around medial side of the distal part of the psoas tendon between psoas & pectineus