surgical approaches to hip

By,Dr. Vijay Kumar LoyaJR1, Orthopaedics,JIPMER

SALIENT POINTS

Approaches to hip

ANTERIOR

LATERAL

POSTERIOR

MEDIAL

Approaches to acetabulum

ILIOINGUINAL

POSTERIOR

ANTERIOR APPROACH

INCISIONANTERIOR HALF OF ILIAC CREST TO ASIS CURVE THE INCISION DOWN SO THAT IT RUNS VERTICALLY FOR 8-10 CMS ALONG

THE LINE LATERAL TO PATELLA

INTERNERVOUS PLANESUPERFICIAL – B/W SARTORIUS – FEMORAL. N

AND TFL – SUPERIOR GLUTEAL NERVE

DEEP – RECTUS FEMORIS – FEMORAL. N

AND GLUTEUS MEDIUS – SUP. GLUTEAL NERVE

DANGERS1. LATERAL FEMORAL CUTANEOUS NERVE – 2.5

cms distal to ASIS, to be retracted medially

• RARELY FEMORAL NERVE- unlikely if deep dissection done in right plane since nerve is most lateral can get damaged

2. ASCENDING BRANCH OF LATERAL FEMORAL CIRCUMFLEX ARTERY – lies 5 cms distal to hip joint

Attachment of fascia lata to iliac crest difficult

Osteotomy of overhang of iliac crest is performed b/w ext. Oblique medially & fascia lata to as far as origin of g.maximus.

TFL, g.medius & g.minimus dissected subperiosteally to expose hip joint capsule.

Closure – iliac osteotomy fragment reattached with non-absorbable sutures through holes drilled.

TRANSVERSE ‘BIKINI’ INCISION – FROM AIIS TO ASIS COURSING OBLIQUELY SUPERIORLY & POSTERIORLY TO ILIAC CREST

REFLECTING ABDUCTOR → SARTORIUS & TFL→ REFLECTED HEAD OF RECTUS FEMORIS→ INCISION OF CAPSULE FROM RECTUS ANTERIORLY TO POSTEROSUPERIOUR MARGIN OF JOINT→ OPEN REDUCTION OF DDH

FOR MINIMALLY INVASIVE MUSCLE SPARING TECHNIQUES FOR THR, ANTERIOR JOINT ARTHOTOMY

TWO FINGER BREADTH BELOW ASIS

EXTENDS DISTALLY FOR 8 CMS B/W TFL & SARTORIUS

CAN BE IDENTIFIED BY PALPATION

MAJOR DISADVANTAGE IS DAMAGE TO LAT. FEMORAL CUT N.

The approach is useful for reaming the acetabulum & is used as the acetabularapproach for 2-incision MIS approach for THR

Femoral preparation is done by using a fracture table with ipsilateral lower extremity in extended & externally rotated position

Lateral capsule must be released to ensure femur is delivered out of incison for preparation in THR esp if fracture table is not used.

Other steps are nearly the same.

INDICATIONS – THR

HEMIARTHOPLASTY HIP

ORIF OF FEMORAL NECK #

ORIF FEMORAL HEAD #

HIP ARTHOTOMY

INTRACAPSULAR BIOPSY

POSITIONSUPINE – CLOSE TO EDGE – BUTTOCK HANGS OVER – TILTING THE TABLE TO

OPP. SIDE

INCISIONFIG OF 4 (FLEX AND ADDUCT SO THAT THE LEG LIES OVER OPPOSITE KNEE) →8-15 cms INCISION

CENTERING ACROSS THE POSTERIOR THIRD OF GT

INTERNERVOUS PLANEINTERNERVOUS PLANE – NO TRUE INTERNERVOUS

PLANE AS BOTH TFL AND GLUTEUS MEDIUS SUPPLIED BY SUP GLUTEAL NERVE

Deep dissection – anterior flap consisting of gluteus medius, minimus & vastus lateralis; alternatively this can be done by osteotomy

Anterior Capsule exposed & capsulotomy performed release from femoral attachment and a ‘T’ into acetabular rim.

TROCHANTERIC OSTEOTOMY –ALLOWS COMPLETE MOBILISATION OF G.MEDIUS AND G.MINIMUS

BASE OF OSTEOTMY IS AT BASE OF VASTUS LATERALIS RIDGE

EITHER A SAW CAN BE USED OR TWO CUTS AT RIGHT ANGLE CAN BE MADE

THE LATTER TECHNIQUE – MAKES IT LIKE A ROOF OF SWISS CHALET, ↓BONE CONTACT AREA & MORE STABLE FIXATION

3 TYPES –

SIMPLE (CHARNLEY) TROCHANTERIC OSTEOTOMY –detaches in a way that allows proximal attachment of gluteus medius and minimus

TROCHANTERIC OSTEOTOMY IN CONTINUITY –leaving the attachment of gluteus mediusproximally & of vastus lateralis distally.

EXTENDED TROCHANTERIC OSTEOTOMY (REVISION THR) includes trochanter with the gluteus attachments but also extends distally to maintain attachment of vastus lateralis

PARTIAL DETACHMENT OF ABDUCTOR MECHANISM – A STAY SUTURE IN ANTERIOR PORTION OF G.MEDIUS AND CUTTING THIS PORTION OFF GT

G.MINIMUS TENDON BELOW IS INCISED

Posteriorly styloid to which piriformis attaches is identified. A 40-50 mm osteotome is driven from trochanteric crest to and through styloid process

Reattached with monofilament no.14 through bone & distributed vertically & transversely or claws are used

Trochanter is freed of soft tissue posteriorly & short rotators released, saw seperates the GT with attachments of G.medius & minimus proximally & vastus lateralis distally, fragment is mobilised from posterior to anterior

Involves posterior lateral one third of the circumference of femur.

Posteriorly gluteus musculature is identified & trochanter is osteotomisedalong linea asperaSeries of drill holes are used to allow osteotomy to hinge anteriorly.

Transverse cut is made at the level of holes. Segment elevated anteriorly with vastus attachment remaining intact

At completion trochanter is reduced to its original bed & sutured with at least three circumferential monofilament wires.

FEMORAL N. – most laterally placed in femoral triangle, Not flexing the hip after dissecting uptoanterior rim of acetabulumPlacing retractors into substance of iliopsoasOr overexuberant retraction can damage it..

VESSELS – FEMORAL ARTERY & VEIN –damaged by acetabular retractors that penetrate iliopsoas substance.Anterior retractors (R) – 1-o` clock position

(L) – 11-o` clock position

PROFUNDA FEMORIS ARTERY

FEMORAL SHAFT# - while hip dislocation espif inadequate capsular release

1. To use a skid while dislcoating femur head out of acetabulum

2. In severe protrusio – osteotomise the rim

3. If extreme force has to be used – double osteotomy at neck

4. Too far incision of fascia lata anteriorlyresist adduction→thus fascia lata incised initially at posterior border of GT.

Antero-lateral Watson-Jones approach – TFL & gluteus medius is seperated mid-way between ASIS & GT.

In Harris lateral approach – GT osteotomydone – risks are trochanteric non-union, trochanteric bursitis, heterotopic ossification.

In McFarland & Osborne lateral approach, combined mass of g.medius & vastus lateraliswith their tendinous junction is elevated & retracted anteriorly.

In Hardinge lateral transgluteal approach the strong mobile tendon of gluteus medius is incised obliquely across GT leaving posterior half still attached to GT.

Frndak et. al modified this approach by placing abductor split 2 cms more anterior, directly over femoral head & neck.

Gibson’s posterolateral approach – iliotibial band is incised along with its fibres, gluteus medius & minimus are divided at their insertions leaving enough tendon attached so that closure is easy & post-op rehabilitationis rapid

POSITIONING – Supine with a bolster under ipsilateral buttock.

DANGERS – NERVES – lateral femoral cutaneous n.

Femoral n. – from retraction

VESSELS – anterior branch of lateral femoral circumflex.

BONE – iatrogenic femur #

Component malposition

LANDMARKS – UNDER FLOUROSCOPIC ALONG FEMUR NECK AXIS FROM HEAD & NECK JUNCTION TO THE BASE4cm

LEG ADDUCTED IN LATERAL BUTTOCK REGION IN LINE WITH PIRIFORMIS FOSSA TO PROX SHAFT FEMUR

The rest of approach similar to anterior approach

Approach to femur uses blunt dissection through posterior incision. Femur is broached keeping abductors anterior to broach & piriformis posterior

INDICATIONS – TOTAL HIP ARTHOPLASTY

HEMIARTHOPLASTY HIP

POSTERIOR WALL AND COLUMN ACETABULAR # ORIF

OPEN REDUCTION OF POST HIP DISLOCATIONS

HIP ARTHOTOMY

PEDICLE BONE GRAFTING

Ideally suited for resection arthopasty&insertion of proximal femoral prosthesis.

Medial circumflex artery should be preserved in hip resurfacing arthoplasty or fracture repair

Do not interfere with abductor mechanism→ immediate post-op rehabilitation fast.

Higher dislocation rate if used in # NOF in elderly patients.

POSITIONING

LATERAL DECUBITUS WITH AN AXILLARY ROLL

KIDNEY RESTS ARE USED AND ALL BONY PROMINENCES ARE PADDED

DANGERS – NERVES – SCIATIC NERVE – from direct injury or retraction or duing repair of external rotators and capsule when closing

FEMORAL NERVE – from retraction and displacement of proximal femur during reaming of the acetabulum or retractor placement

OBTURATOR N. – retractors

VESSELS – INF. GLUTEAL ARTERY – direct injury or retraction

MEDIAL FEMORAL CIRCUMFLEX – during takedown of external rotators from bone of posterior proximal femur

OBTURATOR ARTERY – retractor in inferior aspect of acetabulum.

LANDMARKS

GT,SHAFT OF PROXIMAL FEMUR

Curved incision 12-16cms in length with the apex centered at posterior aspect of trochanter starting on the lateral aspect of

proximal femur.

DEEP DISSECTION –G.Maximus cut in line with its fibres

Gluteus medius released from crest of trochanter →short rotators exposed

Internally rotate the lower extremity at the hip to aid exposure of external rotator tendons

Posterior joint Capsule incised to expose head & neck

Closure is extremly important with posterior exposure to lessen possibility of dislocation

Short rotators are retrieved and are then reattached through bone holes in the posterior margin of trochanterin the region of anatomic attachment

As with other limited exposures, special retractors are used

7-10 cms posterior incison –along post.border of GT extending from tip to tubercle of vastus lateralis ridge.

INDICATIONS – OPEN REEDUCTION OF CONGENITAL DISLOCATION OF HIP

PSOAS RELEASE

INFERIOR NECK BIOPSY

OBTURATOR NEUROECTOMY AND DECOMPRESSION

POSITIONING - SUPINE

DANGERS – NERVES – Anterior & Posterior division of obturator nerve

VESSELS – Medial femoral circumflex artery

LANDMARKS

PUBIC TUBERCLE, ADDUCTOR TENDONS

Medial incision 2-3cms from pubic tubercle over tendon of adductor longus.

SUPERFICIAL DISSECTION B/W Adductor longus & Gracilis

DEEP DISSECTION – Adductor magnus & Adductor brevisanteriorly. Anterior branch of obturator nerve has segmental branches that innervate adductor magnus, which should not be forcefully retracted

Adductor brevis is retracted anteriiorly. LT and psoas tendon retracted and hip joint is usually visualised

Proximal 5 cms of subtrochanteric shaft can also be visualised by this process.

INDICATIONS – ANTERIOR COLUMN, FEW TRANSVERSE, BOTH COLUMNS FRATURE ORIF ACETABULUM

ALLOWS INSERTION INTO POSTERIOR COLUMNS ALSO.

PROTRUSIO ACETABULI FRACTURE ORIF

Usually performed in collobration with general surgeon

POSITIONING – SUPINE WITH IPSILATERAL GT AT THE EDGE OF OPERATING TABLE

SOFT BUMP UNDER PELVIS CAN BE HELPFUL RADIOLUCENT TABLE CAN BE HELPFUL Done with a urinary catheter in situ as full

bladder may oscure vision DANGERS – STRUCTURES1. Bladder2. Spermatic cord3. Round ligament

NERVES – 1. FEMORAL N.

2. LATERAL FEMORAL CUTANEOUS N.

VESSELS

1. Femoral artery & vein

2. Inferior epigastric artery & vein

3. Neurovascular sheath damage→hematoma

4. Lymphatics → post-op lymphedema

LANDMARKS – Pubic tubercle, ASIS, iliac crest

INCISION – Medial 1 cm above pubic tubercle curving to a lateral landmark 4-5 cms from

ASIS 1 cm above the iliac crest

Subcutaneous tissue dissected exposing sup.oblique fascia

Lat. Femoral cut nerve sometimes may have to be divided

External oblique fascia divided in line with its fibers.

Round ligament & spermatic cord isolated & protected.

Rectus incised from pubic tubercle, space of retzius developed.

Int. Oblique & transversus abdominisincised.

Ligate inf. epigastricartery as they cross field.

Femoral sheath & iliopsoas tendon exposed.

Structures isolated & protected.

LATERAL – FROM PSOAS TO LATERAL ASPECT OF INCISION – exposed iliac wing & sacroiliac joint.

MIDDLE – PSOAS – FEMORAL VESSELS –Anterior column & medial wall & iliopubiceminence

MEDIAL – FEMORAL VESSELS – MEDIAL ASPECT OF INCISION exposing sup pubic rami & symphysis, protect bladder.

INDICATIONS – POST. WALL & POST. COLUMN T-TYPE TRANSVERSE POSTERIOR WALL SOME TRANSVERSE COLUMN ACETABULAR # POSITIONING – Lateral for simple posterior # Prone on radiolucent table – transverse &

combined component # Allows oblique imaging Needs a specialised pelvic traction table for

dislocating hip.

DANGERS – Sciatic nerve – in posterior column displacement – exposed & protected.

In prone position – hip extended & knee flexed to take tension off the nerve.

Lateral ascending br. of Medial circumflex artery – preserved by dividing piriformis, obturator & external rotators 1-2 cm posterior to femoral insertions.

Superior gluteal artery & nerve enter from undersurface and retarction can damage it.

Inf. Gluteal artery may be damaged from traumatic injury performed for #.

If damaged during surgical approach, it may retract into pelvis neccesitating rolling patient over & controlled through retroperitoneal approach and ligating ext. iliac artery.

LANDMARKS – GT, ILIAC CREST, PSIS, ASIS.

INCISION – Below the posterior third of iliac crest longitudinally over the centre of GT extending

8-10 cms past GT

After fascia lata, gluteus maximus incised along anterior border to expose abductors & external

rotators.

Tension over Sciatic nerve relieved.External rotators tensed by internally rotating hip &

detached 1 cm off their tendinous origin.Posterior capsular attachments – traumatically disrupted if needed for visualisation & anatomical reduction of #

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