SURGICAL APPROACHES TO HIP Jt

Dr.SATEESH CHANDRA ORTHO PG

GMC

APPROACHES OF HIP4 Basic approaches : Anterior -Less commonly used for THR ;

b/w sartorious & TFL. Anterolateral - Most common approach for

THR; b/w TFL & G.medius Posterior- Most common approach around

hip; b/w GL.medius & maximus Medial-rarely used

ANTERIOR APPROACH:(SMITH PETERSON APPROACH)

Gives safe access to hip & iliumINDICATIONS: Open reduction of congenital dislocations of hip when

dislocated femoral head is anterosup. To the true acetabulum

Synovial biopsies Intra articular fusions THR Hemiarthroplasty Excision of tumors Pelvic osteotomies using upper part of approach

POSITION:

Supine with sand bag under the buttock for pelvic osteotomy

LANDMARKS:ASIS, iliac crest.

INCISION:Long incision over anterior half of the iliac

crest to the ASIS.Curve down from ASIS vertically for 8-10cms

heaving towards lateral side of patella.

INTERNERVOUS PLANE:

Superficial plane b/w sartorius (innervated by femoral N.) & TFL(innervated by sup.glut.N)

Deep plane lies b/w RF(by femoral N.) & GL.medius(supplied by sup.glut.N.)

SUPERFICIAL DISSECTION Externally rotate the leg to stretch sartorius. Carefully cut through the gap b/t sartorius and TFL

about 3” distal to the ASIS. Avoid cutting Lat. cut .N. of thigh, incise deep fascia. Retract sartorius upwards & medially; TFL down &

laterally Detach the TFL at iliac origin. Ligate the ascending branch of Lat.circumflex Fem A.

in this plane.

DEEP DISSECTION: Separating sartorius & TFL exposes 2 muscles the GL. Medius &

Rectus femoris. Pass into the plane b/w Rect,F & GL.medius which is lateral to

the Femoral.A. Retract the R.F ,expose the capsule of hip jt. Retract the iliopsoas passing medially towards lesser trochanter. Adduct & externally rotate the leg to stretch the capsule. Incise the capsule as required ( T/longitudanal)& dislocate the

hip by ext.rotation.

DANGERS: NERVES:LFCN. of thigh may be injured b/w sartorius & TFL.Femoral N. – may be injured if plane is missed during

deep dissection as it lies anterior to hip , medial to RF,lateral to the femoralA.

VESSELS: Ascending branch of lat.circumflex F.A. may be injured

in the plane b/t TFL & sartorius.

ENLARGING THE APPROACH:In superficial dissection - by detaching sartorius at the

origin.In deep dissection- origin of GL.medius ,minimus to be

detached.

EXTENSILE MEASURES:Can be extended posteriorly to expose iliac crest.Can be extended distally along anterolateral thigh into

plane b/w V.lateralis & Rectus .femoris gives good exposure of entire shaft of femur.

Can be extended to allow inner & outer walls of plvis at hip for osteotomies

V.LAT

R.F

Periosteum femur

ANTEROLATERAL APPROACH:( WATSON-JONES APPROACH)

Most commonly used for THR Releases all abductor mechanism, hence hip can be

adducted fully hence acetabulum is fully exposed. Abducor mechanism released either by trochanteric

osteotomy / by cutting the ant.part of GL.medius & the whole Gl.minimus off the G.T

INDICATIONS: THR ORIF of # NOF Hemiarthroplasty Synovial biopsy Biopsy Femoral N.

POSITION: Supine so close to the edge that thebuttock of the

affected side hangsover. Flex the leg upto 30 deg. , adduct it so that leg lies

across the opposite knee. Tilt the table away, drape the pt. so that the limb

can be moved during surgery.

LANDMARKS: ASIS GT Femoral shaft V.Lat ridge

INCISION: 8-15cm longitudanal&straight centered over the Tip of

GT. Incision crossess the post.3rd of the GT before running

down the shaft.

INTERNERVOUS PLANE: No internervous plane. Surgical plane is b/w TFL & GL.medius(supplied by

sup.GT N.) Nerve to TFL enters the muscle at its origin. So as long as the plane is extended upto the illium the

TFL remains uneffected.

SUPERFICIAL DISSECTION: cut the S.C tissue to reach the fascia over posterior margin of GT & incise

fascia lata there to enter the overlying bursa. Divide the fibers of fascia lata proximally & anteriorly in the direction of

ASIS, & also distally to expose the vast,lateralis muscle. Lift the ant. Flap & detach few fibers of GL.medius to develop a plane b/w

TFL & GL.medius. Series of vessels come across the plane act as guide & need to be ligated. Retract the GL.med. & mins proximally & laterally to uncover the sup

margin of Jt, capsule.

Externally rotate the hip to stretch the capsule

Inscise it

To expose V lat. origin

Reflect v.lat origin for ~1cm to expose the jt. Anteriorly keeping the fat pad intact

DEEP DISSECTION: Detach abdutor mechanism & dissecting up the

femoral neck superficial to the capsule until a retractor can be placed over ant. Lip of acetabulum

2 techniques for good exposure of acetabulum by

Neutralising abductor mechanism &allowing femur to fall posteriorly.

Trochanteric osteotomy % detachment of abductor mechanism. Dissect ant surface if hip jt.capsule in line with

femoral neck & head. Detach reflected head of Rect.F from Jt. Capsule

to expose the ant. rim of acetabulum

Elevate the psoas tendon from capsulePlace Homan retractor over ant lip of acetabulum

beneath the RF & psoas as the nervous bundle is anterior to the psoas.

Incise the capsule longitudinally T H.DANGERS:NERVESFemoral N. Most commonly neuropraxia due to

excess medial retraction. FemoralA/V due to poor handling.Prevented by proper placing of retractor 1 o’ clock position for Rt. Hip 11 o’ clock position for Lt. hip Profunda femoris A.# of femoral shaft

ENLARGING THE APPROACH:Post. Fascia lata may prevent adduction of hip

which is needed for hip dislocation.Overcome by incision over post.flap of TFL

obliquely upwards in line with Gl. Max.EXTENSILE MEASURES:Can be extended distally to expose the lateral

aspect of femur.Can’t be extended proximally.

LATERAL APPROACH TO HIP: Exellent approach to hip replacement. No need for trochanteric osteotomy. Early mobilisation of pt possible as the

Gl.medius is preserved. But not a wider approach as anterolateral

approach.POSITION:Supine with GT at the edge of the table.LANDMARKS:ASISG.TShaft of femur

INCISION:Start about 5cm above the tip of GT pass over centre of tip of GT

to extend ~8cm down the shaft.

INTERNERVOUS PLANE:No internervous plane as G.M & V.L split in their own line.SUPERFICIAL DISSECTION: Cut through the fat & deepfascia Pull the TFL anteriorly,GMposteriorly Detach fibers of GL.medius & develop a plane b/w V.lat &

glut.medius.

DEEP DISSECTION: Split the GL. Medius starting in the middle of GT. Don’t go beyond 3cm up the GT.to preserve sup.GL.N. Split the fibers of V.lats at the base of the GT, Develop ant. f;lap consisting of ,GL.MED , GL.MIN & V.L Detach muscles from GT Continue disection anteriorly along femoral neck till

ant.capsule of hip. Develop space b/w hip capsules & muscles Enter the capsule using T shaped incision Ostetomise the neck , extract the head with cork screw to

expose the acetabulum.

DANGERS:NERVES: Sup.GL.N. damage at the upper end of incision

above GT. Prevented by stay suture in the GL. Med Femoral N. damaged by inadvertly placed

retraction Prevented by placing retractor strictly on the

bone.VESSELS: Fem. Vessels by retractor ENLARGING THE APPROACH: EXTENSILE MEASURE: Can be extended down to expose the shaft of

femur.

POSTERIOR APPROACH:(MOORES APPROACH)

Most commonly used approach & practical Easy ,safe, quick Not used for# neck of femurINDICATIONS:HemiarthroplastyTHR including revisionORIF of post. Acetabular #Dependent drainage in hip sepsisRemoval loose bodiesPedicle bone grafting OPEN reduction of posterior dislocation

POSITION:True lateral with affected limb above

LANDMARK:GTINCISION: 10-15cm curved centered on posterior aspect of GT Begin proximally 6-8cms posterosuperior to posterior

aspect of GT Continue to GT Curve the incision in line with fibers of GT Continue along shaft of femurINTERNERVOUS PLANE: No true plane

SUPERFICIAL DISSECTION:Cut the fascia lata to expose the V.lat.Superiorly split the fibers of GM(very important) gently.DEEP DISSECTION: Retract GL.maximus & deep fascia to expose

posterolateral aspect of hip. Cover by short ext.rotators. Internally rotate the hip to move sciaticN. away from

the field. Detach piriform & obt.internus retract them posteriorly. Incise the hip jt, capsule , to expose the head & neck of

femur. Internally rotate femur for hip dislocation.

DANGERS:Sciatic N &Inf GL.A (both may be damaged

while splitting GL. Max.ENLARGING THE APPROACH:LOCALLYBy extending the skin / fascial incisionBy detaching upper ½ of Q.femoris 1cm from

insertion.By detaching the origin of GL.max for femoral

neck & shaft.

MEDIAL APPROACH(LUDOLFFS APPROACH)

INDICATIONS: Open reduction of congenital dislocation of hip. Biopsy & RX of tumors of the inf.portion of femoral neck &

medial aspect of proximal shaft. Psoas release Obturator neurectomy. By making short transverse/longitudinal incision-used for

adductor release

POSITION:Supine with affected hipflexed , abducted & externally rotated.Sole of foot lies along the medial side of opp. Knee.LANDMARKS:Adductor longus traced to its originPubic tubercleGTINCISION:Longitudinal incision on the medial thigh starting 3cm below pubic tubercle

that runs down over adductor longusLength depends on amount of femur to be exposedINTERNERVOUS PLaNE:Superficial dissection b/w adductor.longus & gracialisDoesn’t involve int.N.plane

SUPERFICIAL DISSECTION:B/w adductor longus & gracialisDEEP DISSECTION:B/w adductor brevis & magnus till lesser

trochanterProtect post.division of obt.N. to preserve

innervation of adductor portion of Ad.magnus.

Place a bone spike above & below the lesser trochanter to isolate psoas tendon.

DANGERS:NERVES:Ant,div of obt.N which lies at the top of the

obt.externus running b/w add.longus & brevis.Post.div of obt.N. lies with in the obt,externus

which it supplies before it leaves the pelvis.Runs down thw thigh on adductor magnus under

the brevis,it also supplies adductor portion of adductor magnus.

These nerves are transected if approach is meant for adductor spasm or else protect them.

VESSELS:Medial femoral circum flex A.-may be injured at

distal part of psoas.

ENLARGING THE APPROACH: Locally can be extended by detaching psoas

& iliacus at L. T can expose 5 more cm of femoral shaft.

EXTENSILE MEASURE:Can never be enlarged