surgical approaches to hip

1. By,
Dr. Vijay Kumar Loya
JR1, Orthopaedics,
JIPMER

3. SALIENT POINTS
 Approaches to hip
 ANTERIOR
 LATERAL
 POSTERIOR
 MEDIAL
 Approaches to acetabulum
 ILIOINGUINAL
 POSTERIOR

5. ANTERIOR APPROACH

7. INCISION
ANTERIOR 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

8. INTERNERVOUS PLANE
SUPERFICIAL – B/W SARTORIUS – FEMORAL. N
AND TFL – SUPERIOR GLUTEAL NERVE

9. DEEP – RECTUS FEMORIS – FEMORAL. N
AND GLUTEUS MEDIUS – SUP. GLUTEAL NERVE

10.  DANGERS
1. 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

12.  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.

13.  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

15.  FOR MINIMALLY INVASIVE MUSCLE SPARING
TECHNIQUES FOR THR, ANTERIOR JOINT
ARTHOTOMY

16. TWO FINGER BREADTH
BELOW ASIS
EXTENDS DISTALLY FOR 8
CMS B/W TFL & SARTORIUS

17. CAN BE IDENTIFIED BY
PALPATION
MAJOR DISADVANTAGE IS DAMAGE
TO LAT. FEMORAL CUT N.

18.  The approach is useful for reaming the
acetabulum & is used as the acetabular
approach 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.

19.  INDICATIONS – THR
 HEMIARTHOPLASTY HIP
 ORIF OF FEMORAL NECK #
 ORIF FEMORAL HEAD #
 HIP ARTHOTOMY
 INTRACAPSULAR BIOPSY

21. POSITION
SUPINE – CLOSE TO EDGE – BUTTOCK
HANGS OVER – TILTING THE TABLE TO
OPP. SIDE

22. INCISION
FIG OF 4 (FLEX AND ADDUCT SO THAT THE LEG
LIES OVER OPPOSITE KNEE) →8-15 cms INCISION
CENTERING ACROSS THE POSTERIOR THIRD OF GT

23. INTERNERVOUS PLANE
INTERNERVOUS PLANE – NO TRUE INTERNERVOUS
PLANE AS BOTH TFL AND GLUTEUS MEDIUS
SUPPLIED BY SUP GLUTEAL NERVE

24. 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.

25.  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

26.  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 medius
proximally & 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

28.  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

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

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

32. 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

34. Involves posterior lateral one third
of the circumference of femur.
Posteriorly gluteus musculature is
identified & trochanter is osteotomised
along linea aspera
Series of drill holes are used to allow
osteotomy to hinge anteriorly.

35. 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.

36.  FEMORAL N. – most laterally placed in femoral
triangle,
Not flexing the hip after dissecting upto
anterior rim of acetabulum
Placing retractors into substance of iliopsoas
Or 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

37.  PROFUNDA FEMORIS ARTERY
 FEMORAL SHAFT# - while hip dislocation esp
if 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 anteriorly
resist adduction→thus fascia lata incised
initially at posterior border of GT.

38.  Antero-lateral Watson-Jones approach – TFL
& gluteus medius is seperated mid-way
between ASIS & GT.
 In Harris lateral approach – GT osteotomy
done – risks are trochanteric non-union,
trochanteric bursitis, heterotopic ossification.
 In McFarland & Osborne lateral approach,
combined mass of g.medius & vastus lateralis
with their tendinous junction is elevated &
retracted anteriorly.

39.  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

40.  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

41. 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

42. 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

43.  INDICATIONS – TOTAL HIP ARTHOPLASTY
 HEMIARTHOPLASTY HIP
 POSTERIOR WALL AND COLUMN ACETABULAR
# ORIF
 OPEN REDUCTION OF POST HIP
DISLOCATIONS
 HIP ARTHOTOMY
 PEDICLE BONE GRAFTING

44.  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.

45. POSITIONING
LATERAL DECUBITUS WITH AN AXILLARY ROLL
KIDNEY RESTS ARE USED AND ALL BONY PROMINENCES ARE
PADDED

46.  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

47.  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.

48. 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.

49. DEEP DISSECTION –
G.Maximus cut in line with its
fibres
Gluteus medius released from
crest of trochanter →short
rotators exposed

50. Internally rotate the lower
extremity at the hip to aid
exposure of external rotator
tendons
Posterior joint Capsule
incised to expose head &
neck

51. 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 trochanter
in the region of anatomic
attachment

52. 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.

54.  INDICATIONS – OPEN REEDUCTION OF
CONGENITAL DISLOCATION OF HIP
 PSOAS RELEASE
 INFERIOR NECK BIOPSY
 OBTURATOR NEUROECTOMY AND
DECOMPRESSION

55. POSITIONING - SUPINE
DANGERS – NERVES – Anterior & Posterior division of
obturator nerve
VESSELS – Medial femoral circumflex artery

56. LANDMARKS
PUBIC TUBERCLE, ADDUCTOR TENDONS
Medial incision 2-3cms from pubic tubercle over tendon of
adductor longus.

57. SUPERFICIAL DISSECTION
B/W Adductor longus &
Gracilis
DEEP DISSECTION – Adductor
magnus & Adductor brevis
anteriorly. Anterior branch of
obturator nerve has segmental
branches that innervate adductor
magnus, which should not be
forcefully retracted

58. 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.

60.  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

61.  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 – STRUCTURES
1. Bladder
2. Spermatic cord
3. Round ligament

62.  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

63. 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

64. 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.

65.  Rectus incised from
pubic tubercle, space
of retzius developed.
 Int. Oblique &
transversus abdominis
incised.
 Ligate inf. epigastric
artery as they cross
field.
 Femoral sheath &
iliopsoas tendon
exposed.
 Structures isolated &
protected.

66.  LATERAL – FROM PSOAS TO LATERAL ASPECT
OF INCISION – exposed iliac wing & sacroiliac
joint.
 MIDDLE – PSOAS – FEMORAL VESSELS –
Anterior column & medial wall & iliopubic
eminence
 MEDIAL – FEMORAL VESSELS – MEDIAL ASPECT
OF INCISION exposing sup pubic rami &
symphysis, protect bladder.

69.  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.

71.  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.

72.  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.

73. 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

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

75. 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 #

76.  HOPPENFELD S, DEBOER P, Surgical Exposures
In Orthopaedics, LWW.
 CANALE ST, BEATY JH, Campbell’s Operative
Orthopaedics, Elsevier.
 MORREY M,MORREY J, Relevant Orthopaedic
Surgical Exposures, LWW.
 MILLER, CHABBRA et. al, Orthopaedic Surgical
Approaches, Saunders.
 BROWN ET, CUI Q et. al, Arthitis & Arthoplasty
The Hip, Saunders.