SURGICAL
EXPOSURES
SURGERY OF THE HIP
by
R. CALANDRUCCIO
In: Atlas of Orthopaedic Surgery
Volume 3
Lower Extremity;
Editors: Laurin, CA, Riley Jr. LH, Roy-Camille R
Reprinted with permission from Masson, copyright
Masson, Paris, 1991
Surgical
approaches to the hip may be classified as:
—
anterior;
—
anterolateral;
—
lateral;
—
posterior;
—
medial;
—
lateral subtrochanteric and proximal femoral shaft.
The
anterior approach utilizes the interval between the sartorius
and tensor fascia. The anterolateral approach utilizes the
interval between the tensor fascia and the gluteus medius.
The lateral approach is essentially dependent upon elevation
of the insertion of the gluteus medius and minimus. The posterior
approach utilizes the interval between the gluteus maximus
and medius; in some instances the muscle fibres of the gluteus
maximus are separated. The medial approach is between the
gracilis and the adductor longus.
Surgical
approaches are different from anatomical dissection in so
much as the tissue planes are only dissected to a limited
extent sufficient to identify specific structures and avoid
nerve and vessel damage. There is usually no need to undermine
the skin or dissect the superficial and deep fascia from the
underlying structures. Extensions of the skin incision should
not be declined simply to minimize the length of the suture
line. “Keyhole” incisions are often dangerous;
skin incisions heal from side to side and not from end to
end.
Surgical
exposures inevitably produce some degree of tissue damage.
The orthopaedic surgeon must be mindful of the potential consequences
of destroying blood supply, especially to bone. However, the
advantages obtained by adequate, open reduction should outweigh
the possible complications of the exposure.
If
the femoral head is to be retained, the surgeon must be mindful
that all surgical exposures of the hip are associated with
the risk of devascularizing the femoral head.
Knowledge
of the anatomical structures in the coronal and sagittal planes,
as well as the cross-sectional relationships, is a prerequisite.
There
are many eponyms related to hip joint exposures. With due
respect to all who have contributed, no attempt was made to
emphasize author recognition.
ANTERIOR
APPROACH
The
anterior iliofemoral approach utilizes the interval between
the sartorius muscle and the tensor fascia lata muscle.
The
entire ilium and hip joint can be reached through the iliac
part of the incision. Nearly all hip surgery can be carried
out through this approach and separate parts can be used for
different purposes. However, it is now mainly used to expose
the anterolateral aspect of the head and neck of the femur
and acetabulum for biopsy or excision of bone in this area.
It is difficult to gain direct access to the entire acetabulum,
or to deliver the proximal femur out of the wound without
extensive stripping of the abductors from the ilium or transecting
the external rotator tendons.
The
lower or distal part of the approach, requires no stripping
of muscles, except possibly release of the tendinous origin
of the rectus femoris. The anatomy of the anterior approach
to the hip is illustrated in figures 5-1, 5-2, 5-3 and 5-4.
Anterior
approach
With
the patient supine a pad is placed under the affected hip
so that the posterior aspect of the ilium can be exposed,
when necessary, and also to facilitate anterior dislocation
of the hip. The leg is draped so the hip and leg can be manipulated
during the approach.
The
skin incision begins at the middle of the iliac crest, 2 centimetres
below the crest of the ilium to avoid a painful postoperative
scar adherent to bone. The incision is extended anteriorly
below the anterior superior iliac spine and curved distally
on the lateral aspect of the thigh (Fig. 5-5).
The
superficial and deep fascia over the sartorius muscle are
divided, medial to the tensor fascia lata muscle. The lateral
femoral cutaneous nerve that penetrates the deep fascia just
below the anterior superior iliac spine is identified and
retracted medially along with the sartorius muscle. The interval
between the tensor fascia lata and the sartorius is more easily
identified distal to the anterior superior iliac spine (Figs.
5-1 and 5-6); so the dissection should therefore be
started distally rather than close to the anterior superior
iliac spine.
Part
of the anterior aspect of the origin of the tensor fascia
is subperiosteally stripped from the ilium. Retraction in
this interval exposes the gluteus medius muscle and the rectus
femoris muscle, which at this level is easily identified because
of its fibrous nature, in contrast to the fleshy surrounding
muscles.
The
ascending branches of the lateral femoral cutaneous circumflex
vessels are usually ligated at the lower end of the incision
(Figs. 5-2 and 5-7).
The
tendinous origin of the rectus femoris is separated from the
underlying joint capsule, and the direct and reflected origins
are released by a transverse cut. The iliopsoas is also separated
from the capsule by blunt dissection and retracted medially.
Most of the anterior aspect of the hip joint is then exposed
(Figs. 5-3, 5-4 and 5-8).
The
capsule may be incised in line with the axis of the femoral
neck and transversely at the edge of the acetabulum, as well
as distally (in the form of the letter H). If it is necessary
to dislocate the hip anteriorly, as much of the capsule is
incised or excised as necessary; part of the labrum may also
be excised. The femoral head is dislocated by adducting, externally
rotating and extending the hip. In young patients, it may
be necessary to incise the ligamentum teres before the hip
can be completely dislocated. The release of the psoas tendon
from the lesser trochanter may also be required. The lesser
trochanter is exposed by externally rotating the leg, retracting
the psoas medially away from the capsule (Figs. 5-4 and 5-8).
To
expose more of the ilium or the superior aspect of the acetabulum,
the abductor muscle origin is stripped subperiosteally from
the wing of the ilium and retracted posteriorly and laterally
(Figs. 5-4 and 5-9). The space between the ilium and this
muscle mass is then packed to control bleeding.
Fig.
5-1. - The line of incision (dotted line)
for the anterior iliofemoral approach.
1. Gluteus maximus;
2. Sartorius;
3. Iliopsoas;
4. Lateral femoral cutaneous nerve;
5. Tensor fascia lata;
6. Gluteus medius;
7. Anterior superior iliac spine;
8. Femoral nerve;
9. Rectus femoris.
Fig.
5-2. - Part of the sartorius, tensor fascia
lata muscle have been resected to expose the deeper
layer that is encountered when the interval between
the tensor fascia lata and sartorius is used.
1-9.
See Fig. 5-1; 10. Anterior joint capsule of hip; 11.
Fascia lata; 12. Ascending branch of lateral femoral
circumflex artery; 13. Profunda femoris arter; 14.
Femoral artery and vein.
Fig.
5-3. - Part of the gluteus medius, minimus
and maximus muscles have been resected to visualize
the underlying anatomy of the anterior approach.
1
to 14. See Fig. 5-1 and 5-2; 15. Greater trochanter;
16. Piriformis; 17. Reflected head of rectus femoris;
19. Gluteus minimus; 19. Inguinal ligament; 20. Direct
head of rectus femoris.
Fig.
5-4. Part of the sartorius, tensor fascia lata,
and gluteus muscles have been resected to reveal the
deep plane of the anterior retracted medially, part
of the anterior capsule has been excised exposing
the hip and anterior aspect of the acetabulum. The
origin of the rectus femoris has also been resected.
1
to 20. See Fig. 5-1, 5-2 and 5-3; 21. Joint capsule
of hip; 22. Femoral head.
Fig.
5-5. The skin incision parallels the iliac
crest, turns downwards below the anterior iliac spine
and extends along the shaft of the femur (anterior
iliofemoral approach) in the direction of the lateral
border of the patella.
1.
Iliac crest; 2. Anterior superior iliac spine.
Fig.
5-6. - The dissection between the tensor fascia
lata and sartorius is started distally rather than
at the anterior superior iliac spine. The lateral
femoral cutaneous nerve is identified and retracted
medially.
3.
Fascia lata; 4. Fascia over tensor fascia lata; 5.
Fascia over sartorius; 6. Lateral femoral cutaneous
nerve.
Fig.
5-7. - Retraction of the tensor fascia lata (9)
and the sartorius (12) exposes the gluteus medius
(11) and rectus femoris (8). The ascending
branch of the lateral femoral circumflex artery (7)
has been ligated. The anterior part of the tensor fascia
lata muscle origin has been stripped from the ilium
(10).
Fig.
5-8. - After detaching the rectus femoris (8)
from its origin and retracting the iliopsoas (14)
medially, much of the anterior aspect of the capsule
is exposed (13).
Fig.
5.9. - After resection of the rectus femoris
origin, subperiosteal stripping of the gluteus medius
and minimus from the ilium exposes the anterior inferior
iliac spine and anterior superior iliac spine. With
additional subperiosteal elevation, the superior aspect
of the acetabulum and much of the iliac wing can be
exposed.
1. Femoral head and neck;
3. Anterior inferior iliac spine;
4. Anterior superior iliac spine.
ANTEROLATERAL
APPROACHES
The
Smith-Petersen anterolateral approach is an extension of the
iliofemoral approach to permit exposure of the subtrochanteric
region.
Illustrations
of the anatomy of the anterolateral approach (Figs. 5-10,
5-11 and 5-12) are provided for correlation with
the surgical approaches.
Fig.
5-10. - Skeletal anatomy for anterolateral
approach.
1.
Femoral head; 2. Anterior inferior iliac spine; 3.
Anterior superior iliac spine; 4. Posterior superior
iliac spine; 5. Vastus ridge; 6. Shaft of femur; 7.
Intertrochanteric line; 8. Greater trochanter.
Fig.
5.11. - Sartorius, tensor fascia lata muscle,
and fascia are partially resected; the gluteus maximus
is reflected posteriorly.
5.
Vastus ridge; 10. Vastus lateralis; 11. Superior gluteal
artery; 12. Gluteus maximus; 13. Gluteus medius; 14.
Fascia lata; 15. Tensor fascia lata; 16. Sartorius
aponeurosis; 17. Ascending branch of lateral femoral
circumflex artery; 18. Iliopsoas; 19. Femoral nerve;
20. Rectus femoris; 21. Sartorius; 25. Capsule; 26.
Fascia lata
1.
Head of femur; 2. Anterior joint capsule of the hip;
4. Anterior superior iliac spine; 9. Greater trochanter;
10. Vastus lateralis; 12. Gluteus maximus; 13. Gluteus
medius; 15. Tensor fascia lata; 16. Sartorius aponeurosis;
17. Ascending branch of lateral femoral circumflex
artery; 18. Iliopsoas; 20. Rectus femoris; 21. Sartorius;
22. Gluteus minimus; 23. Piriformis; 24. Acetabular
rim and labrum; 25. Capsule; 26. Fascia lata.
1°
Smith-Petersen anterolateral approach
Smith-Petersen
described an anterolateral approach for open reduction and
internal fixation under direct vision of recent fractures
and nonunions of the femoral neck and slipped capital femoral
epiphysis. The distal extension of the iliofemoral incision
exposes the trochanteric region and the upper femur between
the vastus lateralis and the rectus femoris.
It
may be necessary to split muscle fibres to expose the anterior
aspect of the femur (Fig. 5-13); however, muscle fibres should
not be split too far distally to avoid damage to branches
of the femoral nerve as they cross from medial to lateral.
Posterior retraction of the fascia lata alone provides exposure
of the lateral subtrochanteric region. The distal end of the
skin incision is curved posteriorly to facilitate exposure
of the subtrochanteric region.
Fig.
5-13. - The Smith-Petersen anterolateral
approach is an extension of the iliofemoral approach.
1.
Vastus lateralis; 2. Shaft of femur; 3. Periosteum;
4. Rectus femoris; 5. Tendons of gluteus minimus and
medius; 6. Sartorius; 7. Iliopsoas; 8. Femoral neck;
9. Fascia lata; 10. Gluteus minimus and medius; 11.
Ilium
2°
Watson-Jones anterolateral approach
The
patient is supine and the hip is slightly flexed to relax
the anterior structures. The incision is begun a finger’s
breadth distal and lateral to the anterior superior iliac
spine and extended distally and posteriorly over the lateral
aspect of the greater trochanter and lateral surface of the
femoral shaft for approximately 5 centimetres (Fig. 5-14).
The
interval between the gluteus medius and tensor fascia lata
is identified more easily midway between the anterior superior
spine and the greater trochanter, rather than at the level
of the trochanter. The coarse grain of the fibres of the gluteus
medius distinguish it from the finer structure of the tensor
fascia lata muscle.
Retraction
of the anterior edge of the gluteus medius posteriorly and
the tensor fascia and rectus anteriorly exposes the joint
capsule (Fig. 5-14 a). The capsule may be incised in
a longitudinal or transverse fashion. The origin of the vastus
lateralis may be reflected distally or split longitudinally
to expose the trochanter and proximal aspect of the anterior
femoral shaft.
Fig.
5-14. - a) The Watson-Jones approach
provides an extension of the lateral subtrochanteric
approach for open reduction of femoral neck fractures.
1.
Vastus lateralis; 12. Vastus ridge; 13. Gluteus medius;
14. Joint capsule; 16. Tensor fascia lata.
b)
1. Vastus lateralis; 14. Capsule; 15. Trochanter
If
additional exposure is required, the anterior fibres of the
gluteus medius and minimus tendon may be incised or the anterior
superior part of the greater trochanter may be osteotomized
with the attached insertion of the gluteus medius muscle (Fig.
5-14 b).
3°
Callahan anterolateral approach
The
skin incision starts just distal to the anterior superior
iliac spine, extends distally to a point approximately three
finger breadth distal to the lateral prominence of the trochanter
and then curves posteriorly, producing a hockey stick shaped
incision (Figs. 5-1 and 5-15).
Fig.
5-15. - The Callahan approach utilizes a hockey
stick shaped incision; the interval between the sartorius
and tensor fascia lata is used to expose the joint.
1.
Incision in vastus lateralis; 2. Gluteus medius; 3.
Sartorius; 4. Capsule; 5. Vastus lateralis; 6. Tensor
fascia lata (sectioned for better visualization).
Insert:
Line of incision.
The
interval between the tensor fascia and the sartorius space
is developed and the tensor fascia lata is divided transversely
in the distal part of the incision. Proximally, the tensor
fascia lata and gluteus muscles are elevated subperiosteally
and retracted posteriorly. The rectus femoris is retracted
medially.
The
capsule is then exposed by medial retraction of the iliopsoas
and rectus femoris.
When
necessary, more exposure can be obtained by subperiosteal
stripping of the tensor fascia lata and gluteus medius muscle
from the wing of the ilium (Fig. 5-15).
4°
Luck anterolateral approach
In
this transverse anterior approach to the hip, the tensor fascia
lata is divided transversely while the gluteus medius and
minimus are not disturbed.
The
skin incision starts over the femoral head, just lateral to
the midpoint between the anterior superior iliac spine and
the symphysis pubis, extends laterally parallel to, or in,
the flexor crease of the hip and ends just lateral to the
greater trochanter (Figs. 5-12 and 5-16 a).
The
fascia lata is incised transversely just distal to the trochanter
to permit identification of the tensor fascia lata muscle
(Fig. 5-11). The muscle is divided at its most distal attachment
to the fascia lata. The incised fascia lata and tensor are
reflected proximally.
The
sartorius and rectus femoris are retracted medially to expose
the capsule (Figs. 5-12 and 5-16 b). The origin of
the rectus femoris may be detached from the pelvis for added
exposure of the joint.
Fig.
5-16. - a and b) The Luck anterior transverse
approach requires sectioning the tensor fascia lata
muscle at its distal insertion into the fascia lata.
1.
Rectus femoris; 2. Transverse incision; 3. Tensor
fascia lata; 4. Anterior superior iliac spine; 5.
Sartorius; 6. Iliopsoas
The lateral aspect of the incision may be curved superiorly
if the trochanter is to be osteotomized or it may be curved
distally if the subtrochanteric and lateral aspects of the
femur are to be exposed for internal fixation or osteotomy
(Figs. 5-11 and 5-16).
5°
Fahey anterolateral approach
This
oblique incision extends from the anterior superior iliac
spine to a point distal to the prominence of the greater trochanter
and ends at the midpoint of the lateral aspect of the thigh
(Fig. 5-17 insert).
Fig.
5-17. - The Fahey approach facilitates arthrotomy
of the hip as well as exposure of the lateral subtrochanteric
area.
1.
Fascia lata; 2. Tensor fascia lata; 3. Head of femur;
4. Gluteus minimus; 5. Straight head of rectus femoris
muscle cut; 6. Psoas muscle; 7. Vastus lateralis;
8. Femoral shaft; 9. Gluteus maximus insertion.
The skin and superficial fascial are retracted and the plane
between the tensor fascia lata and the sartorius is developed.
The iliotibial band is divided transversely at the distal
insertion of the tensor fascia lata muscle into the iliotibial
band. The straight head of the rectus is divided and the psoas
tendon is separated from the anterior capsule and retracted
medially. The joint capsule is now opened longitudinally and
cut transversely near the rim of the acetabulum.
The
vastus lateralis muscle is separated from the femur and retracted
anteriorly to expose the subtrochanteric and lateral aspects
of the proximal femur (Fig. 5-17).
6°
Charnley anterolateral approach
With
the patient supine, the hip is placed near the edge of the
table so that the skin and adipose tissues of the buttock
will hang over the side. A sandbag under the buttock will
elevate the trochanter and make draping easier. The sandbag
may have to be removed when the implants are inserted in order
to assess their position more accurately. For this reason,
some prefer an air bag that can be deflated or they temporarily
tilt the table. The leg is draped so that it can be manipulated
during the procedure. The hip is flexed 30 degrees and adducted
slightly to make the trochanter more prominent and to move
the tensor fascia lata anteriorly.
The
incision starts several centimetres distal to the iliac crest,
extends to the tip of the trochanter, crosses the posterior
aspect of the trochanter and runs down the shaft of the femur.
The incision may also start more anteriorly, at the level
of, and approximately 5 centimetres behind, the anterior superior
spine (Fig. 5-18).
Fig.
5-18. - A straight (Fig. 5-19) or a cursed
(Fig. 5-18) incision may be used for the anterolateral
approach.
1.
Anterior superior iliac spine; 2. Sartorius; 3. Tensor
fascia lata; 4. Rectus femoris; 5. Vastus lateralis;
6. Iliotibial band; 7. Biceps femoris; 8. Gluteus
maximus; 9. Gluteus medius; 10. Iliac crest.
Fig.
5-19. - The tensor fascia is incised in line
with the skin incision and behind the tensor fascia
lata muscle.
3.
Fascia over tensor fascia lata; 5. Vastus lateralis;
6. Iliotibial band.
Fig.
5-20. - The fat tissue is removed with blunt
dissection revealing the underlying joint capsule
and medially the tendon of the rectus femoris muscle.
External rotation of leg makes capsule more taut.
5.
Vastus lateralis; 11. Tendon of rectus femoris; 12.
Psoas; 13. Greater trochanter.
The subcutaneous adipose tissue is incised in line with the
skin incision down to the deep fascia. The fascia is incised
starting over the greater trochanter and then distally for
approximately 5 centimetres, exposing the underlying vastus
lateralis. The fascial incision is extended proximally behind
the posterior border of the tensor fascia lata muscle (Fig.
5-19). If the fascial incision is too posterior, the gluteus
maximus fibres will be encountered; if it is too anterior,
the tensor fascia lata muscle fibres will be sectioned.
Some
authors prefer to go through the fascia covering the tensor
muscle and detach this muscle inferiorly from the fascia lata
(Roy-Camille).
Retraction
of fascia lata muscle anteriorly and the gluteus maximus posteriorly,
exposes the underlying gluteus medius and greater trochanter.
Any fibres of the gluteus medius arising from the undersurface
of the fascia lata are detached by blunt dissection.
The
interval between the anterior edge of the gluteus medius and
the tensor fascia lata is identified; the gluteus medius and
minimus are retracted laterally and posteriorly, while the
tensor is retracted medially thereby exposing the fatty tissue
overlying the joint capsule. The origin of the vastus lateralis
is detached from the front of the greater trochanter. The
hip is now externally rotated and slightly flexed to reduce
the tension on the abductor muscles and make the anterior
part of the capsule taut (Fig. 5-20).
If
the procedure is to be done without osteotomizing the greater
trochanter, an incision is made in the anterior insertion
of the gluteus medius and minimus detaching them from the
greater trochanter, but leaving a cuff of tendon for re-attachment
(Fig. 5-21). The incision is then vertical and proximal, in
the substance of the gluteus medius (Fig. 5-21, insert).
The
capsule is cut and the head and neck are exposed (Fig. 5-22).
With the leg adducted, the capsule is sufficiently resected
so that with external rotation, the hip is dislocated anteriorly.
Additional capsule is cut as necessary to retract the head
and neck posteriorly for visualization of the acetabulum.
Fig.
5-21. - If the trochanter is not osteotomized,
an incision is made in the anterior insertion of the
gluteus medius detaching it from the trochanter but
leaving a cuff of tendon for re-attachment. The incision
in the gluteus medius is extended proximally from
the tip of the trochanter (see insert).
3.
Tensor fascia lata; 5. Vastus lateralis; 9. Gluteus
medius; 11. Rectus femoris; 13. Greater trochanter;
14. Joint capsule.
Fig.
5-22. - With the leg adducted the capsule is
resected and then with flexion and external rotation
the hip is dislocated anteriorly.
3.
Tensor fascia lata; 8. Gluteus maximus; 9. Gluteus
medius; 13. Greater trochanter; 15. Neck of femur;
16. Head of femur.
Fig.
5-23. - A long heavy clamp is inserted either
intracapsular as above, or extracapsular, to act as
a guide for the osteotomy of the greater trochanter
using a Gigli saw, an osteotome or an oscillating
saw.
Fig.
5-24. - An osteotomy of the greater trochanter
should exit on the trochanter just above the prominence
of the abductor tubercle.
If the joint is exposed by osteotomizing the trochanter, an
instrument is inserted as illustrated in figure 5-23 under
and medial to the gluteus medius and minimus, either intracapsular
or extracapsular, to serve as a guide for osteotomy of the
greater trochanter. The vastus lateralis origin from the trochanter
stripped and retracted distally. A wide osteotome, a Gigli
saw or a reciprocating saw are used to osteotomize the greater
trochanter as illustrated in figures 5-23 and 5-24. Care is
taken not to damage the sciatic nerve posterior to the greater
trochanter. Part of the abductor tubercle should be left attached
to the shaft (Fig. 5-24).
The
osteotomized greater trochanter is retracted superiorly and
then, with slight flexion of the hip, it is possible to detach
the origin of the rectus from the front of the hip joint (Fig.
5-25). The capsule is now incised in line with the neck of
the femur and transversely at the acetabulum. With external
rotation, the hip can usually be dislocated anteriorly, though
it may be necessary to incise the attachment of the gluteus
maximus to the posterior aspect of the femur (Fig. 5-26 b).
It may also be necessary to incise the capsule inferiorly
and to detach the psoas tendon from the lesser trochanter.
The
neck of the femur is then osteotomized, either by using a
Gigli saw or reciprocating saw. An osteotome should not be
used for fear of fracturing the inferior cortex of the neck
(Fig. 5-27).
After
the head has been removed, a flat retractor can be inserted
behind the lip of the acetabulum to lever the internally rotated
femur posteriorly, thus providing direct access to the acetabulum
(Fig. 5-28).
Self-retaining
retractors are utilized to retract the osteotomized greater
trochanter and the cut surface of the femur as well as the
fascia lata and gluteus maximus (Fig. 5-29).
If
at any time during the procedure exposure of the shaft is
necessary, the skin incision is extended along the shaft of
the femur and the vastus lateralis is either split, as illustrated
in figure 5-30, or retracted.
Fig.
5-25. -
The hip is flexed and the rectus femoris origin is
detached from the edge of the acetabulum.
3.
Tensor fascia lata; 4. Reflected head of rectus femoris;
9. Gluteus medius; 13. Osteotomized greater trochanter.
Fig.
5-26. - The capsule is incised as illustrated
and with external rotation and adduction the hip is
dislocated. If necessary, the fibres of the gluteus
maximus attached to the femur are incised (insert).
5.
Vastus lateralis; 8. Gluteus maximus tendon; 14. Joint
capsule; 15. Femoral head and neck; 17. Line of proximal
fasciotomy; 18. Superior rim and labrum of acetabulum;
19. Femoral shaft.
Fig.
5-27. - The femoral head can be divided
with a Gigli saw or, better still, with an end-cutting
reciprocating saw.
Fig.
5-28. - After osteotomy of the femoral
neck, the femur is retracted posteriorly by a retractor
inserted behind the posterior edge of the acetabulum.
3.
Tensor fascia lata; 5. Vastus lateralis; 6. Fascia
lata; 9. Gluteus medius; 13. Greater trochanter; 14.
Joint capsule; 15. Neck of femur; 20. Acetabulum.
Fig.
5-29. - Self
retaining retractors are inserted between the gluteus
maximus posteriorly and the tensor fascia lata anteriorly;
a second self-retaining retractor between the greater
trochanter and osteotomized surface of the femur provides
excellent exposure of the acetabulum. A Hohmann's
retractor inserted over the anterior quadrant of the
acetabulum is also helpful.
Fig.
5-30. - If necessary, at any time in
the procedure, the vastus lateralis can be divided
or the whole muscle retracted anteriorly to expose
the shaft of the femur.
4.
Reflected head of rectus femoris; 5. Vastus lateralis;
6. Fascia lata; 9. Gluteus medius; 13. Proximal femur
(greater trochanter osteotomized); 14. Joint capsule;
15. Femoral head and neck; 19. Shaft of femur; 21.
Capsule and roof of acetabulum.
LATERAL
APPROACHES
1°
Ollier lateral approach
The
U-shaped incision starts near the anterior superior iliac
spine, continues downwards and distal to the trochanter, curves
across the lower aspect of the trochanter, extends posterior
superiorly, ending midway between the trochanter and posterior
superior iliac spine. The gluteal fascia is incised in line
with the skin incision (Fig. 5-31 a).
The
interval between the tensor fascia and the gluteus medius
is identified midway between the anterior superior iliac spine
and the trochanter. The anterior border of the gluteus medius
is dissected down to the trochanter. Posteriorly, the interval
between the anterior border of the gluteus maximus and the
posterior border of the gluteus medius muscle is identified.
The anterior edge of the gluteus maximus is reflected posteriorly
by extending the fascial incision distally.
The
trochanter is now osteotomized obliquely at its base, taking
care to preserve the insertion of the gluteus medius and minimus,
as well as the piriformis, obturator and gemelli muscles.
The trochanter with its tendinous insertions is then reflected
upwards and backwards to expose the joint (Fig. 5-31 b).
Additional
exposure may be obtained by adding a distal extension from
the base of the trochanter parallel to the femur for a distance
of approximately 10 centimetres, transforming the original
U-shaped skin incision into a Y configuration.
Fig.
5-31. - a and b) Ollier lateral approach.
1. Gluteus medius; 2. Gluteus maximus; 3. Detached
greater trochanter; 4. Superior rim of acetabulum;
5. Capsule of hip joint.
2° Hardinge lateral approach
The
patient is in the lateral position to facilitate a direct
lateral approach following an anterior dislocation of the
hip.
The
bulk of the gluteus medius is preserved intact and the trochanter
is not osteotomized. It does not provide as wide an exposure
as the anterolateral approaches with osteotomy of the trochanter
or the posterior approaches.
The
tensor fascia lata is retracted anteriorly and the gluteus
maximus posteriorly (Fig. 5-32 a). The incision follows
the superior and anterior borders of the greater trochanter,
incising the attachment of the gluteus medius but with a cuff
of tendon still attached to the greater trochanter (Fig. 5-32
b).
The
incision starts at the apex of the trochanter and extends
proximally in line with the fibres of the gluteus medius.
Distally, the incision extends into the anterior surface of
the femur, detaching part of the vastus lateralis. The part
of the gluteus medius that is detached from the trochanter
is essentially the internal rotator segment; that which is
left attached is the main part of the abductor mass of the
gluteus medius.
The
leg is adducted and the portion of the vastus lateralis that
arises from the intertrochanteric line, the insertion of the
gluteus medius and ligament of Bigelow are detached and retracted.
Further detachment and elevation of these muscles and ligaments
allow anterior dislocation of the hip following adduction
and external rotation of the leg (Fig. 5-32 c). At
the time of closure, the incision in the gluteus medius and
vastus lateralis is closed (as illustrated in figure 5-32
d).
Fig.
5-32. - a, b, c and d) Hardinge direct
lateral approach with anterior dislocation of the
hip.
1. Abductor portion of gluteus medius; 2. Internal
rotator protion of gluteus medius.
3° McFarland and Osborne
lateral
approach
The
McFarland and Osborn approach is similar to the Hardinge approach
except that the hip is dislocated posteriorly with the patient
in the lateral position. It is based on the observation that
the gluteus medius and the vastus lateralis are in direct
functional continuity through the thick tendon and periosteum
covering the greater trochanter. The integrity of the gluteus
medius muscle is protected during the posterior dislocation
of the hip. The two muscles meet at a right angle anteriorly,
so with detachment of the periosteum and tendon it is possible
to displace the two muscles forward like a bucket handle (Fig.
5-33 b). If the periosteum is difficult to strip,
a small amount of bone is osteotomized with the tendinous
attachment to allow anterior retraction.
Fig.
5-33. - McFarland and Osborne approach
with detachment of gluteus medius and vastus lateralis
in continuity. Posterior dislocation after detaching
gluteus minimus.
1. Vastus lateralis; 2. Tensor fascia lata; 3.
Gluteus medius; . Gluteus maximus; 5. Gluteus minimus;
6. Greater trochanter.
The
posterior border of the gluteus medius is clearly defined
and separated from the piriformis by blunt dissection (Fig.
5-33 a). The gluteus minimus is divided so that it
can be retracted upwards to expose the capsule of the joint
(Figs. 5-33 c and d). The hip is dislocated
posteriorly by internal rotation and adduction of the hip.
At
closure, the gluteus minimus and capsule are reattached as
one. The gluteus medius and vastus lateralis are returned
to their original position and sutured to the undisturbed
portion of the vastus lateralis while the insertion of the
gluteus maximus to the femur is repaired if it has been sectioned.
4°
Jergesen and Abbott lateral approach
An
oblique incision is made from the anterior superior iliac
spine to 5 centimetres below the gluteal fold with the patient
in the direct lateral position (Fig. 5-34 a).
The
interval between the tensor and the gluteus medius is developed
and the fascia is incised distally in line with the posterior
aspect of the femoral shaft (Fig. 5-34 b). Anteriorly
the dissection extends between the tensor and gluteus medius
to the capsule (Fig. 5-34 c). The origin of the rectus
is retracted medially.
Curved
instruments are placed between the capsule and the gluteus
minimus and medius muscles so that the trochanter can be osteotomized
extracapsularly (Fig. 5-34 d). The anterior and anterolateral
capsule is then incised; the attachment of the psoas tendon
to the lesser trochanter may be transected. The hip is then
dislocated anteriorly.
Fig.
5-34. - a, b and c) The Jergesen and
Abbott approach permits extensive exposure of the
hip and allows anterior and posterior dislocation
after osteotomizing the greater trochanter.
1. Tensor fascia lata; 2. Iliotibial tract; 3. Fascia
lata; 4. Gluteus minimus; 5. Lateral femoral circumflex
vessels; 6. Psoas; 7. Rectus femoris; 8. Gemelli and
obturator externus; 9. Piriformis; 10. Gluteus medius.
If further exposure is required, or if the hip is to be dislocated
posteriorly, the tendinous attachment of the gluteus maximus
to the femoral shaft is incised near the trochanter. The external
rotator muscles are also detached from the back of the femur.
The osteotomized trochanter is retracted superiorly and the
capsule can now be incised or excised both anteriorly and
posteriorly. The entire circumference of the acetabulum is
now exposed.
5°
Harris lateral approach
This
approach permits both anterior and posterior dislocations
of the hip. The patient is in the lateral position.
The
skin incision is U-shaped with the bottom of the U at the
posterior border of the greater trochanter. It starts 5
centimetres posterior and slightly proximal to the anterior
superior iliac spine, curves distally and posteriorly to the
posterior superior corner of the greater trochanter and then
longitudinally for approximately 8 centimetres, curving gradually
anteriorly and distally so that both limbs of the U are almost
symmetrical (Fig. 5-35). The iliotibial band is incised to
the distal aspect of the skin incision.
The
femoral insertion of the gluteus maximus on the gluteal tuberosity
is identified and the incision in the fascia lata is extended
approximately one finger’s breadth anterior to that
insertion. The incision in the iliotibial band is carried
proximally along the skin incision releasing the fascia over
the gluteus medius.
The
exposure to the posterior aspect of the joint capsule is limited
by the posterior aspect of the fascia lata and the gluteus
maximus fibres that insert into it. For wider posterior exposure,
for posterior dislocation of the head, a short oblique incision
can be made into the deep surface of the posteriorly reflected
fascia lata and into part of the substance of the gluteus
maximus. This transverse incision is at the level of the greater
trochanter (Fig. 5-35).
Fig.
5-35. - Harris lateral approach. A
relaxing incision is made in the posterior part of the
fascia lata and extended into part of the gluteus maximus
to expose the short external rotators and the posterior
portion of the capsule.
1. Vastus lateralis; 2. Greater trochanter; 3. Gluteus
maximus; 4. Gluteus medius.
Fig.
5-36. - The line of the osteotomy of
the trochanter is defined. The osteotomy may be
performed with a wide osteotome or reciprocating saw.
Fig.
5-37. - The osteotomized greater trochanter
is reflected and the short external rotator muscles
are detached from their insertion into the greater
trochanter. The posterior capsule can then be
visualized and is detached from the posterior rim
of the acetabulum (not illustrated).
2. Osteotomized greater trochanter; 4. Gluteus medius;
7. Iliopsoas; 8. Obturator externus (cut); 9. Obturator
internus; 10. Piriformis; 11. Gluteus minimus.
Fig.
5-38. - The hip is dislocated anteriorly
by external rotation, adduction and the osteotomized
greater trochanter is placed in the acetabulum (2).
Fig.
5-39. - The entire circumference of
the acetabulum is exposed by retracting the greater
trochanter superiorly and dislocating the femoral
head posteriorly by internal rotation. 7. Iliopsoas;
12. Acetabulum.
To
develop the anterior exposure of the joint, the iliotibial
band and fascia lata muscle are reflected anteriorly. Before
osteotomizing the greater trochanter and the attached abductor
muscles, the origin of the vastus lateralis is reflected distally,
exposing the abductor tubercle at the inferior level of the
trochanter.
An
instrument is now passed transversely between the capsule
and the abductor muscles (Fig. 5-36). The greater trochanter
is osteotomized with either a wide osteotome or a reciprocating
saw, starting below the abductor tubercle and in line with
the femoral neck. The piriformis, obturator externus and internus
are incised where they attach to the trochanter (Fig. 5-37).
The anterior and posterior aspects of the capsule are now
incised or excised exposing the neck and head, as well as
the lateral aspect of the acetabulum. Special care must be
taken to avoid damage to the sciatic nerve posteriorly.
To
expose the joint anteriorly, a blunt instrument such as a
Bennett retractor is placed deep to the rectus femoris on
the anterior inferior iliac spine, and soft tissues are thus
retracted medially. By reflecting the greater trochanter superiorly,
the acetabulum is exposed. A thin retractor can be placed
between the capsule and iliopsoas to expose the anterior and
inferior aspects of the capsule. As much of the capsule as
desired is excised anteriorly and posteriorly.
The
femoral head can now be dislocated posteriorly. To expose
the full circumference of the head, the osteotomized part
of the trochanter with the attached muscle pedicle is placed
in the acetabulum and the femur is externally rotated (Fig.
5-38). To expose the entire acetabulum, the greater trochanter
is retracted superiorly and the femoral head is dislocated
posteriorly by adducting, flexing and internally rotating
the hip (Fig. 5-39). Flexion of the knee reduces tension on
the sciatic nerve while the head is dislocated posteriorly.
At
the time of closure, the hip is placed in approximately 20
degrees of abduction and slight external rotation. The trochanter
is fixed to the side of the femoral shaft with several wire
loops or two screws.
It
is rarely necessary to dislocate the hip both anteriorly and
posteriorly to visualize both the anterior and posterior parts
of the capsule. However, if the patient has a flexion contracture,
the anterior exposure allows release of the capsule, as well
as of the rectus and psoas. The arthroplasty may be performed
following either anterior or posterior dislocation.
POSTERIOR
APPROACH
A
number of approaches are classified as posterior. They vary
from the extensive Henry approach that releases the gluteus
maximus from the iliac crest, the iliotibial band and the
femoral shaft to essentially expose all of the posterior structures
(Figs. 5-41 and 5-42) to the limited muscle splitting approach
of Ober for drainage of the hip joint.
They
all have in common the posterior retraction of the gluteus
maximus to enter the posterior aspect of the hip and the release
of the short external rotator muscles to enter the hip joint.
They
vary mainly as to whether the deep posterior compartment is
entered by incising the iliotibial band and the gluteus maximus
muscle in line with the axis of the shaft, or separating the
muscle fibres of the gluteus maximus proximally. They also
vary depending on whether the abductors are released from
the trochanter and, if released, whether the tendinous attachment
is transected or the trochanter is osteotomized.
Fig.
5-40. - Skeletal anatomy in reference
to posterior approach.
Fig.
5-41. - The gluteus maximus and medius
have been partially resected to demonstrate the structures
that are exposed following retraction of these muscles.
1. Gluteus maximus; 2. Gluteus medius; 3. Superior
gluteal artery; 4. Gluteus minimus; 5. Greater trochanter;
6. Obturator externus; 7. Sciatic nerve; 8. Quadratus
femoris; 9. Vastus lateralis; 10. Medial femoral circumflex
artery; 11. Adductor magnus; 12. Common tendon of
hamstrings (origin); 13. Ischial tuberosity; 14. Inferior
gemellus; 15. Obturator internus; 16. Superior gemellus;
17. Inferior gluteal nerve and artery; 18. Piriformis;
19. Superior gluteal nerve.
Fig.
5-42. - The short external rotator muscles,
the sciatic nerve, the gluteus maximus and medius
have been transected.
1. Gluteus maximus; 2. Gluteus medius; 3. Superior
gluteal nerve and artery; 4. Gluteus minimus; 5. Greater
trochanter; 6. Tendon of obturator externus (insertion);
7. Sciatic nerve; 8. Quadratus femoris; 9. Vastus
lateralis; 10. Medial femoral circumflex artery; 11.
Adductor magnus; 12. Common tendon of hamstrings (origin);
13. Sacrotuberous ligament; 14. Inferior gemellus;
15. Tendon of obturator internus (insertion); 15.
Obturator internus; 16. Superior gemellus; 17. Inferior
gluteal artery; 18. Tendon of piriformis (insertion);
18. Piriformis; 19. Superior gluteal nerve and artery;
20. Lateral joint capsule of hip; 21. Tendon of iliopsoas
(insertion into lesser trochanter); 22. Head of femur
Almost all of the approaches have the option to release the
abductors, depending on the need for added exposure.
The
posterior approach that Moore popularized, and which is often
referred to as the "Southern approach", is a variation
of the original Henry approach and of the modifications subsequently
made by Kocher, Osborne and Gibson. The Moore approach will
be discussed here because it is the most commonly used approach
for endoprostheses, total hip arthroplasty, open reduction
of hip dislocation, removal of loose fragments in the joint,
repair of acetabular fractures, drainage of the hip and vascular
muscle pedicle graft procedures.
Three
anatomical illustrations are included in this section for
reference (Figs. 5-40, 5-41 and 5-42).
Moore
posterior approach
The
patient is securely fixed in the lateral position with the
involved side uppermost. The leg is draped so that it can
be manipulated during the procedure. It is well to drape in
such a manner that the anterior superior spine can be palpated
as a reference point.
The
incision starts 10 centimetres from the posterior superior
iliac spine, is directed laterally and distally to the back
of the trochanter and extends for 10 or more centimetres,
parallel to the shaft of the femur (Fig.5-43).
The
deep fascia is exposed and the iliotibial band is incised
from the trochanter to the distal end of the incision (Fig.
5-44). The fascial incision is now carried into the gluteus
maximus muscles separating the oblique, coarse fibres in the
direction of the skin incision.
Retraction
of the gluteus maximus muscle reveals (Fig. 5-45) the
back of the trochanter and the adipose tissue overlying the
short external rotator muscles. Special care is taken to place
the inferior retractor in the gluteus maximus muscle and not
place the tip injudiciously for fear of injury to the sciatic
nerve. In most instances, the sciatic nerve does not have
to be identified and protected; however, in patients with
protrusio acetabuli or in congenital dislocation of the hip,
the nerve may be near the back edge of the acetabulum and
it is wise to identify it and to protect it.
Fig.
5-43. - Moore posterior approach.
Fig.
5-44. - The incision is made in the
fascia lata at and below the greater trochanter before
extending the incision proximally into the fibres
of the gluteus maximus.
Fig.
5-45. - Retraction of the gluteus medius
and gluteus maximus exposes the short external rotator
muscles.
1. Gluteus medius; 2. Vastus lateralis; 3. Quadratus
femoris; 4. Fascia lata; 5. Gluteus maximus.
Blunt dissection will usually remove the adipose tissue from
the short external rotators; internal rotation of the hip
makes them more prominent and displaces their insertion away
from the sciatic nerve (Fig. 5-46). The external
rotator muscles are transected near their attachment to the
trochanter. Prior to sectioning of the tendons, they may be
tagged with a nonabsorbable suture so that they may be re-attached
at the end of the procedure.
The
capsule may or may not be sectioned along with the short external
rotators (Fig. 5-47). The capsule is now opened in
line with the axis of the neck and a transverse incision is
made at the edge of the acetabulum.
Fig.
5-46. - Internal rotation and detachment
of the short external rotator muscles along the back
of the trochanter (dotted line).
1. Sciatic nerve.
Fig.
5-47. - The short external rotators
have been sectioned and reflected posteriorly to protect
the sciatic nerve. The quadratus femoris has been
released from the trochanter; the iliopsoas tendon
is now seen and may be sectioned to allow dislocation
of the hip. Also the gluteus maximus tendon attached
to the femur has been released prior to dislocation.
1. Gluteus medius; 2. Vastus lateralis; 3. Quadratus
femoris (cut); 4. Fascia lata; 5. Gluteus maximus;
6. Iliopsoas tendon.
Fig.
5-48. - The head is dislocated by adduction,
internal rotation and flexion of the hip with the
foot above. The transverse axis of the knee joint
is parallel to the floor which provides a point of
reference for anteversion of the neck of the femur.
Fig.
5-49. - Ludloff medial approach. Skeletal
anatomy of the medial approach of the hip.
1. Lesser trochanter; 2. Anterior superior iliac spine;
3. Inguinal ligament.
The hip is now gently adducted, internally rotated and flexed.
Dislocation should not be forceful especially if there is
any degree of osteopenia or weakening of the shaft for any
reason. More capsule may have to be incised, especially inferiorly
and medially; it may also be necessary to incise the quadratus
femoris muscle to dislocate the hip. In addition, it is at
times necessary to detach the psoas tendon from the lesser
trochanter. The lesser trochanter can be identified after
release of the quadratus. Removal of part of the labrum and
posterior osteophytes on the acetabulum, in order to dislocate
the hip with ease, is sometimes necessary. Sectioning the
neck with an end-cutting reciprocating saw may be necessary
if the hip is fused, if there are intra-articular adhesions,
or if the head is grossly distorted and cannot be easily dislocated.
The
hip may now be dislocated as illustrated in figure 5-48.
This places the axis of the knee joint parallel to
the floor so that the anteversion of the neck and the position
of the femoral prosthesis can be properly evaluated.
In
procedures in which the femoral head is not sacrificed, such
as drainage of the hip, reduction of a posterior dislocation,
removal of fragments from the joint, repair of acetabular
fractures, or resurfacing procedures, special care must be
taken to avoid injury to the medial circumflex and retinacular
vessels. The short external rotator muscles are sectioned
close to the edge of the acetabulum, rather than at the insertion
in the trochanter, and the capsular incisions are made near
the acetabular edge rather than near the attachment of the
capsule to the neck. The medial circumflex vessels are at
risk during the dissection near the attachment of the psoas
tendon to the lesser trochanter (Fig. 5-49).
MEDIAL
APPROACH
Ludloff
described a medial approach for open reduction of congenital
dislocation of the hip, but it is now most used for obturator
neurectomy, psoas tendon release and selective adductor tenotomy.
To a lesser extent, it is used for biopsy and removal of tumors
near the lesser trochanter, the medial aspect of the neck
and the proximal shaft of the femur. It is difficult to extend
the incision proximally. Furthermore, the medial circumflex
vessel, the main blood supply to the femoral head, may be
jeopardized.
For
this reason, and because of a lack of familiarity with this
exposure, most surgeons prefer to expose the lesser trochanter
through a Hueter-Schede approach (lower limit of the Smith-Petersen
iliofemoral incision) or through the posterior approach.
Ludloff
medial approach.
With
the patient supine and a pad under the buttock, the affected
hip is flexed, abducted and externally rotated (Fig. 5-49).
Very careful preparation and draping of the operative field
is necessary because of the proximity of the perineum.
A
longitudinal incision is made over the adductor longus; with
the leg in the above position it is the most prominent of
the adductor muscles (Fig. 5-50). The incision begins approximately
3 centimetres below the pubic tubercle and extends distally
for at least 8 centimetres.
The
gracilis muscle lies posterior to the adductor longus. These
two muscles are innervated by the anterior branch of the obturator
nerve at the proximal end of the incision (Fig. 5-51). Separation
of the two muscles (Fig. 5-52) and retraction of the adductor
longus superiorly and the gracilis inferiorly exposes the
underlying adductor brevis muscle (Fig. 5-53); the adductor
magnus is posterior to the brevis. The anterior branch of
the obturator nerve overlies the adductor brevis (Figs. 5-51
and 5-53). Retraction of the adductor longus and brevis superiorly
exposes the posterior branch of the obturator nerve overlying
the adductor magnus (Figs. 5-51 and 5-54). It is the adductor
brevis, therefore, that separates the anterior and posterior
branches of the obturator nerve (Fig. 5-51). The adductor
brevis is innervated by the anterior branch and the adductor
magnus is innervated by the sciatic nerve.
Retraction
of the adductor brevis anteriorly and the adductor magnus
inferiorly exposes the lesser trochanter, the medial aspect
of the neck and the proximal aspect of the femur (Fig. 5-54).
Careful blunt dissection is advised. The medial femoral
circumflex artery passes around the medial side of the
psoas tendon and is, therefore, subject to damage, especially
in children (see Fig. 5-42).
Fig.
5-50. - Ludloff medial approach.
Superficial anatomy of the medial approach. The incision
and dissection are made between the adductor longus
and gracilis muscles as indicated by the dotted line.
4. Sartorius; 5. Iliacus; 6. Psoas muscle; 7. Femoral
nerve; 8. Femoral artery; 9. Iliac vein; 10. Pectineus;
11. Gracilis; 12. Adductor longus; 13. Profunda femoris
artery; 14. Adductor magnus.
Fig.
5-51. - Part of the sartorius, gracilis
|
|
|
|
|
|
|
|
|
SURGICAL
EXPOSURES
SURGERY OF THE HIP
by
R. CALANDRUCCIO
In: Atlas of Orthopaedic Surgery
Volume 3
Lower Extremity;
Editors: Laurin, CA, Riley Jr. LH, Roy-Camille R
Reprinted with permission from Masson, copyright
Masson, Paris, 1991
Surgical approaches to the hip may be classified as: — anterior; — anterolateral; — lateral; — posterior; — medial; — lateral subtrochanteric and proximal femoral shaft. The anterior approach utilizes the interval between the sartorius and tensor fascia. The anterolateral approach utilizes the interval between the tensor fascia and the gluteus medius. The lateral approach is essentially dependent upon elevation of the insertion of the gluteus medius and minimus. The posterior approach utilizes the interval between the gluteus maximus and medius; in some instances the muscle fibres of the gluteus maximus are separated. The medial approach is between the gracilis and the adductor longus. Surgical approaches are different from anatomical dissection in so much as the tissue planes are only dissected to a limited extent sufficient to identify specific structures and avoid nerve and vessel damage. There is usually no need to undermine the skin or dissect the superficial and deep fascia from the underlying structures. Extensions of the skin incision should not be declined simply to minimize the length of the suture line. “Keyhole” incisions are often dangerous; skin incisions heal from side to side and not from end to end. Surgical exposures inevitably produce some degree of tissue damage. The orthopaedic surgeon must be mindful of the potential consequences of destroying blood supply, especially to bone. However, the advantages obtained by adequate, open reduction should outweigh the possible complications of the exposure. If the femoral head is to be retained, the surgeon must be mindful that all surgical exposures of the hip are associated with the risk of devascularizing the femoral head. Knowledge of the anatomical structures in the coronal and sagittal planes, as well as the cross-sectional relationships, is a prerequisite. There are many eponyms related to hip joint exposures. With due respect to all who have contributed, no attempt was made to emphasize author recognition. ANTERIOR APPROACH The anterior iliofemoral approach utilizes the interval between the sartorius muscle and the tensor fascia lata muscle. The entire ilium and hip joint can be reached through the iliac part of the incision. Nearly all hip surgery can be carried out through this approach and separate parts can be used for different purposes. However, it is now mainly used to expose the anterolateral aspect of the head and neck of the femur and acetabulum for biopsy or excision of bone in this area. It is difficult to gain direct access to the entire acetabulum, or to deliver the proximal femur out of the wound without extensive stripping of the abductors from the ilium or transecting the external rotator tendons. The lower or distal part of the approach, requires no stripping of muscles, except possibly release of the tendinous origin of the rectus femoris. The anatomy of the anterior approach to the hip is illustrated in figures 5-1, 5-2, 5-3 and 5-4. Anterior approach With the patient supine a pad is placed under the affected hip so that the posterior aspect of the ilium can be exposed, when necessary, and also to facilitate anterior dislocation of the hip. The leg is draped so the hip and leg can be manipulated during the approach. The skin incision begins at the middle of the iliac crest, 2 centimetres below the crest of the ilium to avoid a painful postoperative scar adherent to bone. The incision is extended anteriorly below the anterior superior iliac spine and curved distally on the lateral aspect of the thigh (Fig. 5-5). The superficial and deep fascia over the sartorius muscle are divided, medial to the tensor fascia lata muscle. The lateral femoral cutaneous nerve that penetrates the deep fascia just below the anterior superior iliac spine is identified and retracted medially along with the sartorius muscle. The interval between the tensor fascia lata and the sartorius is more easily identified distal to the anterior superior iliac spine (Figs. 5-1 and 5-6); so the dissection should therefore be started distally rather than close to the anterior superior iliac spine. Part of the anterior aspect of the origin of the tensor fascia is subperiosteally stripped from the ilium. Retraction in this interval exposes the gluteus medius muscle and the rectus femoris muscle, which at this level is easily identified because of its fibrous nature, in contrast to the fleshy surrounding muscles. The ascending branches of the lateral femoral cutaneous circumflex vessels are usually ligated at the lower end of the incision (Figs. 5-2 and 5-7). The tendinous origin of the rectus femoris is separated from the underlying joint capsule, and the direct and reflected origins are released by a transverse cut. The iliopsoas is also separated from the capsule by blunt dissection and retracted medially. Most of the anterior aspect of the hip joint is then exposed (Figs. 5-3, 5-4 and 5-8). The capsule may be incised in line with the axis of the femoral neck and transversely at the edge of the acetabulum, as well as distally (in the form of the letter H). If it is necessary to dislocate the hip anteriorly, as much of the capsule is incised or excised as necessary; part of the labrum may also be excised. The femoral head is dislocated by adducting, externally rotating and extending the hip. In young patients, it may be necessary to incise the ligamentum teres before the hip can be completely dislocated. The release of the psoas tendon from the lesser trochanter may also be required. The lesser trochanter is exposed by externally rotating the leg, retracting the psoas medially away from the capsule (Figs. 5-4 and 5-8). To expose more of the ilium or the superior aspect of the acetabulum, the abductor muscle origin is stripped subperiosteally from the wing of the ilium and retracted posteriorly and laterally (Figs. 5-4 and 5-9). The space between the ilium and this muscle mass is then packed to control bleeding.
ANTEROLATERAL APPROACHES The Smith-Petersen anterolateral approach is an extension of the iliofemoral approach to permit exposure of the subtrochanteric region. Illustrations of the anatomy of the anterolateral approach (Figs. 5-10, 5-11 and 5-12) are provided for correlation with the surgical approaches.
1° Smith-Petersen anterolateral approach Smith-Petersen described an anterolateral approach for open reduction and internal fixation under direct vision of recent fractures and nonunions of the femoral neck and slipped capital femoral epiphysis. The distal extension of the iliofemoral incision exposes the trochanteric region and the upper femur between the vastus lateralis and the rectus femoris. It
may be necessary to split muscle fibres to expose the anterior
aspect of the femur (Fig. 5-13); however, muscle fibres should
not be split too far distally to avoid damage to branches
of the femoral nerve as they cross from medial to lateral.
Posterior retraction of the fascia lata alone provides exposure
of the lateral subtrochanteric region. The distal end of the
skin incision is curved posteriorly to facilitate exposure
of the subtrochanteric region.
2° Watson-Jones anterolateral approach The patient is supine and the hip is slightly flexed to relax the anterior structures. The incision is begun a finger’s breadth distal and lateral to the anterior superior iliac spine and extended distally and posteriorly over the lateral aspect of the greater trochanter and lateral surface of the femoral shaft for approximately 5 centimetres (Fig. 5-14). The interval between the gluteus medius and tensor fascia lata is identified more easily midway between the anterior superior spine and the greater trochanter, rather than at the level of the trochanter. The coarse grain of the fibres of the gluteus medius distinguish it from the finer structure of the tensor fascia lata muscle. Retraction of the anterior edge of the gluteus medius posteriorly and the tensor fascia and rectus anteriorly exposes the joint capsule (Fig. 5-14 a). The capsule may be incised in a longitudinal or transverse fashion. The origin of the vastus lateralis may be reflected distally or split longitudinally to expose the trochanter and proximal aspect of the anterior femoral shaft.
If additional exposure is required, the anterior fibres of the gluteus medius and minimus tendon may be incised or the anterior superior part of the greater trochanter may be osteotomized with the attached insertion of the gluteus medius muscle (Fig. 5-14 b). 3° Callahan anterolateral approach The skin incision starts just distal to the anterior superior iliac spine, extends distally to a point approximately three finger breadth distal to the lateral prominence of the trochanter and then curves posteriorly, producing a hockey stick shaped incision (Figs. 5-1 and 5-15).
The interval between the tensor fascia and the sartorius space is developed and the tensor fascia lata is divided transversely in the distal part of the incision. Proximally, the tensor fascia lata and gluteus muscles are elevated subperiosteally and retracted posteriorly. The rectus femoris is retracted medially. The capsule is then exposed by medial retraction of the iliopsoas and rectus femoris. When necessary, more exposure can be obtained by subperiosteal stripping of the tensor fascia lata and gluteus medius muscle from the wing of the ilium (Fig. 5-15). 4° Luck anterolateral approach In this transverse anterior approach to the hip, the tensor fascia lata is divided transversely while the gluteus medius and minimus are not disturbed. The skin incision starts over the femoral head, just lateral to the midpoint between the anterior superior iliac spine and the symphysis pubis, extends laterally parallel to, or in, the flexor crease of the hip and ends just lateral to the greater trochanter (Figs. 5-12 and 5-16 a). The fascia lata is incised transversely just distal to the trochanter to permit identification of the tensor fascia lata muscle (Fig. 5-11). The muscle is divided at its most distal attachment to the fascia lata. The incised fascia lata and tensor are reflected proximally. The sartorius and rectus femoris are retracted medially to expose the capsule (Figs. 5-12 and 5-16 b). The origin of the rectus femoris may be detached from the pelvis for added exposure of the joint.
5° Fahey anterolateral approach This oblique incision extends from the anterior superior iliac spine to a point distal to the prominence of the greater trochanter and ends at the midpoint of the lateral aspect of the thigh (Fig. 5-17 insert).
The vastus lateralis muscle is separated from the femur and retracted anteriorly to expose the subtrochanteric and lateral aspects of the proximal femur (Fig. 5-17). 6° Charnley anterolateral approach With the patient supine, the hip is placed near the edge of the table so that the skin and adipose tissues of the buttock will hang over the side. A sandbag under the buttock will elevate the trochanter and make draping easier. The sandbag may have to be removed when the implants are inserted in order to assess their position more accurately. For this reason, some prefer an air bag that can be deflated or they temporarily tilt the table. The leg is draped so that it can be manipulated during the procedure. The hip is flexed 30 degrees and adducted slightly to make the trochanter more prominent and to move the tensor fascia lata anteriorly. The incision starts several centimetres distal to the iliac crest, extends to the tip of the trochanter, crosses the posterior aspect of the trochanter and runs down the shaft of the femur. The incision may also start more anteriorly, at the level of, and approximately 5 centimetres behind, the anterior superior spine (Fig. 5-18).
Some authors prefer to go through the fascia covering the tensor muscle and detach this muscle inferiorly from the fascia lata (Roy-Camille). Retraction of fascia lata muscle anteriorly and the gluteus maximus posteriorly, exposes the underlying gluteus medius and greater trochanter. Any fibres of the gluteus medius arising from the undersurface of the fascia lata are detached by blunt dissection. The interval between the anterior edge of the gluteus medius and the tensor fascia lata is identified; the gluteus medius and minimus are retracted laterally and posteriorly, while the tensor is retracted medially thereby exposing the fatty tissue overlying the joint capsule. The origin of the vastus lateralis is detached from the front of the greater trochanter. The hip is now externally rotated and slightly flexed to reduce the tension on the abductor muscles and make the anterior part of the capsule taut (Fig. 5-20). If the procedure is to be done without osteotomizing the greater trochanter, an incision is made in the anterior insertion of the gluteus medius and minimus detaching them from the greater trochanter, but leaving a cuff of tendon for re-attachment (Fig. 5-21). The incision is then vertical and proximal, in the substance of the gluteus medius (Fig. 5-21, insert). The capsule is cut and the head and neck are exposed (Fig. 5-22). With the leg adducted, the capsule is sufficiently resected so that with external rotation, the hip is dislocated anteriorly. Additional capsule is cut as necessary to retract the head and neck posteriorly for visualization of the acetabulum.
The osteotomized greater trochanter is retracted superiorly and then, with slight flexion of the hip, it is possible to detach the origin of the rectus from the front of the hip joint (Fig. 5-25). The capsule is now incised in line with the neck of the femur and transversely at the acetabulum. With external rotation, the hip can usually be dislocated anteriorly, though it may be necessary to incise the attachment of the gluteus maximus to the posterior aspect of the femur (Fig. 5-26 b). It may also be necessary to incise the capsule inferiorly and to detach the psoas tendon from the lesser trochanter. The neck of the femur is then osteotomized, either by using a Gigli saw or reciprocating saw. An osteotome should not be used for fear of fracturing the inferior cortex of the neck (Fig. 5-27). After the head has been removed, a flat retractor can be inserted behind the lip of the acetabulum to lever the internally rotated femur posteriorly, thus providing direct access to the acetabulum (Fig. 5-28). Self-retaining retractors are utilized to retract the osteotomized greater trochanter and the cut surface of the femur as well as the fascia lata and gluteus maximus (Fig. 5-29). If at any time during the procedure exposure of the shaft is necessary, the skin incision is extended along the shaft of the femur and the vastus lateralis is either split, as illustrated in figure 5-30, or retracted.
LATERAL APPROACHES 1° Ollier lateral approach The U-shaped incision starts near the anterior superior iliac spine, continues downwards and distal to the trochanter, curves across the lower aspect of the trochanter, extends posterior superiorly, ending midway between the trochanter and posterior superior iliac spine. The gluteal fascia is incised in line with the skin incision (Fig. 5-31 a). The interval between the tensor fascia and the gluteus medius is identified midway between the anterior superior iliac spine and the trochanter. The anterior border of the gluteus medius is dissected down to the trochanter. Posteriorly, the interval between the anterior border of the gluteus maximus and the posterior border of the gluteus medius muscle is identified. The anterior edge of the gluteus maximus is reflected posteriorly by extending the fascial incision distally. The trochanter is now osteotomized obliquely at its base, taking care to preserve the insertion of the gluteus medius and minimus, as well as the piriformis, obturator and gemelli muscles. The trochanter with its tendinous insertions is then reflected upwards and backwards to expose the joint (Fig. 5-31 b). Additional exposure may be obtained by adding a distal extension from the base of the trochanter parallel to the femur for a distance of approximately 10 centimetres, transforming the original U-shaped skin incision into a Y configuration.
The patient is in the lateral position to facilitate a direct lateral approach following an anterior dislocation of the hip. The bulk of the gluteus medius is preserved intact and the trochanter is not osteotomized. It does not provide as wide an exposure as the anterolateral approaches with osteotomy of the trochanter or the posterior approaches. The tensor fascia lata is retracted anteriorly and the gluteus maximus posteriorly (Fig. 5-32 a). The incision follows the superior and anterior borders of the greater trochanter, incising the attachment of the gluteus medius but with a cuff of tendon still attached to the greater trochanter (Fig. 5-32 b). The incision starts at the apex of the trochanter and extends proximally in line with the fibres of the gluteus medius. Distally, the incision extends into the anterior surface of the femur, detaching part of the vastus lateralis. The part of the gluteus medius that is detached from the trochanter is essentially the internal rotator segment; that which is left attached is the main part of the abductor mass of the gluteus medius. The leg is adducted and the portion of the vastus lateralis that arises from the intertrochanteric line, the insertion of the gluteus medius and ligament of Bigelow are detached and retracted. Further detachment and elevation of these muscles and ligaments allow anterior dislocation of the hip following adduction and external rotation of the leg (Fig. 5-32 c). At the time of closure, the incision in the gluteus medius and vastus lateralis is closed (as illustrated in figure 5-32 d).
lateral approach The McFarland and Osborn approach is similar to the Hardinge approach except that the hip is dislocated posteriorly with the patient in the lateral position. It is based on the observation that the gluteus medius and the vastus lateralis are in direct functional continuity through the thick tendon and periosteum covering the greater trochanter. The integrity of the gluteus medius muscle is protected during the posterior dislocation of the hip. The two muscles meet at a right angle anteriorly, so with detachment of the periosteum and tendon it is possible to displace the two muscles forward like a bucket handle (Fig. 5-33 b). If the periosteum is difficult to strip, a small amount of bone is osteotomized with the tendinous attachment to allow anterior retraction.
The posterior border of the gluteus medius is clearly defined and separated from the piriformis by blunt dissection (Fig. 5-33 a). The gluteus minimus is divided so that it can be retracted upwards to expose the capsule of the joint (Figs. 5-33 c and d). The hip is dislocated posteriorly by internal rotation and adduction of the hip. At closure, the gluteus minimus and capsule are reattached as one. The gluteus medius and vastus lateralis are returned to their original position and sutured to the undisturbed portion of the vastus lateralis while the insertion of the gluteus maximus to the femur is repaired if it has been sectioned. 4° Jergesen and Abbott lateral approach An oblique incision is made from the anterior superior iliac spine to 5 centimetres below the gluteal fold with the patient in the direct lateral position (Fig. 5-34 a). The interval between the tensor and the gluteus medius is developed and the fascia is incised distally in line with the posterior aspect of the femoral shaft (Fig. 5-34 b). Anteriorly the dissection extends between the tensor and gluteus medius to the capsule (Fig. 5-34 c). The origin of the rectus is retracted medially. Curved instruments are placed between the capsule and the gluteus minimus and medius muscles so that the trochanter can be osteotomized extracapsularly (Fig. 5-34 d). The anterior and anterolateral capsule is then incised; the attachment of the psoas tendon to the lesser trochanter may be transected. The hip is then dislocated anteriorly.
5° Harris lateral approach This approach permits both anterior and posterior dislocations of the hip. The patient is in the lateral position. The skin incision is U-shaped with the bottom of the U at the posterior border of the greater trochanter. It starts 5 centimetres posterior and slightly proximal to the anterior superior iliac spine, curves distally and posteriorly to the posterior superior corner of the greater trochanter and then longitudinally for approximately 8 centimetres, curving gradually anteriorly and distally so that both limbs of the U are almost symmetrical (Fig. 5-35). The iliotibial band is incised to the distal aspect of the skin incision. The femoral insertion of the gluteus maximus on the gluteal tuberosity is identified and the incision in the fascia lata is extended approximately one finger’s breadth anterior to that insertion. The incision in the iliotibial band is carried proximally along the skin incision releasing the fascia over the gluteus medius. The exposure to the posterior aspect of the joint capsule is limited by the posterior aspect of the fascia lata and the gluteus maximus fibres that insert into it. For wider posterior exposure, for posterior dislocation of the head, a short oblique incision can be made into the deep surface of the posteriorly reflected fascia lata and into part of the substance of the gluteus maximus. This transverse incision is at the level of the greater trochanter (Fig. 5-35).
To develop the anterior exposure of the joint, the iliotibial band and fascia lata muscle are reflected anteriorly. Before osteotomizing the greater trochanter and the attached abductor muscles, the origin of the vastus lateralis is reflected distally, exposing the abductor tubercle at the inferior level of the trochanter. An instrument is now passed transversely between the capsule and the abductor muscles (Fig. 5-36). The greater trochanter is osteotomized with either a wide osteotome or a reciprocating saw, starting below the abductor tubercle and in line with the femoral neck. The piriformis, obturator externus and internus are incised where they attach to the trochanter (Fig. 5-37). The anterior and posterior aspects of the capsule are now incised or excised exposing the neck and head, as well as the lateral aspect of the acetabulum. Special care must be taken to avoid damage to the sciatic nerve posteriorly. To expose the joint anteriorly, a blunt instrument such as a Bennett retractor is placed deep to the rectus femoris on the anterior inferior iliac spine, and soft tissues are thus retracted medially. By reflecting the greater trochanter superiorly, the acetabulum is exposed. A thin retractor can be placed between the capsule and iliopsoas to expose the anterior and inferior aspects of the capsule. As much of the capsule as desired is excised anteriorly and posteriorly. The femoral head can now be dislocated posteriorly. To expose the full circumference of the head, the osteotomized part of the trochanter with the attached muscle pedicle is placed in the acetabulum and the femur is externally rotated (Fig. 5-38). To expose the entire acetabulum, the greater trochanter is retracted superiorly and the femoral head is dislocated posteriorly by adducting, flexing and internally rotating the hip (Fig. 5-39). Flexion of the knee reduces tension on the sciatic nerve while the head is dislocated posteriorly. At the time of closure, the hip is placed in approximately 20 degrees of abduction and slight external rotation. The trochanter is fixed to the side of the femoral shaft with several wire loops or two screws. It is rarely necessary to dislocate the hip both anteriorly and posteriorly to visualize both the anterior and posterior parts of the capsule. However, if the patient has a flexion contracture, the anterior exposure allows release of the capsule, as well as of the rectus and psoas. The arthroplasty may be performed following either anterior or posterior dislocation. POSTERIOR APPROACH A number of approaches are classified as posterior. They vary from the extensive Henry approach that releases the gluteus maximus from the iliac crest, the iliotibial band and the femoral shaft to essentially expose all of the posterior structures (Figs. 5-41 and 5-42) to the limited muscle splitting approach of Ober for drainage of the hip joint. They all have in common the posterior retraction of the gluteus maximus to enter the posterior aspect of the hip and the release of the short external rotator muscles to enter the hip joint. They vary mainly as to whether the deep posterior compartment is entered by incising the iliotibial band and the gluteus maximus muscle in line with the axis of the shaft, or separating the muscle fibres of the gluteus maximus proximally. They also vary depending on whether the abductors are released from the trochanter and, if released, whether the tendinous attachment is transected or the trochanter is osteotomized.
The posterior approach that Moore popularized, and which is often referred to as the "Southern approach", is a variation of the original Henry approach and of the modifications subsequently made by Kocher, Osborne and Gibson. The Moore approach will be discussed here because it is the most commonly used approach for endoprostheses, total hip arthroplasty, open reduction of hip dislocation, removal of loose fragments in the joint, repair of acetabular fractures, drainage of the hip and vascular muscle pedicle graft procedures. Three anatomical illustrations are included in this section for reference (Figs. 5-40, 5-41 and 5-42). Moore posterior approach The patient is securely fixed in the lateral position with the involved side uppermost. The leg is draped so that it can be manipulated during the procedure. It is well to drape in such a manner that the anterior superior spine can be palpated as a reference point. The incision starts 10 centimetres from the posterior superior iliac spine, is directed laterally and distally to the back of the trochanter and extends for 10 or more centimetres, parallel to the shaft of the femur (Fig.5-43). The deep fascia is exposed and the iliotibial band is incised from the trochanter to the distal end of the incision (Fig. 5-44). The fascial incision is now carried into the gluteus maximus muscles separating the oblique, coarse fibres in the direction of the skin incision. Retraction of the gluteus maximus muscle reveals (Fig. 5-45) the back of the trochanter and the adipose tissue overlying the short external rotator muscles. Special care is taken to place the inferior retractor in the gluteus maximus muscle and not place the tip injudiciously for fear of injury to the sciatic nerve. In most instances, the sciatic nerve does not have to be identified and protected; however, in patients with protrusio acetabuli or in congenital dislocation of the hip, the nerve may be near the back edge of the acetabulum and it is wise to identify it and to protect it.
The capsule may or may not be sectioned along with the short external rotators (Fig. 5-47). The capsule is now opened in line with the axis of the neck and a transverse incision is made at the edge of the acetabulum.
The hip is now gently adducted, internally rotated and flexed. Dislocation should not be forceful especially if there is any degree of osteopenia or weakening of the shaft for any reason. More capsule may have to be incised, especially inferiorly and medially; it may also be necessary to incise the quadratus femoris muscle to dislocate the hip. In addition, it is at times necessary to detach the psoas tendon from the lesser trochanter. The lesser trochanter can be identified after release of the quadratus. Removal of part of the labrum and posterior osteophytes on the acetabulum, in order to dislocate the hip with ease, is sometimes necessary. Sectioning the neck with an end-cutting reciprocating saw may be necessary if the hip is fused, if there are intra-articular adhesions, or if the head is grossly distorted and cannot be easily dislocated. The hip may now be dislocated as illustrated in figure 5-48. This places the axis of the knee joint parallel to the floor so that the anteversion of the neck and the position of the femoral prosthesis can be properly evaluated. In procedures in which the femoral head is not sacrificed, such as drainage of the hip, reduction of a posterior dislocation, removal of fragments from the joint, repair of acetabular fractures, or resurfacing procedures, special care must be taken to avoid injury to the medial circumflex and retinacular vessels. The short external rotator muscles are sectioned close to the edge of the acetabulum, rather than at the insertion in the trochanter, and the capsular incisions are made near the acetabular edge rather than near the attachment of the capsule to the neck. The medial circumflex vessels are at risk during the dissection near the attachment of the psoas tendon to the lesser trochanter (Fig. 5-49). MEDIAL APPROACH Ludloff described a medial approach for open reduction of congenital dislocation of the hip, but it is now most used for obturator neurectomy, psoas tendon release and selective adductor tenotomy. To a lesser extent, it is used for biopsy and removal of tumors near the lesser trochanter, the medial aspect of the neck and the proximal shaft of the femur. It is difficult to extend the incision proximally. Furthermore, the medial circumflex vessel, the main blood supply to the femoral head, may be jeopardized. For this reason, and because of a lack of familiarity with this exposure, most surgeons prefer to expose the lesser trochanter through a Hueter-Schede approach (lower limit of the Smith-Petersen iliofemoral incision) or through the posterior approach. Ludloff medial approach. With the patient supine and a pad under the buttock, the affected hip is flexed, abducted and externally rotated (Fig. 5-49). Very careful preparation and draping of the operative field is necessary because of the proximity of the perineum. A longitudinal incision is made over the adductor longus; with the leg in the above position it is the most prominent of the adductor muscles (Fig. 5-50). The incision begins approximately 3 centimetres below the pubic tubercle and extends distally for at least 8 centimetres. The gracilis muscle lies posterior to the adductor longus. These two muscles are innervated by the anterior branch of the obturator nerve at the proximal end of the incision (Fig. 5-51). Separation of the two muscles (Fig. 5-52) and retraction of the adductor longus superiorly and the gracilis inferiorly exposes the underlying adductor brevis muscle (Fig. 5-53); the adductor magnus is posterior to the brevis. The anterior branch of the obturator nerve overlies the adductor brevis (Figs. 5-51 and 5-53). Retraction of the adductor longus and brevis superiorly exposes the posterior branch of the obturator nerve overlying the adductor magnus (Figs. 5-51 and 5-54). It is the adductor brevis, therefore, that separates the anterior and posterior branches of the obturator nerve (Fig. 5-51). The adductor brevis is innervated by the anterior branch and the adductor magnus is innervated by the sciatic nerve. Retraction of the adductor brevis anteriorly and the adductor magnus inferiorly exposes the lesser trochanter, the medial aspect of the neck and the proximal aspect of the femur (Fig. 5-54). Careful blunt dissection is advised. The medial femoral circumflex artery passes around the medial side of the psoas tendon and is, therefore, subject to damage, especially in children (see Fig. 5-42).
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||