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Approaches
Hip & Pelvis

Lateral Approach (Hardinge)

“In an appropriately consented and marked patient I would perform a WHO sign in and time out, prior to proceeding…”

 

Positioning

  • Lateral position

  • Hip posts (ASIS post and posterior post in-line posteriorly)

    • Ensure can flex hip to 90o

  • Scrub, prep and drape patient

  • Adequate exposure for incision

 

Inter-muscular plane

  • No true Internervous plane

  • Intermuscular plane:

    • Splits gluteus medius distal to innervation (superior gluteal nerve)

    • Splits vastus lateralis lateral to innervation (femoral nerve)

 

Incision

  • 5cm proximal to tip of greater trochanter

  • Longitudinal incision centered over tip of greater trochanter and extends down the line of the femur about 8cm

 

Superficial dissection

  • Incise through subcutaneous fascia. Control bleeding with diathermy.

  • Use self-retainer to keep tissues under tension.

  • Split fascia lata with scissors / scalpel. Extend proximally and distally

  • Place Charnley retractor under fascia lata to increase exposure (careful not to catch sciatic nerve posteriorly)

 

Deep dissection

  • Remove trochanteric bursa with scissors to expose abductors

  • Omega incision around abductor insertion to leave a cuff of tendon for repair (either with scalpel / cutting diathermy)

  • Extend inferiorly through fibres of vastus lateralis

  • Detach gluteus medius and minimus off the femoral neck and retract them medially (can use stay suture)

  • Perform straight / T-shaped capsulotomy incision

  • Dislocate hip

 

Dangers

  • Superior gluteal nerve

    • Runs between gluteus medius and minimus at 3-5cm above greater trochanter

    • Avoid by:

      • Limiting proximal incision of gluteus medius

      • Stay suture at apex of gluteal split

    • Leads to Trendelenburg gait pattern

  • Femoral nerve

    • Most lateral structure in neurovascular bundle of anterior thigh

    • Keep retractors on bone

    • Can get iatrogenic injury with retractors placed into psoas muscle

Posterior Approach (Moore or Southern)

“In an appropriately consented and marked patient I would perform a WHO sign in and time out, prior to proceeding…”

Positioning

  • Lateral position

  • Hip blocks

  • Scrub, prep and drape patient

  • IV Abx at induction

 

Intermuscular plane:

  • Splits fibres of gluteus maximus (inferior gluteal nerve)

 

Incision

  • Curved incision over posterior aspect of greater trochanter

  • Starts 7cm supero-posterior to GT and curving down over GT and down femur

 

Superficial dissection

  • Incise subcutaneous fat to fascia lata

  • Incise fascia lata to reveal vastus lateralis distally and gluteus maximus proximally

  • Split fibres of gluteus maximus in line with the incision

    • Cauterise bleeding vessels (as very vascular area)

 

Deep dissection

  • Have assistant to internally rotate the hip to put tension on the short external rotators

  • Place a stay suture in short external rotator tendon cuff (piriformis / obturator internus tendon / sup. + inf. gemelli)

  • Incise and detach external rotators from femoral attachment and reflect backwards to protect the sciatic nerve.

  • Feel for acetabulum and perform straight / T-shaped capsulotomy

 

Dangers

  • Sciatic Nerve

    • Exits pelvis below the piriformis muscle

    • Runs on the posterior surface of quadratus femoris

    • Preventing injury:

      • Extend hip and flex knee to prevent injury

      • Gentle traction

      • Release short external rotators posteriorly to protect nerve

  • Inferior gluteal artery

  • Femoral nerve / artery / vein

  • Superior gluteal artery + nerve

 

Note: inferior gluteal artery and sciatic nerve both leave below piriformis muscle

Antero-lateral Approach (Watson-Jones)

“In an appropriately consented and marked patient I would perform a WHO sign in and time out, prior to proceeding…”

Positioning

  • Lateral positions

  • Hip posts

  • IV Abx at induction

 

Inter-muscular plane

  • Between tensor fascia lata + gluteus medius (both superior gluteal nerve)

 

Skin incision

  • Make incision 2.5cm posteroinferiorly to ASIS

  • Curved incision centered over the anterior 1/3 of the GT down the line of the femur

 

Superficial dissection

  • Incise subcutaneous fat feeling for GT and femur staying inline when dissecting down

  • Insert self-retainer to but maximum tension on tissues

  • Below subcutaneous fat is thick band of fascia lata

  • Incise fascia lata with scissors / blade and extend incision proximally and distally

  • Clear trochanteric bursa from trochanter

 

Deep dissection

  • Visualise abductors, ask assistant to externally rotate and abduct the leg to put tissues under tension

  • Detach abductors from GT with cutting diathermy (an alternative is to perform a trochanteric osteotomy).

  • Expose capsule and perform T-shaped / straight capsulotomy

  • Dislocate hip - the hip joint will now be exposed

 

Dangers

  • Femoral nerve

    • Most commonly due to compression neuropraxia by medial retraction

    • Direct injury can be caused from placing retractor into the psoas muscle

  • Femoral artery and vein

    • Can be damaged by retractors that penetrate the psoas

    • Confirm that the anterior retractor is directly on bone

  • Abductor limp

    • Caused by trochanteric osteotomy / disruption of abductor mechanism

  • Femoral shaft fractures

    • Usually occurs during dislocation (be sure to perform an adequate capsulotomy)

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