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
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Lateral position
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Hip posts (ASIS post and posterior post in-line posteriorly)
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Ensure can flex hip to 90o
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Scrub, prep and drape patient
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Adequate exposure for incision
Inter-muscular plane
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No true Internervous plane
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Intermuscular plane:
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Splits gluteus medius distal to innervation (superior gluteal nerve)
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Splits vastus lateralis lateral to innervation (femoral nerve)
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Incision
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5cm proximal to tip of greater trochanter
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Longitudinal incision centered over tip of greater trochanter and extends down the line of the femur about 8cm
Superficial dissection
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Incise through subcutaneous fascia. Control bleeding with diathermy.
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Use self-retainer to keep tissues under tension.
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Split fascia lata with scissors / scalpel. Extend proximally and distally
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Place Charnley retractor under fascia lata to increase exposure (careful not to catch sciatic nerve posteriorly)
Deep dissection
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Remove trochanteric bursa with scissors to expose abductors
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Omega incision around abductor insertion to leave a cuff of tendon for repair (either with scalpel / cutting diathermy)
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Extend inferiorly through fibres of vastus lateralis
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Detach gluteus medius and minimus off the femoral neck and retract them medially (can use stay suture)
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Perform straight / T-shaped capsulotomy incision
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Dislocate hip
Dangers
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Superior gluteal nerve
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Runs between gluteus medius and minimus at 3-5cm above greater trochanter
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Avoid by:
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Limiting proximal incision of gluteus medius
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Stay suture at apex of gluteal split
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Leads to Trendelenburg gait pattern
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Femoral nerve
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Most lateral structure in neurovascular bundle of anterior thigh
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Keep retractors on bone
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Can get iatrogenic injury with retractors placed into psoas muscle
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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
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Lateral position
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Hip blocks
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Scrub, prep and drape patient
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IV Abx at induction
Intermuscular plane:
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Splits fibres of gluteus maximus (inferior gluteal nerve)
Incision
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Curved incision over posterior aspect of greater trochanter
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Starts 7cm supero-posterior to GT and curving down over GT and down femur
Superficial dissection
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Incise subcutaneous fat to fascia lata
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Incise fascia lata to reveal vastus lateralis distally and gluteus maximus proximally
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Split fibres of gluteus maximus in line with the incision
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Cauterise bleeding vessels (as very vascular area)
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Deep dissection
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Have assistant to internally rotate the hip to put tension on the short external rotators
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Place a stay suture in short external rotator tendon cuff (piriformis / obturator internus tendon / sup. + inf. gemelli)
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Incise and detach external rotators from femoral attachment and reflect backwards to protect the sciatic nerve.
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Feel for acetabulum and perform straight / T-shaped capsulotomy
Dangers
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Sciatic Nerve
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Exits pelvis below the piriformis muscle
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Runs on the posterior surface of quadratus femoris
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Preventing injury:
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Extend hip and flex knee to prevent injury
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Gentle traction
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Release short external rotators posteriorly to protect nerve
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Inferior gluteal artery
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Femoral nerve / artery / vein
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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
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Lateral positions
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Hip posts
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IV Abx at induction
Inter-muscular plane
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Between tensor fascia lata + gluteus medius (both superior gluteal nerve)
Skin incision
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Make incision 2.5cm posteroinferiorly to ASIS
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Curved incision centered over the anterior 1/3 of the GT down the line of the femur
Superficial dissection
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Incise subcutaneous fat feeling for GT and femur staying inline when dissecting down
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Insert self-retainer to but maximum tension on tissues
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Below subcutaneous fat is thick band of fascia lata
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Incise fascia lata with scissors / blade and extend incision proximally and distally
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Clear trochanteric bursa from trochanter
Deep dissection
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Visualise abductors, ask assistant to externally rotate and abduct the leg to put tissues under tension
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Detach abductors from GT with cutting diathermy (an alternative is to perform a trochanteric osteotomy).
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Expose capsule and perform T-shaped / straight capsulotomy
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Dislocate hip - the hip joint will now be exposed
Dangers
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Femoral nerve
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Most commonly due to compression neuropraxia by medial retraction
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Direct injury can be caused from placing retractor into the psoas muscle
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Femoral artery and vein
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Can be damaged by retractors that penetrate the psoas
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Confirm that the anterior retractor is directly on bone
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Abductor limp
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Caused by trochanteric osteotomy / disruption of abductor mechanism
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Femoral shaft fractures
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Usually occurs during dislocation (be sure to perform an adequate capsulotomy)
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