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