Surgical approaches to the HIP

ANTERIOR

ANTERIOR

ANTERO-LATERAL

ANTERIOR

ANTERO-LATERAL

LATERAL

ANTERIOR

ANTERO-LATERAL

LATERAL

POSTERIOR

ANTERIOR

ANTERO-LATERAL

LATERAL

POSTERIOR

MEDIAL

Surgical Approaches

Indications

Positioning

Landmarks for the incision

Internervous plane

Superficial structures

Deep structures

Nerves

Blood vessels

(How to extend the approach)

Anterior

Approach to the hip

SMITH-PETERSON

TFL Sartorius

Glut Medius Rectus Femoris

Anterior Approach

Indications

• Open reduction displaced subcapital

femoral neck fracture

• Biopsies

• Excision of tumours

• Pelvic Osteotomies

• Drainage of hip sepsis

Anterior Approach

Indications

• Open reduction displaced subcapital

femoral neck fracture

• Biopsies

• Excision of tumours

• Pelvic Osteotomies

• Drainage of hip sepsis

Anterior Approach

Landmarks & Incision

Towards lateral edge patella

Anterior Approach

Landmarks & Incision

✓

Anterior Approach

Internervous Planes

Superficial

Tensor fascia lata

(Superior gluteal nerve)

Tensor fascia lata

(Superior gluteal nerve)

Sartorius

(Femoral Nerve)

Sartorius

(Femoral Nerve)

Anterior Approach

Superficial

• Palpate gap between

sartorius and tensor

fascia lata

Lateral cutaneous nerve

of the thigh

2-3cm

Anterior Approach

Internervous Plane

Deep

Rectus femoris

(Femoral Nerve)

Rectus femoris

(Femoral Nerve)

Gluteus medius Gluteus medius

(superior gluteal

nerve)

Anterior Approach

Deep

• Ascending Br Lateral

circumflex femoral

artery needs to be

ligated

• Retract gluteus

medius laterally

• Detach rectus femoris

from both its origins

and retract medially

Anterior Approach

Tips

• Iliopsoas retracted

medially

• May need releasing

from its insertion

• Adduct and externally

rotate before incising

the capsule

Anterior Approach

Nerves

1.Lateral femoral

cutaneous nerve

2-3 cm below ASIS

2. Femoral Nerve

medial to rectus

femoris

Anterior Approach

Vessels

• Ascending branch of

the lateral femoral

circumflex femoral

artery.

• Between layers

Anterolateral

Approach to the Hip

WATSON-JONES

TFLGlut Medius

Vastus Lateralis

Anterolateral Approach

Indications

• Total Hip Replacement

• Hemiarthroplasty

• Open reduction & internal

fixation of femoral neck

fractures

• Biopsy

Anterolateral Approach

Indications

• Total Hip Replacement

• Hemiarthroplasty

• Open reduction & internal

fixation of femoral neck

fractures

• Biopsy

Anterolateral Approach

Positioning

• Lying supine • Lying on side

Anterolateral Approach

Landmarks & Incision

Anterolateral Approach

Intermuscular Plane

• No true Internervous plane

• Nerve enters tensor fascia lata close to the iliac crest

Superior Gluteal N

Anterolateral Approach

Superficial Dissection

• Skin

• Superficial fascia

• Fascia Lata

• Bursa

Anterolateral Approach

Deep Dissection

Anterolateral Approach

Deep Dissection

Retracted Glut MediusRetracted Glut Medius

Retracted TFLRetracted TFL

Retracted

Vastas lateralis

Retracted

Vastas lateralis

Anterolateral Approach

Deep Structures-Alternative

Cut Gluteus Medius

or

Trochanteric Osteotomy

Anterolateral Approach

Deep Dissection

• Dissect up the surface of the hip joint capsule in line with the femoral neck and head

• Longitudinal incision through the capsule to the acetabulum.

• Dislocate the hip after performing an adequate capsulotomy.

Anterolateral Approach

Deep Structures

Tips

• Release Traction

• Flex the hip 30 degrees

Anterolateral Approach

NERVES

Femoral Nerve

• Lateral structure in

femoral traingle

VESSELS

Femoral Artery & Vein

Porfunda femoris

Anterolateral Approach

Protect Nerves & Vessels

Retractors

UNDER Iliopsoas

Lateral

Approach to the Hip

HARDINGE

Fascia Lata

Glut Medius Vastus Lateralis

Lateral Approach

Incision

• Longitudinal above

the centre of greater

trochanter

• Down the line of the

shaft

Lateral Approach

Internervous plane

gluteus medius

Vastus lateralis

Lateral Approach

Internervous plane

gluteus medius

Vastus lateralis

Lateral Approach

Internervous plane

gluteus medius

Vastus lateralis

Sup gluteal N

Femoral N

Lateral Approach

Superficial Dissection

• Skin

• Superficial fascia

• Fascia lata

• BURSA

• Dissect gluteus

medius from fascia

Lateral Approach

Deep Dissection

Lateral Approach

Nerves

Superior gluteal nerve

• Between medius and

minimus

• 5cm above greater

trochanter

Lateral Approach

Nerves

Femoral Nerve

• Most lateral structure

in the neurovascular

bundle

• Position of retractors

Lateral Approach

Vessels

Femoral Artery & Vein

• Retractors

Lateral circumflex artery

• Cut as vastus lateralis

is mobilised

Posterior

Approach to the Hip

SOUTHERN

Glut Maximus

Glut Medius Short

External

Rotators

Posterior Approach

Indications

•Total hip Replacement

•Open reduction and internal fixation of

posterior acetabular fractures

•Open reduction posterior hip dislocations

•Pedicle bone grafting

Posterior Approach

Indications

•Total hip Replacement

•Open reduction and internal fixation of

posterior acetabular fractures

•Open reduction posterior hip dislocations

•Pedicle bone grafting

Posterior Approach

Landmarks

Posterior Approach

Internervous Plane

No true internervous

plane

• Inferior gluteal nerve

innervates the muscle

medial to the incision

Posterior Approach

Superficial Structures

• Skin

• Superficial fascia

• Fascia lata

• BURSA

• Gluteus maximus by

blunt dissection

Posterior Approach

Superficial Structures

BLOOD SUPPLY TO GLUTEUS MAXIMUS

Posterior Approach

Deep Structures

Posterior Approach

Deep Dissection – PROTECT SCIATIC N

Posterior Approach

Nerves

Sciatic nerve

•Retractors

•Is it too small?

Has it divided into common

peroneal and tibial within

pelvis?

15%

Posterior Approach

Vessels

Inferior gluteal artery

• Leaves pelvis

beneath piriformis,

spreads cephalad

under gluteus

maximus

Lateral Circumflex

Vessels

• Quadratus Femoris

Medial

Approach to the Hip

Adductor

LongusGracilis

Adductor Magnus

Adductor Brevis

Medial Approach

Indications

• Open Relocation of dysplastic hips

(Excellent exposure psoas- blocks reduction)

• Biopsy and treatment of tumours

(Medial side proximal shaft and inferior portion of the neck)

• Psoas Release

• Adductor Release

Medial Approach

Position

• Supine

• Hip

• flexed

• abducted

• externally rotated

• Sole foot against

other knee

Medial Approach

Landmarks

Palpate adductor longus

and find its origin at

the pubis

3 cm

Medial Approach

Internervous Planes

Medial Approach

Internervous Planes

GRACILIS

ADDUCTOR MAGNUS

ADDUCTOR BREVIS

ADDUCTOR LONGUS

ANT

OBT

NERVE

POST

OBT

NERVE

TIBIAL

BRANCH

Medial Approach

Internervous Planes

GRACILIS

ADDUCTOR MAGNUS

ADDUCTOR BREVIS

ADDUCTOR LONGUS

ANT

OBT

NERVE

POST

OBT

NERVE

TIBIAL

BRANCH

1

2

Medial Approach

Superficial dissection

• Dissection between

gracilis and adductor

longus developed by

glove

Medial Approach

Superficial dissection

• Dissection between

gracilis and adductor

longus developed by

glove

Medial Approach

Deep Dissection

•Dissect between adductor

brevis and magnus until

reach lesser trochanter

•Retractors above and below

the lesser trochanter to

isolate the psoas tendon

Medial Approach

Nerves

• Anterior division of

the obturator nerve

Medial Approach

Nerves

• Posterior division of

the obturator nerve

Medial Approach

Vessels

Medial femoral

circumflex artery

Passes down

medial side of psoas

Need to isolate and

cut psoas under direct

vision

?

ANTERIOR

ANTERO-LATERAL

LATERAL

POSTERIOR

MEDIAL