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Anterior approach to the hip

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Introduction

Indications

  • Synovial biopsies
  • Intra-articular fusions
  • Total hip replacement / hemiarthroplasty
  • Excision of tumors, especially of the pelvis
  • Osteotomies using the upper part of the approach
  • Open reduction of congenital dislocations of the hip when the dislocated femoral head lies anterosuperior to the true acetabulum

Advantage

  • Can be used as a minimal incision surgery (MIS) approach to total hip replacement (THR) with lower risk of dislocation and very little muscle damage

Disadvantage

  • Does not expose the acetabulum as completely
  • Learning curve for MIS approach to THR

Position of patient

  • Position the patient supine on the operating table
  • For MIS THR, position the patient in a lateral position with supports on the sacrum and pubic symphysis; drop the anterior half of the table to allow external rotation and adduction of the femur after dislocation

Landmarks and incision

Landmarks

  • The anterior superior iliac spine is subcutaneously palpable by bringing the thumbs up from beneath the bony protuberance
  • The iliac crest is felt subcutaneously

Incision

  • Start the incision on the anterior half of the iliac crest to the anterior superior iliac spine, then curve the incision down so that it runs vertically for 8 to 10 cm, heading toward the lateral side of the patella

Internervous plane

  • The superficial plane between the sartorius (femoral nerve) and the tensor fasciae latae (superior gluteal nerve)
  • The deep plane between the rectus femoris (femoral nerve) and the gluteus medius (superior gluteal nerve)

Superficial dissection

  • Identify the gap between the tensor fasciae latae and the sartorius by palpation 2 to 3 inches below the anterior superior iliac spine; external rotation of the leg stretches the sartorius muscle, making it more prominent
  • Dissect downward along the intermuscular interval, taking care to avoid cuting the lateral femoral cutaneous nerve (lateral cutaneous nerve of the thigh), which pierces the deep fascia of the thigh close to the intermuscular interval
  • Incise the deep fascia on the medial side of the tensor fascia latae
  • Retract the sartorius upward and medially and the tensor fascia latae downward and laterally
  • Detach the iliac origin of the tensor fasciae latae to develop the internervous plane
  • Ligate the large ascending branch of the lateral femoral circumflex artery, which crosses the gap between the two muscles below the anterior superior iliac spine

Deep dissection

  • Identify the deep layer of the hip musculature, the rectus femoris (femoral nerve) and the gluteus medius (superior gluteal nerve
  • Detach the rectus femoris from both its origins (reflected and direct head) and retract it medially; retract the gluteus medius laterally
  • Medially retract the iliopsoas as it approaches the lesser trochanter and release the joint capsule
  • Define the capsule with blunt dissection; adduct and externally rotate the leg to stretch it
  • Incise the capsule with either a longitudinal or a T-shaped capsular incision
  • Dislocate the hip by external rotation after the capsulotomy
  • With MIS exposure for arthroplasty, it may be valuable to do a high osteotomy just below the head, dislocate (leaving the head fragment in place), re-osteotomize the neck at the level indicated by templating, and then extract the head

Dangers

Lateral femoral cutaneous nerve (lateral cutaneous nerve of the thigh)

  • Incise the deep fascia on the medial side of the tensor fascia latae
  • Staying within the fascial sheath of this muscle will avoid damaging the lateral femoral cutaneous nerve because the nerve runs over the fascia of the sartorius

Femoral nerve

  • Lies within the femoral triangle medial to the rectus femoris; it is not really in danger
  • Locate the femoral pulse by palpation within the femoral triangle; the artery lies medial to the nerve

Ascending branch of the lateral femoral circumflex artery

  • Crosses the operative field, running proximally in the internervous plane between the tensor fasciae latae and the sartorius
  • Ligate or coagulate it when you separate the two muscles

How to enlarge the approach

Superficial surgical dissection

  • Detach the origins of the tensor fasciae latae and the sartorius

Deep surgical dissection

  • Detach the origins of the gluteus medius and minimus from the outer wing of the ilium by blunt dissection

Extensile measures

  • The approach can be extended to allow visualization of both the inner and outer walls of the pelvis at the level of the hip joint to allow pelvis osteotomy

Figures

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