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Introduction
  • Provides exposure to
    • hip joint
    • ilium
  • Indications
    • THA
    • open reduction of congenital hip dislocations
    • synovial biopsies
    • intra-articular fusions
    • excision of pelvic tumors
    • pelvic osteotomies
    • irrigation and debridement of infected, native hip
 
Planes
 
Position and Preparation
  • Anesthesia
    • options include
      • block vs. general anesthesia
  • Position
    • supine
 
Approach
  • Incision
    • make incision from anterior half of iliac crest to ASIS
    • from ASIS curve inferiorly in the direction of the lateral patella for 8-10 cm 
  • Superficial dissection
    • identify gap between sartorius and tensor fasciae latae
    • dissect through subcutaneous fat (avoid lateral femoral cutaneous n.)
    • incise fascia on medial side of tensor fascia latae
    • detach origin of tensor fasciae latae of iliac to develop internervous plane
    • ligate the ascending branch of the lateral femoral circumflex artery (crosses gap between sartorius and tensor fascia latae)
  • Deep dissection
    • identify plane between rectus femoris and gluteus medius
    • detach rectus femoris from both its origins
    • retract rectus femoris and iliopsoas medially and gluteus medius laterally to expose the hip capsule
    • adduct and externally rotate the hip to place the capsule on stretch
    • incise capsule with a longitudinal or T-shaped capsular incision 
    • dislocate hip with external rotation after capsulotomy is complete
  • Proximal extension
    • indications
      • bone graft harvest
    • dissection
      • extend proximal incision posteriorly along the iliac crest
  • Distal extension
    • indications
      • intra-operative fracture of distal femur
    • dissection
      • lengthen skin incision downward along anterolateral aspect of thigh
      • incise fascia latae in line with skin incision
      • stay in the interval between the vastus lateralis and rectus femoris




 


Dangers
  • Lateral femoral cutaneous nerve 
    • reaches thigh by passing under inguinal ligament
      • the course is variable and the LFCN can be seen passing medial or lateral to ASIS 
    • most commonly seen when incising fascia between the sartorius and the tensor fascia latae
    • injury may lead to painful neuroma or decreased sensation on lateral aspect of thigh
  • Femoral nerve
    • should remain protected as long as you stay lateral to sartorius muscle
  • Ascending branch of lateral femoral circumflex artery  
    • found proximally in the internervous plane between the tensor fascia latae and sartorius
    • be sure to ligate to prevent excessive bleeding
 

 

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