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Hip Anterior Approach (Smith-Petersen)

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Topic updated on 12/11/14 8:14am
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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Qbank (2 Questions)

TAG
(SBQ12.4) Which of the following statements about the lateral femoral cutaneous nerve is true? Topic Review Topic

1. Innervates the medial aspect of the proximal thigh
2. Originates from the dorsal roots of L4-L5
3. Course runs medial to the femoral artery
4. Courses along the medial border of the psoas muscle
5. Courses under the inguinal ligament

PREFERRED RESPONSE ▶
TAG
(OBQ09.103) What two nerves make up the internervous plane in the Smith-Petersen anterior hip approach? Topic Review Topic

1. There is no internervous plane
2. Femoral nerve and inferior gluteal nerve
3. Femoral nerve and superior gluteal nerve
4. Obturator nerve and superior gluteal nerve
5. Obturator nerve and inferior gluteal nerve

PREFERRED RESPONSE ▶
TAG
(OBQ07.263) The ascending branch of the lateral femoral circumflex artery is at risk with which of the following surgical approaches? Topic Review Topic

1. Stoppa approach
2. Kocher-Langenbach approach
3. Ilioinguinal approach
4. Watson-Jones approach
5. Smith-Petersen approach

PREFERRED RESPONSE ▶
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