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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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Questions (2)

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

QID:2916
1

There is no internervous plane

6%

(71/1181)

2

Femoral nerve and inferior gluteal nerve

7%

(82/1181)

3

Femoral nerve and superior gluteal nerve

85%

(999/1181)

4

Obturator nerve and superior gluteal nerve

2%

(18/1181)

5

Obturator nerve and inferior gluteal nerve

0%

(5/1181)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

The internervous plane in the Smith-Petersen anterior hip approach is made by the femoral nerve and superior gluteal nerve.

The anterior Smith-Petersen hip approach uses the superficial internervous plane between the sartorius (femoral nerve) and the tensor fascia latae (superior gluteal nerve). The deep plane for access to the hip joint capsule uses the same internervous plane but is between the rectus femoris (femoral nerve) and the gluteus medius (superior gluteal nerve). In this approach to the hip, one must be conscious to avoid damaging the lateral femoral cutaneous nerve.

Illustration A and B show the superficial and deep internervous plane.

ILLUSTRATIONS:

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Question COMMENTS (2)

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

QID:924
1

Stoppa approach

2%

(16/859)

2

Kocher-Langenbach approach

10%

(86/859)

3

Ilioinguinal approach

4%

(35/859)

4

Watson-Jones approach

14%

(117/859)

5

Smith-Petersen approach

70%

(604/859)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

The ascending branch of the lateral femoral circumflex artery is at risk during the Smith-Petersen approach to the hip. In this approach, an internervous interval between the femoral nerve (sartorius, superficial; rectus femoris, deep) and superior gluteal nerve (tensor fascia latae, superficial; gluteus medius, deep) is utilized.
The ascending branch of the lateral femoral circumflex artery runs proximally in the internervous plane between the two deep muscles.

Incorrect Answers
Answer 1: http://www.orthobullets.com/approaches/12056/stoppa-approach-to-acetabulum
Answer 2: http://www.orthobullets.com/approaches/12015/posterior-approach-to-the-acetabulum-kocher-langenbeck
Answer 3: http://www.orthobullets.com/approaches/12016/ilioinguinal-approach-to-the-acetabulum
Answer 4: http://www.orthobullets.com/approaches/12021/hip-anterolateral-approach-watson-jones


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Question COMMENTS (2)
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