|
http://upload.orthobullets.com/topic/12021/images/1.jpg
http://upload.orthobullets.com/topic/12021/images/1s.jpg
http://upload.orthobullets.com/topic/12021/images/2.jpg
http://upload.orthobullets.com/topic/12021/images/2s.jpg
http://upload.orthobullets.com/topic/12021/images/3.jpg
http://upload.orthobullets.com/topic/12021/images/3s.jpg
Introduction
  • Provides exposure to
    • acetabulum
    • proximal femur
  • Indications include
    • THR
      • minimally invasive approach does not improve post-op gait kinematics when compared to traditional trans-gluteal approach
      • patient at high risk for dislocation may benefit from antero-lateral approach since no posterior soft tissue disruption
      • some concern that this approach can weaken the abductor and cause limping
    • hemiarthroplasty
    • ORIF of femoral neck fracture
    • synovial biopsy of hip
    • biopsy of femoral neck
    
Intermuscular plane
  
Preparation
  • Anesthesia
    • general or spinal/epidural is appropriate
  • Position
    • generally performed in the lateral decubitus position
    • patient's buttock close to the edge of the table to let fat fall away from incision
  • Landmarks
    • ASIS
    • greater trochanter
    • shaft of the femur
 
Approach
  • Incision
    • make incision starting 2.5 cm posterior and distal to ASIS
    • as it runs distal, it becomes centered over the tip of the greater trochanter 
      • crosses posterior 1/3 of trochanter before running down the shaft of the femur
  • Superficial dissection
    • incise fat in line with incision and clear fascia lata
    • incise fascia
      • incise in direction of fibers, this will be more anterior as your dissect proximal
      • incise at the posterior border of the greater trochanter
    • develop interval between tensor fasciae latae and gluteus medius
      • there will be a small series of vessels in this interval
    • externally rotate the hip to put the capsule on stretch
    • identify origin of vastus lateralis
  • Deep dissection
    • detach abductor mechanism by one of two mechanisms
      • trochanteric osteotomy (shown in this illustration)
        • distal osteotomy site is just proximal to vastus lateralis ridge 
      • partial detachment of abductor mechanism
        • place stay suture to prevent muscle split and damage to superior gluteal nerve
        • nerve is 5cm proximal to the acetabular rim
    • expose anterior joint capsule
    • detach reflected head of rectus femoris from the joint capsule to expose the anterior rim of the acetabulum
      • easier with leg flexed slightly
    • elevate part of the psoas tendon from the capsule
    • perform anterior capsulotomy
    • dislocate hip with external rotation
  • Extension 
    • proximal
      • incise more fasciae latae proximally to allow increased adduction and external rotation of the leg
    • distal
      • incise down the deep fascia of the leg
      • allows access to the vastus lateralis which can be elevated to allow direct access to the entire femur
 














Dangers
  • Femoral nerve
    • most common problem is compression neuropraxia caused by medial retraction
    • direct injury can occur from placing retractor into the psoas muscle
  • Femoral artery and vein
    • can be damaged by retractors that penetrate the psoas
    • confirm that anterior retractor is directly on bone
  • Abductor limp
    • caused by trochanteric osteotomy and/or disruption of abductor mechanism
    • caused by denervation of the tensor fasciae by aggressive muscle split
  • Femoral shaft fractures
    • usually occurs during dislocation (be sure to perform and adequate capsulotomy)
 




 

Please rate topic.

Average 4.3 of 15 Ratings

Questions (2)
EVIDENCE & REFERENCES (3)
VIDEOS (1)
Topic COMMENTS (8)
Private Note