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Updated: Feb 5 2020

Hip Direct Lateral Approach (Hardinge, Transgluteal)

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Introduction
  • Exposure to
    • hip joint
  • Indications
    • total hip arthroplasty
      • has lower rate of total hip prosthetic dislocations
    • proximal femur fracture

Plane
  • Internervous plane
    • no true internervous plane 
  • Intermuscular plane
    • splits gluteus medius distal to innervation (superior gluteal nerve)
    • vastus lateralis is also split lateral to innervation (femoral nerve)

Preparation
  • Anesthesia
    • options
      • general
      • spinal
  • Position
    • lateral
    • supine

Approach
  • Incision
    • begin 5cm proximal to tip of greater trochanter
    • longitudinal incision centered over tip of greater trochanter and extends down the line of the femur about 8cm
  • Superficial dissection
    • split fascia lata and retract anteriorly to expose tendon of gluteus medius
    • detach fibers of gluteus medius that attach to fascia lata using sharp dissection
  • Deep dissection
    • split fibers of gluteus medius longitudinally starting at middle of greater trochanter 
      • do not extend more than 3-5 cm above greater trochanter to prevent injury to superior gluteal nerve
    • extend incison inferior through the fibers of vastus lateralis
    • develop anterior flap
      • anterior aspect of gluteus medius from anterior greater trochanter with its underlying gluteus minimus
      • anterior part of vastus lateralis
      • requires sharp dissection of muscles off bone or lifting small fleck of bone
    • expose anterior joint capsule 
      • follow dissection anteriorly along greater trochanter and onto femoral neck which leads to capsule
      • gluteus minimus needs to be released from anterior greater trochanter









Structures at Risk
  • Superior gluteal nerve
    • runs between gluteus medius and minimus 3-5 cm above greater trochanter 
    • protect by 
      • limiting proximal incision of gluteus medius
      • putting a stay suture at the apex of gluteal split
    • leads to Trendelenburg gait pattern 
  • Femoral nerve
    • most lateral structure in neurovascular bundle of anterior thigh
    • keep retractors on bone with no soft tissue under to prevent iatrogenic injury

Question
1 of 5
In scope icon N/A
QID 219581 (Type "219581" in App Search)
A 72-year-old female presents to the clinic with worsening left knee pain. She has attempted NSAIDs, physical therapy, and multiple corticosteroid injections, however her pain is recalcitrant to conservative measures. She has a fixed coronal plane deformity with minimal correctability and a 15-degree flexion contracture on exam. Weight-bearing radiographs are demonstrated in Figures A and B. After discussion, the patient agrees to proceed with total knee arthroplasty (TKA). Which of the following should be considered when performing total knee arthroplasty in this patient?
  • A
  • B

Pie-crusting the medial collateral ligament utilizing an 18-gauge needle

6%

62/988

Resect less distal femur than the surgeon’s typical standard TKA protocol

32%

315/988

Releasing the fascial septum between the peroneus longus and extensor digitorum longus

46%

451/988

Performing a staged, medial-opening high tibial osteotomy 6 months prior to TKA

6%

63/988

Using a cruciate retaining implant to minimize overall constraint and improve range of motion

9%

87/988

  • A
  • B

Select Answer to see Preferred Response

Approaches | Hip Direct Lateral Approach (Hardinge, Transgluteal)
  • Approaches
  • - Hip Direct Lateral Approach (Hardinge, Transgluteal)
8:48 min
5/2/2021
1522 plays
5.0
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