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Introduction
  • Provides exposure to
    • acetabulum
    • proximal femur
  • Indications
    • THA
    • hip hemiarthroplasty
    • removal of loose bodies
    • dependant drainage of septic hip
    • pedicle bone grafting
  • Associated approaches
    • Kocher-Langenbeck
      • more extensile exposure used for complicated acetabular work
      • same interval as posterior approach to hip
      • incision slightly more anterior over greater trochanter

Planes
  • Internervous plane
    • no internervous plane
  • Intermuscular plane
    • gluteus maximus
      • innervated by inferior gluteal nerve
      • muscle split is stopped when first nerve branch to upper part of muscle is encountered
  • Vascular plane
    • superior gluteal artsupplies proximal 1/3 of muscle
    • inferior gluteal artery
      • supplies distal 2/3 of muscle
    • line of fat on surface of gluteus maximus marks interval
 
Preparation
  • Anesthesia
    • general most common
  • Position
    • lateral position
      • indications
        • hip arthroplasty
          • position of choice
        • posterior wall and lip fractures
          • skeletal traction may be used in lateral position
      • advantages
        • allows for femoral head dislocation
        • allows buttock tissue to "fall away" from the field
    • prone position
      • indications
        • transverse fractures of acetabulum

Approach
  • Incision
    • make 10 to 15 cm curved incision one inch posterior to posterior edge of greater trochanter (GT)
      • begin 7 cm above and posterior to GT
      • curve posterior to the GT and continue down shaft of femur
    • mini-incision approach shows no long-term benefits to hip function
  • Superficial dissection
    • incise fascia lata to uncover vastus lateralis distally 
    • lengthen fascial incision in line with skin incision
    • split fibers of gluteus maximus in proximal incision
      • cauterize vessels during split to avoid excessive blood loss
  • Deep dissection
    • internally rotate the hip to place the short external rotators on stretch 
    • place stay suture in piriformis and obturator internus tendon (short external rotators)
      • evidence shows decreased dislocation rate when short external rotators repaired during closure
    • detach piriformis and obturator internus close to femoral insertion
      • reflect backwards to protect sciatic nerve
    • incise capsule with longitudinal or T-shaped incision
    • dislocate hip with internal rotation after capsulotomy
  • Proximal extension
    • may extend proximal incision towards iliac crest for exposure of ilium
  • Distal extension
    • extend incision distally down line of femur down to level of knee
    • vastus lateralis may either be split or elevated from lateral intermuscular septum



Dangers
  • Sciatic nerve
    • location
      • initially located along posterior surface of quadratus femoris muscle
        • quadratus femorus anatomy is constant; rarely damaged in setting of fracture
    • prevention
      • extend hip and flex knee to prevent injury
      • use proper gentle retraction and release short external rotators (obturator internus) posteriorly to protect the sciatic nerve from traction 
    • treatment of injury
      • treat injury with observation and use of ankle-foot orthosis
    • prognosis
      • recovery of tibial division is good despite severe initial damage
      • recovery of peroneal division is dependent on severity of initial injury
  • Inferior gluteal artery
    • location
      • leaves pelvis below piriformis 
    • treatment of injury
      • if cut and retracts into pelvis, flip patient, open abdomen, and tie off internal iliac artery
  • First perforating branch of profunda femoris
    • at risk
      • during release of gluteus maximus insertion 
  • Femoral vessels
    • at risk
      • with failure to protect anterior aspect of the acetabulum
      • with placement of retractors anterior to the iliopsoas muscle 
  • Superior gluteal artery and nerve 
    • location
      • leaves pelvis through the greater sciatic notch
        • contents of greater sciatic notch include
          • superior gluteal nerve
          • superior gluteal artery and vein
      • runs over the piriformis between the gluteus medius and minimus
      • enters the deep surface of the gluteus medius.
        • do not split gluteus medius more than 5 cm proximal to greater trochanter due to risk of denervating the muscle
        • also at risk during the lateral (Hardinge) approach to the hip
  • Quadratus femoris
    • excessive retraction and injury must be avoided to prevent damage to medial circumflex artery
  • Heterotopic ossification (HO)
    • debride necrotic gluteus minimus muscle to decrease incidence of HO



 

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