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Tenotomy of which muscle performed during an anteromedial approach for surgical reduction of a congenitally dislocated hip places the medial femoral circumflex artery at risk?
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Weinstein and Ponseti suggested that the anteromedial approach provides "a safe, effective way to reduce a dislocated hip in infancy". The superficial plane is between gracilis and adductor longus. The deep plane is between adductor brevis and adductor magnus. During this approach, the iliopsoas tendon can be released, but should be fully exposed above and below the lesser trochanter so as not to injure the medial femoral circumflex artery.
Weinstein SL, Ponseti IV.
J Bone Joint Surg Am. 1979 Jan;61(1):119-24. PMID: 759421 (Link to Abstract)
Weinstein, JBJS 1979
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Following an uneventful medial approach to the hip, the iliopsoas tendon is released. Which of the following neurovascular structures is most at risk during release of the tendon?
medial femoral circumflex artery
The medial approach to the hip gives excellent exposure to the insertion of the psoas tendon on the lesser trochanter. The medial femoral circumflex artery is at risk when performing a psoas release with this approach.
The medial approach to the hip involves utilizing the interval between adductor longus and gracilis, then adductor brevis and magnus in order to arrive at the lesser trochanter, psoas tendon, and hip capsule. The medial femoral circumflex artery branches off the profundus femoris (~85%) or femoral artery (15%) and then wraps posterior to the iliopsoas tendon before traveling posterior to the femoral neck to supply the femoral head.
Gautier et al. found from a cadaveric study on 24 hips that the MFCA originated from the profunda femoris in 20/24 specimens, while the origin of the MFCA was the common femoral artery in 4/24 of the specimens.
Illustration A and B shows the surgical plane of the medial approach to the hip as it accesses the lesser trochanter. Illustration C shows the anatomy of the Medial femoral circumflex artery in relation to the iliopsoas tendon and medial approach to the hip.
Answer 1: The obturator nerve is a more superficial structure. While it is seen during the approach, it is not in the vicinity of the iliopsoas tendon.
Answer 2: The obturator artery lies within the pelvis.
Answer 3: Although the femoral artery can be the origin of the MFCA, it is a more superficial structure and is not exposed during this approach.
Answer 4: The sciatic nerve is a posterior structure and not seen in this exposure.
Gautier E, Ganz K, Krügel N, Gill T, Ganz R
J Bone Joint Surg Br. 2000 Jul;82(5):679-83. PMID: 10963165 (Link to Abstract)
Gautier, JBJS 2000
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