Hip Anterior Approach (Smith-Petersen) - Approaches

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
Internervous plane-Superficial sartorius (femoral n.) tensor fasciae latae (superior gluteal n.) Internervous plane-Deep rectus femoris (femoral n.) gluteus medius (superior gluteal n.)
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