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Updated: Feb 5 2020

Hip Direct Lateral Approach (Hardinge, Transgluteal)
  • Exposure to
    • hip joint
  • Indications
    • total hip arthroplasty
      • has lower rate of total hip prosthetic dislocations
    • proximal femur fracture

  • 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)

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

  • 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

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