Hip Medial Approach - Approaches

Introduction
Indications open reduction of congenital hip dislocation psoas release (approach gives excellent exposure to psoas tendon) biopsy and treament of tumors of the inferior portion of the femoral neck and medial aspect of proximal femoral shaft obturator neurectomy

Plane
Superficial no superficial internervous plane as both the adductor longus and gracilis are innervated by the anterior division of the obturator nerve Deep internervous plane between adductor brevis and adductor magnus adductor brevis supplied by the anterior division of the obturator nerve adductor magnus has dual innervation adductor portion is supplied by the posterior division of the obturator nerve ischial portion by the tibial portion of the sciatic nerve
Preparation
Position patient is supine with the affected hip in a flexed, abducted, and externally rotated position
Approach
Incision longitudinal incision over the adductor longus begin incision 3 cm below the pubic tubercle length of incision is determined by the amount of femur that needs to be exposed Superficial dissection develop plane between gracilis and adductor longus muscles Deep dissection develop plane between adductor brevis and adductor magnus until you feel lesser trochanter on the floor of the wound protect posterior division of the obturator nerve isolate psoas tendon by placing narrow retractor above and below lesser trochanter
Dangers
Medial femoral circumflex artery passes around medial side of the distal part of the psoas tendon at risk in children when releasing psoas tendon must isolate psoas tendon and cut under direct vision Anterior division of obturator nerve supplies adductor longus, adductor brevis,and gracilis in the thigh Posterior division of obturator nerve lies within substance of oburator externus supplies adductor portion of adductor magnus Deep external pudendal artery at risk proximally lies anterior to pectineus near the origin of the adductor longus