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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 
 

 

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Questions (2)

(OBQ09.16) 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? Review Topic

QID: 2829
1

semimembranosus

2%

(16/878)

2

biceps femoris

2%

(15/878)

3

iliopsoas

82%

(718/878)

4

rectus femoris

12%

(103/878)

5

sartorius

2%

(20/878)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ08.18) 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? Review Topic

QID: 404
1

obturator nerve

16%

(229/1453)

2

obturator artery

5%

(78/1453)

3

femoral artery

12%

(179/1453)

4

medial femoral circumflex artery

65%

(940/1453)

5

sciatic nerve

1%

(20/1453)

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PREFERRED RESPONSE 4
EVIDENCE & REFERENCES (4)
Topic COMMENTS (3)
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