Updated: 11/7/2014

Hip Medial Approach

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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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