So much attention has been focused in recent years upon tile anterior approach to the hip joint that the advantages of the posterior approach have been ignored almost entirely and many surgeons have no experience of it. The descriptions given in some standard text-books are incomplete or even inaccurate. Moreover, the impression is prevalent that haemorrhage during the operation may be troublesome. This view cannot possibly be entertained by anyone who is familiar with the procedure. A few small vessels may have to be clamped, but it is seldom necessary to apply a ligature. To anyone who is not well acquainted with the anatomy of the buttock the description of the operation may sound complicated ; but in reality the anatomical simplicity is most striking. The earliest account of a posterior exposure is that of von Langenbeck (1874). The patient was laid upon the sound side with the affected hip flexed 45 degrees, a position in which the axis of the thigh corresponds approximately with a line joining the greater trochanter with the posterior superior iliac spine. The incision began in this line, three finger-breadths proximal to the tip of the greater trochanter, and extended about three finger-breadths down the line of the thigh (Fig. 1). While the wound was retracted the lower limb was rotated outwards and inwards to facilitate detachment of the muscles and capsule from the trochanter and neck of the femur. The ligamentum teres was cut or torn across, and the head of the femur was dislocated from the acetabulum.
The Langenbeck approach was modified by Kocher (1907). The first edition of Kocher’s “Operative Surgery” was published in 1892, but the earliest description of his approach to the hip joint that I have been able to find is in an article by his pupil Dumont, published with Kocher’s permission in 1887. All Kocher’s incisions served the fundamental principleprimurn non nocere; they were designed to pass between adjacent nerve territories. In the hip joint the tissues were separated between the territories of the superior and inferior gluteal nerves-between the gluteus medius, gluteus minimus and tensor fasciae latae on the one hand and gluteus maximus on the other. The skin incision was angled. Beginning at the upper anterior border of the greater trochanter, its lower or vertical limb extended distally along tile line of the shaft of the femur; the upper limb passed obliquely backwards towards the posterior superior spine along or near the upper border of the gluteus maximus. Kocher’s work was translated into English by Stiles (1911); during the life-time of the translator, Kocher’s approach to the hip joint was widely employed in Great Britain but was never well known in the United States of America or in Canada. On the continent of Europe it is still first in favour (Klapp 1923). During the last thirty-five years a modification of Kocher’s posterior approach has been used by the present writer as a routine procedure; in the belief that the exposure has outstanding advantages, he has therefore undertaken the following detailed description.