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Overview
  • Ball-and-socket type of diarthrodial joint
  • Stability 
    • conferred by bony architechture
    • augmented by acetabular labrum and hip capsule
  • Acetabulum
    • formed from three ossification centers
      • ilium
      • ischium
      • pubis
    • posterosuperior portion has thicker cartilage for weightbearing purposes
Osteology
  • Acetabulum 
    • anteverted 15 degrees
    • abducted 45 degrees (caudal tilt)
    • divided into four quadrants 
      • line drawn from ASIS through center of acetabulum
        • anterior and posterior quadrants
      • line perpendicularly bisecting previous line
        • superior and inferior quadrants
      • posterior-superior 
        • contains superior gluteal nerve and vessels and sciatic nerve
        • safest zone for screw placement
      • posterior-inferior
        • contains inferior gluteal nerve and internal pudendal vessels
        • second safest zone for screw placement
      • anterior-inferior 
        • contain the obturator vessels
        • unsafe for screws
      • anterior-superior
        • contains external iliac artery and vein
        • unsafe for screws
  • Proximal femur 
    • femoral head
      • center of femoral head should be at the level of the tip of the greater trochanter
    • femoral neck
      • anteverted 15 degrees (in relation to femoral condyles)
      • neck shaft angle of 125 degrees
    • greater and lesser trochanters
Capsule & Ligaments
  •  Hip joint capsule 
    • attaches anteriorly to the along the intertrochanteric crest
    • extends posteriorly only partially across the femoral neck 
      • basicervical and intertrochanteric regions are extracapsular
    • three ligaments
      • iliofemoral ligament (Y ligament of Bigelow)
        • strongest ligament
        • AIIS to intertrochanteric line
        • taut in full hip extension
        • prevents anterior dislocation / hyperextension
      • ischiofemoral
        • reinforces posterior capsule
      • pubofemoral
  • Ligamentum teres
    • cotyloid notch to fovea of femoral head
  • Transverse acetabular ligament
    • the most inferior portion of labrum
    • provides anatomic landmark for reaming
Blood Supply
  • Blood supply to femoral head changes with age
    • birth to 4 years of age 
      • medial and lateral circumflex and ligamentus teres
    • 4 years of age to adult 
      • posterosuperior and posteroinferior retinacular vessels from medial femoral circumflex
      • piriformis start nails
        • damage posterosuperior retinacular vessels
        • can cause AVN of femoral head
    • adult age
      • medial femoral circumflex
      • avoid transection the quadratus during posterior approach and damaging the MFC artery
  • Ligamentum teres
    • arterial branch of the posterior division of the obturator artery to the femoral head
    • not significant in adults
  • Abdominal aorta 
    • external iliac artery
      • common femoral artery
        • at risk during screw placement in anterosuperior quadrant during THA
        • profunda femoris
          • lateral femoral circumflex
            • ascending branch at risk during anterolateral approach
          • medial femoral circumflex
            • major blood supply to femoral head
            • at risk during psoas tenotomy
        • femoral artery perforators
          • supply vastus lateralis
    • internal iliac artery
      • obturator (posterior branch)
        • supplies transverse acetabular ligament
        • at risk with screw placement in anteroinferior acetabulum and acetabular retractors
      • superior gluteal
      • inferior gluteal
        • supplies short external rotators and gluteus maximus
        • runs along the piriformis after it exits the greater sciatic notch 
      • internal pudendal
        • re-enters pelvis via lesser sciatic notch
  • Corona mortis 
    • connection between inferior epigastric branch of the external iliac vessls and the obturator vessels
Neurologic
  • Lumbosacral plexus 
    • T12-S4 nerve roots
    • lies posterior to psoas muscle
  • Sciatic nerve 
    • posterior division
      • peroneal
        • lateral in comparision to tibial division
      •  
        • most commonly injured neural structure during THA
        • runs deep to long head of biceps femoris
      • superior gluteal
      • inferior gluteal
      • piriformis
      • posterior femoral cutaneous
    • anterior division
      • tibial
      • nerve to quadratus femoris
      • nerve to obturator internus
      • pudendal
      • coccygeus
  • Obturator nerve 
  • Femoral nerve 
    • between iliacus and iliopsoas 
    • branches to muscle, overlying skin, and hip joint
  • Lateral femoral cutanous nerve 
    • L2-L3 nerve roots; branch of the lumbar plexus
    • deep to inguinal ligament near ASIS
  • Genitofemoral nerve
    • branch of the lumbar plexus
    • pierces iliopsoas and runs on its anteromedial surface
Musculature
  • Hip flexors
    • iliopsoas 
    • rectus femoris 
    • sartorius 
    • pectineus 
    • iliacus 
  • Hip adductors
    • posterior adductor magnus 
    • adductor longus 
    • adductor brevis 
    • gracilis 
  • External rotators
    • gluteus maximus 
    • piriformis 
    • obturator externus 
    • obturator interus 
    • superior gemellus 
    • inferior gemellus 
    • quadratus femoris 
  • Hip abductors
    • gluteus medius 
    • gluteus minimus 
    • tnesor fasciae latae 
  • Hip extensors
    • gluteus maximus 
    • hamstring tendons
      • semitendinosis 
      • semimembranosus 
      • long head of the biceps femoris 
Approaches to the hip
  • Anterior - Smith-Petersen 
  • Anterolateral - Watson-Jones 
  • Medial 
  • Direct lateral - Hardinge 
  • Posterior - Southern or Moore 
 

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