PRESENTOR- UMESH YADAV

SURGICAL APPROACHES TO HIP JOINT

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BACK TO BASICS- ANATOMY REVISION

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MUSCLE INSERTIONS ON GT-Piriformis- ApexG.minimus- Lateral part on anterior surfaceG. medius- Lateral surface.Obturator internus & two gemilli- Upper medial surfaceObturator externus- Trochantric fossa

ORIGIN- V. lateralis

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IliopsoasOriginPsoas Major:transverse processes of T12-L5Iliacus: Iliac fossaInsertionLesser trochanterof the femurInnervationFemoral n.ActionHip flexion, trunk flexion, anterior pelvic tilt

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ANTERIOR COMPARTMENTSartorius & Quadriceps

NS- FEMORAL NERVE (L2,L3,L4)

Sartorius- “Tailor”Origin---ASISInsertion—Proximal-medial surface of the tibia (via the pes anserinus)Innervation--Femoral n.Action-Flexor ,aBDuctor @lateral rotater of thigh.Knee flexor Longest muscle in the body

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QUADRICEPS COMPLEX- 4

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Rectus FemorisOrigin- Straight head- AIISReflected head- IlliumInsertionTibial tuberosity via the quadriceps tendonInnervation-Femoral n.ActionHip flexion, knee extension.Of 4 Qu, RF crosses knee @ hip joint.

Genu articularis-Ant shaft- Synovial membrane of kneeF-Pull synovial membrane during knee extension-prevent damage

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MEDIAL COMPARTMENT(ADDUCTOR COMPARTMENT)

• Adductor Longus• Adductor brevis• Adductor magnus• Gracilis• Pectineus• Nerve supply- Obturator Nerve

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Adductor Longus

Origin-Anterior surface of the body of the pubisInsertion-Middle 1/3 of the linea aspera of the femurInnervation-Obturator n.Action-HipADD, Hip flexion

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ADDuctor Brevis

Origin-Proximal Attachment: Anterior surface of the inferior pubic ramusInsertionProximal 1/3 of the linea aspera of the femurInnervationObturator n.ActionHip ADD, Hip flexion

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Adductor Magnus-Largest muscle of this compartment.Origin-IPR,IT, Ramus of ischium Insertion-ExtensorHead: ADDuctor tubercle on distal femur.GT,Linea asperaInnervation-Tibial portion of the sciatic n.And obturator nerveActionHip extension, Hip ADD

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Pectineus

Origin-Pectineal line on superior ramusInsertion-Pectineal line on posterior surface of the femur inf. To LTInnervation-Femoral N. and Obturator N.Action-Hip ADD, hipflexion

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Gracillis

Origin-Body and inferior ramus of the pubisInsertionProximal-medial aspect of the tibia With insertions of sartorius and ST.(pes anserinus- Expanded insertion resembles foot of a goose)Innervation-Obturator n.ActionHip ADD, hip flexion, knee flexion.Weakest of medial adductor group.

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PES ANSERINUS- FOOT OF GOOSE

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SUBTROCHANTRIC FRACTURES

• Deforming forces on the proximal fragment are – abduction

• gluteus medius and gluteus minimus

– flexion• iliopsoas

– external rotation• short external rotators

• Deforming forces on distal fragment– adduction & shortening

• adductors

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POSTERIOR ASPECT

HAMSTRINGSNS- TIBIAL PART OF SCIATIC NERVE

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HAMSTRINGS-Semitendinosus

OriginIschial tuberosityInsertionProximal-medial surface of the tibia (pesanserinus)InnervationTibial portion of the sciatic n.ActionHip extension, knee flexion

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Semimembranosus

OriginIschial tuberosityInsertionMedial condyle of the tibia, posterior aspectInnervationTibial portion of the sciatic n.ActionHip extension,knee flexion

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Biceps FemorisOrigin- Long head- Ischial tuberosityShort head-linea asperaInsertion-Head of the fibulaInnervation-Tibial portion of the sciatic n.Action-Hip extension, knee flexion

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GLUTEAL REGION

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Gluteus Maximus

Origin- Posterior ilium, sacrum,coccyxInsertion-ITB,gluteal tuberosity of femurInnervation-Inferior gluteal n.Action--Chief extensor of thigh at hip-Lateral rotation of thigh-Abduction of thigh

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Gluteus MediusOrigin-Outer surface of the iliumInsertion-Greater trochanterof the femurInnervation-Superior gluteal n.Action-Hip ABD & medial rotator of thigh

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Gluteus MinimusOrigin-Outer surface of the ilium, inferior to the gluteus mediusInsertionGreater trochanterInnervationSuperior gluteal n.ActionHip ABD, Medial rotaters of thigh

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• Intrinsic Hip ER: (6 muscles)• Piriformis,• Obturator Internus, • Obturator Externus, • Gemelus Superior, • Gemelus Inferior,• Quadratus Femoris

• Piriformis Syndrome:• The sciatic nerve passes deep to

the piriformis in most cases (approximately 85% of people)but can in fact pierce the piriformis itself, predisposing to piriformis syndrome and subsequent sciatica.

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Tensor Fascia Lata Muscle-"stretcher of the wide band"

• Origin- Ant part of outer lip of iliac crest.

• Insertion-Between the two layers of the iliotibial band of the fascia lata.

• Nerve-Superior gluteal nerve (L4, L5, S1)

• TFL muscle is a tensor of the fascia lata; continuing its action-Thigh - flexion, medial rotation,abduction. Trunk stabilization.

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ILLIOTIBIAL BAND/TRACT• Maissiat's band or IT

Band.• Fibrous reinforcement

of the fascia lata.• Origin- External lip of

the iliac crest • Insertion- Lateral

condyle of tibia at Gerdy's tubercle.

• G maximus muscle and the TFL insert upon the tract.

OVERVIEW

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HIP JOINT-FROM WHERE TO ENTER….

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CONFUSION OVER THE NAMES ???

• Campbell…..• ANTERIOR- SP APPROACH• MOD. ANTEROLATERAL APPROACH- MODIFIED SP• LATERAL APRROACH- WATSON JONES

• HOPENFIELD…• ANTERIOR- SP APPROACH• ANTEROLATERAL- WATSON JONES APP• LATERAL..

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ANTERIOR ILIOFEMORAL APPROACH:

(SMITH PETERSON APPROACH) Gives safe access to hip & ilLiumINDICATIONS:• Open reduction of congenital dislocations of hip when dislocated

femoral head is anterosup. to the true acetabulum• Synovial biopsies• Intra articular fusions• THR• Hemiarthroplasty• Excision of tumors• Pelvic osteotomies using upper part of approach

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LANDMARKS:ASIS, iliac crest.INCISION:Long incision over anterior half of the iliac crest to the ASIS.

Curve down from ASIS vertically for 8-10cms heaving towards lateral side of patella.

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INTERNERVOUS PLANE:

Superficial plane b/w Sartorius (innervated by femoral N.) & TFL(innervated by Sup.glut.N)

Deep plane lies b/w RF (by femoral N.) & G.medius ( by Sup.glut.N.)

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Carefully cut through the gap b/t sartorius and TFL about 3” distal to the ASIS.Avoid cutting Lat. cut .N. of thigh, incise deep fascia.

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Retract sartorius upwards & medially; TFL down & laterallyDetach the TFL at iliac origin.Ligate the ascending branch of Lat.circumflex Fem A. in this plane.

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Separating sartorius & TFL exposes 2 muscles the GL. Medius & Rectus femoris.Pass into the plane b/w Rect,F & GL.medius which is lateral to the Femoral.A.Detach and retract the R.F ,expose the capsule of hip jt.

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Adduct & externally rotate the leg to stretch the capsule.Incise the capsule as required ( T/longitudanal)& dislocate the hip by ext.rotation.

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DANGERS: NERVES:LFCN. of thigh- may be injured b/w sartorius & TFL.Femoral N. – may be injured if plane is missed during deep dissection as

it lies anterior to hip , medial to RF, lateral to the femoralA. VESSELS: Ascending branch of Lat.Circumflex F.A.- May be injured in the plane

b/t TFL & Sartorius.

ENLARGING THE APPROACH:PROXIMAL EXTENSION- For bone graft harvestingDISTAL EXTENSION- For intraoperative fracture of distal femurIn superficial dissection - by detaching sartorius at the origin.In deep dissection- Stay in plane b/w vastus lateralis & rectus femoris.

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• Reattachment of fascia lata to iliac crest difficult• Osteotomy of overhang of iliac crest is performed

b/w Ext. Oblique medially & fascia lata to as far as origin of g.maximus.

• TFL, G.medius & G.minimus dissected subperiosteally to expose hip joint capsule.

• Closure – Iliac osteotomy fragment reattached with non-absorbable sutures through holes drilled.

SCHAUBEL MODIFICATION OF SP ANTERIOR APPROACH

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• IND-For irreducible congenital dislocation of the hip in a young child.

• TRANSVERSE ‘BIKINI’ INCISION – From anterior inferior and medial to the ASIS and coursing obliquely superiorly and posteriorly to the middle of the iliac crest.

• REFLECTING ABDUCTOR → SARTORIUS & TFL→ REFLECTED HEAD OF RECTUS FEMORIS→ INCISION OF CAPSULE FROM RECTUS ANTERIORLY TO POSTEROSUPERIOUR MARGIN OF JOINT→ OPEN REDUCTION OF DDH

SOMMERVILLE ANTERIOR APPROACH

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ANTEROLATERAL APPROACH:( WATSON-JONES APPROACH)

• Most commonly used for THR• Releases all abductor mechanism, hence hip can be adducted fully

hence acetabulum is fully exposed.• Abducor mechanism released either by trochanteric osteotomy / by

cutting the ant.part of GL.medius & the whole Gl.minimus off the G.T

INDICATIONS:• THR• ORIF of # NOF• Hemiarthroplasty• Synovial biopsy• Biopsy Femoral N.

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POSITION:• Supine so close to the edge that the buttock of the affected side

hangsover.• Flex the leg upto 30 deg. , adduct it so that leg lies across the

opposite knee.

LANDMARKS:• ASIS • GT• Femoral shaft• V.Lat ridge

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• INCISION:• 8-15cm longitudnal & straight centered over the Tip

of GT.• Incision crosses the post.3rd of the GT before

running down the shaft.

INTERNERVOUS PLANE:• No internervous plane.• Surgical plane is b/w TFL & GL.medius(supplied by

Sup.GT N.)

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Cut the S.C tissue to reach the fascia over posterior margin of GT & incise fascia lata there to enter the overlying bursa.Divide the fibers of fascia lata proximally & anteriorly in the direction of ASIS, & also distally to expose the vast,lateralis muscle.

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Lift the ant. Flap & detach few fibers of GL.medius to develop a plane b/w TFL & GL.medius.Series of vessels come across the plane act as guide & need to be ligated.

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Retract the GL.med. & mins proximally & laterally to uncover the sup margin of Jt, capsule.

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• 1)TROCHANTERIC OSTEOTOMY –ALLOWS COMPLETE MOBILISATION OF G.MEDIUS AND G.MINIMUS

• BASE OF OSTEOTMY IS AT BASE OF VASTUS LATERALIS RIDGE

• 2)PARTIAL DETACHMENT OF ABDUCTOR MECHANISM – A STAY SUTURE IN ANTERIOR PORTION OF G.MEDIUS AND CUTTING THIS PORTION OFF GT

• G.MINIMUS TENDON BELOW IS INCISED

EXPOSURE OF ACETABULUM – NEUTRALISING ABDUCTOR MECHANISM

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UMYDetach reflected head of Rect.F from Jt. Capsule to expose the ant. rim of acetabulum

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Place Homan retractor over ant lip of acetabulum beneath the RF & psoas as the nervous bundle is anterior to the psoas.Incise the capsule longitudinally.

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• FEMORAL N-Not flexing the hip after dissecting upto anterior rim of acetabulum

Placing retractors into substance of iliopsoas Or overexuberant retraction can damage it..• VESSELS – FEMORAL ARTERY & VEIN – damaged by

acetabular retractors that penetrate iliopsoas substance.

Anterior retractors (R) – 1-o` clock position (L) – 11-o` clock position.

• PROFUNDA FEMORIS ARTERY • FEMORAL SHAFT# - while hip dislocation esp if

inadequate capsular release

DANGERS

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LATERAL APPROACH TO HIP:• Exellent approach to hip replacement.• No need for trochanteric osteotomy.• Early mobilisation of pt possible as the Gl.medius is

preserved.• But not a wider approach as anterolateral approach.POSITION:Supine with GT at the edge of the table.LANDMARKS:ASISG.TShaft of femur

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INCISION:Start about 5cm above the tip of GT pass over centre of tip of GT to extend ~8cm

down the shaft.

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INTERNERVOUS PLANE:No internervous plane as G.M & V.L split in their own line.

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SUPERFICIAL DISSECTION:Cut through the fat & deep fasciaPull the TFL anteriorly,GMposteriorly Detach fibers of GL.medius & develop a plane b/w V.lat & glut.medius.

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DEEP DISSECTION:Split the GL. Medius starting in the middle of GT.Don’t go beyond 3cm up the GT.to preserve sup.GL.N.Split the fibers of V.lats at the base of the GT,

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Develop ant. flap consisting of ,GL.MED , GL.MIN & V.LDetach muscles from GTContinue disection anteriorly along femoral neck till ant.capsule of hip.Develop space b/w hip capsules & muscles

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DANGERS:NERVES:• Sup.GL.N. damage at the upper end of incision

above GT.• Prevented by stay suture in the GL. Med• Femoral N. damaged by inadvertly placed retraction• Prevented by placing retractor strictly on the bone.VESSELS:• Fem. Vessels by retractor

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HARRIS APPROACH

• LATERAL APPROACH FOR EXTENSIVE EXPOSURE OF THE HIP.

• Permits hip dislocation ant & post. But requires GT osteotomy.So risks are Trochanteric non-union, Trochanteric bursitis, Heterotopic ossification

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SOME OTHER MODIFICATIONSMcFarland & Osborne lateral approach• Preserves the integrity of the

gluteus medius muscle.

• Combined mass of g.medius & vastus lateralis with their tendinous junction is elevated & retracted anteriorly.

Hardinge lateral Transgluteal approach• Strong mobile tendon of

gluteus medius is incised obliquely across GT leaving posterior half still attached to GT.

• GT Osteotomy is avoided.

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GIBSON MODIFIED KL incision making it more anterior but still angled.

• Iliotibial band is incised along with its fibres, gluteus medius & minimus are divided at their insertions leaving enough tendon attached so that closure is easy & post-op rehabilitation is rapid

Gibson’s Posterolateral approach

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Gibson Approach Modified By Marcy and Fletcher

• For insertion of a prosthesis in which the hip is dislocated by internal rotation .

• Anterior part of the joint capsule is preserved to keep the hip from dislocating anteriorly after surgery.

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MODIFIED GIBSON APPROACH ???Useful alternative forKocher Langenbeckposterior approachto acetabulum.

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C

ADE- KOCHER LANGENBECK INCISIONBDE-GIBSON ORIGINAL SKIN INCISIONCDE- MODIFIED GIBSON APPROACH

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What are the modifications ???• Making vertical skin incision.- More cosmetic in

obese female dec risk of postop “saddlebag” soft tissue deformity.

• Limiting extent of hip joint capsultomy.• Rather G Max splitting, interval between G max &

TFL is developed.So, vascular supply of ant portion of G max is not at risk.

• Better anterosuperior visualization & access.

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POSTERIOR APPROACH:(MOORES APPROACH- SOUTHERN EXPOSURE)

• Most commonly used approach & practical• Easy ,safe, quickINDICATIONS:HemiarthroplastyTHR including revisionORIF of post. Acetabular #Dependent drainage in hip sepsisRemoval loose bodiesPedicle bone graftingOpen reduction of posterior dislocation

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POSITION:True lateral with affected limb above

LANDMARK:GTINCISION:• 10-15cm curved centered on posterior aspect of GT• Begin proximally 6-8cms posterosuperior to posterior aspect of GT • Continue to GT• Curve the incision in line with fibers of G MAX • Continue along shaft of femur.

Incision is identical to Kocher-Langenbeck App, except localized posterior to GT

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UMYCut the fascia lata to expose the V.lat.Superiorly split the fibers of GM(very important) gently.

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Retract GL.maximus & deep fascia to expose posterolateral aspect of hip.Cover by short ext.rotators.Internally rotate the hip to move sciatic N. away from the field.

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Detach piriform & obt.internus retract them posteriorly to protect sciatic nerveIncise the hip jt, capsule , to expose the head & neck of femur.Internally rotate femur for hip dislocation.

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DANGERS:Sciatic Nerve-PREVENTION- Extend hip & flex knee to prevent-Gentle retraction & release short ext rotators.VESSELS-Inferior Gluteal A- Leaves below piriformisFemoral vessels

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MEDIAL APPROACH(LUDOLFFS APPROACH)

INDICATIONS:• Open reduction of congenital dislocation of hip.• Biopsy & RX of tumors of the inf.portion of femoral

neck & medial aspect of proximal shaft.• Psoas release• Obturator neurectomy.• By making short transverse/longitudinal incision-

used for adductor release

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POSITION:Supine with affected hip flexed , abducted & externally rotated.Sole of foot lies along the medial side of opp. Knee.LANDMARKS:Adductor longus traced to its originPubic tubercleGT

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INCISION:Longitudinal incision on the medial thigh starting 3cm below

pubic tubercle that runs down over adductor longusLength depends on amount of femur to be exposed

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INTERNERVOUS PLANE:Superficial dissection b/w adductor.longus & gracialis-BOTH ANT DIVISON OF OBTURATOR NERVEDoesn’t involve Int.N.plane

UMYSUPERFICIAL DISSECTION:B/w adductor longus & gracialis

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B/w adductor brevis & magnus till lesser trochanterProtect post.division of obt.N. to preserve innervation of adductor portion of Ad.magnus.

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DANGERS:NERVES:Ant,div of obt.N- which lies at the top of the obt.externus

running b/w add.longus & brevis.Post.div of obt.N. lies with in the obt,externus which it

supplies before it leaves the pelvis.Runs down the thigh on adductor magnus under the

brevis,it also supplies adductor portion of adductor magnus.

These nerves are transected if approach is meant for adductor spasm or else protect them.

VESSELS:Medial femoral circum flex A.-may be injured at distal part

of psoas.

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QUESTION?????

• Which of the following approaches for total hip arthroplasty is reported to have the lowest prosthetic dislocation rate?

• 1. Posterior approach with posterior soft tissue repair• 2. Anterolateral (Watson Jones)• 3. Direct lateral (Hardinge)• 4. Transtrochanteric• 5. Posterior approach without posterior soft tissue

repair

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Ans--LATERAL APPROACH

• The metanalysis by Masonis and Bourne found a dislocation rate for 14 studies involving 13000 total hips-

• 1.27% for the transtrochanteric approach, 3.23% for the posterior approach (3.95% without posterior repair and 2.03% with posterior repair),

• 2.18% for the anterolateral approach, • 0.55% for the direct lateral approach.

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