This document provides an overview of various approaches to the hip joint for surgical procedures. It describes several anterior, lateral, posterior, and medial approaches. The key approaches discussed include the Smith-Petersen anterior approach, Watson-Jones lateral approach, Moore posterior approach, and Ferguson medial approach. For each approach, the document outlines the relevant indications, surgical technique including incision placement and tissue dissection, as well as advantages and disadvantages. The goal of the approaches is to provide exposure of the hip joint and surrounding structures while avoiding damage to major neurovascular structures.

1. Approaches to hip joint
Moderator:Dr Neeraj Mahajan
Moderator :Dr Amrit rai
Presented by :
Dr Sandeep verma
3rd year PG OU-II

2. HIP
Anterolateral approach
Anteromedial
Posteriomedial

3. PRINCIPLE OF SURGERY IN HIP JOINT
• Thorough knowledge of anatomy and variations
• Basics of surgery should be always followed including hand scrub ,part
preparation of the area ,positioning the patient ,draping ,identification of
landmarks and making incision along skin creases and surgical planes.
• Focused dissection:Directly approach the operative area whether it is a bone or a
joint thus minimizing dissection.
• Follow internervous plane to avoid damage to and denervating the muscles.
• Sometimes it is not possible to dissect along the internervous plane,so muscle
splitting approaches needed
I. Split muscle along the lines of the fibers.
II. Splitting muscle as far as possible from neuromuscular junction to avoid
denervation
III. Bulk of muscle should be retracted along with nerves

4. Anterior approach
Anterior iliofemoral approach
to hip
SMITH PETERSON
Modified iliofemoral approach
to the hip
SMITH PETERSON
Anterior approach to hip using transverse approach
SOMERVILLE

5. SMITH PETERSON APPROACH
Indications
I. Open reduction of congenital dislocation of the hip when the dislocated femoral
head lies anterior superior to the acetabulum
II. Synovial biopsies
III. Intra articular fusions
IV. Total hip replacement
V. Hemiarthroplasty
VI. Excision of tumours especially of the pelvis
VII. Hip arthrodesis
VIII. Decompression of the joint and pus drainage in septic arthritis

6. SMITH PETERSON APPROACH
• Place the patient supine on the operating table

7. Make an 8 to 10 cm incision following the anterior half of the iliac crest to
the anterior superior iliac spine ,then downwards and slightly laterally 10 to
12 cm

8. Go through internervous plane
1.Superfically between sartorius supplied by femoral nerve and tensor fascia
lata supplied by superior gluteal nerve

9. Deeply between rectus femoris supplied by femoral nerve and gluteus medius
supplied by superior gluteal nerve.

10. NOTE
You will come across Lateral femoral cutaneous nerve over inter-
nervous plane, kindly protect it and ascending branch of the lateral
femoral circumflex artery ,ligate it or coagulate

11. SOMERVILLE APPROACH
• Used for irreducible congenital dislocation of hip in a young child
• Make a straight skin incision ,beginning anteriorly inferior and medial
to anterior superior spine and coursing obliquely superiorly and
posteriorly to the middle of crest and expose the crest

12. 1.Reflect abductors subperiosteally from the iliac wing distally to the capsule
of joint
2. Increase exposure of the capsule by separating the tensor fasciae lata from
sartorius for about 2.5 cm inferior to the ASIS
.

13. 1.Expose the reflected head of rectus femoris from acetabulum
2.Near the acetabulum rim , make a small incision in the capsule
.

14. 1.Examine inside of acetabulum and remove any inverted labrum
2.Reduce the head into the acetabulum by abducting the thigh 30 degree and
internally rotating it.
3.Hold the joint in this position and close the capsule

15. LATERAL APPROACH TO THE HIP
Lateral approach to the hip
WATSON JONES APPROACH
Lateral approach for extensive exposure of the hip
HARRIS APPROACH
Lateral approach to the hip preserving the gluteus
medius
MACFARLAND AND OSBORNE
Lateral trans-gluteal approach to the hip
HAY AS DESCRIBED BY MCLAUCHLAN
Lateral trans-gluteal approach to the hip
HARDINGE

16. WATSON JONES APPROACH
INDICATIONS
• Hip arthroplasty
• Fracture of femur head
• Open reduction of femoral neck fractures
• Femoral acetabular impingement

17. • Begin incision 2.5 cm distal and lateral to ASIS
• Curve it distally and posteriorly over lateral aspect of the greater
trochanter and lateral surface of the femoral shaft.

18. Locate interval between gluteus medius and tensor fasciae latae

19. Incise the capsule of the joint longitudinally along the anterio-superior
surface of the femoral neck

20. • In the distal part of incision the origin of vastus lateralis may be
reflected distally or split longitudinally to expose base of trochanter
and proximal part of the femoral shaft

21. WATSON JONES APPROACH
ADVANTAGES
I. Stability and reduced chance s of posterior dislocation
II. Less risk of sciatic nerve damage
DISADVANTAGES
I. Weakening of abductors during dissection or by denervation.
II. Injury to superior gluteal nerve.
III.Injury to lateral circumflex femoral artery.
IV.Rarely injury to femoral vessels and nerve.

22. HARRIS APPROACH
• Make a U shaped incision with its base at the posterior border of the
greater trochanter

23. • Divide Iliotibial band proximal to greater trochanter amd place a
finger on insertion of gluteus maximus deep to the band and fascia
lata incised 1 finger breath anterior to insertion without cutting into
insertion of gluteus maximus

24. • For wide exposure posteriorly and to provide space into which
femoral head can be dislocated ,a short oblique incision has been
made in posteriorly reflected fascia lata , extending into gluteus
maximus.

25. • Osteotomize greater trochanter to free abductors and reflect distally
the origin of vastus lateralis .
• Free the superior part of joint capsule.
• Divide insertion of piriformis, obturator externus and obturator
internus

26. • Expose full circumference of femoral head by placing greater
trochanter and its muscle pedicle into acetabulum and externally
rotating femur.

27. • Entire acetabulum can be exposed by retracting the greater trochanter
superiorly and dislocating the femoral head posteriorly.
• When closing wound position the limb in almost full abduction and in
about 10 degree of external rotation. Transplant the greater trochanter
distally, and fix it directly to lateral side of femoral shaft with K wire ,screws
or cable wire.

28. MACFARLAND & OSBORNE APPROACH
• Make a mid-lateral skin incision centered over the greater
trochanter.

29. • Expose the gluteal fascia and iliotibial band and divide them in a straight
mid-lateral line along the entire length of the skin incision.
• Reflect gluteus maximus posteriorly and tensor fasciae latae anteriorly.

30. • Gluteus medius identified and from posterior border make an incision
down to the bone through the periosteum and fascia obliquely and
distally across the greater trochanter to middle of the lateral aspect of
the femur.

31. • Combined muscle mass consisting of gluteus medius and vastus
lateralis with their tendinous junction elevated and retracted
anteriorly

32. • Tendon of gluteus minimus is split and divided before retraction
proximally.

33. • Open capsule to expose the joint.

34. HARDINGE APPROACH
INDICATIONS
I. Total hip replacement , hip resurfacing.
II. Fracture of femoral neck.
III. Open reduction of femoral neck fractures.
IV. Proximal femoral osteotomy.

35. • Position the patient supine on the operating table with GT at the edge
of the table

36. • Make a posteriorly directed lazy J incision centered over the greater
trochanter

37. • Divide the fascia lata in line with skin incision centered over greater
trochanter.
• Retract tensor fascia lata anteriorly and gluteus maximus posteriorly,
exposing origin of vastus lateralis and the insertion of the gluteus
medius.

38. • Incise the tendon of the gluteus medius obliquely across the greater
trochanter, leaving the posterior half attached to the trochanter.
• Carry the incision proximally in the line with the fibers of the gluteus
medius at the junction of the middle and posterior third of the muscle.
• Note :- Split should be no further than 4 to 5 cm from the tip of greater
trochanter to avoid injury to the superior gluteal nerve and artery.

39. • Elevate tendinous insertion of the anterior portion of gluteus
minimus and vastus lateralis muscle.
• Abduction of thigh exposes the anterior capsule of the hip joint.
• Incision given to expose the joint.

40. HARDINGE APPROACH
• ADVANTAGES
I. Good access to the hip with preservation of vascularity.
II. Minimal risk of damage to sciatic nerve.
DISADVANTAGES
I. Damage to gluteal muscle mainly gluteus medius and loss of
abductor function
II. Heterotropic ossification may be a problem.

41. HAY AS DESCRIBED BY MCLAUCHLAN
• Make a longitudinal skin incision centered midway between the
anterior and posterior borders of the GT

42. • Incise the deep fascia and tensor fascia lata in line with the skin
incision.
• Retract these structure to expose GT with gluteus medius attached to
it proximally and the vastus lateralis attached distally.

43. • Split the gluteus medius in the line of its fibers for a distance of no
more than 4 to 5 cm to avoid damage to the superior gluteal
neurovascular bundle.
• Elevate two rectangular slices of GT ,one anteriorly and one
posteriorly with an osteotome.
• These slices of trochanter have gluteus medius attached proximally
and vastus lateralis attached distally.Retract to reveal gluteus
minimus

44. • Rotate the hip externally and split the gluteus minimus in the line of
its fibers or detach it from the greater trochanter.
• Incise the capsule of the hip joint and dislocate the hip anteriorly by
flexion and external rotation

45. HAY AS DESCRIBED BY MCLAUCHLAN
• When closing ,suture the capsule if enough of it is left
• Internally rotate the hip and suture the trochanteric slices to the
periosteum and the other soft tissue covering the trochanter.

46. POSTERIOLATERAL APPROACH(GIBSON)
• Begin the proximal limb of the incision at a point 6 to 8 cm anterior to
the PSIS and just distal to the iliac crest ,overlying the anterior border
of the gluteus maximus muscle.
• Extend it distally to the anterior edge of the GT and farther distally
along the line of the femur for 15 to 18 cm .

47. • Reflect the soft tissue and expose the deep fascia.
• Incise the iliotibial band in line with its fibers ,beginning at the distal
end of the wound and extending proximally to the GT.
• Retract anterior and posterior mases to expose the GT with attached
muscles.

48. • Separate the posterior border of gluteus medius from adjacent
piriformis tendon by blunt dissection.
• Divide the gluteus medius and minimus at their insertion ,but leave
enough of their tendons attached to the GT to permit closure
• Reflect these muscles anteriorly
• Now the joint capsule can be seen

49. • Hip can be dislocated by flexing the hip and knee and abducting and
externally rotating the thigh

50. Posterior approach to the hip
Osborne approach
Moore approach

51. • OSBORNE APPROACH
• Begin the incision 4.5 cm distal and lateral to the PSIS and continue it
laterally and distally ,remaining parallel with the fibers of the gluteus
maximus muscle to the posterior superior angle of GT and distally
along the posterior border of the trochanter for 5 cm

52. • Gluteus maximus is splitted parallel with line of the incision and
retracted

53. • Divide piriformis ,gemellus and obturator internus muscles and retract
medially to expose posterior aspect of joint capsule.

54. MOORE APPROACH
INDICATIONS
• Hip arthroplasty
• Acetabular reconstruction during revision
• Muscle pedicle bone grafting
• Acetabular fractures for fixation of posterior wall/column

56. • Start the incision approx. 10 cm distal to the PSIS and extend it
distally and laterally parallel with the fibers of the gluteus maximus to
the posterior margin of the GT. Direct the incision distally 10 to 13 cm
parallel with the femoral shaft.

57. • Gluteus maximus is spilitted in line with its fibers and retracted to
expose sciatic nerve ,GT and short external rotators muscles.

58. • Free short external rotators muscles from femur and retracted
medially to expose the joint capsule

59. • Open the joint capsule and dislocate hip joint by flexing ,adducting
and internally rotating thigh

60. MOORE APPROACH
• ADVANTAGES
I. Good exposure of both acetabulum and femoral head and neck
DISADVANTAGES
I. Blood supply to femoral head is likely to get damaged resulting in
osteonecrosis restricting its use in conservative hip surgery such as open
hip debridement ,open surgery for hip impingement.
II. Damage to sciatic nerve
III. Injury to inferior gluteal vessels
IV.Higher dislocation rate if soft tissue reconstruction is inadequate.

61. MEDIAL APPROACH TO THE HIP
FERGUSON;HOPPENFELD AND DEBOR
INDICATIONS
I. Open reduction of DDH.
II. Approach of choice for lesion near lesser trochanter
III. Biopsy and treatment of tumours of inferior portions and femoral neck and medial
aspect of proximal shaft.
IV. Psoas release
V. Obturator neurectomy
DISADVANTAGES
I. Incision closer to perineum.
II. Limited exposure of capsule of hip joint.
III. Deep incision –vascular injury.

63. • Make a longitudinal incision on the medial aspect of the thigh,
beginning about 2.5 cm distal to the pubic tubercle and over the interval
between the gracilis and the adductor longus muscles.

64. • Develop the plane between the adductor longus and brevis
muscles anteriorly and the gracilis and adductor magnus muscles
posteriorly

65. Adductor longus has been retracted anteriorly, and gracilis and
adductor magnus have been retracted posteriorly

66. • Expose and protect the posterior branch of the obturator nerve
and the neurovascular bundle of the gracilis muscle. Locate lesser
trochanter and the capsule of the hip joint in the floor of the
wound

67. DANGERS
1.Anterior branch obturator nerve lies on the front of adductor brevis
and neurovascularbundle of gracilis muscle.
2.Posterior division lies in the substance of obturator externus,runs
down the high on adductor magnus and under adductor brevis.
3.Medial circumflex artery passes on distal part of psoas tendon

68. THANK YOU.