This document describes several surgical approaches to the hip and acetabulum. It discusses the Smith-Petersen anterior approach, which provides access to the anterior hip joint. It also covers the Watson-Jones anterolateral approach, most commonly used for total hip replacement. Additionally, it summarizes the Southern posterior approach, lateral approach, and medial (Ludloff's) approach. For the acetabulum, it outlines the ilioinquinal and posterior (Kocher-Langenbeck) approaches. Each approach is defined by its indications, patient positioning, incision, exposure, dangers, and relevant references.

1. Surgical Approaches
To Hip & Acetabulum
Dr Sijan Bhattachan
MS Orthopaedics second year resident
NAMS

2. ANTERIOR
APPROACH TO THE
HIP

3. • Smith Peterson approach
• Gives safe access to the hip joint and ilium.

4. Indications
• Open reduction of congenital dislocations of
the hip when the dislocated femoral head
lies anterosuperior to the true acetabulum.
• Synovial biopsies
• Intraarticular fusions
• Total hip replacement
• Hemiarthroplasty
• Excision of tutors, especially of the pelvis
• Pelvic osteotomies

5. Position of patient
• Supine

6. Incision
• Long incision following the anterior half of
the iliac crest to the ASIS
• Curve down so that it runs vertically for some
8-10 cm, heading toward the lateral side of
patella

7. Internervous plane
• Superficial plane between Sartorius & Tensor
fascia late
• Deep plane between Rectus femoris &
Gluteus medium

8. Superficial dissection
• Identify the gap between TFL and Sartorius
by palpation
• Dissect down through subcutaneous fat along
the inter muscular interval.
• Avoid cutting lateral femoral cutaneous
nerve
• Large ascending branch of lateral femoral
circumflex artery crosses the gap between
the two muscles below the ASIS; Ligated or
coagulated/

12. Deep dissection
• Detach Rectus femoris from both its origins
and retract medially; Retract gluteus medius
laterally
• Capsule of hip joint is then exposed.
• Retract iliopsoas medially
• Adduct and fully externally rotate the leg to
put capsule on stretch
• Incise capsule as the surgery requires either a
longitudinal or T shaped incision

19. Dangers
• Lateral femoral cutaneous nerve
• Femoral nerve
• Ascending branch of lateral femoral
circumflex artery

20. Advantages:
• Excellent access to the anterior hip joint
• Good muscle function- if the surgeon stays within
limitations and employs sound postoperative care
• Can be extended distally and laterally through the
iliotibial band for features of lateral exposure
• May be extended proximally and medially and then
subperiosteally to expose the entire acetabulum
• Ready source of bone graft material

21. Disadvantages:
• Necessity for prolonged protection to avoid risk of late
detachment of TFL and gluteal medius because of major
muscle dissection.
• High incidence of heterotrophic bone formation and joint
stiffness
• Injuries to lateral femoral cutaneous nerve and disturbing
dysaesthasia of thigh
• Exposure to femoral medullary canal is limited.

22. ANTEROLATERAL
APPROACH TO THE
HIP

23. ANTEROLATERAL APPROACH TO THE HIP:
• Watson Jones approach
• Most commonly used for total hip replacement
• It combines an excellent exposure of the acetabulum with
safety during reaming of femoral shaft
Uses :
• Total hip replacement
• Hemiarthroplasty
• ORIF of femoral neck fractures
• Synovial biopsy of the hip
• Biopsy of the femoral neck

24. Position
• Supine, so close to the edge that the buttock
of the affected side hangs over

25. Incision
• 8-15 cm straight longitudinal incision
centered on the tip of the greater trochanter

26. Internervous plane
• No true internervous plane, since both
gluteus medius and tensor fascia latae have a
common nerve supply, the superior gluteal
nerve.

27. Superficial dissection
• Incise the fascia lata at the posterior margin
of greater trochanter, then extend
proximally and distally; elevate this flap
anteriorly
• Detach few fibers of gluteus medius & locate
the interval between tensor fasciae and
gluteus medius.

31. Deep dissection
• It consists of detaching part or all of the
abductor mechanism and then dissecting up
the femoral neck superficial to the capsule of
the joint
• Two techniques improve exposure of the
acetabulum by neutralising the abductor
mechanism,allowing femur to fall
posteriorly—Trochanteric osteotomy
—Partial detachment of abductor mechanism

32. Osteotomy of greater trochanter

34. Partial resection of gluteus medius tendon

37. Exposure of acetabulum

39. Dangers
• Femoral nerve
• Femoral vessels
• Profunda femoris artery
• Femoral shaft fractures

40. Lateral Approach to
Hip Joint

41. Position
• Supine on operating table with the GT at the
edge of table

42. Incision
• Longitudinal incision begining 5 cm above the
tip of GT and extending down the line of
shaft of femur for approx. 8 cm

43. Internervous plane
• No true internervous plane
• Fibers of gluteus medius are split in their
own line distal to the point where the
superior gluteal nerve supplies the muscle
• Vastus lateralis also split in its own line

44. Superficial dissection
• Incise fat and underlying fascia in line with
skin incision
• Retract cut edges of the fascia to pull the
tensor fasciae latae anteriorly and gluteus
maximus posteriorly

46. Deep dissection
• Split the fibers of gluteus medius in the
direction of their fibres beginning in the
middle of trochanter
• Split the fibers of vastus lateralis muscle
overlying the lateral aspect of the base of GT
• Enter the capsule using longitudinal T shaped
incision

52. Dangers
• Superior gluteal nerve ; runs between the
gluteus medius and minimus muscles approx.
3-5 cm above the upper border of GT
• Femoral nerve
• Femoral vessels
• Transverse branch of lateral circumflex
artery

53. Modified Hardinge(modified direct lateral
transgluteal approach)
Modified Hardinge approach is direct lateral approach by placing the abductor "split" more
anterior, directly over the femoral head and neck

54. Posterior Approach
to the Hip

55. • Southern Moore approach
• Allows easy, safe and quick access to the
joint.
• Avoid loss of abductor power.
• Higher dislocation rate as compared to
anterior approach

56. Indications
• Hemiarthroplasty
• THR, including revision surgery
• Open reduction and internal fixation of
posterior acetabular fractures
• Dependent drainage of hip sepsis
• Removal of loose bodies from the hip joint
• Pedicle bone grafting
• Open reduction of posterior hip dislocation

57. Position
• True lateral position,with affected limb
uppermost

58. Incision
• 10-15 cm curved incision centered on the
posterior aspect of GT

59. Internervous plane
• No true internervous plane
• Gluteus maximus is split in the line of its
fibres

60. Superficial dissection
• Incise fascia lata on the lateral aspect of
femur to uncover the vastus lateralis and
extend superiorly.
• Split the fibers of gluteus maximus by blunt
dissection

61. Deep dissection
• On retracting the fibers of split gluteus
maximus and deep fascia thigh, short
external rotator muscles are seen that cover
the posterolateral aspect of hip joint
• Internally rotate the hip to put short external
rotators on stretch
• Detach the muscles close to their femoral
insertion and reflect them backward
• Hip joint capsule can be incised

66. Dangers
• Sciatic nere
• Inferior gluteal artery

67. Medial Approach to
Hip joint

68. • Ludloff’s approach
• Indications
-Open reduction of congenital dislocation of hip
-Biopsy and treatment of tumors of the inferior
portion of femoral neck and medial aspect of
proximal shaft
-Psoas release
-Obturator neurectomy

69. Position
• Supine with affected hip flexed,abducted and
externally rotated

70. Incision
• Longitudinal incision on the medial side of
the thigh,starting at a point 3 cm below the
pubic tubercle

71. Internervous plane
• No true internervous plane
• Superficially, between adductor longus and
gracilis
• Deeply between adductor brevis and
adductor magnus

75. APPROACHES TO
ACETABULUM
1. ILIOINGUINAL APPROACH
2. POSTERIOR APPROACH

76. ILIOINGUINAL
APPROACH
• Allows exposure of the inner surface of pelvis
from SIJ to the pubic symphysis.
• Also allows visualisation of anterior and
medial surfaces of the acetabulum; suitable
for exposure of anterior column fractures of
acetabulum

77. Position
• Supine with GT at the edge of table

78. Incision
• Curved anterior incision beginning 5 cm
above the ASIS.
• Extend the incision medially, passing 1 cm
above the pubic tubercle to end in the
midline

79. Internervous plane
• No true internervous plane
• Dissection consists essentially of lifting off
muscular,nervous and vascular structures
from the inner wall of the pelvis

80. Superficial dissection
• Dissect down through the subcutaneous fat to
expose aponeurosis of external oblique
muscle

84. 3 windows
• Lateral window; lateral to iliopsoas gives
access to the inner surface of the ilium
• Middle window; medial to iliopsoas but
lateral to femoral vessels, gives access to the
quadrilateral plate
• Medial window; medial to the femoral
vessels, gives access to the superior pubic
ramus and symphysis

86. Dangers
• Femoral nerve
• Lateral cutaneous nerve of thigh
• Femoral vessels
• Inferior epigastric vessels
• Spermatic cord
• Urinary bladder

87. POSTERIOR APPROACH
• Kocher-Langenbeck approach
• Gives access to the posterior wall of
acetabulum and its posterior column.
• Easiest of all acetabular approaches and
extensive blood loss is not usually
encountered.

88. Indications;
Reduction & fixation of
• Fractures of the posterior lip of acetabulum
• Fractures of posterior column
• Fractures of posterior lip and column
• Simple transverse fractures
• Transverse fractures with associated
posterior lip fractures

89. Position
• Lateral/ Prone

90. Incision
• Longitudinal incision centered on the GT
extending from just below the iliac crest to
10 cm below the tip of GT

91. Superficial dissection

93. POSTERIOR APPROACH

94. References :
• Hoppenfeld surgical exposures in orthopaedics 4th edition
• Campbell’s operative orthopaedics 12th edition