Surgical anatomy and approaches to hip

1. Topic- Surgical hip
approaches
Presenter – Dr. Karthik M V
Moderator – Dr. Jayant Jain

2. Introduction
• Largest joint of the body
• It is a synovial articulation between the
head of femur and the acetabulum of the
pelvic bone.
• The joint is a multi-axial ball and socket
joint designed for stability and
weightbearing at the expense of mobility

3. • The acetabular fossa is orientated inferiorly
(45°) and anteriorly (15°) and laterally.
• The acetabular rim is circular but deficient
in the lower one-fifth where it is completed
by transverse acetabular ligament (TAL)
• The depth of acetabulum provides coverage
to the femoral head. This depth is
augmented by the labrum, which runs
circumferentially around its perimeter to the
base of the fovea, where it becomes TAL

4. Femur
• The femur is the longest and strongest bone in the
human body. It is mostly cylindrical throughout its
length, and it is anterolaterally bowed in its
midportion
• Head is covered by articular hyaline cartilage in
approximately 60–70% of a sphere also the fovea
centralis is devoid of cartilage.
• The neck of the femur is approximately
5 cm long. The proximal metaphysis and neck are
anteverted by approximately 14°. The angle
between the
femoral shaft and the neck is approximately 125°

6. Capsule
• The capsule is attached along the anterior and posterior periphery of the acetabulum
just outside the acetabular labrum.
• Inferiorly, the capsule is attached to the transverse acetabular ligament.
• The capsule is attached to the femur anteriorly along the intertrochanteric line, but
posteriorly it attaches to middle of the neck so that the Basi cervical portion and
intertrochanteric crest are extracapsular posteriorly

7. Ligaments
• Ileofemoral ligament (Bigelow):
This is fan-shaped modified “λ”
structure that resembles inverted
letter Y
• It is the strongest ligament in the
body
• Attached to the lower portion of the
anterior inferior iliac spine and the
diverging fibers of the Y fan out to
attach along the intertrochanteric
line.
• Taut in: full extension

8. • Pubofemoral ligament: It arises
from pubic portion of the
acetabular rim and the
obturator aspect of the superior
pubic ramus and blends with
the inferior-most fibers of the
iliofemoral ligament.
• Taut in: Hip extension and
abduction

9. • Ischio-femoral Ligament : It arises from
the ischial portion of the acetabular
rim and spirals laterally and upward to
blend in the capsule
• It Blends with the posterior surface of
the capsule and zona orbicularis
• Taut in: Extension

10. • Ligamentum teres—it is intra-
articular but actually
extra-synovial as it is surrounded by
synovial membrane.
• The ligamentum attaches to the
fovea of the femoral head and
acetabular central fovea
• Zona orbicularis —“annular
ligament” encircles the femoral neck
like a button hole and again plays
little role in stability

11. Muscles

14. Movements
• Flexion of 120°
• Extension 20°
• Abduction 40–45°
• Adduction of 20–25°
• Internal rotation 35°
• External rotation 45°

15. Surgical approaches

16. The characteristic of a good approach should:
• Provide adequate approach to both femoral head and acetabulum.
• Involve minimal dissection of soft tissues.
• Reduce operative time and blood loss.
• Should be between intervascular and interneural plane to minimize
morbidity.
• Provide least postoperative pain and early mobilization.
• Be associated with minimal chance of damage to neurovascular bundles
and other vital structures and with minimal risk of infection or thrombosis.
• Should reliably restore the anatomy after procedure so that functional
deterioration is minimal and stability of joint is maintained

17. • Anterior approach – interval b/w
sartorius and tensor fascia lata.
• Anterolateral approach – interval
b/w tensor fascia lata and gluteus
medius.
• Posterior approach – interval b/w
gluteus medius and maximus or
gluteus maximus splitting.
• Medial approach – interval b/w
adductor longus and Gracilis.

18. Anterior Approach
(Smith-Petersen, Iliofemoral)
It exploits internervous plane b/w Sartorius (femoral nerve) & Tensor
Fascia Lata ( Superior gluteal nerve).
Indications:
• Open reduction of congenital dislocations of the hip when the dislocated femoral
head lies anterosuperior to the true acetabulum
• Synovial biopsies
• Intra-articular fusions
• Total hip replacement
• Hemiarthroplasty
• Excision of tumors, especially of the pelvis

19. • The patient is placed supine with a small sandbag under the affected buttock.

20. • Curvilinear Incision starting from the ant. half of iliac crest to ASIS and from there curve it
vertically down for 8-10cm

21. Internervous Plane:
The superficial plane Sartorius (femoral nerve) and the tensor fasciae latae (superior gluteal nerve)

22. Identify the gap between the tensor fasciae latae and the sartorius by palpation

23. The lateral femoral cutaneous nerve (lateral cutaneous nerve of the thigh) pierces the deep fascia close to the
intermuscular interval between the tensor fasciae Iatae and the sartorius

24. Incise the deep fascia on the medial side of the tensor fascia latae. Retract the sartorius upward and
medially and the tensor fascia downward and laterally.

25. The deeper internervous plane lies between the rectus femoris (femoral nerve) and the gluteus medius
(superior gluteal nerve)

26. The deep layer of musculature, consisting of the rectus femoris and the gluteus medius, is now visible.
The ascending branch of the lateral femoral circumflex artery must be ligated.

27. • Detach the rectus femoris from both its origins, the anterior inferior iliac spine and the superior lip of
the acetabulum, and retract it medially. Retract the gluteus medius laterally.

28. The hip joint capsule is now partly exposed. Retract the iliopsoas tendon medially

29. • The hip joint capsule is fully exposed. Detach the muscles of the ilium if further exposure is needed

30. • Adduct and external rotate to stretch capsule, incise capsule by longitudinal or T-
shaped incision, dislocate hip after capsulotomy by External rotation.

31. After incising the joint capsule; Proximal extension of the wound exposes the ilium. Distal extension of the
incision exposes the anterior aspect of the femur

33. Sommerville anterior approach
• Indication: For irreducible congenital dislocation of the hip in a young child
• Incision: Transverse “Bikini” incision – anteriorly- Inferior and medial to ASIS and
coursing obliquely superiorly and posteriorly to the middle of the iliac crest.
• For reduction of CDH following sequential steps must be performed: Psoas
tenotomy > Complete medial capsulotomy > excision of hypertrophied lig. Teres >
reduction of femoral head into true acetabulum

35. Minimally invasive Anterior approach to hip
• Reduction of displaced femoral neck fractures
• Drainage of hip infections
• Elective joint replacement surgery

36. Make an 8-cm longitudinal incision beginning 1 cm below and 1 cm lateral to the anterior superior iliac spine. Aim
the incision toward the head of the fibula. The center of the incision should be at the level of the tip of the greater
trochanter.

37. Identify the interval between sartorius and tensor fasciae latae and incise the deep fascia covering the tensor fasciae
latae muscle at its medial edge.

38. Retract the tensor fasciae latae laterally to expose the rectus muscle covered by a fascial layer

39. Incise the fascial sheath covering the anterior aspect of the rectus to expose the muscle.

40. Retract the rectus muscle medially to expose the fascia covering the posterior aspect of the muscle. Incise
this fascial sheath longitudinally to reveal the lateral circumflex vessels

41. Ligate the lateral circumflex vessels. Expose the anterior hip joint capsule covered by fatty tissue. Some fibers of psoas—
the iliocapsularis muscle will need to be separated from the capsule by sharp dissection. Incise the anterior capsule of the
hip joint longitudinally.

42. Anterolateral approach (Watson-jones
approach)
• Excellent exposure of acetabulum with safety during reaming of
femoral shaft.
• It exploits intermuscular plane b/w Tensor fascia latae & Gluteus
medius.
• It involves partial or complete detachment of abductors so that hip
can be adducted during reaming.

43. • Abductor mechanism released by either trochanteric osteotomy or
detaching anterior part of gluteus medius and whole of minimus.
• There is no true internervous plane for this approach, since the
gluteus medius and the tensor fasciae latae have a common nerve
supply, the superior gluteal nerve.

44. • Indications:
• Total hip replacement
• Hemiarthroplasty
• Open reduction and internal fixation of femoral neck fractures
• Synovial biopsy of the hip
• Biopsy of the femoral neck

45. Position of the patient on the operating table for the anterolateral approach to the hip.
Bring the greater trochanter to the edge of the table, and allow the buttocks, skin, and fat to fall
posteriorly, away from the operative plane

46. Incision for the anterolateral approach to the hip- 8-15cm straight longitudinal incision centered
over tip of greater trochanter

47. Incise the fascia lata posterior to the tensor fasciae latae.

48. Retract the fascia lata and the tensor fasciae latae muscle, which it envelopes,
anteriorly, revealing the gluteus medius and a series of vessels that cross the interval between the tensor fasciae
latae and the gluteus medius.

49. Retract the gluteus medius posteriorly and the tensor fasciae latae anteriorly, uncovering the fatty layer
directly over the joint capsule

50. Bluntly dissect the fat pad off the anterior portion of the joint capsule to expose it and the rectus femoris
tendon

51. Osteotomize the greater trochanter

52. Reflect the osteotomized portion of the trochanter superiorly (with the attached gluteus medius) to reveal the joint
capsule

53. The joint capsule may also be exposed by partial resection of the gluteus medius tendon from the
anterior portion of the trochanter.

54. Reflect the head of the rectus femoris from the anterior portion of the joint
capsule.

55. Incise the anterior joint capsule to reveal the femoral head and neck and the acetabular rim. If further
proximal exposure is needed, incise the fascia lata proximally toward the iliac crest and along the iliac crest
anteriorly.

56. To expose the acetabulum, dislocate and resect the femoral head. Placing three or four
Hohmann-type retractors around the lip of the acetabulum provides excellent exposure

57. Extend the incision down the lateral aspect of the thigh, incising the deep fascia and splitting the vastus
lateralis in line with its musculature to reach the lateral aspect of the femur

59. Lateral approach
• Indications: Total hip replacement surgeries
• Good approach to femur head
• Avoids need for trochanteric osteotomy
• Early mobilization ( bulk of gluteus medius preserved)

60. Position of the patient on the operating table for the anterolateral approach to the hip.
Bring the greater trochanter to the edge of the table, and allow the buttocks, skin, and fat to fall posteriorly, away
from the operative plane.

61. Make a longitudinal incision centered over the tip of the greater trochanter in the line of the femoral shaft

62. • Internervous plane:
• There is no true internervous plane.
• The fibres of the gluteus medius muscle are split in their own line distal to the
point where the superior gluteal nerve supplies the muscle.
• The vastus lateralis muscle is also split in it’s own line lateral to the point where it
is supplied by the femoral nerve.

63. Divide the deep fascia in the line of the skin incision, retracting the fascial edges to pull the tensor fasciae latae
anteriorly.

64. Split the fibers of gluteus medius above the tip of the greater trochanter and extend this incision distally
on the lateral aspect of the trochanter until 2 cm of the vastus lateralis is also split

65. Develop this anterior flap and divide the tendon of the gluteus minimus muscle to reveal the
anterior aspect of the hip joint capsule

66. Enter the capsule using a longitudinal T-shaped incision.

67. Osteotomize the femoral neck using an oscillating saw.

68. Extract the femoral head. Insert appropriate retractors to reveal the acetabulum.

70. Hardinge modification: (Direct Lateral
approach)
• Position: Patient supine with greater trochanter at the edge of the table
• Incision: Make a posteriorly directed lazy “J” incision centered over greater
trochanter
• The only difference in this step: Instead of osteotomizing GT, incise the tendon of
gluteus medius obliquely across the GT leaving the posterior half still attached to
the trochanter. Carry the incision proximally in line with the fibres of Gluteus
medius
• Distally carry the incision anteriorly in line with the fibers of vastus lateralis.
• Advantages : GT and bulk of gluteus medius preserved allowing rapid
rehabilitation.

73. Posterior approach (Moore’s approach-
Southern exposure)
• Most common approach used to expose hip joint
• Easy, safe, and quick access to joint
• No interference with abductor mechanism
• Excellent visualisation of femoral shaft
• Popular for revision joint replacement
• Division of posterior capsule, higher rates of dislocation

74. Indications:
• Hemiarthroplasty
• Total hip replacement, 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 dislocations

75. Position of the patient on the operating table for the posterior approach to the hip joint
True lateral position, affected limb uppermost, padding of bony prominences

76. There is no true internervous plane. Split the fibers of the gluteus maximus, a procedure that does not
cause significant denervation of the muscle.

77. A: Skin incision for the posterior approach to the hip joint. B: Incise the fascia lata
• 10-15cm curved incision centered
on the posterior aspect of greater
trochanter
• Begin incision 6-8cm above and
posterior to posterior aspect of
trochanter
• Runs along fibers of gluteus
maximus
• Curve the incision across the
buttock, cutting posterior aspect of
trochanter, continue along shaft of
femur
• Flex hip to 90 degree– longitudinal
incision over posterior aspect of
trochanter– ‘ Moore-style’ incision

78. Retract the gluteus maximus to reveal the fatty layer over the short external rotators of
the hip
• Remember that the sciatic nerve
leaves the pelvis and run down
the back of thigh on the short
external rotators, encased in fatty
layer.
• Don’t dissect to see the nerve,
unnecessary bleeding from the
vessels lying in the fat around it.

79. Push the fat posteromedially to expose the insertions of the short rotators. Note that the sciatic nerve is not
visible; it lies within the substance of the fatty tissue. Place your retractors within the substance of the gluteus
maximus superficial to the fatty tissue.

80. A, B: Internally rotate the femur to bring the insertion of the short rotators of the hip as
far lateral to the sciatic nerve as possible.
C: Detach the short rotator muscles close to their femoral insertion and reflect them backward, laying them
over the sciatic nerve to protect it.
• Insert stay sutures into the
piriformis and obturator internus
tendons just before they insert
to GT
• Detach the muscles 1cm from
their femoral insertion and
reflect backward

81. Incise the posterior joint capsule to expose the femoral head and
neck.

82. To gain additional exposure, cut the quadratus femoris and the tendinous insertion of the gluteus
maximus.

84. Medial approach (Ludloff’s Approach)
Indications:
• Open reduction of congenital dislocation of the hip. The approach gives an excellent
exposure of the psoas tendon, which can block reduction of the hip.
• Biopsy and treatment of tumors of the inferior portion of the femoral neck and
medial aspect of proximal shaft
• Psoas release
• Obturator neurectomy

85. Make a longitudinal incision on the
medial side of the thigh, starting at a
point 3 cm
below the pubic tubercle. The incision
runs down over the adductor longus. Its
length
is determined by the amount of femur
that must be exposed.
Place the patient supine on the operating
table with the affected hip flexed,
abducted,
and externally rotated

86. The intermuscular interval between the adductor
longus and the gracilis is not an internervous plane
because both muscles are innervated by the anterior
division of the obturator nerve. The plane is safe,
however, because the muscles receive their nerve
supplies proximal to the dissection.

87. A: Develop the plane between the gracilis and the adductor longus.

88. B: Retract the adductor longus and the gracilis to reveal the adductor brevis with the overlying
anterior division of the obturator nerve.
C: Retract the adductor brevis from the muscle belly of the adductor magnus to uncover the
posterior division of the obturator nerve. Note the lesser trochanter in the depths of the wound.

89. The deep muscular layer of the medial approach to
the hip. The dissection lies between the adductor
brevis and the adductor magnus. The gracilis,
adductor longus, and sartorius have been resected
to reveal the deeper structures of the medial
aspect of the thigh.
Anterior and posterior divisions of the obturator
nerve to the adductor longus and adductor brevis
will be visible.

90. References
• Surgical exposures in orthopaedics, stanley hoppenfeld, 5th edition
• Campbell’s operative Orthopaedics, 14th edition
• Netter’s Atlas
• Essential Orthopaedics, Manish Kumar Varshney
• Orthopaedics principles and its applications, Turek 8th edition

91. THANK YOU