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Salient Anatomical features of Hip
Joint
Articulation• Hip joint is a ball and socket
type of synovial joint.
• The hip joint is the articulation between the hemispherical head of femur and the cup shaped acetabulum of the hip bone
• The articular surface of the acetabulum is horseshoe shaped and is deficient inferiorly at the acetabular notch
Articulation• The cavity of acetabulum is deepened by the
presence of a fibrocartilaginous rim called acetabular labrum
• The labrum bridges across the acetabular notch and is here called the transverse acetabular ligament
• The articular surfaces are covered with hyaline cartilage
Neck-Shaft Angle
Fibrous Capsule
• Attached on hip bone to acetabular labrum and on femur to the intertrochanteric line in front and 1cm medial to the crest behind.
Hip Muscles
• Anterior– Rectus Femoris– Sartorius(tailor)– Iliopsoas Muscle
Group• Iliacus• Psoas Major
• Lateral– Gluteus Medius– Gluteus Minimus– Tensor Fascia Lata– Six Intrinsic External
Rotators• Piriformis• Quadratus Femoris• Obturator Internus• Obturator Externus• Gemellua Superior• Gemellus Inferior
• Medial– Adductor
Brevis– Adductor
Longus– Adductor
Magnus– Pectineus– Gracilus
APPROACHES TO HIPANTERIOR APPROACHES. • Iliofemoral approach of Smith-Peterson.• Limited anterior.• Somerville technique.ANTEROLATERAL APPROACHES.• Antero lateral approach of Smith-Peterson.• Antero lateral approach of Watson - Jones.• Modified Watson Jones: Lateral approach of WatsonLATERAL APPROACHES• Mc Farand and Osborne • Hardinge and Frndak and Mallory.• Transtrochanteric approach • Mc Lauchlan : Hay • Harris
POSTERIOR APPROACHES. • Austin Moore (southern) • Osborne • Posterolateral approach of GibsonMEDIAL APPROACHES. • Ludloff• Ferguson, Hoppenfeld, Deboer.ANTEROMEDIAL APPROACH OF ZATSEPIN AND
GAMIDOV.
The intermuscular intervals used in the anterior, anterolateral, and posterior approaches to the hip.
ANTERIOR APPROACH TO THE HIP
ANTERIOR APPROACH OF (SMITH-PETERSEN) TO THE HIP
Indications:• Open reduction of congenital dislocation of the hip when the
dislocated femoral head lies anterior superior to the true acetabulum.
• Synovial biopsies• Intra-articular fusions• Total hip replacement• Hemiarthroplasty• Excision of tumours, especially of the pelvis• Pelvis osteotomies• Arthrotomy of hip joint• Anterior column fractures of acetabulum• Insertion of pin or nail in fracture femoral neck
Position of the patient
• The patient is placed supine with a small sandbag under the affected buttock.
Incision
Curvilinear Incision starting from the ant. half of iliac crest to ASIS and from there curve it down for 8-10cm
Internervous Plane:• The superficial planeSartorius (femoral nerve) and the tensor fasciae latae (superior gluteal nerve)
The lateral femoral cutaneous nerve (lateral cutaneous nerve of the thigh) pierces the deep fascia close to the intermuscular interval
between the tensor fasciae latae and the sartorius.
Identify the gap between the tensor fasciae latae and the sartorius by palpation.
Incise the deep fascia on the medial side of the tensor fasciae latae. Retract the sartorius upward and medially and the tensor fascia
downward and laterally.
The deeper internervous plane lies between the rectus femoris (femoral nerve) and the gluteus medius
(superior gluteal nerve).
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.
Detach the rectus femoris from both its origins, the anterior inferior iliac spine and the superior lip of the acetabulum.
The hip joint capsule is now partly exposed. Retract the iliopsoas tendon medially.
The hip joint capsule is fully exposed. Detach the muscles of the ilium if further exposure is needed.
Incise the hip joint capsule.
Proximal extension of the wound exposes the ilium. Distal extension of the incision exposes the anterior aspect of the femur in the interval
between the vastus lateralis and the rectus femoris.
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• Relaxation of gluteal muscles in cases of high riding
dislocations
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 stiffnessInjuries to lateral femoral cutaneous nerve and disturbing dysesthasia of thigh
• Exposure to femoral medullary canal is limited.
ANTEROLATERAL APPROACH TO THE HIP
ANTEROLATERAL APPROACH TO THE HIP: • Most commonly used for total hip replacement• It combines an excellent exposure of the acetabulum with
safety during reaming of femoral shaft• Popularized by Watson-Jones and modified by Charnley,
Harris and Muller.
Uses :• Total hip replacement• Hemiarthroplasty• ORIF of femoral neck fractures• Synovial biopsy of the hip• Biopsy of the femoral neck
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.
Incision for the anterolateral approach to the hip.
Incision: • Flex the leg about 300 and adduct it so that it is lying
across the opposite knee both to bring the trochanter into greater relief and to move the tensor fasciae latae anterior make 8-15 cm straight longitudinal incision centered on the tip of the greater trochanter the incision crosses the posterior third of the trochanter before running down the shaft of the femur.
Inter-nervous plane:• 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.
Incise the fascia lata posterior to the tensor fasciae latae.
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.
Retract the gluteus medius posteriorly and the tensor fasciae latae anteriorly, uncovering the fatty layer
directly over the joint capsule.
Bluntly dissect the fat pad off the anterior portion of the joint capsule to expose it and the rectus femoris tendon.
Osteotomize the greater trochanter.
Reflect the osteotomized portion of the trochanter superiorly (with the attached gluteus medius) to reveal the joint capsule.
The joint capsule may also be exposed by partial resection of the gluteus medius tendon from the anterior portion of the trochanter.
Reflect the head of the rectus femoris from the anterior portion of the joint capsule.
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. To facilitate dislocation of the hip, incise
the tight fascia lata and the fibers of the gluteus maximus (inset).
To expose the acetabulum, dislocate and resect the femoral head. Placing three or four Homan-type retractors around the lip of the acetabulum
provides excellent exposure.
HOW TO ENLARGE THE APPROACH• Local measures like incising the fasciae latae
anteriorly or posteriorly.• Extensile measures extending the skin incision
down the lateral aspect of the thigh and splitting the vastus lateralis to gain access to the lateral aspect of the femur. This approach can not be usefully extended proximally.
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.
To be Continued..
Lateral Approach to Hip Joint
LATERAL APPROACH TO THE HIP:• The direct lateral approach (or transgluteal
approach) allows excellent exposure of the hip joint.• It avoids the need for trochanteric osteotomy.
Because the bulk of the gluteus maximus muscle is preserved intact.
Indications:• Total hip replacement surgeries• Good approach to femur head
Position of the patient on the operating table for the lateral 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.
Position of the patient and incision:• Supine on the operating table with the greater trochanter at the
edge of the table. This allows the buttock muscles and gluteal fat to fall posteriorly away from the operative plane.
• Make a longitudinal incision centered over the tip of the greater trochanter in the line of the femoral shaft.
Incision:• Begin the incision 5cm above the tip of the
greater trochanter make a longitudinal incision that passes over the centre of the tip of the greater trochanter and extends down the line of the shaft of the femur for approximately 8cm.
Internervous plane:• There is no internervous plane.• The fibers 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 splint in its own line lateral to the point where it is supplied by the femoral nerve.
Divide the deep fascia in the line of the skin incision, retracting the fascial edges to pull the tensor fascia
latae anteriorly.
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.
Develop this anterior flap and divide the tendon of the gluteus minimus muscle to reveal the anterior aspect of the hip joint capsule.
Enter the capsule using a longitudinal T-shaped incision.
Osteotomize the femoral neck using an oscillating saw.
Extract the femoral head. Insert appropriate retractors to reveal the acetabulum.
Dangers:• Superior gluteal nerve runs between gluteus medius and
gluteus minimus muscle approximately 3-5cms above the upper border of the greater trochanter more proximal dissection may cut this nerve or may produce a traction injury. For this reason insert a stay suture at the apex of the gluteus medius split. This will ensure that the split does not inadvertently extend itself during the operation.
• The femoral nerve the most lateral structure is anterior neurovascular bundle of the thigh is vulnerable to inappropriate placed retractors.
Vessels:• The femoral artery and vein are also vulnerable to
inappropriately placed anterior retractors.• The transverse branch of the lateral circumflex artery of
the thigh is cut as the vastus lateralis mobilized. It must be cauterized during the approach.
How to enlarge the approach:• The approach can easily be extended distally to
expose the shaft of the femur, split the vastus lateralis muscle in the direction of the fibers. The incision cannot be extended proximally.
Advantages:• Improved exposure to acetabulum and femoral neck• Preserves the integrity of gluteus mediusDisadvantages:• Difficulty to do revision surgery by this approach as
it does not provide as wide an exposure as anterolateral
• Slightly increased blood loss comparatively.
Hardinge Modification: (Direct Lateral Approach) (Trans Gluteal)
Position: • Patient supine with greater trochanter at the edge of
table. Incision: • Make a posteriorly directed lazy “J” incision centered
over greater trochanter.
The only Difference in this Step: • Instead of osteotomizing greater trochanter, incise the
tendon of gluteus medius obliquely across the greater trochanter leaving the posterior half still attached to the trochanter. Carry the incision proximally in line with the fibers of gluteus medius.
• Distally carry the incision anteriorly in line with the fibers of vastus lateralis.
Advantages: • Greater trochanter and bulk of gluteus
medius preserved allowing rapid rehabilitation.
Posterior Approach to the Hip
POSTERIOR APPROACH: The posterior approach is the most common approach
used to expose the hip joint. Popularized by Moore, it is often called the southern approach.
Indication: • Hemiarthroplasty.• THR including revision surgery.• ORIF of post acetabular fractures.• Dependent drainage of hip sepsis.• Removal of loose body from hip joint • Pedicle bone grafting.• Open reduction of posterior hip dislocation
Position of the patient on the operating table for the posterior approach to the hip joint.
There is no true internervous plane. Split the fibers of the gluteus maximus, a procedure that does not cause significant
denervation of the muscle.
(A) Skin incision for the posterior approach to the hip joint. (B) Incise the fascia lata.
Incision: • Start 10 cm distal to the PSIS extended distally, laterally
parallel to fibers of gluteus maximus to posterior margin of greater trochanter then direct the incision 10-13 cm distally parallel to femoral shaft
.
Position
Danger Point: Avoid incision on greater trochanter (Bony prominence painful and scar) Approach: Expose and divide deep fascia. Separate the fibers of gluteus maximus (by blunt dissection). First Muscle Layer.
Retract the gluteus maximus to reveal the fatty layer over the short external rotators of the hip.
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.
(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.
Incise the posterior joint capsule to expose the femoral head and neck.
To gain additional exposure, cut the quadratus femoris and the tendinous insertion of the gluteus maximus.
Advantages:• Relative stability of operated hip.• Brief period of immobilization.• Rapidity with which joints may be opened and closed
though relatively blood less plane.• Excellent exposure of posterior lip and posterior column
of acetabulum.
Disadvantages: • Dependent incision with a tendency to oedema. • Acetabular exposure is inferior.• Increased post operative infection.• Weakening of posterior capsule of hip, so increased
chance of dislocation.• Vascular damage. • Only limited exposure of sciatic Nerve is possibility of
sciatic nerve injury.
Medial Approach to Hip joint
Medial adductor approach of Ludloff:• 1908 – He originally described a posteromedial approach.• 1939 – He modified it to present anteromedial approach.
Uses / Indications: • Open reduction of congenital dislocation of hip.• Approach of choice for lesions and lesser trochanter (such as
osteoid osteoma)• Biopsy and treatment of tumours of inferior portions and
femoral neck and medial aspect of proximal shaft.• Psoas release.• Obturator neurectomy.
Disadvantages: • Incision closer to perineum • Limited exposure of capsule of hip joint. • Deep incision – vascular injury.
Position of the patient on the operating table for the medial approach to the hip.
Osteology of the medial approach to the hip.
Anatomy of the medial approach to the hip. The thigh is abducted, slightly flexed, and externally rotated. The plane of the superficial
dissection runs between the adductor longus and the gracilis.
Superficial dissection: • Incise deep fascia along posterior margin of adductor
longus.• Develop the plane between adductor longus and
gracilis.
Deep dissection: • Continue the dissection in the interval between
adductor brevis and adductor magnus until you feel the lesser trochanter. Develop the plane between adductor longus and brevis anteriorly and gracilis, adductor magnus posteriorly.
• Flex, abduct and externally rotate to bring lesser trochanter close to the skin.
Incision for the medial approach to the hip.
Intrernervous plane: • In superficial dissection does not exploit any
internervous plane. (because both adductor longus and gracilis – both are innervated by anterior division of obturator nerve.
More deeply: • The plane of dissection is between adductor
brevis (supplied by anterior division of obturator nerve) and adductor magnus (Adductor portion from posterior division of obturator nerve and ischial portion by tibial portion of sciatic nerve.
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.
(A) Develop the plane between the gracilis and the adductor longus. (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.
• Danger Point 1: Anterior branch obturator nerve lies on the front of adductor brevis and neurovascular bundle of gracilis muscle.
• Danger Point 2: Posterior division lies in the substance of obturator externus, runs down the thigh on adductor magnus and under adductor brevis.
• Danger point 3: Medial circumflex artery passes on distal part of psoas tendon. (it is in danger if you try detach the psoas with out isolating the tendon and cutting under direct vision especially in children)
Thank You
