For surgery, the hip can be approached by many surgical approaches. The choice of particular approach is based on the procedure and need for exposure of a particular part, associated shaft or acetabular fixation and the preference of the surgeon.
There are numerous approaches and some are modifications of original approaches. Most of the approaches bear the name of its inventor but that could be difficult to remember. Most of the approaches can be grouped as anterior, posterior, medial and lateral approaches. In between, we can have groups like anterolateral, posterolateral etc.
Most of the approaches of the hip also provide access to the acetabular region and proximal femur, depending on the access desired.
Following approaches encompass the general approaches to hip and proximal femur. Specific approaches for hip arthroplasty would be discussed separately.
Anatomy and Surgical Approaches
A brief about surgical anatomy is discussed before we discuss approaches.
Bony landmarks are difficult to identify owing to muscle mass. Landmarks used are
- Anterior superior iliac spine (ASIS)
- Posterior superior iliac spine
- Greater trochanter
- Pubic tubercle
- Pubic symphysis.
Though hip is covered by 21 muscles all around, certain muscles assume more significance during surgery.
Tensor fascia latae and gluteus maximus together with the iliotibial band form the outer layer of the muscular envelope of the gluteal region. One of these muscles or the iliotibial band must be split in order to gain access to the deeper muscles of the gluteal region.
The gluteus medius is the major abductor of the hip joint to stabilizes the hip joint in the swing phase of the gait together with gluteus minimus.
The lateral approaches are designed to either avoid detachment of the gluteus medius or displace the abductors by stripping.
The piriformis, one of the external rotators is the key to understanding the neurovascular anatomy of the gluteal region.
Superior gluteal vessels and nerve enter the gluteal region above the pelvis pass below it.
The iliopsoas tendon inserts into the lesser trochanter posteromedially and needs to be released to facilitate exposure of the hip in the anterior and medial approaches.
Also red, anatomy of hip
Vessels and Nerves
The superior gluteal artery is most at risk at its division at the upper border of piriformis about three finger breaths anterior to the posterior superior iliac spine.
The deep branch with the corresponding nerve traverse about 4-6 cm above the acetabular rim and is at risk.
The lateral femoral circumflex artery is a branch of the profunda femoris artery requires ligation during the Smith-Petersen approach.
The nerves of surgical importance in hip operations include
- Lateral femoral cutaneous nerve – encountered during anterior approaches
- Femoral nerve
- Superior and inferior gluteal nerves – in danger in gluteus splitting approaches
- Sciatic and obturator nerve – posterior approaches
The lateral femoral cutaneous nerve is the most. The sciatic nerve is an important posterior relation.
Joint capsule and Ligament
The hip capsule is a strong fibrous tissue that extends down to the intertrochanteric line anteriorly but is deficient posteriorly.
The capsule is reinforced anteriorly by the iliofemoral ligament of Bigelow; inferiorly by the pubofemoral condensation and posteriorly by a thin ischiofemoral ligament.
Anterior Approaches for Hip Surgery
Smith-Petersen is used often. Nearly all surgery of the hip joint may be carried out through this approach, or separate parts can be used for different purposes. The entire ilium and hip joint can be reached through the iliac part of the incision
Smith-Petersen also modified and improved this approach for extensive surgery of the hip by reflecting the iliacus muscle from the medial surface of the anterior part of the ilium and by detaching the rectus femoris muscle from its origin.
The incision is begun at the iliac crest can be taken posteriorly on the crest as desired. Carry it anteriorly to the anterior superior iliac spine and distally and slightly laterally 10 to 12 cm.
Divide the superficial and deep fasciae. Free the attachments of the gluteus medius and the tensor fasciae latae muscles from the iliac crest.
Strip the periosteum with the attachments of the gluteus medius and minimus muscles from the lateral surface of the ilium using a periosteal elevator.
For control of bleeding, packs may be used between the bone and stripped tissue.
The dissection can be extended through the deep fascia of the thigh and between the tensor fasciae latae laterally and the sartorius and rectus femoris medially.
Ascending branch of the lateral femoral circumflex artery lies 5 cm distal to the hip joint. It should be clamped and ligated.
The lateral femoral cutaneous nerve that passes over the sartorius 2.5 cm distal to the anterior superior spine is retracted medially.
If the structures are tight, osteotomy of the anterior superior iliac spine is done and it is allowed to retract with its attached muscles to a more distal level.
For accessing joint, the capsule is incised transversely after exposure. To reveal the femoral head and the proximal margin of the acetabulum.
Alternatively, the capsule also may be sectioned along its attachment to the acetabular labrum (cotyloid ligament) to give the required exposure.
To take out the head, the ligamentum teres may be divided using scissors or knife.
This provides giving access to all parts of the joint.
Reattachment of the fascia lata to the fascia on the iliac crest can be difficult and hence this modification was done.
Instead of dividing the fascia lata at the iliac crest, an osteotomy of the overhang of the iliac crest is performed between the attachments of the external oblique muscle medially and the fascia lata. The osteotomy may be carried posteriorly as far as the origin of the gluteus maximus. The tensor fasciae latae, gluteus medius, and gluteus minimus muscle attachments are subperiosteally dissected distally to expose the hip joint capsule. The abductors and short external rotators may be dissected from the greater trochanter as necessary.
At closure, the iliac osteotomy fragment is reattached with 1-0 or 2-0 nonabsorbable sutures passed through holes drilled in the fragment and the ilium.
It uses a transverse bikini incision and was propagated for irreducible congenital dislocation of the hip in a young child.
This approach also allows for sufficient exposure of the ilium, and access to the acetabulum is satisfactory. Even when the acetabulum is abnormal in location as in congenital dislocation of hip .
This approach was developed for congenital dislocation of hip as that requires access to many structures.
[Following sequence needs to follow – psoas tenotomy, complete medial capsulotomy, excision of hypertrophied ligamentum teres, and reduction of the femoral head into the true acetabulum.]
The patient is placed supine with a sandbag beneath the affected hip.
A straight skin incision begins anteriorly inferior and medial to the anterior superior spine. It goes obliquely superiorly and posteriorly to the middle of the iliac crest.
Deepen the incision to expose the crest.
The muscles are reflected subperiosteally from the iliac wing proximal to distal till capsule is reached. Increase the exposure of the capsule by separating the tensor fasciae latae from the sartorius muscle for about 2.5 cm inferior to the anterior superior spine.
Then the reflected head of the rectus femoris is separated from the acetabulum and capsule. The straight head that attaches to the anterior inferior iliac spine is mostly left untouched but may be detached to increase exposure.
Incise the capsule to access the joint.
During closure muscles are reattached to the iliac crest and skin is closed.
Smith-Petersen described a modification that retains the advantages of the anterior iliofemoral approach but exposes the trochanteric region laterally. This enables the surgeon to work on femoral neck and trochanteric regions.
The approach is useful in procedures such as osteotomy for slipping of the proximal femoral epiphysis and nonunions of the femoral neck.
This approach provides continuous exposure of the anterior aspect of the hip from the acetabular labrum to the base of the trochanter.
Make an incision along the anterior third of the iliac crest and along the anterior border of the tensor fasciae latae muscle. Then curve it posteriorly at a point 8 to 10 cm below the base of the greater trochanter [It marks the insertion of tensor fasciae latae into the iliotibial band]
Fascia is incised along the anterior border of the tensor fasciae latae muscle.
The lateral femoral cutaneous nerve, which usually is medial to the medial border of the tensor fasciae latae and close to the lateral border of the Sartorius should be identified and protected.
Incise the muscle attachments from the lateral aspect of the ilium along the iliac and reflect the periosteum, carrying the stripping distally to superior margin of the acetabulum.
Muscle attachments between the anterior superior iliac spine and the acetabular labrum should be divided forming a flap consisting of the tensor fasciae latae, the gluteus minimus, and the anterior part of the gluteus medius.
Distally, extend the fascial incision across the insertion of the tensor fasciae latae into the iliotibial band exposing the lateral part of the rectus femoris and the anterior part of the vastus lateralis muscles.
Incise the capsule on the inferior aspect of the capsule just lateral to the acetabular labrum.
Extend it proximally, parallel with the acetabular labrum, to the superior aspect of the capsule.
Below, curve it inferolaterally to the base of greater trochanter dividing the part of the reflected head of the rectus femoris that blends into the capsule inferior to its insertion into the superior margin of the acetabulum. This reinforcement makes the repair easier.
This approach provides exposure to the acetabulum and proximal femur [some authors do mention this as the lateral approach but is more commonly included in anterolateral approaches]
The approach is used for the following procedures
- Total Hip Replacement
- especially in patients with high risk for dislocation since no posterior soft tissue disruption.
- Concerns of abductor weakening and limping.
- Open reduction of the femoral neck or trochanteric fracture
- Synovial biopsy of hip
- Biopsy of the femoral neck
The incision starts 2.5 cm distal and lateral to the anterior superior iliac spine and curved distally and posteriorly to the lateral aspect of the greater trochanter and continued to the lateral surface of the femoral shaft to 5 cm distal to the base of the trochanter.
Incise subcutaneous fat in line with incision and clear the fascia lata before incising it in direction of fibers. Typically, this is more anterior as you dissect the proximal part.
The interval is developed between the tensor fasciae latae and gluteus medius. The interval is easier to recognize by beginning the separation midway between the anterior superior spine and the greater trochanter, before the tensor fasciae latae blends with its fascial insertion. The two muscles can be identified by their respective muscle fiber direction.
The fibers of gluteus medius are coarser than the finer structure of the tensor fasciae latae muscle.
Proximal extension of the incision would expose the inferior branch of the superior gluteal nerve, which innervates the tensor fasciae latae muscle.
For deep exposure of joint detach reflected head of rectus femoris from the joint capsule to expose the anterior rim of the acetabulum. Eleate part of the psoas tendon from the capsule to perform anterior capsulotomy.
After reaching the capsule of the hip joint, incise it longitudinally along the anterosuperior surface of the femoral neck.
For exposing the base of the trochanter and proximal part of the femoral shaft, the vastus lateralis muscle can be reflected from its attachment at greater trochanter or splitting longitudinally.
For a wider field, the gluteus medius needs to be detached from its insertion either by osteotomy or by cutting and resuturing.
Osteotomy is preferred as it can be easily reattached later.
The osteotomy site is just proximal to vastus lateralis ridge.
It must be remembered that superior gluteal nerve is 5cm proximal to the acetabular rim.
Harris developed an extensive approach for hip exposure. It permits dislocation of the femoral head anteriorly and posteriorly. The approach requires an osteotomy of the greater trochanter and thus carries a risk of nonunion or trochanteric bursitis.
Increased incidence of heterotopic ossification is also reported after total hip arthroplasty using a transtrochanteric lateral approach.
The patient is placed on the unaffected hip and the affected hip is elevated by 60 degrees and maintained by using sandbags or a long thick blanket roll extending from beneath the scapula to the sacrum.
The incision is U shaped with the base on the posterior border of the greater trochanter.
The incision begins about 5 cm posterior and slightly proximal to the anterior superior iliac spine, curved distally and posteriorly to the posterosuperior corner of the greater trochanter.
It is further extended for about 8 cm and then curved gradually anteriorly and distally, making a symmetrical U.
The iliotibial band is divided distally, in line with the skin incision. With help of finger palpation to get an idea about the insertion of the gluteus maximus on the gluteal tuberosity, the incision on the fascia lata is one fingerbreadth anterior to this insertion.
Release the fascia overlying the gluteus medius. Reflect anteriorly the anterior part of the iliotibial band and the tensor fasciae latae.
Make a short oblique incision in the deep surface of the posteriorly reflected fascia extending into the substance of the gluteus maximus. Begin this incision at the level of the middle of the greater trochanter, and extend it medially and proximally into the gluteus maximus parallel to its fibers for 4 cm.
Perform an osteotomy of the greater trochanter to lift the abductor muscles after reflecting distally the origin of the vastus lateralis.
Reflect superiorly the greater trochanter and its attached abductor muscles to expose the superior and anterior parts of the capsule.
Protect the sciatic nerve by retracting posterior flap with a smooth retractor and free the superior part of the joint capsule from the greater trochanter by dividing the piriformis, obturator externus, and obturator internus at their femoral insertions. Then excise the anterior and posterior parts of the capsule as far proximally as the acetabulum.
Anteriorly, deep to the rectus femoris insert a small, blunt-pointed retractor.
With a thin retractor between the capsule and the iliopsoas to expose the anterior and inferior parts of the capsule.
Excise as much of the capsule as desired.
Femoral head can be dislocated anteriorly by extending, adducting, and externally rotating the femur. If required the iliopsoas can be divided at its insertion.
If the acetabulum needs to be exposed, the femoral head can be dislocated posteriorly by flexing the knee and adducting, flexing, and internally rotating the hip.
The limb is kept in almost full abduction and in about 10 degrees of external rotation.
McFarland and Osborne
The incision is midlateral and centered over the greater trochanter. The length of the incision may vary according to the desired exposure and the amount of subcutaneous fat.
Gluteal fascia and the iliotibial band are divided along the entire length of the skin incision.
The gluteus media is retracted posteriorly and tensor fasciae latae anteriorly.
Separate gluteus medius by blunt dissection the piriformis and gluteus minimus.
Beginning at a point where the posterior border of joins the posterior edge of the greater trochanter make an incision deep down to the bone obliquely and distally across the greater trochanter and continuing it distally on the vastus lateralis.
Using a sharp chisel, lift in one piece, the attachment of the gluteus medius, the periosteum, the tendinous junction of the gluteus medius and vastus lateralis, and the origin of the vastus lateralis [ This lifted portion of the vastus lateralis peeled off includes that attached to the proximal part of the linea aspera, the distal border of the greater trochanter, and part of the shaft of the femur.]
Retract the whole combined muscle mass, consisting of the gluteus medius and vastus lateralis with their tendinous junction.
Expose the capsule of the hip joint by splitting the minimus tendon or dividing it.
During the closure, suture the capsule and gluteus minimus as one structure.
This approach, which actually is a modification of the McFarland and Osborne approach to avoid the osteotomy of the greater trochanter.
The approach was originally defined in the supine position. But the lateral position is also used.
Many surgeons prefer is the approach for total hip arthroplasty as the approach has been associated with a lesser number of total hip prosthetic dislocations.
Make a posteriorly directed lazy-J incision centered over the greater trochanter. The incision begins 5 cm proximal to the tip of the greater trochanter and extends down the line of the femur about 8 cm.
Divide the fascia lata in line with the skin incision and retract anteriorly to expose tendon of the gluteus medius. The fibers of gluteus medius that attach to fascia lata are detached are using sharp dissection
Retract the tensor fasciae latae anteriorly and the gluteus maximus posteriorly, exposing the origin of the vastus lateralis and the insertion of the gluteus medius.
Incise the tendon of the 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 the gluteus medius at the junction of the middle and posterior thirds of the muscle. The muscle fibers could be split with blunt dissection as well.
The gluteus medius should not be dissected for more than 5 cms to avoid injuring the vessel.
Distally, carry the incision anteriorly in line with the fibers of the vastus lateralis down to bone along the anterolateral surface of the femur.
Elevate the tendinous insertions of the anterior portions of the gluteus minimus and vastus lateralis muscles. Abduction of the thigh exposes the anterior capsule of the hip joint.
Incise the capsule as desired.
During closure, repair the tendon of the gluteus medius with nonabsorbable braided sutures.
McLauchlan actually has credited this approach to Hay. It is a direct lateral approach through gluteus medius.
The patient is kept in a lateral position and a lateral skin incision passing through the center of anteroposterior width is used. The incision can be placed more posteriorly in lateral rotational deformities of the hip.
Cut the deep fascia and the tensor fasciae latae in line with the skin incision.
Retract these structures anteriorly and posteriorly to expose greater trochanter along with attached gluteus medius proximally and the vastus lateralis distally.
The gluteus medius is split in the line of its fibers till its attachment. Distally, vastus lateralis is split from its insertion.
So far except for trochanter, the tissue to be retracted has been split.
Starting midline of the trochanter, two rectangular slices of greater trochanter are lifted – one anteriorly and one posteriorly. Each of the pieces has a part of gluteus medius attached proximally and vastus lateralis distally.
Retract anteriorly and posteriorly to reveal the gluteus minimus.
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 to expose hip joint. For acetabulum exposure, the hip can be dislocated
Internally rotate the hip and suture the trochanteric slices to the periosteum and the other soft tissue covering the trochanter.
Gibson modified Kocher Langenbeck approach.
The patient is placed in a lateral position.
The incision starts 6 to 8 cm anterior to the posterior superior iliac spine and just distal to the iliac crest. This would overlie the anterior border of the gluteus maximus muscle. The incision is carried distally to the anterior edge of the greater trochanter and then along the line of the femur for 15 to 18 cm.
Skin and subcutaneous tissue are divided and reflected.
The iliotibial band is incised in line with its fibers, beginning at the distal end of the wound and extending proximally to the greater trochanter.
Abduct the thigh and through the proximal end of the incision in the band, palpate the sulcus at the anterior border of the gluteus maximus muscle, and extend the incision proximally along this sulcus.
Adduct the thigh, reflect the anterior and posterior masses, and expose the greater trochanter and the muscles that insert into it.
Separate the posterior border of the gluteus medius muscle from the adjacent piriformis tendon by blunt dissection.
Divide the gluteus medius and minimus muscles at their insertions leaving enough stump for repair. To preserve the insertion of the abductor muscles, osteotomize the trochanter.
Reflect these muscle anteriorly.
Anterosuperior capsule is visible and is excised.
Superiorly, it is incised in the axis of the femoral neck from the acetabulum to the intertrochanteric line.
Dislocate the hip by flexing, abducting and externally rotating.
When wide exposure of the joint, especially of the acetabulum, is needed, more extensive division of the muscles may be necessary.
It is also called Southern Approach.
The approach provides exposure to the acetabulum and proximal femur. It is used in hip arthroplasty, drainage of septic hip [The incision encourages dependent drainage].
Kocher-Langenbeck is a related, similar approach that uses more extensile exposure used for complicated acetabular work.
The patient is placed in lateral position on the unaffected hip.
The incision is begun 10 cm distal to the posterior superior iliac spine, extended distally and laterally parallel with the fibers of the gluteus maximus till the posterior margin of the greater trochanter. Then the incision is continued distally parallel the femoral shaft.
The deep fascia is divided in line with the skin incision.
With blunt dissection, separate the fibers of the gluteus maximus. Superior gluteal vessels in the proximal part of the exposure should be protected.
Retract the proximal fibers of the gluteus maximus proximally, and expose the greater trochanter
Retract the distal fibers distally, and partially divide their insertion into the linea aspera in line with the distal part of the incision.
Expose the sciatic nerve and retract it carefully. With experience, surgeons may prefer not to expose the sciatic nerve.
The sciatic nerve can be located along the posterior surface of quadratus femoris muscle. Anatomy of quadratus femoris anatomy is fairly constant and rarely damaged in trauma too.
Extension of hip and flexion of the knee relaxes the nerve and reduces injury risk.
The nerve to the quadratus femoris and inferior gemellus should be severed. It is a branch of sacral plexus that contains fibers to the joint capsule.
The gemelli and obturator internus are divided. If desired, the tendon of the piriformis at their insertion on the femur can be divided and retracted medially.
The capsule is exposed and incised from distal to proximal along the line of the femoral neck to the rim of the acetabulum.
The hip can be dislocated by flexion, adduction and internal rotation.
Ferguson, Hoppenfeld, and deBoer
This approach is based on the medial approach by Ludloff that was developed for congenital dislocation of the hip.
The incision is made 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.
The plane is developed between adductor longus and brevis muscles anteriorly and the gracilis and adductor magnus muscles posteriorly.
The posterior branch of the obturator nerve is visible on the belly of the adductor magnus. Identify the anterior branch of the obturator nerve lying on the anterior surface of the adductor brevis. Isolate the lesser trochanter in the base of the wound by blunt dissection and transect the iliopsoas tendon. This allows exposure of the medial hip joint capsule.
Lateral Approach to the Proximal Shaft and the Trochanteric Region
In closure, the vastus lateralis muscle falls over the lateral surface of the femur. Suture the fascia lata and close the remainder of the wound routinely.
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