‣
Anterior Smith-Peterson Approach
- Danger - LFCN
- Position - supine
- Incision – Longitudinal incision from ASIS to lateral patella
- Dissection – Skin, subcut ➔ Between Sartorius (Femoral Nerve) and TFL (Superior Gluteal Nerve) ➔ Between rectus femoris and glute medius ➔ ligate the ascending branch of the lateral femoral circumflex artery ➔ detach straight/direct head from AIIS and reflected head from joint capsule ➔ Reflected muscles ➔ Capsulotomy
‣
- It pierces the deep fascia of the thigh close to the intermuscular interval
‣
Anterolateral Watson's Approach
- Plane = Between TFL and Glute medius (both innervated by Superior gluteal nerve)
- Position - lateral position
- Incision - Centered at the GT, 8-15cm straight incision
- Dissection - Skin ➔ Fat ➔ Fascia Lata ➔ Retract glute medius posteriorly and TFL anteriorly to reveal fat over the joint capsule
‣
Lateral Modified Hardinge
- Danger - superior gluteal nerve - do not split glute medius more than 5cm above the GT
- Plane = Glute splitting. Anterior 1/3 and posterior 2/3 (some authors say anterior half) → anterior gluteal flap
- Incision - Centered at the Greater Trochanter, 8-15cm straight incision
- Dissection - Skin → Fat → Fascia Lata → Identify glute medius anterior 1/3, cutting down to the proximal Vastus lateralis in line with its fibers → T-shape capsulotomy
‣
Posterior Southern-Moore Approach
- Dangers - Sciatic nerve, posterior circumflex artery (if not doing THR), inferior gluteal artery (main blood supply to glute max) (injury can lead to uncontrollable bleeding).
- Plane = Gluteus maximus splitting
- Dissection - Split gluteus maximus, clear fat, identify Short External Rotator (SER), incise SER near its attachment, capsulotomy
‣
How do you perform an Extended Trochanteric Osteotomy (ETO)?
- https://www.youtube.com/watch?v=BLNFOBX9-do
- Expose the lateral femur by elevating the vastus lateralis off the linea aspera
- Use an oscillating saw or high-speed burr to detach as far distally as necessary (based on pre-op planning); create a "horseshoe-shaped" distal end to reduce stress risers
- Stay just anterior to the linea aspera
- Once you reach the pre-determined point, continue anterolaterally for 1/3 of the femoral circumference.
- Cementless - to bottom of porous coating
- Cemented - to proximal extent of cement plug
- Anteriorly, make multiple drill holes about 5mm apart along the line of osteotomy
- Using wide osteotomes, go through the posterior osteotomy to reach the anterior cortex and bridge the drill holes → Hinge opens anteriorly
- The proximal lateral fragment is then hinged forward with the gluteus muscles attached
- Prior to canal preparation or component reinsertion, apply cerclage cables distal to the transverse osteotomy site to prevent distal femoral fracture
- Reduce the ETO and secure with cerclage wires
‣
‣
Ganz Trochanteric Flip Osteotomy aka Safe Surgical Dislocation of Hip
- Reference: AO site
- This is essentially an anterior hip dislocation via a posterior approach using a GT osteotomy
- Position - lateral
- Incision - as per posterior approach, splitting the gluteus maximus muscle
- Dissection - identify the SER muscles and posterior border of gluteus medius and retract anteriorly
- Trochanteric flip osteotomy - identify Vastus lateralis distally and trace to GT, make a 1.5cm thick osteotomy → Flip GT anteriorly
- Dissection - Z-shaped capsular incision to expose the joint, taking care not to cut the labrum → Dislocate the hip anteriorly
- Closure - fix GT osteotomy with 2 screws
‣
Hip Arthroscopy
- Technique – Supine traction table, image intensifier guidance
- Anterolateral portal – 2cm anterior and superior to Greater Trochanter [FIRST portal]
- Viewing portal
- Beware Superior gluteal nerve
- Anteroposterior portal – Intersection between longitudinal line from Anterior Superior Iliac Spine (ASIS) and Greater Trochanter
- Beware Lateral Femoral Cutaneous Nerve
📖
All the words of my mouth are righteous; there is nothing twisted or crooked in them. Proverbs 8:8