Traditional Surgical Approaches

Any discussion regarding minimally invasive approaches to the hip joint is predicated by the context in which it developed. The hip joint is the most deeply recessed joint in the body. Because of the many musculotendinous investing structures surrounding it, a number of open surgical approaches were developed. Each of these methods, importantly, passes through fascial planes between muscles supplied by major nerves. These planes are well detailed by Henry.1 Indications for hip surgery have historically been confined to regularly identified pathological entities. In the pediatric population these pathologies include: joint sepsis, calcified loose bodies, treatment of joint instability, and tumors. In skeletally mature adults, joint arthrotomy has been utilized for osteonecrosis, osteotomy, cheilectomy, sepsis, removal of loose or foreign bodies, synovectomy, fracture management, and prosthetic replacement. This chapter will review the seminal features of the principal surgical approaches to the hip.

Posterolateral Approach

The posterolateral approach provides excellent exposure of the acetabulum and proximal femur for primary or revisional total hip replacement. Because the abductor muscle group is preserved, there is minimal muscle stripping or damage in this approach. Rehabilitation of the patient following surgery is shortened because of this muscle preservation. If necessary, this approach can also be converted to become more extensile (iliofemoral, trochanteric slide, or osteotomy). In addition, the posterolateral approach minimizes the likelihood of gluteal nerve injury or heterotopic bone formation. When performed for prosthetic replacement, the posterolateral approach has historically been associated with a higher incidence of posterior dislocation than other approaches.2 However, recent modifications in the surgical technique have significantly reduced this likelihood. Pellicci, Poss, and Goldstein have all published rates less than 1%.3,4

Surgical Technique

The patient is placed in the direct lateral decubitus position. The pelvis is securely fixed with a pegboard device or its equivalent, carefully padding the contralateral peroneal nerve and proximal chest wall structures. The operative leg is draped free, and the perineum protected out of the operative field. The skin incision is centered over the greater trochanter. Distally it parallels the femoral shaft and proximally it is extended, in slightly curvilinear fashion, posteriorly. The ili-otibial band and gluteus maximus fascia are then split in line with the skin incision. The leg is then extended and internally rotated. The trochanteric bursa is incised and the short external rotators identified. The sciatic nerve is palpated, adjacent to the ischium, and protected throughout. The posterior border of the abductors (gluteus medius and minimus) is then identified and retracted anteriorly. (Figure 9.1.) This maneuver allows visualization of the piriformis, gemelli, obturators, and quadratus. These short rotators are then sequentially incised from their femoral attachments. With retraction above and below the femoral neck, the posterior capsule is then incised. Commencing proximally near 12 o'clock, the incision extends to the intertrochanteric line and then distally at 7 o'clock, creating a trapezoid-shaped flap that is posteriorly based. This capsular flap is carefully protected for later reattachment. Following capsulotomy, the hip is further internally rotated until the femoral head is dislocated. Further mobilization of the femur can be accomplished by incising the inferior capsule along the iliopsoas sheath. The anterior capsule is preserved, unless contracted. Acetabular exposure can be facilitated by displacing the femur anteriorly and this may require judicious capsular incision, gluteus maximus tendon release, and appropriate retraction.

Once the intra-articular procedure has been accomplished, closure is begun. The posterior capsular flap is reapproxi-mated to the greater trochanter with #5 nonabsorbable sutures through drill holes. The leg remains in neutral rotation during this stitching. The short rotators are reattached to the posterior tendinous border of the abductors, carefully avoiding

Delayed Union Nonunion Decortication
Figure 9.1. Identifying landmarks for posterolateral approach.

overtightening. Sciatic nerve integrity is again confirmed by palpation. The fascia and subcutaneous tissues are then closed in sequential layers. Following skin closure, a sterile bandage is applied and the patient is carefully transferred to the recovery room.

Trochanteric Osteotomy

Conventional trochanteric osteotomy was initially described by Charnley in England in association with total joint replacement.5 This approach is utilitarian and can be combined with other approaches if necessary. This approach has been utilized for primary and revision total hip replacement; for preservation of the femoral head blood supply when arthro-plasty is not planned; for extensile exposure in markedly obese patients; for lateral iliac exposure during pelvic osteotomy or acetabular cage placement; for distorted anatomy such as developmental dysplasia of the hip; for mobilization of joint ankylosis from protrusio collagen disease or fusion; for fracture plating of the anterior or posterior columns; and for distal transplantation for joint instability or leg length adjustment.

While advantageous in many situations, trochanteric osteotomy has drawbacks. Nonunion of the osteotomized fragment may occur in up to 37% of cases.6-15 The fixation wires or cables may irritate surrounding structures, causing bursitis or iliotibial band tendonitis. In addition these wires may break and, if migration occurs, may provoke third-body wear in the joint.16 Heterotopic bone formation may also occur and potentially limit hip motion. On rare occasions sciatic nerve injury has occurred from trochanteric wiring.17

Surgical Technique

With the patient in the lateral decubitus position an incision is made, centered over the greater trochanter. The fascia is incised in line with the skin. The vastus lateralis fascia is then incised in L fashion 0.5 cm distal to the vastus tubercle. The transverse extent of the fascial incision is to the anterior border of the trochanter. A joker or wing-tipped elevator is then placed beneath the gluteus minimus tendon above the hip capsule to direct the saw blade. The osteotomy encompasses the sulcus between the lateral portion of the origin of the vastus intermedius muscle and the insertions of the gluteus medius and minimus. The short external rotators may be preserved or released, depending on soft tissue tension. (Figure 9.2.) Following osteotomy, the trochanter is retracted proximally. The capsular attachments of the gluteus minimus and psoas are carefully freed up using blunt elevators. Once exposed, the joint capsule can be excised if contracted or incised in T-like fashion for later reapproximation.

Following completion of the intra-articular procedure, the trochanter is reattached. Numerous methods have been described. Charnley's two-wire technique and Harris's 3- and 4-wire techniques remain popular. (Figure 9.3.) On occasion, bolts and screws have been utilized, though breakage and pull-out have occurred with these methods. More recently, multi-filament cable in association with a trochanteric grip has become available to increase mechanical advantage, reduce wire breakage, and minimize the likelihood of trochanteric bursi-tis. Although fixation reliability has increased15 there are reports of cable debris migration into the prosthetic joint.18 Thus, even though trochanteric osteotomy provides excellent extensile exposure of the hip, concern regarding complications proscribes its routine use.

Figure 9.2. Surgical technique approach to trochanteric osteotomy.

Figure 9.2. Surgical technique approach to trochanteric osteotomy.

Anterolateral Approach The Hip

Anterolateral Approach

An alternative approach for hip joint exposure is the anterolateral approach. This technique can be performed with the patient either in the lateral decubitus or supine position. The approach obviates the concern of those surgeons who feel that the posterolateral approach gives insufficient acetabular exposure. It also avoids the complications associated with trochanteric osteotomy. Described early by McFarland, the approach is muscle splitting and may be extended distally via a myofascial sleeve into the quadriceps.19 This approach can be extensive for procedures involving the acetabulum and/or femur. It is advantageous for those situations where preservation of the femoral head blood supply is necessary, or for prosthetic revision surgery.

There are limitations to the anterolateral approach. If the abductor muscle split is incorrectly performed or carried too far proximally, neurovascular injury can occur or permanent muscle weakness ensue.20 In addition, an increased incidence of heterotopic bone formation has been described.21 Conversely, because the posterior capsule is preserved, the incidence of prosthetic dislocation is remarkably low.22 This approach is not indicated for situations where leg length readjustment is required.

Prosthetic Femoral HeadAnterolateral Approach
Figure 9.4. Identifying landmarks for the anterolateral approach.

Surgical Technique

When performed in the lateral position, the procedure is advantaged when the patient is inclined slightly posteriorly. Following prepping, the surgical field should be draped so that the superior, anterior, and posterior iliac spines are exposed along with the iliac crest proximally, and the greater trochanter and femoral shaft distally. The incision extends proximally from the greater trochanter to the level of the iliac spines.

Distally, the incision parallels the anterior border of the femoral shaft. The fascia is incised in line with the skin incision, between the posterior border of the tensor fascia lata and anterior to the insertion of the tendon of the gluteus maximus. The abductor muscles are then identified. (Figure 9.4.) A muscle split is then performed anterior to the tendinous portion of the abductors and extended proximally less than 4 cm above the tip of the greater trochanter to avoid injury to the inferior branch of the superior gluteal nerve and artery.22 Distally, the muscle split is carried along the anterior border of the greater trochanter and into the vastus fascia. Should femoral shaft exposure be necessary, the fascial incision can be carried posteriorly just below the vastus tubercle and then distally along the linea aspera. The vastus lateralis muscle can then be reflected anteriorly, and the shaft is now accessible.

Once the intra-articular procedure has been completed, closure is begun. The abductor muscle mass should be secured to the greater trochanter via multiple drill holes and #5 non absorbable sutures. Secure anatomic anchorage is paramount. The vastus lateralis fascia is then reapproximated to the linea aspera, and the iliotibial band fascia restored with interrupted sutures.

The anterolateral approach is adaptable to many different surgical situations. The utility of its potential for proximal and distal extension, shortened operative time, and minimized blood loss make it an attractive option as long as secure abductor reattachment can be assured.

Trochanteric Slide

The trochanteric slide approach incorporates some of the advantages of the two previously described exposures. This technique involves removal of the greater trochanter from posterior to anterior while maintaining the integrity of the abductor muscles and the vastus lateralis muscle in continuity. Trochanteric osteotomy ensures extensile exposure of the ac-etabulum and pelvis. Reflection of the vastus lateralis allows the surgeon to address femoral pathology. In contrast to conventional trochanteric osteotomy, the trochanteric slide is a myosseous sleeve and, should bony nonunion occur, superior migration of the trochanteric fragment is much less likely. Thus abductor function is more reliably preserved. Avulsion of the abductor muscles from the trochanter, as has been reported with the anterolateral approach,23 does not occur due to the myosseous sleeve continuity.

Figure 9.5. Surgical approach for trochanteric slide.

Figure 9.5. Surgical approach for trochanteric slide.

Hip Replacement Hardinge Approach Pics

There are many potential applications for the trochanteric slide. These include revision total hip replacement with or without leg length adjustment; periprosthetic femoral fracture; access to and treatment of femoral cortical deficiency; removal of extraosseous bone cement; osteotomy of the femur to correct varus, valgus, or rotational malalignment; and trochanteric repositioning or rotational, length, or offset improvement. On the acetabular side, the slide approach facilitates bone grafting; insertion of bilobed cups; vertical relocation of the high hip center for developmental dysplasia, or girdlestone conversion; and removal of heterotopic bone or excessive scarring.

Despite the considerable utility of the trochanteric slide approach, there are some potential drawbacks. Trochanteric osteotomy can result in delayed union or nonunion, resulting in abductor muscle weakness. Fixation of the osteotomized bone, whether with wire or cables, can break, unravel, or even migrate into the articulation. In addition, the fixation may provoke trochanteric bursitis. To avoid tethering of the inferior branch of the superior gluteal nerve, certain extensive ac-etabular reconstructions (whole acetabular allograft, or insertion of an acetabular cage device) are more safely accomplished by conventional trochanteric osteotomy.

Surgical Technique

With the patient secured in the lateral decubitus position, the skin and fascia are incised in a manner similar to that used for the posterolateral approach. Distally the vastus lateralis fascia is then incised 1 cm anterior to the linea aspera. The entire lateralis muscle is then reflected anteriorly, exposing the femoral shaft. The vertical length of the fascial incision is unlimited, but should be commensurate with the index procedure. Perforator vessels are carefully identified and ligated.

Proximally, the posterior border of the abductor tendon is identified and retracted anteriorly. A blunt-tipped elevator is then placed beneath the gluteus minimus and above the joint capsule from posterior to anterior.

The patient's leg is then slightly rotated internally, and the trochanteric osteotomy initiated just deep to the abductor tendons, the depth guided by the elevator. The oscillating saw is directed from posterior to anterior, maintaining the abductors and lateralis in continuity. (Figure 9.5.) The patient's leg is then progressively rotated externally to complete the anterior extent of the cut. With the lower leg now positioned perpendicular to the floor and protected in a sterile leg bag, the surgeon retracts the trochanter and muscle mass anteriorly. A complete capsulotomy or capsulectomy can now be readily accomplished.

Following completion of the intra-articular reconstruction, the trochanter is reapproximated. Holes are drilled in the lesser trochanter for placement of cerclage wires or cables. A trochanteric grip can be incorporated if necessary. The vas-tus lateralis fascia is then closed with absorbable suture.

The trochanteric slide approach provides extensile exposure for a wide variety of hip conditions. When necessary, this versatile approach can provide the surgeon with anatomic femoral procedural orientation, access to the anterior and posterior columns of the pelvis, and myosseous continuity to facilitate postoperative function.

Direct Lateral and Modified Dall Approach

Another variant for hip joint arthrotomy is the direct lateral approach. In 1954, McFarland and Osborne described a laterally based technique for hip joint entry.19 In 1982, Hardinge modified the approach such that the muscular posterior of the gluteus medius and minimus, the anterior capsule, and the anterior portion of the vastus lateralis are reflected anteriorly, thus exposing the femoral neck.24 The advantages of this approach are the preservation of the greater trochanter and the tendinous portion of the gluteus medius, the expedient joint entry, and the remarkable reduction in posterior prosthetic implant dislocation.25 Conversely, the limitations of this approach include increased potential for heterotopic bone for-mation.26 Neurovascular injury may also occur with this procedure. Baker found a 15% incidence of abductor denervation,27 but Ramesh found 11% of patients had electromyographic evidence of damage to the superior gluteal nerve.28 Persistent limp and/or avulsion of the reattached abductor muscles have also been described with this approach. In addition, access to the posterior column of the pelvis is limited, should plating be required. Superior iliac exposure for allo-grafting or cage insertion should not be performed through this approach, to avoid injury to the superior gluteal nerve or artery.

Surgical Technique

The direct lateral approach can be performed with the patient in either the supine position, as favored by Hardinge, or the lateral decubitus position as popularized by Chandler. The skin incision is positioned over the interval between the tensor fascia lata and the gluteus maximus. From 5 cm proximal to the greater trochanter the incision is carried distally for 15 cm over the midline of the femoral shaft. The fascial incision, commencing distally, is extended proximally between the tensor fascia lata and the gluteus maximus. The tendinous fibers of the gluteus medius are identified after dividing the trochanteric bursa. The muscle splitting of the abductor is done parallel to the anterior border of the greater trochanter, thus preserving abductor function. The proximal extent of the muscle split should be less than 4 to 5 cm above the greater trochanter. Beneath the gluteus medius the intervening fat is reflected, and the gluteus minimus split 1 cm anterior to its posterior border. The inferior extent of the gluteus medius split is extended distally just anterior to the vastus tubercle using cutting cautery. (Figure 9.6.) It is paramount to leave a strong cuff of fascia on the trochanter for later repair. Distal to the trochanter the anterior fascia of the quadriceps is incised for 6 cm. Beneath the muscle the transverse branch of the lateral circumflex vessel is identified and ligated. The leg is then progressively rotated externally while the anterior aspect of the femur is subperiosteally dissected. The entire cuff of gluteus medius, minimus, anterior capsule, and quadriceps can then be retracted anteriorly, allowing anterior dislocation of the hip.

A modification of this technique involves an oblique partial trochanteric osteotomy contouring the above-noted muscles. This method, described by Dall, allows postprocedure bone-to-bone trochanteric coaptation rather than soft tissue-to-bone healing. (Figure 9.7.) Some authors have diminished enthusiasm for this approach because of bone nonunion and trochanteric bursitis.29

With the femoral head resected and the femur translated posteriorly, a complete capsulectomy is possible. Following completion of the intra-articular reconstruction, closure is begun. The capsule is reapproximated from proximal to distal. If a Dall anterior trochanteric osteotomy has been performed, the anterior bone segment is reduced and held with three #5 nonabsorbable sutures or #16 gauge wire through drill holes. (Figure 9.8.) When a direct lateral approach has been utilized, the abductor soft tissues are secured to the decorticated greater trochanter via multiple drill holes and nonabsorbable #5 suture. Secure anchorage is requisite. (Figure 9.9.) The anterior

Direct Lateral Hardinge Approach
Figure 9.6. Identifying landmarks for direct lateral approach.
Figure 9.7. Osteotomized trochanter using the modified Dall approach.

cuff of gluteus medius is reapproximated with #1 resorbable suture, as is the vastus lateralis fascia.

The direct lateral and Dall oblique trochanteric osteotomy approaches provide excellent exposure of the acetabulum and

Femur Surgery
Figure 9.8. Surgical repair of modified Dall approach.

femur for primary and simple revision procedures. Preservation of the posterior soft tissues greatly reduces the potential for posterior prosthetic dislocation, and early postoperative flexion range of motion is facilitated.

Figure 9.9. Surgical repair of direct lateral approach.

Figure 9.9. Surgical repair of direct lateral approach.

Hardinge Direct LateralGirdlestone Intertrochanteric Resection
Figure 9.10. Surgical dislocation of the femoral head.
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