2. INTRODUCTION: POSTERIOR APPROACH
• The most common and practical approach used to expose the hip joint
• Popularized by Moore, it is often called the Southern approach
• allow easy, safe, and quick access to the joint and can be performed with
only one assistant
• avoid the loss of abductor power in the immediate postoperative period
• allow excellent visualization of the femoral shaft, thus are popular for
revision joint replacement surgery, in cases in which the femoral
component needs to be replaced
3. POSTERIOR APPROACHES
• Because access to the joint involves division of the posterior capsule, if
dislocation of any prosthesis occurs, it will result from flexion and internal
rotation of the hip
• There may be a higher dislocation rate than that from anterior approaches
in elderly bedridden patients who often lie in bed with their hips in a flexed
and adducted position.
• Austin Moore (Southern)
• Osborne
• Posterolateral approach of Gibson
4. 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
5. POSITION OF THE PATIENT
• True lateral position: affected limb uppermost
• Bony prominences of the legs and pelvis are protected: pads
placed under the lateral malleolus and knee of the bottom leg
and a pillow between the knees
• The limb is draped free
6. LANDMARKS
• The greater trochanter is palpated
on the outer aspect of the thigh
• The posterior edge of the
trochanter is more superficial than
the anterior and lateral portions,
and, as such, it is easier to palpate
7. INCISION
• A 10- to 15-cm curved incision is made
centered on the posterior aspect of the
greater trochanter
– Starting point: 6 to 8 cm above and
posterior to the posterior aspect of the
greater trochanter
– Incision is curved across the buttock
distally and laterally, cutting over the
posterior aspect of the trochanter
8. INCISION
parallel to fibers of gluteus maximus, and
continued down along the shaft of the
femur
• If you flex the hip 90 degrees and make a
straight longitudinal incision over the
posterior aspect of the trochanter, it will
curve into a “Moore-style” incision when
the limb is straight.
9. INTERNERVOUS PLANE
• There is no true internervous
plane in this approach
• The gluteus maximus, which is
split in the line of its fibers, is
not significantly denervated
because it receives its nerve
supply well medial to the split
10. SUPERFICIAL SURGICAL DISSECTION
• The fascia lata is incised on the lateral aspect
of the femur to uncover vastus lateralis, and is
lengthened superiorly in line with the skin
incision, and fibers of the gluteus maximus
are split by blunt dissection
• The superior and inferior gluteal arteries
ramify outward like the spokes of a bicycle
wheel; hence, splitting the muscle inevitably
crosses a vascular plane.
11. DEEP SURGICAL DISSECTION
• The fibers of the split gluteus maximus
and the deep fascia of the thigh are
retracted, placing the retractors
superficial to the fatty tissue.
• Underneath is the fatty tissue and short
external rotator muscles
• The sciatic nerve leaves the pelvis
through the greater sciatic notch and
runs down the back; lying in substance
fatty tissue and hence not visible
12. • The hip is internally rotated to put the short
external rotator muscles on a stretch (making
them more prominent) and to pull the operative
field as farther from the sciatic nerve as possible
• Stay sutures are inserted into the piriformis and
obturator internus tendons just before they
insert into the greater trochanter;
Detached 1 cm from their femoral insertion and
reflected backward, laying them over the sciatic
nerve to protect it
13. • Normally, the quadratus femoris should be
left alone as it contains troublesome
vessels that arise from the medial
circumflex artery.
• The posterior aspect of the hip joint
capsule is now fully exposed
• The hip joint capsule can be incised with a
longitudinal or T-shaped incision
• The hip is dislocated with internal rotation
after capsulotomy
14.
15. DANGERS
Sciatic nerve
• It can be damaged if it is compressed by the posterior blade of a self-retaining retractor used
to split the gluteus maximus.
• The sciatic nerve sometimes divides into its tibial and common peroneal branches within the
pelvis; on occasion, two “sciatic nerves” can be exposed during this approach. It is in danger if
it is overlooked.
Vessels
• T he main trunk of inferior gluteal artery leaves the pelvis beneath the piriformis. It spreads
cephalad to supply the deep surface of the gluteus maximus
• If it is cut and retracts into the pelvis and bleeding is brisk, the patient is turned over into the
supine position, abdomen opened, and the artery’s feeding vessel, the internal iliac artery, is
ligated.
16. HOW TO ENLARGE THE APPROACH
• The upper half of the quadratus femoris is divided
about 1 cm from its insertion to make hemostasis
easier
– Its excellent blood supply is useful both when the
muscle is transposed and in treatment of some cases
of nonunion of femoral neck fractures
• The insertion of the gluteus maximus tendon is
detached from the femur to increase the exposure of
the femoral neck and shaft, especially in revision
joint replacement.
17. Chapter 6, Verse 5
uddharedaatmanaatmaanam
naatmaanamavasaadayeth |
aatmaiva hyaatmano bandhuraatmaiva ripuraatmanah ||
Let a man raise himself by his own efforts. Let him not
degrade himself.
Because a person's best friend or his worst enemy is
none other than his own self.
THANK YOU..
