Basic Anatomy, positioning and Surgical Approaches to Hip Joint

1. Surgical Approaches
To Hip Joint
Dr. Apoorv Jain
D’Ortho, DNB Ortho
drapoorvjain23@gmail.com
+91-9845669975

2. Salient Anatomical
features of Hip
Joint

3. 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

5. 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

6. Neck-Shaft Angle

7. 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.

9. Hip Muscles
• Anterior
–Rectus Femoris
–Sartorius(tailor)
–Iliopsoas Muscle
Group
• Iliacus
• Psoas Major

10. • Lateral
– Gluteus Medius
– Gluteus Minimus
– Tensor Fascia Lata
– Six Intrinsic External
Rotators
• Piriformis
• Quadratus Femoris
• Obturator Internus
• Obturator Externus
• Gemellua Superior
• Gemellus Inferior

11. • Medial
–Adductor
Brevis
–Adductor
Longus
–Adductor
Magnus
–Pectineus
–Gracilus

12. APPROACHES TO HIP
ANTERIOR 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 Watson
LATERAL APPROACHES
• Mc Farand and Osborne
• Hardinge and Frndak and Mallory.
• Transtrochanteric approach
• Mc Lauchlan : Hay
• Harris

13. POSTERIOR APPROACHES.
• Austin Moore (southern)
• Osborne
• Posterolateral approach of Gibson
MEDIAL APPROACHES.
• Ludloff
• Ferguson, Hoppenfeld, Deboer.
ANTEROMEDIAL APPROACH OF ZATSEPIN AND
GAMIDOV.

14. The intermuscular intervals used in the anterior,
anterolateral, and posterior approaches to the hip.

15. ANTERIOR APPROACH TO
THE HIP

16. 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

17. Position of the patient
• The patient is placed supine with a small sandbag
under the affected buttock.

18. Incision
Curvilinear Incision starting from the ant. half of iliac crest
to ASIS and from there curve it down for 8-10cm

19. Internervous Plane:
• The superficial plane
Sartorius (femoral nerve) and the tensor fasciae latae (superior gluteal
nerve)

20. 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.

21. Identify the gap between the tensor fasciae latae and
the sartorius by palpation.

22. 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.

23. The deeper internervous plane lies between the rectus
femoris (femoral nerve) and the gluteus medius
(superior gluteal nerve).

24. 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.

25. Detach the rectus femoris from both its origins, the anterior
inferior iliac spine and the superior lip of the acetabulum.

26. The hip joint capsule is now partly exposed.
Retract the iliopsoas tendon medially.

27. The hip joint capsule is fully exposed. Detach the muscles
of the ilium if further exposure is needed.

28. Incise the hip joint capsule.

29. 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.

30. 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

31. 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 stiffness
Injuries to lateral femoral cutaneous nerve
and disturbing dysesthasia of thigh
• Exposure to femoral medullary canal is
limited.

32. ANTEROLATERAL
APPROACH TO THE HIP

33. 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

34. 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.

35. Incision for the anterolateral approach to the
hip.

36. 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.

37. Incise the fascia lata posterior to the tensor fasciae
latae.

38. 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.

39. Retract the gluteus medius posteriorly and the
tensor fasciae latae anteriorly, uncovering the fatty
layer directly over the joint capsule.

40. Bluntly dissect the fat pad off the anterior portion of the
joint capsule to expose it and the rectus femoris tendon.

41. Osteotomize the greater trochanter.

42. Reflect the osteotomized portion of the trochanter superiorly
(with the attached gluteus medius) to reveal the joint capsule.

43. The joint capsule may also be exposed by partial resection of the
gluteus medius tendon from the anterior portion of the trochanter.

44. Reflect the head of the rectus femoris from the
anterior portion of the joint capsule.

45. 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).

46. 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.

47. 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.

48. 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.

49. To be Continued..

50. Lateral Approach to
Hip Joint

51. 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

52. 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.

53. 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.

54. 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.

55. Divide the deep fascia in the line of the skin incision,
retracting the fascial edges to pull the tensor fascia
latae anteriorly.

56. 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.

57. Develop this anterior flap and divide the tendon of the gluteus minimus
muscle to reveal the anterior aspect of the hip joint capsule.

58. Enter the capsule using a longitudinal T-shaped incision.

59. Osteotomize the femoral neck using an oscillating saw.

60. Extract the femoral head. Insert appropriate
retractors to reveal the acetabulum.

61. 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.

62. 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 medius
Disadvantages:
• Difficulty to do revision surgery by this approach as
it does not provide as wide an exposure as
anterolateral
• Slightly increased blood loss comparatively.

63. 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.

64. Advantages:
• Greater trochanter and bulk of gluteus
medius preserved allowing rapid
rehabilitation.

65. Posterior Approach
to the Hip

66. 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

67. Position of the patient on the operating table for the
posterior approach to the hip joint.

68. There is no true internervous plane. Split the fibers
of the gluteus maximus, a procedure that does not
cause significant denervation of the muscle.

69. (A) Skin incision for the posterior approach to the
hip joint. (B) Incise the fascia lata.

70. 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

71. 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.

72. 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.

73. (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.

74. Incise the posterior joint capsule to expose the femoral
head and neck.

75. To gain additional exposure, cut the quadratus femoris
and the tendinous insertion of the gluteus maximus.

76. 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.

77. Medial Approach
to Hip joint

78. 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.

79. Position of the patient on the operating table for the
medial approach to the hip.

80. Osteology of the medial approach to the hip.

81. 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.

82. 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.

83. Incision for the medial approach to the hip.

84. 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.

85. 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.

86. (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.

87. • 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)

88. Thank You