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Surgical Approaches for the Hip

This page summarises the different approaches surgeons can make when performing hip operations.

Surgeons

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In order to gain access to the diseased hip joint the surgeon will use different surgical techniques and approaches consistent with the anatomy of the area.

There are four approaches to the hip and access takes advantage of the muscular planes surrounding the hip joint. Specialist hip surgeons are familiar with all approaches but there may be a preference for a certain approach. However, there are times when a particular approach offers the best exposure to provide a successful outcome.

The Anterior (Front) Approach

Anterolateral incision

This approach is also known as the Smith–Petersen approach and exposes the interval between the sartorious muscle supplied by the femoral nerve and the tensor fascia lata supplied by the superior femoral nerve to enter the hip joint.

Anterior supine incision

This is an excellent approach for minimally invasive surgery (MIS) and is also used to perform a pelvic osteotomy, biopsies and for a hemiarthroplasty following a fracture neck of femur.

The Lateral (Side) Approaches

Lateral incision

The direct lateral approach is via the upper end of the thigh bone (the greater trochanter). The greater trochanter is cut (osteotomised) exposing the capsule of the hip joint. This provides an unparalleled view of the hip joint once the capsule has been excised. The hip joint is then dislocated prior to cutting the femoral neck. The acetabular socket and femur can then be exposed to allow for insertion of the hip prosthesis. The cut greater trochanter requires reattachment by cables or wires and/or screws. Trochanteric bursitis or non-union of the osteotomised trochanter may occur with this approach.

The opinion of the author is that the trochanteric osteotomy violates the upper femur. The trochanter normally takes the insertion of the abductor muscles and so an osteotomy can often affect the gait of the patient on a permanent basis.

In the anterolateral approach the skin incision is made in the line of the shaft of the femur and the length of this incision varies depending on the exposure required to insert the hip in the optimum anatomical position.

Exposure

The subcutaneous tissue is incised down to a tough leathery layer (tensor fascia lata) which envelopes the lateral aspect of the thigh muscles. The fascia lata is split in line with the fibres and the skin incision.

Deep Exposure

An incision is made to mobilise the anterior part of the abductor muscles attaching to the greater trochanter and extends from the tendinous portion of gluteus medius into the vastus lateralis muscle.

This provides the surgeon with a continuous layer which can be elevated from the bone and exposes the capsule of the hip joint. A capsulotomy (opening of the capsule) is performed to allow dislocation of the hip joint; the femoral neck and the femoral head are removed. This exposes the acetabular socket and femoral canal, allowing for insertion of the hip prosthesis.

The hip tissues are closed in layers and sometimes a drain may be placed deep within the wound.

Posterior (Rear) Approach

Posterior incision

The patient is positioned on the side and held by padded supports.

Skin

A lateral incision is made and curved in a posterior direction across the buttock.

Exposure

The subcutaneous tissue is incised down to a tough leathery layer (tensor fascia lata) which envelopes the lateral aspect of the thigh muscles.

Deep Exposure

The sciatic nerve leaves the pelvis through the greater sciatic notch and is identified as it lies over the short posterior muscles (the external rotators).

The short rotators are detached from the insertion on the femur. Evert Smith preserves the piriformis muscle thus adding to the stability of the hip prosthesis following the operation and reducing the number of posterior muscles which require incision.

A capsulotomy (opening of the capsule) is performed to allow dislocation of the hip joint; the femoral neck and the femoral head are removed. This exposes the acetabular socket and femoral canal, allowing for insertion of the hip prosthesis.

The hip tissues are closed in layers and sometimes a drain may be placed deep within the wound.

The advantage of this approach is that it allows access to the hip and avoids disruption to the abductor muscles attached to the upper end of the thigh bone.

Approaches for Revision Hip Surgery

The approaches to the hip joint are the same when performing primary hip replacements but are often extended to allow for improved exposure for a more complex operation.

The trochanteric slide — in this extended approach the vastus lateralis muscle is mobilised as are the short rotators, the greater trocahanter is left attached to the gluteus medius and minimus muscles as well as the thigh muscles. At the end of the operation the greater trochanter is reattached by cables or wires and/or screws. This extended approach provides excellent exposure of the socket and the femoral canal.

The trochanteric osteotomy can be extended down the femur to any pre-planned level to allow exposure into the canal of the femur. This exposure can then be used to remove a well fixed cemented prosthesis or porous coated cementless components.

These techniques allow the hip surgeon to remove the hip prosthesis and avoid further destruction of the surrounding bone. The femur bone can be reattached using wires or cables.

Appointments

To make an appointment e–mail Sue Misir, secretary to Mr Evert Smith, or telephone:

  • 0117 907 4228 (private)
  • 0117 323 5194 (NHS)

For an NHS appointment your GP will need to refer you. How?

Clinic locations and directions

Evert Smith is an Orthopaedic Surgeon in whom I have absolute faith and confidence.

Bob Gibbons, 2007.

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