Surgical approaches to hip joint

ANATOMY OF HIP JOINT AND
SURGICAL APPROACHES TO HIP
Dr.
CH. ADITYA

 It is the largest and most stable of
the joints.
 2nd
largest weight bearing joint
 Hip joint is a synovial
articulation between head of
femur and acetabulum .
 Type: Multiaxial ball and socket
type of synovial joint
 Hip joint is designed for stability
over a wide range of movements
HIP JOINT

1. lunate surface of the acetabulum
2.spherical head of femur
ARTICULAR SURFACES OF HIPARTICULAR SURFACES OF HIP

Acetabulum
04/15/18 4
Horse-shoe shaped
articular surface
Deepened by
fibro-cartilaginous
rim called
acetabular
labrum
Nonarticular
part, acetabular
fossa, lodges
pad of fat
Deficient
inferiorly as the
acetabular
notch that is
bridged up by
transverse
acetabular
ligament
It is positioned in
downward and outward
direction

ANATOMICAL ASPECTS
Anatomy of upper end of femur
• The upper end consists of head, neck, greater and
lesser trochanters, inter-trochanteric line and inter-
trochanteric crest.
• The head is articular, forms two –thirds of a sphere
and fits as a ball in the acetabular socket to form the
hip joint.
• It is covered with articular hyaline cartilage; except
near its center where a pit or fovea exists for the
attachment of the ligamentum teres.
• It is related anteriorly to the femoral artery.

NECK
• It is about 5 cm long, directed upwards, forwards and
medially forming an angle of 1250
with the shaft.
• It is strengthened posteromedially by the calcar
femorale.
• The anterior surface is entirely intracapsular and
related to the iliofemoral ligament .
• The posterior surface is partly extracapsular.

GREATER TROCHANTER
• It has three surfaces- anterior, lateral and
medial, and two borders – upper and
posterior.
• The anterior surface is rough and receives the
insertion of gluteus minimus.
• The lateral surface is quadrilateral & receives
the insertion of gluteus medius,and gluteus
maximus respectively.
• The medial surface presents a depression, the
trochanteric fossa OR pyriform fossa, the
fossa receives the insertion of obturator
externus.

LESSER TROCHANTER
• It is a conical projection directed
postero medially from the shaft
providing attachment to iliopsoas
tendon.
• In 1957, Harely and Griffin gave
the definition of the calcar
femorale, as a dense vertical
plate of bone within the femur
which orginates in the
posteromedial portion of the
shaft, under the lesser
trochanter, and radiates through
the cancellous tissues towards
the greater trochanter

INTERTROCHANTERIC LINE
• The intertrochanteric line separates the
anterior surface of neck from the shaft
• It gives attachments to iliofemoral ligament,
vastus lateralis and vastus medialis

ANGLE OF FEMORAL TORSION
• It is the angle subtended between the long
axis of femoral neck and the transcondylar
axis of the femur.
• Average values in newborn is 30-400
and in
adults 8-150
.

Trabecular Pattern of proximal femur
• These are formed along the
lines of Stress visible on
the AP view of the X-rays
of Hips
• 5 Groups
 Principal Compressive
Group
 Secondary Compressive
Group
 Principal Tensile Group
 Secondary Tensile Group
 Greater Trochanter Group

Trabecular Pattern
Ward’s Triangle
• Is the area of the least Bone Mineral Density in the Femoral Neck
Babcock’s Triangle
• Frequently a site of Tubercular lesions.

• Strong, thick
• MEDIALLY : attached to margin of acetabulum,
transverse acetabular ligament, and
adjacent margin of obturator foramen
• LATERALLY : attached to intertrochantric line
of femur . Just proximal to intertrochantric crest
on posterior surface.
• Femoral neck : intracapsular
• Greater and lesser trochanter: extracapsular
CAPSULE

SYNOVIAL MEMBRANE
• Extensive synovial membrane
within the capsule.
• Lines the intracapsular portion of
neck of femur and both surfaces of
acetabular labrum, transverse
ligament and fat in acetabular
fossa.
• Forms a tubular covering around
the ligament of head of femur and
lines the fibrous membrane of joint

LIGAMENTS
• 3 ligaments reinforce the external surface of fibrous membrane
and stabilize the joint they are
• 1) iliofemoral ligament
• 2) pubofemoral ligament
• 3) ischiofemoral ligament
• Fibers of all three ligaments are oriented in a spiral fashion
around the hip joint so that they become taught when joint is
extended.

• Ligament of Bigelow
• One of the strongest ligament in
the body
• Triangular , Y-shaped
• Apex attached to Anterior
inferior iliac spine
• Base to intertrochanteric line
• Reinforces joint anteriorly
• Prevents over extension while
standing
• Prevents trunk from falling
backwards while standing
ILIOFEMORAL LIGAMENT

PUBOFEMORAL LIGAMENT
• Support the joint inferomedially
• Triangular in shape
• Attachment:-
– Superiorly, attached to the
iliopubic eminence, the
obturator crest
– Inferiorly, merges with the
capsule and lower band of
iliofemoral ligament
• It limits extension & abduction

• Reinforces posterior aspect of
fibrous membrane.
• MEDIALLY: attached to ischium,
just posteroinferior to acetabulum
• LATERALLY: to greater
trochanter deep to the iliofemoral
ligament.
• Limits FLEXION
ISCHIOFEMORAL LIGAMENT

• Round Ligament/ Ligament of Head of
Femur
• Triangular and Flat
• Flattened band : Apex – fovea, Base to
acetabular notch & transverse ligament.
• Ensheathed by synovial membrane.
• Transmits arteries to head of femur
from acetabular branches of medial
circumflex and femoral arteries.
LIGAMENT TERES

Movements
• The hip joint has a wide range of movement but less than the
shoulder joint
• Some of the movement has been sacrificed to provide strength
and stability
• The strength of the joint depends largely on the shape of the
bones taking part in the articulation and on strong ligaments
 Descriptive planes:
• Flexion/extension : sagittal plane
• abduction/adduction : frontal plane
• medial /lateral rotation : transverse plane (circumduction)

MOVEMENTS
Obturator internus & externus, gemullus
superior inferior, quadratus femoris, &
piriformis, posterior fibres of gluteus medius &
minimus,& superior fibres of gluteus maximus
Lateral rotation
Medial rotation
pectineus, adductor longus, brevis,
magnus, gracilis
Adduction
gluteus medius, minimus, tensor fascia lataAbduction
gluteus maximus , semimembranosis,
semitendinosis, biceps femoris
Extension
iliopsoas, sartorius , rectus femoris, tensor
fascia lata
Flexion
MusclesAction
gluteus medius, minimus, tensor fascia
lata

MUSCLES OF HIP JOINT
- muscles of the gluteal region
- muscles of thigh

The thigh is divided into 3 compartments3 compartments
by 3 intermuscular septa (extending from deep fascia into femur)
The thigh is divided into 3 compartments3 compartments
by 3 intermuscular septa (extending from deep fascia into femur)
AnteriorAnterior
CompartmentCompartment
Extensors of knee:Extensors of knee:
Quadriceps
femoris
Flexors of hip:Flexors of hip:
1. Sartorius
2. psoas major
3. Iliacus
Nerve supply:Nerve supply:
Femoral nerveFemoral nerve
MedialMedial
CompartmentCompartment
Adductors of hip:Adductors of hip:
1. Adductor longus
2. Pectineus
3. Adductor brevis
4. Adductor
magnus
(adductor part)
5. Gracilis
Obturator nerveObturator nervePosterior CompartmentPosterior Compartment
Flexors of knee & extensorsFlexors of knee & extensors
of hip:of hip:
Hamstrings
Sciatic nerve

SartoriusSartoriusSartoriusSartorius
INSERTIONINSERTION
Upper part of
medial surface
of tibia
SS
ACTIONACTION
(TAILOR’S POSITION)(TAILOR’S POSITION)
Flexion, abduction &
lateral rotation of hip
joint
Flexion of knee joint
ORIGINORIGIN
Anterior
superior iliac
spine

Iliacus & Psoas major (Iliopsoas)Iliacus & Psoas major (Iliopsoas)Iliacus & Psoas major (Iliopsoas)Iliacus & Psoas major (Iliopsoas)
INSERTION:INSERTION:
Lesser trochanter
of femur
ACTION:ACTION:
Flexion of
hip joint
ORIGIN:ORIGIN:
Psoas major: T12
& lumbar vertebrae
Iliacus: Iliac fossa

Quadriceps FemorisQuadriceps FemorisQuadriceps FemorisQuadriceps Femoris
ORIGIN:ORIGIN:
Rectus femoris:Rectus femoris: Anterior
inferior iliac spine, and
upper part of acetabulum
Vastus intermedius:Vastus intermedius:
Front of shaft of femur
Vastus medialis:Vastus medialis:
Posterior border of femur
Vastus lateralis:Vastus lateralis:
Posterior border of femur

Quadriceps FemorisQuadriceps FemorisQuadriceps FemorisQuadriceps Femoris
Into PATELLAPATELLA
(Patella is a sesamoid(Patella is a sesamoid
bone)bone)
From patella into
TUBEROSITY OF TIBIATUBEROSITY OF TIBIA
through LigamentumLigamentum
Patellae (PatellarPatellae (Patellar
Ligament)Ligament)
ACTION:ACTION:
Extension ofExtension of
knee jointknee joint

MUSCLES:MUSCLES:
1.1.PectineusPectineus
2.2.Adductor longusAdductor longus
3.3.Adductor brevisAdductor brevis
4.4.Adductor magnusAdductor magnus
(Adductor portion)(Adductor portion)
5.5.GracilisGracilis
ACTION:ACTION:
ADDUCTION OF HIP JOINTADDUCTION OF HIP JOINT
N.B.: Gracilis also flexesN.B.: Gracilis also flexes
knee jointknee joint
NERVE SUPPLY:NERVE SUPPLY:
OBTURATOR NERVEOBTURATOR NERVE
Adductor magnus
(Adductor portion)
Medial Compartment of ThighMedial Compartment of ThighMedial Compartment of ThighMedial Compartment of Thigh
11
22
33
44
Adductor magnus
(Hamstring portions)
11
22
33
44

PectineusPectineusPectineusPectineus
ORIGIN:ORIGIN:
Superior pubic ramus
Back of femur (below
lesser trochanter)
ACTION:ACTION:
Flexion &
adduction of hip
joint

InsertionInsertion
Posterior border of femur (Linea Aspera)
Upper part of medial
surface of tibia
(behind sartorius)
Adductor longusAdductor longus Adductor brevisAdductor brevis
Adductor magnusAdductor magnus
(adductor portion)(adductor portion)
GracilisGracilis
OriginOrigin
Body of pubis Body of pubis
Inferior pubic ramus
Inferior pubic ramus
Ischial ramus
AdductorAdductor
hiatushiatus
HamstringHamstring
hiatushiatus
AdductoAdducto
r partr part

POSTERIOR COMPARTMENT OF THE THIGH
• Muscles:
• Hamstring muscles:
• Biceps femoris.
• Semitendinosus.
• Semimembranosus.
• Blood supply:
• Branches of the profunda
femoris artery.
• Nerve supply:
• Sciatic nerve.
CONTENTS

Biceps Femoris : • Origin:
– The long head from the ischial
tuberosity.
– The short head from the linea
aspera .
• Insertion:
• Into the head of the fibula.
Nerve supply:
• The long head is supplied by the tibial
part of the sciatic;
• the short head is supplied by the
common peroneal part of the sciatic.
Action :
• Flexion of knee.
• Lateral rotation of flexed leg.
• Long head: extends hip.

SEMITENDINOSUS
• Origin:
• Ischial tuberosity.
• Insertion:
• Upper part of the medial surface
of the shaft of the tibia (SGS)..
Nerve supply:
• Tibial portion of the sciatic.
Action:
• Flexes and medially rotates the leg
at the knee joint;
• Extends the thigh at the hip joint.

SEMIMEMBRANOSUS
• Origin:
• Ischial tuberosity.
• Insertion:
• Posterior surface of the medial
condyle of the tibia.
• It forms the oblique popliteal
ligament, which reinforces the
capsule on the back of the knee
joint.
Nerve supply:
• Tibial portion of the sciatic nerve.
Action:
• Flexes and medially rotates the leg
at the knee joint;
• Extends the thigh at the hip.

Muscles of the Gluteal Region
 MUSCLES
• Gluteus maximus
• Gluteus medius
• Gluteus minimus
• Tensor fascia lata
• Piriformis
• Superior Gemellus
• Inferior Gemellus
• Obturator internus
• Quadratus femoris

Gluteus Maximus
•Forms the prominence of
buttock
•Origin:
– Outer surface of ilium
behind the posterior
gluteal line
– Lumbar fascia
– Posterior surface of
sacrum & coccyx
– Sacrotuberous ligament
ilium
S
C

• Insertion:
– Most of the muscle
(3/4th
) inserted into the
iliotibial tract
– Deeper fibers inserted
to the gluteal tuberosity
• Nerve supply:
– Inferior gluteal nerve
(L5, S1, 2)
Gluteus
maximus
Iliotibial
tract

Actions:
Extends & laterally rotates the hip joint
Extends the knee joint (through iliotibial tract)
Gives simultaneous stability to the hip and
knee joints through the iliotibial tract
Gluteus maximus is the chief antigravity muscle of the
hip. It is used in standing up from a sitting position,
running & climbing up stairs. In each case extension of
the hip moves the trunk upwards. The muscle must be
extremely powerful to raise the weight of the body
against gravity. This is called "forced extension".

Gluteus Medius
• Origin: outer surface of ilium
between the middle and
posterior gluteal lines
• Insertion: Lateral surface of
greater trochanter
• Nerve supply: Superior gluteal
nerve (L4,5, S1)
• Action:
– Abducts & medially rotates
the thigh
– Steady pelvis in walking

Gluteus Minimus
• Origin: outer surface of
ilium
• Insertion: Anterior
surface of greater
trochanter
• Nerve supply: Superior
gluteal nerve (L4,5, S1)
• Action: Abducts &
medially rotates the
thigh

Tensor Fascia Lata
• Origin: Outer edge of iliac
crest between anterior
superior iliac spine & iliac
tubercle
• Insertion: Into the iliotibial
tract
• Nerve supply: Superior
gluteal nerve (L4,5, S1)
– Action:
– Flexion of the hip
– Internal rotation
– Abduction of the hip
Tensor
fascia lata
Iliotibial
tract

Piriformis
• Origin: Anterior surface of
S2,3,4 vertebrae
• Insertion: Upper border of
greater trochanter
• Nerve supply: Anterior rami
of S1,2
• Action:
– Lateral rotator of thigh
– Assists in stabilizing hip
joint especially in
abduction
Piriformis forms an
important landmark in the
region

Obturator Internus
• Origin: Inner surface of
obturator membrane
and adjacent bone
• Insertion: Upper border
of greater trochanter
along with gemelli
• Nerve supply: nerve to
obturator internus
(L4,S1)
• Action: Lateral rotator
of thigh

Superior & Inferior Gemelli
• Origin:
– Superior from ischial spine
– Inferior from ischial
tuberosity
• Insertion: Upper border of
greater trochanter
• Nerve supply:
– Superior from nerve to
obturator internus (L4, S1)
– Inferior from nerve to
quadratus femoris (L4, S1)
• Action: Lateral rotators of thigh

Quadratus Femoris
• Origin: Lateral border
of ischial tuberosity
• Insertion: Quadrate
tubercle of femur
• Nerve supply: nerve to
quadratus femoris
(L4,S1)
• Action: Lateral rotator
of thigh

HIP JOINT: NERVE SUPPLY
• Femoral nerve
• Anterior and posterior divisions of Obturator nerve
• Nerve to Quadratus femoris
• Sciatic nerve
• Superior gluteal nerve
Hilton’s law: “the nerve supplying the joint also
supply the muscles moving the joint & the skin
covering the insertion of these muscles”
• Femoral nerve not only supplies hip joint via intermediate and
cutaneous nerve of thigh, also supplies skin of front and
medial side of thigh
• Posterior division of obturator nerve supplies both hip and knee joint.
Therefore sometimes there is referred pain to knee joint.

BURSAE AROUND HIP JOINT
Bursae: small fluid filled
pockets located in
connective tissue. They
develop where tendons or
ligaments rub against other
tissue.

SURGICAL APPROACHES TO HIP JOINT
1. SELECTION OF SPECIFIC APPROACH
2. ANATOMICAL PRINCIPLES
3. CONCEPT OF INTERNERVOUS PLANE AND MUSCLE
SPLITTING INCISIONS
4. CLASSIFICATION OF APPROACHES

SELECTION OF SPECIFIC APPROACH:
1. Access needed: acetabulum/ femoral head/ both
2. Potential for complications
3. The procedure to be performed
4. Experience of the surgeon and
5. Need for maintaining primary blood supply to
femoral head.
6. Age of the patient

• A good approach to the hip should have
• good access to both femoral head and acetabulum,
• should have minimal dissection of soft tissues, leading
to reduced operative time and blood loss,
• less post operative pain and early mobilisation,
• least risk of damage to neurovascular bundles, muscles
and tendons
• minimal risk of infection, thrombosis and dislocation.
• However in practice there is no one ideal approach
hence many approaches have been described and used

• Before performing any surgical approach it is important
understand the anatomical principles that lie behind
the surgical dissection.
• positioning the patient,
• draping and preparing the area,
• identification of landmarks and
• making the incision along skin creases, are important to
remember.
• It is also important to note that all incisions should be
made along the identified line of incision but the initial
incision is best made within the middle half of the
incision line so that if needed this can be extended in
either direction

INTERNERVOUS PLANE
• The concept of “internervous plane” is
important to understand before any surgical
approach is done. This means that all deep
dissection should be done by dissecting and
separating the muscles between two nervous
planes so that all muscles supplied by one
nerve and it’s branches are retracted towards
one side to avoid damage and denervating the
muscles

MUSCLE SPLITTING INCISIONS
 The principles of muscle splitting incision are
1.Always muscles are split longitudinally along
the line of the fibres.
2. Splitting is done away from the
neuromuscular junction to avoid denervation.
3. Bulk of the muscle is retracted along with the
nerve-so that most of the muscle will retain
the nerve supply

Classification of surgical approaches
• A. BASED ON THE DIRECTION
• 1. Anterior type
• 2. Lateral and antero lateral type
• 3. Posterior type
• 4. Medial type
• 5. Combined e.g. anterior and posterior
• B. BASED ON INCISION AND INVASIVENESS
• 1. Standard incision e.g. Posterior
• 2. Mini incision posterior (MIS)

• C. BASED ON TYPE OF SURGERY
• 1. Open surgical e.g. anterior
• 2. Arthroscopic
• It is also important to know that certain new
approaches described are essentially a modification
of an existing approach. E.g. Trochanteric flip
approach is a modification of an anterior type
approach.

HIP JOINT-FROM WHERE TO ENTER….
UMY

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

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

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

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

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

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

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

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.

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.

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

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.

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

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

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

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.

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

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
• Injury to lateral femoral cutaneous nerve.
• Exposure to femoral medullary canal is
limited.

• IND-For irreducible congenital dislocation of the hip
in a young child.
• TRANSVERSE ‘BIKINI’ INCISION – From anterior
inferior and medial to the ASIS and coursing
obliquely superiorly and posteriorly to the middle of
the iliac crest.
• For reduction of CDH following sequential steps must
be performed:
• Psoas tenotomy → complete medial capsulotomy→
excision of hypertrophied lig teres→ reduction of
femoral head into true acetabulum.
SOMMERVILLE ANTERIOR APPROACH

ANTEROLATERAL APPROACH:
( WATSON-JONES APPROACH)
• Most commonly used for THR
• Releases all abductor mechanism, hence hip can be adducted fully
hence acetabulum is fully exposed.
• It combines an excellent exposure of the acetabulum with safety
during reaming of femoral shaft
• Abductor mechanism released either by trochanteric osteotomy / by
cutting the ant.part of GL.medius & the whole Gl.minimus off the G.T
INDICATIONS:
• THR
• ORIF of # NOF
• Hemiarthroplasty
• Synovial biopsy
• Biopsy Femoral Neck. UMY

POSITION:
• Supine, close to the edge of the table so that the buttock of the
affected side hangsover.
• Flex the leg upto 30 deg. , adduct it so that leg lies across the
opposite knee.
LANDMARKS:
• ASIS
• GT
• Femoral shaft
• V.Lat ridge
UMY

• INCISION:
• 8-15cm longitudnal & straight centered over the Tip
of GT.
• Incision crosses the post.3rd
of the GT before
running down the shaft.
INTERNERVOUS PLANE:
• No internervous plane.
• Surgical plane is b/w TFL & GL.medius(supplied by
Sup.GT N.)
UMY

Incise the fascia lata posterior to the tensor fasciae
latae.

Retract the fascia lata and the tensor fasciae latae muscle, anteriorly,
revealing the gluteus medius and a series of vessels that cross the
interval between the tensor fasciae latae and the gluteus medius.

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

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

Osteotomize the greater trochanter.

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

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

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).

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.

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.

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.

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.
• It permits early mobilization of pt following the
surgery as the Gl.medius is preserved intact.
• But not a wider approach as anterolateral approach
with trochanteric osteotomy
Indications:
• Total hip replacement surgeries
• Good approach to femur head

POSITION: place the patient
supine on the operating table
with the greater trochanter at
the edge of the table, which
allows the buttocks, and gluteal
fat to fall posteriorly, away
from the operative plane.
LANDMARKS:
ASIS
G.T
Shaft of femur

INCISION:
• Begin the incision 5cm above the tip of GT.
• Make a longitudinal incision centered over the tip
of the greater trochanter in the line of the femoral
shaft for approximately 8cm.

Internervous plane:
• There is no true
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 split in its own line
lateral to the point where it
is supplied by the femoral
nerve.

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

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.

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

Enter the capsule using a longitudinal T-shaped incision.

Osteotomize the femoral neck using an oscillating saw.

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

Dangers:
• Superior gluteal nerve is damaged when the g.medius is
split more proximally above the GT, prevented by
putting a stay suture at the apex of the gluteus medius
split.
• The femoral nerve the most lateral structure in the
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.

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.

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.

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

POSTERIOR APPROACH:
(MOORES APPROACH- SOUTHERN EXPOSURE)
• Most commonly used approach & practical
• Easy ,safe, quick
• Popularized by Moore, it is often called the southern
approach.
INDICATIONS:
• Hemiarthroplasty.
• THR including revision surgery.
• ORIF of posterior acetabular fractures.
• Dependent drainage of hip sepsis.
• Removal of loose body from hip joint
• Pedicle bone grafting.
• Open reduction of posterior hip dislocation

LANDMARKS:
palpate the greater trochanter on the outer
aspect of the thigh
POSITION:
 Place the patient in
true lateral position with
affected limb above
Bony prominences are
protected with adequate
pads

INCISION:
 Make a 10cm to 15cm
curved incision centered on
the posterior aspect of GT.
Begin proximally 6-8cm
above and posterior to the
posterior aspect of GT.
Curve the incision across
the buttock along the
posterior aspect of GT and
extend down along the shaft
of femur
Danger Point:
Avoid incision on greater
trochanter (Bony prominence
painful and scar)

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

Approach:
Expose and divide deep fascia. Separate the fibers of gluteus maximus
(by blunt dissection).
Retract the gluteus maximus to reveal the fatty layer over the short
external rotators of the hip.

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.

 Internally rotate the femur to bring the insertion of the short rotators
of the hip as far lateral to the sciatic nerve as possible.
 Detach the short rotator muscles close to their femoral insertion and
reflect them backward, laying them over the sciatic nerve to protect it.

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

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

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.
• Possibility of sciatic nerve injury.

MEDIAL APPROACH
(LUDLOFFS APPROACH)
• 1908 – He originally described a posteromedial approach.
• 1939 – He modified it to present anteromedial approach.
INDICATIONS:
• Open reduction of congenital dislocation of hip.
• Biopsy & RX of tumors of the inf.portion of femoral neck & medial
aspect of proximal shaft.
• Psoas release
• Obturator neurectomy.
• By making short transverse/longitudinal incision-used for adductor
release
DISADVANTAGES:
• Incision closer to perineum
• Limited exposure of capsule of hip joint.
• Deep incision – vascular injury.

POSITION:
Supine with affected hip flexed , abducted & externally rotated.
Sole of foot lies along the medial side of opp. Knee.
LANDMARKS:
Adductor longus traced to its origin
Pubic tubercle
GT
UMY

 Make a longitudinal incision on medial side
of thigh, starting at a point 3cm below the
pubic tubercle
INCISION:

INTERNERVOUS PLANE
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

More deeply:
• The plane of dissection lies 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.
Deep dissection:
• Continue the dissection in the interval between
adductor brevis and adductor magnus until you
feel the lesser trochanter.

(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.

• DANGERS:
• NERVES:
• Anterior division of obturator nerve lies on top of
obturator externus and runs down the medial side of
thigh between adductor longus and adductor brevis .
• Posterior division of obturator nerve lies in the
substance of obturator externus, then runs down the
thigh on adductor magnus and under adductor brevis.
• VESSELS: Medial circumflex femoral artery passes
around the medial side of distal part of psoas tendon. (it
is in danger, especially in children, if you try detach the
psoas with out isolating the tendon and cutting it under
direct vision)

Surgical approaches to hip joint

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Surgical approaches to hip joint