Posterior approach to the hip (Moore or Southern)
approaches FMH
approaches FMH
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Cartes-fiches
Indications
THA
hemiarthroplasty
ORIF of posterior acetabular fxs
open reduction of posterior hip dislocations
dependent drainage of hip sepsis
removal of loose bodies
pedicle bone grafting
Intermuscular plane
fibers of gluteus maximus split (inferior gluteal nerve)
Position
Position
place in true lateral position
drape in order to allow full motion of hip
Incision
Incision
make 10 to 15 cm curved incision centered on posterior aspect of greater trochanter
begin 7 cm above and posterior to GT
curve over the GT and continue down shaft of femur
mini-incision approach shows no longterm benefits to hip function
Superficial dissection
Superficial dissection
incise fascia lata to uncover vastus lateralis distally
lengthen fascial incision in line with skin incision
split fibers of gluteus maximus in proximal incision (this is a vascular plane, so split muscle gently and cauterize vessels as they appear)
Deep dissection
Deep dissection
internally rotate the hip to place the short external rotators on stretch
place stay suture in piriformis and obturator internus tendon (short external rotators)
detach piriformis and obturator internus close to femoral insertion and reflect backwards to protect sciatic nerve
incise capsule with longitudinal or T-shaped incision
dislocate hip with internal rotation after capsulotomy
Dangers
Sciatic nerve
can be damaged by retractors (keep them on the muscles)
remember sciatic nerve can split into tibial and peroneal branches in the pelvis. If you visualize the nerve and it appears small, remember there may be another branch
Inferior gluteal artery
leaves pelvis beneath piriformis
if it is cut and retracts into the pelvis, then treat by flipping patient, open abdomen, and tie of internal iliac artery
First perforating branch of profunda femoris
at risk of injury with release of the gluteus maximus insertion
Femoral vessels
at risk with failure to protect anterior aspect of the acetabulum, or with placement of retractors anterior to the iliopsoas muscle
Where is the origin of the muscle located between the anterior acetabulum and iliac vessels?
The psoas muscle serves to protect the iliac vessels from retractors/instruments anterior to the acetabulum, and this muscle originates off the transverse processes of L1-L5. The referenced article by Skaggs et el found that the iliac vessels were on average 1 cm away from the iliopsoas at the level of the pelvic brim, but could be as close as 4mm in children. They also found that the neurovascular structures were on average 3.1 cm away from the iliopsoas at the level of its insertion at the lesser trochanter.
The medial femoral circumflex artery and first perforating branch of the profunda femoris artery anastamose at which of the following locations?
Medial to the gluteus maximus insertion
The medial femoral circumflex artery is the primary blood supplier to the adult femoral head. This artery anastamoses with the first perforating branch of the profunda femoris just medial to the gluteus maximus insertion. This is important, as sectioning the gluteus maximus tendon during posterior approaches can put both of these vessels (and the anastamosis) at risk.
A 57-year-old female with degenerative hip arthritis has questions regarding mini-incision total hip arthroplasty (THA) with comparison to traditional THA. Which of the following statements is true regarding the mini-incision technique?
No significant difference in hip function at 1 year
Mini-incision THA has not been shown to have any clinical benefit in terms of hip function at long term followup. Proponents of this technique claim less soft tissue damage may allow for faster recovery. Digioia et al, looked at mini-incision THA vs standard THA using navigation. Although limp, distance walked, and stair function was better at 6 months with mini-incision THA, there were no significant differences in pain, function, or motion at 1 year.
2) DiGioia AM 3rd, Plakseychuk AY, Levison TJ, Jaramaz B. Mini-incision technique for total hip arthroplasty with navigation. J Arthroplasty. 2003 Feb;18(2):123-8. PMID:12629599 (Link to Abstract)
