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Hip


Anterior approach to the hip - Smith-Petersen

Uses the internervous plane between:

Tensor fasciae latae laterally (sup gluteal n.) & sartorius medially (femoral n.)
then Gluteus medius laterally (sup gluteal n.) & rectus femoris medially (femoral n.).

Its main indication is for :

Open reduction of Congenital dislocation of the hip if the femoral head lies anteriorly to the true acetabulum. But can also be used for hip arthrodesis, tumor excision, synovial biopsy and hip arthroplasty surgery, Ganz osteotomy for DDH, Shelf procedure for acetabular dysplasia, Posterior hip # dislocations

Position - Supine position - sand bag under buttock


Incision

Begin the incision at the middle of the iliac crest or, for a larger exposure, as far posteriorly on the crest as desired. Carry it anteriorly to the anterosuperior iliac spine and then distally and slightly laterally 10 to 12 cm towards lateral patella. Increase gap between TFL and sartorius by external rotation of thigh.


Superficial Dissection

WATCH OUT FOR the lateral femoral cutaneous nerve. It passes over the sartorius 2.5 cm distal to the anterosuperior spine; retract it to the medial side. Dissect through the deep fascia of the thigh and between the tensor fasciae latae laterally (sup gluteal n.) and the sartorius medially (femoral n.).




Deep Dissection

IDENTIFY, clamp and ligate the ascending branch of the lateral femoral circumflex artery , which lies 5 cm distal to the hip joint over rectus femoris.


Enter between Gluteus medius laterally (sup gluteal n.) & rectus femoris medially (femoral n.). Usually need to detach rectus femoris from it's origins (AIIS & superior lip of acetabulum).


Expose and incise the capsule transversely and reveal the femoral head and the proximal margin of the acetabulum. The capsule may also be sectioned along its attachment to the acetabular labrum (cotyloid ligament) to give the required exposure. If necessary, the ligamentum teres may be divided with a curved knife or with scissors and the femoral head dislocated, giving access to all parts of the joint.


Closure

Close capsule if possible. Reattach rectus femoris tendon Reattach gluteal fascia to fascia of abdominal wall muscles with interrupted sutures Close TFL fascia same way. Watch out for branches of lat cutaneous nerve

Extensile approach

The entire ilium and hip joint can be reached through the iliac part of the incision; all structures attached to the iliac crest from the posterosuperior iliac spine to the anterosuperior iliac spine are freed and are reflected from the lateral surface of the ilium; dissection is carried distally to the anteroinferior iliac spine. Divide the superficial and deep fasciae, and free the attachments of the gluteus medius and the tensor fasciae latae muscles from the iliac crest . With a periosteal elevator, strip the periosteum with the attachments of the gluteus medius and minimus muscles from the lateral surface of the ilium. Control bleeding from the nutrient vessels by packing the interval between the ilium and the reflected muscles.

Smith-Petersen has also modified and improved this approach for extensive surgery of the hip by reflecting the iliacus muscle from the medial surface of the anterior part of the ilium and by detaching the rectus femoris muscle from its origin.


Schaubel modified the Smith-Petersen anterior approach after finding reattachment of the fasia lata to the fascia on the iliac crest difficult. Instead of dividing the fascia lata at the iliac crest, an osteotomy of the overhang of the iliac crest is performed between the attachments of the external oblique muscle medially and the fascia lata. The osteotomy may be carried posteriorly as far as the origin of the gluteus maximus. The tensor fasciae latae, gluteus medius, and gluteus minimus muscle attachments are subperiosteally dissected distally to expose the hip joint capsule. The abductors and short external rotators may be dissected from the greater trochanter as necessary for total hip arthroplasty, prosthetic replacement of the femoral head, or arthrodesis of the hip. At closure, the iliac osteotomy fragment is reattached with No. 1-0 or No. 2-0 nonabsorbable sutures passed through holes drilled in the fragment and the ilium.

Short notes version (HDE Atkinson)

Smith-Petersen [ilio-femoral] i/n TFL(sup glut)& Sart (fem) Supine.
Excellent exposure- for almost any hip procedure! Hueter = small inc. (Modified Bikini line incision skin crease 1cm below AIIS)

I: parallel to middle iliac crest to ASIS then distal vertically 10cm. 
Free glut med & TFL from crest and glut min from iliac wing pack to control nutrient vessels. 
Expose acetabulum. CAR E: buttock may slough if sup gluteal damaged.

Develop plane between: TFL/glut med lat and Sartorius / Rectus fem medially onto capsule. Detach rectus straight & reflected heads off AIIS and sup acetabulum. CARE:-ligate ascending

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