Anterior Approach to Hip Joint

  • The anterior approach to hip joint, also known as the Smith-Petersen approach, gives safe access to the hip joint and ilium.

  • The anterior approach to hip joint is used for:
    1. Total hip arthroplasty.
    2. Open reduction of congenital hip dislocations.
    3. Synovial biopsies.
    4. Intra-articular fusions.
    5. Excision of pelvic tumors.
    6. Irrigation and debridement of infected, native hip.
  • The upper part of the anterior approach to hip may also be used for the following:
    • Pelvic osteotomies.

  • Place the patient supine on the operating table.
  • If the anterior approach to hip is to be used for pelvic osteotomy, place a small sandbag under the affected buttock to push the affected hemipelvis forward.

  • Landmarks:
    1. Anterior superior iliac spine.
    2. Iliac crest .
  • Incision:
    • Make incision from anterior half of iliac crest to anterior superior iliac spine.
    • From Anterior superior iliac spine curve inferiorly in the direction of the lateral patella for 8-10 cm.

  • The anterior approach to hip joint (Smith-Petersen approach) has a Superficial and Deep internervous plane:
    • Superficial Internervous plane lies between:
      • Sartorius muscle (innervated by the femoral nerve).
      • Tensor fasciae latae muscle (innervated by the superior gluteal nerve).
    • Deep Internervous plane lies between:
      • Rectus femoris muscle (innervated by the femoral nerve).
      • Gluteus medius muscle (innervated by the superior gluteal nerve).

  • Identify gap between sartorius and tensor fasciae latae.
  • Dissect through subcutaneous fat (avoid lateral femoral cutaneous nerve).
  • Incise fascia on medial side of tensor fascia latae.
  • Detach origin of tensor fasciae latae of iliac to develop internervous plane.
  • Ligate the ascending branch of the lateral femoral circumflex artery (crosses gap between sartorius and tensor fascia latae).

  • Identify plane between rectus femoris and gluteus medius.
  • Detach rectus femoris from both its origins.
  • Retract rectus femoris and iliopsoas medially and gluteus medius laterally to expose the hip capsule.
  • Adduct and externally rotate the hip to place the capsule on stretch.
  • Incise capsule with a longitudinal or T-shaped capsular incision.
  • Dislocate hip with external rotation after capsulotomy is complete.

  • Proximal extension:
    • Indications:
      • Bone graft harvest.
    • Dissection:
      • Extend proximal incision posteriorly along the iliac crest.
  • Distal extension:
    • Indications:
      • Intra-operative fracture of distal femur.
    • Dissection:
      • lengthen skin incision downward along anterolateral aspect of thigh.
      • incise fascia latae in line with skin incision.
      • stay in the interval between the vastus lateralis and rectus femoris muscles.

  • The structures at risk during the anterior approach to hip joint¬† include:

    1. Lateral femoral cutaneous nerve:
      • Reaches thigh by passing under inguinal ligament.
        • The course is variable and the lateral femoral cutaneous nerve can be seen passing medial or lateral to anterior superior iliac spine.
      • Most commonly seen when incising fascia between the sartorius and the tensor fascia latae.
      • Injury may lead to painful neuroma or decreased sensation on lateral aspect of thigh.
    2. Femoral nerve:
      • Should remain protected as long as you stay lateral to sartorius muscle.
    3. Ascending branch of lateral femoral circumflex artery:
      • Found proximally in the internervous plane between the tensor fascia latae and sartorius muscles.
      • Be sure to ligate it to prevent excessive bleeding.

  • Surgical Exposures in Orthopaedics book - 4th Edition
  • Campbel's Operative Orthopaedics book 12th
anterior approach to hip joint Smith Petersen approach approach to hip joint anterior approach to hip joint Smith Petersen approach approach to hip joint anterior approach to hip joint anterior approach to hip joint anterior approach to hip joint anterior approach to hip joint anterior approach to hip joint
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