Hardinge Approach to Hip Joint (Direct Lateral Approach)

  • Hardinge Approach to Hip Joint (Direct Lateral Approach) allows excellent exposure of the hip joint for joint replacement. It avoids the need for trochanteric osteotomy.

  • The approach does not give as wide an exposure as the anterolateral approach to hip joint with trochanteric osteotomy.
  • Hardinge Approach to Hip Joint (Direct Lateral Approach) is used for:
    •  Total hip arthroplasty.
      • Has lower rate of total hip prosthetic dislocations.
    • Proximal femur fracture.

  1. Lateral position.
  2. Supine position with the greater trochanter at the edge of the table.

  • Landmarks:
    1. Anterior superior iliac spine.
    2. The lateral aspect of the greater trochanter.
    3. The line of the femur bone.
  • Incision:
    • Begin 5cm proximal to tip of greater trochanter.
    • Longitudinal incision centered over tip of greater trochanter and extends down the line of the femur about 8 cm.

  • There is no true internervous plane for hardinge approach to hip joint (direct lateral approach).
  • Intermuscular plane:
    • Splits gluteus medius distal to innervation (innervated by superior gluteal nerve)
    • Vastus lateralis is also split lateral to innervation (innervated by femoral nerve)

  • Split fascia lata and retract it anteriorly to expose tendon of gluteus medius.
  • Detach fibers of gluteus medius that attach to fascia lata using sharp dissection.

  • Split fibers of gluteus medius longitudinally starting at middle of greater trochanter:
    • do not extend more than 3-5 cm above greater trochanter to prevent injury to superior gluteal nerve.
  • Extend incision inferior through the fibers of vastus lateralis.
  • Develop anterior flap.
    • Anterior aspect of gluteus medius from anterior greater trochanter with its underlying gluteus minimus.
    • Anterior part of vastus lateralis muscle.
    • Requires sharp dissection of muscles off bone or lifting small fleck of bone.
  • Expose anterior joint capsule:
    • Follow dissection anteriorly along greater trochanter and onto femoral neck which leads to capsule.
    • Gluteus minimus needs to be released from anterior greater trochanter.

  • Distal Extension:
    • Hardinge Approach to Hip Joint (Direct Lateral Approach) can easily be extended distally:
    • To expose the shaft of the femur, split the vastus lateralis muscle in the direction of its fibers (Lateral Approach to femur).
  • Proximal Extension:
    • The incision cannot be extended proximally.

  • The structures at risk during hardinge approach to hip joint (direct lateral approach) includes:
    1. Superior gluteal nerve:
      • Runs between gluteus medius and minimus muscles 3-5 cm above greater trochanter.
      • Can be protected by:
        • limiting proximal incision of gluteus medius muscle.
        • putting a stay suture at the apex of gluteal split.
      • Its injury leads to Trendelenburg gait pattern.
    2. Femoral nerve:
      • Most lateral structure in neurovascular bundle of anterior thigh.
      • Keep retractors on bone with no soft tissue under to prevent iatrogenic injury.

  • Surgical Exposures in Orthopaedics book - 4th Edition
  • Campbel's Operative Orthopaedics book 12th
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