Hardinge Approach

Hardinge Approach to Hip Joint (or Direct Lateral Approach) allows excellent exposure to 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.

See Also: Hip Joint Anatomy

Hardinge Approach to Hip Joint indications

Hardinge Approach to Hip Joint (Direct Lateral Approach) is used for:

1. Total hip arthroplasty: it has lower rate of total hip prosthetic dislocations.
2. Proximal femur fracture.

Position of the Patient

1. Lateral position.
2. Supine position with the greater trochanter at the edge of the table, this allows the buttock muscles and gluteal fat to fall posteriorly away from the operative plane.

Landmarks and Incision

• Landmarks:
  1. Anterior superior iliac spine.
  2. The lateral aspect of the greater trochanter.
  3. The line of the femur bone.
• Incision:
  • Begin the incision 5 cm above the tip of the greater trochanter.
  • Make a longitudinal incision that passes over the center of the tip of the greater trochanter and extends down the line of the shaft of the femur for approximately 8 cm.

Internervous plane

There is no true internervous plane for Hardinge approach to hip joint (direct lateral approach).

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.

Superficial dissection

• Incise the fat and underlying deep fascia in line with the skin incision.
• Retract the cut edges of the fascia to pull the tensor fasciae latae anteriorly and the gluteus maximus posteriorly.
• Detach any fibers of the gluteus medius that attach to the deep surface of this fascia by sharp dissection. The vastus lateralis and the gluteus medius are now exposed.

Deep dissection

• Split the fibers of the gluteus medius muscle in the direction of their fibers beginning in the middle of the trochanter. Do not go more than 3 cm above the upper border of the trochanter because more proximal dissection may damage branches of the superior gluteal nerve.
• Split the fibers of the vastus lateralis muscle overlying the lateral aspect of the base of the greater trochanter.
• Next, develop an anterior flap that consists of the anterior part of the gluteus medius muscle with its underlying gluteus minimus and the anterior part of the vastus lateralis muscle.
• You will need to detach the muscles from the greater trochanter either by sharp dissection or by lifting off a small flake of bone.
• Continue developing this anterior flap, following the contour of the bone onto the femoral neck, until the anterior hip joint capsule is fully exposed.
• You will need to detach the insertion of the gluteus minimus tendon to the anterior part of the greater trochanter.
• Develop the plane between the hip joint capsule and the overlying muscles, using a swab pushed into the potential space using a blunt instrument.
• Enter the capsule using a longitudinal T-shaped incision.
• Osteotomize the femoral neck, extract the femoral head using a cork screw.
• Complete the exposure of the acetabulum by inserting appropriate retractors around the acetabulum.

Approach Extension

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:

• Hardinge Approach to Hip Joint (Direct Lateral Approach) cannot be extended proximally.

Dangers

The structures at risk during hardinge approach to hip joint (direct lateral approach) include:

1. Superior gluteal nerve:
   • Superior gluteal nerve runs between gluteus medius and minimus muscles 3-5 cm above greater trochanter.
   • It can be protected by limiting proximal incision of gluteus medius muscle and putting a stay suture at the apex of gluteal split.
   • Its injury leads to Trendelenburg gait pattern.
2. Femoral nerve:
   • The Femoral nerve is the most lateral structure in neurovascular bundle of anterior thigh.
   • Keep retractors on bone with no soft tissue under to prevent iatrogenic injury.

References

1. Surgical Exposures in Orthopaedics book – 4th Edition
2. Campbel’s Operative Orthopaedics book 12th
3. Hardinge K. The direct lateral approach to the hip. J Bone Joint Surg Br 1982;64B:17–18. Link