Medial Approach to Hip Joint

  • The uses of the medial approach to hip joint include the following:

    1. Open reduction of developmental dysplasia of the hip.
    2. Psoas tendon release (approach gives excellent exposure to psoas tendon).
    3. Biopsy and treatment of tumors of the inferior portion of the femoral neck and medial aspect of proximal femoral shaft
    4. Obturator neurectomy.
    5. The upper part of the approach can be used for an obturator neurectomy.

  • Place the patient supine on the operating table with the affected hip flexed, abducted, and externally rotated.

  • Landmarks:
    1. Adductor longus muscle.
    2. pubic tubercle.
  • Incision:
    • Longitudinal incision over the adductor longus,
    • Begin incision 3 cm below the pubic tubercle.
    • Length of incision is determined by the amount of femur that needs to be exposed.

  • Superficial:
    • No superficial internervous plane as both the adductor longus and gracilis muscles are innervated by the anterior division of the obturator nerve.
  • Deep:
    • Internervous plane between adductor brevis and adductor magnus muslces:
      • Adductor brevis supplied by the anterior division of the obturator nerve.
      • Adductor magnus has dual innervation:
        • Adductor portion is supplied by the posterior division of the obturator nerve.
        • Ischial portion by the tibial portion of the sciatic nerve.

  • Develop a plane between gracilis and adductor longus muscles.

  • Develop plane between adductor brevis and adductor magnus until you feel lesser trochanter on the floor of the wound.
  • Try to protect the posterior division of the obturator nerve, the innervation to the muscle’s adductor portion, to preserve the hip extensor function of the adductor magnus.
  • Place a narrow retractor (such as a bone spike) above and below the lesser trochanter to isolate the psoas tendon.

  • The medial approach to hip joint can’t be extended.

  • The structures at risk during medial approach to hip joint  includes:
    1. Medial femoral circumflex artery:
      • Passes around medial side of the distal part of the psoas tendon.
      • At risk in children when releasing psoas tendon,
        • Must isolate psoas tendon and cut under direct vision.
    2. Anterior division of obturator nerve:
      • Supplies adductor longus, adductor brevis and gracilis muscles in the thigh.
    3. Posterior division of obturator nerve:
      • Lies within substance of obturator externus muscle.
      • Supplies adductor portion of adductor magnus.
    4. Deep external pudendal artery:
      • At risk proximally.
      • Lies anterior to pectineus near the origin of the adductor longus muscle.

  • Surgical Exposures in Orthopaedics book - 4th Edition
  • Campbel's Operative Orthopaedics book 12th
Medial Approach to Hip Joint Medial Approach to Hip Joint Medial Approach to Hip Joint Medial Approach to Hip Joint Medial Approach to Hip Joint
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