Medial Approach to Hip Joint
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The uses of the medial approach to hip joint include the following:
- Open reduction of developmental dysplasia of the hip.
- Psoas tendon release (approach gives excellent exposure to psoas tendon).
- Biopsy and treatment of tumors of the inferior portion of the femoral neck and medial aspect of proximal femoral shaft
- Obturator neurectomy.
- 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:
- Adductor longus muscle.
- 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.
- Internervous plane between adductor brevis and adductor magnus muslces:
- 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:
- 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.
- Anterior division of obturator nerve:
- Supplies adductor longus, adductor brevis and gracilis muscles in the thigh.
- Posterior division of obturator nerve:
- Lies within substance of obturator externus muscle.
- Supplies adductor portion of adductor magnus.
- Deep external pudendal artery:
- At risk proximally.
- Lies anterior to pectineus near the origin of the adductor longus muscle.
- Medial femoral circumflex artery:
- Surgical Exposures in Orthopaedics book - 4th Edition
- Campbel's Operative Orthopaedics book 12th
Orthopedic Approaches App
