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Anatomical Basis for Surgical Approaches to the Hip

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Anatomical Basis for Surgical Approaches to the Hip
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  Annals of Medical and Health Sciences Research | Jul-Aug 2014 | Vol 4 | Issue 4 | 487  Address for correspondence:  Dr. Emeka G. Anyanwu, Department of Anatomy, College of Medicine, University of Nigeria Enugu Campus, Enugu, Nigeria. E-mail: anyanwugemeks@yahoo.com Introduction Operations of the hip joint are among the most common  procedures in orthopedics. [1]  Surgical exposure of the hip joint is required for tumor surgery, treatment of infection in the hip  joint, treatment of hip fractures, hemi-arthroplasty as well as  primary and revised total hip replacement. [2-7]  The principles of surgical exposure include a thorough knowledge of anatomy of the region and its variations, [8-11]  proper patient positioning and adequate incisions. Dissections through natural cleavage  planes help to minimize bleeding and disruption of important functional structures. Classication of surgical approaches to the hip joint into well-dened groupings is usually difcult. However, a general classication on the basis of the approach to the capsule of the hip joint into anterior, anterolateral, lateral, posterior and medial approaches [1,9]  has been used. These surgical approaches should provide sufcient anatomic orientation and exposure to allow surgical procedures to be performed safely.The minimally-invasive two-incision approach to the hip joint is also described.Skin incisions for various surgical approaches to the hip joint are created to maximize surgical exposure and whenever  possible old scars should be incorporated. Hip surgery usually requires careful pre-operative planning and the choice of surgical approach is one of the most important components of this plan. [12]  An ideal approach should be safe, simple and anatomic, thus preventing unnecessary devascularization. It should provide satisfactory exposure to the joint and not result in unnecessary bone and soft-tissues damage. [9,12] There are certain factors that inuence the choice of surgical approach to the hip joint. Among these factors are the indication for the procedure; the type of implant to be used; the presence of acetabular or femoral bone loss; the training and personal preferences of the surgeon and the inuence of  previous surgical incisions. [1,8,9,12]  Of these factors, the inuence of the surgeon’s training and preferences in the choice of surgical approach to the hip appears to be overwhelming. Anatomical Basis for Surgical Approaches to the Hip Onyemaechi NOC, Anyanwu EG 1  , Obikili EN 1  , Ekezie J 2 Department of Surgery, University of Nigeria Teaching Hospital Enugu, 1 Department of Anatomy, College of Medicine, University of Nigeria, Enugu Campus, Enugu, 2 Department of Prosthesis and Orthopedic Technology, School of Health Technology, Federal University of Technology, Owerri, Nigeria Abstract The hip joint is one of the most surgically exposed joints in the body. The indications for surgical exposure are numerous ranging from simple procedures such as arthrotomy for joint drainage in infection to complex procedures like revised total hip replacement. Tissue dissections based on sound knowledge of anatomic orientations is essential for best surgical outcomes. In this review, the anatomical basis for the various approaches to the hip is presented. Systematic review of the literature was done by using PubMed, Cochrane, Embase, OVID, and Google databases. Out of the initial 150 articles selected from the the review and selection criteria, only 37 that suited the study were eventually used. Selected articles included case reports, clinical trials, review and research reports. Each of these approaches has various modifications that seek to correct certain difficulties or problems encountered with previous descriptions.  An ideal approach for a procedure should be safe and provide satisfactory exposure of the joint. It should avoid bone and soft tissue damage as well as avoid unnecessary devascularization.  Among the factors that determine the choice of surgical approach to the hip are the indication for the procedure; the influence of previous surgical incisions as well as the personal preferences and training of the operating surgeon. Keywords:  Anatomy, Arthroplasty, Hip joint, Surgical approach Access this article onlineQuick Response Code:Website:  www.amhsr.org DOI: 10.4103/2141-9248.139278 Review Article [Downloaded free from http://www.amhsr.org ]  Onyemaechi, et    al  .: Surgical approach to hip 488 Annals of Medical and Health Sciences Research | Jul-Aug 2014 | Vol 4 | Issue 4 | Many surgeons usually use a preferred approach to the hip for routine hip operations. This approach will be the one to which the surgeon was most widely exposed during residency or fellowship training; [12]  with little consideration given to the anatomical basis for the approach. [1,9-11]  It is important to stress that no one surgical approach is the most appropriate for all hip exposures. The need to choose an approach that provides the  best exposure for a specic procedure and causes minimum anatomic disruptions cannot be over-emphasized. Therefore, the surgeon must be familiar with the anatomy of the various approaches if the clinical result is to be optimized.The aim of this study is to review the anatomical basis for the various approaches to the hip and to highlight the need for surgeons to be conversant with the full gamut of surgical approaches to the hip, so that the most appropriate one can  be used for each procedure. All the approaches have their advantages and also disadvantages and it is very imperative that surgeons must have precise details of this information  prior to any surgery. Methods of Literature Search Systematic review of the literature was done by using PubMed, Cochrane, Embase, OVID, and Google databases to look for peer reviewed papers using the key words “Anatomy, Arthroplasty, Hip joint, Surgical approach”. Only studies in English were included. Search duration covered all  publication prior to the time of the search (2012). Out of the initial 150 articles selected from the the review and selection criteria, only 37 that suited the study were eventually used. Selected articles included case reports, clinical trials, review and research reports. All articles on surgery of the hip joint that had focus outside the contest of the review were excluded. Anatomy and Surgical Approaches Bony landmarks Identication of bony landmarks surrounding the hip joint may  be difcult because of the large surrounding muscle envelope. These landmarks are the anterior superior iliac spine (ASIS),  posterior superior iliac spine, the greater trochanter, the pubic tubercle and pubic symphysis. These landmarks are important in creating incisions for surgical approaches to the hip. Muscles The hip joint is covered by a large muscle envelope with 21 muscles crossing the joint. In hip surgery, certain muscles have major surgical signicance. The tensor fascia latae and gluteus maximus have been described as the doorway to the hip  joint. [13]  These muscles together with the iliotibial band form the outer layer of the muscular envelope of the gluteal region. One of these muscles or the iliotibial band must be split in order to gain access to the deeper muscles of the gluteal region. The gluteus medius is another muscle of surgical importance. It is the major abductor of the hip joint and together with the gluteus minimus help to stabilize the hip joint in the swing  phase of the gait cycle.The lateral approaches are designed to either avoid detachment of the gluteus medius or displace the abductors by mechanisms that facilitate reattachment. [9,14,15]  The gluteus minimus plays a much less role. It is a weak abductor of the hip but also provides some exion and internal rotation of the hip. It contributes to the stability of the hip joint in the swing phase of the gait cycle. Accurate reattachment of its tendon must not be overlooked during hip surgery.Of the short external rotators of the hip, the piriformis is of great surgical importance, [13]  it provides the key to the understanding the neurovascular anatomy of the gluteal region. Therefore, the superior gluteal vessels and nerve enter the gluteal region above the pelvis pass below it. The iliopsoas tendon inserts into the lesser trochanter posteromedially. Its release is needed to facilitate exposure of the hip in the anterior and medial approaches. Vessels The groin and gluteal regions have an extensive arterial blood supply. A sound knowledge of the anatomy of these vessels is important not only to minimize intra-operative bleeding,  but also to prevent the effect of vascular complications on the outcome of the procedure. [9,16]  The superior gluteal artery is most at risk at its division at the upper border of piriformis. This “danger spot” is located three nger breaths anterior to the posterior superior iliac spine. The deep branch is also at risk as it traverses with the corresponding nerve about 4-6 cm above the acetabular rim. [9]  The lateral femoral circumex artery, a branch of the profunda femoris artery is encountered and requires ligation during Smith-Petersen approach.Although the incidence of major vascular injury during hip surgery is about 0.2-0.3%, [17]  they can pose a threat to the survival of the limb and the patient. A good knowledge of the anatomy and mechanisms of vascular injury is important to avoid vascular complications. Nerves The nerves of surgical importance in hip operations include lateral femoral cutaneous nerve, the femoral nerve, the superior and inferior gluteal nerves, the sciatic and obturator nerve. The lateral femoral cutaneous nerve is the most encountered during anterior approaches. Sciatic nerve is an important posterior relation of the hip. The incidence of the sciatic nerve injury associated with posterior approaches to the hip is estimated at 0.7-1.0%. [18]  The various anatomical arrangements of the sciatic nerve in relationship to the  piriformis must be known to the surgeon. The nerve must be identied and protected. [19]  The superior gluteal nerve has a signicant potential for injury particularly in [Downloaded free from http://www.amhsr.org]  Onyemaechi, et    al  .: Surgical approach to hip Annals of Medical and Health Sciences Research | Jul-Aug 2014 | Vol 4 | Issue 4 | 489 gluteus-splitting approaches. The “safe area” when splitting the abductors (gluteus medius) is 5 cm from the tip of the greater trochanter. [9,17,20]  Other authors report that the course of the superior gluteal nerve runs as close as 3 cm from the tip of the greater trochanter. [21] Joint capsule and ligament The hip capsule is a strong brous tissue that extends down to the intertrochanteric line anteriorly; however, posteriorly it is decient. The capsule is reinforced anteriorly by the iliofemoral ligament of Bigelow; inferiorly by the pubofemoral condensation and posteriorly by a thin ischiofemoral ligament. The ligamentum fovea extends from the fovea of the femoral head to the acetabular fovea. Anterior Approaches The anterior approach is also known as anterior iliofemoral or Smith-Petersen approach. [22]  It affords good exposure of the acetabulum and avoids disruption of the abductor mechanism. The indications for this approach include open reduction of congenital dislocation of the hip, synovial biopsy, hemiarthroplasty, pelvic osteotomies, total hip replacement and  joint drainage and irrigation for infection. The skin incision is made from the middle of the iliac crest and carried anteriorly to the ASIS. From there the incision is carried distally and slightly laterally for 8-10 cm.The mini-incision anterior approach starts at a point 2 cm  posterior and 2 cm caudal to the ASIS and extends 6-8 cm along an imaginary line joining the ASIS to the head of bula. The supercial and deep fasciae are divided and the attachments of the gluteus medius and tensor fasciae latae from the iliac crest are freed. Identify the interval between the tensor fasciae latae and the Sartorius by blunt dissection approximately 2-3 inches  below the ASIS [Figure 1].Identify and protect the lateral femoral cutaneous nerve, which  pierces the deep fascia close to the intramuscular interval.The Sartorius is retracted upward and medially and the tensor fasciae latae is retracted downward and laterally. The ascending  branch of the lateral circumex femoral artery crosses this interval. It must be identied, clamped and ligated. The deep dissection is through the interval between the rectus femoris (femoral nerve) and the gluteus medius (superior gluteal nerve). The rectus femoris is detached from its srcins and retracted medially while the gluteus medius is retracted laterally. The capsule of the hip joint is now exposed.Somerville [23]  described an anterior approach using a transverse “bikini” incision for irreducible congenital dislocation of the hip in a young child. This approach allows sufcient exposure of the ilium and acetabulum. Schaubel [24]  modied the Smith-Petersen approach. He found reattachment of fascia lata to the fascia on the iliac crest difcult, so he performed an osteotomy of the iliac crest between attachments of the external oblique muscle medially and the fascia lata laterally. The tensor fasciae latae, gluteus medius and gluteus minimums attachments were subperiosteally dissected to expose the hip  joint capsule. At closure, the iliac osteotomy is reattached with non-absorbable sutures. Merits 1. Both the supercial and deep dissections are through internervous planes2.It provides good exposure of the anterior column andmedial wall of acetabulum, thus very commonly usedin surgery of congenital hip dislocation and acetabular dysplasia3.It avoids disruption of the abductor mechanisms, thus preventing post-operative limping4.There is low risk of dislocation. Demerits 1.It provides unsatisfactory access to the posterior columnof the acetabulum and femoral medullary canal2.There is incongruency of the skin incision with the planeof intramuscular interval. Anterolateral Approach This approach combines an excellent exposure of the acetabulum with safety. It exploits the intramuscular plane  between the tensor fasciae latae and gluteus medius. [7,25]  Watson-Jones [26]  popularized this approach, but it has been modified by Charnley, [27]  Harris [28]  and Muller. [29]  It also involves partial or complete detachment of some or all of the abductor mechanism so that the hip can be adducted and the acetabulum can be more fully exposed. The indications for this approach include: Total hip replacement; hemiarthroplasty; open reduction and internal xation of the femoral neck fractures, synovial biopsy of the hip and biopsy of the femoral neck. The skin incision starts at a point 2-3 cm posterior to Figure 1:  Anterior approach [Downloaded free from http://www.amhsr.org ]  Onyemaechi, et    al  .: Surgical approach to hip 490 Annals of Medical and Health Sciences Research | Jul-Aug 2014 | Vol 4 | Issue 4 | the ASIS and is directed toward the mid portion of the greater trochanter. It then continues 10-15 cm along the axis of the femur [Figure 2]. Incise the fascia lata in line with the skin incision at the posterior margin of the greater trochanter.Extend this incision superiorly and anteriorly toward the ASIS and also distally and anteriorly to expose the underlying vastus lateralis.Identify the interval between the gluteus medius and tensor fasciae latae by blunt dissection. This is best done at a point mid-way between the ASIS and greater trochanter to avoid injury to the inferior branch of the superior gluteal nerve that supplies the tensor fasciae latae.The gluteus medius and the underlying gluteus minimus are retracted proximally and laterally to expose the superior aspect of the joint capsule covering the femoral neck. The ascending  branch of the lateral circumex femoral artery that passes deep to tensor fasciae latae and gluteus medius requires ligation as the gap between these muscles is opened up. The superior retinacular vessels which are a major source of blood supply to the head of the femur are however not interrupted; therefore, the chances of avascular necrosis of the femoral head are low. Merits 1.It retains the advantages of the anterior approach.2.It provides good exposure of the femoral neck.3.There is low risk of avacular necrosis of the femoral head. Demerits 1.There is limited exposure of the acetabulum.2.There is risk of damage to superior gluteal nerve. Lateral Approaches The lateral approaches can be subdivided into direct lateral and trans-trochanteric techniques. Both methods displace a portion of or the entire abductor mechanisms to facilitate exposure. [9] Direct lateral approaches are based on the observation that the gluteus medius and vastus lateralis can be regarded as being in direct functional continuity through the thick tendinous  periosteum covering the greater trochanter. [14,30] It was rst introduced by McFarland and Osborne [14]  in 1954, and was modied by Hardinge [15]  in 1982. McFarland and Osborne technique A mid-lateral skin incision centered over the greater trochanter is made [Figure 3]. Expose the fascia lata and iliotibial band and divide them in the line of skin incision. The gluteus maximus is retracted posteriorly and the tensor fasciae latae anteriorly. The gluteus medius is now identied and separated from surrounding muscles by blunt dissection. Incise the  posterior border down to the bone obliquely downwards across the greater trochanter and along the vastus lateralis. Elevate the tendon of gluteus medius, the periosteum and srcin of vastus lateralis in one piece and retract anteriorly to expose the gluteus minimus. Divide the tendon of gluteus minimus and retract proximally to expose the joint capsule.In 1982, Hardinge modified this technique (trans-gluteal approach) by incising the tendon of gluteus medius obliquely across the greater trochanter leaving the posterior half still attached to the trochanter [Figure 4]. He observed that the  post-operative abductor weakness was less and the rehabilitation of patients was faster. It is important to note that the abductor split must never be more than 5 cm above the tip of the greater trochanter to avoid injury to superior gluteal vessels and nerve. Merits 1.It provides adequate exposure of the acetabulum2.It avoids the problems of trochanteric reattachment. Figure 2:  Antero‑lateral approach Figure 3:  McFarland and osbrne technique [Downloaded free from http://www.amhsr.org]
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