Posterior approach to the hip

Posterior approach to the hip BY Dr. Bipul Borthakur, Professor,Dept Of Orthopaedics, SMCH

1. POSTERIOR APPROACH TO HIP BY; Dr. Bipul Borthakur Professor, D ept of Orthopaedics, SMCH

2. INTRODUCTION: POSTERIOR APPROACH The most common and practical approach used to expose the hip joint Popularized by Moore , it is often called the Southern approach allow easy, safe, and quick access to the joint and can be performed with only one assistant avoid the loss of abductor power in the immediate postoperative period allow excellent visualization of the femoral shaft , thus are popular for revision joint replacement surgery , in cases in which the femoral component needs to be replaced

3. POSTERIOR APPROACHES Because access to the joint involves division of the posterior capsule, if dislocation of any prosthesis occurs, it will result from flexion and internal rotation of the hip There may be a higher dislocation rate than that from anterior approaches in elderly bedridden patients who often lie in bed with their hips in a flexed and adducted position. Austin Moore (Southern) Osborne Posterolateral approach of Gibson

4. INDICATIONS Hemiarthroplasty Total hip replacement, including revision surgery Open reduction and internal fixation of posterior acetabular fractures Dependent drainage of hip sepsis Removal of loose bodies from the hip joint Pedicle bone grafting Open reduction of posterior hip dislocations

5. POSITION OF THE PATIENT True lateral position : affected limb uppermost Bony prominences of the legs and pelvis are protected: pads placed under the lateral malleolus and knee of the bottom leg and a pillow between the knees The limb is draped free

6. LANDMARKS The greater trochanter is palpated on the outer aspect of the thigh The posterior edge of the trochanter is more superficial than the anterior and lateral portions, and, as such, it is easier to palpate

7. INCISION A 10- to 15-cm curved incision is made centered on the posterior aspect of the greater trochanter Starting point: 6 to 8 cm above and posterior to the posterior aspect of the greater trochanter Incision is curved across the buttock distally and laterally, cutting over the posterior aspect of the trochanter

8. INCISION parallel to fibers of gluteus maximu s , and continued down along the shaft of the femur If you flex the hip 90 degrees and make a straight longitudinal incision over the posterior aspect of the trochanter , it will curve into a “Moore-style” incision when the limb is straight.

9. INTERNERVOUS PLANE There is no true internervous plane in this approach The gluteus maximus , which is split in the line of its fibers, is not significantly denervated because it receives its nerve supply well medial to the split

10. SUPERFICIAL SURGICAL DISSECTION The fascia lata is incised on the lateral aspect of the femur to uncover vastus lateralis , and is lengthened superiorly in line with the skin incision, and fibers of the gluteus maximus are split by blunt dissection The superior and inferior gluteal arteries ramify outward like the spokes of a bicycle wheel; hence, splitting the muscle inevitably crosses a vascular plane.

11. DEEP SURGICAL DISSECTION The fibers of the split gluteus maximus and the deep fascia of the thigh are retracted, placing the retractors superficial to the fatty tissue. Underneath is the fatty tissue and short external rotator muscles The sciatic nerve leaves the pelvis through the greater sciatic notch and runs down the back; lying in substance fatty tissue and hence not visible

12. The hip is internally rotated to put the short external rotator muscles on a stretch (making them more prominent) and to pull the operative field as farther from the sciatic nerve as possible Stay sutures are inserted into the piriformis and obturator internus tendons just before they insert into the greater trochanter ; Detached 1 cm from their femoral insertion and reflected backward, laying them over the sciatic nerve to protect it

13. Normally, the quadratus femoris should be left alone as it contains troublesome vessels that arise from the medial circumflex artery. The posterior aspect of the hip joint capsule is now fully exposed The hip joint capsule can be incised with a longitudinal or T-shaped incision The hip is dislocated with internal rotation after capsulotomy

14. DANGERS Sciatic nerve It can be damaged if it is compressed by the posterior blade of a self-retaining retractor used to split the gluteus maximus . The sciatic nerve sometimes divides into its tibial and common peroneal branches within the pelvis; on occasion, two “sciatic nerves” can be exposed during this approach. It is in danger if it is overlooked. Vessels T he main trunk of inferior gluteal artery leaves the pelvis beneath the piriformis . It spreads cephalad to supply the deep surface of the gluteus maximus If it is cut and retracts into the pelvis and bleeding is brisk, the patient is turned over into the supine position, abdomen opened, and the artery’s feeding vessel, the internal iliac artery, is ligated .

15. HOW TO ENLARGE THE APPROACH The upper half of the quadratus femoris is divided about 1 cm from its insertion to make hemostasis easier Its excellent blood supply is useful both when the muscle is transposed and in treatment of some cases of nonunion of femoral neck fractures The insertion of the gluteus maximus tendon is detached from the femur to increase the exposure of the femoral neck and shaft, especially in revision joint replacement .

16. Chapter 6, Verse 5 uddharedaatmanaatmaanam naatmaanamavasaadayeth | aatmaiva hyaatmano bandhuraatmaiva ripuraatmanah || Let a man raise himself by his own efforts. Let him not degrade himself. Because a person's best friend or his worst enemy is none other than his own self. THANK YOU..