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POSTERIOR APPROACH OF HIP

POSTERIOR APPROACH

• THE POSTERIOR APPROACH IS MOST COMMON APPROACH UED TO EXPOSE THE HIP JOINT.

• IT WAS POPULARISED BY MOORE AND OFTEN CALLED THE SOUTHERN APPROACH.

• INDICATION:

HEMIARTHROPLASTY

THR INCLUDING REVISION SURGERY

ORIF OF POST ACETABULAR FRACTURE

DEPENDENT DRAINAGE OF HIP ABSCESS

REMOVAL OF LOOSE BODY FROM HIP JOINT

PEDICLE BONE GRAFTING

OPEN REDUCTION OF POSTERIOR HIP DISLOCATION


Position of the patient on the operating table for the posterior approach to

The hip joint.


INCISION
Start 10 cm distal to PSIS extended distally,
Laterally parallel to fibers of gluteus maximus
to posterior margin of greater trochanter
then direct the incision 10-13 cm distally parallel
To femoral shaft.
There is no true internervous plane.Split the fibers of gluteus maximus, a
procedure that doesn’t cause significant denervation of muscle.
DANGER POINT:
Avoid incision on greater trochanter (boy prominence painful and scar)

APPROACH:
Expose and divide deep fascia. Seprate the fibers of gluteus maximus(by blunt dissection)

Retract the gluteus maximus to reveal the fatty layer over short external rotators of the hip
Push the fat posteromedialy to expose the insertions of short rotateros, sciatic nerve is not visible, it
lies with in the substance of fatty tissue, place your retractors with in the substance of gluteus
maximus superficial to the fatty tissue
(A, B) Internally
rotate the femur to bring the insertion of the short
rotators of the hip as far lateral to the sciatic nerve as possible. (C) Detach the short rotator muscles
close to their femoral insertion and reflect them backward, laying them over the sciatic nerve to
protect it.
Incise the posterior joint capsule to expose the femoral head and neck
• TO GAIN ADDITIONAL EXPOSURE, CUT THE QUADRATUS FEMORIS AND THE TENDINOUS
INSERTION OF THE GLUTEUS MAXIMUS.
ADVANTAGE:
RELATIVE STABILITY OF OPERATED HIP.

• Brief period of immboilisation.

• Rapidity with which joint may be opened and closed though relatively blood less plane.

• Excelent exposure of posterior lip and posterior coloumn of acetabulum.

DISADVANTAGE:
• Dependent incision with a tendency to oedema

• Acetabular exposure is inferior

• Increased post operative infection

• Weakening of posterior capsule of hip,so increased chances of dislocation

• Vascular damage

• Only limited exposure of sciatic nerve is possibility of sciatic nerve injury.


POSTEROLATERAL
APPROACH TO HIP
POSTEROLATERAL APPROACH
• ALEXANDER GIBSON IS RESPONSIBLE FOR REDISCOVERY IN NORTH AMERICA.

• IT WAS FIRST DESCRIBED AND RECOMMENDED BY KOCHER AND LANGENBECK.

• DETACHING GLUTEAL MUSCLE FROM ILIUM AND INTERFERING WITH THE FUNCTION OF ILIOTIBIAL BAND ARE UNNECESSARY ,SO REHABILITATION IS RAPID.

• INDICATIONS:
THA

HIP HEMIARTHROPLASTY

REMOVAL OF LOOSE BODIES

DEPENDANT DRAINAGE OF SEPTIC HIP

PEDICLE BONE GRAFTING

POSTERIOR WALL FRACTURE

POSTERIOR COLUMN FRACTURE

POSTERIOR WALL AND POSTERIOR COLUMN FRACTURE

SIMPLE TRANSVERSE FRACTURE (PATIENT PRONE)


FRACTURE MUST BE LESS THAN 15 DAYS OLD
FRACTURE LINE LOCATED AT OR BELOW ACETABULAR ROOF
NO MAJOR ANTERIOR DISPLACEMENT
• Place the patient in lateral position
• Begin the proximal limb of the incision at a point
6 to 8 cm anterior to the PSIS and just
distal to the iliac crest, overlying
The anterior border of the gluteus maximus muscle.
Extend it distally to the
anterior edge of the greater trochanter and
Farther distally along the line of the femur for 15 to 18 cm.
• By blunt dissection, reflect the flaps of skin and subcutaneous fat
• from the underlying deep fascia a short distance
anteriorly and posteriorly.
Incise the iliotibial band in line with its fbers, beginning
at the distal end of the wound and extending proximally
to the greater trochanter.
• Abduct the thigh, insert the gloved finger through the
proximal end of the incision in the band,

locate by palpation the sulcus at the anterior border of the gluteus


maximus muscle, and extend the incision proximally along
this sulcus.

• Adduct the thigh, reflect the anterior and


posterior masses, and expose the greater trochanter and
the muscles that insert into it .

Separate the posterior border of the gluteus medius
muscle from the adjacent piriformis tendon by blunt
dissection.
■ Divide the gluteus medius and minimus muscles at their
insertions, but leave enough of their tendons attached to
the greater trochanter to permit easy closure of the
wound. Reflect these muscles (innervated by the superior
gluteal nerve) anteriorly. The anterior and
superior parts of the joint capsule now can be seen.
• Incise the capsule superiorly in the axis of the femoral neck
from the acetabulum to the intertrochanteric line;
incise as much of the capsule as desired along the joint

Line anteriorly and along the anterior intertrochanteric line laterally.

• The hip now can be dislocated by flexing the hip and knee and
abducting and externally rotating the thigh.
• ■SUFFCIENT EXPOSURE OF THE HIP OFTEN CAN BE OBTAINED WITH
LESS EXTENSIVE DIVISION OF THE MUSCLES INSERTING ON THE
TROCHANTER
• THE EXTENT OF DIVISION DEPENDS ON THE TYPE OF
OPERATION PROPOSED, THE AMOUNT OF EXPOSURE REQUIRED,
THE TIGHTNESS OF THE SOFT TISSUES, AND THE PRESENCE OR
ABSENCE OF CONTRACTURES AROUND THE JOINT. CONVERSELY,
WHEN WIDE EXPOSURE OF THE JOINT, ESPECIALLY OF THE ACETABULUM, IS NEEDED,
• MORE EXTENSIVE DIVISION OF THE MUSCLES
MAY BE NECESSARY. GIBSON THOUGHT THAT REATTACHING THE
MUSCLES TO THE GREATER TROCHANTER BY INTERRUPTED SUTURES
IS ADEQUATE.
■ TO PRESERVE THE INSERTION OF THE ABDUCTOR MUSCLES, OSTEOTOMIZE THE TROCHANTER AND LATER

REATTACH IT WITH TWO WIRE


LOOPS, 6.5-MM LAG SCREWS, OR CABLE GRIP. WIRE LOOPS ARE
PASSED THROUGH THE INSERTION OF THE MUSCLES PROXIMAL TO
THE TROCHANTER AND THROUGH A HOLE DRILLED IN THE FEMORAL
SHAFT 4 CM DISTAL TO THE OSTEOTOMY .
MODIFIEFD GIBSON APPROACH

• Modification of Gibson approach by mercy and fletcher

for insertion of prosthesis in which


hip is dislocated by internal rotation

and anterior part of joint capsule is preserved

to keep the hip from dislocating anteriorly after surgery


EXTENDED TROCHANTRIC
OSTEOTOMY
INDICATION

• DIFFICULT FEMORAL REVISION LIKE WELL FIXED FEMORAL COMPONENT/CEMENT REMOVAL


• ACETABULAR EXPOSURE
• ABDUCTOR TENSION ADJUSTMENT
• NEUTRAL REAMING OF VARUS/VALGUS REMODELLING
• PROMOTION OF FEMORAL REMODELLING
CONTRAINDICATION

• ANTICIPATED STEM REVISION


• IMPACTION GRAFTING
ADVANTAGE

• VERSATILE
• EASY
• REDUCES :OPERATIVE TIME & BLOOD LOSSE
• INCIDENCE OF CORTICAL PERFORATION DUE TO CEMENT REDUCED
• NEUTRAL REAMING
• CAN BE USED IN MALUNION OF GT
• UNION 99-100%
DISADVANTAGE

• DEVASCULARISATION OF SEGMENTS
• LIMITED USE IN CEMENTED REVISION
• FEMUR#
TYPES OF OSTEOTOMY
• SIMPLE (CHARNLEY) TROCHANTERIC OSTEOTOMY-
• DETACHES IN AWAY THAT ALLOW PROXIMAL ATTACHMENT OF GLUTEUS AND MINIMUS
• TROCHANTRIC OSTEOTOMY IN CONTINUITY
• LEAVING THE ATTACHMENT OF GLUTEUS MEDIUS PROXIMALLY AND OF VASTUS LTERALIS
DISTALLY
• EXTENDED TROCHANTERIC OSTEOTOMY (REVISION THR)-
• INCLUDE TROCHANTER WITH GLUTEUS ATTACHEMENTS BUT ALSO EXTENDS DISTALLY TO
MAINTAIN ATTACHMENT OF VASTUS LATERALIS.
COMPLICATIONS
• Complications of trochanteric osteotomy can be divided into two broad categories:
• Those related to osteotomy healing and those related to the mode of fixation. Nonunion or a fibrous
union.
• If the trochanter does not heal by bony bridging,may manifest as
• Impaired gait,
• trendelen-burg lurch,
• subluxation, or
• patient may have trochanteric pain and bursitis may be related to a prominent trochanter or to
irritating hardware.
• Fraying and breakage of hardware can lead not only to pain, but also to wear and the need for early
revision.