9.1.1 Principal Indications

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  Femoroacetabular impingement

  
  
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  T-fracture of the acetabulum

  
  
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  Transverse acetabular fractures involving the posterior wall

  
  
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  Pipkin fractures

  
  
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  Osteochondritis dissecans of the hip

  
  
• 
  

  Intra-articular therapy of cartilage and bone damage due to femoral head necrosis

  
  
• 
  

  Hip resurfacing arthroplasty

9.1.2 Positioning and Incision

We recommend placing the patient in the lateral position with the symphysis and sacrum supported and the operated leg on a foam pad. The incision, approximately 30 cm in length, is the same as the one described by Gibson for the posterolateral approach and curves posteriorly with the hip flexed. The fascia lata is split distally, and the incision is extended proximally and posteriorly into the aponeurosis of gluteus maximus. The leg is then extended, and self-retaining retractors or a Charnley frame can be inserted ( Fig. 9.1 ). The posterior part of gluteus medius and its relation to the piriformis tendon can be exposed by incising the trochanteric bursa and dissecting it posteriorly.

The approach is continued according to the guidelines published by Ganz (2001). Unlike the classic posterolateral approach, in the Ganz technique the blood supply of the femoral head is spared by preserving the vessels supplying it, including the short external rotators. The vastus lateralis muscle is first retracted in anterior direction, anterior to the attachment of the gluteus maximus tendon, and a Hohmann elevator is passed beneath it. A shallow trochanteric osteotomy, either level or oblique, is then performed with saw and osteotome. The posterior tip of the trochanter is left intact to protect the vessels. The trochanter is then separated from the femur and dislocated in anterior direction, preserving its muscle connection to gluteus medius and vastus lateralis ( Fig. 9.2 ). To do this, it is necessary to divide residual fibers of gluteus minimus from the posterior angle of the trochanter with a scalpel. With this osteotomy technique, the piriform fossa should not be touched. This renders the hip joint capsule, including its cranial boundary, readily visible. A Hohmann elevator can now be inserted over the anterior acetabular rim with the thigh slightly flexed. It should be noted that the medial circumflex femoral artery and vein run proximally beneath the quadratus femoris muscle and over obturator externus, and subsequently flow subsynovially into the capsule and femoral head ( Fig. 9.2 ).

The blood supply of the femoral head is also provided by more distal vessels and by anterior branches of the lateral circumflex femoral artery. The leg is now extended and maximally externally rotated ( Fig. 9.3 ). This provides visualization of the entire anterior, superior, and also inferior parts of the hip joint capsule. The capsule is now incised along the posterior and superior rim of the acetabulum, continued parallel to the more cranial iliofemoral ligament and then in a caudal direction as far as the psoas tendon. In the event of posterior acetabular pathology (acetabular rim fractures or injuries to the posterior pelvic column), the capsule incision can be extended posteriorly with the leg internally rotated.

It is also possible to notch the tendinous insertion of the piriformis muscle without endangering the vascular supply of the femoral head. The hip is now dislocated with the leg cautiously flexed and externally rotated ( Fig. 9.4 ). The lower leg is placed in a sterile bag. A Hohmann elevator can now be inserted anterior to the labrum with a second one posteriorly, giving complete exposure of the entire circumference of the acetabulum ( Fig. 9.5 ). Should exposure of the acetabular roof be necessary, the reflected head of rectus femoris can be detached and another Hohmann retractor can be inserted in the ilium beneath gluteus minimus.

9.1.3 Wound Closure

After reduction of the hip in extension and internal rotation, the capsule is sutured with braided absorbable size 1 suture material. The musculotendinous combination of the greater trochanter, vastus lateralis, gluteus medius, and gluteus minimus is replaced and fixed to the original osteotomy with two size 3.5 or 4.5 cortical screws.

9.1.4 Dangers

Trochanteric pseudarthrosis has been described as a potential postoperative complication. Heterotopic periarticular ossification may occur, especially after acetabular fractures. If the femoral head and neck are skeletized excessively, vascular injury in the form of partial femoral head necrosis is possible.

9.2.1 Principal Indication

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  Hip arthroplasty

The lateral decubitus position is the same as that used for the usual Gibson posterolateral approach. The pelvis is stabilized by supports both posteriorly at the level of the lumbosacral junction and anteriorly at the symphysis. Both thighs are flexed approximately 45°, and the leg to be operated on is placed on a foam pad and is freely mobile. Because of the relatively short skin incision, I recommend marking it on the skin beforehand, if necessary using an image converter. Two-thirds of the incision should be proximal to the tip of the trochanter. Depending on the patient′s size, the length of the incision is 7–12 cm ( Fig. 9.6 ).

Following the skin incision, the subcutaneous tissue is elevated from the fascia over gluteus maximus with a pad or abdominal sponge, and a wound spreader is inserted ( Fig. 9.7 ). To protect the skin, it is advisable to place pads between the skin and the jaws of the retractor. In this way, the skin window can be shifted proximally and distally by traction and pressure on the self-retaining retractor to allow a sufficiently long incision of the gluteus maximus and adjacent fascia lata over the greater trochanter.

The leg is then maximally extended and internally rotated by the second assistant ( Fig. 9.8 ). The self-retaining retractor is reinserted more deeply into gluteus maximus and opened. The trochanteric bursa, which covers the external rotators and adjacent gluteal muscles, is now dissected and retracted posteriorly ( Fig. 9.9 ). At this point, the position of the sciatic nerve should be located by palpation.

9.2.2 Exposure of the Hip Joint

The piriformis tendon is the key to atraumatic exposure of the joint capsule. First, the gluteus medius is cautiously retracted proximally with a Langenbeck retractor, and the roundish white tendon of piriformis is then detached as far distally as possible in the trochanteric fossa. It should be noted that the form of the piriformis muscle is quite variable, and it is often fused with the neighboring gluteus minimus. In these cases, the boundaries of piriformis must be defined by palpation alone, and it must be divided from gluteus minimus. The whitish joint capsule is now exposed. Gluteus minimus, which covers the capsule, is dissected off it carefully with a narrow raspatory, extending the hip slightly again so that an angled Hohmann elevator can be inserted ( Fig. 9.9 ).

The joint capsule and adjacent rotators are now divided from proximal to distal by a slightly curved incision that ends distally at the upper border of quadratus femoris. Further flexion and internal rotation of the hip expose the medial circumflex femoral artery and accompanying veins lying on the tendon of obturator externus, which is beneath quadratus femoris. The vessels must be ligated and divided. The obturator externus tendon is divided ( Fig. 9.10 ). The self-retaining retractor can now be inserted at a deeper level. A Hohmann retractor is placed cranially over the femoral neck, and the neck and head of the femur are now exposed ( Fig. 9.11 ). The femoral neck osteotomy can now be performed in situ with a narrow and relatively short oscillating saw, the direction of which depends on the caput-collum-diaphyseal angle of the femur. In coxa vara, the superior part of the osteotomy should be divided with a chisel. Alternatively, it is possible to dislocate the femoral head prior to the osteotomy and then divide the femoral neck ( Fig. 9.11 ).

9.2.3 Exposure of the Acetabulum

To expose the acetabulum, two Hohmann retractors are usually inserted in the anterior and posteroinferior positions ( Fig. 9.12 ). The inferior joint capsule is now dissected off the underlying obturator externus with blunt dissecting scissors, and the capsule is then split radially as far as the transverse ligament. If necessary, a third Hohmann retractor can be placed distally in the obturator foramen ( Fig. 9.12 ). Sponges must be placed beneath all retractors throughout the operation to protect the skin from pressure injury. The operation table is now tilted by approximately 20° toward the surgeon to provide optimal exposure and illumination of the acetabulum.

9.2.4 Wound Closure

For wound closure, the assistant holds the thigh extended with the knee flexed and the leg internally rotated to approximately 30° initially. Starting proximally, the capsule is closed together with the adherent musculotendinous layer with three or four sutures. To ensure that the capsule is watertight, the sutures are tied with the thigh slightly externally rotated. This allows reconstruction of the ischiocrural ligament and prevention of postoperative dislocation. If the leg has a pronounced externally rotated deformity preoperatively, we do not reattach the piriformis tendon ( Fig. 9.13 ). A subfascial drain is placed, and the wound is closed in layers.

9.2.5 Dangers

The sciatic nerve is not normally at risk in primary operations. However, the level of nerve division is variable, and when it is at a high level the fibular part may perforate the piriformis muscle and therefore run further laterally than usual. For this reason, palpation at the start of the operation is recommended. In revision surgery, scarring may also cause the sciatic nerve to be in abnormal position. In my opinion, the described minimally invasive approach is unsuitable for revision operations.

Deliberate exposure and ligature or coagulation of the medial circumflex femoral vessels is important to avoid postoperative bleeding. During inferior dissection and incision of the joint capsule, the close relation of the capsule, obturator externus, and medial circumflex femoral artery should be noted.

To avoid postoperative dislocation, I recommend closing the joint capsule and preserving it, together with the attached rotator muscles.

9.3.1 Principal Indications

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  Total joint replacement

  
  
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  Femoral neck fractures

  
  
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  Femoral neck osteotomies

  
  
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  Juvenile slipped femoral capital epiphysis

  
  
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  Hip joint synovectomy

9.3.2 Positioning and Incision

The patient is placed in the supine position with a pad under the buttocks. The incision corresponds to the slightly curved one shown in Fig. 9.24 . After splitting the subcutaneous tissue and the fascia lata parallel to the skin incision, the gluteus medius and minimus and vastus lateralis are divided in their anterior third in line with their fibers ( Fig. 9.14 ).

It should be ensured that the tendoperiosteal tissue between the gluteus medius and vastus lateralis on the front of the greater trochanter is carefully stripped from the bone in one layer. This detachment is best accomplished by diathermy.

9.3.3 Exposure of the Hip Joint Capsule

The anterior portions of the joint capsule are dissected free with a Cobb elevator. A curved Hohmann elevator is inserted between the origin of the rectus muscle and the anterior acetabular wall. A cranially placed Hohmann elevator intervenes between the joint capsule and gluteus minimus, and another is placed distally between iliopsoas and the joint capsule. If necessary, a second anterior Hohmann elevator may be inserted somewhat distal to the large curved elevator. The incision of the hip joint capsule is T-shaped ( Fig. 9.15 ). After broad opening of the joint capsule near the acetabulum, two Hohmann elevators may be inserted between the capsule and the femoral neck. No damage to the femoral head circulation is likely to result from this procedure ( Fig. 9.16 ).

9.3.4 Anatomical Site

As shown in Fig. 9.17 , one of the advantages of the transgluteal approach is that the superior gluteal nerve is protected against undue retractor pressure by the wide muscular coat of gluteus minimus (cf. Fig. 9.28 ). The course of the superior gluteal nerve has been better revealed by detaching the gluteus medius muscle from the iliac crest and greater trochanter. Other advantages of this approach are clear exposure of the femoral neck, the upper parts of the hip joint capsule, and the femoral neck resection plane for total hip replacement.

9.3.5 Wound Closure

( Fig. 9.18 )

The wound is closed by apposition of the muscles split in line of their fibers (gluteus medius and minimus and vastus lateralis). The fascioperiosteal plate is firmly sutured in the region of the greater trochanter.

9.3.6 Note

The transgluteal approach is routinely employed by the authors for total hip replacement. In this approach, osteotomy of the greater trochanter seldom proves necessary.

9.4.1 Principal Indications

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  Total joint replacement

  
  
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  Hemiarthroplasty

  
  
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  Femoral neck fractures

  
  
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  Femoral neck osteotomies

  
  
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  Juvenile slipped femoral capital epiphysis

  
  
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  Hip joint synovectomy