(1)
Department of Orthopaedic Surgery, New York University – NYU Langone Orthopedic Hospital, New York, NY, USA
Introduction
Proximal femur fractures are a common injury and almost always require surgical intervention. Although many fracture types can be reduced indirectly, an open approach may be required to achieve an anatomic reduction. In addition, approaches to the proximal femur also need to be useful for an arthroplasty procedure, should one be required.
A number of approaches to the proximal femur and hip exist. In this chapter we describe the anterior and anterolateral approaches, as well as the posterior approach to the proximal femur and hip. A surgeon dealing with trauma to the proximal femur should be familiar with and comfortable performing these approaches in order to properly address these injuries.
Anterior approach | Femoral neck fracture fixation |
Total hip arthroplasty | |
Hemiarthroplasty | |
Anterolateral approach | Femoral neck fracture fixation |
Total hip arthroplasty | |
Hemiarthroplasty | |
Posterior approach | Total hip arthroplasty |
Hemiarthroplasty |
Anterior Approach: Smith-Peterson
The anterior approach to the hip has been gaining popularity over the past decade, both for reduction of femoral neck fractures and for arthroplasty of the hip. Interest in the anterior approach has been increasing; it is a well-established surgical approach that was originally described by Carl Heuter in his text Der Grundriss der Chirurgie (The Compendium of Surgery), published in 1881 [1]. Smith-Peterson [2] described a similar anterior approach to the hip a number of years later, and is credited with spreading the anterior approach to the English-speaking world.
Differing from the Smith-Peterson approach , Heuter’s does not require a tenotomy of the rectus tendon in order to access the hip. An additional advantage of the Heuter approach is that the lateral femoral cutaneous nerve is easily avoided and does not require direct visualization or retraction [1]. This approach is very useful for the reduction of a femoral neck fracture, although a separate lateral incision is needed for internal fixation; it can also be used for total hip arthroplasty or hemiarthroplasty if necessary. It should be noted that this approach is not useful for intertrochanteric/pertrochanteric fractures, as it is not easily extensile at this level, and, if fixation is required, access to the greater trochanter is limited.
Patient Positioning
The patient is placed in the supine position on an orthopedic table or a radiolucent operating room table per the surgeon’s preference. If an arthroplasty is planned, it is important that the orthopedic table have the capability of extending the operative extremity. If a flat table is used for the arthroplasty, the patient should be positioned such that the hip is located just proximal to the break of the table so that the extremity can be extended by breaking the table.
For a femoral neck fracture, a closed reduction maneuver, as originally described by Ledbetter (1938), is performed as an initial step in order to attempt an adequate closed reduction [3]. If this fails, an open reduction needs to be performed prior to internal fixation.
Surgical Anatomy and Approach
The anterior superior iliac spine (ASIS) and the greater trochanter are marked. A line is drawn from the center of the ASIS to the tip of the greater trochanter. A point 2 cm along this line from the ASIS marks the proximal extent of the incision. A vertical line of approximately 8 cm is then drawn distally along the direction of the tensor muscle belly towards the lateral aspect of the patella (Fig. 3.1). Angling the incision in this direction (approximately 20° lateral to the midline) helps avoid the distal cutaneous branches of the lateral femoral cutaneous nerve. A separate 10 cm incision drawn over the lateral aspect of the greater trochanter is used for the insertion of hardware.
Fig. 3.1
The line drawn from ASIS to the tip of the greater trochanter is shown above. A point on this line—2 cm from the ASIS—is chosen and extended towards the lateral aspect of the patella, roughly 6–8 cm (courtesy of Dr. Roy Davidovitch)
The dissection is carried down to the fascia overlying the tensor fascia latae. The direction of the underlying muscle fibers should be from ASIS to the lateral side of the knee. The fascia is then incised over the tensor muscle in the same direction as the fibers (Fig. 3.2).
Fig. 3.2
Correct location for incision in fascia that is 1 cm lateral to ASIS and 5 mm medial to perforators (courtesy of Dr. Roy Davidovitch)
The fascia is then gently elevated off the tensor muscle, using blunt finger dissection . The interval between the tensor muscle laterally, and fatty areolar tissue medially, is developed (Fig. 3.3). Developing the proper surgical interval is essential, as there are perforating vessels on the fascia of the tensor muscle coursing from posterior to anterior; this helps identify the tensor muscle. Once the interval is developed, there should be muscle on the lateral side, and the fatty tissue on the medial side. If muscle is encountered on both sides there is a high liklihood that the surgeon is within the wrong interval.
Fig. 3.3
Blunt dissection , with fascia medially and tensor muscle belly laterally (courtesy of Dr. Roy Davidovitch)
The femoral neck is then palpated. Once it has been palpated, a blunt, narrow, curved Hohmann retractor is placed over the superior aspect of the femoral neck capsule. The interval between the tensor anda the rectus muscle is developed distally. Care is taken not to penetrate the loose layer of tissue septum underneath these muscles. The ascending branch of the lateral circumflex artery is located within this tissue and must first be identified. The vessels are then isolated, and electrocautery is used to achieve hemostasis (Fig. 3.4).
Fig. 3.4
The location of the circumflex vessels is shown. It is necessary to locate and cauterize these vessels to achieve adequate hemostasis (courtesy of Dr. Roy Davidovitch)
The fascial septum is incised and the anterior pericapsular fat pad comes into view. A plane between the anterior fat pad and the capsule is created, and the anterior hip capsule is clearly visualized. Next, a second blunt, curved Hohmann retractor is placed around the inferior femoral neck capsule. A cerebellar retractor is placed from cephalad into the wound to retract the tissue medially and laterally, directly overlying the femoral neck. A complete view of the anterior capsule is essential before the anterior capsulectomy is performed (Fig. 3.5). An anterior retractor placed over the anterior acetabular rim may help in this exposure, although it is not routinely used.
