Lateral Approach to the Hip and Proximal Femur

LATERAL APPROACH TO THE HIP AND PROXIMAL FEMUR

USES

This approach is used for screw fixation of hip fractures. The proximal extension of this approach is used for the starter hole for intramedullary rodding of the femur.

ADVANTAGES

This approach provides direct access down to the femur. If the vastus lateralis is retracted anteriorly, this approach becomes an internervous one.

DISADVANTAGES

This approach allows very limited exposure to the femoral neck.

STRUCTURES AT RISK

There are no nerves and no significant arteries at risk. The arteries that are at risk are primarily the perforators coming from the posterior direction along the lateral aspect of the femur. If they are not cauterized prior to being transected, they can retract in a medial direction behind the femur and create problems with bleeding.

TECHNIQUE

For hip fractures, the incision usually starts 1 or 2 cm distal to the tip of the greater trochanter and proceeds distally for a distance of 5 cm, plus the length of the plate that is going to be used. The incision is carried through the subcutaneous tissue down through the fascia lata, which is split in line with the fibers in the midline. Proximal division of this fascia will usually go into the muscular portion of the tensor fascia. This division exposes the vastus lateralis, which is in its own fascia. The fascia is split in the midlateral line. At this point, the vastus lateralis needs to be separated from the posterior portion of the fascia, which is usually best accomplished with a periosteal elevator, moving from distal to proximal, lifting the fibers away. This separation allows the entirety of the vastus lateralis to be retracted anteriorly toward its nerve supply. As you approach the femur, you must be on the alert for the perforating arteries and veins, which can be cauterized. If the muscle is split in the middle of its fibers, then the area of the muscle posterior to the split will be denervated.

Once the vastus lateralis is retracted in an anterior direction, the lateral femur is exposed and the rest of the procedure can be completed.

TRICKS

The major trick is to be aware of the perforating blood vessels. They can be problematic if they are cut, and then they retract medially and continue bleeding. The other helpful trick is to peel the posterior portion of the vastus lateralis off of its fascia and retract the muscle as a whole anteriorly. During closure, the muscle will fall back in place and can be covered by closing the fascia.

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