Hip and Pelvis

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Chapter 6

Hip and Pelvis

David B. Weiss, Seth R. Yarboro, James A. Browne

Regional Anatomy and Surgical Intervals

Regional Anatomy

Osteology

Pelvis (Figs. 6-1 and 6-2)

Iliac crest (palpable throughout its entire length)

• Landmark for several skin incisions

• External lip

• Iliac tubercle (outer surface of iliac crest about 5 cm posterior to the anterior superior iliac spine [ASIS])

• Site for external fixator pin

• ASIS and posterior superior iliac spine (PSIS)

• Landmarks for incisions and for bone grafting

FIGURE 6-1 Osseous anatomy of the outer portion of the hemipelvis and acetabulum.

FIGURE 6-2 Osseous anatomy of the inner portion of the hemipelvis from the sacroiliac joint to the pubic symphysis.

Proximal Femur (Figs. 6-3 and 6-4)

Palpable landmarks

• Greater trochanter (abductor attachment for increased moment arm and mechanical advantage)

• Attachment point for abductor muscles

• Intertrochanteric line (ridge connecting the greater and lesser trochanter)

• Fractures may travel along this line, and it marks the approximate location of the hip capsule insertion

• Lesser trochanter (insertions of the iliacus and the psoas muscles)

• Located posterior and medial and serves as an important marker of instability when fracture lines travel through this region

• Piriformis fossa

• Posterior to the midaxis of the femoral neck, in line with the medullary canal

• The starting point for some femoral nails

• Fovea (ligament of the femoral head attachment)

• Fractures below this area are out of the weight-bearing surface

FIGURE 6-3 Osseous anatomy of the anterior portion of the proximal femur.

FIGURE 6-4 Osseous anatomy of the posterior aspect of the proximal femur.

Arthrology

Hip Joint (Figs. 6-5 to 6-7)

Ball and socket with only sliding—no translation

Static restraints

• Ligaments

• Hip-stabilizing ligaments

• Iliofemoral

• Iliopectineal

• Pubofemoral

• Ischiofemoral

• Labrum

• Articular congruity

Dynamic restraints

• Gluteus medius and minimus

• Iliopsoas

• External rotators

• Iliotibial band

FIGURE 6-5 Anterior aspect of the hip capsule showing the iliofemoral and pubofemoral ligaments.

FIGURE 6-6 Posterior aspect of the hip capsule showing the iliofemoral and ischiofemoral ligaments.

FIGURE 6-7 A disarticulated hip joint revealing intracapsular stabilizing structures, such as the labrum, and the ligamentum within the fovea centralis.

Sacroiliac Joint

Small translations of the joint

Largely stabilized by ligaments

• Pelvis and sacroiliac ligament joint stabilizers

• Sacrotuberous ligament (connects the posterior inferior iliac spine and the lateral aspect of the sacrum to the coccyx and ischial tuberosity)

• Sacrospinous (connects the lateral part of the sacrum and the coccyx to the spine of the ischium)

• Anterior sacral ligaments

• Posterior sacral ligaments

• Iliolumbar ligaments (transverse process of the lower lumbar vertebrae to the ilium)

Muscles

Proximal Femoral Insertions (Figs. 6-8 to 6-13)

FIGURE 6-10 Musculature of the anterior pelvis and thigh with further muscles removed, including the rectus femoris, vastus lateralis, vastus medialis, and the adductor longus, gracilis, and pectineus, revealing the adductor magnus and minimus and the vastus intermedius.

FIGURE 6-11 Posterior musculature of the pelvis and thigh region.

FIGURE 6-12 Posterior musculature of the pelvis and thigh region with the gluteus maximus and medius removed, revealing the posterior external rotators of the hip joint.

FIGURE 6-13 Posterior musculature of the pelvis and thigh region with further musculature removed from the image in Figure 6-12, including the long head of the biceps femoris and the semitendinosus, revealing the semimembranosus and adductor magnus.

Nerves

Extension of Nerves from the Lumbosacral Plexus (Fig. 6-14)

Branches of the sacral plexus

• Sciatic nerve (L4 and L5 and S1, S2, and S3)

• Exits the greater sciatic notch (GSN) and travels inferiorly, passing along the posterior aspect of the ischial tuberosity before passing into the posterior compartment of the thigh

• The typical course is anterior to the piriformis and posterior to the superior/inferior gemellus, obturator internus, and quadratus femoris, but significant variation either through or around the piriformis can exist

• Has tibial and peroneal divisions that are indistinguishable around the hip but later divide

• The peroneal portion is more superficial and thus more prone to injury from posterior wall fracture and/or posterior hip dislocation or from retraction

• Superior gluteal nerve (innervates the gluteus medius, gluteus minimus, and tensor fasciae latae muscles)

• Exits the GSN and turns sharply superior to innervate the gluteus medius/minimus and tensor fasciae latae

• A risk of injury exists with extensive superior and medial dissection above the GSN

• Inferior gluteal nerve (innervates the gluteus maximus)

• Exits the GSN inferior to the sciatic nerve and enters the gluteus maximus

• Is at risk with extensive medial dissection around the posterior column near the GSN

Branches of the lumbar plexus

• Lateral femoral cutaneous nerve

• Exits the pelvis just medial to the ASIS (with wide variation up to 3 cm to either side)

• Wide variation also exists with regard to the position of this nerve in relation to the sartorius muscle; it typically runs along the superficial lateral border, but it may run deeper or along the medial tensor fasciae latae (TFL)

• Provides pure sensory innervation to anterolateral thigh

• At risk with dissection or retraction during Smith-Petersen and direct anterior hip approaches and with ilioinguinal pelvic approaches

• Obturator nerve

• Innervates the adductors and travels inferior and lateral along the true pelvis below the pelvic brim and along the quadrilateral plate

• Enters medial compartment of thigh as it penetrates superior aspect of obturator membrane in obturator foramen

• Is at risk with exposure and retractor or hardware placement during ilioinguinal or Stoppa approaches

• Femoral nerve (largest branch L2, L3, and L4)

• Exits the pelvis over the anterior wall of the hip and lateral to the femoral artery and vein

• Is at risk with anterior retractor placement during anterior and posterior approaches to the hip and during middle window dissection and retraction for ilioinguinal approaches

• Anterior division—sensation to the anterior and medial thigh via the medial and intermediate cutaneous nerves of the thigh

• Posterior division—quadriceps muscles and saphenous nerve

FIGURE 6-14 Divisions of the lumbosacral plexus. n, Nerve.

Vascularity (Fig. 6-15)

Cross-Sectional Anatomy (Figs. 6-16 to 6-19)

Hazards (Figs. 6-20 and 6-21)

Femoral Triangle

Bordered by the inguinal ligament, sartorius, and the adductor longus, the structures from lateral to medial consist of the femoral nerve, artery, vein, and lymphatics (see Fig. 6-20)

FIGURE 6-16 Cross-sectional coronal anatomy of the pelvis and lumbosacral region.

FIGURE 6-17 Cross-sectional sagittal anatomy of the pelvis and lumbosacral region.

FIGURE 6-18 Cross-sectional transverse anatomy of the proximal femur and pelvis at the level of the hip joint.

FIGURE 6-19 A, Cross-sectional transverse anatomy of the proximal third of the thigh region. B, Cross-sectional transverse anatomy of the middle third of the thigh region. C, Cross-sectional transverse anatomy of the distal third of the thigh region.

FIGURE 6-20 Hazards around the hip and pelvis, including neurovasculature and hollow structures. Anteriorly, the neurovascular bundle from lateral to medial contains structures that form the mnemonic “NAVEL” (femoral Nerve over the psoas, femoral Artery, femoral Vein, Empty space, and Lymphatics). The bladder lies directly behind the superior pubic rami behind the potential space of Retzius (see Fig. 6-33). a, Artery; n, nerve; v, vein.

Nerves

Sciatic Nerve

Exits from the greater sciatic notch and from the inferior surface of the piriformis and over the external rotators of the hip; variations of its course include division around the piriformis, running posterior to the piriformis, or piercing the piriformis to prevent excessive traction on the nerve

Femoral Nerve

At risk from direct injury in an anterior approach to the hip or ilioinguinal approach; indirect injury from retractor placement can occur, especially for retractors placed around the lesser trochanter and along the anterior wall of the acetabulum

Obturator Nerve

Direct or indirect injury may occur along the inferior aspect of the acetabulum

Superior Gluteal Nerve

Located between the gluteus minimus and medius 3 to 5 cm superior to the tip of the greater trochanter; at risk with excessive dissection medial and superior to the GSN

Inferior Gluteal Nerve

Exits the greater sciatic notch inferior to the sciatic nerve and enters the gluteus maximus; at risk with excessive dissection medial and inferior to the GSN

Lateral Femoral Cutaneous Nerve

Arises from the fascia just medial to the anterior superior iliac spine; variations exist where the nerve may arise out of the fascia over, under, or through the sartorius muscle

Posterior Femoral Cutaneous Nerve

The posterior femoral cutaneous nerve travels with the posterior aspect of the sciatic nerve until it travels superficial to this nerve at the biceps femoris; typically it is not visualized unless the direct posterior approach to the ischial tuberosity is used (which is rare)

Vascular

Femoral Artery

Direct injury during an ilioinguinal approach or indirect injury from retractor placement during hip approaches

Superior Gluteal Artery

Exits the GSN at the superior border of the piriformis and enters the gluteus medius; at risk during dissection medial and superior to the GSN; if it retracts through the GSN, a separate anterior approach or angiography is required to obtain hemostasis

Inferior Gluteal Artery

Exits the pelvis underneath the piriformis and supplies the deep aspects of the gluteus maximus; if the muscle is split too superiorly, it may damage the main trunk

Ascending Branch of the Lateral Femoral Circumflex

Lies within the intermuscular septum of the sartorius and tensor fascia; may require ligation during the direct anterior hip or Smith-Petersen approach

Medial Femoral Circumflex Artery

Lies anterior to the quadratus femoris; at risk with extensive inferior dissection in Kocher-Langenbeck approaches to the posterior wall/column

Avoid dissecting below the obturator internus or the blood supply to the femoral head is at risk of being compromised

Bladder

May be directly injured during anterior approaches to the pelvis with either dissection or retraction

Be especially cautious if previous surgery has been performed in the region because adhesions may increase the risk of bladder injury

May be indirectly injured during hip/pelvis surgery from reamers/pins/drills that inadvertently overpenetrate medial acetabular bone

Landmarks (Figs. 6-22 to 6-25)

FIGURE 6-24 Axial CT cut at the level of roof of the acetabulum showing areas accessible from different approaches. Studying the appropriate imaging is an essential part of preoperative planning.

FIGURE 6-25 Anteroposterior pelvis showing areas accessible via the anterior acetabular exposures.

Surgical Approaches to the Pelvis

Posterior Approach to the Sacroiliac Joint

Indications

Fixation of disruption to the sacroiliac joint, fractures of the ilium adjacent to the sacroiliac joint, and irrigation and debridement of infection in the area

Positioning (Fig. 6-26)

Prone

Bolsters and padding should be placed to allow expansion of the chest and abdomen without restriction

The anus should be isolated from the field with an isolation type of drape

Use of a radiolucent table with fluoroscopic assistance is advised

FIGURE 6-26 The prone position with bumps to pad all prominences. For the posterior approach to the sacroiliac joint, the bony prominences are well padded, and the chest and abdomen are free to expand by being suspended by longitudinal padding along the sides of the patient.

Dangers

Structures

Inferior gluteal nerve

Superior gluteal nerve

Sacral nerve roots (from screw fixation)

Superior cluneal nerves

Vessels

Branches of the superior and inferior gluteal arteries are in danger and should be cauterized if encountered

Landmarks

Posterior iliac crest and PSIS

Incision (Fig. 6-27)

The incision is 8 to 12 cm centered 2 to 3 cm below and slightly lateral to the PSIS (Fig. 6-28)

Superficial dissection

• No true internervous plane

• Subcutaneous tissue is incised in line with the incision, uncovering the fascia of the gluteus maximus and medius

• Incise the fascia of the maximus over the crest of the ilium

• Reflect the gluteus maximus subperiosteally downward and laterally (branches of the inferior gluteal artery may be present)

• This maneuver uncovers the gluteus medius and the piriformis emerging from the greater sciatic notch (the superior gluteal nerve and artery are emerging as well; Fig. 6-29)

Deep dissection

• In trauma cases, the sacroiliac joint capsule may be disrupted and easily visualized; otherwise, it may need to be incised to visualize the reduction

• The gluteus medius cannot be elevated far anteriorly because the neurovascular bundle to the muscle is present (superior gluteal nerve and artery)

Extensile measures

• The incision superiorly can be carried out in a curving fashion along the crest of the ilium superiorly and anteriorly to uncover the wing of the ilium

FIGURE 6-27 The incision for the posterior approach to the sacroiliac joint is vertical in nature from just above the posterior superior iliac spine distally about 10 cm. The incision can be extensile in nature along the iliac crest if necessary.

FIGURE 6-28 Superficial dissection is carried down the posterior superior iliac spine and the fascia of the gluteus maximus, and the fascia capsule over the sacroiliac joint is uncovered. One will likely only see the maximus fascia unless the superior extensile component is utilized.

FIGURE 6-29 Deeper dissection involves incising the gluteus maximus fascia and subperiosteally elevating the maximus off of the ilium just lateral to the posterior superior iliac spine (PSIS). The joint capsule of the sacroiliac joint, if it is not traumatically disrupted, may need to be incised for anatomic reduction of the joint surface.

Anterior Approach to the Pubic Symphysis (Video 6-1)

Indication

Plating of pubic symphysis diastasis

Positioning

Supine (Fig. 6-30)

• Use a midline sacral bump to elevate the pelvis to allow sacroiliac screw placement if needed; a stack of two bath blankets that have each been folded in thirds and placed with the inferior border at approximately the level of the scrotum works well; it is important to center them in the midline to prevent the patient from tilting to one side, which will allow for proper angulation of a drill bit posterior if sacroiliac (SI) or sacral screws are needed

FIGURE 6-30 Supine positioning of the patient for the approach to the pubic symphysis.

Foley catheter in place

Dangers

Structures

Bladder

Vessels

Superficial epigastric artery and vein

Landmarks

Pubic symphysis and pubic tubercles

Incision

A 10-cm incision is centered at the pubic symphysis

In line with the skin crease and about 2 cm above the pubic symphysis and superior rami (Fig. 6-31)

FIGURE 6-31 The incision for the approach to the pubic symphysis. The landmarks are the pubic tubercles, pubic symphysis, and superior rami. The incision is centered around the pubic symphysis just above the superior edge of the rami. The dissection is taken to the underlying fascia. Note the Foley catheter in place to decompress the bladder during the procedure.

Superficial Dissection

No true internervous plane

Subcutaneous tissue is incised in line with the incision, uncovering the rectus sheath

Ligation of the superficial epigastric artery and vein as they run across the field from inferior to superior may be necessary but will likely be avoided for incisions less than 12 cm (Fig. 6-32)

FIGURE 6-32 Deep dissection entails a vertical split in the rectus fascia and confirmation of location in the midline, then carefully creating a split deeply between the rectus fascia by making a small incision and inserting a narrow malleable retractor to protect the bladder before splitting the remainder of the deep fascia in line with the incision.

Deep Dissection Midline

Rectus abdominis insertion is fairly broad and can be elevated off the superior and posterior aspects of the pubic symphysis to just past the pubic tubercle without the need to repair back to bone; one or both sides of the insertion may be traumatically avulsed (typically it is the more seriously injured side of the hemipelvis)

Retract the rectus abdominis laterally and superiorly

A layer of extraperitoneal fat may be present between the rectus abdominis and the bladder

Dissection of the posterior aspect of the superior rami and pubic symphysis can be accomplished digitally (preperitoneal space of Retzius; Figs. 6-33 and 6-34)

FIGURE 6-33 Blunt dissection of the potential space of Retzius should be performed to ensure that the bladder is protected.

FIGURE 6-34 Deep finger dissection of the posterior aspect of the symphysis after midline split of the rectus. The gap and displacement of the symphysis can usually be palpated now.

Use a medium or wide malleable retractor along the posterior aspect of the symphysis to protect the bladder

Closure

Use of a closed suction drain in the space of Retzius is advised to decrease the risk of a postoperative hematoma and infection

Repair of the rectus abdominis superficial and deep fascia can be performed by incorporating both as one layer, but avoid incorporating significant muscle into the repair

Subcutaneous and skin closure is accomplished in the normal fashion

Extensile Measures

Can be used in conjunction with the ilioinguinal approach

Ilioinguinal Approach to the Pelvis (Video 6-2)

Background

The ilioinguinal approach comprises three windows that may not all need to be fully opened or used for a given approach; careful study of the injury films and preoperative planning will indicate which windows to use

The modified Stoppa approach (discussed in more detail at the end of the section) is a variation on the ilioinguinal approach that does not use the middle window at all

Indications

Open reduction and internal fixation of certain acetabular fractures

• Primarily anterior column/wall, associated both column, T types, and some transverse and anterior column posterior hemitransverse

Positioning

Supine on a flat radiolucent table with use of a midline sacral bump to place the lumbar spine in slight hyperextension and to elevate the posterior pelvis to allow easier access to the posterior iliac wing

Prepare and drape to the bottom of the rib cage superiorly and the base of the penis or superior labia inferiorly (see Fig. 6-30)

Landmarks

Pubic symphysis, ASIS, iliac crest

Incision

Draw the incision from medial 2 cm above the pubic symphysis curving laterally and superiorly to the ASIS and then following the iliac crest posterior to just beyond its maximum lateral convexity (approximately 10 cm proximal to the ASIS; Fig. 6-35)

Begin with the lateral aspect of the incision, stopping at the ASIS; perform the superficial and deep portions of this window first so that venous bleeding from the perforators in the iliac wing may be controlled with packing while dissecting the second and third windows

Surgical Dissection

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Hip and Pelvis

Regional Anatomy

Pelvis (Figs. 6-1 and 6-2)

Proximal Femur (Figs. 6-3 and 6-4)

Arthrology

Hip Joint (Figs. 6-5 to 6-7)

Sacroiliac Joint

Muscles

Proximal Femoral Insertions (Figs. 6-8 to 6-13)

Nerves

Extension of Nerves from the Lumbosacral Plexus (Fig. 6-14)

Vascularity (Fig. 6-15)

External Iliac Artery and Vein

Femoral Artery

Cross-Sectional Anatomy (Figs. 6-16 to 6-19)

Hazards (Figs. 6-20 and 6-21)

Nerves

Femoral Nerve

Obturator Nerve

Superior Gluteal Nerve

Inferior Gluteal Nerve

Lateral Femoral Cutaneous Nerve

Posterior Femoral Cutaneous Nerve

Vascular

Superior Gluteal Artery

Inferior Gluteal Artery

Ascending Branch of the Lateral Femoral Circumflex

Medial Femoral Circumflex Artery

Bladder

Landmarks (Figs. 6-22 to 6-25)

Posterior Approach to the Sacroiliac Joint

Positioning (Fig. 6-26)

Dangers

Vessels

Landmarks

Incision (Fig. 6-27)

Anterior Approach to the Pubic Symphysis (Video 6-1)

Positioning

Dangers

Vessels

Landmarks

Incision

Superficial Dissection

Deep Dissection Midline

Closure

Extensile Measures

Ilioinguinal Approach to the Pelvis (Video 6-2)

Indications

Positioning

Dangers

Nerves

Vessels

Landmarks

Incision

Surgical Dissection

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