Hip and Pelvis

Published on 16/03/2015 by admin

Filed under Orthopaedics

Last modified 22/04/2025

Print this page

rate 1 star rate 2 star rate 3 star rate 4 star rate 5 star
Your rating: none, Average: 4 (2 votes)

This article have been viewed 10744 times

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)

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

Vascularity (Fig. 6-15)

Internal Iliac Artery

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

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

Femoral Triangle

Nerves

Sciatic Nerve

Surgical Approaches to the Pelvis

Posterior Approach to the Sacroiliac Joint

Indications

Incision (Fig. 6-27)

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

Indication

Ilioinguinal Approach to the Pelvis (Video 6-2)image

Background

Surgical Dissection

Lateral Window

Middle and Medial Window

Continue the incision from the ASIS to the pubic symphysis or slightly beyond; divide the subcutaneous tissue sharply or with electrocautery to expose the external abdominal oblique fascia, which inserts into the inguinal ligament

The lateral femoral cutaneous nerve will be near the medial edge of the ASIS, but its course is somewhat variable up to 3 cm; identify the superficial inguinal ring at the medial aspect of the dissection (Fig. 6-36)

Divide the external oblique fascia, taking 1 to 2 mm of the inguinal ligament with it to allow better closure; medially avoid injuring the spermatic cord/round ligament with blunt dissection around these structures (Fig. 6-37)

Identify and protect the lateral femoral cutaneous nerve, which may require dissecting it free to allow retraction

Incise the internal abdominal oblique fascia carefully because the femoral vessels and nerve are just beneath it; medially incise the rectus sheath 1 cm proximal to its insertion to allow repair and elevate (Fig. 6-38); finger dissection behind the pubis will develop the space of Retzius between the bladder and pubis; the inferior epigastric artery and vein cross just medial to the inguinal ring and should be ligated

Use a lap pad to elevate the extraperitoneal fat from the femoral vessels; bluntly dissect the femoral sheath medially and the femoral nerve and iliopsoas tendon laterally and protect these groups with slings (Fig. 6-39); avoid excessive retraction on the femoral vessels to avoid damage to intertwined lymphatics

Identify the iliopectineal fascia—deep between femoral sheath medially and femoral nerve laterally—and carefully divide this down to the pelvic brim and posteriorly toward the SI joint; in older persons it may be attenuated

Carefully retract the femoral vessels medially, look for anastomosis between the femoral and obturator vessels (corona mortis), and ligate if present

This process leaves 3 windows to work between (Fig. 6-39)

• A lateral window between the iliacus and the lateral portion of the incision through which the iliac wing and sacroiliac joint are exposed

• A middle window between the psoas/femoral nerve and the femoral vessels for exposure of and/or clamp placement for the anterior column and medial wall of the acetabulum and iliopubic eminence

• A medial window between the femoral vessels and the medial aspect of the incision to the pubic symphysis, exposing the superior rami; care should be taken to retract and protect the bladder in this window

Surgical Dissection

Lateral Window

Medial Window

Start with the pubic symphysis approach (see p. 285)

Once deep dissection is complete and the bladder is protected, carefully dissect laterally along the superior pubic rami

At approximately the midpoint of the rami, carefully dissect the tissue below the femoral vessels either bluntly or with scissors to identify the presence of corona mortis; divide and ligate if seen (vascular clips are helpful here; Fig. 6-40)

Continue elevating laterally to the quadrilateral plate and then continue posterior to the SI joint as needed; the iliopectineal fascia will need to be divided to expose the true pelvis and the inferior portion of the quadrilateral plate (Fig. 6-41)

This maneuver will expose the medial surface of the acetabulum and the pelvic brim down into the true pelvis (Fig. 6-42)

• The obturator artery and nerve should be visible along the inferior aspect of the quadrilateral plate; avoid excessive retraction and be careful with plate/screw/drill placements to avoid inadvertent damage

Posterior Approach to the Acetabulum (Kocher-Langenbeck)

Indications

Dangers

Sciatic Nerve

Deep Dissection

Make sure that tension is off the sciatic nerve by extending the hip and flexing the ipsilateral knee

Place tension on the external rotators by internally rotating the hip

The external rotators (the piriformis, gemelli, and obturator internus) are detached 1 cm off the bone in their tendinous portions (protecting the capsular and femoral head blood supply; Fig. 6-47); they should be tagged to facilitate retraction, as well as protection of sciatic nerve; of note, the piriformis and obturator internus typically have good tendinous tissue to suture, whereas the gemelli are less predictable

The sciatic nerve is identified and protected for the duration of the procedure; a sciatic notch retractor or Hohmann retractor may be placed in the lesser sciatic notch to aid visualization; the knee must remain flexed during this portion of the exposure (and the hip should remain extended if it is in a lateral position)

Posterior capsular attachments will typically be maintained at the lateral posterior wall fragment or may be traumatically disrupted; the posterior wall fragment is often reflected laterally for exposure; if necessary, the traumatic arthrotomy may be extended for exposure

Proximally, the gluteus minimus may be debrided with a rongeur to aid in the visualization of the ilium and possibly decrease the risk of heterotopic ossification

Surgical Approaches to the Hip

Overview of the Five Basic Approaches to the Hip (Figs. 6-48 to 6-50)

Anterior Approach (Smith-Petersen)

Anterior (Smith-Petersen) Approach to the Hip (Video 6-3)image

Indications

Direct Anterior Mis Total Hip Replacement Considerations (Fig. 6-58)

The anterior approach to the hip has been used for MIS for a total hip replacement, but we caution that expertise must be acquired before this approach is used

The approach is useful for reaming of the acetabulum and is used as the acetabular approach for the two-incision MIS approach for total hip replacement

The femoral preparation can be performed by using a fracture table with the ipsilateral lower extremity in the extended and externally rotated position

Use of a femoral neck elevator or bone hook to visualize the femur better allows preparation for the femoral component

The lateral capsule must be released to ensure that the femur can be delivered out of the incision for exposure to prepare the femur during total hip arthroplasty, especially if a fracture table is not used

Superficial dissection can be taken down to the sartorius tensor fascia interval (see Fig. 6-58)

The tensor fascia can be incised, and blunt dissection used to develop the interval (Fig. 6-59)

Ligation of the ascending branch of the lateral femoral circumflex should be carried out (Fig. 6-60)

Release of the rectus femoris off of the capsule is performed, and the capsule is cleared off with an elevator

This maneuver exposes the joint capsule, which can be incised for exposure of the joint (Fig. 6-61)

Retractors are placed in an intracapsular position and a two-step osteotomy of the femoral neck is completed (Fig. 6-62)

The approach should include adequate exposure for visualization of all pertinent anatomic structures to prepare the femur and the acetabulum adequately for implant stability

Posterior Approach to the Hip (Video 6-4)image

Indications

Deep Dissection

Incise the fascia lata laterally and extend into the gluteus maximus fascia in line with the muscle fibers

Bluntly dissect the gluteus maximus muscle fibers, watching for intramuscular small vessels, and coagulate them along the way

With a lap pad, bluntly sweep any underlying fat from the posterior aspect of the hip posteriorly (Figs. 6-66 and 6-67)

Identify the piriformis tendon insertion into the piriformis fossa

Internally rotate the lower extremity at the hip to aid in exposure of the external rotator tendons

Dissect the piriformis tendon from the fossa and from the obturator externus and inferior and superior gemelli tendons (tag these structures with sutures for closure repair; see Fig. 6-68)

The quadratus femoris is taken down, leaving a cuff of tissue on the femur for repair

Care should be taken to identify by site or palpation the position of the sciatic nerve as it exits beneath the piriformis muscle because its placement can vary, and it should be protected during the procedure

The joint capsule is incised, and the arthrotomy is performed according to the procedure. The hip is then atraumatically dislocated in a posterior direction (Fig. 6-69).

Medial Approach to the Hip (Video 6-5)image

Indications

Deep Dissection (Fig. 6-74)

Lateral Approach to the Hip (Video 6-6)image

Indications

Deep Dissection

Incise the fascia over the tensor and the gluteus maximus to retract the tensor fascia anteriorly and the gluteus maximus muscle posteriorly

The gluteus medius and vastus lateralis are exposed

A self-retaining retraction system can be used after the superficial dissection is completed (Fig. 6-81)

Split the medius no more than 5 cm above the tip of the greater trochanter and carry this dissection 2 to 3 cm into the vastus lateralis muscle (see Figs. 6-82 and 6-83)

This deep dissection creates an anterior flap consisting of the gluteus medius, the gluteus minimus tendon, and the vastus lateralis; alternatively, this deep dissection can be taken with a broad osteotome to take a thin flap of bone off with the attachment of the minimus, vastus, and medius

Place a blunt retractor to dissect this flap from the anterior capsule to expose it

The capsulotomy can be performed with release from the femoral attachment and a “T” into the acetabular rim; blunt retractors can be placed around the neck of the femur to expose the joint better (Figs. 6-84 and 6-85)

Anterolateral Approach to the Hip (Video 6-7)image

Indications

Deep Dissection

The anterior third of the medius is isolated to split the fibers (Fig. 6-91)

The medius and minimus can be taken together or layer by layer

If the anterior flap is taken together, the capsule can be left and uncovered by blunt dissection (Fig. 6-92)

The capsule is incised for a capsulotomy at the base of the neck of the femur and a “T” is made to the acetabular rim

With external rotation, adduction maneuver, and aid of a bone hook, the femoral head can be dislocated (Fig. 6-93)

Anterior, posterior, and superior retractors are placed to expose the acetabulum (Fig. 6-94)

Trochanteric Approaches to the Hip (Figs. 6-96 and 6-97)

Indications

image
FIGURE 6-97 Trochanteric slide.

Hip Arthroscopy

Indications

Related posts:

Approach to the Surgical Patient Wrist and Hand Shoulder and Arm Knee and Lower Leg Elbow and Forearm Foot and Ankle