After administration of general or regional anesthesia, both feet are placed in the boots. The patient is placed in the supine position on the PROfx or HANA table, a perineal post is placed, and the boots are attached to the table (Fig. 19-1). The hip that will not be operated on is placed in neutral or mild internal rotation (to maximize offset), neutral extension, and slight abduction and will serve as a radiographic reference for the operated side. Avoiding external rotation (ER) of the hip to be operated on will make the external landmarks of the hip more reliable and enhance the landmark of the natural bulge of the tensor fascia lata muscle.

The typical team consists of the surgeon, an assistant, an anesthesiologist, a scrub nurse, a circulating nurse table operator, and a radiograph technician. Although the incision is normally small (8 to 10 cm), the author prefers to drape a relatively wide area. The normal incision starts 2 to 3 cm posterior and 1 to 2 cm distal to the anterosuperior iliac spine. This straight incision extends in a distal and slightly posterior direction to a point 1 to 3 cm anterior to the greater trochanter. On thinner people the bulge of the tensor fascia lata muscle marks the center of the line of the incision. After incision of the skin and subcutaneous tissue, the tensor can be seen through the translucent fascia lata. The author places a vinyl circumferential skin retractor (Protractor) undermining slightly the fat layer off the underlying fascia. The fascial lata should be incised in line with the skin incision over the tensor where the fascia lata is translucent and anterior to the denser tissue of the iliotibial tract. The fascial incision should be continued slightly distal and proximal beyond the ends of the skin incision (Fig. 19-2).

The surgeon should lift the fascia lata off the medial portion of the tensor and follow the interval medial to the tensor in a posterior and proximal direction. Dissection by feel is most efficient at this point, and the lateral hip capsule can be easily palpated just distal to the anteroinferior iliac spine. A cobra retractor should be placed along the lateral hip capsule to retract the tensor and gluteus minimus laterally, and the sartorius and rectus femoris muscles should be retracted medially with a Hibbs retractor. The reflected head of the rectus that follows the lateral acetabular rim will be visible. A small periosteal elevator placed just distal to the reflected head and directed medial and distal elevates the iliopsoas and rectus femoris muscles from the anterior capsule. The elevator opens the path for a second cobra retractor placed on the medial hip capsule. Using this technique, a view of 180° of the circumference of the hip capsule is obtained within a few minutes (Fig. 19-3).

The medial and lateral retraction of the cobras brings the lateral femoral circumflex vessels into view as they cross the distal portion of the wound. These vessels are clamped, cauterized, and transected. Further distal splitting of the aponeurosis that overlies the anterior capsule and vastus lateralis muscle (and at times excision of a fat pad) enhances exposure of the capsule and the origin of the vastus lateralis. The anterior capsule may be either excised or opened as flaps and repaired as part of the closure. (The author prefers to retain the capsule in most cases.) The surgeon should open the capsule with an incision that parallels the anterolateral femoral neck. The proximal portion of this incision crosses the anterior rim of the acetabulum and the reflected capsular origin of the rectus femoris. The distal portion exposes the lateral shoulder of the femoral neck at its junction with the anterior greater trochanter. The junction of the capsule and the origin of the vastus lateralis muscle identify the intertrochanteric line. The distal anterior capsule should be detached from the femur at the anterior intertrochanteric line and suture tags placed on the anterior and lateral capsule at the distal portion of the incision that separates them. The cobra retractors should be placed intracapsular medial and lateral to the neck. Exposure of the base of the neck is facilitated by a Hibbs retractor that retracts the vastus and distal tensor.

A narrow Hohmann retractor is now placed on the anterolateral acetabular rim. With this exposure, the anterolateral labrum (and often associated osteophytes) is excised. Distal traction on the extremity will create a small gap between the femoral head and the roof of the acetabulum. A femoral head skid is placed into this gap and then placed in a more medial position. The traction is partially released. The patient’s hip should be externally rotated about 20°, and a femoral head corkscrew should be inserted into the head in a vertical direction. As the extremity and hip are externally rotated and leverage is applied to the skid and corkscrew, the hip should be dislocated anteriorly and the femur externally rotated 90° (Fig. 19-4).

After dislocation, the surgeon should place the tip of a narrow Hohmann retractor distal to the lesser trochanter and beneath the vastus lateralis origin. The capsule should be detached from the medial neck and the lesser trochanter, and the medial posterior neck exposed. The patient’s hip is then internally rotated and reduced, the cobra retractors are replaced around the medial and lateral neck, and the vastus origin and distal tensor are retracted with a Hibbs. The surgeon cuts the femoral neck with a reciprocating saw at the desired level and angle as indicated by the preoperative plan (Fig. 19-5). The neck cut is completed with an osteotome that divides the lateral neck from the medial greater trochanter and is directed posterior and slightly medial to avoid the posterior greater trochanter. The head is extracted with the corkscrew. Light traction will distract the neck osteotomy and facilitate this extraction.