Atlas of Hip Surgery E-Book

• Herausgeber: Thieme
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 499

Veröffentlichungsjahr: 1995

Beschreibung

This beautifully illustrated atlas presents a practice-oriented, comprehensive description of hip surgery. Each procedure is divided into indications, approaches, complications, and pitfalls. Based on the authors' extensive experience in surgery and anatomy, this atlas is useful to residents, as well as to experienced surgeons wishing to review techniques used less frequently.

Leseprobe

Atlas of Hip Surgery

Edited by

R. Bauer, F. Kerschbaumer, and S. Poisel

with contributions by

R. BauerS. PoiselF. KerschbaumerH. WagnerE. NiederM. Wagner

494 illustrations by G. Spitzer, S. Cull, R. Henkel, and S. Spitzer

1996Georg Thieme Verlag Stuttgart . New YorkThieme Medical Publishers Inc., New York

Library of Congress Cataloguing-in-Publication Data

Atlas of Hip Surgery/ ed. by R. Bauer ... With contributions by R. Bauer ... Ill. by G. Spitzer ... – Stuttgart; New York : Thieme ; New York : Thieme Med. Publ., 1996

Einheitssacht.: Orthopadische Operationslehre <engl.>

NE: Bauer, Rudolf [Hrsg.]; Spitzer, Gerhard [Ill.]; EST

Translated by John Grossman, M.A.

This book is an authorized and revised translation of the German edition published and copyrighted 1994 by Georg Thieme Verlag, Stuttgart, Germany. Title of the German edition: Orthopadische Operationslehre, Band II/1: Becken und untere Extremitat

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This book, including all parts thereof, is legally protected by copyright. Any use, exploitation or commercialization outside the narrow limits set by copyright legislation, without the publisher’s consent, is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing or duplication of any kind, translating, preparation of microfilms, and electronic data processing and storage.

Important Note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book.

Nevertheless this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect of any dosage instructions and forms of application stated in the book. Every user is requested to examine carefully the manufacturers’ leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user’s own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed.

© 1996 Georg Thieme Verlag Rüdigerstraße 14, D-70469 Stuttgart, Germany Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, N.Y. 10016

Typesetting by Druckhaus Götz GmbH, D-71636 Ludwigsburg Printed in Germany by K. Grammlich GmbH D-72124 Pliezhausen

ISBN 3-13-102461-5 (GTV, Stuttgart)

ISBN 0-86577-601-6 (TMP, New York)           1 2 3 4 5 6 eISBN 9783131775313

Addresses

Bauer, R., Prof. Dr. Head, Orthopädische Universitätsklinik, Anichstr. 35, 6020 Innsbruck, Austria

Kerschbaumer, F., Prof. Dr. Head, Abteilung für Rheumaorthopädie, Orthopädische Universitätsklinik, Marienburgstr. 2, 60528 Frankfurt, Germany

Nieder, E., Dr. Endoklinik, Holstenstr. 2, 22767 Hamburg, Germany

Poisel, S., Prof. Dr. Institut für Anatomie der Universität, Müllerstr. 59, 6010 Innsbruck, Austria

Wagner, H., Prof. Dr. Head, Orthopädische Klinik Wichernhaus, 90592 Schwarzenbruck/Nürnberg, Germany

Wagner, M., Dr. Orthopädische Klinik Wichernhaus, 90592 Schwarzenbruck/Nürnberg, Germany

Preface

Our first atlas, Operative Approaches in Orthopedic Surgery and Traumatology, was rewarded with high sales in its many editions (German, English, French, Italian, Japanese, and Spanish) for its novel presentation of surgical procedures. Following the same concept—namely, color illustrations with concise accompanying text—we then published the three German volumes on orthopedic operations: Spine; Pelvis and Lower Extremities; and Shoulder and Upper Extremities.

The basis for this atlas is, in addition to the operative experience of the authors, the anatomic substrate. We have also taken all the major approaches for the discussed operations from the Atlas of Operative Approaches in Orthopedic Surgery and Traumatology and compiled them in the introductory chapter. In the following chapters, the most triedand- true techniques and standard operative procedures are presented step by step, including the indications, pitfalls, and complications.

Taking the international market into consideration, we have divided the contents of the entire work in accord with nosological and topographical specialization into individual volumes covering the spine, hip, knee, tumor surgery and amputations, pediatric orthopedics, and upper extremities, the first two of which are now published. In this way, the specialist has the possibility of purchasing individual volumes dealing with his or her particular field of interest.

We would like to thank the authors, without whose contributions this atlas would not have been possible. Then we would like to extend our thanks to Dr. G. Hauff, Mr. A. Menge, and the staff at Thieme for their cooperation and the high quality of their work. We are grateful to the graphic artists, Ms. S. Cull, Mr. R. Henkel, Prof. G. Spitzer, and S. Spitzer who transformed their sketches from the operating theater and dissection table into excellent illustrations. The dissection of cadavers was done at the Institute for Anatomy of the University of Innsbruck. Austria, for which our thanks go to Prof. W. Platzer.

Autumn 1995R. Bauer, Innsbruck F. Kerschbaumer, Frankfurt S. Poisel, Innsbruck

Contents

1 Approaches

R. Bauer, F. Kerschbaumer, S. Poisel

Pelvis

Posterior Approach to the Hip Joint

Bauer Transgluteal Approach

References

2 Reconstructive Hip Surgery

H. Wagner, M. Wagner

Using Fluoroscopy in the Operating Room

With the Patient Supine

Visualization of the Hip Joint

Measuring the Length of the Femur

With the Patient Positioned Laterally

General Hip Surgery

Arthrocentesis of the Hip Joint

Arthrography of the Hip

Hip Surgery

Hip Surgery Using an Anterior Approach

Hip Surgery Using an Anterolateral Approach

Hip Surgery Using the Bauer Transgluteal Approach

Surgical Correction of a Snapping Hip

Acetabular Surgery

Open Reduction of a Developmentally Dislocated Hip Using an Anterior Approach

Shelf Procedures

Acetabular Osteotomy

Salter Pelvic Osteotomy (Innominate Osteotomy)

Sutherland Pelvic Osteotomy (Double Innominate Osteotomy)

Steel Pelvic Osteotomy (Triple Innominate Osteotomy)

Chiari Pelvic Osteotomy

Proximal Femur Surgery

Preoperative Planning for Osteotomies of the Proximal Femur

Pediatric Surgery

Intertrochanteric Varus Derotation Osteotomy

Subtrochanteric Valgus Rotation Osteotomy

Operations on Adolescents and Young Adults

Trochanteric Advancement

Trochanterplasty

Intertrochanteric Osteotomie Using Osteotomy Plates

Intertrochanteric Varus Osteotomy

Valgus Intertrochanteric Osteotomy

Intertrochanteric Extension Osteotomy

Intertrochanteric Flexion Osteotomy with Anterior Capsulectomy

Intertrochanteric Rotation/Derotation Osteotomy

Intertrochanteric Shortening Osteotomy

Intertrochanteric Osteotomy for Treatment of a Slipped Capital Femoral Epiphysis

Intertrochanteric Osteotomy for Treatment of Femoral Neck Nonunions

Intertrochanteric Double Osteotomy with and without Extension of the Femoral Neck

Stabilizing a Slipped Capital Femoral Epiphysis with Kirschner Wire or Screw Fixation

Subcapital Osteotomy of the Femoral Neck for a Slipped Capital Femoral Epiphysis

Subtrochanteric Supporting Osteotomies

Arthrodesis

References

3 Primary Total Hip Arthroplasty

F. Kerschbaumer

Cemented Acetabular Cup

Zweymüller Cementless Acetabular Cup

Special Cases

Dysplastic Acetabulum

Müller Cemented Stem

Spotorno Cementless Straight-Stem Implant

Custom Implants

Aldinger Custom Cementless Stems Designed Using CT Scans

Egoform Custom Cementless Stems Designed Using Radiographic Measurements

References

4 Revision Total Hip Arthroplasty

E. Nieder

Preoperative Planning

Differential Diagnosis

Microbiological Evaluation

Blood Product Management

Radiographic Evaluation

Approaches to the Hip

Positioning

Posterior Approach to the Hip

Transtrochanteric Approach to the Hip

Transgluteal Approach to the Hip

Extending the Approaches Distally

Evaluating the Approaches to the Hip

Removing Total Hip Implants

Removing Cemented Stems

Cortical Windows for Removing Cemented Stems

Transfemoral Removal of Cemented Stems

Removing Fractured Cemented Stems

Removing Cemented Acetabular Cups

Removing Cementless Stems

Removing Cementless Acetabular Components

Reimplanting Acetabular Components

Reconstructing the Acetabulum with Graft

Saddle Prosthesis

Complications Specific to the Saddle Prosthesis Supplement: Mounting a Saddle Prosthesis on a Taper from a Different System

Reimplanting Femoral Components

Long-Stem Implants

Reconstructing the Proximal Femur with Graft

Total Femoral Prosthesis

Soft-Tissue Reconstruction and Closure

Posterior Approach to the Hip

Transtrochanteric Approach to the Hip

Transgluteal Approach to the Hip

After Distally Extended Approaches

Postoperative Management

Postoperative Surgical Management

Physical Therapy

References

Index

1 Approaches

R. Bauer F. Kerschbaumer S. Poisel

Pelvis

Posterior Approach to the Hip Joint

Primary Indications

– Arthroplasty

– Acetabular fractures and fractures of the posterior column of the pelvis

– Tumors

Positioning and Incision

The patient is usually placed in a lateral position for arthroplasty.

The patient may also be positioned prone for internal fixation of a fracture of the posterior column of the pelvis.

In the lateral position, anterior and posterior supports are required to stabilize the trunk and pelvis. The leg is draped to permit free movement. The curved incision begins approximately two finger widths below the posterior superior iliac spine, coursing distally across the greater trochanter (Fig. 1.1).

After dividing the subcutaneous tissues, the surgeon splits the fascia lata. This incision is then extended proximally, parallel to the fibers of the gluteus maximus. The surgeon must now maximally internally rotate the leg to avoid damaging the sciatic nerve when the short external rotators are cut. The short rotators should be cut one finger width medially of their insertion (see Fig. 1.2), to permit them to be reattached later.

Fig. 1.1 The posterior approach to the hip joint. Positioning and incision.

The detached external rotators are retracted posteriorly and protected with a blunt retractor.

Fig. 1.2 With the leg in internal rotation, the short external rotators and the piriformis are tenotomized.

1 Gemellus inferior

2 Gemellus superior

3 Obturator internus

4 Piriformis

5 Gluteus minimus

6 Gluteus medius

7 Gluteus maximus

8 Quadratus femoris

9 Vastus lateralis

10 Fascia lata

11 Sciatic nerve

Exposure of the Hip Joint

The gluteus medius and gluteus minimus muscles are retracted anteriorly. A “T” incision is made to open the joint capsule (Fig. 1.3). Two curved Hohmann retractors can be inserted around the femoral neck to expose it more completely. If broad exposure of the acetabulum is required, as in total hip arthroplasty, the greater trochanter can be osteotomized (Fig. 1.4). Before performing the osteotomy, the surgeon should insert a sound beneath the gluteal musculature to gauge thr proper plane of osteotomy. To avoid damaging the blood supply to the femoral head, the osteotomy should not be made too low on the femur. Alternatively, the surgeon may employ a gable-shaped osteotomy using two osteotomes.

After the osteotomy of the greater trochanter is completed, the greater trochanter with the attached gluteal musculature is retracted proximally, and a sharp Hohmann retractor is impacted into the ilium (Fig. 1.5). This permits increased exposure of the acetabulum and the femoral head. If the hip must be dislocated, this is done with the leg flexed and adducted in internal rotation.

Fig. 1.3 With the short external rotators retracted, the capsule of the hip joint is opened with a “T” incision.

1 Hip joint capsule

2 Greater trochanter

3 Gluteus maximus

4 Gluteus medius

5 Gluteus minimus

6 Piriformis, gemelli, obturator internus, and obturator externus.

7 Quadratus femoris

8 Vastus lateralis

Fig. 1.4 With the hip joint open, the femoral neck can be more completely exposed by inserting two curved Hohmann retractors around it. If necessary, the greater trochanter can be osteotomized (dotted line).

1 Femoral head

2 Femoral neck

3 Joint capsule

4 Acetabular labrum

5 Greater trochanter

6 Deep branch of the medial femoral circumflex artery

Fig. 1.5 Hip joint following osteotomy of the greater trochanter. The gluteal musculature with the attached trochanter is retracted proximally and a sharp Hohmann retractor is impacted into the ilium.

1 Cut surface of the greater trochanter

2 Femoral neck

3 Femoral head

4 Gluteus medius

5 Gluteus minimus

6 Piriform muscle, gemellus muscles, and interal obdurator

7 Quadratus femoris

8 Vastus lateralis

9 Deep branch of the medial femoral circumflex artery

Exposure of the Posterior Column of the Pelvis

If the posterior column of the pelvis is to be exposed, the incision in the gluteus maximus may have to be extended proxi-mally (Fig. 1.6). If this is the case, osteotomy of the greater trochanter is unnecessary. A Cobb elevator is used to retract the short external rotators posteriorly. A curved periosteal elevator is used to expose the greater sciatic notch; here, a curved Hohmann retractor may be carefully used. Care should be taken to avoid placing too much tension on the retractor, as this may damage the sciatic nerve.

If further exposure of the posterior column of the pelvis to the ischium is required, the skin incision may be extended dis-tally, and the tendinous attachment of the gluteus maximus to the femur may be incised. This allows the surgeon to retract the short external rotators posteriorly, permitting exposure of the ischium as far as the ischial tuberosity. If increased exposure of the proximal ilium is required (as with acetabular or pelvic fractures), the surgeon can subperiosteally dissect the gluteal musculature after osteotomy of the greater trochanter, exposing the ilium as far as the anterior inferior iliac spine.

Fig. 1.6 Exposure of the posterior column of the pelvis and the greater sciatic notch after extending the incision proximally and distally.

1 Greater trochanter

2 Femoral neck

3 Body of the ischium

4 Greater sciatic notch

5 Acetabular labrum

6 Hip joint capsule

7 Vastus lateralis

8 Gluteus medius

9 Gluteus maximus

10 Gluteus minimus

11 Gemellus superior

12 Obturator internus

13 Gemellus inferior

14 Piriformis

15 Quadratus femoris

16 Sciatic nerve

Anatomical Site

In Figure 1.7, the gluteus maximus has been divided perpendicular to the direction of the fibers, exposing the blood vessels and nerves that supply it. The fatty tissue surrounding the sciatic nerve has been removed. The sciatic nerve generally extends distally between the piriformis and the gemellus superior, but it can also penetrate the piriformis. Note the course of the medial femoral circumflex artery and its position with respect to the short external rotators.

Closure

The wound is closed by suturing the fascia lata and the fibers of the gluteus maximus. When a trochanteric osteotomy has been performed, the greater trochanter must first be reattached and secured by wire in two planes. Normally it is not necessary to reattach the short rotators.

Hazards

In revision surgery, the sciatic nerve may be obscured by scar tissue. Exposure of the nerve is recommended in such cases. The superior gluteal vessels can be damaged when the greater sciatic notch is exposed. If the anatomic joint is to be preserved, the surgeon should take care to avoid damaging the branch of the medial femoral circumflex artery that supplies the femoral head (Figs. 1.4 and 1.5).

Note

Posterior approaches to the hip joint have been described as “posterolateral approaches” by Gibson, Marcy, and Fletcher, and by Moore and others.

Posterior approaches with the patient prone have been described by Kocher, by Langenbeck, and by Henry, and others.

There are no major differences in the approaches, although details such as the exposure of the acetabulum and direction of dislocation of the hip vary.

Fig. 1.7 Anatomical site. The gluteus maximus has been split transversely (left).

1 Gluteus maximus

2 Gluteus medius

3 Gluteus minimus

4 Piriformis

5 Gemellus superior

6 Obturator internus

7 Gemellus inferior

8 Quadratus femoris

9 Adductor minimus

10 Long head of the biceps femoris

11 Semitendinosus

12 Adductor magnus

13 Gracilis

14 Sacrotuberous ligament

15 Superior gluteal artery and vein, superior gluteal nerve

16 Inferior gluteal artery and vein, inferior gluteal nerve

17 Internal pudendal vessels and pudendal nerve

18 Medial femoral circumflex artery

19 Anastomosis to the inferior gluteal artery

20 Inferior clunial nerves

21 Posterior femoral cutaneous nerve

Bauer Transgluteal Approach

Primary Indications

– Total hip arthroplasty

– Fractures of the femoral neck

– Osteotomy of the femoral neck

– Treatment of slipped capital femoral epiphysis

– Synovectomy of the hip joint

Positioning and Incision

The patient is positioned supine with a cushion beneath the buttocks. The skin incision extends about 15 cm in a slight curve, and is centered over the greater trochanter. The incision begins approximately one hand width posterior to the anterior superior iliac spine, coursing distally across the greater trochanter (Fig. 1.8). After dividing the subcutaneous tissue and the fascia lata parallel to the skin incision, the surgeon splits the anterior third of the gluteus medius, the gluteus minimus, and the vastus lateralis parallel to the direction of their fibers (Fig. 1.9). Electrocautery is used to subperi-osteally dissect the tendinous and periosteal tissues between the gluteus medius and the vastus lateralis of the bone in a single layer.

Fig. 1.8 The transgluteal approach to the hip joint. Positioning and incision.

Fig. 1.9 The transgluteal approach to the hip joint. The gluteaus medius and the vastus lateralis are incised at the boundary between the lateral and anterior thirds of the muscle (right leg is shown).

1 Tensor fasciae latae

2 Vastus lateralis

3 Gluteus maximus

4 Gluteus medius

5 Fascia lata

6 Greater trochanter

Exposure of the Hip Joint Capsule

Using a Cobb elevator, the surgeon exposes the anterior capsule. A curved Hohmann retractor is inserted between the origin of the rectus and the anterior wall of the acetabulum. On the cranial side, a Hohmann retractor is placed between the joint capsule and the gluteus medius, and an additional one is placed further distally between the iliopsoas and the joint capsule. If necessary, a second anterior Hohmann re-tractor may be inserted distal to the large curved retractor. The capsule is opened with a broad “T” incision made close to the acetabulum (Fig. 1.10). After the capsule has been opened, two Hohmann retractors may be inserted between the capsule and the femoral neck. This procedure does not endanger the blood supply to the femoral neck (Fig. 1.11).

Fig. 1.10 The muscle layer consisting of the gluteus medius and minimus, the tendinous and periosteal tissues at the greater trochanter, and the vastus lateralis is retracted toward the anterior. After the capsule of the hip joint is exposed, Hohmann retractors are inserted. The capsule is opened with a “T” incision.

1 Iliopsoas

2 Vastus intermedius

3 Vastus lateralis

4 Gluteus medius

5 Gluteus minimus

6 Iliofemoral ligament

7 Gluteus minimus bursa

Fig. 1.11 Hip joint after opening the capsule. Hohmann retractors have been placed behind the femoral neck with the leg adducted in maximum external rotation.

1 Joint capsule

2 Acetabular labrum

3 Femoral head

4 Femoral neck

Anatomical Site

As can be seen in Figure 1.12, the advantage of the trans-gluteal approach is that the gluteus minimus with its broad layer of muscle tissue protects the superior gluteal nerve from being pinched by the retractors. The separation of the gluteus medius from the iliac crest and the greater trochanter improves the exposure of the superior gluteal nerve. Further advantages of this approach are the broader exposure of the femoral neck, the proximal part of the hip joint capsule, and the femoral neck osteotomy plane when implanting a total hip.

Closure

The wound is closed by suturing the muscles that have been split parallel to the direction of their fibers (gluteus medius, gluteus minimus, and vastus lateralis; Fig. 1.13). The fascial and periosteal layers above the greater trochanter are securely sutured.

Note

The authors routinely use the transgluteal approach in total hip arthroplasty. Osteotomy of the greater trochanter is rarely necessary when using this approach.

Fig. 1.12 Anatomical site. Exposure of the superior gluteal nerve in the transgluteal approach. The gluteus medius has been partially separated from the iliac crest and the greater trochanter, creating a posterior flap.

1 Gluteus medius

2 Gluteus minimus

3 Tensor fasciae latae

4 Vastus lateralis

5 Vastus intermedius

6 Greater trochanter

7 Femoral head

8 Superior gluteal nerve

Fig. 1.13 The musculature is closed with interrupted sutures.

1 Gluteus medius

2 Tensor fasciae latae

3 Vastus lateralis

References

Anson BJ, McVay CB. Surgical Anatomy; vol 1. Philadelphia: Saunders; 1971.

Banks SW, Laufmann H. An Atlas of Surgical Exposures of the Extremities. Philadelphia; Saunders; 1968.

Bauer RF, Kerschbaumer F Poisel S, Oberthaler W. The transgluteal approach to the hip joint. Arch Orthop Traumat. 1979; 95:47.

Cosentino R. Atlas of Anatomy and Surgical Approaches in Orthopaedic Surgery; vol 11. Springfield, Ill.: Thomas; 1973.

Fahey JJ. Surgical approaches to bones and joints. Surg Clin N Amer. 1949; 29:65.

Gibson A. Posterior exposure of the hip joint. J Bone Jt Surg. 1950; 32B:183.

Henry A. Extensile Exposure. Edinburgh: Churchill-Livingstone; 1973.

Honnart F. Voies d’abord en chirurgie orthopedique et traumatologique. Paris: Masson; 1978.

Hoppenfeld S, de Boer P. Surgical Exposures in Orthopaedics. Philadelphia: Lippincott; 1984.

Lanz T von, Wachsmuth W. Praktische Anatomie, Bd. 1/4. Berlin: Springer; 1972.

McFarland B, Osborne G. Approach to the hip. J Bone Jt Surg. 1954; 36B:364.

Marcy GH, Flechter RS. Modification of the posterolateral approach to the hip for insertion of femoral head prosthesis. J Bone Jt Surg. 1954; 36A:142.

Moore AT. The self-locking metal hip prosthesis. J Bone Jt Surg. 1957; 39A:811.

Nicola T. Atlas operativer Zugangswege in der Orthopädie. Munich: Urban & Schwarzenberg; 1971.

Platzer W. Volume 1: Bewegungsapparat. In: Taschenatlas der Anatomie. 4th ed. Kahle E, Leonhardt H, Platzer W. eds, 1979. Stuttgart: Thieme; 1984.

Ruedi T, Hochstetter AHC, Schlumpf R. Operative Zugänge zur Osteosynthese. Berlin: Springer; 1984.

Schauwecker F. Osteosynthesepraxis. Stuttgart: Thieme; 1981.

Smith-Petersen MN. Approach to and exposure of the hip joint for mold arthroplasty. J Bone Jt Surg. 1949; 31A:40.

2 Reconstructive Hip Surgery

H. Wagner M. Wagner

Using Fluoroscopy in the Operating Room

With the Patient Supine

Visualization of the Hip Joint

Indications

Verifying the position of the femoral neck or head, verifying the position of implants, locating the roof of the acetabulum for corrective osteotomies, verifying coverage of the femoral head, and using Kirschner wire to determine the horizontal plane.

Technique

If the hip joint is to be visualized in an anteroposterior projection, the patient is placed supine on a radiolucent operating table (Figs. 2.1 and 2.2). The sterilely draped, C-shaped arm of the fluoroscope is brought into position above the hip from the contralateral side. A long Kirschner wire can be placed over the hip parallel to the iliac spina to mark the horizontal plane of the pelvis in the fluoroscopic image.

When the femoral neck is visualized in the lateral plane (Lauenstein view), the patient is placed supine with the leg externally rotated 90° and the knee flexed at a right angle (Figs. 2.3 and 2.4). To visualize the femoral neck in the lateral plane as it would appear with the patient standing erect, the calf must be positioned over the contralateral leg parallel to the surface of the table with the knee flexed at a right angle. If the hip is limited and this degree of external rotation is not feasible, then the pelvis should be rotated to place the calf in this position.

Fig. 2.1 Anteroposterior fluoroscopy of the hip joint. The patient is supine on a radiolucent operating table. The two monitors of the image intensifier can be seen in the background.

Fig. 2.2 The image shows the anteroposterior view of the hip joint with the Kirschner wire marking the horizontal plane.

Fig. 2.3 Lateral fluoroscopy of the femoral nack. The patient is supine on a radiolucent operating table. The leg is externally rotated 90°, and the knee is flexed at a right angle.

Fig. 2.4 The image shows the lateral view of the femoral neck.

Measuring the Length of the Femur

Indications

Preoperative planning, including shortening osteotomies, valgus intertrochanteric osteotomies to prevent an increase in leg length, and in all other osteotomies performed on the femur to adjust leg length.

Technique

Measurements are made with the patient supine on a radiolu-cent table. The joint is visualized in the center of the monitor image (Fig. 2.5). The position of the tip of the pointer is marked on the skin (Figs. 2.6 and 2.7). The pointer should be at least 1 meter long to protect personnel from excessive radiation exposure. When leg length is measured in the operating room under sterile conditions, the position may be marked with a fine clamp attached to the skin or incision sheeting instead of marking the skin with a marking pen.

The same procedure is repeated at the knee. (Figs. 2.8 and 2.9). The distance between the two marks is then measured. This yields a very accurate measurement of the length of the femur. A long tape measure or cerclage wire may be used for measuring the distance.

Fig. 2.5 Measuring the length of the femur is done with the patient lying supine on a radiolucent table. The C arm of the image intensi-fier is brought into position above the hip, and the joint appears in the center of the monitor.

Fig. 2.6 The tip of a long pointer is placed on the skin, resting over the joint. Joint and pointer appear in the center of the monitor.

Fig. 2.7 The image shows the tip of the pointer superimposed on the joint.

Fig. 2.8 The tip of a long pointer is placed on the skin, resting over the knee joint.

Fig. 2.9 The image shows the tip of the pointer superimposed on the knee joint.

With the Patient Positioned Laterally

Indications

Verifying the position of implants when using the posterior approach to the hip joint.

Technique

The C arm of the image intensifier is not draped, but additional sterile draping is applied to the patient. The arm is positioned over the patient, and the hip is visualized in an anteroposterior projection (Fig. 2.10).

Fig. 2.10 Position of the C arm when imaging the hip joint with the patient in the lateral position.

General Hip Surgery

Arthrocentesis of the Hip Joint

Indications

Aspiration of septic, aseptic, or bloody fluid; injection of medications; arthrography.

Positioning

The patient is positioned appropriately for the planned procedure. A radiolucent table permits fluoroscopy.

Technique

Arthrocentesis of the hip joint may be performed from any direction if the surgeon carefully avoids neurovascular structures. The patient is usually supine, and an anterior approach is used. This has definite advantages for orientation: With the patient supine, the anterior superior iliac spine, the symphysis, and the femoral artery distal to the inguinal ligament are readily palpable; in slender patients, even the anterior inferior iliac spine and the joint capsule are palpable. When aspirating the joint anteriorly, the surgeon feels the characteristic firm resistance of the iliofemoral ligament (which is fused with the anterior joint capsule) as the cannula is inserted into the joint. When this resistance is overcome, the tip of the cannula has entered the joint capsule. The image inten-sifier can be used for orientation with the patient supine.

When warranted by particular findings, lateral or posterior approaches may also be performed with the patient positioned appropriately.

The best approach direction of the cannula depends on the respective findings. Care should be taken to avoid injury to the articular cartilage. If a large amount of fluid has collected in the hip joint, aspiration is easy to perform because the joint capsule is expanded, and the cannula punctures it well before reaching the articular cartilage. When aspirating a joint capsule that lies close to the head of the femur, insert the cannula into the inferior section of the joint, where the joint capsule is generally relaxed. This applies in particular to subluxed hips, in which there is a wide cavity between the femoral head and the acetabular fossa. However, arthrocentesis is often not feasible in a hip with degenerative joint disease where scar tissue is present.

The surgeon first locates the anterior superior iliac spine and the pubic symphysis. The midpoint on the line defined by these two points is where the femoral artery crosses the medial segment of the femoral head; the pulse of the artery can be readily felt at this point. In adults, the best insertion point for the cannula lies 3 cm lateral and 6 cm distal to this point because the cannula is lateral of the femoral nerve (Fig. 2.11). In children, the distances are proportionally smaller. At the point of entry, a skin incision about 2 mm long is made with a narrow scalpel to prevent the cannula from carrying skin particles into the subcutaneous tissues.

The cannula is advanced at a superior angle of approximately 25° and a posterior angle of approximately 45°, meeting the firm resistance of the joint capsule with the iliofemoral ligament. The capsule can be palpated and penetrated with the cannula. The fluid in the capsule then drains through the cannula. If the capsule does not contain any fluid, Ringer’s solution may be injected. If the cannula is positioned correctly, this can be done easily. If the Ringer’s solution can only be injected under high pressure, this is an indication that the tip of the cannula is not in the joint. It should be advanced or inserted from a different direction as required. The position of the cannula can be easily verified using fluoroscopy. A return flow (or rapid sequence of drips) of Ringer’s solution from the capsule is another reliable sign that the tip of the cannula is positioned correctly. If viscous fluid flows out of the cannula, the surgeon may be certain of having punctured the joint capsule.

Fig. 2.11 Landmarks for anterior arthrocentesis of the hip with the patient supine.

On rare occasions, aspiration of the hip joint is performed with the patient positioned laterally with the leg adducted. Here, the cannula is inserted above the apex of the greater trochanter, and the surgeon may target the anterior superior, superior, and posterior superior portion of the capsule of the hip joint. The remainder of the procedure is performed as described previously (Fig. 2.12).

Fig. 2.12 Arthrocentesis of the hip with the patient positioned laterally with the leg adducted. The cannula is inserted superior to the greater trochanter and advanced into the capsule.

Arthrography of the Hip

Indications

Visualizing intra-articular structures that do not appear in plain radiographs, such as the joint capsule, articular cartilage, intra-articular connective tissue structures, and chondral fragments.

The contrast medium used in arthrography expands the joint capsule, making it possible to visualize how the capsule unfolds or adheres. Any interposed soft-tissue structures are also revealed.

Positioning

The patient is generally positioned supine on a radiolucent table, facilitating the use of fluoroscopy for orientation.

Technique

In arthrography, radiopaque liquid or radiolucent gaseous contrast media are injected into the hip by means of arthrocentesis. These contrast media show up in the radiograph and help visualize the surrounding structures. In double-contrast arthrography, radiopaque and radiolucent contrast media are used simultaneously. This procedure is more complicated, but it can provide more detailed radiographic findings.

Arthrography of the hip must be performed under sterile conditions. This is best done in the operating room with the patient sterilely prepped and draped. After aspirating the hip, the surgeons verifies the correct position of the cannula within the capsule by injecting Ringer’s solution into the capsule. The surgeon should feel no resistance initially, but increasing resistance as the solution is injected. When the syringe is removed, there should be a return flow or a rapid sequence of drips of Ringer’s solution from the cannula. Viscous fluid flowing out of the cannula is a reliable indication that the tip of the cannula is positioned correctly within the joint capsule.

Now the contrast medium is injected into the joint. A great advantage of using a syringe is that the surgeon can feel and maintain the pressure under which the contrast medium is injected. While injecting the contrast medium, the surgeon should monitor the gradual expansion of the capsule with fluoroscopy to ensure optimum filling. To protect surgical staff from excessive radiation exposure, the cannula and syringe should be connected by extension tubing that permit the surgeon’s hands to remain outside of the radiation beam (Fig. 2.13).

Gas arthrography produces radiographs that permit the surgeon to assess the intra-articular soft-tissue structures (Fig. 2.14). Carbon dioxide gas is commonly used as a contrast medium. It has the advantage of being quickly absorbed if it inadvertently enters the venous bloodstream, greatly reducing the risk of a gas embolism. Atmospheric air is flushed from the system by filling the syringe and connecting hose with Ringer’s solution. Then the gas is drawn into the syringe through a sterile hose connection to the cylinder and the Ringer’s solution is gradually flushed out.

Fig. 2.13 Arthography of the hip joint of a child (with carbon dioxide) under sterile conditions in an operating room. The cannula lies in the left hip and is connected to the contrast-medium syringe via an extension tube. The system is first filled with carbon dioxide gas from a pressurized cylinder.

1 Sterilely draped image intensifier

2 Carbon dioxide cylinder

3 Sterile extension tube for filling the syringe.

Fig. 2.14 Gas arthrography of a dislocated hip in a child. The femoral head is displaced, and the joint capsule is only partially unfolded, indicating intra-articular adhesion. The articular cartilage, the acetabular labrum, the elongated ligament of the femoral head, and the distended pulvinar are readily discernible.

Fig. 2.15 Radiopaque arthrography of the same hip shown in Fig. 2.14. The peripheral structures are well defined, whereas the central soft-tissue structures are obscured by the contrast medium.

When a radiopaque contrast medium is used in arthrography, the syringe and connecting hose are filled with liquid contrast medium, which is injected into the hip through the cannula. Radiopaque arthrography provides high-contrast images of the intra-articular structures (Fig. 2.15). However, only the peripheral soft-tissue structures are revealed by the contrast medium; central structures are wholly or partially obscured.

In double-constrast arthrography, the radiopaque liquid is injected into the hip first. After the joint is put through its range of motion, the contrast medium is drained. Next, the joint is filled with carbon dioxide. Radiopaque liquid contrast medium adheres to the capsule walls (synovial membrane, interposed soft-tissue structures, and articular cartilage), while the radiolucent gas lightens the capsule interior (2.16). This produces impressive radiographs in which the light interior of the capsule is framed by thick dark lines.

The surgeon should remember that redundancy in the capsule may form folds or potential spaces, which neither liquid nor gas contrast medium can penetrate. Arthrography cannot detect these structures, regardless of the contrast media used. As the contrast medium dilates the capsule, these folds are distended. The potential spaces become actual spaces and may be visualized. With capsular distension, however, the lateral displacement of the femoral head increases. The surgeon should take this into consideration when assessing the arthrogram.

Fig. 2.16 Double-contrast arthrography of the same hip shown in Fig. 2.14. Radiopaque liquid contrast medium adheres to the surface of the soft-tissue structures, while the carbon dioxide gas makes the capsule interior appear lighter.

Hip Surgery

Hip Surgery Using an Anterior Approach

Indications

Broad exposure of the hip in treating degenerative joint disease (inflammation, formation of scar tissue, ossification), deformities in the immediate proximity of the joint, and traumatic injuries. The approach is used for hip surgery, synovectomy, and corrective surgery involving the acetabulum.

Positioning and Incision

With the patient positioned supine, a curved skin incision is made parallel to the iliac crest, beginning lateral of the anterior superior iliac spine and coursing distally to the middle of the lateral thigh.

Technique

The anterior approach is the most challenging and versatile approach to the hip. It permits broad exposure of the hip and the lateral and medial surface of the iliac wing, and can be easily extended as far as necessary. A further advantage of the incision is that it courses along the dividing line between the femoral and gluteal neurovascular structures. A disadvantage is that it may require separating muscles from their origins over a broad area, which requires particular caution.

The skin incision courses 2–3 cm lateral of the iliac crest (Fig. 2.17). After splitting the muscle fascia parallel to its fibers, the surgeon transects the tensor fasciae latae and retracts it laterally. The medial fascia is kept in place to protect the lateral femoral cutaneous nerve (Fig. 2.18), which lies medial to the incision. After the deep layer of the fascia has been split, the rectus femoris and ascending branch of the lateral femoral circumflex artery (Fig. 2.19) are visible. Limited exposure of the hip capsule may now be obtained by retracting the pericapsular fat, and a partial capsulectomy can be performed without significant risk to the surrounding musculature.

Fig. 2.17 In the anterior approach to the hip, the skin incision courses 2–3 cm lateral of the iliac crest.

Fig. 2.18 After the muscle fascia is split parallel to the direction of its fibers, the tensor fasciae latae is dissected from the medial fascia and retracted laterally.

1 Iliac crest

2 Anterior superior iliac spine

3 Sartorius

4 Superficial layer of the fascia lata

5 Deep layer of the fascia lata

6 Tensor fasciae latae

7 Iliotibial tract

Fig. 2.19 After the deep layer of the fascia has been split, the sartorius is retracted medially, and the tensor fasciae latae laterally. The rectus femoris with its two heads of origin and the ascending branch of the lateral femoral circumflex artery are visible is the deepest layer.

1 Iliac crest

2 Anterior superior iliac spine

3 Sartorius

4 Rectus femoris

5 Direct origin of the rectus femoris

6 Reflected origin of the rectus femoris

7 Ascending branch of the lateral femoral circumflex artery

8 Tensor fasciae latae

9 Iliotibial tract

Broader exposure of the hip requires more extensive soft-tissue dissection. The tensor fasciae latae and the gluteus me-dius are successively dissected from the lateral surface of the iliac wing. After the pericapsular fat is retracted, the capsule of the hip is clearly visible beneath the origin of the rectus femoris (Fig. 2.20). This degree of exposure is often sufficient for limited surgical procedures about the hip.

If more extensive exposure of the hip is required, the direct and reflect origins of rectus femoris are resected (Fig. 2.21). When severe soft-tissue contracture is present or the anterior margin of the ilium and anterior capsule or the inner surface of the ilium must be visualized, the the soft-tissue structures are dissected from the anterior superior iliac spine and the inner surface of the iliac wing. A broad blunt elevator is inserted under the soft tissue on the medial surface of the ilium and lifted. The surgeon first severs the sartorius and the inguinal ligament at the iliac spine with a scalpel (Fig. 2.22). Then the iliacus can be bluntly retracted from the medial surface of the ilium; if necessary, it can be retracted posteriorly as far as the sacroiliac joint.

Fig. 2.20 The musculature covering the hip is dissected along the outer surface of the iliac wing, exposing the joint capsule.

1 Iliac crest

2 Anterior superior iliac spine

3 Sartorius

4 Direct origin of the rectus femoris

5 Reflected origin of the rectus femoris

6 Hip joint capsule

7 Ascending branch of the lateral femoral circumflex artery

8 Tensor fasciae latae

9 Fascia lata

10 Iliotibial tract

Fig. 2.21 Dissecting the rectus Ifemoris by resecting the reflected origin and transecting the direct origin.

1 Iliac crest

2 Anterior superior iliac spine

3 Sartorius

4 Direct origin of the rectus femoris

5 Reflected origin of the rectus femoris

6 Hip joint capsule

7 Ascending branch of the lateral femoral circumflex artery

8 Tensor fasciae latae

9 Fascia lata

10 Gluteus medius

11 Gluteus minimus

12 Elevator in the greater sciatic notch

The surgeon lifts the anterior soft tissue using a short, sharp-tipped elevator impacted in the pubis and retracts the pelvic and trochanteric musculature posteriorly with a blunt elevator in the greater sciatic notch (Fig. 2.23). This exposes two-thirds of the circumference of the hip capsule. The surgeon opens the capsule with a “T” incision, taking care not to damage the acetabular labrum or the cartilage of the femoral head. Opening the two capsule flaps exposes the joint completely (Fig. 2.24). The surgeon can now perform a synovectomy or capsulectomy, or dislocate the hip with the leg flexed and adducted in external rotation.

Fig. 2.22 Dissecting the soft-tissue structures from the medial side of the anterior superior iliac spine and the inner surface of the ilium.

1 Iliac crest

2 Anterior superior iliac spine

3 Inguinal ligament

4 Sartorius

5 Iliopsoas

6 Pubic ramus

7 Transected rectus femoris

8 Hip joint capsule

Fig. 2.23 The anterior soft tissue is lifted using a short, sharp-tipped elevator impacted in the pubis, and the pelvic and trochanteric musculature is retracted posteriorly with a blunt elevator in the greater sciatic notch. The capsule is opened with a “T” incision.

1 Sartorius

2 Iliopsoas

3 Short, sharp-tipped elevator impacted in the pubis

4 Blunt elevator in the greater sciatic notch

5 Tensor fasciae latae

Fig. 2.24 Broad exposure of the hip joint after opening the incised capsule.

1 Acetabular labrum

It is not always necessary to suture the capsule when closing the wound; reattaching the musculature is more important. The direct origin of the rectus femoris is reattached to the anterior inferior iliac spine, the inguinal ligament and the sar-torius to the anterior superior iliac spine, and the gluteus me-dius and tensor fasciae latae to the iliac crest (Fig. 2.25). Secure fixation of the muscular origins may require suture to the bone via drill holes or suture anchors. Excessive tension on the pelvic and trochanteric musculature can be effectively relieved by alternately incising the superficial muscle fascia perpendicular to the direction of its fibers.

Fig. 2.25 Reattaching the musculature.

1 Iliac crest

2 Anterior superior iliac spine

3 Inguinal ligament

4 Sartorius

5 Anterior inferior iliac spine

6 Rectus femoris

7 Fascia lata

8 Tensor fasciae latae

Hip Surgery Using an Anterolateral Approach

Indications

The anterolateral approach provides limited exposure of the anterior hip, yet it does so with minimal soft-tissue detachments. In hip surgery, this option should be weighed against the extensive exposure of the anterior approach before beginning. The anterolateral approach offers the additional advantage of permitting simultaneous exposure of the proximal femur.

Positioning and Incision

With the patient positioned supine, a longitudinal skin incision is made that begins at the apex of the greater trochanter and courses distally (Fig. 2.26).

Technique

After the fascia is split, the hip joint is exposed between the tensor fasciae latae and the vastus lateralis without significant damage to the musculature of the hip. Broad exposure of the proximal femur is also possible.

The anterior margin of the gluteus medius is conservatively detached from its insertion on the greater trochanter to provide access to the anterior surface of the hip joint capsule (Fig. 2.27). The pericapsular fat is retracted from the anterior surface of the joint capsule with a sharp periosteal elevator, exposing the entire anterior capsule (Fig. 2.28). The reflected origin of the rectus femoris is now visible in the deep layer. Elevators are inserted on the superior, medial, and inferior sides of the femoral neck, providing broad exposure of the joint capsule (Fig. 2.29). The surgeon opens the capsule with a “T” incision, taking care not to damage the acetabular la-brum or the cartilage of the femoral head.

The capsule flaps are opened like doors, providing access sufficient for performing a partial synovectomy or partial capsulectomy (Fig. 2.30). Further soft-tissue dissection is necessary if the hip is to be dislocated or a prosthesis implanted.

Closure is begun by suturing the anterior margin of the gluteus medius back to its insertion on the greater trochanter (Fig. 2.31). After placing a subfascial drain, the surgeon closes the fascia lata with a secure vertical mattress suture, overlapping the lips of the wound (Fig. 2.32). The wound is then closed in layers.

Fig. 2.26 In the anterolateral approach, the longitudinal skin incision begins at the apex of the greater trochanter and courses distally.

Fig. 2.27 After the fascia lata is split, the anterior margin of the gluteus medius is conservatively detached from its insertion on the greater trochanter.

1 Gluteus medius

2 Vastus lateralis

3 Fascia lata, divided longitudinally

Fig. 2.28 The pericapsular fat is retracted from the anterior surface of the joint capsule with a sharp periosteal elevator.

Fig. 2.29 The reflected origin of the rectus femoris is visible in the deep layer. Elevators are inserted on the superior, medial, and inferior sides of the femoral neck, providing broad exposure of the joint capsule, which is then incised.

1 Fascia lata

2 Gluteus medius

3 Reflected origin of the rectus femoris

4 Hip joint capsule

5 Vastus lateralis

Fig. 2.30 Opening the door-like capsule flaps provides broad exposure of the hip joint.

1 Reflected origin of the rectus femoris

2 Acetabular labrum

Fig. 2.31 Closure is begun by reattaching the anterior margin of the gluteus medius to its insertion on the greater trochanter.

Fig. 2.32 The fasica lata is closed with a vertical mattress suture, overlapping the lips of the wound.

Hip Surgery Using the Bauer Transgluteal Approach

Indications

The transgluteal approach permits broad lateral exposure of the hip joint and the proximal femur. Its range of indications is the same as with the anterolateral approach; synovectomy of the hip, open reduction and internal fixation of femoral neck fractures, femoral neck osteotomies, slipped capital femoral epiphysis, and total hip arthroplasty. Compared with the anterolateral approach, the transgluteal approach has the advantage of greater simplicity with broader exposure of the hip. However, the procedure requires extensive dissection of the gluteus medius and vastus lateralis.

Positioning and Incision

With the patient positioned supine, a longitudinal skin incision is made which courses across the greater trochanter (see Fig. 1.8).

Technique

After dividing the fascia lata parallel to the skin incision, the surgeon splits the gluteus medius, the gluteus minimus, and the vastus lateralis parallel to the direction of their fibers. The anterior half of the tendinous insertion of these muscles is dissected off the greater trochanter in a single layer to preserve the soft-tissue envelope laterally and posteriorly (see Fig. 1.9).

With the anterior joint capsule exposed, elevators are placed between the rectus femoris and the anterior acetabular la-brum, superiorly between the capsule and the gluteus minimus, inferiorly between the capsule and the iliopsoas tendon. The surgeon opens the capsule with a “T” incision, taking care not to damage the acetabular labrum or the cartilage of the femoral head (see Fig. 1.10).

After opening the capsule widely, the surgeon places blunt Hohmann retractors between it and the lateral and medial femoral neck (see Fig. 1.11). The surgical options permitted by this exposure range from synovectomy to dislocation of the hip for total joint arthroplasty.

When the wound is closed, the divided musculature is approximated and sutured. Retention sutures are used to close the incision in the tendinous insertions of the two muscles over the greater trochanter (see Fig. 1.13). After placing a suction drain, the surgeon closes the fascia lata with an overlapping retention suture.

Hip Surgery Using the Posterior Approach

Indications

The posterior approach primarily exposes the posterior hip with minimal soft-tissue detachment through a small incision. This approach is indicated primarily in treating acetabular fractures, in arthroplasty, and in excising localized tumors.

Positioning and Incision

The patient is generally positioned laterally with the leg draped to permit free movement; the prone position is used only if the procedure so requires. The skin incision begins at the intertrochanteric crest and extends 3 cm distally, parallel to the direction of the fibers of the gluteus maximus and the fascia lata (see Fig. 1.1). The incision may be extended distally as far as necessary if exposure of the femur is required. In adipose patients, the lateral position has the advantage that gravity causes the excess soft tissue to fall away from the incision, and the distance between the skin and the hip joint is shorter. This reduces venous stasis and bleeding.

Technique

When the fascia lata and gluteus maximus are divided parallel to the direction of their fibers and retracted, the cushion of fatty tissue covering the short external rotators and the sciatic nerve is exposed. Always expose the sciatic nerve when using the posterior approach; often there will be perineural adhesions that can now be removed, and the nerve is most easily protected when exposed. The subfascial cushion of fatty tissue is retracted laterally when exposing the sciatic nerve and then returned to its original position. It should not be resected because it has an important protective function.

With the leg in internal rotation, the surgeon severs the short external rotators and the piriformis at the intertrochanteric crest (see Fig. 1.10). The surgeon should preserve a strip of tissue 1 cm wide at the insertion to facilitate subsequent reattachment. If this is not possible due to scarring, then the short external rotators may later be reattached to the bone.

The musculature is dissected from the joint capsule and retracted posteriorly, the gluteus medius and gluteus minimus are lifted with an elevator, and another elevator is inserted at the lower margin of the femoral neck. The surgeon now makes a “T” incision in the broadly exposed capsule (see Fig. 1.3), and opens the flaps like doors (see Fig. 1.4). Two elevators can be inserted on either side of the femoral neck to increase exposure of the hip joint.

If the capsule remains limited, as is often the case when there is severe periarticular scarring, a trochanteric osteotomy can be performed to improve exposure (see Fig. 1.5). Before performing the osteotomy, the surgeon should insert a narrow curved elevator anteriorly to gauge the proper plane of osteotomy and to prevent damage to the blood supply to the femoral neck.

If the hip is to be dislocated, this is done posteriorly with the leg flexed and in internal rotation. When closing the wound, the surgeon must securely reduce the osteotomized greater trochanter and verify that the sciatic nerve is not damaged by the sutures when the external rotators are reattached. When closing the fascia lata, make sure that the hip musculature is under sufficient tension to ensure stability.

Surgical Correction of a Snapping Hip

Indication

In a snapping hip, the iliotibial tract moves anteriorly and posteriorly over the greater trochanter when the hip is flexed, extended, and rotated in flexion. This generally occurs when the patient stands or walks. This phenomenon is palpable at the greater trochanter, but can be so severe that it is visible or audible. The large bursa located between the greater trochanter and the iliotibial tract can become inflamed by mechanical irritation, causing severe pain.

The snapping hip phenomenon is not necessarily pathologic; often the patient has the “ability” to induce and control the phenomenon voluntarily, so that surgical treatment is not necessarily indicated. However, surgical intervention is often indicated when the condition is accompanied by severe pain, loss of function, weakness, and rapid onset of fatigue.

Pronounced thickening of the iliotibial tract can be observed in a snapping hip; the gluteus maximus can be seen to fan out into posterior margin of the iliotibial tract, and its superior fibers are closer to horizontal than normal (Fig. 2.33). The tension of the iliotibial tract exerts an anterior pull on the tract, while the gluteus maximus exerts a posterior pull. With the hip flexed, or if the femur is in external rotation, the iliotibial tract is anterior to the greater trochanter. With the hip extended, or if the femur is in internal rotation, the gluteus maximus pulls the iliotibial tract posteriorly across the greater trochanter. The result is a forceful snapping motion. The common treatment of suturing the iliotibial tract leaves these tensile mechanisms intact, which explains the frequency of recurrence.

Fig. 2.33 Snapping hip with pronounced thickening of the iliotibial tract. The superior fibers of the gluteus maximus are closer to horizontal than normal.

1 Iliac crest

2 Tensor fasciae latae

3 Iliotibial tract

4 Gluteus maximus

5 Position of the greater trochanter (dotted line)

Positioning and Incision

The patient is positioned laterally. The skin incision is made across the posterior margin of the greater trochanter (Fig. 2.35). Positioning the patient laterally with the leg draped to permit free movement permits the surgeon to intraopera-tively verify elimination of the snapping mechanism.

Technique

The snapping phenomenon is reliably eliminated by improving the way tensile forces act on the anatomic structures. The gluteus maximus is dissected from the posterior margin of the iliotibial tract with a longitudinal incision extending distally 5 cm from the apex of the greater trochanter. This causes the iliotibial tract to retract anteriorly. The posterior edge of the incision is sutured to the greater trochanter and the tendon of the gluteus medius and the gaping split in the fascia lata is left open (Fig. 2.34). The iliotibial tract now remains anterior to the greater trochanter in every movement and the snapping action is eliminated. The longitudinal incision in the fascia lata does significantly affect the tension acting on the lateral hip, nor does it significantly impair hip stability.

When the subcutaneous fatty tissue is retracted, the fascia lata appears as a broad band. After this, the thickened iliotibial tract can be seen anteriorly, and the gluteus maximus posteriorly. The dividing line between the two is sharply demarcated (Fig. 2.36). The fascia lata is incised with a scalpel along the dividing line between the iliotibial tract and the gluteus maximus (Fig. 2.37). Using a sharp periosteal elevaotor, the surgeon carefully separates all the muscle fibers from the iliotibial tract.

After the incised fascia is retracted, a large thick-walled trochanteric bursa (often inflamed) generally appears on the outer surface of the greater trochanter. This bursa is resected completely (Fig. 2.38).

The posterior edge of the incised fascia is retracted to the posterior margin of the greater trochanter and fixed in this position. The anterior edge of the incised fascia with the iliotibial tract automatically retracts to behind the anterior margin of the greater trochanter. The posterior edge of the incised fascia with the gluteus maximus is securely fixed with several sutures to the posterior margin of the greater trochanter, the posterior margin of the gluteus medius tendon, and the vastus lateralis (Fig. 2.39). The broad gap in the fascia, extending 5 cm distally from the apex of the greater trochanter, is left open when the wound is closed. Fine fascial tissue will soon form to bridge the gap. The surgeon closes the wound over a suction drain.

Fig. 2.34 The posterior incised edge of the fascia lata is sutured to the tendon of the gluteus medius, the posterior margin of the greater trochanter, and the tendon of the vastus lateralis. The gaping incision in the fascia lata posterior to the iliotibial tract is left open.

Fig. 2.35 Lateral positioning and incision for surgical treatment of a snapping left hip. The skin incision is made across the posterior margin of the greater trochanter.

1 Iliotibial tract

2 Tendon of the gluteus medius

3 Vastus lateralis

Fig. 2.36 When the subcutaneous fat is retracted, the sharply demarcated dividing line between the thickened iliotibial tract and the gluteus maximus is exposed.

1 Iliotibial tract

2 Gluteus maximus

Fig. 2.37 The fascia lata is incised along the anterior margin of the gluteus maximus. The distended trochanteric bursa and the gluteus medius are now visible in the deep layer.

1 Iliotibial tract

2 Gluteus maximus

3 Trochanteric bursa

4 Gluteus medius

Fig. 2.38 The thick-walled trochanteric bursa is resected.

1 Iliotibial tract

2 Trochanteric bursa

3 Gluteus maximus

4 Gluteus medius

Fig. 2.39 The posterior edge of the incised fascia with the gluteus maximus is securely fixed with several sutures to the posterior margin of the greater trochanter, the posterior margin of the gluteus medius tendon, and the vastus lateralis. The anterior edge of the incised fascia with the iliotibial tract automatically retracts to behind the anterior margin of the greater trochanter and does not require fixation.

1 Iliotibial tract

2 Greater trochanter

3 Gluteus maximus

4 Gluteus medius

Acetabular Surgery

Open Reduction of a Developmentally Dislocated Hip Using an Anterior Approach

Indications

Congenital subluxation or dislocation of the hip or teratologic dislocation if radiological and arthrographic findings or previous conservative treatment have shown that closed reduction will not be successful. The surgical treatment is most effective on children between 6 and 18 months old.

Positioning and Incision

The patient is positioned supine for the anterior approach. Since soft tissue is easily displaced in infants, a short skin incision is sufficient, keeping in mind that the scar will become larger as the child grows.

Technique

The soft-tissue structures that inhibit reduction are resected to permit the femoral head to enter the acetabulum so that it is in direct contact with the articular surface of the acetabulum. Even slight remaining lateral displacement will inevitably result in dislocation.

The dislocation of the joint has expanded the joint capsule and elongated the ligament of the head of the femur. The acetabular labrum no longer fits snugly against the femoral head and has drawn together in the form of a ring, shortening the transverse acetabular ligament. In addition to these deformities, the lack of compression from the femoral head results in hyperplasia of the pulvinar.

When closed reduction is attempted, all of these soft-tissue structures can help inhibit reduction:

The shrunken acetabular labrum, drawn together distally by the transverse acetabular ligament, reduces the size of the acetabular opening, preventing the femoral head from deeply engaging the acetabulum. The elongated ligament of the head of the femur and enlarged pulvinar cover the floor of the acetabulum and do not leave sufficient space to deeply engage the femoral head. In addition to his, the expanded joint capsule impinges between the greater trochanter and the roof of the acetabulum and prevents the proximal femur from reaching a sufficiently medial position.

Correct open reduction requires the removal of all these soft-tissue impediments: The superior and anterior sections of the joint capsule, the ligament of the head of the femur and the transverse acetabular ligament are resected, and the size of the pulvinar is reduced accordingly. Lastly, radial postero-superior and anterosuperior incisions are made in the shrunken acetabular labrum so that it can unfold and remain in intimate contact with the femoral head after reduction. Such a thorough removal of the impediments to reduction is only possible through a surgical approach that exposes the entire circumference and roof of the acetabulum. Partial removal of the impediments will limit the reliability of the reduction.

The curved skin incision extends approximately 4 cm and courses 1 cm lateral of and parallel to the iliac crest, equally proximal and distal to the anterior superior iliac spine (Fig. 2.40). When the subcutaneous fatty tissue is retracted, the anterior margin of the fascia of the tensor fasciae latae is split parallel to the direction of its fibers. The medial fascia is retracted medially to protect the lateral femoral cutaneous nerve embedded in the fatty tissue. The surgeon then dissects the tensor fasciae latae and the anterior section of the gluteus medius from the outer surface of the ilium (Fig. 2.41). After elevating the sartorius to expose the rectus femoris with its two heads of origin, the surgeon exposes the joint capsule and the lateral surface of the ilium (Fig. 2.42). The reflected origin is resected. Now, the soft-tissue attachments of the joint capsule, visible as a snow white body, must be carefully dissected. This significantly reduces bleeding and improves exposure. The iliopsoas tendon and the distal surface of the anterior inferior iliac spine now come into view in the deep layer of the wound. Finally, the surgeon incises the joint capsule along the acetabular labrum, taking care not to damage the labrum or the cartilage of the femoral head (Fig. 2.43).

Fig. 2.40 Positioning and incision for open reduction of a dislocated left hip. The skin incision 1 cm lateral of and parallel to the iliac crest.

Fig. 2.41