Hip – Posterior

Moore

Southern

Principles

  • do no interfere with abductor mechanism of hip
    • avoid loss of abductor power

Position

  • lateral position
  • protect & pad bony prominences
  • prep & drape limb free

Landmarks

  • Greater Trochanter
  • Iliac crest
  • Shaft of femur

Incision

  • 15 cm curved incision centred on the posterior aspect of greater trochanter
  • Start: begins 8 cm above & posterior to the posterior aspect of the greater trochanter
  • End: down shaft of femur

Internervous Plane

  • No true internervous plane
  • Gluteus maximus split

Superficial Dissection

  • Incise fascia lata on lateral aspect of femur to uncover vastus lateralis
  • Lengthen the fascial incision superiorly in line with skin incision & split the fibers of gluteus maximus by blunt dissection
    • Ligate branches of superior & inferior gluteal arteries that are encountered
  • Retract fibres of gluteus maximus
  • Exposes short external rotators & overlying fatty tissue
    • Obturator internus
    • Two gemelli
    • Quadratus femoris

Deep Dissection

  • Palpate & identify the sciatic nerve
  • IR the hip to put the short IR on stretch & put the operative field farther from the sciatic nerve
  • Stay sutures into piriformis & obturator internus tendons
  • Detach the muscles close to their femoral insertion
    • Reflect them backwards to cover & protect the sciatic nerve
  • If necessary I would extend my dissection to include quadratus femoris
    • But haemostasis of the branches from the lateral circumflex artery can be problematic
  • Exposes hip joint capsule
    • Place stay suture in capsule
    • Incise with a T shaped capsulotomy

Dangers

  • Nerves
    • Sciatic
  • Vessels
    • Inferior gluteal artery
    • Lateral circumflex artery