Hip – Anterolateral (Hardinge/Transguteal)

Position

Supine (as first descried by Hardinge, K. (1982))

  • buttock over hangs over edge of table
  • tilt table away so patient lies flat
  • prep & drape leg free

Lateral Decubitis

  • Patient centered on table
  • Posterior (Sacral) and anterior (ASIS) pelvic supports
  • Hips and Knees flexed to 30 degrees (gel pads to protect boney protrubances)
  • Prep & drape leg free

Landmarks

  • ASIS
  • Greater trochanter
  • Shaft of femur
  • Vastus lateralis ridge

Incision

  • Flex the hip 30°
  • Incision has the GT at its mid point longitudinally
  • Extends 8cm parallel to the shaft of the femur along its anterior border
  • Proximally it extends in a posterior direction ending at the level of the ASIS

Internervous Plane

  • Intermuscular plane*
  • Tensor fascia lata – Split lateral to innervation
    • Superior gluteal nerve
  • Gluteus medius – Split distal to innervation
    • Superior gluteal nerve
  • *No true Internervous plane as muscles share common innervation

Superficial Dissection

  • Continue the incision through subcutaneous fat down to deep fascia
  • The gluteal fascia and illiotibial band are exposed using blunt dissection and dived along the whole length and in the same direction as the skin incision.
  • The tensor fascia lata is retracted anteriorly and the gluteus maximus posteriorly

Deep Dissection

  • Detaching the abductor mechanism – if needed
    • 1. Trochanter Osteotomy
      • starting at Vastus Lateralis Ridge
        • straight
        • Chevron
      • Use
        • Gigli saw
        • Osteotome
        • Saw
    • 2. Detaching Gluteus Medius
      • Place a stay suture in the anterior portion of Gluteus Medius
      • Identify the small prominence that lies at the uppermost end of the ridge of the vastus lateralis.
      • Starting at this point and continuing to the APEX of the GT, the tendon of the Gluteus medius is incised using diathermy.
      • Leave a cuff to be re-attached at closing.
      • Extend the incision proximally between the fibres of gluteus medius.
      • Do not extend more than 3-5 cm above greater trochanter to prevent injury to superior gluteal nerve
      • Dissect off the Gluteus minimus tendon and the ligament of Bigelow
      • Adduct and externally rotate the thigh
  • Exposes Hip Joint Capsule
  • Incise the capsule radially around its circumference

Dangers

  • Nerve
    • Femoral nerve
  • Vessels
    • Femoral artery & vein
    • Profunda femoris artery
  • Fracture
    • Femoral shaft
    • Acetabular floor

References

  • HARDINGE K: The direct lateral approach to the hip. J Bone Joint Surg Br. 1982;64:17–19.