החלפת מפרק ירך בגישה קדמית
Hueter Hip anterior approach technique
Indications
approach to the hip joint: THA, bipolar/ partial hip replacement
minimally invasive approach: minimal muscle section or denervation
reduction of dislocation rate
Patient positioning
supine position on an ordinary or orthopedic table (+++)
pelvis well horizontal, stabilized by the pelvic column support and counter-support on the contralateral iliac crest
Key points
TFL muscle
rectus femoris muscle
anterior circumflex artery
psoas muscle
Risks
femoral nerve: only threatened by the anterior retractor, which is carefully placed
lateral cutaneous nerve (e.g. femoral cutaneous): its irritation justifies the offset incision on the TFL sheath; it is threatened during closure
Skin landmarks / incision
ASIS + head of the fibula
8-12 cm long incision, one finger's breadth outside the ASIS and directed downwards towards the head of the fibula
Step-by-step description
Subcutaneous tissue
TFL sheath: incised in a straight line 10 mm from the anteromedial edge of the muscle
TFL (innervated by the superior gluteal nerve): release of its sheath by dissection in an avascular adherence plane. Placement of 2 retractors to expose the fascia of the rectus femoris
Rectus femoris and anterior circumflex artery: cautious incision of the rectus femoris sheath which is loaded under the internal retractor
Appearance of the anterior circumflex artery: ligature and section. The upper part of the vastus lateralis bundle is respected
Section of the reflected tendon of the rectus femoris
Opening of the psoas sheath (ending on the lesser trochanter) and approach to the antero-inferior capsule: the muscle insertions of the psoas on the capsule are released, and the surface of the capsule is liberated until the inferior face of the neck to arrive at the obturator hole under the radiological U. A curved retractor is placed there.
Approach to the superior capsule: curved retractor placed on the upper face of the capsule to recline outward: gluteus minus, gluteus medius, and TFL
Exposure of the proximal insertion of the capsule and the anterior wall of the acetabulum: DANGER femoral nerve nearby cautiously placed with bone contact, a retractor is pressed on the superior strait under the ASIS
Exposure of the distal capsular insertion on the anterior intertrochanteric line
Capsulectomy/otomy large / extraction of the head / acetabulum cleaning
Femoral exposure: external hyper-rotation at 90°, then hyper-extension and adduction, then leg on the ground
Reduction by TRACTION in the axis in EXTENSION + INTERNAL ROTATION
Extensions of the approach
upward: Smith-Petersen approach
downward: Zarad-Niceck approach
Closure
lateral cutaneous nerve threatened during the closure of the TFL sheath: take very fine points and be on the edge of the sheath
subcutaneous tissue and skin closure
החלפת מפרק ירך בגישה קדמית
