Hueter Hip anterior approach technique

Hueter Hip anterior approach technique

Non exhaustive, depending on individual care, speak with us.

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Indications

approach to the hip joint: THA, bipolar/ partial hip replacement

minimally invasive approach: minimal muscle section or denervation

reduction of dislocation rate

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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

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Key points

TFL muscle

rectus femoris muscle

anterior circumflex artery

psoas muscle

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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

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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

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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

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Extensions of the approach

upward: Smith-Petersen approach

downward: Zarad-Niceck approach

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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

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