1/4/2010
 Hip and Thigh Anatomy Dissection
+ Surgical approaches
1.) Anterior Approach (Smith Peterson): Pt is typically supine.
- Skin incision: Longitudinal incision in line from ASIS to lateral patella
* Can extend proximally along iliac crest
- Internervous planes between femoral nerve and superior gluteal nerve
* Superficially dissect between sartorius (Femoral nerve) and Tensor fascia latta
(Superior gluteal nerve)
* Deep dissection between rectus femoris and gluteus medius
- After skin incision dissect into subcutaneous tissues and identify the sartorius—tensor interval
* Easiest to define 3-4 cm distal to ASIS, then work proximally
* Lateral femoral cutaneous nerve pierces deep fascia of thigh in this region and
roughly travels along the surface of the sartorius
* Release medial fascia of tensor and continue towards deep dissection (allows you
protec t the LFCN because it will be medial to you)
- Once deep to sartorius—tensor interval, identify the ascending branch of lateral femoral
circumflex artery.
* Can ligate this artery if needed
- Identify the deep muscles: Gluteus medius and rectus femoris. Continue through this interval
to expose the anterior joint capsule
* Always keep femoral nerve medial to the rectus
* Reflected head of rectus originates on superior lip of acetabulum (direct head
originates from ASIS)
* With reflected head of rectus retracted medially (or released from the superior lip of
acetabulum) the anterior joint capsule should be visible.
* Gluteus minimus inserts onto anterior joint capsule and can be elevated off
- Perform capsulotomy for exposure to hip joint
2.) Anterolateral approach (Watson Jones): Pt is typically supine
- Skin incision: Starts 2-3 cm posterior to the ASIS and travels vertically towards greater
trochanter. Continues distally along the anterior line of greater trochanter in line with femur
- Internervous plane: Dissection between tensor fascia latta and gluteus medius, both are
innervated by superior gluteal nerve
* Dissect down to expose the fascia of the TFL, incise this in line with skin incision. Then
retract the fascia over TFL medially to expose the gluteus medius inserting onto greater
trochanter
* Move medial to gluteus medius and enter interval between medius/minimus and
rectus femoris
- Deep dissection similar to anterior approach
* Identify the two heads of rectus
* Can also perform osteotomy of the greater trochanter (or perform partial release of
the gluteus medius) for deep expose to anterior neck and joint
3.) Lateral approach (Hardinge): Pt typically in lateral position
- Skin incision: Longitudinal centered directly over greater trochanter
- Dissect through subcutaneous fat to expose tensor fascia over greater trochanter
* Incise tensor fascia in line with incision, can gently curve towards ASIS at superior
portion
* Expose the greater trochanter with gluteus medius inserting and vastus lateralis
originating distal to the vastus ridge
- Using cautery and staying towards the anterior 1/3 of the greater troch, release the medius off
the trochanter and split it along its anterior fibers
* Can’t split more than 5 cm from trochanter because superior gluteal nerve will be
located in this region and if injured the abductors are dennervated.
- Moving distally in the same line, release the vastus lateralis in line with its fibers
- Continue to move subperiosteally towards the anterior hip capsule (place leg in side bag to
flex, adduct, and externally rotate the hip and place capsule on more tension)
* Once capsule exposed, then make T shaped capsulotomy with long arm of T
extending along the femoral neck and short arms of T available to be tagged and later
closed.
4.) Posterior approach (Southern Approach): Pt is typically in lateral position
- Proposed advantage: Does not affect abductors and often better exposure of femoral shaft for
revision procedures.
- Skin incision: Incision is curvilinear, centered over the posterior aspect of the greater
trochanter. Superior to trochanter the incision runs posteriorly in line with fibers of the gluteus
max. Inferior to the trochanter the incision is line with the femoral shaft. Many people will flex
the hip to approximately 90 degrees and draw a straight line centered over the posterior third of
the greater trochanter. When the hip is brought back to neutral position it will be a curvilinear
line.
- Dissection plane: No internervous plane, but G. max is split in line with it’s fibers, which is
thought to protect it from denervation.
* Sharp dissection is carried down to expose the iliotibial band and the fascia overlying
G. max.
* Iliotibial band is split in line with femoral shaft, which will show the bursa over the
greater trochanter and the vastus lateralis along the femoral shaft.
* The fascia overlying the G. max is split in line with its fibers and then the muscle is
bluntly split with your fingers.
* Identify the short external rotators. Internally rotate the hip, and release the rotators.
* Expose posterior capsule and perform capsulotomy. Capsule will need to be repaired
at the end of the case.
+ Vascular supply:
1.) Femoral artery, continuation of external iliac artery. Branches to form deep artery of thigh
and distally gives off descending genicular artery before entering adductor hiatus
2.) Deep artery of thigh branches from femoral artery within femoral triangle. Gives
perforating branches along length of femur
3.) Lateral circumflex femoral artery: Deep to sartorius and rectus femoris
- Ascending branch to anterior greater trochanter
- Transverse branch
- Descending branch travels deep to rectus
4.) Medial circumflex femoral artery: Between pectineus and iliopsoas to posterior fem. Neck
- Ascending branch runs on quadratus femoris
5.) Obturator artery gives off acetabular branch that travels within ligamentum teres
6.) Superior gluteal artery: Largest branch of internal iliac artery. Enters pelvis superior to the
piriformis. Supplies blood to the gluteus medius and minimus. Forms part of the dual blood
supply to the maximus. Frequently injured in pelvic fractures.
7.) Inferior gluteal artery: Travels with inferior gluteal nerve. Supplies gluteus maximus.
+ Nervous supply:
1.) Femoral nerve: Travels between psoas and iliacus. Gives off saphenous branch in femoral
triangle.
- Quads (Vastus medialis, intermedius, lateralis, & rectus femoris)
- Sartorius
- Pectineus
- Psoas
- Articularis genu
2.) Superior gluteal nerve: Emerges from pelvis superior to piriformis.
- Tensor fascia latta
- Gluteus medius
- Gluteus minimus
3.) Inferior gluteal nerve: Exits inferior to piriformis and enters gluteus maximus.
- Gluteus maximus
4.) Sciatic nerve: Exits via greater sciatic foramen. Travels deep to piriformis (therefore not
protected by reflecting piriformis.
- Semitendinosus (Tibial division)
- Semimembranosus (Tibial division)
- Biceps femoris (Long head by tibial division, Short head by peroneal division)
5.) Obturator nerve: Exits pelvis via obturator canal, splits into anterior and posterior divisions.
Can be injured by retractors placed deep to transverse acetabular ligament.
- Gracillis
- Adductor longus
- Adductor magnus
- Adductor brevis
6.) Lateral femoral cutaneous nerve: Crosses ASIS. Purely sensory nerve to lateral thigh.
7.) Posterior femoral cutaneous nerve: Sensory nerve. Gives branches to inferior cluneal
nerves and perineal branches.
8.) Nerve to obturator internus: Enters obturator internus immediatelly and also gives branch
to superior gemellus
- Obturator internus
- Superior gemelli
9.) Nerve to quadratus femoris: Travels with sciatic nerve and then passes deep to quadratus
femoris to enter the anterior surface of the muscle. Also supplies the inferior gemelli.
- Quadratus femoris
- Inferior gamelli