Archives of Orthopaedic and Traumatic Surgery
Arch Orthop Traumat Surg 95, 47-49 (1979)
© J F Bergmann Verlag 1979
The Transgluteal Approach to the Hip Joint R Bauer, F Kerschbaumer, S Poisel, and W Oberthaler Universitatsklinik fiir Orthopadie, Innsbruck (Vorstand: Univ -Prof Dr R Bauer), Anatomisches Institut der Universitat Innsbruck (Vorstand: Univ -Prof Dr W Platzer), Anichstr 35, A-6020 Innsbruck, Austria
Summary A modified lateral transgluteal approach to the hip joint without osteotomy of the trochanter is described The advantage of this approach is a better view of the acetabular rim, prevention of gluteal muscle damage and protection of the superior gluteal nerve. Zusammenfassung Ein modifizierter lateraler transglutealer Hiiftgelenkszugang ohne Trochanterosteotomie wird beschrieben Die Darstellung des Gelenkes erfolgt durch Spaltung des M gluteus medius und minimus sowie des M vastus lateralis in einer Schicht. Vorteil des Zuganges ist eine bessere Ubersicht fiber die Gelenkscircumferenz, eine Muskelschonung und Schutz vor Verletzung des N gluteus superior.
Of the lateral hip joint approaches, that specified by Watson-Jones finds frequent use in hip surgery. Demonstration of the joint is achieved by forcing apart the gluteus minimus and medius muscles on one side and the tensor fascia muscle on the other side. Thus the antero-lateral part of the capsule is brought into good view Should it, however, be necessary to have a view of the complete circumference of the socket, e g , for implantation of an endoprosthesis, it is necessary in addition to detach part of the gluteal muscles from the great trochanter This involves mainly the ventral fibres of the gluteus medius muscle and practically the complete tendon of the gluteus minimus muscle Should this detachment not be carried out, the muscles must be forcefully separated by the use of hooks, in which case tears are difficult to avoid. Both the extensive detachment of the gluteal muscles Offprint requests to: Prof Dr R Bauer (address see above)
from the trochanter and the muscle lesions caused by hook pressure may diminish the final result of replacement hip function expectation. For this reason a lateral approach, avoiding such damage, is advocated.
Description of Approach The skin incision begins approximately 3-4 cm proximal and dorsal to the anterior and superior iliac spine and runs in a smooth curve over the trochanter, approximately 7-8 cm distally The fascia is opened in the direction of the fibre (Fig 1) Then, with the use of the diathermy knife, an incision is made at the junction of the anterior and middle thirds of both the vastus lateralis muscle and the gluteal muscles, beginning proximally By this incision the periosteal and soft tissues which connect the fibers of the gluteal and vastus lateralis muscle and which cover the trochanter can be separated from it, so that the ventral part of the gluteal and vastus lateralis muscle can be retracted anteriorly in one coherent layer. It is important that the fibro-periostal tissue is separated close to the trochanteric bone, and this is most simply and quickly done with the diathermy knife The fibres of the gluteus medius and gluteus minimus muscles are separated by blunt dissection (Fig 2) This can lead to hemorrhage from small veins which have to be cauterised The demonstration of the complete hip joint is now possible as follows: Using a Cobb elevator and beginning distally, release of the intertrochanteric region is carried out and a Hohmann lever is inserted medially A second angled Hohmann lever is introduced between the
0344-8444/79/0095/0047/$ 1 00
48
R Bauer et al : The Transgluteal Approach to the Hip Joint
Fig 1 The incision of fascia lata Fig 3 Exposure of the hip joint
One hundred patients from 1974 and 1975, respectively, compared in half of whom the standard Watson-Jones approach had been used are in the others, the transgluteal approach.
Fig 2 Separation of gluteal and vastus muscle fibres
straight head of rectus and the anterior joint capsule. Now the layer between the lateral joint capsule and the remaining portion of the gluteus minimus muscle and piriformis tendon is carefully opened, with the Cobb, and a third Hohmann lever inserted Thus, the anterior half of the hip joint capsule and the femoral neck are completely demonstrated (Fig 3) In some cases, e.g , rheumatoid arthritis, the ilio-psoas muscle and its
tendons may be adherent to the capsule In these cases careful separation or the layers with scissors and Cobb elevator is recommended The opening of the capsule can now be carried out as planned In the case of total hip prosthesis implantation, the complete capsule near the acetabular marsin can be removed after the removal of the femoral head without a great deal of difficulty The closure of the incision is achieved distally in the aponeurotic region with 3/0 non-resorbable suture and proximally, in the gluteal muscles, with resorbable single knot sutures. This so-called transgluteal approach modification has been used almost routinely for all major hip operation, especially endoprosthetic replacement, since 1975.
The following were assessed: Subjective patient opinion, pain, limping, Trendelenburg, periarticular calcification. At follow-up examination (1978), 27 of 100 patients limped after transgluteal approach compared with 38 of 100 after the conventional approach This, however, was not statistically significant and there was no great difference in regard to pain, subjective patient opinion or periarticular calcification.
Discussion Using the lateral approach, the joint capsule can be ideally demonstrated by trochanteric osteotomy (Jergenson-Abbot, Harris) Should one wish to avoid osteotomy, then the capsule is exposed either anterolaterally (Watson-Jones) or postero-laterally (Gibson, McFarland-Osborne) in which case either the front or rear of the joint is seen. The postero-lateral approach requires section of the tendons of the piriformis and gemelli muscles, whereas the antero-lateral approach necessitates section of the gluteus minimus and anterior portions of the gluteus medius and vastus lateralis muscles transverse to direction of the fibres The antero-lateral approach is restricted proximally by the superior gluteal nerve which runs into the tensor fascia lata muscle and supplies it Stretching or section of this nerve can result in loss of function of this muscle.
49
R Bauer et al : The Transgluteal Approach to the Hip Joint
The approach which has been described by the
References
authors lies not antero-laterally but laterally and does
not require trochanter osteotomy. We believe the advantages to be: 1 A better view of the anterior, posterior, and lateral acetabular margin. 2 Prevention of muscle damage. 3 Protection of the superior gluteal nerve. 4 A better rehabilitation of the gluteal and vastus muscle fibres because they are cut in the direction of the fibres. 5 Complete demonstration of the calcar-femoris, advantage in total hip replacement.
Gibson, A : The posterolateral approach to the hip joint Instructional course lectures AAOS 10, 175 (1953) Harris, W : A new lateral approach to the hip joint J Bone Jt. Surg 49-A, 891 (1949) Jergensen, F , Abbott, L C : A comprehensive exposure of the hip joint J Bone Jt Surg 37-A, 798 (1955) McFarland, B , Osborne, G : Approach to the hip J Bone Jt. Surg 36-B, 364 (1954) Watson-Jones, R : Fractures of the neck of the femur Br J. Surg 23, 787 (1936)
Received February 23, 1979 / Accepted June 12, 1979
Arch Orthop Traumat Surg 95, 47-49 (1979)
© J F Bergmann Verlag 1979
The Transgluteal Approach to the Hip Joint R Bauer, F Kerschbaumer, S Poisel, and W Oberthaler Universitatsklinik fiir Orthopadie, Innsbruck (Vorstand: Univ -Prof Dr R Bauer), Anatomisches Institut der Universitat Innsbruck (Vorstand: Univ -Prof Dr W Platzer), Anichstr 35, A-6020 Innsbruck, Austria
Summary A modified lateral transgluteal approach to the hip joint without osteotomy of the trochanter is described The advantage of this approach is a better view of the acetabular rim, prevention of gluteal muscle damage and protection of the superior gluteal nerve. Zusammenfassung Ein modifizierter lateraler transglutealer Hiiftgelenkszugang ohne Trochanterosteotomie wird beschrieben Die Darstellung des Gelenkes erfolgt durch Spaltung des M gluteus medius und minimus sowie des M vastus lateralis in einer Schicht. Vorteil des Zuganges ist eine bessere Ubersicht fiber die Gelenkscircumferenz, eine Muskelschonung und Schutz vor Verletzung des N gluteus superior.
Of the lateral hip joint approaches, that specified by Watson-Jones finds frequent use in hip surgery. Demonstration of the joint is achieved by forcing apart the gluteus minimus and medius muscles on one side and the tensor fascia muscle on the other side. Thus the antero-lateral part of the capsule is brought into good view Should it, however, be necessary to have a view of the complete circumference of the socket, e g , for implantation of an endoprosthesis, it is necessary in addition to detach part of the gluteal muscles from the great trochanter This involves mainly the ventral fibres of the gluteus medius muscle and practically the complete tendon of the gluteus minimus muscle Should this detachment not be carried out, the muscles must be forcefully separated by the use of hooks, in which case tears are difficult to avoid. Both the extensive detachment of the gluteal muscles Offprint requests to: Prof Dr R Bauer (address see above)
from the trochanter and the muscle lesions caused by hook pressure may diminish the final result of replacement hip function expectation. For this reason a lateral approach, avoiding such damage, is advocated.
Description of Approach The skin incision begins approximately 3-4 cm proximal and dorsal to the anterior and superior iliac spine and runs in a smooth curve over the trochanter, approximately 7-8 cm distally The fascia is opened in the direction of the fibre (Fig 1) Then, with the use of the diathermy knife, an incision is made at the junction of the anterior and middle thirds of both the vastus lateralis muscle and the gluteal muscles, beginning proximally By this incision the periosteal and soft tissues which connect the fibers of the gluteal and vastus lateralis muscle and which cover the trochanter can be separated from it, so that the ventral part of the gluteal and vastus lateralis muscle can be retracted anteriorly in one coherent layer. It is important that the fibro-periostal tissue is separated close to the trochanteric bone, and this is most simply and quickly done with the diathermy knife The fibres of the gluteus medius and gluteus minimus muscles are separated by blunt dissection (Fig 2) This can lead to hemorrhage from small veins which have to be cauterised The demonstration of the complete hip joint is now possible as follows: Using a Cobb elevator and beginning distally, release of the intertrochanteric region is carried out and a Hohmann lever is inserted medially A second angled Hohmann lever is introduced between the
0344-8444/79/0095/0047/$ 1 00
48
R Bauer et al : The Transgluteal Approach to the Hip Joint
Fig 1 The incision of fascia lata Fig 3 Exposure of the hip joint
One hundred patients from 1974 and 1975, respectively, compared in half of whom the standard Watson-Jones approach had been used are in the others, the transgluteal approach.
Fig 2 Separation of gluteal and vastus muscle fibres
straight head of rectus and the anterior joint capsule. Now the layer between the lateral joint capsule and the remaining portion of the gluteus minimus muscle and piriformis tendon is carefully opened, with the Cobb, and a third Hohmann lever inserted Thus, the anterior half of the hip joint capsule and the femoral neck are completely demonstrated (Fig 3) In some cases, e.g , rheumatoid arthritis, the ilio-psoas muscle and its
tendons may be adherent to the capsule In these cases careful separation or the layers with scissors and Cobb elevator is recommended The opening of the capsule can now be carried out as planned In the case of total hip prosthesis implantation, the complete capsule near the acetabular marsin can be removed after the removal of the femoral head without a great deal of difficulty The closure of the incision is achieved distally in the aponeurotic region with 3/0 non-resorbable suture and proximally, in the gluteal muscles, with resorbable single knot sutures. This so-called transgluteal approach modification has been used almost routinely for all major hip operation, especially endoprosthetic replacement, since 1975.
The following were assessed: Subjective patient opinion, pain, limping, Trendelenburg, periarticular calcification. At follow-up examination (1978), 27 of 100 patients limped after transgluteal approach compared with 38 of 100 after the conventional approach This, however, was not statistically significant and there was no great difference in regard to pain, subjective patient opinion or periarticular calcification.
Discussion Using the lateral approach, the joint capsule can be ideally demonstrated by trochanteric osteotomy (Jergenson-Abbot, Harris) Should one wish to avoid osteotomy, then the capsule is exposed either anterolaterally (Watson-Jones) or postero-laterally (Gibson, McFarland-Osborne) in which case either the front or rear of the joint is seen. The postero-lateral approach requires section of the tendons of the piriformis and gemelli muscles, whereas the antero-lateral approach necessitates section of the gluteus minimus and anterior portions of the gluteus medius and vastus lateralis muscles transverse to direction of the fibres The antero-lateral approach is restricted proximally by the superior gluteal nerve which runs into the tensor fascia lata muscle and supplies it Stretching or section of this nerve can result in loss of function of this muscle.
49
R Bauer et al : The Transgluteal Approach to the Hip Joint
The approach which has been described by the
References
authors lies not antero-laterally but laterally and does
not require trochanter osteotomy. We believe the advantages to be: 1 A better view of the anterior, posterior, and lateral acetabular margin. 2 Prevention of muscle damage. 3 Protection of the superior gluteal nerve. 4 A better rehabilitation of the gluteal and vastus muscle fibres because they are cut in the direction of the fibres. 5 Complete demonstration of the calcar-femoris, advantage in total hip replacement.
Gibson, A : The posterolateral approach to the hip joint Instructional course lectures AAOS 10, 175 (1953) Harris, W : A new lateral approach to the hip joint J Bone Jt. Surg 49-A, 891 (1949) Jergensen, F , Abbott, L C : A comprehensive exposure of the hip joint J Bone Jt Surg 37-A, 798 (1955) McFarland, B , Osborne, G : Approach to the hip J Bone Jt. Surg 36-B, 364 (1954) Watson-Jones, R : Fractures of the neck of the femur Br J. Surg 23, 787 (1936)
Received February 23, 1979 / Accepted June 12, 1979
