PAEDIATRIC- ANTERIOR approach to hip

Question 1

What is this approach aka?

Answer 1

SMITH- PETERSEN

Question 2

What is it indications?

Answer 2

THA OPEN REDUCTION OF CONGENTIAL HIP DISLOCATIONS SYNOVIAL BIOPSIES PELVIC OSTEOTOMIES

Question 3

Can you describe the inter nervous planes?

Answer 3

Superifical= SARTORIUS- (FEMORAL N) TENSOR FASCIA LATAE (SUP GLUTEAL N) Deep=RECTUS FEMORIS (FEMORAL N) GLUTEUS MEDIUS (SUP GLUTEAL N)

Question 4

What position would the pt be in?

Answer 4

Supine

Question 5

Describe the initial incision ?

Answer 5

Make incision from ANTERIOR HALF OF ILIAC CREST to ASIS FROM ASIS CURVE INFERIORLY indirection of lateral PATELLA for 8-10cm

Question 6

Carry onto to describe the superficial dissection?

Answer 6

Identify GAP between SARTORIUS AND TFL Dissect THRU SUBCUTANOUS FAT - avoid LAT FEMORAL CUTANEOUS N -retract Incise FASCIA on MEDIAL side of TFL DETACH ORIGIN OF TFL OF ILIAC LIGATE ASCENDING BRANCH LAT FEMORAL CIRCUMFLEX ARTERY (crosses gap between sartorial and tfl)

Question 7

Carry onto to describe the deep dissection?

Answer 7

Identify plane between RECTUS FEMORIS and GLUTEUS MEDIUS Detach RECTUS FEMORIS from BOTH its origins Retract Rectus femoris and ILIOPOAS MEDIALLY and GLUTEUS MEDIUS LATERALLY to expose the hip capsule ADDUCT AND EXT ROTATE hip ->put CAPSULE ON STRETCH INCISE CAPSULE- longitudinal/t shaped incision DISLOCATE HIP with ext rotation

Question 8

Can this approach be extended proximally? How?

Answer 8

Yes - for bone harvest graft. extend proximal incision posteriorly along the ILIAC CREST

Question 9

Can this approach be extended Distally? How?

Answer 9

Yes of intraop fracture of distal femur. lengthen skin incision down along anterolat aspect of thigh. incise fascia lata in line with ski incision Stay within the interval between vastus lateralis and rectus femoris

Question 10

Describe the dangers of this approach?

Answer 10

1) LATERAL FEMORAL CUTANEOUS N- reached thigh by passing under the INGUINAL LIGAMENT- course can be variable- medial or lateral to ASIS. NORMALLY seen when incising fascia between SARTORIUS AND TENSOR FASCIA LATAE INJURY -> NEUROMA 2) FEMORAL NERVE- remain protected as long as you stay LATERAL OF SARTORUS 3) ASCENDING BRANCH OF LAT FEMORAL CIRCUMFLEX ATERY- found proximally in inter nervous plane between sartorial and tensor fascia late- be sure to ligate to prevent xs bleeding