PAEDIATRIC- Medial approach to the hip

Question 1

What are the indications for this approach?

Answer 1

OPEN REDUCTION OF DDH <15MO
OPEN INCISION FOR SEPTIC ARTHRITIS OF HIP
RELEASE OF PSOAS

Question 2

What are the internervous planes?

Answer 2

Superificial - none both adductor longus and gracilis are supplied by the ANTERIOR DIVISION OF OBTURATOR NERVE
Deep- between ADDUCTOR BREVIS ( ANT DIV OF OBTURATOR N) and ADDUCT MAGNUS ( DUAL Iinnervation- POST DIV OF OBTURATOR N and ISCHIAL portion by tibial portion of SCIATIC N)

Question 3

What position is the child in?

Answer 3

Supine

hip abducted, flexed and externally rotated

Question 4

Now describe how you preform this approach?

Answer 4

incision - 3cm inferior from pubic tubercle
incise along adductor longus tendon

superificial - develop plane between
ADDUCTOR LONGUS
GRACIILIS
both ANT DIV OF OBTRUATOR N

Deep- develop plane between
ADDUCTOR BREVIS (ant div obturator)
ADDUCTOR MAGNUS ( post div obturator and tibial portion of sciatic n)
UNTIL YOU FEEL LESSER TROCHANTER IN FLOOR OF WOUND
ISOLATE PSOAS TENDON- narrow retractors above and below lesser trochanter and divide psoas
Capsulotomy- ant and medial portions

Question 5

Describe the dangers with this approach?

Answer 5

1) MEDIAL FEMORAL CIRCUMFLEX ARTERY- passes around medial distal portion of psoas so must cut psoas under direct vision
2) ANT DIVISION of OBTURATOR N- supplied add longus, add brevis and gracilis
3) POST DIVISION of OBTURATOR N- supplies add magnus- within substance of obturator externs

4) DEEP EXTERNAL PUDENDAL ARTERY
at risk proximally, lies ANT to PECTINEUS nr the origin of the ADDUCTOR LONGUS