Minimally Invasive Medial Hip Approach

Orthopaedics & Traumatology: Surgery & Research 100 (2014) 687–689

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Technical note

Minimally invasive medial hip approach

∗

P. Chiron , J. Murgier , E. Cavaignac , R. Pailhé , N. Reina

Service d’orthopédie-traumatologie, institut de l’appareil locomoteur, cinquième étage, hôpital Pierre-Paul-Riquet, 308, avenue de Grande-Bretagne,

31059 Toulouse, France

r t

i c l e i n f o

a b s t r a c t

Article history: The medial approach to the hip via the adductors, as described by Ludloff or Ferguson, provides restricted

Accepted 12 June 2014

visualization and incurs a risk of neurovascular lesion. We describe a minimally invasive medial hip

approach providing broader exposure of extra- and intra-articular elements in a space free of neurovas-

Keywords: cular structures. With the lower limb in a “frog-leg” position, the skin incision follows the adductor longus

Minimally invasive surgery

for 6 cm and then the aponeurosis is incised. A slide plane between all the adductors and the aponeurosis

Hip approach

is easily released by blunt dissection, with no interposed neurovascular elements. This gives access to

Adductors

the lesser trochanter, psoas tendon and inferior sides of the femoral neck and head, anterior wall of the

Iliopsoas

acetabulum and labrum. We report a series of 56 cases, with no major complications: this approach allows

Fracture

treatment of iliopsoas muscle lesions and resection or ﬁlling of benign tumors of the cervical region and

Foreign body

Tumor enables intra-articular surgery (arthrolysis, resection of osteophytes or foreign bodies, labral suture).

1. Introduction adductor longus muscle, the relief of which is easily seen in this

position, for about 6 cm. The medial accessory saphenous vein may

Ludloff [1,2] ﬁrst described a trans-adductor approach to the hip, cross the incision superﬁcially and should be released and inclined

passing forward of the adductor longus and brevis and behind the outward. Lymph vessels are not encountered in this space. The

pectinate muscle [3]. Ferguson and Kiely et al. [4,5] described an aponeurosis of the adductor longus is then incised, taking care not

approach between the adductor longus and brevis and the adduc- to dissect further forward or beyond the aponeurosis, so as to con-

tor magnus (Fig. 1). Both provide a narrow view of the inferior serve the femoral vascular pedicle. A slide plane between all of the

joint region and involve risk to both the anterior and posterior adductors and the aponeurosis is easily released by blunt dissec-

branches of the obturator nerve [6]. Given the technical difﬁculties, tion, with no interposed neurovascular elements. This gives the tip

despite subsequent modiﬁcations [7], these approaches are little of the foreﬁnger access to the lesser trochanter, which can be fully

used. We here describe an original minimally invasive approach palpated in this position; Hohmann retractors can then be ﬁtted

anterior to all of the adductor muscles (adductor longus, adductor on either side, while keeping bone contact. At this point, the lesser

brevis, pectinate and adductor magnus), which we call the “medial trochanter is perfectly visualizable, with the iliopsoas conjoint ten-

hip approach”, giving access to the iliopsoas tendon and the infe- don insertion downwards and inwards. Isolated iliopsoas conjoint

rior intra-articular region, without risk of neurovascular lesion and tendon surgery is now feasible. To approach the capsule, the ten-

with enlarged exposure facilitating the numerous procedures that don is identiﬁed and the lateral retractor is repositioned inwards

will be detailed below. of the psoas tendon, between tendon and capsule, to displace the

tendon laterally and expose the capsule. Above, the medial cir-

cumﬂex arteriovenous pedicle of the hip crosses the capsule and

2. Technique

can be released from the posterior capsular plane by raspatory and

inclined upward. The Hohmann retractor under the medial circum-

The patient is positioned in dorsal decubitus, with the hip

ﬂex arteriovenous pedicle and resting on the anterosuperior wall

in ﬂexion-abduction-external rotation, in the so-called “frog-leg”

of the acetabulum allows all the superior part of the capsule to

position. The skin incision begins at the groin fold and follows the

be exposed. Capsule dissection can be extended beyond the cap-

sule, depending on the joint regions to be exposed. Arthrotomy is

∗ then performed, with an incision along the axis of the femoral neck

Corresponding author. Service d’orthopédie-traumatologie, institut de l’appareil

and two other incisions, one at the base of the neck and the other

locomoteur, cinquième étage, hôpital Pierre-Paul-Riquet, 308, avenue de Grande-

peripheral to the anterior-superior acetabular wall, conserving the

Bretagne, 31059 Toulouse, France. Tel.: +33 5 61 32 22 32.

E-mail address: [email protected] (J. Murgier). labrum and creating a book-form opening. The retractors are then

http://dx.doi.org/10.1016/j.otsr.2014.06.009

688 P. Chiron et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) 687–689

Fig. 2. Anatomic region accessible on the medial hip approach. Right hip joint in

frog’s-leg position.

positioned intra-articularly on either side of the neck; the medial

retractor can thus rest against the anterior acetabular wall; a third

retractor can be positioned on the superior wall and push back the

circumﬂex pedicle. The whole anterior half of the head, the base of

the neck to the lesser trochanter and the anterosuperior, anterior

and antero-inferior acetabular walls and labrum are thus exposed

(Fig. 2).

At end of surgery, the capsule can be sutured tight. If necessary,

the adductor longus can be lengthened by tenotomy of the white

ﬁbers. Hemostasis is checked; a drain is ﬁtted; and the adductor

longus aponeurosis is sutured before skin closure (ﬁlm). Brieﬂy, the

key-points are: to follow the space between the adductor muscles

and their aponeurosis, to incline the iliopsoas conjoint tendon out-

ward and the circumﬂex pedicle upward, and to dissect the capsule

before opening it.

3. Present series

Fifty-six patients were operated on between August 2007 and

January 2014. Mean age was 47.3 years (range, 18–76 years) and

the F/M sex ratio 1.07. The following procedures (sometimes asso-

ciated) were performed using the “medial hip approach”:

•

Extra-articular: lengthening, longitudinal incision or tenotomy of

the iliopsoas or adductor longus muscle (44 cases);

•

intra-articular: osteoid osteoma (two cases), capsule arthrolysis

(36 cases), antero-inferior cervical osteoplasty/osteophytectomy

(three cases), intra-articular foreign-body ablation (post-

traumatic, osteochondromatosis) (two cases), ablation of

malunion following fracture-dislocation of the femoral head

(three cases), 5-o’clock labral lesion suture (one case), bone

Fig. 1. Cross-sectional views of various approaches. A. Ludloff’s approach: between

biopsy (one case), and curettage and ﬁlling of chondroma (two

the adductor longus and pectinate muscles (crossing the anterior branch of the

obturator nerve). B. Ferguson’s approach: between the adductor brevis and mag- cases).

nus muscles (crossing the posterior branch of the obturator nerve). C. Medial hip

approach: between the adductor and pectinate muscles anteriorly and their aponeu-

rosis posteriorly. Q: Quadriceps; IP: iliopsoas muscle; P: pectinate muscle; AL:

There was one early surgical revision for postoperative

adductor longus muscle; G: gracilis muscle; AB: adductor brevis muscle; AM: adduc-

hematoma requiring evacuation, without sequelae. There were no

tor magnus muscle; FV: femoral vessels; Nerves: anterior and posterior obturator

nerves. cases of lymphedema or other surgery-related complications. Heal-

ing was systematically achieved within 21 days.

P. Chiron et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) 687–689 689

4. Discussion Appendix A. Supplementary data

The medial hip approach can be very useful in recent fracture- Supplementary data associated with this article can be found, in

dislocation of the hip, enabling ﬁxation of inferior head fragments the online version, at doi:10.1016/j.otsr.2014.06.009.

or extraction [8]. Other medial approaches to the hip require

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have no conﬂicts of interest to declare.