Article

With respect to soft tissue preservation during lateral and posterolateral approaches, the following may be advisable based on the anatomic observations of this study. 1. To maximize the surgical exposure while minimizing damage to the associated neurovascular structures, the gluteus maximus should be released from its anterior insertion at the iliotibial band (as in the Gibson approach) rather than split (as in the Kocher-Langenbeck approach). This method is recommended because of the high variability in the course of the IGN/IGA structures that may be located as close as 7 cm to the greater trochanter. The shared fascial layer between the gluteus maximus and medius should be maintained with the maximus during the Gibson approach, ensuring the integrity of the neurovascular branches that supply the maximus muscle. 2. For the transgluteal (Hardinge) approach, the proximal extension of the gluteus medius muscle split should be limited to 4 to 5 cm from the tip of the greater trochanter. This muscle split should be even shorter at the anterior trochanter. This anatomic limitation suggests that a surgical dislocation (for intracapsular procedures, HRA, femoral neck osteotomy, or other procedures) performed through a gluteus medius splitting approach is limited by the size of the femoral head and neck. Given the relative anatomic size of these structures, neurovascular damage to the SGA is likely. 3. The piriformis muscle is a posterior hip stabilizer and its tendon inserts at the tip of the greater trochanter. It is a landmark for the identification of the anastomosis with the MFCA. The deep branch of the MFCA is located distal to the piriformis and it perforates the hip capsule in this location. Therefore, approaching the hip from posterior endangers this vessel, in particular, if the posterior approach extends distally to the piriformis tendon. The dislocation of the hip anterior or posterior is not critical so long as the obturator externus tendon is intact (protector of MCFA); however, the execution of a posterior approach to allow sufficient mobilization of the proximal femur includes the release of the short external rotators, including the obturator externus. 4. Finally, based on the authors' anatomic dissections and the capacity of preserving femoral head vascularity during intracapsular procedures of the hip such as HRA, the digastric trochanteric osteotomy (also known as the trochanteric slide osteotomy) is ideally suited to providing optimal exposure of the acetabulum and the proximal femur and maintaining the soft tissue integrity of the hip joint. As such, it facilitates the correction of proximal femoral abnormalities of the head ("pistol grip") or neck (short, varus) that need to be addressed to obtain a sufficient intra- and extra-articular hip clearance. © 2005 Elsevier Inc. All rights reserved.
With respect to soft tissue preservation during lateral and posterolateral approaches, the following may be advisable based on the anatomic observations of this study. 1. To maximize the surgical exposure while minimizing damage to the associated neurovascular structures, the gluteus maximus should be released from its anterior insertion at the iliotibial band (as in the Gibson approach) rather than split (as in the Kocher-Langenbeck approach). This method is recommended because of the high variability in the course of the IGN/IGA structures that may be located as close as 7 cm to the greater trochanter. The shared fascial layer between the gluteus maximus and medius should be maintained with the maximus during the Gibson approach, ensuring the integrity of the neurovascular branches that supply the maximus muscle. 2. For the transgluteal (Hardinge) approach, the proximal extension of the gluteus medius muscle split should be limited to 4 to 5 cm from the tip of the greater trochanter. This muscle split should be even shorter at the anterior trochanter. This anatomic limitation suggests that a surgical dislocation (for intracapsular procedures, HRA, femoral neck osteotomy, or other procedures) performed through a gluteus medius splitting approach is limited by the size of the femoral head and neck. Given the relative anatomic size of these structures, neurovascular damage to the SGA is likely. 3. The piriformis muscle is a posterior hip stabilizer and its tendon inserts at the tip of the greater trochanter. It is a landmark for the identification of the anastomosis with the MFCA. The deep branch of the MFCA is located distal to the piriformis and it perforates the hip capsule in this location. Therefore, approaching the hip from posterior endangers this vessel, in particular, if the posterior approach extends distally to the piriformis tendon. The dislocation of the hip anterior or posterior is not critical so long as the obturator externus tendon is intact (protector of MCFA); however, the execution of a posterior approach to allow sufficient mobilization of the proximal femur includes the release of the short external rotators, including the obturator externus. 4. Finally, based on the authors' anatomic dissections and the capacity of preserving femoral head vascularity during intracapsular procedures of the hip such as HRA, the digastric trochanteric osteotomy (also known as the trochanteric slide osteotomy) is ideally suited to providing optimal exposure of the acetabulum and the proximal femur and maintaining the soft tissue integrity of the hip joint. As such, it facilitates the correction of proximal femoral abnormalities of the head ("pistol grip") or neck (short, varus) that need to be addressed to obtain a sufficient intra- and extra-articular hip clearance. © 2005 Elsevier Inc. All rights reserved.

Langue : ANGLAIS