8/7/2019 chirurgie sold

1/4

PO STER IOR EXPO SURE O F THE H IP JO IN T

VOL . 32 B , xo . 2, M AY 1950 18 3

ALEXAND ER G IBSON , \V INN IPEG , CANADA

I)ir ec tor, D ep a;tnoen t o f O rth opa ed ic Surge ry , D eer Lo dg e H osp ita l, II i n ;z ipeg

So m uch a tten tion has been focused in recen t years upo n tile an te rio r approach to th eh ip jo in t th at the ad van tages o f th e pos te rio r app roach h av e b een ignored a lm ost en tire lyan d m any su rgeons h av e no experience of it. T he desc rip tio ns g iv en in som e s tan dardtex t-boo ks are incom ple te o r ev en inaccu ra te . M oreover, th e im pression is p reva len t tha th aem o rrhage d uring the op eration m ay be trou b lesom e. T h is v iew canno t possib ly been te rta ined by anyone w ho is fam ilia r w ith the p rocedure . A few sm all vessels m ay have tob e c lam ped , bu t it is se ldom necessa ry to app ly a liga tu re .

T o anyone w ho is no t w ell acqua in ted w ith theana tom y o f the bu ttock th e desc rip tion of th e opera tionm ay so und com plica ted ; bu t in reality the ana tom ica ls im plicit\ is m o st strik ing . T he earlie s t accoun t o f apos te rio r expo sure is tha t o f vo n L angenb eck (1874 ).T he pa tien t w as la id u pon th e sound side w ith th eaffec ted h ip flex ed 45 degrees, a po sition in w h ich th eax is o f the th igh correspo nds approx im ate ly w ith alin e jo in ing the grea te r troch an te r w ith the pos te rio rsu perio r iliac sp ine . T he in c is ion began in th is lin e,th ree fin ger-b read ths p rox im al to th e tip o f the grea te rtrochan te r, and ex ten ded abou t th ree fin ger-b read thsdow n the line o f the th igh (F ig . 1 ). \V h ile the w ound w as FIGretrac ted the low er lim b w as ro ta ted ou tw ard s and L ang enb eck in cis ion .inw ards to fac ilita te d etachm ent o f th e m u sc les andcapsu le from the trochan te r and n eck o f the fem ur. T he lig am en tum teres w as cu t o r to rnacro ss , and the head of the fem ur w as d isloca ted from the ace tabu lum .

T he L angenbeck app roach w as m odified by K ocher (1 907). T he firs t ed ition of K o ch ersO p erative S urgery w as pub lish ed in 1 892 , bu t the earlies t desc rip tion of h is app roach tothe h ip jo in t tha t I h av e been ab le to find is in an article by h is pu p il D um ont, pub lish edw ith K ochers p erm ission in 1 887 . A ll K ochers in c is ions served the fundam enta l p rinc ip le -pr im urn non no cere ; th ey w ere des igned to p ass be tw een ad jacen t nerv e te rrito ries. In theh ip jo in t the tissues w ere sep ara ted be tw een th e te rrito ries o f the superio r an d in fer io r g lu tea lne rves-be tw een the g lu teus m ed ius, g lu teus m in im us and tensor fasc iae la tae on the onehand and g lu teus m ax im us on th e o ther. T he sk in in cis ion w as ang led . B eg inn ing a t theupper an te rio r b order o f the g reate r trochan te r, its low er or vertica l lim b ex ten ded d ista llya long tile line of the shaft o f the fem ur; the upp er lim b passed ob lique ly b ackw ards tow ardsthe pos terio r superio r sp ine a long or near the upper bord er o f the g lu teus m ax im u s.

K ochers w ork sas tran sla ted in to E ng lish by S tile s (1 911); du ring the life -tim e ofthe trans la to r, K och ers app roach to the h ip jo in t w as w ide ly em ployed in G rea t B rita inb u t w as never w ell know n in the U nited S ta tes o f Am erica or in C anada . O n theco n tinen t o f E urope it is still first in fav our (K lapp 1923). D uring the last th irty -five yearsa m odifica tion of K ochers po ste rio r approach has been used by the presen t w rite r as arou tine procedure; in th e be lief tha t the exp osure has ou ts tan d ing adv an tag es , he hasthe re fo re u ndertaken the fo llow in g de ta iled d esc rip tio n .

8/7/2019 chirurgie sold

2/4

18 4 A . G IB SO N

THE JOUR NAL O F BON E A ND JO IN T SURGERY

TECHN IQUE OF OPER A TIONlilt I)a tie flt is 1 ) lac l 111)1)1) the sO ufl(I S i(le ill th e la te ra l 1)Osi t iOI l ; k id ney Supports

ensure th at tue 1)O sitio l l is llla in tain e(l secure ly th rou ghou t tile opera tion . T he sk ill incis ionis sh oW Il ill Figure . O n ly tw o landm arks a re necessary -the pos te rio r SU J)e rio r sp i l le of theiIiUlll a ild the llI)I)e an te rio r ang le o f the grea te r trochan te r (F ig . 3 ) . T u e g lu teus n lax iillu sis attac iled to the crest o f the ilium fo r abou t tw o inches ill front of t ile pos ter io r s tipe rio r51 ) 1 1W . T iit- u pe r p ar t o f th e sk in in cis ion ou tlines th e ipper border o f the m usc le an d sh ou ldb e arch e(l s ligh tl\ fo rw ards from a po in t tw o an(l a ha lf inches in fron t o f the I )O s te rio r su l)e rio rSJ)ill( to the tpe r an ter io r b order o f the g reate r troch an ter ; tile low er I) 1 rt ex ten tls d ista llya long the line of the th igh fo r six o r sev en inches. file first inc is ion (liv ides sk ill andSul) cUta f leo lI s fa t ; snlall vessels m ay req u ire c lan ip ing . lhe f laps are ref lec ted backw ardsalld fo rw ards fr a short d is ta llce to (lisp lay clea rly the g lu teo -fen lo ra i fiscia.

J _ _ . .-- -FIG. 2 FIG. 3\lO (Iitfl(l l .ocher in cis io ll. Th e tip e r half of tile sk ill illc is iO n is arched s l igh t lyfo rwa rds ( FIg . 2) . It co rre spo nds ap pro x im ate ly to th e an ter io r I )O r(le r of t lwg lu te tis IllaX iIiII IS . F ig u re 3 5IlI ) \Vs tue re la tion of th e sk in iflcls iO ll to th e u nd erly in g

hone s .

Ihe nex t ste l) (F ig . 4) is to inc ise th e deep fasc ia vertica lly in the low er ha lf o f th e iflcisioll.The pos te rio r f lap is ra ised , de fin ing the upper border o f the g lu teus m ax im us . T he g lu tea lfasc ia is (Iiv ide (l alon g th is bord er. T he w hole m ass fo rm ed by g lu teu s maximus and itsapo neuro tic p ro long a tion in to the fasc ia la ta is retrac ted backw ard s. S epara tion of its (lee !)aspec t is m ade easy by th e la rge bursa w hich lies be tw een th e tendon o f g lu teus I l lax imusand the up per pos te rio r p art o f the fem ur. It is no t a lw ay s necessa ry to re flec t th e m u sc leas h igh as the cres t o f the ilium . \V e now have a d issec tin g room view of tile g lu tea l reg ion :the m usc les a ttached to th e g reate r trochan te r-g lu teus m ed ius , g lu teu s m in im us , p irifo rm is ,ob tu ra to r in te rn us and g em elli, ob tu ra to r ex ternus an ti q uadra tus fem o ris-a re a ll c lea rlydef ined .

f iie n ex t s tep is to de tach these muscles f rom the g rea te r trochan te r. T hose su pp liedby tile superio r g lu tea l n erve (g lu teu s flled ius and g lu teus m in im u s) a re re trac ted fo rw ards,and the o thers b ackw ards . T he pos te rio r border o f g lu teus m ed ius is eas ily dem arca ted fromthe J)irifo rm is b y b lun t (lis sec tion (F ig . 5 ) . T he g lu teus m ed ius is fo llow ed dow n to itsa ttachm en t to th e ou te r s ide of the grea ter trochan te r an ti is ( le tache(1 th e inse rtion is

8/7/2019 chirurgie sold

3/4

FIG. 4 FIG. 5

FIG. 6 F I G . 7Th e sllort m uscles Ila ve b een d eta ched from th e g rea t tro chan te r an d retracted to exp ose the capsu leo f th e h ip jo in t w hich is incised and refle cte d an te rio rly by de tach in g it from the m arg in of theace tab ulum and base of the neck o f th e fem ur (F ig . 6 ). Th e head of th e fem ur is d isloca ted b y fle x io n ,

ad du ctio n and exte rna l ro ta tion o f the lim b (F ig . 7 ).

18 5

VOL. 32B , NO . 2, MA Y 1950

Th e glu te al fascia is d iv id ed in the sam e line a s tile sk in in c is io n (F ig . 4 ). The w ho le m ass ofthe glu teus m axim u s w ith its ap oneuro tic pro lo nga tio n is then eas ily retracted ba ckw ard s,

expo sin g the short transv erse m uscle s a ttac lled to the g reater tro chante r (F ig . 5).

8/7/2019 chirurgie sold

4/4

18 6 A . G IB SO N

tend ino us and there is little b leed ing . B y ro tating the th igh ou tw ard s it is easy to de tachthe inser tion of g lu teus m .in im u s from the an te rio r su r face of the grea te r trochan te r in ashee t con tinuo us w ith the a ttachm ent o f g lu teu s m ed ius . S im ila rly , the in se rtion of p irifo rm isto the tip o f th e grea te r trochan te r is d iv id ed ; i f necessary the inse rtio n o f the ex te rna l ro ta to rsis a lso severed . D etachm ent o f the quadra tus fem oris is seldom necessa ry . W hen the m u sc leinse rtio ns h ave been d etached and retrac ted a ll asp ec ts o f the cap su le o f th e jo in t a re expo sedin the bo ttom of the w ound .

T he jo in t capsu le is in c ised superio rly in the line of the neck of the fem ur f rom its u ppera ttachm ent at th e rim of th e ace tabu lum to its d is ta l a ttachm en t a t the base of the n eck(F ig . 6 ). B y ro ta ting the lim b it is a s im p le m atter to d e tach th e w hole cap su le from thean ter io r rim o f the ace tab u lum and from the an te rio r in te r-trochan te ric lin e . Th e pos te rio rpart o f the capsu le m ay a lso be inc ised , b u t th is is n o t essen tia l.

T he fina l s tep in the exposure is to d isloca te the head of the fem ur from the ace tabu lumby flex ing th e th igh an d ro ta ting it la te ra lly (F ig . 7 ). O ccasiona lly it m ay be necessa ry toch ise l o steoph y tes from the ace tabu la r r im in order to perm it d isengagem ent o f the head ofthe bo ne . T he ligam en tum teres is usua lly rup tu red . T h e m anoeuv re of d is loca tion isperfo rm ed by an assistan t w ho se du ty it is to co n tro l the pos ition of th e lim b so tha t the headof th e fem u r and cav ity o f th e ace tab u lum are eas ily access ib le .

COMMEN TThe advantag es o f th e poster ior approach are tha t it is rap id , alm o st b lood less anda tten ded by little shock . T he pow er of th e m usc les is u n im paired , fo r they are n o t de tachedfrom an ex tens iv e iliac o r ig in as in th e Sp renge l Beckenrand ap proach (1897 ). T he g lu teusm ax im us an d tensor fasc iae latae , w h ich are so im portan t fo r stab ility o f the h ip , a re n o tw eakened and the opera tion causes no instab ility .

T he or ig in al p urpose o f th is exposure , as used by L angenbeck , w as to secure dra inagein suppu ra tive a rth ritis. In K ochers h ands it w as em ployed to g ive fu ll and free access tothe ace tab u lum in the su rg ica l trea tm en t o f tubercu los is o f the h ip jo in t. In m odern surgeryit has a s till w ider f ie ld o f use fu ln ess. In p oste rio r frac tu re -d islo ca tions of the h ip jo in t,d irec t ex posure o f the site o f th e in ju ry is ga in ed . W hen opera tion is requ ired to securerep lacem ent o f a slipped upper fem ora l ep iphys is the po ste rio r part o f the jo in t w ith th ed isp laced ep iphy sis is exposed read ily . T he app roach is idea l fo r expo sure o f th e scia tic nervein the b u tto ck , and fo r d ealing w ith in ju ries o f the g lu tea l a rter ies . In ar th rodes is o f theh ip jo in t the an te rio r flap m ay be re trac ted to a llow access to the ilium w hich m ay be requ iredfo r u se as a gra ft, and the field of im plan ta tio n o f the gra ft is d isp layed w ith the least po ss ib letraum a. In cu p-a rth rop las ty of the h ip jo in t the s im p lic ity and efficacy of the m ethod g iv ethe m ost u se fu l app lica tion of a ll.

It is n o t too m uch to say tha t as a rou tine proced ure fo r exposure of the h ip jo in t thep oste rio r ap proach is fac ile prin ceps .

REFERENCESD UMON T , F . (1 88 7): D ie Re sek tio n des H u ftg ele nke s nach K och er. C orresp ond en z-B latt f#{ 252} r Schwe ize rAe rz te , 17 , 225 .KLAPP , R . (19 23 ): in B ie r, A ., Braun, H ., and Kummell, H ., C hirurg ische O pe ra tions lehre. L eipz ig : J. A .B arth . F if th ed ition , Vol. 5 , 37 8 .KOcHER , T . (19 07 ): C h iru rg isch e O p era tio nsle hre . F if th ed it ion . Jena: Gus tav F ischer , 7 ,447 . (T rans late dS tiles, H . J. E din burgh : A . and C . B lack , 1 911 ).LANGENBECK , B. vo x (18 74): U eb er d ie Sch ussve rle tzu ng en d es H #{252 }ftgelenk s. Archiv f#{ 252} rK lin is che C li iru rg ie .16 , 26 3 .SPRENGEL, 0 . (189 7): B e itra ge zur w issenscha ftlichen M edicin . Fe sts chr ift erSam m lung deutsche rNatur for sche r un d Aerz te . . . Braunschwe ig , 51 . -

THE JOUR NAL O F BONE A ND JO INT SURGERY