Combined Anterior and Posterior Approach to the Hip Joint in

Reconstructive and Complex Arthroplasty

R a l p h Lus sk in , M D , A r n o l d G o l d m a n , M D , a n d M i c h a e l A b sa t z , M D

Abstract: The combined anterior and posterior approach permits access to the front and back of the hip joint for reconstruction and complex arthroplasty, usually without osteotomy of the greater trochanter, with minimal muscle re- lease. There is ease of access to the anterior and posterior capsule, which can be resected under direct vision, thus permitting accurate hemostasis. The entire acetabular rim is exposed for bone grafting as required. The authors review the useful standard approaches and illustrate the combination of the anterior and posterior approaches through a straight lateral incision. Concomitant explora- tion of the sciatic nerve is demonstrated, as is the osteotomy of the trochanter performed when the ilium superior to the acetabulum must be reconstructed. The utility and limitations of the operation is illustrated by representative cases. This extensile procedure usually can prevent neurologic and vascular compro- mise and allows excellent observation of the skeletal structures for accurate component alignment. Key words: hip arthroplasty, anterior/posterior ap- proach.

While standard approaches to the hip are often satisfactory, certain circumstances require a more ex- tensive and extensile approach. We describe a com- bined anterior and posterior approach that has proven to be simple and rapid and which permits extensive reconstruction. There is minimal bleeding and ma x im um exposure. In addition, it is easily mas- tered, as it combines two standard routes of access to the hip via a single lateral incision: the postero- lateral (Gibson) and the anterolateral (Watson- Jones). Either can be quickly convened to the com- bined approach if preoperative planning has in- cluded the requirement for a more extensive pro- cedure and if a utilitarian and nontraumafic lateral incision has been used.

From the Department of Orthopedic Surgery, New York University Medical Center, New York, New York.

Reprint requests: Ralph Lusskin, MD, Department of Ortho- paedic Surgery, New York University Medical Center, 530 First Avenue, New York, NY 10016.

The combined approach has been described by Tronzo (32), w h o uses it for arthroplasty; fusion, and bone grafting in femoral neck fractures. Additional circumstances that have dictated this combined op- eration include prior arthrodesis of the hip, partial ankylosis produced by incarceration of the femoral head by osteophytes, severe bilateral deformities, and revision arthroplasty with the need for recon- struction of the acetabulum by bone grafting. In ad- dition, the procedure has proved excellent where he- mostasis was a priority, as in the presence of aortic stenosis and coronary artery disease, where hypo- tensive episodes would not be tolerated.

Standard Exposures

Many approaches to the hip joint have been de- veloped for anhrodesis, arthroplasty, or intemal fix-

314 The Journal of Arthroplasty Vol. 3 No. 4 December 1988

ation of fractures of the femoral neck (7, 18). Each has its advantages and disadvantages as to the area and quality of exposure and the ease of protection of associated neurovascular structures. Harry (15- 17, 19) has provided several excel]ent reviews of hip joint anatomy and surgical exposures.

The anterior Smith-Petersen (31) approach takes advantage of the interval between the sartorius and the tensor fascia lata. One must protect the lateral femoral cutaneous nerve and ligate the branches of the lateral femoral circumflex artery and veins. One disadvantage of the approach is poor access to the acetabulum without extensive elevation of the glu- teus medius and minimus from the ilium. Periosteal stripping of these muscles produces considerable bleeding. The posterior aspect of the hip cannot be exposed properiy through this incision.

The anterolateral or Watson-Jones approach uses the interval between the gluteus medius and tensor fascia lata (33). Several modifications have been de- scribed. Harris (13) described the lateral incision with osteotomy of the greater trochanter to gain ac- cess to the hip. This also permits distal transposition of the greater trochanter. After osteotomy of the greater trochanter, the hip can be dislocated both anteriorly, by externally rotating the hip, or poste- riorly, by intemal rotation, after division of the ex- ternal rotators. Osteotomy of the trochanter, how- ever, is followed by a significant incidence of nonunion, limp, and pain (2, 3-4 , 6, 12, 14, 22, 26, 28-30) .

The direct lateral approach as described by Har- dinge (11) splits the tendinous attachment of gluteus medius longitudinally. The anterior gluteus medius and its tendon with a periosteal sleeve are raised to- gether. Leaving a cuff of tissue facilitates closure of the approach. This approach can be extended distally down the femur (1, 5, 10). Foster and Hunter (8) modify the Hardinge approach by using the anterior exposure and displacing the anterior two-thirds of the gluteus medius tendon. These direct lateral ap- proaches increase anterior and superior acetabular exposure but do not allow for reconstruction of the posterior acetabulum in revision surgery without a posterior exposure of the hip. This can be performed through the wide exposure by division of the pos- terior capsule from in front.

Posterior approaches have been described by Moore (25), Kocher (20), Langenbeck (21), Gibson (9), Marcy and Fletcher (24), and Osbourne (27). The exposure is dependent on a blunt dissection of the gluteus maximus. Observation of the sciatic nerve is facilitated and protection of the nerve can be provided by the pirifolmis and obturator externus and intemus tendons when they are retracted by re-

tention sutures. Retraction of the external rotators and dissection of the posterior capsule allows dis- location of the hip by internal rotation. The greater trochanter can be divided for better exposure of the hip joint, should that be necessary.

The "southern" approach, a posterior approach described by Moore, allows complete access to the hip joint posteriorly. The skin incision begins just lateral to the sacral prominence in the midportion of the gluteus maximus and runs in line with the un- derlying fibers of the gluteus maximus. That muscle is split bluntly in line with its fibers. Minimal bleed- ing is encountered unless the inferior gluteal vessels are opened. The incisions for all of these posterior approaches are similar, differing in their position on the gluteal prominence. They are dictated by the deep approach through the gluteus maximus.

The medial approach, as originally described by Ludloff (23) utilizes the interval between the ad- ductor longus and brevis anteriorly and the gracilis and adductor magnus posteriorly. Due to the fact that the exposure affords an excellent view of the psoas tendon, which can prevent relocation, this ap- proach can be used in open reduction of congenital dislocation of the hip.

All of the above exposures are used for total hip arthroplasty, but all have limitations in some cir- cumstances. There remains a need for complete ex- posure allowing careful reconstructions of the joint from front and back with minimal trauma. Some patients with degenerative joint disease will develop joint contractures that will make capsulotomy and subsequent dislocation from one approach difficult and hazardous. The completely ankylosed hip poses a special challenge. The combined anterior and pos- terior approach to the hip, which does allow division and subsequent repair of the gluteus medius and minimus muscles or their tendons, eliminates the need for osteotomy of the greater trochanter.

Combined Anterior and Posterior Approach

The patient is placed on the contralateral side, sup- ported by positioning bags, kidney rests, and chest braces. A chest pad is placed under the thorax to protect the axillary nerve by eliminating pressure on the lateral aspect of the shoulder. The entire leg, hip, and lilac region is prepared and draped with appro- priate sealing of the perineum and rectum. The skin incision is a straight lateral incision with the middle of the greater trochanter at its midpoint (Fig. 1). The

Combined AP Approach to the Hip • Lusskin et al. 315

• " - . . oo . A :: -

Fig. 1. Incision. The patient is in the lateral recumbent " ' " position.

skin incision should stop short of the iliac crest by at least 4 cm to protect the superior gluteal nerve to the tensor fascia lata and gluteus medius. The prox- imal extent of the incision is approximately to the level of the anterior superior iliac spine (ASIS). This permits easy access without forceful and traumatic retraction.

This approach to the hip can also be performed through a somewhat elongated Gibson posterola- teral incision. The skin incision should be lengthened superiorly and inferiorly to ease anterior retraction. Thus if a posterolateral incision has been used the more extensive combined approach can be devel- oped should it prove necessary to get to the front of the hip.

The fascia overlying the anterior edge of the glu- teus maximus is then incised sharply (Fig. 2). This approach utilizes the avascular port ion of the fascia lata and avoids splitting the gluteus maximus muscle

Fig. 3. The fascia lata is divided and the gluteus medius and greater trochanter are exposed. Anterior and posterior routes to the hip are shown.

deep surface of the fascia can be separated from the overlying fascia with a periosteal elevator. Thus they are not denervated.

The space over the femur is then dissected ante- riorly and posteriorly, and vessels are coagulated as they are encountered (Fig. 3). Bipolar cautery, which reduces the zone of tissue necrosis, can be Used for most, if not all, of this operation. The bursal tissue over the greater trochanter is excised. The hip is then internally rotated putting the external rotators on stretch (Fig. 4). The sciatic nerve is identified and the external rotators are divided up to the gluteus min- imus tendon after sutures are placed in the tendons for retraction and later repair.

The posterior capsule is now exposed and divided

and gluteal vessels. Muscle fibers attaching to the

. ; =i_.__ ""• . . , .

Fig. 2. Exposure of fascia lata, tensor fascia lata, and glu- teus maximus. The incision in the fascia lata is indicated.

° -

Fig. 4. The femur is internally rotated to show the posterior approach to the hip. The sciatic nerve lies over the external rotators and then passes beneath the gluteus maximus ten- don. The incision in the external rotators and the interval between the gluteus minimus and piriformis are indicated.

316 The Journal of Arthroplasty Vol. 3 No. 4 December 1988

Fig. 5. Posterior approach to the hip. The external rotators are divided and turned posteriorly over the sciatic nerve. The capsule of the hip is opened.

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Fig. 6. Anterior approach to the hip. The femur is exter- nally rotated. Incision along the inferior edge of gluteus medius is indicated.

or excised (Fig. 5). The posterior half of the superior and inferior capsule can be divided and cauterized as necessary. In especially tight or contracted hips the tendinous insertion of the gluteus maximus can be divided while taking care to note the large first perforating artery from the profunda femoris, which lies beneath it and the quadratus femoris,

The superior muscle incision does not go as high as the lilac crest, Foster and Hunter found the su- perior gluteal nerve to lie 4 - 6 cm from the acetabular rim (average, 4.9 cm). Usually the hip is dislocated in flexion and internal rotation, The hip is then ex- tended to neutral position on the table. Posterior os- teophytes that block dislocation are removed as re- quired. An osteotomy of the femoral neck can be performed in situ and the femoral head and neck excised when the head is incarcerated or the liga- m e n t u m teres not accessible.

If there is an anterior capsule contracture or an- kylosis preventing dislocation, the anterior aspect of the hip is then exposed. This is approached with the limb in external rotation and abduction, if possible. The inferior border of the gluteus medius is identified (Fig. 6). An incision is made through the areolar tis- sue at this line. The anterior femoral circumflex branches are cauterized. The areolar tissue beneath the gluteus medius anterior to the capsule is reflected from the underlying anterior and superior capsule. A H o h m a n or other blunt retractor is placed beneath the rectus femoris tendon over the femoral neck, al- lowing complete exposure of the anterior capsule of the hip joint. This capsule is then incised and excised under direct vision (Fig. 7). The tendinous insertions of the gluteus medius and minimus are not disturbed rout inely but may be partially released if needed. Usually at least half of these tendons can be left in-

tact. The cut portion is later repaired with figure-of- eight suture.

The incision in the anterior capsule in this fashion permits easy control of bleeding. The hip is then dis- located or the femoral neck transected. Anterior os- teophytes can be excised. Should bone grafting of the anterior rim of the acetabulum be required, screws can be inserted readily from the front of the hip. Osteotomy of the femoral neck or femoral head is simple and safe with the combined anterior and posterior exposure. The femur and acetabulum are subsequently prepared for insertion of the appropri- ate components or for other surgery. These steps may be performed from the front or the back of the hip. After insertion of the prosthesis, the hip is reduced. Anterior release of the rectus femoris tendon is pos- sible under direct vision.

O

Fig, 7, Anterior approach to the hip. The anterior capsule is opened. The superior and inferior capsule can be reached easily from the anterior portion of the combined approach.

Combined AP Approach to the Hip * Lusskin et al. 317

Although this "combined" technique is not as ex- tensive an approach to the superior aspect as the di- rect lateral approach of Hardinge or the transtro- chanteric approach, it can be easily convened to either, should that prove necessary. Ordinarily the gluteus medius and minimus tendons are left intact and must be worked around. The interval developed anteriorly is the same as that used in the Watson- Jones incision once the tensor fascia latagluteus fas- cia cut is made. Because of the long incision the an- terior exposure is much more extensive than with the Watson-Jones incision, which is a lateral one with a rather limited anterior extension. The anterior neurovascular structures (femoral nerve and femoral anery and vein) are protected during the anterior portion of the approach.

During closure of the wound the external rotators, previously tagged, are repaired back to the greater trochanter through drill holes made with a small bit. If they are tight they may be sutured to the posterior edge of the gluteus medius with the hip placed in external rotation. The gluteus medius and minimus may be lengthened with a Z cut. Closure of the wound is performed over suction catheters placed both anteriorly and posteriorly.

After operation, the patient is placed in an ab- duction pillow and started on isometric exercises. Care is taken to protect the peroneal nerve in the postoperative period. Leg straps should be loosened as soon as the patient is in the postoperative unit and is able to cooperate. The knees should be slightly flexed. Sand bags that press on the peroneal nerve should be avoided.

This combined approach can give excellent ex- posure both posteriorly and anteriorly and can also be extended distally to the entire femoral shaft. When extended distally the vastus lateralis is raised from the femur. As stated, when extended superiorly the nerve supply to tensor fascia lata should be pro- tected.

Capsulotomy of the hip is performed under direct vision. When the anterior exposure becomes nec- essary it requires little additional dissection to gain direct exposure of the capsule, which can be coag- ulated, reducing blood loss. Postoperative pain is usually minimal, as little tension is placed on the tissues during exposure, bone reconstruction, and prosthesis insertion. This approach is useful in re- vision hip surgery as the femoral and sciatic nerves can be protected from excess compression or stretch.

Our experience with 28 cases of complex or re- vision arthroplasty has been good. We usually start with the posterior portion of the approach and then go anteriorly should that be required. No unexpected

problems have arisen with the procedure. There have been no neurologic or bleeding complications.

Case Reports

The following case reports illustrate the Utility and limitations of this approach. One hip dislocated while the patient was still paralyzed in the recovery room following reconstruction. In this patient (case 4) the trochanter was divided to graft the roof of the acetabulum. The end result was good, as the position of the components was correct. The sciatic nerve was explored and treated with external and internal lysis for traumatic neuropathy during the surgery in this case. In case 3 the sciatic nerve was protected during revision when a previous revision on the contralat- eral side had been followed by sciatic neuropathy.

Case 1

A 56-year-old thin woman with long-standing rheumatoid arthritis involving multiple joints de- veloped progressive pain and deteriorating function of the right hip. There was approximately 2 inches of relative shortening of the right leg. Hip motion was markedly restricted, except for painful flexion to 100 °. Radiographs revealed a severe arthroplasty of the right hip with protrusio. There was erosion of the roof and floor of the acetabulum. The femoral head was partially destroyed, with upward and me- dial displacement of the proximal femur remnants within the acetabulum (Fig. 8A).

On November 4, 1987, a reconstructive arthro- plasty was performed using the combined anterior- posterior approach. The femoral head and neck were used as a bone graft to reconstruct the floor and roof of the acetabulum. Sintered biologic fixation aceta- bular and femoral implants (DePuy Tri-lock) were used to replace the hip joint; The trochanter was not removed and the abductor tendons were undis- turbed. The patient was out of bed within 48 hours and began to stand non-weight-bearing on the fourth postoperative day despite major impairments of both arms and hands. She began weight bearing 12 weeks after surgery, at which time the grafts ap- peared well healed (Fig. 8B). There were no com- plications.

318 The Journal of Arthroplasty Vol. 3 No. 4 December 1988

W . . . . .

Fig. 8. Complex arthroplasty for rheumatoid arthritis of the hip requiring bone grafting of acetabulum performed by combined approach. (A) Preoperative radiograph, showing erosion of floor and roof of the acetabulum, with advanced changes in the femoral head. (B) Postoperative radiograph, showing status 3 months after surgery. The greater trochanteer was not divided.

Case 2

A 71-year-old muscular, overweight man had pro- gressive pain and impairment of right hip function over a 4-year period. He exhibited a pronounced limp on the right with 1¼ inch shortening. The right hip was in f'Lxed adduction of 10 °. The range of flex- ion was 30°-90 °. There was no rotation. Radi- ographs revealed a pronounced anhropathy of the affected hip with joint narrowing, cyst formation, hy- pertrophic acetabular and femoral head changes with flattening of the femoral head. The acetabulum was enlarged and there was upward luxation of the femoral head with insufficiency of the acetabular roof (Fig. 9A).

On October 28, 1987, following a 15-pound weight reduction, a reconstructive arthroplasty was performed. The sciatic nerve was exposed and pro- tected. A combined anterior and posterior approach permitted adequate access for dislocation of the hip as well as bone grafting of the acetabulum using the excised femoral head. The trochanter was not di- vided and the gluteal tendons were not lengthened. The acetabular component was placed low and the leg length was corrected. He was out of bed within

24 hours and was ambulating non-weight-bearing within 48 hours. Weight bearing was started within 12 weeks, at which time his bone graft appeared well united. There were no neurologic deficits. He re- gained good hip motion (Fig. 9B).

Case 3

A 38-year-old woman with previous bilateral total hip arthroplasfies for congenital dislocation of the hip was treated for increasing bilateral hip pain. The previous hip arthroplasties, performed via somewhat limited posterior approaches, had been followed by transient neuropathies of the sciatic nerves. Radi- ographs revealed that the acetabular components of both hips were loose (Fig. 10A). On February 7, 1976, a reconstruction of the right hip was performed through a posterior approach. A screw-in acetabular component was used (Fig. 10B). Following surgery she was noted to have a neuropathy of the sciatic nerve involving mainly the peroneal division. Pain diminished with antiinflammator~ medication, and her neural deficit began to improve but did not re- solve completely.

Combined AP Approach to the Hip * Lusskin et al. 319

Fig. 9. Arthroplasty for advanced osteoarthritis in a muscular man with erosion of the superior acetabulum. (A) Preoperative radiograph. (B) Postoperative status following bone grafting during implantation of the sintered acetabular and femoral components.

On March 24, 1987, the left hip was explored via a combined anterior-posterior approach in the lateral position. The sciatic nerve was exposed and pro- tected (Fig. 10C). The reconstruction of the hip then proceeded with division of the gluteus medius ten- don (Fig. 10D). Her postoperative course was un- eventful, wi th no neuritis or neural deficit.

Case 4

A 54-year-old man, an office manager, sustained a fracture of the pelvis with dislocation of the hip and fracture of the roof of the acetabulum in a motor vehicle accident on February 21, 1987. An open re-

Fig. 10. Revision arthroplasty of the hip, with release of sciatic nerve to prevent neuropathy. (A) Radiographs showing bilateral loosening of the cemented acetabular components. (B) Status following revisison of the right hip via the anterior- lateral approach. There was neuropathy of the sciatic nerve following this procedure. (Figure continues)

320 The Journal of Arthroplasty Vol. 3 No. 4 December 1988

Fig. 10. (C) Exposure and release of the sciatic nerve prior to exposure of hip by combined anterior and posterior approach. Trochanteric wires from previous surgery are seen. These were not disturbed. (D) Postoperative radiograph, showing the new implant in place. There was no neuropathy of the sciatic nerve.

duct ion with internal fixation of the pelvic fractures was per formed February 27, 1987. A rehabilitation p rog ram was started but the patient noted increasing pa in and disability. Following the injury he com- plained of pain and numbness in the sole of the foot and there was calf weakness.

Examinat ion on July 21, 1987 revealed a disabled man , 6 feet 3 inches tall w h o weighed 230 pounds. The right leg was swollen about the hip and thigh and was held in external rotation. There was short- ening. Range of mot ion was restricted with flexion range 20o-90 ° with marked crepitation, abduction

Fig. 11. Reconstruction of the hip following failed acetabular reconstruction. Extensive exposure of lateral ilium required osteotomy of trochanter. (A) Status prior to anhroplasty. Loose hardware, nonunion of superior rim of acetabulum, and subluxation of the femoral head, with a defect in femoral head, were present. (B) Status 3 months after surgery. The acetabular bone graft is healing well. Trochanter has healed without internal fixation other than sutures. Sciatic nerve lysis by posterior portion of combined approach was followed by early recovery from traumatic neuropathy.

Combined AP Approach to the Hip • Lusskin et al. 321

20 °, external rotation 45 °, and internal rotation - 2 0 °. There was hypesthesia of the plantar surface of the foot and the calf was weak. Motor exami- nation was difficult to perform because the patient could not bear full weight on the affected leg.

Radiographs of the right hip revealed his status following ORIF of the right pelvis. There was a re- construction plate on the posterior ilium and ischium with a healed fracture of the posterior column. There was upward subluxation of the head of the femur with a large notch in the femoral head. The superior acetabular fragment had migrated upward and out- ward, and there was a large false acetabulum su- periorly~ The trochanter had been repaired with two screws. There was loose hardware (Fig. 4A).

He was placed on a weight reduction regimen and lost 35 pounds. Conditioning was begun, including trunk, arm, and leg exercises. On October 21, 1987, a reconstruction of the hip was performed. The initial approach was by combined anterior and posterior. The sciatic nerve was explored under magnification. Nn external and internal neurolysis was performed through the zone of fibrosis behind the acetabulum. Loose screws were then located and removed. Be- cause a more extensive superior approach was re- quired, a rather superficial osteotomy of the greater t rochanter was performed, just deep enough to in- clude the insertions of the gluteus medius and min- imusl The nonuni ted superior acetabular fragment was then removed and the entire capsule excised. The hip was dislocated and an osteotomy of the fem- oral neck performed. The femur could then be brought distally to its proper level. The femoral head and neck was fashioned into a graft and secured to the pelvis with three conical screws. The socket was then reamed and the hip reconstructed with the bi- ologic fixation prosthesis.

While the patient was in the recovery room and still paralyzed from epidural anesthesia, the hip dis- located. An immediate reduction was performed. Wilkie boots were applied and worn for 3 weeks. The position of the components was judged to be proper. The patient was turned and mobilized in a stretcher chair in the postoperative weeks. He was then mobilized in a non-weight-bearing status for 3 months , at which time radiographs showed that the graft had incorporated well and the components ap- peared well stabilized (Fig. 4B). There had been no fur ther dislocation, the sciatic neuropathy cleared completely, and the patient is now ambulating with a cane wi thout pain. He has returned to work. The postoperative regimen included low-dose coumadin prophylaxis against thromboembolism.

This case illustrates both the utility and the limits of the combined approach. Neural and vascular

structures can be approached as needed and the in- cision modified as required. There have been no other complications in this series.

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