Courtesy: Saqib Masud FRCS,John Davies FRCS

Overview

The anterior approach to the hip, commonly known as the Smith–Peterson approach, provides safe and direct access to the hip joint.

Indications

This approach is widely used for:

• Hip joint procedures

• Pelvic osteotomies

• Total hip replacement (THR)

 It also allows extension to the pelvis when required.

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Patient Positioning

• Patient is placed in the supine position

Modifications

For Pelvic Osteotomy

• A small sandbag under the ipsilateral buttock improves exposure

For Total Hip Replacement

• A traction table may be used to:

  • Facilitate limb positioning

  • Improve surgical access

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Surface Landmarks

Key anatomical landmarks guiding the incision:

• Iliac crest

• Anterior superior iliac spine (ASIS)

• Shaft of the femur

 These landmarks help determine the orientation of incision and dissection

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Skin Incision

• Begins over the anterior iliac crest

• Extends toward the ASIS

• Then curves distally for 8–10 cm along the anterior thigh

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Internervous Plane

This approach utilizes a safe internervous interval:

 This allows muscle separation without denervation

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Identification of the Intermuscular Interval

• Interval lies between tensor fasciae latae (TFL) and sartorius

• Best identified 5–7 cm distal to ASIS

Surgical Tip

• External rotation of the leg makes the sartorius more prominent, aiding identification

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Structures at Risk

Lateral Femoral Cutaneous Nerve (LFCN)

Location

• Pierces deep fascia 2–3 cm medial and inferior to ASIS

Risk

• Vulnerable during superficial dissection

Protection Strategies

• Incise fascia medial to TFL

• Stay within the TFL fascial sheath

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Vascular Structures

• Ascending branch of the lateral femoral circumflex artery lies within the interval

 Must be identified and controlled to prevent bleeding

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Muscle Retraction

After identifying the interval:

• Tensor fasciae latae — retracted laterally

• Sartorius (+ LFCN) — retracted medially

 This exposes the deeper anterior hip structures

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Deep Dissection

Intermuscular Plane

• Between:

  • Gluteus medius (lateral)

  • Rectus femoris (medial)

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Rectus Femoris Release

To improve exposure, rectus femoris is detached.

Origins

• Direct head — Anterior inferior iliac spine (AIIS)

• Reflected head — Superior acetabular rim

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Neurovascular Structures at Risk

• Femoral nerve

• Femoral artery

Location

• Medial to rectus femoris within the femoral triangle

 Careful retraction is essential to avoid injury

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Exposure of the Hip Joint

• Iliopsoas muscle is retracted medially

• This exposes the anterior hip capsule

Limb Positioning

• Abduction

• Full external rotation

 Helps tension the capsule and facilitates exposure

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Capsulotomy and Hip Dislocation

• The anterior capsule is incised

• Hip joint is then dislocated for surgical intervention

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Extension of the Approach

Local Extension

Exposure can be increased by releasing:

• Tensor fasciae latae

• Sartorius

• Gluteus medius

• Gluteus minimus

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Proximal Extension

• Incision extended along the iliac crest

• Allows access to:

  • Inner pelvis

  • Outer pelvis

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Distal Extension

• Extended along the anterolateral thigh

• Provides access to the entire femoral shaft

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Summary

• The Smith–Peterson approach utilizes a safe internervous plane

• Provides excellent exposure of:

  • Hip joint

  • Anterior pelvic structures

• Key to success:

  • Accurate identification of landmarks

  • Protection of LFCN and femoral neurovascular structures

• Approach is highly versatile, allowing proximal and distal extension as needed

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