Anterior(Smith-Peterson) approach to the Hip

Courtesy: Harry Benjamin Laing, MRCS, UK

Overview

• The anterior approach to the hip joint is a commonly used surgical technique that provides access to the hip through natural muscular intervals.
• This method minimizes muscle damage because the dissection follows intermuscular and internervous planes.
• Proper preparation, positioning, and understanding of anatomical landmarks are essential for safe exposure of the hip joint.

Preoperative Preparation

• Ensure the patient has provided informed consent before the procedure.
• Mark the operative site clearly before surgery.
• Perform the standard surgical safety checklist before starting the procedure.
• Confirm that all necessary instruments and team members are prepared.

Patient Positioning

• Position the patient in a supine position on the operating table.
• Place a sandbag or support under the appropriate area to optimize surgical exposure.
• Proper positioning improves access to anatomical landmarks and facilitates surgical dissection.

Surface Anatomical Landmarks

Key surface landmarks help guide the incision and approach:

• Iliac crest
• Anterior superior iliac spine
• Lateral border of the patella

These landmarks assist in identifying the correct surgical corridor.

Surgical Planes and Muscle Intervals

The anterior approach utilizes natural muscle intervals to reduce tissue damage.

Superficial intermuscular plane

• Located between the Sartorius muscle and the tensor fasciae latae muscle.

Deep intermuscular plane

• Located between the rectus femoris muscle and the gluteus medius muscle.

Following these intervals allows safe access to deeper structures while preserving muscle function.

Nerve Supply of Key Muscles

Understanding nerve supply is important to protect neurological structures during surgery.

Muscles supplied by the superior gluteal nerve:

• Tensor fasciae latae
• Gluteus medius
• Portions of the gluteal muscle group involved in abduction

Muscles supplied by the femoral nerve:

• Sartorius
• Rectus femoris

These relationships form the basis of the internervous surgical plane.

Exposure of the Hip Capsule

• The origin of the rectus femoris muscle may be detached or retracted medially.
• This maneuver exposes the hip joint capsule.
• Adduction and external rotation of the leg may improve visualization of the capsule and joint structures.

Structures at Risk During the Approach

Lateral femoral cutaneous nerve

• Travels superficially across the Sartorius muscle.
• Care must be taken to avoid injury during superficial dissection.

Ascending branch of the lateral femoral circumflex artery

• Located between the Sartorius muscle and tensor fasciae latae muscle.
• This vessel typically requires identification and ligation to prevent bleeding.

Possible Extension of the Approach

Proximal extension

• The incision may be extended proximally along the iliac crest.
• This may be required when harvesting bone grafts or when wider exposure is necessary.

Distal extension

• The incision may be extended distally toward the lateral border of the patella.
• Dissection proceeds between the rectus femoris and vastus lateralis muscles.
• This extension may be useful in situations such as managing an intraoperative femoral fracture.

Key Advantages of the Anterior Hip Approach

• Utilizes natural muscular intervals.
• Preserves muscle function.
• Provides direct access to the hip joint capsule.
• Allows extension of exposure when necessary.