Courtesy: Amr Abdelgawad, Maimonaides Medical Centre, Brooklyn, NewYork, USA

Iliac Crest Bone Graft Harvesting

• Bone graft can be harvested from anterior or posterior iliac crest.
• Anterior iliac crest: structure at greatest risk is the lateral femoral cutaneous nerve.
• Lateral femoral cutaneous nerve lies approximately 2–3 cm medial to the ASIS.
• Posterior iliac crest graft: cluneal nerves at risk (?8 cm lateral to PSIS).
• Distal extension may risk injury to superior gluteal neurovascular bundle.

Ilioinguinal Approach

• Commonly used for acetabular fractures involving anterior column.
• Key structure: iliopectineal fascia.
• This fascia separates iliopsoas muscle and femoral nerve (laterally) from iliac vessels (medially).
• Fascia must be released to access the true pelvis.

Anterior Intrapelvic (Stoppa) Approach

• Provides excellent access to quadrilateral plate.
• Important structure at risk: corona mortis.
• Corona mortis is an anastomosis between external iliac/inferior epigastric vessels and obturator vessels.
• Located approximately 6 cm lateral to the pubic symphysis.

Hip Surgical Approaches

• Smith-Petersen (anterior) approach.
• Watson-Jones (anterolateral) approach.
• Hardinge (direct lateral) approach.
• Posterior approach through gluteus maximus.

Smith-Petersen (Anterior) Approach

• Interval between sartorius and tensor fascia lata.
• Sartorius supplied by femoral nerve.
• Tensor fascia lata supplied by superior gluteal nerve.
• This is the only true interneural approach to the hip.
• Structures at risk: lateral femoral cutaneous nerve and ascending branch of lateral femoral circumflex artery.

Watson-Jones (Anterolateral) Approach

• Interval between tensor fascia lata and gluteus medius.
• Not a true interneural plane because both muscles are supplied by the superior gluteal nerve.

Direct Lateral (Hardinge) Approach

• Approach splits the gluteus medius.
• Do not extend more than 5 cm proximal to greater trochanter.
• Risk of injury to superior gluteal nerve.
• Hip dislocation occurs anteriorly in this approach.

Posterior Hip Approach

• Approach through gluteus maximus.
• Gluteus maximus supplied by inferior gluteal nerve.
• Short external rotators (piriformis, obturator internus, gemelli) released.
• Associated with higher risk of postoperative dislocation.

Hip Arthroscopy Portals

• Posterolateral portal close to sciatic nerve.
• Internal rotation of hip moves femur away from sciatic nerve to reduce risk.
• Anterior portal close to lateral femoral cutaneous nerve and ascending branch of lateral femoral circumflex artery.
• Anterolateral portal close to superior gluteal vessels.

Surgical Hip Dislocation – Trochanteric Osteotomy

• Used to safely dislocate hip without compromising blood supply.
• Blood supply mainly from medial femoral circumflex artery.
• Trochanteric osteotomy keeps piriformis and external rotators intact.
• Osteotomy typically 1–1.5 cm thick.
• Z-shaped capsulotomy performed to preserve vascular supply.

Blood Supply of Femoral Head

• Main supply: deep branch of medial femoral circumflex artery.
• Artery arises from profunda femoris artery.
• Passes between pectineus and iliopsoas muscles.
• Travels posteriorly along quadratus femoris.
• Then runs beneath obturator externus and external rotators before entering capsule.
• Inferior gluteal artery may contribute in some individuals.

Greater and Lesser Sciatic Notch Anatomy

• Separated by sacrospinous ligament.
• Lesser sciatic notch contains obturator internus and gemelli muscles.
• Greater sciatic notch contains piriformis muscle.

Structures Above and Below Piriformis

• Above piriformis: superior gluteal nerve and artery.
• Below piriformis: sciatic nerve, inferior gluteal nerve and artery.
• Also below piriformis: pudendal nerve, internal pudendal artery, nerve to obturator internus, nerve to quadratus femoris.

L5 Nerve Root in Pelvic Fixation

• L5 root passes anterior to sacral ala.
• Anteriorly placed iliosacral screws may injure L5 root.
• L5 root lies about 2 cm from sacroiliac joint.
• Screws should not extend more than ~1.5 cm anterior to SI joint.

Acetabular Teardrop

• Radiographic landmark used in acetabular fractures and total hip arthroplasty.
• Represents bone between cotyloid fossa and quadrilateral plate.

Pelvic Teardrop Corridor

• Used for anterior external fixation pins.
• Corridor between AIIS and PSIS.
• Best visualized on obturator outlet view.

Hip Joint Biomechanics

• Hip is a ball-and-socket joint.
• Allows three degrees of freedom: flexion/extension, abduction/adduction, rotation.
• Does not allow translation.
• Maximum joint pressure occurs in extension and internal rotation.
• Patients with effusion prefer flexion and external rotation.

Hip Ligaments

• Iliofemoral ligament (Y ligament of Bigelow) – strongest ligament in body.
• Extends from AIIS to intertrochanteric line.
• Pubofemoral ligament – from pubis to femur.
• Ischiofemoral ligament – from ischium to femur.
• Ischiofemoral ligament limits internal rotation.

Femoral Triangle

• Borders: inguinal ligament (superior), sartorius (lateral), adductor longus (medial).
• Floor: iliopsoas, pectineus, adductor longus.
• Contents (lateral to medial): femoral nerve, femoral artery, femoral vein, deep inguinal lymph node.
• Femoral nerve lies outside femoral sheath.