40. MINIMALLY INVASIVE MEDIAL APPROACH TO THE HIP JOINT: DESCRIPTION AND INDICATIONS

Abstract

Purpose of the study: Transadductor approaches to the hip joint have been described in the spastic child. Ludl-off as well as Ferguson pass behind the short adductor and the pectineus, a narrow route with a risk of injuring the obturator nerve. We describe a simple minimally invasive approach.

Material and method: The incision is made with the hip in the flexion, external rotation, abduction, from the pubic insertion of the long adductor following along the mass of the muscle for 6 to 8 cm. The aponeurosis of the long adductor is cut just deep enough to see the muscle fibres. Careful finger dissection of the muscle sheath common to the three anterior adductor muscles leads directly to the lesser trochanter. Two forceps are inserted on either side of the lesser trochanter, exposing the lesser trochanter and the tendon of the iliopsoas muscle. Dissection of the iliopsoas muscle held aside (follow the tendon on its lateral aspect leading to the vessels). An angled spreader is positioned between the anterior aspect of the capsule and the medial border of the tendon, displacing the tendon laterally and exposing the capsule. Extra-articular exposure of the capsule with a rugine to displace the posterior medial circumflex pedicle. Longitudinal incision of the capsule continued along the inter-trochanteric line to the peri-acetabular region. The medial as well as the anterior aspect of the neck can be visualized by rotating the hip. The inferior and anterior portion of the head is visible: the iliopubic branch and the entire superior and medial wall of the acetabulum can be exposed.

Results: We performed 29 medial approaches. Nine for periprostheic pain, four for fresh fracture of the femoral head during posterior dislocation, four for old fractures of the femoral head during posterior dislocation, three for chondromatosis, three for tumours of the femoral head or the acetabulum, six for retractile periarthritis without arthroplasty. Hip arthroplasty (7) or not (6), median pain could be induced by the presence of retractile periarthritis with presence of synovial adherences to the femoral neck penetrating into the joint space; release relieved pain in 11/13.

Conclusion: The medial approach to the hip joint is a useful orthopaedic technique with a rapid learning curve.