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Anterolateral Approach to Hip Joint: (Watson Jones)

- See: Smith Peterson Approach

- Discussion:
    - major problems with the Watson Jones technique are dealing w/ gluteus medius & minimus, which lie over anteior capsule and
             must be damaged or cut to obtain adequate exposure;
    - original Charnely technique used anterolateral approach w/ pt supine, osteotomy of greater troch, & ant dislocation of hip;
    - this approach is used less commonly now as result of problems related to reattachement of the greater trochanter;
    - other major problem is dealing w/ medius & minimus, which lie over anterior capsule & are damaged or cut to obtain
             adequate exposure;

- Incision:
    - skin incision is made 2.5 cm behind ASIS to tip of greater trochanter;
    - then extend incision vertically down along anterior margin of trochanter for about 10cm;
    - or carry incision it to a point just posterior to trochanter, & then angle it about 110 deg anteriorly and distally to parallel the femoral shaft;

- Interneural Interval:
    - interval between tensor fascia lata & gluteus medius is identified;
          - overlying gluteal fascia is divided allowing these muscles to be separated up to iliac crest;
          - upper ends of these 2 muscles may be fused;
   - dissection of interval may facilitated more easily by beginning separation between ASIS & greater trochanter, before tensor
          fasica lata ends w/ its fascial insertion;
    - carry dissection proximally to expose branch of superior gluteal nerve, which innervates TFL;
          - tensor fascia lata is most likely to be denervated at this time;

- Alternative:
    - or make similar incision in underlying iliotibial band & retract tensor fascia lata medially & gluteus medius laterally;
    - then incise transversely gluteus medius attachment to greater troch until bursa between gluteus mimimus & troch is opened;

- Deep Dissection:
    - anterior parts of gluteus medius & minimus are raised from hip bone & retracted posteriorly;
    - upper part of Capsule of hip joint will been seen, w/ reflected head of rectus femoris attached to upper part of acetabular rim;
           - this head can be detached to give greater exposure of capsule, which may if indicated, may be incised or removed;
    - ascending branch of lateral femoral circumflex art. & its accompanying veins cross gap deep to these muscles and must be ligated;

- Osteotomy:
    - osteotomy of greater troch is performed only if necessary to obtain exposure or to correct posterior displacement of trochanter;

- Capsule:
    - make a longitudinal incision in the joint Capsule
    - make a transverse incision in the anterior margin of the acetabulum.
    - exteranally rotate the limb;
    - femoral head is exposed for osteotomy and removal from acetabulum;
    - if the posterior wall of the neck is longer than the anterior neck, there will be increased anteversion;
    - perform a complete capsulectomy - especially w/ an external rotational deformity;
    - pull anteriorly piriformis tendon and the attachments of the other short external rotators and divide them;
         - avoid quadratus femoris muscle because dividing it may cause troublesome bleeding from branch of medial circ. art;
    - femoral nerve & vessels are anteroinferior to acetabulum and must be carefully protected.
    - carefully section quadratus femoris muscle until the perivascular fat surrounding the circumflex anastomosis is identified;

- Hazards:
    - ascending branch of LFCA and accompanying veins are large vessels that pass deep to rectus femoris,  tensor fascia lata,
            and gluteus medius, & require ligation as the gap between the tensor and gluteus medius is opened up;
    - nerve to tensor fascia lata also crosses gap (at higher level than vessels) and should be preserved, but it can be sacrificed 
            if necessary for adequate exposure;
    - sciatic nerve must not be damaged if joint is being dislocated to remove the head for a prosthetic replacement;
    - consider detaching & spliting only anterior third of gluteus medius to limit risk of damage to superior gluteal nerve, which passes
            4.5 cm above and 2 cm behind the tip of greater trochanter

The course of the superior gluteal nerve in the lateral approach to the hip.

Surgical approaches for primary total hip arthroplasty. A prospective comparison of the Marcy modification of the Gibson and Watson-Jones approaches.

The trochanteric approach to the hip for prosthetic replacement.

The direct lateral approach to the hip for arthroplasty. Advantages and complications.

Translateral surgical approach to the hip. The abductor muscle "split".

Comparison of heterotopic bone after anterolateral, transtrochanteric, and posterior approaches for total hip arthroplasty.

MRI findings of gluteus minimus muscle damage in primary total hip arthroplasty and the influence on clinical outcome