Ortho Preferred Malpractice Insurance
Home » Joints » Hip » Medial Approach to Hip

Medial Approach to Hip

- Discussion:
    - optimal age for the medial approach:
            - is of more value in the child younger than 18 months but older than 7 months;
            - when this procedure is used in infants younger than 7 months, there may be a higher risk of AVN, but some authors feel that the risk of AVN is increased in children older than 10 months of age;
    - anatomical considerations:
            - medial approach may occur either anteromedial or posteromedial depending whether surgeon goes anterior or posterior to adductor brevis;
            - procedure may involve division of the psoas tendon, since it can be an extra-articular barrier to reduction;
    - advantages:
            - minimum dissection & blood loss;
            - allows direct approach to common obstacles to reduction (such as the psoas tendon);
                  - psoas tendon, capsular constriction, & transverse acetabular ligament;
    - disadvantages:
            - poor access to acetabulum (neolimbus, ligamentum teres, & pulvinar);
            - does not allow capsulorraphy (which is required in older patients);
            - AVN: risk of AVN is about 15%;
            - need for additional surgical procedures: 10-20%;
    - contra-indications:
            - medial approach is usually not used once child who has begun to walk;
            - medial approach not used when femoral head has migrated proximally;

- Antermedial Approach:
    - may be indicated for children w/ DDH who are less than 24 months old;
    - may be contraindicated for older children and for children w/ high hip dislocation;
    - address obstacles to reduction;
    - avoids damage to the abductors and damage to the iliac apophysis;
    - has low incidence of recurrent dislocations & AVN (however, some point out that there is damage to the medial circumflex vessels w/ this approach);
    - incision:
           - incision proceeds anterior to adductor brevis & either anterior or posterior to pectineus, to expose iliopsoas & hip capsule;
           - branch of MFCA must be ligated during anteromedial approach;
    - reference:
           - Anteromedial approach to reduction for congenital hip dysplasia. Weinstein SL. Orthop. Surg. 1987(6):2.

- Ludloff Approach:
    - dissection is between adductor longus & brevis muscles anteriorly, and gracilis & adductor magnus muscles posteriorly;
           - deeper dissection is between adductor brevis & adductor magnus;
    - make longitudinal incision on medial aspect of thigh, beginning about 2.5 cm distal to pubic tubercle & over interval between gracilis & adductor longus muscles;
    - this should reveal the adductor brevis w/ overlying anterior branch of obturator nerve & this is retracted to observe posterior branch overlying the adductor magnus;
    - develop plane between adductor longus & brevis muscles anteriorly and gracilis & adductor magnus muscles posteriorly;
    - expose posterior branch of obturator nerve & neurovascular bundle of the gracilis;
    - lesser trochanter & capsule of hip joint are located in floor of wound;
    - reference:
           - Open Reduction through a Medial Approach for Congenital Dislocation of the Hip.  A Critical Review of the Ludloff Approach in Sixty-six Hips.

- Posteromedial Approach: (Ferguson Approach)
    - low incidence of AVN and recurrent dislocation;
    - place pt in supine position w/ affected hip abducted & flexed 90 deg;
    - make straight incision along the posterior margin of the adductor longus beginning at its origin and extending distally;
    - incise the deep fascia in line with the skin incision and by blunt dissection with the finger separate the adductor longus anteriorly from the adductor magnus and gracilis posteriorly;
    - course between adductor brevis and adductor magnus directly to hip capsule;
    - identify the psoas tendon, and divide it transversely;
    - reference:
          - Open reduction for congenital dislocation of the hip using the Ferguson procedure. A review of twenty-six cases.

Developmental Dislocation of the Hip Successfully Treated by Preoperative Traction and Medial Open Reduction: A 22-year Mean Followup

Long-term outcome after open reduction through an anteromedial approach for congenital dislocation of the hip.

Congenital dislocation of the hip

The ferguson medial approach for open reduction of developmental dysplasia of the hip. A clinical and radiological review of 49 hips.

Open Reduction Through a Medial Approach in Developmental Dislocation of the Hip: A Follow-up Study to Skeletal Maturity.