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Anterior Approach to the Hip (Smith Petersen)

- See: Watson Jones Approach

- Discussion:
    - Smith Petersen improved & revived the anterior iliofemoral approach;
    - entire ilium and hip joint can be reached thru iliac part of incision;
    - w/ this approach there is a need for extensive detachment of tendinous insertions & retraction of muscle, w/ potential damage to
              femoral artery and nerve and traction on lateral femoral cutaneous nerve;
    - among the indications for this approach are ganz osteotomy for DDH and posterior hip frx dislocations;

- Technique:
    - begin incision at middle of iliac crest or, farther posteriorly if required;
    - accentuate the gap between the tensor fascia lata and sartorius by external rotation of the thigh;
    - lateral femoral cutaneous nerve:
           - divide the overlying fascia w/ scissors takeing care to avoid damaging lateral femoral cutaneous nerve:
           - this nerve passes over sartorius 2.5 cm distal to ASIS;
           - it pierces deep fascia of thigh 7 cm below ASIS;
           - identify the nerve and retract it medially with sartorius
           - references:
                  - Lateral Femoral Cutaneous Nerve Impairment After Direct Anterior Approach for Total Hip Arthroplasty
                  - The Anatomical Course of Lateral Femoral Cutaneous Nerve with Special Attention to Anterior Approach to Hip Joint 

    - identify ascending brach of LFCA, which lies 5 cm distal to hip joint;
            - ref: Potential Risk to the Superior Gluteal Nerve During the Anterior Approach to the Hip Joint: An Anatomical Study.
    - divide the superficial and deep fascia, and free the attachments of gluteus medius & tensor fasciae latae from iliac crest
           - strip periosteum w/ attachments of medius & minimus muscles from lateral surface of the ilium;
    - continue dissection through deep fascia of thigh & between tensor fascia lata laterally & sartorius & rectus femoris medially;
           - this exposes medius & rectus femoris;
    - rectus femoris is detached from its two origins:
           - straight head from AISIS
           - reflected head from the anterior lip of acetabulum
           - at this point, capsule of hip joint is exposed

- Deep Exposure:
       - Motor-Evoked Potential Analysis of Femoral Nerve Status During the Direct Anterior Approach for Total Hip Arthroplasty

2019 Frank Stinchfield Award: A comparison of prosthetic joint infection rates between direct anterior and non-anterior approach total hip arthroplasty

Direct Anterior Approach: Risk Factor for Early Femoral Failure of Cementless Total Hip Arthroplasty: A Multicenter Study.


Anterior approach for total hip arthroplasty: beyond the minimally invasive technique.