The ‘Hardinge direct lateral or transgluteal approach’ has many different flavours. There will be small variations in the approach from surgeon to surgeon, therefore most people will described there approach as a modified Hardinge approach.
Indications:
- Trauma – Hemiarthroplasty
- THR – lower dislocation rate
Video:
Positioning:
Supine, GT at the edge of the table (buttock muscles, and fat falls posteriorly)
Incision:
5cm above the tip of GT. Longitudinal incision over the centre of the tip of the GT and extend down femural shaft for 8cm.
Internervous plane:
Not a true IN plane. Gluteus medius muscle fibres split inline with fibres, distal to point where the superior gluteal nerve supplies the muscle, thus preserving the bulk of it and avoiding a trochanteric osteotomy. Vastus lateralis split lateral to point where femoral nerve supplies it.
Superficial Dissection:
Skin, fat, deep fascia. Split gluteus medius muscle in direction of fibres, in the around level of the greater trochanter (aiming to take 1/3 off). Do not go more than 3cm above upper border of trochanter (sup gluteal nerve). Split vastus lateralis muscle overlying the lateral aspect of base of GT.
Deep Dissection:
Split fibers of glut medius in the direction of the fibers, in the middle of the trochanter. (don’t go beyond 3cm above the upper border of trochanter as sup glut nerve). Create an anterior flap consisting of anterior part of gluteus medius and underlying gluteal minimus, dissecting off bone. Follow contour of bone onto the femoral neck, until anterior hip joint capsule is fully exposed. Develop plane between the hip joint capsule and overlying muscles.
Dangers:
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Nerves
- Superior gluteal nerve: between medius and minimus 3-5cm above tip of GT
- Femoral nerve: most lateral in triangle. Inappropriately placed retractors on anterior acetabulum.
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Vessels
- Femoral artery & vein: anterior retractors
- Transverse branch of lateral circumflex artery