The Anterior Approach to Hip and Pelvis

Objective Exposure of the anterior pelvic column and the anterior hip in the internervous plane between the femoral nerve (sartorius and rectus muscle) and the superior gluteal nerve (tensor fasciae latae, gluteus medius, and gluteus minimus muscle) as well as between the blood supply of the external (medial) and internal iliac artery (lateral). Indications All pelvic osteotomies. Shelf procedures. Anterior labral lesions. Fractures of the femoral head, anterior column, anterior acetabular wall, and high transverse acetabular fractures. Contraindications None. Surgical Technique Incision along the iliac crest, over the anterosuperior iliac spine to the lateral aspect of the proximal thigh. Separation of sartorius and tensor fasciae latae. Osteotomy and medial reflection of the anterosuperior iliac spine. Subperiosteal detachment of the abdominal muscles and the iliacus muscle. Division of both origins of the rectus. Elevation of the iliocapsular muscle and the psoas tendon. Incision and medial retraction of the periosteum at the anterior surface of the anterior acetabular wall to expose the acetabular floor. Detachment of the tensor fasciae latae, gluteus medius, and gluteus minimus muscles to expose the outer ilium. Results To date, this modified Smith-Petersen approach has been used in approximately 700 periacetabular osteotomies. Complications: transient femoral (n = 1), sciatic (n = 5), and lateral femorocutaneous (30%) nerve deficits. Distal aspect of the scar always large, revision rare (n = 3). No vascular injuries. Resection of heterotopic ossification in five of six patients. Very low rates of infection, hematoma, deep thrombophlebitis, and embolism.