- Exposure:
- for hips w/ severe osteoarthritis (or w/ heavily scarred hips) it may be necessary to fully release the quadratus femoris, and a portion of the
gluteal sling;
- because the majority of the
maximus inserts into the IT band, there is little consequence of releasing the gluteal sling;
- amount of gluteus tendon released is dependent upon how easy it is to retract proximal femur anteriorly;
- protect the sciatic nerve:
- note that hip flexion and knee extension will place the sciatic nerve under tension, and will risk a traction
palsy with posterior retration;;
- Capsule:
- see:
anterior capsule:
- it is important to leave the superior half of the anterior capsule intact, inorder to avoid anterior instability;
- insert a bone hook around the greater trochanter and retract it anteriorly and laterally, which puts the anterior capsule on stretch;
- use heavy Mayo scissors to incise the inferior half of the capsule off of its attachment to the femur;
- only incise enough capsule to allow sufficient anterior translation of the proximal femur so that the acetabulum is exposed;
- Retractors:
- anterior retractor:
- place long sharp retractor underneath the "elevated" anterior capsule (and underneath the psoas major tendon,
and on top of the pelvic brim to pull stump of neck anteriorly;
- care must be taken at this stage to avoid
vascular injuries;
- postero-inferior rectration:
- a "sciatic nerve retractor" or a sharp Homan retractor is placed just inferior to the posterior 1/3 of the transverse acetabular ligament;
- hence the retractor comes to rest at the posterior ischial surface and superior to the obturator externus groove;
- in some cases, a second retractor needs to be placed directly inferior to the transverse acetabular ligament;
- retractors may be placed beneath the Charnley retractor and secured w/ a clamp, which then allows the assistant to handle anterior retractor;
- if retractor is placed too anteriorly, the retractor may injure the obturator artery;
- if retractor is placed to posteriorly, the retractor may injure the
sciatic nerve;
- superior rectraction:
-
glutei medius and
minimus are distracted anteriorly;
- they may be restrained by inserting steinmann pin into ilium, 2 cm superior to superior margin of the acetabular labrum;
- Labrum and Transverse Acetabular Ligament:
- expose the bony margins of the rim of acetabulum around it entire circumference to facilitate proper placement of acetabular reaming;
- anterior osteophytes are removed with a rongeur;
- superior osteophytes do not require removal because they rarely cause impingement & can augment acetabular coverage of cup;
- excise the acetabular labrum circumferentially;
- draw soft tissues into the acetabulum and divide them immediately adjacent to the acetabular rim (keep the knife blade within the acetabulum);
- transverse acetabular ligament often hypertrophied or calcified & requires at least partial removal (generally the inner half is release;
- branches of
obturator artery may bleed in this area
- if the transverse acetabular ligament needs to be transected, then release it in its posterior half, in order to avoid bleeding from the obturator artery;
Extensile triradiate approach for complex acetabular reconstruction in total hip arthroplasty.
False aneurysm of the common femoral artery after total hip arthroplasty. A case report. 
