MODIFIED POSTERIOR APPROACH TO THE HIP JOINT

K.MOHAN IYER, MCh.Orth(Liverpool,UK),MS.Orth(Bom)

FCPS.Orth(BOM),D’Orth(Bom),MBBS(Bom)

Consultant Orthopaedic Surgeon,

Bangalore,Karnataka,India

DEDICATIONS

To the memory of my respected teacher,(Late)Mr.Geoffrey V Osborne

and

My wife,Mrs.Nalini K.Mohan

My Daughter Deepa Iyer,MBBS,MRCP(UK)

My Son,Rohit Iyer (B.E)

FOREWORD The Foreword has been given by a well known and famous Orthopaedic Surgeon based at

Zurich(Switzerland) who has himself done original research of this topic and written an article in the

coveted Journal of Arthroplasty,which has been quoted In the book at Reference No.17 as Failure of

Reinserted Short External Rotator Muscles after Total Hip Arthroplasty-Thomas Stahelin,P.Vienne and

O.Hershe,The Journal Arthroplasty,2002,Vol.17,No.5:604-607

I have been involved in extensive studies on the resuture and reattachment of the short lateral

muscles by using markers many years ago(2002)and came to the conclusion that nearly 70% of the

failures occurred on the first post-operative day itself and hence this modification of the Posterior

Approach as described by K.Mohan Iyer in this book is a major contribution to the Surgery of the Hip

Joint in the field of Orthopedic Surgery,which has been quoted in several books till today.I certainly

encourage all orthopedic residents and Orthopedic Surgeons who adopt the conventional Posterior

Approach as described by Austin Moore in 1957,all around the world to read this book which has been

written and presented meticulously citing many articles from 1981 till today and since it offers greater

stability to the Hip Joint posteriorly as shown by the cadaveric studies before its clinical application

since 1981.

Dr. med. Thomas Stähelin - von Büren orthopädische Chirurgie und Traumatologie des

Bewegungsapparates FMH

St. Klara-Rain 1 CH-6370 Stans Tel 041 610 33 33 Fax 041 610 09 58

Skype thomasstahelin

Preface

I have been mainly motivated and inspired to write this small book,because of a Technical Note:Iyer KM.Technical note on Modified Posterior Approach to the Hip Joint.Journal of Orthopaedic Case Reports 2015 Jan-March;5(1):69-72.

The 1st foreword for this 2nd book THE HIP JOINT has been kindly given by my esteemed

Professor George Bentley,M.B,Ch.M,D.Sc,FRCS(ENG),FRCS(ED),F.Med.Sci.

Incidentally,I am also writing a detailed 2nd book entitled THE HIP JOINT,listing the recent trends in Orthopaedics prevailing all around the world.

Emeritus Professor and Director.Institute of Orthopaedics and Musculo-Skeletal Science.

University College London.

Honorary Consultant Orthopaedic Surgeon,Royal National Orthopaedic Hospital,London.

Professor of Orthopaedic and Accident Surgery and Consultant Orthopaedic and Spinal Surgeon,

University of Liverpool and Royal Liverpool and Children's Hospitals,

SICOT,1972 – Present (43 years).

Chairman of Scientific Publications-EFORT

Editor-in Chief of

1).European Surgical Orthopaedics and Traumatology-in 7 volumes-Published June 2014-

Springer,Heidelberg.

2).Instructional Course Lecture Series of EFORT -Annually-2009 to present-

Springer,Heidelberg.

Professor George Bentley knew me and late Geoffrey V Osborne very well and hence this is a

fitting tribute to him.

The 2nd foreword has been kindly given by Dr.S Terry Canale MD.Harold B Boyd Professor and

Chair,Department of Orthopaedic Surgery,Campbell Clinic, Campbell Foundation,1211

Union Avenue, Suite 510,University of Tennessee,Memphis, TN 38104, a book

which is likened as the Bible in Orthopedics,because my original research on the Hip

Joint,first came out in that book in its 9th Edition in 1992 till the 12th Edition today.

This modification also gives the younger aspiring Orthopedic Surgeons an opportunity to study the evolvement of the Modified Posterior Approach to the Hip Joint.

This term entitled `Modified Posterior Approach to the Hip Joint’,has been coined by my respected teacher (Mr.F.H.Beddow) Senior Consultant Orthopaedic Surgeon,University of Liverpool,UK,and has been mentioned as an article in Rheumatoid Arthritis Surgical Society(1990)-Reference No.13:Clinical Experience with the Iyer modification of the Posterior Approach to the Hip: F.H.Beddow and C.Tulloch, J.Bone Joint Surg(BR) 1991,73B,Supp II:164-165,when he described his experience on 220 Total Hip Replacements done by this approach.

I have mainly written this preface in memory of late Mr.Geoffrey V Osborne,who was like a fatherly figure to me.After his retirement from the University of Liverpool,he was busy writing a thesis for his PhD in printing from the University of Liverpool,UK,which he managed to get in the end.

During his later years just before his retirement,he was extremely keen to propagate his approach and nicknamed it as the `Liverpool Approach’ along with Professor Robert Owen.

I had worked with him at Southport and at the Royal Liverpool Hospital in the city of Liverpool,UK,when Professor George Bentley was the newly appointed Professor of Orthopaedic and Accident Surgery at the University of Liverpool,UK,before he moved down to the Royal National Orthopaedic Hospital at London.He was friendly and affectionate in life and very humourous in nature.I have visited his palatial house at Southport which is about 20 miles from the city of Liverpool on numerous occasions for various reasons and his wife was extremely affectionate to look after us,when we visited his house.

He inspired me with his approach and knowledge of Orthopaedics,that is unforgetable,and I would not have followed his footsteps,had it been for him.I just have hallucinations that he is very much present there and I am sharing with him the joy of being in India.He was a patron of the Indian Orthopedic Association and he patiently listened when I presented my original research on the Hip Joint ,done in Liverpool,with my respected teacher and late Dr.Rasik M.Bhansali who was the chairman at the Conference of the Association of Surgeons of India in December 1982.

Above all,I must thank Mr.Santosh Kumar,Project Manager of Notion Press,Chennai,India for his patience in enlightening me in detail about the Guided Self Publishing Process for my book.

I highly appreciate the help of my son,Mr.Rohit Iyer in the presentation and publication of this book.

K.Mohan Iyer

Karnataka,India

M.Ch.Orth(Liverpool,UK),M.S.Orth.(Bom),

F.C.P.S.Orth.(Bom),D’Orth.(Bom)MBBS(Bom)

MODIFIED POSTERIOR APPROACH TO THE HIP JOINT

Numerous new Approaches to the Hip Joint are described since the 1990’s and they are mostly based

on older approaches which have been modified to a specific purpose or for a specific reason.The

approach is based on the access needed,the potential for complications,the purpose for which it is

needed along with the experience of the Surgeon.The basic need is the requirement to maintain the

primary blood supply to the femoral head from the medial femoral circumflex artery and its ascending

branches.In Total Hip Arthroplasty,disruption of the ascending branches is of no consequence,while in

Hip Resurfacing or Osteotomy,the anterior,anterolateral ,lateral or medial approaches are more

preferred in order to prevent osteonecrosis of the femoral head.The lateral approaches,which require

osteotomy which have a significant nonunion rate should also be taken into account.Overall the

Surgical approaches to the hip may be broadly classified as:

anterior; anterolateral; lateral; posterior; medial; lateral subtrochanteric and proximal femoral

shaft(Refr.No:1)

Posterior Approach is normally preferred when the viability of the femoral head is not required,such

as Resection Arthroplasty or insertion of a proximal femoral prostheses.However when the viability of

the femoral head is necessary as in Hip Resurfacing Arthroplasty or fracture repair,the medial

circumflex artery and its ascending branches must be protected.The piriformis,Obturator internus and

the gamelli must be separated well away from the posterior aspect of the greater trochanter and the

attachments of the Obturator externus and quadratus femoris must be preserved.

Gibson was mainly responsible for the description of the posterolateral approach,which was first

described and recommended by Kocker and Langenbeck,since detaching the gluteal muscles from the

ilium resulting in interference with function of the Iliotibial tract is unnecessary , and hence post-

operative recovery is rapid.Another modification of the Gibson Approach where the Hip Joint is

dislocated by internal rotation,thus preserving the anterior part of the joint capsule and preventing

the dislocation of the Hip joint post-operatively anteriorly was described by Marcy and Fletcher,for

insertion of prostheses.The conventionally known `Southern Approach’ was developed by Austin

Moore in 1957,and was called so partly because it utilized the lower part of the Kocker procedure and

partly because of its origination by him in the Southern States of America.It is essentially similar to the

Kocker and Gibson Approaches,with the important differences that the Gluteus Medius and Minimus

being not detached from the greater trochanter and that the Hip is dislocated by medial rotation

rather than by lateral rotation.

A number of approaches are classified as posterior. They range from the extensive Henry approach

which releases the gluteus maximus from the iliac crest, the iliotibial band and the femoral shaft to

essentially expose all of the posterior structures to the limited muscle splitting approach of Ober for

drainage of the hip joint.

All the Posterior Approaches have in common the posterior retraction of the gluteus maximus to

enter the posterior aspect of the hip and the release or section of the short external rotator muscles

to enter the hip joint.

The posterior approach to the hip joint has enjoyed varying degrees of popularity among orthopedic

surgeons over the past 125 years. There is general agreement that the posterior approach offers the

advantages of reduced blood loss, early post-operative recovery and a reduced hospital stay. The

main arguments against the use of posterior approach are an increased risk of dislocation following

hip replacement surgery(Refr No:2)

In spite of well-fixed, well-aligned components, bearing exchange has a high risk of chronic instability,

which may be attributed to the resection of stabilizing soft tissue structures to gain exposure. This

creates a difficult situation for the surgeon and an inexplicable one for the patient with a previously

well-functioning implant. The senior author modified a technique previously described by Shaw that

included an osteotomy of the posterior one third of the greater trochanter and preservation of

posterior soft tissues. Thirty-five patients underwent 47 revision procedures utilizing this approach,

including 16 modular component and 31 more extensive procedures. There were no dislocations or

significant complications and no loss of reduction or nonunion. The approach offers excellent

exposure while preserving stabilizing soft tissues.(Refr.No:3)

Based on the results of their study, there appears to be statistical difference between the two groups,

that is bipolar being better in functional aspects. The results of our study showed that the incidence

of complications were lower after bipolar hemiarthroplasty.(Refr.No:4)

Posterior surgical approaches leave the abductors undisturbed but have been associated classically

with a higher rate of postoperative instability. Over the last decade, there has been a growing

interest in modifying the posterior approach in order to decrease instability rates.

Although some authors have suggested that the higher instability rate associated with the posterior

approach is related to poor positioning of the acetabular component , several cadaveric and clinical

studies suggest that the integrity of the posterior soft-tissue structures is the critical factor for early

stability after arthroplasty through a posterior approach.

The posterior approach is the most common and practical of those used to expose the hip joint.

Popularized by Moore, it is often called the southern approach.

All posterior approaches allow easy, safe, and quick access to the joint and can be performed with

only one assistant. Because they do not interfere with the abductor mechanism of the hip, they avoid

the loss of abductor power in the immediate postoperative period. Posterior approaches allow

excellent visualization of the femoral shaft, thus are popular for revision joint replacement surgery in

cases in which the femoral component needs to be replaced.(Refr.No:5)

Because access to the joint involves division of the posterior capsule, if dislocation of any prosthesis

occurs, it will result from flexion and internal rotation of the hip. Thus, there may be a higher

dislocation rate than that from anterior approaches if the posterior approach is used in fractured neck

of femur surgery in elderly bedridden patients who often lie in bed with their hips in a flexed and

adducted position.

The author’s original paper written over 30 years ago presented an original technique devised to

confer greater stability to the hip joint posteriorly to minimize the greater incidence of dislocation

which has been reported extensively in literature.(Refr.No:6)

CADAVERIC STUDY:

The purpose of the study with cadavers was mainly to compare, with respect to stability of the hip

joint, this approach with that after the Southern Approach as described by Austin Moore (1957).The

strength of fixation of the reattached trochanter was assessed by applying the standard dislocation

manoeuvre.

Three cadavers were obtained within 18 hours of death and in each both the hips were exposed. On

one side the Southern approach was used and on the other side this posterior approach. A soft top

uncemented Monk’s prosthesis was inserted into each hip (6 in all) and closure was carried out as far

as the fascial layer, which was left open to expose the reattached lateral rotators. The pelvis was fixed

to a device which measured the ranges of flexion and extension, adduction and abduction and

internal and external rotation of the hip being tested.(Figs: 1 & 2) Torque was applied in internal

rotation when the hip was held at a fixed angle of flexion and adduction(Fig:3) The corresponding

angle of internal rotation obtained with the torque applied was recorded when the sutures broke or

the hip dislocated.

In 2 cadavers the hips exposed by this approach withstood the maximal torque applied(68 Newton

metres, Nm) without any dislocation or disruption of the trochanteric fixation while in the hips

replaced by the Southern approach disruption of the sutures in the lateral rotators occurred between

40 to 50 Nm,with dislocation of the prosthesis. In one cadaver the hip exposed by the Southern

approach disrupted at 30 Nm with breakage of all sutures in the lateral rotators together with

dislocation of the prosthesis, while the other hip exposed by this approach withstood a torque of 50

Nm after which it dislocated, leaving the trochanteric fixation and the sutures in the gluteus medius

intact.

Thus it was found that in all 3 cadavers the forces required to dislocate the hip and disrupt the

reattachment of the lateral rotators were considerably more using this new approach than with the

Southern approach, thereby confirming the greater posterior stability of the recommended

modification.

Figure 1:Device used to test stability of the hip joint showing pelvis fixed and protactors to measure

the angle of flexion/extension, adduction/abduction and internal/external

rotations(Courtesy:Photograph reproduced with the kind permission of Injury/Elsevier)

Figure 2:Device used to test stability of the hip joint showing pelvis fixed and protactors to measure

the angle of flexion/extension, adduction/abduction and internal/external

rotations(Courtesy:Photograph reproduced with the kind permission of Injury/Elsevier)

Figure 3:Internal rotation torque being applied when the hip joint was standardized to a fixed angle of

flexion and adduction (Courtesy:Photograph reproduced with the kind permission of Injury/Elsevier)

Clinical Technique:

The patient is placed on the sound side. The skin incision extends from just distal and lateral to the

posterior superior iliac spine towards the lateral edge of the greater trochanter, with a curve in the

direction of the fibres of gluteus maximus, and extends down the shaft of the femur for about 10 cm.

The gluteal fascia and the ilio-tibial tract are exposed; the deep fascia incised vertically in the lower

part of the incision and the incision is curved upwards through the middle of the fibres of gluteus

maximus.

The muscles now seen converging on the greater trochanter from above downwards are gluteus

medius; piriformis; obturator internus, flanked by the superior and inferior gaemelli; quatratus

femoris, and the upper edge of the adductor magnus. All these muscles lie edge to edge, with the

sciatic nerve well away from the insertion of the short lateral rotators(Fig.No:4)

Fig.4:Line Diagram showing the osteotomy of the posterior overhanging part of the greater

trochanter:(Courtesy:Line Diagram reproduced with the kind permission of Injury/Elsevier):A,Gluteus

maximus;B,Gluteus medius;C,piriformis;D,triradiate tendon;E,quadratus femoris;F,sciatic

nerve;G,greater trochanter,H,osteotome

The posterior border of the gluteus medius in the upper part and the quadrate tubercle with the

lower border of the quadrate femoris in the lower part are then identified.

The greater trochanter is cut through so that the detached part includes the insertion of the following

structures. From below upwards these are quatratus femoris, obturator internus with the inferior and

superior gaemelli, piriformis and the posterior third of the fibres of the gluteus medius. The

osteotomy extends from the junction of the posterior third and anterior two-thirds of the lateral

border of the greater trochanter obliquely downwards and posteriorly to the shaft of the femur just

distal to the quadrate tubercle.(Fig.No:5)

Fig.5:Line Diagram showing the osteotomy completed and the flap retracted. (Courtesy:Line Diagram

reproduced with the kind permission of Injury/Elsevier);A,Gluteus maximus;B,gluteus

medius;C,piriformis;D,triradiate tendon;E,quadratus femoris;G,greater trochanter

The posterior triangular flap containing the overhanging posterosuperior part of the greater

trochanter at its apex is then dissected free and turned down to expose the capsule of the hip

joint.(Fig.No:6) The capsule is then incised to expose the joint(Fig.No:7)

Fig.No.6:Line Diagram to show that the Osteotomy is completed and the flap retracted,after incising

the capsule to expose the Hip Joint,(Courtesy:reproduced with the kind permission of Injury/Elsevier)

Line diagram showing the following structures:A,gluteus maximus,B,gluteus

medius;C,piriformis;D,triradiate tendon;E,quadratus femoris;G,greater

trochanter;I,acetabulum;J,femoral head

Fig.No.7: Photograph showing Capsule of the Hip Joint incised to expose the

joint.(Courtesy:Photograph reproduced with the kind permission of Injury/Elsevier)

Iyer,Shatwell and Elloy(Refr.No:7) reported on early results in 44 patients who had a hemiarthroplasty

done with no dislocation in this series.

The weakest part of the Hip Joint is the posterior envelope which contains the short lateral

rotators.This point has been reinforced by various authors on dislocation of the Hip Joint.

There are certain anatomical variations in the tendons of piriformis and obturator

internus which could result in piriformis sparing approaches to the hip(Refr.Nos:8 & 9)

the most posterior margins of the piriformis and obturator internus

attachments are located more than one-third of the way along the greater trochanter, suggesting that

osteotomies would not include these external rotators in the majority of cases.

A modified dorsal approach with osteotomy of a bone shell with the attached short external rotator

muscles which are resutured, is described. The advantages have been less dislocations, less sciatic

nerve injuries, and an increased operative access.(Refr.No:10)

The Modified Posterior Approach follows the anatomical intermuscular plan and permits full exposure

of both the proximal femur and the acetabulum. Compared to the literature, preserving the piriformis

tendon seems to be superior to repairing it as is done in the Southern Approach in terms of

dislocation of the Endoprosthesis or THR.

They vary mainly as to whether the deep posterior compartment is entered by incising the iliotibial

band and the gluteus maximus muscle in line with the axis of the shaft, or by separating the muscle

fibres of the gluteus maximus proximally. They also vary depending on whether the abductors are

released from the greater trochanter and, if released, whether the tendinous attachment is

transected or the greater trochanter is osteotomized.

Almost all of the Posterior approaches have the option to release the abductors, depending on the

need for added exposure.

Mark Coventry did concur with the concept of this approach in imparting more stability posteriorly

postoperatively,as compared to all other posterior approaches to the hip joint described since

1874,which either divide the short external rotators or pass between them which thereby increase the

risk of postoperative dislocation of the hip.(Refr.No:11)

Hedley et al have devised a modification of the posterior approach to the hip joint in which the

short lateral rotators are resutured during closure of the hip joint.However they do not have any

experience with this approach.(Refr.No:12)

After I described this Approach,it was quite encouraging that my respected teacher(Mr.F.H.Beddow)

in Liverpool,UK did a series of 220 Primary Total Hip Replacements by my technique and noted only 2

dislocations throughout his series.

Beddow and Tulloch reported on their experience using this approach in 220 cases of primary total

hip replacement in which there were only 2 cases of dislocation(Refr.No 13)

James Shaw mentioned the usefulness of this approach in complex primary cases and revision hip

surgery stressing on the excellent exposure of the acetabulum and femoral shaft,while eliminating

many of the problems associated with other techniques.He described his own experience by

reattaching the trochantric fragment with 2 lag screws.He did stress this approach gives an excellent

exposure of both the acetabulum and femur without dissection through scarred anterior or posterior

soft tissue planes or forceful retraction on adjacent tissues and that the potential for damage to the

sciatic or femoral nerves or femoral vessels is considerably less.He also noted the obvious advantages

to postoperative function as the muscle insertions of the short lateral rotators are

undisturbed,thereby restoring hip stability and leaving an intact and considerably uncompromised

envelope of soft tissues on the prosthetic joint.(Refr.No:14)

Terry Canale (Campbell’s Operative Orthopaedics,9th Edition,1992) does make a reference to this

approach in their chapters on Surgical Approaches and Complications after Total Hip Arthroplasty

with respect to dislocations.(Refr.No:15)

Callaghan,Rosenberg and Rubash(The Adult Hip,1998) mention the advantages of preserving the

original soft tissue attachments of the posterior aspect of the hip joint,as obtained with this

approach.They also stress on the excellent exposure of both the acetabulum and femoral shaft

achieved with this approach in being applicable to both revision arthroplasty and complex primary

arthroplasty.(Refr.No:16)

Thomas Stahelin et al(2002) have stated that the failure rate of reinserted short lateral rotators was

extremely high at 70% with majority of failures occurring within the first postoperative day.They also

concluded that bone to bone reattachment as done in this approach is more secure,as proved by the

cadaveric study.(Refr.No:17)

Deepa Iyer(2006) was fascinated by this Orthopaedic Dilema in the elderly that she studied this

fracture in detail and noted its importance for the junior doctors in training,thereby decreasing

morbidity by early diagnosis and treatment. (Refr.No:18)

Robert H.Cofield(2010) of Mayo Clinic in Rochester,Minnesota,USA has been using this approach for

the last 25 years with no regrets.He is extremely happy using this approach since I presented it during

the Scientific Congress of the AseanOrthopaedic Association in Singapore in 1984.(Refr.No:19)

Mayo Clinic conducted a study of 68 consecutive cases by the Modified Posterior Approach to the Hip

Joint.There were no cases of late instability. Posterior approach to the hip joint through a

posterior trochanteric osteotomy is associated with high union rates and a low rate of late instability

after hip replacement.(Refr.No:20)

They concluded one disadvantage of the posterior trochanteric osteotomy is the potential for injury to

the superior gluteal nerve if the gluteus medius muscle split is extended proximally more than 5 cm

from the tip of the trochanter.

The Posterior approach that Moore popularized, and which is often referred to as the "Southern

approach", is a variation of the original Henry approach and of the modifications subsequently made

by Kocher, Osborne and Gibson.

The Moore approach is the most commonly used approach for endoprostheses, total hip arthroplasty,

open reduction of hip dislocation, removal of loose fragments in the joint, repair of acetabular

fractures, drainage of the hip and vascular muscle pedicle graft procedures.

Here the capsule is sectioned along with the short lateral rotators to gain entry into the Hip

Joint,thereby leaving the closure of the Hip Joint vulnerable to dislocation.

In procedures in which the femoral head is not sacrificed, such as drainage of the hip, reduction of a

posterior dislocation, removal of fragments from the joint, repair of acetabular fractures, or

resurfacing procedures, special care must be taken to avoid injury to the medial circumflex and

retinacular vessels.

The short external rotator muscles are sectioned close to the edge of the acetabulum, rather than at

the insertion in the trochanter, and the capsular incisions are made near the acetabular edge rather

than near the attachment of the capsule to the neck. The medial circumflex vessels are at risk during

the dissection near the attachment of the psoas tendon to the lesser trochanter .

In the Modified Posterior Approach to the Hip Joint,bleeding is minimal,because the plane of cleavage

through the gluteus maximus is through its middle thus leaving intact the branches of the superior

gluteal artery in the proximal half and branches of the inferior gluteal artery in the distal half,and

hence there is no need to worry about the amount of blood lost.Bleeding is further reduced as the

leash of vessels which lies at the inferior border of the short lateral rotators is neither cut nor

handled.

The most important advantage is that the sciatic nerve is not isolated at any step in this approach,as

corresponding to the level of the greater trochanter,it lies well medially.Above all,it is firmly held

between the piriformis tendon and the triradiate tendon,when the greater trochanter is turned

posteriorly,thereby preventing any movement of the nerve.

With this modified posterior approach to the Hip Joint,the gluteus medius is neither cut at its origin

nor insertion,thereby leaving the abductor mechanism intact.

In this Modified Posterior Approach,Union of the trochanteric fragment should normally occur,as it is

through cancellous bone and in close proximity to the anastomosis in the trochanteric fossa.

The concept of trochanteric osteotomy was mainly used in difficult exposures and soft tissue

tensioning. Contemporary THA accentuates a streamlined approach to surgery and recovery while

maximizing long-term success. Hamblin estimated that 10% to 20% of hips require TO for restoration

of normal joint anatomy(Refr.No:21).Rates of trochanteric osteotomy reflect geographic trends and

surgeon preferences. Trochanteric Osteotomy techniques can be generally divided into standard,

slide, and repeat osteotomy groups.The standard osteotomy may be oblique or posterior. The

standard TO was originally popularized for use in hip arthroplasty by Charnley(Refr.No: 22 ).After

exposure of the hip, a Cushing elevator is inserted from anterior to posterior in the interval between

the tendon of the gluteus minimus and the superior part of the hip capsule. Next, the origin of the

vastus lateralis is elevated from the vastus tubercle. The osteotomy cut traverses the sulcus between

the lateral portion of the origin of the vastus intermedius muscle and the insertions of the gluteus

medius and minimus. The osteotomy is started 1 cm distal to the vastus tubercle and is performed

with an oscillating saw or osteotome, which is aimed at the Cushing elevator(Refr.No:23)

Complications of trochanteric osteotomy can be divided into two broad categories: those related to

osteotomy healing and those related to the mode of fixation. Nonunion or a fibrous union of the

trochanter is not necessarily a complication with clinical significance.[If the trochanter does not heal

by bony bridging , however, associated issues of pain, hardware breakage, or abductor dysfunction

may manifest as impaired gait, Trendelenburg lurch, subluxation, or dislocation of the hip

replacement. Even when union of the trochanter occurs, the patient may still have problems.

Trochanteric pain and bursitis may be related to a prominent trochanter or to irritating hardware.

Fraying and breakage of hardware can lead not only to pain, but also to wear and the need for early

revision.

In comparison to the conventional sliding trochanteric or extended trochanteric approach,which

are more helpful by improving biomechanics of the abductor mechanism in work done on in difficult

primary total hip replacement,or failed total hip replacements and in well fixed stem components or

in previously osteotomised trochanters.,this modification is adequate to carry out routine work on

the hip joint.

Though Surgeons may adopt any approach to the hip joint in which they are familiar or trained,this

modification may be helpful when the greater trochanter is intact in cases when treating a dislocated

hip joint,when the blame for the dislocation may be avoided on the posterior approach to the hip

joint.

Instability following weakening of the already weak posterior capsule and short lateral rotators of the

Hip leading to dislocation has been a cause for concern and controversy in the past.The main purpose

of this modification is to overcome this danger and yet retain the advantages of the posterior

approach.

Bleeding is slight in this approach because the plane of cleavage through the gluteus maximus is

through its middle,which leaves intact the branches of the superior gluteal artery in its proximal half

and branches of the inferior gluteal artery in its distal half.The blood loss is reduced considerably,as

the leash of blood vessels which lies at the inferior edge of the lateral rotators is neither cut nor

handled.

The other advantage is that the sciatic nerve need not be isolated at any step in this modification,and

corresponding to the level of the greater trochanter the sciatic nerve lies well medially.Secondly,it is

held between the piriformis and the triradiate tendon when the greater trochanter is turned

posteriorly,thus preventing movement of the nerve.

Union of the trochanteric fragment should occur because the osteotomy is through cancellous bone

and in close proximity to the anastomosis in the trochanteric fossa.

With this modification,though turned aside,the gluteus medius is cut neither at its insertion nor its

origin,thus leaving the abductor mechanism intact.

There are certain disadvantages which we have to bear with and which is not in every case treated

by this modification,such as heterotrophic ossification,trochantric Osteotomy where the bone takes

more time to unite resulting in non-union or fibrous union along with greater trochantric bursitis and

also breakage of the wires.

Certain unsolved controversies still exist with regards Trochanteric Osteotomy as follows:-

1) Although the indications of exposure and soft tissue tensioning are well accepted, the exact

application of these indications is somewhat controversial.2)Greater trochanteric osteotomy is

rarely used in contemporary hip replacement, and its application is likely related to both the type

of surgery and the surgeon's predisposition.

3) Some surgeons apply the approach more liberally than others. Likewise, the type of internal

fixation needed to maximize healing is not universally agreed upon.

4) Based on newly available literature, I would recommend avoiding or removing multifilament

cables; this advice will likely be considered controversial.5)Various options are available, and

surgeon preference dominates their application

6) Also, newer unproven technologies such as locking plates and nonmetallic tensioning wire may

prove beneficial, but objective studies will be required if their usage is to be endorsed.

In this method of Modified Posterior Approach to the Hip Joint(Refr.No:24),the fixation is carried

out in a simple manner using two gauge 18 wires to hold the trochanteric osteotomy and

reconstitute the Hip Joint.(Fig.No.8)

Fig.No.8:Photograph showing Trochanter re-attached back with two stainless steel wires to

reconstitute the Hip Joint.(Courtesy:Photograph reproduced with the kind permission of

Injury/Elsevier)

References:

1. Surgery Exposure Hip by R. CALANDRUCCIO

In: Atlas of Orthopaedic Surgery Editors: Laurin, CA, Riley Jr. LH, Roy-Camille R,1991,

Volume 3. Lower Extremity;

2. An Extensile Posterior Exposure for Primary and Revision Hip Arthroplasty by C. S. Ranawat, V.

J. Rasquinha, A. S. Ranawat, K. Miyasaka,Minimally Invasive Total Joint Arthroplasty, 2004, pp 39-

46.

3. Oblique Posterior Trochanteric Osteotomy in Revision Total Hip Arthroplasty by Steven A.

Stuchin, MD & Jennifer S. Millman, BS The Journal of Arthroplasty Volume 26, Issue 3 , Pages 472-

475 , April 2011

4. Treatment of Femoral Neck Fractures: Unipolar Versus Bipolar Hemiarthroplasty,by

Somashekar, MS, Sathya Vamsi Krishna, MS, Sridhara Murthy JN, MS,in Malaysian Orthopaedic

Journal 2013 Vol 7 No 3.

5. Stanley Hoppenfeld, Piet deBoer, and Richard Buckley: Surgical Exposures in Orthopaedics: The

Anatomic Approach, 4th edition(2009)

6. A New Posterior Approach to the Hip Joint – K.Mohan Iyer,

Injury,1981,13,76-80.

7. Experience with Thompson’s prosthesis using the New Posterior

Approach – K.Mohan Iyer,M.A.Shatwell and M.A.Elloy,

Injury,1982,14, 243-244.

8. Piriformis and obturator internus morphology: a cadaveric study. Clinical Anatomy 01/2011

24(1):70-6.

9. INCIDENCE OF PIRIFORMIS TENDON PRESERVATION ON THE DISLOCATION RATE

OF TOTAL HIP REPLACEMENT FOLLOWING THE POSTERIOR APPROACH

A Series of 226 cases*

http://www.lebanesemedicaljournal.org/articles/60-1/original3.pdf

Charbel D. MOUSSALLEM1, Fadi A. HOYEK2, Jean-Claude F. LAHOUD3

10. Modified technique in the dorsal approach in total hip arthroplasty

Ragnar Johnsson, Einar Hallin, Bertil Nordström, Lars Lidgren

Archives of Orthopaedic and Trauma Surgery. 09/1981; 99(1):43-45. DOI: 10.1007/BF00400908

11. Mark B.Coventry,The Year Book of Orthopaedics ,1982,371-373

12. A Posterior Approach to the Hip Joint with complete posterior

capsular and muscular repair:Hedley et al,The Journal of

Arthroplasty,1990,Vol.5,Supplement,October 1990:S 57 to S 66.

13. Rheumatoid Arthritis Surgical Society-Clinical Experience

with the Iyer modification of the Posterior Approach to the Hip:

F.H.Beddow and C.Tulloch,J.Bone Joint Surg(BR) 1990,73B,

Suppl II:164-165.

14. Experience with modified Posterior Approach to the Hip Joint.A

Technical note:Shaw J.A:J Arthroplasty,1991,Vol.6,No.1:11-18.

15. Campbell’s Operative Orthopaedics, S.TerryCanale(1992),NinthEdition,Volume 1,

Pages:140,387,466.

16. Callaghan,Rosenberg and Rubash The Adult Hip(Lippincott-Raven),1998,Volume 1,

Pages:700-701,718.

17. Failure of Reinserted Short External Rotator Muscles after Total

Hip Arthroplasty-Thomas Stahelin,P.Vienne and O.Hershe

The Journal of Arthroplasty,2002,Vol.17,No.5:604-607.

18.Deepa Iyer The Orthopaedic Enigma:A Simplified Classification.The Internet Journal of

Orthopaedic Surgery,2006,Vol 3,Number 2.

19.Cofield H.Robert.(2010)Personal Communication.

20. Primary hip arthroplasty through a limited posterior trochnteric osteotomy-JaoquinSanchez-

Sotelo,John Gipple,Daniel Berry,Charles Rowland,Robert Cofield(2005)Acta Orthop Belg.,71,548-

554

21.Hamblin DL: Complications of trochanteric osteotomy. In: Ling RSM, ed. Complications of

total hip replacement, New York: Churchill Livingstone; 1984.

22.Charnley J: The long-term results of low-friction arthroplasty of the hip performed as a primary

intervention. J Bone Joint Surg Br 1972; 54:61.

23. Charnley J: Arthroplasty of the hip: a new operation. Lancet 1961; 1:1129.

24.Iyer KM.Technical note on Modified Posterior Approach to the Hip Joint.Journal of

Orthopaedic Case Reports 2015 Jan-March;5(1):69-72