![]() | Only 14 pages are availabe for public view |
Abstract Hardinge’s direct lateral (transgluteal) approach to the hip is one of most commonly used surgical approaches for hip arthroplasty. As it gives excellent exposure of the hip joint and a clear operating field. This approach allows good exposure of the acetabulum, facilitating cup positioning which may reduce the risk of hip dislocation and also diminishes risk of injury to the sciatic nerve associated with posterior approach. However, there is a risk of damaging superior gluteal nerve (SGN), with the potential consequence of denervation of the anterior part of the gluteus medius and tensor fascia lata, which causes abductor weakness, pain, and limping (1) The superior gluteal nerve has no sensory distribution and therefore patients do not complain sensory loss and weakness of the abductor muscles is attributed to mechanical rather than to neurological dysfunction. This may occur either through denervation of the gluteal flap, following damage to the inferior branch of the superior gluteal nerve, or by failure to establish reattachment of the flap to the greater trochanter (2). The mechanism of damage of superior gluteal nerve is variable and not completely understood, many authors confirm that excessive proximal extension of the split in the gluteus medius could damage the SGN, excessive traction and compression during the operation might contribute significantly to postoperative nerve dysfunction (1). Hardinge was aware of these problems and cautioned against excessive retraction of the gluteal flap. Jacobs and Buxton advised manual traction which is considered to be safer than the use of the self-retaining retractor. Dall described a modification of the technique, in which a sliver of trochanteric bone is taken with the gluteal flap so as to allow better fixation of the flap to the greater trochanter during closure. Duparc F, Thomine JM described a modification of the transgluteal approach, in which the division of the anterior bundle of the gluteus medius, does not exceed 40 mm, and the safety conditions regarding the inferior branch of the SGN are respected. No anterior detachment of the ”common” tendinous fibers of the gluteus medius, gluteus minimus and vastus lateralis is performed (3). |