Quadriceps Coxae-Sparing Modified Posterior Approach to the Hip Joint for Hemiarthroplasty.

Background: Various approaches have been described for hip arthroplasty Description: The patient is anesthetized and placed in a lateral decubitus position. Bolsters are utilized over the pubis and sacral areas to provide stable pelvic orientation. The contralateral limb is flexed at the hip (∼45°) and knee (90°), with adequate padding under the fibular head and lateral malleolus. Another padded bolster is placed between the legs to keep the topmost lower limb in neutral to slight abduction at the hip. The operative limb is flexed at the hip (∼30°), and a 10 to 15-cm straight skin incision is marked on the lateral aspect of hip, centered on the posterolateral tip of the greater trochanter. The deep fascia is opened distally to proximally, incised distally with scissors, and separated proximally with finger dissection. This step creates an intermuscular plane between the gluteus maximus posteriorly and tensor fasciae latae anteriorly. A Charnley hip retractor is applied. Internal rotation of the hip allows identification of the posterior border of the gluteus medius and short external rotators. The fat pad over the QC is swept medially with an abdominal sponge to identify the muscles. A plane is identified between the quadratus femoris and inferior gemellus. Next, a plane is developed between the QC and posterior hip capsule with use of a blunt hemostat from inferior to superior. Abduction of the hip just beyond neutral relaxes the QC and allows superior retraction. The quadratus femoris is detached from the trochanteric crest with use of a diathermy needle until the lesser trochanter is visualized. A capsulotomy is performed in a lazy L-shaped manner, with the first limb of the incision along the distal margin of the QC and the second along the base of the femoral neck. The second limb of the incision raises the musculocapsular flap consisting of the obturator externus along the osseous margin with use of a diathermy needle. This musculocapsular flap is tagged with sutures, which helps in its retraction posteriorly to protect the sciatic nerve and later aids in repair. Bipolar hemiarthroplasty is performed in a conventional manner. The musculocapsular flap is repaired transosseously, and the wound is closed in a layered fashion. Alternatives: Alternatives to this QC-sparing technique include the use of a conventional posterior approach, piriformis-preserving posterior approach, direct lateral approach, modified lateral approach, or direct anterior approach. Rationale: Preservation of the QC helps improve prosthetic hip stability in internal rotation, possibly because of the preserved proprioception. A minimally invasive approach reduces recovery time during rehabilitation. Preservation of the QC does not hinder visualization or result in component malposition Expected Outcomes: Ball et al. Important Tips: Place a padded bolster between the legs to keep the topmost lower limb in neutral to slight abduction at the hip.Develop a plane between the QC and posterior hip capsule with use of a blunt hemostat or a Cobb elevator from inferior to superior in order to help mobilize the QC and release their capsular attachments.Hip abduction just beyond neutral relaxes the QC and allows insertion of a Hohmann retractor deep to the QC in order to protect and lever them superiorly.A small Langenbeck retractor inserted deep to the QC protects them from shredding during broaching. Internal rotation at the hip beyond 90° (in 90° flexion and neutral adduction/abduction) further protects the QC from harm.