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Hip Medial Approach

(OBQ09.16) Tenotomy of which muscle performed during an anteromedial approach for surgical
reduction of a congenitally dislocated hip places the medial femoral circumflex artery at risk?
Review Topic
1.

semimembranosus

2.

biceps femoris

3.

iliopsoas

4.

rectus femoris

5.

sartorius
PREFERRED RESPONSE 3
Weinstein and Ponseti suggested that the anteromedial approach provides "a safe, effective way to
reduce a dislocated hip in infancy". The superficial plane is between gracilis and adductor longus.
The deep plane is between adductor brevis and adductor magnus. During this approach, the
iliopsoas tendon can be released, but should be fully exposed above and below the lesser trochanter
so as not to injure the medial femoral circumflex artery.

(OBQ08.18) Following an uneventful medial approach to the hip, the iliopsoas tendon is released.
Which of the following neurovascular structures is most at risk during release of the tendon?
Review Topic
1.

obturator nerve

2.

obturator artery

3.

femoral artery

4.

medial femoral circumflex artery

5.

sciatic nerve

PREFERRED RESPONSE 4
The medial approach to the hip gives excellent exposure to the insertion of the psoas tendon on the
lesser trochanter. The medial femoral circumflex artery is at risk when performing a psoas release
with this approach.
The medial approach to the hip involves utilizing the interval between adductor longus and gracilis,
then adductor brevis and magnus in order to arrive at the lesser trochanter, psoas tendon, and hip
capsule. The medial femoral circumflex artery branches off the profundus femoris (~85%) or femoral
artery (15%) and then wraps posterior to the iliopsoas tendon before traveling posterior to the

femoral neck to supply the femoral head.


Gautier et al. found from a cadaveric study on 24 hips that the MFCA originated from the profunda
femoris in 20/24 specimens, while the origin of the MFCA was the common femoral artery in 4/24 of
the specimens.
Illustration A and B shows the surgical plane of the medial approach to the hip as it accesses the
lesser trochanter. Illustration C shows the anatomy of the Medial femoral circumflex artery in relation
to the iliopsoas tendon and medial approach to the hip.
Incorrect Answers:
Answer 1: The obturator nerve is a more superficial structure. While it is seen during the approach, it
is not in the vicinity of the iliopsoas tendon.
Answer 2: The obturator artery lies within the pelvis.
Answer 3: Although the femoral artery can be the origin of the MFCA, it is a more superficial
structure and is not exposed during this approach.
Answer 4: The sciatic nerve is a posterior structure and not seen in this exposure.

Stoppa Approach to Acetabulum


(OBQ13.112) When performing an anterior intrapelvic approach to the acetabulum, ligation of the
anastamoses between the obturator vessels and which of the following vessels should be performed
to gain appropriate access to the true pelvis? Review Topic
1.

External iliac vessels

2.

Internal iliac vessels

3.

Superior gluteal vessels

4.

Femoral vessels

5.

Femoral cutaneous vessels

PREFERRED RESPONSE 1
The Stoppa, or anterior intrapelvic approach, requires ligation of the corona mortis (defined as the
vascular connections between the obturator and external iliac systems) to gain visualization laterally
and into the true pelvis.
The corona mortis is located behind the superior pubic ramus at a variable distance from the
symphysis pubis. The name "corona mortis" or crown of death testifies to the importance of this
feature, as significant hemorrhage may occur if inadvertently cut and it is difficult to achieve
subsequent hemostasis.
Tornetta et al. performed a cadaveric dissection to determine the occurrence and location of the
corona mortis. They found that an anastomoses between the obturator and external iliac systems

occurred in 84% of the specimens. Thirty-four percent had an arterial connection, 70% had a venous
connection, and 20% had both.
Archdeacon et al. discuss the indications, set-up, and technique for the Stoppa approach to the
pelvis. They state that the vascular anastomoses between the external iliac and obturator vessels
are encountered as the artery and vein course over the superior ramus traveling toward the
obturator foramen. They state that these vessels must be ligated or clipped to advance the
dissection further along the pelvic brim and quadrilateral surface.
Illustration A shows the corona mortis as an anastomoses between the obturator and external iliac
vascular systems.
Incorrect Answers:
Answers 2-5: These do not typically anastomose with the obturator vessels.
(OBQ10.53) A 55-year-old male involved in a motor vehicle collision sustains an acetabular fracture.
Which of the following approaches would provide the best exposure for open reduction internal
fixation of the displaced fragments seen on the 3-D CT image in Figure A?

1.

Modified Stoppa approach

2.

Extended Iliofemoral

3.

Kocher-Langenbeck

4.

Medial window of the ilioinguinal

5.

Simultaneous anterior and posterior exposure

PREFERRED RESPONSE 1
Figure A represents an acetabular fracture pattern with medial displacement of the quadrilateral
plate. Limited bone stock and anatomic access create a surgical challenge to treat these fractures.

Both an ilioinguinal and modified Stoppa approach allow access to this area. However, use of the
Stoppa approach often allows the middle window of the ilioinguinal approach to be avoided, resulting
in minimal dissection of the inguinal canal, femoral nerve, and external iliac vessels.
Cole et al discuss their initial experience using the modified Stoppa approach for fixation of
acetabular fractures. Of the 55 fractures treated, 89 % of the post operative radiographs had either
an excellent or good rating.
Qureshi et al discuss their technique for infrapectineal plating that allows for stable fixation by
resisting medial displacement through the quadrilateral surface.

Tibia Posterolateral Approach


(OBQ08.201) What is the internervous plane for the posterolateral approach to the tibial shaft?
Review Topic
1.

sural and superficial peroneal nerves

2.

saphenous and tibial nerves

3.

sural and saphenous nerves

4.

tibial and superficial peroneal nerves

5.

superficial and deep peroneal nerves


PREFERRED RESPONSE 4
The posterolateral approach to the tibia is a technically demanding approach that is used when the
anterior or anteromedial approaches are not possible due to skin issues. The internervous plane
exists between the gastrocnemius, soleus and FHL muscles posterior (tibial nerve) and the peroneus
longus and brevis anteriorly (superficial peroneal nerve). The neurovascular structures (tibial nerve,
posterior tibial artery, and peroneal artery) are located between the soleus and tibialis posterior.
(OBQ05.102) What two muscles lie on the posterior aspect of the interosseous membrane and tibia
in the lower leg, and must be elevated during a posterolateral approach to the tibia for treating a
nonunion? Review Topic

1.

Flexor digitorum longus and tibialis posterior

2.

Peroneus longus and peroneus brevis

3.

Peroneus brevis and peroneus tertius

4.

Tibialis posterior and tibialis anterior

5.

Tibialis posterior and flexor hallucis longus

PREFERRED RESPONSE 1
The flexor digitorum longus and tibialis posterior lie on the posterior aspect of the interosseous
membrane and tibia. Flexor hallucis longus lies on the posterior border of the fibula.
The posterolateral approach to the tibia is useful to expose the middle two thirds of the tibia, and is
often used when the anterior and anterior medial approaches are limited by skin issues. It is useful
for plating of fractures and treatment of nonunions including bone grafting because it allows for soft
tissue coverage of a bone that is otherwise subcutaneous.
The superficial internervous plane lies between the gastrocnemius/soleus (tibial nerve) and peroneal
muscles (superficial peroneal nerve). The deep dissection involves detaching FHL and soleus from
the posterior border of the fibula and then dissecting medially to separate the posterior tibialis off the
posterior surface of the interosseous membrane and the posterior tibialis and flexor digitorum longus
off the posterior surface of the tibia.
Illustration A shows a cross section of the surgical approach.

Anterior Approach to Cervical Spine


(OBQ06.221) A myelopathic patient undergoes anterior cervical diskectomy and fusion through a left
sided approach. Facial asymmetry is noticed postoperatively in the recovery room. A clinical photo is
shown in Figure A. What additional finding would likely be found on physical exam?

1.

Pupillary dilation and hyperhidrosis on the patient's right side

2.

Pupillary dilation and hyperhidrosis on the patient's left side

3.

Pupillary constriction and hyperhidrosis on the patient's right side

4.

Pupillary constriction and anhidrosis on the patient's left side

5.

Pupillary constriction and anhidrosis on the patient's right side


PREFERRED RESPONSE 4
The patient has a left-sided Horner's syndrome which would be characterized by ptosis, pupillary
constriction and anhidrosis on the patient's left side
Horner's syndrome is a rare but known complication of anterior approaches to the cervical spine.
Horners Syndrome classically presents with 1. ipsilateral ptosis (drooping eyelid caused by injury to
nerve to Mullers muscle) 2. ipsilateral miosis (pupillary constriction caused by injury to long ciliary
nerve to pupil dilator) and 3. usually (but not always) ipsilateral anhidrosis. Horner's Syndrome is
caused by an injury to the cervical sympathetic ganglia/trunk, which are located anterolaterally to the
longus colli and longus capitis muscles. These muscles lie anterolaterally to the cervical vertebral
bodies. Injury to the nerves can occur either during dissection or with aggressive (injudicious)
retraction during an anterior approach to either side of the cervical spine. It has been postulated that
this complication can be avoided if subperiosteal dissection of the longus colli muscles is performed.
Fountas et al. investigated complications associated with anterior cervical discectomy and fusion
(ACDF). They found the incidence of Horner's syndrome was 0.1% (1 of 1140)in patients undergoing
first-time ACDF for cervical radiculopathy and/or myelopathy. The most common complication was
the development of isolated postoperative dysphagia, which observed in 9.5% of patients.
Bertalanffy et al. looked at complications of anterior cervical discectomy without fusion (ACD) in 450
consecutive patients. They reported an incidence of Horner's syndrome in 1.1% of patients. Wound
infection developed in 1.6%.
Figure A shows a patient with left sided Horner's Syndrome. Notice the drooping eyelid and pupillary
constriction on the left relative to the right hand side. Illustration A depicts the anatomic location of
the sympathetic chain in relation to the vertebral bodies.
(OBQ05.53) A 53-year-old female is 8 hours status post the procedure seen in Figure A. You are
called to the room by the nurse who reports the patient is having difficulty breathing. On arrival, you
note that the patient has stridor on inspiration and a firm mass under the incision. What is the most
likely cause of her respiratory compromise?

1.

Postoperative edema

2.

Hematoma

3.

Vocal cord paralysis

4.

Allergic reaction

5.

Laryngospasm
PREFERRED RESPONSE 2
This patient is presenting with respiratory obstruction following a cervical corpectomy. Physical exam
is consistent with a retropharyngeal hematoma as the cause of obstruction. The differential diagnosis
of acute postoperative obstruction of the upper airway includes laryngospasm, hematoma, paralysis
of the vocal cords, allergic reaction and edema. According to the first referenced article by Emery et
al, edema is believed to be the most common cause of postoperative respiratory difficulties. In this
clinical case, the patient has a tense mass under the incision which would not be found with
obstruction caused by edema. Risk factors for respiratory failure as a cause of death were severe
myelopathy and multilevel corpectomy. The referenced article by Roy discussed the importance of
surgical decompression of patients presenting postoperatively with a tense neck mass (hematoma)
and respiratory difficulties.

Extensile (extended iliofemoral) Approach to Acetabulum


(OBQ12.271) A 32-year-old male sustains a complex both-column acetabular fracture and the
operating surgeon decides to utilize an extended iliofemoral approach. The patient should be
counseled that as compared with other surgical approaches to the acetabulum, the extended
iliofemoral approach has the highest rate of which of the following? Review Topic
1.

Fracture union

2.

Malunion

3.

Pudendal nerve palsy

4.

Corona mortis injury

5.

Heterotopic ossification
PREFERRED RESPONSE 5
The extended iliofemoral approach has the highest rate of heterotopic ossification as compared to
other acetabular approaches, which is thought to be due to the extensive muscle release from the
outer table of the pelvis.
The extended iliofemoral approach to the acetabulum is a large, extensile exposure that allows

access to a large area of the pelvis and acetabulum, including the entire lateral aspect of the
innominate bone. This approach is most commonly utilized for complex fractures involving both
columns, or for malunion/nonunion surgeries of the acetabulum. In addition to the risk of heterotopic
ossification, this exposure is also associated with a prolonged patient recovery period and
permanent hip abductor weakness, also secondary to the nature of the exposure.
Griffin et al. reviewed 106 patients operated on using an extended iliofemoral approach with a
minimum follow-up of two years. Fracture reduction was anatomical in 76%, and 64% of patients
reported good or excellent functional outcomes; reduction was correlated with outcome in this
analysis. Significant heterotopic ossification was seen in 30%.
Illustration A shows the approach, with the amount of innominate bone exposure shown in detail.
Incorrect Answers:
1) Fracture union has not been shown to be increased with this particular approach.
2) Return to work is typically delayed in this patient population due to a long recovery period.
3) Pudendal nerve palsy has not been shown to be increased in this approach as compared to the
other acetabular approaches.
4) The corona mortis is not typically injured with this approach, and is usually noted during the
Stoppa approach, where it can be inadvertently injured.
(OBQ04.52) Which isolated acetabular fracture pattern would be most appropriately treated with the
approach shown in Figure A?

1.

Comminuted posterior wall fracture

2.

Posterior wall and posterior column fracture

3.

Transtectal transverse fracture with impacted roof

4.

Anterior column and posterior hemitransverse fracture

5.

Simple posterior wall fracture


PREFERRED RESPONSE 3
Figure A outlines the surgical incision for the extended iliofemoral approach. This approach was
developed by Emile Letournel as a simultaneous approach to both columns of the acetabulum. This
approach exposes the entire lateral innominate bone by posterior reflection of the abductors and

reflection of short external rotators. It can be extended anteriorly into the first iliac window of the
ilioinguinal incision if needed. Indications for this approach include: transverse and T-type fractures
with posterior wall involvement or an impacted roof, both-column fractures with posterior wall or
posterior column comminution, sacroiliac joint involvement, and transverse fractures more than three
weeks old. Disadvantages of this approach include: significant stripping of the bone which can lead
to heterotopic bone formation, and prolonged abductor weakness and recovery period. The incision
starts at the posterosuperior iliac spine, follows the iliac crest to the anterosuperior spine, and then
turns slightly lateral to parallel the femur on the anterolateral aspect of the thigh.
Judet et al review 129 surgically treated acetabular fractures and describe mechanism of injury,
radiographic findings, and options for treatment.
Answer choices 1,2, and 5 are typically treated through a Kocher-Langenbeck approach. Answer
choice 4 is usually treated through an ilioinguinal approach.

Hip Anterior Approach (Smith-Petersen)


(OBQ09.103) What two nerves make up the internervous plane in the Smith-Petersen anterior hip
approach? Review Topic
1.

There is no internervous plane

2.

Femoral nerve and inferior gluteal nerve

3.

Femoral nerve and superior gluteal nerve

4.

Obturator nerve and superior gluteal nerve

5.

Obturator nerve and inferior gluteal nerve


PREFERRED RESPONSE 3
The internervous plane in the Smith-Petersen anterior hip approach is made by the femoral nerve
and superior gluteal nerve.
The anterior Smith-Petersen hip approach uses the superficial internervous plane between the
sartorius (femoral nerve) and the tensor fascia latae (superior gluteal nerve). The deep plane for
access to the hip joint capsule uses the same internervous plane but is between the rectus femoris
(femoral nerve) and the gluteus medius (superior gluteal nerve). In this approach to the hip, one
must be conscious to avoid damaging the lateral femoral cutaneous nerve.
Illustration A and B show the superficial and deep internervous plane.
(OBQ07.263) The ascending branch of the lateral femoral circumflex artery is at risk with which of
the following surgical approaches? Review Topic

1.

Stoppa approach

2.

Kocher-Langenbach approach

3.

Ilioinguinal approach

4.

Watson-Jones approach

5.

Smith-Petersen approach
PREFERRED RESPONSE 5
The ascending branch of the lateral femoral circumflex artery is at risk during the Smith-Petersen
approach to the hip. In this approach, an internervous interval between the femoral nerve (sartorius,
superficial; rectus femoris, deep) and superior gluteal nerve (tensor fascia latae, superficial; gluteus
medius, deep) is utilized.
The ascending branch of the lateral femoral circumflex artery runs proximally in the internervous
plane between the two deep muscles.
Incorrect Answers
Answer 1: http://www.orthobullets.com/approaches/12056/stoppa-approach-to-acetabulum
Answer 2: http://www.orthobullets.com/approaches/12015/posterior-approach-to-the-acetabulumkocher-langenbeck
Answer 3: http://www.orthobullets.com/approaches/12016/ilioinguinal-approach-to-the-acetabulum
Answer 4: http://www.orthobullets.com/approaches/12021/hip-anterolateral-approach-watson-jones

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