Anterolateral approach for ORIF (femoral neck fractures), possible for prosthesis (neck or head fractures)
1. Preliminary remarks
The anterolateral approach (Watson-Jones) to the proximal femur, through the interval between glutei and tensor fascia lata provides somewhat limited access to the hip joint along with the lateral proximal femur. With well-positioned retractors and adequate soft-tissue releases, it is possible to perform open reduction of displaced femoral neck fractures, and some femoral head fractures. A more medial approach to the hip joint (iliofemoral or Smith-Petersen), medial to the tensor fascia lata, may improve access to the femoral head and neck, but for fixation of the neck with a sliding hip screw, a separate lateral incision will be required.
2. Skin incision
Start the slightly anteriorly curved skin incision about 7-10 cm proximal of the lateral part of the greater trochanter (directed towards the tubercle of the iliac crest – the posterior landmark of tensor fascia lata origin). Distally, the incision extends along the femur about 10 cm below the greater trochanter.
3. Incision of fascia lata
Expose the fascia lata sharply. Incise the fascia lata over the femur and extend this incision proximally along the posterior border of the tensor fascia lata.
4. Deep surgical dissection
With the greater trochanter and the gluteus medius muscle exposed, retract the tensor fascia lata anteriorly and the gluteus medius muscle posteriorly. Expose the interval between the gluteus medius and the tensor fascia lata and extend it proximally over the hip joint. This can be best done by blunt dissection. Be aware of vessels running across this interval. They require ligation or cautery.
Exposure of hip capsule Place a Hohmann retractor into the bone proximal to the hip capsule. Additional retractors anteriorly and posteriorly will open the dissected interval. External rotation of the leg improves access to the hip capsule.
Anterior release of vastus lateralis The origin of the vastus lateralis muscle should be released from the anterior inferior trochanteric region to expose the underlying hip capsule. Retract the muscle inferiorly. Adjust the retractors as necessary, and debride periarticular fat to expose the hip capsule.
5. Opening of the joint capsule
Make an T-shaped incision in the capsule, …
…and place two retraction sutures, anteriorly and posteriorly. Protect the acetabular labrum. This capsulotomy shows the anterior femoral head and neck. Lateral traction and repositioning of the leg can improve visualization. The incision can be extended distally over the proximal vastus lateralis to allow insertion of screws or DHS for femoral neck fracture fixation.
6. Wound closure
Perform a meticulous debridement of all soft tissues before starting wound closure. Remove necrotic tissue and irrigate the entire wound to decrease the risk of periarticular ossification. Insert suction drains if desired. Close the fascia lata incision with interrupted sutures. Close the subcutaneous tissue and skin as desired.