Anterior approach for prosthetic replacement with archtable.

Description of the anterior approach to the hip joint.

1. Skin Incision: 1 cm distal and lateral to the SIAS. The incision is about 8 cm long. Important: before the incision identify the space between sartorius and tensor by palpation; sign the space. Your skin incision must be lateral to this space.

2. Incision of the tensor fasciae latae aponevrosis: you must see the muscle below! Identify the direction of the muscle fibers: distally they must lateralize - otherwise you are above the sartorius (it is no problem, but you should always be aware where you are!. The best fasciae incision is: the most anterior to the sartorius, but always above the tensor muscle! With the fasciae incision you must reach the iliac crest.

3. Tensor mobilisation to lateral: by blunt dissection (large periost sleever) bring the tensor muscle lateral and go down between tensor and septum intermuscolaris. So you reach the femur neck (still covered by the depp fascia - of the tensor).

4. Deep fascia incision: on the distal sid of the wound you will see the vessels (and nerve:n. gluteus superior). Coagulate the ramus ascendens of the circumflex artery.

5. Mobilise rectus femoris: muscle medial - approach to the neck lateral

6. Capsule preparation: prepare the hip capsule with a blunt large dissector. The dissector is between hip capsule and rectrus femuris. In this created space you will bring a long Hohmann elevator. Bring a curved Hohmann elevator to the lateral femural neck side. Now the neck must be clearly visible.

7. Capsule incision: I now prefer to do the incision a reversed T like. Do capsule escission only in really severe contracted hips and rheumatoid arthritis with severe sinovialitis.

8. Neck osteotomy

9. Extraction of the femoral head: traction table in soft distraction (2 cm applied): remove al levers during head extraction (avoiding muscle damage)

10. Acetabulm preparation: Long Hohmann lever to the anterior rim (about 10 in left hip) from inside the capsule; curved posterior rum lever to the posterior acetabular rim (from inside) - in contracted hips: outside the labrum. Normally I try to bring the lever between the acetabular bone and the posterior labrum. Preparation of the acetabulum in a usual manner.

12. Cup positioning - if you desire further fixation with screws you can do it easily (you need correct instruments). Cup liner

13. Femur preparation: Arch-table brings leg in 90° external rotated position (measured respectively the patella, foot often is pointing towards the floor). 1 lever on the medial side respect femur neck. 1 long lever posterior to the trochanter major in the external rotated position. Now go with the leg in extension and adduction. Huge extension movement, small adduction for straight traditional stems (like Zweymueller, CLS, Corrail). Start with the femural boraching - this depends on the femoral stem design. For traditional stems you can use compressing device for easier preparation.

14. Intraoperative X-ray with the correct rasp.

15. Definitive Femural stem - reduction with the desired head length. We do leg length measuring by referring points to cresta iliaca and femur diaphysis distal.

16. LIA: lokal anesthesia- for painless postoperative hours (like nerve blocks)

17. Closure: capsula, tensor fasciae, subcutaneous tissue and skin