Posterior Approaches to the Hip

Historical Background of the Posterior Approach to the Hip

This procedure was initially described as a surgical approach to the hip joint for the treatment of infection and war wounds. Bernhard von Langenbeck is credited with the first description in 1867 of what he termed “the longitudinal incision to the hip.” With the hip in a flexed position, he fashioned an incision “from above the ischiadic notch to the middle of the greater trochanter that reaches the joint passing between the bundles of the gluteal muscles.” Langenbeck applied this surgical approach for resection of the femoral head (what he called “hip joint resection”) and used hooks or “ball-screw” devices to extract the femoral head after cutting the ligamentum teres.

Kocher modified Langenbeck's approach by extending it in a caudal direction. He stated, “The incision is an angular (or curved) one, extending from the base of the outer surface of the great trochanter upwards to its anterior superior angle, and from thence obliquely upwards and backwards in the direction of the gluteus maximus.” Division of the gluteus maximus tendon and anterior reflection of the gluteus medius and minimus were followed by internal rotation of the hip and detachment of the piriformis and the other short external rotators. Regarding this approach, Kocher said that “it is a further development of Langenbeck's method by the oblique incision.”

Melham and associates, in their 2000 article entitled “Hyphenated-History: The Kocher-Langenbeck Surgical Approach,” stated as follows:

The Kocher-Langenbeck surgical approach continues to be widely used today by both orthopaedic trauma surgeons and reconstructive hip surgeons. By many it is considered to be a workhorse approach for posterior wall fractures of the acetabulum, femoral neck fractures treated via hemiarthroplasty, and total hip replacement. The durability of an idea born in the nineteenth century on the battlefields of Europe and refined in the operating theaters of Bern is indeed impressive. If he were around today, Kocher's humility would certainly be challenged by the widespread use of his particular portion of hyphenated-history.

Dr. Alexander Gibson and Dr. A. T. Moore are largely credited with popularization of the posterior approach, often referred to as the “Southern approach,” which is used today for THA. Although their initial description of the posterior approach has undergone several modifications since its initial description in 1950, the fundamentals of the exposure remain largely intact. Many of the modifications involve different placement and size of the skin incision, preferential detachment of the short external rotators, and posterior capsular repair. The usefulness of this approach can be appreciated by the diverse surgical procedures that can be performed through the posterior approach. These include hemiarthroplasty and total arthroplasty of the hip, hip resurfacing, open reduction and internal fixation of acetabular fractures, and arthrotomy and drainage of the hip joint for infection.

Surgical Anatomy of the Posterior Approach to the Hip

Muscular Anatomy

The muscles covering the posterior aspect of the hip joint are divided into deep and superficial layers. Henry described the outer layer as the “deltoid” muscle of the hip, similar to the deltoid of the shoulder. This layer consists of the gluteus maximus, the fascia lata, and the tensor fascia lata, which together form the outer sheath of the hip musculature ( Fig. 17.1 ).

The deep layer of the hip encountered during the posterior approach consists of the short external rotators. From cephalad to caudad, they include the piriformis, superior gemelli, obturator internus, inferior gemelli, obturator externus, and quadratus femoris ( Fig. 17.2 ). The musculotendinous insertions of the gluteus medius and minimus insert at the tip of the greater trochanter and are not disturbed during the posterior approach to the hip. Table 17.1 lists the origins and insertions of pertinent muscles of the posterior approach along with their neurologic innervation.

TABLE 17.1

Anatomic, Functional, and Nervous Innervation of Posterior Structures of the Hip

Muscle	Origin	Insertion	Function	Innervation
	Posterior ilium	Iliotibial band	Hip extension and external rotation	Inferior gluteal nerve
Gluteus maximus	Sacrum and coccyx	Gluteal tuberosity
	Sacrum	Upper border greater trochanter	Hip abduction and external rotation	1st and 2nd sacral nerves
Piriformis
Superior gemelli	Inner aspect obturator foramen	Medial surface greater trochanter	Hip external rotation	Sacral plexus
Obturator internus
Inferior gemelli
Obturator externus	Upper border ischial tuberosity	Linea quadrata of femur	Hip external rotation	Sacral plexus
Quadratus femoris
Gluteus medius	Outer surface of ilium	Anterior border of greater trochanter	Hip abduction and internal rotation	Superior gluteal nerve
Gluteus minimus