Recovery and Rehabilitation: Western Health; 2013. PDF Do lifestyle restrictions and precautions prevent dislocation after When refering to evidence in academic writing, you should always try to reference the primary (original) source. Hardinge Approach to Hip Joint (Direct Lateral Approach) cannot be extended proximally. Heavy sutures, typically placed through holes in the bone, are used to reattach the anterior flap to the intertrochanteric region. It exposes the femur well with good access to the joint. The incision can be prolonged distally over the proximal vastus lateralis to allow for insertion of plate fixation. Risk of dislocation & hip precautions: Risk is incredibly low (<1%). Develop the plane between the hip joint capsule and the overlying muscles, using a swab pushed into the potential space using a blunt instrument. Posterior Approach to the Acetabulum (Kocher-Langenbeck) Hip - Hardinge Direct Lateral Approach - ST3 Ortho Interview Questions Divide the fascia lata over the greater trochanter, extending it distally over the proximal femoral shaft and proximally splitting the gluteus maximus fibers to reveal the underlying gluteus medius. Superficial dissection. But there is also more than one way to go about performing a hip replacement surgery - known as different "approaches.". This site does not constitute medical advice. Robotic Assisted Total Hip Replacement. Additionally, the modified Hardinge approach was the most familiar approach for us and is widely used in the treatment of pediatric hip septic arthritis and femoral neck fracture [17]. Orthopaedic Specialists of North Carolina. Exposure of the proximal femur is gained by gentle external rotation of the leg. The incision is in line with the femur and it goes from 5cm proximal to greater trochanter to 10cm distal to the greater trochanter. Incise the fat and underlying deep fascia in line with the skin incision. DTIT]Hiv_~Zd #Ke0z3U?7-3KG|~LH22R9U I2JcAvaePNmgVhDcOb't^OaLK3mTj .!JR5\bdTg?`S>8y^|\Qm/Tt(Qm &+)YRJMj'9pGL4YakEXx Z}]2 5lFJA 1I*k@v35l`zg>}aUP=jv9-vfqXR4!KNax(vqz_ 8r Sc?^bUv=hrPe]F? The main landmark for the incision is the greater trochanter which overlies the hip joint itself. The anterolateral approach (Watson-Jones) to the proximal femur, through the interval between glutei and tensor fasciae latae provides somewhat limited access to the hip joint along with the lateral proximal femur. Hip dysplasia can present unique challenges in achieving stability with THA and, as such, there is a higher incidence of instability . endobj Underneath the fascia is the muscle layer. No hip extension. Begin the incision 5 cm above the tip of the greater trochanter. Adjust the retractors as necessary and debride periarticular fat to expose the hip capsule. Being compliant with range-of-motion restrictions for 12 weeks after Anterior, Posterior or Lateral hip replacement approach allows the joint capsule to heal and shrink enough to resist dislocation.Posterior and Lateral surgical approach restrictions are completely different than for an Anterior surgical approach. The advantages of this approach include a significantly lower dislocation rate compared with other approaches while allowing for excellent acetabular visualization. Care transfer. A modified anterolateral approach. The direct lateral approach to the hip for arthroplasty. Get Top Tips Tuesday and The Latest Physiopedia updates, The content on or accessible through Physiopedia is for informational purposes only. ;ul] 0>ycNz]u +.6^tim - this approach allows a rather direct approach to the hip with minimal need for surgical assistants and affords excellent acetabular exposure; After surgery, moving the operated leg into flexion past 90 degrees, abduction past mid-line and/or internal rotation can move the femoral head against the posterior capsules incision risking dislocation or stretching out the capsule before it heals. Preserve a substantial portion of gluteus medius insertion posteriorly. Hardinge Approach to Hip Joint (Direct Lateral Approach) can easily be extended distally: To expose the shaft of the femur, split the vastus lateralis muscle in the direction of its fibers (. He owns and operates an orthopedic physical therapy practice. Over my career, I have seen several posterior approach total hip replacement dislocations, some as many as 20 years after surgery before they experienced their first dislocation. Choosing the optimal surgical approach can minimize these risks and therefore improve the outcome of THA. Do not cross your legs. Translateral surgical approach to the hip. Web site http:// www.orthoanswer.org/hip/total-hip-replacement/recovery.html. 2023 Lineage Medical, Inc. All rights reserved, Hip Direct Lateral Approach (Hardinge, Transgluteal), Approaches | Hip Direct Lateral Approach (Hardinge, Transgluteal), has lower rate of total hip prosthetic dislocations, begin 5cm proximal to tip of greater trochanter, longitudinal incision centered over tip of greater trochanter and extends down the line of the femur about 8cm, detach fibers of gluteus medius that attach to fascia lata using sharp dissection, split fibers of gluteus mediuslongitudinally starting at middle of greater trochanter, do not extend more than 3-5 cm above greater trochanter to prevent injury to, extend incison inferior through the fibers of, anterior aspect of gluteus medius from anterior greater trochanter with its underlying gluteus minimus, requires sharp dissection of muscles off bone or lifting small fleck of bone, follow dissection anteriorly along greater trochanter and onto femoral neck which leads to capsule, gluteus minimus needs to be released from anterior greater trochanter, runs between gluteus medius and minimus 3-5 cm above greater trochanter, limiting proximal incision of gluteus medius, most lateral structure in neurovascular bundle of anterior thigh, keep retractors on bone with no soft tissue under to prevent iatrogenic injury, - Hip Direct Lateral Approach (Hardinge, Transgluteal), Shoulder Anterior (Deltopectoral) Approach, Shoulder Lateral (Deltoid Splitting) Approach, Shoulder Arthroscopy: Indications & Approach, Anterior (Brachialis Splitting) Approach to Humerus, Posterior Approach to the Acetabulum (Kocher-Langenbeck), Extensile (extended iliofemoral) Approach to Acetabulum, Hip Anterolateral Approach (Watson-Jones), Hip Posterior Approach (Moore or Southern), Anteromedial Approach to Medial Malleolus and Ankle, Posteromedial Approach to Medial Malleolus, Gatellier Posterolateral Approach to Ankle, Tarsus and Ankle Kocher (Lateral) Approach, Ollier's Lateral Approach to the Hindfoot, Medial approach to MTP joint of great toe, Dorsomedial Approach to MTP Joint of Great Toe, Posterior Approach to Thoracolumbar Spine, Retroperitoneal (Anterolateral) Approach to the Lumbar Spine. <>>> Release the capsule sufficiently anteroinferiorly and anterosuperiorly to expose the femoral head and neck and permit free external rotation of the femur. Muscle, Are you sure you want to trigger topic in your Anconeus AI algorithm? Hardinge Approach to Hip Joint (Direct Lateral Approach) is used for: There is no true internervous plane for Hardinge approach to hip joint (direct lateral approach). How To Choose A Surgeon For Hip Replacement, Speed Up Recovery After Total Hip Replacement, Can I Sit In A Recliner After Hip Replacement, Crossing Legs After Total Hip Surgery: (A PTs Complete Guide), Stairs After Total Hip Replacement: A Physical Therapy Guide, Ice After Total Knee Replacement: A PTs Complete Guide. 1173185, Tran P, Fraval A. The approach does not give as wide an exposure as theanterolateral approach to hip jointwith trochanteric osteotomy. Hospital for Special Surgery. See Also: Hip Joint Anatomy Hardinge Approach to Hip Joint indications. mini-incision approach shows no longterm benefits to hip function extend to 10 cm below tip of greater trochanter Superficial dissection through subcutaneous fat incise fascia lata in lower half of incision extend proximally along anterior border of gluteus maximus split gluteus maximus muscle along avascular plane Deepen the incision through the gluteus medius and minimus proximally, retracting the anterior flap to show the hip capsule superiorly and adjacent supraacetabular ilium. A surgical incision, approximately 6 cm in size, is made to the anterolateral side of the thigh to gain access to the hip joint. Hardinge Approach to Hip Joint indications. The different incisions used in a hip replacement surgery are all defined by their relation to the musculature of the hip. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4536510/, https://www.ncbi.nlm.nih.gov/books/NBK537031/. *The anterolateral approach to hip* Required fields are marked *, This renowned classic provides unparalleled coverage of manual muscle testing, plus evaluation and treatment of faulty and painful postural conditions. March 10, 2021 Asan Medical Center, Seoul, Korea. A common way the No Crossing Mid-line rule is broken is by sleeping on the unoperated side and allowing the operated leg to drop down to the bed crossing the mid-line. Use retractors, to pull the edges of the fascia lata away so as to get a good view and access to the abductor muscles-the gluteus medius and minimus and the hip joint underneath that. Precautions include: This 2 minute video reviews the three main hip precautions used for several weeks after posterior THR to prevent complications such as dislocation. Expose the fascia lata and iliotibial band and divide them in the line of skin incision. The thoroughly updated Fifth Edition is completely reorganized and has new, expanded treatment and exercise sections in each chapter. Partial anterior trochanteric osteotomy in total hip arthroplasty: Surgical technique and preliminary results of 127 cases, Clifford R. Wheeless, III, M.D. No hip flexion past 90 degrees with the Posterior Approach: The most common way that rule is broken is getting up from sitting and leaning too far forward. With well-positioned retractors and adequate soft-tissue releases, it is possible to perform open reduction of proximal periprosthetic femoral fractures or revision arthroplasty. W4.0{('#. }fQvh6'h4!Bw1t2^8[\-0b[~v-G/vtm{B)%)\9%P#Ihqq$.s^OS#U#2joRttl{j9T%#&JyXEuDj%'UEm#"h#MX";5Q NNDj{~W\^(&0ooL^ryal^p TaF)~eGK6LSSbgqml nF_opnnQMK-Mn]tu9KH%&| sX "*v58\_ax}CH.#q(.3YJY*hx}!@y/qwcN(a5H`w.B`ctIm,WgwO x][s~wgRD-UIz73Zy H$'KF/q~no=mwqw_\W/"(n>|AGHDEE*n>|Qb//_|o8OL}u8fL5QKTa^D&OkNS`$4WqEyj_,2 9v4uq63L_@H88U0L'Zt'WK[u^R-`LU$RX~\ouPXkI,g: +n;HTfC*7R.L,_{*./`>>='hK~ The approach does not give as wide an exposure as the anterolateral approach to hip joint with trochanteric osteotomy. In the Posterior Approach to Total Hip Replacement, the patient is placed side-lying and the operated hip capsule is cut posteriorly. - consider the Hardinge approach for patients w/ significant contracture; Surgical Exposures in Orthopaedics book 4th Edition, Campbels Operative Orthopaedics book 12th. Surgeons will also use a curved femoral replacement because the typical straight femoral components are extremely difficult to insert without injuring the abductor muscles. - note that many patients will have a reduced hip flexion contracture under anesthesia, which will give the surgeon the false sense of having corrected the contracture; General guidelines (0-6 weeks) adhere to precautions Normalize gait pattern with appropriate aids based on WB'ing status ( time frame for using aids based on the discretion of therapist )on the discretion of therapist ) Hip ROM within restrictions Basic quadricep strength Total Hip Arthroplasty Do not allow surgical leg to externally rotate (turn outwards). Many surgeons now perform minimally invasive surgery in hip replacement. No crossing legs with the Posterior Approach: No crossing the legs is probably the most confusing instruction my patients receive.See my article on No Crossing The Legs.. The provocative position for hip dislocation is: hip extension, external rotation. Happy Total Hip Recovery Without Dislocation. Comparison of heterotopic bone after anterolateral, transtrochanteric, and posterior approaches for total hip arthroplasty. Next, develop an anterior flap that consists of the anterior part of the gluteus medius muscle with its underlying gluteus minimus and the anterior part of the vastus lateralis muscle. - consider the Hardinge approach for any patient who will have difficulty with complying with the usual hip precautions following surgery; This capsule will need to have time to heal before it can withstand the pressure from the femoral head as it rotates forward when the patient moves into the range-of-motion of external rotation and extension. Damage to the superior gluteal nerve after the Hardinge approach to the hip. In most cases Physiopedia articles are a secondary source and so should not be used as references. A layered closure is preferred for periprosthetic fractures. The anterolateral approach/ the modified hardinge approach - commonly used for hemiarthroplasty in fracture neck of femur,total hip replacement. Dislocation after total hip arthroplasty using the anterolateral abductor split approach. I have seen the transition from ALL surgeons doing posterior approach total hip surgeries, to the currently popular anterior approach, with some surgeons doing variations like the lateral approach to hip replacement. Incise the fascia lata over the femur and extend this incision proximally along the posterior border of the tensor fascia lata. Please consult a licensed physician and/or physical therapist in your area for specific medical advice about your condition. The anterolateral approach (Watson-Jones) to the proximal femur, through the interval between glutei and tensor fasciae latae provides somewhat limited access to the hip joint along with the lateral proximal femur. Exposure of the hip using a modified anterolateral approach. Direct lateral approach also called as the trans-gluteal approach initially described by Kocher in 1903 popularised by Hardinge in the modern age gives good exposure to the hip joint preserving most of gluteus medius minimus and vastus lateralis, and the vascularity. Total hip arthroplasty (THA) is generally considered to be one of the most successful orthopedic surgical procedures. Insert suction drains if desired. An EMG and clinical review. Your email address will not be published. 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 fasciae latae origin). I dont expect my patients to be as strict with the restrictions after 12 weeks but I do expect them to be aware of the restrictions and follow them as best they can after the 12-week mark. As a licensed physical therapist I have seen hundreds, if not thousands, of total hip replacement surgeries over the more than 4 decades of treating patients as a hospital-based physical therapist, outpatient physical therapy owner/operator, and for the past several years seeing total hip replacement patients in their homes just a day or two after their surgeries. jwplayer('jwplayer_IwFksVzC_vRGjQ34u_div').setup( Anterolateral approach. Split the fibers of the gluteus medius muscle in the direction of their fibers beginning in the middle of the trochanter. Precautions include: o Posterior Precautions: o No hip flexion >90 degrees o No hip internal rotation or adduction beyond neutral We also participate in other affiliate programs which compensate us for referring traffic. The fibers of the gluteus medius muscle are split in their own line distal to the point where the superior gluteal nerve supplies the muscle. The hip joint is then dislocated and the acetabular socket and femur are exposed for preparation and insertion of the prosthesis components. Proper Reaming and Cup Positioning in Primary Total Hip Replacement The posterior capsule and muscles are not cut. Surgical approaches in THA include anterior, lateral [anterolateral (Hardinge) and direct lateral (Watson-Jones . Another place my posterior approach hip replacement patients break the no hip flexion past 90-degree rule is when they are sitting on the commode. Make a longitudinal incision that passes over the center of the tip of the greater trochanter and extends down the line of the shaft of the femur for approximately 8 cm. The abductor muscle "split". Indications: Trauma - Hemiarthroplasty THR - lower dislocation rate Video: Positioning: Supine, GT at the edge of the table (buttock muscles, and . The same range-of-motion restrictions from the Posterior Surgical Approach (outlined above) apply to the Lateral Surgical Approach PLUS the restriction of no ACTIVE hip abduction (bringing the leg out to the side). ;{Cuh*m`UnQ@R0qp,m=JgUaD2SQX(+J4rE -4ag]u&r{q#O]|?( L48K5m!0KAF84kJL{M[YM]J The lateral aspect of the greater trochanter. Sleep on your surgical side when side lying. We are compensated for referring traffic and business to companies linked to on this site. - note that if a Steinman pin as been used to retract the medius, it should be removed at this point, since it may placed signficant tension on the medius and give a false sense of hip stability; - Cautions: The surgeon uses a special surgical table specifically designed to position the patient so that the hip joint may be easily accessed from the front as opposed to the side or back. The hip is dislocated through this posterior incision in the joint capsule by the surgeon taking the patients leg into flexion, internal rotation (pigeon-toe), and adduction (across mid-line of the body) to expose the femoral head and acetabular (hip) socket for preparation to receive the replacement components. Hamstring Curl Machine (hip precautions) 9. A hematoma requiring evacuation must be avoided. If the hip replacement was done through the more traditional posterior or antero- lateral/Hardinge approach - most patients have hip precautions for upto 6-8 weeks. Patient positioning in case of anterolateral approach to the right hip -patient is on his left hand side, surgeon stands behind and looks down on the patients right hip which has been prepared. Getting up from sitting, the patient must consciously remember to scoot to the front of the chair, extend the operated legs knee, and push themselves up with their arms and unoperated leg while keeping their trunk erect. The joint capsule seals the hip joint, much like a zip-lock baggie, to keep the lubricating fluids inside the capsule and bathing the hip joint in this fluid. See my article on No Crossing The Legs.. Are Hip Precautions Necessary Post Total Hip Arthroplasty?. easier with leg flexed slightly. Passive range of motion into hip abduction is permissible but it must be totally passive with the patient completely relaxed and someone else passively moving the leg into abduction. For further exposure of the femur and placement of hardware, the vastus lateralis can be released and repaired later. By reducing the size of their incisions to as small as 2.5 inches, they hope to reduce soft tissue damage and speed healing. The 3-in-1 commode chair offers the additional benefit of having handholds to help with standing AND can be used in the shower as a shower chair. Age In Place School is a participant in affiliate advertising programs designed to provide fees by advertising and linking to their products. 2 0 obj split fascia lata and retract anteriorly to expose tendon of gluteus medius. - ensure that the sterile drapes are tied together underneath the operating room table (by the unscrubbed assistant) so that the drapes do not slide off the table as the leg is placed in the saddle bag; - Final Trial: This 1 minute video shows the precautions. The lower leg is placed into a pocket made from sterile drapes. The abductor muscle "split". Patient positioning in case of anterolateral approach to the right hip -patient is on his left hand side, surgeon stands behind and looks down on the patients right hip which has been prepared. All the patients underwent bipolar hemiarthroplasty through modified Hardinge approach. The vastus lateralis and the gluteus medius are now exposed. Transcending Aging Independently Because of this, I recommend my posterior approach hip replacements follow the three restrictions for the rest of their lives. This is because muscles/tendons are usually cut/detached during the operation and then repaired during closure. The layers being encountered are: The lower the commode the more difficult the problem.Comfort height commodes greatly decrease the patients tendency to lean more forward than allowed and makes it easier to come to standing without bending the hip more than 90 degrees. Draw a line between the anterior one third and posterior two thirds of the muscle and that line would be the line in which we split the muscle fibres. Patients can also have as little as a 3-inch incision. The greater trochanter is reattached later by wires or cables. nZ!g A mid-lateral skin incision centered over the greater trochanter is made [Figure 3]. Comparison of heterotopic bone after anterolateral, transtrochanteric, and posterior approaches for total hip arthroplasty. Hip Replacement Approaches - BoneSmart The posterior (also referred to as a Moore or Southern) approach allows the surgeon to access the hip joint from the back. Posterior Approach Total Hip Replacement Precautions: No hip flexion greater than 90 degrees, no crossing the legs, and no internal rotation of the leg: In the Posterior Approach to Total Hip Replacement, the patient is placed side-lying and the operated hip capsule is cut posteriorly. In: Azar FM, Beaty JH, Canale ST, eds. The Femoral nerve is the most lateral structure in neurovascular bundle of anterior thigh. - if the surgeon attempts to correct the contracture by performing an aggressive anterior capsulotomy, then there is an increased risk of dislocating out the front; - PreOp: We need to do so in a way that let us repair it in the end. No internal rotation with the Posterior Approach: The most common way that rule is broken is by pivoting on the operated leg when turning in that direction. The anterior hip replacement procedure has fewer precautions. The 'Hardinge direct lateral or transgluteal approach' has many different flavours. That is usually the journal article where the information was first stated. Total hip replacement. % GkRH!TGFmx0kmFIJe+GIORI]zS#e' mvbRNI(FI&9hDw|pdaOYL;dG4ZA_+h: MOazznTT~# V`~}%}7m=6G`P+nN&M'R6jV{(JBiz4~=V#cWvP5(hA+H/~7 2Gw#QQOz90sT9{7"wTo$;9noE0J=70wzx+2r7dvD&XR2H{ _J3D(m 5'AVDWh'0&[FOtFd.bYJm3e,L@/Qn?];Tg1 Read more, Physiopedia 2023 | Physiopedia is a registered charity in the UK, no. Dr. Wheeless enjoys and performs all types of orthopaedic surgery but is renowned for his expertise in total joint arthroplasty (Hip and Knee replacement) as well as complex joint infections. The GJNH recommends patients follow hip precautions for 12 week post THA using both posterior and modified Hardinge anterolateral approach and irrespective of type of prosthesis. Many believe that keeping these muscles intact helps prevent post-surgical dislocations. The size of the components was determined on the basis of preoperative template measurements and intraoperative assessment. Incision. We used this modified SPAIRE approach as this patient lives in a 'Mahjong' center . Environmental modifications that are recommended to prevent hip dislocations including removing tripping hazards from home and installing grab rails around the house. The approaches are posterior (Moore or southern), lateral (Hardinge or Liverpool), antero . Detach any fibers of the gluteus medius that attach to the deep surface of this fascia by sharp dissection. ); The Foundation for the Advancement in Research in Medicine, Inc. A 501(c)(3) non-profit organization. Examination and Special Tests Of The Knee, Kanavels Signs, Infection of the flexor tendons. Do not go more than 3 cm above the upper border of the trochanter because more proximal dissection may damage branches of the superior gluteal nerve. Exposure of the hip by anterior osteotomy of the greater trochanter. The capsule is one of the primary dislocation prevention structures, so care is taken by restricting range-of-motion until the capsule is well healed and capable of resisting dislocation. If you believe that this Physiopedia article is the primary source for the information you are refering to, you can use the button below to access a related citation statement. Our Mantra: Copyright@orthopaedicprinciples.com. Outline an incision to release the anterior gluteus medius from the greater trochanter. . Do not step backwards with surgical leg. There will be small variations in the approach from surgeon to surgeon, therefore most people will described there approach as a modified Hardinge approach. In addition, it can be adapted for small incision surgery. Perform a meticulous debridement of all soft tissues before starting wound closure. But there is also more than one way to go about performing a hip replacement surgery known as different approaches.. 2023 Lineage Medical, Inc. All rights reserved, Hip Anterolateral Approach (Watson-Jones), Approaches | Hip Anterolateral Approach (Watson-Jones), minimally invasive approach does not improve post-op gait kinematics when compared to traditional trans-gluteal approach, patient at high risk for dislocation may benefit from antero-lateral approach since no posterior soft tissue disruption, some concern that this approach can weaken the abductor and cause limping, general or spinal/epidural is appropriate, generally performed in the lateral decubitus position, patient's buttock close to the edge of the table to let fat fall away from incision, as it runs distal, it becomes centered over the tip of the greater trochanter, crosses posterior 1/3 of trochanter before running down the shaft of the femur, incise in direction of fibers, this will be more anterior as your dissect proximal, incise at the posterior border of the greater trochanter, there will be a small series of vessels in this interval, trochanteric osteotomy (shown in this illustration), distal osteotomy site is just proximal to vastus lateralis ridge, place stay suture to prevent muscle split and damage to superior gluteal nerve, nerve is 5cm proximal to the acetabular rim, incise more fasciae latae proximally to allow increased adduction and external rotation of the leg, allows access to the vastus lateralis which can be elevated to allow direct access to the entire femur, most common problem is compression neuropraxia caused by medial retraction, direct injury can occur from placing retractor into the psoas muscle, can be damaged by retractors that penetrate the psoas, confirm that anterior retractor is directly on bone, caused by trochanteric osteotomy and/or disruption of abductor mechanism, caused by denervation of the tensor fasciae by aggressive muscle split, usually occurs during dislocation (be sure to perform and adequate capsulotomy), - Hip Anterolateral Approach (Watson-Jones), Shoulder Anterior (Deltopectoral) Approach, Shoulder Lateral (Deltoid Splitting) Approach, Shoulder Arthroscopy: Indications & Approach, Anterior (Brachialis Splitting) Approach to Humerus, Posterior Approach to the Acetabulum (Kocher-Langenbeck), Extensile (extended iliofemoral) Approach to Acetabulum, Hip Direct Lateral Approach (Hardinge, Transgluteal), Hip Posterior Approach (Moore or Southern), Anteromedial Approach to Medial Malleolus and Ankle, Posteromedial Approach to Medial Malleolus, Gatellier Posterolateral Approach to Ankle, Tarsus and Ankle Kocher (Lateral) Approach, Ollier's Lateral Approach to the Hindfoot, Medial approach to MTP joint of great toe, Dorsomedial Approach to MTP Joint of Great Toe, Posterior Approach to Thoracolumbar Spine, Retroperitoneal (Anterolateral) Approach to the Lumbar Spine. J Bone Joint Surg Br 1982;64B:1718. Physiopedia articles are best used to find the original sources of information (see the references list at the bottom of the article). Direct lateral approach to the proximal femur - AO Foundation 2 Comments . The approach can be extended distally, for adequate exposure of the fracture. - significant hip flexion contracture: Remember we are not going beyond 5 cms from tip of the greater trochanter to avoid damage to superior gluteal artery and nerve.

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