VIDEO VIGNETTE: Surgical Pearls for the Direct Superior Approach
Anthony K. Hedley, MD, FRCS, from the Hedley Orthopaedic Clinic in Phoenix, Arizona, has been using the direct superior approach for all his primary total hip arthroplasty procedures for about 4 years.
He calls this “an elegant approach to the hip,” and at ICJR’s 3rd Annual Pan Pacific Orthopaedic Congress, Dr. Hedley shared a surgical video describing in detail his top pearls for the direct superior approach.
It is important for the patient to be placed on the lateral side and moved as far forward as possible so that the operative leg can be adducted over the side of the operating table. This allows atraumatic femoral preparation.
The incision is made from the tip of the greater trochanter, proximally following the direction of the fibers of the gluteus maximus. Dr. Hedley noted that the incision does not cut into the tensor fascia latae; it is purely a muscle split exposure.
Split the fibers of the gluteus maximus until the piriformis muscle and the tendon of the quadratus femoris are visible. These will be taken down together.
The piriformis and quadratus femoris tendon are taken off the trochanter, and Dr. Hedley then puts a stitch through them and the angle of the skin, dragging them backwards to form a soft retractor and move the sciatic nerve out of the way. The rotators are “swept” off the hip capsule to expose the edge of the gluteus minimus. The capsule is further cleaned off and the operating field is then ready.
The key to the approach, Dr. Hedley said, is the acetabular reamer. Some surgeons start with a straight reamer to medialize the direction of the reaming and then switch to the angled reamer. Dr. Hedley only uses the angled reamer – which is angled at 60° – initially pushing it medially for the same effect as starting with the straight reamer.
With the leg adducted over the side of the operating table, the leg is internally rotated 40°. Retractors are placed inferiorly and superiorly, which exposes the cut end of the femur for a completely straight approach to reaming, with no muscle or other soft tissue in the way.
Click the image above to watch Dr. Hedley’s presentation.