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Hip: caudolateral approach

ISSN 2398-2950

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Introduction

  • To access the hip joint.

Uses

Disadvantages

  • Risk of iatrogenic damage to sciatic nerve as it courses caudal to greater trochanter and caudal gluteal neurovascular bundle .

Alternative techniques

  • Craniolateral approach to hip Hip: craniolateral approach - gives good exposure for many procedures.
  • Dorsal approach to hip Hip: dorsal approach - provides complete exposure of hip region for extensive exploration or reconstruction of fractures.
  • Hemipelvis approach to hip - useful for open reduction and internal fixation of multiple pelvic fractures that have acetabular component.
  • Ventral approach to hip - provides limited exposure to joint - adequate for femoral head and neck surgery only.

Requirements

Materials required

Minimum equipment

Preparation

Site preparation

Major landmarks

Preparation

  • Standard aseptic (clip, clean, scrub and drape) .

Restraint

Technique

Approach

Step 1 - Skin incision

  • A curved incision starts near the dorsal midline and continues caudal to the trochanter, and extends over the proximal third of the femur.

Step 2 - Subcutaneous incision

  • Fascia of superficial gluteus muscle and tensor fascia lata is incised along the cranial border of the biceps muscle.

Step 3 - Dissection

  • Elevation, or partial tenotomy, of superficial gluteus muscle close to its attachment, extending incision into the fascia lata .
  • Retract superficial gluteus muscle craniodorsally.
  • Retract biceps femoris caudally.
  • Inwardly rotate femur to permit transection of combined tendon of internal obturator and gemelli muscles close to trochanteric fossa .
    Sciatic nerve courses caudal to greater trochanter - risk of iatrogenic damage.

A stay suture in the tendon of the internal obturator and gamelli muscles will aid their retraction and will protect the sciatic nerve and circumflex femoral vessels as the obturator fossa of the ischium is exposed.

Step 4 - Arthrotomy

  • Incise joint capsule to access joint cavity.

Core procedure

Step 1 - Primary procedure

  • Dissection of a portion of the origin of the deep gluteal muscle enhances the exposure of the caudodorsal acetabular labrum.
    A Hohman retractor placed ventral to the femoral head helps retract the external obturator and quadriceps muscles.
  • Further dissection depends upon primary procedure.

Exit

Step 1 - Closure of joint capsule

  • Close joint capsule using routine methods and materials.

Step 2 - Closure of fascia

  • Repair sectioned tendons using routine methods and materials.
  • A modified Bunnell Meyer or locking loop suture of an appropriate long-lasting absorbable material facilitates attachment of the combined tendons of the internal obturator and gamelli muscles to the insertion of the deep and middle gluteal muscles.
  • Repair sectioned muscles using routine materials and methods.
  • Close fascia using routine materials and methods.

Step 3 - Skin closure

  • Close the skin using routine materials and methods.

Aftercare

Outcomes

Further Reading

Publications

Refereed papers