import { ComparisonTable, ContentSection, EvidenceCard, ExamCheatSheet, ExamPearl, ExamWarning, InfoCard, InfoCardGrid, MedicalImage, MnemonicCard, OnePagerSummary, SafetyAlert, Tab, Tabs, Timeline, TimelineItem, VivaScenario, VivaScenarioSection } from '@/components/mdx' {/* SECTION 1: ONE-PAGER SUMMARY */} {/* SECTION 2: EXAM WARNING */} The medial approach is **primarily historical** and used almost exclusively in **pediatric orthopedics** for DDH open reduction. Adult arthroplasty surgeons rarely use this approach. Know it exists, but focus exam preparation on anterior, lateral, and posterior approaches. The **obturator nerve** runs 2-3cm from the skin incision, deep to the pectineus muscle. Injury causes weakness of adduction and sensory loss over medial thigh. The anterior branch runs between adductor longus and brevis; posterior branch between adductor brevis and magnus. The **medial femoral circumflex artery** (MFCA) provides critical blood supply to the femoral head. It runs between pectineus and iliopsoas, then posterior to the femoral neck. Injury can cause **AVN of femoral head** - catastrophic in pediatric patients. There is **no true internervous plane** in the medial approach. The adductor interval (between adductor longus and gracilis/adductor brevis) involves muscles with shared obturator innervation. This approach works by muscle retraction, not nerve-sparing dissection. {/* SECTION 2.5: QUICK DECISION GUIDE */} {/* SECTION 3: MNEMONICS */} {/* SECTION 4: OVERVIEW AND BACKGROUND */} ### Historical Context The medial approach to the hip was first described by **Karl Ludloff in 1908** for open reduction of congenital hip dislocation (DDH) in infants. It gained popularity in the early 20th century as one of several approaches for managing DDH before modern understanding of closed reduction and Pavlik harness treatment. ### Modern Applications The Ludloff medial approach has very limited applications in modern orthopedic surgery: **Primary Current Use:** - Open reduction of DDH in infants (6-18 months age range) - Considered by some as less traumatic than anterior approach in very young children **Rare Adult Applications:** - Open psoas tendon release (now mostly done arthroscopically) - Access to medial hip capsule (rarely needed) - Historical interest and exam knowledge **NOT Used For:** - Primary total hip arthroplasty - Revision hip surgery - Acetabular fracture fixation - Femoral neck fracture fixation ### Key Statistics {/* SECTION 5: ANATOMY AND BIOMECHANICS */} {/* MISSING IMAGE: /images/topics/hip-medial-approach/web-sourced/2-left-illustration-and-right-photograph-of-posterio.png {/* MISSING IMAGE: /images/topics/hip-medial-approach/web-sourced/2-left-illustration-and-right-photograph-of-posterio.png */} */} {/* MISSING IMAGE: /images/topics/hip-medial-approach/web-sourced/1-photograph-of-a-right-hip-demonstrating-footprints.png {/* MISSING IMAGE: /images/topics/hip-medial-approach/web-sourced/1-photograph-of-a-right-hip-demonstrating-footprints.png */} */} ### Adductor Compartment Anatomy The medial approach works through the **adductor compartment** of the thigh: **Superficial Layer (Anterior to Posterior):** 1. Pectineus - femoral nerve innervation (accessory obturator sometimes) 2. Adductor longus - obturator nerve (anterior division) 3. Gracilis - obturator nerve (anterior division) **Deep Layer:** 1. Adductor brevis - obturator nerve (anterior division) 2. Adductor magnus (adductor portion) - obturator nerve (posterior division) 3. Obturator externus - obturator nerve (posterior division) ### Critical Neurovascular Structures **Obturator Nerve:** - Originates from L2-L4 (lumbar plexus) - Exits pelvis through obturator canal - Divides into anterior and posterior divisions near obturator foramen - **Anterior division**: Runs between adductor longus and brevis - **Posterior division**: Runs between adductor brevis and magnus - Provides motor to adductors and sensation to medial thigh **Medial Femoral Circumflex Artery (MFCA):** - Branch of profunda femoris (deep femoral) artery - Runs posteriorly between pectineus and iliopsoas - Courses behind femoral neck to supply femoral head - **PRIMARY blood supply to femoral head in adults** - Injury can cause AVN of femoral head **Other Structures:** - Profunda femoris artery (origin of MFCA) - External pudendal vessels (superficial) - Femoral vein (medially in femoral triangle) ### The Adductor Interval (Surgical Plane) The "interval" used in the medial approach is between: - **Adductor longus** (anteriorly) - **Gracilis** and **adductor brevis** (posteriorly) This is **NOT a true internervous plane** because both muscles are supplied by the obturator nerve. The approach works by retracting muscles, not by exploiting nerve boundaries. {/* SECTION 5b: INTERNERVOUS PLANE */} ### No True Internervous Plane Unlike the posterior approach to the hip (which has a true internervous plane between inferior gluteal and superior gluteal nerve territories), the medial approach has **NO true internervous plane**. **Why Not an Internervous Plane?** The surgical dissection passes through the adductor compartment, where all muscles are innervated by the obturator nerve: - Pectineus: Femoral nerve (L2-L3) - but accessory obturator in 10% - Adductor longus: Obturator nerve (anterior division, L2-L4) - Adductor brevis: Obturator nerve (anterior division, L2-L4) - Gracilis: Obturator nerve (anterior division, L2-L4) - Adductor magnus (adductor part): Obturator nerve (posterior division, L2-L4) **Clinical Implication:** - The approach works by **retracting** muscles, not by dissecting between nerve territories - Care must be taken not to injure branches of the obturator nerve - Excessive retraction can cause traction neuropraxia of the obturator nerve **Comparison with Other Hip Approaches:** | Approach | Internervous Plane | Significance | |----------|-------------------|--------------| | Posterior (Moore) | **TRUE** - Gmax (inf gluteal) vs GM (sup gluteal) | Only true internervous plane | | Anterior (Smith-Petersen) | **TRUE** - Sartorius (femoral) vs TFL (sup gluteal) | Well-defined plane | | Direct Lateral (Hardinge) | **FALSE** - Splits gluteus medius | Risk of abductor weakness | | Medial (Ludloff) | **FALSE** - Through adductor muscles | All obturator innervated | **Examination Pearl:** When asked about the internervous plane of the medial approach, the correct answer is: "There is no true internervous plane. The approach passes through the adductor interval, but all surrounding muscles are supplied by the obturator nerve." {/* SECTION 5c: PATIENT POSITIONING */} ### Supine Position with Hip Abduction **Standard Position:** The patient is positioned supine on a radiolucent table with the affected hip exposed. **Key Positioning Elements:** 1. **Supine Position** - Patient lies flat on back - Pelvis must be level (check ASIS equality) - Radiolucent table for imaging if needed 2. **Hip Position** - Affected hip flexed approximately 45 degrees - Externally rotated approximately 45 degrees - Abducted to expose medial thigh - This relaxes the adductor muscles and opens the interval 3. **Knee Position** - Knee flexed approximately 45-90 degrees - Reduces tension on adductor muscles - May rest on a bolster or assistant holds leg 4. **Contralateral Leg** - Positioned out of the way - May be placed in stirrup or on arm board **Alternative: Frog-Leg Position:** - Hip flexed, abducted, and externally rotated - Knee flexed, foot resting on opposite thigh or table - "Figure of 4" position - More commonly used in pediatric DDH cases **Imaging Considerations:** - Fluoroscopy access if needed (rarely in adult cases) - For DDH: arthrogram may be performed to assess reduction **Draping:** - Circumferential draping of the entire lower limb - Medial thigh from groin crease to mid-thigh exposed - Genitalia must be protected and isolated {/* SECTION 5d: PATHOPHYSIOLOGY */} ### Rationale for Medial Approach The medial approach was developed to address specific pathology that required medial access to the hip joint: **Historical Indication - DDH Open Reduction:** In developmental dysplasia of the hip (DDH), the femoral head is dislocated posterosuperiorly from the acetabulum. The medial approach allows: 1. **Release of Obstructions to Reduction:** - Iliopsoas tendon (can be divided) - Pulvinar (fibrofatty tissue in acetabulum) - Ligamentum teres (hypertrophied) - Transverse acetabular ligament (may need release) 2. **Direct Access to Capsule:** - Medial capsule can be opened - Can access the joint without major muscle damage 3. **Preservation of Blood Supply:** - Theoretically avoids MFCA if careful (debated) - May cause less AVN than anterior approach (controversial) **Biomechanical Considerations:** The approach disrupts: - Adductor muscle function (temporary weakness from retraction) - Potentially the psoas tendon (if released) - Does NOT affect abductors or hip extension The approach preserves: - Gluteus medius and minimus (abductors) - Gluteus maximus (extension) - Short external rotators (posterior stability) **Limitations for Adult Hip Surgery:** 1. **Cannot Visualize Acetabulum Well:** - Medial approach gives very limited acetabular exposure - Cannot place acetabular component for THA 2. **Cannot Expose Femoral Shaft:** - No access to proximal femoral diaphysis - Cannot perform femoral osteotomy 3. **High Risk to MFCA:** - The medial femoral circumflex artery is in the surgical field - Damage can cause AVN of femoral head {/* SECTION 6: CLASSIFICATION SYSTEMS */} ### Medial Approach Variants | Variant | Key Features | Primary Use | |---------|--------------|-------------| | **Ludloff (Classic)** | Through adductor interval, pectineus retracted | DDH open reduction | | **Ferguson** | Medial to adductor longus | Modified DDH reduction | | **Weinstein** | Modified Ludloff with extended capsulotomy | DDH in older infants | | **Anteromedial** | Combined anterior + medial elements | Extended exposure | **Ludloff Approach (1908):** - Original description for DDH open reduction - Incision in groin crease, centered over adductor longus - Pectineus retracted laterally, adductor longus medially - Access through interval between pectineus and adductor brevis **Ferguson Approach:** - Modified medial approach - Incision slightly more distal - Dissection medial to adductor longus rather than between pectineus and adductor longus *Both approaches are primarily pediatric and rarely used in adult orthopedic surgery.* ### DDH Severity and Approach Selection The medial approach is selected based on age and DDH severity: **Age-Based Approach Selection:** - Under 6 months: Pavlik harness (closed management) - 6-18 months: Closed reduction OR open reduction (medial or anterior) - 18 months to 3 years: Open reduction + pelvic osteotomy (usually anterior) - Over 3 years: Anterior approach preferred + pelvic osteotomy **Tonnis Classification (Pediatric DDH):** - **Grade I**: Subluxation, femoral head under 75% coverage - **Grade II**: Femoral head lateral but below acetabulum - **Grade III**: Femoral head at level of acetabulum - **Grade IV**: Femoral head above acetabulum (high dislocation) **Approach Selection by DDH Severity:** - Tonnis I-II: Closed reduction usually successful - Tonnis III: Open reduction may be needed (medial approach option) - Tonnis IV: Open reduction + osteotomy usually needed (anterior preferred) *The medial approach is controversial even in pediatric DDH - some surgeons prefer anterior approach for all open reductions.* ### Obturator Nerve Injury Classification Classification of obturator nerve injury (can occur with medial approach): **Seddon Classification:** - **Neuropraxia**: Temporary conduction block, full recovery expected - **Axonotmesis**: Axon damage, nerve tube intact, recovery possible - **Neurotmesis**: Complete nerve transection, surgical repair needed **Clinical Grading of Obturator Palsy:** - **Complete**: No hip adduction, sensory loss medial thigh - **Partial (anterior division)**: Weakness of adductor longus, brevis, gracilis - **Partial (posterior division)**: Weakness of adductor magnus, obturator externus **Recovery Prognosis:** - Neuropraxia from retraction: Weeks to months, good prognosis - Direct injury: Variable, may require nerve repair - Complete transection: Poor without surgical repair *Document any pre-operative adductor weakness before medial approach surgery.* {/* SECTION 7: CLINICAL ASSESSMENT */} ### Pre-operative Assessment for Medial Approach **History:** - Age of patient (medial approach most appropriate for infants) - Duration of hip pathology - Previous treatments (Pavlik harness, closed reduction attempts) - Walking ability (for older children/adults) **Physical Examination:** 1. **Hip Range of Motion:** - Assess flexion, extension, rotation - Document any contractures - Limited abduction may indicate DDH 2. **Adductor Assessment:** - Adductor tightness common in DDH - Grade adductor strength (baseline documentation) - Assess for obturator nerve function pre-operatively 3. **Gait Pattern (if ambulatory):** - Trendelenburg gait suggests abductor weakness - Limb length discrepancy with DDH 4. **Leg Length:** - True leg length measurement - Galeazzi test in infants (DDH) **Special Tests:** - **Barlow test**: Hip can be dislocated posteriorly (DDH) - **Ortolani test**: Dislocated hip can be reduced with abduction (DDH) - **Ober test**: IT band contracture - **Thomas test**: Hip flexion contracture {/* SECTION 8: INVESTIGATIONS */} ### Imaging for Medial Approach Cases **Plain Radiography:** - AP pelvis: Assess hip joint congruence - Lateral hip: Evaluate femoral head position - Shenton line disruption indicates subluxation/dislocation **Ultrasound (Pediatric DDH):** - Graf classification for infant hips - Alpha and beta angles - Dynamic assessment of stability - Gold standard for under 4 months age **Arthrography:** - Intra-operative during DDH reduction - Assess adequacy of reduction - Identify soft tissue blocks to reduction **MRI:** - Assess cartilaginous structures (not visible on X-ray) - Evaluate labrum, ligamentum teres - Rarely needed for medial approach planning **CT Scan:** - Assess bony anatomy in complex cases - Version measurements - Rarely needed for medial approach ### Operative Planning Checklist | Parameter | Assessment | Significance | |-----------|------------|--------------| | Patient age | Under 18 months ideal | Older = anterior approach preferred | | DDH severity | Tonnis classification | Higher grades may need anterior approach | | Previous surgery | Any prior incisions | May affect approach choice | | Bilateral DDH | Both hips involved | Staged procedures vs bilateral | | Femoral head vascularity | Pre-op MRI if concern | AVN risk assessment | {/* SECTION 9: MANAGEMENT ALGORITHM */} ### Decision Algorithm for Hip Approach Selection **Is the patient an ADULT with hip pathology?** - YES → Medial approach is **NOT indicated** - Choose: Anterior, lateral, or posterior approach **Is this a PEDIATRIC DDH case?** - Age under 6 months → Closed management (Pavlik) - Age 6-18 months → Consider medial approach for open reduction - Age over 18 months → Anterior approach preferred **Is this for psoas tendon release?** - Prefer: Arthroscopic release (modern standard) - Alternative: Open medial approach (rarely needed) **Key Decision Points:** 1. Age of patient (medial approach best for young infants) 2. Nature of pathology (DDH vs other) 3. Need for acetabular visualization (if yes, NOT medial) 4. Need for femoral osteotomy (if yes, NOT medial) *In Orthopaedic exam context, focus on knowing indications and contraindications rather than detailed technique.* ### Ludloff Medial Approach - Key Steps **Incision:** - Transverse incision in groin crease (2-3cm medial to femoral pulse) - 4-5cm length, centered over adductor longus origin - Alternatively: Longitudinal incision along adductor longus **Superficial Dissection:** - Identify adductor longus muscle - Retract adductor longus medially - Identify pectineus (lateral) and adductor brevis (posterior) **Deep Dissection:** - Retract pectineus laterally (protect femoral NV bundle) - Identify lesser trochanter and iliopsoas insertion - Psoas tendon may be released for DDH reduction - Identify and protect obturator nerve (runs between brevis and magnus) **Capsulotomy:** - Incise hip capsule - Remove obstacles to reduction (pulvinar, ligamentum teres) - Reduce femoral head into acetabulum (DDH cases) **Closure:** - Capsule: May close loosely or leave open (controversial) - Muscles: Return to anatomical position - Skin: Interrupted sutures *This is a brief overview - the medial approach is rarely performed and technique varies.* ### Post-operative Management (DDH Cases) **Immobilization (Pediatric DDH):** - Hip spica cast for 6-12 weeks - Position: Flexion 90-100°, abduction 45°, neutral rotation - "Human position" to maintain reduction **Imaging:** - Post-reduction X-ray or arthrogram to confirm - Follow-up X-rays at 6 weeks, 3 months, 6 months **Weight-Bearing:** - Non-weight-bearing in spica cast - Protected weight-bearing after cast removal - Full activity gradually over months **Follow-up:** - Serial X-rays until skeletal maturity - Monitor for AVN of femoral head - Monitor for residual dysplasia requiring osteotomy **Complications to Monitor:** - AVN of femoral head (most feared) - Redislocation (inadequate reduction or immobilization) - Residual dysplasia (may need later osteotomy) *Adult applications are so rare that standard post-operative protocols do not apply.* {/* SECTION 10: SURGICAL TECHNIQUE DETAIL */} ### Detailed Surgical Steps **Step 1: Incision and Superficial Dissection** - Transverse or longitudinal incision in proximal medial thigh - Identify and protect superficial vessels (external pudendal) - Incise deep fascia over adductor compartment **Step 2: Interval Identification** - Palpate adductor longus tendon (most anterior of adductors) - Identify interval between pectineus (lateral) and adductor longus (medial) - Alternatively: between adductor longus (anterior) and gracilis (posterior) **Step 3: Deep Dissection** - Retract pectineus laterally (VERY CAREFULLY - femoral vessels nearby) - Retract adductor longus medially - Identify adductor brevis deep to longus - PROTECT the obturator nerve running on surface of adductor brevis **Step 4: Iliopsoas Identification** - Identify lesser trochanter (insertion of iliopsoas) - Psoas tendon can be palpated inserting onto lesser trochanter - For DDH: psoas tendon often released to facilitate reduction *Continue with capsule exposure and reduction as described below.* ### Capsule Exposure and DDH Reduction **Step 5: Capsule Exposure** - Dissect carefully toward hip capsule - Medial capsule is thin and closely applied to psoas - MFCA runs in this region - careful hemostasis essential **Step 6: Capsulotomy (for DDH)** - Longitudinal or T-shaped capsulotomy - Remove pulvinar (fibrofatty tissue in acetabulum) - Divide hypertrophied ligamentum teres if blocking reduction - May need to release transverse acetabular ligament **Step 7: Reduction (DDH)** - Apply gentle traction and abduction to reduce femoral head - Confirm reduction with arthrography - Stability testing with flexion/extension **Step 8: Closure** - Capsule may be closed loosely or left open - Allow muscles to fall back into place - Skin closure with absorbable sutures *Immobilize in hip spica cast post-operatively.* ### Critical Landmarks | Landmark | Significance | |----------|--------------| | Adductor longus tendon | Most anterior adductor, guides interval | | Pectineus muscle | Lateral boundary, femoral vessels beyond | | Lesser trochanter | Insertion of iliopsoas | | Obturator nerve | Runs on adductor brevis surface | ### Surgical Pearls 1. **Stay medial to pectineus** - femoral vessels are just lateral 2. **Identify obturator nerve early** - protect throughout 3. **Psoas release helps reduction** - divide at lesser trochanter 4. **MFCA is posterior** - avoid posterior dissection 5. **Arthrogram confirms reduction** - essential in DDH cases *This approach provides limited exposure - know its limitations.* **Medial Femoral Circumflex Artery:** The MFCA runs posterior to the iliopsoas and around the femoral neck. It is the PRIMARY blood supply to the femoral head. Any injury can cause **AVN**. Be extremely careful when dissecting near the lesser trochanter and capsule. **Obturator Nerve:** The anterior division runs between adductor longus and brevis. The posterior division runs between adductor brevis and magnus. Both are at risk during deep dissection. Excessive retraction causes neuropraxia. {/* SECTION 13: COMPLICATIONS */} ### Complications Specific to Medial Approach **Avascular Necrosis (AVN) of Femoral Head:** - **Incidence**: 5-15% in DDH open reduction series - **Mechanism**: Injury to MFCA during surgery, or excessive pressure on femoral head - **Risk factors**: Older age at surgery, more severe dislocation, previous closed reduction attempts - **Prevention**: Meticulous surgical technique, avoid excessive manipulation - **Management**: Containment strategies, may need arthroplasty if severe **Obturator Nerve Palsy:** - **Incidence**: Rare (under 2%) if careful technique - **Presentation**: Weakness of hip adduction, sensory loss medial thigh - **Prevention**: Identify nerve, avoid excessive retraction, protect branches - **Recovery**: Neuropraxia usually recovers in weeks to months **Redislocation/Subluxation (DDH cases):** - **Incidence**: 5-10% in published series - **Cause**: Inadequate reduction, instability, non-compliance with immobilization - **Prevention**: Confirm reduction with arthrography, adequate immobilization - **Management**: Repeat closed or open reduction, consider pelvic osteotomy AVN of the femoral head is the **most feared complication** of open reduction for DDH. The medial femoral circumflex artery supplies most of the femoral head blood. It runs in the surgical field of the medial approach. Even with perfect technique, AVN can occur due to pressure effects from reduction. Always counsel families about this risk. {/* SECTION 14: POSTOPERATIVE CARE */} ### Post-operative Protocol (Pediatric DDH) **Immediate Post-operative Period:** - Hip spica cast application in operating room - Position: Flexion 90-100°, abduction 40-50°, neutral rotation - "Human position" for hip stability - Confirm position with X-ray **Spica Cast Care:** - Cast typically for 6-12 weeks total (often split into two periods) - Skin care around cast edges - Monitor for cast complications (pressure sores, tight cast) - May change cast at 6 weeks under anesthesia **Imaging Follow-up:** - Post-operative X-ray to confirm reduction - X-ray at cast removal - Regular follow-up X-rays until skeletal maturity **Mobilization After Cast Removal:** - May need abduction brace/splint - Physiotherapy for range of motion - Gradual return to weight-bearing - Full activities over 3-6 months **Long-term Follow-up:** - Annual X-rays until skeletal maturity - Monitor for: - Residual dysplasia (may need pelvic osteotomy) - AVN changes (Kalamchi-MacEwen classification) - Coxa vara/valga - Leg length discrepancy {/* SECTION 15: OUTCOMES AND PROGNOSIS */} {/* REMOVED: 5-diagram-showing-each-hip-by-age-at-openreduction-s.png */} ### Expected Outcomes **DDH Open Reduction via Medial Approach:** **Favorable Prognostic Factors:** - Earlier age at reduction (under 12 months) - Less severe initial dislocation - Successful concentric reduction achieved - No AVN complications **Poorer Prognosis:** - Delayed diagnosis/treatment (over 18 months) - Higher Tonnis grade at presentation - AVN development - Residual instability requiring further surgery The **Severin classification** is used to grade radiographic outcomes after DDH treatment: - **I**: Normal - **II**: Mild deformity, normal head:acetabulum relationship - **III**: Dysplasia without subluxation - **IV-VI**: Progressive subluxation/dislocation Grades I-II are considered satisfactory. This classification is assessed at skeletal maturity. {/* SECTION 16: EVIDENCE BASE */} {/* SECTION 9: VIVA SCENARIOS */} {/* SECTION 11: AUSTRALIAN CONTEXT */} ### Orthopaedic Examination Perspective **Relevance to Orthopaedic Exam:** The medial approach to the hip is **LOW YIELD** for the adult reconstruction and general orthopedic components of the Orthopaedic exam. Key points to know: 1. **Historical knowledge only** - understand it exists and basic anatomy 2. **NOT used for THA** - know why (poor exposure, MFCA risk) 3. **Pediatric indication** - primarily for DDH open reduction 4. **Obturator nerve** and **MFCA** as key structures at risk **Australian Practice:** - Medial approach is rarely performed in adult practice - DDH management in Australia follows established pediatric protocols - Most surgeons use anterior, lateral, or posterior approaches for adult hip surgery **For Orthopaedic Candidates:** Focus your hip approach preparation on: 1. **Anterior approach (Smith-Petersen)** - increasingly popular 2. **Anterolateral (Watson-Jones)** - common for hemiarthroplasty 3. **Direct lateral (Hardinge)** - most common in Australia 4. **Posterior (Moore/Southern)** - important alternative Know the medial approach exists, its basic anatomy and indications, but do not spend excessive time on detailed technique. If asked about hip approaches in the Orthopaedic viva, start with the approaches you would actually use in practice (anterior, lateral, posterior). If asked specifically about the medial approach, demonstrate you know it exists, its primary use (pediatric DDH), and why it is not used for adult THA (limited exposure, MFCA risk). {/* SECTION 12: EXAM CHEAT SHEET */}

Hip Medial Approach (Ludloff)

Hip Medial Approach (Ludloff)