Straight anterior approach or Smith Petersen is very useful and the most common open approach I use. The standard interval is between Sartorius and Tensor fascia Lata (TFL) superficially and between rectus femoris (RF) and Gluteus medius deep. Deeper to these, there is another interval that is not mentioned, between iliocapsularis (IC) anteriorly and gluteus minimus posteriorly. Both these muscles are attached to the capsule and need elevation of the red fibers off the white capsule. Branches of the lateral femoral circumflex artery and other minor named vessels are encountered and cauterized with no problems. Incising the fascia over TFL lateral to TFL-Sartorius interval and retracting all the fibers of TFL laterally protects the main branch of LFCN better without even exposing it. More medial exposure of the joint, the anterior wall and superior pubic ramus require release of RF origin and retraction medially or work medial to RF by retracting it laterally. The nerve supply to the rectus from the femoral nerve limits lateral retraction and distal extension of this interval.
Anterior approach is useful for reduction of all femoral head and neck fractures, anterior acetabular wall fractures, arthrotomy of the hip, open reduction of developmentally dislocated hip, open reduction of unstable slip, cam osteoplasty, labral repair, rim trimming, hip arthroplasty, psoas tenotomy, flexion contracture release, reconstructive procedures on the head and excision of the head, innominate osteotomy, it can be extended proximally to reach the SI joint, and perform the entire procedure of Periacetabular osteotomy.
Anterior approach to the hip medial to Rectus Femoris tendon.
The standard anterior approach (Smith-Petersen) does not expose the hip joint adequately without release or relaxation of the Rectus femoris tendon. Dr. Prasad Gourineni used a less invasive anterior approach medial to the Rectus tendon to drain septic hips, acetabular rim trimming, labral repair, femoral neck osteoplasty, and open reduction of femoral head and neck fractures after ensuring the safety of this approach in cadavers. The proximal branch innervating the rectus tendon was always distal to the hip joint (unpublished data).
Images of anterior approach
Image of femoral neck fracture fixation.