Hip - Medial Approach

Modern Study Review (AI-Generated)

High-Yield Summary

The Medial Approach to the Hip (Ludloff approach) offers direct access to the medial proximal femur, primarily indicated for open reduction of femoral fractures involving the lesser trochanter, adductor tendon transfers, and medial femoral neck procedures. While less common in contemporary arthroplasty or minimally invasive hip surgery, it remains valuable for select trauma and reconstructive cases. Its principal advantage is the use of a safe internervous plane that minimizes disruption of major neurovascular structures.

Applied Anatomy & Intervals

Internervous Interval

Between the anterior branch of the obturator nerve (innervating adductor longus and gracilis) and the posterior branch of the obturator nerve (innervating adductor brevis and part of adductor magnus).
Note: The adductor magnus has dual innervation from the posterior obturator nerve and the tibial portion of the sciatic nerve, requiring careful dissection to avoid denervation.

Anatomic Landmarks

Pubic tubercle: Incision begins approximately 3 cm distal.
Medial thigh: Overlying the adductor longus muscle.
Lesser trochanter: Key bony landmark for deep exposure and tendon identification.

Patient Positioning & Setup

Table Type: Standard operating table with capability for hip flexion and abduction.
Patient Position: Supine, with the affected hip flexed, abducted, and externally rotated to optimize medial thigh and lesser trochanter exposure.
Specialized Equipment:
Limb positioner or assistant to maintain hip position.
Retractors designed for medial thigh soft tissue retraction.
C-arm fluoroscopy usually not required but available for fracture fixation confirmation.

Surgical Technique (The “Vital Steps”)

Incision & Superficial Dissection

Make a longitudinal incision on the medial thigh starting 3 cm distal to the pubic tubercle, centered over the adductor longus.
Carefully incise subcutaneous tissue to expose the fascia overlying the adductor muscles.

Deep Dissection & Exposure

Develop the plane between adductor longus and gracilis muscles.
Further dissect the interval between adductor brevis and adductor magnus.
Identify the lesser trochanter as a key landmark.
Place retractors above and below the lesser trochanter to isolate the psoas tendon and protect neurovascular structures.

The “Danger Zone”

Structure	Location / Risk Area	Protection Strategy
Anterior division of obturator nerve	Lies on top of obturator externus, medial thigh between adductor longus and brevis	Identify and preserve during dissection; avoid traction injury
Posterior division of obturator nerve	Within obturator externus, runs on adductor magnus under adductor brevis	Gentle dissection; avoid deep penetration into muscle substance
Medial femoral circumflex artery	Passes medial to distal psoas tendon near lesser trochanter	Retract psoas tendon carefully; avoid aggressive cautery or retraction

Post-Operative Pearl

Early mobilization is encouraged; however, avoid forced hip extension and adduction for 4–6 weeks to protect healing medial soft tissues and prevent stretch injury to obturator nerve branches.

Classic Clinical Notes