. 2019 Sep 26;8(10):e1247–e1253. doi: 10.1016/j.eats.2019.06.014

Table 2.

Pearls and Pitfalls for Open Anterior Capsule Reconstruction of the Hip Using an Achilles Tendon Allograft

Pearls	Pitfalls
1. Use a flat-top radiolucent table to prepare for possible intraoperative fluoroscopy. 2. Place a bump under the ischiums (folded flannel blanket works well) to allow some extension to the hip, which allows for easier exposure. 3. Prep the leg free to allow full control of the limb throughout the procedure. 4. Bias the skin incision lateral, centered over the TFL to prevent unintentional dissection medial to the Sartorius. 5. Ensure complete hemostasis of the ascending branch of the lateral circumflex femoral artery to prevent uncontrolled bleeding later on in the case. 6. Use of DAA retractors is advised for proper and full exposure. 7. Consider a metal suture anchor at the medial site anterior to the LT; this is an area of dense cortical bone.	1. Rushing through the exposure. The exposure is the foundation of this reconstructive procedure. 2. One must stay superficial to the hip capsule; do not stray into the anterior capsule remnant while reflecting the iliocapsularis and reflected head of the rectus femoris from the anterior capsule. 3. Allowing the superior acetabular retractor to fall away from the line perpendicular to the inguinal ligament (this may cause a femoral nerve palsy). 4. Fracture of the bone plug on the allograft while either drilling the suture holes or docking the graft. 5. Inadequate tensioning of the graft in flexion and internal rotation of the hip, causing a lax graft and defeating the purpose of the reconstruction.

Pearls

Pitfalls

1.
Use a flat-top radiolucent table to prepare for possible intraoperative fluoroscopy.
2.
Place a bump under the ischiums (folded flannel blanket works well) to allow some extension to the hip, which allows for easier exposure.
3.
Prep the leg free to allow full control of the limb throughout the procedure.
4.
Bias the skin incision lateral, centered over the TFL to prevent unintentional dissection medial to the Sartorius.
5.
Ensure complete hemostasis of the ascending branch of the lateral circumflex femoral artery to prevent uncontrolled bleeding later on in the case.
6.
Use of DAA retractors is advised for proper and full exposure.
7.
Consider a metal suture anchor at the medial site anterior to the LT; this is an area of dense cortical bone.

1.
Rushing through the exposure. The exposure is the foundation of this reconstructive procedure.
2.
One must stay superficial to the hip capsule; do not stray into the anterior capsule remnant while reflecting the iliocapsularis and reflected head of the rectus femoris from the anterior capsule.
3.
Allowing the superior acetabular retractor to fall away from the line perpendicular to the inguinal ligament (this may cause a femoral nerve palsy).
4.
Fracture of the bone plug on the allograft while either drilling the suture holes or docking the graft.
5.
Inadequate tensioning of the graft in flexion and internal rotation of the hip, causing a lax graft and defeating the purpose of the reconstruction.

DAA, direct anterior approach; LT, lesser trochanter; TFL, tensor fascia lata.