This section is from the book "Applied Anatomy: The Construction Of The Human Body", by Gwilym G. Davis. Also available from Amazon: Applied anatomy: The construction of the human body.
The operations on the hip are usually done either for hip-disease or congenital luxations. More rarely traumatic or pathological luxations or intracapsular fractures may be operated on. The joint may be approached either anteriorly or laterally. Lateral operations are the more mutilating, while anterior ones are often sufficient and less serious.
In approaching the joint from the side the incision of Langenbeck is preferred. It begins well up on the buttocks on a line with the posterior superior spine (page 500) and is continued down over the great trochanter in the axis of the thigh. If made with the limb flexed the line of incision will be straight. The muscular fibres and tendon of the gluteus maximus are cut in the line of the incision. This exposes the posterior edge of the gluteus medius, which is to be pulled forward, and the pyriformis, which is to be drawn backward or loosened from its insertion into the trochanter. The capsule can then be incised and the joint examined. Further exposure may be obtained by loosening the gluteus medius and gluteus minimus from their insertion in the top of the trochanter and pushing them forward. The ligamentum teres is often destroyed by the disease. Removal of the head of the femur enables the acetabulum to be examined and carious bone curetted away if necessary. The incision through the gluteus maximus muscle will be almost parallel to its fibres and near its anterior edge. Care is to be taken not to go too high up between the pyriformis and gluteus medius because the main trunks of the gluteal artery and superior gluteal nerve make their exit there from the great sacro-sciatic notch. The principal bleeding will come from branches of the gluteal artery descending from that point. This operation is practically limited to cases of extensive caries in which it is desired to do a radical operation (Fig. 527).
Boeckmann, of St. Louis, made a large horseshoe-shaped flap over the greater trochanter. Its base was upward and it consisted of skin and superficial fascia. This flap was raised and a chain-saw passed underneath the muscles inserting into the top of the greater trochanter, and the latter was then sawed off and turned up as a flap. This exposed the upper surface of the head and neck of the femur. The operation was done for intracapsular fracture, the fragments being pinned together with ivory pegs and the trochanter brought down and again fastened in place with ivory pegs. The skin-flap was also brought down and sutured. While good ex- posure can be obtained by this method, it is almost too severe and has not been generally adopted.
Pig. 527. - The lateral mode of approach in operating on the hip-joint; large incision made to show relation of the parts involved.
Lorenz, in congenital luxations, incised from the anterior superior spine down and out toward the trochanter. The tensor fasciae femoris is pushed forward and the glutei muscles backward. Hoffa modified this operation by making his incision along the anterior edge of the greater trochanter. As the hip-joint is nearer the anterior than the lateral surface of the body we believe it to be better to approach it from the front rather than from the side.
Liicke made an incision from just below the anterior superior spine running downward and inward along the inner margin of the sar-torius. The sartorius and rectus muscles were displaced outward and the iliopsoas inward.
Huter, Parker, and Barker made the incision directly downward from the anterior superior spine and pulled the sartorius and rectus inward and the tensor fasciae femoris and gluteus medius and minimus outward (Fig. 528).
The method of Huter, Parker, and Barker, is not difficult. The only vessel encountered is a branch of the external circumflex. One should not go too low, or some muscular branches of nerves going to the vastus externus will be wounded. No muscles are divided. The writer has used this method with satisfaction in cases of hip disease and intracapsular fracture.
If additional room is desired the fascia lata may be divided laterally and the tensor fasciae femoris and gluteus medius muscles may be detached from the spine of the ilium and back along the crest, as done by Codivilla. They are to be again sewed back into place before closing the wound.
Ludlof, in congenital luxations, abducted the thigh to a right angle and made his incision along the tendon of the adductor longus. This muscle was then drawn downward and the pectineus upward and the joint exposed. The writer prefers to make an incision along the inner side of the femoral vein. The vessels are then to be drawn upward and outward and the pectineus downward and inward and the capsule is at once evident.
Fig. 528. - Anterior operation on the hip-joint.