S i8 APPLIED ANATOMY. 



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 exten- 

 sive 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 



Gluteus maximus 



Gluteus medius 



Head of femur '-~ 

 Greater trochanter 



Gemelli 



Obturator internus 

 Quadratus femoris 



Posterior superior spine 



Branches of sciatic artery 



Pyriformis 



Sciatic nerve 



~~ - Gluteus maximus 



FIG. 527. The lateral mode of approach in operating on the hip- joint; large incision made to show relation of the 



parts involved. 



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. 



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. 



