434 THE INFERIOR EXTREMITY 



limbs together, the pelvis is depressed upon the affected side 

 when the abducted limb is placed upon the ground, and the 

 acetabulum looks almost directly downwards like an inverted 

 cup, thus ensuring stability. Adduction of the sound limb is 

 necessary, and the centre of gravity, which is upset by the tilting 

 of the pelvis, is restored by a compensatory lumbo-thoracic 

 scoliosis. The sole of the boot on the sound limb may be 

 thickened to make certain that the pelvis will be sufficiently 

 tilted, and later, as the ankylosed joint grows stronger, the 

 thickening may be gradually reduced. Finally, the sole of the 

 boot on the affected limb may be gradually thickened, in the 

 hope that the tilting of the pelvis will give way to a gradual 

 angulation in the proximal part of the femoral shaft. 



When excision of the hip-joint is performed in those cases 

 in which the limb is markedly adducted, a preliminary tenotomy 

 of the shortened adductors is necessary. This enables the 

 limb to be abducted, and allows the trochanter to be placed 

 and kept in the acetabulum. Further, as the aim is to obtain 

 an ankylosed joint with the limb abducted, the adductors will 

 no longer be required. A vertical incision is made along the 

 tendon of the adductor longus, and that muscle is exposed 

 together with the gracilis at its medial border. Both are cut 

 across with scissors, and their ends retract, exposing the adductor 

 brevis and the anterior division of the obturator nerve. Both 

 these structures are divided, and the adductor magnus, with the 

 posterior branch of the obturator nerve on its surface, is brought 

 into view. The nerve is cut through and the greater part of 

 the muscle is divided. The wound is then closed, and the 

 excision is performed in the manner already described. 



The Anterior Route for Excision of the Hip-Joint 

 is carried out through a vertical incision, made dis tally from 

 the anterior superior iliac spine, and the skin, superficial and 

 deep fasciae are divided. The sartorius is exposed at the medial 

 side of the wound, running distally and medially (p. 398), while 

 laterally the anterior margin of the tensor fasciae latse is found. 

 The wound is deepened in the V-shaped interval between these 

 muscles, until the rectus femoris is brought into view. This 

 muscle is retracted medially, and at this stage the ascending 

 branch of the lateral circumflex (p. 409) may be divided. The 

 anterior aspect of the capsule is then exposed. 



This route may be adopted in tuberculous disease of the hip- 

 joint when there is an abscess opening on the anterior aspect of 



