RU2654599C1 - Method of experimental surgical access to the hip joint in the petrochanteric pelvic fractures - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to experimental medicine and can be used for experimental surgical access to the hip joint in the pertrochanteric pelvic fractures. On the skin the three main landmarks of the incision is made with a marker, the first of which is the point, which is at the level of the anterior superior spine of the ilium and posteriorly from it, the second landmark is at the point of intersection of a vertical line, passing posteriorly from the apex of the greater trochanter in the projection of the intertrochanteric crest, and a horizontal line passing above the apex of the greater trochanter, and the third landmark is below the base of the greater trochanter and in the projection of the anterior border of the femur. Line of the future incision are reconstructed with the marker at the indicated points. Incision is made. Suture of muscles and soft tissues is made.

EFFECT: method allows to reduce the operating time, to develop access for all variants of the acetabular fractures.

1 cl, 42 dwg

Description

The method relates to operative surgery, topographic anatomy, traumatology, operative orthopedics, hip replacement, experimental surgery, rehabilitation of patients with injuries and diseases of the pelvic bones.

In his work, E.A. Litvinova [Litvina E.A. Modern surgical treatment of multiple and combined fractures of the limbs and pelvis: abstract. dis. ... cand. honey. Sciences: 01/14/15 / E.A. Litvin. - Moscow, 2010. - 45 pp.] Notes that in the treatment of severe pelvic fractures, often encountered in combined and multiple trauma, orthopedic traumatologists rarely use primary pelvic stabilization, which is an essential component of anti-shock and resuscitation measures. Quite often, the final reposition and stable fixation of pelvic and acetabular fractures is unreasonably delayed. The increase in the period of the preoperative period, according to the author, sharply complicates reposition, increases the invasiveness of the intervention and the amount of surgical blood loss [Choice of surgical access in the treatment of two-column acetabular fractures / A.A. Grin, A.V. Runkov, I.L. Shlykov // Traumatology and Orthopedics of Russia. - 2014. - No. 1 (71). - S. 92-97; Litvina E.A. Modern surgical treatment of multiple and combined fractures of the limbs and pelvis: abstract. dis. ... cand. honey. Sciences: 01/14/15 / E.A. Litvina - Moscow, 2010 .-- 45 p .; Keggi K.J. et all. Anterior approach to total, hip replacement: Surqical technique and clinical results of our first one thousand cases usinq noncemented prostheses. Yale j. Biol. Med. 1993, v. 66, p. 243-256; Knight RA, Smith H (1958) Central fractures of the acetabulum. J Bone Joint Surg 40: 1; Letournel E (1980) Acetabulum fractures: classification and management. Clin Orthop 151: 81; Matte J, Anderson L, Epstein H, Hendrick P (1986) Fractures of the acetabulum: a retrospective analysis. Clin Orthop 205: 230; Matte J, Letournel E, Browner B (1986) Surgical management of acetabular fractures. Mosby, St. Louis (American Academy of Orthopedic Surgeons Instructional Course Lectures, N35, p. 38)].

Closed lateral pelvic fractures with unrepaired displacement of fragments naturally lead to the development of post-traumatic coxarthrosis. The treatment of closed acetabular fractures with displacement of fragments is currently one of the difficult problems that an orthopedic traumatologist is forced to solve when choosing a method of surgical treatment [O. Buachidze and other Surgery of the hip joint, M .: Medicine, 2002, 15-20; The choice of surgical access in the treatment of two-column acetabular fractures / A.A. Grin, A.V. Runkov, I.L. Shlykov // Traumatology and Orthopedics of Russia. - 2014. - No. 1 (71). - S. 92-97].

According to various authors, acetabular fractures account for up to 22% of all pelvic injuries, two-column fractures are found among them in 19.4-22.6% of cases [Letournel E. The results of acetabular fractures treated surgically: twenty-one years experience . In: The hip: proceedings of the Seventh Open Scientific Meeting of The Hip Society. Mosby, St. Louis. 1979; Letournel E. Fractures of the pelvis and acetabulum. Ninth AFOR Course and Workshop. Paris 1993. P. 253-313; Letournel E (1980) Acetabulum fractures: classification and management. Clin Orthop 151: 81; Ochs B.G., Marintschev I., Hoyer H. et al. Changes in the treatment of Acetabular fractures over 15 years: Analysis of 1266 cases treated by the German Pelvic Multicentre Study Group (DAO / DGU). J. Injury. 2010; 8: 839-851]. The lesions under consideration relate to “complete” intraarticular fractures, since not a single part of the articular surface of the acetabulum remains connected with the axial skeleton. With significant displacements and instability of the fragments, this damage is called a floating floating acetabulum.

Indications for open reduction and internal fixation, many authors consider the displacement of fragments of VP. The solution to this complex problem is multicomponent: determining the timing of surgical intervention, planning the volume of surgical intervention and, accordingly, surgical access, the choice of which depends on the clinical and radiological assessment of the type of fracture, the use of effective and less traumatic methods of reposition, ensuring, if possible, anatomical reposition of fragments and execution stable fixation, anesthetic management of surgical intervention.

It is difficult to choose one of the surgical approaches to the hip joint that would provide a solution to all problems, given the presence of only a variety of options for fractures of the EP presented in the literature. An orthopedic traumatologist is required to know several classic accesses to the hip joint and take them as a basis when performing surgery.

Currently, there are four classical surgical access to TBS [Dadaev M.Kh. Modified posterior-lateral access for total hip arthroplasty / M.Kh. Dadaev, N.G. Goncharov, V.G. Golubev, A.A. Ostanokov, I.A. Rezunenko, D.A. Chuzhmakov, V.V. Yulov // Abstracts of the IX Congress of Orthopedic Traumatologists: 3 vols. Volume I. Saratov, 2010 - 580 pp .: ill .; Prokhorenko V.M. (State Institution of Novosibirsk Research Institute of Traumatology and Orthopedics of the Ministry of Health of the Russian Federation): “Method of surgical access for operations on the hip joint”, RU (11) 2281710 (13) C2. 6. 6 .; Brady L.P. Lateral oblique incision for the Charnley low friction arthroplasty / L.P. Brady // Clin. Orthop. - 1986. - V. 118. - P. 7; Epstein HC (1980) Traumatic dislocations of the hip. Williams & Wilkins, Baltimore; Judet R, Judet J, Letournel E (1964) Fractures of the acetabulum. Classification and surgical approaches for open reduction. J Bone Joint Surg [Am] 46: 1615; Harris W.H. Extensive exposure of the hip joint / W.H Harris // Clin. Orthop. - 1973. - V. 91. - P. 58; Harris W.H. A new approach to total hip replacement without osteotomy of the greater trochanter / W.H. Harris // Clin. Orthop. - 1975. - V. 106. - P. 19].

A close solution to the problem can be found in the method of V.M. Prokhorenko (State Institution of Novosibirsk Research Institute of Traumatology and Orthopedics of the Ministry of Health of the Russian Federation): “Method of surgical access for operations on the hip joint”, RU (11) 2281710 (13) C2 [5]. The method consists in the following: “they access the surgical scar remaining after previous interventions and excise it; simultaneously, to the entire depth, from top to bottom, longitudinally dissect the soft tissues to the femur, starting from the proximal outer surface of the femur, through the point between the anterior and middle third of the width of the greater trochanter; the pelviotrochanteric muscles are longitudinally separated, and the anterior soft tissue flap thus obtained, stupidly and sharply peeling from the bone structures, is removed anteriorly; at the end of the surgery, the flap is laid and fixed in the same place. " The closest solution is described in the developed on the basis of the Ural NIIITO them. V.D. Chaklin extended posterior-lateral Y-shaped access to the hip joint [Choice of surgical access in the treatment of two-column acetabular fractures / A.A. Grin, A.V. Runkov, I.L. Shlykov // Traumatology and Orthopedics of Russia. - 2014. - No. 1 (71). - S. 92-97]. This is a modified posterolateral approach with an additional “beam” from the greater trochanter in the direction of the anterior iliac spine. With this access, the authors perform osteotomy of the greater trochanter, while the possibility of osteotomy of the anterior awns of the pelvic bone is provided. This access provides a complete overview and the ability to manipulate fragments of the front and rear columns from the outside and partially from the inside of the pelvis. On the operating table, the patient is in a position on his side.

However, this method has its drawbacks: 1 - in the patient’s position on the side, the femoral head tends to "fall" into the pelvic cavity, aggravating the position of the fragments, especially with complex comminuted fractures, which can complicate the process of reposition; 2 - when using the Y-shaped access in one patient, sciatic nerve neuropathy was obtained, accompanied by paresis of the peroneal muscles and in two patients - intraoperative damage to the lower gluteal artery; 3 - when using Y-shaped access, heterotopic ossification was noted.

The technical result is to develop a method of experimental surgical access to the hip joint during an extravertebral fracture of the pelvis.

The technical result is achieved in the following way.

The corpse is laid on its side, three main landmarks of the incision are marked with a marker on the skin, the first of which is a point located at the level of the anterior superior iliac spine and posterior to it, the second landmark is at the intersection of the vertical line passing posterior to the apex of the greater trochanter the projection of the intertrochanteric ridge, and the horizontal line passing above the top of the greater trochanter, and the third landmark is below the base of the greater trochanter and in the projection of the anterior edge of the femur, the restoration marker t the line of the future incision at the indicated points, after which the skin and subcutaneous fat are cut along the intended line, the wound is expanded, then the border line between the muscle stretching the wide fascia and the gluteus maximus muscle is determined, and these muscles are divided along this line, while muscle dissection and disengagement is performed in the upward direction, bringing to the place of attachment of the posterior portion of the muscle, which stretches the wide fascia to the outer lip of the iliac crest, then, in order to mobilize, the upper bundles are cut off Olsha gluteal muscles (m. gluteus maximus), attached to the wide fascia (fascia lata) and the ileo-tibial tract (traktus iliotibialis), while excision is performed within the wide fascia without muscle damage, then the incision is continued downward, for which the ileo-tibial tract is widened over the greater trochanter the fascia of the thigh and the incision end below the base of the greater trochanter, and then the formed posterior and anterior muscular edges, including the mobilized superior bundles of the gluteus maximus muscle, are diluted with retractors, respectively, posteriorly and anteriorly, and posterior to the posterior muscular margin, in order to prevent damage to the supply artery, they produce until the vascular bundle appears in the upper corner of the wound, in which the superficial branch of the superior gluteal artery passes, and expose the gluteus maximus muscle and trochanteric femoris, then fibers of the gluteus maximus muscle are diluted and, if necessary, cut through its entire thickness, while the dissection of the middle gluteal muscle begins at the front-outer part of the base of the apex of the greater trochanter and lead along the muscle fibers of the anterior part of the middle gluteal muscle in the direction of the upper edge of the anterior lower iliac spine, then perform another incision, which begins from the posterior-outer part of the base of the apex of the greater trochanter and direct it along the anatomical border located between the lower edge of the middle and small muscles on one side, and piriform, twin and obturator muscles on the other hand, dividing them among themselves, while dividing them up and back, in order to prevent damage to the superior gluteal nerve and artery, innervate nourishing and nourishing the middle and small gluteal muscles, continue until the neurovascular bundle appears in the upper posterior corner of the muscle wound, then the tendon of the middle gluteal muscle is divided into two parts, the front part belonging to the group of muscle fibers that perform the function of the internal rotator of the thigh, and the back part, belonging to the group of muscle fibers that perform the function of the external rotator of the thigh, after which both parts of the tendon are completely separated from the apex of the greater trochanter, and each part of the tendon is reinforced by stitching the lavsan using one of the classic tendon sutures in such a way that the tendon part is formed in the form of a cone, from which at least two threads come out, then the tendon of the gluteus maximus muscle is pulled up to expose the gluteus maximus muscle, then it is dissected or cut into the entire thickness of the gluteus maximus fiber muscles in the same direction as the middle gluteus, starting at the anteroposterior base of the apex of the greater trochanter in the direction of the upper edge of the anterior lower iliac spine, after which detachment of the gluteus maximus and take it up along with the gluteus maximus muscle to expose the joint capsule, then perform separation from the place of attachment of the piriform, twin and locking muscles to the trochanteric fossa, stitch them with Dacron thread and retract them posteriorly and laterally from the back to the back the edges of the acetabulum with exposure of the latter up to the exposure of the sciatic spine, the edge of the small sciatic notch, sciatic bone and tubercle of the sciatic bone, and optionally to expose the ischial tubercle and the junction of the posterior acetabulum and the ischial body, partial separation of the quadratus muscle from the ischial tuberosity is performed, then the outer, medial and intermediate broad muscles of the thigh are separated with the anteroposterior surface of the trochanteric region exposed and the joint capsule is excised, then the upper edge of the acetabulum, the anterior lower iliac spine, the front edge of the acetabulum and the location of the pubic body from the acetabulum are exposed then the posterior iliac dislocation of the femur is performed, which became possible after the proximal femur was mobilized, the thigh is bent, while the head, neck and trochanteric region of the thigh allow revision and manipulation of the acetabulum, then the proximal part of the thigh is retracted posteriorly and revised and manipulations on the anterior part of the acetabulum, then the femur is transferred to the position of the anterior suprapubic dislocation, the thigh is set in the extension position, the wound with the expanders, the proximal part of the thigh is anterior and revised and manipulated in the posterior part of the acetabulum, then, if necessary, bone autoplasty of the acetabulum is performed, the fatty tissue is detached up to the crest of the anterior part of the iliac wing, the skin and fatty tissue are moved away with the expanders, from the muscle, the crest of the anterior part of the iliac wing and perform a graft sampling, after finishing work on the acetabulum, the RA, then in the anterior part of the apex of the greater trochanter in the projection of the intertrochanteric linea (linea intertrochanterica) and at the level of the upper edge of the femoral neck, the first anterior canal is 6 mm in diameter, running in the anteroposterior direction from the inside outward, from top to bottom with the exit in the anterior-outer parts under the trochanteric region, then along the formed channel form the channel in the same direction, but with a diameter of 10 mm to a depth of 10 mm, then in the back of the top of the greater trochanter in the projection of the intertrochanteric crest (crista intertrochanterica) and at the level of vert the flax fossa (fossa trochanterica) of the femur perform the second posterior canal, 6 mm in diameter, going in the posterior-anterior direction from the inside outward, from top to bottom with exit to the posterior-outer part of the undervert region, then along the formed channel form a canal in the same direction, but already with a diameter of 10 mm to a depth of 10 mm, while the distance between the openings of the canals in the subrochanteric region should not be less than 10 mm, after that, in the subrovertinal region, the tendon part of the external broad thigh muscle is separated downward, then through the middle and back parts of the tendon of the middle gluteus muscle draw a cerclage wire directly above the part stitched with lavsan thread and lay both its ends along the formed cones, after which the filaments and wire of the front and back parts of the tendon are collected in a bundle and these bundles are passed through the corresponding front and back bony channels so that the tendon parts formed in the form of cones are embedded in the corresponding bone channels, and the separated part of the gluteus maximus muscle is sutured to the fixed transossally of the front part of the tendon of the middle gluteal muscle, then the thigh is removed 30 degrees in a neutral position between flexion and extension in the hip joint and the ends of the threads and wire are pulled with the maximum penetration of the ends of the tendon into the channels, then the ends of the wire from two channels are twisted in several turns, and the threads they bind, and then the excess part of the wire is removed with nippers and the ends of the mylar thread are cut off, after which the separated tendon part of the external broad thigh muscle is laid in place oh, at the same time, lavsan and wire knots are covered and then fix it to the subrochanteric region, and when the wound is sutured, the lower twin and square muscles, partially detached from the tubercle of the ischium, are sutured to the extra-pelvic part of the internal obstructive muscle and to the external obturator, then the muscles are stapled and reinserted and soft tissues, while further removing the lavsan threads used as holders, the wound is drained and sutured.

The invention is illustrated by the following figures.

In FIG. 1. A photo of the corpse lying on the right side with a surgical diaper sheathing the surgical field, and with a marked marker for the cut of the skin, is presented.

In FIG. 2. A photo of the cut of the skin and subcutaneous fat with exposure of the broad fascia of the thigh is presented. 1 - dissection and disengagement of the muscles is performed in the upward direction, bringing to the place of attachment of the back portion of the muscle, stretching the wide fascia to the outer lip of the iliac crest. 2 - cut-off line of the upper bundles of the gluteus maximus muscle (m. Gluteus maximus), attached to the wide fascia (fascia lata) and the ileo-tibial tract (traktus iliotibialis), while the cut-off is performed within the wide fascia without muscle damage.

In FIG. 3. A dissection photo of the ileo-tibial tract of the broad fascia of the femur with the end of the incision below the base of the greater trochanter is presented. 3 - the zone of cutoff of the upper bundles of the gluteus maximus (m. Gluteus maximus), attached to the wide fascia (fascia lata) and the ileo-tibial tract (traktus iliotibialis).

In FIG. 4. A photo of the section of the middle gluteal muscle is presented, which begins at the front-outer part of the base (4) of the apex (5) of the greater trochanter.

In FIG. 5. A photo of the section is presented, which starts from the back-outer part of the base (6) of the apex (5) of the greater trochanter, and directs it along the anatomical border (7) located between the lower edge of the middle and small gluteal muscles (8) on one side, and piriform, twin and obturator muscles (9) on the other hand.

In FIG. 6. A photo of the separation (10) of the tendon (11) of the gluteus midi muscle (12) is divided into two parts.

In FIG. 7. A photo is presented of the front part (13) related to the group of muscle fibers that perform the function of the inner rotator of the thigh, and the back part (14) related to the group of muscle fibers that perform the function of the outer rotator of the thigh; 5 - the top of the greater trochanter.

In FIG. 8. A photo of reinforcing the anterior (13) and posterior (14) parts of the tendon by flashing lavsan thread (16) with one of the classic tendon sutures in such a way that the tendon was formed in the form of a cone (15) is presented.

In FIG. 9. A photo of the middle gluteus muscle (12) and the gluteus maximus (17) taken up is presented.

In FIG. 10. A photo of the detachment of the gluteus maximus muscle (17) and its abduction along with the gluteus maximus muscle (12), with exposure of the tendons of the piriformis, twin and obturator muscles (9) and the joint capsule (18), are presented.

In FIG. 11. A photo of separation from the place of attachment to the trochanteric fossa of the tendons of the pear-shaped, twin and obturator muscles (9), which are stitched with Dacron thread (16) and retracted posteriorly and laterally; 5 - the top of the greater trochanter; 12 - the middle gluteus muscle; 16 - a mylar thread; 17 - gluteus maximus muscle; 18 - capsule of the joint.

In FIG. 12. A photo of the separation of the external, medial and intermediate wide muscles of the thigh (21) with exposure of the front-outer surface of the trochanteric region (25), the upper edge of the acetabulum (19), the anterior lower iliac spine (20), and the front edge of the acetabulum ( 22) and the location of the pubic body from the acetabulum (23) and the femoral head (24); 5 - the top of the greater trochanter; 18 - capsule of the joint.

In FIG. 13. A photo of the posterior iliac dislocation of the femur is presented; 24 - the head of the femur; 26 - acetabulum.

In FIG. 14. A photo of the anterior suprapathous dislocation of the femur is presented; 24 - the head of the femur; 26 - acetabulum.

In FIG. 15. A photo of the implementation of the first front channel with a diameter of 6 mm; 27 - drill with a diameter of 6 mm.

In FIG. 16. A photo of channel formation with a diameter of 10 mm along the already formed channel to a depth of 10 mm is presented; 28 - drill with a diameter of 10 mm.

In FIG. 17. A photo of the formation in the posterior part of the apex of the greater trochanter in the projection of the intertrochanteric crest (crista intertrochanterica) and at the level of the trochanteric fossa (fossa trochanterica) of the femur of the second posterior canal, initially 6 mm in diameter, is presented.

In FIG. 18. A photo of the formation in the posterior part of the apex of the greater trochanter in the projection of the intertrochanteric crest (crista intertrochanterica) and at the level of the trochanteric fossa (fossa trochanterica) of the femur of the second posterior canal with a diameter of 10 mm to a depth of 10 mm is presented.

In FIG. 19. A photo of conducting through the anterior (13) part of the tendon of the middle gluteal muscle of the cerclage wire (29) directly above the part stitched with Dacron thread (16) and laying both ends along the formed cones is presented; 14 - the back of the tendon of the middle gluteal muscle.

In FIG. 20. A photo is shown of passing through the back (14) part of the tendon of the middle gluteus muscle of the cerclage wire (29) directly above the part stitched with lavsan thread (16) and laying both ends along the formed cones; 13 - the front part of the tendon of the middle gluteal muscle.

In FIG. 21. A photo of holding a bundle of wire (29) and filaments (16) of the anterior (13) and posterior (14) tendons of the middle gluteal muscle through the anterior and posterior bone channels, respectively, is presented.

In FIG. 22. A photograph of the introduction of the anterior (13) and posterior (14) tendon parts of the middle gluteus muscle (12) into the corresponding bone channels and stitching of the separated part of the gluteus maximus muscle (17) to the fixed transosseous anterior part of the tendon of the gluteus maximus muscle (12); 5 - the top of the greater trochanter; 16 - threads; 29 - wire; 30 - a knot of threads when hemming the separated part of the gluteus maximus muscle; 31 - separated tendon of the external broad muscle of the thigh.

In FIG. 23. A photo of twisting the ends of the wire (29) from two channels by several turns is presented, and the threads (16) are connected; 5 - the top of the greater trochanter.

In FIG. 24. A photo is a section of the skin and subcutaneous fat.

In FIG. 25. A photo of the longitudinal separation of the muscle stretching the wide fascia of the thigh (32) and the gluteus maximus muscle and cutting off the superior bundles of the gluteus maximus muscle (m. Gluteus maximus) (33), attached to the broad fascia of the thigh (34); 5 - the top of the greater trochanter; 12 - the middle gluteus muscle.

In FIG. 26. A photo is presented of a dissection of the middle gluteus muscle (12) from the anteroposterior and posterior-outer parts of the base (6) of the apex (5) of the greater trochanter. 9 - piriform, twin and obturator muscles.

In FIG. 27. A photo is presented of the division of the tendon of the middle gluteus muscle (12) into two parts, the front part (13) related to the group of muscle fibers that perform the function of the internal rotator of the thigh, and the back part (14) related to the group of muscle fibers that perform the function of the outer thigh rotator, with their separation from the top of the greater trochanter (5).

In FIG. 28. A photo of the reinforcement of the anterior (13) and posterior (14) parts of the tendon of the middle gluteus muscle (12) by flashing with Dacron thread (16) so that the tendon part was formed in the form of a cone from which at least two strands came out was presented. 5 - the top of the greater trochanter.

In FIG. 29. A photo of the middle gluteus muscle (12) and the gluteus maximus muscle (17) retracted upward is presented; 5 - the top of the greater trochanter.

In FIG. 30. A photo is presented of the detachment of the gluteus maximus muscle (17) and its removal upwards along with the gluteus medius muscle (12), with separation from the place of attachment of the piriform, twin and obtuse muscles (9) to the trochanteric fossa, which are stitched with Dacron thread (16) and divert in the direction posteriorly and laterally; 5 - the top of the greater trochanter; 18 - capsule of the joint.

In FIG. 31. A photo of the separation of the external, medial and intermediate wide muscles of the thigh (21) with exposure of the front-outer surface of the trochanteric region (25), the upper edge of the acetabulum (19), the anterior lower iliac spine (20), and the front edge of the acetabulum ( 22) and the location of the pubic body from the acetabulum (23) and the femoral head (24); 5 - the top of the greater trochanter; 18 - capsule of the joint.

In FIG. 32. A photo of the posterior iliac dislocation of the femur; 24 - the head of the femur; 26 - acetabulum.

In FIG. 33. A photo of the anterior suprapathic dislocation of the femur is presented; 24 - the head of the femur; 26 - acetabulum.

In FIG. 34. A photograph of the implementation of the first front channel with a diameter of 6 mm; 27 - drill with a diameter of 6 mm.

In FIG. 35. A photo of the formation of a channel with a diameter of 10 mm along the already formed first channel to a depth of 10 mm is presented; 28 - drill with a diameter of 10 mm.

In FIG. 36. A photo of the formation in the posterior part of the apex of the greater trochanter in the projection of the intertrochanteric crest (crista intertrochanterica) and at the level of the trochanteric fossa (fossa trochanterica) of the femur of the second posterior canal, initially 6 mm in diameter, is presented.

In FIG. 37. A photo of the formation in the posterior part of the apex of the greater trochanter in the projection of the intertrochanteric crest (crista intertrochanterica) and at the level of the trochanteric fossa (fossa trochanterica) of the femur of the second posterior canal with a diameter of 10 mm to a depth of 10 mm is presented.

In FIG. 38. A photo of conducting through the front (13) and back (14) parts of the tendon of the middle gluteal muscle (12) of the cerclage wire (29) directly above the part stitched with Dacron thread (16) is presented; 31 - tendon of the external broad muscle of the thigh.

In FIG. 39. A photo of laying both ends of the wire (29) along the formed cones of the anterior (13) and posterior (14) parts of the tendon of the middle gluteal muscle is presented.

In FIG. 40. A photo of holding a bundle of wire (29) and filaments (16) of the anterior (13) and posterior (14) tendons of the middle gluteal muscle through the anterior and posterior bone channels, respectively, is presented.

In FIG. 41. A photo is presented of the introduction of the anterior (13) and posterior (14) tendon parts of the middle gluteus muscle (12) into the corresponding bony channels and suturing of the separated part of the gluteus maximus muscle (17) to the transosseously fixed front part of the tendon of the gluteus maximus muscle (12); 5 - the top of the greater trochanter; 16 - threads; 29 - wire; 30 - a knot of threads when hemming the separated part of the gluteus maximus muscle; 31 - separated tendon of the external broad muscle of the thigh.

In FIG. 42. A photo of the twisting of the ends of the wire (29) from two channels by several turns is presented, and the threads (16) are connected; 5 - the top of the greater trochanter.

The method is as follows

The corpse is laid on its side, three main landmarks of the incision are marked with a marker on the skin, the first of which is a point located at the level of the anterior superior iliac spine and posterior to it, the second landmark is at the intersection of the vertical line passing posterior to the apex of the greater trochanter the projection of the intertrochanteric ridge, and the horizontal line passing above the top of the greater trochanter, and the third landmark is below the base of the greater trochanter and in the projection of the anterior edge of the femur, the restoration marker m the line of the future incision at the indicated points (Fig. 1), after which we perform the cut of the skin and subcutaneous fat along the planned line, the wound is expanded (Fig. 2), then we determine the boundary line between the muscle stretching the wide fascia and the gluteus maximus muscle and of this line, we divide these muscles longitudinally, while dissection and disengagement of the muscles is performed in the upward direction, bringing to the place of attachment of the posterior portion of the muscle, stretching the wide fascia to the outer lip of the iliac crest (Fig. 2-1), after that, in order to mobilize, we cut off the upper bundles of the gluteus maximus muscle (m. Gluteus maximus), attached to the wide fascia (fascia lata) and the ileo-tibial tract (traktus iliotibialis), while cutting is performed within a wide fascia without muscle damage (Fig. 3-3), then continue the incision downward, for which we dissect the ileo-tibial tract of the broad fascia of the thigh over the greater trochanter and end the incision below the base of the greater trochanter, and then the posterior and anterior muscular edges, including the mobilized upper bunches of big of the gluteal muscle, we dilute the retractors posteriorly and anteriorly, respectively, and the posterior posterior muscular edge is removed to prevent damage to the supply artery until the vascular bundle appears in the upper corner of the wound, in which the superficial branch of the superior gluteal artery passes, and the middle gluteus maximus muscle is exposed rotated the hips (Fig. 3), then the fibers of the middle gluteal muscle are bred as far as possible, and if necessary, cut into its entire thickness, while the dissection of the middle gluteal muscle begins at Edna outer part of the base-apex of the greater trochanter (FIG. 4 - 4, 5) and we carry along the muscle fibers of the anterior part of the middle gluteal muscle in the direction of the upper edge of the anterior lower iliac spine, then we perform another incision that starts from the posterior-outer part of the base of the apex of the greater trochanter (Fig. 5 - 5, 6 , 7, 8) and direct it along the anatomical border, located between the lower edge of the middle and small muscles on the one hand and piriform, twin and obturator muscles on the other hand, dividing them among themselves, while separating them up and back to preventdamage to the upper gluteal nerve and artery that innervate and nourish the middle and small gluteal muscles, we continue until the neurovascular bundle appears in the upper posterior corner of the muscle wound, then divide the tendon of the middle gluteal muscle into two parts (Fig. 6 - 10, 11, 12 ), the front part related to the group of muscle fibers that perform the function of the inner rotator of the thigh, and the back (Fig. 7 - 13, 11, 12), related to the group of muscle fibers that perform the function of the outer rotator of the thigh, after which both parts of the tendon are completely detach from the top shki greater trochanter, and each portion of the tendon by stitching armiruem lavsan thread (Fig. 8 - 13, 14, 15, 16) with one of the classic sutures of the tendon so that the tendon part is formed in the form of a cone, from which at least two strands come out, then the tendon of the middle gluteus muscle is retracted upward with exposure of the gluteus maximus muscle (Fig. . 9 - 12, 17), then pulp or dissect the entire thickness of the gluteus maximus muscle fiber in the same direction as the gluteus maximus muscle, starting at the front-outer part of the base of the apex of the greater trochanter in the direction of the upper edge of the anterior lower iliac spine, last of this, we make detachment of the gluteus maximus and take it up along with the gluteus maximus muscle (Fig. 10 - 9, 12, 17, 18) with exposure of the joint capsule, then we perform separation from the place of attachment of the piriform, twin and obturator muscles to the trochanteric fossa, with lavsan thread and we take them in the direction posteriorly and laterally (Fig. 11-5, 9, 12, 17, 18) with further separation from the posterior edge of the acetabulum with exposure of the latter, up to the exposure of the sciatic spine, the edge of the small sciatic notch, ischium and mound with of the proximal bone, and if necessary, additional exposure of the ischial tuberosity and the junction of the posterior acetabulum and the body of the sciatic bone, we perform a partial separation from the tubercle of the sciatic bone of the square muscle, then we separate the outer, medial and intermediate broad muscles of the thigh with exposure of the front-outer surface of the trochanteric areas and excise the joint capsule (Fig. 12 - 5, 19, 20, 21, 22, 23, 24), then expose the upper edge of the acetabulum, the anterior lower iliac spine, the front edge of the acetabulum and the location of the pubic bone from the acetabulum (Fig. 12 - 5, 19, 20, 21, 22, 23, 24, 25), then we perform the posterior iliac dislocation of the femur, which became possible after the mobilization of the proximal femur, the hip is bent, while the head, neck and trochanteric region of the thigh allow for revision and manipulation on the acetabulum (Fig. 13 - 24, 26), then proxy retractors we remove the imperial part of the thigh posteriorly and carry out revision and manipulations on the anterior part of the acetabulum, then we translate the femur into the position of the anterior suprapubic dislocation, set the femur to the extension position (Figs. 14–24, 26), remove the proximal part of the thigh anterior with anterior and perform an audit and manipulations on the posterior part of the acetabulum, then, if necessary, the implementation of bone autoplasty of the acetabulum, we carry out the detachment of adipose tissue up to the crest of the anterior part of the wing move the iliac bone, skin and fatty tissue with the expander upward, expose the crest of the anterior part of the ilium wing from the muscle and perform graft collection, after the end of work on the acetabulum, perform hip reduction, then at the front of the apex of the greater trochanter in the projection of the intertrochanteric line (linea intertrochanterica) and at the level of the upper edge of the femoral neck we carry out the first front channel with a diameter of 6 mm, going in the front-back direction from the inside out, from top to bottom with the exit in the front-outer part the subverticular region (Fig. 15-27), then along the formed channel we form the channel in the same direction, but with a diameter of 10 mm to a depth of 10 mm (Fig. 16-28), then in the back of the top of the greater trochanter in the projection of the intertrochanteric crest (crista intertrochanterica) and at the level of the trochanteric fossa (fossa trochanterica) of the femur, we perform the second posterior canal, 6 mm in diameter, going in the posterior-anterior direction from the inside outward, from top to bottom with the exit to the posterior-outer part of the undervert region (Fig. 17-27), then along formed channel form the channel in the same direction, but already the diameter 10 mm to a depth of 10 mm, while the distance between the openings of the canals in the subrochanteric region should not be less than 10 mm (Fig. 18-28), after that, in the subrovertial region, we perform the separation of the tendon part of the external broad thigh muscle downward, then through the front ( Fig. 19 - 13, 14, 16, 29), and the back (Fig. 20 - 13, 14, 16, 29), part of the tendon of the middle gluteal muscle, we carry out the cerclage wire directly above the part stitched with Dacron thread and lay both its ends along formed cones (FIG. 19 - 13, 14, 16, 29), after which we collect the filaments and wires of the anterior and posterior parts of the tendon into a bundle and conduct these bundles through the corresponding anterior (Fig. 21 - 13, 14, 16, 29) and posterior bone channels in this way so that the tendon parts formed in the form of cones are embedded in the corresponding bone channels, and the separated tendon part of the gluteus maximus muscle is sutured to the fixed transosseous anterior part of the tendon of the gluteus maximus muscle (Fig. 22 - 5, 12, 13, 14, 16, 17, 29, 30, 31), then the hip is removed 30 degrees in the neutral between bending and p by bending in the hip joint, we stretch both the ends of the threads and wire with the maximum insertion of the tendon ends into the channels, then twist the ends of the wire from two channels with several turns (Fig. 23 - 5, 13, 14, 16, 29), and we connect the threads, and then we remove the excess part of the wire with the help of wire cutters and cut the ends of the dacron thread, after that we put the separated tendon part of the external broad muscle of the thigh into place, while covering the dacron and wire knots, and then fix it to the undervert region, and when suturing wounds, and the lower twin and square muscles, partially detached from the sciatic tubercle, are sutured to the extra-pelvic part of the internal obturator muscle and to the external obturator muscle, then stitching and reininsion of the muscles and soft tissues are performed, while further removing the dacron threads used as holders, we drain the wound and we sew.

Experimental example

The corpse is laid on its side, according to the points and lines outlined on the skin, an incision is made in the skin and subcutaneous fat, the wound is expanded (Fig. 24-1), then the boundary line between the muscle stretching the wide fascia and the gluteus maximus muscle is determined, and this the lines divide these muscles longitudinally, while the dissection and muscle disengagement are performed in the upward direction, leading to the place of attachment of the posterior portion of the muscle, stretching the wide fascia to the outer lip of the iliac crest (Figs. 25-5, 12, 32, 33, 34), after that, in order to mobilize, cut off the top bunches of the gluteus maximus muscle (m. gluteus maximus), attached to the wide fascia (fascia lata) and the ileo-tibial tract (traktus iliotibialis), while clipping is performed within the wide fascia without muscle damage (Fig. 25 - 5, 12, 32, 33, 34), then the incision is continued downward, for which the ilio-tibial tract of the broad fascia of the thigh is cut above the greater trochanter and the incision is completed below the base of the trochanteric, and then the posterior and anterior muscular edges, including the mobilized superior bundles of the gluteus maximus, are mobilized, early breadths are bred the bodies, respectively, posteriorly and anteriorly, and the posterior posterior muscular margin is removed to prevent damage to the supply artery until a vascular bundle appears in the upper corner of the wound, in which the superficial branch of the superior gluteal artery passes and the middle gluteus maximus and trochanter are exposed (Fig. . 25 - 5, 12, 32, 33, 34), then the fibers of the middle gluteal muscle are diluted if possible, and if necessary, cut into its entire thickness, while the dissection of the middle gluteal muscle begins at the front-outer part of the base of the apex of the greater trochanter (Fig. 26 - 5, 6, 9, 12) and lead along the muscle fibers of the anterior part of the middle gluteus muscle in the direction of the upper edge of the anterior lower iliac spine, then another incision is made that starts from the posterior-outer part of the base of the apex of the greater trochanter (Fig. 26 - 5, 6, 9, 12), and direct it along a natomic border, located between the lower edge of the middle and small muscles on the one hand, and piriform, twin and obturator muscles on the other hand, dividing them among themselves, while separating them up and back to prevent damage to the superior gluteal nerve and artery innervating and feeding the middle and small gluteal muscles, continue until a neurovascular bundle appears in the upper posterior corner of the muscle wound, then the tendon of the gluteus midi muscle is divided into two parts (Fig. 27 - 5, 12, 13, 14): the front part related to the group of muscle fibers performing the function of the internal rotator of the thigh, and the rear part (Fig. 27 - 5, 12, 13, 14) relating to the group of muscle fibers performing the function of the external femoral rotator, after which both parts of the tendon are completely separated from the apex of the greater trochanter, and FIG. 28 - 5, 13, 14, 16) with one of the classic tendon sutures, in this way each part of the tendon is reinforced by stitching with lavsan thread so that the tendon part is formed in the form of a cone from which at least two threads come out, then the tendon of the middle gluteus muscle is removed upward with exposure of the gluteus maximus muscle (Fig. 29 - 5, 9, 12, 17), then fiberize or dissect the entire thickness of the gluteus maximus muscle fiber in the same direction as the gluteus maximus muscle, starting at the front-outer part of the base of the apex large skewer in in the direction of the upper edge of the anterior lower iliac spine, then the gluteus maximus is detached and brought up along with the gluteus maximus muscle (Fig. 30 - 5, 9, 12, 16, 17, 18) with exposure of the joint capsule, then separation from the places of attachment to the trochanteric fossa of the tendons of the piriform, twin and obturator muscles, are stitched with lavsan thread and retracted posteriorly and laterally (Fig. 31 - 5, 18, 19, 20, 21, 22, 23, 24, 25) with further separation from the posterior edge of the acetabulum with exposure of the latter up to about the sciatic spine, the edge of the small sciatic notch, sciatic bone and the ischial tuberosus, and, if necessary, the additional exposure of the sciatic tubercle and the junction of the posterior acetabulum and the sciatic bone joint are performed, a partial separation from the tubercle of the sciatic bone of the quadratus muscle is performed, then the external copper is separated, then the outer is separated and the intermediate broad muscles of the thigh with exposure of the front-outer surface of the trochanteric region (Fig. 31 - 5, 18, 19, 20, 21, 22, 23, 24, 25) and the joint capsule is excised, then the upper edge of the acetabulum, the anterior lower iliac spine, the front edge of the acetabulum and the location of the pubic bone from the acetabulum are exposed hollows (Fig. 31 - 5, 18, 19, 20, 21, 22, 23, 24, 25), then perform the posterior iliac dislocation of the femur, which became possible after the mobilization of the proximal femur, the hip is bent, while the head, the neck and trochanteric region of the thigh allow revision and manipulation of the acetabulum (Fig. 32 - 24, 26), then the proximal part of the thigh is retracted posteriorly with retractors and the revisions and manipulations are performed on the anterior part of the acetabulum, then the femur is placed in the position of the anterior suprapubic dislocation, the thigh is set in the extension position (Figs. 33 - 24, 26), the proximal part of the thigh with retractors remove anteriorly and carry out revision and manipulations on the posterior part of the acetabulum, then, if necessary, bone autoplasty of the acetabulum is performed, fatty tissue is detached upward to the crest of the anterior part of the iliac wing, the skin and fatty tissue are pushed up by the expanders upwards, the crest of the anterior part of the ilium is exposed from the muscle and graft is taken, after the end of work on the acetabulum, the thigh is rotated, then in the anterior part of the apex of the greater trochanter in the projection of the intertrochanteric the line (linea intertrochanterica) and at the level of the upper edge of the femoral neck perform the first front channel with a diameter of 6 mm, going in the front-back direction from the inside outward, from top to bottom an outlet in the anteroposterior portion of the undervert region (FIG. 34-27), then along the formed channel, a channel is formed in the same direction, but already with a diameter of 10 mm to a depth of 10 mm (Figs. 35-28), then at the back of the top of the greater trochanter in the projection of the intertrochanteric crest (crista intertrochanterica) and at the level of the trochanteric fossa (fossa trochanterica) of the femur, a second posterior canal with a diameter of 6 mm is performed, going in the posterior-anterior direction from the inside outward, from top to bottom with exit to the posterior-outer part of the undervert region (Fig. 36-27), then along the formed channels form the channel in the same direction, but already the diameter ohm 10 mm to a depth of 10 mm, while the distance between the openings of the canals in the subrochanteric region should not be less than 10 mm (Figs. 37-28), after that, in the subrovertial region, the tendon part of the external broad thigh muscle is separated downward, then through the front ( Fig. 38 - 12, 13, 14, 16, 29, 31) and the back of the tendon of the gluteus maximus muscle conduct a cerclage wire directly above the part stitched with mylar thread (Fig. 38 - 12, 13, 14, 16, 29, 31), and lay both its ends along the formed cones (Figs. 39 - 13, 14, 16, 29), after which the filaments and wire of the front and back tendons are collected in a bundle and these bundles are passed through the corresponding anterior (Figs. 40 - 13, 14, 16, 29) and posterior bone canals so that the tendon parts formed as cones are embedded in the corresponding bone canals, and the separated part of the tendon of the gluteus maximus muscle is sutured to the fixed transossal anterior part of the tendon of the middle gluteus muscle (Fig. 41 - 5, 12, 13, 14, 16, 17, 29, 30, 31), then the thigh is retracted 30 degrees in a neutral position between flexion and extension in the hip joint and the ends of the threads and wire are pulled with the maximum insertion of the tendon ends into the canals (Fig. 41 - 5, 12, 13, 14, 16 , 17, 29, 30, 31), then the ends of the wire from two channels are twisted in several turns (Fig. 42 - 5, 16, 29), and the threads are tied, and then the excess part of the wire is removed with the help of wire cutters and the ends of the mylar thread are cut, after that, the separated tendon part of the external broad muscle of the thigh is placed in place, while the cover lavsan and wire nodes are then fixed and then fixed to the subtrochanteric region, and when the wound is sutured, the lower twin and square muscles, partially detached from the tubercle of the ischium, are sutured to the extra-pelvic part of the internal obstructive muscle and to the external obturator, then the muscles and soft tissues are stitched and reinserted, furthermore, the lavsan threads used as holders are removed, the wound is drained and sutured.

Thus, the developed method of experimental anatomical and surgical substantiation of operative access to the hip joint during transverse fractures of the pelvic bones using the basics of classical approaches has several advantages, consisting in the following provisions:

• only one external access to the hip joint is used, which allows direct access to the proximal femur and, especially, to all sections of the acetabulum and around the acetabulum of the ilium and sciatic bones, which allows you to perform all the necessary surgical aids on the acetabulum, namely :

- an open reposition of fragments of the acetabulum, taking into account all options for fractures of the acetabulum,

- an open reposition of the ilium, sciatic and pubic bones,

- osteosynthesis of acetabular fragments, taking into account all variants of acetabular fractures,

- osteosynthesis of the ilium, sciatic and pubic bones using a variety of fixatives;

• if it is necessary to perform bone autoplasty of the acetabulum, bone autograft can be taken from this crest from the crest of the anterior part of the iliac wing;

• access is carried out with the prevention of damage to muscle vessels and nerves;

• it is not necessary to perform classical osteotomy of the greater trochanter to improve access to the acetabulum, which reduces the amount of blood loss and reduces the time of the operation;

• performing the separation of the tendon of the middle gluteal muscle from the trochanteric region in order to accelerate and facilitate access to the hip joint (and acetabulum) with its subsequent transossal refixing, taking into account the difference in function of the anterior and posterior parts of the tendon, allows:

- maintain muscle function,

- and in the early stages to restore muscle function as an external and internal hip rotator and movements in the operated joint as a whole;

• it takes up to 9 minutes to complete the separation of the tendon of the middle gluteal muscle from the trochanteric region in order to accelerate and facilitate access to the hip joint (and acetabulum) with its subsequent transossal refixing, taking into account the difference in the function of the anterior and posterior parts of the tendon;

• allows in the early stages to begin active restoration of movements in the operated joint due to the reinforcement and fixing of both parts of the tendon of the middle gluteal muscle;

• objectively there is a positive therapeutic effect, consisting of:

- to reduce the time of surgery, because only one external access to the hip joint is used, therefore, in reducing blood loss; - reducing tissue trauma by optimizing the performance of surgical intervention;

• the presence of an economic effect consisting in reducing the cost of treatment through the use of only one external access to the hip joint, and, consequently, reducing the expenditure of surgical material;

• there is a social effect by improving the quality of life of the patient.

Claims (1)

The method of experimental surgical access to the hip joint during the anterosorbic fracture of the pelvic bones, which consists in the posterolateral access to the hip joint with an additional incision from the greater trochanter in the direction of the anterior spine of the ilium, characterized in that the corpse is laid on its side, three main landmarks of the incision are marked on the skin with a marker , the first of which is a point that is at the level of the anterior superior iliac spine and posterior to it, the second landmark is at the intersection I have a vertical line running back from the top of the greater trochanter in the projection of the intertrochanteric crest, and a horizontal line passing above the top of the greater trochanter, and the third landmark is below the base of the greater trochanter and in the projection of the anterior edge of the femur, the marker restores the line of the future incision at the indicated points, after which a cut of the skin and subcutaneous fat is performed along the planned line, the wound is expanded, then the border line between the muscle stretching the wide fascia and the gluteus maximus muscle is determined these muscles are longitudinally divided along this line, while the dissection and muscle disengagement are performed in the upward direction, leading to the place of attachment of the posterior portion of the muscle, which stretches the broad fascia to the external lip of the iliac crest, after which, in order to mobilize, the upper bundles of large gluteal muscle (m. gluteus maximus), attached to the wide fascia (fascia lata) and the ileo-tibial tract (traktus iliotibialis), while excision is performed within the wide fascia without muscle damage, then the incision is continued downward, for which the ileo-tibial tract is widened over the greater trochanter fascia of the thigh, and the incision ends below the base of the greater trochanter, and then the formed posterior and anterior muscular edges, including the mobilized superior bundles of the gluteus maximus muscle, are diluted with conservatives, respectively, posteriorly and anteriorly, posterior to the posterior muscular margin, in order to prevent damage to the supply artery, they produce until the vascular bundle appears in the upper corner of the wound, in which the superficial branch of the superior gluteal artery passes, and expose the gluteus maximus muscle and trochanteric femoris, then fibers of the gluteus maximus muscle are diluted and, if necessary, cut through its entire thickness, while the dissection of the middle gluteal muscle begins at the front-outer part of the base of the apex of the greater trochanter and lead along the muscle fibers of the anterior part of the middle gluteal muscle in the direction of the upper edge of the anterior lower iliac spine, then another incision is made, which starts from the posterior-outer part of the base of the apex of the greater trochanter, and directs it along the anatomical border located between the lower edge of the middle and small muscles on one side, and piriform, twin and obturator muscles on the other hand, dividing them among themselves, while dividing them up and back to prevent damage to the superior gluteal nerve and artery, innervir eating and nourishing the middle and small gluteal muscles, continue until a neurovascular bundle appears in the upper posterior corner of the muscle wound, then the tendon of the middle gluteal muscle is divided into two parts, the front part belonging to the group of muscle fibers performing the function of the internal femoral rotator, and the back part, belonging to the group of muscle fibers that perform the function of the external rotator of the thigh, after which both parts of the tendon are completely separated from the apex of the greater trochanter and each part of the tendon is reinforced by flashing lavsanova using one of the classic tendon sutures in such a way that the tendon part is formed in the form of a cone, from which at least two threads come out, then the tendon of the gluteus maximus muscle is pulled up to expose the gluteus maximus muscle, then it is dissected or cut into the entire thickness of the gluteus maximus fiber muscles in the same direction as the middle gluteus, starting at the anteroposterior base of the apex of the greater trochanter in the direction of the upper edge of the anterior lower iliac spine, after which t detach the gluteus maximus and take it up along with the gluteus maximus muscle to expose the joint capsule, then perform separation from the place of attachment of the piriformis, twin and obtuse muscles to the trochanteric fossa, stitch them with Dacron thread and retract them posteriorly and laterally with further separation from the posterior edge of the acetabulum with exposure of the latter up to the exposure of the sciatic spine, the edge of the small sciatic notch, sciatic bone and tubercle of the sciatic bone, and optionally To expose the ischial tubercle and the junction of the posterior acetabulum and the ischial body, partial separation of the square muscle from the ischial tubercle is performed, then the outer, medial and intermediate broad muscles of the thigh are separated with the anteroposterior surface of the trochanteric area exposed and the joint capsule is excised, then expose the upper edge of the acetabulum, the anterior lower iliac spine, the front edge of the acetabulum and the location of the pubic bone from the acetabulum then the posterior iliac dislocation of the femur is performed, which became possible after the proximal femur was mobilized, the thigh is bent, while the head, neck and trochanteric region of the thigh allow revision and manipulation of the acetabulum, then the proximal part of the thigh is retracted posteriorly and revised and manipulations on the anterior part of the acetabulum, then the femur is transferred to the position of the anterior suprapubic dislocation, the thigh is set in the extension position, the wound with the expanders, the proximal part of the thigh is taken anteriorly and revised and manipulated on the posterior part of the acetabulum, then, after the end of the work on the acetabulum, the thigh is rotated, then in the front of the apex of the greater trochanter in the projection of the intertrochanteric line (linea intertrochanterica) and at the level of the upper edge of the femoral neck the bones perform the first front channel with a diameter of 6 mm, going in the anteroposterior direction from the inside outwards, from top to bottom with the exit in the anteroposterior part of the undervert region, then along the form The canal forms the canal in the same direction, but with a diameter of 10 mm to a depth of 10 mm, then in the back of the apex of the greater trochanter in the projection of the intertrochanteric crest (crista intertrochanterica) and at the level of the trochanteric fossa (fossa trochanterica) of the femur, the second posterior canal with a diameter of 6 mm, going in the back-front direction from the inside outward, from top to bottom with the exit in the back-outer part of the undervert region, then along the formed channel a channel is formed in the same direction, but with a diameter of 10 mm to a depth of 10 mm, the distance between the openings of the channels in the under-neck region should not be less than 10 mm, then in the under-neck region the tendon part of the external broad thigh muscle is separated downward, then through the front and back parts of the tendon of the middle gluteal muscle, a cerclage wire is drawn directly over the part stitched with mylar thread, and stack both its ends along the formed cones, after which the filaments and wire of the front and back parts of the tendon are collected in a bundle, and these bundles are passed through the corresponding front and back bony canals so that the tendon-shaped conical parts penetrate into the corresponding bony canals, and the separated part of the gluteus maximus muscle is sutured to the fixed transosseous anterior part of the tendon of the gluteus maximus muscle, then the thigh is retracted 30 degrees in neutral between flexion and extension in the hip the joint position and the ends of the threads and wire are pulled with the maximum introduction of the ends of the tendon into the channels, then the ends of the wire from two channels are twisted several turns mi, and the strands are tied, and then the excess part of the wire is removed with nippers and the ends of the dacron thread are cut off, after that the separated tendon part of the external broad muscle of the thigh is put in place, while the dacron and wire knots are covered and then fix it to the subtrochanteric region, and when the wound is sutured, the lower twin and square muscles, which are partially separated from the sciatic tubercle, are sutured to the outside of the pelvic part of the internal obstructive muscle and to the external obstructive muscle, then stitching and reininsion are performed ShTs and soft tissues, thus further removed Dacron filaments used as a taped, wound drained and sutured.

Images