Anatomical Basis And Clinical Application Of Interval Approach In The Front Of The Gluteus Medius For Intertrochanteric Fracture

Part Ⅰ：Anatomical basis of interval approach in the front of thegluteus medius to proximal femurObjective：To investigate the anatomic characteristics of the interval approach inthe front of the gluteus medius based on the modified lateral approach to the femoralneck and trochanter, which included confirming and measuring important anatomiclandmarks. This cadaveric study was designed to clarify the anatomical basis of usingan interval approach in the front of the gluteus medius to repair intertrochantericfractures.Methods： The legs of8formalin-fixed Asian cadavers were dissected,simulating an anterolateral surgical approach and The anatomic landmarks ofrespective nerves and vascularities was measured.Results：The interval approach in the front of the gluteus medius providedexcellent exposure of the greater trochanter, the lesser trochanter and the femoralneck. The gluteus medius branch of the ascending branch of the lateral femoralcircumflex artery and the most inferior branch of the superior gluteal nerve werefound to cross the spatium intermusculare. The distance from the spatiumintermuscular to the anterior superior iliac spine was （5.13±0.52） cm(4.25～6.30cm）.The distance from the gluteus medius branch of the ascending lateralfemoral circumflex artery, in the intermuscular plane, to the lateral protrusive point ofthe greater trochanter was (5.57±0.39cm, range5.05~6.62cm); and the distance fromthe inferior-most branch of the superior gluteal nerve to the lateral protrusive point ofthe greater trochanter was (8.15±0.67cm, range7.13~9.56cm).Conclusions：The interval approach in the front of the gluteus medius isrelatively safe, provides excellent exposure and causes less soft-tissue damage thanthe traditional approach, and it represents a promising new method to surgically treatintertrochanteric fractures. Part Ⅱ：Clinical application of interval approach in the front of thegluteus medius for intertrochanteric fractureObjective：To study the clinical effectiveness of interval approach in the front ofthe gluteus medius to repair intertrochanteric fracture of the femur in elderly patientcomparing with conventional lateral approach.Methods： Between February2011and February2013,67patients withintertrochanteric fracture were analyzed retrospectively. Of67patients,35underwentinterval approach in the front of the gluteus medius combined with fixation of DHS(improved group), and32underwent conventional lateral approach combined withfixation of DHS (control group). There was no significant difference in gender, age,singh index, side, fracture type, injury cause and complication between2groups(P>0.05). The operation time, intraoperative blood loss and fluoroscopy’s times,postoperative drainage volume and hospitalization time were recorded. The hipfunction was evaluated according to self-established criterion at6and12month afterthe surgery.Results：The operation was completed successfully and there were no injuries ofsignificant vessels and nerves in all patients. Bone union was achieved in both group,the fracture healing time was3-5months (mean,3.7months).61patients werefollowed up14-24months (mean,18.2months). The operation time, intraoperativeblood loss and fluoroscopy’s times, postoperative drainage volume andhospitalization time were significantly less than those of control group (p<0.05).According to self-established criterion, improved group was significantly better thancontrol group in recovery of hip joint motion and function at6and12month after thesurgery (p<0.05). In the incidence of postoperative complications, there was no significant difference in the incidence of incision infection, limb shortening internalfixation loosening and main screw cutting-out from femoral head in both group(p>0.05), however, the incidence of coax vara and total complicatons weresignificantly lower comparing with the control group (p<0.05).Conclusions：Comparing with conventional lateral approach, interval approachin the front of the gluteus medius has the advantages of sufficient exposure, shorteroperation time and less soft-tissue damage in treating intertrochanteric fracture, whichis beneficial to early postoperative rehabilitation.