- Technique: 
- at a point 3-5 cm above post. tip of greater troch., an incision is made which extends obliquely (proximally & posteriorly) for 10 cm;
- for obese pts begin incision well above greater troch. (7-10 cm) & again extend proximally and posteriorly;
- otherwise one will be fighting w/ a thick layer of subQ fat;
- incise tensor fascia & split
gluteus max in line w/ its fibers;
- this incision needs to be at least as long as the skin incision;
- define interval between insertions of
piriformis & tendinous posterior aspect of
medius into greater trochanter;
- the surgeon can run his long finger along the posterior edge of the proximal femur to accurately judge the direction of the
femur w/o need for flouro;
- the surgeon's index finger can simultaneously palpate the gluteus medius tendon
about 2 cm from its posterior edge at the level of the greater trochanter;
- this marks the location for splitting the tendon w/ a tonsil clamp;
- when the
lateral position is used, the hip can be flexed which allows nail to be inserted behind the
tendon (hence no splitting is required);
- Hazards:
- trochanteric pain and stiffness may occur in over 40% of patients and may be related due
to rough handleing of the gluteus medius tendon;
- it is essential to carefully split the medius tendon no higher than 5 cm above the greater
trochanter inorder to avoid injury to the
superior gluteal nerve;
- after the gluteus medius tendon is split for the first time, further trauma to the tendon should be avoided;
Gluteus medius tendon injury during reaming for gamma nail insertion.
