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Surgical Technique THR: Split the Maximus

- Discussion:
    - bluntly split gluteus maximus proximally in direction of its fibers & coagulate any vessels w/in substance of muscle;
    - note that muscle does not have to be split in line w/ incision, but can be split in line w/ its fibers in a direction superior to skin incision;
          - splitting the muscle inevitably crosses a vascular plane (branches of the inferior gluteal artery), and by spliting slightly superior
                 to the skin incision may prevent some bleeding;
                 - if the muscle is split gently, one may be able to pick up and coagulate crossing vessels before they are avulsed;
          - in morbidly obese patients, it may be necessary to split the gluteus maximus fibers more posteriorly inorder to facilitate femoral reaming (since this
                 gives the best exposure when the hip is flexed at 90 deg);
          - the maximus muscle will not be significantly denervated becuase it receives its nerve supply is well medial to the split;
    - extend fascial incision distally far enough to expose tendinous insertion of gluteus maxius on the posterior femur;
    - now adduct thigh & insert gloved finger thru proximal end of incision in band, locate by palpation sulcus at anterior border of maximus muscle,
          & extend incision proximally  along this sulcus;
    - inferior gluteal nerve which provides motor supply to maximus muscle is below line of incision thru muscle;
    - superior gluteal nerve supplying medius & minimus tensor fascia lata
          is protected because it runs between the two gluteus muscles

The course of the inferior gluteal nerve in the posterior approach to the hip.