Approaches and their intervals

Question 1

Ludloff approach (or Ferguson, more correctly)

Answer 1

P: Supine
L: Pubic tubercle, adductor longus (if palpable)
I: longitudinal, starting 3cm below pubic tubercle
S: Longus and Gracillis (long and slender)
D: Brevis and Magnus (short and big), palpate LT in the base of the wound.
Dangers: Posterior division of Obturator nerve. Brevis supplied by Anterior division of Obturator, Magnus supplied by Posterior division of Obturator (as well as tibial portion of sciatic), Medial Circumflex Femoral Artery (medial side of psoas), Deep external pudendal artery (anterior to pectineus)
E: Isolate psoas well before cutting (if doing psoas release), work posterior to psoas if exposing capsule (can also cut longus and retract pectineus medial to help expose capsule).

• superficial interval between longus and gracilis
• deep interval between brevis and magnus
  (Long and Slender, Short and Big)
• anterior and posterior branches obturator nerve on brevis
• divide psoas (MCFA is medial to tendon)
• take circumflex vessels off capsule

Danger: MCFA

Question 2

Smith Petersen

Answer 2

P: Supine, bump under loin, leg draped free
L: Iliac crest, ASIS, Lateral border of patella
I: Along crest towards ASIS, then towards patella
S: Sartorius and TFL, protect lateral femoral cutaneous nerve, incise medial side of TFL, ligate ascending branch of lateral femoral circumflex artery between Sart and TFL.
D: RecFem and GlutMed, Detach RecFem from both origins, retract RecFem and Iliopsoas medially, retract GlutMed laterally
Dangers: Lateral femoral cutaneous nerve, Femoral nerve, Ascending branch of lateral femoral circumflex artery
Exposure: T- capsulotomy. Distal extension between RecFem and VastLat

Anterior approach to the hip - Paeds DDH in this context

• vertical incision not very cosmetic
• use horizontal / bikini incision to reduce hip
• between sartorius and TFL to access blocks to reduction
• split apophysis if performing pelvic osteotomy
• separate lateral approach if adding FDRO

Question 3

Stoppa approach

Answer 3

P: Supine
L: Pubis, Umbilicus, ASIS
I: Phannensteil or vertical
S: Rectus abdominis along linea alba
D: Posterior part of rectus abdominis released from pubic symphysis, Iliopectineal fascia released along arcuate line, Corona mortis divided
Dangers: Corona mortis, External iliac vessels, Bladder (use catheter), Obturator nerve and vessels
E: Iliopsoas elevated, hohmann in the ilium and one in the sciatic notch.

Question 4

Kocher-Langenbeck approach

Answer 4

P: Lateral or Prone
L: Iliac crest, PSIS, GT
I: Longitudinal from iliac crest, lateral to PSIS over GT
S: Skin, Fat, Fascia lata from distal to anterior border of GlutMax proximally, Split GlutMax along interVASCULAR plane (superior and inferior at top 1/3rd), Detach SERs 1.5 cm from insertion on GT (to avoid damaging blood supply to femoral head), Follow ObtIntern into sciatic notch.
D: Trochanteric slide osteotomy
Dangers: Sciatic nerve, Inferior gluteal artery, Superior gluteal artery and nerve
E: GlutMax posteriorly, GlutMed and Min anterior, Flex knee to avoid traction on sciatic nerve, GT osteotomy to avoid traction on GlutMed/Min

Question 5

Watson-Jones approach

Answer 5

P: Lateral
L: ASIS, GT, Femur
I: along the line from ASIS to GT (posterior 1/3) and femoral shaft
S: TFL and GlutMed interval, Split TFL closer to posterior border of GT, retract GlutMed laterally
D: detach part of abductors from GT or do GT osteotomy, Release reflected head of rectus
Dangers: Femoral nerve, artery and vein
E: T-capsulotomy, if doing THR then resect a section of femoral neck and use corkscrew (otherwise lots of ER to dislocated head), distal extension under VastLat

Question 6

Hardinge approach

Answer 6

P: Lateral (or supine)
L: GT, femur
I: Longitudinal along GT
S: Split fascia lata ans separate it from GlutMed
D: Split GlutMed at middle of GT (do not extend more than 3-5cm proximal to avoid superior gluteal nerve), Extend distally through vastus lateralis (innervated by femoral nerve), elevated GlutMed and GlutMin together and retract anteriorly
Dangers: Superior gluteal nerve (between GlutMed and GlutMin 3-5 cm proximal to GT), Femoral nerve
E: T capsulotomy

Question 7

Anterior approach to Ankle joint

Answer 7

P: Supine
L: Malleoli
I: longitudinal 15cm incision
S: Skin, fat, Protect Superficial Peroneal Nerve, Fascia, Retinaculum, Find interval between EDL and EHL proximally, identify Anterior tibial artery and Deep peroneal nerve, Mobilize EHL and NV medially, mobilize EDL laterally.
D: Incisie capsule longitudinally, subperiosteally elevate
Dangers: SPN, DPN, AntTib Artery
E: subperiosteal elevation as above to expose tibia and talus.

Question 8

Anteromedial approach to Ankle joint

Answer 8

P: Supine
L: Medial malleolus
I: Over anterior 1/3 or medial mal
S: Long saphenous vein and nerve anterior to MM
D: Capsulotomy
Dangers: Long saphenous nerve and vein
E: Can expose deltoid and tibialis posterior

Question 9

Dual approach to talus fractures

Answer 9

Medial side (most comminution is dorsomedial)
- Between tibialis anterior and tibialis posterior
- Deep deltoid provides blood supply, protect it, do medial mal osteotomy rather than cut deltoid
Lateral side
- Between tibia and fibula proximally in line with 4th ray
- Elevated EDB to access subtalar joint