Surgical Approaches Flashcards
Stoppa Approach
Indications
acetabular fractures
pelvic ring injuries
Approach provides access to
pubic body
superior pubic ramus
pubic root
ilium above and below the pectineal line
quadrilateral plate
medial aspect of the posterior column
sciatic buttress
anterior sacroiliac joint
upper ilium and iliac crest
Preparation & Positioning
Preparation
a radiolucent table is required
Foley catheter is required to improve visualization
Position
supine
ipsilateral limb is draped free into the field
hip and knee are flexed to relax the ilipsoas/femoral neurovascular bundle
operating surgeon is on the opposite side of the table
Approach
Incision a transverse incision is made approximately 2 cm above the symphysis
this is carried short of each external inguinal ring
for the “lateral window”, an incision is made along the iliac crest, starting ~2 cm posterior to the ASIS, following the iliac crest posteriorly
Superficial dissection
subcutaneous tissue and rectus fascia are incised transversely
the pyrimidalis muscle is released and tagged for later repair
the rectus abdominus fascia is split along the linea alba
the transversalis fascia is opened superior to the pubic symphysis
this opens the potential space of Retzius (space behind the symphysis and anterior to the bladder)
for the “lateral window”, the insertion of the external oblique is released, permitting dissection into the internal iliac crest fossa (requires elevation of the iliacus muscle)
Deep dissection the origin of the rectus abdominus muscle is released off the posterior pubic rami but maintained anteriorly
a Hohmann retractor is used to retract the rectus anteriorly
the iliopectineal fascia is released to enter the true pelvis
anastamoses between the external iliac and obturator vessels (corona mortis) should be identified along the superior pubic ramus and ligated
the iliopsoas can now be subperiosteally elevated, and a retractor is used to retract the iliopsoas and external iliac vessels
the entire pelvic brim should be visualized at this time
the obturator neurovascular bundle is exposed and protected as the quadrilateral surface and posterior column are dissected
Dangers & Complications
Obturator nerve and vessels
retracted carefully during exposure of the quadrilateral plate and posterior column
Corona mortis
these anastamoses must be ligated as they appear on the lateral 1/3 of the superior pubic ramus
they are nearly universally present but vary significantly in size
External iliac vessels
exposed and retracted early in the exposure; must be mobilized to expose the iliac fossa and false pelvis
Bladder
Foley catheter limits injury; placement of a malleable retractor anterior to bladder also helps protect
Kocher-Langenbock Approach
Introduction
Southern/Moore approach and the Kocher-Langenbeck approach both use the same interval
Kocher-Langenbeck is used to refer to an approach used to address the acetabulum which is more extensile
Southern/Moore approach more commonly refers to a more limited hip arthroplasty approach
incision is identical to Kocher-Langenbeck, except localized posterior to greater trochanter
Provides exposure to
posterior wall of acetabulum
lateral aspect of the posterior column of acetabulum
indirect access to true pelvis and anterior aspect of posterior column through palpation
proximal femur
Indications
THA
hip hemiarthroplasty
removal of loose bodies
dependant drainage of septic hip
pedicle bone grafting
posterior wall fx
posterior column fx
posterior wall and posterior column fx
simple transverse fx (patient prone)
fx must be less than 15 days old
fx line located at or below acetabular roof
no major anterior displacement
Intermuscular plane
No internervous plane
gluteus maximus innervated by inferior gluteal nerve
nerve branches of upper 1/3 of muscle cross intended interval of dissection halfway between level of greater trochanter and PSIS
muscle split is stopped when first nerve branch to upper part of muscle is encountered
Vascular planeupper 1/3 of muscle
supplied by superior gluteal artery
lower 2/3 of muscles
supplied by inferior gluteal artery
line of fat on surface marks interval
Preparation
Anesthesia
patient must be relaxed
Position lateral position
posterior wall and lip fxs (can use skeletal traction when using lateral position)
allows for femoral head dislocation
position of choice for joint arthroplasty
allows buttock tissue to “fall away” from the field
prone position
for transverse fx (flex the knee to prevent stretching of sciatic nerve)
femoral head is maintained in reduced position throughout procedure
improves quadrilateral surface access
improved access to cranial and anterior aspect of posterior wall fractures
Imaging
ensure appropriate imaging can be obtained prior to formal prepping and draping
Approach
Incision longitudinal incision centered over greater trochanter start just below iliac crest, lateral to PSIS
mini-incision approach shows no longterm benefits to hip function
extend to 10 cm below tip of greater trochanter
Superficial dissection
through subcutaneous fat
incise fascia lata in lower half of incision
extend proximally along anterior border of gluteus maximus
split gluteus maximus muscle along avascular plane
release portion of gluteal sling to aide in anterior retraction of muscle belly
detach short external rotators after tagging the piriformis should be tagged and released approximately 1.5cm from the tip of the greater trochanter to avoid damaging the blood supply to the femoral head the piriformis will provide a landmark leading to the greater sciatic notch the contents of the greater sciatic notch include:
piriformis
superior and inferior gluteal vessels and nerves
sciatic and posterior femoral cutaneous nerves
internal pudendal vessels
nerves to the obturator internus and quadratus femoris
the obturator internus should be tagged 1.5 cm from the greater trochanter and blunt dissection should be used to follow its origin to the lesser sciatic notch
posterior retraction will protect the sciatic nerve
clear abductors and soft tissue to visualize posterior capsule and posterior wall region
Deep dissection
no further dissection is needed in setting of isolated posterior wall fracture
palpable exposure of quadrilateral plate to assess reduction of posterior column accomplished by elevation of obturator internus elevation
access can be enlarged by release of sacrospinous ligament
hip joint exposure
perform marginal capsulotomy
capsular attachments to posterior wall fragments need to be kept intact to prevent devascularization
femoral traction can allow visualization of intra-articular surface of hip joint
osteotomy of greater trochanter
extends access along external surface of anterior column
Dangers
Sciatic nerveinitially located along posterior surface of quadratus femoris muscle
quadratus femorus anatomy is constant; rarely damaged in setting of fracture
extend hip and flex knee to prevent injury
minimize chance of injury by using proper gentle retraction and releasing your short external rotators (obturator internus) posteriorly to protect the sciatic nerve from traction
treat injury with observation and use of ankle-foot orthosis
prognosis for recovery of tibial division is good despite severe initial damage
prognosis for recovery of peroneal division is dependant on severity of initial injury
Inferior gluteal artery
leaves pelvis beneath piriformis
if it is cut and retracts into the pelvis, then treat by flipping patient, open abdomen, and tie off internal iliac artery
First perforating branch of profunda femoris
at risk of injury with release of gluteus maximus insertion
Femoral vessels
at risk with failure to protect anterior aspect of the acetabulum, or with placement of retractors anterior to the iliopsoas muscle
Superior gluteal artery and nerve
leaves the pelvis above the piriformis and enters the deep surface of the gluteus medius.
this tethering limits upward retraction of gluteus medius and blocks you from reaching the iliac crest
injury can cause excessive bleeding
Quadratus femoris
excessive retraction and injury must be avoided to prevent damage to medial circumflex artery
Heterotopic Ossification
debride necrotic gluteus minimus muscle to decrease incidence of HO
Extended Illiofemoral approach to pelvis
The extended iliofemoral approach exposes the entire lateral innominate bone
Indications
Transtectal transverse fracture with roof impaction
Transverse with posterior wall fractures
T-type fractures, especially with posterior wall involvement
T-type fractures with pubic symphysis dislocation
Both-column fractures with posterior wall or posterior column comminution, sacroiliac joint involvement, or very high posterior column involvement
Delayed fixation of both column, T-type, or transverse + posterior wall fractures (typically > 3 weeks)
Malunion/nonunion/deformity correction surgeries
Preparation
Position
lateral decubitus positioning is utilized in this approach.
Approach
Incision the incision is carried along the iliac crest
starting from the PSIS and running anteriorly to the ASIS
it is then continued down from the ASIS in line with the posterior femur
Superficial dissection
separate the abdominal musculature from the gluteal musculature at the iliac crest.
develop the interval between the sartorius and tensor fasciae latae.
retract the tensor laterally and dissect through the fascia lata distal to the muscle (longitudinally).
elevate the tensor fasciae latae from the ASIS.
Deep dissection
dissect gluteal muscles off iliac crest
subperiosteally dissect the gluteal muscles off the iliac crest from anterior to posterior and cephalad to caudad.
continue the elevation until the PSIS and greater sciatic notch are encountered.
the lateral branches of the anterior femoral circumflex vessels must be ligated to further retract the tensor and fascia lata laterally.
elevate the direct head of the rectus femoris from the pelvis as well as the gluteus minimus (off the proximal femur).
sequentially tag and resect the insertions of the
gluteus medius/minimus
piriformis
conjoint tendon (superior and inferior gemelli/obturator internus)
Take care to protect the superior gluteal artery and nerve as well as the sciatic nerve.
release hip capsule, if not injured.
access to the internal iliac fossa may be obtained inferiorly by releasing the indirect head of the rectus femorus and superiorly by releasing the abdominal musculature off the iliac wing and elevating the iliacus from the internal fossa.
elevating the abdominal musculature from the iliac crest and iliacus from the internal fossa in this approach will completely devitalize the wing. This aspect of the approach should be used on a very limited basis.
Wound closure
3 drains are placed before closure, one along the posterior column, another in the distal portion of the incision, and a third in the internal iliac fossa
order of wound closure/repair:
hip capsule, external rotators
gluteus medius, must be fixed anatomically and with strong sutures
gluteus minimus
rectus femoris origin with transosseous sutures, knee extension facilitates this repair
sartorius and abdominal muscles if taken down
fascia, subcutaneous layers, and skin
Dangers & Complications
Heterotopic Ossification
highest rate of heterotopic bone formation of all pelvic approaches
Extended patient recovery period
Permanent hip abductor weakness is expected
Iatrogenic injurystructures at risk
superior gluteal artery and vein
sciatic nerve
lateral femoral cutaneous nerve (lateral branches always transected)
perforating branches of the femoral artery
Anterior Approach to Cervical Spine
Overview
widely used approach that exposes anterior vertebral bodies from C2 to T1
Indications cervical radiculopathy
anterior cerical disctomy & fusion (ACDF)
myelopathy
anterior corpectomy and fusion
tumor
anterior corpectomy and fusion
odontoid fracture
C2 anterior screw osteosynthesis
infection & epidural abscess
anterior cervical discectomy & fusion (ACDF)
Applied surgical anatomy
It is important to understand the three fascial layers of the neck superficial fascia
formed by the investing layer of deep cervical fascia
platysma and external jugular vein are only structures superficial to it
surround neck like a collar, but splits around the SCM and trapezius
pretracheal fascia
continous with carotid sheath at sheath’s lateral margin
superior and inferior thyroid vessels run from the carotid sheath through the pretracheal fascia to the midline
prevertebral fascia
thick and tough fascia that lines in front of the prevertebral muscles
the cervical sympathetic trunk (runs over transverse processes) runs on its surface
Landmarks
carotid tubercle is the anterior tubercle of the transverse process of C6
Planes
Superificial
divide platysma which is innervated high up in the neck by the facial (seventh) cranial nerve
Middle
sternocleidomastoid (spinal accessory nerve)
strap muscles (segmental innervation from C1, C2, C3)
Deep
left longus colli muscles (segmental branches of cervical nerves)
right longus colli muscles
Preparation
Anesthesia
general as airway needs to be protected
Position
supine
Imaging cross table lateral required to identify correct level
shoulders/arms often pulled caudal to obtain better visualization of C7
Approach
Incision
make transverse skin crease incision at appropriate level
extend obliquely from the midline to the posterior border of the SCN
side
surgeons preference
Superficial Dissection
incise fascia over platysma
spit platysma with finger
identify anterior border of SCM
incise fascia and retract SCM lateral
identify and retract strap muscles medially (sternohyoid and sternothyroid)
identify the carotid pulse and retract carotid sheath lateral
cut through pretrachial fascia
localize superior and inferior thyroid arteries and tie off if necessary
Deep dissection split longus colli muscles and anterior longitudinal ligament
be aware of sympathetic chain that lies on longus colli lateral to vertebral body
subperiostally disect to expose anterior surface of vertebral body
retract longus colli muscles and ALL laterally
identify level with needle in disc space and lateral xray
Structures at Risk
Recurrent laryngeal nerve
injury rate 2.3% (same injury rate for left RLN and right RLN)
left RLN
ascends in neck in tracheoesophageal groove after branching off from parent nerve the vagus at the level of the arch of the aorta
right RLN
runs alongside the trachea in the neck after hooking around the right subclavian artery
crosses from lateral to medial to reach midline
more vulnerable than left during exposure because
it has a more variable course
lies more anterolateral
protect by placing retractors under medial edge of longus colli muscle
Sympathetic nerves and stellate gangliondamage or irritation causes Horner’s syndrome
characterized by ptosis, anhydrosis, miosis, enophthalmos and loss of ciliospinal reflex on the affected side of the face
caused by injury to sympathetic chain, which sits on the lateral border of the longus colli muscle at C6
protect by subperiosteal dissection of longus colli muscles from midline
Carotid sheath and contents
protected by the anterior border of SCM
be careful with lateral retractor placement
Postoperative retropharyngeal hematoma
presents with respiratory difficulties
tense hematomas should be emergently decompressed if causing respiratory compromise
physical exam will show a tense mass under the incision
most common cause is postsurgical edema
Volar Approach to the Radius
Henry’s approach
Access
provides exposure to the volar aspect of the radial shaft
Indications
ORIF of proximal radius and radial shaft fractures
radial osteotomy
tumor/abscess biopsy and excision
anterior exposure of bicipital tuberosity
superficial radial nerve compression syndrome (Wartenberg Syndrome)
Internervous Plane
Proximally between:
brachioradialis (radial nerve)
pronator teres (median nerve)
Distally between:
brachioradialis (radial nerve)
FCR (median nerve)
Preparation
Position
place arm supine on table with armboard and supinate arm
Approach
Incision longitudinal incision
begin just lateral to biceps tendon on flexor crease of elbow
end at radial styloid process
Superficial dissection
incise the deep fascia in line with skin incision
develop a plane between BR and FCR distally
move proximal to develop plane between PT and BR
identify the superficial radial nerve beneath BR
ligate the branches of the radial artery to aid lateral retraction of BR
Deep dissection - proximal third
follow the biceps tendon to its insertion on the bicipital tuberosity
radial to the insertion of biceps tendon incise the bursa to gain access to the proximal part of radius (radial artery which runs along the ulnar side of the biceps tendon)
fully supinate the forearm to displace the PIN radially and bring the origin of the supinator muscle into the anterior aspect of the radius
incise the supinator muscle along the line of its broad insertion and continue subperiosteal dissection laterally
Deep dissection - middle third
pronate the forearm to bring the insertion of the pronator teres, along the radial aspect of the radius, into view
detach the pronator insertion from bone and retract medially
Deep dissection - distal third
partially supinate the forearm
dissect the periosteum off the lateral aspect of the distal third of the radius, lateral to the pronator quadratus and flexor pollicis longus
Dangers
Posterior interosseous nerveenters the supinator muscle beneath a fibrous arch known as the arcade of Frohse
the arch is formed by the thickened edge of the superficial head of the supinator muscle
compression of the nerve at this point produces paralysis or dysfunction of the extensors known as posterior interosseous nerve entrapment syndrome
step to protect the PIN include
dissecting supinator off radius subperiostally
do not place retractors on posterior surface of radial neck
avoid excessive radial retraction of supinator
injury
injury leads to a neuropraxia that takes 6-9 months to resolve
Superficial radial nerve
runs down forearm under body of brachioradialis
vulnerable with manipulation of mobile wad of three
damage to it can cause a painful neuroma
Radial artery
runs down middle of forearm under brachioradialis
DIrect Lateral Hip approach
essential what I did for hemis
Indications total hip arthroplasty
has lower rate of total hip prosthetic dislocations
proximal femur fracture
Plane
Internervous plane
no true internervous plane
Intermuscular plane
splits gluteus medius distal to innervation (superior gluteal nerve)
vastus lateralis is also split lateral to innervation (femoral nerve)
Preparation
Anesthesia options
general
spinal
Position
lateral
supine
Approach
Incision
begin 5cm proximal to tip of greater trochanter
longitudinal incision centered over tip of greater trochanter and extends down the line of the femur about 8cm
Superficial dissection
split fascia lata and retract anteriorly to expose tendon of gluteus medius
detach fibers of gluteus medius that attach to fascia lata using sharp dissection
Deep dissection split fibers of gluteus medius longitudinally starting at middle of greater trochanter
do not extend more than 3-5 cm above greater trochanter to prevent injury to superior gluteal nerve
extend incison inferior through the fibers of vastus lateralis
develop anterior flap
anterior aspect of gluteus medius from anterior greater trochanter with its underlying gluteus minimus
anterior part of vastus lateralis
requires sharp dissection of muscles off bone or lifting small fleck of bone
expose anterior joint capsule
follow dissection anteriorly along greater trochanter and onto femoral neck which leads to capsule
gluteus minimus needs to be released from anterior greater trochanter
Structures at Risk
Superior gluteal nerve
runs between gluteus medius and minimus 3-5 cm above greater trochanter
protect by
limiting proximal incision of gluteus medius
putting a stay suture at the apex of gluteal split
leads to Trendelenburg gait pattern
Femoral nerve
most lateral structure in neurovascular bundle of anterior thigh
keep retractors on bone with no soft tissue under to prevent iatrogenic injury
Anterior Hip Approach
Provides exposure to
hip joint
ilium
Indications
THA
open reduction of congenital hip dislocations
synovial biopsies
intra-articular fusions
excision of pelvic tumors
pelvic osteotomies
irrigation and debridement of infected, native hip
Planes
Internervous plane-Superficial
sartorius (femoral n.)
tensor fasciae latae (superior gluteal n.)
Internervous plane-Deep
rectus femoris (femoral n.)
gluteus medius (superior gluteal n.)
Position and Preparation
Anesthesia options include
block vs. general anesthesia
Position
supine
Approach
Incision
make incision from anterior half of iliac crest to ASIS
from ASIS curve inferiorly in the direction of the lateral patella for 8-10 cm
Superficial dissection
identify gap between sartorius and tensor fasciae latae
dissect through subcutaneous fat (avoid lateral femoral cutaneous n.)
incise fascia on medial side of tensor fascia latae
detach origin of tensor fasciae latae of iliac to develop internervous plane
ligate the ascending branch of the lateral femoral circumflex artery (crosses gap between sartorius and tensor fascia latae)
Deep dissection
identify plane between rectus femoris and gluteus medius
detach rectus femoris from both its origins
retract rectus femoris and iliopsoas medially and gluteus medius laterally to expose the hip capsule
adduct and externally rotate the hip to place the capsule on stretch
incise capsule with a longitudinal or T-shaped capsular incision
dislocate hip with external rotation after capsulotomy is complete
Proximal extension indications
bone graft harvest
dissection
extend proximal incision posteriorly along the iliac crest
Distal extension indications
intra-operative fracture of distal femur
dissection
lengthen skin incision downward along anterolateral aspect of thigh
incise fascia latae in line with skin incision
stay in the interval between the vastus lateralis and rectus femoris
Dangers
Lateral femoral cutaneous nerve reaches thigh by passing under inguinal ligament
the course is variable and the LFCN can be seen passing medial or lateral to ASIS
most commonly seen when incising fascia between the sartorius and the tensor fascia latae
injury may lead to painful neuroma or decreased sensation on lateral aspect of thigh
Femoral nerve
should remain protected as long as you stay lateral to sartorius muscle
Ascending branch of lateral femoral circumflex artery
found proximally in the internervous plane between the tensor fascia latae and sartorius
be sure to ligate to prevent excessive bleeding
Posterior Hip
Southern Moore Approach
Provides exposure to
acetabulum
proximal femur
Indications
THA
hip hemiarthroplasty
removal of loose bodies
dependant drainage of septic hip
pedicle bone grafting
Associated approachesKocher-Langenbeck
more extensile exposure used for complicated acetabular work
same interval as posterior approach to hip
incision slightly more anterior over greater trochanter
Planes
Internervous plane
no internervous plane
Intermuscular planegluteus maximus
innervated by inferior gluteal nerve
muscle split is stopped when first nerve branch to upper part of muscle is encountered
Vascular plane
superior gluteal artsupplies proximal 1/3 of muscle
inferior gluteal artery
supplies distal 2/3 of muscle
line of fat on surface of gluteus maximus marks interval
Preparation
Anesthesia
general most common
Positionlateral positionindicationship arthroplasty
position of choice
posterior wall and lip fractures
skeletal traction may be used in lateral position
advantages
allows for femoral head dislocation
allows buttock tissue to “fall away” from the field
prone positionindications
transverse fractures of acetabulum
Approach
Incision make 10 to 15 cm curved incision one inch posterior to posterior edge of greater trochanter (GT)
begin 7 cm above and posterior to GT
curve posterior to the GT and continue down shaft of femur
mini-incision approach shows no long-term benefits to hip function
Superficial dissection
incise fascia lata to uncover vastus lateralis distally
lengthen fascial incision in line with skin incision
split fibers of gluteus maximus in proximal incision
cauterize vessels during split to avoid excessive blood loss
Deep dissection
internally rotate the hip to place the short external rotators on stretch
place stay suture in piriformis and obturator internus tendon (short external rotators)
evidence shows decreased dislocation rate when short external rotators repaired during closure
detach piriformis and obturator internus close to femoral insertion
reflect backwards to protect sciatic nerve
incise capsule with longitudinal or T-shaped incision
dislocate hip with internal rotation after capsulotomy
Proximal extension
may extend proximal incision towards iliac crest for exposure of ilium
Distal extension
extend incision distally down line of femur down to level of knee
vastus lateralis may either be split or elevated from lateral intermuscular septum
Dangers
Sciatic nerve location initially located along posterior surface of quadratus femoris muscle
quadratus femorus anatomy is constant; rarely damaged in setting of fracture
prevention
extend hip and flex knee to prevent injury
use proper gentle retraction and release short external rotators (obturator internus) posteriorly to protect the sciatic nerve from traction
treatment of injury
treat injury with observation and use of ankle-foot orthosis
prognosis
recovery of tibial division is good despite severe initial damage
recovery of peroneal division is dependent on severity of initial injury
Inferior gluteal arterylocation
leaves pelvis below piriformis
treatment of injury
if cut and retracts into pelvis, flip patient, open abdomen, and tie off internal iliac artery
First perforating branch of profunda femorisat risk
during release of gluteus maximus insertion
Femoral vesselsat risk
with failure to protect anterior aspect of the acetabulum
with placement of retractors anterior to the iliopsoas muscle
Superior gluteal artery and nerve location
leaves pelvis through the greater sciatic notchcontents of greater sciatic notch include
superior gluteal nerve
superior gluteal artery and vein
runs over the piriformis between the gluteus medius and minimus
enters the deep surface of the gluteus medius.
do not split gluteus medius more than 5 cm proximal to greater trochanter due to risk of denervating the muscle
also at risk during the lateral (Hardinge) approach to the hip
Quadratus femoris
excessive retraction and injury must be avoided to prevent damage to medial circumflex artery
Heterotopic ossification (HO)
debride necrotic gluteus minimus muscle to decrease incidence of HO
Tibia Posterolateral Approach
Exposure to
middle two thirds of the tibia
entire fibula
use when anterior and anterior medial approach limited by skin issues
Indications
ORIF of tibia fractures
bone grafting for nonunion or delayed union
implantation of electrical stimulators
excision or biopsy of bone lesions
osteotomy
fibula resection for fibula transfer
Plane
Internervous plan between tibial nerve (posterior compartment)
gastrocnemius
soleus
FHL
superficial peroneal nerve (lateral compartment)
peroneus bevis
peroneus longus
Preparation
Anesthesia options include
general
spinal
peripheral nerve block
Position
prone or in lateral position
Tourniquet
exsanguinate limb using elevation or Esmarch
Approach
Incision longitudinal incision on lateral border of the gastrocnemius
make of desired length
Superficial dissection reflect skin flaps
take care not to damage the short saphenous vein
incise fascia
incise in line with the incision
develop intermuscular plane
develop plan between the gastrocnemius and soleus (posterior group) and peroneal muscles (lateral group)
muscular branches of peroneal artery lie with peroneus brevis proximally and may need to ligated
retract the soleus and gastrocnemius posteromedially
once done identify the origin of FHL and soleus on the posterior border of the fibula
Deep dissection detach the FHL and soleus
detach from the posterior border of the fibula and retract posteromedially
may expose entire length of fibula)
detach posterior tibialis
remove off the posterior surface of the interosseous membrane
the posterior tibial artery and nerve will be posterior to posterior tibialis and FHL
follow IOM to tibia
follow the posterior surface of the interosseous membrane to the lateral border of the tibia
release posterior tibialis and FDL of tibia
dissect the posterior tibialis and flexor digitorum longus off the posterior surface of the tibia to expose the desired segment of tibia
Extensile measure proximal cannot be extended into the proximal fourth of the tibia
popliteus muscle, posterior tibial artery, and tibial nerve preclude proximal dissection
distal
may be extended distally to become continuous with the posterior approach to the ankle
Closure loosely close the deep fascia on the lateral side of the leg
use interrupted sutures
Structures at Risk
Short saphenous vein
Peroneal artery and branches
avoid injury by staying on the posterior surface of the interosseous membrane
branches may be ligated and coagulated
Posterior tibial artery and nerve
avoid injury by staying on the posterior surface of the interosseous membrane
Medial Hip Approach
Indications
open reduction of congenital hip dislocation
psoas release (approach gives excellent exposure to psoas tendon)
biopsy and treament of tumors of the inferior portion of the femoral neck and medial aspect of proximal femoral shaft
obturator neurectomy
Plane
Superficial
no superficial internervous plane as both the adductor longus and gracilis are innervated by the anterior division of the obturator nerve
Deep internervous plane between adductor brevis and adductor magnus
adductor brevis supplied by the anterior division of the obturator nerve
adductor magnus has dual innervation
adductor portion is supplied by the posterior division of the obturator nerve
ischial portion by the tibial portion of the sciatic nerve
Preparation
Position
patient is supine with the affected hip in a flexed, abducted, and externally rotated position
Approach
Incision
longitudinal incision over the adductor longus
begin incision 3 cm below the pubic tubercle
length of incision is determined by the amount of femur that needs to be exposed
Superficial dissection
develop plane between gracilis and adductor longus muscles
Deep dissection develop plane between adductor brevis and adductor magnus until you feel lesser trochanter on the floor of the wound
protect posterior division of the obturator nerve
isolate psoas tendon by placing narrow retractor above and below lesser trochanter
Dangers
Medial femoral circumflex artery
passes around medial side of the distal part of the psoas tendon
at risk in children when releasing psoas tendon
must isolate psoas tendon and cut under direct vision
Anterior division of obturator nerve
supplies adductor longus, adductor brevis,and gracilis in the thigh
Posterior division of obturator nerve
lies within substance of oburator externus
supplies adductor portion of adductor magnus
Deep external pudendal artery
at risk proximally
lies anterior to pectineus near the origin of the adductor longus
