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Orthopedic Surgery Ultimate > Thigh/Knee Approaches > Flashcards

Thigh/Knee Approaches Flashcards

1
Q

position for lateral approach to the femur

A

trochanteric #: supine

internal rotation 15°

in traction table

shaft #: lateral

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2
Q

incision for lateral approach to the femur

A

longitudinal incision over middle of GT extending down lateral side of thigh, length and position depending on where the fracture is

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3
Q

internervous plane for lateral approach to the femur

A

none. this is a vastus split

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4
Q

superficial dissection for lateral approach to the femur

A

incise fascia lata of thigh (usually the fibres of TFL end at the GT, but sometimes you need to split fibres there too)

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5
Q

deep dissection for lateral approach to the femur

A

incise fascia covering vastus lateralis

split the vastus lateralis with 2 homans

cauterize vessels as they arise from within the vastus

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6
Q

dangers for lateral approach to the femur

A

1) numerous perforating vessels from the profunda femoris artery

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7
Q

position for posterolateral approach to the femur

A

supine

sandbag under operative side buttock

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8
Q

incision for posterolateral approach to the femur

A

longitudinal starting at the lateral femoral condyle and extending proximally along the posterior edge of the femur

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9
Q

internervous plane for posterolateral approach to the femur

A

between vastus lateralis and the lateral intermuscular septum

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10
Q

superficial dissection for posterolateral approach to the femur

A

incise deep fascia of the thigh

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11
Q

deep dissection for posterolateral approach to the femur

A

dissect between the vastus lateralis and the lateral intermuscular septum and reflect the muscle anteriorly beginning at the distal end of the incision

ligate perforating femoral branches and superior lateral geniculate vessels

when you reach bone, begin to strip subperiosteally

use retractors to aid anterior displacement of vastus lateralis

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12
Q

dangers for posterolateral approach to the femur

A

1) perforating arteries
2) superior lateral geniculate artery and vein

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13
Q

position for anteromedial approach to the distal femur

A

supine

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14
Q

incision for anteromedial approach to the distal femur

A

make 10-15 cm longitudinal incision over interval between rectus femoris and vastus medialis, extending distally to medial edge of patella

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15
Q

internervous plane for anteromedial approach to the distal femur

A

none

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16
Q

superficial dissection for anteromedial approach to the distal femur

A

incise fascia

ID interval between rectus and vastus medialis

develop plane by retraction and blunt dissection

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17
Q

deep dissection for anteromedial approach to the distal femur

A

begin distally

open knee capsule

split quads tendon on its medial border

develop interval between vastus medialis and rectus

split vastus intermedius in line with fibres

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18
Q

dangers for anteromedial approach to the distal femur

A

1) medial superior genicular artery - ligate to avoid hematoma formation
2) low fibres of vastus medialis attach to patella - make sure you take a small cuff of tendon so you can repair this later to prevent lateral subluxation of the patella

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19
Q

position for posterior approach to the femur

A

prone

pelvis and chest longitudinal supports

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20
Q

incision for posterior approach to the femur

A

longitudinal 20 cm loong down the midline of the posterior aspect of the thigh ending proximally at the inferior margin of the gluteal fold

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21
Q

internervous plane for posterior approach to the femur

A

lateral intermuscular septum and biceps femoris

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22
Q

superficial dissection for posterior approach to the femur

A

incise deep fascia

watch for posterior femoral cutaneous nerve which runs in groove between biceps and semi T

ID lateral border of biceps

develop plane between biceps and vastus lateralis

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23
Q

deep dissection for posterior approach to the femur

A

begin proximally

retract biceps medially and vastus laterally

blunt dissection for plane

ID short head of biceps arising from posterolateral lip of linea aspera and detach it and reflect medially

*when distal, retract biceps laterally to expose sciatic nerve, then retract it laterally with biceps

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24
Q

dangers for posterior approach to the femur

A

1) sciatic nerve medial to biceps
2) nerve to biceps enters very proximal and medial, so usually not a worry

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25
Q

position for minimal access approach to the distal femur

A

supine

sandbag under thigh to put knee in 30° flexion

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26
Q

incision for minimal access approach to the distal femur

A

6-8 cm incision longitudinal over anterior half of the lateral femoral condyle extending rostral from the joint line

second incision site will be along lateral femur at a position dependent on fixation to be used

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27
Q

internervous plane for minimal access approach to the distal femur

A

distally between vastus lateralis and biceps femoris

proximally, none, as you split vastus lateralis

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28
Q

superficial dissection for minimal access approach to the distal femur

A

begin distally

divide lateral retinaculum to see joint capsule

develop plane between vastus lateralis and the lateral intermuscular septum

ligate branchs of lateral genicular artery

proximally, use vastus split as previously described

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29
Q

deep dissection for minimal access approach to the distal femur

A

divide knee joint capsule and synovium

split and retract vastus lateralis proximally

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30
Q

danger for minimal access approach to the distal femur

A

1) superior genicular artery and veins need to be ligated

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31
Q

position for minimal access approach to proximal femur for intramedullary nailing

A

supine (better fracture control and distal locking screw):

traction table

adduct leg

lateral flexion of trunk away from site

flex and abduct the opposite hip and flex the knee

reduce #

use steinmann pin to manipulate the proximal fragment if necessary

lateral (better entry point, needed for obese patients):

traction

adduct leg

flex contralateral limb at hip and knee

pad bony prominences

reduce #

use steinmann pin if necessary

*very obese = consider retrograde nailing

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32
Q

incision for minimal access approach to proximal femur for intramedullary nailing

A

entry point where a line drawn along the femoral shaft up and over the GT intersects a perpendicular line drawn from the ASIS posteriorly

(this incision will be 3-7 cm depending on the nail you are using)

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33
Q

internervous plane for minimal access approach to proximal femur for intramedullary nailing

A

none

split fibres of glut max and glut med

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34
Q

superficial dissection for minimal access approach to proximal femur for intramedullary nailing

A

fascia

split glut max for 3 cm

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35
Q

deep dissection for minimal access approach to proximal femur for intramedullary nailing

A

continue distally to split glut med

ID medial aspect of GT

use fluoro to line the guidewire up AP and lateral with the medullary canal

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36
Q

danger for minimal access approach to proximal femur for intramedullary nailing

A

1) too lateral with your nail and you will get a varus deformity
2) too far medial and you will get an iatrogenic # of the femoral neck
3) superior gluteal nerve runnign through glut med 3-5 cm above the tip of GT

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37
Q

position for minimal access approach to retrograde intramedullary nailing of femur

A

supine

flex knee with triangle ridge to 90°

sandbag under buttock

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38
Q

incision for minimal access approach to retrograde intramedullary nailing of femur

A

palpate medial border of patella

3 cm longitudinal incision 1 cm from medial border of patella about 2 cm distal to the distal pole of the patella

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39
Q

internervous plane for minimal access approach to retrograde intramedullary nailing of femur

A

none - you are just passing through medial retinaculum and synovium

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40
Q

superficial dissection for minimal access approach to retrograde intramedullary nailing of femur

A

incise capsule

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41
Q

deep dissection for minimal access approach to retrograde intramedullary nailing of femur

A

divide synovium

ID intercondylar notch

42
Q

danger for minimal access approach to retrograde intramedullary nailing of femur

A

1) infrapatellar branch of saphenous nerve should be distal to the incision
2) PCL on lateral aspect of medial femoral condyle may be damaged by reamers

43
Q

position for arthorscopic approach to the knee

A

supine

tourniquet

knee free to manipulate

44
Q

incision for arthorscopic approach to the knee

A

lateral: find where the lateral joint line meets the edge of the patella tendon

make an 8 mm stab incision 1-1.5 cm proximal to the joint line

medial: same procedure but medially

*note that the lateral incision should be slightly lower due to the lateral tibial condyle being slightly lower

45
Q

internervous plane for arthorscopic approach to the knee

A

none

46
Q

dissection for arthorscopic approach to the knee

A

flex knee to 90°

incise retinaculum

insert arthroscopic sheath and blunt trochar

extend knee and remove trochar

insert 30° camera

switch on irrigation

switch on light

47
Q

what is the order of scoping in knee arthroscopy?

A

start in extension

suprapatellar pouch

patellofemoral joint

lateral recess

popliteal recess

anterolateral meniscus

medial femoral recess

now flex to 90°

valgus + external rotation

medial compartment

ACL + PCL

varus stress with figure of 8 position

lateral compartment

48
Q

danger for arthorscopic approach to the knee

A

1) articular cartilage
2) meniscus

49
Q

position for medial parapatellar approach to the knee

A

supine

knee flexed

hip support to stop abduction

50
Q

incision for medial parapatellar approach to the knee

A

longitudinal midline from 5 cm above the patella to below the level of the tibial tubercle

51
Q

internervous plane for medial parapatellar approach to the knee

A

none

52
Q

superficial dissection for medial parapatellar approach to the knee

A

leave some capsular tissue on medial edge of patella to fascilitate repair

enter midline through quads tendon

retract or excise fat pad

53
Q

deep dissection for medial parapatellar approach to the knee

A

dislocate patella laterally

flex the knee to 90°

54
Q

dangers for medial parapatellar approach to the knee

A

1) infrapatellar branch of the saphenous nerve
2) avulsion of the patella ligament during difficult dislocation

55
Q

position for approach to medial meniscectomy

A

supine

sandbag under thigh

remove end of table to allow 90° knee flexion

tourniquet

56
Q

incision for approach to medial meniscectomy

A

begin at inferomedial corner of patella

angle it inferiorly and posteriorly ending 1 cm below the joint line

57
Q

internervous plane for approach to medial meniscectomy

A

none

58
Q

superficial dissection for approach to medial meniscectomy

A

incise medial retinaculum

incise joint capsule

59
Q

deep dissection for approach to medial meniscectomy

A

incise synovium and enter above the joint line to avoid damaging structures within

60
Q

danger for approach to medial meniscectomy

A

1) infrapatellar branch of the saphenous nerve
2) popliteal artery posterior to joint capsule should be safe
3) coronary ligament if incision too distal
4) superficial medial ligament if incision too posterior
5) fat pad in anterior knee joint should be spared to prevent adhesions and maintain blood supply to patella
6) medial meniscus can be damaged during approach if incision too distal

61
Q

position for medial approach to knee

A

supine

knee flexed

hip externally rotated to rest affected lateral ankle on shin of unaffected leg

tourniquet

62
Q

incision for medial approach to knee

A

longitudinal, curved starting 2 cm proximal to adductor tubercle down to 6 cm below the joint line on the anteromedial tibia running 3 cm medial to patella

63
Q

internervous plane for medial approach to knee

A

none

64
Q

superficial dissection for medial approach to knee

A

fascia

spare the saphenous nerve (not the infrapatellar branch) and saphenous vein

65
Q

deep dissection for medial approach to knee

A

incise either anterior or posterior to the MCL

anterior:

fascia along border of sartorius starting at the pes and moving to 5 cm proximal to joint

retract the 3 pes muscles posteriorly

expose superficial MCL

now go to medial parapatellar to expose the ligament from inside

posterior:

same except after retraction of pes, then separate medial head of gastrocs from semi M to see posteriomedial corner

66
Q

danger for medial approach to knee

A

1) neuroma formation if infrapatellar branch of saphenous not buried in fat
2) saphenous vein in posterior corner of superficial dissection
3) medial inferior geniculate artery curves around the upper end of tibia
4) popliteal artery lies against posterior joint capsule in midline

67
Q

position for approach to lateral meniscectomy

A

supine

sandbag under thigh

knee free to flex >90°

tourniquet

68
Q

incision for approach to lateral meniscectomy

A

start at the inferolateral corner of the patella continuing downward and backward for about 5 cm remaining anterior and superficial to LCL

69
Q

internervous plane for approach to lateral meniscectomy

A

none

70
Q

superficial dissection for approach to lateral meniscectomy

A

incise anterolateral aspect of the knee capsule

71
Q

deep dissection for approach to lateral meniscectomy

A

incise synovium and fat opening anterolateral portion of joint beginning well above to avoid meniscal damage

72
Q

danger for approach to lateral meniscectomy

A

1) lateral inferior geniculate artery
2) LCL if too posterior with incision
3) lateral meniscus if too distal with incision

73
Q

position for lateral approach to the knee

A

supine

sandbag under buttock

flex knee to 90°

tourniquet

74
Q

incision for lateral approach to the knee

A

long, curved 3 cm lateral to patella extending distal over Gerdy’s tubercle to 4-5 cm past the joint line, while the upper end should be extended along the line of the femur

75
Q

internervous plane for lateral approach to the knee

A

between IT band and biceps femoris

76
Q

superficial dissection for lateral approach to the knee

A

fascia

avoid common peroneal on posterior border of biceps tendon

retract IT band anterior

retract biceps posterior with peroneal nerve

77
Q

deep dissection for lateral approach to the knee

A

enter joint either in front of or behind LCL:

anterior: make sure to stay superior to joint line to avoid meniscal damage as you enter the joint
posterior: dissect between lateral head of gastrocs and the posterolateral corner

ligate superior geniculate arteries

arthrotomy well above joint line to avoid damage to meniscus or tendon of popliteus

78
Q

dangers for lateral approach to the knee

A

1) common peroneal nerve on posterior border of biceps
2) lateral superior geniculate artery between lateral gastrocs and corner
3) popliteus tendon within the joint posterolaterally
4) lateral meniscus if too distal with incision
5) coronary ligament if too distal with incision

79
Q

position for posterior approach to the knee

A

prone

lateral pillows

tourniquet

80
Q

incision for posterior approach to the knee

A

curved incision starting laterally over biceps muscle, obliquely across the popliteal fossa turning downward over medial head of gastrocs and inferiorly into the calf

81
Q

internervous plane for posterior approach to the knee

A

none

82
Q

superficial dissection for posterior approach to the knee

A

incise skin and ID vein with medial sural cutaneous nerve

incise fascia using medial sural cutaneous nerve as a guide tracing it back to the tibial nerve - dissect to the apex

dissect out the common peroneal nerve from the apex

now find aartery and vein which run deep and medial to tibial nerve

find the 5 branches of the popliteal artery near the knee (2 superior, 2 inferior, 1 middle)

83
Q
A

biceps femoris

84
Q
A

plantaris

85
Q
A

common peroneal nerve

86
Q
A

lateral head of gastrocs

87
Q
A

medial sural cutaneous nerve

88
Q
A

small saphenous vein

89
Q
A

medial head of gastrocs

90
Q
A

tibial nerve

91
Q
A

semi M

92
Q

deep dissection for posterior approach to the knee

A

posteromedial:

detach medial gastrocs and retract with vessels/nerves inferolaterally

posteriolateral:

detach lateral gastrocs and pull medial developing the plane between biceps and gastrocs

93
Q

why would you use the posterior approach to the knee if you can see both corners with either lateral or medial approaches?

A

avulsed PCL tibial component is the only real reason

94
Q

danger for posterior approach to the knee

A

1) medial sural cutaneous nerve travelling lateral to the small saphenous vein
2) tibial nerve
3) common peroneal nerve
4) small saphenous vein
5) popliteal vessels

95
Q

position for lateral approach to distal femur for ACL surgery

A

supine

sandbag under thigh

knee in 30° flexion

tourniquet

96
Q

incision for lateral approach to distal femur for ACL surgery

A

10 cm incision parallel to and over the indentation between the biceps femoris and IT band ending distally at the flare of the lateral femoral condyle

97
Q

internervous plane for lateral approach to distal femur for ACL repair

A

vastus lateralis and biceps femoris

98
Q

superficial dissection for lateral approach to distal femur for ACL repair

A

incise IT band slightly anterior to lateral intermuscular septum

99
Q

deep dissection for lateral approach to distal femur for ACL repair

A

ID vastus lateralis and retract anteriorly

ID lateral superior geniculate artery - ligate

incise periosteum at junction of shaft and flare

dissect with an elevator distally and medially until you get to the intercondylar notch via the posterior distal femur

pass instrument posterior to femur until it is visible in the medial parapatellar incision

100
Q

danger for lateral approach to distal femur for ACL repair

A

1) peroneal nerve posterior to biceps
2) lateral superior geniculate artery must be ligated
3) popliteal artery if plane does not stay subperiosteal

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