Thigh/Knee Approaches Flashcards
position for lateral approach to the femur
trochanteric #: supine
internal rotation 15°
in traction table
shaft #: lateral
incision for lateral approach to the femur
longitudinal incision over middle of GT extending down lateral side of thigh, length and position depending on where the fracture is
internervous plane for lateral approach to the femur
none. this is a vastus split
superficial dissection for lateral approach to the femur
incise fascia lata of thigh (usually the fibres of TFL end at the GT, but sometimes you need to split fibres there too)
deep dissection for lateral approach to the femur
incise fascia covering vastus lateralis
split the vastus lateralis with 2 homans
cauterize vessels as they arise from within the vastus
dangers for lateral approach to the femur
1) numerous perforating vessels from the profunda femoris artery
position for posterolateral approach to the femur
supine
sandbag under operative side buttock
incision for posterolateral approach to the femur
longitudinal starting at the lateral femoral condyle and extending proximally along the posterior edge of the femur
internervous plane for posterolateral approach to the femur
between vastus lateralis and the lateral intermuscular septum
superficial dissection for posterolateral approach to the femur
incise deep fascia of the thigh
deep dissection for posterolateral approach to the femur
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
dangers for posterolateral approach to the femur
1) perforating arteries
2) superior lateral geniculate artery and vein
position for anteromedial approach to the distal femur
supine
incision for anteromedial approach to the distal femur
make 10-15 cm longitudinal incision over interval between rectus femoris and vastus medialis, extending distally to medial edge of patella
internervous plane for anteromedial approach to the distal femur
none
superficial dissection for anteromedial approach to the distal femur
incise fascia
ID interval between rectus and vastus medialis
develop plane by retraction and blunt dissection
deep dissection for anteromedial approach to the distal femur
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
dangers for anteromedial approach to the distal femur
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
position for posterior approach to the femur
prone
pelvis and chest longitudinal supports
incision for posterior approach to the femur
longitudinal 20 cm loong down the midline of the posterior aspect of the thigh ending proximally at the inferior margin of the gluteal fold
internervous plane for posterior approach to the femur
lateral intermuscular septum and biceps femoris
superficial dissection for posterior approach to the femur
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
deep dissection for posterior approach to the femur
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
dangers for posterior approach to the femur
1) sciatic nerve medial to biceps
2) nerve to biceps enters very proximal and medial, so usually not a worry
position for minimal access approach to the distal femur
supine
sandbag under thigh to put knee in 30° flexion
incision for minimal access approach to the distal femur
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
internervous plane for minimal access approach to the distal femur
distally between vastus lateralis and biceps femoris
proximally, none, as you split vastus lateralis
superficial dissection for minimal access approach to the distal femur
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
deep dissection for minimal access approach to the distal femur
divide knee joint capsule and synovium
split and retract vastus lateralis proximally
danger for minimal access approach to the distal femur
1) superior genicular artery and veins need to be ligated
position for minimal access approach to proximal femur for intramedullary nailing
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
incision for minimal access approach to proximal femur for intramedullary nailing
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)
internervous plane for minimal access approach to proximal femur for intramedullary nailing
none
split fibres of glut max and glut med
superficial dissection for minimal access approach to proximal femur for intramedullary nailing
fascia
split glut max for 3 cm
deep dissection for minimal access approach to proximal femur for intramedullary nailing
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
danger for minimal access approach to proximal femur for intramedullary nailing
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
position for minimal access approach to retrograde intramedullary nailing of femur
supine
flex knee with triangle ridge to 90°
sandbag under buttock
incision for minimal access approach to retrograde intramedullary nailing of femur
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
internervous plane for minimal access approach to retrograde intramedullary nailing of femur
none - you are just passing through medial retinaculum and synovium
superficial dissection for minimal access approach to retrograde intramedullary nailing of femur
incise capsule
deep dissection for minimal access approach to retrograde intramedullary nailing of femur
divide synovium
ID intercondylar notch
danger for minimal access approach to retrograde intramedullary nailing of femur
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
position for arthorscopic approach to the knee
supine
tourniquet
knee free to manipulate
incision for arthorscopic approach to the knee
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
internervous plane for arthorscopic approach to the knee
none
dissection for arthorscopic approach to the knee
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
what is the order of scoping in knee arthroscopy?
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
danger for arthorscopic approach to the knee
1) articular cartilage
2) meniscus
position for medial parapatellar approach to the knee
supine
knee flexed
hip support to stop abduction
incision for medial parapatellar approach to the knee
longitudinal midline from 5 cm above the patella to below the level of the tibial tubercle
internervous plane for medial parapatellar approach to the knee
none
superficial dissection for medial parapatellar approach to the knee
leave some capsular tissue on medial edge of patella to fascilitate repair
enter midline through quads tendon
retract or excise fat pad
deep dissection for medial parapatellar approach to the knee
dislocate patella laterally
flex the knee to 90°
dangers for medial parapatellar approach to the knee
1) infrapatellar branch of the saphenous nerve
2) avulsion of the patella ligament during difficult dislocation
position for approach to medial meniscectomy
supine
sandbag under thigh
remove end of table to allow 90° knee flexion
tourniquet
incision for approach to medial meniscectomy
begin at inferomedial corner of patella
angle it inferiorly and posteriorly ending 1 cm below the joint line
internervous plane for approach to medial meniscectomy
none
superficial dissection for approach to medial meniscectomy
incise medial retinaculum
incise joint capsule
deep dissection for approach to medial meniscectomy
incise synovium and enter above the joint line to avoid damaging structures within
danger for approach to medial meniscectomy
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
position for medial approach to knee
supine
knee flexed
hip externally rotated to rest affected lateral ankle on shin of unaffected leg
tourniquet
incision for medial approach to knee
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
internervous plane for medial approach to knee
none
superficial dissection for medial approach to knee
fascia
spare the saphenous nerve (not the infrapatellar branch) and saphenous vein
deep dissection for medial approach to knee
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
danger for medial approach to knee
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
position for approach to lateral meniscectomy
supine
sandbag under thigh
knee free to flex >90°
tourniquet
incision for approach to lateral meniscectomy
start at the inferolateral corner of the patella continuing downward and backward for about 5 cm remaining anterior and superficial to LCL
internervous plane for approach to lateral meniscectomy
none
superficial dissection for approach to lateral meniscectomy
incise anterolateral aspect of the knee capsule
deep dissection for approach to lateral meniscectomy
incise synovium and fat opening anterolateral portion of joint beginning well above to avoid meniscal damage
danger for approach to lateral meniscectomy
1) lateral inferior geniculate artery
2) LCL if too posterior with incision
3) lateral meniscus if too distal with incision
position for lateral approach to the knee
supine
sandbag under buttock
flex knee to 90°
tourniquet
incision for lateral approach to the knee
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
internervous plane for lateral approach to the knee
between IT band and biceps femoris
superficial dissection for lateral approach to the knee
fascia
avoid common peroneal on posterior border of biceps tendon
retract IT band anterior
retract biceps posterior with peroneal nerve
deep dissection for lateral approach to the knee
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
dangers for lateral approach to the knee
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
position for posterior approach to the knee
prone
lateral pillows
tourniquet
incision for posterior approach to the knee
curved incision starting laterally over biceps muscle, obliquely across the popliteal fossa turning downward over medial head of gastrocs and inferiorly into the calf
internervous plane for posterior approach to the knee
none
superficial dissection for posterior approach to the knee
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)
biceps femoris
plantaris
common peroneal nerve
lateral head of gastrocs
medial sural cutaneous nerve
small saphenous vein
medial head of gastrocs
tibial nerve
semi M
deep dissection for posterior approach to the knee
posteromedial:
detach medial gastrocs and retract with vessels/nerves inferolaterally
posteriolateral:
detach lateral gastrocs and pull medial developing the plane between biceps and gastrocs
why would you use the posterior approach to the knee if you can see both corners with either lateral or medial approaches?
avulsed PCL tibial component is the only real reason
danger for posterior approach to the knee
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
position for lateral approach to distal femur for ACL surgery
supine
sandbag under thigh
knee in 30° flexion
tourniquet
incision for lateral approach to distal femur for ACL surgery
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
internervous plane for lateral approach to distal femur for ACL repair
vastus lateralis and biceps femoris
superficial dissection for lateral approach to distal femur for ACL repair
incise IT band slightly anterior to lateral intermuscular septum
deep dissection for lateral approach to distal femur for ACL repair
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
danger for lateral approach to distal femur for ACL repair
1) peroneal nerve posterior to biceps
2) lateral superior geniculate artery must be ligated
3) popliteal artery if plane does not stay subperiosteal
