SURGICAL APPROACHES TO THE KNEE JOINT

Dr.PRASHANTH KUMARSVS MEDICAL COLLEGE

The knee is a synovial hinge joint, supported and stabilized by powerful muscular and ligamentous forces.

It is superficial on three sides (anterior, medial,and lateral), and approaches to it are comparatively straightforward.

Because the knee joint is only covered by skin and retinaculae on three of its four sides, the joint is ideal for arthroscopic approaches.

Arthroscopy of the knee is also facilitated by the large size of the joint cavity.

Arthroscopic approaches have largely replaced open surgical approaches for the treatment of meniscal pathology, anterior cruciate ligament reconstruction, and removal of loose bodies.

Two arthroscopic approaches are described that allow complete exploration of the knee joint

Seven open approaches to the knee are described.

These approaches are useful where arthroscopic equipment is not available.

They are also of great importance when dealing with trauma of the knee joint associated with open wounds.

Because the major neurovascular structures of the leg all pass posterior to the joint, the posterior approach is used mainly for exploration of these structures.

The medial parapatellar approach, the most common knee incision, can be used for a variety of procedures.

The length of the incision depends on the pathology to be treated; when it is used fully, this approach gives an unrivaled exposure of the whole joint.

It is suitable for total joint replacement.

The approach for medial meniscectomy is much more restricted.

The introduction of the operative arthroscope has limited its use.

The medial approach to the knee joint affords easier access to the medial supporting structures of the knee.

Because of its slightly more posterior placement and the curving nature of the approach, a flap can be developed that allows better visualization of the posteromedial corner of the joint.

The approach for lateral meniscectomy provides adequate exposure, but its use is limited.

The lateral approach is used for ligamentous reconstruction of the knee’s lateral supporting structures.

The lateral approach to the distal femur, an adjunct to the medial parapatellar incision, is used for repairs of ruptured anterior cruciate ligaments.

The approach enters the intercondylar notch from behind, allowing reattachment of the distal stump of a torn anterior cruciate ligament or the insertion of a graft.

It usually is used in conjunction with an anteromedial approach to the knee.

The posterior approach to the knee is performed rarely, and when it is, it is usually for the repair of neurovascular structures.

PRINCIPLE OF SURGICAL APPROACHTABLE: radio lucent, adjustable it should be correct height for the

surgeon’s size

POSITION: Patient is in best position that he cannot

move during the procedure bony prominences should be are well

padded

Surgery under tourniquet provides better visualisation of structure including vessels and nerves

Drapping of the part should be meticulous preferably with impermeable drapes

SKIN INCISION: Appropriate length of incision Should be in

the natural crease of the skin to avoid undesirable scar

It Should follow lines of cleavage, planes of fascia

SOFT TISSUE DESSECTION: Thorough knowledge of anatomy of the part

is needed rather than the approach described or tought by others

Respect the soft tissue during approach Should pass between muscles rather than

through them Important vessels, nerves should be spared

by locating and protecting them Thorough hemostasis should be secured

APPROACHES OF THE KNEE JOINT1.Anteromedial approaches - anteromedial para patellar -subvastus anteromedial 2.Anterolateral approach3.Posterolateral approach4.Postero medial approach5.Medial approaches to the knee and supporting

structures6.Transverse approaches to menisci7.Lateral approaches to the knee and supporting

structures8.Extensile approaches to the knee -Mc cannell extensile approach -fernandez extensile anterior approach 9.posterior approach

MEDIAL PARA PATELLAR APPROACH(VON LANGENBECK APPROACH) Used to gain access to suprapatellar pouch, patella

and medial side of the joint

INDICATIONS1. Synovectomy2. Medial meniscectomy3. Removal of loose bodies4. Ligamentous reconstruction5. Patellectomy6. Drainage of the knee joint in case of sepsis7. Total knee replacement8. Repair of ACL9. ORIF of distal femur # when medial plate is

used

POSITION: supine place the sand bag on the table that it

supports the heel when the knee is flexed to 90*

and Support the outer aspect of the upper

thigh

LANDMARKS: patella, patellar ligament, tibial tubercle

INCISION: longitudinal straight

incision extending from 5cm above the superior pole of patella to below the level of the tibial tubercle.

NO INTERNERVOUS PLANE IN THIS APPROACH

SUPERFICIAL DISSECTION: Develop a medial skin

flap to expose the quadriceps tendon, medial border of the patella & patellar tendon

Enter the joint by cutting the joint capsule by leaving a cuff of capsular tissue medial to the patella and lateral to the quadriceps to facilitate closure

Divide the quadriceps tendon in midline to enter suprapatellar pouch

DEEP DISSECTION: Dislocate the patella

laterally and rotate it to 180* then flex the knee to 90*

If the patella not dislocated easily- extend the skin incision superiorly and split the quadriceps muscle just lateral to it’s medial border

If the patella still does not dislocatable- carefully remove the patellar ligament attachment with underlying block of bone after predrilling the block for screw fixation during closure

DANGERS: Avulsion of patellar tendon Infra patellar br.of the sephanous nerve

ENLARGE THE APPROACH:

Superior Extension by approach between rectus femoris and vastus medialis then split the underlying vastus intermedius to expose the distal 1/3 of femur

Inferior extension can be done by removal of patellar ligament attachment with underlying block of bone after predrilling the block for screw fixation during closure

SUBVASTUS ANTEROMEDIAL APPROACH

INDICATIONS: Lesser anteromedial procedures Medial knee procedures

CONTRAINDICATIONS: Previous knee arthroplasty Obese pt >200 lbs

ADVANTAGES: Preserves vascularity of patella Preserves the quadriceps tendon by providing

more stability to the patello femoral joint

POSITION Supine Knee flexed to 90*

SKIN INCISION: begining 8cm above the

patella carrying distally just medial and 2cm distal to the tibial tubercle

SUPERFICIAL DISSECTION: Incise the superficial

fascia slighly medial to the patella and bluntly dissect the vastus medialis fascia down to its insertion

DEEP DISSECTION: Identify the inferior

edge of vastus medialis and bluntly dissect the intermuscular septum about 10cm proximal to the adductor tubercle

Identify the tendinous insertion of muscle on medial to the patellar retinaculum and lift the v.medialis anteriorly

perform ‘L’ shaped arthrotomy beginning medially through the vastus insertion on medial patellar retinaculum and carrying it along the medial edge of the patella

Partially release the medial edge of patellar tendon and evert the patella laterally with knee joint extension

ANTEROLATERAL APPROACH(KOCHER’S APPROACH)

INDICATIONS: lenghthening of iliotibial band excision of fibular head To Decompress peroneal nerve Access to lateral femoral condyle& lat.tibial

condyle Lateral meniscectomy Total knee arthroplasty Fixed valgus deformity

SKIN INCISION: Begin the incision

7.5 cm proximal to the patella at the insertion of the vastus lateralis into the quadriceps tendon,

continue it distally along the lateral border of the Q.tendon, patella and patellar tendon upto 2.5cm distal to the tibial tuberosity

SUPERFICIAL DISSECTION:

Carry the superficial dissection as skin incision

DEEP DISSECTION Gentle sharp

dissection through the joint capsule

Retract the patella medially to expose the articular surface of the joint

DISADVANTAGES : It is difficult to displace the patella

medially It require longer incision Often require patellar tendon must be

freed subperiosteally / subcortically

POSTERO LATERAL APPROACH(HENDERSON APPROACH)

INDICATIONS: Drainage of posterior compartment in

pyogenic arthritis Loose bodies

POSITION: Supine Knee flexed in 90*

SKIN INCISION: Curved incision on

lateral side of the knee just anterior to the biceps femoris tendon and head of the fibula

DEEP DISSECTION: Trace the anterior

surface of the lateral inter muscular septum to the linea aspera 5cm proximal to the lateral femoral condyle

Expose the lateral femoral condyle and the origin of the fibular collateral ligament

Mobilize and retract the popliteus tendon posteriorly that is between biceps tendon and fibular collateral ligament

Make a longitudinal incision through the capsule and synovium to access to posterior compartment.

DANGERS: Common Peroneal

nerve

POSTEROMEDIAL APPROACH(HENDERSON APPROACH)

INDICATIONS: Drainaige of postero medial compartment, Loose bodies

POSITION: Supine Knee flexed 90*

INCISION: A curved incision

7.5cm long , distally from the adductor tubercle and along the tibial collateral ligament, anterior to relaxed tendons of semimembranosus, semitendinosus and gracilis.

DEEP DISSECTION: Expose and incise

the oblique part of the tibial collateral ligament,

Incise the capsule longitudinally to enter the postero medial compartment by retracting hamstring muscles posteriorly

MEDIAL APPROCHES TO THE KNEE AND ITS SUPPORTING STRUCTURES

CAVE’S TECHNIQUE

HOPPENFELD AND DEBOER TECHNIQUE

CAVE’S TECHNIQUE

INDICATIONS: Medial meniscectomy Access to anterio compartment Access to posterior compartment

POSITION: Knee flexed at right

angle

INCISION: Begin the skin incision

1cm posterior, 1cm proximal to the joint line

Carry the skin incision distal and anteriorly , 0.5cm distal to the joint line upto anterior border of the patellar tendon

Reflect the subcutaneous tissue with skin flaps

TO EXPOSE THE ANTERIOR COMPARTENT:

an incision that begins anterior to the tibial collateral ligament continue distally and anteriorly ina curve similar to skin incision and ends just distal to joint line.

TO EXPOSE THE POSTERIOR COMPARTMENT:

make a 2nd deep incision posterior to the tibial collateral ligament, from the level of femoral epicondyle straight distally across the joint line

TO EXPOSE ANTERIOR COMPARTENT:

an incision that begins anterior to the tibial collateral ligament continue distally and anteriorly ina curve similar to skin incision and ends just distal to joint line.

TO EXPOSE POSTERIOR COMPARTMENT:

make a 2nd deep incision posterior to the tibial collateral ligament, from the level of femoral epicondyle straight distally across the joint line

HOPPENFELD AND DEBOER TECHNIQUEINDICATIONS Medial collateral ligament

repair Medial joint capsule Medial meniscectomy ACL repair

POSITION Supine Flex the knee to 60* Abduct and externally

rotate the hip Place the foot on the

opposite shin

LAND MARKS: Adductor tubercle

INCISION: Make a long curved

incision Begins 2cm proximal to the adductor tubercle

Curve it anteroinferiorly about 3cm medial to medial border of the patella and end it 6cm distal to the joint line on anteromedial aspect of the tibia

NO TRUE INTERNERVOUS PLANE

SUPERFICIAL DISSECTION:

Raise the skin flaps

Incise the fascia along the anterior border of the sartorius starting at the tibial attachment of the muscle extending to 5cm proximal to the joint line

DEEP DISSECTION: Flex the knee

further and allow sartorius to retract posteriorly that exposes semitendinosus and gracilis

Rectract all three components of pes anserinus posteriorly and exposes tibial attachment of the medial collateral ligament

To Open The Joint Anteriorly:

Make a longitudinal medial papapatellar incision through the retinaculum and synovium.

To Open The Joint Posteriorly:

Make a incision through the capsule posterior to the tibial collateral ligament

To Expose The Posterior 1/3 Of Meniscus:

Posteromedial Corner Of The Knee:

Retract the 3 components of the pes anserinus posteriorly and separate the medial head of the gastrocnemius muscle from posterior capsule of the knee almost to midline bluntly it allow access to surgical area

DANGERS: Infra patellar branch of saphenous.nerve Saphenous vien Medial inferior genicular artery Popliteal artery

This Incision Already Is Extensive That Provides Exposure To All Medial Structurs .It Can’t Be Extended Usefully

SPECIAL STRUCTURES

The fat pad occupies varying amounts of the anterior portion of the knee joint and should not be damaged.

Damage may produce adhesions within the joint and,in theory, can interfere with the blood supply to the patella

The medial meniscus may be incised accidentally during the opening of the synovium unless the knee joint is entered well above the joint line.

SPECIAL PROBLEMS

Hematomas under the skin flap that develop postoperatively can cause skin necrosis.

Therefore, the large skin flaps that are created in this approach should be drained well.

APPLIED SURGICAL ANATOMY OF THE MEDIALSIDE OF THE KNEE Overview As Warren and Marshall pointed out, the

ligaments on the medial side of the knee are merely “condensations within tissue planes.”

They blend with each other at various points, making definition of each layer difficult, especially in cases of trauma, when bleeding and edema can complicate the problem further.

For this reason, it is important to have an understanding of the normal anatomy and supporting structures on the medial side of the knee.

The anatomy of the medial side is understood readily when it is described in three separate layers.

Approaches to the knee enter the joint by incising these layers sequentially, from outside to inside

Incision The lines of cleavage of the skin run roughly

transversely across the knee joint. Therefore, the more transverse the incision,

the more cosmetic the resulting scar. Longitudinal incisions, such as those that are

used for the medial parapatellar approaches, often leave broad, obvious scars, which are distressing, especially in young women

SPECIAL ANATOMIC POINTS Three muscles, the sartorius,

semitendinosus, and gracilis, insert into the upper part of the subcutaneous surface of the tibia.

Each muscle has a different nerve supply: sartorius - femoral nerve, semitendinosus-sciatic nerve, and gracilis - obturator nerve In addition,each muscle crosses both the hip

and the knee.

The actions of the three muscles are duplicated by other, more powerful, muscles.

At their pelvic origins, the three attach to three points on the bony pelvis that are separated as widely as the pelvis allows:

anterior superior iliac spine (sartorius),

ischial tuberosity (semitendinosus), and

inferior pubic ramus (gracilis). With these origins and insertions, the

muscles are arranged ideally to stabilize the pelvis on the leg

The sartorius, semitendinosus, and gracilis insert into the subcutaneous surface of the tibia at a point called the pes anserinus (goose foot).

Acting together, they not only flex the knee, but also internally rotate the tibia

TRANSVERSE APPROACH TO MENISCI

FOR MEDIAL MENISCUS:

POSITION : Supine Sand bag under

the affected thigh

Make a transverse skin incision 5cm at the level of the articular surface of tibia

Extend from medial border of patellar tendon to anterior border of the tibial collateral ligament.

Incise the capsule along the same line and dissect the proximal edge of the capsule and retract proximally

Open the synovium along the proximal border of the medial meniscus

Divide the anterior attachment of meniscus, retract the tibial collateral ligament to excise the meniscus

FOR LATERAL MENISCUS POSITION: supine Crossed leg

position

Make a oblique incision about 7.5cm centered over the joint line

In the capsule HOCKY STICK incision runs along the joint line and curves obliquely proximally along the anterior border of the iliotibial band

Retract the capsule and incise the synovial membrane tranversely to expose the lateral meniscus

ADVANTAGE: For medial meniscus approach –the scar

has no contact with femoral articular surface

LATERAL APPROACHES TO THE KNEE AND ITS SUPPORTING STRUCTURES

Hoppenfeld And Deboer Technique Bruser Technique

HOPPENFELD AND DEBOER TECHNIQUEPOSITION: Supine Sand bag under the

buttock of affected side

Flex the knee to90*

LAND MARKS: Lateral border of the

patella Lateral joint line Gerdy tubercle

INCISION: A long curved

incision begin 3cm lateral to the middle of the patella extend it distally over the gerdy tubercle on the tibia, end it 4-5cm distal to the joint line, complete the incision proximally by curving along the line of the femur.

There Is Internervous Plane Between The Iliotibial Band (S.G.N) And The Biceps Femoris (S.N).

SUPERFICIAL DISSECTION: mobilize the skin flaps, Incise the fascia between

iliotibial band and biceps femoris,

Retract the iliotibial band anteriorly and biceps femoris and common peroneal nerve posteriorly to expose the superficial lateral ligament and posterolateral corner of the knee capsule

DEEP DISSECTION: Enter the joint either

infront or behind the superficial lateral ligament

Anterior arthrotomy: To access lateral meniscus-

incise the capsule infront of ligament begin 2cm above the joint line.

Posterior arthrotomy: To inspect the posterior

horn of lateral meniscus-dessect between lateral head of the gastrocnemius and the posterolateral corner of the joint capsule

Ligate the lateral superior genicular arteries

Make alongitudinal incision in the capsule

DANGERS: Common peroneal nerve Lateral superior genicular artery Popliteal tendon Lateral meniscus & its coronary lig.

BRUCER TECHNIQUE

POSITION: Supine drape the limb

that permits full flexion of the knee

Flex the knee fully so that the foot rests on the table

INCISION: Begin the incision

anteriorly point where the patellar tendon crosses the joint line,

Continue it posteriorly along the joint line and end it at imaginary line extending from proximal end of the fibula to lateral femoral condyle

Incise the subcutaneous tissue and expose the iliotibial band

Split the iliotibial band and retract the margins,

Locate the inferior genicular artery betweeen collateral ligament and meniscus

Incise the synovium

Lateral meniscus lie in the depth of the incision

DANGERS: Fibular collateral

ligament Lateral inferior

genicular artery

APPLIED SURGICAL ANATOMY OF THE LATERAL SIDE OF THE KNEE

The supporting structures on the lateral side of the knee fall into three layers.

Because the anatomy can be distorted in pathologic states, a clear understanding of the normal anatomy is required before explorations are carried out.

Landmarks and Incision Oblique or longitudinal skin incisions cross

the lines of cleavage almost perpendicularly and may result in broad scars.

EXTENSILE APPROACHES TO KNEE

Mc Connell Extensile ApproachFernandez Extensile Approach

MC CONNELL EXTENSILE APPROACH It allows access to anterior, posterior, medial,

lateral side of the knee through a single incision

ADVANTAGES: Excellent exposure Unobtrusive scar Scar hidden by skin creases Less prone to hypertrophy Permits the harvest and transfer of the iliotibial

band and patellar tendon for grafts in reconstruction of the ligaments

Capsular reinforcement Meniscal reattachment Repair of the intraarticular #

POSITION: Supine Knee in acute flexion Foot rests on the operating table

INCISION: Transverse anterior incision between 3 points -Medial flexion crease -Inferior pole of

patella -Lateral flexion crease Make a lateral extension along the posterior

margin of the iliotibial band Medial extension slightly posteromedially in a

distal direction from the apex of the medial flexion crease for 9-10cm

Incise the fascia without subcutaneous elevation of the skin

Gentle Sharp dissection immediately against the fascia with knee in flexion increases exposure of joint capsule.

FERNANDEZ ENXTENSILE APPROACH POSITION: Supine drape the limb to allow

knee in 60* flexionINCISION: Begin a lateral

parapatellar incision 10cm proximal to the lateral joint line continue distally along the lateral border of the patella, patellar tendon and tibial tuberosity and end it 15cm distal to the lateral joint line

SUPERFICIAL DISSECTION:

Develop skin flaps deep in subcutaneous tissue extending

medially to anterior edge of the tibial collateral ligament and

Laterally to exposing the iliotibial band and the proximal origin of the anterior tibial and peroneous muscles

DEEP DISSECTION: To expose the lateral

tibial metaphysis: Dettach the anterior

tibial muscle and retract it distally, elevate the iliotibial band by deviding transeversely at the joint line / performing flat osteotomy of gerdy tubercle

To expose the posteromedial portion of the the tibial metaphysis:

Devide the tibial insertion of the pes anserina or elevate it as an osteoperiosteal flap

Elevate the tibial tuberosity, patellar tendon and incise the joint capsule transeversely, medially, laterally at the joint line

Carry the each limb of the capsular incision proximally to the level of the anterior border of the vastus medialis and vastus lateralis

Further exposure of articular surface of the tibia :

Dettach one or both menisci by transsection of the anterior horn, cutting the transverse ligament,and dividing the anterior portion of the coronary ligament.

POSTERIOR APPROACH It is rarely needed because medial and lateral approaches

provides good access to the half of the posterior capsule It should be used mainly for exploring the structures

within the popliteal fossa and for reattaching the avulsed tibial insertion of the PCL

INDICATION1. Repair of nuerovascular structures in trauma case2. repair of avulsion # of this site of attachment of PCL to

tibia3. Resection of gastrocnemius contractures4. Lenghthening of hamstrings tendon5. Excision of baker’s cyst and other popliteal cysts6. Access of posterior capsule of the knee7. Posterior part of the menisci8. Access Posterior aspect of femur and tibia

POSITIONPronetourniquet can be used all procedures except vascular repair

LAND MARKSTwo heads of gastrocnemius muscle originSemitendinosussemitendinosus

INCISION: Gentle curved incision

starting laterally over biceps femoris bring the incision obliquely across the popliteal fossa turn downwards over the medial head of the gastrocnemius and run the incision inferiorly into the calf muscles

NO TRUE INTERNERVOUS PLANE

SUPERFICIAL DISSECTION:

reflect the skin with subcutaneous fat,

Small sephanous vien/ medial sural cut.nerve can be used as a guide to dissecting popliteal fossa,

Incise the fascia just medial to small sephanous vien, dissect upto apex of the popliteal fossa following the tibial nerve

Dissect out the common peroneal nerve in a proximal to distal direction along the posterior border of the biceps femoris,

Identify popliteal artery and vien that are deep and medial to the tibial nerve,

To mobilize the artery one or more of its five branches to be ligated,

Careful to mobilise the pop.vien that is directly posterior to the pop.artery in the fossa and it moves posterolateral side of the artery,

DEEP DISSECTION: Retract the muscles of the

boudaries of pop fossa

To Access To Posteromeidial Joint Capsule:

Dettach the tendinous origin of the medial head of the gastrocnemius from the back of the femur and Retract laterally and inferiorly

Pull the nerves and vessels to reach the postero medial corner of the joint

Now exposure is as same as that achieved by posterior extension of the medial approach

To Acces To Posterolateral Corner Of The Knee : Detach the lateral head of the gastrocnemius

muscle from the lateral femoral condyle, Make the interval between it and biceps

femoris muscle as the same exposure in the lateral approach to the knee

DANGERS: Medial sural cut.nerve Small sephanous vien Tibial nerve Common peroneal nerve Popliteal vessels

APPLIED SURGICAL ANATOMY OF THE POSTERIORAPPROACH TO THE KNEE The anatomy of the posterior approach to the

knee is the anatomy of the popliteal fossa. The popliteal fossa is diamond shaped in

cadavers. In live patients, the lower “V” of the diamond

(the gap between the two heads of the gastrocnemius muscle) is nonexistent until the heads are retracted from one another.

INCISION

The lines of cleavage in the skin run almost transversely across the back of the knee joint.

The curved incision described, therefore, has a variable relation to these lines.

The resultant scar usually is cosmetically acceptable.

The incision crosses a major flexor crease at the back of the knee, but because the incision is almost parallel to the skin crease at this level, a flexion contracture of the knee does not occur when the wound heals.