LATERAL APPROACH

Indications:

ORIF of IT# (M.C. INDICATION) Insertion IF in the Rx of of subcapital # SCFE ST & IT osteotomy . ORIF of subtrochanter # , femoral shaft # ,supracondylar# Extra articular arthrodisis of Hip JT. Rx of COM femur. Biopsy.

POSITION: Supine on orthopedic table with leg int. rotated to 15 deg ( to overcome the femoral anteversion & to bring the

lateral surface of femur to true lateral).

LANDMARKS: Post. Edge of G.T

Restrain against traction

Abduct

Internally rotate

INCISION:

Longitudanal incision beginning over middle of the G.T. extending down the lat. Side of the thigh with length depending on requirement.

INTERNERVOUS PLANE: No internervous plane as the muscle split is vastus lateralis

supplied by femoral N. far proximally.

Greater trochanter

SUPERFICIAL DISSECTION:

Cut the S.C. tissue & Fascia lata in line with the skin TFL is split in the line to expose V.lateralis.

Incise fascia lataFascia over distal tensor fasciae latae

Lliotibial band

DEEP DISSECTION:

Incise the fascial covering of V.lateralis. Insert a retractor(Homan’s/Bennet’s) through the V.lateralis

running the tip of retractor over anterior aspect of the shaft. Then put 2nd retractor through same gap down to femur

shaft.

Fascia lata Vastus lateralis Incise v.lat

Pull the 2 retractors apart to split the muscle. Continue splitting the muscle & coagulating the vessels

coming in b/t across the field. Splitting V.Lateralis exposes lateral surface of the femur

Vastus lat. With perforating vessels

Proximal femur

Fascia lata

Periosteum

DANGERS: Bleeding from perforating branches of profonda femoral A.

prevented by coagulation/ligation.

ENLARGING THE APPROACH:Can be extended down to the knee Jt. For full exposure of

lateral surface of femur.

Fascia lataV.LAT Femur periosteum Tendinous portion

of V.lat

POSTEROLATERAL APPROACH:

INDICATIONS:Ideal appoach for distal 3rd femur but can expose entire length

of femur ORIF of femoral# espescially supracondylar. Open I.M nailing for # shaft if closed nailing not possible. Non union # femur Femoral osteotomy Rx of chronic osteomyelitis Biopsy.

POSITION: Supine with sand bag under the buttock of affected side.

LANDMARKS:Lateral femoral epicondyle

INCISION:Longitudinal incision with length depending on requirement

with distal part of incision on lateral epicondyle femur, continue proximally along posterior aspect of femur.

INTERNERVOUS PLANE:Exploit the plane b/t vasti ( supplied by femoral nerve) &

hamstrings supported by sciatic N.

Lliliotibibial band over V.lat.(femoralN.)

Hamstrings(sciatic N.)

DEEP DISSECTION:Cut the fascia lata,follow the plane b/t V. lateralis & Lat.Int.mus.

Septum

Identify & ligate/coagulate perforating branches/ branches of superior geniculate vessels.

Fascia lata V.lat

Fascia fascia lata V.lat

Lliotibial bandLat.int.musc.sep Perforating

vesselsDistal femur

Continue detaching V. lat. From lat. Int. mus.septum till linea aspera.

Strip off muscles covering the shaft through subperiosteal plane.

lat.int.mus.sepFascia over V.lat

Fascia over V.lat Periosteum covering femur

Lat lip of linea aspera Lat.int.mus.sepa

DANGERS:

VESSELS: Perforating branches of profondefemuria A. Superiolateral geniculate A. & V.

ENLARGING THE APPROACH: Can be extended proximally upto GT. To expose entire

femoral shaft. Can be extended into a parapatellar approach.

ANTERO MEDIAL APPROACH TO THE DISTAL 2/3 FEMUR:

Excellent approach for lower 2/3rd femur & knee jt.

INDICATION: ORIF of # distal femur particularly those extending into

knoo jt. ORIF of # shaft of femur . Rx of chr.osteomylitis Biopsy & Rx of bone tumors Quadrisepsplasti.

POSITION: Supine

LANDMARKS:V.medialis forming a distinct bulge superior to the upper pole

of patella.

INCISION:

10-15cm longitudinal on to ant.medial aspect b/t V.M. & R.F.

INTERNERVOUSPLANE:No internervous plane.

patella

SUPERFICIAL DISSECTION:

Incise fascia lata, retract R.T. laterally and follow the plane b/t V.M & R.F.

Fascia over sartorius Fascia over V.medialisIncise fascia

Quadriceps tendon

RF

V.MEDIALIS V.intincise fascia and medial patellar retinaculum

RF

DEEP DISSECTION: Begin distally opening the capsule of knee jt. in line

with incision by cutting through the medial patellar retinaculum.

Continue proximally splitting the quadriceps tendon on its medial border & with in substance of it for easy closure.

incise fascia & medial patellar retinaculum

V.medialis Inscise V.int Supra patellar pouch

Quadriceps tendon

RF

Continue to develop intervel b/t the R.F & V.M

Split the V.I in line to uncover the femur.

V.M V.I femur

periosteumRF V.I

DANGERS: VESSELS:

Medial sup. Geniculate A. winds round the distal femur may look small but to be ligated as it may bleed profusely.

MUSCLES & LIGAMENTS:

Damage to the lowest fibers of V.medialis causes lat.subluxation of patella

Prevention –by taking small cuff of quadriceps tendon with V.medialis .

ENLARGING THE APPROACH: Sup.extension in same plane gives excellent approach to lower 2/3

femur.

Inf.extension by curving laterally-good exposure to knee.

POSTERIOR APPROACH

Rare approach to middle 3/5th of femur in other approaches contraindicated due to local problems.

INDICATIONS: Inf. Nonunion Rx of chr.osteomyelitis Biopsy &Rx of tumor Exploration of sciatic N.

Approach is lat.to the biseps in proximal ½ medial to the biseps in distal ½.

.

POSITION: Supine with adequate cushioning below

chest & pelvis.

LANDMARKS: Gluteal folds

INCISION: ~ 20cm longitudinal through midline of the posterior

aspect of the thigh with upper end at inferior margin of gluteal fold.

INTERNERVOUS PLANE: B/w lat. Inter muscular septum & biceps.

.

Post.F.cut.N

Biceps femoris (cut.N.)

Lliotibial bandover v.lat(F.N)

SUPERFICIAL DISSECTION: Incise deep fascia in line with / lat. To skin incision avoiding

damage to lat.cut.N. of thigh which runs longitudinally b/t biceps & semitendinous.

Develop a plane b/w biceps femoris & V.lateralis.Fascia over semi.mem.

Fascia over semitendinous Post.F.cut.N.

Biceps.F.inscise fascia

Long head of B Short head of BAdutor magnus

V.latInscise periosteum over linea aspera

DEEP DISSECTION: Begin proximally to retract the biceps medially & laterally inter

mus.septum laterally developing a plane b/w them. Retract short head of biceps medially at linea aspera, detach its origin

to expose the femur.

Reflect the long head of biceps laterally in distal ½ to expose sciatic N

.

Biceps Fem

V.L periosteum Linea aspera

Fascia over semi memembranous

Aductor magnus

Long head of Biceps Shrt head Sciatic N.

Retract the nerve laterally to expose the femur

Sciatic N.

Linea aspera

DANGERS:

Sciatic N. lying medial to the biceps in proximal ½ may be damaged

It may be damaged due to overzelous manipulation.

Prevented by running in proper plane & gentle manipulation.

N. To biceps femoris.

APPROACH CANNOT BE ENLARGED

MINIMAL ACCESS APPROACH TO DISTAL FEMUR

Done by means of 2 windows. Distal window in effect is a parapatellar approach for

viewing articular surfaces of distal femur. Proximal window provides access to femoral shaft & is a

part of lateral approach.

INDICATION:

ORIF of distal femoral # , especially intra articular associatrd with metaphyseal injuries.

.

POSITION:Supine with knee in 30 deg. Flexion.

LANDMARKS: Lat.jt. Line of knee Lat. Margin of patella, ant.surface of lat.condyle femur

INCISION:

6-8cm longitudinally over ant.1/2 of lat.condyle femur, extending upward from it.

2nd incision longitudinally on lat.aspect, femur length depending on implant used.

Proximally divide the SC fat & fascia over V. lateralis.

INTERNERVOUS PLANE: Distally internervous plane b/w V.lat & biceps femoris.

Proximally no internervous plane exists.

SUPERFICIAL DISSECTION: Begin distally to divide SC fat . Lateral patellar retinaculum to expose jt. Capsule. Develop plane b/w lat.int.mus.septum posteriorly &

V.lateralis anteriorly. Coagulate/ligate the branches of sup.geniculate A. & V.

crossing the field.

DEEP DISSECTION:Distally divide jt. Capsule & synovium to expose the articular

surface by retracting patella & flexing & extending the knee jt.

Proximally split the V.lateralis & develop a subepi periosteal plane b/w the 2 windows.

DANGERS:Superior geniculate A& Vs tend to be numerous & adherent to

the periosteum may be injured.

Prevented by isolation & ligation/ cauterisation.

ENLARGING THE APPROACH:LOCAL MEASURES:Ext. fixation / distraction clamp can be applied to the lat.aspect of

femur & tibia to expose the articular surfaces of knee jt.

EXTENSILE MEASURES:

2 Incisions can be united to make a single incision to expose entire lat.aspect of femur..

MINIMAL ACCESS APPROACH TO THE PROXIMAL FEMUR FOR IM NAILING

INDICATIONS: Acute # shaft femur Pathological # shaft femur Delayed union & nonunion.

Entry point for insertion of the nail into femur is determined radiografically which depends on the shape of the nail & anatomy of proximal femur.

For the nails which are straight in A.P plane the skin incision , entry point (piriform fossa) & medullary canal should be in straight line.

For the nails angled at their upper end require incision over GT

POSITION:

Supine Lateral

Good for# reduction Gives easy access to entry point

SUPINE POSITION:5 min of preoperative time shortens 2hrs of operative time. Place the pt. supine on traction table with traction applied to

affected limb as much as possible around traction post. Laterally flex the trunk away. Flex and abduct the opposite hip & flex the knee. Get adequate AP , lateral view of # & entry point # should be reduced/reducible before surgery.

Adduct hip

LATERAL POSITION:Put the pt on traction table laterally with affected limb up in

traction with pin/boot.

Adduct leg over traction pole, contralateral limb in flexion at hip & knee with adequate padding.

Good quality radiograph taken in AP & lateral view for entry point & # site.

# should be reduced/reducible before surgery.

Better approach to proximal femur than supine position.

LANDMARKS:GT, ASIS,shaft of femur.

INCISION:

Radiographic Landmark Centered on the skin mark with a size depending on the

type of nail used. Nails with proximal jig that are considerably offset from nail

need ~ 3cm incision Those with proximal jigs attached close to the nail require

longer incision ~7cm.

RADIOGRAPHIC TEQUNIQUE

LANDMARK TECHNIQUE

SUPERFICIAL DISSECTION: Incise the S.C fat & fascia overlying the GL.max. Split the fibers of GL.max ~3cm in line with incision.

DEEP DISSECTION: Continue the dissection distally to split the fibers of

GL.medius & gain access to the medial aspect of GT. Insert a marker wire to the entry point under C-arm guidance

in A.P & lat. Views.

DANGERS:

BONE DEFORMITY:Too lateral entry / rigid nail / # in proximal / 3rd femur may

cause varus deformitty at # site.

Entry which lies far medially may cause iatrogenic # neck of femur/ may damage blood supply to the head of femur.

NERVES:Sup. GL. N. may be damage that runs 3-5cms above the tip

of GT A.P in the GLT.MAX. if femur is not adducted

MINIMAL ACCESS SURGERY FOR RETROGRADE IM NAILING OF FEMUR

Excellent percutaneous access to the distal femoral condylar region.

INDICATION:Insertion of retrograde IM nails for # shaft femur.

POSITION:Supine with large triangular ridge underneath the knee to flex it to

90deg.

Keep a small sand bag under the ipsilateral buttock to keep the patella facing anteriorly.

LANDMARKS:Medial border of patella.

INCISION:3cm incision , 2cm proximal to distal pole of patella ~ 1cm from

medial branch.

SUPERFICIAL DISSECTION:Cut through through S.C tissue , identify joint capsule , divide

it longitudinally.

DEEP DISSECTION: Divide the synovium, separate I with retractor to view

intercondylar notch. With C-arm insertion point & direction of guide wire must be

confirmed.

DANGERS: Injury to the infrapatellar branch of saphenous N. – If

dissection extended distally. Femoral attachment site of PCL may be damaged by

reaming/nailing.

INTERNERVOUS PLANE:No intervenous/intramuscular plan dissection splits

GL.max/GL.medius.