Approaches
Lateral
Posterolateral
Anteromedial
Posterior
Lateral Approach
Concept
Split vastus lateralis
Indications
ORIF of femoral neck fractures
Subtrochanteric or intertrochanteric osteotomy
ORIF of femoral shaft or supracondylar femoral fractures
Extra articular hip arthrodesis
Treatment of chronic femoral osteomyelitis
Biopsy and treatment of bone tumors
Approach
Lateral position or fracture table
- pad all prominences
Longitudinal incision from middle of GT down lateral side of thigh
- fasica lata split
- may need to split TFL in line of fibres proximally to expose VL ( 30%)
- vastus lateralis split in line of fibres
- ligating perforators as located
- subperiosteal dissection of femoral shaft
Medial approach
Indications
Distal femoral fracture
Medial hoffa fracture
Techique
AO surgery reference medial approach
Medial incision in line with adductor tubercle
- incision fascia
- reflect vastus medialis anteriorly
- reflect sartorius and adductor magnus tendon posteriorly
- identify and ligate geniculate artery
- popliteal neurvascular bundle is posterior to the femur
Posterolateral Approach
Concept
Elevate vastus lateralis anteriorly from lateral intermuscular septum
Indications
ORIF Supracondylar fracture
Non unions of femoral fractures
Femoral osteotomy
Osteomyelitis
Biopsy and treatment of bone tumors
Technique
Position
- use sandbag under buttock to expose posterolateral thigh
Incision
- lateral epicondyle distally up posterolateral thigh proximally
Internervous plane
- between the vastus lateralis (covered by the ITB) and biceps femoris
Superficial dissection
- dissect the VL off the lateral intermuscular septum after posterior surface of ITB located
- difficult often as the VL has origin from the LIMS
- ligate the perforators
- locate the linea aspera and take the periosteum off here
- need retractor to elevate the vastus proximally due to bulk of muscle
Extensile measures
- can extend into lateral parapatellar approach to knee
- allows visualisation of the knee joint for fracture reduction
- skin incision then curved anteriorly to Gerdy's tubercle
Anteromedial Approach
Concept
Between Vastus Medialis and Rectus Femoris
Indications
ORIF of medial distal femoral fractures
Treatment of osteomyelitis
Biopsy of bone tumors
Technique
Position
- supine with leg draped free
Incision
- 10-15 cm incision medial thigh between the rectus femoris and vastus medialis
- extend distally as medial parapatellar incision if knee joint needs to be opened
No internervous plane
Superficial dissection
- retract the RF laterally
- begin distally and open the knee capsule in line with skin incision through the medial patellar retinaculum
- split quads tendon with cuff of tendon on the VM allowing closure
- expose the vastus intermedius proximally
- split in line of fibres and subperiosteal dissection to expose femur
- medial superior geniculate artery crosses field above the knee and should be controlled
- must have good repair of the vastus medialis distally to avoid lateral patellar subluxation
Extensile measures
- the incision can not be extended proximally as the vessels and nerve interfere
Posterior Approach
Concept
Between vastus lateralis and biceps femoris proximally
Access to middle 3/5 of femur and sciatic nerve
Indications
Infected non union of femur
Chronic osteomyelitis
Biopsy and treatment of bone tumors
Exploration of sciatic nerve
Approach
Position
- prone position with support and padding of pelvis and chest
Incision
- straight longitudinal incision down midline of posterior aspect of thigh
- ending proximally at inferior gluteal fold
Internervous plane
- between lateral intermuscular septum and biceps muscle
Superficial dissection
- incise deep fascia in line of skin incision
- protect the posterior cutaneous nerve of thigh (in groove between semitendinosis and biceps)
- identify lateral margin of biceps proximally and develop plane between the biceps and VL
- retract long head biceps medially at proximal end and nerve retracted with it
Deep Dissection
- detach short head of biceps from femur to expose shaft
- distally long head of biceps retracted laterally and nerve exposed
- sciatic nerve retracted laterally and posterior aspect of femur exposed
- sciatic nerve not identified proximally but must be seen distally
- cannot be extended proximally or distally