High Yield Topics

SURGICAL APPROACHES TO THE LOWER EXTREMITY

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Ovid: Chapman’s Orthopaedic Surgery

Editors: Chapman, Michael W.
Title: Chapman’s Orthopaedic Surgery, 3rd Edition
> Table of Contents > SECTION I
– SURGICAL PRINCIPLES AND TECHNIQUES > CHAPTER 3 – SURGICAL
APPROACHES TO THE LOWER EXTREMITY

CHAPTER 3
SURGICAL APPROACHES TO THE LOWER EXTREMITY
Marc F. Swiontkowski
Patricia A. Post
M. F. Swiontkowski Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, 55455.
P. A. Post Department of Orthopaedics and Rehabilitation, Vanderbilt University, Nashville, TN, 37232.

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HIP
ANTERIOR APPROACHES
Hardinge Approach
The Hardinge approach is a direct lateral approach to the hip described by Kevin Hardinge in 1982 (1) for total hip arthroplasty, based on a modification of the original description of this approach by McFarland and Osborne (4).
Hardinge described its use with the patient supine; however, most
surgeons today use the lateral/decubitus position because it provides
better access for two surgeons standing on opposite sides of the table.
It also allows for increased mobility of the operated extremity (Fig. 3.1).The
advantage of the supine position is that it makes orientation of the
components easier and facilitates comparison of leg lengths for
correction of discrepancy.
Figure 3.1. With the patient in the lateral decubitus position, notice that anterior superior iliac spines are vertically aligned.
The Hardinge approach is useful for hemiarthroplasty for
femoral neck fracture, as well as for total hip arthroplasty. It allows
the surgeon direct visualization of the acetabulum and excellent access
to the entire circumference. It avoids morbidity from osteotomy of the
greater trochanter and maintains the continuity of the abductor
mechanism. Because the posterior portion of the gluteus medius muscle,
with its thick tendon, is left intact, early rehabilitation is
possible. Partial weight bearing with crutches is usually possible
immediately after surgery.
  • Begin the skin incision about 3–4 inches
    (7 to 10 cm) distal to the prominence of the greater trochanter in the
    midportion of the lateral aspect of the thigh, directly over the femur.
    Extend it in line with the femur over the prominence of the trochanter,
    inclining about 20° posteriorly in the proximal one-third of the wound.
    The total incision length is usually 8–10 inches (20 to 25 cm); in
    obese or muscular patients, a longer incision is necessary (Fig. 3.2).
    Figure 3.2. Make the initial incision in line with the neutral axis of the femur.
  • Incise sharply down to the deep fascia
    with minimal undermining of the subcutaneous tissue. Divide the gluteal
    fascia and iliotibial band in line with the skin incision. Retract the
    tensor fascia lata anteriorly, separating it from its conjoined origin
    with the gluteus medius. Avoid injury to the superior gluteal nerve and
    artery by dissecting this interval with a relatively blunt instrument.
    We prefer a large-key periosteal elevator (Fig. 3.3).
    Figure 3.3. Charnley initial incision retractor in place.
  • At the trochanteric ridge formed by the
    origin of the vastus lateralis, at the mid-lateral point of the greater
    trochanter, use an electrocautery knife set on “cutting” to incise the
    gluteus medius longitudinally, extending distalward through the vastus
    lateralis, curving slightly

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    anteriorly.
    Control bleeding from the transverse branch of the lateral circumflex
    artery in the vastus lateralis origin. Reflect the gluteus medius
    insertion and vastus lateralis muscles in continuity anteriorly off the
    greater trochanter, taking care to stay on bone to maintain the maximum
    thickness of tendon. Do not cut across the muscle fibers of the gluteus
    medius proximally; split them in line with the incision with a
    large-key periosteal elevator. Do not split proximally more than 5 cm
    above the trochanter to avoid injury to the superior gluteal nerve (Fig. 3.4).

    Figure 3.4. Anterior insertion of the gluteus medius is mobilized.
  • Retract the gluteus medius; in the supine
    position, adduct the thigh to facilitate exposure of the gluteus
    minimus, which is reflected off the hip joint capsule superiorly. In
    his original description, Hardinge incises the capsule, does not excise
    it, and repairs it following arthroplasty. To permit adequate access to
    the acetabulum for noncemented cups, we prefer to isolate the hip joint
    capsule, placing a cobra retractor anteroinferiorly and
    superoposteriorly to expose the capsule. We then excise the anterior
    two thirds of the capsule intact (Fig. 3.5).
    Figure 3.5. Expose the capsule.
  • Dislocate the hip by flexing and
    adducting it while levering the femoral head out of the acetabulum,
    cutting the ligamentum teres. When using the lateral decubitus
    position, drop the leg off the edge of the table into a sterile pocket
    formed from a large drape sheet. Transect the femoral neck with an
    oscillating saw (Fig. 3.6A).
    Figure 3.6. A: Superior retractor is held in place by 1/8 in. Steinmann pins or drill bits. B: Place the tibia in a pouch positioned vertical to the floor.
  • This position gives ideal exposure of the
    femur for insertion of a prosthesis. Protect the insertion of the
    posterior portion of the gluteus medius during preparation of the femur
    with appropriate retractors, which also elevate the trochanter to
    provide better exposure (Fig. 3.6B).
  • When preparing and inserting the
    acetabulum, keep the leg on the operating table in line with the torso,
    using specially designed or sharp-tipped Hohmann retractors to
    facilitate exposure of the acetabulum.

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  • For repair of the gluteus medius, place a
    series of heavy (we prefer #5 Tevdek) sutures through the bone of the
    greater trochanter. Then direct the suture in a horizontal mattress
    fashion through the tendinous portion of the gluteus medius, securing
    it firmly to bone. Make these holes and place the sutures prior to
    insertion of the prosthesis using an awl, drill-point, or towel-clip.
    Next, repair the longitudinal split in the gluteus medius and vastus
    lateralis with #1 sutures. Close the split in the deep fascia and
    iliotibial band in a similar fashion (Fig. 3.7).
    Figure 3.7. A: Reattachment of the gluteus minimus. B: Suturing of the gluteus medius and vastus lateralis.
Smith-Petersen Approach
Refer to Chapter 2 for the extended iliofemoral approach.
Watson-Jones Approach
The Watson-Jones anterior approach to the hip joint,
femoral neck, and proximal femur is useful for capsular incisions,
reduction of femoral neck fractures, upper femoral osteotomies, and
internal fixation of proximal femoral fractures. One advantage of this
approach is that it exposes the femoral neck, thereby allowing the
surgeon to accurately identify femoral anteversion.
  • At a point 2–3 cm posterior to the
    anterosuperior iliac spine, begin the incision directed toward the
    midportion of the greater trochanter (Fig. 3.8A). Then angle the incision into a straight lateral orientation and proceed distally 10–15 cm.
    Figure 3.8. Watson-Jones anterolateral approach to the hip. A: Skin incision. B: The vastus lateralis is retracted anteriorly, as is the tensor fascia, exposing the anterior hip capsule. 1, Gluteus medius; 2, nerve to tensor fasciae latae; 3, hip joint capsule; 4, iliopsoas; 5, lateral circumflex femoral vessels; 6, vastus intermedius; 7, vastus lateralis (reflected); 8, greater trochanter. (From Schlumpf R. Proximal Femur: Lateral Approach. In: Rüedi T, von Hochstetter AHC, Schlumpf R, eds. Surgical Approaches for Internal Fixation. Berlin: Springer-Verlag, 1984:115–121.)
  • Identify the interval between the gluteus
    medius and tensor fascia lata, best done at a point halfway between the
    anterosuperior iliac spine and the greater trochanter.
  • Place a pointed retractor posterior to
    the tensor fascia lata with the point on the anterior rim of the
    acetabulum. With posteriorly directed retraction of the gluteus medius,
    expose the hip capsule (Fig. 3.1B). Chapman
    (personal communication, 1993) facilitates this exposure by first
    splitting the fascia lata distally. As the dissection is carried
    proximally, the interval between the bellies of the tensor fascia lata
    and gluteus medius muscles becomes more obvious. Thus it is easier to
    identify the superior gluteal artery and nerve and avoid wandering in
    the wrong interval.
  • Incise the hip capsule in line with the
    femoral neck in its midportion. To gain greater exposure to the femoral
    neck and head, extend the capsular incision perpendicular to the plane
    of the initial incision by dissecting the capsule off the
    intertrochanteric ridge superiorly and inferiorly.
  • For greater exposure of the proximal
    femoral shaft, detach the vastus lateralis from the vastus tubercle
    portion of the anterior intertrochanteric line. From this point
    distally, split the vastus longitudinally or retract it anteriorly,

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    and detach it from the insertion on the most proximal portion of the linea aspera to gain access to the femoral shaft.

  • For wider exposure to the intracapsular
    femur, detach the anterior fibers of the gluteus medius from the
    anterior one half of the tendinous insertion on the greater trochanter,
    leaving a cuff of tendon on the trochanter for later repair.
Harris Approach
Joint reconstructive procedures that require wide
exposure of the femoral neck and acetabulum call for the Harris
anterolateral approach to the hip joint. This approach is useful in
that the hip can be dislocated anteriorly or posteriorly.
  • Place the patient in the lateral position
    with the unaffected hip facing down. Bean bags, kidney rests, or “hip
    positioners” attached to the operating table help to maintain the true
    lateral position. Abduct the affected limb 60° and keep the hip
    extended and the knee flexed. A Mayo stand with a pillow and sterile
    cover relieves the assistants of considerable burden in maintaining
    this position.
  • Make a lazy U–shaped skin incision
    beginning 5 cm posterior and 2 cm proximal to the anterosuperior iliac
    spine. Curve the incision distally toward the posterior greater
    trochanter (Fig. 3.9A), and extend it distally and slightly anteriorly for a distance of 15 cm.
    Figure 3.9. Harris anteriolateral approach to the hip. A: Skin incision. B:
    The anterior aspect of the gluteus maximus insertion on the iliotibial
    tract is incised 1.5 cm posteriorly to allow greater exposure of the
    posterior aspect of the greater trochanter. C: The trochanter is osteotomized, exposing the external rotators and hip capsule. 1, Gluteus medius; 2, gluteus minimus; 3, greater trochanter (osteotomized); 4, piriformis; 5, obturator internus; 6, obturator externus; 7, iliopsoas. (From Rosenthal S. Surgical Approaches. In: Crenshaw AH, ed. Campbell’s Operative Orthopaedics, 6th ed. St. Louis: CV Mosby, 1980:70.)
  • Working distally to proximally, divide
    the iliotibial band in line with its fibers. At the level of the
    trochanter, direct the fascia lata incision 1 cm anterior to the
    insertion of the gluteus medius on the greater trochanter, and continue
    the incision of this layer anteriorly in line with the incision.
  • To provide posterior exposure, make an
    oblique incision in the deep surface of the posteriorly reflected
    fascia lata and into the substance of the gluteus medius for a distance
    of 5 cm (Fig. 3.9B). Place a pointed Hohmann
    retractor on the anterior acetabulum to retract the anterior part of
    the tensor fascia lata and iliotibial band anteriorly.
  • Sharply dissect the origin of the vastus
    lateralis from the vastus tubercle portion of the intertrochanteric
    line. Isolate the abductors from the joint capsule anteriorly by blunt
    dissection.
  • Elevate the periosteum from the proximal
    femur transverse to the long axis of the femur at a distance of 3–3.5
    cm from the tip of the trochanter. At this point, before osteotomizing
    the greater trochanter, the surgeon may choose to predrill or measure
    holes for later osteotomy screw or wire fixation. Direct the osteotomy
    superiorly and medially toward a point 5 mm lateral to the superior hip
    capsular attachment on the femoral neck (Fig. 3.9C).
  • Free the superior part of the joint
    capsule from the abductors. By virtue of the posterior fascia lata and
    gluteus medius incision, posterior exposure is now possible. Divide the
    piriformis and external rotators at their femoral insertions. For
    arthroplasties, excise the posterior and anterior capsule, as necessary.
  • Place a narrow Hohmann or Bennett
    retractor deep to the rectus femoris on the anteroinferior iliac spine
    to improve visualization anteriorly. To expose the iliopsoas tendon,
    flex the hip and rotate it externally. This tendon can be divided and
    sutured to a remnant of intact

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    anterior
    capsule if desired to correct a flexion contracture. The hip can be
    dislocated anteriorly to gain access to the entire femoral head and
    neck by placing the greater trochanter into the acetabulum. For
    exposure of the acetabulum, retract the greater trochanter superiorly
    and dislocate the femoral head posteriorly. Maintain the abducted
    position of the limb for trochanteric reattachment and wound closure.

POSTERIOR APPROACHES
Moore Approach
The Moore or “Southern” exposure provides excellent
access to the posterior femoral neck for bone graft procedures,
posterior drainage of septic joints, or reconstructive procedures of
the proximal femur.
  • Place the patient in the lateral position
    with the unaffected side facing down. Bean bags, kidney rests, or “hip
    positioners” attached to the operating table are excellent adjuncts for
    maintaining the true lateral position. Alternatively, the procedure can
    be done with the patient prone. The prone position may be recommended
    for certain femoral neck bone grafting procedures.
  • Begin the incision 10 cm distal to the
    posterosuperior iliac spine, and extend it laterally and distally in
    line with the gluteal fibers (Fig. 3.10A) to
    the posterior margin of the greater trochanter. Then carry the incision
    distally for a distance of 15–20 cm in line with the femoral shaft.
    Figure 3.10. Moore posterior approach to the hip. A: Skin incision. B:
    Detachment and retraction of the external rotators; incision of the hip
    capsule. (From Thomas HA. The Hip. In: Hoppenfeld S, deBoer P, eds. Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia: JB Lippincott, 1984:342.)
  • Divide the thick fascia lata distally and
    the thin gluteal fascia proximally in line with the skin incision.
    Divide the deep fibers of the gluteal musculature bluntly using a
    finger-spreading technique, preserving the branches of the superior
    gluteal nerve and vessels in the proximal dissection. Partially divide
    the distal insertion of the fibers of the gluteal musculature from
    their femoral insertion to allow distal retraction. Retract in a plane
    perpendicular to the gluteal split, and expose the greater trochanter.
  • Identify the sciatic nerve in the medial
    portion of the wound and carefully protect it. Divide the external
    rotators and the tendon of the piriformis at their femoral insertions,
    and retract them medially, forming a protective sling over the sciatic
    nerve (Fig. 3.10B). Expose the posterior part
    of the hip capsule, and incise along the axis of the femoral neck. For
    exposure of the femoral neck, dissect the distal insertion of the
    capsule from the posterior intertrochanteric ridge. Protect the medial
    femoral circumflex artery inferiorly; it supplies the femoral head in
    its terminal branch, the lateral epiphyseal artery. For procedures that
    require hip dislocation, flex the hip to 90°, keeping the knee flexed,
    and externally rotate the thigh.
Ludloff Medial Approach
The Ludloff medial approach is most useful for open
reduction of congenitally dislocated hips; for resection of small,
primary, benign bone tumors in the region of the lesser trochanter; and
for obturator neurectomies.
  • Position the patient supine, with the
    affected hip flexed, abducted, and externally rotated. This position
    brings the lesser trochanter closer to the skin surface.
  • Make a longitudinal incision on the
    medial thigh, starting 3 cm distal to the pubic tubercle in line with
    the adductor longus, which is easily palpable (Fig. 3.11A).
    Develop the plane between the adductor longus and brevis muscles
    anteriorly and the adductor magnus and gracilis muscles posteriorly.
    The posterior branch of the obturator nerve is visible on the belly of
    the adductor magnus; protect it unless it is to be cut to relieve
    muscular spasticity. The anterior branch lies on the anterior surface
    of the adductor brevis and is protected by retraction of this muscle.
    The lesser trochanter is visible in the base of the wound (Fig. 3.11B).
    Isolate the iliopsoas tendon with blunt dissection. It is then easily
    transected, allowing greater exposure of the medial hip capsule.
    Figure 3.11. Ludloff medial approach to the hip. A: Skin incision; patient positioning. B:
    The adductor longus is retracted anteriorly, exposing the lesser
    trochanter, inferior hip capsule, and posterior branches of the
    obturator nerve. 1, Adductor longus; 2, lesser trochanter; 3, adductor brevis; 4, gracilis; 5, adductor magnus; 6, obturator nerve, posterior branch. (From Thomas HA. In: Hoppenfeld S, deBoer P, eds. Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia: JB Lippincott, 1984:349, 351.)
  • Open the capsule in line with the inferior capsular attachment, and extend the capsular incision in a perpendicular

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    orientation; this favors visualization of the acetabulum and femoral head.

THIGH—FEMORAL SHAFT
Lateral Approach
The lateral or posterolateral approach to the femur is
useful for tumor resection or internal fixation of shaft fractures. It
is the preferred approach to the femoral shaft for most situations.
  • Position the patient in the lateral or the supine position.Elevate the hindquarter 30° to 45° with a pad under the buttock.
  • Make an incision of the necessary length along a line between the greater trochanter and the lateral femoral condyle (Fig. 3.12A). Divide the superficial and deep fascia in line with the incision.
    Figure 3.12. Lateral approach to the femoral shaft. A: Skin incision and level of cross section. B: Plane of dissection shown in cross section. C: The vastus lateralis has been mobilized anteriorly and the perforating vessels ligated, exposing the entire femoral shaft. 1, Vastus lateralis; 2, lateral circumflex femoral vessels; 3, joint capsule (knee); 4, lateral superior genicular artery; 5, perforating arteries, posterior vastus branches; 6, lateral intermuscular septum; 7, incision. (From Schlumpf R. Femoral Shaft: Lateral Approach. In: Rüedi T, von Hochstetter AHC, Schlumpf R, eds. Surgical Approaches for Internal Fixation. Berlin: Springer-Verlag, 1984:125-127.)
  • For the preferred posterolateral
    approach, retract the vastus lateralis anteriorly, and dissect the
    muscle off the lateral intermuscular septum where it attaches to the
    linea aspera of the femur (Fig. 3.12B). Make the incision 2–3 cm more posterior to help with this part of the exposure.
  • Carefully identify, ligate, and divide
    the perforating branches of the profunda femoris in the middle third of
    the femoral shaft (Fig. 3.12C). If the surgeon
    inadvertently transects at the level of the septum, these vessels can
    retract to the medial side of the septum, producing impressive
    hemorrhage.
  • For the lateral approach, divide the
    vastus lateralis and intermedius in line with the incision. As in the
    posterolateral approach, identify and ligate the perforating branches
    of the profunda femoris with the descending branch of the lateral
    femoral circumflex artery in the proximal third of the femoral shaft,
    and the superolateral geniculate artery in the distal third.
Anterolateral Approach
The anterolateral approach to the femoral shaft is
useful if poor skin or violation of muscle compartments by tumor render
the posterolateral or lateral approaches impossible. It is not the
exposure of choice for most conditions, because

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postoperative
quadriceps adhesions can result, particularly if the knee cannot be
mobilized immediately after surgery. Combined with an anterolateral
approach to the knee joint, it becomes a versatile and wide exposure
for T-type intra-articular fractures of the distal femur. Meticulous
layered closure and immediate mobilization of the knee joint prevents
loss of motion due to quadriceps adhesions. M. W. Chapman, the editor
of this book, prefers this approach for comminuted intra-articular
fractures of the distal femur (personal communication, 1999).

  • Make a skin incision along the line
    between the anterosuperior iliac spine and the lateral border of the
    quadriceps tendon as it inserts into the patella. Incise the
    superficial and deep fascia in line with the incision, and develop the
    interval between the rectus femoris medially and the vastus lateralis
    laterally (Fig. 3.13A). This interval is easily identified proximally.
    Figure 3.13. Anterolateral approach to the femoral shaft. A: Skin incision and level of cross section. B:
    Plane of dissection between the rectus femoris and vastus lateralis
    through the vastus intermedius. (From Schlumpf R. Distal Femur: Lateral
    Approach. In: Rüedi T, von Hochstetter AHC, Schlumpf R, eds. Surgical Approaches for Internal Fixation. Berlin: Springer-Verlag, 1984:132-135.) C:
    Retraction of the vastus intermedius and rectus femoris anteriorly and
    vastus lateralis inferiorly exposes the entire femoral shaft. D: The dissection can be carried out distally to expose the articular surface of the distal femur and knee joint. 1, Vastus lateralis; 2, rectus femoris; 3, vastus intermedius; 4, periosteum; 5, femur; 6, lateral circumflex femoral artery. (From Thomas HA. The Femur. In: Hoppenfeld S, deBoer P, eds. Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia: JB Lippincott, 1984:372.)
  • Divide the thinnest and midline portion
    of the vastus intermedius in line with its fibers, and expose the femur
    by subperiosteal dissection (Fig. 3.13B). The
    exposure is best limited to the distal two thirds of the femoral shaft,
    because proximally the innervation to the vastus lateralis limits
    exposure.
  • If it is desirable to expose the
    articular condyles and knee, carry the incision through a lateral
    parapatellar approach to the knee. The patella can be dislocated
    medially (Fig. 3.13C, Fig. 3.13D).
Posterior Approach
The posterior approach, as originally described, is
useful only for the middle three fifths of the femoral shaft. It is
probably indicated only for treatment of tumors and exploration of the
sciatic nerve. It can be extended into Henry’s exposure of the sciatic
nerve to provide a comprehensive extensile approach to the posterior
thigh.
  • Position the patient prone on the
    operating table, using appropriate bolsters to allow free abdominal and
    chest movement. Align the incision with the femur from 5 cm distal to
    the gluteal fold to 10 cm proximal to the popliteal crease (Fig. 3.14A). Incise the superficial and deep fascia in line with the skin incision, avoiding the posterior femoral cutaneous nerve.
    Figure 3.14. Posterior approach to the femoral shaft. A: Skin incision and level of cross section. B:
    Plane of dissection between the semimembranosus and adductor magnus and
    the semitendinosus. (From Schlumpf R. Femoral Shaft: Lateral Approach.
    In: Rüedi T, von Hochstetter AHC, Schlumpf R, eds. Surgical Approaches for Internal Fixation. Berlin: Springer-Verlag, 1984:124.) C: Lateral retraction of the sciatic nerve. 1, Biceps femoris, short head; 2, biceps femoris, long head; 3, linea aspera; 4, semimembranosus; 5, sciatic nerve; 6, adductor magnus; 7, semitendinosus. (From Thomas HA. The Femur. In: Hoppenfeld S, deBoer P, eds. Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia: JB Lippincott, 1984:376.)
  • Identify the interval between the biceps
    femoris and the vastus lateralis. In the proximal part of the
    dissection, detach the short head of the biceps femoris sharply from
    the linea aspera. Then reflect it medially (Fig. 3.14B) to expose the femoral shaft.
  • In the distal half of the wound, retract the long head of the biceps laterally to expose the sciatic nerve (Fig. 3.14C).
    Gently retract the sciatic nerve laterally to expose the femur. Take
    the adductor magnus and biceps femoris off the linea aspera sharply.
    For sciatic nerve explorations, begin the deep dissection in this
    distal half of the wound.
Medial Approach
The medial approach is useful primarily for repair of
the femoral artery; usually such arterial injuries are associated with
fractures. It is also occasionally useful for medial internal fixation
of fractures or osteotomies.
  • With the patient supine and the hip
    flexed and externally rotated, position the knee in flexion. Begin the
    incision at the mid thigh and extend it distally to 5 cm distal to the
    adductor tubercle (Fig. 3.15A). Carefully
    incise the superficial fascia and the deep fascia, which is quite thin
    in this region; at the same time, avoid the saphenous vein and nerve,
    which are superficial.
    Figure 3.15. Medial approach to the distal femur. A: Skin incision. B:
    The intramuscular septum falls posteriorly with the knee in flexion.
    Mobilize it anteriorly or take it down and reattach it to gain exposure
    to the midline of the distal femur. 1, Medial condyle, femur; 2, vastus medialis muscle; 3, adductor tendon; 4, femoral shaft; 5, deep fascia; 6, intramuscular septum; 7, sartorius; 8, saphenous nerve and superior geniculate artery; 9, biceps femoris muscle; 10, popliteal vessels; 11, gastrocnemius muscle. (From Stead Z. Medial Route Extended to Femoropopliteal Trunks to the Shaft. In: Henry AK, ed. Extensile Exposure, 2nd ed. Edinburgh: Churchill Livingstone, 1973:216.)

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  • Distally identify the anterior edge of
    the sartorius, which falls posteriorly with progressive knee flexion.
    The adductor tendon is visible. Mobilize it anteriorly or take it down
    and reattach it to gain exposure to the midline of the distal femur.
  • Incise its fascia with care posteriorly (Fig. 3.15B).
    Posterior to the adductor, the popliteal vessels and, more deeply, the
    tibial branch of the sciatic nerve are visible. Position internal
    fixation plates anteriorly to the adductor tubercle after performing
    subperiosteal dissection, taking care to avoid violating the joint
    capsule.
Henry’s Exposure of the Sciatic Nerve
Henry (4) described a
combination of approaches that allow the sciatic nerve to be explored
from its extrapelvic origin to the popliteal fossae (2).
  • Position the patient prone and outline the “question mark” incision (Fig. 3.16A).
    Avoid injury to the posterior cutaneous nerve of the thigh as it exits
    from beneath the gluteus maximus and runs distally down the thigh.
    After incising the deep gluteal fascia, develop the interval between
    the gluteus medius and maximus.
    Figure 3.16. Henry’s exposure of the sciatic nerve. A: Skin incision. B: Mobilization of the gluteal mass medially on its neurovascular bundle to expose the sciatic nerve. 1, Gluteus maximus; 2, gluteus medius; 3, iliotibial tract; 4, piriformis; 5, gemellus superior; 6, obturator internus; 7, gemellus inferior; 8, obturator externus; 9, greater trochanter; 10, quadratus femoris; 11, adductor magnus; 12, sciatic nerve. (From Stead Z. Structures Under the Gluteal Lid. In: Henry AK, ed. Extensile Exposure, 2nd ed. Edinburgh: Churchill Livingstone, 1973:189.)
  • Cut the gluteus maximus free from its insertion into the

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    femur, and fold the entire gluteus maximus flap back medially on its
    neurovascular bundle. The sciatic nerve, proximally exposed, is easily
    traced to the superior margin of the long head of the biceps femoris,
    where it passes deeply to this muscle (Fig. 3.16B). From this point distally, the entire exposure is as previously described for the posterior approach.

KNEE
ANTERIOR APPROACHES
Anteromedial Approach
The anteromedial approach allows adequate exposure of
the knee joint for most intraarticular problems. The list includes
meniscectomy (total or partial), removal of loose bodies, stabilization
of osteochondral fractures, ligament or meniscal repair, drainage
procedures, ligament reconstructions, fixation or excision of patella
fractures, and synovectomy. The anteromedial deep dissection can be
combined with a straight anterior skin incision (Fig. 3.17)
for more extensive exposure for these conditions and for total knee
replacement. Use it whenever possible, because it gives the best
possible route for reexploration, whenever repeat procedures may be
required or when later reconstructive procedures are anticipated.
Figure 3.17. Anterior and anteromedial exposure to the knee. A: Skin incisions; anterior (solid line), anteromedial (dotted line). B: The deep exposure for the two approaches is the same. 1, Quadriceps tendon; 2, articular surface, patella; 3, lateral meniscus; 4, patellar ligament; 5, medial tibial plateau; 6, medial meniscus; 7, anterior cruciate ligament; 8, medial femoral condyle. (From Thomas HA. The Knee. In: Hoppenfeld S, deBoer P, eds. Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia: JB Lippincott, 1984:376.)
  • For the anterior incision, make a
    straight incision midline extending 10 cm above the patella to 3 cm
    below the tibial tubercle (Fig. 3.17A). For the
    anteromedial incision, begin on the medial side of the quadriceps
    tendon, 5–7 cm above the patella. Curve the incision around the
    superomedial border of the patella, then distally to the medial side of
    the tibial tubercle. Preserve the infrapatellar branches of the
    saphenous nerve whenever possible.
  • The deep dissection is identical for both procedures (Fig. 3.17B).
    Divide the vastus medialis muscle from the quadriceps tendon on the
    medial side, leaving a 5 mm cuff of tendon on the muscle side. Extend
    the quadriceps tendon split proximally to the extent of the skin
    incision. Divide the capsule and synovium together, 5 mm lateral to the
    medial border of the patella.
  • Carry this deep dissection down to the
    medial side of the tibial tubercle. Flex the knee, completely divide
    the synovium in line with the capsular incision, and dislocate the
    patella laterally (Fig. 3.17B) to expose the
    notch of the femur, revealing the anterior cruciate and medial
    meniscus. Carefully preserve the patellar tendon insertion if the
    patella is to be inverted for joint replacement procedures.
    Subperiosteal dissection of the medial one half of the tendon at the
    joint line will decrease the tension in the tendon during this maneuver.
Anterolateral Approach
The anterolateral approach does not yield as complete
exposure to all joint structures as do the anteromedial and the
anterior approaches. It is useful for exposure of the anterior two
thirds of the lateral meniscus, for isolated lateral compartment
reconstructive procedures, and for internal fixation of lateral tibial
plateau or femoral condyle fractures, particularly if combined with
anterolateral exposure of the femoral shaft.
  • With the knee in slight flexion, begin
    the incision 10 cm proximal to the patella in line with the insertion
    of the vastus lateralis on the quadriceps tendon (Fig. 3.18A).
    Curve the incision gently at the lateral patellar border, and extend it
    distally to the level of the tibial tubercle lateral to it. The deep
    capsular incision is 5 mm lateral to the insertion of the vastus
    lateralis on the quadriceps tendon.
    Figure 3.18. Anterolateral approach to the knee. A: Skin incision. B: Medial subluxion of the patella exposes the anterior cruciate and lateral meniscus. 1, Patella; 2, posterior cruciate ligament; 3, lateral femoral condyle; 4, anterior cruciate ligament; 5, fibular collateral ligament; 6, lateral meniscus; 7, transverse ligament; 8, fibular head; 9, tibial tuberosity; 10, lateral tibial surface. (From McConnell J. Surgical Approaches. In: Edmonson AS, Crenshaw AH, eds. Campbell’s Operative Orthopaedics, 6th ed, vol 1. St. Louis: CV Mosby, 1980:44.)
  • Incise the synovium in the same plane, and sublux the patella medially to expose the anterior cruciate and lateral meniscus (Fig. 3.18B). The patella cannot be inverted medially because of the strong medial orientation of the quadriceps attachments.
POSTEROLATERAL APPROACHES
Henderson Approach (3)
The posterolateral approach to the knee is most
frequently used for lateral extraarticular ligament reconstructions or
in combination with an anteromedial approach for an

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intraarticular
reconstruction. It is also useful for exposure of the posterior half of
the lateral meniscus and for explorations of the common peroneal nerve
and its branches.

  • With the knee flexed 90°, make a gently curved 15 cm incision (dotted line in Fig. 3.19A)
    just anterior to the biceps femoris tendon and fibular head to expose
    the fascia lata. Keep the position of the common peroneal nerve (Fig. 3.19B) in mind constantly.
    Figure 3.19. Henderson’s posterolateral approach to the knee. A: Skin incision can be extended proximally (dotted line) for exposure of the fascia lata. B: Exposure of the common peroneal nerve and fibular collateral ligament. 1, Biceps femoris; 2, common peroneal nerve; 3, lateral head of gastrocnemius (cut); 4, lateral femoral condyle; 5, fibular head; 6, fibular collateral ligament; 7, vastus lateralis; 8, iliotibial band.
  • Proximally, follow the anterior surface
    of the lateral intramuscular septum back to the linea aspera. At this
    point, the nerve is just posterior to the dissection.
  • Expose the lateral femoral condyle and
    fibular collateral ligament origin in the midportion of the wound. The
    lateral head of the gastrocnemius muscle is evident posteriorly and
    protects the nerve at that level. The posterior half of the lateral
    meniscus is visible posterior to the fibular collateral ligament with
    the popliteus tendon coming up from posteroinferior to the
    posterior-midmeniscus region (Fig. 3.19B). This
    tendon may be retracted posteriorly as the capsule and synovium are
    opened through a longitudinal incision above the menisci.
Bruser Approach
The Bruser approach permits good exposure of the entire
lateral meniscus. Resection of the meniscus does not require release of
the fibular collateral ligament.
  • Position and drape the patient to allow
    full flexion; more than 100° of flexion is helpful. Make the incision
    parallel to the lateral meniscus, beginning anteriorly at the lateral
    border of the patellar tendon (Fig. 3.20A). Its posterior limit is at a line between the fibular head and lateral femoral condyle. Divide the subcutaneous

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    tissue in line with the incision, and divide the iliotibial band in line with its fibers.

    Figure 3.20. Bruser’s posterolateral approach to the knee. A: Line of skin incision parallel to the lateral meniscus located halfway between the patella and tibial tubercle (arrow). B: Division of the iliotibial band. 1, Iliotibial band; 2, popliteal tendon; 3, fibular collateral ligament; 4, torn lateral meniscus. (From McConnell J. Surgical Approaches. In: Edmonson AS, Crenshaw AH, eds. Campbell’s Operative Orthopaedics, 6th ed, vol. 1. St. Louis: CV Mosby, 1980:47.)
  • The knee must be flexed during this part
    of the dissection to prevent transection of the iliotibial band. Divide
    the iliotibial band along the lines of its fibers to Gurde’s tubercle,
    expose the fibula, collateral ligament, and the torn lateral meniscus
    central to it. The relaxed fibular collateral ligament must be
    protected posteriorly when this incision is made (Fig. 3.20B).
    The inferolateral geniculate artery should be ligated, because it lies
    at the posterolateral corner of the meniscus. Incise the synovium,
    allowing complete exposure of the meniscus.
Posteromedial Approach
The posteromedial approach described by Henderson (2)
is useful for exposure of the posteromedial corner of the knee joint
for posterior meniscal horn resections, posteromedial corner
reconstructions, or repair or reconstruction of the posterior cruciate
ligament.
  • Position the patient supine with the hip in external rotation and the knee flexed 90°.
  • Make a 10 cm incision from the adductor
    tubercle along the course of the tibial collateral ligament and
    anterior to the pes anserine tendons (Fig. 3.21A).
    Figure 3.21. Henderson’s posteromedial approach to the knee. A: Skin incision. B: The deep dissection is carried out anterior to the pes anserine tendons. 1, Sartorius; 2, gracilis; 3, semimembranosus; 4, semitendinosus; 5, medial femoral condyle; 6, medial meniscus. (From Thomas HA. In: Hoppenfeld S, deBoer P, eds. Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia: JB Lippincott, 1984:400, 415.)
  • Incise the oblique portion of the tibial collateral ligament in line with the tendons, and also incise the capsule below (Fig. 3.21B).
    This incision exposes the medial meniscus and allows access to the
    posteromedial compartment. For capsular and posterior cruciate
    reconstructions, it is necessary to develop the interval between the
    capsule and the pes anserine tendons and semimembranosus.
  • Retract the hamstrings and medial head of
    the gastrocnemius muscle posteriorly. For wider exposure, take down the
    origin of the medial head of the gastrocnemius.
Posterior Approach
The posterior approach to the knee is rarely needed, but
it provides invaluable exposure of the posterior neurovascular
structures and joint capsule. Indications for its use include exposure
of the popliteal neurovascular structures, posterior cruciate ligament
repairs, release of posterior knee contractures, and resection of
popliteal masses.
  • Position the patient prone. Initiate an S-shaped incision (Fig. 3.22A)
    with the superior arm lateral and the transverse portion at the level
    of the posterior crease (orient the incision transversely along the
    flexion crease and direct it superolaterally and inferomedially).
    Carefully incise the popliteal fascia in the midline.
    Figure 3.22. Posterior approach to the knee. A: Skin incision. B: A linear split of the deep fascia. 1, Semimembranosus; 2, popliteal vein; 3, medial head of gastrocnemius; 4, small saphenous vein; 5, medial sural cutaneous nerve; 6, popliteal fascia; 7, lateral head of gastrocnemius; 8, biceps femoris; 9, common peroneal nerve. C: Sectioning of the gastrocnemius heads. 1, Semimembranosus; 2, tibial nerve; 3, medial head of gastrocnemius; 4, popliteal vein; 5, posterior joint capsule; 6, popliteal artery; 7, oblique popliteal ligament; 8, medial inferior genicular artery; 9, medial head of gastrocnemius; 10, small saphenous vein; 11, medial sural cutaneous nerve; 12, fascia; 13, lateral head of gastrocnemius; 14, plantaris; 15, lateral inferior genicular artery; 16, common peroneal nerve; 17, arcuate ligament; 18, lateral head of gastrocnemius; 19, plantaris; 20, biceps femoris. (From Thomas HA. The Knee. In: Hoppenfeld S, deBoer P, eds. Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia: JB Lippincott, 1984:431.)
  • linear split of the deep fascia exposes
    the common peroneal nerve, the popliteal vein, and two heads of the
    gastrocnemius. Identify the sural nerve as it rests in the midline in
    the distal portion of the wound, and trace it proximally until it leads
    you to the tibial component of the sciatic nerve (Fig. 3.22B).
  • Identify the common peroneal nerve from
    proximal to distal as it runs along the posterior border of the biceps
    femoris. The popliteal vein lies over the tibial nerve at the level of
    the gastrocnemius muscle heads. The popliteal artery lies deep and
    medial to the tibial nerve. There are five geniculate arteries that
    limit retraction of the artery. One of the branches may have to be
    ligated, depending on the direction that the dissection needs to take.
  • To reach the posteromedial or
    posterolateral corners of the joint section, the medial head or lateral
    head of the gastrocnemius muscle can be sectioned, leaving a tendinous
    cuff to repair (Fig. 3.22C). In this way, the
    entire posterior capsule (popliteal artery, tibial nerve, and deep
    capsular structures) in its medial and lateral extent can be exposed.
    The capsule must be opened transversely to expose the posterior
    cruciate ligament in the midline.
TIBIA AND FIBULA
PROXIMAL ANTERIOR APPROACH FOR MEDIAL OR LATERAL DEEP EXPOSURE
We highly recommend the straight anterior approach for
reduction of medial or lateral tibial plateau fractures, or for
resection of tumors or infectious processes involving this region of
the tibia.

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  • With the knee gently flexed, make the
    distal half of the straight anterior approach to the knee joint,
    beginning at the superior pole of the patella. After incising the
    subcutaneous tissue in line with the incision, subcutaneously dissect
    in the lateral or medial direction (or both), with the knee flexed to
    90° (Fig. 3.23).
    Figure 3.23. Anterior approach to the proximal tibial shaft. The skin incision of the anterior approach to the knee (see Fig. 3.17) can be extended distally to expose the proximal tibia. The pes anserine tendons can be released subperiosteally (dotted line) to expose the medial tibial condyle. 1, Quadriceps tendon; 2, quadriceps femoris, vastus medialis; 3, suprapatellar recess; 4, infrapatellar fatty body of Hoffa; 5, tibial tuberosity; 6, anterior cruciate ligament; 7, posterior cruciate ligament; 8, anterior horn, medial meniscus; 9,
    pes anserinus. (From Schlumpf R. Knee Joint and Proximal Tibia: Lateral
    Parapatellar Approach. In: Rüedi T, von Hochstetter AHC, Schlumpf R,
    eds. Surgical Approaches for Internal Fixation. Berlin: Springer-Verlag, 1984:151.)
  • To gain exposure medially, elevate the
    pes anserine insertion and superficial portion of the medial collateral
    ligament subperiosteally. Divide the meniscotibial ligament (i.e., the
    deep portion of the medial collateral ligament) beneath the meniscus,
    allowing visualization of the tibial joint surface. Leave enough tissue
    attached to the tibia to allow reattachment of the meniscus.
  • To gain exposure laterally, open the
    joint capsule lateral to the patellar tendon. Elevate the musculature
    of the anterior compartment subperiosteally posterior to the level of
    the fibular collateral ligament. Elevate Gurde’s tubercle with an
    osteotome or reflect the iliotibial band insertion to allow more
    complete exposure for application of plates to the proximal lateral
    tibia. Examine the joint surface by incising the meniscotibial
    attachments of the anterior half of the lateral meniscus.
HENRY’S EXPOSURE OF THE PERONEAL NERVE AND PROXIMAL FIBULA
Henry (4) described a complete exposure of the fibula that, in its proximal half, allows complete exposure of the peroneal nerve.
  • Position the patient laterally with the
    affected limb up. Make the skin incision in line with the fibula
    distally (to trace the superficial branch of the peroneal nerve) and
    biceps femoris proximally, curving posteriorly at the joint line at an
    angle of 45° (Fig. 3.24A).
    Figure 3.24. Henry’s exposure of the peroneal nerve and proximal fibula. A: Skin incision. 1, Common peroneal nerve; 2, head of fibula. B:
    The peroneal muscles have been divided transversely and retracted
    anteriorly to expose the motor divisions of the deep peroneal nerve
    proximally. 1, Common peroneal nerve (lat. popliteal); 2, head of fibula; 3, gastrocnemius; 4, soleus; 5, peroneus longus. (From Stead Z. In: Henry AK, ed. Extensile Exposure, 2nd ed. Edinburgh: Churchill Livingstone, 1973:293, 295.)
  • Identify the common peroneal nerve where
    it lies deep to the biceps tendon in the proximal portion of the wound.
    Handle the nerve gently in a rubber sling for retraction. Divide the
    deep fascia in line with the nerve,

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    developing
    a plane of division between the soleus and peroneal muscles. A thin
    extension of the peroneus longus origin must be divided at the fibular
    neck (Fig. 3.24B).
    The nerve is now freed as it curves anteriorly, dividing into muscular
    branches. Elevate the peroneal muscles subperiosteally to expose the
    upper one half of the fibula.

TIBIAL SHAFT: ANTERIOR APPROACH
The entire shaft of the tibia can be exposed by the
anterior route for osteotomies, internal fixation of fractures or
nonunions, excision of bone tumors, or drainage of infectious processes.
  • Position the patient supine with a pad
    under the affected hip to gain slight internal rotation of the leg.
    Make the incision 10–15 cm lateral and parallel to the crest of the
    tibia (Fig. 3.25). Distally, incise along the
    medial border of the anterior tibial tendon to allow intraarticular
    exposure, if required. Reflect the skin and periosteum as a single
    layer for a medial exposure. Alternatively, lateral subperiosteal
    dissection allows retraction of the anterior compartment musculature.
    Avoid complete soft-tissue elevation medially and laterally because of
    the effect on bone blood supply with this radical exposure.
    Figure 3.25. Anterior approach to the tibial shaft. A: Skin incision, just lateral to the tibial crest can be extended proximally and distally to expose the entire shaft (dotted lines). 1, Tibial tuberosity; 2, anterior border; 3, medial malleolus. B:
    A cross section of the mid calf reveals the plane of dissection to the
    lateral surface of the tibia and medially to the fascia of the deep
    posterior compartment (arrows). 1, Extensor digitorum; 2, tibialis anterior; 3, extensor hallucis longus; 4, deep peroneal nerve, anterior tibial vessels; 5, peroneus longus; 6, peroneus brevis; 7, superficial peroneal nerve; 8, lateral head, gastrocnemius; 9, medial head, gastrocnemius; 10, soleus; 11, plantaris; 12, flexor hallucis longus; 13, tibialis posterior; 14, flexor digitorum longus; 15, peroneal artery; 16, tibial nerve with posterior tibial vessel; 17, sural nerve with small saphenous vein; 18,
    saphenous nerve with great saphenous vein. (From Schlumpf R. Tibial
    Shaft: Anterior Approach. In: Rüedi T, von Hochstetter AHC, Schlumpf R,
    eds. Surgical Approaches for Internal Fixation. Berlin: Springer-Verlag, 1984:155, 156.)
TIBIAL SHAFT: POSTEROMEDIAL APPROACH
In cases of fracture, nonunion, malunion, bone tumor, or
infection associated with poor anterior skin coverage, elect a
posteromedial approach to the tibial shaft, particularly for the
proximal third. The two-incision method of compartment release also
calls for a posteromedial approach for release of the deep posterior
compartment.
  • Position the patient supine. Flex the
    affected hip and rotate it externally with the knee flexed. Make the
    incision in line with the tibia 1–2 cm posterior to the posterior

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    border of the tibia (Fig. 3.26A). Protect the saphenous vein and nerve as the subcutaneous tissue is incised in line with the skin incision.

    Figure 3.26. Posteromedial approach to the tibial shaft. A: Skin incision. B: The deep dissection exposing the fascia. 1, Saphenous nerve; 2, great saphenous vein; 3, crural fascia (superficial); 4, medial condyle, tibia; 5, medial malleolus. (From Schlumpf R. Tibial Shaft: Posteromedial Approach. In: Rüedi T, von Hochstetter AHC, Schlumpf R, eds. Surgical Approaches for Internal Fixation. Berlin: Springer-Verlag, 1984:159, 161.)
  • Divide the superficial compartment fascia
    5 mm posterior to the posterior border of the tibia. Carry out the deep
    dissection exposing the fascia of the lower leg posterior to the
    saphenous nerve and vein. Divide the deep fascia posterior to the
    border of the tibia in line with the fibers of the flexor hallucis
    longus proximally, flexor digitorum longus in the mid tibia, and
    posterior tibialis distally (Fig. 3.26B). Retract the muscles posteriorly, exposing the tibia for the required procedure.
TIBIA AND FIBULA SHAFTS: POSTEROLATERAL APPROACH OF HARMON (2)
The posterior exposure allows access to the middle two
thirds of the tibia and is also useful when the anterior and
anteromedial aspects of the leg have poor soft-tissue coverage. It is
the classic exposure for bone grafting of tibial nonunions.
  • Position the patient prone or on his side with the affected leg up. Make the skin incision (Fig. 3.27A) longitudinally along the lateral border of the gastrocnemius (Fig. 3.27B).
    The deep plane is between the peroneal musculature (laterally) and the
    superficial and deep posterior compartment musculature (medially),
    exposing the intraosseous membrane.
    Figure 3.27. Harmon posterolateral approach to the tibial shaft. A: Skin incision. B: The deep plane is between the peroneal musculature and the superficial and deep posterior compartment musculature. 1, Tibia; 2, interosseous membrane; 3, soleus and gastrocnemius; 4, fibula; 5, peroneal muscles. (From Edmonson AS, Crenshaw AH, eds. Campbell’s Operative Orthopaedics, 6th ed, vol 1. St. Louis: CV Mosby, 1980:39.)
  • Develop the plane between the triceps
    surae posteriorly and peroneal muscles anteriorly, exposing the
    posterior surface of the fibula. Elevate the flexor hallucis longus
    portion of the posterior tibial muscle that originates from the
    intraosseous septum, and strip the muscle medially off the posterior
    surface of the tibia. Take care in the proximal one third of the wound
    to avoid the peroneal artery and vein. The posterior tibial artery and
    nerve lie between the flexor hallucis longus and the posterior tibial
    muscle and are not easily seen; avoid medial retraction at any place
    other than the subperiosteal level.
  • With careful subperiosteal dissection,
    expose the posterior surface of the middle two thirds of the tibia. In
    nonunions for which this approach is most commonly

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    used,
    callus, scar, and loss of the interosseous membrane can make exposure
    in the region of the nonunion difficult. To facilitate exposure, use a
    long incision. Expose the interosseous membrane and posterior tibia
    first in areas of undisturbed anatomy proximally and distally to the
    fracture. Once you have established the proper plane of dissection, it
    is fairly easy to expose the nonunion. As you pass medial to the
    peroneal muscles and follow the fibula to the interosseous membrane,
    the line of dissection is more or less directly anterior. To avoid
    perforating the membrane, use a large-key or Cobb elevator to develop
    the exposure. In compartment syndrome where compartment fasciotomy is
    required, swelling and hematoma can obscure the fascial septae dividing
    the anterior, lateral, and posterior compartments. In this situation,
    develop the skin and subcutaneous tissue flaps for 2.5–3 cm anteriorly
    and posteriorly. In the midportion of the wound, make a transverse
    incision through the deep fascia. Identification of the longitudinally
    running fascial divisions between the compartments is then easy.

ANKLE
Anterior Approach
The anterior approach to the ankle is useful for many
techniques of ankle arthrodesis, internal fixation of distal tibia
(i.e., intraarticular) fractures, joint debridement and removal of
loose bodies, synovectomy, drainage of septic joints, and joint
replacement arthroplasty. Through this approach, both malleoli and the
whole articular surface of the distal tibia can be exposed.
  • Position the patient supine with a folded
    sheet under the hip of the affected side in order to internally rotate
    the limb. Make a longitudinal 15 cm incision midway between the lateral
    and medial malleoli, beginning 10 cm proximal to the joint line (Fig. 3.28A).
    Identify and protect the terminal branches of the superficial peroneal
    nerve. Incise the deep fascia of the leg in line with the skin
    incision. Identify the interval between the extensor hallucis longus
    and the extensor digitorum longus. Protect the anterior tibial artery
    and the deep peroneal nerve, which are just medial to the extensor
    hallucis tendon.
    Figure 3.28. Anterior approach to the ankle. A: Skin incision. B: Division of the extensor retinaculum exposes the extensor hallucis and extensor digitorum tendons. 1, Extensor digitorum longus; 2, deep peroneal nerve and anterior tibial artery (neurovascular bundle); 3, extensor retinaculum; 4, extensor hallucis longus. C: Division of the joint capsule exposes the joint. 1, Extensor digitorum longus; 2, joint capsule of ankle; 3, extensor retinaculum; 4, dome of talus; 5, distal tibia; 6, extensor hallucis longus. (From Thomas HA. The Ankle and Foot. In: Hoppenfeld S, deBoer P, eds. Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia: JB Lippincott, 1984:472, 473.)
  • Retract the tendon of the extensor
    hallucis medially, taking the neurovascular bundle with it, and the
    extensor digitorum longus laterally (Fig. 3.28B).
    Distally, at the level of the ankle joint, the neurovascular bundle
    crosses the ankle joint behind the extensor hallucis tendon. Mobilize
    it carefully as the joint is exposed.
  • The capsule is visible beneath the
    tendons and can be longitudinally incised or dissected off the distal
    tibia as the procedure requires (Fig. 3.28C).
Anteromedial Approach
We recommend the anteromedial approach to the ankle for
internal fixation of intraarticular fractures of the distal tibia and
medial malleolus. It is an extensile continuation of the anterior
approach to the tibial shaft (Fig. 3.25).
  • Following the course of the tibialis
    anterior tendon, curve the incision medially toward the tip of the
    medial malleolus, beginning 5 cm above the ankle joint (Fig. 3.29).
    Identify the saphenous vein and nerve. Divide the ankle capsule
    anterior to the deltoid ligament. Deeply develop the interval between
    the tibialis anterior tendon and the medial malleolus. Retract the
    tendon laterally, and open the joint by longitudinal incision and
    subperiosteal dissection.
    Figure 3.29. Anteromedial approach to the ankle. 1, Saphenous nerve; 2, saphenous vein. (From Schlumpf R. Medial Malleolus and Distal Tibia. In: Rüedi T, von Hochstetter AHC, Schlumpf R, eds. Surgical Approaches for Internal Fixation. Berlin: Springer-Verlag, 1984:167.)
Anterolateral Approach
The anterolateral approach extended distally allows exposure of the joints of the hind foot and the ankle joint.

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It is useful for ankle arthrodesis, triple arthrodesis, and talectomy.

  • Make a 15 cm incision centered over the distal tibiofibular joint, beginning 5 cm proximal to the ankle joint (Fig. 3.30A).
    Curve the incision anteriorly, crossing the ankle joint 2 cm medial to
    the tip of the lateral malleolus and extending onto the dorsum of the
    foot 2 cm medial to the base of the fifth metatarsal. The incision
    crosses the distal tibiofibular joint and angles anteriorly over the
    cuboid. Identify and protect the branches of the superficial peroneal
    nerve and the saphenous vein.
    Figure 3.30. Anterolateral approach to the ankle. A: Skin incision. B: Deep dissection exposes the sinus tarsi distally. 1, Extensor retinaculum; 2, anterior inferior tibiofibular ligament; 3, sinus tarsi fat pad; 4, peroneus tertius tendon; 5, extensor digitorum longus tendons. C: Retraction of the tendons exposes the anterior ligament complex of the ankle. 1, Interosseous membrane; 2, extensor retinaculum; 3, distal fibula; 4, anterior inferior tibiofibular ligament; 5, anterior talofibular ligament; 6, sinus tarsi fat pad; 7, extensor digitorum brevis; 8, joint capsule of ankle; 9, distal tibia. (From Thomas HA. The Ankle and Foot. In: Hoppenfeld S, deBoer P, eds. Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia: JB Lippincott, 1984:497.)
  • Develop the interval between the major
    peroneal muscles laterally and the extensor muscles anteriorly. The
    deep dissection is conducted between the extensor tendons and the
    peroneal tendons, exposing the sinus tarsi distally (Fig. 3.30B).
  • Retract the extensor tendons medially to expose the ankle capsule (Fig. 3.30C).
    The origin of the extensor digitorum brevis can be elevated off the
    calcaneus to expose the calcaneocuboid and talonavicular joints and the
    fat within the sinus tarsi.
Posterior Approach
The posterior approach is useful for tendon
lengthenings, release of the posterior capsule of the ankle, and
exposure of posterior malleolus fractures.

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  • The skin incision is based on the medial
    border of the triceps surae tendon. Make a 10 cm longitudinal incision
    along the posterolateral border of the tendo calcaneus to its insertion
    on the calcaneus (Fig. 3.31A). Protect the terminal branches of the sural nerve laterally. Retract the tendo calcaneus medially (Fig. 3.31B).
    Lengthening of the tendon can be performed if the procedure requires
    it. Divide the areolar tissue anterior to the tendon, and enter the
    space between the flexor hallucis longus tendon medially and the
    peroneal tendons laterally.
    Figure 3.31. Posterior approach to the ankle. A: Skin incision. B: Deep dissection. 1, Flexor hallucis longus; 2, tibia; 3, ankle joint; 4, talus; 5, subtalar joint; 6, Achilles tendon. (From Stead Z. Exposing the Back of the Distal End of the Tibia. In: Henry AK, ed. Extensile Exposure, 2nd ed. Edinburgh: Churchill Livingstone, 1973:270-271.)
  • Deep dissection carries the triceps surae
    tendon and neurovascular bundle medially. Sharply dissect the lateral
    fibers of the flexor hallucis muscle belly from the posterior fibular
    border, and develop this interval, exposing the distal tibia, posterior
    ankle joint, and posterior talus (Fig. 3.31B). The retracted flexor hallucis longus protects the medial neurovascular structures.
Posteromedial Approach
The posteromedial approach is indicated for clubfoot
release, exploration of the neurovascular structures, exposure of
posterior malleolus fractures, and tendon lengthenings or transfers.

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  • Position the patient supine in the figure-four position, with the affected ankle resting on the opposite thigh.
  • Make a 10 cm longitudinal incision along
    the posterior tibial tendon, midway between the medial malleolus and
    the tendo calcaneus (Fig. 3.32A). Incise the deep fascia in line with the skin incision (Fig. 3.32B).
    Division of the superficial retinaculum exposes the posterior tibial,
    flexor digitorum, and flexor hallucis tendons and the posterior tibial
    artery and nerve.
    Figure 3.32. Posteromedial approach to the ankle. A: Skin incision. B: Division of the superficial retinaculum. 1, Tibialis posterior; 2, flexor digitorum longus; 3, posterior tibial artery; 4, posterior tibial vein; 5, posterior tibial nerve; 6, flexor hallucis longus; 7, fascia over deep flexor compartment; 8, fibrous pulley over flexor hallucis longus (opened). (From Thomas HA. The Ankle and Foot. In: Hoppenfeld S, deBoer P, eds. Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia: JB Lippincott, 1984:485, 486.)
  • Retract the tendon of the flexor hallucis
    longus medially after dissecting its lateral fibers off the fibula,
    protecting the nerve and artery, and exposing the distal posteromedial
    corner of the tibia with the ankle joint capsule.
Posterolateral Approach
The posterolateral approach is useful for visualization
of posterior malleolus fractures, posterior capsulotomy, posterior
subtalar facet arthrodesis, and tendon lengthenings and transfers.
  • Position the patient prone. Make a
    longitudinal 10 cm incision halfway between the posterior border of the
    lateral malleolus and the lateral border of the Achilles tendon (Fig. 3.33A).
    The lateral border of the triceps surae tendon is a landmark for the
    incision. Protect the terminal branch of the sural nerve. The peroneus
    brevis consists of a muscle belly in this region, and the peroneus
    longus is tendinous. Incise the peroneal retinaculum to allow easy
    repair.
    Figure 3.33. Posterolateral approach to the ankle. A: Skin incision. B: The tendon is retracted medially and the peroneal tendons laterally. 1, Flexor hallucis longus (detached); 2, posterior tibia (incise periosteum); 3, posterior inferior tibiofibular ligament; 4, transverse tibiofibular ligament; 5, posterior joint capsule of ankle; 6, posterior talofibular ligament. (From Thomas HA. The Ankle and Foot. In: Hoppenfeld S, deBoer P, eds. Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia: JB Lippincott, 1984:489, 491, 517.)
  • Detach the lateral fibers of the flexor
    hallucis longus where they arise from the fibula. Retract this muscle
    medially, exposing the posterolateral ligament complex (Fig. 3.33B). Longitudinal subperiosteal dissection exposes the distal tibia, and a linear capsular incision exposes the joint.
EXPOSURES FOR ANKLE FRACTURES
For simple fractures of the malleoli, straight
longitudinal skin incisions directly over the malleoli (rather than
curved incisions) permit direct access, are extensile, and have low
morbidity (Fig. 3.34).
Figure 3.34. Medial and lateral approaches to the ankle. A: Lateral approach. The skin, subcutaneous tissue, and periosteum is incised in line with the distal fibula. B:
Medial approach. The incision is placed centrally in the midportion of
the medial malleolus. The skin, subcutaneous tissue, and periosteum
dissection is in line with the incision. Care must be taken not to
divide the saphenous vein.
FOOT
SKIN INCISIONS
In general, skin incisions in the foot should be longitudinal and extensile. They should give optimal exposure to the

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area required and have the possibility of extension to the proximal or
distal joint. Preserve cutaneous nerves and veins if it is technically
possible to do so.

TARSUS
Anterior Approach
The more distal extension of the anterior approach to
the ankle joint allows good exposure of the talonavicular joint,
naviculocuneiform joint, and the first metatarsal–cuneiform joint.
Preserve the dorsal veins and gain direct exposure of the joints of the
mid foot between the tendons of the extensor digitorum. More distal
exposure and deep dissection exposes the bases of the metatarsals.
  • Beginning proximally, make the anterior incision (Fig. 3.35)
    in line with the lateral aspect of the second metatarsal, and continue
    it distally. Retract the deep peroneal nerve and dorsalis pedis artery
    medially with the extensor hallucis longus and tibialis anterior
    tendons, exposing the dorsal capsular structures of these joints.
    Figure 3.35. Anterior approach to the tarsus. This exposure is the distal extension of the anterior approach to the ankle (see Fig. 3.28). (From Thomas HA. The Ankle and Foot. In: Hoppenfeld S, deBoer P, eds. Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia: JB Lippincott, 1984:472, 513.)
  • Incise the capsule of the involved joint
    longitudinally and dissect subperiosteally to expose the joint(s) for
    arthrodesis or open reduction of articular surfaces.
Lateral Kocher Approach
The lateral Kocher approach yields combined exposure of the ankle, midtarsal, and subtalar joints (Fig. 3.36).
Figure 3.36. Lateral approaches to the tarsus: Kocher and Ollier. A: Skin incisions. 1, Skin incision, Kocher approach; 2,
skin incision, Ollier approach. (From Stead Z. Exposure of the Distal
Two-Thirds of the Anterior Neurovascular Bundle. In: Henry AK, ed. Extensile Exposure, 2nd ed. Edinburgh: Churchill Livingstone, 1973:277.) B:
Deep dissection of the Ollier approach consists of detaching the
extensor digitorum brevis and retracting distally exposing the
midtarsus. The deep exposure of the Kocher approach is similar in its
distal arm but yields better access to the subtalar joint because of
its proximal arm. 1, Anterior talofibular ligament; 2, sinus tarsi fat pad; 3, posterior talocalcaneal joint; 4, peronei; 5, calcaneocuboid joint; 6, extensor digitorum brevis; 7, talonavicular joint. (From Thomas HA. The Ankle and Foot. In: Hoppenfeld S, deBoer P, eds. Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia: JB Lippincott, 1984:503.)
  • Begin the incision as far proximally as indicated, and

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    proceed longitudinally 2 cm posterior to the fibula. Gently curve the
    incision anteriorly at the distal flare of the fibula, and reach the
    midpoint of the bone 2.5 cm distal to the tip (Fig. 3.36A).
    Curve the incision 110° anteriorly in the direction of the
    talonavicular joint. Incise the peroneal fascia, and retract the
    tendons posteriorly, protecting the sural nerve.

  • Divide the talocalcaneal ligament to expose the subtalar joint capsule (Fig. 3.36B).
    If possible, avoid dividing the peroneal tendons because of the risk of
    scarring within the sheath; if necessary, use a step-cut technique. The
    calcaneonavicular joint capsule can be visualized by dissection further
    distally, following the peroneus brevis tendon.
  • To visualize the articular surface of the
    tibia, divide the anterior talofibular ligament and sublux the talus by
    varus stress. Divide the capsule and synovium anterior to the fibula,
    revealing the articular surfaces of the ankle.
Lateral Ollier Approach
The lateral Ollier approach provides excellent exposure
of the talonavicular joint, calcaneocuboid joint, and lateral subtalar
joint. It provides an excellent cosmetic result because of the
abundance of soft tissue in the area.
  • Begin the incision 3 cm posterior to the calcaneocuboid joint (Fig. 3.36A).
    Follow the skin lines in an anteromedial direction, and end the
    incision over the dorsal aspect of the talonavicular joint. Do not
    undermine the skin flaps.
  • Detach the origin of the extensor digitorum brevis, and retract it distally (Fig. 3.36B).
    If possible, preserve the fat within the sinus tarsi to maintain the
    contour of the foot and improve soft-tissue coverage. Medially, retract
    the extensor tendons to expose the talonavicular joint. Laterally,
    retract the peroneal tendons to fully expose the calcaneocuboid joint
    and the posterior facet of the subtalar joint. The joint capsules can
    be sharply dissected free in line with the joint surfaces to expose the
    joints as necessary.
Lateral Gatellier and Chastung Approach
Open reduction of large posterolateral distal tibial
fractures in the setting of a trimalleolar ankle fracture calls for the
lateral Gatellier and Chastung approach. This method can also be used
for anterolateral osteochondral fractures.
  • Make the incision along the fibula, beginning 15 cm proximally from the tip (Fig. 3.37A).
    Curve the incision anteriorly along the pathway of the peroneal tendons
    at the tip of the fibula. Expose the fibula subperiosteally. Incise the
    periosteal tendon sheath, allowing the tendons to sublux anteriorly,
    and turn the fibula distally through the fracture.
    Figure 3.37. Lateral approach to the tarsus of Gatellier and Chastung. A: Skin incision and level of fibular osteotomy. B:
    The fibula has been osteotomized and reflected, based on the
    calcaneofibular ligament. Sectioning of the anterior and posterior
    talofibular ligaments exposes the ankle joint. (From Stead Z. Exposure
    of the Fibula and Nerves Related to It. In: Henry AK, ed. Extensile Exposure, 2nd ed. Edinburgh: Churchill Livingstone, 1973:293.)
  • Alternatively, make an osteotomy 7–10 cm
    from the fibular tip to allow this same maneuver. The calcaneofibular
    and talofibular ligaments serve as the hinge for the fibula to allow
    complete exposure of the distal tibia and ankle joint (Fig. 3.37B).
    Fix the fracture or osteotomy of the fibula anatomically and rigidly,
    and carefully reconstruct the peroneal tendon sheath. The disadvantage
    of this approach is devascularization of the distal tibia.
CALCANEUS
Medial Approach
The medial approach is occasionally indicated for open reduction of the calcaneus and for management of bone tumors.
  • Make the incision from an anterior
    position located 3 cm anterior and 4 cm inferior to the tip of the
    medial malleolus. Extend the incision in a straight line to the medial
    border of the Achilles tendon. Divide the deep fascia in line with the
    incision, and similarly divide the fat deep to this layer.
  • Retract the abductor hallucis inferiorly, and expose the body of the calcaneus subperiosteally. Divide the plan

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    tar aponeurosis and strip the muscle origins inferiorly to expose the
    plantar surface. Whenever possible, minimize the dissection of the
    specialized plantar tissues because of the highly specialized septa
    that originate in the body of the calcaneus.

Lateral Approach
The lateral exposure allows excellent observation of the
subtalar joint for isolated subtalar arthrodesis or open reduction of
this joint.
  • Begin the incision at the lateral border of the tendo calcaneus at its insertion (Fig. 3.38).
    Extend the incision obliquely to a point 4 cm distal to the lateral tip
    of the malleolus. Protect the terminal branch of the sural nerve
    posteriorly.
    Figure 3.38. Lateral approach to the calcaneus. The skin incision is essentially that of Figure 3.36,
    extended 2 cm distally. The peroneal tendon sheath is opened, and the
    tendons are subluxed anteriorly to expose the subtalar joint. 1, Lateral malleolus; 2, posterior talocalcaneal joint; 3, peroneal fascia; 4, peroneal tubercle; 5, peroneal tendons. (From Thomas HA. The Ankle and Foot. In: Hoppenfeld S, deBoer P, eds. Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia: JB Lippincott, 1984:506.)
  • Expose the peroneal tendons, and retract
    superiorly to expose the bone and subtalar joint. In extreme
    circumstances, the tendons can be sectioned and resutured. Handle the
    fragile skin and soft tissues carefully in cases of trauma to lessen
    the relatively high risk of wound complications after this exposure.
Benirschke popularized a “hockey-stick” approach for
internal fixation of fractures of the calcaneus because it allows
better exposure of the posterior calcaneus (personal communication,
1988). It is essentially a lateral approach, but the skin incision
parallels the Achilles tendon as far as 1–2.5 cm above the
weight-bearing surface of the foot, where it then turns anteriorly,
parallel to the plantar aspect of the heel (Fig. 3.39).
Carry the incision to the calcaneocuboid joint, and develop the
proximal flap at a subperiosteal level. The sural nerve and peroneal
tendons are maintained within this thick flap. Do not make the corner
too short. Avoid excessive fixed retraction to prevent slough of the
corner of the flap.
Figure 3.39. Lateral approach to the calcaneus for open reduction and internal fixation (ORIF), as popularized by Benirschke. A: The skin incision is more vertical and posteriorly placed than the standard lateral approach (see Fig. 3.38).
This enables full exposure of the calcaneal tuberosity. The incision is
curved anteriorly at the inferior border of the calcaneus. B:
The flap is elevated and includes the skin and subcutaneous fat, the
calcaneal fibular ligament and perineal tendon sheaths. Kirschner wires
can be placed in the talus to retract the flap.
“U” Approach
The “U” approach can be used for radical clubfoot releases and exposure of the entire subtalar joint for arthrodesis.
  • Position the patient prone. Connect the
    posterior two thirds of the medial and lateral approaches at the level
    of the insertion of the tendo calcaneus. To expose the subtalar joint
    completely, step-cut to lengthen the tendo calcaneus. Carefully
    preserve the sural nerve during this exposure. Expose the body of the
    calcaneus medially and laterally by subperiosteal dissection.

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Split Heel Approach
The only indication for the split heel approach of Gaenslen is osteomyelitis of the calcaneus.
  • Position the patient prone. Make a longitudinal incision in the middle of the heel (Fig. 3.40A).
    Figure 3.40. Gaenslen’s split heel approach to the calcaneus. A: Skin incision. B:
    The specialized fibrofatty tissue of the heel pad has been divided in
    line with the incision. The tuber of the calcaneus and the plantar
    fascia has been divided and the plantar neurovascular bundle protected
    distally. 1, Calcaneus; 2, plantar nerve; 3, plantar artery; 4, plantar fascia. (From Edmonson AS, Crenshaw AH, eds. Campbell’s Operative Orthopaedics, 6th ed, vol 2. St. Louis: CV Mosby, 1980:1317.)
  • Split the tuber of the calcaneus 2–3 cm;
    make certain that the skin incision is long enough to allow the split.
    Divide the plantar aponeurosis from the plantar surface of the
    calcaneus at the level of the abductor digiti quinti (Fig. 3.40B).
  • Protect the lateral plantar artery and
    nerve and retract them medially in the distal portion of the wound.
    Divide the quadratus plantae longitudinally with sharp dissection and
    split the calcaneus longitudinally with a sharp osteotome. Spread the
    two halves to allow complete resection of necrotic bone. Preserve the
    cortical shell as much as possible.
METATARSALS
Dorsal Approach
The metatarsal shafts are best exposed through
longitudinal incisions on the medial side of the foot over the first
metatarsal, on the lateral side of the foot over the fifth, or through
the second-to-third or third-to-fourth metatarsal intervals. For
multiple metatarsal fractures, the middle three bones can be reached
through the two intervals. If feasible, preserve veins along with minor
cutaneous nerve branches. Retract the extensor tendons medially or
laterally, and directly expose the bone.
Plantar Approach
The plantar approach is advisable for direct exposure of
the individual neurovascular bundles. Use the dorsal approach for
metatarsal bony problems because of the multiple layers of flexor
tendons. The intervals for the incisions are the same as the dorsal
incisions. Incise the deep fascia in line with the skin, and retract
the flexor tendons medially or laterally as indicated. The
neurovascular bundles lie among the flexor digitorum brevis, abductor
hallucis, abductor digiti quinti, and the long flexor tendons.
METATARSOPHALANGEAL JOINTS
Dorsal Approach
  • Approach the second through fifth metatarsophalangeal joints through dorsal incisions lateral to the extensor tendons (Fig. 3.41). In the case of the fifth meta

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    tarsophalangeal joint, make the incision on the medial side of the extensor tendon.

    Figure 3.41. Dorsal approach to the metatarsophalangeal joints. A: Skin incision outlined lateral to the extensor complex. 1, Saphenous nerve; 2, deep peroneal nerve; 3, branches of superficial and peroneal nerves; 4, extensor digitorum longus. B:
    The extensor tendon can be retracted laterally, exposing the
    metatarsophalangeal joint. For exposure of the metatarsal shafts, the
    incisions are carried more proximally, the dorsal veins preserved
    whenever possible, and the tendons retracted medially or laterally. 1, Extensor digitorum longus tendon; 2, joint capsule. (From Thomas HA. The Ankle and Foot. In: Hoppenfeld S, deBoer P, eds. Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia: JB Lippincott, 1984:525.)
  • Retract the tendons, and open the joint capsule by a longitudinal incision.
  • For resection of common digital
    (Morton’s) neuromas, make a longitudinal incision over the dorsum of
    the web space of concern. Dissect deeply, taking care to identify and
    retract the extensor tendons and superficial sensory nerves. Identify
    the digital nerves and trace them proximally to the common digital
    nerve.
Plantar Approach
Some surgeons prefer a plantar, more direct approach to
the common digital nerves. A plantar approach is indicated as well in
cases of metatarsophalangeal joint sepsis. Make longitudinal incisions
between the metatarsal heads. The neurovascular bundles are located
deep to the long flexor tendons, which must be retracted to expose the
metatarsophalangeal joints to the side of least resistance. Although
earlier teaching indicated that plantar scars are painful, well-placed
ones usually are not.
First Metatarsal Head Exposure
Approach the first metatarsophalangeal joint best
through a 4 cm dorsomedial incision. Protect the dorsal digital nerve,
and turn the joint capsule back on a distally based flap for
reconstructive bunion procedures.
INTERPHALANGEAL JOINTS
Approach the toe interphalangeal joints dorsally with
straight linear incisions by retracting the extensor mechanism to one
side. Carefully repair the extensor mechanism. The interphalangeal
joints can also be exposed by mid-lateral incisions, carefully
retracting the neurovascular bundles plantarward. In general, we do not
recommend a plantar incision, because the stout flexor tendons and
neurovascular bundles are problems from this approach.
REFERENCES
Each reference is categorized according to the following
scheme: *, classic article; #, review article; !, basic research
article; and +, clinical results/outcome study.
* 1. Hardinge K. The Direct Lateral Approach to the Hip. J Bone Joint Surg Br 1982;64:17.
* 2. Harmon PH. A Simplified Approach to the Posterior Tibia for Bone Grafting and Fibular Transference. J Bone Joint Surg Br 1945;27A:496.
* 3. Henderson MS. Posterolateral Incision for the Removal of Loose Bodies from the Posterior Compartment of the Knee Joint. Surg Gynecol Obstet 1921;33:698.
* 4. Henry AK. Extensile Exposure, 2nd ed. Edinburgh: Churchhill Livingstone, 1973.
* 5. McFarland B, Osborne G. Approach to the Hip: A Suggested Improvement on Kocher’s Method. J Bone Joint Surg Br 1954;36:364.

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