Authors: Hoppenfeld, Stanley; deBoer, Piet; Buckley, Richard
Title: Surgical Exposures in Orthopaedics: The Anatomic Approach, 4th Edition
Copyright ©2009 Lippincott Williams & Wilkins
> Table of Contents > Nine – The Femur
Nine
The Femur
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Operations on the femur are extremely common. The
lateral approach to the proximal femur, which is used to treat the
growing number of patients who have intertrochanteric hip fractures, is
the most frequently used approach in orthopaedic surgery.
lateral approach to the proximal femur, which is used to treat the
growing number of patients who have intertrochanteric hip fractures, is
the most frequently used approach in orthopaedic surgery.
The four basic approaches to the femoral shaft, the lateral, posterolateral, anterolateral, and anteromedial,
all penetrate elements of the quadriceps muscle. Only the
posterolateral approach uses an internervous plane, but all are
relatively straightforward because the femoral nerve, which supplies
the quadriceps femoris muscle, divides proximally in the thigh,
allowing the more distal muscle elements to be separated without
denervation. (The posterior approach is reserved for exploration of the
sciatic nerve and for patients who cannot undergo more anterior
approaches because of skin problems.)
all penetrate elements of the quadriceps muscle. Only the
posterolateral approach uses an internervous plane, but all are
relatively straightforward because the femoral nerve, which supplies
the quadriceps femoris muscle, divides proximally in the thigh,
allowing the more distal muscle elements to be separated without
denervation. (The posterior approach is reserved for exploration of the
sciatic nerve and for patients who cannot undergo more anterior
approaches because of skin problems.)
The minimal access approach to the distal femur utilizes
two windows. The lower window is derived from the lateral parapatellar
approach to the knee and the upper window from the lateral approach to
the femoral shaft. As in all minimal access surgical approaches,
imaging during surgery is mandatory.
two windows. The lower window is derived from the lateral parapatellar
approach to the knee and the upper window from the lateral approach to
the femoral shaft. As in all minimal access surgical approaches,
imaging during surgery is mandatory.
Femoral shaft fractures are now most commonly treated
with intramedullary nails inserted using a closed technique. A minimal
access approach to the proximal femur for the insertion of
intramedullary nails is described.
with intramedullary nails inserted using a closed technique. A minimal
access approach to the proximal femur for the insertion of
intramedullary nails is described.
Because the key vascular structures spiral down the
thigh, passing in an anterior to posterior direction, the anatomy of
the thigh is discussed in a separate section in this chapter following
the descriptions of the surgical approaches. Within this section, the
unique anatomic features of each approach are discussed individually.
thigh, passing in an anterior to posterior direction, the anatomy of
the thigh is discussed in a separate section in this chapter following
the descriptions of the surgical approaches. Within this section, the
unique anatomic features of each approach are discussed individually.
Lateral Approach
The lateral approach is the incision used most often for
gaining access to the upper third of the femur. It also can be extended
inferiorly to expose virtually the whole length of the bone. Although
it is an extremely quick and easy approach, it involves splitting the
vastus lateralis muscle. The subsequent blood loss that results from
the rupture of vessels during this procedure may make surgery awkward,
but rarely is life-threatening.
gaining access to the upper third of the femur. It also can be extended
inferiorly to expose virtually the whole length of the bone. Although
it is an extremely quick and easy approach, it involves splitting the
vastus lateralis muscle. The subsequent blood loss that results from
the rupture of vessels during this procedure may make surgery awkward,
but rarely is life-threatening.
The uses of the lateral approach include the following:
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Open reduction and internal fixation of intertrochanteric fractures (this is by far the most common use of the approach)
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Insertion of internal fixation in the treatment of subcapital fractures or slipped upper femoral epiphysis
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Subtrochanteric or intertrochanteric osteotomy
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Open reduction and internal fixation of
femoral shaft fractures, subtrochanteric fractures, and supracondylar
fractures of the femur -
Extraarticular arthrodesis of the hip joint
-
Treatment of chronic osteomyelitis of the femur
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Biopsy and treatment of bone tumors
Position of the Patient
Patients with trochanteric fractures should be placed on
an orthopaedic table in the supine position so that their fractures can
be manipulated or controlled during surgery. Use an orthopaedic table
for any procedure that involves the use of an image intensifier (Fig. 9-1).
Internally rotate the leg 15° to overcome the natural anteversion of
the femoral neck and to bring the lateral surface of the bone into a
true lateral position.
an orthopaedic table in the supine position so that their fractures can
be manipulated or controlled during surgery. Use an orthopaedic table
for any procedure that involves the use of an image intensifier (Fig. 9-1).
Internally rotate the leg 15° to overcome the natural anteversion of
the femoral neck and to bring the lateral surface of the bone into a
true lateral position.
For surgery on the shaft of the femur, use a lateral
position. Place the patient on his or her side, with the affected limb
uppermost. Take care to pad the bony prominences of the bottom limb to
avoid pressure necrosis of the skin. Place other pillows between the
two limbs to pad the medial surface of the knee and the medial
malleolus of the side that is being operated on.
position. Place the patient on his or her side, with the affected limb
uppermost. Take care to pad the bony prominences of the bottom limb to
avoid pressure necrosis of the skin. Place other pillows between the
two limbs to pad the medial surface of the knee and the medial
malleolus of the side that is being operated on.
Landmarks and Incision
Landmarks
The posterior edge of the greater trochanter is relatively uncovered. Palpate it, moving the fingers anteriorly and proximally to identify its tip.
The shaft of the femur is palpable as a line of resistance on the lateral side of the thigh.
Incision
Make a longitudinal incision, beginning over the middle
of the greater trochanter and extending down the lateral side of the
thigh over the lateral aspect of the femur. The length and position of
the incision will vary with the requirements of the surgery (Fig. 9-2).
of the greater trochanter and extending down the lateral side of the
thigh over the lateral aspect of the femur. The length and position of
the incision will vary with the requirements of the surgery (Fig. 9-2).
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Figure 9-1 Position of the patient on the operating table for the lateral approach to the proximal femur.
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Radiographic control of the length and position of the
incision significantly reduces the length of the incision. Because it
is accurately sited, this in turn reduces the amount of dissection and
soft-tissue damage necessary for adequate exposure.
incision significantly reduces the length of the incision. Because it
is accurately sited, this in turn reduces the amount of dissection and
soft-tissue damage necessary for adequate exposure.
Internervous Plane
There is no internervous or intermuscular plane, because
the dissection splits the vastus lateralis muscle, which is supplied by
the femoral nerve. The muscle receives its nerve supply high in the
thigh, however, so splitting the muscle distally does not denervate it.
the dissection splits the vastus lateralis muscle, which is supplied by
the femoral nerve. The muscle receives its nerve supply high in the
thigh, however, so splitting the muscle distally does not denervate it.
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Figure 9-2 Incision for the lateral approach to the proximal femur.
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Superficial Surgical Dissection
Incise the fascia lata of the thigh in line with the
skin incision. At the upper end of the wound, the distal portion of the
tensor fasciae latae may have to be split in line with its fibers to
expose the vastus lateralis
skin incision. At the upper end of the wound, the distal portion of the
tensor fasciae latae may have to be split in line with its fibers to
expose the vastus lateralis
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(Fig. 9-3).
This split is needed in about one third of patients, those who have
tensor fasciae latae fibers extending distally beyond the greater
trochanter.
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Figure 9-3 Incise the fascia lata in line with the skin incision.
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Deep Surgical Dissection
Carefully incise the fascial covering of the vastus lateralis muscle (Fig. 9-4).
Insert a Homan or Bennett retractor through the muscle, running the tip
of the retractor over the anterior aspect of the femoral shaft. Then,
insert a second retractor through the same gap and down to the femoral
shaft. Manipulate the second retractor so that it moves underneath the
femur, and pull the two retractors apart to split the vastus lateralis
in the line of its fibers (Fig. 9-5).
Insert a Homan or Bennett retractor through the muscle, running the tip
of the retractor over the anterior aspect of the femoral shaft. Then,
insert a second retractor through the same gap and down to the femoral
shaft. Manipulate the second retractor so that it moves underneath the
femur, and pull the two retractors apart to split the vastus lateralis
in the line of its fibers (Fig. 9-5).
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Figure 9-4 Incise the fascia covering the vastus lateralis.
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Continue splitting by blunt dissection. As dissection
proceeds, several vessels that cross the field will be exposed.
Coagulate them, if possible, before they are avulsed by the blunt
dissection.
proceeds, several vessels that cross the field will be exposed.
Coagulate them, if possible, before they are avulsed by the blunt
dissection.
Splitting the vastus lateralis reveals the underlying lateral surface of the femur.
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Figure 9-5
Split the fibers of the vastus lateralis. To develop a subperiosteal plane, squeeze two Homan retractors down to the femoral shaft and separate them to split the vastus lateralis further. |
Dangers
Vessels
Numerous perforating branches of the profunda femoris artery traverse the vastus lateralis muscle (see Fig. 9-36).
They are damaged during the approach and should be ligated or
coagulated. These arterial branches can be identified more easily if
the muscle is split gently with a blunt instrument rather than cut
straight through with a knife.
They are damaged during the approach and should be ligated or
coagulated. These arterial branches can be identified more easily if
the muscle is split gently with a blunt instrument rather than cut
straight through with a knife.
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Figure 9-6 The incision may be extended distally to expose the entire shaft of the femur.
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How to Enlarge the Approach
Extensile Measures
The approach is most useful for exposing the proximal
third of the bone for internal fixation of a hip fracture. It can be
extended to the knee joint, however, to allow full exposure of the
lateral aspect of the femoral shaft for reduction and fixation of all
types of femoral fractures (Fig. 9-6; see Figs. 9-39 and 9-40).
third of the bone for internal fixation of a hip fracture. It can be
extended to the knee joint, however, to allow full exposure of the
lateral aspect of the femoral shaft for reduction and fixation of all
types of femoral fractures (Fig. 9-6; see Figs. 9-39 and 9-40).
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Posterolateral Approach
The posterolateral approach1
can expose the entire length of the femur. Because it follows the
lateral intermuscular septum, it does not interfere with the quadriceps
muscle. Although other lateral approaches involve splitting the vastus
lateralis or vastus intermedius muscles, the functional results of the
posterolateral approach do not differ significantly from those of other
approaches, probably because the vastus lateralis originates partly
from the lateral intermuscular septum. As a result, surgery still
involves detaching a part of the muscle’s origin and does not use a
true intermuscular plane.
can expose the entire length of the femur. Because it follows the
lateral intermuscular septum, it does not interfere with the quadriceps
muscle. Although other lateral approaches involve splitting the vastus
lateralis or vastus intermedius muscles, the functional results of the
posterolateral approach do not differ significantly from those of other
approaches, probably because the vastus lateralis originates partly
from the lateral intermuscular septum. As a result, surgery still
involves detaching a part of the muscle’s origin and does not use a
true intermuscular plane.
The lateral intramuscular septum lies posterior to the
femoral shaft at its proximal end. This septum overlies the middle of
the shaft at its distal end. The posterolateral approach is therefore
ideal for exposure of the distal one third of the femur. The more
proximal the approach, the greater the bulk of the vastus lateralis
that will need to be retracted anteriorly and the more difficult the
approach will be.
femoral shaft at its proximal end. This septum overlies the middle of
the shaft at its distal end. The posterolateral approach is therefore
ideal for exposure of the distal one third of the femur. The more
proximal the approach, the greater the bulk of the vastus lateralis
that will need to be retracted anteriorly and the more difficult the
approach will be.
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Figure 9-7 Position of the patient on the operating table for the posterolateral approach to the femur.
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The uses of the posterolateral approach include the following:
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Open reduction and plating of femoral fractures, especially supracondylar fractures
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Open intramedullary nail placement for femoral shaft fractures if facilities for closed nailing do not exist
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Treatment of nonunion of femoral fractures
-
Femoral osteotomy (which is performed rarely in the region of the femoral shaft)
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Treatment of chronic or acute osteomyelitis
-
Biopsy and treatment of bone tumors
Position of the Patient
Place the patient supine on the operating table with a sandbag beneath the buttock on the affected side to
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elevate the buttock and to rotate the leg internally, bringing the posterolateral surface of the thigh clear of the table (Fig. 9-7).
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Figure 9-8
The internervous plane lies between the vastus lateralis (which is supplied by the femoral nerve) and the hamstring muscles (which are supplied by the sciatic nerve). |
Landmarks and Incision
Landmarks
Palpate the lateral femoral epicondyle
on the lateral surface of the knee joint. The epicondyle actually is a
flare of the condyle. Moving superiorly, note that the femur cannot be
palpated above the epicondyle.
on the lateral surface of the knee joint. The epicondyle actually is a
flare of the condyle. Moving superiorly, note that the femur cannot be
palpated above the epicondyle.
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Figure 9-9 Incision for the posterolateral approach to the thigh.
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Incision
Make a longitudinal incision on the posterolateral
aspect of the thigh. Base the distal part of the incision on the
lateral femoral epicondyle and continue proximally along the posterior
part of the femoral shaft. The exact length of the incision depends on
the surgery to be performed (Fig. 9-9).
aspect of the thigh. Base the distal part of the incision on the
lateral femoral epicondyle and continue proximally along the posterior
part of the femoral shaft. The exact length of the incision depends on
the surgery to be performed (Fig. 9-9).
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Figure 9-10 Incise the fascia of the thigh in line with its fibers and the skin incision.
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Internervous Plane
The approach exploits the plane between the vastus lateralis muscle (which is supplied by the femoral nerve) and the lateral intermuscular septum, which covers the hamstring muscles (which are supplied by the sciatic nerve; Fig. 9-8).
Superficial Surgical Dissection
Incise the deep fascia of the thigh in line with its fibers and the skin incision (Fig. 9-10).
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Figure 9-11 Identify the vastus lateralis under the incised fascia lata.
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Deep Surgical Dissection
Identify the vastus lateralis under the fascia lata (Fig. 9-11).
Follow the muscle posteriorly to the lateral intermuscular septum.
Then, reflect the muscle anteriorly, dissecting between muscle and
septum. Begin at the distal end of the incision where the plane is
easiest to identify and develop. Numerous branches of the perforating
arteries cross this septum to supply the muscle; they must be ligated
or coagulated (Fig. 9-12). If the approach involves the supracondylar region, identify and ligate the numerous branches of
Follow the muscle posteriorly to the lateral intermuscular septum.
Then, reflect the muscle anteriorly, dissecting between muscle and
septum. Begin at the distal end of the incision where the plane is
easiest to identify and develop. Numerous branches of the perforating
arteries cross this septum to supply the muscle; they must be ligated
or coagulated (Fig. 9-12). If the approach involves the supracondylar region, identify and ligate the numerous branches of
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the superior lateral geniculate vessels, which cross the operative
fields. Failure to do so will result in profuse hemorrhage, which will
be difficult to control.
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Figure 9-12 Elevate the vastus lateralis anteriorly, separating the muscle from the septum.
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Continue the dissection, following the plane between the
lateral intermuscular septum and the vastus lateralis muscle, detaching
those parts of the vastus lateralis that arise from the septum until
the femur is reached at the linea aspera (Fig. 9-13).
Incise the periosteum longitudinally at this point and strip off the
muscles that cover the femur, using subperiosteal dissection. Detaching
muscles from the linea aspera itself usually has to be done by sharp
dissection (Fig. 9-14).
lateral intermuscular septum and the vastus lateralis muscle, detaching
those parts of the vastus lateralis that arise from the septum until
the femur is reached at the linea aspera (Fig. 9-13).
Incise the periosteum longitudinally at this point and strip off the
muscles that cover the femur, using subperiosteal dissection. Detaching
muscles from the linea aspera itself usually has to be done by sharp
dissection (Fig. 9-14).
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Figure 9-13
Detach those portions of the vastus lateralis that arise from the septum until the femur and linea aspera are reached. Then, incise the periosteum longitudinally. |
It is very easy to open up the plane between the vastus
lateralis muscle and the lateral intermuscular septum in the distal
third of the femur. Moving
lateralis muscle and the lateral intermuscular septum in the distal
third of the femur. Moving
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proximally,
the muscle becomes thicker, and it becomes more difficult to lift the
muscle bulk anteriorly to reveal the femoral shaft. To aid in this
process, place a Homan or Bennett retractor over the anterior aspect of
the femoral shaft, lifting the vastus lateralis forward. A retractor
placed on the lateral intermuscular septum will help open up the gap
and facilitate proximal dissection.
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Figure 9-14 Expose the shaft of the femur.
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Dangers
Vessels
The perforating arteries
(which are branches of the profunda femoris artery) pierce the lateral
intermuscular septum to supply the vastus lateralis muscle. They must
be ligated or coagulated one by one as the dissection progresses. If
they are torn flush with the lateral intermuscular septum, they may
begin to bleed out of control as they retract behind it (Fig. 9-40).
(which are branches of the profunda femoris artery) pierce the lateral
intermuscular septum to supply the vastus lateralis muscle. They must
be ligated or coagulated one by one as the dissection progresses. If
they are torn flush with the lateral intermuscular septum, they may
begin to bleed out of control as they retract behind it (Fig. 9-40).
The superior lateral geniculate artery and vein
cross over the lateral surface of the femur at the top of the femoral
condyles. These vessels will need to be ligated for exposure to the
bone.
cross over the lateral surface of the femur at the top of the femoral
condyles. These vessels will need to be ligated for exposure to the
bone.
How to Enlarge the Approach
Extensile Measures
The major value of this incision lies in its exposure of
the distal two thirds of the femur. It can be extended superiorly,
however, up to the greater trochanter, to expose virtually the entire
femoral shaft. Note that, superiorly, the tendon of the gluteus maximus
muscle lies behind the lateral intermuscular septum.
the distal two thirds of the femur. It can be extended superiorly,
however, up to the greater trochanter, to expose virtually the entire
femoral shaft. Note that, superiorly, the tendon of the gluteus maximus
muscle lies behind the lateral intermuscular septum.
The approach can be extended easily into a lateral
parapatellar approach to the knee joint. This allows accurate
visualization of the entire distal end of the femur. This extension is
used to allow reduction and fixation of intraarticular fractures of the
distal femur.
parapatellar approach to the knee joint. This allows accurate
visualization of the entire distal end of the femur. This extension is
used to allow reduction and fixation of intraarticular fractures of the
distal femur.
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Anteromedial Approach to the Distal Two Thirds of the Femur
The anteromedial approach provides an excellent view of
the lower two thirds of the femur and the knee joint. Its uses include
the following:
the lower two thirds of the femur and the knee joint. Its uses include
the following:
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Open reduction and internal fixation of
fractures of the distal femur, particularly those that extend into the
knee joint and require medial plating (its major use) -
Open reduction and internal fixation of femoral shaft fractures
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Treatment of chronic osteomyelitis
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Biopsy and treatment of bone tumors
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Quadricepsplasty
Position of the Patient
Place the patient supine on the operating table, and drape the extremity so that it can move freely (Fig. 9-15).
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Figure 9-15 Position of the patient on the operating table for the anteromedial approach to the femur.
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Landmark and Incision
Landmark
The vastus medialis muscle
is a distinct bulge superomedial to the upper pole of the patella. Only
the inferior portion can be seen and palpated distinctly. The vastus
medialis atrophies rapidly in many patients with knee pathology;
therefore, it may be difficult to find.
is a distinct bulge superomedial to the upper pole of the patella. Only
the inferior portion can be seen and palpated distinctly. The vastus
medialis atrophies rapidly in many patients with knee pathology;
therefore, it may be difficult to find.
Incision
Make a 10- to 15-cm longitudinal incision on the
anteromedial aspect of the thigh over the interval between the rectus
femoris and vastus medialis muscles. (There are no specific landmarks
for this interval other than the contour of the vastus medialis.)
Extend the incision distally along the medial edge of the patella to
the joint line of the knee, if the knee joint
anteromedial aspect of the thigh over the interval between the rectus
femoris and vastus medialis muscles. (There are no specific landmarks
for this interval other than the contour of the vastus medialis.)
Extend the incision distally along the medial edge of the patella to
the joint line of the knee, if the knee joint
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must be opened. The exact length of the incision depends on the pathology being treated (Fig. 9-16).
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Figure 9-16 Incision for the anteromedial approach to the thigh.
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Internervous Plane
There is no internervous plane; the dissection descends
between the vastus medialis and rectus femoris muscles, both of which
are supplied by the femoral nerve. The intermuscular plane can be used
safely to expose the distal two thirds of the femur, however, because
both muscles receive their nerve supplies well up in the thigh.
between the vastus medialis and rectus femoris muscles, both of which
are supplied by the femoral nerve. The intermuscular plane can be used
safely to expose the distal two thirds of the femur, however, because
both muscles receive their nerve supplies well up in the thigh.
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Figure 9-17
Incise the fascia lata in line with the skin incision, and identify the interval between the vastus medialis and the rectus femoris. |
Superficial Surgical Dissection
Incise the fascia lata (deep fascia) in line with the
skin incision, and identify the interval between the vastus medialis
and rectus femoris muscles (Fig. 9-17). Develop this plane by retracting the rectus femoris laterally (Fig. 9-18).
skin incision, and identify the interval between the vastus medialis
and rectus femoris muscles (Fig. 9-17). Develop this plane by retracting the rectus femoris laterally (Fig. 9-18).
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Figure 9-18
Develop the plane between the vastus medialis and the rectus femoris, retracting the rectus femoris laterally. Begin the parapatellar incision into the joint capsule. |
Deep Surgical Dissection
Begin distally, opening the capsule of the knee joint in
line with the skin incision by cutting through the medial patellar
retinaculum (see Fig. 9-18). Continue
proximally, splitting the quadriceps tendon almost on its medial
border. Open up the plane by sharp dissection, staying within the
substance of the quadriceps tendon and leaving a small cuff of the
tendon with the vastus medialis attached to it. This preserves the
insertion of these fibers and allows easy closure. If the vastus
medialis is stripped off the quadriceps tendon, it is very difficult to
reinsert, and muscle function will be compromised. Next, continue to
develop the interval between the vastus medialis and rectus femoris
muscles proximally to reveal the vastus intermedius muscle. Split the
vastus intermedius in line with its fibers; directly below lies the
femoral shaft covered with periosteum. Continue the dissection in the
epi- periosteal plane to get to the bone (Figs. 9-19 and 9-20).
line with the skin incision by cutting through the medial patellar
retinaculum (see Fig. 9-18). Continue
proximally, splitting the quadriceps tendon almost on its medial
border. Open up the plane by sharp dissection, staying within the
substance of the quadriceps tendon and leaving a small cuff of the
tendon with the vastus medialis attached to it. This preserves the
insertion of these fibers and allows easy closure. If the vastus
medialis is stripped off the quadriceps tendon, it is very difficult to
reinsert, and muscle function will be compromised. Next, continue to
develop the interval between the vastus medialis and rectus femoris
muscles proximally to reveal the vastus intermedius muscle. Split the
vastus intermedius in line with its fibers; directly below lies the
femoral shaft covered with periosteum. Continue the dissection in the
epi- periosteal plane to get to the bone (Figs. 9-19 and 9-20).
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Figure 9-19
Continue the parapatellar incision proximally, opening the joint capsule and suprapatellar region. Carry the incision into the substance of the vastus intermedius. |
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Figure 9-20 Incise the periosteum of the femur longitudinally, and expose the distal femur by subperiosteal dissection.
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Dangers
Vessels
The medial superior genicular artery
crosses the operative field just above the knee, winding around the
lower end of the femur. Although it looks small, it must be ligated or
coagulated to avoid hematoma formation (see Fig. 10-43).
crosses the operative field just above the knee, winding around the
lower end of the femur. Although it looks small, it must be ligated or
coagulated to avoid hematoma formation (see Fig. 10-43).
Muscles and Ligaments
The lowest fibers of the vastus medialis
muscle insert directly onto the medial border of the patella. Their
main job is to stabilize the patella and prevent lateral subluxation
(see Fig. 9-37). The fiber attachments of the
muscle inevitably are disrupted during this approach, unless a small
cuff of quadriceps tendon is taken with the muscle. Make sure to repair
the incision meticulously during closure to prevent subsequent lateral
subluxation of the patella.
muscle insert directly onto the medial border of the patella. Their
main job is to stabilize the patella and prevent lateral subluxation
(see Fig. 9-37). The fiber attachments of the
muscle inevitably are disrupted during this approach, unless a small
cuff of quadriceps tendon is taken with the muscle. Make sure to repair
the incision meticulously during closure to prevent subsequent lateral
subluxation of the patella.
How to Enlarge the Approach
Extensile Measures
Superior Extension. The
approach can be extended along the same interval between the rectus
femoris and vastus medialis muscles. To extend the deep dissection,
continue to split the vastus intermedius muscle. The extension offers
excellent exposure of the lower two thirds of the femur. Higher up,
however, the femoral artery, vein, and nerve intrude into the
dissection; the upper third of the femur is explored best by a lateral
approach.
approach can be extended along the same interval between the rectus
femoris and vastus medialis muscles. To extend the deep dissection,
continue to split the vastus intermedius muscle. The extension offers
excellent exposure of the lower two thirds of the femur. Higher up,
however, the femoral artery, vein, and nerve intrude into the
dissection; the upper third of the femur is explored best by a lateral
approach.
Inferior Extension.
Continue the skin incision downward, and curve it laterally so that it
ends just below the tibial tubercle. Incise the medial retinaculum in
line with the skin incision, making the patella more mobile and subject
to lateral subluxation for full exposure of the knee joint. Take care
not to avulse the quadriceps tendon from its insertion during the
maneuver (see Medial Parapatellar Approach in Chapter 10).
Continue the skin incision downward, and curve it laterally so that it
ends just below the tibial tubercle. Incise the medial retinaculum in
line with the skin incision, making the patella more mobile and subject
to lateral subluxation for full exposure of the knee joint. Take care
not to avulse the quadriceps tendon from its insertion during the
maneuver (see Medial Parapatellar Approach in Chapter 10).
Posterior Approach
The posterior approach4
is useful in patients who cannot undergo more anterior approaches
because of local skin problems. It provides access to the middle three
fifths of the bone, as well as to the sciatic nerve. Although it is
performed rarely, its uses include the following:
is useful in patients who cannot undergo more anterior approaches
because of local skin problems. It provides access to the middle three
fifths of the bone, as well as to the sciatic nerve. Although it is
performed rarely, its uses include the following:
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Treatment of infected cases of nonunion of the femur
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Treatment of chronic osteomyelitis
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Biopsy and treatment of bone tumors
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Exploration of the sciatic nerve
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Figure 9-21 Position of the patient on the operating table for the posterior approach to the femur.
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The approach is unusual in that surgery remains lateral
to the biceps muscle in its proximal half, but proceeds medial to it in
its distal half. This is because of the relationship of the posterior
aspect of the femur to the sciatic nerve.
to the biceps muscle in its proximal half, but proceeds medial to it in
its distal half. This is because of the relationship of the posterior
aspect of the femur to the sciatic nerve.
Position of the Patient
Place the patient prone on the operating table,
supporting the pelvis and chest on longitudinally placed pillows or
thick foam pads to allow the abdomen and chest to move freely, ensuring
adequate ventilation (Fig. 9-21).
supporting the pelvis and chest on longitudinally placed pillows or
thick foam pads to allow the abdomen and chest to move freely, ensuring
adequate ventilation (Fig. 9-21).
Landmark and Incision
Landmark
The gluteal folds are visible clearly on the buttock.
Incision
Make a straight longitudinal incision about 20 cm long
down the midline of the posterior aspect of the thigh. The incision
should end proximally at the inferior margin of the gluteal fold, and
its length will vary with surgical need (Fig. 9-23).
down the midline of the posterior aspect of the thigh. The incision
should end proximally at the inferior margin of the gluteal fold, and
its length will vary with surgical need (Fig. 9-23).
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Figure 9-22
The internervous plane lies between the vastus lateralis (which is supplied by the femoral nerve) and the biceps femoris (which is supplied by the sciatic nerve). |
Internervous Plane
The plane of dissection lies between the lateral intermuscular septum, which covers the vastus lateralis muscle (which is supplied by the femoral nerve), and the biceps femoris muscle (which is supplied by the sciatic nerve; Fig. 9-22).
Superficial Surgical Dissection
Incise the deep fascia of the thigh in line with the
skin incision, or lateral to it, taking care not to damage the
posterior femoral cutaneous nerve, which runs longitudinally under the
deep fascia (and roughly in line with the fascial incision), in the
groove between the biceps and semitendinosus muscles (Fig. 9-24). Identify the lateral border of the biceps femoris in the proximal end of the
skin incision, or lateral to it, taking care not to damage the
posterior femoral cutaneous nerve, which runs longitudinally under the
deep fascia (and roughly in line with the fascial incision), in the
groove between the biceps and semitendinosus muscles (Fig. 9-24). Identify the lateral border of the biceps femoris in the proximal end of the
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wound by palpating it. Then, develop the plane between the biceps
femoris and vastus lateralis muscles, which are covered by the lateral
intermuscular septum (Fig. 9-25).
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Figure 9-23 Make a straight longitudinal incision in the midline of the posterior aspect of the thigh.
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Deep Surgical Dissection
Begin proximally. Retract the long head of the biceps
femoris muscle medially and the lateral intermuscular septum laterally,
developing the plane with a finger (see Fig. 9-25).
Identify the short head of the biceps as it arises from the lateral lip
of the linea aspera. Detach its origin from the femur by sharp
dissection, and reflect it medially to expose the posterior aspect of
the femur (Fig. 9-26).
femoris muscle medially and the lateral intermuscular septum laterally,
developing the plane with a finger (see Fig. 9-25).
Identify the short head of the biceps as it arises from the lateral lip
of the linea aspera. Detach its origin from the femur by sharp
dissection, and reflect it medially to expose the posterior aspect of
the femur (Fig. 9-26).
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Figure 9-24
Incise the deep fascia of the thigh in line with the skin incision or just lateral to it, taking care not to damage the posterior femoral cutaneous nerve. |
In the distal half of the wound, retract the long head of the biceps laterally to expose the sciatic nerve (Fig. 9-27). Gently retract the sciatic nerve laterally
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to reveal the posterior aspect of the femur, which is covered with periosteum (Fig. 9-28). Develop an epi-periosteal plane between the periosteum and overlying soft tissues (Fig 9-29: see Fig. 9-28).
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Figure 9-25 Identify the lateral border of the biceps femoris; develop the plane between the biceps femoris and the vastus lateralis.
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Figure 9-26
Detach the origin of the short head of the biceps from the femur by sharp dissection, and reflect it medially to expose the posterior aspect of the femur. |
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Figure 9-27 Retract the long head of the biceps laterally to expose the sciatic nerve.
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Figure 9-28 Retract the sciatic nerve laterally to expose the posterior aspect of the femur. Incise the periosteum.
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Figure 9-29 Develop the subperiosteal plane to expose the posterior aspect of the femur.
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Dangers
Nerves
The sciatic nerve courses
down the back of the thigh in the posterior compartment. Because it
lies medial to the biceps muscle in the upper part of the incision, it
is protected from damage during the proximal part of the approach as
long as the correct intermuscular plane is maintained. Distally, the
nerve must be identified and care taken not to retract it overzealously
(see Fig. 9-41).
down the back of the thigh in the posterior compartment. Because it
lies medial to the biceps muscle in the upper part of the incision, it
is protected from damage during the proximal part of the approach as
long as the correct intermuscular plane is maintained. Distally, the
nerve must be identified and care taken not to retract it overzealously
(see Fig. 9-41).
The nerve to the biceps femoris
branches from the sciatic nerve and enters the biceps from its medial
side well up in the thigh. Because the dissection is on the safe
lateral side, the nerve cannot be damaged proximally.
branches from the sciatic nerve and enters the biceps from its medial
side well up in the thigh. Because the dissection is on the safe
lateral side, the nerve cannot be damaged proximally.
How to Enlarge the Approach
The approach cannot be extended usefully either
superiorly or inferiorly. It is valuable solely for its exposure of the
middle three fifths of the shaft of the femur.
superiorly or inferiorly. It is valuable solely for its exposure of the
middle three fifths of the shaft of the femur.
Minimal Access Approach to the Distal Femur
The minimal access approach to the distal femur utilizes
two windows. The distal window is in effect a lateral parapatellar
approach to the knee and allows visualization of the articular surface
of the distal femur. The proximal window provides access to the femoral
shaft and is a portion of the lateral approach to the femoral shaft
(see Fig. 9-6). The minimally invasive
approach is indicated for open reduction and internal fixation of
distal femoral fractures, especially those that involve intra-articular
fractures associated with complex metaphyseal injuries.
two windows. The distal window is in effect a lateral parapatellar
approach to the knee and allows visualization of the articular surface
of the distal femur. The proximal window provides access to the femoral
shaft and is a portion of the lateral approach to the femoral shaft
(see Fig. 9-6). The minimally invasive
approach is indicated for open reduction and internal fixation of
distal femoral fractures, especially those that involve intra-articular
fractures associated with complex metaphyseal injuries.
Position of the Patient
Place the patient supine on the table with a bolster under the thigh so that the knee rests in approximately 30º of flexion (Fig. 9-30).
If a tourniquet is to be used, place the tourniquet high on the
patient’s thigh and exsanguinate the limb using a compressive bandage
or elevate for 3 to 5 minutes before the tourniquet is inflated. Use a
radiolucent table and ensure that adequate imaging can be obtained of
the knee and femoral shaft by using an image intensifier before
prepping and draping.
If a tourniquet is to be used, place the tourniquet high on the
patient’s thigh and exsanguinate the limb using a compressive bandage
or elevate for 3 to 5 minutes before the tourniquet is inflated. Use a
radiolucent table and ensure that adequate imaging can be obtained of
the knee and femoral shaft by using an image intensifier before
prepping and draping.
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Figure 9-30 Position for the lateral approach to the distal femur.
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Landmarks and Incisions
Palpate the lateral joint line of the knee by flexing
and extending the joint. The lateral margin of the patella and anterior
surface of the lateral femoral condyle are easily palpable. The femoral
shaft, however, is merely felt as a resistance beneath the tight
iliotibial band.
and extending the joint. The lateral margin of the patella and anterior
surface of the lateral femoral condyle are easily palpable. The femoral
shaft, however, is merely felt as a resistance beneath the tight
iliotibial band.
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Figure 9-31
Distally make a 6- to 8-cm incision over the anterior half of the femoral condyle beginning at the joint line. Proximally make a longitudinal incision over the lateral aspect of the femoral shaft. The position and length of the proximal incision depends on the site of the pathology and the implant to be used for treatment. |
Incision
Make a 6- to 8-cm longitudinal incision over the
anterior half of the lateral femoral condyle, extending upwards from
the joint line. Make a second proximal longitudinal incision overlying
the lateral aspect of the shaft of the femur (Fig. 9-31). The positioning and length of this second incision will relate to the
anterior half of the lateral femoral condyle, extending upwards from
the joint line. Make a second proximal longitudinal incision overlying
the lateral aspect of the shaft of the femur (Fig. 9-31). The positioning and length of this second incision will relate to the
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implant being used, and the site of the incision must be determined using image intensification.
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Figure 9-32
Distally incise the subcutaneous tissues in the line of the skin incision to reveal the fascia overlying the vastus lateralis and the lateral patellar retinaculum. Proximally incise the subcutaneous tissues in the line of the skin incision to reveal the fascia covering the vastus lateralis. |
Internervous Plane
Distally, the dissection explores the internervous plane
between the vastus lateralis muscle supplied by the femoral nerve and
the biceps femoris muscles supplied by the sciatic nerve. Proximally,
no internervous plane is available for surgery, but splitting the
vastus lateralis muscle usually does not result in significant
denervation.
between the vastus lateralis muscle supplied by the femoral nerve and
the biceps femoris muscles supplied by the sciatic nerve. Proximally,
no internervous plane is available for surgery, but splitting the
vastus lateralis muscle usually does not result in significant
denervation.
Superficial Surgical Dissection
Begin distally. Incise the skin and subcutaneous tissue
in the line of the skin incision. Divide the lateral retinaculum to
visualize the joint capsule. At the proximal end of the distal window,
develop a plane between vastus lateralis anteriorly and the lateral
intramuscular septum posteriorly. Numerous branches of the superior
lateral genicular artery with associated veins cross the operating
field at this point and will need to be ligated or diathermied.
in the line of the skin incision. Divide the lateral retinaculum to
visualize the joint capsule. At the proximal end of the distal window,
develop a plane between vastus lateralis anteriorly and the lateral
intramuscular septum posteriorly. Numerous branches of the superior
lateral genicular artery with associated veins cross the operating
field at this point and will need to be ligated or diathermied.
Proximally incise the subcutaneous fat in the line of
the skin incision and then divide the deep fascia overlying the vastus
lateralis also in a longitudinal fashion (Fig. 9-32).
the skin incision and then divide the deep fascia overlying the vastus
lateralis also in a longitudinal fashion (Fig. 9-32).
Deep Surgical Dissection
Distally divide the knee joint capsule and synovium
longitudinally to expose the entire distal end of the femur. Retract
the patella using an appropriate retractor and visualize all aspects of
the joint by flexing and extending the knee. Proximally split the
vastus lateralis muscle in a line of its fibers to give direct access
to the periosteum on the lateral aspect of the femoral shaft (Fig. 9-33).
Finally, develop an epi-periosteal plane between the two windows on the
lateral aspect of the femur using a blunt dissector or the surgical
implant (Fig. 9-34).
longitudinally to expose the entire distal end of the femur. Retract
the patella using an appropriate retractor and visualize all aspects of
the joint by flexing and extending the knee. Proximally split the
vastus lateralis muscle in a line of its fibers to give direct access
to the periosteum on the lateral aspect of the femoral shaft (Fig. 9-33).
Finally, develop an epi-periosteal plane between the two windows on the
lateral aspect of the femur using a blunt dissector or the surgical
implant (Fig. 9-34).
Dangers
The superior genicular artery and veins need to be seen
and ligated. These vessels tend to be numerous and are closely adherent
to the periosteum. If these
and ligated. These vessels tend to be numerous and are closely adherent
to the periosteum. If these
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vessels are not controlled, a large hematoma will result postoperatively.
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Figure 9-33
Distally incise the lateral patellar retinaculum and the underlying joint capsule to enter the knee joint and expose the distal end of the femur. More proximally, incise the deep fascia to reveal the lateral aspect of the distal femur. Proximally incise the fascia overlying the vastus lateralis and split the fibers of that muscle to expose the periosteum covering the lateral aspect of the femoral shaft. |
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Figure 9-34 Connect the two incisions by developing an epi-periosteal plane along the lateral aspect of the femur using blunt dissection.
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How to Enlarge the Approach
Local measures
An external fixator or a distraction clamp can be
applied to the lateral aspect of the femoral shaft and the lateral
aspect of the tibia. This will cause the lateral aspect of the knee to
open up, facilitating visualization of the articular surface.
applied to the lateral aspect of the femoral shaft and the lateral
aspect of the tibia. This will cause the lateral aspect of the knee to
open up, facilitating visualization of the articular surface.
Extensile Measures
The two skin incisions can be united and the vastus
lateralis divided in the line of its fibers to provide access to the
entire lateral aspect of the shaft of the femur. This maneuver will, of
course, increase the degree of soft-tissue damage and will reduce the
blood supply to the femoral metaphysis.
lateralis divided in the line of its fibers to provide access to the
entire lateral aspect of the shaft of the femur. This maneuver will, of
course, increase the degree of soft-tissue damage and will reduce the
blood supply to the femoral metaphysis.
Applied Surgical Anatomy of the Thigh
Overview
Muscle Groups
There are three major muscle groups in the thigh (Figs. 9-35, 9-36 and 9-37):
-
The adductors of the hip are supplied by
the obturator nerve and occupy the medial segment of the thigh. The
adductor magnus both adducts and extends the hip, and it has a dual
nerve supply, the obturator and sciatic nerves. -
The extensors of the knee are supplied by the femoral nerve and occupy the anterior segment of the thigh.
-
The flexors of the knee (which also
extend the hip) are supplied by the sciatic nerve and lie in the
posterior segment of the thigh.
The knee extensors are separated from the hip adductors
by the thin medial intermuscular septum and from the knee flexors by
the tough lateral intermuscular septum. The adductors and flexors are
not separated by an intermuscular septum.
by the thin medial intermuscular septum and from the knee flexors by
the tough lateral intermuscular septum. The adductors and flexors are
not separated by an intermuscular septum.
Nerves
Three major nerves run down the thigh. The obturator nerve, which arises from the lumbar plexus (L2-4), runs in the adductor group, supplying all these muscles.
The sciatic nerve, which
arises from the lumbosacral plexus (L4-5, S1-3), lies in the posterior
segment of the thigh, supplying the hamstrings and the extensor portion
of the adductor magnus. Running deep to the long head of the biceps and
lying on the adductor magnus, it ends medial to the biceps as the
muscle crosses from the ischial tuberosity toward the head of the
fibula (see Fig. 9-41).
arises from the lumbosacral plexus (L4-5, S1-3), lies in the posterior
segment of the thigh, supplying the hamstrings and the extensor portion
of the adductor magnus. Running deep to the long head of the biceps and
lying on the adductor magnus, it ends medial to the biceps as the
muscle crosses from the ischial tuberosity toward the head of the
fibula (see Fig. 9-41).
The femoral nerve, which is
a branch of the lumbar plexus (L2-4), divides into its branches soon
after entering the thigh and supplies all the extensors of the knee (Fig. 9-38).
a branch of the lumbar plexus (L2-4), divides into its branches soon
after entering the thigh and supplies all the extensors of the knee (Fig. 9-38).
Vessels
The femoral artery is the
artery of transit through the thigh. Its major branch, the profunda
femoris artery, is the main blood supply of the thigh musculature.
After the femoral artery gives off the profunda femoris artery in the
femoral triangle, it gives off no other major branches of importance in
the thigh (Fig. 9-39).
artery of transit through the thigh. Its major branch, the profunda
femoris artery, is the main blood supply of the thigh musculature.
After the femoral artery gives off the profunda femoris artery in the
femoral triangle, it gives off no other major branches of importance in
the thigh (Fig. 9-39).
The femoral artery actually enters the thigh under the
inguinal ligament at the midinguinal point, directly over the head of
the femur, which is why the femoral pulse is the surface marking of the
femoral head. The artery then travels distally on the iliopsoas muscle
and disappears at the bottom of the femoral triangle beneath the
sartorius muscle, running on the adductor longus muscle. There, the
artery lies in a depression known as the subsartorial canal of Hunter.
The canal runs between the extensor and adductor compartments of the
thigh and is roofed by a thick fascial layer and the sartorius muscle.
The posterior wall is formed by the adductor muscles (the adductor
longus superiorly and the adductor magnus inferiorly), and the anterior
wall is formed by the vastus medialis muscle. Running with the artery
in the canal is the saphenous nerve (a cutaneous nerve that is derived
from the femoral nerve), the femoral vein, and, in the upper half, the
nerve to the vastus medialis muscle.
inguinal ligament at the midinguinal point, directly over the head of
the femur, which is why the femoral pulse is the surface marking of the
femoral head. The artery then travels distally on the iliopsoas muscle
and disappears at the bottom of the femoral triangle beneath the
sartorius muscle, running on the adductor longus muscle. There, the
artery lies in a depression known as the subsartorial canal of Hunter.
The canal runs between the extensor and adductor compartments of the
thigh and is roofed by a thick fascial layer and the sartorius muscle.
The posterior wall is formed by the adductor muscles (the adductor
longus superiorly and the adductor magnus inferiorly), and the anterior
wall is formed by the vastus medialis muscle. Running with the artery
in the canal is the saphenous nerve (a cutaneous nerve that is derived
from the femoral nerve), the femoral vein, and, in the upper half, the
nerve to the vastus medialis muscle.
The femoral artery ultimately pierces the adductor
magnus muscle one handbreadth above the knee to join the sciatic nerve
in the popliteal fossa before entering the posterior compartments of
the thigh. There, it lies deep and medial to the sciatic nerve (Fig. 9-41).
magnus muscle one handbreadth above the knee to join the sciatic nerve
in the popliteal fossa before entering the posterior compartments of
the thigh. There, it lies deep and medial to the sciatic nerve (Fig. 9-41).
The femoral artery is lateral to the femoral vein in the femoral triangle, but medial to it in the popliteal
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fossa, perhaps as a result of the rotation of the limb that occurs during fetal development.
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Figure 9-35
The superficial musculature of the lateral aspect of the thigh. The iliotibial band (tract) overlies the vastus lateralis proximally. |
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Figure 9-36
The tensor fasciae latae, the vastus lateralis, and a portion of the vastus intermedius have been resected to reveal the femur and the lateral intermuscular septum. Note the perforating vessels as they pierce the septum. Note that the vastus lateralis bulges posteriorly. |
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Figure 9-37 The superficial musculature of the anterior aspect of the thigh.
Rectus Femoris. Origin. Reflected head from just above acetabulum and anterior capsule of hip joint; straight head from anterior inferior iliac spine. Insertion. Upper border of patella, tibial tubercle. Action. Powerful extensor of knee and weak flexor of hip. Nerve supply. Femoral nerve (L2-L4).
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Figure 9-38
The sartorius, the rectus femoris, the tensor fasciae latae, the vastus lateralis, and the vastus intermedius have been resected to reveal the course of the femoral and profunda femoris arteries; note the relationship of the arteries to the quadriceps and the adductor muscles. Vastus Lateralis. Origin.
Upper half of intertrochanteric line. Vastus lateralis ridge, lateral lip of linea aspera, and upper two thirds of lateral supracondylar line of femur. Also from lateral intermuscular septum. Insertion. Lateral border of patella and tibial tubercle. Action. Extensor of knee. Nerve supply. Femoral nerve (L2-L4). Vastus Intermedius. Origin. Anterior and lateral aspect of upper two thirds of femoral shaft. Insertion. Tibial tubercle. Action. Extensor of knee. Nerve supply. Femoral nerve (L2-L4). Vastus Medialis. Origin. Medial lip of linea aspera and spiral line of femur. Insertion. Tibial tubercle and medial border of patella. Action. Extensor of knee. Nerve supply. Femoral nerve (L2-L4).
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Figure 9-39
The complete course of the femoral artery and profunda femoris artery. Note the perforating branches of the profunda femoris artery. Note that the adductor longus muscle has been resected to show the course of the profunda femoris artery, which runs posterior to it. |
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Figure 9-40
The superficial musculature of the posterior aspect of the thigh. Note the central course of the posterior femoral cutaneous nerve. Biceps Femoris. Origin. Long head from ischial tuberosity. Short head from linea aspera and lateral supracondylar line of femur. Insertion. Head of fibula. Action. Flexor of knee, extensor of hip, and lateral rotator of leg. Nerve supply. Long head: sciatic nerve (tibial division) (L5, S1, S2). Short head: sciatic nerve (common peroneal division) (S1-S2).
Semimembranosus. Origin. Ischial tuberosity. Insertion. Medial condyle of tibia. Action. Weak extensor of hip, flexor of knee, and medial rotator of leg. Nerve supply. Tibial nerve (L5, S1, S2).
Semitendinosus. Origin. Ischial tuberosity (common origin with biceps femoris). Insertion. Subcutaneous surface of tibia. Action. Flexor of knee, extensor of hip, and medial rotator of leg. Nerve supply. Tibial nerve (L5, S1, S2).
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Figure 9-41
The course of the sciatic nerve and the anatomic location of the linea aspera. The gluteus maximus and hamstring muscles are resected. |
The artery also changes position in relation to the
femur; it is anterior to it at its upper end, medial to it in its
middle portion, and behind it at its lower end. These changes influence
not only the planning of approaches, but also the insertion of skeletal
pins for traction and the application of external fixative devices.
femur; it is anterior to it at its upper end, medial to it in its
middle portion, and behind it at its lower end. These changes influence
not only the planning of approaches, but also the insertion of skeletal
pins for traction and the application of external fixative devices.
The profunda femoris artery
supplies the thigh musculature. It arises from the femoral artery in
the femoral triangle, coming off its lateral side before passing behind
it quickly. The two arteries then leave the femoral triangle. The
profunda femoris artery passes behind the adductor longus muscle,
whereas the femoral artery passes anterior to it. Thus, the muscle is
sandwiched between the two arteries (Fig. 9-40; see Fig. 9-39).
supplies the thigh musculature. It arises from the femoral artery in
the femoral triangle, coming off its lateral side before passing behind
it quickly. The two arteries then leave the femoral triangle. The
profunda femoris artery passes behind the adductor longus muscle,
whereas the femoral artery passes anterior to it. Thus, the muscle is
sandwiched between the two arteries (Fig. 9-40; see Fig. 9-39).
Four of the perforating branches of the profunda femoris
artery pass posteriorly through the medial compartment of the thigh.
They wind around the femur just as the medial femoral circumflex artery
does and enter the anterior compartment again by piercing the lateral
intermuscular septum. They must be ligated at that point in the
posterolateral approach to the femur (see Fig. 9-39)
artery pass posteriorly through the medial compartment of the thigh.
They wind around the femur just as the medial femoral circumflex artery
does and enter the anterior compartment again by piercing the lateral
intermuscular septum. They must be ligated at that point in the
posterolateral approach to the femur (see Fig. 9-39)
The medial femoral circumflex artery
passes between the iliopsoas and pectineus muscles to lie on the upper
border of the adductor longus muscle. From there, it winds around the
interval between the quadratus femoris and adductor magnus muscles,
where it divides. The ascending branch runs along the superior border
of the quadratus femoris, where it may be cut in posterior approaches
to the hip, causing troublesome bleeding. The horizontal branch passes
between the quadratus femoris and the adductor magnus to form one limb
of the cruciate anastomosis (see Fig. 9-39).
passes between the iliopsoas and pectineus muscles to lie on the upper
border of the adductor longus muscle. From there, it winds around the
interval between the quadratus femoris and adductor magnus muscles,
where it divides. The ascending branch runs along the superior border
of the quadratus femoris, where it may be cut in posterior approaches
to the hip, causing troublesome bleeding. The horizontal branch passes
between the quadratus femoris and the adductor magnus to form one limb
of the cruciate anastomosis (see Fig. 9-39).
The lateral femoral circumflex artery
passes lateral to the rectus femoris muscle, where it appears in the
upper part of the anterolateral approach. There, it divides into three
branches:
passes lateral to the rectus femoris muscle, where it appears in the
upper part of the anterolateral approach. There, it divides into three
branches:
-
The ascending branch runs upward toward
the anterior superior iliac spine in the intermuscular interval between
the sartorius and tensor fasciae latae muscles. There, it requires
ligation in the anterior approach to the hip. -
The transverse branch continues to wind
around the femur and joins the transverse branch of the medial femoral
circumflex, contributing to the cruciate anastomosis. -
The descending branch passes along the
interval between the vastus intermedius and vastus lateralis muscles,
where it is encountered in the anterolateral approach to the femur (see
Fig. 9-39).
The saphenous vein arises on
the dorsum of the ankle at the medial end of the dorsal venous arch.
Passing anterior to the medial malleolus (where it can be found during
cutdown for the insertion of intravenous lines), it passes behind the
knee before spiraling forward on the medial side of the thigh into the
femoral vein. The saphenous vein is the major superficial vein of the
thigh, but although it frequently is the object of general surgical
procedures, it has little importance for the orthopaedic surgeon.
the dorsum of the ankle at the medial end of the dorsal venous arch.
Passing anterior to the medial malleolus (where it can be found during
cutdown for the insertion of intravenous lines), it passes behind the
knee before spiraling forward on the medial side of the thigh into the
femoral vein. The saphenous vein is the major superficial vein of the
thigh, but although it frequently is the object of general surgical
procedures, it has little importance for the orthopaedic surgeon.
Landmark and Incisions
Landmark
Most of the femur is cloaked
deeply in muscle; only the greater trochanter and the femoral condyles
are easily palpable. The femur has a natural anterior bow, which is
important for the design of intramedullary rods.
deeply in muscle; only the greater trochanter and the femoral condyles
are easily palpable. The femur has a natural anterior bow, which is
important for the design of intramedullary rods.
The angle between the femoral shaft and the femoral neck
varies but is usually about 130°. The femoral neck is displaced about
15° in anteversion on the femoral shaft. These angles should be borne
in mind when pins or nails are inserted up the femoral neck.
varies but is usually about 130°. The femoral neck is displaced about
15° in anteversion on the femoral shaft. These angles should be borne
in mind when pins or nails are inserted up the femoral neck.
Incisions
Longitudinal incisions in the thigh parallel the lines
of cleavage of the skin; the resultant scars usually are cosmetically
acceptable.
of cleavage of the skin; the resultant scars usually are cosmetically
acceptable.
Superficial and Deep Surgical Dissection
Four of the approaches to the femur penetrate the knee
extensor compartment. (The posterior approach penetrates the hamstring
compartment and is considered separately.)
extensor compartment. (The posterior approach penetrates the hamstring
compartment and is considered separately.)
The knee extensor compartment consists of a single
muscle that arises from four heads and inserts through the extensor
apparatus of the knee into the tibial tubercle. This muscle, the
quadriceps femoris, is the largest muscle in the body. It is supplied
by the femoral nerve (see Fig. 9-41; see Figs. 9-37, 9-38 and 9-39).
muscle that arises from four heads and inserts through the extensor
apparatus of the knee into the tibial tubercle. This muscle, the
quadriceps femoris, is the largest muscle in the body. It is supplied
by the femoral nerve (see Fig. 9-41; see Figs. 9-37, 9-38 and 9-39).
Different muscle elements in the quadriceps group
contract differently. Because the gliding that occurs between muscle
elements is so vital to function, any incision that penetrates the
muscle may endanger its efficacy. The distal third of the quadriceps is
free to glide over the anterior aspect of the femur, because no part of
the muscle is attached to that part of the bone.
contract differently. Because the gliding that occurs between muscle
elements is so vital to function, any incision that penetrates the
muscle may endanger its efficacy. The distal third of the quadriceps is
free to glide over the anterior aspect of the femur, because no part of
the muscle is attached to that part of the bone.
The four heads of the quadratus femoris are as follows:
-
Rectus femoris. The rectus femoris is bipennate in structure, like the feathers of an arrow. It is the
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only part of the quadriceps that crosses two joints, the hip and knee,
as it descends the thigh over the vastus intermedius. Its ability to
slide over the vastus intermedius during movement of the knee is the
result of the presence of a thick fascial layer on its underside.
Because its origins are so close to the hip joint, both heads of the
rectus femoris must be detached to allow access to the anterior aspect
of the hip and to the inner and outer walls of the pelvis at the upper
margin of the acetabulum. -
Vastus lateralis.
The plane between the lateral intermuscular septum and the vastus
lateralis is difficult to define, and dissection is bloody, mainly
because the muscle arises in part from the septum itself. Following the
plane between the lateral intermuscular septum and the muscle leads to
the posterior aspect of the femur at the linea aspera (the origin of
the muscle) and not onto the lateral aspect of the bone. The plane is
defined most easily and is most useful in the distal third of the femur.The vastus lateralis glides on the vastus intermedius
during movement. As is true for the rectus femoris, its deep surface is
covered with a thick fascial attachment. -
Vastus intermedius.
The vastus intermedius cloaks the anterior and lateral aspects of the
upper two thirds of the femoral shaft and forms the innermost layer of
the quadriceps. This muscle is split during most approaches to the
femur. -
Vastus medialis.
The nerve supply of the vastus medialis is the largest branch of the
femoral nerve, a branch that contains a large number of proprioceptive
fibers. When trauma affects the knee, fibers of the vastus medialis
that attach to the patella tend to lose tone quickly, possibly because
of a neuromuscular reflex mediated via the nerve to the vastus
medialis. Wasting of these muscle fibers produces a subjective sense of
instability that persists until the muscle bulk returns to normal.
Therefore, rehabilitating the vastus medialis is vital in the treatment
of any knee injury.The lowest fibers of the vastus medialis insert into the
patella, pulling it medially. They are crucial in preventing lateral
subluxation of the patella during flexion of the knee.
Posterior Approach to the Femur
The posterior approach involves dissection of the posterior compartment of the thigh (Figs. 8-42 and 8-43).
The key to the approach lies in understanding the anatomy of the
sciatic nerve and its relationship to the biceps femoris muscle.5
The key to the approach lies in understanding the anatomy of the
sciatic nerve and its relationship to the biceps femoris muscle.5
The sciatic nerve runs vertically down the thigh more or
less in a straight line. The biceps femoris muscle angles across the
posterior aspect of the thigh in a medial to lateral direction, forming
a bridge under which the sciatic nerve runs. The nerve, therefore, lies
underneath the biceps femoris in the proximal thigh and lateral to it
in the distal thigh. Hence, during exposure of the proximal half of the
posterior aspect of the bone, the biceps should be retracted medially,
taking with it and protecting the sciatic nerve. For more distal
exposures, the biceps require retraction laterally, and the nerve must
be retracted with it. If a wide exposure of the whole length of this
piece of the bone is required, the long head of the biceps should be
divided; the proximal half of the muscle, together with the short head,
should be retracted medially with the sciatic nerve.
less in a straight line. The biceps femoris muscle angles across the
posterior aspect of the thigh in a medial to lateral direction, forming
a bridge under which the sciatic nerve runs. The nerve, therefore, lies
underneath the biceps femoris in the proximal thigh and lateral to it
in the distal thigh. Hence, during exposure of the proximal half of the
posterior aspect of the bone, the biceps should be retracted medially,
taking with it and protecting the sciatic nerve. For more distal
exposures, the biceps require retraction laterally, and the nerve must
be retracted with it. If a wide exposure of the whole length of this
piece of the bone is required, the long head of the biceps should be
divided; the proximal half of the muscle, together with the short head,
should be retracted medially with the sciatic nerve.
The three hamstring muscles arise from the ischium and
run down the posterior compartment of the thigh. All cross two joints,
the hip and the knee, and all act as hip extensors and knee flexors.
The hamstring muscles are supplied by branches of the sciatic nerve.
run down the posterior compartment of the thigh. All cross two joints,
the hip and the knee, and all act as hip extensors and knee flexors.
The hamstring muscles are supplied by branches of the sciatic nerve.
Semimembranosus Muscle
The insertions of the semimembranosus muscle greatly reinforce the posterior and posteromedial joint capsule of the knee (see Applied Surgical Anatomy of the Medial Side of the Knee in Chapter 10).
The muscle may be transferred to the anterior surface of the lateral
femoral condyle, together with the semitendinosus tendon, to correct
internal rotation deformity of the hip in patients with a variety of
neurologic lesions, a technique that is used only rarely.6
The muscle may be transferred to the anterior surface of the lateral
femoral condyle, together with the semitendinosus tendon, to correct
internal rotation deformity of the hip in patients with a variety of
neurologic lesions, a technique that is used only rarely.6
Semitendinosus Muscle
As its name implies, the semitendinosus muscle has an
extremely long tendon in relation to the size of its muscle belly. The
tendon is at least 13 cm long and can be used in a variety of surgical
procedures. It may
extremely long tendon in relation to the size of its muscle belly. The
tendon is at least 13 cm long and can be used in a variety of surgical
procedures. It may
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be
left attached to the tibia, even as it is attached via a drill hole to
the patella, to hold that bone medially in cases of recurrent
dislocation.7 It also may be used for posterior8 and anterior9
cruciate reconstruction; in that procedure, the tendon is separated
from the muscle at the musculotendinous junction and is threaded
through the femur so that it mimics the function of the missing
cruciate ligaments. In addition, it may be used to reinforce a torn
medial collateral knee ligament.
 |
|
Figure 9-42
Place the patient supine on the traction table. Reduce the fracture by traction and manipulation. Adduct the leg as much as possible around the traction pole. Abduct and flex the opposite hip to allow c.-arm access to the whole of the femur. |
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 |
|
Figure 9-43 (A) Adducting the leg moves the skin incision distally. (B)
In obese patients, nailing in this supine position is impossible. Note that even with maximal adduction, the ideal incision lies above the iliac crest. |
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Minimal Access Approach to the Proximal Femur for Intramedullary Nailing
The minimal access approach to the proximal femur is
used for the insertion of intramedullary nails for the treatment of the
following:
used for the insertion of intramedullary nails for the treatment of the
following:
-
Acute femoral shaft fractures
-
Pathological femoral shaft fractures
-
Delayed union and nonunion of femoral shaft fractures
The entry point for the insertion of an intramedullary
nail into the femur is determined radiographically. It depends on the
design of the nail and the anatomy of the proximal femur in the
individual patient. The majority of intramedullary nails are straight
when viewed in the anterior-posterior plane. The nail should be
inserted so that its entry point into the bone is exactly in line with
the intramedullary canal on both anterior-posterior and lateral
radiographs. The use of preoperative templates overlying radiographs
allows for a precise calculation of the entry point. The nearest
anatomical landmark to this entry point is the piriform fossa, but it
cannot be used reliably in all patients because it does not always line
up with the intramedullary canal in both planes. In addition, the fossa
cannot be palpated because of overlying musculature.
nail into the femur is determined radiographically. It depends on the
design of the nail and the anatomy of the proximal femur in the
individual patient. The majority of intramedullary nails are straight
when viewed in the anterior-posterior plane. The nail should be
inserted so that its entry point into the bone is exactly in line with
the intramedullary canal on both anterior-posterior and lateral
radiographs. The use of preoperative templates overlying radiographs
allows for a precise calculation of the entry point. The nearest
anatomical landmark to this entry point is the piriform fossa, but it
cannot be used reliably in all patients because it does not always line
up with the intramedullary canal in both planes. In addition, the fossa
cannot be palpated because of overlying musculature.
For nails that are straight when viewed in the
anterior-posterior plane, the skin incision, the entry point of the
nail in the bone, and the medullary canal of the femur should all be in
a straight line.
anterior-posterior plane, the skin incision, the entry point of the
nail in the bone, and the medullary canal of the femur should all be in
a straight line.
Some nails are angled at their upper end and require
insertion via the tip of the greater trochanter. These nails require a
skin incision directly over the tip of the greater trochanter.
insertion via the tip of the greater trochanter. These nails require a
skin incision directly over the tip of the greater trochanter.
Position of the Patient
Two positions are available for the insertion of femoral
nails. The supine position allows easier control of fracture reduction
and distal locking of the nail (Fig. 9-42). The lateral position allows easier access to the entry point in the proximal end of the femur.
nails. The supine position allows easier control of fracture reduction
and distal locking of the nail (Fig. 9-42). The lateral position allows easier access to the entry point in the proximal end of the femur.
Supine Position
Place the patient supine on a traction table. Employ
traction using a supracondylar femoral pin or a traction boot. Adduct
the leg as much as possible around the traction post to make it
anatomically possible to enter the upper end of the femur via the skin
on the lateral aspect of the buttock. Laterally flex the trunk of the
patient away from the operative side. Flex and abduct the opposite hip
and flex the knee, placing the leg in a support (see Figs. 9-42 and 9-43A).
Ensure that adequate anterior-posterior and lateral radiographs of the
entry point of the nail and the fracture site can be obtained. Be sure
that the fracture is reduced or reducible before commencing surgery.
Although this may be time-consuming, it is important to obtain
good-quality radiographs before commencing surgery, or you will
struggle to obtain quality imaging during the case. Five minutes of
preoperative time may shorten your operating time by 2 hours.
traction using a supracondylar femoral pin or a traction boot. Adduct
the leg as much as possible around the traction post to make it
anatomically possible to enter the upper end of the femur via the skin
on the lateral aspect of the buttock. Laterally flex the trunk of the
patient away from the operative side. Flex and abduct the opposite hip
and flex the knee, placing the leg in a support (see Figs. 9-42 and 9-43A).
Ensure that adequate anterior-posterior and lateral radiographs of the
entry point of the nail and the fracture site can be obtained. Be sure
that the fracture is reduced or reducible before commencing surgery.
Although this may be time-consuming, it is important to obtain
good-quality radiographs before commencing surgery, or you will
struggle to obtain quality imaging during the case. Five minutes of
preoperative time may shorten your operating time by 2 hours.
In displaced subtrochanteric femoral shaft fractures,
the proximal fragment will flex and abduct due to the unopposed pull of
the psoas and the abductor muscles. Displaced proximal femoral
fractures cannot be reduced by traction alone. Control of the proximal
fragment frequently requires percutaneous insertion of a Steinmann pin
into the proximal fragment, allowing its manipulation.
the proximal fragment will flex and abduct due to the unopposed pull of
the psoas and the abductor muscles. Displaced proximal femoral
fractures cannot be reduced by traction alone. Control of the proximal
fragment frequently requires percutaneous insertion of a Steinmann pin
into the proximal fragment, allowing its manipulation.
Inserting a nail in a very obese patient cannot be done successfully in the supine position (Fig. 9-43).
Lateral Position
Place the patient in a lateral position on a traction
table with the affected limb uppermost. Apply traction to the femur
through a distal supracondylar pin or a plaster boot. Adduct the leg
over the traction pole. Place the contralateral limb in a flexed
position at both hip and knee. Take care to pad the bony prominences of
the bottom leg to prevent skin breakdown due to pressure. Ensure that
adequate anterior-posterior and lateral radiographs of the entry point
and the fracture site can be obtained. The fracture must be reduced or
reducible before commencing surgery. Proximal femoral fractures will
require ancillary modes of reduction (Steinmann pins) (see Supine Position above).
table with the affected limb uppermost. Apply traction to the femur
through a distal supracondylar pin or a plaster boot. Adduct the leg
over the traction pole. Place the contralateral limb in a flexed
position at both hip and knee. Take care to pad the bony prominences of
the bottom leg to prevent skin breakdown due to pressure. Ensure that
adequate anterior-posterior and lateral radiographs of the entry point
and the fracture site can be obtained. The fracture must be reduced or
reducible before commencing surgery. Proximal femoral fractures will
require ancillary modes of reduction (Steinmann pins) (see Supine Position above).
The lateral position allows easier access to the
proximal femur than the supine position because it allows more
adduction, which is particularly useful in obese patients. In cases of
extreme obesity, even this position may not permit successful
intramedullary nailing; such patients are probably best treated by a
retrograde nailing technique with an entry point into the bone in the
intercondylar notch.
proximal femur than the supine position because it allows more
adduction, which is particularly useful in obese patients. In cases of
extreme obesity, even this position may not permit successful
intramedullary nailing; such patients are probably best treated by a
retrograde nailing technique with an entry point into the bone in the
intercondylar notch.
Landmarks and Incision
Landmarks
The greater trochanter is a large mass of bone that projects upward and backward from the junction of the shaft of the femur and its neck (see Fig. 8-43).
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 |
|
Figure 9-44
Palpate the shaft of the femur through the vastus lateralis muscle. Draw a line on the skin, marking the line of the shaft of the femur. Note that this line is curved. |
The anterior superior iliac spine can be felt as the anterior margin of the iliac crest (see Fig. 8-43).
The shaft of the femur can be felt as resistance through the massive vastus lateralis muscle on the lateral side of the thigh.
Incision
There are two techniques for planning the correct placement of the incision.
Radiographic Technique.
Palpate the shaft of the femur on the lateral aspect of the thigh
through the bulk of the vastus lateralis muscle. With a marker pen,
draw a line on the skin, marking the lateral aspect of the shaft of the
femur (Fig. 9-44). This line is curved because
the femur is bowed anteriorly when viewed in the lateral plane. Extend
this gently curving line proximal to the tip of the greater trochanter,
up to the level of the iliac crest (Fig. 9-45).
Palpate the shaft of the femur on the lateral aspect of the thigh
through the bulk of the vastus lateralis muscle. With a marker pen,
draw a line on the skin, marking the lateral aspect of the shaft of the
femur (Fig. 9-44). This line is curved because
the femur is bowed anteriorly when viewed in the lateral plane. Extend
this gently curving line proximal to the tip of the greater trochanter,
up to the level of the iliac crest (Fig. 9-45).
Place a long guidewire, such as a reaming guidewire, on
the anterior aspect of the thigh. Using radiographic control, ensure
that the guidewire is overlying the center of the medullary canal when
viewed in the anterior-posterior plane (Fig. 9-46).
the anterior aspect of the thigh. Using radiographic control, ensure
that the guidewire is overlying the center of the medullary canal when
viewed in the anterior-posterior plane (Fig. 9-46).
Take a long artery forceps and move it proximally along
the line you have drawn on the skin. Screen this instrument using an
image intensifier in the anterior-posterior planes (see Fig. 9-46). When the image of the tip of the forceps coincides with the guidewire radiographically, mark the skin (see Fig. 9-46).
This skin mark will be the center of the skin incision. A wire inserted
through this incision and through the correct entry point in the bone
will pass perfectly down the center of the medullary canal of the femur
in both anterior-posterior and lateral planes.
the line you have drawn on the skin. Screen this instrument using an
image intensifier in the anterior-posterior planes (see Fig. 9-46). When the image of the tip of the forceps coincides with the guidewire radiographically, mark the skin (see Fig. 9-46).
This skin mark will be the center of the skin incision. A wire inserted
through this incision and through the correct entry point in the bone
will pass perfectly down the center of the medullary canal of the femur
in both anterior-posterior and lateral planes.
If the patient is obese and/or you are unable to adduct
the leg, then this entry point will be above the level of the iliac
crest (see Fig. 9-43B).
Such an entry point is clearly not usable. If this is the case, then
alternative techniques using curved instrumentation will need to be
used through a more proximally based incision.
the leg, then this entry point will be above the level of the iliac
crest (see Fig. 9-43B).
Such an entry point is clearly not usable. If this is the case, then
alternative techniques using curved instrumentation will need to be
used through a more proximally based incision.
Landmark Technique.
Palpate the shaft of the femur through the bulk of the vastus lateralis
muscle. With a marker pen, draw a curved line on the skin of the
lateral aspect of the thigh, marking the shaft of the
Palpate the shaft of the femur through the bulk of the vastus lateralis
muscle. With a marker pen, draw a curved line on the skin of the
lateral aspect of the thigh, marking the shaft of the
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femur (see Fig. 9-44). Extend this line proximally beyond the tip of the greater trochanter, curving it slightly posteriorly.
 |
|
Figure 9-45 Extend the drawn line above the tip of the greater trochanter to the level of the anterior superior iliac spine.
|
Palpate the anterior superior iliac spine. Draw a line
perpendicularly downward from the iliac spine toward the buttock. The
incision should be centered at the point where these two lines cross (Fig. 9-47).
perpendicularly downward from the iliac spine toward the buttock. The
incision should be centered at the point where these two lines cross (Fig. 9-47).
Incision
Make a longitudinal incision centered on the skin mark.
The size of the incision depends on the type of nail to be used. Nails
that have proximal interlocking jigs that are considerably offset from
the nail can be inserted through a 3-cm incision. Nails whose proximal
jigs attach close to the nail require a longer skin incision (up to 7
cm).
The size of the incision depends on the type of nail to be used. Nails
that have proximal interlocking jigs that are considerably offset from
the nail can be inserted through a 3-cm incision. Nails whose proximal
jigs attach close to the nail require a longer skin incision (up to 7
cm).
Internervous Plane
There is no internervous plane or intramuscular plane.
The dissection splits fibers of the gluteus maximus and gluteus medius
but does not denervate either muscle.
The dissection splits fibers of the gluteus maximus and gluteus medius
but does not denervate either muscle.
Superficial Surgical Dissection
Incise the subcutaneous fat and the fascia overlying the
gluteus maximus in line with the incision. Split the fibers of gluteus
maximus for 3 cm in the line of its fibers using a curved clamp.
gluteus maximus in line with the incision. Split the fibers of gluteus
maximus for 3 cm in the line of its fibers using a curved clamp.
Deep Surgical Dissection
Continue the dissection distally using a long curved
clamp to split the fibers of the gluteus medius muscle to gain access
to the proximal femur. Careful use of a finger as a blunt dissector to
identify the medial aspect of the greater trochanter is often helpful
as well. Insert a marker wire (or rod) through the completed dissection
onto the proximal end of the femur, and adjust the position of the wire
using X-ray control in both anterior-posterior and lateral planes until
clamp to split the fibers of the gluteus medius muscle to gain access
to the proximal femur. Careful use of a finger as a blunt dissector to
identify the medial aspect of the greater trochanter is often helpful
as well. Insert a marker wire (or rod) through the completed dissection
onto the proximal end of the femur, and adjust the position of the wire
using X-ray control in both anterior-posterior and lateral planes until
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the
wire is at the correct entry point into the bone. The wire must line up
with the intramedullary canal on both anterior-posterior and lateral
planes (Figs. 9-48 and 9-49).
 |
|
Figure 9-46
Place a long guidewire on the anterior surface of the thigh and position it under image intensifier control so that its image overlies the center of the medullary canal of the femur. Take a long artery forceps and move it proximally along the drawn line on the lateral aspect of the thigh. When the image of the forceps coincides with the image of the guidewire radiographically, mark the skin. |
The exact techniques for entering the proximal femur
vary from nail to nail. You must consult the appropriate literature to
ensure that the instrumentation is used correctly.
vary from nail to nail. You must consult the appropriate literature to
ensure that the instrumentation is used correctly.
Dangers
Bone Deformity
The presence of an incorrect entry point is potentially hazardous in intramedullary nailing of the femur.
An entry point that is too far lateral commonly occurs. This will create a varus deformity
at the fracture site if the nail used is rigid, and the fracture is in
the proximal third of the femur. Lateral entry points may also create
an iatrogenic fracture of the medial femoral cortex during nail
insertion.
at the fracture site if the nail used is rigid, and the fracture is in
the proximal third of the femur. Lateral entry points may also create
an iatrogenic fracture of the medial femoral cortex during nail
insertion.
An entry point that is too far medial may create an
iatrogenic fracture of the femoral neck, usually a vertical
basicervical fracture. On occasion, medial entry points may also damage
the blood supply to the femoral head, creating avascular necrosis.
iatrogenic fracture of the femoral neck, usually a vertical
basicervical fracture. On occasion, medial entry points may also damage
the blood supply to the femoral head, creating avascular necrosis.
Nerves
The superior gluteal nerve runs posteriorly to anteriorly through the substance of the gluteus medius muscle
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3 to 5 cm above the tip of the greater trochanter. If the femur is
adducted, the nerve will not be damaged during insertion of a nail. If,
however, a retrograde nailing technique is used when the femur is not
necessarily abducted, then damage to the nerve may occur.
 |
|
Figure 9-47
Landmark technique. Draw a line perpendicularly downwards from the anterior superior iliac spine. Where this line crosses the previously drawn line on the lateral aspect of the thigh, mark the skin. |
 |
|
Figure 9-48
Split the fibers of the gluteus maximus in line with the skin incision. Deepen the incision down to the femur by splitting the fibers of the gluteus medius. |
 |
|
Figure 9-49 Insert a guidewire (or rod) into proximal femur, checking its position in both A-P and lateral planes using a C-arm.
|
How to Enlarge the Approach
This approach cannot be usefully enlarged proximally or distally because it does not utilize an internervous plane.
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Minimal Access Surgery for Retrograde Intramedullary Nailing of the Femur
The minimal access approach for retrograde
intramedullary nailing utilizes a small portion of the medial
parapatellar approach to the knee. It allows excellent percutaneous
access to the distal femoral intercondylar region. Its sole use is for
the insertion of retrograde intramedullary nails used to treat femoral
shaft fractures.
intramedullary nailing utilizes a small portion of the medial
parapatellar approach to the knee. It allows excellent percutaneous
access to the distal femoral intercondylar region. Its sole use is for
the insertion of retrograde intramedullary nails used to treat femoral
shaft fractures.
Position of the Patient
Place the patient supine on a radiolucent table. Place a
large triangular ridge underneath the knee to allow the knee to flex to
90º. Finally, place a small sandbag under the ipsilateral buttock to
correct the natural external rotation of the limb and ensure that the
patella faces directly anteriorly. This will allow you to more
accurately access rotational control during fracture reduction and
fixation.
large triangular ridge underneath the knee to allow the knee to flex to
90º. Finally, place a small sandbag under the ipsilateral buttock to
correct the natural external rotation of the limb and ensure that the
patella faces directly anteriorly. This will allow you to more
accurately access rotational control during fracture reduction and
fixation.
 |
|
Figure 9-50
Make a 3-cm longitudinal incision approximately 1 cm from the medial border of the patella, beginning about 2 cm proximal to the distal pole of the patella. |
Landmarks and Incision
Palpate the medial border of the patella. Make a 3-cm
longitudinal incision approximately 1 cm from the medial border of the
patella, beginning about 2 cm proximal to the distal pole of the
patella (Fig. 9-50).
longitudinal incision approximately 1 cm from the medial border of the
patella, beginning about 2 cm proximal to the distal pole of the
patella (Fig. 9-50).
Internervous Plane
There is no internervous plane available for this
approach. The approach is merely through the medial patella retinaculum
and synovium.
approach. The approach is merely through the medial patella retinaculum
and synovium.
Superficial Surgical Dissection
Deepen the incision through subcutaneous tissue in the
line of the skin incision. Identify the capsule of the knee joint and
divide it longitudinally (Fig. 9-51).
line of the skin incision. Identify the capsule of the knee joint and
divide it longitudinally (Fig. 9-51).
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 |
|
Figure 9-51
Deepen the incision through subcutaneous tissue in the line of the skin incision. Identify the capsule of the knee joint and divide it longitudinally. |
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 |
|
Figure 9-52
Divide the underlying synovium of the knee. Insert two retractors to visualize the intercondylar notch and the insertion of the posterior cruciate ligament onto the lateral aspect of the medial femoral condyle. |
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 |
|
Figure 9-53
Insert a guidewire into the distal femur. The entry point in the intercondylar notch varies with the implant to be used, and accurate positioning of the guidewire must be confirmed by C-arm imaging at the time of surgery. |
Deep Surgical Dissection
Divide the underlying synovium of the knee. Insert two
retractors to visualize the intercondylar notch. The insertion point
and direction of guidewires used for nail introduction must be
confirmed using appropriate X-ray control (Figs. 9-52 and 9-53).
retractors to visualize the intercondylar notch. The insertion point
and direction of guidewires used for nail introduction must be
confirmed using appropriate X-ray control (Figs. 9-52 and 9-53).
Dangers
The infrapatella branch of the saphenous nerve should
lie distal to the distal end of the incision. It is only in danger if
the incision is extended distally.
lie distal to the distal end of the incision. It is only in danger if
the incision is extended distally.
The posterior cruciate ligament
inserts into the lateral aspect of the medial femoral condyle. The
insertion may be damaged by the intramedullary nail or the reamers used
to create the opening if the entry point is not correctly located.
inserts into the lateral aspect of the medial femoral condyle. The
insertion may be damaged by the intramedullary nail or the reamers used
to create the opening if the entry point is not correctly located.
How to Enlarge the Approach
Local Measures
The approach can be extended a short distance both
proximally and distally, and this may be required in obese patients.
The skin incision may be extended distally and an extra-articular
approach to the proximal tibia may be used to insert a tibial nail in
cases of floating knee. (See Minimal Access Approach to the Proximal Tibia page 589).
proximally and distally, and this may be required in obese patients.
The skin incision may be extended distally and an extra-articular
approach to the proximal tibia may be used to insert a tibial nail in
cases of floating knee. (See Minimal Access Approach to the Proximal Tibia page 589).
References
1. Marcy GH: The posterolateral approach to the femur. J Bone Joint Surg 29:676, 1947
2. Thompson JE: Anatomical methods of approach in operations on the long bones of the extremities. Ann Surg 68:309, 1918
3. Henry AK: Exposure of the humerus and femoral shaft. Br J Surg 12:84, 1924
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4. Bosworth DM: Posterior approach to the femur. J Bone Joint Surg 26:687, 1944
5. Gray H: Anatomy of the human body, 27th ed. Goss CM, ed. Philadelphia, Lea & Febiger, 1959: 1049
6. Sutherland
DH, Schottstaedt ER, Larsen LJ et al: Clinical and electromyographic
study of seven spastic children with internal rotation gait. J Bone
Joint Surg [Am] 51:1070, 1969
DH, Schottstaedt ER, Larsen LJ et al: Clinical and electromyographic
study of seven spastic children with internal rotation gait. J Bone
Joint Surg [Am] 51:1070, 1969
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