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1

Stoppa Approach

Indications 

acetabular fractures

pelvic ring injuries

Approach provides access to  

pubic body

superior pubic ramus

pubic root

ilium above and below the pectineal line

quadrilateral plate 

medial aspect of the posterior column

sciatic buttress

anterior sacroiliac joint

upper ilium and iliac crest

Preparation & Positioning

Preparation 

a radiolucent table is required

Foley catheter is required to improve visualization

Position 

supine 

ipsilateral limb is draped free into the field

hip and knee are flexed to relax the ilipsoas/femoral neurovascular bundle

operating surgeon is on the opposite side of the table

Approach

Incision a transverse incision is made approximately 2 cm above the symphysis 

this is carried short of each external inguinal ring

for the "lateral window", an incision is made along the iliac crest, starting ~2 cm posterior to the ASIS, following the iliac crest posteriorly

Superficial dissection 

subcutaneous tissue and rectus fascia are incised transversely 

the pyrimidalis muscle is released and tagged for later repair 

the rectus abdominus fascia is split along the linea alba 

the transversalis fascia is opened superior to the pubic symphysis 

this opens the potential space of Retzius (space behind the symphysis and anterior to the bladder) 

for the "lateral window", the insertion of the external oblique is released, permitting dissection into the internal iliac crest fossa (requires elevation of the iliacus muscle)

Deep dissection the origin of the rectus abdominus muscle is released off the posterior pubic rami but maintained anteriorly 

 a Hohmann retractor is used to retract the rectus anteriorly

the iliopectineal fascia is released to enter the true pelvis

anastamoses between the external iliac and obturator vessels (corona mortis) should be identified along the superior pubic ramus and ligated 

the iliopsoas can now be subperiosteally elevated, and a retractor is used to retract the iliopsoas and external iliac vessels

the entire pelvic brim should be visualized at this time 

the obturator neurovascular bundle is exposed and protected as the quadrilateral surface and posterior column are dissected

Dangers & Complications

Obturator nerve and vessels

retracted carefully during exposure of the quadrilateral plate and posterior column

 Corona mortis

these anastamoses must be ligated as they appear on the lateral 1/3 of the superior pubic ramus

they are nearly universally present but vary significantly in size

External iliac vessels

exposed and retracted early in the exposure; must be mobilized to expose the iliac fossa and false pelvis

Bladder

Foley catheter limits injury; placement of a malleable retractor anterior to bladder also helps protect

 

2

Kocher-Langenbock Approach

Introduction

Southern/Moore approach and the Kocher-Langenbeck approach both use the same interval

Kocher-Langenbeck is used to refer to an approach used to address the acetabulum which is more extensile

Southern/Moore approach more commonly refers to a more limited hip arthroplasty approach

incision is identical to Kocher-Langenbeck, except localized posterior to greater trochanter

Provides exposure to 

posterior wall of acetabulum

lateral aspect of the posterior column of acetabulum

indirect access to true pelvis and anterior aspect of posterior column through palpation

proximal femur

Indications 

THA

hip hemiarthroplasty

removal of loose bodies

dependant drainage of septic hip

pedicle bone grafting

posterior wall fx

posterior column fx

posterior wall and posterior column fx

simple transverse fx (patient prone)

fx must be less than 15 days old

fx line located at or below acetabular roof

no major anterior displacement

Intermuscular plane

No internervous plane

gluteus maximus innervated by inferior gluteal nerve

nerve branches of upper 1/3 of muscle cross intended interval of dissection halfway between level of greater trochanter and PSIS

muscle split is stopped when first nerve branch to upper part of muscle is encountered

Vascular planeupper 1/3 of muscle

supplied by superior gluteal artery 

lower 2/3 of muscles 

supplied by inferior gluteal artery 

line of fat on surface marks interval

Preparation

Anesthesia 

patient must be relaxed

Position lateral position  

posterior wall and lip fxs (can use skeletal traction when using lateral position)

allows for femoral head dislocation

position of choice for joint arthroplasty

allows buttock tissue to "fall away" from the field

prone position  

for transverse fx (flex the knee to prevent stretching of sciatic nerve)

femoral head is maintained in  reduced position throughout procedure

improves quadrilateral surface access

improved access to cranial and anterior aspect of posterior wall fractures

Imaging 

ensure appropriate imaging can be obtained prior to formal prepping and draping

Approach

Incision longitudinal incision centered over greater trochanter start just below iliac crest, lateral to PSIS

mini-incision approach shows no longterm benefits to hip function 

extend to 10 cm below tip of greater trochanter

Superficial dissection 

through subcutaneous fat

incise fascia lata in lower half of incision

extend proximally along anterior border of gluteus maximus

split gluteus maximus muscle along avascular plane

release portion of gluteal sling to aide in anterior retraction of muscle belly

detach short external rotators after tagging the piriformis should be tagged and released approximately 1.5cm from the tip of the greater trochanter to avoid damaging the blood supply to the femoral head the piriformis will provide a landmark leading to the greater sciatic notch  the contents of the greater sciatic notch include:  

piriformis

superior and inferior gluteal vessels and nerves

sciatic and posterior femoral cutaneous nerves

internal pudendal vessels

nerves to the obturator internus and quadratus femoris

the obturator internus should be tagged 1.5 cm from the greater trochanter and blunt dissection should be used to follow its origin to the lesser sciatic notch 

posterior retraction will protect the sciatic nerve

clear abductors and soft tissue to visualize posterior capsule and posterior wall region

Deep dissection 

no further dissection is needed in setting of isolated posterior wall fracture

palpable exposure of quadrilateral plate to assess reduction of posterior column accomplished by elevation of obturator internus elevation 

access can be enlarged by release of sacrospinous ligament

hip joint exposure 

perform marginal capsulotomy

capsular attachments to posterior wall fragments need to be kept intact to prevent devascularization

femoral traction can allow visualization of intra-articular surface of hip joint

osteotomy of greater trochanter

extends access along external surface of anterior column

Dangers

Sciatic nerveinitially located along posterior surface of quadratus femoris muscle 

quadratus femorus anatomy is constant; rarely damaged in setting of fracture

extend hip and flex knee to prevent injury

minimize chance of injury by using proper gentle retraction and releasing your short external rotators (obturator internus) posteriorly to protect the sciatic nerve from traction

treat injury with observation and use of ankle-foot orthosis 

prognosis for recovery of tibial division is good despite severe initial damage

prognosis for recovery of peroneal division is dependant on severity of initial injury

Inferior gluteal artery

leaves pelvis beneath piriformis

if it is cut and retracts into the pelvis, then treat by flipping patient, open abdomen, and tie off internal iliac artery

First perforating branch of profunda femoris

at risk of injury with release of gluteus maximus insertion

Femoral vessels

at risk with failure to protect anterior aspect of the acetabulum, or with placement of retractors anterior to the iliopsoas muscle

Superior gluteal artery and nerve

leaves the pelvis above the piriformis and enters the deep surface of the gluteus medius.

this tethering limits upward retraction of gluteus medius and blocks you from reaching the iliac crest

injury can cause excessive bleeding

Quadratus femoris

excessive retraction and injury must be avoided to prevent damage to medial circumflex artery

Heterotopic Ossification

debride necrotic gluteus minimus muscle to decrease incidence of HO

3

Extended Illiofemoral approach to pelvis

The extended iliofemoral approach exposes the entire lateral innominate bone

Indications

Transtectal transverse fracture with roof impaction 

Transverse with posterior wall fractures

T-type fractures, especially with posterior wall involvement

T-type fractures with pubic symphysis dislocation

Both-column fractures with posterior wall or posterior column comminution, sacroiliac joint involvement, or very high posterior column involvement 

Delayed fixation of both column, T-type, or transverse + posterior wall fractures (typically > 3 weeks)

Malunion/nonunion/deformity correction surgeries

Preparation

Position 

lateral decubitus positioning is utilized in this approach.

Approach

Incision the incision is carried along the iliac crest

starting from the PSIS and running anteriorly to the ASIS

it is then continued down from the ASIS in line with the posterior femur

Superficial dissection 

separate the abdominal musculature from the gluteal musculature at the iliac crest.

develop the interval between the sartorius and tensor fasciae latae.

retract the tensor laterally and dissect through the fascia lata distal to the muscle (longitudinally).

elevate the tensor fasciae latae from the ASIS.

Deep dissection 

dissect gluteal muscles off iliac crest

subperiosteally dissect the gluteal muscles off the iliac crest from anterior to posterior and cephalad to caudad.

continue the elevation until the PSIS and greater sciatic notch are encountered.

the lateral branches of the anterior femoral circumflex vessels must be ligated to further retract the tensor and fascia lata laterally.

elevate the direct head of the rectus femoris from the pelvis as well as the gluteus minimus (off the proximal femur). 

sequentially tag and resect the insertions of the 

gluteus medius/minimus

piriformis

conjoint tendon (superior and inferior gemelli/obturator internus)

Take care to protect the superior gluteal artery and nerve as well as the sciatic nerve. 

release hip capsule, if not injured.

access to the internal iliac fossa may be obtained inferiorly by releasing the indirect head of the rectus femorus and superiorly by releasing the abdominal musculature off the iliac wing and elevating the iliacus from the internal fossa. 

elevating the abdominal musculature from the iliac crest and iliacus from the internal fossa in this approach will completely devitalize the wing.  This aspect of the approach should be used on a very limited basis.

Wound closure 

3 drains are placed before closure, one along the posterior column, another in the distal portion of the incision, and a third in the internal iliac fossa

order of wound closure/repair:

hip capsule, external rotators

gluteus medius, must be fixed anatomically and with strong sutures

gluteus minimus

rectus femoris origin with transosseous sutures, knee extension facilitates this repair

sartorius and abdominal muscles if taken down

fascia, subcutaneous layers, and skin

Dangers & Complications

Heterotopic Ossification

highest rate of heterotopic bone formation of all pelvic approaches  

Extended patient recovery period

Permanent hip abductor weakness is expected

Iatrogenic injurystructures at risk

superior gluteal artery and vein

sciatic nerve

lateral femoral cutaneous nerve (lateral branches always transected)

perforating branches of the femoral artery

 

4

Anterior Approach to Cervical Spine

Overview 

widely used approach that exposes anterior vertebral bodies from C2 to T1

Indications cervical radiculopathy

anterior cerical disctomy & fusion (ACDF)

myelopathy

anterior corpectomy and fusion

tumor

anterior corpectomy and fusion

odontoid fracture

C2 anterior screw osteosynthesis

infection & epidural abscess

anterior cervical discectomy & fusion (ACDF)

Applied surgical anatomy

It is important to understand the three fascial layers of the neck superficial fascia

formed by the investing layer of deep cervical fascia

platysma and external jugular vein are only structures superficial to it

surround neck like a collar, but splits around the SCM and trapezius

pretracheal fascia

continous with carotid sheath at sheath's lateral margin

superior and inferior thyroid vessels run from the carotid sheath through the pretracheal fascia to the midline

prevertebral fascia

thick and tough fascia that lines in front of the prevertebral muscles

the cervical sympathetic trunk (runs over transverse processes) runs on its surface

Landmarks 

carotid tubercle is the anterior tubercle of the transverse process of C6

Planes

Superificial 

divide platysma which is innervated high up in the neck by the facial (seventh) cranial nerve

Middle 

sternocleidomastoid (spinal accessory nerve)

strap muscles (segmental innervation from C1, C2, C3)

Deep

left longus colli muscles (segmental branches of cervical nerves)

right longus colli muscles

Preparation

Anesthesia 

general as airway needs to be protected

Position 

supine

Imaging cross table lateral required to identify correct level 

shoulders/arms often pulled caudal to obtain better visualization of C7

Approach

Incision 

make transverse skin crease incision at appropriate level

extend obliquely from the midline to the posterior border of the SCN

side 

surgeons preference

Superficial Dissection 

incise fascia over platysma

spit platysma with finger

identify anterior border of SCM

incise fascia and retract SCM lateral

identify and retract strap muscles medially (sternohyoid and sternothyroid)

identify the carotid pulse and retract carotid sheath lateral

cut through pretrachial fascia

localize superior and inferior thyroid arteries and tie off if necessary

Deep dissection split longus colli muscles and anterior longitudinal ligament

be aware of sympathetic chain that lies on longus colli lateral to vertebral body

subperiostally disect to expose anterior surface of vertebral body

retract longus colli muscles and ALL laterally

identify level with needle in disc space and lateral xray

Structures at Risk

Recurrent laryngeal nerve

injury rate 2.3% (same injury rate for left RLN and right RLN)

left RLN 

ascends in neck in tracheoesophageal groove after branching off from parent nerve the vagus at the level of the arch of the aorta  

right RLN 

runs alongside the trachea in the neck after hooking around the right subclavian artery

crosses from lateral to medial to reach midline

more vulnerable than left during exposure because 

it has a more variable course

lies more anterolateral

protect by placing retractors under medial edge of longus colli muscle

Sympathetic nerves and stellate gangliondamage or irritation causes Horner's syndrome 

characterized by ptosis, anhydrosis, miosis, enophthalmos and loss of ciliospinal reflex on the affected side of the face

caused by injury to sympathetic chain, which sits on the lateral border of the longus colli muscle at C6

protect by subperiosteal dissection of longus colli muscles from midline

Carotid sheath and contents

protected by the anterior border of SCM

be careful with lateral retractor placement

Postoperative retropharyngeal hematoma 

presents with respiratory difficulties 

tense hematomas should be emergently decompressed if causing respiratory compromise 

physical exam will show a tense mass under the incision

most common cause is postsurgical edema 

 

5

Volar Approach to the Radius

Henry's approach

Access 

provides exposure to the volar aspect of the radial shaft

Indications 

ORIF of proximal radius and radial shaft fractures

radial osteotomy

tumor/abscess biopsy and excision

anterior exposure of bicipital tuberosity

superficial radial nerve compression syndrome (Wartenberg Syndrome)

    

Internervous Plane

 Proximally between: 

brachioradialis (radial nerve)   

pronator teres (median nerve)  

Distally between: 

brachioradialis (radial nerve) 

FCR (median nerve) 

 

Preparation

 Position 

place arm supine on table with armboard and supinate arm

  

Approach

Incision longitudinal incision 

begin just lateral to biceps tendon on flexor crease of elbow

end at radial styloid process 
 

Superficial dissection 

incise the deep fascia in line with skin incision

develop a plane between BR and FCR distally

move proximal to develop plane between PT and BR

identify the superficial radial nerve beneath BR

ligate the branches of the radial artery to aid lateral retraction of BR
 

Deep dissection - proximal third 

follow the biceps tendon to its insertion on the bicipital tuberosity

radial to the insertion of biceps tendon incise the bursa to gain access to the proximal part of radius (radial artery which runs along the ulnar side of the biceps tendon)

fully supinate the forearm to displace the PIN radially and bring the origin of the supinator muscle into the anterior aspect of the radius

incise the supinator muscle along the line of its broad insertion and continue subperiosteal dissection laterally
 

Deep dissection - middle third 

pronate the forearm to bring the insertion of the pronator teres, along the radial aspect of the radius, into view

detach the pronator insertion from bone and retract medially
 

Deep dissection - distal third

partially supinate the forearm

dissect the periosteum off the lateral aspect of the distal third of the radius, lateral to the pronator quadratus and flexor pollicis longus

 

  








 

Dangers

Posterior interosseous nerveenters the supinator muscle beneath a fibrous arch known as the arcade of Frohse

the arch is formed by the thickened edge of the superficial head of the supinator muscle

compression of the nerve at this point produces paralysis or dysfunction of the extensors known as posterior interosseous nerve entrapment syndrome

step to protect the PIN include

dissecting supinator off radius subperiostally

do not place retractors on posterior surface of radial neck

avoid excessive radial retraction of supinator

injury

injury leads to a neuropraxia that takes 6-9 months to resolve

Superficial radial nerve

runs down forearm under body of brachioradialis

vulnerable with manipulation of mobile wad of three

damage to it can cause a painful neuroma

Radial artery

runs down middle of forearm under brachioradialis

  


 

 

6

DIrect Lateral Hip approach

 

essential what I did for hemis

Indications total hip arthroplasty 

has lower rate of total hip prosthetic dislocations 

proximal femur fracture

 

Plane

Internervous plane

no true internervous plane 

Intermuscular plane

splits gluteus medius distal to innervation (superior gluteal nerve)

vastus lateralis is also split lateral to innervation (femoral nerve)

 

Preparation

Anesthesia options 

general

spinal

Position

lateral

supine

 

Approach

Incision 

begin 5cm proximal to tip of greater trochanter

longitudinal incision centered over tip of greater trochanter and extends down the line of the femur about 8cm

Superficial dissection 

split fascia lata and retract anteriorly to expose tendon of gluteus medius

detach fibers of gluteus medius that attach to fascia lata using sharp dissection

Deep dissection split fibers of gluteus medius longitudinally starting at middle of greater trochanter  

do not extend more than 3-5 cm above greater trochanter to prevent injury to superior gluteal nerve 

extend incison inferior through the fibers of vastus lateralis

develop anterior flap 

anterior aspect of gluteus medius from anterior greater trochanter with its underlying gluteus minimus

anterior part of vastus lateralis

requires sharp dissection of muscles off bone or lifting small fleck of bone

expose anterior joint capsule  

follow dissection anteriorly along greater trochanter and onto femoral neck which leads to capsule

gluteus minimus needs to be released from anterior greater trochanter
 

Structures at Risk

Superior gluteal nerve

runs between gluteus medius and minimus 3-5 cm above greater trochanter 

protect by  

limiting proximal incision of gluteus medius

putting a stay suture at the apex of gluteal split

leads to Trendelenburg gait pattern 

Femoral nerve

most lateral structure in neurovascular bundle of anterior thigh

keep retractors on bone with no soft tissue under to prevent iatrogenic injury

7

Anterior Hip Approach

Provides exposure to 

hip joint

ilium

Indications 

THA

open reduction of congenital hip dislocations

synovial biopsies

intra-articular fusions

excision of pelvic tumors

pelvic osteotomies

irrigation and debridement of infected, native hip

 

Planes

Internervous plane-Superficial   

sartorius (femoral n.) 

tensor fasciae latae (superior gluteal n.) 

Internervous plane-Deep 

rectus femoris (femoral n.) 

gluteus medius (superior gluteal n.) 

 

Position and Preparation

Anesthesia options include 

block vs. general anesthesia

Position 

supine

 

Approach

Incision 

make incision from anterior half of iliac crest to ASIS

from ASIS curve inferiorly in the direction of the lateral patella for 8-10 cm 

Superficial dissection 

identify gap between sartorius and tensor fasciae latae

dissect through subcutaneous fat (avoid lateral femoral cutaneous n.)

incise fascia on medial side of tensor fascia latae

detach origin of tensor fasciae latae of iliac to develop internervous plane

ligate the ascending branch of the lateral femoral circumflex artery (crosses gap between sartorius and tensor fascia latae)

Deep dissection 

identify plane between rectus femoris and gluteus medius

detach rectus femoris from both its origins

retract rectus femoris and iliopsoas medially and gluteus medius laterally to expose the hip capsule

adduct and externally rotate the hip to place the capsule on stretch

incise capsule with a longitudinal or T-shaped capsular incision 

dislocate hip with external rotation after capsulotomy is complete

Proximal extension indications 

bone graft harvest

dissection 

extend proximal incision posteriorly along the iliac crest

Distal extension indications 

intra-operative fracture of distal femur

dissection 

lengthen skin incision downward along anterolateral aspect of thigh

incise fascia latae in line with skin incision

stay in the interval between the vastus lateralis and rectus femoris 




 

 

Dangers

Lateral femoral cutaneous nerve reaches thigh by passing under inguinal ligament 

the course is variable and the LFCN can be seen passing medial or lateral to ASIS 

most commonly seen when incising fascia between the sartorius and the tensor fascia latae

injury may lead to painful neuroma or decreased sensation on lateral aspect of thigh

Femoral nerve

should remain protected as long as you stay lateral to sartorius muscle

Ascending branch of lateral femoral circumflex artery  

found proximally in the internervous plane between the tensor fascia latae and sartorius

be sure to ligate to prevent excessive bleeding

8

Posterior Hip

Southern Moore Approach

Provides exposure to 

acetabulum

proximal femur

Indications 

THA 

hip hemiarthroplasty

removal of loose bodies

dependant drainage of septic hip

pedicle bone grafting

Associated approachesKocher-Langenbeck 

more extensile exposure used for complicated acetabular work

same interval as posterior approach to hip

incision slightly more anterior over greater trochanter

 

Planes

Internervous plane

no internervous plane

Intermuscular planegluteus maximus 

innervated by inferior gluteal nerve

muscle split is stopped when first nerve branch to upper part of muscle is encountered

Vascular plane

superior gluteal artsupplies proximal 1/3 of muscle

inferior gluteal artery

supplies distal 2/3 of muscle

line of fat on surface of gluteus maximus marks interval

 

Preparation

Anesthesia 

general most common

Positionlateral positionindicationship arthroplasty

position of choice

posterior wall and lip fractures

skeletal traction may be used in lateral position

advantages

allows for femoral head dislocation

allows buttock tissue to "fall away" from the field

prone positionindications

transverse fractures of acetabulum

 

Approach

Incision make 10 to 15 cm curved incision one inch posterior to posterior edge of greater trochanter (GT) 

begin 7 cm above and posterior to GT

curve posterior to the GT and continue down shaft of femur

mini-incision approach shows no long-term benefits to hip function 

Superficial dissection 

incise fascia lata to uncover vastus lateralis distally 

lengthen fascial incision in line with skin incision

split fibers of gluteus maximus in proximal incision 

cauterize vessels during split to avoid excessive blood loss

Deep dissection 

internally rotate the hip to place the short external rotators on stretch 

place stay suture in piriformis and obturator internus tendon (short external rotators) 

evidence shows decreased dislocation rate when short external rotators repaired during closure

detach piriformis and obturator internus close to femoral insertion 

reflect backwards to protect sciatic nerve

incise capsule with longitudinal or T-shaped incision

dislocate hip with internal rotation after capsulotomy

Proximal extension 

may extend proximal incision towards iliac crest for exposure of ilium

Distal extension 

extend incision distally down line of femur down to level of knee

vastus lateralis may either be split or elevated from lateral intermuscular septum



 

Dangers

Sciatic nerve location initially located along posterior surface of quadratus femoris muscle 

quadratus femorus anatomy is constant; rarely damaged in setting of fracture

prevention 

extend hip and flex knee to prevent injury

use proper gentle retraction and release short external rotators (obturator internus) posteriorly to protect the sciatic nerve from traction 

treatment of injury 

treat injury with observation and use of ankle-foot orthosis

prognosis 

recovery of tibial division is good despite severe initial damage

recovery of peroneal division is dependent on severity of initial injury

Inferior gluteal arterylocation

leaves pelvis below piriformis 

treatment of injury

if cut and retracts into pelvis, flip patient, open abdomen, and tie off internal iliac artery

First perforating branch of profunda femorisat risk

during release of gluteus maximus insertion 

Femoral vesselsat risk

with failure to protect anterior aspect of the acetabulum

with placement of retractors anterior to the iliopsoas muscle 

Superior gluteal artery and nerve location
leaves pelvis through the greater sciatic notchcontents of greater sciatic notch include

superior gluteal nerve

superior gluteal artery and vein

runs over the piriformis between the gluteus medius and minimus

enters the deep surface of the gluteus medius.

do not split gluteus medius more than 5 cm proximal to greater trochanter due to risk of denervating the muscle

also at risk during the lateral (Hardinge) approach to the hip

Quadratus femoris 

excessive retraction and injury must be avoided to prevent damage to medial circumflex artery

Heterotopic ossification (HO)

debride necrotic gluteus minimus muscle to decrease incidence of HO

9

Tibia Posterolateral Approach

Exposure to 

middle two thirds of the tibia

entire fibula

use when anterior and anterior medial approach limited by skin issues

Indications 

ORIF of tibia fractures

bone grafting for nonunion or delayed union

implantation of electrical stimulators

excision or biopsy of bone lesions

osteotomy

fibula resection for fibula transfer


 

Plane

Internervous plan between  tibial nerve (posterior compartment)

gastrocnemius 

soleus 

FHL 

superficial peroneal nerve (lateral compartment)

peroneus bevis 

peroneus longus 

Preparation

Anesthesia options include 

general

spinal

peripheral nerve block

Position 

prone or in lateral position

Tourniquet 

exsanguinate limb using elevation or Esmarch

Approach

Incision longitudinal incision on lateral border of the gastrocnemius

make of desired length

Superficial dissection reflect skin flaps

take care not to damage the short saphenous vein

incise fascia

incise in line with the incision

develop intermuscular plane

develop plan between the gastrocnemius and soleus (posterior group) and peroneal muscles (lateral group)

muscular branches of peroneal artery lie with peroneus brevis proximally and may need to ligated

retract the soleus and gastrocnemius posteromedially

once done identify the origin of FHL and soleus on the posterior border of the fibula

Deep dissection detach the FHL and soleus

detach from the posterior border of the fibula and retract posteromedially

may expose entire length of fibula)

detach posterior tibialis

remove off the posterior surface of the interosseous membrane

the posterior tibial artery and nerve will be posterior to posterior tibialis and FHL

follow IOM to tibia

follow the posterior surface of the interosseous membrane to the lateral border of the tibia

release posterior tibialis and FDL of tibia

dissect the posterior tibialis and flexor digitorum longus off the posterior surface of the tibia to expose the desired segment of tibia 

Extensile measure proximal  cannot be extended into the proximal fourth of the tibia 

popliteus muscle, posterior tibial artery, and tibial nerve preclude proximal dissection

distal  

may be extended distally to become continuous with the posterior approach to the ankle

Closure loosely close the deep fascia on the lateral side of the leg 

use interrupted sutures

Structures at Risk

Short saphenous vein

Peroneal artery and branches

avoid injury by staying on the posterior surface of the interosseous membrane

branches may be ligated and coagulated

Posterior tibial artery and nerve 

avoid injury by staying on the posterior surface of the interosseous membrane

 

10

Medial Hip Approach

Indications 

open reduction of congenital hip dislocation

psoas release (approach gives excellent exposure to psoas tendon)

biopsy and treament of tumors of the inferior portion of the femoral neck and medial aspect of proximal femoral shaft

obturator neurectomy

    

Plane

Superficial  

no superficial internervous plane as both the adductor longus and gracilis are innervated by the anterior division of the obturator nerve

Deep internervous plane between adductor brevis and adductor magnus  

adductor brevis supplied by the anterior division of the obturator nerve

adductor magnus has dual innervation

adductor portion is supplied by the posterior division of the obturator nerve

ischial portion by the tibial portion of the sciatic nerve

  
 

Preparation

Position 

patient is supine with the affected hip in a flexed, abducted, and externally rotated position 

 

Approach

Incision

longitudinal incision over the adductor longus 

begin incision 3 cm below the pubic tubercle

length of incision is determined by the amount of femur that needs to be exposed

Superficial dissection 

develop plane between gracilis and adductor longus muscles

Deep dissection develop plane between adductor brevis and adductor magnus until you feel lesser trochanter on the floor of the wound

 protect posterior division of the obturator nerve

isolate psoas tendon by placing narrow retractor above and below lesser trochanter

 



 

Dangers

Medial femoral circumflex artery

passes around medial side of the distal part of the psoas tendon  

at risk in children when releasing psoas tendon 

 must isolate psoas tendon and cut under direct vision 

Anterior division of obturator nerve

supplies adductor longus, adductor brevis,and gracilis in the thigh

Posterior division of obturator nerve

lies within substance of oburator externus

supplies adductor portion of adductor magnus

Deep external pudendal artery

at risk proximally

lies anterior to pectineus near the origin of the adductor longus