Surgical Approaches Short Notes - Henry Dushan Atkinson FRCS Tr & Orth November 2006

NOTES ON SURGICAL APPROACHES - Dushan Atkinson

ANKLE

ANTEROLATERAL

Universal approach supine. Sand bag under buttock

-I: med and parallel to fibula curving distally towards 4 ^th MT

-divide fascia and sup and inf extensor retinacula

-between EDL and peron. Tertius, can release EDB retract ant.

CARE:superf. peroneal N. crosses! retract medially. Also perforating peroneal artery on lateral side.

NB:excellent view of anterolat ankle & most of tarsus

-: cant see med ankle nor navic / med 2 cunieforms

ANTERIOR

-I: ant longitudinal 7.5 cm prx, 5cm distal.CARE SPN lat.

-between EHL and EDL

-CARE:identify n/v (DPN) bundle and retract medially

-thru periosteum/capsule and synovium:

full view ant ankle/both malleoli, Arthodesis/Arthroplasty.

NB Nicolaadvises approach Tib Ant/EHL retrac NV laterally

POSTEROLATERAL

Gatellier and Chastang pt prone

-I: along posterolat edge of T.A. (or midway TA and fib)

-retract TA., excise fat, go between peronei and FHL

-CARE: keep lat to FHL to protect Post tibial A & N.

watch sural nerve inferiorly and medially, and peroneal artery along post inteross membrane

TRANSFIBULAR

if fibular not #d can divide 10cmprox to tip, divide Ant tib fib ligs and interosseous

membrane. Preserve post tib fib lig,CFL and ATFL as hinge. Screw fix fibular and

syndesmosis at end.

POSTEROMEDIAL

clubfoot, talocalcaneal bar resection.supine

I: halfway between TA and medial tibia 5cm prox.

At level of MM curve anteriorly to navicular tuberosity.

Split deep fascia and flex retinac longit.

Silastic sling NV bundle, retract post. Tib postretract ant

MEDIAL

Colonna and Ralston mod. Of Broomhead

I: 10cmprox and 2.5cm post to MM, curve to centre of MM, then 4cm post inferiorly to heel

Incise Flexretinac and retract n/v and FHL post-lat;

Retract tib post and FDL anter. Expose post tib #

MEDIAL(transmalleolar)

Koenig and Schaeffer Expose talus. OCD ofankle/talus

I: curve prox to MM.

Pre-drill MM. Divide with osteotome, preserve deltoid

Cancellous screw at end +/- wire.

Watch Saph N V anteriorly

FOOT

LATERAL

Ollier subtalar/Grice/triple/calcaneo navicular bar resection. Supine, sandbag buttock:

I: 3cm distal to LM curve anteriorly to dorso-lateral TNJ

Incise IER in incision line. Retract EDL/tertius medially and peroneii inferiorly. Divide EDB and retract distally. Sinus tarsi.

I:L-shaped. Vertical lat to TA, trans plantar/lat skin junction. to CCJ

Incise straight down to bone. Full thickness flap. Dissect flap anteriorly stay onbone. Sural N and peroneii in flap. Can Z-divide peroneii, if needed. Bent K-wire retractors in talar neck and fibula.

Suction drain and sutures for 3/52

DORSOLATERAL

CCJ/5 ^th MT I: LM to 5 ^th MT CARE SuralN. release/retract EDB ant.

MEDIAL

(cont Posteromed ankle incision) from MM to navicular tuberosity

Identify AbH on medial side of 1 ^st MT. Turn it down. Exposemidfoot.

DORSAL 1 ^st Ray

basalosteotomy 1 ^st MT.

I: medial and parallel to EHL from Nav tuberosity to 1 ^st MT

MEDIAL 1 ^st MTPJ

Distal osteotomy, arthrodesis I: 7cm centred over medial MTPJ

Reflect skin flap CARE: dorsomedial cut nerve (SPN branch)

DORSAL 2-4 ^th MTPJs

I: parallel to extsor tends over web-spaces. Retract dors dig. nerves.

DORSAL approach Mortons.

I: over webspace. Deep fascia in line with incision.

Divide transverse intermetatarsal lig.

Separate MT heads self-retainer. Push on sole to bring nerve up.

TOE IPJ

Great toe medial incision. 5 ^th toe lateral incision.

2-4 ^th lateral to extensor tendon. Retract nerves away.

Longit or transverse capulotomy.

ANTERIOR

-I: curved on either side of anterior border. Reflect skin.

-CARE: poor soft tiss cover. Tib ant and EHL cross distal 1/4 .

MEDIAL

Phemister+: useful for non-union work/ compartment syndrome

-I: along posteromed border tibia.

-open fascia and stick to bone. Retract soleus posteriorly. Fascia of sup/deep is behind with FDL under it

POSTEROLAT

Henry -pt prone/on side Non-unions and poor antero/ med skin

-I: 13cm prox to LM. along lat border gastroc /fibula

-develop plane between gastoc/soleus and peronei down to fibula then stick to bone Strip FHL off post fibula and retract posteriorly.

Pass medially on-bone keeping on i/o membrane by stripping tib post off it. Retract tib post posteriorly with FHL thereby protecting N/V bundle (tib N posttib A).

CP NERVE

- Prone,sand bag under ASIS. Neurol repair.

I:curvilinear post-med border biceps curves forward dist to fib head

Open fascia in line with wound. Nerve there!

Develop plane betw LH gastroc and B femoris. CARE Lat cut N calf.

Divide prox Per Longus. Expose DPN SPN.

KNEE

ANTERIOR

-Variations : med or lat parapatellar arthrotomy; Inf geniculate A

Quads snip; Patella turndown; tib tuberosity osteotomy

CARE: medially infrapatellar branch of Saph N.

MEDIAL

Hoppenfeld & Deboer MCL repair. Tib Plat ORIF

Supine. Hip ER. Knee flexed 30 deg. Foot on opposite shin.

I: Tib tuber to 3cm med to patella up to 2cm above adductor tubercle.

Cut and bury or retract infrapatellar N (saph branch).

Longit fascial incision at sartorius attachment and retract posteriorly. Can take back all pes anserinus. Take vast med sup/anteriorly.

LATERAL

Orif plateau,LCL PLC repair. Supine. Sand bag. Kneeflex 90 deg

I: Curved incision ant to Biceps tendon, extend ant or post to IT band.

Incise between IT band and biceps. CARE CPN posterior to biceps.

Retract ITB ant, biceps post. Down onto LCL and PLC capsule. Avoid meniscus by incising 2cmproximal to joint line

MENISCAL SUTURE

Inside out:Make skin incision first [more posterior than u think] dissect down to capsulethen can retrieve sutures through it.

MM- saphenous N @ risk [runs hands breadth post to med border of Patella]

LM- CPN @risk keep all sutures anterior to [or through] biceps.

POSTEROMEDIAL

for exc. politeal cysts, reattachment of avulsed PCL

pt prone/or supine Hip ER and knee flexed.

-I: oblique incision. Adductor tubercle to posterior tibial margin.

-find edge of sartorius, retract posteriorly (Saph N protected behind). Keep ant to medhead of gastroc. Incise capsule.

POSTERIOR

Brackett & Osgood post menisci, PCL. Prone knee slightly flexed.

-Joint-line well below flexure crease in pop fossa.

-I: 10cmprox lazy S centre poplit space (prox limb Medial Semiten) 5cm distally over lat head of gastroc.

CLUE:Identify Sural N (post cut N calf), between heads of gastrocs. And short saph V lateral to it (MIDLINE). Trace thru deep fascia to origin (Tib N) proximally in pop fossa. Expose tibial N distally as far as branches to heads of gastocnemiae, then proximally to CPN; Divide Med Gastroc at origin and reflect laterally to protect vessels. next dissect popliteal A & V lying ant andmed to tibial N.

Expose the superomed and superolat genicular vessels [just prox to gastroc origins]. -The middle genicular vessels may need ligation Incise capsule; down to PCL.

FEMUR