Download Approaches to the knee

Knee
Approach
Indication
Position
Medial
Parapatellar
TKR
I&D
ORIF distal
femur
Supine
Sandbag to
int rot leg
Sandbag to
support heel
w/ knee @
90 degrees
+ tourniquet
Medial
approach
Repair of
medial
ligaments
Medial
meniscus
surgery
Supine
Tourniquet
Internervous/
Intermuscular
plane
Intermuscular:
Rectus femoris
(Femoral) +
vastus
medialis
(Femoral)
Incision
Superficial dissection
Deep dissection
Dangers
5cm above
superior pole of
patella to tibial
tubercle straight
incision
Dislocate patella + flip
laterally
Flex knee to 90 to expose
knee joint
none
Long curved
incision 2cm
prox to
adductor
tubercle – start
midline and end
6cm below joint
line
Divide sub cut tissues
Deepen dissection b/w
vastus medialis + quads
tendon
Develop medial skin flap to
expose quads tendon,
medial border of patella
Perform medial parapatellar
arthrotomy
Excise infrapatellar fat pad
Raise skin flaps to expose
fascia
Sacrifice infrapatellar branch
of saphenous nerve
Superior lateral genicular
artery: at risk during lateral
retinacular release
Infrapatella branch of
saphenous N: becomes
subcutaneous on medial
aspect of knee
Skin necrosis: increased if
revision surgery – cross old
incisions at 90 degrees
Infrapatellar branch of
saphenous N
Saphenous vein – b/w
Sartorius + gracilis
Medial inferior genicular
artery – under medial head
of gastrocs
Popliteal artery – adjacent
to medial head of gastrocs
Incise anterior border of
Sartorius and retract
posteriorly w/ gracilis +
semitendinosis. Continue
either anterior OR
posterior to superficial
medial collateral lig.
Anterior: Longitudinal
medial parapatellar
incision to access joint
Posterior: separate
medial head of gastroc
from semimembranosus
and posterior capsule
Lateral
approach
Lateral ligament
repair
Lateral
Meniscus repair
Supine
Tourniquet
ITB (sup glut
N)
Biceps femoris
(Sciatic N)
3cm lateral to
edge of patella
to 4-5cm distal
to joint –
centred on
Gerdy’s tubercle
Mobilize skin flaps
Incise fascia between ITB +
biceps femoris
Retract ITB anteriorly +
biceps femoris posteriorly
Retract lateral head of
gastrocs posteriorly
Either anterior or
posterior to LCL
Posterior
Posterior tibial
plateau #
Exploration of
popliteal artery
Prone
Slightly
flexed knee
None gastrocnemius
S-curve invision:
lateral over
biceps femoris,
across flexor
crease and
extending
distally along
medial head of
gastrocs
Full thickness
fasciocutaneous flaps
Sural N and short saphenous
vein should be protected at
distal apex run superficially
Retract gastrocs laterally
to expose capsule
Elevate popliteus + soleus
subperiosteally off tibia
Common peroneal: at risk
on posterior border of
biceps femoris
Popliteal artery: at risk
posterior to posterior horn
of lateral meniscus
Popliteus tendon: attaches
to posterior aspect of
lateral meniscus
Lateral superior genicular
artery (b/w femur + vastus
lateralis)
Lateral inferior genicular
artery (b/w lateral head of
gastrocs + posterolateral
corner)
Popliteal artery
Tibial N
Sural N and short
saphenous vein: superificial
dissection at distal apex of
popliteal fossa