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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