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Surgical Approaches to Bones and Joints
SURGICAL APPROACHES TO BONES AND JOINTS JOHN J.FAHEY, M.D., F.A.C.S.*
THIS presentation will be limited to certain approaches that have been found useful in exposing the long bones and joints of the lower extremity. No attempt will be made to describe all the exposures, as this subject has been well presented in a few books devoted to approaches to bones and joints,!' 2 and in a chapter in one of the orthopedic texts. 3 The proper exposure of a bone or joint aids in avoiding nerve injury and reducing hemorrhage, it minimizes muscle and soft tissue damage, healing is more prompt, and adhesions and scar formation are much less likely to occur. Screws, plates and other means used to accomplish fixation wiIl require removal less frequently because of irritation, pressure and bursa formation, if muscles are properly separated at operation. The application of a Martin bandage or a pneumatic tourniquet reduces blood loss and makes the operative field easier to visualize, thereby reducing the operative time and enhancing the chances of better technic. There is less requirement for repeated sponging, ligating vessels, and other factors which are unfavorable to healing. The extremity is elevated, and a Martin bandage is wrapped from the toes upward, each turn just overlapping the edge of the previous one. A towel which is triple folded is placed around the thigh, and the first three turns of the tourniquet are made loosely, before it is tightened. If the first few turns of the Martin bandage are made extremely tight, and at one place, there is a likelihood of the tourniquet twisting like a cord and damaging the muscles. This is particularly true where the thigh is heavy or the individual is obese. Bending the knee before the tourniquet is applied may prevent damage to the quadriceps, because when the tourniquet is applied with the knee straight, and the knee is flexed during the operation, there is a possibility of a partial rupture. A Steinman pin inserted anteroposteriorly through the soft tissues above the greater trochanter, and the application of a tourniquet above it, make possible a higher bloodless field on the thigh. The length of time a tourniquet may saJely be left in place depends upon the age of the patient, the circulatory status of the extremity, and the skill with which it has been applied. If these conditions are optimum, one hour and fifteen minutes is safe. Unusual prolongation of time may result in nerve and vascular damage. Where one might suspect that large vessels have been cut, before the wound is closed the tourniquet may be released and the vessels ligated, thus preventing a troublesome hematoma. In most instances, however, a pressure dressing after the wound is closed wiIl control the hemorrhage. From the Department of Orthopedic Surgery, University of Illinois College of Medicine, Chicago. * Assistant Professor of Orthopedic Surgery, University of Illinois College of Medicine; Senior Attending Orthopedic Surgeon, St. Francis Hospital, Evanston, Illinois. 65
GG
JOHN J. FAHEY
HIP JOINT EXPOSURES FOR DRAINAGE
In cases of pyogenic arthrosis which require drainage, an anterior incision may be used. This incision extends from the anterior superior spine downward for 4 or 5 inches. The sartorius is separated from the tensor muscle, and the capsule exposed and incised. The hip may be drained through a lateral approach, such as is used for nailing intracapsular femoral neck fractures. The tendinous portion of the vastus lateralis is turned downward from the trochanter, the distal portion of the capsule is cut from the intertrochanteric line, and the hip joint is exposed. The posterior approach, described by Ober,4 is usually more satisfactory because it takes advantage of gravity. This incision is made over the posterior portion of the femoral neck, in line with the posterior superior spine and the midportion of the greater trochanter. The fibers of the gluteus maximus are divided, and the obturator internus, superior and inferior gemelli muscles may be cut! inch from their insertion, and the posterior hip capsule opened. HIP EXPOSURES FOR RECONSTRUCTIONS, ARTHROPLASTIES AND FRACTURES
The supra-articular subperiosteal approach described by SmithPetersen5 affords good exposure for the femoral head and neck, in many types of reconstructive operations about the hip. The same author, in his works on acetabuloplasty 6 and arthroplasty, 7 showed how the sartorius and iliacus could be reflected and the straight head of the rectus femoris cut, exposing the anterior acetabular wall. Preservation of the stump of the rectus tendon and the anterior inferior iliac spine frequently requires revision of the primary operation, because of calcification and spur formation in the stump. To obviate this complication, Smith-Petersen recently suggested that the direct head of the rectus be divided at its origin from the anterior inferior spine and reflected laterally, without being dissected from its sheath. The inferior half of the anterior inferior iliac spine is then sacrificed. 8 Most intracapsular fractures of the neck of the femur can be manipulated and internal fixation performed through a lateral approach, with x-ray control. An incision is made on the posterolateral aspect of the femur (Fig. 35) from the middle of the greater trochanter downward, the length depending on the particular operation. The fascia lata is cut posterior to the tensor muscle. The vailtus lateraJis is then retracted anteriorly from the shiny attachment of the fascia lata to the bone, anterior to the gluteus maximus insertion, forming the upper portion of the lateral intermuscular septum. No retraction is required posteriorly. This incision exposes the upper end of the femur for osteotomy, blind hip nailing, biopsy, excision of tumors, or other operative procedures in this region, with little blood loss and minimal damage to the large vastus lateralis muscle. 9
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This incision permits excellent exposure in cases in which the blaue plate is used for osteotomy or intertrochanteric fractures. The large plate is covered by relatively undamaged muscle, avoiding bursa formation and even subsequent drainage, which require removal of the plate. If the posterior tendinous fibers of the vastus lateralis is cut from its origin to the posterior portion of the trochanter (Fig. 36), in cases that require a long exposure, such as is necessary in using the blade plate, retraction anteriorly of the vastus lateralis muscle will be facilitated. When the incision extends this l~ngth, it is advisable to locate and clamp a few perTensor fasciae
f~rnoris In.,
B.
c. Fig. a5.-Drawing showing lateral approach to the upper femur for hip nailing, blade plate for osteotomy and trochanteric fractures, trochanteric transplants, and other operative procedures. The vastus lateralis is separated from the fascia lata attachment to the bone, anterior to the gluteus maximus insertion, and retracted forward.
forating vessels that pierce the lateral intermuscular septum, to prevent them from retracting. HIP EXPOSURES REQUIRING VIEW OF FEMORAL NECK AND SUBTROCHANTERIC REGION
In certain operations about the hip, such as open reduction of fractures, osteotomy of the femoral neck, and fixation for· slipped femoral epiphysis, it is necessary to expose not only the femoral neck and head, but the subtrochanteric region laterally (Fig. 37), in order to introduce a pin or nail up into the femoral neck and head. A similar exposure is desirable in per-
68
JOHN J. FAHEY
Fig. 36.-Photograph of same approach as in Figure 35. If the posterior fibers of the vastus lateralis to the trochanter are cut in instances where the exposure is long, as in blade plate fixation, it will facilitate forward retraction of the muscle.
---------
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:
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(,:~'(:
,''''' ~-, \,
--.
~~ Elevation of vast.lat.:m.. by Chandler elevator
Headof- . fenlur posed by Cross incision of capsule
Ten.sor fa~;ciale~~~~~~ femoris
B. Fig. 37.-Exposure for femoral head and trochanteric region. A straight incision extends from the anterior superior spine to the lower region of the trochanter. The tensor muscle is separated from the sartorius, and the fascia lata is cut transversely below the muscle. The rectus femoris is cut if indicated, and the psoas retracted medially. The entire vastus lateralis is retracted anteriorly.
SURGICAL APPROACHES TO BONES AND JOINTS
69
forming the Brackett and Whitman reconstructions, where the trochanter is transplanted downward. A straight incision extends from the anterior superior spine to below the bulge of the trochanter. The skin is retracted medially, and the plane is developed between the tensor fascia femoris and sartorius. At the lower portion of the tensor muscle, the fascia is cut transversely. The straight head of the rectus is cut just below its origin from the anterior inferior iliac spine. The ascending and lateral branches of the lateral circumflex artery are tied as they pass beneath the rectus muscle. The psoas muscle is then identified and separated from the capsule of the hip, and retracted inward with a Chandler retractor, in the iliac fossa. The capsule of the hip is then opened longitudinally and cut transversely about ! inch from the acetabular rim. The vastus lateralis muscle is then retracted anteriorly from the lateral intermuscular septum. If the trochanter is transplanted downward, or the exposure is long on the upper shaft, the posterior tendinous fibers of the vastus lateralis are cut from the trochanter. In exposing fractures of . the femoral neck, it is usually not necessary to cut the straight head of the rectus, but it gives better exposure for the reconstructive procedures. POSTERIOR HIP APPROACHES
The Kocher incision1o for drainage has already been described. If the acetabular rim is to be repaired for fractures, or the sciatic nerve is explored, a satisfactory view can be accomplished by Osborne's incision. l l This incision begins I! inch below and lateral to the posterior superior iliac spine, extends to the superior portion of the trochanter, and runs downward along the posterior portion of the trochanter for a few inches. The fibers of the gluteus maximus muscle are separated, and the insertion of the muscle cut. The obturator internus and gemelli muscles are sectioned! inch from their insertion and retracted laterally. Exposure of the lesser trochanter is easily accomplished by a posterior approach. With the patient in a prone position, an incision is made on the posterior lateral aspect of the thigh, beginning 2 inches above the top of the greater trochanter. The plane between the vastus lateralis and fascia lata is established, and the gluteus maximus and quadratus femoris insertions are cut and reflected, and the lesser trochanter is exposed after the upper portion of the psoas is detached. APPROACHES TO THE FEMORAL SHAFT
The type of exposure used will depend upon the type of pathologic involvement and its particular location in the femoral shaft. The anterolateral incision12 is made on a line between the anterior superior spine and the anterior portion of the lateral femoral condyle. The rectus femoris is separated from the vastus lateralis, and the fibers of the vastus intermedius muscle are incised. This incision is particularly suitable for lesions involving the anteromedial portion, as it permits good visualiza-
JOHN J. FAHEY
70
tion. It is unsuitable for securing good drainage, and is more likely to interfere with the return of knee function, because of the damage to the quadriceps. H enry2 uses this incision for the upper and lower thirds, as well as the midportion. However, the descending branches of the external circumflex artery and the femoral nerve branches to the vastus lateral is and vastus intermedius are encountered in the upper third, and may be damaged. In the 10\\"er third of the femur, the vastus lateral is is closely adherent to the other muscles, forming the quadriceps, and one must be eareful to avoid the quadrieeps pouch. The posterolateral exposure is frequently desirable. The patient is turned on the uninvolved side, or best with feet strapped to the foot of a
j Sartorius
TIl.
I
- \ - --Fascia lata-- --
B.
C
I
Fig. 38.-Exposure of the lower medial aspect of the femur. The incision is made over the lower one-fourth of the posteromedial aspect of the femur, and the vast us medialis separated from the adductor magnus. If a mOTe posterior exposure if! desirable, the adductor is detached subperiosteally.
tilted Albee-Compel' table. The ineision extends from the posterior portion of the trochanter to the lateral portion of the patella, and the vaHtus lateralis is separated from the lateral intermuscular septum. It is difficult to retract this muscle sufficiently for exposing the anterior and medial portions of the femur in extensive reconstruetions, and lower down, perforating vessels pierce the later?>l intermuscular septum, to reach the vastus lateralis muscle. However, in the upper third of the femur this approaeh has a deeided advantage, as there are only a few small perforating vessels and less retraetion is required to expose all portions of the femur, the extensive nerve supply to the vastus lateralis and intermedius
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71
is not disturbed, and the muscle is not likely to be torn. This approach is especially suited to certain types of bone plating and in some cases of osteomyelitis, and has the advantage that the complete muscle flap covers the bone. It is particularly valuable in obtaining proper drainage. If it is advisable to approach the posterior aspect of the shaft of the femur, the operation is best performed with the patient in a prone position, using the approach described by Bosworth. 13 A posterior midline incision is made and may extend from the popliteal space to the gluteal fold. If the upper portion of the femur is to be exposed, the approach is lateral to the long head of the biceps. In the lower femoral approach, the entrance is medial to the long head of the biceps and sciatic nerve. In exposing the entire middle three-fifths of the femur, the lower attachment of the long head of the biceps is divided and retracted medially with the sciatic nerve. This exposure may be objectionable from the standpoint of necessitating the .administration of anesthesia with the patient in a prone position, and the danger of injurin,,; the sciatic nerve from pressure. Because of the possibility of involvement of the sciatic nerve, this approach is not advisable for drainage in cases of osteomyelitis. However, it may prove a valuable exposure in cases of scarring and drainage anteriorly, or for biopsy and resection of discrete benign bone lesions. For lesions involving the medial and posterior portions of the lower one-third, the incision is made over the lower third, extending upward from the adductor tubercle (Fig. 38). The sartorius is retracted posteriorly, and the vastus medialis is separated from the adductor magnus tendon and retracted laterally. The adductor magnus tendon may be freed subperiosteally if it is necessary to expose the posterior portion of the femur in this region. EXPOSURES OF THE KNEE JOINT
For draining pyogenic arthrosis of the knee, an incision is made on each side of the patella, extending from the quadriceps pouch to just below the joint level, a few inches long, and the synovial membrane is sutured to the skin. A small straight incision may be all that is necessary to remove a loose body or perform a biopsy on the joint. Frequently when the knee is explored, it is improtant to visualize the entire joint in order properly to remove a torn cartilage and inspect the opposite one, or to determine the source of the loose body or other pathologic condition. The median parapatellar incision is an excellent approach for exploration of the joint, removal of loose bodies, synovectomy, and repair of a fractured patella. The incision begins over the medial portion of the quadriceps tendon above the upper border of the patella, curves downward along the medial margin of the patella and patellar tendon, and ends just inferior to the tibial tubercle. The vastus medialis is cut from its attachment to the rectus tendon high enough so that the patella
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JOHN J. FAHEY
can be dislocated over the condyle of the femur. The knee is flexed and both sides of the joint can be explored. The posterior and medial compartment of the knee joint can be exposed by a longitudinal incision extending from just in back of the medial femoral epicondyle to the medial side of the tibia. The capsule is incised anteriorly to the sartorius muscles and the posterior part of the knee is explored.
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Gastro.cnemius &soleusxn
B
Fig. 39,-Drawing showing posterior approach to the tibia, With the patient in the prone position, a posterolateral incision is made, and the gastrocnemius and soleus separated from the peroneal muscles, and retracted medially. The flexor hallucis longus is removed subperiosteally from the posterior surface of the fibula, and with the posterior tibial muscle and the long flexor of the toes, retracted medially. These muscles are not shown in the drawing,
An incision for exposing the posterior lateral compartment of the knee has been described by Henderson.H It is made on the lateral side of the knee, anterior to the head of the fibula and biceps tendon. The biceps is retracted posteriorly and the joint opened. APPROACHES TO THE TIBIA
Usually the tibia is approached through a straight longitudinal incision over the medial surface of the tibia, or by a curved incision with its convexity posterior. The curved incision has the advantage of having the scar over the soft tissue, rather than the bone. When the operation
SURGICAL APPROACHES TO BONES AND JOINTS
73
can be performed on the lateral tibial surface, and it is desirable not to have the incision on the medial aspect, the incision can be made with its convexity laterally, but one should avoid having it pass transversely over the crest above and below. In certain instances in which scarring or anterior drainage is associated with nonunion, a posterior exposure is advisable for performing a
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inCi9io'\ !i F>bwo
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Fig. 4O.-Drawing showing Henry's approach to the fibula. Through a posterolateral incision, the common peroneal nerve is identified in the popliteal region, and on the lateral aspect of the fibular neck. The peroneus longus is removed from the fibula above the nerve, so that it can be retracted upward. The peroneal muscles are then separated from the gastrocnemius and soleus, and removed subperiostealy from the fibula, and retracted anteriorly.
bone graft. Such an approach has recently been described by Harmon. 15 With the patient in a prone position (Fig. 39) an incision is made in the posterolateral aspect of the leg in its lower three-fourths. The gastrocnemius and soleus are retracted medially from the peroneal muscles. The flexor hallucis longus is then reflected subperiosteally from the posterior surface of the fibula, and retracted medially. The tibialis posterior is
74
JOHN J; FAHEY
removed from the interosseus membrane and the posterior surface of the tibia and, along with the long flexor of the toes, retracted medially, exposing the posterior surface of the tibia. It would not be advisable to use this exposure for the upper one-fourth of the tibia, as one is likely to damage the large vessels. APPROACHES TO THE FIBULA
The fibula is best exposed according to the incision described by Henry.2 An incision is made from the posterior margin of the biceps tendon in the popliteal region, extending to the posterior tip of the
Fig. 41.-Anteromedial exposure of the ankle joint for arthrodesis. The flexor halluc is longus tendon and tibial vessels and nerves are retracted laterally, and tibial tendon medially. This incision affords good exposure of the lower tibia for removing a bone graft. Extension of the incision exposes the astragaloscaphoid joint.
fibula (Fig. 40). The peroneus longus, above the common peroneal nerve is detached from the lateral surface of the head of the fibula, and then the nerve is retracted above the head. The peroneus longus and brevis are retracted anteriorly, and the soleus posteriorly, after these muscles are stripped from the bone. The lower portion of the fibula is subcutaneous. APPROACHES TO THE ANKLE
Arthrodesis of the ankle and panastragular arthrodesis are two of the common operative procedures performed about the ankle. An anteromedial approach (Fig. 41) affords an excellent exposure for these pro-
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75
cedures. By retracting the long extensor of the big toe, the tibial vessels and nerve laterally, and the anterior tibial tendon medially, an excellent view of the ankle is obtained and a bone graft can easily be removed with a motor saw from the lower end of the tibia. The astragulus is easily accessible through this same view. The incision can be extended over the astraguloscaphoid joint, if one contemplates doing a panastragular arthrodesis. In order to complete the panastragular arthrodesis, an additional incision is made from the tip of the external malleolus to the base of the fourth metatarsal. The calcaneocuboid joint is exposed by osteoperiosteal flaps, as advocated by Chandler.16 The soft tissue in the sinus tarsi is removed and the peroneal tendons are retracted posteriorly. The subastragular and calcaneocuboid joints are then fused, completing the panastragular arthrodesis. SUMMARY An appreciation of the anatomical structures and the proper exposure will aid in accomplishing the optimum end result in surgery of the extremities. The type of exposure used to expose the long bones and joints will depend upon the pathology and the particular site of the bone or joint involvement. The presence of drainage or scar formation may necessitate the utilization of an exposure which avoids such areas. The use of a tourniquet and the proper position will aid in accomplishing the operation easily and skillfully. The retraction anteriorly of the entire vastus lateralis from the shiny attachment of the fascia lata anterior to the gluteus maximus insertion will simplify the surgical technic in performing fixation for femoral neck fractures, in the use of the blade plate for osteotomy and intertrochanteric fractures, and in other procedures in this region. There is less likelihood of subsequent bursa formation and other complicating factors which would require the removal of the fixing material. REFERENCES ]. Nicola, Toufick.: Atlas of Surgical Approaches to Bones and·Joints. New York, The Macmillan Co., 1945, pp. 117-209. 2. Henry, Arnold K.: Extensile Exposure Applied to Limb Surgery. Baltimore, Williams & Wilkins Co., 1946. a. Campbell, Willis C.: Operative Orthopedics, Chap. 6: Surgical Approaches. St. Louis, C. V. Mosby Co., 1939, pp.146-205. 4. Ober, Frank R.: Posterior Arthrotomy of the Hip Joint. J.A.M.A. 83:1500, 1924. 5. Smith-Petersen, M. N.: A New Supra-Articular Subperiosteal Approach to the Hip Joint. Am. J. Orthop. Surg. 15:592, 1917. 6. Smith-Petersen, M. N.: Treatment of Malum Coxae Senilis, Old Slipped Upper Femoral Epiphysis, Intra-Pelvic Protrusion of the Acetabulum, and Coxa Plana, by Means of Acetabuloplasty. J. Bone & Joint Surg. 19:869-880 (Oct.) 1936. 7. Smith-Petersen, M. N.: Arthroplasty of the Hip. J. Bone & Joint Surg. 21 :269288,1939.
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JOHN J. FAHEY
8. Smith-Petersen, M. N.: Evolution of Mould Arthroplasty of the Hip Joint. J. Bone & Joint Surg. 30(1) :59-75 (Feb.) 1948. 9. Fahey, John J.: Lectures on Regional Orthopaedic Surgery and Fundamental Orthopaedic Problems: Orthopaedic Anatomy of the Hip. J. W. Edwards, 1947, pp. 3340. 10. Kocher, Theodore: Textbook of Operative Surgery. London, A. & C. Black, Ltd., 1911. 11. Osborne, R. P.: The Approach to the Hip Joint. A Critical Review and a Suggested New Route. Brit. J. Surg. 18:49,1930-31. 12. Thomson, James E.: Anatomical Methods of Approach in Operations on the Long Bones of the Extremities. Ann. Surg. 68:309, 1918. 13. Bosworth, David M.: Posterior Approach to the Femur. J. Bone & Joint Surg. 26:687-690 (Oct.) 1944. 14. Henderson, Melvin S.: Postero-Lateral Incision for the Removal of Loose Bodies from the Posterior Compartment of the Knee Joint. Surg., Gynec. & Obst. 33: 698,1921. 15. Harmon, Paul H.: A Simplified Surgical Approach to the Posterior Tibia for Bone Grafting and Fibular Transference. J. Bone & Joint Surg. 27: 496-499 (July) 1945. 16. Chandler, Fremont A.: Personal communication.
THIS presentation will be limited to certain approaches that have been found useful in exposing the long bones and joints of the lower extremity. No attempt will be made to describe all the exposures, as this subject has been well presented in a few books devoted to approaches to bones and joints,!' 2 and in a chapter in one of the orthopedic texts. 3 The proper exposure of a bone or joint aids in avoiding nerve injury and reducing hemorrhage, it minimizes muscle and soft tissue damage, healing is more prompt, and adhesions and scar formation are much less likely to occur. Screws, plates and other means used to accomplish fixation wiIl require removal less frequently because of irritation, pressure and bursa formation, if muscles are properly separated at operation. The application of a Martin bandage or a pneumatic tourniquet reduces blood loss and makes the operative field easier to visualize, thereby reducing the operative time and enhancing the chances of better technic. There is less requirement for repeated sponging, ligating vessels, and other factors which are unfavorable to healing. The extremity is elevated, and a Martin bandage is wrapped from the toes upward, each turn just overlapping the edge of the previous one. A towel which is triple folded is placed around the thigh, and the first three turns of the tourniquet are made loosely, before it is tightened. If the first few turns of the Martin bandage are made extremely tight, and at one place, there is a likelihood of the tourniquet twisting like a cord and damaging the muscles. This is particularly true where the thigh is heavy or the individual is obese. Bending the knee before the tourniquet is applied may prevent damage to the quadriceps, because when the tourniquet is applied with the knee straight, and the knee is flexed during the operation, there is a possibility of a partial rupture. A Steinman pin inserted anteroposteriorly through the soft tissues above the greater trochanter, and the application of a tourniquet above it, make possible a higher bloodless field on the thigh. The length of time a tourniquet may saJely be left in place depends upon the age of the patient, the circulatory status of the extremity, and the skill with which it has been applied. If these conditions are optimum, one hour and fifteen minutes is safe. Unusual prolongation of time may result in nerve and vascular damage. Where one might suspect that large vessels have been cut, before the wound is closed the tourniquet may be released and the vessels ligated, thus preventing a troublesome hematoma. In most instances, however, a pressure dressing after the wound is closed wiIl control the hemorrhage. From the Department of Orthopedic Surgery, University of Illinois College of Medicine, Chicago. * Assistant Professor of Orthopedic Surgery, University of Illinois College of Medicine; Senior Attending Orthopedic Surgeon, St. Francis Hospital, Evanston, Illinois. 65
GG
JOHN J. FAHEY
HIP JOINT EXPOSURES FOR DRAINAGE
In cases of pyogenic arthrosis which require drainage, an anterior incision may be used. This incision extends from the anterior superior spine downward for 4 or 5 inches. The sartorius is separated from the tensor muscle, and the capsule exposed and incised. The hip may be drained through a lateral approach, such as is used for nailing intracapsular femoral neck fractures. The tendinous portion of the vastus lateralis is turned downward from the trochanter, the distal portion of the capsule is cut from the intertrochanteric line, and the hip joint is exposed. The posterior approach, described by Ober,4 is usually more satisfactory because it takes advantage of gravity. This incision is made over the posterior portion of the femoral neck, in line with the posterior superior spine and the midportion of the greater trochanter. The fibers of the gluteus maximus are divided, and the obturator internus, superior and inferior gemelli muscles may be cut! inch from their insertion, and the posterior hip capsule opened. HIP EXPOSURES FOR RECONSTRUCTIONS, ARTHROPLASTIES AND FRACTURES
The supra-articular subperiosteal approach described by SmithPetersen5 affords good exposure for the femoral head and neck, in many types of reconstructive operations about the hip. The same author, in his works on acetabuloplasty 6 and arthroplasty, 7 showed how the sartorius and iliacus could be reflected and the straight head of the rectus femoris cut, exposing the anterior acetabular wall. Preservation of the stump of the rectus tendon and the anterior inferior iliac spine frequently requires revision of the primary operation, because of calcification and spur formation in the stump. To obviate this complication, Smith-Petersen recently suggested that the direct head of the rectus be divided at its origin from the anterior inferior spine and reflected laterally, without being dissected from its sheath. The inferior half of the anterior inferior iliac spine is then sacrificed. 8 Most intracapsular fractures of the neck of the femur can be manipulated and internal fixation performed through a lateral approach, with x-ray control. An incision is made on the posterolateral aspect of the femur (Fig. 35) from the middle of the greater trochanter downward, the length depending on the particular operation. The fascia lata is cut posterior to the tensor muscle. The vailtus lateraJis is then retracted anteriorly from the shiny attachment of the fascia lata to the bone, anterior to the gluteus maximus insertion, forming the upper portion of the lateral intermuscular septum. No retraction is required posteriorly. This incision exposes the upper end of the femur for osteotomy, blind hip nailing, biopsy, excision of tumors, or other operative procedures in this region, with little blood loss and minimal damage to the large vastus lateralis muscle. 9
SURGICAL APPROACHES TO BONES AND JOINTS
67
This incision permits excellent exposure in cases in which the blaue plate is used for osteotomy or intertrochanteric fractures. The large plate is covered by relatively undamaged muscle, avoiding bursa formation and even subsequent drainage, which require removal of the plate. If the posterior tendinous fibers of the vastus lateralis is cut from its origin to the posterior portion of the trochanter (Fig. 36), in cases that require a long exposure, such as is necessary in using the blade plate, retraction anteriorly of the vastus lateralis muscle will be facilitated. When the incision extends this l~ngth, it is advisable to locate and clamp a few perTensor fasciae
f~rnoris In.,
B.
c. Fig. a5.-Drawing showing lateral approach to the upper femur for hip nailing, blade plate for osteotomy and trochanteric fractures, trochanteric transplants, and other operative procedures. The vastus lateralis is separated from the fascia lata attachment to the bone, anterior to the gluteus maximus insertion, and retracted forward.
forating vessels that pierce the lateral intermuscular septum, to prevent them from retracting. HIP EXPOSURES REQUIRING VIEW OF FEMORAL NECK AND SUBTROCHANTERIC REGION
In certain operations about the hip, such as open reduction of fractures, osteotomy of the femoral neck, and fixation for· slipped femoral epiphysis, it is necessary to expose not only the femoral neck and head, but the subtrochanteric region laterally (Fig. 37), in order to introduce a pin or nail up into the femoral neck and head. A similar exposure is desirable in per-
68
JOHN J. FAHEY
Fig. 36.-Photograph of same approach as in Figure 35. If the posterior fibers of the vastus lateralis to the trochanter are cut in instances where the exposure is long, as in blade plate fixation, it will facilitate forward retraction of the muscle.
---------
/ / ' . " .i\
:
I;t'1cision
(,:~'(:
,''''' ~-, \,
--.
~~ Elevation of vast.lat.:m.. by Chandler elevator
Headof- . fenlur posed by Cross incision of capsule
Ten.sor fa~;ciale~~~~~~ femoris
B. Fig. 37.-Exposure for femoral head and trochanteric region. A straight incision extends from the anterior superior spine to the lower region of the trochanter. The tensor muscle is separated from the sartorius, and the fascia lata is cut transversely below the muscle. The rectus femoris is cut if indicated, and the psoas retracted medially. The entire vastus lateralis is retracted anteriorly.
SURGICAL APPROACHES TO BONES AND JOINTS
69
forming the Brackett and Whitman reconstructions, where the trochanter is transplanted downward. A straight incision extends from the anterior superior spine to below the bulge of the trochanter. The skin is retracted medially, and the plane is developed between the tensor fascia femoris and sartorius. At the lower portion of the tensor muscle, the fascia is cut transversely. The straight head of the rectus is cut just below its origin from the anterior inferior iliac spine. The ascending and lateral branches of the lateral circumflex artery are tied as they pass beneath the rectus muscle. The psoas muscle is then identified and separated from the capsule of the hip, and retracted inward with a Chandler retractor, in the iliac fossa. The capsule of the hip is then opened longitudinally and cut transversely about ! inch from the acetabular rim. The vastus lateralis muscle is then retracted anteriorly from the lateral intermuscular septum. If the trochanter is transplanted downward, or the exposure is long on the upper shaft, the posterior tendinous fibers of the vastus lateralis are cut from the trochanter. In exposing fractures of . the femoral neck, it is usually not necessary to cut the straight head of the rectus, but it gives better exposure for the reconstructive procedures. POSTERIOR HIP APPROACHES
The Kocher incision1o for drainage has already been described. If the acetabular rim is to be repaired for fractures, or the sciatic nerve is explored, a satisfactory view can be accomplished by Osborne's incision. l l This incision begins I! inch below and lateral to the posterior superior iliac spine, extends to the superior portion of the trochanter, and runs downward along the posterior portion of the trochanter for a few inches. The fibers of the gluteus maximus muscle are separated, and the insertion of the muscle cut. The obturator internus and gemelli muscles are sectioned! inch from their insertion and retracted laterally. Exposure of the lesser trochanter is easily accomplished by a posterior approach. With the patient in a prone position, an incision is made on the posterior lateral aspect of the thigh, beginning 2 inches above the top of the greater trochanter. The plane between the vastus lateralis and fascia lata is established, and the gluteus maximus and quadratus femoris insertions are cut and reflected, and the lesser trochanter is exposed after the upper portion of the psoas is detached. APPROACHES TO THE FEMORAL SHAFT
The type of exposure used will depend upon the type of pathologic involvement and its particular location in the femoral shaft. The anterolateral incision12 is made on a line between the anterior superior spine and the anterior portion of the lateral femoral condyle. The rectus femoris is separated from the vastus lateralis, and the fibers of the vastus intermedius muscle are incised. This incision is particularly suitable for lesions involving the anteromedial portion, as it permits good visualiza-
JOHN J. FAHEY
70
tion. It is unsuitable for securing good drainage, and is more likely to interfere with the return of knee function, because of the damage to the quadriceps. H enry2 uses this incision for the upper and lower thirds, as well as the midportion. However, the descending branches of the external circumflex artery and the femoral nerve branches to the vastus lateral is and vastus intermedius are encountered in the upper third, and may be damaged. In the 10\\"er third of the femur, the vastus lateral is is closely adherent to the other muscles, forming the quadriceps, and one must be eareful to avoid the quadrieeps pouch. The posterolateral exposure is frequently desirable. The patient is turned on the uninvolved side, or best with feet strapped to the foot of a
j Sartorius
TIl.
I
- \ - --Fascia lata-- --
B.
C
I
Fig. 38.-Exposure of the lower medial aspect of the femur. The incision is made over the lower one-fourth of the posteromedial aspect of the femur, and the vast us medialis separated from the adductor magnus. If a mOTe posterior exposure if! desirable, the adductor is detached subperiosteally.
tilted Albee-Compel' table. The ineision extends from the posterior portion of the trochanter to the lateral portion of the patella, and the vaHtus lateralis is separated from the lateral intermuscular septum. It is difficult to retract this muscle sufficiently for exposing the anterior and medial portions of the femur in extensive reconstruetions, and lower down, perforating vessels pierce the later?>l intermuscular septum, to reach the vastus lateralis muscle. However, in the upper third of the femur this approaeh has a deeided advantage, as there are only a few small perforating vessels and less retraetion is required to expose all portions of the femur, the extensive nerve supply to the vastus lateralis and intermedius
SURGICAL APPROACHES TO BONES AND JOINTS
71
is not disturbed, and the muscle is not likely to be torn. This approach is especially suited to certain types of bone plating and in some cases of osteomyelitis, and has the advantage that the complete muscle flap covers the bone. It is particularly valuable in obtaining proper drainage. If it is advisable to approach the posterior aspect of the shaft of the femur, the operation is best performed with the patient in a prone position, using the approach described by Bosworth. 13 A posterior midline incision is made and may extend from the popliteal space to the gluteal fold. If the upper portion of the femur is to be exposed, the approach is lateral to the long head of the biceps. In the lower femoral approach, the entrance is medial to the long head of the biceps and sciatic nerve. In exposing the entire middle three-fifths of the femur, the lower attachment of the long head of the biceps is divided and retracted medially with the sciatic nerve. This exposure may be objectionable from the standpoint of necessitating the .administration of anesthesia with the patient in a prone position, and the danger of injurin,,; the sciatic nerve from pressure. Because of the possibility of involvement of the sciatic nerve, this approach is not advisable for drainage in cases of osteomyelitis. However, it may prove a valuable exposure in cases of scarring and drainage anteriorly, or for biopsy and resection of discrete benign bone lesions. For lesions involving the medial and posterior portions of the lower one-third, the incision is made over the lower third, extending upward from the adductor tubercle (Fig. 38). The sartorius is retracted posteriorly, and the vastus medialis is separated from the adductor magnus tendon and retracted laterally. The adductor magnus tendon may be freed subperiosteally if it is necessary to expose the posterior portion of the femur in this region. EXPOSURES OF THE KNEE JOINT
For draining pyogenic arthrosis of the knee, an incision is made on each side of the patella, extending from the quadriceps pouch to just below the joint level, a few inches long, and the synovial membrane is sutured to the skin. A small straight incision may be all that is necessary to remove a loose body or perform a biopsy on the joint. Frequently when the knee is explored, it is improtant to visualize the entire joint in order properly to remove a torn cartilage and inspect the opposite one, or to determine the source of the loose body or other pathologic condition. The median parapatellar incision is an excellent approach for exploration of the joint, removal of loose bodies, synovectomy, and repair of a fractured patella. The incision begins over the medial portion of the quadriceps tendon above the upper border of the patella, curves downward along the medial margin of the patella and patellar tendon, and ends just inferior to the tibial tubercle. The vastus medialis is cut from its attachment to the rectus tendon high enough so that the patella
72
JOHN J. FAHEY
can be dislocated over the condyle of the femur. The knee is flexed and both sides of the joint can be explored. The posterior and medial compartment of the knee joint can be exposed by a longitudinal incision extending from just in back of the medial femoral epicondyle to the medial side of the tibia. The capsule is incised anteriorly to the sartorius muscles and the posterior part of the knee is explored.
l :,~·,,··::··\ ~'.:::
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Fig. 39,-Drawing showing posterior approach to the tibia, With the patient in the prone position, a posterolateral incision is made, and the gastrocnemius and soleus separated from the peroneal muscles, and retracted medially. The flexor hallucis longus is removed subperiosteally from the posterior surface of the fibula, and with the posterior tibial muscle and the long flexor of the toes, retracted medially. These muscles are not shown in the drawing,
An incision for exposing the posterior lateral compartment of the knee has been described by Henderson.H It is made on the lateral side of the knee, anterior to the head of the fibula and biceps tendon. The biceps is retracted posteriorly and the joint opened. APPROACHES TO THE TIBIA
Usually the tibia is approached through a straight longitudinal incision over the medial surface of the tibia, or by a curved incision with its convexity posterior. The curved incision has the advantage of having the scar over the soft tissue, rather than the bone. When the operation
SURGICAL APPROACHES TO BONES AND JOINTS
73
can be performed on the lateral tibial surface, and it is desirable not to have the incision on the medial aspect, the incision can be made with its convexity laterally, but one should avoid having it pass transversely over the crest above and below. In certain instances in which scarring or anterior drainage is associated with nonunion, a posterior exposure is advisable for performing a
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Fig. 4O.-Drawing showing Henry's approach to the fibula. Through a posterolateral incision, the common peroneal nerve is identified in the popliteal region, and on the lateral aspect of the fibular neck. The peroneus longus is removed from the fibula above the nerve, so that it can be retracted upward. The peroneal muscles are then separated from the gastrocnemius and soleus, and removed subperiostealy from the fibula, and retracted anteriorly.
bone graft. Such an approach has recently been described by Harmon. 15 With the patient in a prone position (Fig. 39) an incision is made in the posterolateral aspect of the leg in its lower three-fourths. The gastrocnemius and soleus are retracted medially from the peroneal muscles. The flexor hallucis longus is then reflected subperiosteally from the posterior surface of the fibula, and retracted medially. The tibialis posterior is
74
JOHN J; FAHEY
removed from the interosseus membrane and the posterior surface of the tibia and, along with the long flexor of the toes, retracted medially, exposing the posterior surface of the tibia. It would not be advisable to use this exposure for the upper one-fourth of the tibia, as one is likely to damage the large vessels. APPROACHES TO THE FIBULA
The fibula is best exposed according to the incision described by Henry.2 An incision is made from the posterior margin of the biceps tendon in the popliteal region, extending to the posterior tip of the
Fig. 41.-Anteromedial exposure of the ankle joint for arthrodesis. The flexor halluc is longus tendon and tibial vessels and nerves are retracted laterally, and tibial tendon medially. This incision affords good exposure of the lower tibia for removing a bone graft. Extension of the incision exposes the astragaloscaphoid joint.
fibula (Fig. 40). The peroneus longus, above the common peroneal nerve is detached from the lateral surface of the head of the fibula, and then the nerve is retracted above the head. The peroneus longus and brevis are retracted anteriorly, and the soleus posteriorly, after these muscles are stripped from the bone. The lower portion of the fibula is subcutaneous. APPROACHES TO THE ANKLE
Arthrodesis of the ankle and panastragular arthrodesis are two of the common operative procedures performed about the ankle. An anteromedial approach (Fig. 41) affords an excellent exposure for these pro-
SURGICAL APPROACHES TO BONES AND JOINTS
75
cedures. By retracting the long extensor of the big toe, the tibial vessels and nerve laterally, and the anterior tibial tendon medially, an excellent view of the ankle is obtained and a bone graft can easily be removed with a motor saw from the lower end of the tibia. The astragulus is easily accessible through this same view. The incision can be extended over the astraguloscaphoid joint, if one contemplates doing a panastragular arthrodesis. In order to complete the panastragular arthrodesis, an additional incision is made from the tip of the external malleolus to the base of the fourth metatarsal. The calcaneocuboid joint is exposed by osteoperiosteal flaps, as advocated by Chandler.16 The soft tissue in the sinus tarsi is removed and the peroneal tendons are retracted posteriorly. The subastragular and calcaneocuboid joints are then fused, completing the panastragular arthrodesis. SUMMARY An appreciation of the anatomical structures and the proper exposure will aid in accomplishing the optimum end result in surgery of the extremities. The type of exposure used to expose the long bones and joints will depend upon the pathology and the particular site of the bone or joint involvement. The presence of drainage or scar formation may necessitate the utilization of an exposure which avoids such areas. The use of a tourniquet and the proper position will aid in accomplishing the operation easily and skillfully. The retraction anteriorly of the entire vastus lateralis from the shiny attachment of the fascia lata anterior to the gluteus maximus insertion will simplify the surgical technic in performing fixation for femoral neck fractures, in the use of the blade plate for osteotomy and intertrochanteric fractures, and in other procedures in this region. There is less likelihood of subsequent bursa formation and other complicating factors which would require the removal of the fixing material. REFERENCES ]. Nicola, Toufick.: Atlas of Surgical Approaches to Bones and·Joints. New York, The Macmillan Co., 1945, pp. 117-209. 2. Henry, Arnold K.: Extensile Exposure Applied to Limb Surgery. Baltimore, Williams & Wilkins Co., 1946. a. Campbell, Willis C.: Operative Orthopedics, Chap. 6: Surgical Approaches. St. Louis, C. V. Mosby Co., 1939, pp.146-205. 4. Ober, Frank R.: Posterior Arthrotomy of the Hip Joint. J.A.M.A. 83:1500, 1924. 5. Smith-Petersen, M. N.: A New Supra-Articular Subperiosteal Approach to the Hip Joint. Am. J. Orthop. Surg. 15:592, 1917. 6. Smith-Petersen, M. N.: Treatment of Malum Coxae Senilis, Old Slipped Upper Femoral Epiphysis, Intra-Pelvic Protrusion of the Acetabulum, and Coxa Plana, by Means of Acetabuloplasty. J. Bone & Joint Surg. 19:869-880 (Oct.) 1936. 7. Smith-Petersen, M. N.: Arthroplasty of the Hip. J. Bone & Joint Surg. 21 :269288,1939.
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8. Smith-Petersen, M. N.: Evolution of Mould Arthroplasty of the Hip Joint. J. Bone & Joint Surg. 30(1) :59-75 (Feb.) 1948. 9. Fahey, John J.: Lectures on Regional Orthopaedic Surgery and Fundamental Orthopaedic Problems: Orthopaedic Anatomy of the Hip. J. W. Edwards, 1947, pp. 3340. 10. Kocher, Theodore: Textbook of Operative Surgery. London, A. & C. Black, Ltd., 1911. 11. Osborne, R. P.: The Approach to the Hip Joint. A Critical Review and a Suggested New Route. Brit. J. Surg. 18:49,1930-31. 12. Thomson, James E.: Anatomical Methods of Approach in Operations on the Long Bones of the Extremities. Ann. Surg. 68:309, 1918. 13. Bosworth, David M.: Posterior Approach to the Femur. J. Bone & Joint Surg. 26:687-690 (Oct.) 1944. 14. Henderson, Melvin S.: Postero-Lateral Incision for the Removal of Loose Bodies from the Posterior Compartment of the Knee Joint. Surg., Gynec. & Obst. 33: 698,1921. 15. Harmon, Paul H.: A Simplified Surgical Approach to the Posterior Tibia for Bone Grafting and Fibular Transference. J. Bone & Joint Surg. 27: 496-499 (July) 1945. 16. Chandler, Fremont A.: Personal communication.