Approaches to the kne joint.pptx

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  • 2. PRINCIPLE OF SURGICAL APPROACH TABLE:       radio lucent, adjustable it should be correct height for the surgeon’s size POSITION: Patient is in best position that he cannot move during the procedure bony prominences should be are well padded Surgery under tourniquet provides better visualisation of structure including vessels and nerves
  • 3.  Drapping of the part should be meticulous preferably with impermeable drapes SKIN INCISION:   Appropriate length of incision Should be in the natural crease of the skin to avoid undesirable scar It Should follow lines of cleavage, planes of fascia
  • 4. SOFT TISSUE DESSECTION:      Thorough knowledge of anatomy of the part is needed rather than the approach described or tought by others Respect the soft tissue during approach Should pass between muscles rather than through them Important vessels, nerves should be spared by locating and protecting them Thorough hemostasis should be secured
  • 5. APPROACHES OF THE KNEE JOINT 1.Anteromedial approaches - anteromedial para patellar -subvastus anteromedial 2.Anterolateral approach 3.Posterolateral approach 4.Postero medial approach 5.Medial approaches to the knee and supporting structures 6.Transverse approaches to menisci 7.Lateral approaches to the knee and supporting structures 8.Extensile approaches to the knee -Mc cannell extensile approach -fernandez extensile anterior approach 9.posterior approach
  • 6. MEDIAL PARA PATELLAR APPROACH (VON LANGENBECK APPROACH)   Used to gain access to suprapatellar pouch, patella and medial side of the joint INDICATIONS 1. Synovectomy 2. Medial meniscectomy 3. Removal of loose bodies 4. Ligamentous reconstruction 5. Patellectomy 6. Drainage of the knee joint in case of sepsis 7. Total knee replacement 8. Repair of ACL 9. ORIF of distal femur # when medial plate is used
  • 7. POSITION:  supine  place the sand bag on the table that it supports the heel when the knee is flexed to 90* and Support the outer aspect of the upper thigh
  • 8. LANDMARKS:  patella,  patellar ligament,  tibial tubercle INCISION:  longitudinal straight incision extending from 5cm above the superior pole of patella to below the level of the tibial tubercle.
  • 9. NO INTERNERVOUS PLANE IN THIS APPROACH SUPERFICIAL DISSECTION:  Develop a medial skin flap to expose the quadriceps tendon, medial border of the patella & patellar tendon  Enter the joint by cutting the joint capsule by leaving a cuff of capsular tissue medial to the patella and lateral to the quadriceps to facilitate closure  Devide the quadriceps tendon in midline to enter suprapatellar pouch
  • 10. DEEP DISSECTION:  Dislocate the patella laterally and rotate it to 180* then flex the knee to 90*  If the patella not dislocated easily- extend the skin incision superiorly and split the quadriceps muscle just lateral to it’s medial border  If the patella still does not dislocatable- carefully remove the patellar ligament attachment with underlying block of bone after predrilling the block for screw fixation during closure
  • 11. DANGERS:  Avulsion of patellar tendon  Infra patellar br.of the sephanous nerve ENLARGE THE APPROACH:  Superior Extension by approach between rectus femoris and vastus medialis then split the underlying vastus intermedius to expose the distal 1/3 of femur  Inferior extension can be done by removal of patellar ligament attachment with underlying block of bone after predrilling the block for screw fixation during closure
  • 12. SUBVASTUS ANTEROMEDIAL APPROACH INDICATIONS:  Lesser anteromedial procedures  Medial knee procedures CONTRAINDICATIONS:  Previous knee arthroplasty  Obese pt >200 lbs ADVANTAGES:  Preserves vascularity of patella  Preserves the quadriceps tendon by providing more stability to the patello femoral joint
  • 13. POSITION  Supine  Knee flexed to 90* SKIN INCISION:  bigining 8cm above the patella carrying distally just medial and 2cm distal to the tibial tubercle SUPERFICIAL DISSECTION:  Incise the superficial fascia slighly medial to the patella and bluntly dissect the vastus medialis fascia down to its insertion
  • 14. DEEP DISSECTION:  Identify the inferior edge of vastus medialis and bluntly dissect the intermuscular septum about 10cm proximal to the adductor tubercle  Identify the tendinous insertion of muscle on medial to the patellar retinaculum and lift the v.medialis anteriorly  perform ‘L’ shaped arthrotomy beginning medially through the vastus insertion on medial patellar retinaculum and carrying it along the medial edge of the patella
  • 15.  Partially release the medial edge of patellar tendon and evert the patella laterally with knee joint extension
  • 16. ANTEROLATERAL APPROACH (KOCHER’S APPROACH) INDICATIONS:  lenghthening of iliotibial band  excision of fibular head  To Decompress peroneal nerve  Access to lateral femoral condyle& lat.tibial condyle  Lateral meniscectomy  Total knee arthroplasty  Fixed valgus deformity
  • 17. SKIN INCISION:  Begin the incision 7.5 cm proximal to the patella at the insertion of the vastus lateralis into the quadriceps tendon,  continue it distally along the lateral border of the Q.tendon, patella and patellar tendon upto 2.5cm distal to the tibial tuberosity
  • 18. SUPERFICIAL DISSECTION:  Carry the superficial dissection as skin incision 
  • 19. DEEP DISSECTION  Gentle sharp dissection through the joint capsule  Retract the patella medially to expose the articular surface of the joint
  • 20. DISADVANTAGES :  It is difficult to displace the patella medially  It require longer incision  Often require patellar tendon must be freed subperiosteally / subcortically
  • 21. POSTERO LATERAL APPROACH (HENDERSON APPROACH) INDICATIONS:  Drainage of posterior compartment in pyogenic arthritis  Loose bodies POSITION:  Supine  Knee flexed in 90*
  • 22. SKIN INCISION:  Curved incision on lateral side of the knee just anterior to the biceps femoris tendon and head of the fibula
  • 23. DEEP DISSECTION:  Trace the anterior surface of the lateral inter muscular septum to the linea aspera 5cm proximal to the lateral femoral condyle  Expose the lateral femoral condyle and the origin of the fibular collateral ligament
  • 24.   Mobilize and retract the popliteus tendon posteriorly that is between biceps tendon and fibular collateral ligament Make a longitudinal incision through the capsule and synovium to access to posterior compartment. DANGERS:  Common Peroneal nerve
  • 25. POSTEROMEDIAL APPROACH (HENDERSON APPROACH) INDICATIONS:  Drainaige of postero medial compartment,  Loose bodies POSITION:  Supine  Knee flexed 90*
  • 26. INCISION:  A curved incision 7.5cm long , distally from the adductor tubercle and along the tibial collateral ligament, anterior to relaxed tendons of semimembranosus, semitendinosus and gracilis.
  • 27. DEEP DISSECTION:  Expose and incise the oblique part of the tibial collateral ligament,  Incise the capsule longitudinally to enter the postero medial compartment by retracting hamstring muscles posteriorly
  • 29. CAVE’S TECHNIQUE INDICATIONS:  Medial meniscectomy  Access to anterio compartment  Access to posterior compartment
  • 30. POSITION:  Knee flexed at right angle INCISION:  Begin the skin incision 1cm posterior, 1cm proximal to the joint line  Carry the skin incision distal and anteriorly , 0.5cm distal to the joint line upto anterior border of the patellar tendon  Reflect the subcutaneous tissue with skin flaps
  • 31. TO EXPOSE THE ANTERIOR COMPARTENT: an incision that begins anterior to the tibial collateral ligament continue distally and anteriorly ina curve similar to skin incision and ends just distal to joint line. TO EXPOSE THE POSTERIOR COMPARTMENT: make a 2nd deep incision posterior to the tibial collateral ligament, from the level of femoral epicondyle straight distally across the joint line
  • 32. TO EXPOSE ANTERIOR COMPARTENT: an incision that begins anterior to the tibial collateral ligament continue distally and anteriorly ina curve similar to skin incision and ends just distal to joint line. TO EXPOSE POSTERIOR COMPARTMENT: make a 2nd deep incision posterior to the tibial collateral ligament, from the level of femoral epicondyle straight distally across the joint line
  • 33. HOPPENFELD AND DEBOER TECHNIQUE INDICATIONS  Medial collateral ligament repair  Medial joint capsule  Medial meniscectomy  ACL repair POSITION  Supine  Flex the knee to 60*  Abduct and externally rotate the hip  Place the foot on the opposite shin
  • 34. LAND MARKS:  Adductor tubercle INCISION:  Make a long curved incision Begins 2cm proximal to the adductor tubercle  Curve it anteroinferiorly about 3cm medial to medial border of the patella and end it 6cm distal to the joint line on anteromedial aspect of the tibia NO TRUE INTERNERVOUS PLANE
  • 35. SUPERFICIAL DISSECTION:  Raise the skin flaps  Incise the fascia along the anterior border of the sartorius starting at the tibial attachment of the muscle extending to 5cm proximal to the joint line
  • 36. DEEP DISSECTION:  Flex the knee further and allow sartorius to retract posteriorly that exposes semitendinosus and gracilis  Rectract all three components of pes anserinus posteriorly and exposes tibial attachment of the medial collateral ligament
  • 37. To Open The Joint Anteriorly:  Make a longitudinal medial papapatellar incision through the retinaculum and synovium. To Open The Joint Posteriorly:  Make a incision through the capsule posterior to the tibial collateral ligament
  • 38. To Expose The Posterior 1/3 Of Meniscus: Posteromedial Corner Of The Knee:  Retract the 3 components of the pes anserinus posteriorly and separate the medial head of the gastrocnemius muscle from posterior capsule of the knee almost to midline bluntly it allow access to surgical area
  • 39. DANGERS:  Infra patellar branch of sephanous.nerve  Sephanous vien  Medial inferior genicular artery  Popliteal artery This Incision Already Is Extensive That Provides Exposure To All Medial Structurs .It Can’t Be Extended Usefully
  • 40. TRANSVERSE APPROACH TO MENISCI  FOR MEDIAL MENISCUS:  POSITION : Supine Sand bag under the affected thigh
  • 41.      Make a transverse skin incision 5cm at the level of the articular surface of tibia Extend from medial border of patellar tendon to anterior border of the tibial collateral ligament. Incise the capsule along the same line and dissect the proximal edge of the capsule and retract proximally Open the synovium along the proximal border of the medial meniscus Devide the anterior attachment of meniscus, retract the tibial collateral ligament to excise the meniscus
  • 42. FOR LATERAL MENISCUS POSITION:  supine  Crossed leg position 
  • 43. Make a oblique incision about 7.5cm centered over the joint line  In the capsule HOCKY STICK incision runs along the joint line and curves obliquely proximally along the anterior border of the iliotibial band  Retract the capsule and incise the synovial membrane tranversely to expose the lateral meniscus 
  • 44. ADVANTAGE:  For medial meniscus approach –the scar has no contact with femoral articular surface
  • 45. LATERAL APPROACHES TO THE KNEE AND ITS SUPPORTING STRUCTURES   Hoppenfeld And Deboer Technique Bruser Technique
  • 46. HOPPENFELD AND DEBOER TECHNIQUE POSITION:  Supine  Sand bag under the buttock of affected side  Flex the knee to90* LAND MARKS:  Lateral border of the patella  Lateral joint line  Gerdy tubercle
  • 47. INCISION:  A long curved incision begin 3cm lateral to the middle of the patella extend it distally over the gerdy tubercle on the tibia, end it 4-5cm distal to the joint line, complete the incision proximally by curving along the line of the femur.
  • 48.  There Is Internervous Plane Between The Iliotibial Band (S.G.N) And The Biceps Femoris (S.N). SUPERFICIAL DISSECTION:    mobilize the skin flaps, Incise the fascia between iliotibial band and biceps femoris, Retract the iliotibial band anteriorly and biceps femoris and common peroneal nerve posteriorly to expose the superficial lateral ligament and posterolateral corner of the knee capsule
  • 49. DEEP DISSECTION:  Enter the joint either infront or behind the superficial lateral ligament Anterior arthrotomy:  To access lateral meniscusincise the capsule infront of ligament begin 2cm above the joint line. Posterior arthrotomy:  To inspect the posterior horn of lateral meniscusdessect between lateral head of the gastrocnemius and the posterolateral corner of the joint capsule  Ligate the lateral superior genicular arteries  Make alongitudinal incision in the capsule
  • 50. DANGERS:  Common peroneal nerve  Lateral superior genicular artery  Popliteal tendon  Lateral meniscus & its coronary lig.
  • 51. BRUCER TECHNIQUE POSITION:  Supine  drape the limb that permits full flexion of the knee  Flex the knee fully so that the foot rests on the table
  • 52. INCISION:  Begin the incision anteriorly point where the patellar tendon crosses the joint line,  Continue it posteriorly along the joint line and end it at imaginary line extending from proximal end of the fibula to lateral femoral condyle
  • 53.    Incise the subcutaneous tissue and expose the iliotibial band Split the iliotibial band and retract the margins, Locate the inferior genicular artery betweeen collateral ligament and meniscus
  • 54. Incise the synovium  Lateral meniscus lie in the depth of the incision  DANGERS:  Fibular collateral ligament  Lateral inferior genicular artery
  • 55. EXTENSILE APPROACHES TO KNEE  Mc Connell Extensile Approach  Fernandez Extensile Approach
  • 56. MC CONNELL EXTENSILE APPROACH           It allows access to anterior, posterior, medial, lateral side of the knee through a single incision ADVANTAGES: Exelent exposure Unobtrusive scar Scar hidden by skin creases Less prone to hypertrophy Permits the harvest and transfer of the iliotibial band and patellar tendon for grafts in reconstruction of the ligaments Capsular reinforcement Meniscal reattachment Repair of the intraarticular #
  • 57. POSITION:  Supine  Knee in acute flexion  Foot rests on the operating table INCISION:  Transverse anterior incision between 3 points -Medial flexion crease -Inferior pole of patella -Lateral flexion crease  Make a lateral extension along the posterior margin of the iliotibial band  Medial extension slightly posteromedially in a distal direction from the apex of the medial flexion crease for 9-10cm
  • 58. Incise the fascia without subcutaneous elevation of the skin  Gentle Sharp dissection immediately against the fascia with knee in flexion increases exposure of joint capsule. 
  • 59. FERNANDEZ ENXTENSILE APPROACH POSITION:  Supine  drape the limb to allow knee in 60* flexion INCISION:  Begin a lateral parapatellar incision 10cm proximal to the lateral joint line continue distally along the lateral border of the patella, patellar tendon and tibial tuberosity and end it 15cm distal to the lateral joint line
  • 60. SUPERFICIAL DISSECTION:  Develop skin flaps deep in subcutaneous tissue extending  medially to anterior edge of the tibial collateral ligament and  Laterally to exposing the iliotibial band and the proximal origin of the anterior tibial and peroneous muscles
  • 61. DEEP DISSECTION:  To expose the lateral tibial metaphysis:  Dettach the anterior tibial muscle and retract it distally, elevate the iliotibial band by deviding transeversely at the joint line / performing flat osteotomy of gerdy tubercle
  • 62. To expose the posteromedial portion of the the tibial metaphysis:  Devide the tibial insertion of the pes anserina or elevate it as an osteoperiosteal flap 
  • 63.   Elevate the tibial tuberosity, patellar tendon and incise the joint capsule transeversely, medially, laterally at the joint line Carry the each limb of the capsular incision proximally to the level of the anterior border of the vastus medialis and vastus lateralis
  • 64. Further exposure of articular surface of the tibia :  Dettach one or both menisci by transsection of the anterior horn, cutting the transverse ligament,and dividing the anterior portion of the coronary ligament. 
  • 65. POSTERIOR APPROACH   It is rarely needed because medial and lateral approaches provides good access to the half of the posterior capsule It should be used mainly for exploring the structures within the popliteal fossa and for reattaching the avulsed tibial insertion of the PCL INDICATION 1. Repair of nuerovascular structures in trauma case 2. repair of avulsion # of this site of attachment of PCL to tibia 3. Resection of gastrocnemius contractures 4. Lenghthening of hamstrings tendon 5. Excision of baker’s cyst and other popliteal cysts 6. Access of posterior capsule of the knee 7. Posterior part of the menisci 8. Access Posterior aspect of femur and tibia
  • 66. POSITION Prone tourniquet can be used all procedures except vascular repair LAND MARKS Two heads of gastrocnemius muscle origin Semitendinosus semitendinosus
  • 67. INCISION:  Gentle curved incision starting laterally over biceps femoris bring the incision obliquely across the popliteal fossa turn downwards over the medial head of the gastrocnemius and run the incision inferiorly into the calf muscles  NO TRUE INTERNERVOUS PLANE
  • 68. SUPERFICIAL DISSECTION:  reflect the skin with subcutaneous fat,  Small sephanous vien/ medial sural cut.nerve can be used as a guide to dissecting popliteal fossa,  Incise the fascia just medial to small sephanous vien, dissect upto apex of the popliteal fossa following the tibial nerve
  • 69.     Dissect out the common peroneal nerve in a proximal to distal direction along the posterior border of the biceps femoris, Identify popliteal artery and vien that are deep and medial to the tibial nerve, To mobilize the artery one or more of its five branches to be ligated, Careful to mobilise the pop.vien that is directly posterior to the pop.artery in the fossa and it moves posterolateral side of the artery,
  • 70. DEEP DISSECTION:  Retract the muscles of the boudaries of pop fossa To Access To Posteromeidial Joint Capsule:  Dettach the tendinous origin of the medial head of the gastrocnemius from the back of the femur and Retract laterally and inferiorly  Pull the nerves and vessels to reach the postero medial corner of the joint  Now exposure is as same as that achieved by posterior extension of the medial approach
  • 71. To Acces To Posterolateral Corner Of The Knee :  Detach the lateral head of the gastrocnemius muscle from the lateral femoral condyle,  Make the interval between it and biceps femoris muscle as the same exposure in the lateral approach to the knee DANGERS:  Medial sural cut.nerve  Small sephanous vien  Tibial nerve  Common peroneal nerve  Popliteal vessels
  • 72. THANK YOU