Residency days

1. Surgical Approaches
to Knee
Sijan Bhattachan
3rd year resident
National Trauma Center, NAMS

2. Layers of Knee
• Medial

4. • Lateral

6. Surgical Approaches
• Anteromedial - Parapatellar Approach
- Subvastus Approach
• Medial approach
• Lateral Approach
• Approach for lateral meniscectomy
• Posterior Approach
• Arthroscopic Approach

7. Anteromedial Parapatellar
Approach (Von Langenbeck)
Indications
• Synovectomy
• Medial meniscectomy
• Removal of loose bodies; Drainage in septic knee
• Ligamentous reconstructions
• Total knee replacement
• ORIF of distal femoral fractures

8. Position
• Sandbag
• Table support

9. Incision
• From a point 5 cm
above the superior pole
of patella to below the
level of tibial tubercle

10. Superficial dissection
• Medial skin flap
• Enter the joint by
cutting through the
joint capsule

12. Deep surgical
dissection
• Dislocate patella
laterally and
rotate it to 180
degrees
• Flex the knee to
90 degrees

13. Dangers
• Infrapatellar branch of saphenous nerve;
Postoperative neuroma
• Avulsion of patellar ligament

14. Extension
• Superior; Extend proximally between Rectus
femoris and Vastus medialis; Split vastus
intermedius
• Inferior;Removal of patellar ligament with underlying
block of bone

15. Anteromedial Subvastus
Approach (Southern Approach)
Advantages;
• Preserves vascularity of patella- spares
intramuscular articular branch of descending
geniculate artery
• Preserves quadriceps tendon by providing more
stability to the patellofemoral joint in TKR.

18. Medial Approach
(Hoppenfeld & Deboer)
Indications
• Exploration & treatment of damage to superficial
MCL and medial joint capsule
• Medial meniscectomy
• Ligamentous repair

19. Position
• Flex knee to 60
degrees.
• Abduct & externally
rotate hip, placing
foot on opposite shin.

20. Incision
• Curved, beginning at a point 2
cm proximal to adductor
tubercle.
• Curve anteroinferiorly to a point
6 cm below the joint line on the
anteromedial aspect of tibia
• Middle of this incision runs 3cm
medial to patella.

21. • Raise skin flaps to
expose fascia
• Exposure extend from
midline anteriorly to
posteromedial corner
posteriorly
• Infrapatellar branch of
saphenous nerve

23. • Tibial insertion
of MCL lies
deep and
distal to
anterior edge
of sartorius ,
6-7 cm below
the joint line

25. • Posterior access to
posterior third of
meniscus and PMC
of knee.
• Expose PMC by
separating medial
head of
gastrocnemius from
semimembranosus
muscle.

27. Dangers
• Infrapatellar branch of saphenous nerve
• Saphenous vein
• Medial inferior genicular artery

28. Lateral Approach
(Hoppenfeld & Deboer)
• Provides access to all the supporting structures on
the lateral side of knee
• Only part of the exposure is needed for any single
procedure.
• Major use is in the assessment of ligamentous
damage.

29. • Curved incision 3 cm
lateral to middle of patella
• Distally over gerdy’s
tubercle.
• Proximally along the line
of femur

30. • Internervous plane

31. • Common Peroneal
nerve

32. • Anterior or Posterior arthrotomy

33. Dangers
• Common peroneal nerve; Along posterior border of
biceps tendon.
• Lateral superior genicular artery; Runs between
lateral head of gastrocnemius and posterolateral
capsule.
• Popliteus tendon; Take care while opening posterior
half of knee joint capsule

34. Approach for lateral
meniscectomy
• Position

35. Incision
• Start at inferolateral corner of patella and continue
downward and backward for about 5 cm

37. Posterior Approach
• Primarily a neurovascular approach
Indications;
• Repair of neurovascular structures in case of trauma
• Repair of avulsion fractures of site of attachment of PCL to tibia
• Recession of gastrocnemius muscle heads in case of contracture.
• Lengthening of hamstring tendons.
• Excision of popliteal cysts
• Access to posterior capsule of knee

38. • Prone position

39. • Gently curved incision
• Start laterally over
biceps femoris.
• Turn downward over
the medial head of
gastrocnemius.

40. • Small saphenous
vein
• Medial sural
cutaneous nerve

41. • Popliteal vessels lie deep and medial to tibial nerve

42. • Common Peroneal Nerve

45. Dangers
• Medial sural cutaneous nerve
• Tibial nerve
• Common peroneal nerve
• Small saphenous vein
• Popliteal vessels

46. Arthroscopic Approaches
Indications;
• Meniscal resection or repair
• Ligaments reconstruction
• Synovial biopsy
• Synovectomy
• Removal of loose bodies
• Debridement

47. Portals
Standard Portals
• Anterolateral
• Anteromedial
• Superolateral
• Posteromedial

48. Optional Portals;
• Posterolateral Portal
• Proximal Midpatellar Medial and Lateral Portals
• Accessory Far Medial and Lateral Portals
• Central Transpatellar Tendon (Gillquist) Portal

49. • With knee flexed to 90 degrees, 8 mm transverse stab
incision.
• Push the sheath and trochar into the AL portal.
• Extend the knee while advancing the arthroscopic
sheath up into the supra patellar pouch.
• Remove the trochar and insert 30 degree arthroscopic
telescope.
• Switch on the irrigation fluid and then the light source.

50. Order of scoping

52. • Flex the knee

53. • Valgus/ER

56. Dangers
• Damage to articular cartilage
• Meniscal injury

57. “Ten seconds of careless
use of an arthroscope within the
knee may create the equivalent
of 10 years of wear in that joint”
- Stanley Hoppenfeld

58. References
• Hoppenfeld surgical exposures in Orthopaedics, 4th
edition.
• Campbell’s Operative Orthopaedics, 13th edition.