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Surgical Approaches around Hip and Knee Kushal.pptx
1. Surgical Approaches to Hip and
Knee
Dr.Kushal Khanal
2nd Year Resident
IOM,TUTH
Moderator : Dr.Dibya Purush Dhakal
2. Ideal Approach
Safe Access
Minimal dissection of soft tissue
Should be between intervascular and interneural
plane
Adequate Exposure
Reduced operative time
Reduced blood loss
Least postoperative complication
3. • Determinants
– Type of surgery-trauma or replacement
– Age of the patient-adult versus child
– Exposure requirement
– Surgeon’s preference and expertise
– Type of implant to be used
4. Anterior Approach to Hip
• Smith-Petersen
• Somerville Approach
-using a transverse “bikini” incision
5. Indication
• Open reduction of DDH
• Synovial biopsies
• Intra-articular fusions
• Total hip replacement
• Hemiarthroplasty
• Excision of tumors, especially of the pelvis
6. • Advantages
– Excellent access to the anterior hip joint
– Better stability following procedure
– Preservation of vascularity
– Ready source of bone graft material
– Avoids the disruption of abductor mechanism
7. • Disadvantages
– Needs extensive pelvic muscle stripping to
visualise acetabulum
– Injuries to lateral femoral cutaneous nerve and
dysesthasia of thigh
– Exposure to femoral medullary canal is limited
14. Anterolateral approach
(Watson- Jones )
• Most commonly used for THR
• It combines an excellent exposure of the
acetabulum with safety during reaming of the
femoral shaft.
Uses:
1. Total hip replacement
2. Hemiarthroplasty
3. Open reduction and internal fixation of
femoral neck fractures
4. Synovial biopsy of the hip
5. Biopsy of the femoral neck
15. • Advantages:
-Retains the advantages of the anterior approach
-Provides good exposure of the femoral neck
-Low risk of avascular necrosis of the femoral head
• Disadvantages:
-Limited exposure of the acetabulum
-Risk of damage to superior gluteal nerve
22. • Structures at risk
– Femoral nerve
– Femoral artery and vein
– Femoral shaft fractures
23. LATERAL APPROACH (HARDINGE)
• Divided: Direct lateral
and Trans-trochanteric
• Direct lateral: Based on
Gluteus medius and
vastus lateralis regarded
as being in direct
functional continuity
through the thick
tendinous periosteum
covering GT
24. Advantages:
• Improved exposure to
acetabulum and
femoral neck
• Preserves the integrity
of gluteus medius
• Preservation of
vascularity
• Minimal risk of damage
to Sciatic nerve
Disadvantages:
• Difficulty to do revision
surgery by this
approach as it does not
provide as wide an
exposure as
anterolateral
• Relatively slightly
increased blood loss
25.
26.
27.
28. Structures at risk
• Nerves:
• Superior gluteal nerve
• Femoral nerve
• Vessels:
• Femoral artery and vein
• Transverse branch of the lateral circumflex artery
29. Modified Hardinge
• Direct lateral approach(Transgluteal)
• No osteotomy of greater trochanter
• Tendon of gluteus medius incised obliquely across
the greater trochanter
• Carry Incision at anterior 1/3rd and posterior 2/3rd of
Gluteus medius
30. Other Lateral Approaches
• McFarland and Osborne:
• Elevate the tendon of gluteus medius ,periosteum and
origin of vastus lateralis in one piece
• Trans-trochanteric Technique:
• Charnley and Ferreiraade: Improving abductor lever
arm by distal and lateral transfer of GT restoring
abductor power
• Harris: Osteomize the GT and reflect the tendon of
gluteus medius with chip of bone proximally and origin
of vastus lateralis reflected distally
31. Posterior approach
(Moore or Southern)
Indication:
1. Hemiarthroplasty
2. Total hip replacement, including revision surgery
3. Open reduction and internal fixation of posterior
acetabular fractures
4. Dependent drainage of hip sepsis
5. Removal of loose bodies from the hip joint
6. Open reduction of posterior hip dislocations
32. Advantages:
• Easy and quick access to hip joint
• Brief period of immobilization
• Excellent visualization of femoral shaft
• Excellent exposure of posterior wall and posterior
column of acetabulum
33. Disadvantages:
• Dependent incision with tendency to oedema
• Acetabular exposure is inferior
• Increased post-operative infection
• Increased probability of post-operative posterior hip
dislocation due to weakened posterior capsule
• Possibility of sciatic nerve injury(0.1%-1%)
39. Medial approach
Indications:
1. Open reduction of DDH
2. Biopsy and treatment of tumors of the inferior
portion of the femoral neck and medial aspect of
proximal shaft
3. Psoas release
4. Obturator neurectomy
40. Surgical Approaches around Knee
• Anteromedial -Parapatellar Approach
-Subvastus Approach
-Midvastus Approach
• Medial Approach(Hoppenfeld and Deboer)
• Lateral Approach(Hoppenfeld and Deboer)
• Posterior Approach
• Posteromedial Approach
• Approach to Tibial Plateau
• Approach to Distal Femur
• Swashbuckler Approach
41. Anteromedial Parapatellar Approach
(Von-Langenbeck)
Indication:
1. Total knee replacement
2. Open reduction and internal fixation of distal femur fracture
3. Synovectomy
4. Meniscectomy
5. Removal of loose bodies and drainage in septic knee
6. Ligament reconstruction
42. • Advantages:
• Excellent exposure to knee joint
• Extensile approach
• Relatively easy to safely execute
• TKR: Ideal for patients with previous scars and obesity;
undergoing revision TKR
• Disadvantages:
• Patellar dislocation and subluxation
• Fragmentation of patella secondary to avascular necrosis
43.
44.
45. • Structures at risk
– Nerves:
• Infrapatellar branch of the
saphenous nerve; painful
neuroma
– Muscle:
• Avulsion of patellar tendon
from tibial tubercle
46. • Superior Extension: Rectus
femoris and vastus medialis
muscles.
• Split vastus intermedius
muscle to expose the distal
two-thirds of the femur
• Better Exposure:Detach the
patellar tendon with an
underlying block of bone
47. Anteromedial Subvastus Approach
(Southern Approach)
• Indication:
1. Total knee replacement
2. Open reduction and internal fixation of distal femur fracture
3. Meniscectomy
4. Removal of loose bodies
48. Advantages:
• Extensor mechanism and the majority of medial vessels
supplying the patella remain intact
• Reduced blood loss and postoperative pain
• Patellar tracking significantly improved
Disadvantages:
• Difficulty with exposure and everting the patella
• Risk of neurovascular damage in Hunters canal
• Ideal for thin patient with mobile soft tissue
49.
50. Midvastus Approach
Advantages:
• Less difficulty with exposure and
everting patella than with
subvastus approach
• Less blood loss compared to
medial parapatellar approach
51. Medial Approach
(Hoppenfeld and Deboer)
• Indication:
1. Exploration and treatment of damage to the superficial
MCL
2. Exploration and treatment of medial joint capsule and
posteromedial corner
3. Medial meniscectomy
57. Lateral Approach (Hoppenfeld and Deboer)
Indications:
• Exploration and treatment of
damage to the LCL
• Exploration and treatment of
lateral joint capsule and
posterolateral corner
• Lateral meniscectomy
61. Posterior Approach
• Primarily neurovascular approach
• Indications:
1. Repair of the neurovascular structures
2. Repair of avulsion fractures of PCL attachment to the tibia
3. Recession of gastrocnemius muscle head in cases of
contracture
4. Access to the posterior capsule of the knee
78. Advantages:
• Good visualization of intraarticular fragments and can be
extended proximally to include metaphyseal fragments
• Sparing of quadriceps muscle bellies
• Surgical scar does not interfere with subsequent total knee
arthroplasty
Disadvantages:
• Lateral parapatellar arthotomy may undermine lateral supply
to anastomotic patellar ring
