Important surgical approaches to acetabulum and pelvis are described.
Ilioinguinal approach, Modified Stoppa Approach, Kocher lagenbeck Approach, Ilifemoral approach and extensile approaches are well illustrated and described.
Deformity: It’s the position of a limb/Joint, from which it cannot be brought back to its normal anatomical position.
Described as abnormalities of :
Length
Angulation
Rotation
Translation
Combination
Safe surgical dislocation for femoral head fractures.dr mohamed ashraf,dr rah...drashraf369
femoral head fractures are very complex fractures that need immediate and prompt surgical intervention.conventional surgical appproaches to hip may lead to short and long term complications.dr mohamed ashraf ,dr rahul thampi et al are presenting their experience with gantz safe surgical dislocation approach to surgical management of femoral head fractures
Deformity: It’s the position of a limb/Joint, from which it cannot be brought back to its normal anatomical position.
Described as abnormalities of :
Length
Angulation
Rotation
Translation
Combination
Safe surgical dislocation for femoral head fractures.dr mohamed ashraf,dr rah...drashraf369
femoral head fractures are very complex fractures that need immediate and prompt surgical intervention.conventional surgical appproaches to hip may lead to short and long term complications.dr mohamed ashraf ,dr rahul thampi et al are presenting their experience with gantz safe surgical dislocation approach to surgical management of femoral head fractures
OPEN INGUINAL HERNIA REPAIR- OPERATIVE SURGERY
#surgicaleducator #operativesurgery #openinguinalherniarepair #usmle #babysurgeon #surgicaltutor
Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• I have already uploaded videos on open and Laparoscopic Appendicectomy, Thyroidectomy, Modified Radical Mastectomy and open and
Laparoscopic Cholecystectomy
• In this video today, I have discussed Open Inguinal Hernia Repair.
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you to watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful.
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
• surgicaleducator.blogspot.com
• youtube.com/c/surgicaleducator
• Thank you for watching the videos.
Basics of patellofemoral instability for postgraduates. Gives brief introduction about patellofemoral joint anatomy, causes, examintaion and treatment for patellofemoral instability
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
5. CHOICE OF APPROACH
•Depends on –
• Location of fracture
• Type of Fracture
• Complexity of Fracture
•Anterior Approach(usually ilioinguinal approach) used for:
• Anterior Wall Fracture
• Anterior Column Fracture
• Associated Anterior and Posterior Hemitransverse
Fracture
• Associated Both Column Fracture
6. Posterior approach preferred for :
• Posterior Wall Fracture
• Posterior Column Fracture
• Posterior Column and posterior wall Fracture
• Posterior wall with Transverse Fracture
•For Transverse Fracture – If high- Iliinguinal Approach
• If low- posterior approach
CHOICE OF APPROACH
8. ILIOINGUINAL APPROACH
• Developed by Letornel in 1960
•Allows exposure to-
• Entire Internal iliac fossa, and pelvic
brim from SI joint to pubic
symphysis
• Quadrilateral surface
• Anterior column and medial aspect
of acetabulum
• superior and inferior pubic rami
9. ILIOINGUINAL APPROACH :INDICATIONS
• Anterior Wall Fracture
• Anterior Column Fracture
• Associated Anterior Column and Posterior Hemitransverse
Fracture
• Associated Both Column Fracture
• Some T-type fracture
• Some transverse type fracture
11. ILIOINGUINAL APPROACH : INCISION
• Incision begun 3-4 cm
above pubic symphysis
• Proceeds laterally to ASIS,
then along 2/3rd of iliac
crest
• Extended beyond convex
portion of ilium
12. ILIOINGUINAL APPROACH : SUPERFICIAL DISSECTION
•Dissect through subcutaneous fat
in the line of the skin incision-
external oblique aponeurosis
exposed muscle.
•The lateral cutaneous nerve of
the thigh will appear in the
lateral edge of the dissection.
•In most cases, the nerve will
need to be divided.
13. ILIOINGUINAL APPROACH : SUPERFICIAL DISSECTION
•External oblique aponeurosis
divided from the superficial
inguinal ring to the ASIS –
unroofing of inguinal canal
•Ilioinguinal nerve
isolated/protected
•spermatic cord/ round ligament
isolated
14. ILIOINGUINAL APPROACH : DEEP DISSECTION
•Rectus abdominis muscle divided
1 cm proximal to its insertion into
the symphysis pubis.
•Using blunt dissection, a plane
between the back of the
symphysis pubis and the
bladder(the Cave of Retzius) is
developed .
15. ILIOINGUINAL APPROACH : DEEP DISSECTION
•Ligate and divide the inferior
epigastric vessels. Complete
the division of the muscular
structures of the posterior
wall of the inguinal canal.
• The peritoneum covered
with extraperitoneal fat is
now exposed.
•
16. ILIOINGUINAL APPROACH : DEEP DISSECTION
•Using a swab, push the
peritoneum upwards to
reveal the femoral
vessels,femoral nerve and
iliopsoas.
•Isolate the femoral vessels
along with sheath and
protected in a sling.
• Strip the iliacus muscle
from the inner aspect of
the ilium.
17. ILIOINGUINAL APPROACH : DEEP DISSECTION
•Continue stripping off the iliacus from
the inner wall of the ilium to reveal the
sacroiliac joint.
•Incise the iliopectineal fascia upto
bone.
•Retract the iliopsoas and the femoral
sheath either medially or laterally to
reveal the medial surface of the
acetabulum, the superior pubic ramus,
and the inner surface of the ilium
round to the sacroiliac joint.
•
18. ILIOINGUINAL APPROACH : DEEP DISSECTION
Three windows are created.
◦ The lateral window, lateral to the iliopsoas gives access to the inner
surface of the ilium
◦ The middle window, medial to the iliopsoas but lateral to the
femoral artery and vein gives access to the quadrilateral plate.
◦ The medial window, medial to the femoral artery and vein
gives assess to the superior pubic ramus and symphysis
19.
20. ILIOINGUINAL APPROACH : CLOSURE
•Drain – placed in Space of Retzius
• Tendons repaired
• Transversalis fascia and conjoined tendon of internal
oblique and transversus abdominis attached to inguinal
ligament
• External oblique aponeurosis repaired
22. ANTERIOR APPROACH : MODIFIED STOPPA
•Anterior Intrapelvic Approach
•First described by Rene Stoppa for hernia repair in 1975.
• Revised for pelvic and acetabular surgery by Hirvensalo et al in
1993.
• “Modified Stoppa” was described in 1994 by Cole and Bohofner.
•Advantages :
• entire anterior column including quadrilateral plate could be
visualized when supplemented with a lateral window
25. STOPPA’S APPROACH: SKIN INCISION
•Pfannensteil Incision
•placed just above the
pubic symphysis.
•Extended laterally on
both sides
26. STOPPA’S APPROACH: SUPERFICIAL DISSECTION
•Divide the subcutaneous tissues
in line with the skin incision in
order to expose the fascia
overlying both rectus muscles of
the abdomen.
27. STOPPA’S APPROACH: DEEP DISSECTION
•The rectus fascia is incised
longitudinally along the linea
alba and muscle bellies are
retracted laterally.
•In the proximal part of the
incision, care should be taken
not to incise the peritoneum.
28. STOPPA’S APPROACH: DEEP DISSECTION
•The medial part of the rectus
muscle is partly detached from
symphysis to allow the rectus to
retract.
•The upper border of the superior
pubic ramus is identified (pecten
pubis) and blunt dissection using a
finger or swab is carried laterally
along the pelvic brim without yet
incising the fascia.
29. STOPPA’S APPROACH: DEEP DISSECTION
•Exposing carefully along the
medial surface of the superior
ramus, the corona mortis
vessels are identified and
ligated (or clipped) as
necessary. The vessels sit
above the fascia and are most
easily identified if the fascia is
not incised prior to ligation.
30. STOPPA’S APPROACH: DEEP DISSECTION
•Then, the thick periosteum
from the superior pubic bone
is dissected sharply using
diathermy, allowing for
deeper blunt dissection.
•Dissection is continued
laterally upto the beginning
of the iliopectineal
eminence.
31. STOPPA’S APPROACH: DEEP DISSECTION
•Beginning of the iliopectineal arch
should be dissected from the bone
and femoral vessels and nerve are
elevated.
•The dissection is continued
subperiosteally more laterally
following the upper border of the
pelvic brim- entire internal surface
of the superior pubic ramus is
exposed.
32. STOPPA’S APPROACH: DEEP DISSECTION
•With a Cobb elevator, the periosteum
and obturator internus are elevated and
the quadrilateral surface can be
sufficiently exposed.
33. STOPPA’S APPROACH: ADDITION OF LATERAL
WINDDOW
•An incision is made along the
iliac crest.
•The incision can be extended
intraoperatively depending on
the necessary exposure.
•For fractures involving the
posterior aspect of the ilium, or
the SI joint, the exposure needs
to be extended posteriorly
almost to the table.
34. •Divide the subcutaneous tissues
and expose the fascia overlying
the external oblique muscle.
•Identify the border between the
gluteus muscles and external
oblique muscles. Incise the
muscular interval with
electrocautery.
•The external oblique muscle is
subperiosteally elevated from the
iliac crest.
•With a small elevator, the iliac
muscles are elevated using the
same subperiosteal layer.
STOPPA’S APPROACH: ADDITION OF LATERAL
WINDDOW
35. •When elevating the iliacus muscle,
bleeding from nutrient vessels can
occur and should be stopped with
bone wax.
•Continue with careful blunt dissection
to the interior part of the SI joint
medially to the pelvic ring.
•Proceed anteromedially at the pelvic
rim as far as to where the
iliopectineal eminence begins.
STOPPA’S APPROACH: ADDITION OF LATERAL
WINDDOW
36. •Continue the dissection with an
instrument such as a Cobb elevator.
•The SI joint capsule should be
identified. Place a Hohmann
retractor into the superior portion
of the SI joint.
STOPPA’S APPROACH: ADDITION OF LATERAL
WINDDOW
37. STOPPA’S APPROACH: WOUND CLOSURE
•Place drain as needed
•The midline incision in the rectus
abdominis and superficial tissues
are closed in layers taking care
to protect the underlying
bladder and peritoneum.
•The lateral window is also closed
in layers reconstructing the
fascial layer preserved in the
approach.
38. STOPPA’S APPROACH : DANGERS
•Obturator Nerve Injury
•External and Internal iliac arteries
•Superior Gluteal Vessels
•Corona Mortis
•Urinary Bladder
39. POSTERIOR APPROACHES : KOCHER LAGENBECK
APPROACH
•Gives access to posterior wall and posterior column
•If trochanteric osteotomy, surgical dislocation of hip is used, anterior
wall can also be visualized
•Indications:
• Posterior Wall Fracture
• Posterior Column Fracture
• Posterior Column and posterior wall Fracture
• Posterior wall with Transverse Fracture
• Some T-type Fractures
40. KOCHER LAGENBECK APPROACH : POSITIONING
•Either Prone or Lateral Position
•Knee Flexed to reduce tension on sciatic nerve
41. •Landmarks :
• Posterior superior iliac spine
• Greater trochanter
• Shaft of femur
•Skin incision started a few
centimeters distal and lateral
to the PSIS.
•Continued over the greater
trochanter.
KOCHER LAGENBECK APPROACH : SKIN INCISION
•Curved distally along the tip of the greater trochanter towards the
lateral aspect of the femoral shaft upto midthigh.
42. •Fascia lata is incised in line
with the skin incision.
•Incision extended
superiorly along the
anterior border of the
gluteus maximus muscle for
a distance of no more than
7 cm , branch of the inferior
gluteal nerve is protected.
KOCHER LAGENBECK APPROACH : SUPERFICIAL
DISSECTION
43. •Split the gluteus maximus in
line with its fibers.
•In the distal half, incise the
iliotibial tract in line with its
fibers up to the mid third of
the thigh.
KOCHER LAGENBECK APPROACH : SUPERFICIAL
DISSECTION
44. •Layer of fat is removed and
short external rotators are
visualized.
•The sciatic nerve is visualized.
•It lies posterior to the gemelli
and internal obturator muscles,
and anterior to the piriformis
muscle, between the greater
trochanter and the ischial
tuberosity.
KOCHER LAGENBECK APPROACH : DEEP DISSECTION
45. •Piriformis tendon is isolated and
a suture is placed 1 cm lateral to
its femoral insertion and
tendon is dissected.
•Reflect the piriformis belly
laterally to expose the
retroacetabular surface to the
greater sciatic notch.
•Avoid cutting quadratus femoris
KOCHER LAGENBECK APPROACH : DEEP DISSECTION
46. •Conjoined tendon of the obturator
internus and superior and inferior
gemelli muscles are isolated and
tagged and incised 1 cm lateral
from their femoral insertions to
protect the medial circumflex
femoral artery.
•Reflect the muscle bellies of the
three conjoined muscles laterally
to access the lesser sciatic notch.
KOCHER LAGENBECK APPROACH : DEEP DISSECTION
47. •Greater sciatic notch, the ischial
spine, and the lesser sciatic
notch are visualized.
•Insert a retractor in the lesser
sciatic notch and one
anterosuperiorly in the direction
of the anterior inferior spine.
Now the posterior column is
visible in its whole extent.
KOCHER LAGENBECK APPROACH : DEEP DISSECTION
50. •Meticulous debridement done
before closure.
•All tendons are reinserted and
split parts of the gluteus
maximus are approximated with
adaptation sutures.
•Perform the closure of the
iliotibial tract, the subcutis and
the skin.
KOCHER LAGENBECK APPROACH : CLOSURE
51. •Skin and superficial dissection
same as Kocher Lagenbeck
approach
•Instead of splitting the fibres of
gluteus maximus, interval is made
anterior to gluteus maximus b/w
Gluteus maximus and medius
•Others same as KL approach
POSTERIOR APPROACHES : MODIFIED GIBSON’S
APPROACH
Advantage : Hip abductor muscles left undisturbed
Rapid post op rehabilitation is possible
Disadvantage : articular surface of acetabulum is not exposed
Three windows are created. The lateral window, lateral to the iliopsoas gives access to the inner surface of the ilium
The middle window, medial to the iliopsoas but lateral to the femoral artery and vein gives access to the quadrilateral plate.
The medial window, medial to the femoral artery and vein gives assess to the superior pubic ramus and symphysis
At this level, the obturator neurovascular bundle is crossing the quadrilateral surface. In most cases it should be mobilized. A spatula or malleable retractor is used to protect the obturator neurovascular bundle and pelvic floor.
With a Cobb elevator, the periosteum and obturator internus are elevated and the quadrilateral surface can be sufficiently exposed.
One Hohmann retractor should be put in the middle part of the superior pubic ramus and another curved Hohmann retractor is placed on the posterior top of the acetabulum on the iliac part of the pelvic brim.
Great care should be taken not to injure the external iliac vein which may be in close proximity to the elevators.
Great care should be taken not to injure the external iliac vein which may be in close proximity to the elevators.
One Hohmann retractor should be put in the middle part of the superior pubic ramus and another curved Hohmann retractor is placed on the posterior top of the acetabulum on the iliac part of the pelvic brim.
Position of the patient for posterior approach to the acetabulum. Note the flexed position of the knee to prevent stretching of the sciatic nerve.
End the incision at the mid third of the thigh (just distal to the insertion of the gluteus maximus tendon).
Make a longitudinal incision centered on the greater trochanter extending from just below the iliac crest to 10 cm below the greater trochanter.
-Incise the fascia lata in line with the skin incision. Extend the incision superiorly along the anterior border of the gluteus maximus musclefor a distance of no more than 7 cm (Fig. 184B),protecting the branch of the inferior gluteal nerve to the anterosuperior portion of the gluteus maximus to avoiddenervating that part of the muscle.
plit the gluteus maximusSplit the gluteus maximus in line with its fibers, starting at the greater trochanter in a proximal direction up to the crossing of the first neurovascular bundle.
This creates a posterior muscle belly (inferior gluteal artery), and an anterior belly (superior gluteal artery) that includes one third of the gluteus maximus and the muscle of the tensor fascia latae.
Incise the iliotibial tractIn the distal half, incise the iliotibial tract in line with its fibers up to the mid third of the thigh.
Avoid damage to the medial circumflex femoral artery which is running in proximity (at the upper border of the quadratus femoris muscle) by leaving 1 cm of tendon attached to the greater trochanter.
A, Skin incision. B, Incision of fascia lata and splitting of gluteus maximus outlined. C, Gluteus maximus has been retracted, exposing short external rotators, sciatic nerve, and superior gluteal vessels. Ascending branch of medial circumflex femoral artery underlies obturator externus and quadratus femoris. D, Hip joint capsule has been exposed by division and posterior reflection of short external rotators. Quadratus femoris and obturator externus are left intact to protect the ascending branch of the medial circumflex artery. E, Osteotomy of greater trochanter and reflection of hamstring origins from ischial tuberosity have enlarged exposure
the incision is carried along the iliac crest
starting from the PSIS and running anteriorly to the ASIS
it is then continued down from the ASIS in line with the posterior femur
separate the abdominal musculature from the gluteal musculature at the iliac crest.
develop the interval between the sartorius and tensor fasciae latae.
retract the tensor laterally and dissect through the fascia lata distal to the muscle (longitudinally).
dissect gluteal muscles off iliac crest
subperiosteally dissect the gluteal muscles off the iliac crest from anterior to posterior and cephalad to caudad.
continue the elevation until the PSIS and greater sciatic notch are encountered.
the lateral branches of the anterior femoral circumflex vessels must be ligated to further retract the tensor and fascia lata laterally.
elevate the direct head of the rectus femoris from the pelvis as well as the gluteus minimus (off the proximal femur).
dissect gluteal muscles off iliac crest
subperiosteally dissect the gluteal muscles off the iliac crest from anterior to posterior and cephalad to caudad.
continue the elevation until the PSIS and greater sciatic notch are encountered.
the lateral branches of the anterior femoral circumflex vessels must be ligated to further retract the tensor and fascia lata laterally.
elevate the direct head of the rectus femoris from the pelvis as well as the gluteus minimus (off the proximal femur).