This is a lengthy presentation but it explains all the approaches to the knee and ankle joint explained in campbel orthopaedic textbook.

1. SURGICAL
APPROACHES FOR
KNEE and ANKLE
-DR. KUNAL ARORA
MODERATOR- DR. UMESH YADAV

2. ANATOMY
Knee joint coronal section

3. Knee joint saggital section

5. The knee is a synovial hinge joint,
supported And stabilized by powerful
muscular and ligamentous forces. It is
superficial on three sides (anterior,
medial,and lateral), and approaches to it
are comparatively straight forward.
Because the knee joint is onlycovered by
skin and retinaculae on three of its four
sides, the joint is ideal for arthroscopic
approaches.

6. APPROACHES
• ANTEROMEDIAL
• ANTEROLATERAL
• POSTEROLATERAL
• POSTEROMEDIAL
• MEDIAL
• LATERAL
• DIRECT POSTERIOR, POSTEROMEDIAL,
POSTEROLATERAL
• TRANSVERSE
• EXTEN SILE

7. ANTEROMEDIAL PARAPATELLAR APPROACH
PRECAUTION
When any anteromedial approach is made, including
one for meniscectomy, the infrapatellar branch of the
saphenous nerve should be protected. The
saphenous nerve courses posterior to the sartorius
muscle and then pierces the fascia lata between the
tendons of the sartorius and gracilis muscles and
becomes subcutaneous on the medial aspect of the
leg; on the medial aspect of the knee it gives off a
large infrapatellar branch to supply the skin over the
anteromedial aspet of the knee.

9. Anteromedial parapatellar
approach (Von Langenbeck)
 Begin the incision at the medial border of
the quadriceps tendon 7 to 10 cm proximal
to the patella, curve it around the medial
border of the patella and back toward the
midline, and end it at or distal to the
tibial tuberosity. As a more cosmetically
pleasing alternative, a longitudinal incision
centered over the patella can be made,
reflecting the subcutaneous tissue and
superficial fascia over the patella medially by
Blunt dissection to the medial border of the
patella.

10.  Divide and retract the
fascia.
Deepen the dissection
between the vastus
medialis muscle and the
medial border of the
quadriceps tendon and
incise the capsule and
synovium along this medial
border and along the
medial border of the
patella and patellar tendon.

11. ■ Retract the patella
laterally and flex the
knee to gain a good
view of the anterior
compartment of the
joint and the
suprapatellar bursa.

12. ■ Attain wider access to the joint in the following ways:
(1) extending the incision proximally,
(2) extending the proximal part of the incision obliquely
medially and separating the fibers of the vastus medialis,
(3) dividing the medial alar fold and adjacent fat pad
longitudinally, and
(4) mobilizing the medial part of the insertion of the patellar
tendon subperiosteally.
■ If contracture of the quadriceps prevents sufficient
exposure,
detach the tibial tuberosity and reattach later witha screw.
Fernandez described an extensive osteotomy of the tibial
tuberosity (see Fig. 1-64) and reattachment of the
tuberosity with three lag screws engaging the posterior
tibial cortex.
This technique achieves rigid fixation and allows early
postoperative rehabilitation.

13. Uses
1. Synovectomy
2. Medial meniscectomy
3. Removal of loose bodies
4. Ligamentous reconstructions
5. Patellectomy
6. Drainage of the knee joint in cases of sepsis
7. Total knee replacement
8. Repair of the anterior cruciate ligament
9. Open reduction and internal fixation of distal
femoral fractures when a medial plate is to be used

14. SUBVASTUS (SOUTHERN) ANTEROMEDIAL APPROACH
TO THE KNEE
Problems with patellar dislocation, subluxation, and
osteonecrosis after total knee arthroplasty performed
through an anteromedial parapatellar approach led to
the rediscovery of the subvastus, or southern,
anteromedial approachfirst described by Erkes in 1929.
This approach preserves the vascularity of the patella
by sparing the intramuscular articular branch of the
descending genicular artery and preserves the quadriceps
tendon, providing more stability to the patellofemoral
joint in total knee arthroplasty

15. (ERKES, AS DESCRIBED BY
HOFMANN, PLASTER, AND
MURDOCK)
■ Make a straight anterior skin
incision, beginning 8 cm above
the patella, carrying it distally
just medial and 2 cm distal to
the tibial tubercle.
■ Incise the superficial fascia
slightly medial to the patella
and bluntly dissect it off the
vastus medialis muscle fascia
down to the muscle insertion.
■ Identify the inferior edge of the
vastus medialis and bluntly
dissect it off the periosteum and
intermuscular septum for a
distance of 10 cm proximal to
the adductor tubercle.

16. ■ Identify the tendinous
insertion of the muscle on
the medial patellar
etinaculum and lift the
vastus medialis muscle
anteriorly and perform an L-
shaped arthrotomy
beginning medially through
the vastus insertion on the
medial patellar retinaculum
and carrying it along the
medial edge of the patella.
■ Partially release the medial
edge of the patellar tendon
and evert the patella laterally
with the knee extended

17. ANTEROLATERAL APPROACH
TO THE KNEE
Usually the anterolateral approach is not as satisfactory as
the anteromedial one, primarily because
1)it is more difficult to displace the patella medially than
laterally.
2) It also requires a longer incision,
3) and often the patellar tendon must be partially freed
subperiosteally or subcortically.
The iliotibial band can be released or lengthened, and the
tight osterolateral corner can be released easily. The
fibular head can be resected through the same incision to
decompress the peroneal nerve if necessary.

18. KOCHER Technique
Begin the incision 7.5 cm proximal to the patella
at the insertion of the vastus lateralis muscle
into the quadriceps tendon; continue it distally
along the lateral border of this tendon, the
patella, and the patellar tendon; and end it
2.5 cm distal to the tibial tuberosity.
■ Deepen the dissection through the joint capsule.
■ Retract the patella medially, with the tendons
attached to it, and expose the articular surface of
the joint.

20. POSTEROLATERAL APPROACH TO THE KNEE
(HENDERSON)
■ With the knee flexed between 60 and 90
degrees, make a curved incision on the
lateral side of the knee, just anterior to the
biceps femoris tendon and the head of the
fibula, and avoid the common peroneal
nerve, which passes over the lateral aspect of
the neck of the fibula.
■ In the proximal part of the incision, trace
the anterior surface of the lateral
Intermuscular septum to the linea aspera 5
cm proximal to the lateral femoral condyle.

21. ■ Expose the lateral
femoral condyle and the
origin of thefibular
collateral ligament.
■ The tendon of the
popliteus muscle lies
between thebiceps
tendon and the fibular
collateral ligament;
mobilize and retract it
posteriorly, and expose
the posterolateral
aspect of the joint
capsule.

22. ■ Make a longitudinal incision through the capsule and synovium of the
posterior compartment. To see the insertion of the muscle fibers of the short
head of the biceps muscle onto the long head of the biceps, develop the
interval between the lateral head of the quadriceps muscle and the long
head of the biceps tendon. To isolate the common peroneal nerve, dissect
directly posterior to the long head of the biceps. These intervals are useful in
repair of the posterolateral corner of the knee.

23. POSTEROMEDIAL APPROACH
TO THE KNEE
(HENDERSON)
■ With the knee flexed 90 degrees, make a curved
incision,slightly convex anteriorly and approximately
7.5 cm long,distally from the adductor tubercle and
along the course of the tibial collateral ligament,
anterior to the relaxed tendons of the
semimembranosus, semitendinosus, sartorius,and
gracilis muscles.

25. ■ Expose and incise the oblique part of the tibial
collateral ligament and incise the capsule longitudinally
and enter the posteromedial compartment of the knee
posterior to the tibial collateral ligament, retracting the
hamstring tendons posteriorly, from the level of the
femoral epicondyle straight distally across the joint line.

26. MEDIAL APPROACHES TO THE KNEE
AND SUPPORTING STRUCTURES
Usually the entire medial meniscus can be excised through a
medial parapatellar incision about 5 cm long. If the posterior
horn of the meniscus cannot be excised through this incision,
a separate posteromedial Henderson approach can be made.
The anterior and posterior compartments may be
entered, however, through an approach in which only one
incision is made through the skin but two incisions are used
through the deeper structures; this type of approach is rarely
indicated.

27. MEDIAL APPROACH TO THE KNEE
The CAVE approach is a curved incision that allows exposure
of the anterior and posterior compartments.
(CAVE)
■ With the knee flexed at a right angle, identify the medial
femoral epicondyle and begin the incision 1 cm posterior to
and on a level with it approximately 1 cm proximal to the joint
line. Carry the incision distally and anteriorly to a point 0.5 cm
distal to the joint line and anterior to the border of the
patellar tendon.

28. ■ After reflecting the subcutaneous tissues, expose the
anterior compartment through an incision that begins
anterior to the tibial collateral ligament, continues
distally and anteriorly in a curve similar to that of the
skin incision, and ends just distal to the joint line.

29. ■ To expose the posterior compartment, make a
second deep incision posterior to the tibial
collateral ligament, from the level of the
femoral epicondyle straight distally across the
joint line.

30. (HOPPENFELD AND DEBOER)
■ With the patient supine and the affected knee flexed
about 60 degrees, place the foot on the opposite
shin and abduct and externally rotate the hip.
■ Begin the incision 2 cm proximal to the adductor
tubercle of the femur, curve it anteroinferiorly about
3 cm medial to the medial border of the patella, and
end it 6 cm distal to the joint line on the
anteromedial aspect of the tibia.

31. ■ Retract the skin flaps to expose
the fascia of the knee and
extend the exposure from the
midline anteriorly to the
posteromedial corner of the knee.
■ Cut the infrapatellar branch of
the saphenous nerve and
bury its end in fat; preserve the
saphenous nerve itself
and the long saphenous vein.
■ Longitudinally incise the fascia
along the anterior border
of the sartorius, starting at the
tibial attachment of the
muscle and extending it to 5 cm
proximal to the joint line.

32. Flex the knee further and allow the sartorius to
retract posteriorly, exposing the semitendinosus and
gracilis Muscles.

33. ■ Retract all three components of the pes
anserinus posteriorly and expose the tibial
attachment of the tibial collateral ligament,
which inserts 6 to 7 cm distal to the joint line.

34. ■ To open the joint anteriorly, make a
longitudinal medial parapatellar incision
through the retinaculum and synovium.

35. ■ To expose the posterior third of the medial meniscus and
the posteromedial corner of the knee, retract the three
components of the pes anserinus posteriorly (Fig. 1-60F)
and separate the medial head of the gastrocnemius
muscle from the posterior capsule of the knee almost to
the midline by blunt dissection (Fig. 1-60G).

36. ■ To open the joint posteriorly, make an incision
through the capsule posterior to the tibial
collateral ligament.

37. LATERAL APPROACHES TO THE KNEE
AND
SUPPORTING STRUCTURES
Lateral approaches permit good exposure for
complete excision of the lateral meniscus.
They do not require division or release of the
fibular collateral ligament.

38. (BRUSER)
■ Place the patient supine and
drape the limb to permit full
flexion of the knee. Flex the
knee fully so that the foot rests
flat on the operating table.
■ Begin the incision anteriorly
where the patellar tendon
crosses the lateral joint line,
continue it posteriorly along
the joint line, and end it at an
imaginary line extending from
the proximal end of the fibula
to the lateral femoral condyle
(Fig. 1-62A).

39. ■ Incise the subcutaneous tissue and
expose the iliotibial
band, whose fibers are parallel with
the skin incision
when the knee is fully flexed. Split
the band in line with its fibers.
Posteriorly, take care to avoid
injuring the relaxed fibular
collateral ligament; it is protected
by areolar tissue, which separates it
from the iliotibial band.
■ Retract the margins of the
iliotibial band; this is possible
to achieve without much force
because the band is relaxed when
the knee and hip are flexed.

40. ■ Locate the lateral inferior genicular artery, which lies
outside the synovium between the collateral ligament
and the posterolateral aspect of the meniscus.
■ Incise the synovium. The lateral meniscus lies in the depth
of the incision and can be excised completely

41. ■ With the knee flexed 90 degrees, close the synovium
(Fig. 1-62D); and with the knee extended, close the
deep fascia.

42. DIRECT POSTERIOR, POSTEROMEDIAL,
AND POSTEROLATERAL APPROACHES TO
THE KNEE
The approach provides access to the posterior
capsule of the knee joint, the posterior part of
the menisci, the posterior compartments of
the knee, the posterior aspect of the femoral
and tibial condyles, and the origin of the
posterior cruciate ligament. All posterior
approaches are done with the patient supine.

44. BRACKETT AND OSGOOD;
PUTTI; ABBOTT AND
CARPENTER
■ Make a curvilinear incision 10
to 15 cm long over the
popliteal space (Fig. 1-67A),
with the proximal limb
following the tendon of the
semitendinosus muscle
distally to the level of the
joint. Curve it laterally across
the posterior aspect of the
joint for about 5 cm and
distally over the lateral head
of the gastrocnemius muscle.
■ Reflect the skin and
subcutaneous tissues to
expose the popliteal fascia.

45. ■ Identify the posterior cutaneous nerve of the calf (the
medial sural cutaneous nerve) lying beneath the fascia
and between the two heads of the gastrocnemius muscle
because it is the clue to the dissection. Lateral to it, the
short saphenous vein perforates the popliteal fascia to
join the popliteal vein at the middle of the fossa. Trace
the posterior cutaneous nerve of the calf (the medial sural
cutaneous nerve) proximally to its origin from the tibial
nerve because the contents of the fossa can be dissected
accurately and safely once this nerve is located. Trace the
tibial nerve distally and expose its branches to the heads
of the gastrocnemius, the plantaris, and the soleus
muscles; these branches are accompanied by arteries and
veins. Follow the tibial nerve proximally to the apex of the
fossa where it joins the common peroneal nerve (Fig.
1-67B). Dissect the common peroneal nerve distally along
the medial border of the biceps muscle and tendon, and
protect the lateral cutaneous nerve of the calf and the
anastomotic peroneal nerve.

46. ■ Expose the popliteal artery and vein, which lie directly
anterior and medial to the tibial nerve. Gently retract the
artery and vein and locate and trace the superolateral and
superomedial genicular vessels passing beneath the hamstring
muscles on either side just proximal to the heads
of origin of the gastrocnemius (Fig. 1-66).

47. ■ Open the posterior
compartments of the joint
with the knee extended and
explore them with the knee
slightly flexed. The medial
head of the gastrocnemius
arises at a more proximal
level from the femoral
condyle than does the
lateral head, and the groove
it forms with
thesemimembranosus
forms a safe and
comparatively avascular
approach to the medial
compartment

48. Turn the tendinous origin of the medial
head of the gastrocnemius laterally
to serve as a retractor for the
popliteal vessels and nerves (Fig. 1-
67D).
■ Greater access can be achieved by
ligating one or more genicular
vessels. If the posterolateral aspect
of the joint is to be exposed, elevate
the lateral head of the
gastrocnemius muscle from the
femur and approach the lateral
compartment between the tendon of
the biceps femoris and the lateral
head of the gastrocnemius muscle.

49. ■ When closing the wound, place interrupted
sutures in the
capsule, the deep fascia, and the skin. The
popliteal fascia
is best closed by placing all sutures before
drawing them
tight. Tie the sutures one by one.

50. USES
1. Repair of the neurovascular structures that run behind
the knee in cases of trauma
2. Repair of avulsion fractures of the site of attachment
of the posterior cruciate ligament to the tibia
3. Recession of gastrocnemius muscle heads in cases
of contracture
4. Lengthening of hamstring tendons
5. Excision of Baker’s cyst and other popliteal cysts
6. Access to the posterior capsule of the knee

51. ANKLE

52. RETINACULAE

53. Anterior Approach to the Ankle
USES
1. Drainage of infections in the ankle joint
2. Removal of loose bodies
3. Open reduction and internal fixation of
comminuted
distal tibial fractures (pilon fractures)
4.Arthrodesis

54. Incision
Make a 15-cm longitudinal incision over the anterior
aspect of the ankle joint. Begin about 10 cm proximal
to the joint, and extend the incision so that it crosses
the joint about midway between the malleoli, ending
on the dorsum of the foot. Take great care to cut only
the skin; the anterior neurovascular bundle and
branches of the superficial peroneal nerve cross the
ankle joint very close to the line of the skin incision

55. Intervenous plane
Although the approach uses no true internervous
plane, the extensor hallucis longus and extensor digitorum
longus muscles define a clear intermuscular
plane. Both muscles are supplied by the deep peroneal
nerve, but the plane may be used because both
receive their nerve supplies well proximal to the level
of the dissection. The plane must be used with great
caution, however, because it contains the neurovascular
bundle distal to the ankle

57. Superficial Surgical Dissection
Incise the deep fascia of the leg in line with the skin
incision, cutting through the extensor retinaculum. Find
the plane between the extensor hallucis longus and
extensor digitorum longus muscles a few centimeters
above the ankle joint, and identify the neurovascular
bundle (the anterior tibial artery and the deep peroneal
nerve) just medial to the tendon of the extensor hallucis
longus . Trace the bundle distally until it crosses the
front of the ankle joint behind the tendon of the
extensor hallucis longus. Retract the tendon of the
extensor hallucis longus medially, together with the
neurovascular bundle. Retract the tendon of the
extensor digitorum longus laterally.

59. Deep Surgical Dissection
For arthrodesis surgery, incise the remaining soft
tissues longitudinally to expose the anterior surface
of the distal tibia. Continue incising down to the
ankle joint, then cut through its anterior capsule.
Expose the full width of the ankle joint by detaching
the anterior ankle capsule from the tibia or the
talus by sharp dissection. Some periosteal stripping
of the distal tibia may be required.

60. Dangers
Nerves
1. Cutaneous branches of the superficial peroneal
nerve run close to the line of the skin incision just
under the skin. Take care not to cut them during
incision of the skin.
2. The deep peroneal nerve and anterior tibial
artery (the anterior neurovascular bundle) must
be identified and preserved during superficial
surgical dissection.

61. Anterior and Posterior Approaches to
the Medial Malleolus
The anterior and posterior approaches
are used mainly for open reduction
and internal fixation of fractures of
the medial malleolus.The approaches
provide excellent visualization of the
malleolus.

62. Incisions
Two skin incisions are available.
1. The anterior incision offers an excellent view of medial
malleolar fractures.Make a 10-cm longitudinal curved incision on
the medial aspect of the ankle, with its midpoint just anterior to
the tip of the medial malleolus. Begin proximally, 5 cm above
the malleolus and over the middle of the subcutaneous
surface of the tibia. Then, cross the anterior third of the
medial malleolus, and curve the incision forward to end some
5 cm anterior and distal to the malleolus. The incision should
not cross the most prominent portion of the malleolus.

63. • 2. The posterior incision allows reduction and
fixation of medial malleolar fractures and
visualization of the posterior margin of the tibia.
Make a 10-cm incision on the medial side of the
ankle. Begin 5 cm above the ankle on the
posterior border of the tibia, and curve the
incision downward, following the posterior
border of the medial malleolus. Curve the
incision forward below the medial malleolus to
end 5 cm distal to the malleolus

64. No true internervous plane exists in this approach,but the approach
is safe because the incision cuts down onto subcutaneous bone.
Superficial Surgical Dissection
Anterior Incision
Gently mobilize the skin flaps, taking care to identify and preserve
the long saphenous vein, which lies just anterior to the medial
malleolus. Accurately locating the skin incision will make it
unnecessary to mobilize the skin flaps extensively. Next to the
vein runs thesaphenous nerve, two branches of which are bound
to the vein. Take care not to damage the nerve; damage leads to
the formation of a neuroma. Because the nerve is small and not
easily identified, the best way to preserve it is to preserve the
long saphenous vein, a structure that on its own is of little
functional significance.
Posterior Incision
Mobilize the skin flaps. The saphenous nerve is not in danger

66. Anterior Incision
Incise the remaining coverings of the medial malleolus
longitudinally to expose the fracture site. Make a small
incision in the anterior capsule of the ankle joint so
that the joint surfaces can be seen after the fracture is
reduced. This is especially importantin vertical
fractures of the medial malleolus where impaction at
the joint surface frequently occurs. The superficial
fibers of the deltoid ligament run anteriorly and distally
downward from the medial malleolus; split them so
that wires or screws used in internal fixation can be
anchored solidly on bone, with the heads of the screws
covered by soft tissue.

69. Posterior
Incise the retinaculum behind the medial malleolus
longitudinally so that it can be repaired. Take care not
to cut the tendon of the tibialis posterior muscle,
which runs immediately behind the medial malleolus;
the incision into the retinaculum permits anterior
retraction of the tibialis posterior tendon. Continue the
dissection around the back of the malleolus, retracting
the other structures that pass behind the medial
malleolus posteriorly to reach the posterior margin (or
posterior malleolus) of the tibia. The exposure allows
reduction of some fractures of that part of the bone.

71. Dangers of the Anterior Incision
Nerves
The saphenous nerve, if cut, may form a neuroma
and cause numbness over the medial side of the
dorsum of the foot. Preserve the nerve by
preserving the long saphenous vein.
Vessels
The long saphenous vein is at risk when the
anterior skin flaps are mobilized. Preserve it if
possible, so that it can be used as a vascular graft
in the future

72. Dangers of the Posterior Incision
All the structures that run behind the medial
malleolus (the tibialis posterior muscle, the
flexor digitorum longus muscle, the posterior
tibial artery and vein, the tibial nerve, and the
flexor hallucis longus tendon) are in danger if
the deep surgical dissection is not carried out
close to bone

73. Posteromedial Approach to the Ankle
The posteromedial approach to the ankle joint is
routinely used for exploring the soft tissues that run
around the back of the medial malleolus. This
approach is used for the release of soft tissue around
the medial malleolus in the treatment of clubfoot.The
approach can also be used to allow access to the
posterior malleolus of the ankle joint, but gives limited
exposure of the fracture site and is technically
demanding. For this reason reduction and fixation of
posterior malleolar fractures is usually achieved by
indirect techniques.

74. Position
Either of two positions is available for this
approach.
First, place the patient supine on the operating
table. Flex the hip and knee, and place the lateral
side of the affected ankle on the anterior surface
of the opposite knee. This position will achieve
full external rotation of the hip, permitting better
exposure of the medial structures of the ankle
Alternatively, place the patient in the lateral
position with the affected leg nearest the table. Flex
the knee of the opposite limb to get its ankle out of
the way.

76. Incision and Superficial Surgical
Dissection
Make an 8- to 10-cm longitudinal incision roughly
midway between the medial malleolus and the
Achilles tendon
Deepen the incision in line with the skin incision to enter the
fat that lies between the Achilles tendon and those
structures that pass around the back of the medial
malleolus. If the Achilles tendon must be lengthened,
identify it in the posterior flap of the wound and perform
the lengthening now. Identify a fascial plane in the anterior
flap that covers the remaining flexor tendons. Incise the
fascia longitudinally, well away from the back of the medial
malleolus

79. Deep Surgical Dissection
There are three different ways to approach the back
of the ankle joint.
First, identify the flexor hallucis longus, the only
muscle that still has muscle fibers at this level. At its
lateral border, develop a plane between it and
the peroneal tendons, which lie just lateral
to it. Deepen this plane to expose the posterior
aspect of the ankle joint by retracting the flexor
hallucis longus medially.

80. Second, identify the flexor hallucis longus and continue
the dissection anteriorly toward the back of the
medial malleolus. Preserve the neurovascular bundle
by mobilizing it gently and retracting it and the flexor
hallucis longus laterally to develop a plane between
the bundle and the tendon of the flexor digitorum longus
Achilles tendon. This approach brings one onto the
posterior aspect of the ankle joint rather more medially
than does the first approach.

81. Third, when all the tendons that run around the
back of the medial malleolus (the tibialis posterior,
flexor digitorum longus, and flexor hallucis longus)
must be lengthened, the back of the ankle can be
approached directly, because the posterior coverings of
the tendons must be divided during the lengthening
Procedure. For all three methods, complete the approach
by incising the joint capsule either longitudinally or
transversely.

84. Dangers
The posterior tibial artery and the tibial nerve (the
posterior neurovascular bundle) are vulnerable during
the approach. Take care not to apply forceful retraction
to the nerve, as this may lead to a neurapraxia.
Note that the tibial nerve is surprisingly large in young
children and that the tendon of the flexor digitorum
longus muscle is extremely small. Take care to identify
positively all structures in the area before dividing any
muscle tendons

85. THANK YOU