This document describes several surgical approaches to the femur bone. It discusses the common lateral, posterolateral, and anteromedial approaches to different sections of the femur. It also covers minimally invasive approaches to the distal and proximal femur. Each approach is described in terms of indications, patient positioning, landmarks, incisions, deep dissection techniques, and potential dangers to avoid injury to surrounding nerves and blood vessels.

1. Surgical approaches to femur

2. Common approaches
 Lateral approach
 Posterolateral approach
 Anteromedial approach to distal two thirds of femur
 Posterior approach
 Minimally invasive approach to distal femur
 Minimally invasive approach to proximal femur for IM nailing
 Minimally invasive surgery for retrograde IM nailing

3. Lateral approach
Most commonly used for accessing upper third of femur
Can be extended inferiorly
Indications
1. ORIF-intertrochanteric #s
2. Internal fixation-SCFE,subcapital #s
3. Subtrochanteric or intertrochanteric osteotomy
4. ORIF-shaft #s, subtrochanteric and supracondylar femur #s
5. Extra-articular arthrodesis of hip joint
6. Treatment of chronic osteomyelitis
7. Biopsy and treatment of bone tumors

4. Position of patient
 Supine
 Internally rotated-15 degrees
 Lateral position for shaft
fractures
 Pad bony prominences

5. Landmarks and incision
 Greater trochanter-identify tip
 Lateral aspect of femur shaft
 Longitudinal incision beginning
over the middle of greater
trochanter and extending over the
lateral aspect of shaft
 Fascia lata incised in line with skin
incision

6. Deep surgical dissection

7. Danger
• Damage to the numerous perforating branches of profunda femoris
artery
• Should be ligated or coagulated
• Split muscle gently with blunt instrument.

8. Extension

9. Posterolateral approach
• Follows the lateral intermuscular septum
Indications
1. ORIF-supracondylar fractures
2. Open IM nailing of shaft fractures
3. Treatment of non-union fractures.
4. Femoral osteotomy
5. Chronic or acute osteomyelitis
6. Biopsy and treatment of bone tumors

10. Position of patient
• Supine
• Elevate buttock and internally rotate
leg-use sandbag

11. Landmarks and incision

12. Deep surgical dissection

13. Cont..

14. Dangers
• Perforating arteries that pierce the septum-must be ligated or
coagulated
• Superior lateral genicular artery and vein-

15. Anteromedial approach to distal two-thirds of
femur
• Excellent view of lower two thirds of femur and knee joint.
Indications
1. ORIF-distal femur #s-especially buttress plating
2. ORIF-shaft #s
3. Treatment of chronic osteomyelitis
4. Bone biopsy and treatment of tumors
5. Quadricepslasty
6. Distal femoral osteotomy.

16. Position, landmarks and incision

17. Deep surgical dissection

18. Cont…
 can be extended superiorly
and inferiorly
 Offers excellent exposure
to lower two thirds but
higher up VAN intrude into
dissection

19. Dangers
• Vessels-medial superior genicular artery crosses the field-ligate or
coagulate to avoid hematoma
• Muscle-disruption of the lowest fibers of the vastus medialis-repair
the incision meticulously to prevent lateral subluxation of patella.

20. Posterior approach
• Useful in patients who cannot undergo more anterior approaches-
due to skin problems
Indications
1. Treatment of infected non-union of femur
2. Treatment of chronic osteomyelitis
3. Bone biopsy and treatment of bone tumors
4. Exploration of sciatic nerve.

21. Position, landmark and incisions

22. Deep surgical dissection
 Begin proximally
 Retract long head of biceps femoris medially and
the lateral intermuscular septum laterally
 Identify short head of biceps femoris,detach its
origin and reflect it medially to expose femur

23. Cont..

24. Dangers
• Nerves
I. Sciatic nerve- proximally it is protected as long as the correct
intermuscular plane is maintained, distally the nerve must be
identified and retracted carefully
II. Nerve to the biceps femoris-well protected as the dissection is on
the lateral side of the muscle.

25. Minimally invasive approach to the distal
femur
• Utilizes two windows
Distal window-in effect a parapatellar approach allowing visualization
of the distal femur articular surface
Proximal window- provides access to the shaft and is a portion of the
lateral approach
Indication: ORIF for distal femoral #s especially intra-articular with
complex metaphyseal injuries.

26. Position, landmark and incisions

27. Deep dissection

28. Dangers
• Superior genicular artery and vein-ligate or coagulate to avoid
hematoma.

29. Minimally invasive approach to the proximal
femur for IM nailing
Used for IM nails in the treatment of:
I. Acute femoral shaft fractures
II. Pathological femoral shaft fractures
III. Delayed union and non-union of femoral shaft #s

30. Position of patient
• Two position are available,

31. Landmarks and incision
• Landmarks: greater trochanter, ASIS , femur shaft
• Incision: two techniques, Radiographic technique and Landmark
technique

32. Conti…

33. Deep dissection

34. Dangers
• Bone deformity;
 Too lateral entry points creates a varus deformity at fracture site and
may also create an iatrogenic # of the medial femoral cortex during
insertion.
Too medial entry points may create iatrogenic NOF # and avascular
necrosis of the head of femur.
• Nerves
Damage to the superior gluteal nerve may occur if retrograde nailing
technique is applied when the femur is not abducted.

35. Minimally invasive surgery for Retrograde IM
Nailing of Femur
Utilizes a small portion of the medial parapatellar approach to the
knee
Allows excellent percutaneous access to the distal femoral
intercondylar region
Its sole use is in the insertion of retrograde IM nails in femur shaft #s

36. Position, landmarks and incision
 Patient supine on radioluscent table
 Place a large triangular ridge underneath the
knee to allow it flex to 90 degrees
 Place a small sandbag under ipsilateral buttock to
correct the natural external rotation-the sandbag
should not block radiographic visualization.
 Palpate medial border of patella

37. Cont..

38. Deep surgical incision

39. Dangers
• Infrapatellar branch of the saphenous nerve is in danger in distal
extension.
• Posterior cruciate ligament insertion may be damaged by the IM nails
or reamers if the entry point is not correctly located.

40. THANK YOU