Surgical approach

Upper extremity
• Shoulder
• Humerus
• Elbow
• Radius
• Ulna
• Wrist
• Hand
Humerus
• Anterolateral approach to the humerus
• Posterior approach to the proximal humerus
• Approaches to distal humeral shaft
• Posterolateral approach to distal humeral shaft
• Posterolateral extensile (cold) approach to distal humerus
Anterolateral approach to the humerus
Posterior approach to the proximal humerus
Posterolateral approach to distal humeral
shaft
Posterolateral extensile (cold) approach to
distal humerus
Elbow
• Posterior approaches
• Posterolateral approach to the elbow
• Extensile posterolateral approach to the elbow
• Posterior approach to the elbow by olecranon osteotomy
• Extensile posterior approach to the elbow
• Lateral approaches
• Lateral approach to the elbow
• Lateral J-shaped approach to the elbow
• Medial approach with osteotomy of the medial epicondyle
• Global approach
Posterolateral approach to the elbow
Extensile posterolateral approach to the
elbow
Posterior approach to the elbow by olecranon
osteotomy
Extensile posterior approach to the elbow
• Place the patient in the lateral decubitus position or tilted 45 to 60 degrees with sandbags placed
under the back and hip. Place the limb across the chest.
• Make a straight posterior incision in the midline of the limb, extending from 7 cm distal to the tip
of the olecranon to 9 cm proximal to it.
• Identify the ulnar nerve proximally at the medial border of the medial head of the triceps, and
dissect it free from its tunnel distally to its first motor branch
• In total joint arthroplasty, transplant the nerve anteriorly into the subcutaneous tissue (Fig. 1-
118B).
• Elevate the medial aspect of the triceps from the humerus, along the intermuscular septum, to
the level of the posterior capsule.
• Incise the superficial fascia of the forearm distally for about 6 cm to the periosteum of the medial
aspect of the olecranon.
• Carefully reflect as a single unit the periosteum and fascia medially to laterally (Fig. 1-118C). The
medial part of the junction between the triceps insertion and the superficial fascia and the
periosteum of the ulna is the weakest portion of the reflected tissue. Take care to maintain
continuity of the triceps mechanism at this point; carefully
Extensile posterior approach to the elbow (2)
• dissect the triceps tendon from the olecranon when the elbow is extended to 20 to 30 degrees to relieve
tensionon the tissues, and then reflect the remaining portion of the triceps mechanism.
• To expose the radial head, reflect the anconeus subperiosteally from the proximal ulna; the entire joint is
now widely exposed (Fig. 1-118D).
• The posterior capsule usually is reflected with the triceps mechanism, and the tip of the olecranon may be
resected to expose the trochlea clearly (see Fig. 1-118D).
• To attain joint retraction in total joint arthroplasty, release the medial collateral ligament from the humerus
if necessary.
• During closure, carefully repair the medial collateral ligament when its release has been necessary.
• Return the triceps to its anatomical position and suture directly to the bone through holes drilled in the
proximal aspect of the ulna.
• Suture the periosteum to the superficial forearm fascia, as far as the margin of the flexor carpi ulnaris (Fig. 1-
118E).
• Close the wound in layers, and leave a drain in the wound. In total joint arthroplasty, dress the elbow with
the joint flexed about 60 degrees to avoid direct pressure on the wound by the olecranon tip.
Extensile posterior approach to the elbow (3)
Lateral approach to the elbow
Lateral J-shaped approach to the elbow
Medial approach with osteotomy of the
medial epicondyle
Global approach to the elbow
Radius
• Posterolateral approach to the radial head and neck
• Approach to the proximal and middle thirds of the posterior surface
of the radius
• Anterolateral approach to the proximal shaft and elbow joint
• Anterior approach to the distal half of the radius
Posterolateral approach to the radial head
and neck
• Begin an oblique incision over the posterior surface of the lateral
humeral condyle, and continue it obliquely distally and medially to a
point over the posterior border of the ulna 3 to 5 cm distal to the tip
of the olecranon
• Divide the subcutaneous tissue and deep fascia along the line of the
incision, and develop the fascial plane between the extensor carpi
ulnaris and the anconeus muscles. This plane can be found more
easily in the distal than in the proximal part of the incision, because in
the proximal part the two muscles blend together at their origin.
Posterolateral approach to the radial head
and neck (2)
• Retract the anconeus toward the ulnar side and the extensor carpi
ulnaris toward the radial side, exposing the joint capsule in the depth
of the proximal part of the wound.
• Note that the fibers of the supinator cross at a right angle to the
wound, near its center and deep (anterior) to the extensor carpi
ulnaris; retract the proximal fibers of the supinator distally.
• Locate the joint capsule in the depth of the wound, incise it, and
expose the head and neck of the radius (see Fig.1-124). The deep
branch of the radial nerve that lies between the two planes of the
supinator remains undisturbed.
Posterolateral approach to the radial head
and neck (3)
Approach to the proximal and middle thirds
of the posterior surface of the radius
Anterolateral approach to the proximal shaft
and elbow joint
Anterior approach to the distal half of the
radius
Ulna
• Begin the incision about 2.5 cm proximal to the elbow joint just lateral to the triceps tendon, continue it
distally over the lateral side of the tip of the olecranon and along the subcutaneous border of the ulna, and
end it at the nction of the proximal and middle thirds of the ulna (Fig. 1-128A).
• Develop the interval between the ulna on the medial side and the anconeus and extensor carpi ulnaris on
the lateral side.
• Strip the anconeus from the bone subperiosteally in the proximal part of the incision; to expose the radial
head, reflect the anconeus radially.
• Distal to the radial head, deepen the dissection to the interosseous membrane after reflecting the part of
the supinator that arises from the ulna subperiosteally.
• Peel the supinator from the proximal fourth of the radius, and reflect radially the entire muscle mass,
including this muscle, the anconeus, and the proximal part of the extensor carpi ulnaris (Fig. 1-128B). This
amply exposes the lateral surface of the ulna and the proximal fourth of the radius. The substance of the
reflected supinator protects the deep branch of the radial nerve (Fig. 1-128C and D)
• In the proximal part of the wound, divide the recurrent interosseous artery, but not the dorsal interosseous
artery.
Ulna (2)
The wrist
Dorsal Approach
Volar approach
Lateral approach
The hand
Lower Extremities
• Toes
• Calcaneus
• Tarsus ankle
• Tibia
• Fibula
• Knee
• Femur
• Hip
Toes
• Approach to the interphalangeal joint
• Medial approach to MTP joint of great toe
• Dorsomedial approach to MTP joint of great toe
• Approach to the lesser toe MTP joint
Approach to the interphalangeal joint
• Make an incision 2,5 cm long on the medial aspect of the toe
• For the interphalangeal joints of the fifth toe, make a lateral incision
• Approach of IP joints of the second, third and fourth toes goes
through an incision just lateral to the corresponding extensor tendon
• Carry the dissection through the subcutaneous tissue and fascia to
the capsule of the joint
• Reflect the edges of the incision with care to avoid damaging the
dorsal or plantar vessels dorsally and plantar nerves plantarward
Medial approach to MTP joint of great toe
Dorsomedial approach to MTP joint of great toe
• Begin the incision just proximal to the interphalangeal joint and
continue it proximally for 5 cm parallel with and medial to the
Extensor halucis longus tendon
• To expose the capsule, divide the fascia and retract the tendon
• The capsule can be incised by forming a flap with its attachment at
the base of the first phalanx, as in the preceding approach or by
continuing the dissection in the plane of the skin incision
Approach to the lesser toe MTP joint
Calcaneus
• Most easily: patient prone
• Medial approach: patient supine, knee flexed and foot crossed over
opposite leg
• Lateral approach: patient supine placing sand bag under the
ipsilateral buttock, internally rotating the hip and everting the foot
• 4 approaches:
• Medial approach
• Lateral approach
• U-shaped approach
• Kocher approach
Medial approaches
Lateral approach
U-shaped approach
Kocher approach
• The Kocher approach is suitable for complete excision o the calcaneus in
cases of tumor or infection.
• Incise the skin over the medial border of the Achilles tendon from 7.5 cm
proximal to the tuberosity of the calcaneus to the inferoposterior aspect of
the tuberosity, continuing it transversely around the posterior aspect of the
calcaneus and distally along the lateral surface of the foot to the tuberosity
of the fifth metatarsal (see Fig. 1-32B).
• Divide the Achilles tendon at its insertion and carry the dissection down to
the bone.
• To reach the superior surface, free all tissues beneath the severed Achilles
tendon.
• The calcaneus may be enucleated with or without its periosteal
attachments.
Tarsus and ankle
• Anterior approaches to tarsus and ankle
• Anterolateral approach to the calcaneus
• Anterior approach to expose the ankle joint and both maleoli
• Lateral approaches to tarsus and ankle
• Kocher lateral approaches to the tarsus and ankle
• Ollier approaches to the tarsus
• Posterolateral approach to the ankle
• Anterolateral approach to the lateral dome of the talus
• Posterior approach to the ankle
• Medial approaches to the ankle
Anterolateral approach to the calcaneus
Anterior approach to expose the ankle joint
and both maleoli
Kocher lateral approaches to the tarsus and
ankle
Ollier approaches to the tarsus
• Begin the skin incision over the dorsolateral aspect of the talonavicular
joint, extend it obliquely inferoposteriorly, and end it about 2.5 cm inferior
to the lateral malleolus
• Divide the inferior extensor retinaculum in the line of the skin incision.
• In the superior part of the incision, expose the long extensor tendons to
the toes and retract them medially, preferably without opening their
sheaths.
• In the inferior part of the incision, expose the peroneal tendons and retract
them inferiorly.
• Divide the origin of the extensor digitorum brevis muscle, retract the
muscle distally, and bring into view the sinus tarsi.
• Extend the dissection to expose the subtalar, calcaneocuboid, and
talonavicular joints.
Posterolateral approach to the ankle
Anterolateral approach to the lateral dome of
the talus
• Make a vertical 10-cm incision along the anterolateral corner
of the ankle, avoiding the lateral branch of the superficial
peroneal nerve.
• Outline the osteotomy of the anterolateral tibia to include
the anterior tibiofibular ligament. The cortical surface of the
fragment should be at least 1 cm2 (Fig. 1-34).
• Predrill the fragment to accept a 4-mm cancellous screw.
• Use a micro-oscillating saw to begin the osteotomy in two
planes. Complete the osteotomy with a small, narrow
osteotome by gently levering it in an externally rotate
ddirection. The cartilaginous surface of the tibia is “cracked”
as the fragment is rotated.
• At wound closure, rotate the fragment back into position
and secure it with a 4-mm cancellous screw and washer.
Posterior approach to the ankle
Medial approaches to the ankle
• ■ Curve the incision just proximal to the medial malleolus (Fig. 1-
36A), and divide the malleolus with an osteotome or small power
saw; preserve the attachment of the deltoid ligament.
• Subluxate the talus and malleolus laterally to reach the joint
surfaces.
• Later replace the malleolus and fix it with one or two cancellous
screws. To make replacement easier, drill the holes for the screws
before the osteotomy, insert the screw, and then remove it. At the
end of the operation reinsert the screws and close the wound.
• The surfaces of the osteotomized bone are smooth, and the
malleolus can rotate on a single screw. Two screws are used to
prevent rotation of the osteotomized medial malleolus (Fig. 1-37).
Interfragmentary technique should be used for screw fixation of
the medial malleolus to provide compression across the
osteotomy site.
Tibia
• Anterior approach to the tibia
• Medial approach to the tibia
• Posterolateral approach to the tibia
• Posterior approach to the superomedial region of the tibia
Anterior approach to the tibia
• Make a longitudinal incision on either side of the anterior border of
the bone.
• Reflect the skin, and incise and elevate the periosteum over the
desired area.
• Strip the periosteum as little as possible, because its circulation is a
source of nutrition for the bone.
Medial approach to the tibia
• Make a longitudinal incision along the posteromedial border of the
tibia.
• Incise the subcutaneous tissues and deep fascia, and reflect the
periosteum from the posterior surface for the required distance.
Posterolateral approach to the tibia
Posterior approach to the superomedial
region of the tibia (Banks and laufman)
• The patient must be prone. Begin the transverse segment of a hockey-stick
incisionat the lateral end of the flexion crease of the knee, and extend it
across the popliteal space. Turn the incision distally along the medial side
of the calf for 7 to 10 cm.
• Develop the angular flap of skin and subcutaneous tissue, and incise the
deep fascia in line with the skin incision
• Identify and protect the cutaneous nerves and superficial vessels.
• Define the interval between the tendon of the semitendinosus muscle and
the medial head of the gastrocnemius muscle.
• Retract the semitendinosus proximally and medially and the gastrocsoleus
component distally and laterally; the popliteus and flexor digitorum longus
muscles lie in the floor of the interval
Posterior approach to the superomedial
region of the tibia (Banks and laufman) (2)
• Elevate subperiosteally the flexor digitorum longus muscle distally
and laterally and the popliteus muscle proximally and medially, and
expose the posterior surface of the proximal fourth of the tibia
.Further elevation of the popliteus will expose the posterior cruciate
ligament fossa.
• If necessary, extend the incision distally along the medial side of the
calf by continuing the dissection in the same intermuscular plane. The
tibial nerve and posterior tibial artery lie beneath the soleus muscle.
Posterior approach to the superomedial
region of the tibia (Banks and laufman) (3)
FIBULA
• Posterolateral approach to the fibula
KNEE
• Anteromedial and anterolateral approaches
• Anteromedial parapatellar approaches
• Subvatus (Southern) anteromedial approaches to the knee
• Anterolateral approaches to the knee
• Posterolateral and posteromedial approaches
• Posterolateral approach to the knee
• Posteromedial approach to the knee
• Medial approaches to the knee and supporting structures
• Cave, Hoppenfeld and deboer
• Transverse approach to the meniscus
• Lateral approaches to the knee and supporting structures
• Bruser, brown et al, hoppenfield and deboer
• Extensile approach to the knee
• Direct posterior, posteromedial and posterolateral approaches to the knee
• Brackett and Osgood, putti, abbot and carpenter
Anteromedial parapatellar approaches
Subvatus (Southern) anteromedial
approaches to the knee
Anterolateral approaches to the knee
Posterolateral approach to the knee
Posteromedial approach to the knee
Medial approaches to the knee and
supporting structures (Cave)
Lateral approaches to the knee and
supporting structures
Extensile approach to the knee
Direct posterior, posteromedial and
posterolateral approaches to the knee
FEMUR
• Anterolateral approach to the femur
• Lateral approach to the femoral shaft
• Posterolateral approach to the femoral shaft
• Posterior approach to the femur
• Medial approach to the posterior surface of the femur in the popliteal
space
• Lateral approach to the posterior surface of the femur in the popliteal
space
• Lateral approach to the proximal shaft and trochanteric region
Anterolateral approach to the femur
Lateral and posterolateral approach to the
femoral shaft
Posterior approach to the femur
Medial and lateral approach to the posterior
surface of the femur in the popliteal space
Lateral approach to the proximal shaft and
trochanteric region
HIP
• Anterior approaches
• Anterior iliofemoral approach to the hip
• Anterior approach to the hip using a transverse incision
• Modified anterolateral iliofemoral approach to the hip
• Lateral approaches
• Lateral approach to the hip
• Lateral approach for extensive exposure of the hip
• Lateral approach of the hip preserving the gluteus medius
• Lateral transgluteal approach to the hip
• Posterior approaches
• Medial approach to the hip
Anterior iliofemoral approach to the hip
Anterior approach to the hip using a
transverse incision
Modified anterolateral iliofemoral approach
to the hip
• Make the skin incision along the anterior third of the iliac crest and along
the anterior border of the tensor fasciae latae muscle; curve it posteriorly
across the insertion of this muscle into the iliotibial band in the
subtrochanteric region (usually at a point 8 to 10 cm below the base of the
greater trochanter) and end it there.
• Incise the fascia along the anterior border of the tensor fasciae latae
muscle. Identify and protect the lateral femoral cutaneous nerve, which
usually is medial to the medial border of the tensor fasciae latae and close
to the lateral border of the sartorius.
• Cleanly incise the muscle attachments to the lateral aspect of the ilium
along the iliac crest to make reflection of the periosteum easier. Reflect it
as a continuous structure, without fraying, distally to the superior margin
of the acetabulum.
Modified anterolateral iliofemoral approach
to the hip (2)
• Divide the muscle attachments between the anterior superior iliac spine and the
acetabular labrum. The posterior flap thus reflected consists of the tensor fasciae
latae, the gluteus minimus, and the anterior part of the gluteus medius (Fig. 1-
68).
• Inferiorly carry the fascial incision across the insertion of the tensor fasciae latae
into the iliotibial band, and expose the lateral part of the rectus femoris and the
anterior part of the vastus lateralis muscles.
• Begin the capsular incision on the inferior aspect of the capsule just lateral to the
acetabular labrum; from this point, extend it proximally, parallel with the
acetabular labrum, to the superior aspect of the capsule, and curve it laterally,
continuing on beyond the capsule to the base of the greater trochanter. This
incision divides that part of the reflected head of the rectus femoris that blends
into the capsule inferior to its insertion into the superior margin of the
acetabulum. By reflecting it with the capsule, the capsular flap is reinforced, and
repair is made easier.
Modified anterolateral iliofemoral approach
to the hip (3)
Lateral approach to the hip
Lateral approach for extensive exposure of
the hip
Lateral approach of the hip preserving the
gluteus medius
Lateral transgluteal approach to the hip
Posterior approach (Osborne)
Posterior approach (Moore)
Medial approach
HIP
• The most important part in surgical approach to the hip are
• Based on access needed
• Potential for complication
• Procedure to be performed
• Experience of surgeon
Anterior approach
Anterior iliofemoral approach
• Almost all surgery of the hip may be carried out through this
approach, but this type of approach is inadequate for reconstructive
operations.
Anterior iliofemoral approach to the hip
Anterior approach to the hip using transverse
incision
• This type of approach allows sufficient exposure of the ilium, and
access to the acetabulum
• This type of approach indicated for reduction of congenitally
dislocated hip
Anterior approach to the hip using transverse
incision (technique)
Anterior approach to the hip using transverse
incision (technique)
Modified anterolateral iliofemoral approach
to the hip
• This type of approach is useful in reconstructive procedures such as
osteotomy for slipping of the proximal femoral epiphysis and non-
union of femoral neck
Modified anterolateral iliofemoral approach
to the hip (Technique)
Lateral Approach
Lateral approach to the hip
Lateral approach to the hip (technique)
Harris lateral approach to hip
(Technique)
McFarland and osborne lateral or
posterolateral approach to hip
Hardinge direct lateral transgluteal approach
Hay lateral transgluteal approach to hip
Posterior approach
Posterior approach
• Posterior approach are ideal when the femoral head viability is
unnecessary, such as resection arthroplasty and insertion of a
proximal femoral prosthesis
Gibson posterolateral approach
Modification of gibson posterolateral
approach
Osborne posterior approach to hip joint
Moore posterior approach to hip joint
Medial approach
Medial approach
• This type of approach described first by ludloff in 1908
• The objective of this technique are to permit surgery on a
congenitally dislocated hip with the hip flexed, abducted and
externally rotated
Ferguson; hoppenfeld and deboer medial
approach to hip joint