APPROACHES:

1. LATERAL
2. POSTEROLATERAL
3. ANTEROLATERAL
4. ANTEROMEDIAL
5. POSTERIOR FOR SCIATIC NERVE
EXPLORATION, CANNOT UNDERGO
ANTERIOR APPROACH (SKIN PROBLEM)
LATERAL APPROACH

NOTES:

1. Most often be used

2. Quick and easy approach
3. Subsequent blood loss

INDICATIONS:

1. ORIF of intertrochanteric fracture

2. Subtrochanteric or intertrochanteric osteotomy
3. ORIF of shaft femoral, supracondylar fracture
4. Extra-articular arthrodesis of hip
5. Osteomyelitis treatment
6. Bone tumor biopsy

POSITION:

1. Orthopaedic table for trochanteric,

subtrochanteric fracture
2. Supine
3. Image intensifier
4. Internally rotate the leg 15°
(to overcome the natural anteversion of the femoral neck)

LANDMARKS:

1. Posterior edge of the greater trochanter

2. Shaft of the femur is palpable as
a line of resistance on the lateral
side of the thigh

INCISION:

1. Longitudinal incision
2. Over the middle of the greater trochanter
3. Extending down the lateral side of the thigh

INTERNERVOUS PLANE:

No internervous or intermuscular plane

- Dissection splits the vastus lateralis muscle (supplied by femoral nerve)

DANGER:

Perforating branches of the profounda femoris artery

SURGICAL DISSECTION:

1. Incise the fascia lata of the thigh

2. Extending split the tensor fasciae lata distally beyond the greater trochanter in 1/3
patients

3. Expose the vastus lateralis

4. Insert a Homan or Bennet retractor
through the muscle
5. Spliting the muscle by blunt dissection
6. Bleeding control
7. Incise the periosteum to expose the bone
POSTEROLATERAL APPROACH

NOTES:

1. Can expose the entire length of the femur (because it follows lateral intermuscular
septum)
2. Not interfere with the quadriceps muscle

INDICATIONS:

1. ORIF of supracondylar fracture

2. Open IM
3. Non union fracture
4. Femoral osteotomy
5. Treatment of chronic or acute osteomyelitis
6. Biopsy of bone tumor

POSITION:

1. Supine
2. A sandbag beneath
the buttock on the affected side

LANDMARK:

Lateral femoral epicondyle

INCISION:

1. Longitudinal incision
2. Incise on the lateral
femoral epicondyle
3. Continue proximally
along the posterior part of the femoral shaft

INTERNERVOUS PLANE:

1. Vastus lateralis muscle

(supplied by
the femoral nerve)
2. Lateral intermuscular
septum which covers
the hamstring muscle
DANGER:

Perforating arteries (branches of the profunda femoris artery)

SURGICAL DISSECTION:

1. Incise the deep fascia of the thigh in line

2. Identify the vastus lateralis and lateral intermuscular septum
3. Dissect between muscle and septum

4. Coagulate or ligate branches of the perforating arteries

5. Continue dissection between the lateral intermuscular septum & vastus lateralis
muscle
6. Detach vastus lateralis until the femur & linea aspera are reached
7. Incise periosteum longitudinally, strip off the muscles that cover the femur
8. Expose the femur using Homan of Bennett’s retrators
ANTEROMEDIAL APPROACH

NOTES:

1. Excellent for distal 2/3 of the femur

2. Excellent for knee joint

INDICATIONS:

1. ORIF of distal femur and or those that extend into the knee joint
2. ORIF of femoral shaft fracture
3. Chronic osteomyelitis treatment
4. Biopsy of bone tumor
5. Quadricepsplasty

POSITION:

Supine

LANDMARK:

Vastus medialis muscle

INCISION:

1. 10-15 cm longitudinal incision

2. On the anteromedial aspect of the thigh
3. Over the interval between
the rectus femoris and vastus
medialis muscles
(no specific landmark for this interval)
4. Extend the incision distally along
the medial edge of the patella
to the joint line of the knee

INTERNERVOUS PLANE: No internervous plane

- Both vastus medialis & rectus femoris muscle supplied by the femoral nerve

DANGERS:

1. Medial superior genicular artery

2. The lowest fibers of the vastus medialis muscle (to stabilize patella & prevent lateral
subluxation)
SURGICAL DISSECTION:

1. Incise the fascia lata

2. Identify interval between the vastus medialis and rectus femoris muscles
3. Retract the rectus femoris laterally
4. Open the capsule of the knee joint by cutting the medial patellar retinaculum
5. Continue proximally

6. Split the quadriceps tendon almost on its medial border

7. Leave a small cuff of the tendon with the vastus medialis attached to it (allow easy
closure)
8. Develop the interval between the vastus medialis and rectus femoris muscle
proximally
9. Expose the vastus intermedius. Split it
10. Incise the periosteum longitudinally
11. Expose the bone
POSTERIOR APPROACH

NOTES:

1. When anterior approach is contraindicated

2. For patients who have local skin problem
3. Provide access to the middle 3/5 of the bone
4. Provide access to the sciatic nerce
5. Rarely performed

INDICATIONS:

1. Non union fracture of femur

2. Chronic osteomyelitis
3. Biopsy of bone tumor
4. Exploration of the sciatic nerve

POSITION:

1. Prone
2. Support the pelvis
and chest

LANDMARK:

Gluteal fold

INCISION:

1. 20 cm longitudinal incision
2. midline of the posterior aspect
of the thigh
3. Stop proximally at the inferior margin
of the gluteal fold

INTERNERVOUS PLANE:

- Between lateral intermuscular septum

- It covers the vastus lateralis muscle
(supplied femoral nerve) &
the biceps femoris
(supplied sciatic nerve)
DANGER:

1. Sciatic nerve
2. Nerve to biceps femoris (branches from sciatic nerve, enter biceps from its medial
side)

SURGICAL DISSECTION:

1. Incise the deep fascia of the thigh

2. In line or lateral to skin incision (protect the posterior femoral cutaneous nerve, in the
groove between the biceps & semitendinosus muscles)
3. Identify the lateral border of the biceps femoris
4. Develop plane between biceps femoris & vastus lateralis muscle which are covered
by lateral intermuscular septum
5. Retract the long head of the biceps femoris medially & lateral intermuscular septum
6. Identify the short head of the biceps (it arises from the lateral lip of the linea aspera)
7. Detach the short head of the biceps by sharp dissection to expose posterior aspect of
femur
8. Retract the long head of the biceps laterally to expose sciatic nerve
9. Retract the sciatic nerve laterally
10. Incise the periosteum longitudinally