SURGICAL APPROACH TO KNEE JOINT PART 1 SIKU.pptx

Knee pathology surgical approach
Trauma and cold case

1. SURGICAL APPROACH TO KNEE JOINT PART -1 Presentor : Dr . S ikandar Kumar Mahto 2nd year Orthopedic resident NMCTH,Birgunj Moderator: Dr. Robin Yadav

2. Layers of knee:Medial There are three anatomic layers to the medial knee: L ayer 1:Sartorius Deep fascia Gracilis Semitendinosus The outer layer of the medial aspect of the knee joint consists of the sartorius , the fascia of the thigh, and the medial patellar retinaculum.

3. Layers of knee:Medial … Layer 2:Semimembranosus Superficial MCL Posterior oblique ligament Medial patellofemoral ligamen layer 3:Deep MCL Capsule Coronary ligament No interervous or intermuscular plane

4. Layers of knee:Latera There are three anatomic layers to the lateral knee Layer 1: ITB Biceps Fascia Layer 2: Patellar retinaculum Patellofemoral ligament

5. Layers of knee:Latera Layer 3: LCL Arcuate ligament Fabellofibular ligament Capsule Internervous plane: between -ITB ( superior gluteal nerve)anteriorly -Biceps femoris tendon (sciatic nerve) posteriorly

6. Surgical Approaches: Anteromedial - Parapatellar Approach - Subvastus Approach Medial approach Lateral Approach Approach for lateral meniscectomy Posterior Approach Arthroscopic Approach

7. Anteromedial Parapatellar Approach (Von Langenbeck ) Indications: Synovectomy Medial meniscectomy Removal of loose bodies; Drainage in septic knee Ligamentous reconstructions TKR ORIF of distal femoral fractures

8. Anteromedial Parapatellar Approach (Von Langenbeck )… Position : Supine - with sandbag below buttock to internally rotate operative leg. - with sandbag on end of table to support heel when knee is flexed to 90 degrees. Position of the patient for the medial parapatellar approach. Begin with the straight leg position, and then flex the knee for the deeper dissection.

9. Anteromedial Parapatellar Approach (Von Langenbeck )… Incision: From a point 5 cm above the superior pole of patella to below the level of tibial tubercle

10. Anteromedial Parapatellar Approach (Von Langenbeck )… Superficial dissection: Medial skin flap Enter the joint by cutting through the joint capsule

11. Anteromedial Parapatellar Approach (Von Langenbeck )… Continue the incision through the joint capsule and along the patellar ligament and quadriceps tendon to gain access to the joint.

12. Anteromedial Parapatellar Approach (Von Langenbeck )… Deep surgical dissection: Dislocate patella and flip laterally. (NOTE : If note then- Extend the incision or - Detach with tibial tuberosity) Flex the knee to 90 degrees

13. Dangers: Superior lateral genicular artery: At risk during lateral retinacular release. Infrapatellar branch of saphenous nerves: -Subcutaneous on medial aspect of knee -Piercing the fascia between the sartorius and gracilis -Sensory to the anteromedial aspect of the knee -Injury can lead to postoperative neuroma. -Resect and bury end to decrease chance of painful neurom Skin Necrosis

14. Extension : Superior - Proximally between Rectus femoris and Vastus medialis . Inferior - Removal of patellar ligament with underlying block of bone.

15. Variants: Midvastus approach: Proximal portion of arthrotomy extend into the muscle belly of the Vastus medialis . Subvastus (Southern) approach: Muscle belly of the V astus medialis is lifted off the intermuscular plane.

16. Anteromedial Subvastus Approach (Southern Approach) Advantages : Preserves vascularity of patella- spares intramuscular articular branch of descending geniculate artery Preserves quadriceps tendon by providing more stability to the patellofemoral joint in TKR.

17. Anteromedial Subvastus Approach (Southern Approach )…

18. Anteromedial Subvastus Approach (Southern Approach )…

19. Medial Approach ( Hoppenfeld & Deboer ) Indications: Exploration & treatment of damage to superficial MCL and medial joint capsule. Medial meniscectomy Or repair Ligamentous repair

20. Medial Approach ( Hoppenfeld & Deboer )… Position : Supine knee flexed at 60 degrees . Hip a bduct & externally rotate F oot on opposite shin. Position for the medial approach to the knee

21. Medial Approach ( Hoppenfeld & Deboer ) Incision: B eginning at a point 2 cm proximal to adductor tubercle . Curve anteroinferiorly to a point 6 cm below the joint line on the anteromedial aspect of tibia Middle of incision runs 3cm medial to patella.

22. Superficial dissection: Raise skin flaps to expose fascia Exposure extend from midline anteriorly to posteromedial corner posteriorly NOTE: Infrapatellar branch of saphenous nerve SACRIFICE

23. Deep dissection: anterior or posterior to superficial MCL Flex the knee and retract the sartorius posteriorly to uncover the remaining components to the pes anserinus .

24. Retract all three pes muscles posteriorly to expose the tibial insertion of the superficial medial ligament. Tibial insertion of MCL lies deep and distal to anterior edge of sartorius , 6-7 cm below the joint line

25. Make a longitudinal medial parapatellar incision to gain access to the inside of the front of the knee joint.

26. Posterior access to posterior third of meniscus and PMC of knee . Expose PMC by separating medial head of gastrocnemius from semimembranosus muscle. Retract the sartorius , semitendinosus, and gracilis posteriorly to expose the posteromedial corner of the joint. Orientation of the knee ( inset).

27. Expose the posteromedial corner of the knee joint by first separating the gastrocnemius muscle and the posterior capsule of the joint, and then performing a capsulotomy posterior to the tibial collateral ligament.

28. Dangers: Infrapatellar branch of the saphenous nerve: -crosses transversely across operative field -usually sacrificed -should be buried in fat to prevent neuroma Saphenous vein: -Located between sartorius and gracilis

29. Medial inferior genicular artery: May be damaged as medial head of gastrocnemius is lifted off tibia Popliteal artery: -Lies along midline posterior joint capsule -Adjacent to medial head of gastrocnemius

30. Lateral Approach ( Hoppenfeld & Deboer ) Provides access to all the supporting structures on the lateral side of knee. Only part of the exposure is needed for any single procedure . Major use is in the assessment of ligamentous damage.

31. Position: Supine and sand bag under the hip

32. Curved and 3 cm lateral to edge of patella. Distally 4-5cm distal to joint line centered over gerdy's tubercle . Proximally along the line of femur

33. Internervous plane: Lies between Iliotibial band(superior gluteal nerve)anteriorly Biceps femoris tendon(sciatic nerve)posteriorly

34. Common peroneal nerve

35. Superficial Dissection: M obilize skin flaps widely I ncise fascia between ITB and biceps femoris Retract ITB anteriorly and biceps posteriorly exposes superficial LCL retract lateral head of gastrocnemius posteriorly NOTE: Avoid common peroneal nerve on posterior border of biceps femoris

36. Deep dissection: A nterior or Posterior to LCL A nterior arthrotomy : exposes entire lateral meniscus P osterior arthrotomy : exposes -posterior horn of lateral meniscus -posterolateral corner

37. Dangers : Common peroneal nerve: At risk on posterior border of biceps femoris Popliteal artery: At risk posterior to posterior horn of lateral meniscus Popliteus tendon: - Runs within joint adjacent to lateral meniscus, -Attaches to posterior aspect of meniscus and femur, -At risk if performing a posterior arthrotomy

38. Lateral superior genicular artery: - At risk between femur and vastus lateralis Lateral inferior genicular artery: -At risk btn lateral head of gastrocnemius and posterolateral corner -Should be ligated

39. References Hoppenfeld surgical exposures in Orthopaedics . Campbell's Operative Orthopaedics .