Medial Approach

MEDIAL APPROACH

USES

This approach is used for medial collateral ligament reconstruction and open medial meniscus repair. The upper portion can be used for retrograde insertion of flexible (Ender) nails. The upper portion medially is also used for medial hamstring lengthenings or releases and can be used to reach the neurovascular structures.

ADVANTAGES

The incision can be easily shifted either anteriorly or posteriorly depending on the structure of interest, and extended distally as far as necessary.

DISADVANTAGES

This approach provides limited anterior exposure. There are problems that require both an anterior and a medial exposure and are better served by an anterior midline or median parapatellar type incision.

STRUCTURES AT RISK

The infrapatellar branch of the saphenous nerve is the most commonly damaged structure. In cases where the branch takes off from the saphenous nerve more proximally, it is definitely at risk and if right in the middle of the incision, may need to be sacrificed. There are no other significant structures at risk, as long as the normal anatomy is identified. The artery is well lateral to the medial knee structures. It is also anterior to the tendons and lies next to the femur. The medial hamstring tendons could be cut if any dissection was done perpendicular to the femur.

TECHNIQUE

The incision is made anteriorly or posteriorly over the structure of interest. It is typically centered on the medial femoral condyle. The incision is carried through the subcutaneous tissue, exposing the fascia. Unlike what is usually seen in the textbooks, the medial collateral ligament and the pes anserine tendons are all merged together without any clear distinction. It is necessary to know where the structures are located so that the fascia can be separated off of them. The medial collateral ligament runs off of the medial femoral condyle down to the proximal tibia, angling slightly anteriorly as it proceeds distally. The pes tendons are more posterior. The saphenous nerve usually runs at approximately the same depth as the pes anserine tendons. It gives off the infrapatellar branch at varying levels so that the nerve may be seen with this approach.

The fascia overlying the medial collateral ligament is split in line with its fibers. Usually, the ligament can be perceived as a thickening of the capsule. Once the ligament is identified, it serves as the guide to entering the knee joint. A capsular incision anteriorly and posteriorly can be created, allowing excellent exposure to do an open repair of the medial meniscus. It also allows the ligament to be reconstructed.

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