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MEDIAL APPROACH TO THE DISTAL THIGH AND FEMUR

USES

This approach is used for fracture work on the distal femur, for resection of medial-based osteochondromas on the femur, and for hamstring release (by keeping the incision slightly posterior). Also, this approach is used to place the starter hole for flexible rod intramedullary fixation done in a retrograde fashion.

ADVANTAGES

For the appropriate pathology, this approach is direct. As long as you stay distal on the femur, you are in an area that is safe from a neurovascular standpoint.

DISADVANTAGES

There is a limit to how far proximally this approach can be extended because of the femoral artery.

STRUCTURES AT RISK

The two significant structures at risk are the saphenous nerve and the femoral artery. Both cross from anterior to posterior in the area of the incision. Usually, the artery crosses 13 cm or more proximal to the knee joint. The nerve can be further distal than that.

TECHNIQUE

The incision starts at the level of the adductor tubercle and proceeds proximally as far as necessary. It is carried through the subcutaneous tissue. The first structure that should be identified is the adductor longus tendon, which is a thick tendinous structure going down toward the adductor tubercle. Once that tendon is identified, a search should be made for the saphenous nerve to be sure that it is protected. The posterior border of the quadriceps muscle is then identified and the muscle is stripped off of the femur and adductor longus tendon in the area of interest, exposing the medial distal femur.

TRICKS

The major trick is to start at the adductor tubercle and to come down and identify the adductor tendon. This tendon then guides you to the quadriceps and keeps you in the safe area.

The second trick is to realize that the artery and saphenous nerve cross from anterior to posterior. The saphenous nerve enters and then exits through the sartorius muscle, but in this approach it is usually seen before it enters the sartorius muscle. The key to identifying it is to be aware of where it is located; look for the thin white structure moving obliquely from anterior to posterior.

HOW TO TELL IF YOU ARE LOST

Related posts:

Volar Approach to the Basal Joint of the Thumb (for Bennett’s Fracture) Paronychium Approach Anterior Approach Anterolateral (Internervous) Approach Posterior Approach Anterior Approach to the Cervical Spine

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