Anteromedial Approach to Femur

The anteromedial approach to femur provides an excellent view of the lower two thirds of the femur and the knee joint.

• Open reduction and internal fixation (ORIF) of distal femur fractures.
  • Particularly fractures with intra-articular extension that require a medial plate.
• Open reduction and internal fixation of femoral shaft fractures.
  • Limited to distal 2/3 of femur by the presence of the femoral neurovascular bundle.
• Treatment of chronic osteomyelitis.
• Biopsy and treatment of bone tumors of the femur.
• Quadricepsplasty.

• Vastus medialis muscle.

• Make a  10-15 cm longitudinal incision centered over the interval between rectus femoris and vastus medialis:
  • Vastus medialis may be atrophied in patients with knee pathology making identification difficult.
  • Extend distally along medial aspect of patella if exposure of the knee joint is required.

•  There is no internervous plane for the anteromedial approach to femur.

• Intermuscular plane lies between:
  1. Rectus femoris muscle.
  2. Vastus medialis muscle.
     • Both are innervated by femoral nerve.
     • Innervation is proximal allowing for safe exposure distally

• Incise in line with skin incision.
• Identify the interval between the vastus medialis and rectus femoris muscles.
  • Develop this plane by retracting the rectus femoris laterally.

• Begin distally by opening the knee joint capsule via the medial retinaculum.

• Leave a cuff of tendon attached to the vastus to allow for later repair.

• Split vastus intermedius muscle in line to expose femur.

• The anteromedial approach to femur can be extended along the same interval between the rectus femoris and vastus medialis muscles.
• To extend the deep dissection, continue to split the vastus intermedius muscle.
• The extension offers excellent exposure of the lower two thirds of the femur.
  

• Continue the skin incision downward, and curve it laterally so that it ends just below the tibial tubercle.
• Incise the medial retinaculum in line with the skin incision, making the patella more mobile and subject to lateral subluxation for full exposure of the knee joint.
• Take care not to avulse the quadriceps tendon from its insertion during the maneuver.

1. Medial superior genicular artery:
   • Crosses field just above knee joint.
2. Vastus medialis muscle:
   • Distal fibers insert directly on medial border of patella.
   • Disrupted during exposure.
   • Meticulous closure to prevent lateral patella subluxation.