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.

  • The anteromedial approach to femur uses include:
    • 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.

  • Place the patient supine on the operating table.
  • Consider bump under contralateral hip to facilitate access to the medial femur

  • Landmarks:
    • Vastus medialis muscle.
  • Incision:
    • 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.

  • Internervous:
    •  There is no internervous plane for the anteromedial approach to femur.
  • Intermuscular:
    • 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 deep fascia
    • 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.

  • Open knee joint capsule:
    • Begin distally by opening the knee joint capsule via the medial retinaculum.
  • Split the quadriceps tendon proximally
    • Leave a cuff of tendon attached to the vastus to allow for later repair.
  • Develop the interval between vastus medialis and rectus femoris muscles.
  • Identify and split vastus intermedius proximally:
    • Split vastus intermedius muscle in line to expose femur.
  • Incise the periosteum longitudinally and elevate as needed for exposure.

  • Proximal Extension:
    • 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.
  • Distal Extension:
    • 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.

  • The structures at risk during the anteromedial approach to femur includes:
    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.

  • Surgical Exposures in Orthopaedics book - 4th Edition
  • Campbel's Operative Orthopaedics book 12th
anteromedial approach to femur 1 anteromedial approach to femur 1 anteromedial approach to femur 1 anteromedial approach to femur 1 anteromedial approach to femur 1
Images Source:
  • Surgical Exposures in Orthopaedics 4th Edition Book.

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