Anteromedial Approach to Femur
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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.
- Open reduction and internal fixation (ORIF) of distal femur fractures.
- 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.
- Make a 10-15 cm longitudinal incision centered over the interval between rectus femoris and vastus medialis:
- Internervous:
- There is no internervous plane for the anteromedial approach to femur.
- Intermuscular:
- Intermuscular plane lies between:
- Rectus femoris muscle.
- Vastus medialis muscle.
- Both are innervated by femoral nerve.
- Innervation is proximal allowing for safe exposure distally
- Intermuscular plane lies between:
- 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:
- Medial superior genicular artery:
- Crosses field just above knee joint.
- Vastus medialis muscle:
- Distal fibers insert directly on medial border of patella.
- Disrupted during exposure.
- Meticulous closure to prevent lateral patella subluxation.
- Medial superior genicular artery:
- Surgical Exposures in Orthopaedics book - 4th Edition
- Campbel's Operative Orthopaedics book 12th