surgical anatomy femur

1. Surgical approaches to femur

2. Common approaches
 Lateral approach
 Posterolateral approach
 Anteromedial approach to distal two thirds of femur
 Posterior approach
 Minimally invasive approach to distal femur
 Minimally invasive approach to proximal femur for IM nailing
 Minimally invasive surgery for retrograde IM nailing

3. Lateral approach
Most commonly used for accessing upper third of femur
Can be extended inferiorly
Indications
1. ORIF-intertrochanteric #s
2. Internal fixation-SCFE,subcapital #s
3. Subtrochanteric or intertrochanteric osteotomy
4. ORIF-shaft #s, subtrochanteric and supracondylar femur #s
5. Extra-articular arthrodesis of hip joint
6. Treatment of chronic osteomyelitis
7. Biopsy and treatment of bone tumors

4. Position of patient
 Supine
 Internally rotated-15 degrees
 Lateral position for shaft
fractures
 Pad bony prominences

5. Landmarks and incision
 Greater trochanter-identify tip
 Lateral aspect of femur shaft
 Longitudinal incision beginning
over the middle of greater
trochanter and extending over the
lateral aspect of shaft
 Fascia lata incised in line with skin
incision

6. Deep surgical dissection

7. Danger
• Damage to the numerous perforating branches of profunda femoris
artery
• Should be ligated or coagulated
• Split muscle gently with blunt instrument.

8. Extension

9. Posterolateral approach
• Follows the lateral intermuscular septum
Indications
1. ORIF-supracondylar fractures
2. Open IM nailing of shaft fractures
3. Treatment of non-union fractures.
4. Femoral osteotomy
5. Chronic or acute osteomyelitis
6. Biopsy and treatment of bone tumors

10. Position of patient
• Supine
• Elevate buttock and internally rotate
leg-use sandbag

11. Landmarks and incision

12. Deep surgical dissection

13. Cont..

14. Dangers
• Perforating arteries that pierce the septum-must be ligated or
coagulated
• Superior lateral genicular artery and vein-

15. Anteromedial approach to distal two-thirds of
femur
• Excellent view of lower two thirds of femur and knee joint.
Indications
1. ORIF-distal femur #s-especially buttress plating
2. ORIF-shaft #s
3. Treatment of chronic osteomyelitis
4. Bone biopsy and treatment of tumors
5. Quadricepslasty
6. Distal femoral osteotomy.

16. Position, landmarks and incision

17. Deep surgical dissection

18. Cont…
 can be extended superiorly
and inferiorly
 Offers excellent exposure
to lower two thirds but
higher up VAN intrude into
dissection

19. Dangers
• Vessels-medial superior genicular artery crosses the field-ligate or
coagulate to avoid hematoma
• Muscle-disruption of the lowest fibers of the vastus medialis-repair
the incision meticulously to prevent lateral subluxation of patella.

20. Posterior approach
• Useful in patients who cannot undergo more anterior approaches-
due to skin problems
Indications
1. Treatment of infected non-union of femur
2. Treatment of chronic osteomyelitis
3. Bone biopsy and treatment of bone tumors
4. Exploration of sciatic nerve.

21. Position, landmark and incisions

22. Deep surgical dissection
 Begin proximally
 Retract long head of biceps femoris medially and
the lateral intermuscular septum laterally
 Identify short head of biceps femoris,detach its
origin and reflect it medially to expose femur

23. Cont..

24. Dangers
• Nerves
I. Sciatic nerve- proximally it is protected as long as the correct
intermuscular plane is maintained, distally the nerve must be
identified and retracted carefully
II. Nerve to the biceps femoris-well protected as the dissection is on
the lateral side of the muscle.

25. Minimally invasive approach to the distal
femur
• Utilizes two windows
Distal window-in effect a parapatellar approach allowing visualization
of the distal femur articular surface
Proximal window- provides access to the shaft and is a portion of the
lateral approach
Indication: ORIF for distal femoral #s especially intra-articular with
complex metaphyseal injuries.

26. Position, landmark and incisions

27. Deep dissection

28. Dangers
• Superior genicular artery and vein-ligate or coagulate to avoid
hematoma.

29. Minimally invasive approach to the proximal
femur for IM nailing
Used for IM nails in the treatment of:
I. Acute femoral shaft fractures
II. Pathological femoral shaft fractures
III. Delayed union and non-union of femoral shaft #s

30. Position of patient
• Two position are available,

31. Landmarks and incision
• Landmarks: greater trochanter, ASIS , femur shaft
• Incision: two techniques, Radiographic technique and Landmark
technique

32. Conti…

33. Deep dissection

34. Dangers
• Bone deformity;
 Too lateral entry points creates a varus deformity at fracture site and
may also create an iatrogenic # of the medial femoral cortex during
insertion.
Too medial entry points may create iatrogenic NOF # and avascular
necrosis of the head of femur.
• Nerves
Damage to the superior gluteal nerve may occur if retrograde nailing
technique is applied when the femur is not abducted.

35. Minimally invasive surgery for Retrograde IM
Nailing of Femur
Utilizes a small portion of the medial parapatellar approach to the
knee
Allows excellent percutaneous access to the distal femoral
intercondylar region
Its sole use is in the insertion of retrograde IM nails in femur shaft #s

36. Position, landmarks and incision
 Patient supine on radioluscent table
 Place a large triangular ridge underneath the
knee to allow it flex to 90 degrees
 Place a small sandbag under ipsilateral buttock to
correct the natural external rotation-the sandbag
should not block radiographic visualization.
 Palpate medial border of patella

37. Cont..

38. Deep surgical incision

39. Dangers
• Infrapatellar branch of the saphenous nerve is in danger in distal
extension.
• Posterior cruciate ligament insertion may be damaged by the IM nails
or reamers if the entry point is not correctly located.

40. THANK YOU