Acetabulum – Posterior Approach

Acetabulum – posterior approach

* position – lat. decubitus

* incision – long. incision centered on GT extending from just below iliac crest ot 10cm below tip of GT

* no internervous plane

* dissection
– incise subcut. fat
– incise fascia lata in line with skin in lower 1/2 of wound & extend sup. along ant. border of GMax
– ID sciatic n.
– retract split edges of fascia to reveal piriformis & short ER
– IR leg to put short ER on stretch
– detach short ER from insertion on femur
– elevate GMed from outer side of ilium
– troch. osteotomy if more visualization needed
– incise capsule

* dangers
– sciatic n. – ID b4 cutting short ER & protect with short ER

– IGA – exits pelvis under piriformis & turns up to supply GMax

Ankle – Anterior Approach

Ankle – anterior approach

* position – supine with tourniquet

* incision – long. incision over ant. ankle halfway btw malleoli

* no internervous plane – use intermuscular plane btw EHL & EDL

* dissection
– incise fascia in line with skin
– ID interval btw EHL & EDL
– find nv bundle just med. to EHL
– follow nv bundle distally to ankle until it crosses behind EHL
– mobilize nv bundle
– incise remaining soft tissue on ant. tibia to expose tibia & ankle joint
– subperiosteal dissection of distal tibia

* dangers
– SPN – run close to line of incision just under skin
– DPN & ATA
> above ankle – btw EHL & TA
> distal to ankle – btw EHL & EDL
> crosses post. to EHL at level of ankle

Ankle – Posteromedial Approach

Ankle – posteromedial approach

* position
– supine with hip flexed & ER and knee flexed
– lateral with affected leg down

* incision – long. incision midway btw Achilles tendon & med. malleolus

* no internervous plane

* dissection
– deepen incision to enter fat that lies btw Achilles & flexor tendons
– ID fascia in ant. flap that covers flexor tendons

> first
– ID FHL
– develop plane btw FHL & peroneal tendons
– expose ankle joint & incise capsule

> second
– ID FHL
– continue dissection ant. toward med. malleolus
– ID nv bundle & retract lat. with FHL
– develop plane btw nv bundle & FDL
– expose ankle & incise capsule

* dangers
– PTA & tibial n. – run btw FDL & FHL with art. ant. to nerve

Arm – Anterior Approach

Arm – anterior approach

• position

• landmarks

• incision

• internervous plane

• superficial dissection

• deep dissection

• dangers

Ankle – Posterolateral Approach

Ankle – posterolateral approach

* position – prone with tourniquet

* incision – long. incision midway btw lat. malleolus & Achilles

* internervous plane – PB (SPN) & FHL (tibial n.)

* dissection
– mobilize skin flaps
– short saphenous vein & sural n. run just behind lat. malleolus
– incise deep fascia of leg in line with incision
– ID 2 peroneal tendons
– PB ant. to PL at level of ankle
– PB muscular down to level of ankle
– incise peroneal retinaculum to release tendons & retract lat.
– expose FHL
– incise lat. fibers of FHL as they arise from fibula
– retract FHL med.
– incise periosteum of distal tibia
– follow post. aspect of tibia down to post. ankle & incise capsule transversely

* dangers
– short saphenous vein & sural n.

Ankle – Medial Approach

Ankle – medial approach

* position – supine with tourniquet

* incision – long. incision centered on tip of medial malleolus, curve forward onto medial side of middle part of foot

* no internervous plane

* dissection
– mobilize skin flaps
– avoid long saphenous vein & saphenous n.
– ID where med. malleolus joins shaft of tibia & make small long. incision in ant. joint capsule
– divide flexor retinaculum & ID TP tendon
– retract TP post.
– expose post. surface of med. malleolus
– score med. malleolus long.
– drill & tap med. malleolus
– using oscillating saw, ostotomize med. malleolus from sup. to inf.
– reflect med. malleolus inf. with deltoid attachment
– evert foot to bring dome of talus into view

* dangers
– saphenous n. & long saphenous vein – run just ant. to med. malleolus
– TP – lies just post. to med. malleolus

Cervical Spine – Anterior Approach

Cervical spine – anterior approach

* position
– supine with sandbag btw shoulder blades
– turn head away from incision
– HOB 30 deg

* landmarks
– hard palate = arch of atlas
– lower border of mandible = C2-3
– hyoid bone = C3
– thyroid cartilage = C4-5
– cricoid cartilage = C6
– carotid tubercle = C6

* incision – transverse incision at level of pathology extending obliquely from midline ot post. border of SCM

* internervous plane
– none superficially
– SCM (spinal accessory n.) & strap muscles (C1-3)
– btw L & R longus colli (segmental branches from C2-7)

* dissection
– incise fascial sheath over platysma in line with skin
– bluntly split platysma long. in line with fibers
– identify ant. border of SCM
– incise fascia ant. to SCM
– retract SCM lat.
– retract sternohyoid & sternothyroid with trachea & esophagus med.
– expose carotid sheath
– develop plane btw med. edge of carotid sheath & midline structures
– cut thru pretracheal fascia on med. side of carotid sheath
– 2 vessels connect carotid sheath with midline structures (sup. & inf. thyroid art.) –> may limit exposure above C3-4
– bluntly dissect heading med. to expose longus colli
– split longus colli long. over midline of vert. bodies
– retract lat.
– place marker & take xray

* dangers
– recurrent laryngeal n. – make be injured with deep dissection
– sympathetic n. & stellate ganglion – lies on longus colli just lat. to vert. bodies
– carotid sheath – protected by ant. border of SCM
– verterbral art. – lies in costotransverse foramen on lat. portion of transverse processes

Cervical Spine – Posterior Approach

Cervical spine – posterior approach

* position – prone

* incision – midline of neck

* internervous plane – midline btw L & R paracervical muscles (post. rami of cervical n.)

* dissection
– continue incision down to spinous processes
– expose post. aspect of vert. subperiosteally
– identify lig. flavum running btw adj. lamina
– remove from leading edge of lamina of inf. vert.
– remove remaining lig. flavum & lamina
– retract SC med.
– identify post. portionof vert. body

* dangers
– SC & nerve roots – don’t retract too vigorously
– venous plexus in canal – use gelfoam or bipolar cautery
– segmental blood supply
> may be cut or stretched as muscles stripped past facet joints
> usu causes no problems
– vert. art. – protected by bone b/c within transverse foramen

Distal Femur – Lateral Approach

Distal femur – lateral approach

* position – supine with bolster under thigh

* incision – over indentation btw BF & IT band to flare of fem. condyle

* internervous plane – BF (sciatic n.) & vastus lat. (fem. n.)

* dissection
– incise IT band just ant. to lat. intermuscular septum
– ID vast. lat. & retract ant.
– below vastus lat. lies lat. sup. genicular art.
– incise periosteum at jxn btw shaft & flare of femur
– subperiosteal dissection distally & med. over the top of the LFC

* dangers
– CPN – can be injured if sug. plane is strayed out of to post. side of BF
– lat. sup. genicualr art.
– popliteal art.

Distal Humerus – Lateral Approach

Distal humerus – lateral approach