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Instructional Course Lecture. ESSKA Congress. London Sept 2000
The surgical approaches to the knee, to the distal femur and to the proximal tibia allow access to the knee and the periarticular structures. Even in times of arthroscopically assisted knee ligament and meniscal surgery, the open procedures and the correct surgical approaches respecting the anatomy of the largest joint of the human body are needed – not only for total knee arthroplasty! There is no single best approach. Often several approaches have to be used for treating one affection. The knee is very sensitive to disruption of its proprioception. Any skin and capsular incision will disrupt parts of it. Surgical approaches do not only have to allow easy access to the anatomical structures but have to respect functional anatomy. One of the most important questions is obviously the one about where to put the skin incision. Regardless of the place of skin incision, any incision of the underlined joint capsule may be performed either laterally, medially, as media split (as described by Insall) or as a medial subvastus (“Southern”) approach (1, 12,13,14).
We describe some of the most common approaches to the knee. They have proven to be effective in the hands of the authors. Reference literature for in-depth study is cited along the text and is listed at the end of paragraph. A sound understanding of knee’s anatomy is essential to obtain safe and reliable approaches to the knee.
Medial approach to the knee
This approach allows good exposure of the medial side of the knee (2, 8, 9, 10, 20, 21). It is one of the most commonly used approaches to the knee worldwide It can easily be extended both proximally and distally and allows therefore – after lateral dislocation and eversion of the patella – easy access to both the medial and lateral compartment. A medial release of the tight structures in varus knees is easily possible. There are only small skin flaps, if any. In addition there is only minimal skin contact with joint surfaces during surgery which may minimize the risk of contamination of the joint.
The single most disadvantage of this approach is the substantial risk to injury to branches of the saphenous nerve. This nerve should be protected if possible. It runs posterior to the sartorius muscle, goes through the fascia between the tendons of the sartorius and gracilis muscles and becomes then subcutaneous on the medial side. The infrapatellar branch supplies the skin of the medial side of the knee. Injury to this branch may lead to neuroma and to severe discomfort of the patient, which may compromise subjective and objective function of the joint, e.g. of even the most perfect aligned total knee arthroplasty. In elderly patients the blood supply to the central portion of the incision may be poor, which increases to risk of skin flap necrosis.
Median (midline) approach to the knee
In general there are the same advantages as in the medial parapatellar approach. Extension proximally and/or distally is possible. In addition a medial or lateral arthrotomy may be performed. The skin incision may be kept quite small, which has been one of the reasons why this approach became so popular for total knee arthroplasty
The major disadvantage of this approach lies in an increased risk of wound healing problems (27,31,34): The incision lies “on the ridge” of the bony underlying structures and will be under tension from medially as well as from laterally. This may compromise proper wound healing, especially in the obese patient. Injury to branches of the infrapatellar part of the saphenous nerve can not be completely avoided with this approach. The blood supply to the patella can be compromised.
Y-shaped approach to the knee (“Mercedes-Benz star” approach)
This approach was claimed to give an excellent exposure to the anterior part of the knee (11). And this especially in complicated proximal tibial fractures. With the osteotomy of the tibial tubercle and retracting the extensor/flexor apparatus one obtains an excellent view over the anterior compartment
The single most important aspect is the fact, that an extremely high amount of wound healing problems had been noted over the years in this approach. And in view of theses potential complications, some authors do not really see an advantage over other approaches in terms of exposure and soft tissue handling.
Lateral parapatellar approach
The approach preserves the medial vascularity of the patella and does not interfere with the infrapatellar branch of the saphenous nerve (3, 8, 16, 18,19,20, 23, 25, 26, 27, 28, 31, 32, 37, 38). In combination with a tubercle osteotomy an excellent exposure of the knee can be obtained without causing any harm to the patellar tendon itself. The exposure to the lateral as well as to the medial side is excellent. Any extension in proximal as well as in distal direction is easily possible. Most compartments, event in difficult knee reconstruction can be reached with one incision. A so-called “lateral retinacular release” is included in the approach, which is helpful when addressing the tight valgus fixed knee in Total Knee Arthroplasty.
One of the major disadvantages of this approach is the fact, that usually a longer skin incision is necessary. Especially when compared with the straight midline approach. In order to avoid any complications with skin flaps care has to be taken to do subfacial and not only subcutaneous dissections. An osteotomy of the tibial tuberosity may be required. This osteotomy by itself however allows again for an excellent overview.
When reaching for the medial collateral ligament or posterior capsule only this approach shows an excellent wound healing potential. It has proven to be very valuable in treating osteochondral defects with the osteochondral transfer technique (Mosaicplasty). With one relatively small incision both recipient site at the medial femoral condyle (reached in knee flexion) as well as the donor site proximally (in knee extension) can be reached, thus keeping soft tissue dissection minimal.
Extensions of the approach in proximal as well as distal direction are difficult or not possible. Once again, the infrapatellar branches of the saphenous nerve may be in jeopardy.
Easy access to the posterior capsule and the posterior aspects of the medial collateral ligament (35). Visualization of the posterior cruciate ligament and the most posterior aspects of the knee can be hampered by the thick synovium. Too much dissection may lead to vascular compromise, soft tissue and skin healing problems.
Especially when utilizing the simplified approach as described by Burks et al (7) it allows easy access to the tibial attachment of the posterior cruciate ligament and facilitates the so-called “on-lay” technique of PCL-reconstruction with auto- or allografts and which has shown in biomechanical testing to be superior to arthroscopically assisted techniques. Baker’s cysts can very easily be reached and excised. Very rarely the medial head of the gastrocnemius muscle needs to be freed.
The patient has to be positioned prone, which not all of the patients who undergo the procedure in regional anesthesia find comfortable. If the patient receives general anesthesia the surgeon should make sure that the patient is placed correctly avoiding any further positional damage to nerves or joints. The “traditional” approach as described by Trickey may compromise vessels and neurologic structures in the popliteal fossa of the knee and may therefore be the cause of damage to those structures, especially when performed by inexperienced surgeons. The skin flaps at the corners of the “lazy S” incision may get healing problems. The incisions – whether “lazy S” or straight – may lead to some wide scarring (7, 15, 33). If postoperative swelling is extensive, there is the risk of restricted venous flow and increased risk of thromboses
A total of seven different approaches to the knee have been described. Those approaches have proven to be most valuable to the authors. Indications, advantages, disadvantages and risks of these approaches have been described.. A thorough knowledge of the anatomy and (bio) mechanics of the knee joint is mandatory in order to perform surgical procedures successfully
Think before you cut (5, 34)
You may not be the last surgeon operating on this knee joint
Split layers in line with fibers
Take care to preserve the infrapatellar branch of the saphenous nerve
Take care to the blood supply of the patella
Do not make dissections in the subcutaneous layer, go down to the subfacial layers
Please visit www.orthopaedics.co.uk for more information.
Abbott LC, Carpenter WF: Surgical approaches to the knee joint. J Bone Joint Surg 27A:277-310,1945
Alm A, Strömberg B: Vascular anatomy of the patellar and cruciate ligaments. Acta Chir Scand (Suppl) 445:25-35,1974
Arnold MP, Friederich NF, Widmer H, Müller W: Lateral approach to the knee combined with an osteotomy of the tibial tuberosity. Its use for total knee replacement. Orthopaedics and Traumatology 7(3):212-220, 1999
Bauer R, Kerschbaumer F, Poisel S: Operative approaches in orthopaedic surgery and traumatology. Georg Thieme, Stuttgart, 1987
Bousquet G: Anatomie et physiologie chirurgicale du genou. Cahiers d’enseignement de la SOFCOT Nr. 1: Les fractures du genou. Expansion scientifiques françaises, Paris, p 9-23, 1975
Brückner H, Brückner H: Bandplastiken im Kniebereich nach dem “Baukastenprinzip”. Zentralbl Chir 97:65-77, 1972
Burks RT, Schaffer JJ: A simplified approach to the tibial attachment of the posterior cruciate ligament. Clin Orthop Rel Res 254:216-219,1990
De Peretti F, Argenson C, Beracassat R, Bourgeon Y: Problèmes artériels et nerveux posés par les incisions cutanées antérieures au niveau de l’articulation du genou. SOFCOT 73 (Suppl 11):231-233, 1973
Engh GA, Holt BT, Parks NL: A midvastus muscle-splitting approach for Total Knee Arthroplasty. Arthroplasty 12(3):322-331, 1997
Faure BT, Benjamin JB, Lindsey B, et al: Comparison of the subvastus and paramedian surgical approach in bilateral knee arthroplasty. J. Arthroplasty 8:511-516, 1993
Fernandez DL: Anterior approach to the knee with osteotomy of the tibial tubercle for bicondylar tibial fractures. J Bone Joint Surg 70A:208-219,1988
Grant JCB, Basmajian JV: Grant’s method of anatomy. Williams & Wilkins, Baltimore, 1965
Honnart F: Voie d’abord en chirurgie orthopédique et traumatologique, Masson, Paris, 1978
Hofmann AA, Plaster RL, Murdock LE: Subvastus (Southern) approach for primary total knee arthroplasty. Clin Orthop Rel Res 269:70-77,1991
Hughston JC: Surgical approach to the medial and posterior ligaments of the knee. Clin Orthop Rel Res 91:29-33,1973
Insall J: A midline approach to the knee. J Bone Joint Surg 53A:1584-1586, 1971
Jaeger JH: Voies d’abord chirurgicales. Les laxités chroniques du genou. In: Bonnel F, Jaeger JH, Mansat CH (ed), Masson, Paris, 1990; pp 63-65.
Kaplan EB: Surgical approach to the lateral (peroneal) side of the knee joint. Surg Gynecol Obstet 104:346-356,1957
Kaplan EB: The iliotibial tract. J Bone Joint Surg 40A:817-832,1958
Kaplan EB: Some aspects of functional anatomy of the human knee joint. Clin Orthop Rel Res 23:18-29,1962
Lange M: Orthopädisch-chirurgische Operationslehre. Bergmann, München, 1951: pp 660-664
Lange M: Orthopädisch-chirurgische Operationslehre. Ergänzungsband: Neueste Operationsverfahren. Bergmann, München, 1968
Lanz von T, Wachsmuth W: Praktische Anatomie. Band 1, Teil 4. Springer, Berlin Heidelberg New York, 1972
Masquelet AC, McCullough CJ, Tubiana R: Voies d’abord chirurgicales du membre inférieur. Masson, Paris, 1994
McIntosh DL, Darby TA: Lateral substitution reconstruction. J Bone Joint Surg 58B:142, 1976
Mertl P, Jarde O, Blejwas D, et al: L’abord latéral du genou avec relèvement de la tubérosité tibiale pour la chirurgie prothétique. Rev Chir Orthop 78:264-268, 1992
Müller W: Das Knie. Form, Funktion und ligamentäre Wiederherstellungschirurgie. Springer-Verlag, Berlin Heidelberg New York, 1982
Scapinelli R: Blood supply of the human patella. J Bone Joint Surg 49B:563, 1967
Scuderi D: Surgical approaches to the knee. In: Scott NW (ed): The Knee. Mosby, St. Louis, 1994
Schmitt O. Mittelmeier H: Die Bedeutung des Musculus vastus medialis und –lateralis für die Biomechanik des Kniegelenks. Arch Orthop Traumat Surg 91:291-295,1978
Stilwell DL: The innervation of tendons and aponeuroses. Am J Anat 100:289-317,1957
Stilwell DL: Regional variations in the innervation of deep fasciae and aponeuroses. Anat Rec 127:635-653,1957
Trickey EL: Rupture of the posterior cruciate ligament of the knee. J Bone Joint Surg 50B:334-341,1968
Trillat, Dejour H, Bousquet G: Chirurgie du genou. Rev Chir Orthop (Suppl) Troisièmes Journées Lyonnaises, Simep, Villeurbanne, 1977
Vince KG, Dorr LD: Surgical techniques of total knee arthroplasty: Principles and controversy. Tech Orthop 17:69-80, 1987
Warren RF, Marshall JL: The supporting structures and layers on the medial side of the knee. J Bone Joint Surg 61A:56-62,1979
Whiteside LA, Ohl MD: Tibial tubercle osteotomy for exposure of the difficult total knee arthroplasty. Clin Orthop 260:6-9, 1990
Wolff MA, Hungerford DS, Krackow KA, et al: Osteotomy of the tibial tubercle during total knee replacement. J Bone Joint Surg 71A:847-852, 1989
Please visit www.orthopaedics.co.uk for more information.
DAVID P JOHNSON
MB ChB FRCS FRCS. MD
Spire Glen Hospital, Redland Hill, Bristol BS6 6HW. UK
Appointments: 0117 970 6655
Web site: www.orthopaedics.co.uk
© OrthopaedicsOpinionOnline 2011 www.OrthopaedicOpinionOnline.co.uk
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