• Surgical approaches are an important component of the T+O curriculum.
• In the adult and pathology or trauma viva it is unlikely candidates will be asked a full viva question on a surgical approach more commonly part of the viva question may involve describing a surgical approach.
• In contrast full surgical viva questions have been known be asked in the basic science viva.
• As a rough estimate approximately 5% of SBA/EMI questions are based around anatomy and surgical approaches.
• As a practising surgeon it is important to have a thorough understanding of the three-dimensional anatomies underlying the common surgical approaches in orthopaedics .In addition, some of the more unusual approaches need to be learned such as the posterior approach to the knee as occasionally they will need to be used.
• It is important to have a set routine in describing a surgical approach that is reproducible. How to extend the approach and also recognise structures at risk are important components of any described surgical approach.
• The following section is an attempt to summarise for fast revision the most important and likely surgical approaches that candidates would be expected to know.

• The vast majority of surgical approach questions are asked as part of another question.
• Usually a radiograph will be shown, which leads on to a management question and then the preferred surgical approach.
• With any surgical approach it is vital to stick to a format to ensure that no important steps are missed during your answer.
• It is important to deal with general surgical principles and below is a suggested plan of action for any surgical approach, which you may be asked about:

1. Preoperative issues
2. Indications
3. Anaesthetic
4. Positioning
5. Anatomical landmarks
6. Superficial surgical dissection
7. Deep surgical dissection
8. Internervous plane
9. Structures at risk.
10. Extensile approach

• Position: beach chair.
• Landmarks: coracoid process and deltopectoral groove.
• Incision: straight incision from the tip of coracoid process along the deltopectoral groove to the deltoid insertion.

Figure 2.Surface landmarks(deltopectoral approach): coracoid process and deltopectoral groove. Incision: straight incision from the tip of the coracoid process along the deltopectoral groove to the deltoid insertion.

• Internervous plane: between axillary nerve (deltoid) and medial/lateral pectoral nerves (pectoralis major).
• Superficial dissection: develop the plane, which is marked by the cephalic vein, retracting it laterally with the deltoid, and cauterising any deltoid branches of the thoracoacromial artery. Retract the conjoint tendon medially (careful of the musculocutaneous nerve along its under surface).

Figure 3. Deltopectoral approach.Deltoid is retracted laterally and the pectoralis major medially to expose the conjoint tendon of the short head of biceps and coracobrachialis muscle. Observe the series of small vessels at the inferior end of the subscapularis muscle

• Deep dissection: subscapularis tenotomy 1–2 cm from its insertion after stay sutures or subscapularis split. Capsular incision along with subscapularis tendon or separately.

Figure 4. Deep dissection (deltopectoral approach).A blunt instrument is passed between capsule and subscapularis muscle.The small vessels on the inferior border of subscapularis often require cautery.Coracoid process osteotomy is often omitted by shoulder surgeons unless additional shoulder exposure is required

• Structures at risk: cephalic vein, musculocutaneous nerve.
• Extension of approach: distally as the anterolateral approach to humerus.

Position: beach chair with sandbag under medial border of scapula.

Landmarks:

• Lateral border acromion
• Lateral side proximal humeral shaft

Figure 1.Lateral approach (Deltoid split). Skin incision. Mark out: spine of scapula, acromion, acromioclavicular joint, lateral clavicle and coracoid.

• Incision: 5 cm longitudinal incision from the anterolateral tip of acromion down the lateral aspect of arm.
• Internervous plane: no true plane.
• Superficial dissection: define the raphe between anterior and middle thirds of deltoid. Split in line with deltoid fibres and stay suture at the inferior apex of split to protect axillary nerve.
• Deep dissection: retract the deltoid to expose the subacromial bursa, which is split to expose the rotator cuff and lateral aspect of proximal humerus. The arm can be rotated to bring different parts of the cuff into surgical field.
• Structures at risk: axillary nerve, 5–7 cm from the acromion.
• Extension of approach: the anterior deltoid can be reflected off the anterior edge of acromion but should be carefully repaired. The incision can be extended proximally across the acromion and distally a second window can be made once axillary nerve is protected.

• Position: lateral decubitus or prone.
• Landmarks: acromion, spine of scapula.
• Incision: linear incision along the spine of scapula up to posterior corner of acromion.
• Internervous plane: between suprascapular nerve (infraspinatus) and axillary nerve (teres minor).

Figure 1. Superficial dissection of the posterior aspect of the shoulder. The plane between deltoid and infraspinatous is easiest to identify at the lateral end of the incision

• Superficial dissection: wide flaps. Detach deltoid off the scapular spine (suture back to the bone at end of operation) and develop plane with infraspinatus (easy laterally).

Figure 2.The posterior portion of deltoid is detached from the spine of the scapula to reveal infraspinatous,teres minor and teres major.The boundaries of the quadrangular space are superiorly lower border teres minor,laterally surgical neck of humerus,medially long head of triceps and anteriorly upper border of teres major.The axillary nerve and posterior circumflex humeral artery run through the space

• Deep dissection: develop interval between infraspinatus (multipennate) and teres minor (unipennate). This may be difficult to find, it is more easily found medially rather than laterally exposing posterior joint capsule.

• Figure 3. The shoulder capsule is retracted to reveal the posterior regions of the glenoid cavity, the neck of the scapula and the head of the humerus

• Structures at risk:

1. Suprascapular nerve – through excessive retraction of infraspinatus
2. Quadrangular space – axillary nerve, posterior circumflex humeral artery
3. Triangular space – radial nerve, circumflex scapular artery
4. Extension of approach: no useful extension

• Position: supine and arm abducted/beach chair.
• Landmarks: coracoid, lateral border of biceps muscle, deltoid tuberosity (insertion).
• Incision: proximally as per the deltopectoral approach to the shoulder. From there continue distally along the lateral border of biceps up to 5 cm above the elbow flexion crease.

• Internervous plane: proximally, between axillary (deltoid) and medial/lateral pectoral nerves (pectoralis major). Distally, musculocutaneous (medial fibres of brachialis) and radial (lateral fibres of brachialis).

Figure 1. Anterior approach to the humeral shaft. Proximally the internervous plane lies between deltoid and pectoralis muscle. Distally the internervous plane lies between brachialis and biceps brachii. The cephalic vein can be retracted laterally in the deltopectoral groove and the muscular interval developed down to the deltoid insertion. Incise the deep fascia distally to identify the distal interval between the brachialis and biceps brachii

• Dissection: proximally develop the plane between deltoid and pectoralis major. The insertions of both can be partially released. Distally, split the deep fascia in line with skin incision and develop the plane between biceps and brachialis, protecting the musculocutaneous nerve. Split brachialis longitudinally along its fibres.

Figure 2. Anterior approach to the humeral shaft distal dissection. Identify the musculocutaneous nerve distally. Retract the biceps medially. Beneath it lies the anterior aspect of brachialis that covers the humeral shaft

• Structures at risk: radial nerve in the spiral groove posteriorly and between brachialis and brachioradialis in the distal third of arm. Axillary nerve with excessive deltoid retraction.
• Extension of approach: no useful extension distally. Proximally into deltopectoral approach to the shoulder.

• Position: lateral (can be done in prone).
• Landmarks: acromion, olecranon fossa.
• Incision: a longitudinal midline incision from 8 cm below the acromion to the olecranon fossa.
• Internervous plane: no true plane.
• Superficial dissection: split the deep fascia. Identify the plane between long and lateral head of triceps (best found proximally) and develop the interval with blunt dissesction.
• Deep dissection: identify the spiral groove and the radial nerve and profunda brachii artery running through it. Distal to that lies the medial head of triceps, which is incised down to the periosteum.

Figure 1. Posterior approach to humerus.The medial head lies below the other two heads.Develop the interval between the two heads by blunt dissection retracting long head medially and lateral head laterally.Identify and protect the radial nerveStructures at risk: radial nerve and profunda brachii artery.

• Extension of approach: no useful extension proximally. Distally can be continued across the olecranon over to the subcutaneous border of the ulna.

• Position: supine with arm board (tourniquet).
• Landmarks: biceps muscle, elbow flexion crease.
• Incision: a curved longitudinal incision along lateral border of biceps from 10 cm proximal to elbow crease till just above elbow crease.
• Internervous plane: no true plane.
• Superficial dissection: split the deep fascia. Retract biceps medially (protecting the lateral cutaneous nerve of forearm). Identify the plane between brachialis and brachioradialis. Identify and protect the radial nerve.
• Deep dissection: staying medial to the radial nerve, incise the lateral border of the brachialis longitudinally down to the periosteum.
• Structures at risk: radial nerve and lateral cutaneous nerve of the forearm.
• Extension of approach: proximal extension between brachialis and lateral head of triceps. Distally can be continued into anterior approach of the elbow, developing the plane between brachioradialis and pronator teres.

• Position: supine with arm board (tourniquet).
• Landmarks: biceps muscle, mobile wad.
• Incision: a lazy-S incision starting 5 cm above the elbow flexor crease on the medial side of biceps and extending distally along medial border of mobile wad (brachioradialis).

Figure 1 .Incision is begun 5cm above the flexor crease of the elbow,over the lateral border of the biceps muscle.The lateral border biceps is followed down distally,but the incision is curved laterally at the  level of the elbow.

• Internervous plane: proximally between radial nerve (brachioradialis) and musculocutaneous nerve (brachialis). Distally between radial nerve (brachioradialis) and median nerve (pronator teres).
• Dissection: usually for exploring neurovascular structures. Ligate the small veins trying to preserve the basilic and cephalic vein. The median nerve and brachial artery lie just underneath the bicipital aponeurosis, which can be incised close to biceps tendon. The lateral cutaneous nerve of the forearm emerges from between biceps and brachialis and the radial nerve from between brachialis and brachioradialis.
• Structures at risk: this approach exposes the neurovascular structures of the cubital fossa very quickly. Structures that may be damaged include lateral cutaneous nerve of the forearm, radial artery and posterior interosseous nerve.
• Extension of approach: to expose neurovascular sturctures, proximal extension as far as the axilla. Distally all the way down alongside the brachioradialis.

• Indication: Incision gives access to the lateral humeral epicondyle, capitellum, radial head, radial collateral ligaments and annular ligaments. ORIF radial head fractures, PIN decompression
• Position: supine on the operating table. Arm rest on a well-padded table with the arm abducted and internally rotated. The elbow is flexed, and its lateral aspect faces the surgeon.
• Landmarks: lateral epicondyle humerus, lateral supracondylar ridge
• Incision: The incision starts on the lateral supracondylar ridge 5cm proximal to the elbow joint. It is extended distally on the lateral surface of the proximal forearm just posterior to the radial head for a distal of 5cm from the elbow joint.
• Internervous plane: no true plane.
• Superficial dissection: subcutaneous tissue is mobilised for wide retraction and exposure.Deep fascia incised in line with the incision.Interval between triceps posteriorly and brachioradialis and extensor carpi radialis longus anteriorly  is developed subperiosteally to expose the lateral humeral epicondyle,lateral joint capsule and radial head.Dissection is continued distally between extensor carpi radialis brevis  and extensor digitorum.
• Deep dissection: The joint capsule incised longitudinally over the lateral aspect of the head of the radius to expose the articular surface of the radial head and lower end of the lateral humeral epicondyle and capitellum
• Structures at risk: PIN which lies close to the anterior capsule over the radial head.

Figure 1. The incision starts over the lateral supracondylar ridge, 5 cm proximal to the elbow joint. It passes distally to the lateral surface of the proximal forearm, posterior to the radial head. Watch for the radial nerve, which runs close to the radial head and neck. It divides into its superficial and deep branches at the level of the radial head.

• Position: supine with arm board (tourniquet).
• Landmarks: lateral humeral epicondyle, radial head.
• Incision: a curved incision 2–3 cm above the lateral humeral epicondyle over the supracondylar ridge and then extending down obliquely onto the subcutaneous ulnar border 5–6 cm from the olecranon tip.
• Internervous plane: between the radial nerve (anconeus) and the posterior interosseous nerve (extensor carpi ulnaris).
• Superficial dissection: full thickness skin flaps are made. Split the deep fascia longitudinally. Proximally expose the lateral epicondyle by retracting the triceps posteriorly and ECRL and brachioradialis anteriorly. Distally develop plane between anconeus and ECU (supinator lies in the depth of this plane).
• Deep dissection: incise the elbow joint capsule longitudinally to expose the radial head, annular ligament and the capitellum. The annular ligament is incised for radial head surgery and later sutured back.
• Structures at risk: radial nerve (anterolateral aspect of the joint capsule) and posterior interosseous nerve (pronate the forearm and do not dissect below the annular ligament), lateral ligament complex.
• Extension of approach: no useful extension.

• Position: lateral decubitus (or prone).
• Landmarks: olecranon process.
• Incision: posterior midline longitudinal incision starting 5 cm proximal to the olecranon (gently curving radially to avoid its tip) and extending onto the subcutuaneous ulnar border.
• Internervous plane: no true plane.
• Superficial dissection: split the deep fascia and create full thickness wide flaps. Identify and dissect out the ulnar nerve.
• Deep dissection: different methods: tongue of triceps, chevron osteotomy of olecranon, triceps on with medial and lateral reflection of triceps from the corresponding intermuscular septums, reflection of the whole of triceps from the olecranon with subsequent suture using drill holes.
• Structures at risk: radial and ulnar nerves.
• Extension of approach: proximal extension depends on the exact deep dissection used. Distally can be extended along the subcutaneous ulnar border.

• Position: supine with arm board (tourniquet). Pad under contralateral shoulder and hip to allow the patient to roll over operating side.
• Landmarks: medial humeral epicondyle.
• Incision: a curved incision centred over the medial humeral epicondyle.
• Internervous plane: proximally between musculocutaneous nerve (brachialis) and radial nerve (triceps). Distally between musculocutaneous nerve (brachialis) and median nerve (pronator teres).
• Dissection: develop the plane between brachialis and triceps proximally taking care to protect the ulnar nerve posteriorly. Distally the ulnar nerve enters the FCU and plane is developed between pronator teres and brachialis. Medial epicondylar osteotomy may improve distal exposure.
• Structures at risk: ulnar nerve, median nerve (as it enters between the two heads of pronator teres) and the medial cutaneous nerve of the forearm.
• Extension of approach: continue the proximal dissection to expose distal humerus. Distal extension is limited by median nerve branches to muscles arising from common flexor origin.

• Position: supine with arm board (tourniquet).
• Landmarks: biceps tendon, radial styloid.

Figure 1. Anterior approach to the radius. Land marks: Biceps tendon, brachioradialis, lateral epicondyle humerus and styloid process of radius. Incision: A longitudinal incision from the elbow flexor crease lateral to biceps tendon down to the radial styloid.

• Incision: a longitudinal incision from lateral to biceps tendon down to radial styloid process.
• Internervous plane: between radial and median nerve (proximally: brachioradialis and pronator teres respec, distally: brachioradialis and flexor carpi radialis, respectively).

• Superficial dissection: incise the deep fascia of the forearm in line with the skin incision. Develop the plane between brachioradialis and FCR. The recurrent radial leash may need ligation to facilitate lateral retraction of brachioradialis.
• Deep dissection: distal third: incise pronator quadratus along its radial border and reflect that along with FPL. Middle third: pronate the forearm and incise PT insertion and reflect subperiosteally reflecting PT and FDS. Proximal third: supinate the forearm and incise supinator along its broad insertion (fibres at right angle to those of PT) with lateral subperiosteal dissection protecting PIN.

Figure 3. Anterior approach to the radius (Henry).

• Structures at risk: superficial radial nerve and radial artery (undersurface of brachioradialis) and post. interosseous nerve (within supinator).
• Extension of approach: proximal extension as anterolateral approach to humerus, distal extension into the wrist joint.

Figure 4.Anterior approach to the radius. How to enlarge the approach proximally and distally

• Position: supine with arm board (tourniquet) and forearm pronated.
• Landmarks: Lister’s tubercle and lateral humeral epicondyle.
• Incision: a longitudinal incision from just anterior to lateral humeral epidonyle down to ulnar side of the Lister’s tubercle at wris

Figure 1. A straight incision is made over the proximal 2/3rds of the radius on a line from the centre of the dorsum of the wrist to a point 1.5cm anterior to the lateral humeral epicondyle with the forearm pronated.

• Internervous plane: between radial and PIN nerves (proximally: ECRB and EDC, respectively, distally: ECRB and EPL, respectively
• Superficial dissection: develop the plane between ECRB and EDC.

Figure 2. Dorsal approach to the radius (superficial dissection).The deep fascia is divided in line with the skin incision. The internervous plane lies between the extensor carpi radialis brevis (ECRB) and the extensor digitorum communis. ECRL: Extensor carpi radialis longus, APL: Abductor pollicis longus and EPB: Extensor pollicis brevis.

• Deep dissection: proximal: supinator cloaks the upper third radius, identify and dissect the PIN either from proximal to distal by detaching ECRB/ECRL or vice versa. Middle: APL and EPB can be incised along its borders to facilitate retraction. Distal: bone is exposed by superficial dissection.

Figure 3. Deep dissection proximally. The posterior interosseous nerve emerges between the superficial and deep head of the supinator muscle about 1 cm proximal to the distal edge of the muscle. ECRB: Extensor carpi radialus brevis, APL: Abductor pollicis longus and EPB: Extensor pollicis brevis.

• Structures at risk: PIN (travels through the supinator and emerges 1 cm proximal to its distal edge).

Figure 4. The posterior interosseous nerve is kept away from the incision by fully supinating the forarm and detaching the insertion of the supinator from the anterior aspect of the radius. APL: Abductor pollicis longus and EPB: Extensor pollicis brevis.

• Extension of approach: can be extended but rarely used.

• Position: supine with arm board (tourniquet) and forearm pronated.
• Landmarks: radial and ulnar styloid processes.
• Incision: 8 cm longitudinal incision along the dorsal aspect of the wrist midway between the radial and ulnar styloid processes.
• Internervous plane: no true plane, but muscles are innervated proximally.
• Superficial dissection: expose extensor retinaculum.
• Deep dissection: depends on the procedure performed. Incise the extensor retinaculum over the third/fourth extensor compartment. Subperiosteally reflect the extensor tendons to expose distal radius or the wrist joint capsule. The extensor retinaculum should be preserved and can be sutured underneath the tendons if needed.

Figure 1. Dorsal approach to the wrist joint.The six extensor tendon compartments of the wrist. I - extensor pollicis brevis (EPB), abductor pollicis longus (APL), II - extensor carpi radialis longus (ECRL), extensor carpi radilalis brevis (ECRB)these two compartments are divided by Lister's tubercle of the radius, III - extensor pollicis longus (EPL), IV - extensor digitorum communis (EDC), V - extensor digiti minimi (EDM) and VI - extensor carpi ulnaris (ECU).

• Structures at risk: PIN (travels through the supinator and emerges 1 cm proximal to its distal edge).
• Extension of approach: can be extended but rarely used.

• Indication:

1. DDH
2. Hip arthrodesis
3. Synovial biopsy

• Position: supine with sandbag under buttock.
• Landmarks: ASIS and iliac crest.
• Incision: longitudinal incision along the anterior half of iliac crest to the ASIS and then curve it down vertically towards lateral side of patella.

• Internervous plane: between femoral and superior gluteal nerves (superficial: sartorius and TFL deep: rectus femoris and gluteus medius).
• Superficial dissection: develop the gap(best found 2–3 cm below ASIS) between tensor fascia lata and sartorius by externally rotating the leg to stretch sartorius. Ligate the ascending branches of lateral femoral circumflex artery. Identify and protect the lateral femoral cutaneous nerve.
• Deep dissection: open up plane between rectus femoris and gluteus medius. Detach the straight head of the rectus from its origin on the AIIS and separate the reflected head from hip joint capsule. sutured underneath the tendons if needed. Capsule of the hip joint is visualised.
• Structures at risk: lateral cutaneous nerve of thigh, ascending branches of lateral femoral circumflex artery and femoral nerve.
• Extension of approach: proximally along iliac crest; distally between rectus femoris and vastus lateralis.

• Position: lateral with supports (or supine with the greater trochanter (GT) off the edge of the table).
• Landmarks: ASIS, GT and femoral shaft.
• Incision: longitudinal midlateral incision centered over GT tip and distally in line with femoral shaft.

 

• Internervous plane: no true plane.
• Superficial dissection: skin, subcutaneous fat. The fascia lata is incised in line with the skin. Trochanteric bursa can be peeled/excised.
• Deep dissection: gluteus medius fibres are split not more than 3 cm above the tip of GT between the anterior and middle thirds (to avoid damaging superior gluteal nerve). The dissection is carried to GT and distally along the femoral shaft. An anterior flap of gluteus medius and vastus lateralis is elevated. The gluteus minimus tendon is divided at its insertion on the GT. The capsule of hip joint is visualised and opened using a T-shaped incision.
• Structures at risk: superior gluteal nerve; femoral nerve, artery and vein (retractors); transverse branch of lateral circumflex fem artery (as vastus lateralis is mobilised).
• Extension of approach: only distally along line of vastus lateralis fibres.

Figure 2. Omega incision into the gluteus medius tendon. This is a modified Hardinge approach maintaining two-thirds of the medius and releasing towards the lesser trochanter and not vertically downwards, maintains the medius–lateralis tension band as well as exposes the acetabulum and the femoral shaft necessary for standard THA.

• Indication:

1. ORIF femoral neck fractures
2. Biopsy femoral neck
3. THA

• This approach avoids the need to cut the gluteus medius muscle but involves considerable pulling (traction) on the gluteus medius and TFL muscles and potentially on the superior gluteal nerve.
• If used for THA it often requires additional division of gluteus medius and minimus which lie over the anterior capsule for adequate exposure which may lead to a Trendelenburg gait.
• Position: supine position with sandbag under buttock and buttock hanging slightly over edge of table.
• Landmarks: ASIS and GT.
• Incision: incision is started 2 cm posterior and distal to the ASIS. It curves distally and posteriorly to the apex of the GT to extend longitudinally down about 6 cm distally along the shaft of the femur.
• Internervous plane: no true internervous plane as tensor fascia lata and gluteus medius share the same nerve supply(superior gluteal nerve).
• Superficial dissection: subcutaneous tissue and fascia lata are incised in the same line as the skin. The interval between gluteus medius and tensor fascia lata is often difficult to delineate. However, it can be found more easily by beginning the separation midway between anterior superior iliac spine and GT before tensor fascia lata blends with its fascial insertion. The incision is continued proximally along the posterior border of tensor fascia lata and the inferior branch of the superior gluteal nerve innervating the TFL is often seen.
• Deep dissection: the tensor fascia with tensor fascia lata is retracted anteriorly and the gluteus medius posteriorly exposing the fatty tissue covering the anterosuperior aspect of the hip capsule. Vastus lateralis is sometimes needed to be reflected from the proximal femur distal to the GT.
• Structures at risk: superior gluteal nerve,
• Extension of approach: the fibres of vastus lateralis may be split longitudinally to expose the upper part of the femoral shaft.

• Position: direct lateral decubitus position.Surgeon works on the anterior side.
• Landmarks: ASIS and GT.
• Incision: the surgeon uses internal and external rotation movements to palpate cutaneously the space between the relatively flat tensor fasciae latae and the more oval gluteal muscles and mark the incision line.
• Oblique incision running from a point 3–4 cm below the tip of the GT to a point about two finger-widths beyond the anterosuperior iliac spine. The direction of the line is determined by palpation of the orientation of the space and also by the angle of inclination of the femoral neck: it is more horizontal in the case of coxa vara and more vertical in coxa valga.
• Superficial dissection: subcutaneous tissue and fascia lata are incised in the same line as the skin.
• Deep dissection: a finger is inserted between the anterior border of the gluteus medius and the posterior border of tensor fascia lata, and the interval between the two muscles opened up. No division of any muscle or tendon.
• The capsule of the hip joint is visualised. The anterior capsule is incised which gives a view of the femoral head and neck.
• Structures at risk: lateral cutaneous nerve of thigh, ascending branches of lateral femoral artery.

• Position: supine with sandbag.Hip at the edge of the table.
• Landmarks: ASIS, GT and shaft of femur.
• Incision: the hip is flexed 30 degrees, adducted and internally rotated. An incision is made just in front of the lateral aspect of the femur that continues to the anterior border of the GT and gently curves posteriorly.
• Internervous plane: there is no true internervous plane as the gluteus medius and tensor fascia lata have a common nerve supply (superior gluteal nerve).
• Superficial dissection: the subcutaneous fat is incised in line with the skin incision. The tensor fascia latae is divided 2–3 cm distal to the GT and is curved proximally to parallel the gluteus maximus. The gluteus medius and vastus lateralis can then be visualised. The anterior capsule is then exposed and stretched by external rotation of the femur. The origin of vastus lateralis at the vastus ridge is identified. The origin is divided with electrocautery and the muscle reflected inferiorly for about 1 cm. Underneath it is the anterior capsule.
• Deep dissection: a trochanteric osteotomy is performed by passing a cholecystectomy clamp posteriorly from the anterosuperior exposed surface of the femoral neck. The capsule is then pierced, and the cut is made with a Gigli saw after it is assured that it is located deep to the posterosuperior surface of the trochanter. The osteotomy site then exits through the vastus ridge.
• The trochanter can also be divided using a large osteotome. The starting point for the osteotomy is about 1 cm below the vastus lateralis insertion. The trochanter is progressively elevated with the attached gluteus medius and minimus muscles.
• Numerous methods have been described for rewiring the trochanter, Charnley’s two wire technique and Harris’s three-quarter wire technique remain popular.
• Structures at risk: sciatic nerve.

• Position: lateral with side supports.
• Landmarks: GT.
• Incision: longitudinal straight incision (with hip flexed 60 degrees) or 15–20 cm curved incision centered over the posterior aspect of GT.

Figure 1. Skin incision for posterior approach hip. Landmarks: Greater trochanter. Incision: A curvilinear incision starting 10cm distal to the PSIS extended distal and laterally parallel to the fibers of gluteus maximus to the posterior margin of the greater trochanter and then direct the incision 10cm distally parallel to the femoral shaft.  p.p1 {margin: 0.0px 0.0px 0.0px 0.0px; font: 8.0px Helvetica}.

• Internervous plane: no true plane, but gluteus maximus fibres split lateral to its nerve supply.
• Superficial dissection: incise fascia lata in line with skin. Gluteus maximus fibres split proximally by blunt dissection. Trochanteric bursa peeled/excised and fat from post. aspect of GT peeled off posteriorly.

Figure 2. The short external rotators are exposed.Check the position of the sciatic nerve within the substance of the fatty tissue. Carefully position Charnley bow retractors around the gluteus maximus muscle and avoid catching the nerve.Place stay sutures into the piriformis and gluteus maximus insertion onto the femur.

• Deep dissection: identify sciatic nerve within fat lying on the external rotators. Insert stay sutures in external rotators and detach them sharply from GT after internal rotating the leg. Watch for bleeding while detaching quadratus femoris (try not to detach completely). Hip joint capsule is now visualised.

Figure 3. Intraoperative picture posterior approach to hip wuth sutures around piriformis tendon and gluteus maximus inserion into greater tuberosity femur

• Structures at risk: sciatic nerve, branches of inferior gluteal artery within gluteus maximus muscle.
• Extension of approach: proximally post column of acetabulum can be exposed and distally quadratus femoris and gluteus maximus tendon can be released and dissection can be carried on distally behind vastus lateralis for ETO.

• Position: supine with affected foot lying along the medial side of contralateral knee.
• Landmarks: pubic tubercle and adductor longus tendon.
• Incision: longitudinal incision along medial side of thigh starting 3 cm below the pubic tubercle and running along adductor longus.
• Internervous plane: superficial: no true plane as both supplied by anterior division of obturator nerve. Deep: between anterior division of obturator nerve (adductor brevis) and posterior division obturator nerve/tibial component of sciatic (adductor magnus).
• Superficial dissection: develop plane between gracilis and adductor longus by blunt dissection.
• Deep dissection: dissect between adductor brevis and magus muscles to expose the post division of obturator nerve. The lesser trochanter can be felt and iliopsoas tendon can be divided if needed exposing the anterior inferior aspect of hip joint capsule.
• Structures at risk: oburator nerve on either side of adductor brevis tendon, medial femoral circumflex artery around the medial side of the distal iliopsoas tendon.
• Extension of approach: no useful extension.

• Position: supine with lateral thigh support (tourniquet).
• Landmarks: patella and tibial tubercle.
• Incision: longitudinal midline incision from 5 cm above the superior pole of patella to below level of tibial tubercle.
• Internervous plane: no true plane.
• Superficial dissection: develop full thickness flaps. Incise the quadriceps tendon and then medial parapatellar incision through the joint capsule and distally along the medial side of patella tendon. Leave a cuff of tissue medial to patella and lateral to quadriceps tendon to help with closure.
• Deep dissection: evert the patella and flex the knee to expose the joint. If difficult to evert patella, then one can do a quadriceps turndown/snip or a tibial tubercle osteotomy.

Figure 1. Deep dissection.A medial parapatellar arthrotomy is performed. Cut through quadriceps tendon,medial border of the patella and medial border of the patella tendon. Leave a cuff of soft tissue on  the medial side of the patella to allow for closure at the end of the operation.

• Structures at risk: infrapatellar branch of the saphenous nerve (may form painful neuroma), patella tendon avulsion from tib tubercle.
• Extension of approach: proximally: between rectus femoris and vastus medialis with subsequent dissection through fibres of intermedius (but only for distal third of femur), distally: techniques mentioned above.

• The medial approach gives a limited exposure of the knee. Its main indication would be ORIF of medial tibila plateau fracture and repair of MCL.
• Position: dupine with tourniquet. Knee is flexed 60 degrees with foot on opposite shin.
• Landmarks: adductor tubercle.
• Incision: curved incision 2 cm proximal to adductor tubercle and going anteroinferiorly to 6 cm below medial joint line onto the anteromedial aspect of tibia running medial and parallel to the patella tendon.
• Internervous plane: no true plane.
• Superficial dissection: skin flaps. Saphenous nerve emerges between gracilis and sartorius. Infrapatellar branch of saphenous nerve is cut.
• Deep dissection: anterior or posterior to superficial MCL. Anterior: incise fascia along anterior border of sartorius and flex knee to retract sartorius posteriorly exposing SemiT and gracilis. All three retracted posteriorly and incise medial parapatellarly anterior to MCL and exposing the joint. Posterior: separate medial head of gastrocnemius from semimembranosus and then separate medial head of gastrocnemius from posterior joint capsule (can be bluntly dissected to midline).
• Structures at risk: saphenous nerve, medial inferior genicular artery, popliteal artery.
• Extension of approach: no true extension.

• Position: supine with sandbag.
• Landmarks: patella, Gerdy’s tubercle, lateral joint line.
• Incision: curved incision from 3 cm lateral to middle of patella down over Gerdy’s tubercle to 5 cm distal to the lateral joint line.
• Internervous plane: between superior gluteal nerve (iliotibial band) and sciatic nerve (biceps femoris).
• Superficial dissection: develop the plane between the iliotibial band and biceps femoris by incising the fascia in between. Retract the structures to expose the fibular collateral ligament.
• Deep dissection: anterior or posterior fibular collateral ligament. Anterolateral: incise the capsule anterior to the ligament taking care of the lateral meniscus. Posterolateral: dissect between lateral head of gastrocnemius and posterolateral corner of knee, coagulating branches of lateral superior genicular artery.
• Structures at risk: common peroneal nerve, lateral superior genicular artery, popliteus tendon, lateral meniscus.
• Extension of approach: no useful extension.

• Position: prone (tourniquet).
• Landmarks: popliteal fossa with its boundaries.
• Incision: curvilinear incision centered over the popliteal fossa starting laterally over the biceps femoris and distally over the medial head of gastrocnemius.

Figure 2. Posterior approach to knee. The popliteal vein lies between the tibial nerve and the popliteal artery.

• Internervous plane: no true plane.
• Superficial dissection: skin flaps with subcutaneous fat. Lateral to the small saphenous vein (lies in the midline of calf) lies medial to sural cutaneous nerve which can be traced to the tibial nerve at the apex of the fossa. Roughly at apex of the fossa the common peroneal nerve is seen. Popliteal artery and vein lie deep and medial to the tibial nerve.
• Deep dissection: the muscles that form the boundaries of the popliteal fossa are retracted to expose the posterior knee joint capsule. The medial and lateral heads of gastrocnemius can be released to increase exposure.

Figure 3. Deep dissection of popliteal fossa. Both the medial and the lateral gastrocnemius heads are detached  but one can detach the origin of the lateral head to expose the posterolateral corner of the joint capsule or the medial head to expose the posteromedial side.

• Structures at risk: medial sural cutaneous nerve, tibial nerve, common peroneal nerve and popliteal vessels. (The vein is posterolateral to artery at the apex, crosses posteriorly behind knee and then lies medial.)
• Extension of approach: no useful extension.

• Position: supine (tourniquet).
• Landmarks: subcutaneous tibial border.
• Incision: longitudinal incision 1 cm lateral and parallel to the anterior subcutaneous border of the tibia.
• Internervous plane: no true plane.
• Superficial dissection: full thickness skin flaps.
• Deep dissection: to expose either the subcutaneous surface (medial) of the tibia or the extensor surface (lateral).
• Lateral: strip off the tibialis anterior muscle laterally. Minimal periosteal stripping.
• Structures at risk: long saphenous vein.
• Extension of approach: This approach can be used to expose the whole length of the tibia.

• Position: lateral with supports.
• Landmarks: dubcutaneous fibular surface, fibular head.
• Incision: longitudinal incision centered over the fibular shaft at level of tibial pathology.
• Internervous plane: superficial: between superficial peroneal nerve (peroneus brevis) and deep peroneal nerve (EDL). Deep: between tibial nerve (tibialis posterior) and deep peroneal nerve (extensor muscles of the ankle and foot.
• Superficial dissection: develop the plane between anterior aspect of peroneus brevis and EDL.
• Deep dissection: detach the extensor muscles from the anterior aspect of the inter-ossesous membrane thus exposing the anterolateral surface of the tibia.
• Structures at risk: small saphenous vein, superficial peroneal nerve, anterior tibial artery, deep peroneal nerve.
• Extension of approach: no useful extension.

• Indications:

1. ORIF fractures
2. Management of delayed/non union

• Position: lateral/prone with supports (tourniquet).
• Landmarks: lateral border of gastrocnemius.
• Incision: longitudinal incision along the lateral border of gastrocnemius posterior to the fibular shaft.
• Internervous plane: between the tibial nerve (gastrosoleus/FHL) and the superficial peroneal nerve (peroneal muscles).
• Superficial dissection: full thickness flaps. Develop the plane between the lateral head of gastrocnemius and soleus muscles posteriorly and the peroneus brevis and longus anteriorly down to the fibular shaft.
• Deep dissection: the lower part of soleus origin and FHL are subperiosteally reflected off the fibular shaft exposing its posterior surface. The interosseous membrane is identified from which the tibialis posterior is detached to expose the posterior surface of tibia.
• Structures at risk: dmall saphenous vein, the posterior tibial artery and nerve is separated from the interosseous membrane by muscles in the deep posterior compartment.
• Extension of approach: can be extended distally into the posterolateral approach to the ankle.

• Position: supine (tourniquet).
• Landmarks: medial/lateral malleoli.
• Incision: longitudinal incision over anterior part of ankle midway between the malleoli.

 

Figure 1. Make a 15-cm longitudinal incision over the anterior aspect of the ankle joint. Begin about 10 cm proximal to the joint, and extend the incision so that it crosses the joint about midway between the malleoli, ending on the dorsum of the foot. Take care to cut only skin; the anterior neurovascular bundle and branches of the superficial peroneal nerve cross the ankle joint very close to the line of the skin incision.

 

 

• Internervous plane: no true plane.
• Superficial dissection: identify and split extensor retinaculum. Develop the plane between EHL and EDL. Isolate and ligate the branches from the anterior tibial artery to facilitate retraction.
• Deep dissection: incise the soft tissues longitudinally to expose the anterior joint capsule of the ankle which is incised longitudinally in line with the skin incision.
• Structures at risk: duperficial peroneal nerve (at time of skin incision), anterior tibial artery and deep peroneal nerve. The EHL tendon crosses the anterior aspect of the NV bundle at the level of the ankle joint.
• Extension of approach: proximally to expose the anterior compartment and distally can be used to expose the distal tibial surface or very rarely into the dorsum of the foot.

• Indications: ORIF fractures of the medial malleolus
• Position: Supine on the operating table. Tourniquet with exsanguination of the leg
• Landmark: Medial malleolus palpable distal end tibia
• Incision: One main approach is used but two alternative incisions (anterior and posterior approaches) are described.

(1) The anterior approach consists of a longitudinal curved incision on the medial aspect of the ankle with its midpoint just anterior to the tip of the medial malleolus. The incision begins 5 cm proximal to the medial malleolus and then curves forwards to end anteriorly and distal to the malleolus. The incision should not cross the most prominent portion of the malleolus. The incision permits inspection of the anteromedial ankle joint and the anteromedial part of the dome of the talus.

(2) The posterior approach involves a 10-cm incision on the medial aspect of the ankle, beginning 5 cm above the ankle on the posterior border of the tibia, curving the incision downwards following the posterior border of the medial malleolus. The incision is curved forwards below the medial malleolus to end 5 cm distal to it. The incision allows visualisation of the posterior margin of the tibia.

Alternatively make a 10cm longitudinal incision on the medial aspect of the ankle joint, centered on the tip of the medial malleolus. Begin the incision over the medial surface of the tibia. Below the malleolus, curve it forward onto the medial side of the middle part of the foot.

• Internervous plane: No true internervous plane exists but the approach is safe because the incision cuts down onto subcutaneous bone.
• Superficial surgical dissection: Skin flaps are mobilized. Identify and preserve the saphenous nerve and long saphenous vein, which lie anterior to the medial malleolus.
• Deep surgical dissection: The periosteum of the medial malleolus is incised longitudinally. With an anterior approach a small incision is made in the anterior capsule of the ankle joint so that the joint surfaces can be visualized.
• With a posterior approach the retinaculum behind the medial malleolus is incised. The tibialis posterior (TP) tendon is retracted anteriorly whilst the remaining structures are freed up and retracted posteriorly.

Structures at risk

• Anteriorly the saphenous nerve, which, if cut, may form a painful neuroma and cause numbness over the medial side of the dorsum of the foot.
• Posteriorly all structures that run behind the medial malleolus (TP, FDL posterior tibial artery and vein, tibial nerve and FHL) are at risk.

Anatomy of the medial side of the ankle

• The posterior neurovascular bundle runs behind the medial malleolus between the tendons of FDL and FHL.
• The posterior tibial artery passes behind FDL before entering the sole of the foot where it divides into medial and lateral plantar arteries.
• Tall Doctors Are Never Happy
• Tibialis Posterior
• Flexor Digitorum Longus
• Artery Nerve
• Flexor Hallucis longus

Figure 1. Use a 10cm longitudinal incision over the medial aspect of the ankle joint,with its centre over the tip of the medial malleolus.The saphenous vein and nerve should be preserved to reduce the chance of neuroma formation and troublesome bleeding and possible wound haematoma.

• Indications: ORIF of lateral malleoli fractures
• Position: Supine on the operating table, with a sandbag under the buttock. Tourniquet with exsanguination.
• Landmarks: The subcutaneous surface of the fibula and lateral malleolus are palpated. The short saphenous vein runs along the posterior border of the lateral malleolus.
• Incision: A 10-15cm longitudinal incision is made along the posterior margin of the fibula all the way to its distal end and continuing for a further 1cm.In fracture surgery centre the incision at the level of the fracture checking if necessary beforehand with II.Avoid a careless placed incision that results in a longer incision than necessary
• Internervous plane: There is no internervous plane as the dissection is being performed down to a subcutaneous bone. For higher fractures the internervous plane lies between the peroneus tertius muscle (deep peroneal nerve) and peroneus brevis muscle (superficial peroneal nerve)
• Superficial surgical dissection: Elevate the skin flaps. Take care not to damage the short saphenous vein, which lies posterior to the lateral malleolus. The sural nerve, which runs with the short saphenous vein, should also be preserved.
• Deep surgical dissection: Dissection is performed down to the subcutaneous surface of the bone. The periosteum of the fibula is incised longitudinally. Avoid excessive stripping off the periosteum as this will increase the risk of infection and delayed fracture healing
• Structures at risk: sural nerve when skin flaps are mobilised which can lead to a painful troublesome neuroma seen in fracture clinic follow up, terminal branches peroneal artery damaged if dissection is excessive
• Extension of approach: can be extended distally down the lateral side of the foot or proximally along the posterior border of the fibula

Figure 1. Lateral fibula skin incision Make a 10-15 cm incision in line with the fibula, starting proximally. If necessary, continue distally a further 2 cm, curving slightly, anteriorly in relation to the tip of the lateral malleolus, in order to increase exposure and release tension.If a posterior plate is planned, place the incision slightly posteriorly, so that the soft-tissue dissection can be minimized. If a lag screw from anterior to posterior (Chaput lesion) is planned, place the incision slightly anteriorly.

Figure 2. The sural nerve is vulnerable when skin flaps are mobilised.

The sural nerve courses from medial to lateral and crosses the lateral border of the Achilles tendon on average 10 cm proximal to its insertion in the calcaneus. At a point 7 cm proximal to the tip of the lateral malleolus, the nerve is on average 2.5cm posterior to the edge of the fibula.

• Position: supine (tourniquet) with a figure of four position/lateral (with opposite side on the top and flexed).
• Landmarks: medial malleolus.
• Incision: 10 cm longitudinal incision midway between medial malleolus and tendoachilles.
• Internervous plane: no true plane.
• Superficial dissection: full thickness flaps of skin and subcutaneous fat. Retract the tendoachilles and the retrotendinous fat to expose the deep posterior compartment.
• Deep dissection: incise the deep fascia and develop the plane between FHL and the NV bundle laterally and the FDL medially, exposing the posterior joint capsule.
• Structures at risk: tibialis posterior tendon, FDL, posterior tibial artery and vein, tibial nerve and FHL.
• Extension of approach: can be extended distally into the posteromedial approach to the foot.

• This approach minimizes sequelae of peroneal tendinitis and devascularization of the anterior skin flap and preserves the sural nerve
• Indications: ORIF of calcaneal fractures.
• Position: Patient is positioned lateral. A tourniquet is applied, and the leg exsanguinated. Place the leg to be operated on posteriorly with the leg under anterior
• Landmarks: Posterior border distal fibula, lateral border Achilles tendon, styloid process at the base 5^th metatarsal bone (along lateral aspect foot)
• Incision: The calcaneus is approached through an L-shape incision. The incision begins laterally 3–4 cm superior to the calcaneal tuberosity and 1–2 cm anterior to the TA. The incision is extended distally and continued retrofibularly to the junction of the dorsal and plantar skin, where a smooth curve is made, curving the incision anteriorly toward the calcaneocuboid joint and the fifth metatarsal base.

• Figure 1. The posterior arm of the incision is placed midway between the fibula and Achilles tendon. The horizontal arm is placed in line with the base of the fifth metatarsal. They meet at a corner where skin handling must be optimize

• Internervous plane: No internervous approach exists in this approach
• Superficial surgical dissection: Mobilize full-thickness skin flaps minimally. Distally, dissect straight down onto the lateral surface of the calcaneum by sharp dissection
• Deep surgical dissection: Sharply incise the periosteum of the calcaneal lateral wall and develop full thickness flaps consisting of periosteum and the overlying soft tissues. until the sinus tarsi, neck, and posterior facet are visualized
• Avoid any undermining of the edges. The peroneal tendons are mobilized subperiosteally and retracted in the anterior flap over the distal end of the fibula. The calcaneofibular ligament is identified and sharply incised transversely to open the capsule of the subtalar joint.
• Try not to cut into the muscle belly of abductor digiti minimae. 1.6mm K-wires can be placed into the talus, fibula, and cuboid. The wires are then bent, allowing a "hands-free" retraction technique 
• Structures at risk: Sural nerve, soft tissues (skin necrosis)

Figure 2. Superficial dissection.The incision is deepened through subcutaneous tissue taking care not to elevate skin flaps.Distally diessection is down to the lateral calcaneal surface.Peroneal tendons are elevated anteriorly.

• Position: lateral/prone (tourniquet) with affected side up.
• Landmarks: fibula and lateral border of tendoachilles.
• Incision: 10 cm longitudinal incision midway between fibula and the tendoachilles.

Figure 1.The posterolateral incision is performed on the medial side of the posterior edge of the fibula. The short saphenous vein and sural nerve run close together and be preserved as a unit.

• Internervous plane: between the superficial peroneal nerve (peroneus brevis) and tibial nerve (FHL).
• Superficial dissection: skin flaps but identify and protect the short saphenous vein and sural nerve. Deep fascia is incised and the peroneal tendons are retracted anteriorly.
• Deep dissection: reflect the peroneus brevis and the FHL from the posterior aspect of the fibula and across the interosseous membrace to expose the posterior malleolus/posterior aspect of distal tibia.
• Structures at risk: sural nerve, short saphenous vein, posterior tibial neurovascular bundle.
• Extension of approach: can be extended proximally into the posterolateral approach to the tibia and distally into the lateral approach to the hindfoot.

Figure 2.Deep dissection. A longitudinal incision is made through the lateral fibers of the flexor hallicis longus as they arise from the fibula.

• Provides exposure to subtalar joint,talonavicular joint,calcaneocuboid joint
• Indications: Triple arthrodesis
• Position: supine/lateral (tourniquet/sandbag).
• Landmarks: lateral malleolus, sinus tarsi.
• Incision: oblique incision starting from just below and posterior to lateral malleolus along lateral side of hindfoot over sinus tarsi going medially towards talocalcaneonavicular joint.
• Internervous plane: between superficial peroneal nerve (peroneal longus/brevis) and deep peroneal nerve (peroneus tertius).
• Superficial dissection: full thickness flaps (careful of over-mobilising). Incise the inferior extensor retinaculum. Expose the peroneal longus/brevis tendons. Distally retract the peroneus tertius and EDL medially.
• Deep dissection: partially detach the fat pad within sinus tarsi, exposing the EDB, which is sharply dissected to expose the dorsal capsules of calcaneocuboid joint laterally and talocalcaneonavicular joint medially. Incise peroneal retinaculum to retract peroneii exposing posterior talocalcaneal joint.
• Structures at risk: skin flaps,extensor longus tendon,peroneus brevis.
• Extension of approach: can be extended proximally into posterolateral approach to the ankle taking care to avoid damaging the sural nerve and the small saphenous vein.

• Position: supine with sandbag between shoulder blades. The table is positioned at 30 degrees head up and the face turned away from the side of the planned incision.
• Landmarks:
• C2–3 – lower border of mandible
• C3 – hyoid
• C4–5 – thyroid cartilage
• C6 – cricoid cartilage and carotid tubercle
• Sternocleidomastoid
• Incision: transverse incision at level of pathology. From posterior border of SCM to midline. If more than three levels are approached then use longitudinal incision.
• Internervous plane: there is no true internevous plane during the anterior approach to the cervical spine
• Superficial dissection: the carotid sheath(laterally) and the trachea and oesophagus(medially).
• Deep dissection: complete blunt dissection through the deeper layers to the prevertebral fascia and vertebral bodies. Reflect subperiosteally prevertebral muscles to expose anterior vertebral bodies.

Figure 1. The sternocleidomastoid and carotid sheath are retracted laterally and the strap muscles,trachea and oesophagus medially..The longus coli and pretrachial fascia are exposed.

• Structures at risk:

1. Carotid vessels
2. Recurrent laryngeal nerve
3. Oesophagus
4. Trachea
5. Thoracic duct
6. Cervical sympathetic chain
7. Vertebral arteries
8. Spinal nerve roots
9. Cervical cord

• Extension of approach: if more than three levels are approached then use longitudinal incision.

• Position: prone with slight head flexion and head rest.
• Landmarks: spinous processes C2/C7/T1.
• Incision: straight longitudinal midline incision.
• Internervous plane: between left and right paracervical muscles.
• Superficial dissection: continue skin incision down to spinous processes. Reflect paraspinal muscles subperiosteally using a Cobb elevator. Carry the dissection laterally to reveal the lamina, facet joints and transverse processes.
• Deep dissection: identify ligamentum flavum and remove it from the superior edge of the inferior lamina. Perform a laminotomy/laminectomy. Expose the blue white dura and epidural fat. Gently retract the spinal cord medially to expose the vertebral body, disc space.

Figure 1. The paraspinal muscles are retracted subperiosteally from the posterior aspect of the cervical spine.

• Structures at risk: spinal cord,nerve roots.
• If the first and second vertebral arches are dissected in too far a lateral position, the vertebral artery may be damaged.
• Extension of approach: very extensible distally and also proximally as high as the occiput of the skull.