Knee and Lower Leg

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Chapter 7

Knee and Lower Leg

Robert F. LaPrade, Nicholas I. Kennedy

Regional Anatomy

Osteology

Distal Femur (Fig. 7-1)

The femur (the largest bone in the body) flares distally and forms two condyles—a larger medial condyle and a longer and more narrow lateral femoral condyle

The intercondylar area serves as the region for cruciate attachments—the lateral, anterior cruciate ligament (ACL) and the medial, posterior cruciate ligament (PCL)

The superficial medial collateral ligament (MCL) attaches adjacent to the medial epicondyle

The medial patellofemoral ligament inserts just distal to the adductor tubercle, and the adductor magnus tendon inserts on the adductor tubercle at the superior aspect of the medial epicondyle; in addition, the posterior oblique ligament attaches adjacent to the gastrocnemius tubercle

The attachment of the lateral collateral ligament (LCL) is adjacent to the lateral epicondyle; it is less prominent than the medial epicondyle

The popliteus tendon lies in a groove distal to the lateral epicondyle and within the popliteal hiatus (at its proximal fifth)

FIGURE 7-1 Bony architecture of the distal femur.

Proximal Tibia (Fig. 7-2)

The tibia is the second longest bone in the body

The plateau areas match the corresponding femoral condyle

• The medial tibial plateau is broad and concave

• The lateral tibial plateau is smaller and convex

The tibial eminences (spines) define the borders of the cruciate ligament insertions

• The ACL lies between the eminences

• The PCL lies within the PCL facet, adjacent to the posterior aspects of the medial and lateral tibial plateaus; in addition, its distal fibers attach at the posterior tibial drop-off, which radiographically is known as the “champagne glass drop-off” of the tibia

The tubercles serve as attachments for tendons

• The tibial tubercle (or tuberosity) serves as the patellar tendon attachment

• Gerdy’s tubercle serves as the iliotibial band attachment

FIGURE 7-2 Bony architecture of the proximal tibia. PCL, Posterior cruciate ligament.

Patella (Fig. 7-3)

The patella is the largest sesamoid bone in the body

It has the thickest articular cartilage in the body

Medial and lateral facets

• The lateral facet is larger

• The facets are separated by a vertical ridge

FIGURE 7-3 Bony architecture of the patella.

Arthrology

Knee Joint (Figs. 7-4 and 7-5)

FIGURE 7-4 Knee (femorotibial) joint.

FIGURE 7-5 Knee joint (hinged open).

Proximal Tibiofibular Joint

Plane gliding joint

Surrounded by a thick capsule

Anterior and posterior ligaments of the head of the fibula stabilize the joint

Patellofemoral Joint

A plane (gliding) joint that stabilizes the patella in the trochlear groove of the femur and enhances the effect of the quadriceps muscles (fulcrum effect)

Medial patellofemoral ligament—the primary restraint to lateral patellar displacement

Capsule/retinaculum

Muscles

Knee and leg muscles are best considered in groups or compartments (Figs. 7-6 and 7-7; Tables 7-1 and 7-2)

FIGURE 7-6 Muscles (anterior and lateral views).

FIGURE 7-7 Muscles (posterior view).

Table 7-1

Muscles of the Thigh

MUSCLE	ORIGIN	INSERTION	INNERVATION
Vastus lateralis	Iliotibial line/greater trochanter/lateral linea aspera	Lateral patella	Femoral
Vastus medialis	Iliotibial line/medial linea aspera/supracondylar line	Medial patella	Femoral
Vastus intermedius	Proximal anterior femoral shaft	Patella	Femoral
Biceps (long head)	Medial ischial tuberosity	Fibular head/lateral tibia	Tibial
Biceps (short head)	Lateral linea aspera/lateral intermuscular septum	Fibular styloid/posterolateral joint capsule	Peroneal
Semitendinosus	Distal medial ischial tuberosity	Anterior tibial crest	Tibial
Semimembranosus	Proximal lateral ischial tuberosity	Oblique popliteal ligament	Tibial
		Posterior capsule
		Posterior/medial tibia
		Fabella/lateral gastrocnemius tendon
		Medial meniscus

Table 7-2

Muscles of the Leg

MUSCLE	ORIGIN	INSERTION	ACTION	INNERVATION
Anterior Compartment
Tibialis anterior	Lateral tibia	Medial cuneiform, first metatarsal	Dorsiflex, invert foot	Deep peroneal (L4)
Extensor hallucis longus	Mid fibula	Great toe distal phalanx	Dorsiflex, extend toe	Deep peroneal (L5)
Extensor digitorum longus	Tibial plateau/fibula	Toe middle and distal phalanges	Dorsiflex, extend toes	Deep peroneal (L5)
Peroneus tertius	Fibula and extensor digitorum longus tendon	Fifth metatarsal	Evert, plantar flex, abduct foot	Deep peroneal (S1)
Lateral Compartment
Peroneus longus	Proximal fibula	Medial cuneiform, first metatarsal	Evert, plantar flex, abduct foot	Superficial peroneal (S1)
Peroneus brevis	Distal fibula	Tuberosity of fifth metatarsal	Evert foot	Superficial peroneal (S1)
Superficial Posterior Compartment
Gastrocnemius	Posterior, medial, and lateral femoral condyles	Calcaneus	Plantar flex foot	Tibial (S1)
Soleus	Fibula/tibia	Calcaneus	Plantar flex foot	Tibial (S1)
Plantaris	Lateral femoral condyle	Calcaneus	Plantar flex foot	Tibial (S1)
Deep Posterior Compartment
Popliteus	Lateral femoral condyle, fibular head	Proximal tibia	Flex, internal rotation knee	Tibial (L5, S1)
Flexor hallucis longus	Fibula	Great toe distal phalanx	Plantar flex great toe	Tibial (S1)
Flexor digitorum longus	Tibia	Second-fifth toe distal phalanges	Plantar flex toes, foot	Tibial (S1, S2)
Tibialis posterior	Tibia, fibula, interosseous membrane	Navicular, medial cuneiform	Invert/plantar flex foot	Tibial (L4, L5)

Anterior Thigh

Quadriceps muscles

• Vastus lateralis, intermedius, and medialis and rectus femoris

Posterior Thigh

Hamstring muscles

• Lateral—biceps femoris (long and short heads)

• Medial—semimembranosus, semitendinosus, sartorius, and gracilis

Adductors—magnus, longus, and brevis

Anterior Leg

Tibialis anterior, extensor hallucis longus, and extensor digitorum longus

Posterior Leg

Gastrocnemius, soleus, plantaris, flexor hallucis longus, flexor digitorum longus, tibialis posterior (deep), and popliteus

Lateral Leg

Peroneus brevis, longus, and tertius (distally)

Nerves

Extension of Nerves from the Lumbosacral Plexus (Fig. 7-8)

Sciatic nerve—divides in midthigh

• Tibial division

• Peroneal division

Obturator nerve

FIGURE 7-8 Major nerves of the thigh and leg.

Vascularity (Fig. 7-9)

Femoral Artery

• Anterior tibial artery

• Posterior tibial artery

• Peroneal artery (usually splits from the posterior branch)

FIGURE 7-9 Major arteries of the thigh and leg.

Cross-Sectional Anatomy (Fig. 7-10)

Thigh

Anterior Compartment

Vastus medialis, vastus intermedius, vastus lateralis, rectus femoris, and sartorius

Superficial femoral artery and vein

Saphenous nerve

FIGURE 7-10 Cross section of the thigh and lower leg.

Medial Compartment

Adductor longus, adductor brevis, adductor magnus, and gracilis

Deep femoral artery and vein

Posterior Compartment

Biceps femoris, semitendinosus, and semimembranosus

Lower Leg

Anterior Compartment

Tibialis anterior, extensor hallucis longus, and extensor digitorum longus

Deep peroneal nerve

Anterior tibial artery and vein

Lateral Compartment

Peroneus longus and brevis

Superficial peroneal nerve

Superficial Posterior Compartment

Gastrocnemius, soleus, and plantaris

Deep Posterior Compartment

Flexor hallucis longus, flexor digitorum longus, and tibialis posterior

Posterior tibial artery and vein

Superficial Landmarks

FIGURE 7-11 Superficial landmarks.

Radiologic Landmarks

(Figs. 7-12 through 7-15)

FIGURE 7-12 Radiologic landmarks of the knee. PCL, Posterior cruciate ligament.

FIGURE 7-13 Radiologic landmarks of the knee.

FIGURE 7-14 Radiologic landmarks of the knee. ACL, Anterior cruciate ligament; MCL, medial collateral ligament.

FIGURE 7-15 Radiologic landmarks of the knee.

Hazards (Fig. 7-16)

Sciatic Nerve

The main nerve to the lower extremity

• Dissection near ischium (proximal hamstring injuries)

FIGURE 7-16 Hazards in the posterior thigh and leg.

Peroneal Nerve

A branch of the sciatic nerve that crosses the fibula before dividing into superficial and deep branches

At risk—peroneal nerve

• As it crosses the neck of the fibula

• Posterolateral lance surgical approaches

• Biceps femoris avulsions

• LCL reconstructions

• Lateral meniscus repairs

At risk—superficial peroneal nerve

• During lower extremity compartment release, approximately 12 cm proximal to the tip of the lateral malleolus

Tibial Nerve

• Popliteal dissection

• PCL inlay reconstructions

• PCL bony avulsion repairs

Vascular

Popliteal Artery and Vein

• Popliteal dissection and PCL transtibial procedure

• Knee arthroplasty, especially in revision cases where bone loss extends posteriorly

• Meniscal root repairs and meniscal transplantations

Geniculate Arteries

• Medial and lateral dissection

Surgical Approaches

Anterior Approaches to the Knee

Indications

Open ligament or cartilage procedures and knee arthroplasty

Standard Approach for Total Knee Arthroplasty (Fig. 7-17)

Positioning

Commercially available leg holders or positioners or a sandbag taped to the surgical bed and a bump under the hip may be helpful

FIGURE 7-17 The standard anterior approach to the knee. A, Incision.B, Parapatellar dissection. C, Patella eversion.D, Midvastus (1 and 2) and subvastus (3 and 4) approaches.

FIGURE 7-17 The standard anterior approach to the knee. A, Incision.B, Parapatellar dissection. C, Patella eversion.D, Midvastus (1 and 2) and subvastus (3 and 4) approaches.

Incision

Medial parapatellar incision (Fig. 7-17, A)

• Traditional incision for knee arthroplasty

• A 10- to 15-cm incision is made just medial to midline beginning several centimeters superior to the patella and extending to the tibial tubercle

Superficial and Deep Dissection (Fig. 7-17, B and C)

Subcutaneous tissue is dissected to expose the quadriceps tendon, patella, and patellar tendon

A vertical incision is made in the retinaculum, leaving a 5-mm strip of tendon for later closure; the incision is curved around the patella and immediately adjacent to the patellar tendon

The patella can be everted, the knee flexed, and the joint exposed

Additional exposure of the proximal tibia can be accomplished by fat pad excision and subperiosteal dissection of the proximal medial tibia

Alternatives to the parapatellar incision include a midvastus or subvastus approach (Fig. 7-17, D)

Closure

The extensor tendon and retinaculum are closed using heavy nonabsorbable suture

Limited Anterior Incision (Quadriceps Sparing; Fig. 7-18, A)

Positioning

Commercially available leg holders or positioners or a sandbag taped to the surgical bed and a bump under the hip may be helpful

FIGURE 7-18 The quadriceps-sparing (limited) approach. A, Lateral and medial incision. B, Patella retraction.

FIGURE 7-18 The quadriceps-sparing (limited) approach. A, Lateral and medial incision. B, Patella retraction.

Incision

A 5-cm vertical incision is made starting distal to the quadriceps muscle

Superficial and Deep Dissection (Figs. 7-18, B, and 7-19)

Subcutaneous tissue is dissected to expose the patella and patellar tendon

A vertical incision is made in the retinaculum, leaving a 5-mm strip of tendon for later closure; the incision is curved along the medial aspect of the patella and immediately adjacent to the patellar tendon

The dissection continues to release the retropatellar fat pad off the tibia (Fig. 7-20)

FIGURE 7-19 A miniarthrotomy incision in the right knee.

FIGURE 7-20 Deep dissection of the right knee for a miniarthrotomy.

Closure

The extensor tendon and retinaculum are closed using heavy nonabsorbable suture

Anterior Approach for Patella Tendon Harvest

Positioning

Commercially available leg holders or positioners may be helpful

The end of the table is dropped to allow the knee to drop into flexion

Incision

The incision is made from the midpatellar region to the tibial tuberosity

Superficial and Deep Dissection (Fig. 7-21)

The paratenon is carefully dissected off the underlying tendon fibers

An appropriate graft is harvested with 20 to 25 mm of bone from the patella and the tibial tubercle (Fig. 7-22)

A bone graft is placed into the patellar defect before closure (Fig. 7-23)

FIGURE 7-21 Patella tendon graft harvest. A, Skin incision.B, Incision of paratenon to expose the patella tendon. C, Harvesting the middle third of the patella tendon.

FIGURE 7-21 Patella tendon graft harvest. A, Skin incision.B, Incision of paratenon to expose the patella tendon. C, Harvesting the middle third of the patella tendon.

FIGURE 7-22 Patellar tendon harvest.

FIGURE 7-23 Harvesting a bone graft for a patellar tendon defect after patellar tendon harvest.

Closure

Nonabsorbable sutures are used to close the tissue over the patella, the patellar tendon is loosely closed, and the patellar tendon paratenon is also closed

Inferomedial Approach for Hamstring Harvest (Video 7-1)

Incision (Fig. 7-24, A)

A 3-cm vertical incision is centered 6 cm distal to the medial joint line midway between the posterior medial tibial crest and the tibial tubercle

FIGURE 7-24 The inferomedial approach for hamstring harvest. A, Incision. B, A hockey-stick incision in the sartorial fascia.C, A right-angle clamp is used to grasp the tendon. D, The tendon is carefully freed of attachments.

FIGURE 7-24 The inferomedial approach for hamstring harvest. A, Incision. B, A hockey-stick incision in the sartorial fascia.C, A right-angle clamp is used to grasp the tendon. D, The tendon is carefully freed of attachments.

Superficial Dissection (Fig. 7-24, B)

Skin and subcutaneous tissue are dissected to expose the underlying sartorial fascia

Deep Dissection (Fig. 7-24, C and D)

The sartorial fascia is carefully reflected off the underlying gracilis and semitendinosus tendons, which are then harvested

Right-angle clamps are often helpful in identifying and dissecting these tendons (Fig. 7-25)

FIGURE 7-25 Hamstring harvest in the left knee.

Alternatively, the tendons can be harvested from the back side of the sartorial fascia by deep reflection

Care should be taken to free up completely any attachments of the tendons (including major slips of the semitendinosus to the medial head of the gastrocnemius) before tendon harvesting (Fig. 7-26)

FIGURE 7-26 Hamstring harvest in the left knee.

Medial Approach to the Knee (Fig. 7-27 and Video 7-2)

Indications

Medial collateral ligament repair or reconstruction and medial meniscal repair

FIGURE 7-27 The medial approach to the knee. A, Incision. B, Superficial dissection.C, An incision is made just posterior to the medial collateral ligament.

FIGURE 7-27 The medial approach to the knee. A, Incision. B, Superficial dissection.C, An incision is made just posterior to the medial collateral ligament.

Positioning

Supine or with use of a knee holder

Can follow with an arthroscopy with the knee in this position

Incision

An 8- to 10-cm vertical incision is centered over the posteromedial joint line

The incision should be over the posterior half of the MCL

Superficial Dissection

Skin and subcutaneous tissues are dissected to expose the sartorial fascia

Identify and protect the saphenous and nerve branches

Dissect deep to the sartorial fascia and make an incision along its fibers

Alternatively, the sartorial fascia can be reflected

Deep Dissection

Expose the MCL (the superficial fibers extend quite distal; the deep fibers are actually the thickened capsule in this area)

A vertical incision can be made just posterior to the deep MCL to allow reefing of the posterior oblique ligament (capsular tissue that is posterior to the deep MCL)

Dissect between the medial head of the gastrocnemius and the direct arm of the semimembranosus to gain access to the posterior knee for a medial meniscal repair

Closure

Repair the sartorius using absorbable suture

Meniscal Repair (Fig. 7-28)

For inside-out meniscal repair, a 3-5 cm incision is made in the same area; most of the incision is below the joint line

The sartorial fascia is split or reflected, and the capsule is exposed

Posterior dissection, anterior to the medial head of the gastrocnemius and proximal to the semimembranosus tendon, is necessary for retractor placement (Figs. 7-29 and 7-30)

FIGURE 7-28 Medial meniscal repair. A, Incision. B, The sartorius is incised and the joint capsule is exposed. MCL, Medial collateral ligament.C, The medial gastrocnemius is identified and retracted. D, Anatomy of the repair exposure. ACL, Anterior cruciate ligament.

FIGURE 7-28 Medial meniscal repair. A, Incision. B, The sartorius is incised and the joint capsule is exposed. MCL, Medial collateral ligament.C, The medial gastrocnemius is identified and retracted. D, Anatomy of the repair exposure. ACL, Anterior cruciate ligament.

FIGURE 7-29 Superficial incision for medial meniscus repair of the right knee.

FIGURE 7-30 Deep incision for medial meniscus repair of the right knee.

Lateral Approach to the Knee (Fig. 7-31 and Video 7-3)

Indications

Lateral or posterolateral repair or reconstruction and lateral meniscal repair

FIGURE 7-31 The lateral approach to the knee. A, Incision.B, Two intervals are identified. C, Deep dissection. IT, Iliotibial; LCL, lateral collateral ligament.

FIGURE 7-31 The lateral approach to the knee. A, Incision.B, Two intervals are identified. C, Deep dissection. IT, Iliotibial; LCL, lateral collateral ligament.

Positioning

Supine or with use of a knee holder

Can follow with an arthroscopy with the knee in this position

Incision

An 8- to 10-cm vertical incision is centered over the midportion of the iliotibial band and passes distally over Gerdy’s tubercle (Figs. 7-32 and 7-33)

FIGURE 7-32 Lateral skin incision outline.

FIGURE 7-33 Skin incision for the lateral approach.

The deep incision should be anterior to the lateral gastrocnemius tendon, posterior to the LCL (palpable with the knee in the figure-4 position) and anterior to the biceps tendon (to protect the peroneal nerve)

Superficial Dissection

Skin and subcutaneous tissues are dissected to expose the iliotibial band and the biceps tendon

Deep Dissection

Identify and protect the peroneal nerve (just posterior to the biceps muscle); carefully dissect the nerve across the neck of the fibula (Fig. 7-34)

FIGURE 7-34 Deep incision to note the peroneal nerve.

Develop the interval between the iliotibial band and the biceps (interval 1) as needed

• Developing the interval allows identification of the tibial attachments of the lateral joint capsule

Split the midportion of the iliotibial band (interval 2; Fig. 7-35)

• This procedure allows identification of the lateral femoral epicondyle and the femoral attachments of the LCL and popliteus tendon (Fig. 7-36)

FIGURE 7-35 Iliotibial head–splitting incision in the right knee.

FIGURE 7-36 Deep dissection and split iliotibial band in the right knee.

Closure

Repair intervals 1 and 2 using absorbable suture

Meniscal Repair (Fig. 7-37)

For inside-out meniscal repair, a smaller, 5-cm incision is made in the same area; most of the incision is below the joint line

The incision can extend along the iliotibial band for larger meniscal repairs or meniscal transplants with the interval developed between the posterior border of the iliotibial band and the biceps femoris to gain access to the lateral joint capsule

The biceps/iliotibial band (interval 1) is developed, and the capsule is exposed

Posterior dissection, anterior to the lateral head of the gastrocnemius, is necessary for retractor placement (Figs. 7-38 and 7-39)

It is often necessary to dissect some fibers of the short head of the biceps femoris and the lateral gastrocnemius off the capsule

FIGURE 7-37 Lateral meniscal repair. A, Incision.B, The interval between the biceps and the iliotibial (IT) band is developed. C, Anatomy of the repair. ACL, Anterior cruciate ligament; IT, iliotibial; LCL, lateral collateral ligament.

FIGURE 7-37 Lateral meniscal repair. A, Incision.B, The interval between the biceps and the iliotibial (IT) band is developed. C, Anatomy of the repair. ACL, Anterior cruciate ligament; IT, iliotibial; LCL, lateral collateral ligament.

FIGURE 7-38 Deep dissection for lateral meniscus repair.

FIGURE 7-39 Deep dissection for lateral meniscus repair.

Posterior Approach to the Knee (Figs. 7-40 and 7-41 and Video 7-4)

Indications

PCL repair or reconstruction (tibial inlay technique)

FIGURE 7-40 The posterior approach to the knee (modified inlay technique). A, Positioning.B, Incision. C, The popliteal fascia is excised.D, The medial head of the gastrocnemius is exposed. E, The interval is identified between the medial head of the gastrocnemius and the semimembranosus.F, A vertical incision in the joint capsule over the posterior cruciate ligament (PCL). G, Steinmann pins retract the gastrocnemius for deep dissection.

FIGURE 7-40 The posterior approach to the knee (modified inlay technique). A, Positioning.B, Incision. C, The popliteal fascia is excised.D, The medial head of the gastrocnemius is exposed. E, The interval is identified between the medial head of the gastrocnemius and the semimembranosus.F, A vertical incision in the joint capsule over the posterior cruciate ligament (PCL). G, Steinmann pins retract the gastrocnemius for deep dissection.

FIGURE 7-41 The traditional posterior approach to the knee. A, Incision. B, Superficial fascial incision. C, The gastrocnemius is exposed. D, Deep dissection. E, The capsule is excised.

Positioning

Lateral decubitus or prone

Incision

Traditional Approach

A long vertical S-shaped incision is made from proximal to distal, beginning laterally, running obliquely across the popliteal fossa, and then extending medially

Inlay Approach

A 10-cm medial hockey-stick incision is made beginning in the popliteal crease horizontally and curving distally on the medial border of the calf, over the medial edge of the medial gastrocnemius tendon

Modified Inlay Approach

A 6-cm horizontal incision is made in the popliteal crease

Superficial Dissection

Traditional Approach

Subcutaneous tissues are dissected to expose the popliteal and gastrocnemius fascia

The small saphenous nerve and vein are identified distally and traced proximally

Inlay Approach

The gastrocnemius fascia is dissected in line with the incision and semitendinosus tendon

An interval between the medial head of the gastrocnemius is developed, and the gastrocnemius is mobilized laterally with the semitendinosus tendon

Modified Inlay Approach

The gastrocnemius fascia is incised horizontally and distally with subcutaneous retraction laterally

Deep Dissection

Inlay and Modified Inlay Approach

The medial head of the gastrocnemius is retracted laterally and held in place with 3/32 Steinmann pins or large curved retractors

The popliteal fascia and muscle belly are split proximally along the PCL facet, exposing the back of the tibia

The two posterior eminences are palpated, and the PCL facet is identified and exposed

Closure

No deep closure is necessary

Placing a drain under the medial head of the gastrocnemius is often helpful

The skin and subcutaneous tissues are closed in the standard fashion

Lateral Approach to the Proximal Tibia (Fig. 7-42)

Indications

Lateral tibial plateau fracture

FIGURE 7-42 The lateral approach to the proximal tibia. A, Incision. B, A lateral hockey-stick incision.C, Tibialis anterior subperiosteal reflection. D, Deep exposure.

FIGURE 7-42 The lateral approach to the proximal tibia. A, Incision. B, A lateral hockey-stick incision.C, Tibialis anterior subperiosteal reflection. D, Deep exposure.

Positioning

The patient is placed in a supine position on a radiolucent surgical table

A bump or triangle is used to allow for knee flexion up to 90 degrees

Incision

A 10-cm vertical lateral parapatellar skin incision

Superficial Dissection

The subcutaneous tissue is reflected laterally to expose the tibialis anterior fascia and anterior compartment musculature

Deep Dissection

A hockey-stick incision is made in the fascia, and the tibialis anterior is subperiosteally reflected laterally with an elevator to expose the proximal tibia

The fascial incision should not be directly on bone to allow for primary closure

An arthrotomy can be made through the proximal portion of the incision to inspect the joint

When the level of the joint line is identified, the coronary ligaments are reflected perpendicular to the skin incision, and the lateral meniscus is tagged with a nonabsorbable mattress stitch, which can be used to mobilize the meniscus and later to perform repair through the capsule

The coronary ligaments and capsule can be sharply incised and the meniscus lifted up to allow better visualization

Closure

Additional nonabsorbable mattress sutures are placed into the meniscus with the ends of these sutures passed through the capsule with a free needle

The capsule is closed and the meniscal sutures are tied, completing the meniscal repair

The tibialis anterior fascia should be loosely closed primarily, with a drain left deep to the muscle

Subcutaneous and skin layers are closed in the usual fashion

Medial Approach to the Proximal Tibia (Fig. 7-43)

Indications

Medial tibial plateau fracture

FIGURE 7-43 The medial approach to the proximal tibia. A, Incision. B, The interval between the sartorius and the semimembranosus.C and D, Deep exposure.

FIGURE 7-43 The medial approach to the proximal tibia. A, Incision. B, The interval between the sartorius and the semimembranosus.C and D, Deep exposure.

Positioning

The patient is placed in a supine position on a radiolucent surgical table

A bump or triangle is used to allow for knee flexion up to 90 degrees

Incision

A 10-cm medial parapatellar incision is made just behind the posteromedial border of the tibia

Superficial Dissection

Subcutaneous tissue and the medial retinaculum are reflected to expose the medial head of the gastrocnemius and the semimembranosus

Deep Dissection

Develop the interval between the medial head of the gastrocnemius and the semimembranosus to expose the medial proximal tibia

An arthrotomy can be made through the proximal portion of the incision to inspect the joint as described previously

Stay anterior to the saphenous vein and nerve

Closure

Subcutaneous and skin layers are closed in the usual fashion

Lateral Approach to the Leg (Fig. 7-44)

Indications

Compartment syndrome and fracture fixation

FIGURE 7-44 Lateral approach to the lower leg. A, Surface anatomy. B, Fascial incision.C, Deep dissection. D, Exposure of the compartments. FHL, Flexor hallucis longus.

FIGURE 7-44 Lateral approach to the lower leg. A, Surface anatomy. B, Fascial incision.C, Deep dissection. D, Exposure of the compartments. FHL, Flexor hallucis longus.

Positioning

Supine with use of a bump

Padding of prominent structures is important

Incision

A 10- to 15-cm longitudinal incision is made directly laterally

For exertional compartment syndrome, one to two smaller incisions may be made

Superficial Dissection

Incise the fascia over the anterior compartment

Protect the superficial peroneal nerve, which is located approximately 12 cm proximal to the distal tip of the lateral malleolus

Identify the septum that divides the anterior and lateral compartments of the leg, and selectively release the fascia over the involved compartments, being careful not to release deep to the fascia

Deep Dissection

Exposure of the posterior tibia (e.g., for bone grafting) can be accomplished by dissecting posterior to the fibula and dissecting the deep posterior compartment (posterior tibialis) off the interosseous membrane to expose the tibia

Closure

Skin and subcutaneous tissues are closed in standard fashion

Medial Approach to the Leg (Fig. 7-45)

Indications

Compartment syndrome and fracture fixation

FIGURE 7-45 The medial approach to the lower leg. A, Incision. B, Fascial incision.C, Deep dissection.

FIGURE 7-45 The medial approach to the lower leg. A, Incision. B, Fascial incision.C, Deep dissection.

Positioning

Supine with use of a bump

Padding of prominent structures is important

Incision

A 10- to 15-cm longitudinal incision is made directly medially, just posterior to the tibia

For exertional compartment syndrome, smaller incisions may be made

Superficial Dissection

Incise the fascia

Deep Dissection

Expose the posterior tibia

Closure

Skin and subcutaneous tissues are closed in standard fashion

Knee Arthroscopy

Indications

Meniscal surgery, cruciate ligament repair or reconstruction, loose body removal, patellar procedures, and articular cartilage procedures

Positioning (Fig. 7-46)

Supine with use of a leg holder or lateral post

FIGURE 7-46 Positioning for knee arthroscopy.

Portals (Figs. 7-47 through 7-50)

Inferolateral

Location: just lateral to the patellar tendon and just above the joint line

Use: primary viewing portal

FIGURE 7-47 Portals for knee arthroscopy.

FIGURE 7-48 Arthroscopic visualization. ACL, Anterior cruciate ligament; PCL, posterior cruciate ligament.

FIGURE 7-49 The proximal portal. A, Establishing the portal. B, The view from the proximal portal.

FIGURE 7-50 Posterior portals. A, The posteromedial portal. B, The view from the posteromedial portal.C, The posterolateral portal. D, The view from the posterolateral portal.

FIGURE 7-50 Posterior portals. A, The posteromedial portal. B, The view from the posteromedial portal.C, The posterolateral portal. D, The view from the posterolateral portal.

Inferomedial

Location: just medial to the patellar tendon and just above the joint line

• Some surgeons localize this portal from outside-in with a spinal needle before establishing the portal

Use: primary instrument portal

• Also can be used for visualization based on access

Proximal Portals

Location: superior to the patella, either lateral or medial

Use: optional use for inflow/outflow

• Also can be used for visualization of patellar tracking

Posteromedial Portal

Location: just above the joint line, posterior to the joint

• Typically located with a spinal needle while viewing the posteromedial aspect of the knee through a Gillquist or modified Gillquist portal (a cannula is introduced into the back of the knee along the inferolateral aspect of the medial femoral condyle)

• Care must be taken to avoid injuring the saphenous vein or nerve while establishing this portal

Use: posterior horn medial meniscus visualization, loose body removal, synovectomy, PCL ganglion cyst, pigmented villonodular synovitis debridement, and PCL transtibial tunnel preparation

Posterolateral Portal

Location: just above the joint line, posterior to the joint

• Typically located with a spinal needle while viewing the posterolateral aspect of the knee through the notch (a cannula is introduced into the back of the knee along the inferomedial aspect of the lateral femoral condyle)

• Care must be taken to avoid injuring the peroneal nerve or LCL while establishing this portal; the portal must be anterior to the biceps tendon

Use: posterior horn lateral meniscus visualization, loose body removal, synovectomy, and PCL ganglion cyst excision

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