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Journal of the Anatomical Society of India

Surgical Incisions - Their Anatomical Basis Part III - Lower Limb

Author(s): 1Patnaik, V.V.G., 2Singla, Rajan, K., 3 Gupta, P.N.

Vol. 50, No. 1 (2001-01 - 2001-06)

Department of Anatomy, Government Medical College, Patiala1, Amritsar2, Department of Orthopedics Government Medical College, Chandigarh3. India

For Reprints, request the first author.

Abstract

The present paper is a continuation of the previous one by the same authors in the last issue. Here, we have made anattempt to delineate various incisions for exposing different bones & joints of lower limb along with important anatomical landmarks to betaken care while designing & executing these.

Key words : Surgical Incisions, Hip, Knee, Ankle, Femur, Tibia, Calcaneus, Toes.

Introduction :

Numerous new approaches to the different regions of lower limb have been described during the past few years, most of which are based on older approaches & are modified for a specific surgical procedure. We will discuss the anatomical basis of the most widely used approaches. Various approaches in lower limb can be classified according to the site as follows :

(A) Approaches to Hip Joint

  1. Anterior approaches :
    1. Smith Peterson approach.
      -Schaubel Modification.
    2. Somerville Bikni Incision.
  2. Antero lateral approach (Smith Peterson, Cave & Van Gorder)
  3. Lateral Approaches :
    1. Watson Jones approach.
    2. Harris approach.
    3. Mc Farland & Osborne approach.
    4. Hardinge approach.
    5. Mc Lauchlan approach.
  4. Postero Lateral Approaches :
    1. Gibson approach.
    2. Marcy & Fletcher Modification.
  5. Posterior Approaches :
    1. Osborne Incision
    2. Moore Incision
  6. Medial Approach (Ludloff) :
  7. Antero Medial Approach (Zanepen & Gamidov) :
  8. Anterior Approaches

1. Smith Peterson : It is also known as Anterior ilio femoral approach. Here, the incision is begun at the middle of the iliac crest & carried anteriorly to the anterior superior iliac spine & then distally & slightly laterally for 10-12 cm. (Fig 1a) .

Attachments of gluteus medius & tensor fascia lata muscle are freed from iliac crest. Dissection is carried between tensor fascia lata laterally & sartorius & rectus femoris medially. Ascending branch of lateral circumflex femoral artery lies 5 cm distal to hip joint which is clamped & ligated. Lateral cutaneous nerve of thigh passes over sartorius 2.5 cm. distal to anterior superior iliac spine; it has to be retracted medially. This exposes the capsule of hip joint which can be incised along its attachment to acetabulum after cutting the origin of rectus femoris.

Schaubel Modification (1980) : Schaubel found reattachment of fascia lata to the fascia on iliac crest difficult so instead of dividing the fascia lata at iliac crest, he performed an osteotomy of iliac crest between attachments of external oblique muscle medially & fascia lata laterally. Tensor fascia lata, gluteus medius & gluteus minimus attachments were subperiostealy dissected distally to expose hip joint capsule.

2. Somerville 'Bikni' Incision : Somerville (1953) described an anterior approach using a transverse 'bikni' incision for irreducible congenital dislocation of hip joint in a young child.

A straight skin incision is made beginning anteriorly, medial & inferior to anterior superior iliac spine& coursing obliquely superiorly & posteriorly to middle of iliac crest. (Fig 1b). The abductor muscles are reflected subperiosteally from iliac bone distally to capsule of hip joint. Tensor fascia lata is separated from sartorius for about 2.5 cm inferior to anterior superior iliac spine. Reflected head of rectus femoris is separated from acetabulum & capsule. For a wide exposure its straight head may also be divided & reflected distally.

(ii) Antero lateral approach : It is used for open reduction & internal fixation of fracture femoral neck. It retains the advantage of anterior ilio femoral approach but exposes the trochanteric region laterally. Since the superior retinacular vessels which are major source of supply to the head of femur do not come in the way the chances of avascular necrosis of head of femur are less.

Missing Image

Fig. 1. Approaches to Hip Joint (a) Smith Peterson approach. (b) Somerville Bikni Incision. (c) Watson Jones lateral approach. (d) Harris technique (e) Mc Farland Osborne technique. (f) Hardinge Modification (g) Mc Lauchlan Incision (h) Gibson's Postero Lateral approach. (i) Osborne's posterior approach (j) Moore's Southern approach (k) Ludloff's Medial approach.

The incision is made along anterior third of iliac crest & then along anterior border of tensor fascia lata, curving posteriorly across the insertion of this muscle into iliotibial tract in the subtrochanteric region (usually 8 to 10 cm below the base of greater trochanter) & end there. Lateral cutaneous nerve of thigh is saved & retracted medially as in anterior ilio femoral approach. Abductor muscles are reflected as in Somerville Incision above & capsule is exposed.

(iii) Lateral Approaches :

  1. Watson Jones Technique (1935) : This is the most commonly used approach among the lateral approaches. The incision is begun 2.5 cm distal & lateral to the anterior superior iliac spine & curved distally & posteriorly over the lateral aspect of greater trochanter & lateral surface of femoral shaft to a point 5 cm distal to the base of trochanter (Fig. 1c). The interval between Gluteus medius & tensor fascia lata is often difficult to delineate. However, Brackett (1912) pointed out that it can be done more easily by beginning the separation midway between anterior superior iliac spine & greater trochanter before tensor fascia lata blends with its fascial insertion. The capsule can be approached through this interval. This approach is used commonly for open reduction of fracture neck of femur & for joint replacement surgery.
  2. Harris Technique : Harris (1973) recommended this approach for an extensive exposure of hip. In this, a U shaped incision is made with its base at posterior border of greater trochanter. It is begun 5 cm posterior & slightly proximal to anterior superior iliac spine, curved distally & posteriorly to posterior superior corner of greater trochanter & then extended longitudinally for 8 cm. Finally it is curved anteriorly & distally making 2 limbs of U symmetrical (Fig. 1d). The approach permits dislocation of femoral head both anteriorly & posteriorly but requires an osteotomy of the greater trochanter with the resulting risk of non union or trochanteric bursitics. Also, as reported by Testa & Mazus (1988), incidence of significant or disabling hetrotropic ossification is increased by this method.
  3. Mc Farland Osborne Technique (1954) : In this, a midlateral skin incision is made centred over the greater trochanter, its length depending upon amount of sub cutaneous fat (Fig. 1e) Gluteal fascia & iliotibial tract are divided in line with skin incision. This technique considers the gluteus medius & vastus lateralis muscles to be in direct functional continuity through thick periosteum covering greater trochanter.
  4. Hardinge Modification (1982) : This is a modification of Mc Farland & Osborne (1954) technique based on the observation that gluteus medius inserts on the greater trochanter by a strong, mobile tendon that curves around the apex of trochanter. In this a posteriorly directed lazy 'J' incision is made centred over the greater trochanter (Fig. 1f). Fascia lata is incised in line with skin incision. Tensor fascia lata is retracted anteriorly & gluteus maximus posteriorly to expose origin of vastus lateralis & insertion of gluteus medius. These are partially divided to reach the anterior aspect of capsule which can be incised as desired. This approach is used for hip replacement surgery.
  5. Mc Lauchlan Incision (1984) : It is a lateral longitudinal skin incision centered midway between anterior & posterior borders of greater trchanter & extending an equal distance proximal & distal to the tip of greater trochanter (Fig. 1g). Tensor fascia lata is incised in line with skin incision & greater trochanter is exposed with gluteus medius attached proximally & vastus lateralis attached distally. The muscles are split in line of their fibres & greater trochanter is cut in form of 2 rectangular slices (with osteotome) having gluteus medius attached proximally & vastus lateralis attached distally on both of these. One is retracted anteriorly & one posteriorly to expose hip joint.

(iv) Postero lateral approach (Gibson, 1953) :

In this, the proximal limb of incision is begun at a point 6-8 cm anterior to posterior superior iliac spine & just distal to iliac crest overlying the anterior border of gluteus maximus muscle. It is extended distally to aniterior border of greater trochanter & further distally in line of femur for 15-18 cm. (Fig. 1h) Iliotibial tract is incised in line with direction of its fibres. Next, gluteus minimus et medius are divided at their insertion to expose the capsule.

(v) Posterior approaches

In posterior approaches to the hip the joint is exposed by cutting the posterior aspect of capsule. These approaches are commonly used for hip replacement surgery but less popular for open reduction & internal fixation of fracture neck of the femur as the superior retinacular vessels & the ascending branch of medial circumflex femoral artery is in jeopardy thereby leading to avascular necrosis of the head of femur.

1. Osborne approach (1931) : The incision is begun 4-5 cm distal & lateral to posterior superior iliac spine & continued laterally & distally remaining parallel to fibres of gluteus maximus to posterior superior angle of greater trochanter & then distally along posterior border of greater trochanter for 5 cm (Fig 1i). Gluteus maximus fibres are separated parallel to skin incision. Since branches of superior gluteal artery are in proximal half of the muscle & those of inferior gluteal artery are in distal half of muscle so little bleeding occurs. Insertion of gluteus maximus to fascia lata is divided for 5 cm corresponding to long limb of incision. Piriformis & gamelli are detached near their insertion & retracted medially. These protect the sciatic nerve & the capsule is now exposed.

2. Moore's approach (1959) : It is also known as "Southern Exposure". The incision is started 10 cm distal to posterior superior iliac spine & extended distally & laterally parallel to fibres of gluteus maximus to posterior margin of greater trochanter. Then it is directed distally for 10-12 cm parallel to femoral shaft (Fig. 1j). Rest of exposure is almost same as in osborne's technique.

(vi) Medial Approach : (Ludloff, 1908) It was developed to permit surgery on a congenitally dislocated hip. The incision is placed on medial aspect of thigh beginning 2.5 cm distal to pubic tubercle & over the interval between gracilis & adductor longus muscle. (Fig 1k). A plane is developed between adductor longus et brevis anteriorly & gracilis & adductor magnus posteriorly. Posterior branch of obturator nerve & neurovascular bundle to gracilis is exposed & protected. Capsule is located in the floor of wound.

(vii) Antero Medial Approach : (Zazepan & Gamidov, 1972) In this, a longitudinal incision is made 15-20 cm long, 2-3 cm medial to femoral artery & 2 cm distal to inguinal ligament. Pectineus & adductor longus are exposed. Next external pudendal & medial circumflex femoral vessels are identified & retracted laterally. Muscles are separated by sharp dissection & lesser trochanter is exposed. Iliopsoas tendon is freed & capsule is exposed.

(B) Approaches to Femur :

(i) Antero Lateral Approach : The skin incision is placed over the middle third of femur in a line between anterior superior spine & lateral margin of patella (Fig. 2a) Dissection is carried in the interval between rectus femoris & vastus lateralis. Vastus intermedius is divided in line with its fibres & femur is exposed.

This approach is suitable for only middle third of femur. In proximal third, injury to lateral circumflex femoral artery & nerve to vastus lateralis can occur, while in distal third supra patellar pouch is encountered which if cut can lead to knee stiffness by formation of adhesions.

(ii) Lateral Approach : The skin incision of desired length is made over the lateral aspect of thigh along a line from greater trochanter to the lateral femoral condyle (Fig. 2b) Vastus lateralis et intermedius are divided in line with direction of fibres to expose the shaft. A branch of lateral circumflex femoral artery is encountered when exposing proximal fourth of femur & superior lateral genicular artery in distal fourth. These can cause troublesome bleeding so should be isolated & ligated. With this method, though entire femoral shaft can be exposed but it can lead to scarring of vastus lateralis to prevent which postero lateral approach is used where the muscle is erased from its origin on the linea aspra.

(iii) Postero Lateral Approach : Here incision is made from base of greater trochanter to lateral condyle (Fig. 2c). Dissection is carried out posterior to vastus lateralis to reach linea aspra. There, this muscle along with vastus intermedius can be erased subperiosteally. In middle third of thigh, 2nd perforating branch of profunda femoris artery has to be ligated & divided. Damage to sciatic nerve & profunda femoris vessel can be prevented by not separating long & short heads of biceps.

(iv) Posterior Approach : This approach is rarely used. The skin is incised longitudinally in the middle of posterior aspect of thigh from just distal to gluteal fold to proximal margin of popliteal fossa. (Fig 2d). Dissection is carried out along lateral border of lateral head of biceps, in proximal part retracting it medially, while in distal part, dissection is done between this head & semitendinosis, retracting lateral head of biceps along with schiatic nerve laterally. A branch of sciatic nerve, supplying to short head of biceps may be saved or divided, depending upon requirement of incision, because it doesn't compose the entire nerve supply of this part of muscle.

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(Fig. 2.Approaches to Femur. (a) Antero lateral (b) Lateral (c) Postero lateral (d) Posterior (e) & (f) Lateral & Medial approaches to posterior surface of lower third of femur (g) Lateral approach to proximal shaft & trochanteric region.)

The approach may damage the sciatic nerve because of rough handling & prolonged or strenous retraction causing disturbing symptoms after surgery or even a permanent disability in the leg so this approach is rarely used.

(v) Lateral approach to posterior surface of lower 1/3rd of femur : (Henry 1927) With knee slightly flexed, the incision is made for 15 cm along posterior margin of iliotibial tract following the angle of knee to the head of fibula (Fig. 2e) Popliteal fossa is reached between posterior border of iliotibial tract & short head of biceps. Branches of perforating vessels are ligated & divided, while popliteal vessels & tibial nerve are retracted posteriorly to expose posterior surface of femur.

(vi) Medial approach to posterior surface of lower 1/3rd of femur : (Henry 1927) With the knee slightly flexed, the incision is begun 15 cm proximal to adductor tubercle & continued distally along adductor tendon following the angle of knee to 5 cm distal to tubercle (Fig 2f) Dissection is carried posterior to sartorius and avoiding damage to synovial membrane, saphenous nerve lying posterior to sartorius & adductor tendon, retracting large vessels & nerves posteriorly ligating & dividing small vessels. Tabial & lateral peroneal nerve lie latero posterior so are not encountered.

(vii) Lateral approach to proximal shaft & trochanteric region : This is the excellent approach for reduction & internal fixation of trochanteric fractures or for subtrochanteric osteotomy. The skin incision is placed 5 cm proximal & anterior to greater trochanter & curved distally & posteriorly over postero lateral aspect of trochanter & then distally over lateral surface of thigh parllel to femur for 10cm. (Fig. 2g) Fascia lata is divided longitudinally posterior to tensor fascia lata to avoid splitting this muscls. Vastus lateralis thus exposed can be erased subperiosteally from its origin or divided. Care should be exercised to ligate & cut perforating arteries before these retract beyond linea aspra.

(C) Approaches to Knee Joint :

(i) Antero Medial Approach : It was Ist described by Langhen beck (1874). The incision is begun at medial border of quadriceps tendon 7–10 cm proximal to patella, curved around the medial border of patella back towards midline to end it at or distal to tibial tuberosity (Fig. 3a). Deep dissection is carried out between vastus medialis & medial border of quadriceps tendon to reach the capsule.

Abbot & Carpentor (1945) pointed out that wide access to joint can be attained in following ways : (a) Extending incision proximally (b) Extending proximal past of incision obliquely medially (c) Dividing medial alar fold longitudinally (d) mobilising medial part of insertion of patellar tendon subperiosteally.

If contracture of quadriceps prevents sufficient exposure, the tibial tuberosity may be detached & reattached later with a screw (Fernandes, 1988).

During any of anterior medial approaches, infra patellar branch of saphenous nerve should be protected. Saphenous nerve courses posterior to sartorius, pierces fascia lata between this muscle & gracilis to become subcutaneus. It gives a large infra patellar branch to supply, skin over anterior medial aspect of knee. Kummel & Zazanis (1974) & Chambers (1972) noted several variations in its location & distribution so no single incision can avoid it for certain. So blunt dissection is adviced between skin & joint capsule to locate & save its branches. Chambers (1972) reported several incidences of unsuccessful surgeries on knee because of neuromas in scar.

(ii) Antero lateral approach (Kochar, 1911) : Usually this approach is not as satisfactory as antero medial because (i) it is more difficult to displace patella medially than laterally (ii) it requires a longer incision (iii) often pateller tendon must be partly freed subperiosteally.

Incision is begun 7.5 cm proximal to patella at insertion of vastus lateralis into quadriceps tendon, continuing distally along lateral border of this tendon, patella & patellar tendon to end 2.5 cm distal to tibial tuberosity. (Fig. 3b)

(iii) Postero lateral approach : (Henderson 1921) : With the knee flexed at 90°, a curved incision is made on lateral side of knee just anterior to biceps femoris tendon & head of fibula (Fig. 3c) thus avoiding common peroneal nerve passing over lateral aspect of neck of fibula. The popliteus tendon lies in between biceps tendon & fibular collateral ligament. It is retracted posteriorly to expose postero lateral aspect of joint capsule.

(iv) Postero Medial approach : With knee flexed 90°, a curved incision is made, slightly convex anteriorly & approximately 7.5 cm long along the course of tibial collateral ligament anterior to relaxed tendons of semimembranosus, semitendinosus, gracills & sartorius (Fig. (3d) oblique part of tibial collateral ligament is incised to expose the capsule.

(v) Medial approach (Hoppen field & Deboer, 1984) : Incision is begun 2 cm proximal to adductor tubercle of femur, curved antero inferiorly about 3cm medial to medial border of patella & ended 6 cm distal to joint line on anterior medial aspect of tibia. (Fig. (3e)) Saphenous nerve & its infra patellar branch are saved. Next 3 muscles of pes anserinus are retracted posteriorly & tibial collateral ligament is exposed. Joint may be opened anterior or posterior to it depending upon the need.

(vi) Lateral approach : Lateral approaches permit good exposure for complete excision of lateral meniscus. These don't require division or release of fibular collateral ligament.

(a) Bruser Technique - (1960) : Knee is flexed fully so that foot rests on table. The incision is begun anteriorly where patellar tendon crosses the lateral joint line, continued posteriorly along joint line ended at an imaginary line extending from proximal end of fibula to lateral femoral condyle (Fig. 3f) Next iliotabial tract is splitted in line of its fibres. Fibular collateral ligament is relaxed & lying posteriorly. Joint capsule is reached anterior to it.

(b) Brown et al (1975) Modification : It is done for lateral menisectomy where in addition to Bruser approach a varus strain in created to open the lateral joint space.

(c) Pogrund technique (1976) : The skin incision is begun near infero lateral aspect of patella & curved gently distally & posteriorly for 4-5cm. Capsule is exposed anterior to iliotibial tract.

(d) Hoppen field & Deboer technique (1984) : Incision is begun 3 cm. lateral to middle of patella, extended distally over Gardy's tubercle on tibia to end it 4-5 cm distal to joint line. Incision is completed proximally by curving it along the line of femur. (Fig. (3g) Further dissection is done between iliotibial tract anteriorly & biceps tendon with common peroneal nerve posteriorly to expose fibular collateral ligament.

(vii) Anterior approaches : (a) Split Patellar approach (Insall, 1984) : In this a lateral parapatellar skin incision is made. Next quadriceps tenden is split in its middle begining 8 cm proximal to patella extending distally over middle of patella through patellar tendon to tibial tuberosity. Longitudinal fibres of extensor mechanism are carefully separated from medial 1/2 of patella. Patella is dislocated laterally, & medial 1/ 2 of qudriceps tendon retracted medially to expose anterior surface of joint capsule.

(b) Extensile anterior approach (Fernands (1988) : A lateral parapatellar incision is begun 10 cm proximal to lateral joint line continued distally along lateral border of patella, pateller tendon & tibial tuberosity to end it 15 cm distal to lateral joint line. (Fig. 3h).This approach allows easy access to both medial & lateral condyles by : (i) Extensive osteotomy of tibial tuberosity allowing proximal reflection of patella & patellar tendon. (ii) transecting anterior horn & anterior portion of coronary ligament of medial or lateral meniscus or both as required.

(viii) Posterior approaches : These involve the structures, those if damaged produce a proximal serious disability so a thorough knowledge of anatomy of popliteal space is mendatory. (Putti, 1974; Abbot & Carpenter, 1945)

  1. Brackelt & Osgood (1911) technique : In this a curvilinear incision, 10-15 cm long is centered over popliteal space. Its proximal limb follows tendon of semi tendinosus distally to level of joint, it is then curved laterally across posterior aspect of joint for 5 cm & then distally over lateral head of gastrocnemius (Fig. 3i) Posterior nerve of calf is identified in popliteal fossa Ist of all which is a guide to further dissection. Lateral to it the short saphenous vein pierces deep fascia to drain into popliteal vein. Nerve is traced proximally to its origin from tibial nerve which further helps rests of dissection as popliteal artery & vein lie deep to it. Later are retracted gentally to approach posterior surface of knee joint.
  2. Minkoff et al (1987) technique : Skin incision is begun 1-2cm below the popliteal crease slightly medial to midline of knee. It is carried transversally & then curving distally just medial & parallel to head of fibula, ending 5-6cm distal to it (Fig 3j). Lateral cutaneus nerve of calf, sural nerve & common peroneal nerve are to be saved in this dissection. This approach gives a good exposure of posterior aspect of lateral tibial plateau & proximal tibiofibular joint.

(ix) Extensile approach to knee : (McConnel, 1976 Technique) McConnell described an extensile approach to the knee that allows access to the anterior, posterior, medial and lateral sides of the knee through a single incision. In addition to excellent exposure, it leaves an unobrusive scar. The incision has the anterier cosmesis of a typical tansverse incision; it is hidden by the skin creases and is less prone to hypertrophy than a longitudinal incision. The medial extension is partially hidden by the contralateral extremity and the lateral extension is less noticeable because it lies in the skin depression along the posterior border of the iliotibial band.

With the knee in acute flexion, the transverse anterior part of incision is made between 3 points- i.e. medial flexion crease, lower pole of patella & lateral flexion crease (Fig. 3k) Its lateral extension is made proximally along posterior margin of iliotibial tract while medial is made postero medially in a distal direction from apex of medial flexion crease for 9-10 cm. (Fig 31 & m respectively)

(x) Exposure of Medial Meniscus :

(i) Transverse approach : The advantage of this approach is that (a) scar has no contact with femoral articular surface. (b) Convalescense is more rapid after menisectomy through this than through other incisions (Charmley 1948). A 5 cm long transverse incision is made at the level of articular surface of tibia extending laterally from medial border of patellar tendon to anterior border of tibial collateral ligament. Capsule is incised along the same line to reach the meniscus.

(ii) Cave's approach : If posterior horn of medial meniscus can't be excised by transverse approach, then this approach is useful as it allows exposure of both anterior & posterior ends. With knee flexed to right angle, the incision is begun 1 cm posterior to & at level with medial femoral epicondyle. i.e. approximately 1 cm proximal to joint line. It is carried distally anterior to a point 0.5 cm distal to joint line & then anteriorly to border of patellar tendon (Fig 3n)

D. Exposure of Tibia :

(i) Anterior approach : The tibia is a superficial bone and can be easily exposed anteriorly without damaging any important structure except the tendons of the tibialis anterior and extensor hallucis longus muscles, which cross the tibia anteriorly in its lower one fourth.

A curved incision is made on either side of anterior border of bone. Periosteum is stripped as little as possible because its circulation is a source of nutrition for the bone.

(ii) Medial approach : It is used for inserting a bone graft in delayed union or non union. Here a longitudinal incision is made along postero medial border of the tibia. Periosteum is reflected from posterior surface (Phemister, 1947).

(iii) Postero lateral approach : This approach is valuable in exposure of middle 2/3rd of tibia when anterior & antero medial aspects are badly scarred. The incision is placed along lateral border of gastrocnemius on the postero lateral aspect of ligament. A plane is developed between gastrocnemius, soleus & flexor hallucis longus posteriorly & peronei anteriorly. The approach provides a complete exposure of flat posterior surface of tibia except its proximal fourth which lies in close relation to popliteus muscle, proximal parts of posterior tibial vessels & nerve. (Harmon, 1945).

(iv) Posterior approach to superomedial region : (Bank & Laufman, 1953) With patient prone, the transverse segment of hockey stick incision is begun at lateral end of flexion crease of knee & extended across the popliteal space. Then it is turned distal wards along medial side of calf for 710 cm (Fig 4) Deep fascia is incised in the line with skin incision. Upper 1/4th of posterior surface of tibia can be exposed by this incision.

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Fig. 4.Posterior approach to superomedial region of Tibia.

E. Exposure of Fibula :

It can be exposed by a postero lateral approach devised by Henry (1927). The incision is begun 13 cm proximal to lateral malleolus & then carried proximally along posterior border of fibula to posterior margin of its head & then further proximally for 10 cm along posterior border of biceps femoris, Common peroneal nerve has to be isolated & saved in the proximal part of the incision near the upper end.

F. Approaches to Ankle joint & tarsus :

(i) Anterolateral approach : gives excellent access to the ankle joint, the talus, and most other tarsal bones and joints, and it avoids all important vessels and nerves, since so many reconstructive operations and other procedures involve the structures exposed, it may well be called the "universal incision" for the foot and ankle. It permits excision of the entire talus. The only tarsal joints that it cannot reach are those between the navicular and the second and first cuneiforms.

The incision is begun over antero lateral aspect of ankle medial to fibula & 5 cm proximal to ankle joint. It is carried distally over the joint, antero lateral aspect of body of talus & calceneo cuboid joint; to end at base of 4th metatarsal bone. Superior & Inferior extensor retinaculae are incised down to the periosteum of tibia, & capsule of ankle joint. The dissection usually divides antero lateral malleolar & lateral tarsal arteries while superficial & deep peroneal nerves are saved.

(ii) Anterior approach : It is considered better than antero lateral approach if both malleoli are to be exposed. Usually the approach is developed between extensor hallucis longus & extensor digitorum longus but Nicola (1945) advises developing it between tabialis anterior & extensor hallucis longus.

The incision is begun on anterior aspect of leg 7.4-10 cm proximal to ankle joint & extended distally to about 5 cm distal to joint. Periosteum, capsule &synovium are incised in line with skin incision.

(iii) Kocher Approach (1911) : It gives excellent exposure of midtarsal, subtalar & ankle joints. From a point just lateral and distal to the head of the talus, curve the incision 2.5 cm inferior to the tip of the lateral malleolus, then posteriorly and proximally, and end it 2.5 cm posterior to the fibula and 5cm proximal to the tip of the lateral malleolus. (Fig. 5a)

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The disadvantage of this procedure is that the skin may slough about the margins of the incision, especially if dislocation of the ankle has been necessary, as in a talectomy. Further, the peroneal tendons must usually be divided.

(iv) Ollier Approach (1892) : This is excellent for triple orthodesis. The skin incision is begun over dorso lateral aspect of talo-navicular joint, extending it obliquely infero posteriorly & ending 2.5 cm below lateral malleolus. (Fig 5b) Inferior extensor retinaculum is divided in line with skin incision & dissection is extended to expose subtalar, calcaneo cuboid & talonavicular joints.

(v) Postero lateral approach : (Gatellier & Chastang, 1924) Incision is begun 12 cm proximal to tip of lateral malleolus extending distally along posterior margin of fibula to tip of malleolus. Then it is curved anteriorly for 2.5 cm in line of peroneal tendons. (Fig. 5c). Peroneal retinaculae are incised to displace the tendons anteriorly. Lateral aspect of the joint is exposed dividing the fibula 10 cm proximal to tip of lateral malleolus. Great care should be used in children to avoid creating a fracture through distal fibular epiphysis, when reflecting fibula.

(vi) Posterior approach : With patient prone a 12 cm incision is made along postero lateral border of tendo achillis down to its insertion on calcaneus. The tendon is lengthened by Z plasty or retracted to expose the ankle joint from posterior aspect.

(vii) Medial approach : It was given by Koening & Schaefer (1929) but not a popular method because despite utmost care it is possible to injure tibial vessels & nerve. The other unimportant approaches are those by Broomhead (1932) & Colonna & Ralston (1951). For details of these, the readers are advised to consult original articles.

G. Approaches to Calcaneus :

(i) Medial approach : Incision is begun 2.5 cm anterior & 4cm inferior to medial malleolus. It is carried posteriorly along medial surface of foot to tendo calcaneus. Abductor hallucis is retracted dorsal wards to reach medial & inferomedial aspects of calcaneus. Its inferior surface can be exposed sub periosteally avoiding medial calcaneal nerve & nerve to abductor digiti minimi.

(ii) Lateral Approach : Incision is begun on lateral margin of tendo calcaneus near its insertion & passed distally to a point 4 cm inferior & 2.5 cm anterior to lateral malleolus. Peroneal tendons may be divided by Z plasty if needed.

(iii) U approach: This is used to access the entire planter surface of calcaneus. With patient prone, the 2 approaches described above are joined to form a large U shaped incision around the posterior four fifth of the bone. (Fig. 6a).

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(iv) Split heel approach is seldom used except for osteomyelitis of calcaneus. In this, a midline incision is given on plantar surface of heel. Its advantage is that the scar retracts inside so there is no problem in weight bearing.

(v) Kocher approach (Curved L) : It is suitable for complete excision of calcaneus. The skin is incised over medial border of tendo calcaneus from a point 7.5 cm proximal to calcaneal tuberosity to its postero inferior aspect. Then the incision is continued transversely around the posterior aspect of calcaneus, then distally along lateral surface of the foot to tuberosity of 5th metatarsal. (Fig 6b)

H. Approaches for Toes.

(i) Interphalangeal joints: For interphalangeal joint of great toe, a 2.5 cm long incision is made on medial aspect of the toe & for interphalangeal joint of 5th toe, a similar incision is made on lateral aspect of 5th toe. The interphalangeal joints of other 3 toes can be approached through incisions made just lateral to corresponding extensor tendons. Care should be exercised to save dorsal or planter digital vessels & nerve. Capsule can be opened longitudinally or transversely.

(ii) Metatarsophalangeal Joints.

(a) M.P. joint of great toe can be approached in either of the 2 common ways.

Medial approach : A 5cm long curved incision is made on medial aspect of joint (Fig 7a). It is begun just proximal to proximal interphalangeal joint, curved over dorsum of metatarsophalangeal joint medial to extensor hallucis longus tendon ended on medial aspect of 1st metatarsus proximal to the joint. 1st dorsal metatarsal artery & branch of superficial peroneal nerve are retracted laterally as these supply medial side of great toe. This exposes the bunion over medial aspect of matatarsal head. Then a curved incision is made through bursa & capsule of joint. (Fig 7b) It is begun over the dorsomedial aspect of joint, continued proximally

Missing Image

Fig. 7. Medial Approach for great toe.

(a) Skin Incision (b) Line of Incision through bursa & capsule of Joint.

dorsal to the metatarsal head & then planter wards & distalwards around the joint & ended distally on medio planter aspect of matatarso phalangeal joint. The incision forms an elliptical, racquiet shaped flap attached to base of proximal phalanx. Although the distal reflection of flap exposes the 1st metatarso phalangeal joint, yet healing of the flap may be delayed so dorso medial approach is prefered.

Dorsomedial approach : The incision is begun just proximal to joint continued proximally for 5 cm parallel & medial to extensor hallucis longus tendon. Further dissection can be carried in plane of skin incision or as in medial approach.

(b) M. P. joint of 2nd to 5th toe : All these are reached by dorso lateral incisions parallel to the corresponding extensor tendons.

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J. Anat. Soc. India 50(1) 48-58 (2001)

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