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Updated: Mar 26 2014

Femur Anteromedial Approach femur ap.jpg femur final ap.jpg
  • Indications
    • Open reduction and internal fixation (ORIF) of distal femur fractures 
      • particularly fractures with intra-articular extension that require a medial plate  
    • ORIF of femoral shaft fractures
      • limited to distal 2/3 of femur by the presence of the femoral neurovascular bundle
    • Treatment of chronic osteomyelitis
    • Biopsy and treatment of bone tumors of the femur
    • Quadricepsplasty

  • Internervous
    • no true internervous plane
  • Intermuscular
    • intermuscular plane between
      • rectus femoris (femoral nerve)  AND
      • vastus medialis (femoral nerve)  q
        • innervation is proximal allowing for safe exposure distally
  • Anesthesia
    • as dictated by the type of procedure 
    • most cases involving the anteromedial approach will require a general anesthetic
  • Position
    • supine on radiolucent table for fracture fixation
    • prepare and drape the affected extremity so that it can be moved freely
    • consider bump under contralateral hip to facilitate access to the medial femur
  • Tourniquet
    • elevate if needed for visualization
    • use sterile tourniquet so as not to limit proximal extension of draping or exposure
  • Incision
    • 10- to 15-cm longitudinal incision 
      • centered over the interval between rectus femoris and vastus medialis
      • vastus may be atrophied in patients with knee pathology making identification difficult
      • extend distally along medial aspect of patella if exposure of the knee joint is required
  • Superficial dissection
    • incise deep fascia
      • incise in line with skin incision
  • Deep dissection
    • open knee joint capsule
      • begin distally by opening the knee joint capsule via the medial retinaculum
    • split the quadriceps tendon proximally
      • leave a cuff of tendon attached to the vastus to allow for later repair
    • develop the interval between vastus medialis and rectus femoris
    • identify and split vastus intermedius proximally
      • split vastus intermedius in line to expose femur
    • incise the periosteum longitudinally and elevate as needed for exposure

  • Medial superior genicular artery
    • crosses field just above knee joint
  • Vastus medialis
    • distal fibers insert directly on medial border of patella
    • disrupted during exposure
    • meticulous closure to prevent lateral patella subluxation
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