Introduction Approach provides exposure to medial structures of the knee Indications repair of medial knee ligaments medial meniscus repair or meniscectomy ACL repair Anatomy There are three anatomic layers to the medial knee layer 1 sartorius deep fascia Zone between layers 1 & 2 gracilis semitendinosus layer 2 semimembranosus superficial MCL posterior oblique ligament medial patellofemoral ligament layer 3 deep MCL capsule coronary ligament No internervous or intermuscular plane Preparation & Position Anesthesia general sciatic or femoral nerve block Position supine with knee flexed 60°, hip abducted and externally rotated Tourniquet applied to thigh Approach Incision landmark palpate adductor tubercle along medial aspect of knee make long, curved incision 2 cm proximal to the adductor tubercle start midline end 6 cm below the joint line with slight anterior curve Superficial dissection raise skin flaps exposing fascia extend to midline anteriorly and to posteromedial corner posteriorly sacrifice the infrapatellar branch of the saphenous nerve crosses the field transversely preserve the saphenous nerve itself emerges between sartorius and gracilis Deep dissection can either be exposed anterior or posterior to superficial medial collateral ligament anterior to the superficial medial collateral ligament provides access to anteromedial side of joint (superficial medial ligament, anterior aspect of medial meniscus, cruciate ligament) incise the fascia along the anterior border of sartorius flex the knee to allow sartorius to retract posteriorly knee flexion uncovers the semitendinosis and gracilis retract all three pes muscles posteriorly to expose the tibial insertion of the superficial medial ligament make a longitudinal medial parapatellar incision to access joint posterior to the superficial medial collateral ligament provides access to posteromedial side of joint (posterior aspect of the medial meniscus, posteromedial corner) incise the fascia along the anterior border of sartorius retract the sartorius posteriorly, together with semitendinosis and gracilis if the capsule is intact, expose the posteromedial corner of the joint by separating the medial head of gastrocnemius from semimembranosus separate the medial head of gastrocnemius from the posterior capsule Dangers Infrapatellar branch of the saphenous nerve crosses transversely across operative field usually sacrificed should be buried in fat to prevent neuroma Saphenous vein located between sartorius and gracilis Medial inferior genicular artery may be damaged as medial head of gastrocnemius is lifted off tibia Popliteal artery lies along midline posterior joint capsule adjacent to medial head of gastrocnemius