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Introduction
  • Indications
    • exposure for lateral knee ligament repair or reconstruction
    • open lateral meniscal repair
 
Anatomy
  • There are three anatomic layers to the lateral knee
    • layer 1
      • ITB 
      • biceps 
      • fascia
    • layer 2
      • patellar retinaculum
      • patellofemoral ligament
    • layer 3
      • LCL
      • arcuate ligament
      • fabellofibular ligament
      • capsule
  • Internervous between
    • iliotibial band (ITB)  (superior gluteal nerve) anteriorly
    • biceps femoris tendon  (sciatic nerve) posteriorly

Preparation
  • Anesthesia
    • general
    • sciatic or femoral nerve block
  • Position
    • supine
      • can place bump under hip
  • Tourniquet
    • applied to thigh

Approach
  • Incision
    • landmarks
      • palpate lateral border of patella over lateral joint
      • palpate Gerdy's tubercle
        • marking insertion of IT band
    • knee should be flexed during approach
    •  make long, curved incision at lateral border of center of patella 
      • begin 3 cm lateral to edge of patella
      • end 4-5 cm distal to joint centered over Gerdy's tubercle
  • Superficial dissection
    • mobilize skin flaps widely
    • incise fascia between ITB and biceps femoris 
      • avoid common peroneal nerve on posterior border of biceps femoris
      • retract ITB anteriorly and biceps posteriorly 
        • exposes superficial lateral collateral ligament (LCL)
    • retract lateral head of gastrocnemius posteriorly
  • Deep dissection
    • can enter knee joint anterior or posterior to LCL
      • anterior arthrotomy 
        • exposes entire lateral meniscus
      • posterior arthrotomy
        • exposes posterior horn of lateral meniscus and posterolateral corner




Dangers
  • Common peroneal nerve
    • at risk on posterior border of biceps femoris
  • Popliteal artery
    • at risk posterior to posterior horn of lateral meniscus
  • Popliteus tendon 
    • runs within joint adjacent to lateral meniscus
    • attaches to posterior aspect of meniscus and femur
    • at risk if performing a posterior arthrotomy
  • Lateral superior genicular artery
    •  at risk between femur and vastus lateralis
  • Lateral inferior genicular artery
    • at risk between lateral head of gastrocnemius and posterolateral corner
    • should be ligated 
 

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