Updated: 4/9/2019

Knee Medial Approach

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Introduction
  • Approach provides exposure to medial structures of the knee
  • Indications
    • repair of medial knee ligaments
    • medial meniscus repair or meniscectomy
    • ACL repair
    Positioning for the medial approach to the knee
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
  Incision
Preparation & Position
  • Anesthesia
    • general
    • sciatic or femoral nerve block
  • Position
    • supine with knee flexed 60°, hip abducted and externally rotated
  • Tourniquet
    • applied to thigh
  Superficial dissection
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
 

Deep dissection: anterior

Deep dissection: posterior

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
 

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