Approaches to distal femur.

Lateral Approach Patient in supine with sandbag under the knee Incision along a line extending from centre of trochanter & lateral femoral epicondyle Fascia lata is split along direction of incision Underlying Vastus lateralis is split, coagulating the various bleeders.

Posterolateral Approach Most commonly used Incision extending form lateral epicondyle proximally along posterior border of shaft IT band is split Vastus lateralis is raised of the lateral intermuscular septum, cauterising the perforating bleeders.

The approach can be extended distally to a lateral parapatellar arthrotomy to expose intrarticular part.

Proximal dissection is difficult as the bulky VL muscle arises partly from the lateral intermuscular septum Bleeding can be uncontrolled if the perforators are not carefully ligated. They may retract beyond the exposed field. Superior geniculate artrey also crosses the lateral femoral condyle.

Anterolateral Approach This approach develops the interval between the vastus lateralis & rectus femoris Deep exposure is by splitting the Vastus intermedius. Quadriceps contracture could be a complication.

Swashbuckler approach Described by Adam J Starr of Texas Scar does not hinder future TKR Does not produce adhesions in Quadriceps mechanism

Anteromedial Approach This approach is used to expose medial condyle fracture The dissection is in between the vastus medialis & rectus femoris Care is taken to detach the vastus medialis along with a cuff of tendinous tissue to aid later repair.

The medial superior genicular artery must be ligated Extension inferiorly as medial parapatellar arthrotomy aids intra articular exposure Proximally extension is limited by the crossing of femoral artery .

Medial approach This appraoch is used to fix medial condyle fractures, medial hoffa fragments And medial plating of distal femur. Incision extends proximally from adductor tubercle. The adductor magnus tendon is identified as it inserts to adductor tubercle The vastus medialis is lifted off the adductor longus & femur.

Two structures at risk are the femoral artery & Saphenous nerve. Both cross the field from anterior to posterior. The femoral artery passes through the adductor tendon at about 13 cm(one hand breadth) from the knee joint line.