J Anat. Soc. India 50(1) 48-58 (2001)

Surgical Incisions — Their Anatomical Basis Part III - Lower Limb1Patnaik, V.V.G., 2Singla, Rajan, K., 3 Gupta, P.N.Department of Anatomy, Government Medical College, Patiala1, Amritsar2, Department of Orthopedics Government MedicalCollege, Chandigarh3. INDIA

For Reprints, request the first author.Abstract. The present paper is a continuation of the previous one by the same authors in the last issue. Here, we have made an

attempt to delineate various incisions for exposing different bones & joints of lower limb along with important anatomical landmarks to betaken care while designing & executing these.

Key words : Surgical Incisions, Hip, Knee, Ankle, Femur, Tibia, Calcaneus, Toes.

Introduction :Numerous new approaches to the different

regions of lower limb have been described duringthe past few years, most of which are based onolder approaches & are modified for a specificsurgical procedure. We will discuss the anatomicalbasis of the most widely used approaches. Variousapproaches in lower limb can be classifiedaccording to the site as follows :(A) Approaches to Hip Joint :(i) Anterior approaches :

1. Smith Peterson approach.- Schaubel Modification.

2. Somerville Bikni Incision.(ii) Antero lateral approach (Smith Peterson,

Cave & Van Gorder)(iii) Lateral Approaches :

1. Watson Jones approach.2. Harris approach.3. Mc Farland & Osborne approach.4. Hardinge approach.5. Mc Lauchlan approach.

(iv) Postero Lateral Approaches :1. Gibson approach.2. Marcy & Fletcher Modification.

(v) Posterior Approaches :1. Osborne Incision2. Moore Incision

(vi) Medial Approach (Ludloff) :(vii) Antero Medial Approach (Zanepen &

Gamidov) :(i) Anterior Approaches

1. Smith Peterson :—It is also known asAnterior ilio femoral approach. Here, the incision isbegun at the middle of the iliac crest & carriedanteriorly to the anterior superior iliac spine & thendistally & slightly laterally for 10-12 cm. (Fig 1a) .

Attachments of gluteus medius & tensor fascia latamuscle are freed from iliac crest. Dissection iscarried between tensor fascia lata laterally &sartorius & rectus femoris medially. Ascendingbranch of lateral circumflex femoral artery lies 5 cmdistal to hip joint which is clamped & ligated. Lateralcutaneous nerve of thigh passes over sartorius 2.5cm. distal to anterior superior iliac spine; it has to beretracted medially. This exposes the capsule of hipjoint which can be incised along its attachment toacetabulum after cutting the origin of rectus femoris.

Schaubel Modification (1980) : Schaubel foundreattachment of fascia lata to the fascia on iliaccrest difficult so instead of dividing the fascia lata atiliac crest, he performed an osteotomy of iliac crestbetween attachments of external oblique musclemedially & fascia lata laterally. Tensor fascia lata,gluteus medius & gluteus minimus attachmentswere subperiostealy dissected distally to expose hipjoint capsule.

2. Somerville ‘Bikni’ Incision :—Somerville(1953) described an anterior approach using atransverse ‘bikni’ incision for irreducible congenitaldislocation of hip joint in a young child.

A straight skin incision is made beginninganteriorly, medial & inferior to anterior superior iliacspine& coursing obliquely superiorly & posteriorly tomiddle of iliac crest. (Fig 1b). The abductor musclesare reflected subperiosteally from iliac bone distallyto capsule of hip joint. Tensor fascia lata isseparated from sartorius for about 2.5 cm inferior toanterior superior iliac spine. Reflected head ofrectus femoris is separated from acetabulum &capsule. For a wide exposure its straight head mayalso be divided & reflected distally.

(ii) Antero lateral approach :—It is used foropen reduction & internal fixation of fracture femoralneck. It retains the advantage of anterior ilio femoralapproach but exposes the trochanteric regionlaterally. Since the superior retinacular vesselswhich are major source of supply to the head offemur do not come in the way the chances ofavascular necrosis of head of femur are less.

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Fig. 1. Approaches to Hip Joint (a) Smith Peterson approach. (b) Somerville Bikni Incision. (c) Watson Jones lateral approach.(d) Harris technique (e) Mc Farland Osborne technique. (f) Hardinge Modification (g) Mc Lauchlan Incision (h) Gibson’sPostero Lateral approach. (i) Osborne’s posterior approach (j) Moore’s Southern approach (k) Ludloff’s Medial approach.

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The incision is made along anterior third ofiliac crest & then along anterior border of tensorfascia lata, curving posteriorly across the insertionof this muscle into iliotibial tract in the sub-trochanteric region (usually 8 to 10 cm below thebase of greater trochanter) & end there. Lateralcutaneous nerve of thigh is saved & retractedmedially as in anterior ilio femoral approach.Abductor muscles are reflected as in SomervilleIncision above & capsule is exposed.(iii) Lateral Approaches :

1. Watson Jones Technique (1935) :—This isthe most commonly used approach among thelateral approaches. The incision is begun 2.5 cmdistal & lateral to the anterior superior iliac spine &curved distally & posteriorly over the lateral aspectof greater trochanter & lateral surface of femoralshaft to a point 5 cm distal to the base of trochanter(Fig. 1c). The interval between Gluteus medius &tensor fascia lata is often difficult to delineate.However, Brackett (1912) pointed out that it can bedone more easily by beginning the separationmidway between anterior superior iliac spine &greater trochanter before tensor fascia lata blendswith its fascial insertion. The capsule can beapproached through this interval. This approach isused commonly for open reduction of fracture neckof femur & for joint replacement surgery.

2. Harris Technique :—Harris (1973)recommended this approach for an extensiveexposure of hip. In this, a U shaped incision is madewith its base at posterior border of greatertrochanter. It is begun 5 cm posterior & slightlyproximal to anterior superior iliac spine, curveddistally & posteriorly to posterior superior corner ofgreater trochanter & then extended longitudinally for8 cm. Finally it is curved anteriorly & distally making2 limbs of U symmetrical (Fig. 1d). The approachpermits dislocation of femoral head both anteriorly &posteriorly but requires an osteotomy of the greatertrochanter with the resulting risk of non union ortrochanteric bursitics. Also, as reported by Testa &Mazus (1988), incidence of significant or disablinghetrotropic ossification is increased by this method.

3. Mc Farland Osborne Technique (1954) :—Inthis, a midlateral skin incision is made centred overthe greater trochanter, its length depending uponamount of sub cutaneous fat (Fig. 1e) Gluteal fascia& iliotibial tract are divided in line with skin incision.This technique considers the gluteus medius &vastus lateralis muscles to be in direct functionalcontinuity through thick periosteum covering greatertrochanter.

4. Hardinge Modification (1982) :—This is a

modification of Mc Farland & Osborne (1954)technique based on the observation that gluteusmedius inserts on the greater trochanter by a strong,mobile tendon that curves around the apex oftrochanter. In this a posteriorly directed lazy ‘J’incision is made centred over the greater trochanter(Fig. 1f). Fascia lata is incised in line with skinincision. Tensor fascia lata is retracted anteriorly &gluteus maximus posteriorly to expose origin ofvastus lateralis & insertion of gluteus medius. Theseare partially divided to reach the anterior aspect ofcapsule which can be incised as desired. Thisapproach is used for hip replacement surgery.

5. Mc Lauchlan Incision (1984) :—It is a laterallongitudinal skin incision centered midway betweenanterior & posterior borders of greater trchanter &extending an equal distance proximal & distal to thetip of greater trochanter (Fig. 1g). Tensor fascia latais incised in line with skin incision & greatertrochanter is exposed with gluteus medius attachedproximally & vastus lateralis attached distally. Themuscles are split in line of their fibres & greatertrochanter is cut in form of 2 rectangular slices (withosteotome) having gluteus medius attachedproximally & vastus lateralis attached distally onboth of these. One is retracted anteriorly & oneposteriorly to expose hip joint.(iv) Postero lateral approach (Gibson, 1953) :—

In this, the proximal limb of incision is begun ata point 6-8 cm anterior to posterior superior iliacspine & just distal to iliac crest overlying the anteriorborder of gluteus maximus muscle. It is extendeddistally to anterior border of greater trochanter &further distally in line of femur for 15-18 cm. (Fig.1h) Iliotibial tract is incised in line with direction of itsfibres. Next, gluteus minimus et medius are dividedat their insertion to expose the capsule.(v) Posterior approaches

In posterior approaches to the hip the joint isexposed by cutting the posterior aspect of capsule.These approaches are commonly used for hipreplacement surgery but less popular for openreduction & internal fixation of fracture neck of thefemur as the superior retinacular vessels & theascending branch of medial circumflex femoralartery is in jeopardy thereby leading to avascularnecrosis of the head of femur.

1. Osborne approach (1931) :—The incision isbegun 4-5 cm distal & lateral to posterior superioriliac spine & continued laterally & distally remainingparallel to fibres of gluteus maximus to posteriorsuperior angle of greater trochanter & then distallyalong posterior border of greater trochanter for 5 cm(Fig 1i). Gluteus maximus fibres are separatedparallel to skin incision. Since branches of superiorgluteal artery are in proximal half of the muscle &those of inferior gluteal artery are in distal half of

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muscle so little bleeding occurs. Insertion of gluteusmaximus to fascia lata is divided for 5 cmcorresponding to long limb of incision. Piriformis &gamelli are detached near their insertion & retractedmedially. These protect the sciatic nerve & thecapsule is now exposed.

2. Moore’s approach (1959) :—It is also knownas “Southern Exposure”. The incision is started 10cm distal to posterior superior iliac spine & extendeddistally & laterally parallel to fibres of gluteusmaximus to posterior margin of greater trochanter.Then it is directed distally for 10-12 cm parallel tofemoral shaft (Fig. 1j). Rest of exposure is almostsame as in osborne’s technique.

(vi) Medial Approach :—(Ludloff, 1908) It wasdeveloped to permit surgery on a congenitallydislocated hip. The incision is placed on medialaspect of thigh beginning 2.5 cm distal to pubictubercle & over the interval between gracilis &adductor longus muscle. (Fig 1k). A plane isdeveloped between adductor longus et brevisanteriorly & gracilis & adductor magnus posteriorly.Posterior branch of obturator nerve & neurovascularbundle to gracilis is exposed & protected. Capsule islocated in the floor of wound.

(vii) Antero Medial Approach :—(Zazepan &Gamidov, 1972) In this, a longitudinal incision ismade 15-20 cm long, 2-3 cm medial to femoralartery & 2 cm distal to inguinal ligament. Pectineus& adductor longus are exposed. Next externalpudendal & medial circumflex femoral vessels areidentified & retracted laterally. Muscles areseparated by sharp dissection & lesser trochanter isexposed. Iliopsoas tendon is freed & capsule isexposed.(B) Approaches to Femur :

(i) Antero Lateral Approach :—The skinincision is placed over the middle third of femur in aline between anterior superior spine & lateral marginof patella (Fig. 2a) Dissection is carried in theinterval between rectus femoris & vastus lateralis.Vastus intermedius is divided in line with its fibres &femur is exposed.

This approach is suitable for only middle thirdof femur. In proximal third, injury to lateralcircumflex femoral artery & nerve to vastus lateraliscan occur, while in distal third supra patellar pouchis encountered which if cut can lead to kneestiffness by formation of adhesions.

(ii) Lateral Approach :—The skin incision ofdesired length is made over the lateral aspect ofthigh along a line from greater trochanter to thelateral femoral condyle (Fig. 2b) Vastus lateralis etintermedius are divided in line with direction offibres to expose the shaft. A branch of lateral

circumflex femoral artery is encountered whenexposing proximal fourth of femur & superior lateralgenicular artery in distal fourth. These can causetroublesome bleeding so should be isolated &ligated. With this method, though entire femoralshaft can be exposed but it can lead to scarring ofvastus lateralis to prevent which postero lateralapproach is used where the muscle is erased fromits origin on the linea aspra.

(iii) Postero Lateral Approach :—Hereincision is made from base of greater trochanter tolateral condyle (Fig. 2c). Dissection is carried outposterior to vastus lateralis to reach linea aspra.There, this muscle along with vastus intermediuscan be erased subperiosteally. In middle third ofthigh, 2nd perforating branch of profunda femorisartery has to be ligated & divided. Damage to sciaticnerve & profunda femoris vessel can be preventedby not separating long & short heads of biceps.

(iv) Posterior Approach :—This approach israrely used. The skin is incised longitudinally in themiddle of posterior aspect of thigh from just distal togluteal fold to proximal margin of popliteal fossa.(Fig 2d). Dissection is carried out along lateralborder of lateral head of biceps, in proximal partretracting it medially, while in distal part, dissectionis done between this head & semitendinosis,retracting lateral head of biceps along with schiatic

Fig. 2. Approaches to Femur. (a) Antero lateral (b) Lateral (c)Postero lateral (d) Posterior (e) & (f) Lateral & Medialapproaches to posterior surface of lower third offemur (g) Lateral approach to proximal shaft &trochanteric region.

2a

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nerve laterally. A branch of sciatic nerve, supplyingto short head of biceps may be saved or divided,depending upon requirement of incision, because itdoesn’t compose the entire nerve supply of this partof muscle.

The approach may damage the sciatic nervebecause of rough handling & prolonged or strenousretraction causing disturbing symptoms after surgeryor even a permanent disability in the leg so thisapproach is rarely used.

(v) Lateral approach to posterior surface oflower 1/3rd of femur :—(Henry 1927) With kneeslightly flexed, the incision is made for 15 cm alongposterior margin of iliotibial tract following the angleof knee to the head of fibula (Fig. 2e) Popliteal fossais reached between posterior border of iliotibial tract& short head of biceps. Branches of perforatingvessels are ligated & divided, while popliteal vessels& tibial nerve are retracted posteriorly to exposeposterior surface of femur.

(vi) Medial approach to posterior surface oflower 1/3rd of femur :—(Henry 1927) With theknee slightly flexed, the incision is begun 15 cmproximal to adductor tubercle & continued distallyalong adductor tendon following the angle of knee to5 cm distal to tubercle (Fig 2f) Dissection is carriedposterior to sartorius and avoiding damage tosynovial membrane, saphenous nerve lyingposterior to sartorius & adductor tendon, retractinglarge vessels & nerves posteriorly ligating & dividingsmall vessels. Tabial & lateral peroneal nerve lielatero posterior so are not encountered.

(vii) Lateral approach to proximal shaft &trochanteric region :—This is the excellentapproach for reduction & internal fixation oftrochanteric fractures or for subtrochantericosteotomy. The skin incision is placed 5 cmproximal & anterior to greater trochanter & curveddistally & posteriorly over postero lateral aspect oftrochanter & then distally over lateral surface ofthigh parllel to femur for 10cm. (Fig. 2g) Fascia latais divided longitudinally posterior to tensor fascialata to avoid splitting this muscls. Vastus lateralisthus exposed can be erased subperiosteally from itsorigin or divided. Care should be exercised to ligate& cut perforating arteries before these retractbeyond linea aspra.(C) Approaches to Knee Joint :—

(i) Antero Medial Approach :—It was Istdescribed by Langhen beck (1874). The incision isbegun at medial border of quadriceps tendon 7–10cm proximal to patella, curved around the medialborder of patella back towards midline to end it at ordistal to tibial tuberosity (Fig. 3a). Deep dissection is

carried out between vastus medialis & medial borderof quadriceps tendon to reach the capsule.

Abbot & Carpentor (1945) pointed out that wideaccess to joint can be attained in following ways :—

(a) Extending incision proximally (b)Extending proximal past of incisionobliquely medially (c) Dividing medial alarfold longitudinally (d) mobilising medialpart of insertion of patellar tendonsubperiosteally.

If contracture of quadriceps prevents sufficientexposure. the tibial tuberosity may be detached &reattached later with a screw (Fernandes, 1988).

During any of anterior medial approaches, infrapatellar branch of saphenous nerve should beprotected. Saphenous nerve courses posterior tosartorius, pierces fascia lata between this muscle &gracilis to become subcutaneus. It gives a largeinfra patellar branch to supply, skin over anteriormedial aspect of knee. Kummel & Zazanis (1974) &Chambers (1972) noted several variations in itslocation & distribution so no single incision canavoid it for certain. So blunt dissection is advicedbetween skin & joint capsule to locate & save itsbranches. Chambers (1972) reported severalincidences of unsuccessful surgeries on kneebecause of neuromas in scar.

(ii) Antero lateral approach (Kochar, 1911):—Usually this approach is not as satisfactory asantero medial because (i) it is more difficult todisplace patella medially than laterally (ii) it requiresa longer incision (iii) often pateller tendon must bepartly freed subperiosteally.

Incision is begun 7.5 cm proximal to patella atinsertion of vastus lateralis into quadriceps tendon,continuing distally along lateral border of thistendon, patella & patellar tendon to end 2.5 cmdistal to tibial tuberosity. (Fig. 3b)

(iii) Postero lateral approach :—(Henderson1921) :—With the knee flexed at 90°, a curvedincision is made on lateral side of knee just anteriorto biceps femoris tendon & head of fibula (Fig. 3c)thus avoiding common peroneal nerve passing overlateral aspect of neck of fibula. The popliteus tendonlies in between biceps tendon & fibular collateralligament. It is retracted posteriorly to expose posterolateral aspect of joint capsule.

(iv) Postero Medial approach :—With kneeflexed 90°, a curved incision is made, slightlyconvex anteriorly & approximately 7.5 cm longalong the course of tibial collateral ligament anteriorto relaxed tendons of semimembranosus,semitendinosus, gracills & sartorius (Fig. (3d))

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Fig. 3. Approaches to knee joint. (a) Antero medial (b) Anterolateral (c) Postero lateral (d) Postero medial (e) Medial(f) & (g) Lateral [f-Bruser; g-Hoppenfield & Deboer] (h)Extensile anterior (Fernandes) (i) & (j) Posterior [i-Brackett & Osgood; j-Minkoff et al.] (k, l, m) Extensile(Mc Connel) (n) Cave’s approach for medial meniscus.

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oblique part of tibial collateral ligament is incised toexpose the capsule.

(v) Medial approach (Hoppen field & Deboer,1984) :—Incision is begun 2 cm proximal toadductor tubercle of femur, curved antero inferiorlyabout 3cm medial to medial border of patella &ended 6 cm distal to joint line on anterior medialaspect of tibia. (Fig. (3e)) Saphenous nerve & itsinfra patellar branch are saved. Next 3 muscles ofpes anserinus are retracted posteriorly & tibialcollateral ligament is exposed. Joint may be openedanterior or posterior to it depending upon the need.

(vi) Lateral approach :—Lateral approachespermit good exposure for complete excision oflateral meniscus. These don’t require division orrelease of fibular collateral ligament.

(a) Bruser Technique — (1960) :—Knee isflexed fully so that foot rests on table. The incision isbegun anteriorly where patellar tendon crosses thelateral joint line, continued posteriorly along joint lineended at an imaginary line extending from proximalend of fibula to lateral femoral condyle (Fig. 3f) Nextiliotabial tract is splitted in line of its fibres. Fibularcollateral ligament is relaxed & lying posteriorly.Joint capsule is reached anterior to it.

(b) Brown et al (1975) Modification :—It isdone for lateral menisectomy where in addition toBruser approach a varus strain in created to openthe lateral joint space.

(c) Pogrund technique (1976) :—The skinincision is begun near infero lateral aspect of patella& curved gently distally & posteriorly for 4-5cm.Capsule is exposed anterior to iliotibial tract.

(d) Hoppen field & Deboer technique (1984):—Incision is begun 3 cm. lateral to middle ofpatella, extended distally over Gardy’s tubercle ontibia to end it 4-5 cm distal to joint line. Incision iscompleted proximally by curving it along the line offemur. (Fig. (3g) Further dissection is done betweeniliotibial tract anteriorly & biceps tendon withcommon peroneal nerve posteriorly to exposefibular collateral ligament.(vii) Anterior approaches :

(a) Split Patellar approach (Insall, 1984) :—Inthis a lateral parapatellar skin incision is made. Nextquadriceps tenden is split in its middle begining 8cm proximal to patella extending distally overmiddle of patella through patellar tendon to tibialtuberosity. Longitudinal fibres of extensor

mechanism are carefully separated from medial 1/2of patella. Patella is dislocated laterally, & medial 1/2 of qudriceps tendon retracted medially to exposeanterior surface of joint capsule.

(b) Extensile anterior approach (Fernands(1988) :—A lateral parapatellar incision is begun 10cm proximal to lateral joint line continued distallyalong lateral border of patella, pateller tendon &tibial tuberosity to end it 15 cm distal to lateral jointline. (Fig. 3h).This approach allows easy access toboth medial & lateral condyles by : (i) Extensiveosteotomy of tibial tuberosity allowing proximalreflection of patella & patellar tendon. (ii) transectinganterior horn & anterior portion of coronary ligamentof medial or lateral meniscus or both as required.(viii) Posterior approaches :—

These involve the structures, those if damagedproduce a proximal serious disability so a thoroughknowledge of anatomy of popliteal space ismendatory. (Putti, 1974; Abbot & Carpenter, 1945)

1. Brackelt & Osgood (1911) technique :—Inthis a curvilinear incision, 10-15 cm long iscentered over popliteal space. Its proximallimb follows tendon of semi tendinosusdistally to level of joint, it is then curvedlaterally across posterior aspect of joint for5 cm & then distally over lateral head ofgastrocnemius (Fig. 3i) Posterior nerve ofcalf is identified in popliteal fossa Ist of allwhich is a guide to further dissection.Lateral to it the short saphenous veinpierces deep fascia to drain into poplitealvein. Nerve is traced proximally to itsorigin from tibial nerve which further helpsrests of dissection as popliteal artery &vein lie deep to it. Later are retractedgentally to approach posterior surface ofknee joint.

2. Minkoff et al (1987) technique :—Skinincision is begun 1-2cm below the poplitealcrease slightly medial to midline of knee. Itis carried transversally & then curvingdistally just medial & parallel to head offibula, ending 5-6cm distal to it (Fig 3j).Lateral cutaneus nerve of calf, sural nerve& common peroneal nerve are to be savedin this dissection. This approach gives agood exposure of posterior aspect oflateral tibial plateau & proximal tibiofibularjoint.

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(ix) Extensile approach to knee : (McConnel,1976 Technique)McConnell described an extensile approach to

the knee that allows access to the anterior, posterior,medial and lateral sides of the knee through a singleincision. In addition to excellent exposure, it leavesan unobrusive scar. The incision has the anteriercosmesis of a typical tansverse incision; it is hiddenby the skin creases and is less prone to hypertrophythan a longitudinal incision. The medial extension ispartially hidden by the contralateral extremity andthe lateral extension is less noticeable because itlies in the skin depression along the posterior borderof the iliotibial band.

With the knee in acute flexion, the transverseanterior part of incision is made between 3 points-i.e. medial flexion crease, lower pole of patella &lateral flexion crease (Fig. 3k) Its lateral extension ismade proximally along posterior margin of iliotibialtract while medial is made postero medially in adistal direction from apex of medial flexion creasefor 9-10 cm. (Fig 31 & m respectively)(x) Exposure of Medial Meniscus :

(i) Transverse approach :—The advantage ofthis approach is that (a) scar has no contact withfemoral articular surface. (b) Convalescense is morerapid after menisectomy through this than throughother incisions (Charmley 1948).

A 5 cm long transverse incision is made at thelevel of articular surface of tibia extending laterallyfrom medial border of patellar tendon to anteriorborder of tibial collateral ligament. Capsule isincised along the same line to reach the meniscus.

(ii) Cave’s approach :—If posterior horn ofmedial meniscus can’t be excised by transverseapproach, then this approach is useful as it allowsexposure of both anterior & posterior ends. Withknee flexed to right angle, the incision is begun 1cm posterior to & at level with medial femoralepicondyle. i.e. approximately 1 cm proximal to jointline. It is carried distally anterior to a point 0.5 cmdistal to joint line & then anteriorly to border ofpatellar tendon (Fig 3n)D. Exposure of Tibia :

(i) Anterior approach :—The tibia is asuperficial bone and can be easily exposedanteriorly without damaging any important structureexcept the tendons of the tibialis anterior andextensor hallucis longus muscles, which cross thetibia anteriorly in its lower one fourth.

A curved incision is made on either side ofanterior border of bone. Periosteum is stripped aslittle as possible because its circulation is a source

of nutrition for the bone.(ii) Medial approach :—It is used for inserting

a bone graft in delayed union or non union. Here alongitudinal incision is made along postero medialborder of the tibia. Periosteum is reflected fromposterior surface (Phemister, 1947).

(iii) Postero lateral approach :—Thisapproach is valuable in exposure of middle 2/3rd oftibia when anterior & antero medial aspects arebadly scarred. The incision is placed along lateralborder of gastrocnemius on the postero lateralaspect of ligament. A plane is developed betweengastrocnemius, soleus & flexor hallucis longusposteriorly & peronei anteriorly. The approachprovides a complete exposure of flat posteriorsurface of tibia except its proximal fourth which liesin close relation to popliteus muscle, proximal partsof posterior tibial vessels & nerve. (Harmon, 1945).

(iv) Posterior approach to superomedialregion :—(Bank & Laufman, 1953) With patientprone, the transverse segment of hockey stickincision is begun at lateral end of flexion crease ofknee & extended across the popliteal space. Then itis turned distal wards along medial side of calf for 7-10 cm (Fig 4) Deep fascia is incised in the line withskin incision. Upper 1/4th of posterior surface oftibia can be exposed by this incision.

Fig. 4. Posterior approach tosuperomedial region ofTibia.

E. Exposure of Fibula :—It can be exposed by a postero lateral

approach devised by Henry (1927). The incision isbegun 13 cm proximal to lateral malleolus & thencarried proximally along posterior border of fibula toposterior margin of its head & then furtherproximally for 10 cm along posterior border ofbiceps femoris, Common peroneal nerve has to beisolated & saved in the proximal part of the incisionnear the upper end.F. Approaches to Ankle joint & tarsus :—

(i) Anterolateral approach :—gives excellentaccess to the ankle joint, the talus, and most other

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tarsal bones and joints, and it avoids all importantvessels and nerves, since so many reconstructiveoperations and other procedures involve thestructures exposed, it may well be called the“universal incision” for the foot and ankle. It permitsexcision of the entire talus. The only tarsal jointsthat it cannot reach are those between the navicularand the second and first cuneiforms.

The incision is begun over antero lateralaspect of ankle medial to fibula & 5 cm proximal toankle joint. It is carried distally over the joint, anterolateral aspect of body of talus & calceneo cuboidjoint; to end at base of 4th metatarsal bone.Superior & Inferior extensor retinaculae are inciseddown to the periosteum of tibia, & capsule of anklejoint. The dissection usually divides antero lateralmalleolar & lateral tarsal arteries while superficial &deep peroneal nerves are saved.

(ii) Anterior approach :— It is consideredbetter than antero lateral approach if both malleoliare to be exposed. Usually the approach isdeveloped between extensor hallucis longus &extensor digitorum longus but Nicola (1945) advisesdeveloping it between tabialis anterior & extensorhallucis longus.

The incision is begun on anterior aspect of leg7.4-10 cm proximal to ankle joint & extended distallyto about 5 cm distal to joint. Periosteum, capsule&synovium are incised in line with skin incision.

(iii) Kocher Approach (1911) :— It givesexcellent exposure of midtarsal, subtalar & anklejoints. From a point just lateral and distal to the head

of the talus, curve the incision 2.5 cm inferior to thetip of the lateral malleolus, then posteriorly andproximally, and end it 2.5 cm posterior to the fibulaand 5cm proximal to the tip of the lateral malleolus.(Fig. 5a)

The disadvantage of this procedure is that theskin may slough about the margins of the incision,especially if dislocation of the ankle has beennecessary, as in a talectomy. Further, the peronealtendons must usually be divided.

(iv) Ollier Approach (1892) :— This isexcellent for triple orthodesis. The skin incision isbegun over dorso lateral aspect of talo-navicularjoint, extending it obliquely infero posteriorly &ending 2.5 cm below lateral malleolus. (Fig 5b)Inferior extensor retinaculum is divided in line withskin incision & dissection is extended to exposesubtalar, calcaneo cuboid & talonavicular joints.

(v) Postero lateral approach :— (Gatellier &Chastang, 1924) Incision is begun 12 cm proximalto tip of lateral malleolus extending distally alongposterior margin of fibula to tip of malleolus. Then itis curved anteriorly for 2.5 cm in line of peronealtendons. (Fig. 5c). Peroneal retinaculae are incisedto displace the tendons anteriorly. Lateral aspect ofthe joint is exposed dividing the fibula 10 cmproximal to tip of lateral malleolus. Great careshould be used in children to avoid creating afracture through distal fibular epiphysis, whenreflecting fibula.

(vi) Posterior approach :— With patientprone a 12 cm incision is made along postero lateralborder of tendo achillis down to its insertion oncalcaneus. The tendon is lengthened by Z plasty orretracted to expose the ankle joint from posterioraspect.

(vii) Medial approach :— It was given byKoening & Schaefer (1929) but not a popularmethod because despite utmost care it is possible toinjure tibial vessels & nerve. The other unimportantapproaches are those by Broomhead (1932) &Colonna & Ralston (1951). For details of these, thereaders are advised to consult original articles.G. Approaches to Calcaneus :—

(i) Medial approach :—Incision is begun 2.5cm anterior & 4cm inferior to medial malleolus. It iscarried posteriorly along medial surface of foot totendo calcaneus. Abductor hallucis is retracteddorsal wards to reach medial & inferomedial aspectsof calcaneus. Its inferior surface can be exposedsub periosteally avoiding medial calcaneal nerve &nerve to abductor digiti minimi.

(ii) Lateral Approach :— Incision is begun onFig. 5. Approachjes to ankle joint. (a) Kocher’s (b) Ollier(c) Postero lateral

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lateral margin of tendo calcaneus near its insertion& passed distally to a point 4 cm inferior & 2.5 cmanterior to lateral malleolus. Peroneal tendons maybe divided by Z plasty if needed.

(iii) U approach:— This is used to access theentire planter surface of calcaneus. With patientprone, the 2 approaches described above are joinedto form a large U shaped incision around theposterior four fifth of the bone. (Fig. 6a).

Medial approach :— A 5cm long curvedincision is made on medial aspect of joint (Fig 7a). Itis begun just proximal to proximal interphalangealjoint, curved over dorsum of metatarsophalangealjoint medial to extensor hallucis longus tendonended on medial aspect of 1st metatarsus proximalto the joint. 1st dorsal metatarsal artery & branch ofsuperficial peroneal nerve are retracted laterally asthese supply medial side of great toe. This exposesthe bunion over medial aspect of matatarsal head.Then a curved incision is made through bursa &capsule of joint. (Fig 7b) It is begun over thedorsomedial aspect of joint, continued proximally

(iv) Split heel approach is seldom usedexcept for osteomyelitis of calcaneus. In this, amidline incision is given on plantar surface of heel.Its advantage is that the scar retracts inside so thereis no problem in weight bearing.

(v) Kocher approach (Curved L) :—It issuitable for complete excision of calcaneus. Theskin is incised over medial border of tendocalcaneus from a point 7.5 cm proximal to calcanealtuberosity to its postero inferior aspect. Then theincision is continued transversely around theposterior aspect of calcaneus, then distally alonglateral surface of the foot to tuberosity of 5thmetatarsal. (Fig 6b)H. Approaches for Toes.

(i) Interphalangeal joints:—For interphal-angeal joint of great toe, a 2.5 cm longincision is made on medial aspect of thetoe & for interphalangeal joint of 5th toe,a similar incision is made on lateralaspect of 5th toe. The interphalangealjoints of other 3 toes can be approachedthrough incisions made just lateral tocorresponding extensor tendons. Careshould be exercised to save dorsal orplanter digital vessels & nerve. Capsulecan be opened longitudinally ortransversely.

(ii) Metatarsophalangeal Joints.(a) M.P. joint of great toe can be approached

in either of the 2 common ways.

Fig. 6. Approaches to Calcaneus (a) U approach (b) Curved Lapproach

6b

7a

7b

Fig. 7. Medial Approach for great toe.(a) Skin Incision (b) Line of Incision through bursa &capsule of Joint.

dorsal to the metatarsal head & then planter wards &distalwards around the joint & ended distally onmedio planter aspect of matatarso phalangeal joint.The incision forms an elliptical, racquiet shaped flapattached to base of proximal phalanx. Although thedistal reflection of flap exposes the 1st metatarsophalangeal joint, yet healing of the flap may bedelayed so dorso medial approach is prefered.

Dorsomedial approach :— The incision isbegun just proximal to joint continued proximally for5 cm parallel & medial to extensor hallucis longustendon. Further dissection can be carried in plane ofskin incision or as in medial approach.

(b) M. P. joint of 2nd to 5th toe :— All theseare reached by dorso lateral incisionsparallel to the corresponding extensortendons.

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