Lateral Approach to Femur

Lateral Approach to Femur indications:

Lateral Approach to femur is an extremely quick and easy approach, it involves splitting the vastus lateralis muscle.

Lateral Approach to femur is used for:

  1. Open reduction internal fixation of intertrochanteric, peri-trochanteric hip, femoral neck fractures.
  2. Open treatment of slipped capital femoral epiphysis.
  3. Sub-trochanteric, intertrochanteric osteotomy.
  4. Open reduction internal fixation of femoral shaft and supracondylar femur fractures.
  5. Extraarticular arthrodesis of the hip joint.
  6. Treatment of chronic osteomyelitis.
  7. Biopsy and treatment of bone tumors.

The subsequent blood loss that results from the rupture of vessels during this procedure may make surgery awkward, but rarely is life-threatening.

Position of the Patient

  • Supine position:
    • With sandbag below buttock to internally rotate operative leg.
  • Supine position on an orthopedic table:
    • Supine position is used for trochanteric fractures.
    • Use an orthopedic table for any procedure that involves the use of an image intensifier.
  • Lateral decubitus:
    • Lateral decubitus position is best for surgery on the shaft of the femur, with the affected limb uppermost.

Landmarks and Incision

  • Landmarks:
    1. Greater trochanter.
    2. Shaft of the femur.
  • Incision:
    • Make a longitudinal incision, beginning over the middle of the greater trochanter and extending down the lateral side of the thigh over the lateral aspect of the femur. The length and position of the incision will vary with the requirements of the surgery.
Lateral Approach to Femur

Internervous plane

  • There is No internervous for lateral approach to femur, because the dissection splits the vastus lateralis muscle, which is supplied by the femoral nerve.
  • The vastus lateralis muscle receives its nerve supply high in the thigh, however, so splitting the muscle distally does not denervate it

Superficial dissection

  • Incise the fascia lata of the thigh in line with the skin incision. At the upper end of the wound, the distal portion of the tensor fasciae latae may have to be split in line with its fibers to expose the vastus lateralis.

Deep dissection

  • Carefully incise the fascial covering of the vastus lateralis muscle.
  • Insert a Homan or Bennett retractor through the muscle, running the tip of the retractor over the anterior aspect of the femoral shaft.
  • Then, insert a second retractor through the same gap and down to the femoral shaft.
  • Manipulate the second retractor so that it moves underneath the femur, and pull the two retractors apart to split the vastus lateralis in the line of its fibers.
  • Continue splitting by blunt dissection. As dissection proceeds, several vessels that cross the field will be exposed. Coagulate them, if possible, before they are avulsed by the blunt dissection.
  • Splitting the vastus lateralis reveals the underlying lateral surface of the femur.

Approach Extension

  • The lateral approach to femur is most useful for exposing the proximal third of the bone for internal fixation of a hip fracture.
  • It can be extended to the knee joint to allow full exposure of the lateral aspect of the femoral shaft for reduction and fixation of all types of femoral fractures.

Dangers

The structures at risk during the lateral approach to femur includes:

  • Perforating branches of the profunda femoris artery is at risk within vastus lateralis dissection. They should be ligated to prevent hematoma.

References

  • Surgical Exposures in Orthopaedics book – 4th Edition

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