DT:20-5-08

ARTHROTOMY OF HIP AND KNEE

MODERATORS:
PROF.JAGANNATH KAMATH
DR.HARSHAVARDHAN
PRESENTED BY:
DR.K.SRIDHAR
KASTURBA MEDICAL COLLEGE
MANGALORE
ARTHRUS-means joint:TOMY-means to open
Indications:
Traumatic:
1.Intraarticular fractures
2.ligament injuries
3.meniscal injuries
4.loose bodies ie osteochondral fractures,intraarticular chip fractures etc
Nontraumatic:
1.Septic arthritis
2.Tubercular arthritis
3.for synovectomy
4.loose bodies
5.foreign bodies
6Intraarticular tumors like lipoma,pigmented villonodular synovitis etc
DRAINAGE
Drainage of the hip may be accomplished through a posterior, medial, lateral, or anterior
approach.
In small children: The anterior approach is preferred for several reasons:
(1) damage to the major blood supply to the femoral head is avoided,
() the chance of postoperative dislocation is reduced, and
In adults: the posterior approach !ill allo! dependent drainage and is a more familiar approach .
Anterior Drainage
(Smith-Petersen)
Incision:"eginned at the middle of the iliac crest and carried anteriorly to the anterosuperior iliac
spine and then distally and slightly laterally 1# to 1 cm.
$ree the attachments of the gluteus medius and the tensor fasciae latae muscles from the iliac
crest.
carry the dissection through the deep fascia of the thigh and bet!een the tensor fasciae latae
laterally and the sartorius and rectus femoris medially.
%&pose and incise the capsule transversely .
'early all surgery of the hip joint may be carried out through this approach.
(nterior femoral incision: e&poses the joint but is inade)uate for reconstructive operations.
Iliac part of the incision: The entire ilium and hip joint can be reached.
Incise the capsule, evacuate the pus, and irrigate the joint !ith saline.
*eave the capsule open but close the s+in loosely over drains.


Posterior Drainage
Moore posterior approach.
,oore-s approach has been facetiously labeled .the southern e&posure..
Incision:/tart 1# cm distal to the posterosuperior iliac spine and e&tend it distally and laterally
parallel !ith the fibers of the gluteus ma&imus to the posterior margin of the greater trochanter.
Then direct the incision distally 1# to 10 cm parallel !ith the femoral shaft.
1lane:.2luteus ma&imus has been split in line !ith its fibers and retracted to e&pose sciatic
nerve, greater trochanter, and short e&ternal rotator muscles./hort e&ternal rotator muscles have
been freed from femur and retracted medially to e&pose joint capsule
3oint capsule has been opened, and hip joint has been dislocated by fle&ing, adducting, and
internally rotating thigh.
Lateral Drainage
4atson53ones
Incision:"egin .6 cm distal and lateral to the anterosuperior iliac spine and curve it distally and
posteriorly over the lateral aspect of the greater trochanter and lateral surface of the femoral shaft
to 6 cm distal to the base of the trochanter.
1lane:interval bet!een the gluteus medius and tensor fasciae latae is located.
Incise the capsule of the joint longitudinally along the anterosuperior surface of the femoral nec+
4atson53ones lateral approach .
Incise the capsule, evacuate the pus, and irrigate the joint !ith saline. 7lose the s+in loosely over
drains.
Medial Drainage
Ludloff

*udloff medial approach to hip joint.
Incision:longitudinal incision 8.6 to 1# cm long on the medial aspect of the pro&imal thigh
and e&pose the pro&imal one fourth of the gracilis and adductor longus muscles
1lane: bet!een adductor longus and gracilis.(dductor longus has been retracted anteriorly
and gracilis and adductor magnus posteriorly.
%vacuate the pus and irrigate the !ound !ith saline
AFTERTREATMENT.
Infant:in a double spica cast !ith the affected e&tremity in moderate abduction. (de)uate
!indo!s are made in the cast for !ound inspection and care.
9lder children and adults:bed rest in "uc+ traction until the !ound has healed and the patient can
control the leg (i.e., can raise the limb from the bed against gravity). 1rotective !eight5bearing
using crutches then is permitted, and active range5of5motion e&ercises are started
ANTERIOR APPROACHES
/omervillie
ANTEROLATERAL APPROACH
Smith-petersen
LATERAL APPROACHES
:arris
,c$arland and 9sborne
:ardinge
McLauchlan:Hay
POSTEROLATERAL APPROACH
Gibson

POSTERIOR APPROACHES
Osborne
Ober
MEDIAL APPROACH
Ferguson;
Hoenfeld and de!oer
Knee
DRAINAGE
In acute septic arthritis, usually anteromedial arthrotomy .is ade)uate.
ANTEROMEDIAL APPROACHES
Anteromedial Parapatellar Approach
Langenbec"
Incision:"egin at the medial border of the )uadriceps tendon 8 to 1# cm pro&imal to the patella, curve it
around the medial border of the patella and bac+ to!ard the midline, and end it at or distal to the tibial
tuberosity.
1lane:Deepen the dissection bet!een the vastus medialis muscle and the medial border of the )uadriceps
tendon and incise the capsule and synovium along this medial border and along the medial border of the
patella and patellar tendon.
Disadvantages:
1.patellar dislocation,sublu&ation.
.osteonecrosis of patella.

Incise the capsule and synovium, carefully evacuate the purulent material, and disrupt any loculations or
adhesions. . *eave the synovium open but loosely close the capsule and s+in over drains.
If the posterior compartment of the +nee is distended and a popliteal abscess is !ell established, parallel anterior
incisions combined !ith posterolateral and posteromedial (:enderson) incisions usually are best.
If possible, posterior drainage should be avoided because the infection may spread through the fascial planes of the
thigh and leg. :o!ever, !hen fluctuation indicates a poc+et of pus in the posterior compartment of the joint that has not
been or that cannot be drained effectively through :enderson incisions, posterior drainage is necessary. It is important to
remember that the posterior compartment may be divided by a median septum into medial and lateral compartments.
These may be effectively drained by the ;lein or ;eli+ian approach
. ( posterior midline approach should not be used to drain an infected +nee because it e&poses the popliteal vessels to
pus and to pressure from the drain and creates a potentially contracting scar across the joint.
Posteromedial Drainage
#lein:
Ta+es advantage of the fact that the bursae bet!een the semimembranosus tendon and the medial head of the
gastrocnemius muscle often communicate !ith the +nee joint. 7onse)uently, an incision into these bursae often leads
directly into that joint.
1osiion:+nee slightly fle&ed
Incision:longitudinal incision 1# cm long centered over the +nee joint and located just lateral to the semimembranosus
tendon. e&pose the tendons of the medial hamstrings.
1lane:Identify the interval bet!een the gastrocnemius and semimembranosus, and follo! the gastrocnemius pro&imally
to its insertion on the medial femoral condyle. %&pose and incise the capsule in this interval.
Posteromedial and Posterolateral Drainage
#eli"ian
;eli+ian approach to drain medial half of posterior compartment of +nee:
Incision:posterior longitudinal incision 8.6 to 1# cm long centered over the joint and the
semimembranosus tendon.
1lane:Develop the interval bet!een this tendon and the medial head of the gastrocnemius
muscle./emimembranosus tendon has been divided, and its pro&imal end has been sutured to
deep fascia.
7apsule is !indo!ed, and posterior horn of medial meniscus has been e&cised.
;eli+ian approach to drain lateral half of posterior compartment of +nee:
Incision has been made medial to biceps femoris tendon to protect common peroneal nerve.
"iceps tendon has been divided at its insertion, popliteus tendon has been freed from its origin,
and free ends of tendons have been sutured to deep fascia.
7apsule is !indo!ed, and !edge of lateral meniscus has been e&cised.
.
ANTEROMEDIAL APPROACHES
Subvastus (Southern)
ANTEROLATERAL APPROACH
#ocher
MEDIAL APPROACHES
$a%e
Hoenfeld and de!oer
TRANSVERSE APPROACHES
LATERAL APPROACHES
!ruser
"ro!n et al.
Hoenfeld and de!oer
EXTENSILE APPROACHES
3.7. ,c7onnell
$ernande<
POSTERIOR APPROACHES
!rac"ett and &sgood
Min"off' (affe' and Menende)
References:
1.7ampbell=s 9perative 9rthopaedics511
th
edition.
./urgical (pproaches >:oppenfeld
0.,ercer=s 9rthopaedic surgery5?
th
edition.
@. British Journal of Sports Medicine, Vol 27, Issue 2 87-89, Copyright !99" #y British $ssociation of
Sport and Medicine
%&. The Journal of Arthroplasty , Volume 21 , Issue 4 , Pages 22 - 26 M . Pagnano , R . Meneghini
6.Tureks textbook of orthopaedics-4
th
ed.