Lateral approach to the femur

Introduction

Indications

• ORIF of intertrochanteric fractures.
• Insertion of internal fixation in the treatment of subcapital fractures or slipped upper femoral epiphysis.
• Subtrochanteric or intertrochanteric osteotomy.
• Open reduction and internal fixation of femoral shaft fractures and supracondylar fractures of the femur.
• Extra-articular arthrodesis of the hip joint.
• Treatment of chronic osteomyelitis of the femur.
• Biopsy and treatment of bone tumors.

Advantages

• Can be extended inferiorly to expose the whole length of the bone.
• Quick and easy approach.

Disadvantage

• Blood loss that results from the rupture of vessels during this procedure

Position of patient

• For trochanteric or subtrochanteric fractures, the patient should be placed on an orthopaedic table in the supine position. Internally rotate the leg 15° to overcome the natural anteversion of the femoral neck to obtain a true lateral position.
• For femoral shaft fractures, place the patient on his or her side, with the affected limb uppermost. Pad the bony prominences of the bottom limb to avoid pressure necrosis of the skin.

Landmarks and incision

Landmarks

• Palpate the greater trochanter by moving the fingers anteriorly and proximally to identify its tip.
• The shaft of the femur is palpable as a line of resistance on the lateral side of the thigh.

Incision

• Longitudinal beginning over the middle of the GT and extending down the lateral side of the thigh over the lateral aspect of the femur. The length will vary with the requirements of the surgery.

Internervous plane

• There is no internervous or intermuscular plane, as the VL muscle receives its nerve supply by the femoral nerve high in the thigh.

Superficial dissection

• Incise the fascia lata 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

• Incise the fascial covering of the vastus lateralis muscle.
• Insert a Homan or Bennett retractor where the tip of the retractor is over the anterior aspect of the femoral shaft. Insert a second retractor through the same gap and down to the femoral shaft.
• Split the vastus lateralis in the line of its fibers.
• Coagulate exposed vessels before they are avulsed by the blunt dissection.

How to enlarge the approach

• Approach can be extended from GT to the knee joint to allow full exposure of the lateral aspect of the femoral shaft.

Dangers

Perforating branches of the profunda femoris artery

• As they traverse the vastus lateralis muscle, the perforating branches of the profunda femoris artery are damaged during the approach and should coagulated.
• Identified easily by splitting gently with a blunt instrument.

Figures