7: The Hindlimb


The Hindlimb




imageApproach to the Greater Trochanter and Subtrochanteric Region of the Femur


imageApproach to the Shaft of the Femur in the Dog


imageApproach to the Shaft of the Femur in the Cat


imageMinimally Invasive Approach to the Shaft of the Femur


imageApproach to the Distal Femur and Stifle Joint Through a Lateral Incision


imageApproach to the Stifle Joint Through a Lateral Incision


imageApproach to the Stifle Joint Through a Medial Incision


imageApproach to the Stifle Joint with Bilateral Exposure


imageApproach to the Distal Femur and Stifle Joint by Osteotomy of the Tibial Tuberosity


imageApproach to the Lateral Collateral Ligament and Caudolateral Part of the Stifle Joint


imageApproach to the Stifle Joint by Osteotomy of the Origin of the Lateral Collateral Ligament


imageApproach to the Medial Collateral Ligament and Caudomedial Part of the Stifle Joint


imageApproach to the Stifle Joint by Osteotomy of the Origin of the Medial Collateral Ligament


imageApproach to the Proximal Tibia Through a Medial Incision


imageApproach to the Shaft of the Tibia


imageMinimally Invasive Approach to the Shaft of the Tibia


imageApproach to the Lateral Malleolus and Talocrural Joint


imageApproach to the Medial Malleolus and Talocrural Joint


imageApproach to the Tarsocrural Joint by Osteotomy of the Medial Malleolus


imageApproach to the Calcaneus


imageApproach to the Calcaneus and Plantar Aspects of the Tarsal Bones


imageApproach to the Lateral Bones of the Tarsus


imageApproach to the Medial Bones of the Tarsus


imageApproaches to the Metatarsal Bones


imageApproach to the Proximal Sesamoid Bones


imageApproaches to the Phalanges and Interphalangeal Joints



Approach to the Greater Trochanter and Subtrochanteric Region of the Femur






Description of the Procedure




The skin incision runs from a point dorsal and slightly cranial to the trochanter, extends over the lateral surface of the trochanter, and ends distally at the proximal one third of the shaft of the femur.


The subcutaneous fat and fascia are incised and cleared from the area so that the superficial leaf of the fascia lata can be clearly visualized. An incision is made through the fascia lata along the cranial border of the biceps femoris muscle.


The biceps is reflected caudally and the skin and fascia lata cranially. The borders of the superficial gluteal muscle are developed by dissection from the surrounding fascia, and the tendon of insertion of this muscle is cut near the femur. Sufficient tendon is left distally to allow suturing at closure.


The superficial gluteal muscle is retracted proximally to expose the greater trochanter and the middle gluteal muscle. An incision is now made through the fibers of origin of the vastus lateralis muscle along the ridge of the third trochanter of the femur. This incision is deepened to include the periosteum in young animals.


Subperiosteal elevation of this proximal lateral portion of the vastus lateralis muscle exposes the proximal shaft of the femur. The adductor muscle on the caudal side of the bone can also be elevated from the bone to give additional exposure.






Approach to the Shaft of the Femur in the Dog



Based on a Procedure of Brinker4





Description of the Procedure




The skin incision is made along the craniolateral border of the shaft of the bone from the level of the greater trochanter to the level of the patella. The subcutaneous fat and superficial fascia are incised directly under the skin incision.


The skin margins are undermined and retracted and the superficial leaf of the fascia lata is incised along the cranial border of the biceps femoris muscle. This incision extends the entire length of the skin incision. If muscle fibers are encountered, the incision should be directed more cranially.


Caudal retraction of the biceps femoris reveals the shaft of the femur. It is necessary to incise the fascial aponeurotic septum on the lateral shaft of the bone to adequately retract the vastus lateralis.


The vastus lateralis and intermedius muscles on the cranial surface of the shaft are retracted by freeing the loose fascia between the muscle and the bone.







Approach to the Shaft of the Femur in the Cat






Description of the Procedure




The skin incision is made along the craniolateral border of the shaft of the bone from the level of the greater trochanter to the level of the patella. The subcutaneous fat and superficial fascia are incised directly under the skin incision.


There are several anatomic differences in the musculature surrounding the hip joint and femur in the cat with which the surgeon must be familiar. The gluteal muscles may be relatively larger in the cat than in the dog. Also, the caudofemoralis muscle, a muscle not present in the dog, is interposed between the superficial gluteal and biceps femoris muscles.


The skin margins are undermined and retracted. An incision is made through the superficial leaf of the fascia lata, along the cranial border of the caudofemoralis and biceps femoris muscles. This incision extends the entire length of the skin incision. If muscle fibers are encountered, the incision should be directed more cranially.


Caudal retraction of the biceps femoris muscle using an atraumatic retractor, such as a Senn or Langenbeck, reveals the shaft of the femur and the sciatic nerve. It is necessary to incise the fascial aponeurotic septum on the lateral shaft of the bone to adequately expose the vastus lateralis.


The origin of the vastus lateralis muscle has a firm insertion along most of the shaft of the femur. To gain exposure of the lateral surface of the femur, the lateral margin of the vastus lateralis muscle is sharply incised.


Using a periosteal elevator, the vastus lateralis muscle is elevated from the shaft of the femur, progressing in a distal-to-proximal direction. For additional exposure proximally, the origin of the vastus lateralis muscle is transected at the third trochanter.


The vastus lateralis and intermedius muscles on the cranial surface of the shaft are retracted to expose the femoral shaft.





Minimally Invasive Approach to the Shaft of the Femur



Based on a Procedure of Pozzi and Lewis36





Description of the Procedure


The magnitude of exposure has been intentionally enlarged in the following descriptive illustrations, to highlight the relevant features of the surgical anatomy. Once familiar with the anatomy, the field of dissection and exposure can be reduced by at least 50% to obtain a true minimally invasive approach to the femur.



For this minimally invasive approach to the femur, two skin incisions that are 3 to 5 cm in length are made over the proximal and distal ends of the femur.


The subcutaneous fat and fascia are incised and retracted to expose the superficial leaf of the fascia lata. An incision is made through the fascia lata along the cranial border of the biceps femoris muscle.


The borders of the superficial gluteal muscle are developed by dissection from the surrounding fascia, and the tendon of insertion of this muscle on the third trochanter is transected near the femur.


The superficial gluteal muscle is retracted proximally to expose the greater trochanter and middle gluteal muscle. An instrument is inserted caudal to the middle gluteal muscle and is used to palpate the medial surface of the greater trochanter and the trochanteric fossa. Location of the trochanteric fossa allows subsequent normograde insertion of an intramedullary pin or interlocking nail. The origin of the vastus lateralis is incised to expose the lateral aspect of the proximal region of the femur.


After identification of the patella and lateral trochlear ridge by palpation, a 2- to 4-cm longitudinal skin incision is made (see Plate 80). The subcutaneous tissue is incised in the same line as the skin incision. An incision is made in the fascia lata along the cranial margin of the biceps femoris muscle.


Retraction of the biceps femoris muscle caudally and vastus lateralis muscle cranially provides exposure of the distal end of the femur. It may be necessary to ligate and transect the distal branch of the caudal femoral artery and vein. However, the capsule of the stifle joint should not be incised unless there is an indication to gain exposure of this joint.


A blunt instrument, such as the soft-tissue retractor illustrated here, is passed along the lateral side of the femoral shaft to create an epiperiosteal tunnel.




Approach to the Distal Femur and Stifle Joint Through a Lateral Incision



Based on a Procedure of Paatsama34






Description of the Procedure




After palpation of the patella and lateral trochlear ridge, a curved parapatellar skin incision is made extending from the tibial tuberosity to the level of the patella, and then an equal distance proximally. The subcutaneous fascia is incised in the same line as the skin incision. The fascia lata and lateral fascia of the stifle joint are exposed by undermining the subcutaneous fat and fascia, which are then retracted with the skin.


Another curved incision, similar to that in the skin, is made through the fascia lata along the cranial border of the biceps. The incision continues distally into the lateral fascia of the stifle joint. As it crosses the trochlear ridge, it curves to parallel the lateral border of the patella and the patellar ligament. Enough fascia is left on the lateral edge of the patella to receive sutures when the joint is closed.


The biceps and attached lateral fascia are retracted caudally. In separating the biceps from the vastus lateralis, an intermuscular septum formed from the fascia lata is found attached to the femur. This fascia must be incised to allow mobilization of the quadriceps and biceps. Muscular branches of the distal caudal femoral vessels crossing the distal femur must be ligated in some cases. A parapatellar incision is now made through the joint capsule.


With the joint extended, the patella and quadriceps can be luxated medially. Lateral retraction of the joint capsule with the biceps and lateral fascia fully exposes the interior of the joint. Incision and retraction of the infrapatellar fat pad may be necessary for inspection of the menisci and cruciate ligaments.



Additional Exposure


Proximally this approach can be extended by combining with the approach to the shaft of the femur (see Plate 77) to expose the entire bone. The muscular branch of the caudal femoral artery that crosses the distal femur to supply the vastus lateralis muscle will need to be ligated. The joint capsule usually need not be incised to expose supracondylar fractures, but it is always incised for exposure of physeal fractures, which are intracapsular.




Approach to the Stifle Joint Through a Lateral Incision





Alternative Approaches


Depending on the compartment of most interest, approaches to the stifle can be made via a medial incision (see Plate 82), bilateral exposure (see Plate 83), or osteotomy of the tibial tuberosity (see Plate 84). For cranial cruciate ligament reconstruction the authors favor a medial approach (see Plate 82), particularly in chronic injuries.




Description of the Procedure




The skin incision starts over the tibial tuberosity lateral to the patellar ligament. It continues proximally to the level of the patella and then an equal distance proximally following the cranial border of the femur (see Comments).


The arthrotomy incision follows the same line as the skin. The distal portion is made in the lateral fascia first with the scalpel, starting opposite the distal pole of the patella and a few millimeters lateral to the patellar ligament and continuing distally to the tibia. A stab incision is made into the joint at the proximal end of this incision, which will allow entry into the joint with little danger of damaging articular cartilage of the femoral condyle. One blade of a scissor is inserted into the joint and the scissor is advanced proximally, cutting joint capsule, lateral parapatellar fibrocartilage, and fascia lata. As the proximal part of the incision is started, it is directed slightly laterally so as to cut through the vastus lateralis parallel to the muscle fibers and to leave enough tissue on the lateral side of the patella to permit suturing.


The patella can now be luxated medially. If the patella will not stay in position medially, the proximal end of the incision is lengthened. Distal retraction of the fat pad exposes the cruciate ligaments and menisci.


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Mar 31, 2017 | Posted by in SUGERY, ORTHOPEDICS & ANESTHESIA | Comments Off on 7: The Hindlimb

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