Authors of section

Authors

Arnold Besselaar, Daniel Green, Andrew Howard

Executive Editor

James Hunter

General Editor

Fergal Monsell

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Minimally invasive osteosynthesis approach

1. Introduction

Approaches for minimally invasive plate osteosynthesis are usually performed laterally. They vary according to the fracture location: proximal, midshaft, or distal.

2. Principles

The advantages of minimally invasive plate osteosynthesis of the femoral shaft include reducing the extent of muscle detachment and limiting the effect on bone vascularity.

Approaches for minimally invasive plate osteosynthesis are usually performed laterally.

A minimum of one small incision to approach the bone is required to place the plate.

A distal approach is most commonly used for fractures in the distal third of the shaft.

Distal approach for plate insertion

A proximal approach is most commonly used for fractures in the proximal third of the shaft.

Midshaft fractures can be approached from either end and the position of the incision can be moved towards the fracture providing better access to the diaphysis.

Additional screws can usually be placed through stab incisions. In some cases, a second small approach is required at the fracture site or at the far end of the plate to allow direct manipulation.

Thorough preoperative planning is compulsory to define the location of the most suitable approach.

Proximal approach for plate insertion

3. MIO approach to the distal femur

Perform a lateral incision as far as the femoral epicondyle distally.

The starting point and length of the incision can be adapted to suit operational requirements.

Lateral incision for distal approach

Incise the fascia lata and split it along its fibers, parallel to the skin incision.

Incision of the fascia lata

Mobilize the inferior margin of the vastus lateralis and retract the muscle anteriorly. The plane between the femur and vastus lateralis is the entry point for the plate.

Mobilization and retraction of the vastus lateralis

Closure

Allow the vastus lateralis to fall back over the plate and femur and close the tensor fascia lata.

The subcutaneous tissue and skin are closed according to surgeon’s preference.

4. MIO approach to the subtrochanteric region

Start the lateral proximal incision at the greater trochanter and continue distally as far as needed.

Lateral incision for proximal approach

Incise the fascia lata with a scalpel and split it with scissors, parallel to the skin incision.

Expose the fascia over the vastus lateralis.

Incision of the fascia lata

If exposure of the proximal femoral shaft is necessary, identify the origin of the vastus lateralis.

Perform an extraperiosteal L-shape incision and retract the muscle anteriorly.

Extraperiosteal L-shape incision for femoral shaft exposure

Elevate the vastus lateralis sufficiently to allow submuscular plate insertion.

Elevation of vastus lateralis

Closure

Repair the origin of vastus lateralis and close the tensor fascia lata.

The subcutaneous tissue and skin are closed according to surgeon’s preference.

5. MIO approach to the femoral shaft

Perform a short incision along a line between the lateral femoral epicondyle and the greater trochanter.

The starting point and the length of the incision depend on the operational requirements for the minimally invasive procedure.

Line for short incisions along the lateral femoral shaft

Incise the fascia lata and expose the fascia of the vastus lateralis.

Incision of the fascia lata

Incise the fascia of the vastus lateralis.

Incision of the fascia of the vastus lateralis

This small lateral incision provides enough access without devascularization of muscle.

Small lateral incision without devascularization

Perform blunt dissection directly through the belly of the vastus lateralis to the bone.

Blunt dissection to the bone

The use of one anterior and one posterior extraperiosteal Hohmann retractors is recommended for exposure of the femoral shaft. These retractors also assist with accurate plate positioning on the femur.

Exposure of the bone with Hohmann retractors

Closure

Allow the vastus lateralis to fall back over the top of the lateral femur and close the tensor fascia lata.

The subcutaneous tissue and skin are closed according to surgeon’s preference.