Distal femur

Principles

Use of the posterior approach: mainly in coronal plane (Hoffa) fractures of the condyle

The posterior approach is mainly used for fractures of the condyles in the coronal plane (Hoffa) in cases of an extremely posterior fracture line. It may also be used in neurovascular repair and posterior cruciate avulsion injuries.

enlarge

Neurovascular structures

The neurovascular structures of the knee joint are at risk during the posterior approach. They are located between the two femoral condyles and the heads of the gastrocnemius muscle.

The location of the anatomical bifurcation of the tibial nerve varies and therefore careful dissection is essential. The use of a tourniquet facilitates the identification of the neurovascular bundle.

enlarge

Skin incision

Make an S-shaped skin incision over the popliteal fossa with the oblique section of the incision lying in the area of the joint line.

The approach can be extended proximally according to the dashed line.

enlarge

Open the deep fascia

Open the deep fascia of the leg in the posterior midline. Crossing veins have to be ligated.

enlarge

Neurovascular structures

Identify and retract the neurovascular structures carefully.

It is essential to ligate the veins in the posterior approach, rather than using cautery.

enlarge

Expose fracture fragment

Identify the posterior capsule of the knee.

Expose the posterior condyle on the fractured side.

Where both condyles are fractured only one condyle is exposed at a time.

Wound closure

After relaxing the tourniquet, ensure good hemostasis. The use of a suction drain can be considered. Close the deep fascia of the leg, followed by skin sutures.