48

J Anat. Soc. India 50(1) 48-58 (2001)

Surgical Incisions — Their Anatomical Basis Part III - Lower Limb

1
Patnaik, V.V.G., 2Singla, Rajan, K., 3 Gupta, P.N.
Department of Anatomy, Government Medical College, Patiala1, Amritsar2, Department of Orthopedics Government Medical
College, Chandigarh3. INDIA

For Reprints, request the first author.

Abstract. The present paper is a continuation of the previous one by the same authors in the last issue. Here, we have made an
attempt to delineate various incisions for exposing different bones & joints of lower limb along with important anatomical landmarks to be
taken care while designing & executing these.
Key words : Surgical Incisions, Hip, Knee, Ankle, Femur, Tibia, Calcaneus, Toes.

Introduction : Attachments of gluteus medius & tensor fascia lata

Numerous new approaches to the different
regions of lower limb have been described during
the past few years, most of which are based on
older approaches & are modified for a specific
surgical procedure. We will discuss the anatomical
basis of the most widely used approaches. Various
approaches in lower limb can be classified
according to the site as follows :
(A) Approaches to Hip Joint :
(i) Anterior approaches :
1. Smith Peterson approach.
- Schaubel Modification.
2. Somerville Bikni Incision.
(ii) Antero lateral approach (Smith Peterson,
Cave & Van Gorder)
(iii) Lateral Approaches :
1. Watson Jones approach.
2. Harris approach.
3. Mc Farland & Osborne approach.
4. Hardinge approach.
5. Mc Lauchlan approach.
(iv) Postero Lateral Approaches :
1. Gibson approach.
2. Marcy & Fletcher Modification.
(v) Posterior Approaches :
1. Osborne Incision
2. Moore Incision
(vi) Medial Approach (Ludloff) :
(vii) Antero Medial Approach
Gamidov) :
(i) Anterior Approaches
1. Smith Peterson :—It is also known as
Anterior ilio femoral approach. Here, the incision is
begun at the middle of the iliac crest & carried
anteriorly to the anterior superior iliac spine & then
distally & slightly laterally for 10-12 cm. (Fig 1a) .
muscle are freed from iliac crest. Dissection is
carried between tensor fascia lata laterally &
sartorius & rectus femoris medially. Ascending
branch of lateral circumflex femoral artery lies 5 cm
distal to hip joint which is clamped & ligated. Lateral
cutaneous nerve of thigh passes over sartorius 2.5
cm. distal to anterior superior iliac spine; it has to be
retracted medially. This exposes the capsule of hip
joint which can be incised along its attachment to
acetabulum after cutting the origin of rectus femoris.
Schaubel Modification (1980) : Schaubel found
reattachment of fascia lata to the fascia on iliac
crest difficult so instead of dividing the fascia lata at
iliac crest, he performed an osteotomy of iliac crest
between attachments of external oblique muscle
medially & fascia lata laterally. Tensor fascia lata,
gluteus medius & gluteus minimus attachments
were subperiostealy dissected distally to expose hip
joint capsule.
2. Somerville ‘Bikni’ Incision :—Somerville
(1953) described an anterior approach using a
transverse ‘bikni’ incision for irreducible congenital
dislocation of hip joint in a young child.
A straight skin incision is made beginning
anteriorly, medial & inferior to anterior superior iliac
spine& coursing obliquely superiorly & posteriorly to
middle of iliac crest. (Fig 1b). The abductor muscles
are reflected subperiosteally from iliac bone distally
to capsule of hip joint. Tensor fascia lata is
separated from sartorius for about 2.5 cm inferior to
anterior superior iliac spine. Reflected head of
rectus femoris is separated from acetabulum &
capsule. For a wide exposure its straight head may
also be divided & reflected distally.
(Zanepen &
(ii) Antero lateral approach :—It is used for
open reduction & internal fixation of fracture femoral
neck. It retains the advantage of anterior ilio femoral
approach but exposes the trochanteric region
laterally. Since the superior retinacular vessels
which are major source of supply to the head of
femur do not come in the way the chances of
avascular necrosis of head of femur are less.
J. Anat. Soc. India 50(1) 48-58 (2001)
Patnaik, V.V.G. et al 49

Fig. 1. Approaches to Hip Joint (a) Smith Peterson approach. (b) Somerville Bikni Incision. (c) Watson Jones lateral approach.
(d) Harris technique (e) Mc Farland Osborne technique. (f) Hardinge Modification (g) Mc Lauchlan Incision (h) Gibson’s
Postero Lateral approach. (i) Osborne’s posterior approach (j) Moore’s Southern approach (k) Ludloff’s Medial approach.

J. Anat. Soc. India 50(1) 48-58 (2001)

50
The incision is made along anterior third of
iliac crest & then along anterior border of tensor
fascia lata, curving posteriorly across the insertion
of this muscle into iliotibial tract in the sub-
trochanteric region (usually 8 to 10 cm below the
base of greater trochanter) & end there. Lateral
cutaneous nerve of thigh is saved & retracted
medially as in anterior ilio femoral approach.
Abductor muscles are reflected as in Somerville
Incision above & capsule is exposed.
(iii) Lateral Approaches :
1. Watson Jones Technique (1935) :—This is
the most commonly used approach among the
lateral approaches. The incision is begun 2.5 cm
distal & lateral to the anterior superior iliac spine &
curved distally & posteriorly over the lateral aspect
of greater trochanter & lateral surface of femoral
shaft to a point 5 cm distal to the base of trochanter
(Fig. 1c). The interval between Gluteus medius &
tensor fascia lata is often difficult to delineate.
However, Brackett (1912) pointed out that it can be
done more easily by beginning the separation
midway between anterior superior iliac spine &
greater trochanter before tensor fascia lata blends
with its fascial insertion. The capsule can be
approached through this interval. This approach is
used commonly for open reduction of fracture neck
of femur & for joint replacement surgery.
2. Harris Technique :—Harris (1973)
recommended this approach for an extensive
exposure of hip. In this, a U shaped incision is made
with its base at posterior border of greater
trochanter. It is begun 5 cm posterior & slightly
proximal to anterior superior iliac spine, curved
distally & posteriorly to posterior superior corner of
greater trochanter & then extended longitudinally for
8 cm. Finally it is curved anteriorly & distally making
2 limbs of U symmetrical (Fig. 1d). The approach
permits dislocation of femoral head both anteriorly &
posteriorly but requires an osteotomy of the greater
trochanter with the resulting risk of non union or
trochanteric bursitics. Also, as reported by Testa &
Mazus (1988), incidence of significant or disabling
hetrotropic ossification is increased by this method.
3. Mc Farland Osborne Technique (1954) :—In
this, a midlateral skin incision is made centred over
the greater trochanter, its length depending upon
amount of sub cutaneous fat (Fig. 1e) Gluteal fascia
& iliotibial tract are divided in line with skin incision.
This technique considers the gluteus medius &
vastus lateralis muscles to be in direct functional
continuity through thick periosteum covering greater
trochanter.
4. Hardinge Modification (1982) :—This is a
Surgical Incisions Lower Limb
modification of Mc Farland & Osborne (1954)
technique based on the observation that gluteus
medius inserts on the greater trochanter by a strong,
mobile tendon that curves around the apex of
trochanter. In this a posteriorly directed lazy ‘J’
incision is made centred over the greater trochanter
(Fig. 1f). Fascia lata is incised in line with skin
incision. Tensor fascia lata is retracted anteriorly &
gluteus maximus posteriorly to expose origin of
vastus lateralis & insertion of gluteus medius. These
are partially divided to reach the anterior aspect of
capsule which can be incised as desired. This
approach is used for hip replacement surgery.
5. Mc Lauchlan Incision (1984) :—It is a lateral
longitudinal skin incision centered midway between
anterior & posterior borders of greater trchanter &
extending an equal distance proximal & distal to the
tip of greater trochanter (Fig. 1g). Tensor fascia lata
is incised in line with skin incision & greater
trochanter is exposed with gluteus medius attached
proximally & vastus lateralis attached distally. The
muscles are split in line of their fibres & greater
trochanter is cut in form of 2 rectangular slices (with
osteotome) having gluteus medius attached
proximally & vastus lateralis attached distally on
both of these. One is retracted anteriorly & one
posteriorly to expose hip joint.
(iv) Postero lateral approach (Gibson, 1953) :—
In this, the proximal limb of incision is begun at
a point 6-8 cm anterior to posterior superior iliac
spine & just distal to iliac crest overlying the anterior
border of gluteus maximus muscle. It is extended
distally to anterior border of greater trochanter &
further distally in line of femur for 15-18 cm. (Fig.
1h) Iliotibial tract is incised in line with direction of its
fibres. Next, gluteus minimus et medius are divided
at their insertion to expose the capsule.
(v) Posterior approaches
In posterior approaches to the hip the joint is
exposed by cutting the posterior aspect of capsule.
These approaches are commonly used for hip
replacement surgery but less popular for open
reduction & internal fixation of fracture neck of the
femur as the superior retinacular vessels & the
ascending branch of medial circumflex femoral
artery is in jeopardy thereby leading to avascular
necrosis of the head of femur.
1. Osborne approach (1931) :—The incision is
begun 4-5 cm distal & lateral to posterior superior
iliac spine & continued laterally & distally remaining
parallel to fibres of gluteus maximus to posterior
superior angle of greater trochanter & then distally
along posterior border of greater trochanter for 5 cm
(Fig 1i). Gluteus maximus fibres are separated
parallel to skin incision. Since branches of superior
gluteal artery are in proximal half of the muscle &
those of inferior gluteal artery are in distal half of
J. Anat. Soc. India 50(1) 48-58 (2001)
Patnaik, V.V.G. et al 51

muscle so little bleeding occurs. Insertion of gluteus circumflex femoral artery is encountered when
maximus to fascia lata is divided for 5 cm exposing proximal fourth of femur & superior lateral
corresponding to long limb of incision. Piriformis & genicular artery in distal fourth. These can cause
gamelli are detached near their insertion & retracted troublesome bleeding so should be isolated &
medially. These protect the sciatic nerve & the ligated. With this method, though entire femoral
capsule is now exposed. shaft can be exposed but it can lead to scarring of
2. Moore’s approach (1959) :—It is also known vastus lateralis to prevent which postero lateral
as “Southern Exposure”. The incision is started 10 approach is used where the muscle is erased from
cm distal to posterior superior iliac spine & extended its origin on the linea aspra.
distally & laterally parallel to fibres of gluteus (iii) Postero Lateral Approach :—Here
maximus to posterior margin of greater trochanter. incision is made from base of greater trochanter to
Then it is directed distally for 10-12 cm parallel to lateral condyle (Fig. 2c). Dissection is carried out
femoral shaft (Fig. 1j). Rest of exposure is almost
posterior to vastus lateralis to reach linea aspra.
same as in osborne’s technique.
There, this muscle along with vastus intermedius
(vi) Medial Approach :—(Ludloff, 1908) It was can be erased subperiosteally. In middle third of
developed to permit surgery on a congenitally thigh, 2nd perforating branch of profunda femoris
dislocated hip. The incision is placed on medial artery has to be ligated & divided. Damage to sciatic
aspect of thigh beginning 2.5 cm distal to pubic nerve & profunda femoris vessel can be prevented
tubercle & over the interval between gracilis & by not separating long & short heads of biceps.
adductor longus muscle. (Fig 1k). A plane is
(iv) Posterior Approach :—This approach is
developed between adductor longus et brevis
rarely used. The skin is incised longitudinally in the
anteriorly & gracilis & adductor magnus posteriorly.
middle of posterior aspect of thigh from just distal to
Posterior branch of obturator nerve & neurovascular
bundle to gracilis is exposed & protected. Capsule is gluteal fold to proximal margin of popliteal fossa.
located in the floor of wound. (Fig 2d). Dissection is carried out along lateral
border of lateral head of biceps, in proximal part
(vii) Antero Medial Approach :—(Zazepan & retracting it medially, while in distal part, dissection
Gamidov, 1972) In this, a longitudinal incision is is done between this head & semitendinosis,
made 15-20 cm long, 2-3 cm medial to femoral retracting lateral head of biceps along with schiatic
artery & 2 cm distal to inguinal ligament. Pectineus
& adductor longus are exposed. Next external
pudendal & medial circumflex femoral vessels are
identified & retracted laterally. Muscles are
separated by sharp dissection & lesser trochanter is
exposed. Iliopsoas tendon is freed & capsule is
exposed.
(B) Approaches to Femur :
(i) Antero Lateral Approach :—The skin
incision is placed over the middle third of femur in a
line between anterior superior spine & lateral margin
of patella (Fig. 2a) Dissection is carried in the
interval between rectus femoris & vastus lateralis.
Vastus intermedius is divided in line with its fibres &
femur is exposed.
2a
This approach is suitable for only middle third
of femur. In proximal third, injury to lateral
circumflex femoral artery & nerve to vastus lateralis
can occur, while in distal third supra patellar pouch
is encountered which if cut can lead to knee
stiffness by formation of adhesions.
(ii) Lateral Approach :—The skin incision of
desired length is made over the lateral aspect of
Fig. 2. Approaches to Femur. (a) Antero lateral (b) Lateral (c)
thigh along a line from greater trochanter to the Postero lateral (d) Posterior (e) & (f) Lateral & Medial
lateral femoral condyle (Fig. 2b) Vastus lateralis et approaches to posterior surface of lower third of
intermedius are divided in line with direction of femur (g) Lateral approach to proximal shaft &
trochanteric region.
fibres to expose the shaft. A branch of lateral
J. Anat. Soc. India 50(1) 48-58 (2001)
52
nerve laterally. A branch of sciatic nerve, supplying
to short head of biceps may be saved or divided,
depending upon requirement of incision, because it
doesn’t compose the entire nerve supply of this part
of muscle.
The approach may damage the sciatic nerve
because of rough handling & prolonged or strenous
retraction causing disturbing symptoms after surgery
or even a permanent disability in the leg so this
approach is rarely used.
(v) Lateral approach to posterior surface of
lower 1/3rd of femur :—(Henry 1927) With knee
slightly flexed, the incision is made for 15 cm along
posterior margin of iliotibial tract following the angle
of knee to the head of fibula (Fig. 2e) Popliteal fossa
is reached between posterior border of iliotibial tract
& short head of biceps. Branches of perforating
vessels are ligated & divided, while popliteal vessels
& tibial nerve are retracted posteriorly to expose
posterior surface of femur.
(vi) Medial approach to posterior surface of
lower 1/3rd of femur :—(Henry 1927) With the
knee slightly flexed, the incision is begun 15 cm
proximal to adductor tubercle & continued distally
along adductor tendon following the angle of knee to
5 cm distal to tubercle (Fig 2f) Dissection is carried
posterior to sartorius and avoiding damage to
synovial membrane, saphenous nerve lying
posterior to sartorius & adductor tendon, retracting
large vessels & nerves posteriorly ligating & dividing
small vessels. Tabial & lateral peroneal nerve lie
latero posterior so are not encountered.
(vii) Lateral approach to proximal shaft &
trochanteric region :—This is the excellent
approach for reduction & internal fixation of
trochanteric fractures or for subtrochanteric
osteotomy. The skin incision is placed 5 cm
proximal & anterior to greater trochanter & curved
distally & posteriorly over postero lateral aspect of
trochanter & then distally over lateral surface of
thigh parllel to femur for 10cm. (Fig. 2g) Fascia lata
is divided longitudinally posterior to tensor fascia
lata to avoid splitting this muscls. Vastus lateralis
thus exposed can be erased subperiosteally from its
origin or divided. Care should be exercised to ligate
& cut perforating arteries before these retract
beyond linea aspra.
(C) Approaches to Knee Joint :—
(i) Antero Medial Approach :—It was Ist
described by Langhen beck (1874). The incision is
begun at medial border of quadriceps tendon 7–10
cm proximal to patella, curved around the medial
border of patella back towards midline to end it at or
distal to tibial tuberosity (Fig. 3a). Deep dissection is
Surgical Incisions Lower Limb
carried out between vastus medialis & medial border
of quadriceps tendon to reach the capsule.
Abbot & Carpentor (1945) pointed out that wide
access to joint can be attained in following ways :—
(a) Extending incision proximally (b)
Extending proximal past of incision
obliquely medially (c) Dividing medial alar
fold longitudinally (d) mobilising medial
part of insertion of patellar tendon
subperiosteally.
If contracture of quadriceps prevents sufficient
exposure. the tibial tuberosity may be detached &
reattached later with a screw (Fernandes, 1988).
During any of anterior medial approaches, infra
patellar branch of saphenous nerve should be
protected. Saphenous nerve courses posterior to
sartorius, pierces fascia lata between this muscle &
gracilis to become subcutaneus. It gives a large
infra patellar branch to supply, skin over anterior
medial aspect of knee. Kummel & Zazanis (1974) &
Chambers (1972) noted several variations in its
location & distribution so no single incision can
avoid it for certain. So blunt dissection is adviced
between skin & joint capsule to locate & save its
branches. Chambers (1972) reported several
incidences of unsuccessful surgeries on knee
because of neuromas in scar.
(ii) Antero lateral approach (Kochar, 1911)
:—Usually this approach is not as satisfactory as
antero medial because (i) it is more difficult to
displace patella medially than laterally (ii) it requires
a longer incision (iii) often pateller tendon must be
partly freed subperiosteally.
Incision is begun 7.5 cm proximal to patella at
insertion of vastus lateralis into quadriceps tendon,
continuing distally along lateral border of this
tendon, patella & patellar tendon to end 2.5 cm
distal to tibial tuberosity. (Fig. 3b)
(iii) Postero lateral approach :—(Henderson
1921) :—With the knee flexed at 90°, a curved
incision is made on lateral side of knee just anterior
to biceps femoris tendon & head of fibula (Fig. 3c)
thus avoiding common peroneal nerve passing over
lateral aspect of neck of fibula. The popliteus tendon
lies in between biceps tendon & fibular collateral
ligament. It is retracted posteriorly to expose postero
lateral aspect of joint capsule.
(iv) Postero Medial approach :—With knee
flexed 90°, a curved incision is made, slightly
convex anteriorly & approximately 7.5 cm long
along the course of tibial collateral ligament anterior
to relaxed tendons of semimembranosus,
semitendinosus, gracills & sartorius (Fig. (3d))
J. Anat. Soc. India 50(1) 48-58 (2001)
Patnaik, V.V.G. et al 53

Fig. 3. Approaches to knee joint. (a) Antero medial (b) Antero

lateral (c) Postero lateral (d) Postero medial (e) Medial
(f) & (g) Lateral [f-Bruser; g-Hoppenfield & Deboer] (h)
Extensile anterior (Fernandes) (i) & (j) Posterior [i-
Brackett & Osgood; j-Minkoff et al.] (k, l, m) Extensile
(Mc Connel) (n) Cave’s approach for medial meniscus.

J. Anat. Soc. India 50(1) 48-58 (2001)

54
oblique part of tibial collateral ligament is incised to
expose the capsule.
(v) Medial approach (Hoppen field & Deboer,
1984) :—Incision is begun 2 cm proximal to
adductor tubercle of femur, curved antero inferiorly
about 3cm medial to medial border of patella &
ended 6 cm distal to joint line on anterior medial
aspect of tibia. (Fig. (3e)) Saphenous nerve & its
infra patellar branch are saved. Next 3 muscles of
pes anserinus are retracted posteriorly & tibial
collateral ligament is exposed. Joint may be opened
anterior or posterior to it depending upon the need.
(vi) Lateral approach :—Lateral approaches
permit good exposure for complete excision of
lateral meniscus. These don’t require division or
release of fibular collateral ligament.
(a) Bruser Technique — (1960) :—Knee is
flexed fully so that foot rests on table. The incision is
begun anteriorly where patellar tendon crosses the
lateral joint line, continued posteriorly along joint line
ended at an imaginary line extending from proximal
end of fibula to lateral femoral condyle (Fig. 3f) Next
iliotabial tract is splitted in line of its fibres. Fibular
collateral ligament is relaxed & lying posteriorly.
Joint capsule is reached anterior to it.
(b) Brown et al (1975) Modification :—It is
done for lateral menisectomy where in addition to
Bruser approach a varus strain in created to open
the lateral joint space.
(c) Pogrund technique (1976) :—The skin
incision is begun near infero lateral aspect of patella
& curved gently distally & posteriorly for 4-5cm.
Capsule is exposed anterior to iliotibial tract.
(d) Hoppen field & Deboer technique (1984)
:—Incision is begun 3 cm. lateral to middle of
patella, extended distally over Gardy’s tubercle on
tibia to end it 4-5 cm distal to joint line. Incision is
completed proximally by curving it along the line of
femur. (Fig. (3g) Further dissection is done between
iliotibial tract anteriorly & biceps tendon with
common peroneal nerve posteriorly to expose
fibular collateral ligament.
(vii) Anterior approaches :
(a) Split Patellar approach (Insall, 1984) :—In
this a lateral parapatellar skin incision is made. Next
quadriceps tenden is split in its middle begining 8
cm proximal to patella extending distally over
middle of patella through patellar tendon to tibial
tuberosity. Longitudinal fibres of extensor
Surgical Incisions Lower Limb
mechanism are carefully separated from medial 1/2
of patella. Patella is dislocated laterally, & medial 1/
2 of qudriceps tendon retracted medially to expose
anterior surface of joint capsule.
(b) Extensile anterior approach (Fernands
(1988) :—A lateral parapatellar incision is begun 10
cm proximal to lateral joint line continued distally
along lateral border of patella, pateller tendon &
tibial tuberosity to end it 15 cm distal to lateral joint
line. (Fig. 3h).This approach allows easy access to
both medial & lateral condyles by : (i) Extensive
osteotomy of tibial tuberosity allowing proximal
reflection of patella & patellar tendon. (ii) transecting
anterior horn & anterior portion of coronary ligament
of medial or lateral meniscus or both as required.
(viii) Posterior approaches :—
These involve the structures, those if damaged
produce a proximal serious disability so a thorough
knowledge of anatomy of popliteal space is
mendatory. (Putti, 1974; Abbot & Carpenter, 1945)
1. Brackelt & Osgood (1911) technique :—In
this a curvilinear incision, 10-15 cm long is
centered over popliteal space. Its proximal
limb follows tendon of semi tendinosus
distally to level of joint, it is then curved
laterally across posterior aspect of joint for
5 cm & then distally over lateral head of
gastrocnemius (Fig. 3i) Posterior nerve of
calf is identified in popliteal fossa Ist of all
which is a guide to further dissection.
Lateral to it the short saphenous vein
pierces deep fascia to drain into popliteal
vein. Nerve is traced proximally to its
origin from tibial nerve which further helps
rests of dissection as popliteal artery &
vein lie deep to it. Later are retracted
gentally to approach posterior surface of
knee joint.
2. Minkoff et al (1987) technique :—Skin
incision is begun 1-2cm below the popliteal
crease slightly medial to midline of knee. It
is carried transversally & then curving
distally just medial & parallel to head of
fibula, ending 5-6cm distal to it (Fig 3j).
Lateral cutaneus nerve of calf, sural nerve
& common peroneal nerve are to be saved
in this dissection. This approach gives a
good exposure of posterior aspect of
lateral tibial plateau & proximal tibiofibular
joint.
J. Anat. Soc. India 50(1) 48-58 (2001)
Patnaik, V.V.G. et al
(ix) Extensile approach to knee : (McConnel,
1976 Technique)
McConnell described an extensile approach to
the knee that allows access to the anterior, posterior,
medial and lateral sides of the knee through a single
incision. In addition to excellent exposure, it leaves
an unobrusive scar. The incision has the anterier
cosmesis of a typical tansverse incision; it is hidden
by the skin creases and is less prone to hypertrophy
than a longitudinal incision. The medial extension is
partially hidden by the contralateral extremity and
the lateral extension is less noticeable because it
lies in the skin depression along the posterior border
of the iliotibial band.
With the knee in acute flexion, the transverse
anterior part of incision is made between 3 points-
i.e. medial flexion crease, lower pole of patella &
lateral flexion crease (Fig. 3k) Its lateral extension is
made proximally along posterior margin of iliotibial
tract while medial is made postero medially in a
distal direction from apex of medial flexion crease
for 9-10 cm. (Fig 31 & m respectively)
(x) Exposure of Medial Meniscus :
(i) Transverse approach :—The advantage of
this approach is that (a) scar has no contact with
femoral articular surface. (b) Convalescense is more
rapid after menisectomy through this than through
other incisions (Charmley 1948).
A 5 cm long transverse incision is made at the
level of articular surface of tibia extending laterally
from medial border of patellar tendon to anterior
border of tibial collateral ligament. Capsule is
incised along the same line to reach the meniscus.
(ii) Cave’s approach :—If posterior horn of
medial meniscus can’t be excised by transverse
approach, then this approach is useful as it allows
exposure of both anterior & posterior ends. With
knee flexed to right angle, the incision is begun 1
cm posterior to & at level with medial femoral
epicondyle. i.e. approximately 1 cm proximal to joint
line. It is carried distally anterior to a point 0.5 cm
distal to joint line & then anteriorly to border of
patellar tendon (Fig 3n)
D. Exposure of Tibia :
(i) Anterior approach :—The tibia is a
superficial bone and can be easily exposed
anteriorly without damaging any important structure
except the tendons of the tibialis anterior and
extensor hallucis longus muscles, which cross the
tibia anteriorly in its lower one fourth.
A curved incision is made on either side of
anterior border of bone. Periosteum is stripped as
little as possible because its circulation is a source
J. Anat. Soc. India 50(1) 48-58 (2001)
55
of nutrition for the bone.
(ii) Medial approach :—It is used for inserting
a bone graft in delayed union or non union. Here a
longitudinal incision is made along postero medial
border of the tibia. Periosteum is reflected from
posterior surface (Phemister, 1947).
(iii) Postero lateral approach :—This
approach is valuable in exposure of middle 2/3rd of
tibia when anterior & antero medial aspects are
badly scarred. The incision is placed along lateral
border of gastrocnemius on the postero lateral
aspect of ligament. A plane is developed between
gastrocnemius, soleus & flexor hallucis longus
posteriorly & peronei anteriorly. The approach
provides a complete exposure of flat posterior
surface of tibia except its proximal fourth which lies
in close relation to popliteus muscle, proximal parts
of posterior tibial vessels & nerve. (Harmon, 1945).
(iv) Posterior approach to superomedial
region :—(Bank & Laufman, 1953) With patient
prone, the transverse segment of hockey stick
incision is begun at lateral end of flexion crease of
knee & extended across the popliteal space. Then it
is turned distal wards along medial side of calf for 7-
10 cm (Fig 4) Deep fascia is incised in the line with
skin incision. Upper 1/4th of posterior surface of
tibia can be exposed by this incision.
Fig. 4. Posterior approach to
superomedial region of
Tibia.
E. Exposure of Fibula :—
It can be exposed by a postero lateral
approach devised by Henry (1927). The incision is
begun 13 cm proximal to lateral malleolus & then
carried proximally along posterior border of fibula to
posterior margin of its head & then further
proximally for 10 cm along posterior border of
biceps femoris, Common peroneal nerve has to be
isolated & saved in the proximal part of the incision
near the upper end.
F. Approaches to Ankle joint & tarsus :—
(i) Anterolateral approach :—gives excellent
access to the ankle joint, the talus, and most other
56
tarsal bones and joints, and it avoids all important
vessels and nerves, since so many reconstructive
operations and other procedures involve the
structures exposed, it may well be called the
“universal incision” for the foot and ankle. It permits
excision of the entire talus. The only tarsal joints
that it cannot reach are those between the navicular
and the second and first cuneiforms.
The incision is begun over antero lateral
aspect of ankle medial to fibula & 5 cm proximal to
ankle joint. It is carried distally over the joint, antero
lateral aspect of body of talus & calceneo cuboid
joint; to end at base of 4th metatarsal bone.
Superior & Inferior extensor retinaculae are incised
down to the periosteum of tibia, & capsule of ankle
joint. The dissection usually divides antero lateral
malleolar & lateral tarsal arteries while superficial &
deep peroneal nerves are saved.
(ii) Anterior approach :— It is considered
better than antero lateral approach if both malleoli
are to be exposed. Usually the approach is
developed between extensor hallucis longus &
extensor digitorum longus but Nicola (1945) advises
developing it between tabialis anterior & extensor
hallucis longus.
The incision is begun on anterior aspect of leg
7.4-10 cm proximal to ankle joint & extended distally
to about 5 cm distal to joint. Periosteum, capsule
&synovium are incised in line with skin incision.
(iii) Kocher Approach (1911) :— It gives
excellent exposure of midtarsal, subtalar & ankle
joints. From a point just lateral and distal to the head
Fig. 5. Approachjes to ankle joint. (a) Kocher’s (b) Ollier
(c) Postero lateral
Surgical Incisions Lower Limb
of the talus, curve the incision 2.5 cm inferior to the
tip of the lateral malleolus, then posteriorly and
proximally, and end it 2.5 cm posterior to the fibula
and 5cm proximal to the tip of the lateral malleolus.
(Fig. 5a)
The disadvantage of this procedure is that the
skin may slough about the margins of the incision,
especially if dislocation of the ankle has been
necessary, as in a talectomy. Further, the peroneal
tendons must usually be divided.
(iv) Ollier Approach (1892) :— This is
excellent for triple orthodesis. The skin incision is
begun over dorso lateral aspect of talo-navicular
joint, extending it obliquely infero posteriorly &
ending 2.5 cm below lateral malleolus. (Fig 5b)
Inferior extensor retinaculum is divided in line with
skin incision & dissection is extended to expose
subtalar, calcaneo cuboid & talonavicular joints.
(v) Postero lateral approach :— (Gatellier &
Chastang, 1924) Incision is begun 12 cm proximal
to tip of lateral malleolus extending distally along
posterior margin of fibula to tip of malleolus. Then it
is curved anteriorly for 2.5 cm in line of peroneal
tendons. (Fig. 5c). Peroneal retinaculae are incised
to displace the tendons anteriorly. Lateral aspect of
the joint is exposed dividing the fibula 10 cm
proximal to tip of lateral malleolus. Great care
should be used in children to avoid creating a
fracture through distal fibular epiphysis, when
reflecting fibula.
(vi) Posterior approach :— With patient
prone a 12 cm incision is made along postero lateral
border of tendo achillis down to its insertion on
calcaneus. The tendon is lengthened by Z plasty or
retracted to expose the ankle joint from posterior
aspect.
(vii) Medial approach :— It was given by
Koening & Schaefer (1929) but not a popular
method because despite utmost care it is possible to
injure tibial vessels & nerve. The other unimportant
approaches are those by Broomhead (1932) &
Colonna & Ralston (1951). For details of these, the
readers are advised to consult original articles.
G. Approaches to Calcaneus :—
(i) Medial approach :—Incision is begun 2.5
cm anterior & 4cm inferior to medial malleolus. It is
carried posteriorly along medial surface of foot to
tendo calcaneus. Abductor hallucis is retracted
dorsal wards to reach medial & inferomedial aspects
of calcaneus. Its inferior surface can be exposed
sub periosteally avoiding medial calcaneal nerve &
nerve to abductor digiti minimi.
(ii) Lateral Approach :— Incision is begun on
J. Anat. Soc. India 50(1) 48-58 (2001)
Patnaik, V.V.G. et al
lateral margin of tendo calcaneus near its insertion
& passed distally to a point 4 cm inferior & 2.5 cm
anterior to lateral malleolus. Peroneal tendons may
be divided by Z plasty if needed.
(iii) U approach:— This is used to access the
entire planter surface of calcaneus. With patient
prone, the 2 approaches described above are joined
to form a large U shaped incision around the
posterior four fifth of the bone. (Fig. 6a).
6b
Fig. 6. Approaches to Calcaneus (a) U approach (b) Curved L
approach
(iv) Split heel approach is seldom used
except for osteomyelitis of calcaneus. In this, a
midline incision is given on plantar surface of heel.
Its advantage is that the scar retracts inside so there
is no problem in weight bearing.
(v) Kocher approach (Curved L) :—It is
suitable for complete excision of calcaneus. The
skin is incised over medial border of tendo
calcaneus from a point 7.5 cm proximal to calcaneal
tuberosity to its postero inferior aspect. Then the
incision is continued transversely around the
posterior aspect of calcaneus, then distally along
lateral surface of the foot to tuberosity of 5th
metatarsal. (Fig 6b)
H. Approaches for Toes.
(i) Interphalangeal joints:—For interphal-
angeal joint of great toe, a 2.5 cm long
incision is made on medial aspect of the
toe & for interphalangeal joint of 5th toe,
a similar incision is made on lateral
aspect of 5th toe. The interphalangeal
joints of other 3 toes can be approached
through incisions made just lateral to
corresponding extensor tendons. Care
should be exercised to save dorsal or
planter digital vessels & nerve. Capsule
can be opened longitudinally or
transversely.
(ii) Metatarsophalangeal Joints.
(a) M.P. joint of great toe can be approached
in either of the 2 common ways.
J. Anat. Soc. India 50(1) 48-58 (2001)
57
Medial approach :— A 5cm long curved
incision is made on medial aspect of joint (Fig 7a). It
is begun just proximal to proximal interphalangeal
joint, curved over dorsum of metatarsophalangeal
joint medial to extensor hallucis longus tendon
ended on medial aspect of 1st metatarsus proximal
to the joint. 1st dorsal metatarsal artery & branch of
superficial peroneal nerve are retracted laterally as
these supply medial side of great toe. This exposes
the bunion over medial aspect of matatarsal head.
Then a curved incision is made through bursa &
capsule of joint. (Fig 7b) It is begun over the
dorsomedial aspect of joint, continued proximally
7a
7b
Fig. 7. Medial Approach for great toe.
(a) Skin Incision (b) Line of Incision through bursa &
capsule of Joint.
dorsal to the metatarsal head & then planter wards &
distalwards around the joint & ended distally on
medio planter aspect of matatarso phalangeal joint.
The incision forms an elliptical, racquiet shaped flap
attached to base of proximal phalanx. Although the
distal reflection of flap exposes the 1st metatarso
phalangeal joint, yet healing of the flap may be
delayed so dorso medial approach is prefered.
Dorsomedial approach :— The incision is
begun just proximal to joint continued proximally for
5 cm parallel & medial to extensor hallucis longus
tendon. Further dissection can be carried in plane of
skin incision or as in medial approach.
(b) M. P. joint of 2nd to 5th toe :— All these
are reached by dorso lateral incisions
parallel to the corresponding extensor
tendons.
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