The Anatomic ApproachFifth Edition

OrthopaedicsSurgical Exposures in

LWBK1531-FM.indd 1 07/20/16 5:33 PM

Copyri

ght ©

2017

Wolt

ers K

luwer

Hea

lth, In

c. Una

uthor

ized r

epro

ducti

on of

this

conte

nt is

proh

ibited

.

Stanley Hoppenfeld, M.D.Clinical Professor of Orthopaedic SurgeryAlbert Einstein College of MedicineAttending PhysicianJack D. Weiler Hospital of the Albert Einstein College of MedicineMontefiore Hospital and Medical CenterBronx, New York

Piet de Boer, M.A., F.R.C.S.Visiting LecturerUniversity of Rijeka Medical SchoolDepartment of AnatomyCroatiaCEOMedical Education Consultants GmbHZurich, Switzerland

Richard Buckley, M.D., F.R.C.S.C.Associate Professor of Orthopaedic TraumatologyUniversity of CalgaryHead, Orthopaedic TraumaDepartment of SurgeryDivision of OrthopaedicsFoothills HospitalCalgary, Alberta, Canada

Illustrations by Hugh A. Thomas

LWBK1531-FM.indd 2 07/20/16 5:33 PM

Copyri

ght ©

2017

Wolt

ers K

luwer

Hea

lth, In

c. Una

uthor

ized r

epro

ducti

on of

this

conte

nt is

proh

ibited

.

Stanley HoppenfeldPiet de BoerRichard BuckleyIllustrations by Hugh A. Thomas

The Anatomic ApproachFifth Edition

OrthopaedicsSurgical Exposures in

LWBK1531-FM.indd 3 07/20/16 5:33 PM

Copyri

ght ©

2017

Wolt

ers K

luwer

Hea

lth, In

c. Una

uthor

ized r

epro

ducti

on of

this

conte

nt is

proh

ibited

.

Acquisitions Editor: Brian BrownEditorial Coordinator: Dave MurphyMarketing Manager: Daniel DresslerProduction Project Manager: Bridgett DoughertyArt Director: Elaine KasmerArtist/Illustrator: Hugh A. ThomasManufacturing Coordinator: Beth WelshPrepress Vendor: Aptara, Inc.

5th edition

Copyright © 2017 Wolters KluwerCopyright © 2009 Lippincott Williams & Wilkins, Copyright © 2003 Lippincott Williams & Wilkins, Copyright © 1994 J.B. Lippincott Company, Copyright © 1984 J.B. Lippincott Company. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at permissions@lww.com, or via our website at lww.com (products and services).

9 8 7 6 5 4 3 2 1

Printed in China

Library of Congress Cataloging-in-Publication Data

Names: Hoppenfeld, Stanley, 1934- author. | De Boer, Piet, author. | Buckley, Richard (Richard Eric), 1958- author.Title: Surgical exposures in orthopaedics : the anatomic approach / Stanley Hoppenfeld, Piet de Boer, Richard Buckley ; illustrations by Hugh A. Thomas.Description: Fifth edition. | Philadelphia : Wolters Kluwer, [2016] | Includes bibliographical references and index.Identifiers: LCCN 2016022861 | ISBN 9781496309471Subjects: | MESH: Orthopedic Procedures–methods | Anatomy, RegionalClassification: LCC RD732 | NLM WE 168 | DDC 617.5–dc23LC record available at https://lccn.loc.gov/2016022861

This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work.

This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to the patient. The publisher does not provide medical advice or guidance and this work is merely a reference tool. Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments.

Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should consult a variety of sources. When prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work.

LWW.com

LWBK1531-FM.indd 4 07/20/16 5:33 PM

Copyri

ght ©

2017

Wolt

ers K

luwer

Hea

lth, In

c. Una

uthor

ized r

epro

ducti

on of

this

conte

nt is

proh

ibited

.

To my wife Norma,my sons Jon-David,

Robert, and Stephen,and my parents Agatha and David,

all in their own special way have made my life fulland made this book possible.

S.H.

To my wife Suzi, my three children James, Kate and Jan

and my two grandchildren Rowan and FinnP.de B.

To my wife Lois,who organizes my “whole”

life and makes it manageable,whom I respect greatly,

and my two children,Shannon and Andrew.

R.B.

Dedication

LWBK1531-FM.indd 5 07/20/16 5:33 PM

Copyri

ght ©

2017

Wolt

ers K

luwer

Hea

lth, In

c. Una

uthor

ized r

epro

ducti

on of

this

conte

nt is

proh

ibited

.

vi

One of the first pieces of advice given to one of the authors just before publication of the first edition of this book was not to spend too much time on the preface. He was assured that “few if any people read prefaces.” So why then create another preface for the fifth edition? The answer must be to inform potential readers of the changes that have been made—why they were made and what is in these changes for the reader.

The changes that have been made fall into two catego-ries—content and format.

The first edition of his book was printed in the United States on a classical printing press. All subsequent edi-tions have been electronic and about 50% of sales of the fourth edition were in the form of an electronic book. Research has shown1 that although younger surgeons gen-erally prefer electronic books, large numbers of them still like a printed copy. One respondent commented that she found “navigating a printed book easier than navigating an electronic one.” We have therefore decided to make the fifth edition available as a single package—electronic and printed.

One of the continuing successes of the book has been the diagrams. The ability of well-drawn diagrams to con-vey three-dimensional images is remarkable. Videos of surgical approaches, which are now freely available on YouTube, are often disappointing. Videos shot during live surgery with a single camera often fail to show what the viewer needs to see. The fifth edition includes videos of 17 surgical approaches. The videos were shot in HD with three different cameras on specially prepared cadaveric material. When the video is not perfectly clear we have included diagrams from the book using a split screen technique. In this way we hope to eliminate the lack of clear three-dimensional clarity that plagues most surgical approach videos.

The common theme in the evolution of surgical appro-aches in orthopaedics and traumatology over the past 32 years since the publication of the first edition of the book has been the development of minimally invasive surgery. There have been two major drivers for this process—preservation of as much blood supply to the fracture site and creating as little soft tissue damage as possible to facili-tate patient recovery following surgery.

The first edition of this book focused on subperiosteal dissection—the classic concept of orthopaedics surgery

in the 1960s and 70s—“get to bone and stay there.” Sub-periosteal dissection ensured that neighboring soft tissues were not damaged but came at a price—the destruction of local blood supply. The second edition of the book abandoned subperiosteal dissection except in exceptional circumstances (i.e., stripping supinator off the proximal radius) in favor of epiperiosteal dissection where the periosteum is preserved. The third edition introduced arthroscopy, which by that time had almost completely replaced open knee and much open shoulder surgery. The approaches for open menisectomy are still described in this edition reflecting the need in certain developing countries but will almost certainly be excluded from the sixth edition.

The fourth edition introduced minimally invasive approaches to the proximal humerus, proximal tibia, and distal tibia as well as minimally invasive spinal approaches.

What then caused us to change the contents of the book? First, our readers told us that certain existing approaches needed updating and clarification. The approaches needed for emergency decompression of a compartment syndrome of the lower leg and forearm have been enlarged and updated. We realize that this surgery needs to be performed as quickly as possible and may be done by junior surgeons who need as much help as they can get. Fixation of dis-tal radial fractures has become routine in many countries and a classic approach has been added replacing the lower end of the AK Henry approach to the whole radius that was present in previous editions.

The advent of routine CT scanning of tibial plateau inju-ries has greatly clarified the fracture anatomy of these dif-ficult injuries. The appreciation of the posterior elements in these injuries has led to the creation of two new surgical approaches to the tibial plateau—the posterior and pos-terolateral approaches.

Although acetabular surgery remains a highly specialized field that should only be done by experts or learners under expert supervision, we were aware that existing descriptions of the ilioinguinal approach were inadequate. This approach has therefore been revised to show the key points especially the iliopectineal fascia—a structure that has never been adequately illustrated. The flip osteotomy of the greater trochanter described in the fourth edition had been updated to show the step technique and the surgical dislocation of the hip has been included for the first time.

Preface

LWBK1531-FM.indd 6 07/20/16 5:33 PM

Copyri

ght ©

2017

Wolt

ers K

luwer

Hea

lth, In

c. Una

uthor

ized r

epro

ducti

on of

this

conte

nt is

proh

ibited

.

Preface vii

The lateral approach to the metatarsophalangeal joint of the hallux has been added to complement the existing dorsal and dorsomedial approaches.

After much deliberation a minimally invasive anterior approach to the hip joint had been included. The literature has been confusing with regard to long-term benefit to the patient of minimally invasive hip surgery and disturbing articles have been published with regard to malposition of implants. This approach however seems to be well established and patients do seem to recover faster—hence its inclusion.

Finally the whole text has been revised and numerous small corrections made. This would have been impossible without the invaluable help of Dr. Peter S. Saubermann, facilitator in the ORTP, University of Basel, Switzerland who has painstakingly examined every line of text and every diagram and who has suggested invaluable changes.

The strength of this book remains what it has been since its inception—clear descriptions of surgical approaches complemented by diagrams made from the point of view of the surgeon. The classical approaches remain its most popular feature. Surgeons all around the world sometimes operate with a nurse holding the book open at a key diagram. We believe that the key to safe surgery is a sound knowledge of anatomy. Paradoxically as approaches become smaller and smaller the need for anatomical knowledge becomes greater. We feel therefore that this book with its title, Surgical Exposures in Ortho-paedics—The Anatomic Approach, is more relevant today than it has ever been.

1. De Boer PG, Fox R. Changing Patterns of Life Long Learning: A Study in Surgeon Education. Stuttgart: Thieme; 2012.

LWBK1531-FM.indd 7 04/08/16 4:58 PM

Copyri

ght ©

2017

Wolt

ers K

luwer

Hea

lth, In

c. Una

uthor

ized r

epro

ducti

on of

this

conte

nt is

proh

ibited

.

viii

Surgical Exposures in Orthopaedics—The Anatomic Approach was first published in 1984, 25 years ago. The standard surgi-cal approach textbooks at the time were out of date and the principle of linking surgical anatomy to surgical approaches using incisive text and wonderfully clear diagrams (then in black and white) was greeted favorably by orthopaedists and trauma surgeons around the world. Throughout its history, this text has remained the number one best seller in its field. It has been translated into five languages and is extensively used around the world on all five continents. On many occa-sions, while travelling around the world to teach, the authors have been thanked by residents who have reported how the book has helped them, often in difficult and emergency situ-ations when working either alone or poorly supervised. It is also clear that residents particularly value those classical sur-gical approaches first described by A.K. Henry in his book on extensile approaches.

Why, then, produce a fourth edition? Standard text-books need to change to reflect those changes that occur within their sphere of interest. The difficulty with this is to differentiate between genuine and permanent changes in the practice of orthopaedics. The young surgeon must be presented with the subject in what can only be described as “the fashion of the time” that occurs in all branches of medicine, especially orthopaedics. In the first edition of the book, great emphasis was given to the concept of subperi-osteal dissection. Subperiosteal dissection ensured that the surgical approach did not damage vital structures close to the bone, but the sacrifice was significant devitalization of the bone and its surrounding soft tissues. The preservation of the blood supply to the area to be exposed has been a consistent theme in the past 24 years. The second edition of the book saw abandonment of the concept of subperiosteal dissection and the establishment of epi-periosteal planes for surgical use.

Minimal access surgery has been present in orthopaedic surgery for many years. Intramedullary nailing, through a closed technique, did not expose the fracture site and pre-served the fracture hematoma. Similarly, external fixation can be seen as an attempt to provide stability to a frac-ture site, while preserving the fracture hematoma and the natural healing processes that occur around the fracture. Arthroscopy is probably the best example of effective use

of minimal access surgery, a fact recognized by the inclu-sion of standard arthroscopic techniques for the knee and shoulder in the third edition.

The fourth edition includes many new approaches involving minimal access surgery. These approaches are used mainly in the field of traumatology and reflect the major surgical interest of two of the authors and the majority of their resident readers. New minimal access approaches are included for the humerus, distal femur, and proximal and distal tibia. New external fixation approaches are included, especially bridging fixation. New approaches for the spine and calcaneus were conspicuously absent in previous edi-tions, now part of this revision.

Minimal access surgery is a classic double edge sword. The purpose of the surgery is to preserve the biology around the site of traumatic injury and to minimize the associated soft-tissue damage in elective orthopaedic surgery. The cost of this technique is decreased visualization, and many of the techniques described require the use of imaging to be safe. C-arm technologies are now readily available throughout the world. Computer-assisted surgery is also growing rap-idly, particularly in the field of joint replacement surgery.

A big danger of minimal access surgery is inadvertent damage to vital structures. It follows, therefore, that sound knowledge of underlying anatomy is even more critical for minimal access surgery than it is for conventional open approaches. Readers are earnestly advised to study the anatomical sections of the new approaches along with the classic approaches to ensure patient safety.

We feel that the fourth edition of the book now incorpo-rates a comprehensive range of surgical approaches required for the treatment of patients with orthopaedic and trauma-tological complaints. Classic extensile surgical approaches, minimal access surgery, arthroscopy, and external fixation are all tools that a competent surgeon must be able to use to fully help patients.

Stanley Hoppenfeld, M.D.Piet de Boer, M.A., F.R.C.S.

Richard Buckley, M.D., F.R.C.S.C.

Prefaceto the Fourth Edition

LWBK1531-FM.indd 8 07/20/16 5:33 PM

Copyri

ght ©

2017

Wolt

ers K

luwer

Hea

lth, In

c. Una

uthor

ized r

epro

ducti

on of

this

conte

nt is

proh

ibited

.

ix

Since its publication in 1984, Surgical Exposures in Ortho-paedics—The Anatomic Approach has been the standard textbook for surgical approaches in orthopaedics and traumatology, regularly consulted by trainees as well as by experienced surgeons throughout the world. Its enduring success is evidence that it continues to meet a need in the practice of orthopaedics and traumatology. Why, then, a third edition?

The field of orthopaedics continues to evolve at a rapid rate. The previous edition introduced the concept of pre-serving blood supply and minimizing soft-tissue damage in fracture surgery in order to preserve the biological enve-lope of the injured bone as much as possible. In this edition we introduce three minimal access approaches to allow the surgeon to perform intramedullary nailing of the femur, tibia, and humerus. Again, we emphasize that “you should make every effort to preserve the soft-tissue attachments of the bone wherever possible. Only expose what you actually need to see to ensure an adequate surgical procedure.”

A significant development in the field has been the enormous increase in arthroscopic procedures, which have largely replaced open operations within the knee joint. Arthroscopy of the shoulder joint, similarly, is a rapidly developing approach. Therefore, this new edition intro-duces arthroscopic approaches to these joints—specifically

the anteromedial and anterolateral approaches to the knee joint, and the anterior and posterior approaches to the shoulder joint, which allow the surgeons to examine the joint and have proved acceptable to large numbers of surgeons for some time.

Although arthroscopic procedures have largely super-seded open procedures and surgery in the developed world, surgeons still need to incorporate the classic surgical approaches to the knee. These approaches and knowledge of their underlying anatomy are useful when a surgeon has to deal with an open wound with associated ligament dam-age or when operating in countries where arthroscopy is not readily available.

The third edition also contains changes in the section on acetabular approaches, particularly in the posterior approach to the acetabulum, which has become the stan-dard approach for these complex and challenging injuries.

In addition, full color has been added to all the illus-trations, enhancing their attractiveness as well as their verisimilitude.

Piet de Boer, M.A., F.R.C.S.Stanley Hoppenfeld, M.D.

Prefaceto the Third Edition

LWBK1531-FM.indd 9 07/20/16 5:33 PM

Copyri

ght ©

2017

Wolt

ers K

luwer

Hea

lth, In

c. Una

uthor

ized r

epro

ducti

on of

this

conte

nt is

proh

ibited

.

x

How do you make a good book better in a radically chang-ing orthopaedic environment? By keeping to basics and heeding the requests of our fellow surgeons who have writ-ten to us over these past nine years, since the publication of the first edition.

The emphasis on the concept of internervous planes remains a hallmark of the book. The basic principle of “do not cut round structures” is further reinforced by adding color to the nerves, arteries, and veins, which enhances the clinical dimensions of the illustrations.

New surgical approaches have been added, such as the anterolateral approach to the shoulder, the anterolateral approach to the tibia, and an improved lateral approach to the hip.

A whole new section on approaches to the acetabulum and pelvis is presented. The chapter is enriched with numer-ous original detailed surgical and anatomic drawings.

A new chapter on safe routes for percutaneous insertion of external fixators into the long bones is offered. The illus-trations with their insets provide three-dimensional clarity and location of the important neurovascular structures.

Although anatomy has clearly not changed in the past nine years, more emphasis has been given to the

preservation of the blood supply to the bone during ortho-paedic surgery. This concept is of particular importance in fracture surgery where the blood supply to the bone has often been disrupted by the original injury. Preservation of blood supply is achieved by maintaining the soft tissue envelope of the bone. The approaches described in this book necessarily describe exposure of the whole anatomical site; the illustrations demonstrate this. In clinical practice you will often only need part of the approach described. You should make every effort to preserve the soft tissue attach-ments of the bone wherever possible. Do not fall into the trap of stripping bone extensively to allow complete expo-sure of all sides of a fracture; dead bone does not unite in the fracture situation.

Only expose what you actually need to see to ensure an adequate surgical procedure. The concept of “biological fixation” of fractures relies on these principles.

Stanley Hoppenfeld, M.D.Piet de Boer, M.A., F.R.C.S.

Prefaceto the Second Edition

LWBK1531-FM.indd 10 07/20/16 5:33 PM

Copyri

ght ©

2017

Wolt

ers K

luwer

Hea

lth, In

c. Una

uthor

ized r

epro

ducti

on of

this

conte

nt is

proh

ibited

.

xi

It has often been said that successful orthopaedic proce-dures are based on a simple principle: Get to bone and stay there. Surgical Exposures in Orthopaedics: The Anatomic Approach, the product of an anatomy course for ortho-paedic surgeons that has been run at the Albert Einstein College of Medicine for the past 15 years, expands on the principle. The book explains the techniques of commonly used orthopaedic approaches and relates the regional anat-omy of the area relevant to the approach.

Safety in surgery depends on knowledge of anatomy and technical skill. The two go hand in hand; one is use-less without the other. Surgical skill can be learned only by practical experience under expert supervision. But the knowledge that underlies it must come from both book and dissection. Structurally, this book is divided into 11 chapters, each dealing with a particular area of the body. The most commonly performed approaches are described; we have omitted approaches designed only for one spe-cific procedure—they are best understood in the original papers of those who first described them. Nevertheless, the vast majority of orthopaedic procedures can be safely and successfully accomplished through the approaches we have included.

Orthopaedics is a rapidly evolving field. New proce-dures are appearing at a prodigious rate; some are dis-carded in a comparatively short time. Thus, any book that concerns itself with the specifics of operative surgery inev-itably becomes dated, sometimes even before publication. To avoid this problem, we have concentrated on getting to the bone or joint concerned, and not on what to do after. When applicable, we have included references to individual surgical procedures but without incorporating their details into our textbook.

The key to Surgical Exposures in Orthopaedics is a consis-tent organization throughout (see Table 1). Each approach is explained; then the relevant surgical anatomy of the area is discussed. When one or more approaches share anatomy, they are grouped together, with the relevant anatomical section at the end. The idea is for the surgeon to read the approach and anatomy sections together before attempt-ing a given procedure, because once the anatomical prin-ciples of a procedure are fully understood, the logic of an approach becomes clear.

SURGICAL APPROACHES

The crucial element in successful surgical approaches is exploiting internervous planes. These planes lie between muscles—muscles supplied by different nerves. Interner-vous planes are helpful mainly because they can be used along their entire length without either of the muscles involved being denervated. These approaches can gener-ally be extended to expose adjacent structures. Virtually all the classic extensile approaches to bone use internervous planes—a concept first described by A. K. Henry, who believed that if the key to operative surgery is surgical anat-omy, then the key to surgical anatomy is the internervous plane.

The approach sections are structured as follows.The introduction to each approach describes indications

and points out the major advantages or disadvantages of the proposed surgery. Significant dangers are also outlined in this section.

Prefaceto the First Edition

Table 1 Chapter Outline

I. Surgical Approach

(Introduction)

Position of Patient on Operating Table

Landmarks and Incision

Internervous Plane

Superficial Surgical Dissection

Deep Surgical Dissection

Dangers

How to Enlarge the Approach

Local Measures

Extensile Measures

II. Applied Surgical Anatomy

Overview

Landmarks and Incision

Superficial Surgical Dissection and Its Dangers

Deep Surgical Dissection and Its Dangers

Special Anatomical Points

LWBK1531-FM.indd 11 07/20/16 5:33 PM

Copyri

ght ©

2017

Wolt

ers K

luwer

Hea

lth, In

c. Una

uthor

ized r

epro

ducti

on of

this

conte

nt is

proh

ibited

.

xii Preface

The position of the patient is critical to clear, full expo-sures, as well as to the comfort of the operating surgeon.

Surgical landmarks form the basis for any incision; they are described with instructions on how to find them. The incision follows these key landmarks. Although the inci-sions described are generally straight, many surgeons pre-fer to use curved or zigzag incisions because they heal with less tension than do equivalent straight incisions.

The approaches often allow exposure of the whole length of a bone; usually, only part of an exposure is required for any given operation. The surgical dissection has been divided into superficial and deep surgical dissections for teaching purposes to reinforce the concept that each layer must be developed fully before the next layer is dissected. Adequate exposure depends on a systematic and deliber-ate technique that exploits each plane completely before deeper dissection begins.

The dangers of each approach are listed under four head-ings: nerves, vessels, muscles and tendons, and special points. The dangers are described, along with how to avoid them.

The approach section concludes with a description of how to enlarge the approach. All too often, the surgeon dis-covers that the incised exposure is inadequate. There are two ways in which the exposure can be enlarged: Local measures include extending skin incisions, reposition-ing retractors, detaching muscles, or even adjusting the light source; and extensile measures are ways in which an approach can be extended to include adjacent bony struc-tures. In approaches through internervous planes, extensile measures may permit the exposure of the entire length of the bone.

ANATOMICAL SECTIONS

The anatomy of each approach begins with a brief overview of the muscular anatomy, along with the arrangement of the neurovascular structures.

The anatomy of the landmarks relates these structures to their surroundings. The anatomy of the skin incision describes the angle between the incision and the natural

lines of skin cleavage first described by Langer—a rela-tionship that may influence the size and prominence of the resultant scar. Nevertheless, the site of a skin incision must be determined largely by safety and effectiveness and not by cosmetic considerations. Skin incisions generally avoid cutting major cutaneous nerves; where they might, the danger is clearly stated.

The anatomy of the superficial and deep surgical dissec-tion discusses the regional anatomy encountered during the approaches—not only the anatomy of the plane to be used but also that of adjacent structures that may appear if the surgeon strays out of plane. Perhaps the greatest value of knowing topographical anatomy is in cases of trauma, where the surgeon may explore wounds with confidence, aware of the potential dangers created by any given wound. Relevant clinical information on the anatomical structures is offered, but a comprehensive clinical picture is beyond the scope of this book. The origins, insertions, actions, and nerve supplies of relevant muscles are listed in legends under the muscles’ illustrations.

The anatomical and surgical illustrations are drawn from the surgeon’s point of view whenever possible, with the patient on the operating table, so that the surgeon can see exactly how the approach must look when he operates.

The anatomical terms used in Surgical Exposures in Orthopaedics are generally those used in modern anatomi-cal textbooks. Terms now in orthopaedic usage sometimes differ from them; when that occurs (for instance, with the flexor retinaculum/transverse carpal ligament), both terms are given. Variation also occurs in usage on either side of the Atlantic; we have used those terms on which the authors (one American and one English) have reached consensus. It has been said that all of orthopaedic surgical approaches can be reduced to one line: “Avoid cutting round struc-tures.” This book has been written to tell you how.

Stanley Hoppenfeld, M.D.Piet de Boer, M.A., F.R.C.S.

LWBK1531-FM.indd 12 07/20/16 5:33 PM

Copyri

ght ©

2017

Wolt

ers K

luwer

Hea

lth, In

c. Una

uthor

ized r

epro

ducti

on of

this

conte

nt is

proh

ibited

.

xiii

Acknowledgments

This book reflects the accumulated experience of many people over many decades. We should like to thank those in particular who helped us during the writing of this book.

To Richard Hutton,my long-term friend and editor, who adds organization and reality to our writings. His love of the English language is reflected in this book.

To Hugh Thomas,my long-term friend and medical illustrator, who added clarity to the book by his imaginative original illustrations, which reflect anatomic knowledge and clinical detail. In preparing the artwork for Surgical Exposures in Orthopaedics—The Anatomic Approach, he managed to draw beautifully on two continents.

To Ray Coomaraswamy, M.D.,for his help and guidance in writing the transabdominal and thoracotomy approaches to the spine. He has furthered his life experience by becoming a psychiatrist.

To David M. Hirsh, M.D.,for his detailed, expert review of the chapter on the hip and for his guidance in its presentation and clinical details.

To Barnard Kleiger, M.D.,for reviewing the chapters on the tibia and fibula and on the foot and ankle. He has been a source of inspiration to us during these years. We miss him.

To Roy Kulick, M.D.,for reviewing the chapter on the hand several times and for giving it that little extra to help its clinical tone.

To Martin Levy, M.D.,for his multiple reviews of the chapter on the knee and for his valuable suggestions and clarity of thought.

To Eric Radin, M.D.,for reviewing parts of our book in its early stages, encouraging us, and making valuable suggestions.

To Arthur Sadler, M.D.,for his review of the chapter on the femur.

To Leonard Seimon, M.D.,for reviewing the medial approach to the hip and sharing his unusual surgical experiences with us.

To Neil Cobelli, M.D.,Chairman of the Department of Orthopaedic Surgery at the Montefiore Medical Center and Director of Orthopaedic Surgery of the Albert Einstein College of Medicine, for his continued interest in teaching anatomy and surgical approaches to the resident staff.

To Jerry Sosler, M.D.,for demonstrating and reviewing the retroperitoneal approach to the spine and his positive suggestions.

To Morton Spinner, M.D.,for reviewing the chapters on the elbow and forearm, helping us with clinical details, and for sharing a lifetime of clinical and surgical experience.

To Keith Watson, M.D.,for reviewing the chapter on the shoulder.

To the British Fellows,who visit the Albert Einstein College of Medicine from St. Thomas Hospital in England each year.

Each has made a major contribution to the educational program and to our Anatomy course: Clive Whaley, Robert Jackson, David Grubel-Lee, David Reynolds, Roger Weeks, Fred Heatley, Peter Johnson, Richard Foster, Kenneth Walker, Maldwyn Griffith, John Patrick, Paul Allen, Paul Evans, Robert Johnson, Martin Knight, Robert Simonis, and David Dempster.

To the Anatomy Department of the Albert Einstein College of Medicine—in particular.

To France Baker-Cohen,who worked closely with us in establishing the course each year, and whom we miss.

LWBK1531-FM.indd 13 07/20/16 5:33 PM

Copyri

ght ©

2017

Wolt

ers K

luwer

Hea

lth, In

c. Una

uthor

ized r

epro

ducti

on of

this

conte

nt is

proh

ibited

.

xiv Acknowledgments

To Michael D’Alessandro,who has kept the rooms and cadaver material for us.

To Dr. M. Bull,Dr. E.M. Chisholm,and the Examiners of the primary fellowship in London, who convinced me that topographical anatomy was worth learning.

To Ronald Furlong,Eric Denman,and David Reynolds,for their efforts in teaching me and others operative surgery.

To Marianne Broadbent,Ken Peel,and the nursing staff and ODAs at the York District Hospital and the Purey Cust Nuffield Hospital, York, for making surgery not only possible and safe, but also for their endless good humor, which makes surgery a pleasure.To the operating staff and technicians of Princess Margaret Hospital, Swindon, and St. Thomas Hospital, London—and especially

Jim Lovegrove,for making surgery possible.

To Alan Apley,not only for providing the model for teaching, but also for writing a book that teaches.

To Professor Kinmonth,Fred Heatley,Malcolm Morrison,and John Wilkinson,for their generous help during my own orthopaedic training.

To the fellow physicians who have participated in teaching the Anatomy course over these many years: Uriel Adar, M.D., Russell Anderson, M.D., Mel Adler, M.D., Martin Barschi, M.D., Robert Dennis, M.D., Michael DiStefano, M.D., Henry Ergas, M.D., Aziz Eshraghi, M.D., Madgi Gabriel, M.D., Ralph Ger, M.D., Ed Habermann, M.D., Armen Haig, M.D., Steve Harwin, M.D., John Katonah, M.D., Ray Koval, M.D., Luc Lapommaray, M.D., Al Larkins, M.D., Mark Lazansky, M.D., Shelly Manspeizer, M.D., Mel Manin, M.D., David Mendes, M.D., Basil Preefer, M.D., Leela Rangaswamy, M.D., Ira Rochelle, M.D., Art Sadler, M.D., Jerry Sallis, M.D., Eli Sedlin, M.D., Lenny Seimon, M.D., Dick Selznick, M.D., Ken Seslowe, M.D., Rashmi Sheth, M.D., Bob Shultz, M.D., Richard Seigel, M.D., Norman Silver, M.D., Irvin Spira, M.D., Moe Szporn, M.D.,

Richard Stern, M.D., Jacob Teladano, M.D., Alan Weisel, M.D., and Charles Weiss, M.D.

To the residents who have participated in the Orthopaedic Anatomy course at the “Einstein,” who have been a continual course of stimulation and inspiration.

To Muriel Chaleff,who spent many hours helping to organize the Orthopaedic Anatomy course at the Albert Einstein College of Medicine. We owe her a great debt of gratitude for the kindness she has shown.

To Leon Strong,my first Professor of Anatomy in Medical School for a stimulating introduction to anatomy.

To Emanuel Kaplan, M.D.,whose great fund of anatomy and comparative anatomy was passed on to many of us while we were residents. His presence is still felt.

To Herman Robbins, M.D.,for his professional support and teaching of anatomy during the many sessions held in the library of the old Hospital for Joint Diseases.

To Dr. and Mrs. N.A. Shore,my long-term friends, who had a positive effect on my medical writings and clinical practice. We greatly miss them.

To Mr. Abraham Irvings,my long-term friend and accountant, who kept the financial records, helping to make this book possible.

To Ruth Gottesman,for making reading possible for all through her great endeavors at the Albert Einstein College of Medicine, Fisher Landau Center for the Treatment of Learning Disabilities.

To David “Sandy” Gottesman,in appreciation of his friendship and professional dissection of the marketplace.

To Marie Capizzuto,my long-term secretary and friend, for her professional help in making this book possible.

To Frank Ferrieri,my long-term friend, in appreciation of his help. His loss is greatly felt.

LWBK1531-FM.indd 14 07/20/16 5:33 PM

Copyri

ght ©

2017

Wolt

ers K

luwer

Hea

lth, In

c. Una

uthor

ized r

epro

ducti

on of

this

conte

nt is

proh

ibited

.

Acknowledgments xv

To Mary Kearney,my secretary, for help in communicating with the J.B. Lippincott Company and mailing and calling, and calling, and calling! We miss her.

To Tracy Davis,for English editing of the Third Edition.

To Barbara Ferrari,for her friendship, positive suggestions, and typing the Third Edition of our book.

To our secretarial staff, and Mary Ann Becchetti, who took hours out of their busy schedules to type, retype, retype, and retype the text until it was perfect.

To J. Stuart Freeman, Jr.,former Senior Editor at Lippincott Williams & Wilkins, who has befriended me over these years and has been a source of positive suggestions and inspiration.

To Robert Hurley,former Executive Editor at Lippincott Williams & Wilkins, in appreciation of his friendship and professional help in structuring the Third Edition.

To Eileen Wolfberg,former Developmental Editor at Lippincott Williams & Wilkins, in appreciation of her detailed work in keeping the production and editing of this book on track and for her good humor at all times.

To Jacques Bouchard,a special thank you to this special spine surgeon who has updated for us all of the latest minimally invasive spine techniques for the cervical, lumbar, and thoracic regions. His organization, thoroughness, and dedication to duty are exemplary. The whole team of authors commends his work.

To the Orthopaedic and Trauma Team in Geneva.A special thank you to Robin Peter, Nicolas Holzer, Jean-Yves Beaulieu, Hermes Miozzari. Panayiotis Christofilo-poulos, Tedi Cicavic, and Jean Fasel for carrying out the dissections shown in the new videos. Also thanks to Toto Gali and his team for filming them and Fredie Patane and his team for editing and final production.

LWBK1531-FM.indd 15 04/08/16 4:58 PM

Copyri

ght ©

2017

Wolt

ers K

luwer

Hea

lth, In

c. Una

uthor

ized r

epro

ducti

on of

this

conte

nt is

proh

ibited

.

xvi

Introduction xviii

Chapter One The Shoulder 1

Anterior Approach to the Clavicle 2Anterior Approach to the Shoulder Joint 4Applied Surgical Anatomy of the Anterior Approach to the Shoulder Joint 17Anterolateral Approach to the Acromioclavicular Joint and Subacromial Space 25Lateral Approach to the Proximal Humerus 29Minimally Invasive Lateral Approach to the Proximal Humerus 33Minimally Invasive Anterolateral Approach to the Proximal Humerus 36Applied Surgical Anatomy of the Anterolateral and Lateral Approaches 38Posterior Approach to the Shoulder Joint 45Applied Surgical Anatomy of the Posterior Approach to the Shoulder Joint 54Arthroscopic Approaches to the Shoulder 57Posterior and Anterior Approaches 59Arthroscopic Exploration of the Shoulder Joint through the Posterior Portal 63

Chapter Two The Humerus 71

Anterior Approach to the Humeral Shaft 72Minimally Invasive Anterior Approach to the Humeral Shaft 78Posterior Approach to the Humerus 81Anterolateral Approach to the Distal Humerus 88Lateral Approach to the Distal Humerus 93Medial Approach to the Distal Humerus 96Applied Surgical Anatomy of the Arm 98

Chapter Three The Elbow 109

Posterior Approach to the Elbow with Olecranon Osteotomy 110Posterior Approach to the Elbow without Olecranon Osteotomy 115Anteromedial Approach to the Elbow 118Posteromedial Approach to the Coronoid Process of the Ulna 122Anterolateral Approach to the Elbow 125Anterior Approach to the Cubital Fossa 131Posterolateral Approach to the Radial Head 135Applied Surgical Anatomy 139

Chapter Four The Forearm 147

Anterior Approach to the Radius 148Applied Surgical Anatomy of the Anterior Compartment of the Forearm 155Exposure of the Shaft of the Ulna 161

Contents

LWBK1531-FM.indd 16 07/20/16 5:33 PM

Copyri

ght ©

2017

Wolt

ers K

luwer

Hea

lth, In

c. Una

uthor

ized r

epro

ducti

on of

this

conte

nt is

proh

ibited

.

Contents xvii

Applied Surgical Anatomy of the Approach to the Ulna 164Posterior Approach to the Radius 165Applied Surgical Anatomy of the Posterior Approach to the Radius 171Anterior and Posterior Approaches for the Treatment of Forearm Compartment Syndrome 175

Chapter Five The Wrist and Hand 183

Dorsal Approach to the Wrist 184Applied Surgical Anatomy of the Dorsal Approach to the Wrist 193Volar Approach to the Distal Radius 196Volar Approach to the Carpal Tunnel and Wrist 200Volar Approach to the Ulnar Nerve 206Applied Surgical Anatomy of the Volar Aspect of the Wrist 210Volar Approach to the Flexor Tendons 219Midlateral Approach to the Flexor Sheaths, Proximal and Middle Phalanges 224Dorsal Approach to Phalanges and Interphalangeal Joints 227Applied Surgical Anatomy of the Finger Flexor Tendons 229Volar Approach to the Scaphoid 232Dorsolateral Approach to the Scaphoid 235Drainage of Pus in the Hand 238Drainage of Paronychia 239Drainage of a Pulp Space Infection (Felon) 240Web Space Infection 241Anatomy of the Web Space of the Fingers 243Anatomy of the Web Space of the Thumb 244Tendon Sheath Infection 244Deep Palmar Space Infection 246Drainage of the Medial (Midpalmar) Space 247Drainage of the Lateral (Thenar) Space 250Applied Surgical Anatomy of the Deep Palmar Space 252Drainage of the Radial Bursa 253Drainage of the Ulnar Bursa 255Anatomy of the Hand 257

Chapter Six The Spine 261

Posterior Approach to the Lumbar Spine 262Minimally Invasive—Posterior Approach to the Lumbar Spine 267Applied Surgical Anatomy of the Posterior Approach to the Lumbar Spine 270Anterior (Transperitoneal and Retroperitoneal) Approach to the Lumbar Spine 273Anterior Retroperitoneal Approach to the Lumbar Spine 280Applied Surgical Anatomy of the Anterior Approach to the Lumbar Spine 284Anterolateral (Retroperitoneal) Approach to the Lumbar Spine 290Posterior Approach to the Subaxial Cervical Spine 300Applied Surgical Anatomy of the Posterior Approach to the Subaxial Cervical Spine 306Posterior Approach to the C1-2 Vertebral Space 312Applied Surgical Anatomy of the Posterior Approach to the C1-2 Vertebral Space 317Anterior Approach to the Cervical Spine 318Applied Surgical Anatomy of the Anterior Approach to the Cervical Spine 324Posterolateral (Costotransversectomy) Approach to the Thoracic Spine 330Anterior (Transthoracic) Approach to the Thoracic Spine 335Posterior Approach to the Thoracic and Lumbar Spines for Scoliosis 344Applied Surgical Anatomy of the Posterior Approach to the Thoracic and Lumbar Spines 349Approach to the Posterior Lateral Thorax for Excision of Ribs 355

LWBK1531-FM.indd 17 07/20/16 5:33 PM

Copyri

ght ©

2017

Wolt

ers K

luwer

Hea

lth, In

c. Una

uthor

ized r

epro

ducti

on of

this

conte

nt is

proh

ibited

.

xviii Contents

Chapter Seven Pelvis and Acetabulum 359

Pelvis 360Acetabulum 360Anterior Approach to the Iliac Crest for Bone Graft 361Posterior Approach to the Iliac Crest for Bone Graft 364Anterior Approach to the Pubic Symphysis 366Anterior Approach to the Sacroiliac Joint 368Posterior Approach to the Sacroiliac Joint 372Applied Surgical Anatomy of the Bony Pelvis 376Ilioinguinal Approach to the Acetabulum 378Applied Surgical Anatomy of the Ilioinguinal Approach to the Acetabulum 387Posterior Approach to the Acetabulum 394

Chapter Eight The Hip 403

Anterior Approach to the Hip 405Minimally Invasive Anterior Approach to the Hip 418Anterolateral Approach to the Hip 423Lateral Approach to the Hip 433Applied Surgical Anatomy of the Anterior, Lateral, and Anterolateral Approaches to the Hip 438Posterior Approach to the Hip 444Applied Surgical Anatomy of the Posterior Approaches to the Hip and the Acetabulum 451Medial Approach to the Hip 456Applied Surgical Anatomy of the Medial Approach 461

Chapter Nine The Femur 465

Lateral Approach 466Posterolateral Approach 470Anteromedial Approach to the Distal Two-thirds of the Femur 474Posterior Approach 478Minimally Invasive Approach to the Distal Femur 483Minimally Invasive Approach to the Proximal Femur for Intramedullary Nailing 486Minimally Invasive Surgery for Retrograde Intramedullary Nailing of the Femur 494Applied Surgical Anatomy of the Thigh 497Posterior Approach to the Femur 506

Chapter Ten The Knee 509

General Principles of Arthroscopy 510Arthroscopic Approaches to the Knee 510Arthroscopic Exploration of the Knee 513Medial Parapatellar Approach 520Approach for Medial Meniscectomy 526Medial Approach to the Knee and Its Supporting Structures 533Applied Surgical Anatomy of the Medial Side of the Knee 542Approach for Lateral Meniscectomy 551Lateral Approach to the Knee and Its Supporting Structures 555Applied Surgical Anatomy of the Lateral Side of the Knee 560Posterior Approach to the Knee 563Applied Surgical Anatomy of the Posterior Approach to the Knee 570Lateral Approach to the Distal Femur for Anterior Cruciate Ligament Surgery 574

LWBK1531-FM.indd 18 07/20/16 5:33 PM

Copyri

ght ©

2017

Wolt

ers K

luwer

Hea

lth, In

c. Una

uthor

ized r

epro

ducti

on of

this

conte

nt is

proh

ibited

.

Contents xix

Chapter Eleven The Tibia and Fibula 583

Anterolateral Approach to the Lateral Tibial Plateau 585Posteromedial Approach to the Proximal Tibia 588Posterolateral Approach to the Tibial Plateau 592Posterior Approach to the Tibial Plateau 598Minimally Invasive Anterolateral Approach to the Proximal Tibia 603Anterior Approach to the Tibia 605Minimally Invasive Anterior Approach to the Distal Tibia 609Posterolateral Approach to the Tibia 611Approach to the Fibula 617Applied Surgical Anatomy of the Leg—Approaches for Decompression of a Compartment Syndrome 622Minimally Invasive Approach for Tibial Nailing 626

Chapter Twelve The Foot and Ankle 633

Anterior Approach to the Ankle 634Anterior and Posterior Approaches to the Medial Malleolus 638Approach to the Medial Side of the Ankle 644Posteromedial Approach to the Ankle 647Posterolateral Approach to the Ankle 652Lateral Approach to the Lateral Malleolus 657Anterolateral Approach to the Ankle and Hindpart of the Foot 660Lateral Approach to the Hindpart of the Foot 664Lateral Approach to the Posterior Talocalcaneal Joint 669Lateral Approach to the Calcaneus 673Applied Surgical Anatomy of the Approaches to the Ankle 675Applied Surgical Anatomy of the Approaches to the Hindpart of the Foot 683Dorsal Approaches to the Middle Part of the Foot 685Dorsal Approaches to the Metatarsophalangeal Joint of the Great Toe 688Dorsomedial Approaches to the Metatarsophalangeal Joint of the Great Toe 691Dorsolateral Approach for Bunion Surgery 693Dorsal Approach to the Metatarsophalangeal Joints of the Second, Third, Fourth, and Fifth Toes 696Dorsal Approach for Morton Neuroma 698Applied Surgical Anatomy of the Foot 700

Chapter Thirteen Approaches for External Fixation 703

The Humerus 704The Radius, Ulna, and Wrist 706The Pelvis 710The Femur 715The Tibia and Fibula 716The Ankle 717

Index 719

LWBK1531-FM.indd 19 07/20/16 5:33 PM

Copyri

ght ©

2017

Wolt

ers K

luwer

Hea

lth, In

c. Una

uthor

ized r

epro

ducti

on of

this

conte

nt is

proh

ibited

.

xx

Surgical technique in orthopaedics varies from surgeon to surgeon; the more experienced the surgeon, the fewer instruments he uses and the simpler his technique becomes. Certain principles, however, remain constant. They are listed below as they apply to each surgical section.

The position of the patient is fundamental to any approach; it is always worth taking time to ensure that the patient is in the best position and that he is secured so that he cannot move during the procedure. Operating tables are well padded, but certain bony prominences—such as the head of the fibula and greater trochanter—are not. These prominences must always be padded adequately to prevent skin breakdown and nerve entrapment during surgery. Patients who are prone must have suitable pad-ding placed under their pelvis, chest, head, and nose to allow respiration during surgery. Many different systems ensure adequate ventilation of the patient; bolsters placed longitudinally under the side of the patient are probably the best. Ventilation of the prone patient must be adequate before surgery, since repositioning of the patient during surgery is difficult and almost inevitably contaminates the sterile field.

The surgeon should be comfortable during surgery, with the patient placed at the correct height for the surgeon’s size or the table low enough to allow him to operate sitting down.

In surgery on the limbs, a tourniquet is often used to create a bloodless field, making identification of vital struc-tures easier and expediting surgery.

To apply the tourniquet, empty the limb of blood, either by elevating it for 3 to 5 minutes or by applying a soft rub-ber compression bandage. The tourniquet should be padded with a soft dressing to prevent the wrinkles (and blisters) that inevitably occur when the skin is pinched. The tour-niquet may be applied to the upper arm or thigh. Both of these areas are well muscled; the major nerves are protected from compression of the tourniquet. The inflated pressure of the tourniquet should be about 275 mm Hg in the upper limb and 450 mm Hg in the lower limb, depending on the circumference of the limb. Test the tourniquet by inflating it before applying it to the patient. In children, inflate the tourniquet to 50% above their systolic pressure. In hyperten-sive patients, inflate it 50% more than their systolic pressure. Finally, do not leave the tourniquet inflated for longer than

1 hour in the upper limb and 1½ hours in the lower limb to minimize the risk; do not use tourniquets when the periph-eral circulation of the patient is suspect or in the presence of sickle cell disease.

Partial exsanguination of the limb, which can be achieved after 2 minutes of elevation, leaves blood in the venous structures. It makes for a bloodier field during sur-gery but does make it easier to identify neurovascular bun-dles—something of immense value in, for example, lateral meniscectomy, where it is safer to identify and to coagulate the lateral inferior geniculate artery than to cut it acciden-tally, learning about it only after the tourniquet has been deflated. Deflate the tourniquet before closure to identify and to coagulate major bleeding points.

The landmarks are critical to the planning of any inci-sion. It is often convenient to mark them on the skin with methylene blue to ensure that the skin incision lines up with them.

All skin incisions heal with the formation of scar tis-sue, which contracts with time. For this reason, skin inci-sions should not cross flexion creases at 90 degrees; cutting perpendicular to flexion creases can cause contractures to develop over the involved joints. That is why incisions that cross major flexion creases are usually curved to tra-verse the crease at about 60 degrees. The techniques of the superficial and deep surgical dissections are the province of practical experience, not book knowledge. However, two techniques are frequently referred to in the book.

Subperiosteal dissection protects vital structures that lie near the bone, helping to prevent their damage by instru-ments. The rule holds true, but vital structures often lie on the periosteum itself: The posterior interosseous nerve, for instance, lies on the periosteum of the neck of the radius. The radial nerve lies on the periosteum on the back of the humerus. In these cases subperiosteal dissection must be strictly subperiosteal, something that may not be possible if the periosteum is damaged in case of fracture. The perios-teum normally detaches easily from the bone except at sites of muscle or ligament attachments where it may adhere strongly. Blunt dissection may be difficult or impossible at the sites of insertion. Note that the periosteum of children is thicker than that of adults, more easily defined, and less adherent to bone. In fracture surgery subperiosteal dissec-tion is rarely indicated except in the region of the proximal

IntroductionOrthopaedic Surgical Technique

LWBK1531-FM.indd 20 07/20/16 5:33 PM

Copyri

ght ©

2017

Wolt

ers K

luwer

Hea

lth, In

c. Una

uthor

ized r

epro

ducti

on of

this

conte

nt is

proh

ibited

.

Introduction xxi

radius and the center of the humeral shaft. Subperiosteal stripping will destroy the periosteal supply of blood to the bone and if extensive will devitalize the fracture site. In such cases periosteal stripping is only permissible to allow accurate reduction of the fracture. The more experienced the surgeon becomes, the less soft-tissue damage he will need to create to allow accurate visualization and reduction of the fracture.

The second technique is that of detaching a muscle from the bone. Remember to strip into the acute angle that fibers make with the bone to which they attach. This is perhaps clearest in the fibula: To detach the peroneal muscles, pass an elevator from distal to proximal; to detach the interos-

seous membrane, where fibers run in a different direction, strip from proximal to distal.

Exposures can be improved in two ways. Local measures enhance the immediate exposure. Extensile measures allow the surgeon to expose adjacent bony structures. It is vital to appreciate that not all approaches are extensile: Specialized approaches should be used only in cases where the pathol-ogy is accurately pinpointed and where the surgeon does not have to expose any adjacent structures. Inadequate exposure is one of the most common causes of surgical fail-ure. If the surgeon is in difficulty, one of the first things he should try is to improve the exposure either by local or by extensile means.

LWBK1531-FM.indd 21 07/20/16 5:33 PM

Copyri

ght ©

2017

Wolt

ers K

luwer

Hea

lth, In

c. Una

uthor

ized r

epro

ducti

on of

this

conte

nt is

proh

ibited

.

xxii

Video List

Anterior Approach to the Ankle Approaches for Decompression of Lower Leg Compartment

SyndromeApproach to the Cubital Fossa Dorsal Approach to the WristForearm ApproachIllioinguinal Approach to the AcetabulumLateral Approach to the CalcaneusLateral Approach to the Hip Minimally Invasive Anterior Approach to the Hip

Minimally Invasive Approach to the Distal Femur Minimally Invasive Lateral Approach to the Proximal

HumerusPosterior Approach to the Acetabulum with Surgical

Dislocation of the HipPosterior Approach to the Distal Humerus Posterior Approach to the Tibial Plateau Posterolateral Approach to the AnkleVolar Approach to the Distal RadiusVolar Approach to the Flexor Tendons

LWBK1531-FM.indd 22 04/08/16 4:57 PM

Copyri

ght ©

2017

Wolt

ers K

luwer

Hea

lth, In

c. Una

uthor

ized r

epro

ducti

on of

this

conte

nt is

proh

ibited

.

The Anatomic ApproachFifth Edition

OrthopaedicsSurgical Exposures in

LWBK1531-FM.indd 23 07/20/16 5:33 PM

Copyri

ght ©

2017

Wolt

ers K

luwer

Hea

lth, In

c. Una

uthor

ized r

epro

ducti

on of

this

conte

nt is

proh

ibited

.

LWBK1531-FM.indd 24 07/20/16 5:33 PM

Copyri

ght ©

2017

Wolt

ers K

luwer

Hea

lth, In

c. Una

uthor

ized r

epro

ducti

on of

this

conte

nt is

proh

ibited

.