Hip Anterolateral Approach (Watson-Jones)

(OBQ11.186) A 67-year-old male with severe hip arthritis presents for evaluation of a total hip
arthroplasty. The patient is requesting a minimally invasive Watson-Jones approach, as he has
heard post-operative mobility is significantly improved compared with a traditional transgluteal
technique. What should the patient be told to expect regarding early post-operative gait kinematics
when comparing these surgical approaches? Review Topic
1.

2.

The minimally invasive Watson-Jones approach results in improved gait velocity, cadence, and
step length
There is no difference in early gait kinematics between the two approaches

3.

The minimally invasive Watson-Jones approach results decreased gait velocity and stride length

4.

The traditional transgluteal approach results in worse early gait kinematics

5.

Early gait kinematics is dependent only on the type of prosthesis used, not surgical approach
PREFERRED RESPONSE 2
Despite the recent enthusiasm for minimally invasive hip surgery, there has been no proven benefit
with regards to early post-operative gait kinematics when comparing the minimally invasive WatsonJones approach with the more traditional transgluteal approach in total hip arthroplasty (THA).
The minimally invasive Watson-Jones approach involves making an incision 8cm in length from the
anterior tubercle of the greater trochanter on a line running from the trochanteric crest to the anterior
superior iliac spine (ASIS).The interval between the gluteus medius and the tensor fascia lata is then
identified and an extra-articular exposure of the capsule can be obtained.
The traditional transgluteal approach involves making a longitudinal incision centered over tip of
greater trochanter, followed by superficial dissection in which the fascia lata is split to expose tendon
of gluteus medius. Deep dissection is carried out by making a longitudinal incision in fibers of gluteus
medius, and then detaching the origin of gluteus minimus from anterior greater trochanter. Finally,
exposure of the anterior joint capsule and capsulotomy can be completed.
Pospischill et al evaluated 20 patients who underwent a primary THA with use of a minimally
invasive modified Watson-Jones approach compared with a group of 20 patients who underwent a
THA with use of a standard transgluteal Hardinge approach. At 3 months, the authors found no
significant benefit for patients who underwent a total hip arthroplasty through a minimally invasive
Watson-Jones approach in comparison with those who were managed with a standard transgluteal
approach.
Pfluger et al compared 50 conventional total hip replacements with 50 procedures performed using
the minimally invasive anterolateral modification of the Watson-Jones approach in terms of blood
loss and the duration of the operation. They found that both groups were virtually identical with
respect to average blood loss and the duration of the procedure.

Knee Arthroscopy
(OBQ05.69) When performing an aspiration or intra-articular injection in the knee, the most accurate
needle placement site is which of the following? Review Topic
1.

At the site of maximal tenderness

2.

Medial to patellar tendon with knee flexed

3.

Lateral to patellar tendon with knee flexed

4.

Medial to proximal patella with knee in extension

5.

Lateral to the patella with knee in extension

PREFERRED RESPONSE 5
Intra-articular administration of medications has been shown to be highest with the injection
performed lateral to the middle to proximal patella with the knee in extension. Extension allows
greater patellar mobility and increases the available space in the patellofemoral joint compared to
flexion. A lateral starting point when injecting into the patellofemoral joint has less overlying soft
tissue than medial, which makes it easier to palpate the bony landmarks and evert the patella.
Jackson et al. evaluated 240 consecutive injections in patients without clinical knee effusion placed
anteromedial, anterolateral, or lateral midpatellar. Using fluoroscopy to confirm location, accuracy
rates were highest for the midlateral portal (93%) compared to anteromedial (75%) or anterolateral
(71%).

Posterior Approach to Elbow

Author: David Abbasi
Topic updated on 08/08/14 4:12pm

(OBQ12.238) Which of the following has been associated with transposition of the ulnar nerve
following fixation of an intra-articular distal humerus fracture? Review Topic
1.

Decreased incidence of ulnar neuropathy

2.

Increased incidence of ulnar neuritis

3.

Increased infection rate

4.

Faster return to function

5.

Decreased medial hardware irritation

PREFERRED RESPONSE 2
Transposition of the ulnar nerve after ORIF of an intra-articular distal humerus fracture has been shown to
be associated with an increased incidence of ulnar neuritis.
Ulnar neuritis is a common complication associated with fixation of distal humerus fractures. The
most common etiology of ulnar neuritis include irritation from the initial trauma or at the time of
surgical intervention. Direct comparison of similar groups with and without transposition indicate that
transposition of the ulnar nerve MAY NOT be helpful in preventing the development of ulnar neuritis
after distal humerus fractures.
Chen et al. retrospective reviewed the incidence of postoperative ulnar nerve dysfunction with or
without ulnar nerve transposition. That found that the symptoms of ulnar neuritis occurred almost
four times more frequently in the transposition group (16 of 48 [33%]) compared to the group without
transposition (eight of 89 [9%]; P = 0.0003).
Vazquez et al. retrospectively reviewed 70 patients to determine the incidence of ulnar nerve
dysfunction after open reduction and internal fixation of distal humerus fractures. Seven patients
(10%) had neuropathy symptoms in the immediate postoperative period from fixation of an intraarticular distal humerus fracture. Four were transposed (P = 0.67). They concluded that no treatment
factors, including nerve transposition, were found to increase the risk of intra-operative ulnar nerve
injury.
Illustration A shows transposition of the ulnar nerve anterior to the medial epicondyle.
Incorrect Answers:
Answer 1: Transposition of the ulnar nerve increases (or does not affect) the incidence of ulnar nerve
neuropathy. No literature supports a decreased incidence of neuropathy.
Answer 3: There is no association between ulnar nerve transposition and infection rates.
Answer 4: Transposition of the ulnar nerve increases ulnar neuritis, which has been shown to slow
return of elbow function.
Answer 5: There is no known association between ulnar nerve transposition and medial hardware
irritation.

Dorsal Approach to Radius (Thompson)

(OBQ04.214) The proximal aspect of the posterior approach (Thompson) to the radius involves what
surgical interval? Review Topic
1.

Extensor carpi radialis brevis and extensor carpi radialis longus

2.

Extensor carpi radialis brevis and extensor digitorum communis

3.

Supinator and brachioradialis

4.

Extensor carpi radialis longus and brachioradialis

5.

Extensor digitorum communis and brachioradialis

PREFERRED RESPONSE 2
The Thompson (posterior) approach to the radius involves the interval between the radial nerve and
the posterior interosseous nerve (a branch of the radial nerve proper). Proximally, the interval is
between the ECRB (radial nerve) and the EDC (PIN), whereas more distally, the interval is between
the ECRB (radial nerve) and EPL (PIN). The approach can simply be thought of as between the
muscles of the mobile wad compartment, and those of the dorsal compartment.

Femur Anteromedial Approach

(OBQ04.31) Hunter's Canal is bordered by what two muscular compartments?
1.

Anterior and lateral compartments of the leg

2.

Lateral and posterior compartments of the leg

3.

Anterior and medial compartments of the thigh

4.

Medial and posterior compartments of the thigh

5.

Anterior and posterior compartments of the forearm

Review Topic

PREFERRED RESPONSE 3
Hunters canal is also known as the adductor canal, which runs behind the sartorius muscle. It is
located between the anterior and medial thigh compartments. The femoral artery and vein pass
through the canal enroute to the space posterior to the knee, the popliteal fossa. Also found in
Hunter's canal are the saphenous nerve and the nerve to vastus medialis, both branches of the
femoral nerve.
Illustration A depicts Hunter's canal with the saphenous nerve passing through it.

Knee Medial Parapatellar Approach

(OBQ10.172) During a total knee arthroplasty using a standard medial parapatellar approach, if a
lateral parapatellar release is required, special attention should be made to preserve which of the
following arteries? Review Topic

1.

Superior lateral genicular

2.

Inferior lateral genicular

3.

Anterior recurrent tibial

4.

Middle genicular

5.

Descending branch of lateral femoral circumflex

PREFERRED RESPONSE 1
The superior lateral genicular artery is the one at greatest risk with a lateral release of the patella.
After a standard medial parapatellar approach to the knee with excision of the fat pad and lateral
meniscus, the superior lateral genicular artery is likely the only remaining blood supply to the patella.
The review article by Kelly emphasizes that the superior lateral genicular artery should be preserved
when possible with the release as it may be the last extraosseous blood supply to the patella.
Resurfacing of the patella further decreases blood supply to the patella by damaging the
intraosseous blood supply of the patella. Illustration A demonstrates the anastomosis network of
arteries surrounding the patella.

Ankle Anterolateral Approach

(OBQ11.6) A 34-year-old female sustains a pilon fracture after jumping from a ledge. An
anterolateral approach is used to obtain plate fixation as shown in Figure A. Which of the following
nerves is MOST at risk during an anterolateral incision and exposure of the fracture as indicated by
the arrow in Figure A? Review Topic

1.

Superficial peroneal nerve in the anterior compartment

2.

Deep peroneal nerve in the anterior compartment

3.

Sural nerve in the superficial posterior compartment

4.

Saphenous nerve in the superficial posterior compartment

5.

Posterior tibial nerve in the deep posterior compartment