Region specific approaches
Theory
- want to traverse one muscle / one compartment
- keep away from NV bundle
- as a rule perform open biopsy through compartment the tumour is in
- this is the compartment that will require surgical removal in wide excision
- direct approach without going through muscle if possible i.e. tibia, distal ulna
Lower Limb
Thigh
1. Lateral compartment ST tumour
- lateral approach
- through ITB
- through vastus lateralis / anterior to lateral intermuscular septum
2. Medial compartment ST tumour
- medial approach
- through gracilis
- keep away from NV bundle
3. Posterior compartment ST tumour
- posterior approach / transmuscular
Femur
1. Femoral head / neck
- depends if lesion benign or malignant
- tdranstrochanteric: for completely contained osseous tumour
- Watson-Jones: however if is malignant will consign patient to extra-articular resection
2. Subtrochanteric
- remember lesions here in elderly may be chondrosarcoma from enchondroma
- lateral approach
3. Femoral Shaft
- lateral through vastus lateralis
- anterior cortical window
4. Condyles
- medial or lateral approach
- incision through medial or lateral vastus
Popliteal fossa
Popliteal fossa / parosteal OS
- posterior approach
- go through hamstrings or gastrocnemius
- depending on whether lesion medial or lateral
Patella
Direct anterior
Tibial
1. Medial plateau proximal tibial bony tumour
- direct medial approach directly onto bone
2. Lateral plateau proximal tibial bony tumour
- through biceps femoris
- avoid CPN
3. Tibial shaft
- through tibialis anterior
4. Medial malleolus
- direct medial approach
5. Posterior distal tibia
- posterolateral approach
Fibula
1. Fibular head
- incision posterior fibular head
- expose and protect CPN
2. Fibular shaft
A. Direct lateral
- straight down to bone
- fibula / peroneals and nerve get taken in salvage
B. Posterolateral approach
3. Lateral malleolus
- direct lateral approach
Leg
1. Proximal posterior compartment ST tumour
- medial to tibia
- preserve anterolateral compartment
2. Proximal anterolateral compartment ST tumour
- direct approach through tibialis anterior
- will likely not be able to preserve CPN
Talus
1. Head and neck
- medial approach between T anterior and T posterior
- may need medial malleolar osteotomy
2. Body
- Ollier's approach
Calcaneum
Bony tumour
- direct lateral
- avoid medial NV bundles
Foot
1. Navicular / Medial cuneiform
- direct medial
2. Cuboid
- direct lateral
3. Intermediate cuneiform
- between EHL and EDC but away from dorsalis pedis
4. Lateral cuneiform
- lateral to EDC
5. Metatarsals / phalangeals
- dorsal approach
6. Soft tissue tumour
- medial or lateral as required
Pelvis
Iliac crest
- definitive surgery via ilioinguinal approach
- best to use iliac crest aspect of this approach
- can go medial or lateral to crest
Anterior column
- Watson - Jones through G medius
- avoid femoral NV bundle
Posterior column
- Kocher - Lagenbeck through G maximus
Pubis
- Pfannenstiel approach
Ischium
- lithotomy position
- detach adductor and hamstrings
Sacrum
Direct posterior approach
Upper Limb
Humerus
1. Proximal humeral bony tumour
- direct lateral
- through deltoid muscle
- never deltopectoral (condemns patient to forequarter amputation)
2. Shaft
- modified Henry
3. Distal humerus bony tumour
- lateral longitudinal to capitellum
- medial approach to trochlea
Radius
1. Proximal bony tumour
- protect radial nerve at all times
A. Radial head: Kocher approach / through anconeus
B. Proximal third: Henry approach / take off supinator
C. Middle third: Henry approach / take off pronator teres
D. Distal third: Henry approach / take off pronator quadratus
2. Distal radius
- dorsal approach as salvage is always wrist fusion
- through second compartment / sacrificeable
Wrist / Hand
1. Carpus
- dorsal approach
2. Metacarpal / phalanges
- dorsal approach
- avoid volar to preserve NV bundle
Ulna
1. Proximal ulna bony tumour
- direct subcutaneous approach
- away from ulna nerve
2. Coronoid
- posterior approach with window for biopsy
3. Distal ulna bony tumour
- direct lateral approach between FCU and ECU
- down onto subcutaneous surface of ulna
Clavicle
Clavicle
- direct subcutaneous
Scapula
Acromion - deltoid split
Spine - transverse approach
Body - Judet posterior approach
Glenoid - posterior approach, through T major
Coracoid - deltopectoral approach
Spine
C1-2 bony tumour
- anterior retropharyngeal approach
- anterior to SCM
- resect submandibular gland and ligate duct
- CN XII superiorly
- between carotid sheath and larynx
- biopsy through longus colli
C3-T1
- Smith-Robinson approach
- vertical incision
- split longus colli
T2 - T12
- posterior approach and transpedicular
- open or CT guided
L1-L5
- anterior retroperitoneal approach