Swashbuckler Approach

Swashbuckler approach or modified anterior approach to the distal femur allows surgical exposure of the entire articular surface of the distal femur.

Modified anterior approach: Quadriceps muscle bellies are spared during this approach

The patient is kept in a supine position with the knee flexed over a roller or triangle pillow

A skin incision of the swashbuckler approach is from tibial tuberosity and extends upward in the midline as per need.

The incision is extended directly down to the fascia of the quadriceps and incised in line with the skin incision

Subcutaneous fat is cut in the line of the incision and dissected

Tensor fascia lata is split and retracted

The vastus lateralis muscle is detached from the lateral intermuscular septum and is retracted laterally and the quadriceps anteriorly

Perforating vessels are ligated and vastus lateralis is elevated completely to expose the distal femur

A superior lateral patella plate is identified

Patella along with the quadriceps belly can be repeated by exposing the anterior knee joint

Raise the belly of the quadriceps to deflect the belly medially

Femur is exposed

If adequate visualization is not available: Tibial tuberosity osteotomy and reattaching are done

Drawbacks of the Swashbuckler approach

Injury to lateral supply to the anastomotic patellar ring which causes anterior knee pain and patellar stress fractures