Articular exposure with the swashbuckler versus a "mini- swashbuckler" approach

Objective: To quantify the articular exposure obtained with a Swashbuckler approach to the distal femur and compare this to a "Mini-swashbuckler" approach. Methods: Forty surgical approaches in 20 fresh-frozen hemipelvis specimens were performed using a Mini-swashbuckler approach followed by a traditional Swashbuckler. Key anatomic landmarks, including the posterior femoral condyles, intercondylar notch, and medial articular margin, were either directly visualised or palpated with a tonsil clamp. Calibrated digital photographs were taken from the surgeon's viewing perspective after each approach. The digital images were then analyzed using a computer software programme, ImageJ (NIH, Bethesda, MD), to calculate the articular surface square area exposed. Results: The Mini-swashbuckler exposed 87% of the articular surface compared to the Swashbuckler approach (29.48 cm² vs 34.03 cm², p < 0.0001). Key anatomic landmarks were directly visualised with both exposures in all subjects, including limbs with severe osteoarthritis. Greater exposure with the Mini-swashbuckler correlated with male gender (p < 0.05) and height (p = 0.03) but not weight or BMI. Conclusions: Although exposure is improved with the use of a Swashbuckler, this difference may not be of clinical importance, since both approaches give either direct visual or tactile access to all critical areas of the distal femur, including the trochlea, entire medial compartment, and both posterior femoral condyles. A less invasive approach allows a smaller surgical dissection without sacrificing the ability to visualise the majority of the articular surface.