Introduction Indications helpful for exposure of entire length of femur ORIF especially supracondylar femur fractures open reduction for IMN passage for femoral shaft fractures treatment of femoral nonunions femoral osteotomies treatment of chronic or acute osteomyelitis biopsy and treatment of bone tumors Internervous plane Between vastus lateralis (femoral nerve) lateral intermuscular septum covering the hamstring muscles (sciatic nerve) Preparation Anesthesia general spinal, epidural, and/or femoral blocks Position supine with sandbag below buttock lateral decubitus Tourniquet can be applied for distal femur surgery Approach Incision landmarks palpate lateral femoral epicondyle for distal landmark make incision longitudinal on the posterolateral aspect of the thigh continue proximally along the posterior part of the shaft Superficial dissection through tensor fascia lata Deep dissection reflect vastus lateralis anteriorly and dissect between it and lateral intermuscular septum easier to identify plan distally can continue vastus lateralis elevation until linea aspera is seen incise the periosteum and continue dissection on top of femur helpful to place homan retractors over anterior and posterior aspects of femur Dangers Perforating branches of profunda femoris artery at risk as they pierce lateral intermuscular septum should be ligated to prevent hematoma Superior lateral geniculate vessels at risk distally near femoral condyles should be ligated to prevent hematoma