Orthopaedic surgical approaches 2022, Dec, 30 | 12:00 am

APPROACHES TO THE The Tibia and Fibula

APPROACHES TO THE The Tibia and Fibula

 

 

 

The Tibia and Fibula

 

 

 

Anterolateral Approach to the Lateral Tibial Plateau Posteromedial Approach to the Proximal Tibia Posterolateral Approach to the Tibial Plateau Posterior Approach to the Tibial Plateau

Minimally Invasive Anterolateral Approach to the Proximal Tibia Anterior Approach to the Tibia

Minimally Invasive Anterior Approach to the Distal Tibia Posterolateral Approach to the Tibia

Approach to the Fibula

Applied Surgical Anatomy of the Leg—Approaches for Decompression of a Compartment Syndrome

Minimally Invasive Approach for Tibial Nailing

 

The tibia and fibula are approximately equal in length but are different in structure and function. The tibia is large, transmits most of the stress of

walking, and has a broad, accessible subcutaneous surface. The fibula is slender and plays an important role in ankle stability as well as taking one-sixth of the load. It is surrounded by muscles, except at its ends. Surgical approaches to the shaft of the fibula are more complex than are those to the tibia, because of both the depth of the bone and the presence of the common peroneal nerve, which winds around its upper third.

There are two main approaches to the tibial shaft. The anterior approach is used most often because it affords easy access to the subcutaneous surface of the bone. The posterolateral approach is rarely used but can save the limb when skin breakdown has made anterior approaches impossible. This approach is most often used for bone grafting for nonunited fractures.

Four surgical approaches are described for access to the tibial plateau. They are all used only for fracture surgery. The anterolateral approach to the tibial plateau gives access to the anterior two-thirds of the lateral tibial plateau and is the workhorse incision used to treat most tibial plateau fractures. The posteromedial approach to the tibial plateau is used to access the medial tibial plateau and is often used together with the anterolateral approach to treat complex proximal tibial fractures (Schatzker Types 5 and 6). The posterolateral approach to the tibial plateau is used to access the posterolateral corner of the tibial plateau and only gives limited access to that area of the bone. The posterior approach to the tibial plateau gives access to the posterior column of the tibial plateau without endangering the neurovascular contents of the popliteal fossa (Fig. 11-1).

 

 

Figure 11-1 The proximal tibia can be approached by four different approaches— anterolateral, posteromedial, posterolateral, and posterior.

 

The minimally invasive anterolateral approach to the proximal tibia utilizes two windows—the proximal which is part of the anterolateral approach to the tibial plateau and the distal which is part of the anterior approach to the tibial shaft.

The minimally invasive anterior approach to the distal tibia is used for percutaneous plating of multifragmentary fractures of the distal tibial metaphysis.

The anatomy of the leg is described in a single section together with the approaches necessary to treat an acute compartment syndrome.

The majority of tibial shaft fractures treated operatively are treated by the insertion of intramedullary nails. The minimally invasive approach for tibial nailing is used in this technique.

 

Anterolateral Approach to the Lateral Tibial Plateau

 

 

The anterolateral approach to the lateral tibial plateau offers safe access to the lateral tibial plateau for:

  1. Open reduction and internal fixation of fractures of the lateral tibial plateau

  2. Bone grafting for delayed union and nonunion of fractures

  3. Treatment of osteomyelitis

  4. Excision and biopsy of tumors

  5. Harvesting of bone graft

The soft tissue covering of the proximal tibia is thin and delicate consisting of skin and underlying fascia only. Soft tissue problems are common in this area and massive swelling or blistering can occur, particularly following high-velocity trauma. Careful assessment of the soft tissues is critical before surgery, and definitive treatment of fractures in this area is frequently delayed to allow swelling to subside and the soft tissues to recover. The anterolateral approach is preferred to a direct anterior approach to the tibia because the skin incised in the anterolateral approach does not directly overlay the bone and because less skin retraction is necessary to access the middle third of the lateral aspect of the lateral tibial plateau.

 

Position of the Patient

 

Place the patient supine on a radiolucent table. Place a firm wedge beneath the knee to flex the joint to approximately 60 degrees (Fig. 11-2). Place a

small bag underneath the buttock to correct the normal external rotation of the lower limb. This will ensure that the patella is facing directly anteriorly. Exsanguinate the limb either by elevating it for 3 to 5 minutes or by applying a soft rubber bandage. Then inflate a tourniquet.

 

 

 

Figure 11-2 Place the patient supine on a radiolucent table, with a firm wedge beneath the knee to flex the joint to approximately 60 degrees.

 

 

Figure 11-3 Make an inverted L-shaped incision. Start approximately 1 to 3 cm distal to the joint line, staying just lateral to the border of the patella tendon. Curve the incision anteriorly over Gerdy tubercle and extend it distally, staying about 1 cm lateral to the anterior border of the tibia.

 

Landmarks and Incision

Landmarks

Palpate the shaft of the proximal tibia along its anterior border. Identify the position of the lateral joint line of the knee by flexing and extending the joint. Palpate Gerdy tubercle just lateral to the patella tendon. All these landmarks are easily palpable, even in an obese patient.

Incision

Make an inverted L-shaped incision. Start approximately 1 to 3 cm distal

to the joint line, staying just lateral to the border of the patella tendon. Curve the incision anteriorly over Gerdy tubercle and then extend it distally, staying about 1 cm lateral to the anterior border of the tibia (Fig. 11-3). The exact length of the incision depends on the pathology to be treated and the implant to be used.

 

Internervous Plane

 

There is no internervous plane in this approach. The dissection is essentially epiperiosteal and does not disturb the nerve supply to the extensor compartment.

 

Superficial Surgical Dissection

 

Deepen the incision proximally through subcutaneous tissue to expose the lateral aspect of the knee joint capsule. Incise the knee joint capsule transversely just below the lateral meniscus. Take care not to divide the lateral meniscus inadvertently. Below the joint line, deepen the incision through subcutaneous tissue and incise the fascia overlying the tibialis anterior muscle (Fig. 11-4).

 

Deep Surgical Dissection

 

Proximally enter the knee joint by dividing the synovium. Carefully detach the lateral meniscus from its soft tissue attachments inferiorly and develop a plane between the undersurface of the lateral meniscus and the underlying tibial plateau. Insert stay sutures to the periphery of the meniscus to facilitate reattachment during closure. Ensure that the anterior attachment of the meniscus remains intact. Detach a sufficient amount of the meniscus to allow adequate visualization of the superior surface of the lateral tibial plateau. Using an elevator inferiorly detach some of the origin of tibialis anterior from the proximal tibia. Try to work in a plane between the periosteum and the muscle (Fig. 11-5).

 

 

Figure 11-4 Deepen the incision proximally through subcutaneous tissue to expose the lateral aspect of the knee joint capsule. Incise the knee joint capsule transversely just below the lateral meniscus. Take care not to divide the lateral meniscus inadvertently. Below the joint line, deepen the incision through subcutaneous tissue to expose the fascia overlying the tibialis anterior muscle.

 

 

Dang

 

 

Nerves

The deep branch of the peroneal nerve has a variable course. Normally, it lies well posterior to the area of dissection and it should not be injured.

The lateral meniscus has to be detached from some of its soft tissue attachments inferiorly to allow adequate visualization of the articular surface of the tibia. Take care not to completely detach it, preserving anterior and posterior attachments, however. It is at most risk during the

incision of the knee joint synovium.

 

How to Enlarge the Approach

Local Measures

Application of a distractor or external fixator to the lateral aspect of the knee between the femur and the tibia allows a varus distraction force to be applied to the knee joint, thereby opening up the lateral compartment.

Extensile Measures

 

Proximal Extension. To extend the approach proximally, continue the skin incision along the lateral aspect of the patella, then curve posteriorly over the lateral aspect of the distal femur. Deepen the incision through the lateral joint capsule to gain access to the knee joint and the distal femur proximally.

 

Distal Extension. To extend the approach distally, continue the incision in a longitudinal fashion, remaining 1 cm lateral to the anterior border of the tibia. Extend it all the way down to the ankle proximally. Deep dissection, either by splitting the tibialis anterior muscle or by detaching it from the lateral aspect of the tibia, allows access to the tibial shaft down to its distal quarter.

 

 

Figure 11-5 Proximally enter the knee joint by dividing the synovium. Carefully detach the lateral meniscus from its soft tissue attachments inferiorly and develop a plane between the undersurface of the lateral meniscus and the underlying tibial plateau. Distally incise the fascia overlying the tibialis anterior muscle. Mobilize the muscle belly from the lateral aspect of the tibial shaft.

 

Posteromedial Approach to the Proximal Tibia

 

 

Complex fractures of the tibial plateau often involve a large posteromedial fragment. Accurate reduction of this fragment onto the tibial shaft is critical to allow reconstruction of the joint and is often the first stage in surgery of bicondylar tibial plateau fractures. Plates applied to the

posteromedial aspect of the tibia prevent varus deformity, the most common deformity of the proximal tibia after fracture. Biomechanically, these plates are on the compression side of the bone and function as buttress plates. Another potential advantage of the approach is that the skin and soft tissues on the posteromedial aspect of the tibia are usually free from blisters that commonly occur on the anterior portion of the tibia following trauma. However, if the soft tissues on the posteromedial aspect of the proximal tibia are poor, surgery must be delayed until the soft tissue conditions have improved.

The indications for this approach include:

  1. Open reduction and internal fixation of fractures of the medial tibial plateau (Schatzker Type 4)

  2. Open reduction and internal fixation of complex bicondylar tibial plateau fractures (Schatzker Types 5 and 6)

  3. Upper tibial osteotomy

  4. Drainage of abscess

  5. Biopsy of tumors

 

Position of the Patient

 

Place the patient supine on a radiolucent table and ensure that adequate visualization of the fracture can be obtained using an image intensifier. Position a sandbag beneath the contralateral hip to roll the patient approximately 20 degrees (Fig. 11-6). This will increase the external rotation of the affected limb, bringing the posteromedial corner of the tibia forward. Ease of access is also improved if the surgeon stands on the opposite side of the table from the approach. Exsanguinate the limb by elevating it for 3 to 5 minutes or by applying a soft rubber bandage. Inflate a tourniquet.

 

 

Figure 11-6 Place the patient supine on a radiolucent table. Position a sandbag beneath the contralateral hip to roll the patient approximately 20 degrees.

 

Landmarks and Incision

Landmarks

The upper end of the tibia is triangular and the posteromedial surface where the tibia flares is easily palpated, even in very obese individuals.

Incisions

Make a 6-cm longitudinal incision overlying the posteromedial border of the proximal tibia. The exact length of the incision will depend on the pathology to be treated and the implant to be used (Fig. 11-7).

 

Internervous Plane

There is no internervous plane in this approach. The plane between the bone and the gastrocnemius muscle is utilized.

 

Superficial Surgical Dissection

 

Deepen the incision through the subcutaneous fat. The long saphenous vein and the saphenous nerve will be just anterior to the surgical approach; these structures should be identified and preserved. Identify the pes anserinus expansion overlying the tibia (Fig. 11-8A).

The tibia can be approached using two different techniques.

Direct approach—Divide the pes anserinus longitudinally in the line of the skin incision. This technique has the advantage of simplicity but repair of the pes is difficult during closure especially since a plate will almost always have been applied to the bone.

Pes reflecting approach—Identify the anterior border of the pes which is the anterior border of the sartorius tendon. Reflect the sartorius tendon posteriorly entering the bursa underneath the tendon. Identify the tendons of gracilis and semitendinosus and reflect all three tendons posteriorly partially resecting them from their insertion into the tibia (Fig. 11-8B).

 

Deep Surgical Dissection

 

The posteromedial border of the tibia is now revealed. To facilitate plate placement develop an epiperiosteal plane between the pes anserinus and the medial head of the gastrocnemius at the posteromedial border of the tibia. The muscle can be gently freed from the bone by blunt dissection (Fig. 11-9).

 

 

Figure 11-7 Make a 6-cm longitudinal incision overlying the posteromedial border of the proximal tibia. The exact length of the incision will depend on the pathology to be treated and the implant to be used.

 

 

Dang

 

 

Vessels

The saphenous nerve and vein are encountered during the superficial

surgical dissection and should be preserved and protected.

 

How to Enlarge the Approach

Proximal Extension

To reach the posteromedial corner of the knee, the incision may be extended proximally around the medial border of the tibia. Access to the popliteal artery and vein for vascular surgery is also possible through this extension.

Distal Extension

To extend the approach distally, continue down along the medial side of the posteromedial tibia. Not only will this give you access to the posteromedial border of the tibia, but it also provides access to both the superficial and deep posterior compartments of the leg for compartment release.

 

 

 

Figure 11-8 A: Deepen the incision through the subcutaneous fat. The long saphenous vein and the saphenous nerve will be just anterior to the surgical approach; these structures should be identified and preserved. Identify the pes anserinus expansion overlying the tibia. B: To approach the tibia, either divide the

pes anserinus longitudinally in the line of the skin incision or identify the anterior border of the pes and partially resect it from its insertion into the tibia, reflecting it posteriorly.

 

 

 

Figure 11-9 Develop an epiperiosteal plane between the pes anserinus and the medial head of the gastrocnemius at the posteromedial border of the tibia. The muscle can be gently freed from the bone by blunt dissection.

Posterolateral Approach to the Tibial Plateau

 

 

The posterolateral approach to the tibial plateau is used exclusively for treatment of tibial plateau injuries involving the posterolateral corner of the plateau which require the application of a buttress plate to that aspect of the bone (Fig. 11-10).10,11

 

Position of the Patient

 

Exsanguinate the limb by elevating it for 3 to 5 minutes and apply a tourniquet. Place the patient prone on the operating table. Allow the limb to naturally externally rotate. Place a small pillow under the ankle to flex the knee approximately 20 degrees (Fig. 11-11).

 

Landmarks and Incisions

 

Palpate the fibular head about 2 to 3 cm below the lateral femoral condyle.

Incision

Make a 10-cm longitudinal incision on the posterolateral aspect of the lower leg. Begin 2 cm above the knee crease and extend the incision distally to follow the medial border of the fibular head and neck (Fig. 11-12).

 

 

Figure 11-10 Area of bone exposed by the posterolateral approach to the tibial plateau.

 

Internervous Plane

 

In common with most local surgical approaches which are not extensile no internervous plane is available for use.

 

Superficial Surgical Dissection

 

Carefully incise the deep fascia along the posterior border of the biceps femoris tendon. Palpate the common peroneal nerve which runs down beneath the tendon and isolate the nerve taking care not to apply traction to it (Fig. 11-13). Develop a plane between the biceps tendon and the common peroneal nerve laterally and the lateral head of the gastrocnemius muscle medially. Retract the biceps tendon laterally and the lateral head of the gastrocnemius medially to expose the underlying popliteus muscle (Figs. 11-14 and 11-15).

 

 

Figure 11-11 Place the patient prone on the operating table with a small pillow under the lower tibia to flex the knee approximately 20 degrees.

 

 

Figure 11-12 Make a 10-cm longitudinal incision beginning 2 cm above the knee crease following the medial border of the fibular head and neck.

 

 

 

Figure 11-13 Incise the deep fascia in the line of the skin incision and identify the biceps femoris and the common peroneal nerve.

 

 

Figure 11-14 Retract the biceps tendon and common peroneal nerve laterally and the lateral head of the gastrocnemius muscle medially.

 

Deep Surgical Dissection

 

Elevate the popliteus muscle off the back of the proximal tibia. Identify the origin of the soleus muscle from the proximal fibula and detach the muscle from the bone for about 5 cm (Fig. 11-16). The posterolateral corner of the knee is now exposed covered by the capsule of the knee joint. The positioning and technique for incision of the knee joint capsule, if needed, is dependent on the site of the pathology to be treated.

Dang

 

 

The common peroneal nerve is vulnerable during the incision of the deep fascia. It may also be damaged by over vigorous retraction of the biceps tendon.

 

How to Enlarge the Approach

 

This approach cannot be usefully enlarged. Therefore accurate localization of the pathology to be treated using CT scanning is advisable to ensure the correct surgical approach is used.

 

 

 

Figure 11-15 The popliteus muscle is now exposed.

 

 

 

Figure 11-16 Elevate the popliteus muscle off the back of the proximal tibia and detach the origin of soleus from the proximal fibula.

 

Posterior Approach to the Tibial Plateau

The posterior approach provides access to the posterior aspect of proximal tibia without endangering the neurovascular structures of the popliteal fossa.12

Its uses include the following:

  1. Open reduction and internal fixation of tibial plateau

  2. Fractures involving the posterior column

  3. Repair of avulsion fractures of the posterior cruciate ligament

 

Position of the Patient

 

Exsanguinate the limb by elevating it for 3 to 5 minutes and apply a tourniquet. Place the patient prone on the operating table and place a bolster beneath the leg from midthigh to ankle. This will allow hyperextension of the knee which is a useful maneuver when reducing posterior column tibial plateau fractures as well as facilitating x-ray imaging when using a C-arm (Fig. 11-17).

 

Landmarks and Incision

Landmarks

Flex and extend the knee to identify the joint line. Palpate the knee joint from behind identifying the fibular head and the biceps tendon laterally and the posteromedial border of the proximal tibia medially.

 

 

 

Figure 11-17 Place the patient prone on the operating table with a bolster under the thigh to allow hyperextension of the knee if needed for fracture reduction.

 

Incision

Begin at the level of the knee joint overlying the biceps tendon. Curve the incision obliquely across the posterior aspect of the knee until the posteromedial border of the tibia is reached. Then extend the incision distally to follow the posteromedial border of the proximal tibia for about 15 cm (Fig. 11-18).

 

Internervous Plane

The internervous plane lies between the most posterior structure of the pes anserinus—the tendon of semitendinosus supplied by the sciatic nerve and the medial head of the gastrocnemius muscle supplied by the tibial nerve.

 

Superficial Surgical Dissection

 

Identify and preserve the long saphenous vein which runs along the posterior border of the semitendinosus muscle. Deepen the incision distally by incising the deep fascia overlying the posteromedial border of the tibia. Identify the tendon of semitendinosus which is the most posterior tendon inserting into the pes anserinus. Identify the medial head of gastrocnemius lying medial to the tendon of semitendinosus (Fig.11-19). Develop a plane between the tendon of semitendinosus and the medial head of the gastrocnemius. More proximally do not incise the deep fascia overlying the popliteal fossa (Fig. 11-20).

 

 

 

Figure 11-18 Make an inverted L-shaped incision. The horizontal limb follows the posterior aspect of the knee joint. The vertical limb follows the posteromedial border of the proximal tibia.

 

 

Figure 11-19 Develop a plane between the tendon of semitendinosus and the medial head of the gastrocnemius.

 

 

Figure 11-20 Develop a plane between the medial head of gastrocnemius and the tendon of semitendinosus.

 

 

Figure 11-21 Detach the popliteus muscle from the posterior aspect of the proximal tibia staying in a subperiosteal plane.

 

Deep Surgical Dissection

 

Retract the medial head of gastrocnemius laterally and identify the posteromedial border of the tibia. The posterior border of the medial collateral ligament may be seen. Retract the pes anserinus medially but do not incise it. The origin of popliteus is seen covering the posteromedial aspect of the proximal tibia. Flex the knee to take tension off the muscle and detach it from the tibia staying in a subperiosteal plane working from medial to lateral (Figs. 11-21 and 11-22).

The whole of the back of the proximal tibia is visualized except the posterolateral corner which is overlain by the fibular head for about 5 cm from the joint line.

 

 

Figure 11-22 The posterior aspect of the proximal tibia is revealed.

 

 

Dang

 

 

The saphenous vein and saphenous nerve must be identified and preserved during the superficial dissection. The deep dissection must remain on bone beneath the popliteus muscle. Straying anterior to the popliteus will result in contact with the neurovascular contents of the popliteal fossa.

Retractors are needed for retracting the medial gastrocnemius laterally and the contents of the popliteal fossa are again put at risk if this is done too vigorously.

If a retractor is placed between the tibia and fibula the anterior tibial artery is at risk as it passes from posterior to anterior compartment just above the interosseous membrane. This structure dictates the distal limit of the approach—approximately 5 cm (Fig. 11-23).

 

 

Figure 11-23 The anterior tibial artery passes from posterior to anterior through the interosseous membrane some 5 cm below the knee. The artery limits exposure distally.

How to Enlarge the Approach

Local Measures

Retraction of the medial head of the gastrocnemius muscle and the popliteus muscle is the key to adequate visualization of the bone. Be aware however that excess retraction may cause compression of the contents of the popliteal fossa.

Extensile Measures

This approach is often used in conjunction with other approaches such as the anterolateral approach to the proximal but it is not classically extensile. It can be extended distally to expose the posteromedial border of the tibia down to the ankle but this is rarely required. It cannot be extended distally to expose the posterior surface of the tibia because the passage of the anterior tibial artery above the superior border of the interosseous membrane limits distal extension of the approach (see Fig. 11-23).

The approach cannot be extended proximally.

 

Minimally Invasive Anterolateral Approach to the Proximal Tibia

 

 

The minimally invasive anterolateral approach offers safe access for open reduction and internal fixation of proximal tibial fractures. The approach is of most use in treating fractures, which do not involve the joint surface, or where reduction and fixation of the intra-articular element of the fracture can be carried out without open exposure of the joint surface.

Precontoured plates are easy to use along the lateral aspect of the proximal tibia and can be applied percutaneously. Note however that in common with the anterolateral approach to the proximal tibia, the soft tissues in this area are often severely compromised by trauma. Massive swelling and blistering are contraindications to immediate surgery.

If plates longer than 10 holes are needed to treat the fracture the deep peroneal nerve and the anterior tibial artery are at risk if stab incisions are used for distal screw placement. Formal dissection of the distal window is required in these cases.13,14

 

Position of the Patient

 

Place the patient supine on a radiolucent table, as for the anterolateral

approach, to the lateral tibial plateau (see Fig. 11-1). Exsanguinate the limb and apply a tourniquet.

Landmarks

Palpate the shaft of the proximal tibia up to the joint line and identify Gerdy tubercle just lateral to the patella tendon. Confirm the position of the joint line by flexing and extending the knee.

Incision

Two incisions are made. Proximally, begin the incision just proximal and lateral to Gerdy tubercle and extend it distally in a curvilinear fashion for approximately 5 to 6 cm.

Distally make a 5- to 6-cm longitudinal incision approximately 2 cm lateral to the tibial crest and parallel with it. The size and length of the distal window depend on the pathology to be treated and the implants to be used. The position of the incision often can only be assessed using the image intensifier control (Fig. 11-24).

 

Internervous Plane

 

There is no internervous plane in this approach. The dissection is epiperiosteal and submuscular and does not disturb the nerve supply to the extensor compartment (deep peroneal nerve).

 

Superficial Surgical Dissection

 

Proximally incise the deep fascia in the line of the skin incision to access the proximal tibia. Retract the tibialis anterior muscle laterally and distally, preserving as much soft tissue as possible.

Distally deepen the approach in the line of the skin incision through subcutaneous tissue, then incise the deep fascia in the line of the skin incision (Fig. 11-25).

 

Deep Surgical Dissection

 

Proximally strip the soft tissues off the proximal tibia to allow adequate visualization of the pathology and placement of implants. Try to preserve as much soft tissue attachments to the bone as possible.

Distally develop a plane between the tibialis anterior muscle and the lateral border of the tibia. This can easily be achieved with blunt dissection using the Cobb elevator.

Finally, develop an epiperiosteal plane to connect the two incisions running along the lateral border of the tibia by using a blunt elevator (Fig. 11-26).

 

 

 

Figure 11-24 Distally make a 5- to 6-cm longitudinal incision approximately 2 cm lateral to the tibial crest and parallel with it. The size and length of the distal window depends on the pathology to be treated and the implants to be used.

 

 

Figure 11-25 Proximally deepen the approach in the line of the skin incision through subcutaneous tissue, then incise the deep fascia in the line of the skin incision to expose the periosteum overlying the lateral aspect of the lateral tibial plateau. Distally incise the subcutaneous tissues and the fascia covering the tibialis anterior muscle in the line of the skin incision. Finally, split the fibers of the tibialis anterior muscle to reveal the periosteum covering the lateral aspect of the tibial shaft.

 

 

Figure 11-26 Develop an epiperiosteal plane to connect the two incisions running along the lateral border of the tibia by using a blunt elevator.

 

 

Dang

 

 

The superficial branch of the peroneal nerve should be posterior to the proximal dissection. The course of the nerve is variable, thus care must be taken during the superficial surgical dissection to ensure that the nerve is not damaged.

The deep peroneal nerve and the anterior tibial artery cross the operative field if plates longer than 10 holes are used. On average these structures are between the 11th and 13th screw hole. In such cases a formal open approach is needed to strip part of tibialis anterior off the tibia and blind stab incisions are contraindicated for screw insertion.

 

How to Enlarge the Approach

Local Measures

The two windows can be connected, and further dissection of the origin of tibialis anterior from the lateral aspect of the tibia allows visualization of the lateral aspect of the whole proximal third of the tibia.

Anterior Approach to the Tibia

The anterior approach offers safe, easy access to the medial (subcutaneous) and lateral (extensor) surfaces of the tibia. It is used for the following:

  1. Open reduction and internal fixation of tibial fractures1

  2. Bone grafting for delayed union or nonunion of fractures2

  3. Excision of sequestra or saucerization in patients with osteomyelitis

  4. Excision and biopsy of tumors

  5. Osteotomy

Plates applied to the subcutaneous surface of the tibia are placed correctly biomechanically on the medial (tensile) side of the bone; they also are easier to contour there. Some surgeons prefer to use the lateral surface for plating, however, to avoid the problems of subcutaneous placement which may result in breakdown of the wound.

The anterior approach is the preferred approach to the tibia except when the skin is scarred or has draining sinuses in it.

 

Position of the Patient

 

Place the patient supine on the operating table. The use of a tourniquet is optional. Tourniquets should not be used if this approach is to be used in conjunction with the exploration of an open wound. If you wish to use a tourniquet, exsanguinate the limb by elevating it for 3 to 5 minutes, then inflate a tourniquet (Fig. 11-27).

 

 

Figure 11-27 Position for the anterior approach to the tibia.

 

Landmarks and Incision

Landmarks

The shaft of the tibia is roughly triangular when viewed in cross section. It has three borders, one anterior, one medial, and one interosseous (posterolateral). These borders define three distinct surfaces: (1) a medial subcutaneous surface between the anterior and medial borders, (2) a lateral (extensor) surface between the anterior and interosseous borders, and (3) a posterior (flexor) surface between the medial and interosseous (posterolateral) borders. The anterior and medial borders and the subcutaneous surface are easily palpable.

Incision

Make a longitudinal incision on the anterior surface of the leg parallel to the anterior border of the tibia and about 1 cm lateral to it. The length of the incision depends on the requirements of the procedure. Because of the poor vascularity of the skin it is safer to make a longer incision than to retract skin edges forcibly to obtain access. The tibia can be exposed along its entire length (Fig. 11-28).

Internervous Plane

 

There is no internervous plane in this approach. The dissection is epiperiosteal and does not disturb the nerve supply to the extensor compartment.

 

Superficial Surgical Dissection

 

Elevate the skin flaps to expose the subcutaneous surface of the tibia. The long saphenous vein is on the medial side of the calf and must be protected when the medial skin flap is reflected (Fig. 11-29).

 

Deep Surgical Dissection

 

Two surfaces of the tibia can be approached through this incision.

Subcutaneous (Medial) Surface

The periosteum of the tibia provides a small but vital blood supply to the bone in fractures where the endosteal blood supply is damaged. For this reason, periosteal stripping must be kept to an absolute minimum. In particular, never strip the periosteum off an isolated fragment of bone, or the bone will become totally avascular.

Lateral (Extensor) Surface

Reflect the tibialis anterior muscle from the periosteum and retract it laterally to expose the lateral surface of the bone. The tibialis anterior is the only muscle to take origin from the lateral surface of the tibia; detaching the muscle completely exposes that surface (see Fig. 11-30)

 

 

Figure 11-28 Make a longitudinal incision on the anterior surface of the leg.

 

 

Dang

 

 

Vessels

The long saphenous vein, which runs up the medial side of the calf, is vulnerable during superficial surgical dissection and should be preserved for future vascular procedures, if at all possible.

 

Special Surgical Points

 

Skin flaps must be closed meticulously after surgery to avoid infection of the tibia. Although longitudinal incisions over the tibia heal well, transverse incisions and irregular wounds may heal poorly, especially in elderly individuals. The skin over the lower third of the tibia is very thin; wounds in that area heal badly, especially in smokers or patients with chronic venous insufficiency.

It is important to minimize the amount of soft tissue that is stripped from bone in this approach when it is used for fracture work. Devascularized bone, no matter how well it is reduced and fixed, will not unite. Using care and appropriate reduction forceps, it usually is possible to preserve soft tissue attachments of all but the smallest fragments of bone.

 

How to Enlarge the Approach

Local Measures

The extent of the exposure is determined by the size of the skin incision; the whole subcutaneous surface of the tibia may be exposed, if necessary.

To reach the posterior surface of the tibia from an anterior approach, continue the epiperiosteal dissection posteriorly around the medial border. Proximally, lift the flexor digitorum longus muscle off the posterior surface of the tibia subperiosteally. Distally, lift off the tibialis posterior muscle. This procedure exposes the posterior surface of the bone, but does not offer as full an exposure as does the posterolateral approach. It also detaches many of the soft tissue attachments to the bone. It probably is useful only for the insertion of bone graft as part of an internal fixation carried out through this anterior route.

Extensile Measures

Proximal Extension. To extend the approach proximally, continue the skin incision along the medial side of the patella. Deepen the incision through the medial patellar retinaculum to gain access to the knee joint and the patella. (For details, see Medial Parapatellar Approach in Chapter 10, Fig. 10-10.) Alternatively, extend the wound proximally along the lateral side of the patella. Deepen that wound through the lateral patellar retinaculum to gain access to the lateral compartment of the knee.

 

 

 

Figure 11-29 Elevate the skin flaps over the medial portion of the tibialis anterior and the subcutaneous medial surface of the tibia. To expose the lateral surface of the tibia, incise the deep fascia over the medial border of the tibialis anterior.

Distal Extension. To extend the approach distally, curve the incision over the medial side of the hind part of the foot. Deepening the wound provides access to all the structures that pass behind the medial malleolus. Continue the incision onto the middle and front parts of the foot. (For details, see Anterior and Posterior Approaches to the Medial Malleolus in Chapter 12, Fig. 12-6.)

 

 

 

Figure 11-30 Elevate the tibialis anterior from the lateral surface of the tibia. Incise the periosteum; elevate it only as necessary.

 

Minimally Invasive Anterior Approach to the Distal Tibia

 

 

Because the distal tibia has a large subcutaneous surface, access to the

bone is easy through skin incisions lying directly over the bone. The soft tissues overlying the distal tibia are thin and fragile, consisting only of skin and underlying fascia. Problems such as swelling, blistering, and profuse edema are common in fractures in this area. The minimally invasive approach to the distal tibia should only be used when the soft tissues are in good condition, and a delay in carrying out definitive surgery in fractures in this area is not uncommon. Chronic venous insufficiency and smoking are also relative contraindications to the use of this approach.

The surgical approach is indicated in:

  1. Open reduction and internal fixation of fractures of the distal tibia, especially multifragmentary fractures of the distal tibial metaphysis

  2. Biopsy of tumor

  3. Corrective osteotomies

  4. Malunion

 

Position of the Patient

 

Position the patient supine on a radiolucent table (see Fig. 12-18). Ensure that adequate x-rays can be taken before prepping and draping the patient. Place a small sandbag beneath the ipsilateral buttock to correct the natural external rotation of the limb. Ensure that the patella is facing anteriorly. This will make it easier for you to assess the quality of the reduction regarding rotation. Exsanguinate the limb either by elevating it for 3 to 5 minutes or by applying a soft rubber bandage. Inflate a tourniquet.

 

Landmarks and Incision

 

Palpate the medial malleolus—the most distal portion of the tibia’s broad subcutaneous surface.

Distally make a 3- to 4-cm incision, starting just distal to the medial malleolus, extending the incision proximally overlying the subcutaneous surface of the tibia, halfway between the anterior and posterior border.

Proximally make a longitudinal incision overlying the subcutaneous surface of the tibia, halfway between the anterior and posterior borders (Fig. 11-31). The positioning and size of proximal incision relates to the implants used and can only be confirmed under image intensifier control.

 

Internervous Plane

There is no true internervous plane in this approach. Dissection is on the subcutaneous surface of the tibia.

 

Superficial Surgical Dissection

 

Deepen the skin incision to expose the periosteum overlying the tibia. Because the periosteum of the tibia is a very precious structure that supplies significant amounts of blood to the bone, it should not be removed (Fig. 11-32). The long saphenous vein and the saphenous nerve run just anterior to the medial malleolus. They may need to be retracted anteriorly to allow plate placement.

 

 

 

Figure 11-31 Distally make a 3- to 4-cm incision starting just distal to the medial malleolus and extend the incision proximally overlying the subcutaneous surface of the tibia, halfway between the anterior and posterior border. Proximally make a longitudinal incision overlying the subcutaneous surface of the tibia, halfway

between the anterior and posterior borders.

 

 

 

Figure 11-32 Proximally and distally deepen the skin incision through subcutaneous tissues to reveal the periosteum covering the subcutaneous surface of the tibia. Try to preserve as much periosteum as possible.

 

Deep Surgical Dissection

 

Develop an epiperiosteal plane between the distal and proximal skin incisions using a blunt dissector, such as a Cobb elevator (Fig. 11-33).

 

 

Dang

 

 

Note that the periosteum covering the tibia is critical for the vascular

supply of the bone. The plane that lies between the periosteum and the subcutaneous tissues is used in this approach (not subperiosteal).

The long saphenous vein and the saphenous nerve lie anterior to the medial malleolus. They must be preserved during the approach.

Wound healing problems are not uncommon in this area especially if locking plates are used for fixation of fractures. This is due to the added thickness of many plates compared with conventional plates. Meticulous assessment of the skin condition is therefore mandatory prior to any surgery.

 

Enlarging the Surgical Approach

Local Measures

The proximal and distal skin incisions can be connected, thereby exposing the periosteum covering the subcutaneous surface of the distal tibia. If such an enlargement is carried out, take care to preserve as much soft tissue connection between the skin and subcutaneous tissue and the underlying structures, to reduce the risk of skin necrosis.

 

 

Figure 11-33 Develop an epiperiosteal plane between the distal and proximal skin incisions using a blunt dissector such as a Cobb elevator.

 

Posterolateral Approach to the Tibia

The posterolateral approach3 is used to expose the middle two-thirds of the tibia when the skin over the subcutaneous surface is badly scarred or infected. It is a technically demanding operation. The approach is suitable for the following uses:

  1. Internal fixation of fractures

  2. Treatment of delayed union or nonunion4 of fractures, including bone grafting

  3. The approach also permits exposure of the middle of the posterior aspect of the fibula.

 

Position of the Patient

 

Place the patient on his or her side with the affected leg uppermost. Protect the bony prominences of the bottom leg to avoid the development of pressure sores. Exsanguinate the limb by elevating it for 5 minutes, then inflate a tourniquet (Fig. 11-34).

 

Landmark and Incision

Landmark

The lateral border of the gastrocnemius muscle is easy to palpate in the calf.

Incision

Make a longitudinal incision over the lateral border of the gastrocnemius muscle centered over the pathology that is to be treated. The length of the incision depends on the length of bone that must be exposed (Fig. 11-35) but a minimum of 10 cm is needed.

 

 

 

Figure 11-34 Position for the posterolateral approach to the tibia.

Internervous Plane

 

The internervous plane lies between the gastrocnemius, soleus, and flexor hallucis longus muscles (all of which are supplied by the tibial nerve) and the peroneal muscles (which are supplied by the superficial peroneal nerve)—between the superficial and deep posterior and lateral muscular compartments (Fig. 11-36).

 

Superficial Surgical Dissection

 

Reflect the skin flaps, taking care not to damage the short saphenous vein, which runs up the posterolateral aspect of the leg from behind the lateral malleolus. Incise the fascia in line with the incision and find the plane between the lateral head of the gastrocnemius and soleus muscles posteriorly, and the peroneus brevis and longus muscles anteriorly. Muscular branches of the peroneal artery lie with the peroneus brevis in the proximal part of the incision and may have to be ligated (Fig. 11-37).

Find the lateral border of the soleus and retract it with the gastrocnemius medially and posteriorly; underneath, arising from the posterior surface of the fibula, identify the flexor hallucis longus (Fig. 11-38).

 

 

 

Figure 11-35 Incision along the lateral border of the gastrocnemius.

 

 

Figure 11-36 The internervous plane lies between the gastrocnemius, soleus, and flexor hallucis longus muscles (which are supplied by the tibial nerve) and the peroneal muscles (which are supplied by the superficial peroneal nerve).

 

 

 

Figure 11-37 Reflect the skin flaps. Incise the fascia in line with the incision. Find the plane between the lateral head of the gastrocnemius and soleus posteriorly, and the peroneus brevis and longus anteriorly.

 

 

Figure 11-38 Detach the origin of the soleus from the fibula, and retract it posteriorly and medially along with the gastrocnemius. Retract the peroneal muscles anteriorly. Detach the flexor hallucis longus from its origin on the fibula. Develop the plane between the gastrocnemius–soleus group posteriorly and the peroneal muscles anteriorly (cross section). Note the flexor hallucis longus on the posterior surface of the fibula.

 

Deep Surgical Dissection

 

Detach the lower part of the origin of the soleus muscle from the fibula and retract it posteriorly and medially. Detach the flexor hallucis longus muscle from its origin on the fibula and retract it posteriorly and medially (Fig. 11-39; see Fig. 11-38). Continue dissecting medially across the interosseous membrane, detaching those fibers of the tibialis posterior muscle that arise from it. The posterior tibial artery and tibial nerve are posterior to the dissection, separated from it by the bulk of the tibialis posterior and flexor hallucis longus muscles (Fig. 11-40). Follow the interosseous membrane to the lateral border of the tibia, detaching the

muscles that arise from its posterior surface subperiosteally to expose its posterior surface (Fig. 11-41).

 

 

Dang

 

 

Vessels

The small (short) saphenous vein may be damaged when the skin flaps are mobilized. Although the vein should be preserved if possible, it may be ligated, if necessary, without impairing venous return from the leg.

Branches of the peroneal artery cross the intermuscular plane between the gastrocnemius and peroneus brevis muscles. They should be ligated or coagulated to reduce postoperative bleeding.

The posterior tibial artery and tibial nerve are safe as long as the surgical plane of operation remains on the interosseous membrane and does not wander into a plane posterior to the flexor hallucis longus and tibialis posterior muscles.

 

 

 

Figure 11-39 Detach the flexor hallucis longus from its origin on the fibula and retract it posteriorly and medially. Continue dissecting posteriorly, staying on the posterior surface of the fibula. Detach the flexor hallucis longus from its origin on the fibula, staying close to the bone (cross section). Retract the muscle medially.

 

 

 

Figure 11-40 Continue dissecting medially across the interosseous membrane, detaching those fibers of the tibialis posterior that arise from it. Continue dissecting across the membrane until the posterior aspect of the tibia can be seen. Incise the periosteum on the lateral border of the tibia. Continue the dissection posteriorly across the fibula and the interosseous membrane until the lateral border of the tibia is reached (cross section). Note that the neurovascular structures are protected by the bulk of the tibialis posterior.

 

How to Enlarge the Approach

Extensile Measures

 

Proximal Extension. The approach cannot be extended into the proximal fourth of the tibia.

There, the back of the tibia is covered by the popliteus muscle and the more superficial posterior tibial artery and tibial nerve, making safe dissection impossible.

Distal Extension. The approach can be made continuous with the posterolateral approach to the ankle if the skin incision is extended distally between the posterior aspect of the lateral malleolus and the Achilles tendon.

 

 

 

Figure 11-41 Detach the muscles that arise from the posterior surface of the tibia subperiosteally. Expose the posterior border of the tibia subperiosteally (cross section). The detached tibialis posterior muscle protects the neurovascular structures.

 

Approach to the Fibula

The approach to the fibula employs a classic extensile exposure5 and offers access to all parts of the fibula. Its uses include the following:

  1. Partial resection of the fibula during tibial osteotomy6 or as part of the treatment of tibial nonunion7,8

  2. Resection of the fibula for decompression of all four compartments of the leg9

  3. Resection of tumors

  4. Resection for osteomyelitis

  5. Open reduction and internal fixation of fractures of the fibula

  6. Removal of bone graft—corticocancellous strut grafts. Vascularized fibula grafts are dissected out with their vascular pedicles.

Although the bone can be exposed completely, only a part of the approach usually is required for any one procedure.

 

Position of the Patient

 

Place the patient on his or her side on the operating table with the affected side uppermost. Pad the bony prominences of the other leg to prevent the development of pressure sores. Exsanguinate the limb by elevating it for 3 to 5 minutes, then apply a tourniquet (see Fig. 11-34). Alternatively, if this approach is used in conjunction with a surgical approach to the tibia, place the patient supine on the operating table. A sandbag placed underneath the affected buttock will rotate the leg internally. Tilting the table away from the operative side will further increase internal rotation and allow adequate exposure of the lateral aspect of the leg. Subsequently, if the sandbag is removed and the table is leveled, the leg will naturally rotate externally, providing access to the tibia.

 

Landmarks and Incision

Landmarks

The head of the fibula is easily palpable about 2 to 3 cm below the lateral femoral condyle.

The common peroneal nerve can be rolled underneath the fingers as it winds around the fibular neck. The lower fourth of the fibula is subcutaneous.

Incision

Make a linear incision just posterior to the fibula, beginning behind the lateral malleolus and extending to the level of the fibular head. Continue the incision up and back, a handbreadth above the head of the fibula and in line with the biceps femoris tendon. Watch out for the common peroneal nerve which runs subcutaneously over the neck of the fibula and can be cut if the skin incision is too bold. The length of the incision depends on the amount of exposure needed (Fig. 11-42).

 

Internervous Plane

The internervous plane lies between the peroneal muscles, supplied by the superficial peroneal nerve, and the flexor muscles, supplied by the tibial nerve (see Fig. 11-36).

 

Superficial Surgical Dissection

 

To expose the fibular head and neck, begin proximally by incising the deep fascia in line with the incision, taking great care not to cut the underlying common peroneal nerve. Find the posterior border of the biceps femoris tendon as it sweeps down past the knee before inserting into the head of the fibula. Identify and isolate the common peroneal nerve in its course behind the biceps tendon; trace it as it winds around the fibular neck (Fig. 11-43). Mobilize the nerve from the groove on the back of the neck by cutting the fibers of the peroneus longus that cover the nerve and gently pulling the nerve forward over the fibular head with a strip of corrugated rubber drain. Identify and preserve all branches of the nerve (Fig. 11-44).

Develop a plane between the peroneal muscles and the soleus; with the common peroneal nerve retracted anteriorly, incise the periosteum of the fibula longitudinally in the line with this plane of cleavage. Continue the incision down to bone (Fig. 11-45).

 

Deep Surgical Dissection

 

Strip the muscle off the fibula by dissection. All muscles that originate from the fibula have fibers that run distally toward the foot and ankle. Therefore, to strip them off cleanly, you must elevate them from distal to proximal. Most muscles originate from periosteum or fascia; they can be stripped. Muscles attached directly to bone are difficult to strip; they usually must be cut (Fig. 11-46, and cross section).

The other structure attached to the fibula, the interosseous membrane, has fibers that run obliquely upward. To complete the dissection, strip the interosseous membrane subperiosteally from proximal to distal (Fig. 11-47, and cross section).

 

 

Dang

 

 

Nerves

The common peroneal nerve is vulnerable as it winds around the neck of

the fibula. The key to preserving the nerve is to identify it proximally as it lies on the posterior border of the biceps femoris. It then can be safely traced through the peroneal muscle mass. If possible, avoid retracting the nerve. The dorsal cutaneous branch of the superficial peroneal nerve is susceptible to injury at the junction of the distal and middle thirds of the fibula; if it is damaged, it causes numbness on the dorsum of the foot.

 

 

 

Figure 11-42 Make a long linear incision just posterior to the fibula.

 

 

Figure 11-43 A: Expose the common peroneal nerve in the proximal end of the incision along the posterior border of the biceps. B: Continue exposing the common peroneal nerve distally as it winds around the neck of the fibula in the substance of the peroneus longus.

 

Vessels

Terminal branches of the peroneal artery lie close to the deep surface of the lateral malleolus. To avoid damaging them, you must keep the dissection subperiosteal.

The small (short) saphenous vein may be damaged; you may ligate it if necessary.

 

How to Enlarge the Approach

Local Measures

The exposure described allows exposure of the entire bone.

Extensile Measures

 

Distal Extension. Extend the skin incision distally by curving it over the lateral side of the tarsus. To gain access to the sinus tarsi and the talocalcaneal, talonavicular, and calcaneocuboid joints, reflect the underlying extensor digitorum brevis muscle. This extension is used frequently for lateral operations on the leg and foot (see Lateral Approach to the Hindpart of the Foot in Chapter 12).

 

 

 

Figure 11-44 Retract the peroneal nerve anteriorly, and incise the fascia between the peroneal muscles and the soleus muscle.

 

 

Figure 11-45 Develop the intermuscular plane between the peroneal muscles and the soleus muscle down the lateral edge of the fibula. Strip the flexor muscles from the posterior aspect of the fibula in a distal to proximal direction.

 

 

 

Figure 11-46 Strip the flexor hallucis longus and the soleus from the posterior aspect of the fibula, and strip the peroneal muscles from the anterior surface of the fibula in a distal to proximal direction. Strip the flexor muscles from the posterior aspect of the fibula (cross section). Avoid neurovascular structures by staying close to the bone.

 

 

Figure 11-47 Retract the peroneal muscles anteriorly. Strip the interosseous membrane from the anterior border of the fibula in a proximal to distal direction. Strip the muscles from the anterior surface of the fibula, and strip the interosseous membrane from its fibular attachment in a proximal to distal direction (cross section).

 

Applied Surgical Anatomy of the Leg— Approaches for Decompression of a Compartment Syndrome

 

 

Overview

 

The tibia and fibula are very different bones. The tibia has a large subcutaneous surface that allows access to the bone along its entire length; the fibula is enclosed almost completely in muscle. Only at its proximal end and in the lower third of the bone does the fibula develop a subcutaneous surface, which terminates in the lateral malleolus. For this reason, operations on most of the fibula almost always involve extensive stripping of muscle off bone. In addition, the tibia has no major

neurovascular structures running directly on it other than its nutrient artery; the fibula has close ties to the common peroneal nerve and its branches.

The deep fascia of the leg is a tough, fibrous, unyielding structure that encloses the calf muscles. Where the bones become subcutaneous, the fascia usually is attached to the border of the bone.

Two intermuscular septa, one anterior and one posterior, pass from the deep surface of the encircling fascia to the fibula and enclose the peroneal or lateral compartment of the leg.

Four separate muscular compartments exist in the lower leg (Fig. 11-48).

 

Anterior (Extensor) Compartment

 

The anterior compartment contains the extensor muscles of the foot and ankle. Its medial boundary is the lateral (extensor) surface of the tibia, and its lateral boundary is the extensor surface of the fibula and anterior intermuscular septum. The anterior compartment is enclosed by the deep fascia of the leg and all its muscles are supplied by the deep peroneal nerve. The compartment’s artery is the anterior tibial artery (Fig. 11-49).

 

 

 

Figure 11-48 The fibro-osseous compartments of the leg.

 

Lateral (Peroneal) Compartment

 

The peroneal compartment is bounded by the anterior intermuscular septum in front, by the posterior intermuscular septum behind, and by the fibula medially. It contains the peroneal muscles which evert the foot. The superficial peroneal nerve supplies all the muscles in the compartment. No artery runs in it; its muscles receive their supply from several branches of the peroneal artery (Fig. 11-50).

 

Superficial Posterior (Flexor) Compartment

 

The superficial flexor compartment contains three muscles: the

gastrocnemius, soleus, and plantaris. The compartment is separated from the lateral (peroneal compartment) by the posterior intermuscular septum. It is separated from the deep posterior flexor compartment by a fascial layer.

 

Deep Posterior Flexor Compartment

 

The deep posterior flexor compartment contains three muscles: the tibialis posterior, flexor hallucis longus, and flexor digitorum longus. It also contains the tibial nerve and posterior tibial artery. It is separated from the superficial flexor compartment by the posterior intermuscular septum and from the anterior compartment by the interosseous membrane.

 

Surgical Approaches for Decompression of Lower Leg Compartment Syndrome

 

The details of pathophysiology and diagnosis of an acute compartment syndrome are beyond the scope of this book but the authors believe that diagnosis is still mainly clinical and that routine decompression of all four compartments is the current gold standard in treatment in the absence of strong evidence that a compartment is not involved. Two approaches are described which will allow adequate decompression of all four compartments.

 

 

Figure 11-49 To decompress the anterior and lateral compartments, make a longitudinal incision overlying the anterolateral aspect of the lower leg. A: Begin at the level of the tibial tubercle and extend the incision to end 6 cm above the level of the ankle. B: Incise the fascia overlying the anterior and lateral compartments in the line of the skin incision. C: Transverse section showing the fascial compartments. Incising the fascia overlying the anterior, lateral, and superficial flexor compartments is easy. Decompressing the deep flexor compartment may involve lifting the soleus muscle of the intermuscular septum and dividing that septum under direct vision, taking care to avoid the posterior

neurovascular bundle.

 

 

 

Figure 11-50 To decompress the superficial and deep flexor compartments, make a longitudinal incision overlying the posteromedial aspect of the lower leg. Begin at the level of the tibial tubercle and extend the incision distally, ending 6 cm above the ankle. At right, transverse section showing the fascial compartments. Incising the fascia overlying the anterior, lateral, and superficial flexor compartments is easy. Decompressing the deep flexor compartment may involve lifting the soleus muscle of the intermuscular septum and dividing that septum under direct vision, taking care to avoid the posterior neurovascular bundle.

Position of the Patient

 

Place the patient supine on the operating table. The use of a tourniquet is clearly contraindicated (see Fig. 11-28).

 

Landmarks and Incisions

 

Palpate the tibial tubercle on the anterior aspect of the proximal tibia and the lateral and medial malleoli at the level of the ankle.

Anterolateral Incision

Make a longitudinal incision overlying the anterolateral aspect of the lower leg (see Fig. 11-49A). Begin at the level of the tibial tubercle and extend the incision to end 6 cm above the level of the ankle.

Posteromedial Incision

Make a longitudinal incision overlying the posteromedial aspect of the lower leg (see Fig. 11-50). Begin at the level of the tibial tubercle and extend the incision distally ending 6 cm above the ankle.

 

Superficial Surgical Dissection

 

To decompress the anterior and lateral compartments incise the fascia overlying the anterior and lateral compartments in the line of the skin incision (Fig. 11-49B). Two separate incisions are required. Ensure that the fascial incision extends the full length of the skin incision.

To decompress the superficial and deep flexor compartments incise the deep fascia in line with the skin incision to expose the soleus muscle. To decompress the deep flexor compartment lift the soleus muscle off the intermuscular septum and divide the septum under direct vision, taking care to avoid the posterior neurovascular bundle which lies just beneath it (Fig. 11-50). Figure 11-48 shows a transverse section of the leg illustrating the fascial compartments.

 

 

Dang

 

 

The posterior neurovascular bundle is at risk if the fascia covering the deep flexor compartment is not divided carefully. The main danger of the approach is however inadequate decompression. A compartment syndrome in not an indication for minimally invasive surgery.

Minimally Invasive Approach for Tibial Nailing

 

 

The minimally invasive approach for tibial nailing is used for the insertion of intramedullary nails used in the treatment of the following:

  1. Fresh tibial shaft fractures

  2. Pathologic tibial shaft fractures

  3. Delayed union and nonunion of tibial shaft fractures

Tibial nails do not have the wide variability in design seen in femoral nails. All tibial nails are angled at their upper end to allow insertion via an anterior route, and all tibial nails are straight when viewed in the anterior–posterior plane.

 

Position of the Patient

 

Two positions may be used for the insertion of tibial nails. Placing the patient on a traction table allows greater control of the fracture and easier distal locking. The free leg position allows greater knee flexion which makes nail insertion easier.

Traction Table

This is the most commonly used position. Place the patient supine on an operating table. Flex the hip to 60 degrees. Place a support behind the posterior aspect of the distal thigh. Take care not to place the support in the popliteal fossa where it will create pressure on the popliteal vein (Fig. 11-51; see Fig. 10-59).

Flex the knee to 100 to 120 degrees, and apply traction either by strapping the patient’s foot to the sole of a traction boot or using a Steinmann pin inserted through the os calcis. A conventional traction boot extends 5 to 8 cm above the heel. The boot will prevent the insertion of distal locking bolts because the required skin incision will be covered by the boot and it therefore should not be used.

Some authors feel that the use of a tourniquet is contraindicated if reaming of the tibial shaft is to be carried out arguing that the lack of convective blood flow will make thermal damage to the bone more likely. It is likely that any tourniquet effect is very slight and that the key to prevention of thermal necrosis lies with the judicious use of sharp

reamers.15 Note that minimal traction is required to reduce a fresh tibial shaft fracture.

Place the contralateral leg in a support with the hip flexed and abducted and the knee flexed (see Fig. 11-51). Ensure that good quality radiographs of the entry point, fracture site, distal and proximal locking areas can be obtained using a C-arm before prepping and draping.

 

 

 

Figure 11-51 Traction table position. Flex the hip to 60 degrees. Flex the knee to 100 to 120 degrees, and apply traction by strapping the foot to the sole of a traction boot. Place the opposite leg in a support with the hip flexed and abducted and the knee flexed.

 

Free Leg Position

Place the patient supine on an operating table. Remove the end of the table, and allow the injured knee to flex over the end of the table. Place the contralateral leg in a support with the hip flexed and abducted and the knee flexed. Do not use a tourniquet (Fig. 11-52).

Landmark and Incision

Landmarks

Palpate the patella on the anterior aspect of the knee. The patellar tendon is felt as a resistance extending from the inferior pole of the patella to the tibial tubercle.

Incision

Make a 5-cm incision on the anterior aspect of the tibia, beginning at the inferior border of the patella and extending the incision down to just above the tibial tubercle (Fig. 11-53). This incision should overlie the medial border of the patellar tendon.

 

Internervous Plane

 

There are no internervous planes involved in this approach.

 

Superficial Surgical Dissection

 

Incise the subcutaneous fat and fibrous tissue arising from the medial aspect of the patellar tendon in the line of the skin incision. Numerous small arterial vessels are usually encountered and will need to be coagulated. Identify the medial border of the patellar tendon and incise this fascia longitudinally along the border (Fig. 11-54).

 

 

Figure 11-52 Free leg position. Place the patient supine on the operating table. Remove the end of the table. Allow the injured knee to flex over the end of the

table. Place the contralateral leg in a support with the hip flexed and abducted and the knee flexed.

 

Deep Surgical Dissection

 

Retract and mobilize the patellar tendon laterally to expose a small bursa between the tendon and the anterior aspect of the tibia—the deep infrapatellar bursa (Fig. 11-55). The precise entry point of the nail into the medullary canal of the tibial shaft can be calculated preoperatively by overlaying a template of the nail on the anterior–posterior radiograph of the injured tibia. In the frontal plane the entry point lies in the axis of the medullary canal of the tibia. In the sagittal plane the entry point of the nail lies at the very proximal end of the tibia at the junction of the anterior and superior aspects of the bone. Note that this entry point, although on the superior aspect of the tibia, is extrasynovial (Fig. 11-56). The entry point for the nail must be confirmed radiographically (in the operating room) in both the anterior–posterior and lateral planes before entry is made.

 

 

Figure 11-53 Make a 5-cm long incision overlying the medial edge of the patellar tendon.

 

 

Figure 11-54 Deepen the skin incision to expose the medial edge of the patellar tendon.

 

 

 

Figure 11-55 Incise the fascia on the medial edge of the patellar tendon and retract the tendon laterally.

 

 

Dang

 

 

Nerves and Vessels

The infrapatellar branch of the saphenous nerve is frequently damaged in this approach. It is impossible to preserve all the branches of the nerve, and patients should be warned that an area of numbness is likely following this surgical approach (see Fig. 10-35).

If a traction table is used and the thigh rest is placed within the popliteal fossa, compression of the popliteal veins can result. This can increase the risk of deep vein thrombosis.

Ligaments and Meniscus

If the entry point is too far posterior, damage to the tibial insertion of the anterior cruciate ligament and the anterior horn of the medial meniscus may occur (Fig. 11-57).

Deformity

If the entry point is too far medial, a valgus deformity will be created at the fracture site in proximal fractures. If the entry point is too far lateral, a varus deformity will be created at the fracture site in proximal fractures.

 

 

 

Figure 11-56 View of the superior surface of the tibia, showing the entry point of the nail. The insertion point is extrasynovial, lying anterior to the tibial insertion of the anterior cruciate ligament and lateral to the anterior horn of the medial meniscus.

 

 

Figure 11-57 Correct and incorrect insertion points. Note that if the entry point is too far posterior then damage to the insertion of the anterior cruciate ligament on the tibia will occur. An entry point that is too far anterior will cause splintering of the anterior cortex of the tibia on nail insertion.

 

Bone

If the entry point is too far inferior on the anterior surface of the tibia, then

splitting of the anterior cortex of the tibia may occur on nail insertion (see Fig. 11-57).

Nail insertion is very difficult if the knee is not flexed to beyond 90 degrees due to pressure of the nail on the anterior aspect of the patella. Such pressure may be sufficient to produce a compression lesion of the patellofemoral joint or even transient subluxation of the patella, producing damage to the articular cartilage of the patella. For that reason, many surgeons prefer a free leg position, which allows greater degrees of flexion than can be easily obtained using a traction table.

 

How to Enlarge the Approach

 

This approach gives excellent visualization of the entry point of the nail but has no other uses. It cannot be usefully enlarged.

 

REFERENCES

  1. MüLLER ME, ALLGöWER M, WILLENEGGER H: Manual of Internal Fixation. New York, NY: Springer-Verlag; 1970.

  2. PHEMISTER DB: Treatment of ununited fractures by onlay bone grafts without screw or tie fixation and without breaking down of the fibrous union. J Bone Joint Surg. 1947;29:946–960.

  3. HARMON PH: A simplified surgical approach to the posterior tibia for bone grafting and fibular transference. J Bone Joint Surg. 1945;27:496–498.

  4. JONES KG, BARNETT HC: Cancellous-bone grafting for nonunion of the tibia through the posterolateral approach. J Bone Joint Surg Am. 1955;37:1250–1259.

  5. HENRY AK: Extensile Exposure. 2nd ed. London, Churchill Livingstone; 1973.

  6. COVENTRY MB: Osteotomy about the knee for degenerative and rheumatoid arthritis: indications, operative technique and results. J Bone Joint Surg Am. 1973;55:234.

  7. BROWN PN, URBAN JG: Early weight bearing treatment of open fractures of the tibia. J Bone Joint Surg Am. 1969;51:59–75.

  8. SORENSON KH: Treatment of delayed union and nonunion of the tibia by fibular resection. Acta Orthop Scand. 1969;40:92–104.

  9. LEACH RE, HAMMOND G, STRIKER WS: Anterior tibial compartment syndrome: acute and chronic. J Bone Joint Surg Am. 1967;49:451–462.

  10. FROSCH KH, BALCAREK P, WALDE T, STüRMER KM. A new

    posterolateral approach without fibula osteotomy for the treatment of tibial plateau fractures. J Orthop Trauma. 2010;24(8):515–520.

  11. WANG SQ, GAO YS, WANG JQ ET AL: Surgical approach for high-energy posterior tibial plateau fractures. Indian J Orthop. 2011;45:125–131.

  12. LUO CF, SUN H, ZHANG B, ZENG BF. Three-column fixation for complex tibial plateau fractures. J Orthop Trauma. 2010;24(11):683–692.

  13. PICHLER W, GRECHENIG W, TESCH NP ET AL: The risk of iatrogenic injury to the deep peroneal nerve in minimally invasive osteosynthesis of the tibia with the less invasive stabilisation system: a cadaver study. J Bone Joint Surg Br. 2009;91(3):385–387.

  14. GARY JL, SCIADINI MF: Injury to the anterior tibial system during percutaneous plating of a proximal tibial fracture. Orthopedics. 2012;35(7):e1125–e1128.

  15. GIANNOUDIS PV, SNOWDEN S, MATTHEWS SJ ET AL: Friction burns

within the tibia during reaming. Are they affected by the use of a tourniquet? J Bone Joint Surg Br. 2002;84(4):492–496.

 

SELECTED BIBLIOGRAPHY

ALTHAUSEN PL, NEIMAN R, FINKEMEIER CF et al: Incision placement for intramedullary tibial nailing: an anatomic study. J Orthop Trauma.

2002;16:687–690.

BHANDARI M, AUDIGE L, ELLIS T et al: Operative treatment of extra-articular proximal tibial fractures. J Orthop Trauma. 2003; 17:591–595.

BORELLI J, CATALANO L: Open reduction and internal fixation of pilon fractures. J Orthop Trauma. 1999;13:573–582.

BORELLI J, PRICKETT W, SONG E ET AL: Extraosseous blood supply of the tibial and the effects of different plating techniques. A human cadaveric study. J Orthop Trauma. 2002;16:691–695.

COLE PA, ZIOWODZKI M, KREGOR PJ: Less invasive stabilization system (LISS) for fractures of the proximal tibia: indications, surgical technique and preliminary results for the UMC clinical trial. Injury.

2003;34(Suppl):A16.

KANKATER K, SINGH P, ELLIOTT DS: Percutaneous plating of low energy unstable tibial plateau fractures. A new technique. Injury. 2001;32:229–

232.

KEATING JF, JAJDUCKA CL, HARPER J: Minimal internal fixation and calcium phosphate cement in the treatment of fractures of the tibial plateau. A pilot study. J Bone Joint Surg Br. 2003;85:68–73.

KIRGIS A, ALBRECHT S: Palsy of the deep peroneal nerve after proximal tibial osteotomy: an anatomical study. J Bone Joint Surg Am.

1992;74:1180.

PATTERSON D, LEWIS GN, CASS CA: Clinical experience in Australia with an implanted bone growth stimulator (1976–1978). Orthop Transcripts. 1979;3:288–289.

WAGNER M, FRIGG R: Internal Fixators. New York, NY: Thieme; 2006.