Minimally Invasive Anterolateral Approach to the Proximal Tibia
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).
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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.
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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.
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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.