Minimally Invasive Anterior Approach to the Distal Tibia
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:
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Open reduction and internal fixation of fractures of the distal tibia, especially multifragmentary fractures of the distal tibial metaphysis
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Biopsy of tumor
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Corrective osteotomies
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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.
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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.
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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.
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Figure 11-33 Develop an epiperiosteal plane between the distal and proximal skin incisions using a blunt dissector such as a Cobb elevator.