Proximal Tibia Surgical approaches

2.  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
 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.

3.  Four surgical approaches are described for access to the tibial plateau.
-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

5.  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 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.

6.  USES:
 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

7.  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

8.  POSITION:
 Place the patient supine on a radiolucent table. Place a firm wedge beneath the knee to flex the
joint to approximately 60 degrees
 inflate a tourniquet

9.  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

10.  Deepen the incision proximally 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.
 deepen the incision through subcutaneous tissue and incise the fascia overlying the tibialis
anterior muscle

11.  Proximally enter the knee joint. 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.
 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.

12.  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

13.  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

14.  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
 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

15.  INDICATIONS:
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

16.  POSITION:
 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

17.  INCISION:
 Make a 6-cm longitudinal incision overlying the
posteromedial border of the proximal tibia.

18.  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

19.  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

21.  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

22. 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.

23.  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

24. POSITION:
 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

25. 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

26.  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.

27.  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

28.  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
 The posterolateral corner of the knee is now exposed covered by the capsule of the knee joint

29. 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

30.  POSITION:
 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

31. INCISION:
 Begin at the level of the knee joint overlying the biceps tendon.
 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

32.  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.

33.  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

34.  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.

35.  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

36. NOTE:
 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

37. 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.

38. 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 . The approach cannot be extended proximally.

39.  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 fractures
2. Bone grafting for delayed union or nonunion of fractures
3. Excision of sequestra or saucerization in patients with osteomyelitis
4. Excision and biopsy of tumors
5. Osteotomy

40.  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.

41. POSITION:
 Place the patient supine on the operating table.
 inflate a tourniquet

42.  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

43.  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

44. 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

46. 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

47. 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. 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.
 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

48.  The posterolateral approach is used to expose the middle two-thirds of the tibia when the skin
over the subcutaneous surface is badly scarred or infected
 The approach is suitable for the following uses:
1. Internal fixation of fractures
2. Treatment of delayed union or nonunion4of fractures, including bone grafting
3. The approach also permits exposure of the middle of the posterior aspect of the fibula.

49.  POSITION:
 Place the patient on his or her side with the affected leg uppermost

50. 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 but a minimum of 10 cm is needed.

51.  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

52.  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

53.  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

54.  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

55.  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

56.  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

57. 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