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