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Indications
  • Exposure to
    • middle two thirds of tibia when anterior approach is not an option due to skin issues
  • Indications include
    • anterolateral bone grafting
    • only provides limited exposure so of limited use for ORIF of tibia fractures


Internervous Plane
  • Interval between
    • peroneus brevis (superficial peroneal nerve) - lateral compartment
    • extensor digitorum longus (deep peroneal nerve) - anterior compartment
Approach
  • Position
    • lateral decubitus or semi-lateral
    • exsanguinate limb if desired
  • Incision
    • make a longitudinal incision over the anterior edge of the fibula (center it over the pathology in the tibia)
  • Superficial dissection
    • Incise tissue and fascia in line with the skin incision, careful not to injure the short saphenous vein that runs along the posterior border of the fibula
    • develop plane between peroneus brevis and extensor digitorum longus
    • dissect down to anterolateral border of the fibula
    • protect the superficial peroneal nerve that lies on the peroneus brevis muscle
    Deep surgical dissection
    • gently detach the extensor musculature form the anterior aspect of the interosseous membrane using blunt instruments or cautery
    • follow the anterior surface of the interosseous membrane to the lateral border of the tibia
      • (failure to stay on the surface of the interosseous membrane may lead to injury to the neurovascular bundle in the anterior compartment
    • expose the anterolateral border of the tibia
      • perform subperiosteal dissection (elevating tibialis anterior) of the lateral surface of tibia moving anteriorly
    • expose desired region of the lateral surface of the tibia
Dangers
  • Short saphenous vein
  • Superficial peroneal nerve (gives off all motor branches in upper third of leg - therefore only sensory branches at the level of this incision)
    • injury to the nerve at this level leads to numbness on the dorsum of the foot
  • Anterior tibial artery and deep peroneal nerve
    • protected as long as you stay on the anterior surface of the interosseous membrane
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