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Introduction
  • Exposure to
    • middle two thirds of the tibia
    • entire fibula
    • use when anterior and anterior medial approach limited by skin issues
  • Indications
    • ORIF of tibia fractures
    • bone grafting for nonunion or delayed union
    • implantation of electrical stimulators
    • excision or biopsy of bone lesions
    • osteotomy
    • fibula resection for fibula transfer


Plane
  • Internervous plan between  
    • tibial nerve (posterior compartment)
      • gastrocnemius 
      • soleus 
      • FHL 
    • superficial peroneal nerve (lateral compartment)
      • peroneus bevis 
      • peroneus longus 
Preparation
  • Anesthesia
    • options include
      • general
      • spinal
      • peripheral nerve block
  • Position
    • prone or in lateral position
  • Tourniquet
    • exsanguinate limb using elevation or Esmarch
Approach
  • Incision
    • longitudinal incision on lateral border of the gastrocnemius
      • make of desired length
  • Superficial dissection
    • reflect skin flaps
      • take care not to damage the short saphenous vein
    • incise fascia
      • incise in line with the incision
    • develop intermuscular plane
      • develop plan between the gastrocnemius and soleus (posterior group) and peroneal muscles (lateral group)
      • muscular branches of peroneal artery lie with peroneus brevis proximally and may need to ligated
    • retract the soleus and gastrocnemius posteromedially
      • once done identify the origin of FHL and soleus on the posterior border of the fibula
  • Deep dissection
    • detach the FHL and soleus
      • detach from the posterior border of the fibula and retract posteromedially
      • may expose entire length of fibula)
    • detach posterior tibialis
      • remove off the posterior surface of the interosseous membrane
      • the posterior tibial artery and nerve will be posterior to posterior tibialis and FHL
    • follow IOM to tibia
      • follow the posterior surface of the interosseous membrane to the lateral border of the tibia
    • release posterior tibialis and FDL of tibia
      • dissect the posterior tibialis and flexor digitorum longus off the posterior surface of the tibia to expose the desired segment of tibia 
  • Extensile measure
    • proximal 
      • cannot be extended into the proximal fourth of the tibia
        • popliteus muscle, posterior tibial artery, and tibial nerve preclude proximal dissection
    • distal 
      • may be extended distally to become continuous with the posterior approach to the ankle
  • Closure
    • loosely close the deep fascia on the lateral side of the leg
      • use interrupted sutures
Structures at Risk
  • Short saphenous vein
  • Peroneal artery and branches
    • avoid injury by staying on the posterior surface of the interosseous membrane
    • branches may be ligated and coagulated
  • Posterior tibial artery and nerve 
    • avoid injury by staying on the posterior surface of the interosseous membrane
 

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