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Introduction
  • Allows exposure of
    • medial malleolus
    • posterior margin of the tibia
  • Indications
    • ORIF of medial malleolus fxs
    • ORIF of pilon fxs
    • ORIF of posterior malleolus fxs
 
Intermuscular interval
  • plane exists between
    • tibialis posterior tendon (tibial nerve)
    • flexor digitorum (tibial nerve)
Approach
  • Position
    • supine
    • exsanguinate limb
  • Incision
    • Make 10 cm longitudinal curved incision with concavity of incision pointing anterior
    •  
      • begin 5 cm above the medial maleollus on the posterior border of the tibia
      • curve incision distally following the posterior border of the medial malleolus
      • end incision 5cm distal to medial malleolus
  • Superficial dissection
    • Mobilize skin flaps
      • should be safetly posterior to long saphenous vein and saphenous nerve
    • Incise retinaculum behind medial malleolus in a way that it can be repaired
  • Deep dissection
    • retract tibialis posterior anteriorly
    • retract remaining structure posteriorly (neurovascular bundle, FHL, FDL)
    • perform subperiosteal dissection to expose posterior border of the tibia
      • stay on bone to avoid injury to posterior structures
Dangers
  • Tibialis posterior muscle
  • Flexor digitorum longus tendon
  • Flexor hallucis longus tendon
  • Posterior tibial artery and vein
  • Tibial nerve
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