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