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Indications
  • Allows visualization of the posterior tibia and popliteal fossa
  • Indications
    • posterior tibial plateau fractures
    • popliteal fossa tumors or foreign bodies
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Plane
  • No true internervous or intermuscular plane
  • Dissection is maintained underneath the gastrocnemius  muscle belly
   
Preparation
  • Anesthesia
    • general anesthesia with endotracheal tube
  • Preparation
    • radiolucent table 
    • C-arm fluoroscopy
  • Position
    • prone positioning is necessary
    • slightly flex knee via a bump under the ankle
   
Approach 
  • Incision
    • inverted L-shaped incision is made
      • horizontal limb is in Langer's lines in the popliteal space
      • vertical limb begins at the medial corner of the popliteal fossa and extends distally
    • S-curve incision
      • above incision can be extended proximally on the lateral side for more extensile exposure
  • Superficial Dissection
    • full thickness fasciocutaneous flaps are created
    • sural nerve and short saphenous vein should be protected
  • Deep Dissection
    • tendon of the gastrocnemius is seen and the muscle is retracted laterally
      • the posterior aspect of the knee capsule is then seen
    • popliteus  and soleus  are subperiosteally elevated off the posterior tibia
      • this exposes almost all of the posterior tibia
  • Approach extension
    • if additional medial access is necessary, the medial head of the gastrocnemius can be released
    • posterolateral extension should be limited due to risk of common peroneal nerve injury
 








Structures at Risk    
  • Popliteal artery
    • risk is minimized with maintenance of access under the gastrocnemius
    • origin before knee
      • a continuation of the superficial femoral artery
      • transition is at hiatus of adductor magnus muscle
      • anchored by insertion of adductor magnus as enters region of posterior knee
    • course in posterior knee
      • relation to anatomy structures of knee
        • lies posterior to the posterior horn of the lateral horn of the lateral meniscus
          • lies directly behind posterior capsule
    • branches within knee
      • at supracondylar ridge gives branches the provide blood supply to the knee
        • above knee joint branches include
          • medial and lateral sural arteries
          • cutaneous branch
          • middle genicular artery
        • at level of knee joint branches include
          • medial genicular artery
          • lateral genicular artery
    • exit of knee
      • anchor
        • as artery exits knee it is anchored by soleus tendon (originates form medial aspect of tibial plateau)
      • distal branches
        • branches into anterior and posterior tibial arteries at distal popliteus muscles
  • Tibial nerve
    • risk is minimized with maintenance of access under the gastrocnemius
  • Sural nerve and short saphenous vein
    • these structures are seen in the superficial dissection and should be protected when possible
 
    Intraoperative Images
   
 

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