Approaches
Posterolateral
Anterolateral
Posterolateral Approach
Indications
- ORIF distal 2/3 tibia
- bone grafting tibial non-unions
- also permits exposure to posterior aspect of fibula
Technique
Position
- lateral position or prone
Landmarks
- fibular shaft and ankle joint
Incision
- longitudinal incision 2cm behind the fibula
Internervous plane
- between posterior & lateral compartments
- anterior - peroneus muscles
- posterior - gastrocnemius, soleus & FHL (distal)
Superficial dissection
- dissect T achilles (gastroc and soleus) posteriorly and peronei muscles anteriorly
- muscular branches of peroneal artery lie with peroneus brevis in proximal part of incision / ligated
Deep dissection
- detach lower part of soleus & FHL from fibula
- continue dissecting across the interosseous membrane, detaching tibialis posterior from it
- follow interosseous membrane to lateral border of tibia
- detaching tibialis posterior from posterior surface of tibia subperiosteal
- posterior tibial artery & tibial nerve are posterior to dissection on tibialis posterior
Dangers
- peroneal artery - branches cross inter-muscular plane bt gastrocnemius & peroneus brevis
- posterior tibial artery & tibial nerve - safe as long as dissection stays on interosseous membrane
- short saphenous vein - may be damage in mobilizing skin flaps
Extensile measures
- proximal - cannot be extended into proximal 1/4 of tibia as it is covered by popliteus
- distal - continuous with posterior approach to ankle
Anterolateral approach
Indications
- exposes middle 2/3 tibia
- technically simple, but only provides limited exposure to tibia for ORIF
- anterolateral bone grafting tibial non-unions
Technique
Position
- lateral position or supine with sandbag under hip
Incision
- longitudinal incision over the shaft of fibula
- length of tibia exposed will be considerably shorter than length of fibula incision
Internervous plane
- between peroneus brevis (posterior) & EDL (anterior)
Superficial dissection
- develop plane between anterior border of peroneus brevis & EDL
- expose anterior aspect of tibia
- protect superficial peroneal nerve which lie on peroneus brevis muscle
Deep dissection
- subperiosteal dissection extensor muscles from anterior surface of interosseous membrane
- extend onto lateral surface of tibia
- only endanger neurovascular bundle if sway off interosseous membrane
Dangers
- SPN - motor branches given off proximal 1/3 then only sensory distally
- anterior tibial artery & DPN
Extensile measures
- cannot be extended easily proximally or distally