Different Surgical Approaches to Tibia

Last Updated on October 29, 2023

Surgical approaches to tibia are named according to the site of incision and the region accessed

Anterolateral Approach to Tibia

Indications

This incision is the classical incision for plating of tibia or open reduction of tibial fractures. The entire tibia from knee to ankle may be exposed through this incision.

It mobilizes the muscles of the anterior compartment.

Steps

• Skin  incision is 1-2 cm lateral to the tibial crest
• It can be continued distally straight over the ankle joint along the line of the anterior tibial tendon.
• The length of the incision depends on the plate length.
• The fascia is incised just lateral to the tibial crest and the dissection is carried down extraperiostally along the lateral surface of the tibia.
• Protect the long saphenous vein when retracting the skin flaps
• The periosteum mobilization may be required for exposure and mobilization of fracture edges. Rest of the periosteum should be left intact
• For exposure of the distal third of the tibia identify, protect and mobilize tibial nerve and vessels. Mobilize them from the tibial surface, along with the anterior compartment muscles.
  • At the junction of the middle and lower thirds of the tibia, the anterior tibial artery and deep peroneal nerve wrap obliquely anteriorly and distally around the lateral surface of the tibia.
    In the distal metaphyseal area, they lie on the periosteum, under the myotendinous portion of tibialis anterior, extensor hallucis longus, and extensor digitorum longus.
• The tendon sheath of tibialis anterior should remain closed if possible. If it is opened, it should be resutured so that the tendon itself is not directly under the incision.
• Close only the skin and subcutaneous tissues. Leave the fascia open to minimize the risk of compartment syndrome.

Posteromedial Approach

Indications

The posteromedial approach can be used for open plate fixation of the tibia on its posterior surface or for releasing the posterior compartment in compartment syndrome.

This approach is chosen, when direct exposure for ORIF is desired, but only the posteromedial soft tissues are safe to incise.

Steps

• Prone or supine position [in the supine position, the leg is flexed and externally rotated for exposure.]
• The incision is  made 1 cm posterior  to the medial border  of the tibia
• Subcutaneous dissection follows carefully so as to identify and/or protect the saphenous vein and nerve which are mobilized anteriorly.
• The fascia is incised in line with the skin incision
• The superficial and deep posterior compartments are mobilized. Gastrocnemius, soleus and flexor digitorum are identified and mobilized with a soft-tissue elevator, depending on the level of the fracture.
• The dissection should be done in an extra-periosteal plane.
• The approach should not be used beyond the posterolateral aspect of the tibia.
• Can expose  3/5 of the posterior tibia.
• Close the tissues barring deep fascia.
• Wound closure

Posterolateral Approach to Tibia

Indications

This approach is used in secondary bone-grafting procedures,  especially if the anterior skin condition is not suitable for surgery.

As it allows access to both the tibia and fibula and is often also used for the treatment of non-unions with posterolateral bone grafting.

Steps

• The incision begins over the lateral border of the gastrocnemius muscles and extends distally to a point that is midway between the Achilles tendon and the fibula. The length of the incision may vary
• Dissect between the superficial posterior and lateral compartments. .Starting distally, the interval between the lateral and posterior compartments is found and dissection is extended proximally.
• Incise the fascia of the gastrocnemius and soleus and mobilize them mobilized medially exposing the posterolateral aspect of the fibula is exposed.
  • Crossing perforating branches of the peroneal vessels should be ligated
• Mobilize flexor hallucis longus mobilized posteromedially and continue medial dissection until the interosseous membrane is encountered.
• Mobilize the remainder of the deep posterior compartment medialwards until the posterior aspect of the tibia is encountered.
• If incision goes way proximally, common peroneal nerve crossing the fibular neck very proximally should be protected
• In wound closure, fascia can be sutured but if there is concern about a developing compartment syndrome, the fascia should be left open and only the skin and subcutaneous layers are closed.

Incision for Closed Nailing

The entry point is established first.

• Identify the tibial crest and place a guide wire along it, extending proximally over the knee.
• The correct insertion point will be at the intersection of the guide wire with the tibial plateau.
• Make a longitudinal skin incision over the planned entry point. Extend it 3-5 cm proximally from the level of the tibial plateau.
• The incision may go either through or around the patellar tendon. Going through the tendon enables to go along the medullary canal.

If the tendon can be retracted sufficiently for direct access, this also can be used.

Minimally Invasive Approaches to Tibia

Lateral Approach

• Indications
  • For minimally invasive osteosynthesis
  • Lateral fixation with a precontoured plate (e.g. LISS plate)
• Incision
  • Proximal incision – Approximately 5 cm long, begins distal to the tibial tubercle and 1.5 – 2 cm lateral to the tibial crest curving slightly posteriorly on the proximal aspect
  • A short distal incision over the distal third of the tibia for plates longer plates is desirable to avoid vital structures being injured by a submuscular plate, or percutaneous screws.
• Incise the fascia a few millimeters lateral to the tibial crest.
• Distally, dissect the tibialis anterior tendon from the bone, preserving the paratenon.
• Retract the tendon together with the deep peroneal nerve and the anterior tibial vessels to the lateral side.
• At the proximal incision, dissect the tibialis anterior muscle from the bone without stripping the periosteum.
  Retract the tibialis anterior muscle laterally.
• Using a soft-tissue elevator, prepare a tunnel between the anterior tibial muscle and the periosteum.
• Protect the anterior tibial vessels and deep peroneal nerve distally. Depending on plate placement they should be gently retracted laterally or lifted anteromedially

Medial approach

• Preferred for distal tibial fractures.
• Make a distal incision about approximately 5 cm long, on the medial surface of the tibia. An additional incision may be required proximally for plate adjustment and screw placement
  • Distal incision could be straight or oblique depending on the need.
  • The oblique incision may increase the risk of injury to the saphenous nerve and vein, which should be identified and protected.
• Deepen the dissection to the periosteum, which is left intact.
• Use a soft-tissue elevator, or an appropriate plate, to prepare a tunnel under the subcutaneous tissues and over the periosteum.

Anteromedial Approach to Tibia

The anteromedial approach is for fractures of the distal third tibial shaft but can be used to expose the entire anteromedial surface.

It should not be used when the medial skin has a substantial contusion.

Steps

• A longitudinal incision 1-2 cm lateral to the tibial crest. Distally, continue along the medial edge of the tibialis anterior in a gentle curve in the direction of the medial malleolus.
• The deep dissection should stay superficial to the fascia layer of the anterior compartment.
• Saphenous vein and nerve, which are at risk at the distal extent of the approach.
• Avoid breaching the tibial tendon sheath should be avoided, as this can cause unwanted adhesions.
• Full-thickness skin and subcutaneous tissue flaps are then mobilized in a medial direction exposing the anteromedial aspect of the tibia