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  • 1. SURGICAL APPOROACHES OF LEG Dr.BALARAJU PG IN MS(ORTHO) GANDHI HOSPITAL
  • 2. Anterolateral Approach to the Lateral Tibial Plateau INDICATIONS 1)ORIF Of lateral tibial plateau # 2)Bone grafting for delayed union and non union of # 3)Osteomyelitis 4)Tumours 5)Proximal tibial osteotomy 6)Bone graft harvesting POSITION Supine
  • 3. LANDMARKS Palpate the shaft of proximal tibia along its anterior border Identify position of lateral knee joint line Palpate Gerdy’s tubercle just lateral to patella tendon INCISION S shaped incision 3-5 cm proximal to joint line,just lateral to patellar tendon. Curve the incision anteriorly over Gerdy’s tubercle and then extend it distally,staying about 1cm lateral to ant border of tibia INTERNERVOUS PLANE NO
  • 4.  Superficial Surgical Dissection  Deepen the incision proximally through subcutaneous tissue to expose the lateral aspect of knee joint capsule  Incise knee joint capsule longitudinally down to the superior border of lateral meniscus  Take care not divide lateral meniscus  Below the joint line deepen the incision through subcutaneous tissue and incise the fascia overlying the tibilis anterior muscle
  • 5.  Deep Surgical Dissection  Proximally enter knee joint by dividing the synovium  Carefully detatch lateral meniscus from its soft tissue attachments inferiorly and develop a plane between the undersurface of lateral meniscus and the underlying tibial plateau  Insert stay sutures to the periphery of meniscus to facilitate reattachment during closure  Ensure that anterior attachment of meniscus remains intact  Detach sufficient amount of meniscus to allow adequate visualisation of superior surface of lateral tibial plateau  Using an elevator ,inferiorly detach some of the origin of tibialis anterior from proximal tibia  Dangers  nerves  Superficial branch of peroneal nerve has variable course.normally,it lies well posterior to the area of dissection and it should not be injured
  • 6. Posteromedial Approach to the Lateral Proximal Tibia  Complex fractures of proximal tibia often involve a large postero medial fragment  Plates applied to postero medial aspect of tibia prevent varus defomity  INDICATIONS  1)ORIF of Medial tibial plateau #  2)ORIF of complex bicondylar tibial plateau #  3)upper tibial osteotomy  4)tumours  5)abscess drainage
  • 7. POSITION SUPINE LANDMARKS Upper end of tibia is triangular Postero medial surface where the tibia flares is easily palpated INCISION 6 cm longitudinal incision overlying the postero medial border of proximal tibia INTERNERVOUS PLANE no
  • 8.  Superficial Surgical Dissection  Deepen the incision through subcutaneous fat  Long saphanous vein and saphanous nerve will be just anterior to our surgical approach ,should be preseved  Identify the pes anserinus expansion overlying the tibia  To approach the tibia ,either divide the pes anserinus longitudinally in the line of skin incision or identyfy anterior border of pes and partially resect it from its insertion into tibia,reflecting it posteriorly
  • 9.  Deep Surgical Dissection  Develop an epi periosteal plane between the pes and medial head of gastrocnemius at postero medial border of tibia  The muscle can be gently freed from the bone by blunt dissection  DANGERS  Long saphanous vein and saphanous nerve will be just anterior to our surgical approach ,should be preseved
  • 10. Anterior Approach to the Tibia  The anterior approach offers safe, easy access to the medial and lateral surfaces of the tibia:  INDICATIONS  Open reduction and internal fixation of tibial fractures  Bone grafting for delayed union or nonunion of fractures  Implantation of electrical stimulators  Excision of sequestra or saucerization in patients with osteomyelitis  Excision and biopsy of tumors  Osteotomy .Position  Supine
  • 11. Landmarks  The shaft of the tibia is roughly triangular when viewed in cross section.  It has three borders, one anterior, one medial, and one interosseous (posterolateral).  These borders define three distinct surfaces:  (1) a medial subcutaneous surface between the anterior and medial borders.  (2) a lateral (extensor) surface between the anterior and interosseous borders.  (3) a posterior (flexor) surface between the medial and interosseous (posterolateral) borders.  The anterior and medial borders and the subcutaneous surface are easily palpable.
  • 12.  Incision  Make a longitudinal incision on the anterior surface of the leg parallel to the anterior border of the tibia and about 1 cm lateral to it.  The length of the incision depends on the requirements of the procedure because of the poor vascularity of the skin.  It is safer to make a longer incision than to retract skin edges forcibly to obtain access. The tibia can be exposed along its entire length  Internervous Plane  There is no internervous plane in this approach.  The dissection essentially is subperiosteal and does not disturb the nerve supply to the extensor compartment.
  • 13. Superficial Surgical Dissection Elevate the skin flaps to expose the subcutaneous surface of the tibia. The long saphenous vein is on the medial side of the calf and must be protected when the medial skin flap is reflected Deep Surgical Dissection Two surfaces of the tibia can be approached through this incision.
  • 14. Subcutaneous (Medial) Surface The periosteum of the tibia provides a small but vital blood supply to the bone in fractures that interfere with its main blood supply. For this reason, periosteal stripping must be kept to an absolute minimum. In particular, never strip the periosteum off an isolated fragment of bone, or the bone will become totally avascular. To expose the bone, incise the periosteum longitudinally in the middle of the subcutaneous surface of the tibia Reflect it anteriorly and posteriorly to uncover only as much bone as is absolutely necessary . Note the superior insertion of the pes anserinus into the subcutaneous surface of the tibia. Detach it if that portion of the bone needs to be exposed, but this rarely is necessary.
  • 15. Lateral (Extensor) Surface Incise the periosteum longitudinally over the anterior border of the tibia. Reflect the tibialis anterior muscle subperiosteally, and retract it laterally to expose the lateral surface of the bone. The tibialis anterior is the only muscle to take origin from the lateral surface of the tibia; detaching the muscle completely exposes that surface .
  • 16. Dangers The long saphenous vein, which runs up the medial side of the calf, is vulnerable during superficial surgical dissection and should be preserved for future vascular procedures, if at all possible . Special Surgical Points Skin flaps must be closed meticulously after surgery to avoid infection of the tibia. Although longitudinal incisions over the tibia heal well, transverse incisions and irregular wounds may heal poorly, especially in elderly individuals. The skin over the lower third of the tibia is very thin; wounds in that area heal badly, especially in patients with chronic venous insufficiency. It is important to minimize the amount of soft tissue that is stripped from bone in this approach when it is used for fracture work. Devascularized bone, no matter how well it is reduced and fixed, will not unite Using care and appropriate reduction forceps, it usually is possible to preserve soft-tissue attachments of all but the smallest fragments of bone.
  • 17. Anterolateral Approach to the Tibia  INDICATIONS  The anterolateral approach is used to expose the middle two thirds of the tibia when the skin over the subcutaneous surface of the bone is unsuitable for a direct anterior approach  .It is of most use in the treatment of infected nonunion of the tibia.  Anterolateral bone grafting of the tibia  Tibia profibula grafting (cross-tibiofibular grafting). This approach is technically simple. because it only provides limited exposure of the tibia, it usually is inadequate for the internal fixation of fractures.  Position  Place the patient on his or her side with the affected limb on top.
  • 18.  Landmarks  Palpate the subcutaneous surface of the fibula in the distal third of the limb. Also palpate the fibula head proximally.  Incision  Make a longitudinal incision that overlies the shaft of the fibula, centering it at the level of the tibial pathology. The length of the incision depends on the length of the tibia that must be exposed. Note that the length of tibia exposed will be considerably shorter than the length of the fibula incision.  Internervous Plane Superficially, the internervous plane lies between the peroneus brevis muscle (which is supplied by the superficial peroneal nerve) and the extensor digitorum longus muscle (which is supplied by the deep peroneal nerve). Deeply, the internervous plane lies between the tibialis posterior muscle (which is supplied by the tibial nerve) and the extensor muscles of the ankle and foot (which are supplied by the deep peroneal nerve). These muscles are separated by the interosseous membrane.
  • 19. Superficial Surgical Dissection  Deepen the incision, taking care not to damage the short saphenous vein that may appear in the posterior aspect of the wound.  Incise the fascia in the line of the skin incision, and identify the underlying peroneal muscles . Develop a plane between the anterior aspect of the peroneus brevis muscle and the extensor digitorum longus muscle to come down onto the anterolateral aspect of the fibula. Protect the superficial peroneal nerve, which can be seen lying on the peroneus brevis muscle.
  • 20.  Deep Surgical Dissection  Gently detach the extensor musculature from the anterior aspect of the interosseous membrane using blunt instruments.  Follow the anterior aspect of this membrane onto the lateral border of the tibia.  Because this approach almost always is used in cases of trauma, the plane often is difficult to develop.  Make sure to stay firmly on the interosseous membrane; straying anteriorly may cause damage to the anterior neurovascular bundle.  Expose the posterolateral corner of the tibia.  Gently strip off as much tissue as necessary from the lateral aspect of the tibia, elevating some of the origin of the tibialis anterior muscle in the process.  As in all approaches to the tibia, only the minimum amount of soft tissue that is required to gain adequate access should be dissected to avoid devascularization of bone.
  • 21. Dangers Vessels and Nerves The small saphenous vein may be damaged in the posterior skin flap . The superficial peroneal nerve runs down the leg in the peroneal or lateral compartment. It gives off all its motor branches in the upper third of the leg. Hence, it is sensory only at the level of this approach. Identify and preserve the nerve to avoid numbness on the dorsum of the foot The anterior tibial artery and the deep pero0neal nerve run down the leg in the anterior compartment, which is anterior to the interosseous membrane Therefore, as long as the plane of operation remains on the interosseous membrane and does not wander off anteriorly, no damage will result until the periosteum of the tibia is reached.
  • 22. Posterolateral Approach to the Tibia(MODIFIED HARMON) The posterolateral approach is used to expose the middle two thirds of the tibia when the skin over the subcutaneous surface is badly scarred or infected.  It is a technically demanding operation.  The approach is suitable for the following uses:  Internal fixation of fractures  Treatment of delayed union or nonunion of fractures, including bone grafting  The approach also permits exposure of the middle of the posterior aspect of the fibula. Position  Place the patient on his or her side, with the affected leg uppermost.
  • 23. Landmark  The lateral border of the gastrocnemius muscle is easy to palpate in the calf. Incision  Make a longitudinal incision over the lateral border of the gastrocnemius muscle. Internervous Plane  The internervous plane lies between the gastrocnemius, soleus, and flexor hallucis longus muscles (all of which are supplied by the tibial nerve),  the peroneal muscles (which are supplied by the superficial peroneal nerve)—between the posterior and lateral muscular compartments
  • 24.  Superficial Surgical Dissection  Reflect the skin flaps, taking care not to damage the short saphenous vein, which runs up the posterolateral aspect of the leg from behind the lateral malleolus.  Incise the fascia in line with the incision and find the plane between the lateral head of the gastrocnemius and soleus muscles posteriorly, and the peroneus brevis and longus muscles anteriorly.  Muscular branches of the peroneal artery lie with the peroneus brevis in the proximal part of the incision and may have to be ligated  Find the lateral border of the soleus and retract it with the gastrocnemius medially and posteriorly; underneath, arising from the posterior surface of the fibula, is the flexor hallucis longus
  • 25.  Deep Surgical Dissection  Detach the lower part of the origin of the soleus muscle from the fibula and retract it posteriorly and medially.  Detach the flexor hallucis longus muscle from its origin on the fibula and retract it posteriorly and medially .  Continue dissecting medially across the interosseous membrane, detaching those fibers of the tibialis posterior muscle that arise from it.  The posterior tibial artery and tibial nerve are posterior to the dissection, separated from it by the bulk of the tibialis posterior and flexor hallucis longus muscles .  Follow the interosseous membrane to the lateral border of the tibia, detaching the muscles that arise from its posterior surface subperiosteally, and expose its posterior surface .
  • 26. Dangers Vessels The small (short) saphenous vein may be damaged when the skin flaps are mobilized. Although the vein should be preserved if possible, it may be ligated, if necessary, without impairing venous return from the leg. Branches of the peroneal artery cross the intermuscular plane between the gastrocnemius and peroneus brevis muscles. They should be ligated or coagulated to reduce postoperative bleeding The posterior tibial artery and tibial nerve are safe as long as the surgical plane of operation remains on the interosseous membrane and does not wander into a plane posterior to the flexor hallucis longus and tibialis posterior muscles
  • 27. POSTERIOR APPROACH TO SUPERO MEDIAL REGION OF TIBIA (BANK AND LAUFMAN) The patient must be prone. Begin the transverse segment of the hockey- stick incision at the lateral end of the flexion crease of the knee, and extend it across the popliteal space. Turn the incision distally along the medial side of the calf for 7 to 10 cm. Develop the angular flap of skin and subcutaneous tissue, and incise the deep fascia in line with the skin incision . Identify and protect the cutaneous nerves and superficial vessels.
  • 28. Define the interval between the tendon of the semitendinosus muscle and the medial head of the gastrocnemius muscle Retract the semitendinosus proximally and medially and the gastrocsoleus component distally and laterally; the popliteus and flexor digitorum longus muscles lie in the floor of the interval Elevate subperiosteally the flexor digitorum longus muscle distally and laterally and the popliteus muscle proximally and medially, and expose the posterior surface of the proximal fourth of the tibia. If necessary, extend the incision distally along the medial side of the calf by continuing the dissection in the same intermuscular plane The tibial nerve and posterior tibial artery lie beneath the soleus muscle.
  • 29. Approach to the Fibula(HENRY)  The approach to the fibula employs a classic extensile exposure and offers access to all parts of the fibula. :  Partial resection of the fibula during tibial osteotomy or as part of the treatment of tibial nonunion  Resection of the fibula for decompression of all four compartments of the leg  Resection of tumors  Resection for osteomyelitis  Open reduction and internal fixation of fractures of the fibula  Removal of bone grafts  Although the bone can be exposed completely, only a part of the approach usually is required for any one procedure.  Position of the Patient  Place the patient on his or her side on the operating table with the affected side uppermost..
  • 30.  Landmarks  The head of the fibula is easily palpable about 2 to 3 cm below the lateral femoral condyle.  The common peroneal nerve can be rolled underneath the fingers as it winds around the fibular neck.  The lower fourth of the fibula is subcutaneous.  Incision  Make a linear incision just posterior to the fibula, beginning behind the lateral malleolus and extending to the level of the fibular head.  Continue the incision up and back, a handbreadth above the head of the fibula and in line with the biceps femoris tendon.  Watch out for the common peroneal nerve, which runs subcutaneously over the neck of the fibula and can be cut if the skin incision is too bold.  Internervous Plane  The internervous plane lies between the peroneal muscles, supplied by the superficial peroneal nerve, and the flexor muscles, supplied by the tibial nerve
  • 31.  Superficial Surgical Dissection  To expose the fibular head and neck, begin proximally by incising the deep fascia in line with the incision, taking great care not to cut the underlying common peroneal nerve.  Find the posterior border of the biceps femoris tendon as it sweeps down past the knee before inserting into the head of the fibula.  Identify and isolate the common peroneal nerve in its course behind the biceps tendon; trace it as it winds around the fibular neck .
  • 32. Superficial Surgical Dissection(cont)  Mobilize the nerve from the groove on the back of the neck by cutting the fibers of the peroneus longus that cover the nerve and gently pulling the nerve forward over the fibular head with a strip of corrugated rubber drain. Identify and preserve all branches of the nerve  Develop a plane between the peroneal and the soleus; with the common peroneal nerve retracted anteriorly, incise the periosteum of the fibula longitudinally in the line with this plane of cleavage. Continue the incision down to bone
  • 33.  Deep Surgical Dissection  Strip the muscle off the fibula by dissection.  All muscles that originate from the fibula have fibers that run distally toward the foot and ankle.  Therefore, to strip them off cleanly, you must elevate them from distal to proximal.  Most muscles originate from periosteum or fascia; they can be stripped.  Muscles attached directly to bone are difficult to strip; they usually must be cut.
  • 34.  Dangers  Nerves  The common peroneal nerve is vulnerable as it winds around the neck of the fibula.  The key to preserving the nerve is to identify it proximally as it lies on the posterior border of the biceps femoris.  It then can be safely traced through the peroneal muscle mass and retracted.  The dorsal cutaneous branch of the superficial peroneal nerve is susceptible to injury at the junction of the distal and middle thirds of the fibula; if it is damaged, it causes numbness on the dorsum of the foot . Vessels Terminal branches of the peroneal artery lie close to the deep surface of the lateral malleolus. To avoid damaging them, you must keep the dissection subperiosteal .
  • 35. Minimal Access Approach to the Proximal Tibia The minimal access approach to the proximal tibia is used for the insertion of intramedullary nails used in the treatment of the following:  Fresh tibial shaft fractures  Pathological tibial shaft fractures  Delayed union and nonunion of tibial shaft fractures  Tibial nails do not have the wide variability in design seen in femoral nails. All tibial nails are angled at their upper end to allow insertion via an anterior route, and all tibial nails are straight when viewed in the anterior-posterior plane.  Position of the Patient  Two positions may be used for the insertion of tibial nails.  Placing the patient on a traction table allows greater control of the fracture and easier distal locking.  The free leg position allows greater knee flexion, which makes nail insertion easier.
  • 36. Traction Table  This is the most commonly used position.  Place the patient supine on an operating table.  Flex the hip to 60°. Place a support behind the posterior aspect of the distal thigh.  Take care not to place the support in the popliteal fossa, where it will create pressure on the popliteal vein  Flex the knee to 100° to 120° of flexion,  Apply traction by strapping the patient's foot to the sole of a traction boot or a Steinmann pin inserted through the os calcis..  Place the contralateral leg in a support with the hip flexed and abducted and the knee flexed
  • 37.  Free Leg Position  Place the patient supine on an operating table.  Remove the end of the table, and allow the injured knee to flex over the end of the table.  Place the contralateral leg in a support with the hip flexed and abducted and the knee flexed. Do not use a tourniquet
  • 38.  Landmarks  Palpate the patella on the anterior aspect of the knee.  The patellar tendon is felt as a resistance extending from the inferior pole of the patella to the tibial tubercle.  Incision  Make a 5-cm incision on the anterior aspect of the tibia, beginning at the inferior border of the patella and extending the incision down to just above the tibial tubercle .  This incision should overlie the medial border of the patellar tendon.  Internervous Plane  There are no internervous planes involved in this approach
  • 39.  Superficial Surgical Dissection  Incise the subcutaneous fat and fibrous tissue arising from the medial aspect of the patellar tendon in the line of the skin incision.  Numerous small arterial vessels are usually encountered and will need to be coagulated.  Identify the medial border of the patellar tendon, and incise this fascia longitudinally along the border .  Deep Surgical Dissection  Retract and mobilize the patellar tendon laterally to expose a small bursa between the tendon and the anterior aspect of the tibia—the deep infrapatellar bursa .  The entry point of the nail lies at the very proximal end of the tibia at the junction of the anterior and superior aspects of the bone.  Note that this entry point, although on the superior aspect of the tibia, is extrasynovial .
  • 40.  Dangers  Nerves and Vessels  The infrapatellar branch of the saphenous nerve is frequently damaged in this approach. It is impossible to preserve all the branches of the nerve, and patients should be warned that an area of numbness is likely following this surgical approach .  If a traction table is used and the thigh rest is placed within the popliteal fossa, compression of the popliteal veins can result. This can increase the risk of deep vein thrombosis.  Ligaments and Meniscus  If the entry point is too far posterior, damage to the tibial insertion of the anterior cruciate ligament and the anterior horn of the medial meniscus may occur  Deformity  If the entry point is too far medial, a valgus deformity will be created at the fracture site in proximal fractures.  If the entry point is too far lateral, a varus deformity will be created at the fracture site in proximal fractures.  Bone  If the entry point is too far inferior on the anterior surface of the tibia, then splitting of the anterior cortex of the tibia may occur on nail insertion
  • 41. Minimal Access Approach to the distal tibia  INDICATIONS  1)ORIF of multi fragmentarary fractures of distal tibial metaphysis  2)tumours  3)osteotomies  4)malunion  POSITION  Supine  LANDMARKS  Medial malleolus
  • 42. INCISION  Distally make a 4 cm incision starting just distal to MM extending incision proximally over lying the subcutaneous surface of tibia,halfway between anterior and posterior border  Proximally make a longitudinal incision over lying the subcutaneous surface of tibia,halfway between anterior and posterior border  INTERNERVOUS PLANE  no
  • 43.  Superficial Surgical Dissection deepen the skin incision to expose the periosteum overlying the tibia.because the periosteum of tibia is very precious structure that supplies significant amount of blood to bone,it should not be removed  Deep Surgical Dissection  Develop an epi periosteal plane between distal and proximal skin incisions using blunt dissector  DANGERS  periosteum of tibia is very precious structure that supplies significant amount of blood to bone,it should not be removed
  • 44. THANK YOU