12 Lower Leg



10.1055/b-0035-121472

12 Lower Leg



12.1 Proximal Approach to the Medullary Cavity of the Tibia


K. Weise, D. Höntzsch



12.1.1 Principal Indications




  • Intramedullary nailing of fractures



  • Pseudarthrosis



12.1.2 Positioning and Incision


Various positions are possible:




  • Supine with the leg raised



  • Supine with the leg hanging down



  • On an extension table


The skin incision is centered over the patellar ligament ( Fig. 12.1 ). Alternatively, it may be lateral to the patellar ligament, but thereafter the approach is largely identical.



12.1.3 Exposure of the Proximal Approach to the Medullary Cavity of the Tibia


The patellar ligament is split by an incision through all the layers, from the lower pole of the patella and its insertion as far as the tibial tuberosity ( Fig. 12.2 ).


The patellar ligament is retracted medially and laterally with Langenbeck retractors ( Fig. 12.3 ); alternatively, retaining sutures may be placed.

Fig. 12.1 Vertical incision centered over the patellar ligament.
Fig. 12.2 The patellar ligament is split through all layers with a single incision that extends a short distance below the skin. 1 Patellar ligament
Fig. 12.3 After splitting the patellar ligament, it is held laterally and medially with Langenbeck retractors so that the junction of the joint surface with the tibial tuberosity can be palpated in a distal direction. A guidewire is shown at the desired entry point. 1 Patellar ligament 2 Guidewire 3 Tibial tuberosity

The entry point for the nail is sought by palpation distally and is not shown directly. A guidewire is shown here, but alternative instrumentation may be used.



12.1.4 Wound Closure


The patellar ligament is closed in one layer, followed by subcutaneous suture and skin suture.



12.2 Direct Posterior Approach to the Tibial Plateau


P. Lobenhoffer, O. Yastrebov



12.2.1 Principal Indications




  • Posteromedial fracture dislocation of the tibial plateau (medial split fracture)



  • Bicondylar fracture dislocation of the tibial plateau



  • Tibial bony avulsion of the posterior cruciate ligament



12.2.2 Positioning and Incision


The patient is placed in the prone position. A tourniquet is applied to the operated leg, and the contralateral leg is lowered. The operated leg should be freely mobile. A rolled towel is placed below the thigh or lower leg depending on the direction of reduction.

Fig. 12.4 Skin incision extending 7 cm distally from the knee joint line, medial to the popliteal fossa over the medial head of gastrocnemius.


12.2.3 Technique

Fig. 12.5 The medial border of the medial head of gastrocnemius is sought following sharp dissection of the subcutaneous tissue and fascia. 1 Gracilis 2 Semitendinosus 3 Semimembranosus 4 Gastrocnemius, medial head 5 Gastrocnemius, lateral head
Fig. 12.6 The gastrocnemius is mobilized laterally by blunt dissection and retracted with a vein hook. The popliteus comes into view. 1 Gastrocnemius, medial head 2 Popliteus
Fig. 12.7 The popliteus is mobilized subperiosteally with a raspatory and retracted distally in a lateral direction. The distal part of the posterior joint capsule is exposed. 1 Gracilis 2 Semitendinosus 3 Semimembranosus 4 Gastrocnemius, medial head 5 Popliteus 6 Medial tibial condyle 7 Gastrocnemius, lateral head
Fig. 12.8 The posterior surface of the medial tibial plateau, the fracture margins, and the caudal fracture tip, which is important for reduction, are exposed. The joint capsule does not have to be opened. 1 Gracilis 2 Semitendinosus 3 Semimembranosus 4 Gastrocnemius, medial head 5 Popliteus 6 Medial tibial condyle 7 Gastrocnemius, lateral head
Fig. 12.9 The distal thigh is positioned on a rolled towel. The posteromedial fragment is reduced by extending the knee with simultaneous axial traction on the lower leg. The reduction is supported by a raspatory or oval awl. The fracture is fixed provisionally with Kirschner wires, and final internal fixation is performed after radiographic confirmation of the reduction.


12.2.4 Wound Closure


The soft tissues cover the internal fixation material spontaneously. The popliteus is reapproximated, and the tourniquet is released. Following hemostasis and irrigation, a Redon drain is inserted, the crural fascia is closed, and the wound is closed in layers.



12.2.5 Dangers




  • Hematoma



  • Deep vein thrombosis



  • Infection



  • Lower leg compartment syndrome



  • Injury to the neurovascular structures



12.3 Posteromedial Approach to the Tibial Plateau


P. Lobenhoffer, O. Yastrebov



12.3.1 Principal Indications




  • Posteromedial fracture dislocation of the tibial plateau



12.3.2 Positioning and Incision


The patient is placed supine. A tourniquet is applied to the leg. The side of the thigh is supported. The operated leg is elevated with the knee flexed to 60–70°. The contralateral leg is lowered.

Fig. 12.10 Skin incision approximately 6–7 cm long extending distally from the knee joint line along the posterior tibial border.


12.3.3 Wound Closure


The tourniquet is released. Following hemostasis and irrigation, a Redon drain is inserted if necessary, and the wound is closed in layers.



12.3.4 Dangers




  • Hematoma



  • Deep vein thrombosis



  • Infection



  • Lower leg compartment syndrome



  • Injury to the neurovascular structures



12.3.5 Technique

Fig. 12.11 The subcutaneous tissue is divided sharply, and the pes anserinus is identified. 1 Superficial crural fascia 2 Superficial part of the pes anserinus 3 Semimembranosus 4 Tibial collateral ligament
Fig. 12.12 Incision of the crural fascia at the posterior border of the tibial collateral ligament, running from the inferior border of semimembranosus as far as the upper border of the pes anserinus. 1 Superficial crural fascia (incised) 2 Superficial part of the pes anserinus 3 Semimembranosus 4 Tibial collateral ligament 5 Gastrocnemius, medial head 6 Medial tibial condyle
Fig. 12.13 The superficial part of the pes anserinus is retracted caudally, and the medial head of gastrocnemius is retracted posteriorly. The extra-articular fracture components are exposed subperiosteally. 1 Superficial crural fascia (incised) 2 Superficial part of the pes anserinus 3 Semimembranosus 4 Tibial collateral ligament 5 Gastrocnemius, medial head 6 Medial tibial condyle


12.4 Posterolateral Approach to the Tibial Plateau with Osteotomy of the Fibula


P. Lobenhoffer, O. Yastrebov



12.4.1 Principal Indications




  • Posterolateral fracture dislocation of the tibial plateau



  • Posterolateral depressed fracture of the tibial plateau



  • Bicondylar fracture dislocation of the tibial plateau



12.4.2 Positioning and Incision

Fig. 12.14 The patient lies supine with the leg raised, or lies on his or her side. Application of a tourniquet. The operated leg is freely mobile.
Fig. 12.15 Curved skin incision, approximately 10 cm in length, beginning 3 cm proximal to the joint line and extending distally on the anterolateral surface of the leg.


12.4.3 Technique

Fig. 12.16 The subcutaneous tissue is divided down to the crural fascia. Subcutaneous dissection continues posteriorly to the head of the fibula. The fascia is split parallel to the fibula, and the common peroneal nerve is exposed and snared. A curved incision is made in the crural fascia along the extensor origin. Note: The superficial peroneal nerve is directly beneath the fascia. 1 Crural fascia 2 Iliotibial tract 3 Common peroneal nerve 4 Head of fibula
Fig. 12.17 The muscles and fascia are mobilized subperiosteally in a caudal direction. The neck of the fibula is exposed, and an incomplete oblique subcapital osteotomy is performed sparing the common peroneal nerve. The osteotomy is then completed with a chisel, and the head of the fibula is retracted dorsocranially. 1 Origin of the foot extensors (tibialis anterior, extensor digitorum longus) 2 Iliotibial tract 3 Common peroneal nerve 4 Head of the fibula 5 Fibular collateral ligament and tendon of biceps femoris 6 Lateral tibial condyle
Fig. 12.18 Gerdy′s tubercle with the attachment of the iliotibial tract is divided and retracted proximally. The joint capsule is incised and dissected subperiosteally with the meniscotibial ligament. These are held proximally with retaining sutures. The fracture morphology and articular surface of the lateral tibial plateau can be assessed exactly. Exposure of the posterolateral tibial plateau is best achieved with the tibia in varus and internally rotated.
Fig. 12.19 Following internal fixation of the tibial plateau, the fibular head is reduced with pointed reduction forceps, sparing the common peroneal nerve. After predrilling, a small fragment screw is inserted bicortically perpendicular to the osteotomy. Fixation with a wire or tension band is an alternative.


12.4.4 Wound Closure


Closure starts with approximation of the joint capsule and reattachment of Gerdy′s tubercle by transosseous suture. The extensors and crural fascia are approximated with a continuous suture. The fascia over the common peroneal nerve is left open. The tourniquet is released. Following hemostasis and irrigation, a Redon drain is inserted if necessary, and the wound is closed in layers.

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Jun 9, 2020 | Posted by in ORTHOPEDIC | Comments Off on 12 Lower Leg

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