Sutgical Exposuresin Orthopaedics: The Anatomic Approach, SecondEdition by Stanley Hoppenfeld and Piet deBoer. |. B.

Lippincott Company, PhiladelphiaO 1994.

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The

Tibia U Fibula

-1

Tlr. tibia and fibul a areapproximately equal in length, but are different in structure and function. The tibia is large, transmits most of the stress of walking, and has a broad, accessiblesubcutaneoussurface.The fibula is slender and plays an important role in ankle stability; it is surrounded by to muscles, except at its ends. Surgical approaches the fibula are more complex than are those to the tibia, becauseof both the depth of the bone and the presenceof the common peroneal nerve, which winds around its upper third. The antefior approach is used There are three main tibial approaches. most often becauseit affords easy accessto the subcutaneous surface of the bone. The anterolateral and posterclateral approachesare used rarely, but can save the limb when skin breakdown has made anterior approachesimpossible during bone grafting for nonunited fractures. The approach to the fibula is classically extensile, using the internervous plane between muscles supplied by the superficial peroneal nerve (the peroneal muscles) and those supplied by the tibial nerve (the flexor muscles). Although this approachcan exposethe whole bone, the full approach rarely is required. Becausethe surgical anatomy of the approachesoverlap, the anatomy of the area is consideredas a whole.

AI{TERIOR APPROACH TO THE TIBIA

to The anterior approachoffers safe,easyaccess the medial (subcutaneous)and lateral (extensor) surfaces of the tibia. It is used for the following: 1. Open reduction and internal fixation of tibial fracturest 2. Bone grafting for delayed union or nonunion of fractures' 3 . Implantation of electrical stimulators3 4. Excision of sequestra or saucerization in patients with osteomyelitis 5 . Excision and biopsy of tumors 6. Osteotomy Plates applied to the subcutaneous surface of the tibia are placed correctly biomechanically on the medial (tensile) side of the bone; they also are prefer to use easierto contour there. Some surgeons the lateral surface for plating, however, to avoid the problems of subcutaneousplacement. The anterior approach is the preferred approach to the tibia except when the skin is scarredor has draining sinuses in it. POSITION OF THE PATIENT Place the patient supine on the operating table. Exsanguinate the limb by elevating it for 3 to 5 minutes, then inflate a tourniquet (Fig. 11-1). 484 LAI{ DMARKS AND INCI SION Land,marks 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, l2l alateral (extensorl sur{acebetween the anterior and interosseous borders,and {3) a posterior (flexor) surfacebetween the medial and interosseous (posterolateral)borders. The anterior and medial borders and the subcutaneous surface are easily palpable. Incisisn, Make a longitudinal incision on the anterior surface of the leg parallel to the anterior border of the tibia and about I cm lateral to it. The length of the incision depends on the requirements of the procedure of because 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 (Fig. 11-2). INTERNERVOUSPLANE There is no internervous plane in this approach. The dissection essentially is subperiosteal and does not disturb the nerve supply to the extensor compartment.

Chapter 11 The Tibia l Fibuta

485

Figure 11-1. Positionfor the anteriorapproach the tibia. to

SUPERFICIII

SURGICAL DI S SECTION

Elevate the skin flaps to exposethe subcutaneous surface of the tibia. The long saphenousvein is on the medial side of the calf and must be protected when the medial skin flap is reflected (Fig. l1-3). DEEP SURGICAL DISSECTION TWo surfacesof the tibia can be approachedthrough this incision. Subcutane (Medial) Surface ous 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 exposethe bone, incise the periosteum longitudinally in the middle of the subcutaneous surface of the tibia. Reflect it anteriorly and posreriorly to uncover only as much bone as is absolutely necessary {Fig. 1l-4). Note the superior insertion of the pes anserinus into the subcutaneous surface of the tibia. Detach it if that portion of the bone needsto be exposed,but this rarely is necessary. 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(seeFigs. ll-4 and l1-21). DAI{GERS Vessels The long saphenousvein, which runs up the medial side of the calf, is vulnerable during superficial surgical dissection and should be preservedfor future vascularprocedures, at all posiible (see if Fig. I I -2I ). SPECIAL SURGICAL POINTS Skin flaps must be closedmeticulously 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 possibleto preservesoft-tissue attachments of all but the smallest fragments of bone. HOW TO ENLARGE THE APPROACH Local Measures The extent of the exposureis determined by the size of the skin incision; the whole subcutaneous surface of the tibia may be exposed,if necessary.

486

in The Surgbal Exposures Orthopaedics: Anatomir Approa.ch

Figure I 1-2. Make a longitudinal incision on the anterior surface of the leg.

Clnpter 11 The Tibin Ct Fibula

487

T t

f?-

Fasciaover t i b i a l i sa n t e r i o r

Figure 11-i . Elevatethe skin flaps over the medial portion of the tibialis anterior and the subcutaneousmedial surfaceof the tibia. To exposethe lateral surfaceof the tibia, incise the deep fascia over the medial border of the tibialis anterior.

To reach the posterior surfaceof the tibia from an anterior approach, continue the subperiosteal dissection posteriorly around the medial border. Proximally lift the flexor digitorum longus muscle off the posterior surfaceof the tibia subperiosteally. Distally, lift off the tibialis posterior muscle. This procedureexposes posterior surfaceof the bone, the but does not offer as full an exposure as does the posterolateral approach.It probably is useful only for the insertion of bone graft as part of an internal fixation carried out through this anterior route. ExtensilcMeasures PROXIMALEXTENSION. extend the approach To proximally, continue the skin incision along the medial side of the patella. Deepen the incision

through the lateral patellar retinaculum to gain access to the lateral compartment of the knee. DISTALEXTENSION. extend the approachdisTo talIy, curve the incision over the medialiide of the hind part of the foot. Deepeningthe wound provides accessto all the structures that pass behind the medial malleolus. Continue the incision onto the middle and front parts of the foot. (For details, see Anterior and Posterior Approaches to the Medial Malleolus in Chapter 12.)

488

Surgiral Exposures in Orthopaedics: The Anatomic Approarh

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Periosteum

Tibia (fracture)

Tibialis anterior

Figure 11-4. F,levatethe tibialis anterior from the lateral surfaceof the tibia. Incise the periosteum; elevate it only as necessary.

AI{TEROLATERAL APPROACH TO THE TIBIA

Tha 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 usedfor (1)anterolateral bone grafting of the tibia and (2) tibia pr-o fibula grafting (REF) (cross-tibiofibular grafting)." it This approachis technically simple. Because only provides limited exposure of the tibia, it usually is inadequate for the internal fixation of fractures. POSITION OF THE PATIENT Place the patient on his or her side with the affected limb on top. Protect the bony prominences of the bottom leg to avoid the development of presswe sores. Exsanguinate the limb either by elevating it for 5 minutes or by applying a compression bandage and then inflating a tourniquet. LAI,IDMARKS AN D INCI SION Land,marks Palpatethe subcutaneoussurfaceof the fibula in the distal third of the limb. AIso 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 dependson the

Chapter 11 The Tibia t Fibula

489

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 ( F i g .1 1 - s ) . INTERNERVOUSPLANE Superficially, the internervous plane lies between the peroneus brevis muscle (which is supplied by the superficial peronealnerve)and the extensordigitorum longus muscle (which is suppliedby the deep peroneal nerve). Deeply, the internervous plane lies betweenthe 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 the interosby seousmembrane. SUPERFICIAL SURGICAL DISSECTION Deepen the incision, taking care not to damagethe short saphenousvein that may appearin the posterior aspectof the wound. Incise the fasciain the line of the skin incision and identify the underlying pero_neal muscles (Fig. 11-5).Develop a plane bet#een the anterior aspect of the peroneusbrevis muscle and the extensor digitorum longus muscle to come down onto the anterolateralaspectof the fibula (Fig. 1l-7). Protect the superficial peronealnerve, whic-h can be seen lying on the peroneus brevis muscle. DEEP SURGICAL DISSECTION Gently detach the extensor musculature from the anterior aspectof the interosseousmembrane using blunt instruments. Follow the anterior aspectof this membrane onto the lateral border of the tibia (Fig. 11-8).Because this approachalmost always is used in casesof 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 th-eposterolateral corner of the tibia. Gently strip off asmuch tissue asnecessary from the lateral aspectof the tibia, elevatingsome of the origin of the tibialis anterior muscle in the process. As in all approaches the tibia, only the minimum amount to of soft tissue that is required to gain adequateaccess should be dissected to avoid devasculirizatron oI bone. DANGERS Vessels and.Nerues The small saphenousvein may be damagedin the posterior skin flap (seeFig. 1L-6A1. The superficial peroneal nerve runs down the leg ig the peroneal or lateral compartment. It gives off all its motor branchesin the upper third o-fthe leg. Hence, it is sensory only at the level of this approach.Identify and preservethe nerve to avoid numbnesson the dorsumof thefoot (see Fig. I l-78lt. The anterior tibial artery and the deepperoneal nerve run down the leg in the anterior compartment, which is anterior to the interosseousmembrane. 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. HOW TO ENLARGE THE APPROACH Local Measures The longer the incision, the less retraction that is required for adequatevisualization. Extensilc Measures This app_-roach cannot be extendedeasily proximally or distally.

Figure 11-5.

Make a longitudinal incision centered over the site of the fracture.

Extensor digitorum

rongus

Peroneus brevis

Superficial peronear n.

Peroneus longus

Extensor digitorum rongus

Extensor hal l uci s longus Anterior tibialn. and n. deep peroneal

ibia

peroneal n. Superficial Peroneus longus and

membrane Interosseous longus Flexor digitorum posterior Tibialis Soleus teri or bi ala., v.; peroneal ti v.; and ti bi aln. rocnemrus

Fi.gure11-6. (A! Identify the peroneal muscles and the short saphenousvein. Inl tdentify the plane between the peroneus brevis and the extensor digitorum longus. digitorum Extensor communls

* @ , @ , . - L

Zrota%*

brevis Peroneus

F i b ul a

Superficial Extensor l ongus A nteri or bi ala., di gi torum ti n. deep peroneal

Tibia

Superficial peroneal n. Peroneus and l ongus brevis Fi bul a Figure 1I -7. (A) Develop a plane in a distal to proximal direction between the peroneus br&is and the extensor digitorum longus. (B) Note the superficial peroneal nerve lying on the peroneusbrevis muscle. --.- lnterosseous membrane

490

Chapter 1I Extensor digitorum

The Tibia l Fibuta

491

rongus,

Interosseous Superficial membrane peroneat n.

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Anterior tibial 4., v.; oeep peroneal n. Peroneus brevis Superficial peroneal n. Fi bul a Peroneus longus and brevis Interosseous membrane

Figure I !'q. Develop a plane by detachingthe extensormusculature from the anterior aspect of the interosseousmembrane to .ipor" the posterot"i.i"f .t*er of the tibia.

POSTEROLATERAL APPROACH TO THE TIBIA

The -posterolateralapproacha used to exposethe is middle two thirds of the tibia when the skin over the subcutaneoussurfaceis badly scarredor infected. It is a technically dema_nding operation.The approach is suitable for the following-uses: 1 . Internal fixation of fractures 2 . Treatment of delayed union or nonunions of fractures, including bone grafting !h9 approachalso permits exposureof the middle of the posterior aspect of the fibula. POSITION OF THE PATIENT Placethe patient on his or her side,with the affected feg uppelmost. Protect the bony prominencesof the bottom leg to avoid the deveiopm.trt of pressure sores. Exsanguinate the limb by elevating it for 5 minutes, then apply a tourniquet (Fig. l l:91. LANDMARK AND INCISION Landrnark The lateral border of the gastrocnemius muscle is easy to palpate in the calf. SUPERFICIAL SURGICAL DISSECTION Incision, n_r".k. longitudinal incision over the lateral border a ot the gastrocnemiusmuscle. The length of the incision dep-eldson the length of bone"th"lm"st be exposed (Fig.ll-10). INTERNERVOUSPLANE

492

Surgiral Exposures in Orthopaedics: The Anatomir Approach

Figure 1I-9.

Position for the posterolateralapproachto the tibia.

Find the lateral borderof the soleusand retract it with the gastrocnemius medially and posteriorly; underneath,arising from the posterior surfaceof the fibula, is the flexor hallucis longus (Fig. 11-13). DEEP SURGICAL DISSECTION Detach the lower part of the origin of the soleus muscle from the fibula and retractit posteriorly and medially. Detach the flexor hallucis longus muscle

from its origin on the fibula and retract it posteriorly Continue and medially (Fig.1I-14, seeFig. 11-13). dissecting medially across the interosseous membrane,detachingthose fibers of the tibialis posterior muscle that arisefrom 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 (Fig. 1l-15). Follow the interosseousmembrane to the lateral border of the tibia, detaching the muscles that arise from its

ei

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Figure 11-10. Incision of the lateral border of the gastrocnemius.

Chapter I1
P e r o n e u so n g u s l ( s u p e r f i c i ap e r o n e a n . ) l l

The Tibia U Fibula

493

Lateralsole (tibial nerve)

astrocnemius

[[fi'Ji'

ucis ronsus

Figure 11-11. The internervous plane lies between the gastrocnemius, soleus,and flexor hallucis longusmuscles (which are supplied by the tibial nerve) and the percneal muscles (which are supplied by the superficial peroneal nervel.

its posterior surfacesubperiosteally,and expose posterior surface(Fig. 11-15). DAI,IGERS Vessels The small (short) saphenousvein may be damaged when the skin flaps are mobihzed. Although the vein should be preservedif possible, it may be ligwithout impairing venous return ated, if necessary, from the leg. Branchesof the peroneal artery cross the intermuscular plane between the gastrocnemius and peroneus brevis muscles. They should be ligated

or coagulatedto reduce postoperativebleeding (see Fig. 1L-271. 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 (see Fig. I I-271. HOW TO ENLARGE THE APPROACH ExtensileMeasures PROXIMAL EXTENSION. The approach cannot be extended into the proximal fourth of the tibia.

Fasciaover p e r o n e u sl o n g u s

,-.=./E{'

L-*--=:ll

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Fasciaover latera head of gastrocnemius

Fasciaover soleus

Figure 11-12. Reflect the skin flaps. Incise the fasciain line with the incision. Find the plane between the lateral head of the gastrocnemius and soleus posteriorly, and the peroneus brevis and longus anteriorly.

-l

494

The in Surgiral Exposures Orthopaedics: AnatornbApproafi

S o l e u s( o r i g i n ) Lateraedgeof fibula l l F l e x o rh a l l u c i s o n g u s e r o n e u sb r e v i s

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Fibula Peronei nterosseous membrane xtensor digitorum terior t i b i a la . Tibialis anterior Deep peroneal nerve Tibia

Gastrocnemius F l e x o rh a l l u c i longus P e r o n e aa . l Posterior t i b i a la . tiOiatis posterior

Figure 11-13. Detach the origin of the soleusfrom the fibula and retract it posteriorly an? medially along with the gastrocnemius.Retract the peroneal muscles anteriorly. Detach the flexor hallucis longusfrom its origin on the fibula. Developthe plane between goup posteriorly and the peronealmuscles anteriorly (cross the gastrocnemius-soleus sectionl. Note the flexor hallucis longus on the posterior surfaceof the fibula.

There, the back of the tibia is coveredby the popliteus muscle and the more superficial posterior tibial artery and tibial nerve, making safe dissection impossible.

DISTALEXTENSION. The approachcan be made continuous with the posterior approachto the ankle if the skin incision is extendeddistally between the posterior aspect of the lateral malleolus and the Achilles tendon.

APPROACH TO THE FIBULA

The approachto the fibula employs a classic extenand offers accessto all parts of the sile exposure6 fibula. Its uses include the following: l. Partial resection of the fibula during tibial osteotomyT or as part of the treatment of tibial nonunlon-'2. Resectionof the fibula for decompressionof all four compartments of the leglo 3. Resectionof tumors
R O

Chapter 1I

The Tibia U Fibula

495

F l e x o rh a l l u c i s

Tibialis

l P e r o n e u so n g u s

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Fasciaover lateral head of gastrocnemius

Soleub
(detached)

F l e x o rh a l l u c i s longus

Figure 11-14. Detach the flexor hallucis longusfrom its origin on the fibula and retract it posteriorly and medially. Continue dissecting posteriorly, staying on the posterior surface of the fibula. Detach the flexor hallucis longus from its origin on the fibula, staying close to the bone (crosssectionl. Retract the muscle medially.

4. Resectionfor osteomyelitis 5. Open reduction and internal fixation of fractures of the fibula 6. Removal of bone grafts Although the bone can be exposedcompletely, only ^ paft of the approachusually is required for any one procedure. POSITION OF THE PATIENT Placethe patient on his or her side on the operating table with the affectedsideuppermost. Padthe bony prominences of the other leg to prevent the development of pressure sores. Exsanguinatethe limb by elevating it for 3 to 5 minutes, then apply a tourniquet (seeFig. 11-9). Alternatively, if this approach is used in conjunction with a surgical approachto the

tibia, place the patient supine on the operating table. A sandbagplaced underneath the affectedbuttock will rotate the leg internally, allowing adequate exposureof the lateral aspectof the leg for the approachto the fibula. Subsequently,if the sandbag is removed, the leg naturally will rotate externally, providing accessto the tibia. LANDMARKS AND INCISION Landrnarks The head of the fibula is easily palpableabout 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.

496

SurgicalExposures Orthopaedics: AnatomirApproail in The

membrane lnterosseous l P e r o n e u so n g Lateraledge of tibia

F l e x o rh a l l u c i sl o n g u s

Peronei Interosseous membrane Tibialis posterior digitorum longus Anterior t i b i a la . F l e x o rh a l l u c i s longus So Gastrocnemius P e r o n e aa . l T i b i a lr i . t i b i a la . Tibialis anterior Deep peronealn. Tibia Flexor digitorum longus

Incision, Make a linear incision just posterior to the fibula beginning behind the lateral malleolus and exrending to the level of the fibular head. Continue the incision up and back, a handbreadthabovethe 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. The length of the incision dependson the amount of exposureneeded(Fig. 1L-I7ll. INTERNERVOUSPLAT{E The internervous plane lies between the percneal muscles, supplied by the superficial peroneal nerve,

and the flexor muscles, supplied by the tibial nerve (see ig.11-11). F SUPEEFICIAL SUNGICAL 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 oJtle bic,epq femoris tendon as it sweepsdown past the knee beforeinserting into the headbf the fibula.

Chapter II

The Tibia U Fibula

Tibialis

Peroneus longus

Fibu ,Tibia

Periosteum

F l e x o rh a l l u c i s longus

"""' 53i""J3

Figure 11-16. Detach the muscles that arise from the posterior surface of the tibia subperiosteally. T,xposethe posterior border of the tibia subperiosteally(cross sectionl. The detachedtibialis posterior muscle protects the neurovascularstructures.

Commonperoneal H e a do f f i b
i 4 w t

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i i(dLi$r i ii+:l.1ire:, ; tli:rt:
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Figure 11-17. Make a long linear incision just posterior to the fibula.

498

in The SurgfualExposures Orthopaedics: Anatomit Approail

Fasciaover peroneus

Commoh

Fasciaover lateral h e a do f g a s t r o c n e m i u s

Fasciaover biceps femori

Common

Fasciaover lateral h e a do f g a s t r o c n e m i u s

Figure 11-18. (A) Expose the common peronealnerve in the proximal end of the incision along the posterior border of the biceps. (B) Continue exposingthe common peroneal nerve distally as it winds around the neck of the fibula in the substanceof the peroneuslongus.

the nerve and gently pulling the nerve forward over the fibular head with a strip of corrugated rubber drain. Identify and preserveall branchesof the nerve ( F i g .1 1 - 1 e ) . 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 (Fig. 11-20). 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 origi-

nate from periosteum or fascia;they can be stripped. Muscles attached directly to bone are difficult to strip; they usually must be cut (Fig.l1-21 and c.rosssection). The other structure attached to the fibula, the interosseousmembrane,has fibers that run obliquely upward. To complete the dissection, strip the interosseousmembrane subperiosteally from proximal to distal (Fig. 1l-22 and uoss-sectionl.

DANGERS Neraes The common peroneal nerve is vulnerable as it winds around the neck of the fibula. The kev to

Chapter 11 The Tibia U Fibula

Common p e r o n e a ln . Fasciaover b i c e p sf e m o

499

Fasciaover p e r o n e u sl o n g u s

Fasciaover neusbrevis

Fasciaover soleus

Fascia overlateral head of gastrocnemius Figure 11-19. Retract the peronealnerve anteriorly and incise the fascia between the peroneal muscles and the soleus muscle.

preservingthe nerve is to identify it proximally asit lies on the posterior border of the bicepsfemoris. It then can be safely traced through the peronealmuscle massand retracted.The dorsalcutaneousbranch of the superficial peroneal nerve is susceptible to iniury at the iunction of the distal and middle thirds of the fibula; if it is damaged, causes it numbnesson the dorsum of the foot (seeFig. 1l-30). Vessels Terminal branchesof the peronealartery lie closeto the deep surface of the lateral malleolus. To avoid damaging them, you must keep the dissection subperiosteal(seeFig. 1l-27lr. The small (short) saphenousvein rrraybe damaged; you may ligate it if necessary.

HOW TO ENLARGE THE APPROACH Local Measures The exposuredescribedallows exposureof the entire bone. ExtensileMeasures DISTAL EXTENSION. Extend the skin incision distally by curving it over the lateral side of the tarsus. To gain accessto the sinus tarsi and the talocalcaneal, talonavicular, and calcaneocuboid joints, reflect the underlying extensor digitorum brevis muscle. This extension is used frequently for lateral operations on the leg and foot (see Lateral Approach to the Hindpart of the Foor in Chapter l2).

APPLIED SURGICAL AI{ATOMY OF THE LEG

OVERVIEW The tibia and fibula are very different bones. The tibia has a large subcutaneoussurface that allows to access the bone along its entire length; the fibula is enclosedalmost completely in muscle. Only at its proximal end and in the lower third of the bone does the fibula develop a subcutaneous surface, which terminates in the lateral malleolus. For this reason, operations on most of the fibula almost always involve extensive stripping of muscle off bone.In addition, the tibiahas no majorneurovascularstructures running directly on it other than its nutrient afteryi the fibula has close ties to the common peroneal nerve and its branches. The deep fascia of the leg is a tough, fibrous, unyielding structure that enclosesthe calf muscles. Where the bones become subcutaneous/the fascia usually is attached to the border of the bone. TWo intermuscular septa,one anterior and one posterior, pass from the deep surface of the encircling fascia to the fibula and enclosethe peronealor lateral compartment of the leg. Three separate muscular compartments exist in the lower leg (Fig. 1I-231. Anterior (Extens Compartrnent or) The anterior compartment contains the extensor musclesof the foot and ankle. Its medial boundary is

Fasciaover p e r o n e u sl o n g u s Common p e r o n e a ln . N e c ko f fi b u l a

I
Peroneus longus Lateraledge of fibula

Fasciaover b i c e p sf e m o r i s

Fasciaover lateral headof gastrocnemius

Soleus

Perforating arteries

Flexor longus

Figure 11-20. Develop the intermuscular plane betweenthe peronealmuscles and the soleus muscle down the lateral edge of the fibula. Strip thellexor muscles from the posterior aspect of the fibula in a distal to proximal direction.
Peroneus longuq

Common peroneal. n..

N e c ko f fi b u l a

Fibula

b Peroneus revis

B i c e p sf e m o r i

Flexor longus Fasciaover lateral h e a do f g a s t r o c n e m i u s Soleus (detached) Soleus

F l e x o rh a l l u c i s longus

Fibula

Gastrocnemtus

Extensor digitorum longus P e r o n e aa . l p p e r o n e a ln .

T i b i a ln ; Posterior t i b i a la . Tibia Flexor digitorum longus

ibialis anterior

Figure 11-21. Strip the flexor hallucis longus and the soleusfrom the posterior aspectof the fibula, and strip the peroneal muscles from the anterior surface of the fibula in a distal to proximal direction. Strip the flexor muscles from the posterior aspect of the fibula (cross sectionl. Avoid neurovascular structures by staying close to the bone.

500

Chapter II

The Tibia U Fibula

501

Peroneusongus l Common peroneal . n

Fascia over biceps femoris

Fasciaover late headof gastrocnemius

F l e x o rh a l l u c i s longus

A c h i l l e st e n d o n

Figure 11-22. Retract the peroneal muscles anteriorly. Strip the interosseousmembrane from the anterior border of the fibula in a proximal to distal direction. Strip the muscles from the anterior surfaceof the fibula and strip the interosseousmembrane from its fibular attachment in a proximal to distal direction (crosssectionl.

the lateral (extensor) surface of the tibia, and its lateral boundary is the extensor surface of the fibula and anterior intermuscular septum. The anterior compartment is enclosedby the deep fascia of the leg and all its muscles are supplied by the deep peroneal nerve. The compartment's artery is the anterior tibial artery. Lateral (Peroneal)Compartment The peroneal compartment is bounded by the anterior intermuscular septum in front, by the posterior intermuscular septum behind, and by the fibula medially. It contains the peroneal muscles/ which evert the foot. The superficial peroneal nerve supplies all

the muscles in the compartment. No artery runs in it; its muscles receive their supply from several branches of the peroneal aftery. Posteriar (Flaor) Compartment The flexor compartment contains the flexors of the foot and ankle. This compartment is separated from the other compartments by ^ fibro-osseous comp,lex:laterally, from the peroneal compartment, by the posterior intermuscular septum and the posterior medial surfaceof the fibula; and anteriorly, from the extensor compartment, by the interosseous membrane and the posterior (flexor) surface of the

502

The Anatomit Approarh Surgiral Exposures in Orthopaedi.cs: ANTERIOR T i b i a l i sa n t e r i o r Fasciaover a n t e r i o rc o m p a r t ment A n t e r i o rt i b i a l artery and veins Deep peronealn. l F l e x o rd i g i t o r u m o n g u s T i b i a l i sp o s t e r i o r o s t e r i o rt i b i a l artery and vein T i b i a ln e r v e S e p t u mo f d e e p f l e x o rc o m p a r t m e n t l F l e x o rh a l l u c i s o n g u s ascraover f l e x o rc o m p a r t m e n t Gastrocnemius POSTERIOR I n t e r o s s e o um e m b r a n e s Peronealartery and veins

E x t e n s o rh a l l u c i sl o n g E x t e n s o rd i g i t o r u ml o n g u I n t e r m u s c u l as e p t u m r S u p e r f i c i a p e r o n e a ln : l Peronei Fasciaover peroneal ompartment c I n t e r m u s c u l as e p t u m r

Figure 11-23. The fibro-osseous compartments the leg. of The flexor compartment consists of two groups of muscles,superficial (gastrocnemius, soleus,plantaris) and deep (tibialis posterior, flexor digitorum longus, flexor hallucis longus),which are separated by a fascial Iayer.

tibia. The tibial nerve innervates all the muscles in the compartment, and the posterior tibial artery supplies them with blood. The peroneal artery also runs in this compartment and forms part of the blood supply of the muscles.

AI{TERIOR APPROACH TO THE TIBIA

LAAIDMARK AND INC/SION Landmark For the surgeon, the subcutaneous swface of the bit tibia is the most accessible of bone in the body. Unfortunately, this easeof accessmakes the bone attractive as a source of grafts. This procedure weakensthe bone, something that is reflectedin the high incidence of subsequentfractures. Incisisn The longitudinal incision roughly parallelsthe lines of cleavagein the skin. The resultant scar is not unduly prominent, but often is visible in women because of its position. SUPERFICIAL SURGICAL DISSECTION The periosteum of the tibia is a thick fibrous membrane that can be peeled off the bone easily, especially in children. Only lO% oI the blood suppiy of the bone comesfrom the periosteum; the remaining 90% comes from medullary vessels.Therefore,the periosteum can be elevatedoff a normal bone without significant impairment of its blood supply. In casesof fracture, however, soft-tissue attachments may form the only remaining blood supply to isolated bone fragments and must be preserved. The long saphenousvein is the longest superficial vein in the body. It originates iust distal and anterior to the medial malleolus and continues proximally on the medial side of the leg superficial to the fascia. It may be ligated if necessary. DEEP SURGICAL DISSECTION Thetibialis anterior is the only muscle to arisefrom the tibia in the anterior compartment (Fig. Il-241. The muscle may be avulsedpartially from the tibia in joggersand other athletes,and is one of the causes of shin splints. The pathology of this particular complaint, however,is unclear.Somebelievethat it results from stressfractures of the tibia itself; others contend that it representsa compartment syndrome.l0 The common peronealnerve runs over the neck of the fibula in the substanceof the peroneuslongus muscle and divides into deepand superficialbranches (Fig. 1L-2s1. The deep peroneal netve continues to wind around the fibular neck deep to the extensor digitorum longus muscle before reaching the anterior

Chapter 11 The Tibia U Fibula

503

Figure 11-24. The superficial structures of the anterior compartment of the leg. Tibialis Anterior. Origin. Lateral condyle of tibia, upper two thirds of lateral surface of tibia, interosseousmembrane, deep fascia,lateral intermuscular septum. Inser tion. Medial cuneiform and base of first metatarcal. Actron. Dorsiflexor and invertor of foot. Newe supply. Deep peroneal nerve. ExtensorHallucis Longus. Origin. Middle half of anterior surfaceof fibula and interosseousmembrane. Insertion. Baseof distal phalanx of hallux. Action. Extensorof hallux and ankle. Nerve supply. Deep peroneal nerve. ExtensorDigitorum Longus. Origin. Upper three fourths of anterior surface of fibula, small areaof.tibia adiacent to superior tibiofibular joint, and interosseousmembrane. Insertion. Via extensor hoods to middle and distal phalangesof lateral four toes.Action. Extensor of toes and of ankle. Nerve supply. Deep peroneal nerve. PeroneusTertius. Origin. Lower third of anterior surface of fibula. Inseftion. Base of fifth metatarsal. Action. Evertor and dorsiflexor of foot. Nerve supply. Deep peroneal nerve.

surfaceof the interosseousmembrane.It runs down the leg on the interosseousmembrane between the tibialis anterior and extensor hallucis longus mussupplying all the muscles of the extensorporc1es, tion of the leg (seeFig. l1-25). The supe{icial peroneal nerve runs down the peronealcompartment of the leg, supplying the per-

oneus longus and brevis muscles. Its dorsal cutaneous branch supplies the skin on the dorsum of the foot (seeFig. l1-25). The anterior tibial aftery is a branch of the popliteal artery.It reachesthe anteriorportion of the leg by passingabovethe interosseousmembrane. It lies so close to the fibula that its venae comitanres

504

Surgiral Exposures in Orthopaedics: The Anatomic Approarh

Patellar ligament

T e n d o no f b i c e p sf e m o r i s T i b i a l i sa n t e r i o r C o m m o np e r o n e a l E x t e n s o r i g i t o r u ml o n g u s d A n t e r i o rt i b i a l a , P e r o n e u so n g u s l Tibial tubercle

,"r..i \",\
\ii
ii i, I ii\
!!lll

I iil

iitt

Medial head of gastrocnemrus

iiii
S u p e r f i c i ap e r o n e a ln . l Deep peronealn; lnterosseous liga Peroneusbrevis Soleus E x t e n s o r i g i t o r u ml o n g u s d Fibula T i b i a l i sa n t e r i o r E x t e n s o r a l l u c i sl o n g u s h A n t e r i o rt i b i a l a : Deep peronealn: Interosseous membrane E x t e n s o r i g i t o r u ml o n g u s d E x t e n s o r a l l u c i sl o n g u s h L a t e r a lm a l l e o l u i s p e d i sa . Peroneusterti D e e pp e r o n e a l . n Tibialis posterior
Lateral malleol ial tlll llii liil iiii
ilt! l:rl

iitl

Medial surface of tibia

Flexor digitorum longus

malleolus

Medial malleolus

4^la'la
Figure 11-25. Muscles of the anterior compartment have been resectedto reveal the anlerior surface of the tibia, the neurovascular structures, the interosseous membrane, and the anterior surface of the fibula.

often leave a notch in the bone large enough to be visible on radiographs,a relationship that must be when the fibular head is excised.The arrespected tery runs with the deep peroneal nerve on the interosseousmembrane, it continues in the foot as the dorsalispedis aftery (seeFig. 11-25). Three other muscles, the extensor hallucis longus, extensor digitorum longus, and peroneus

tertius, also occupy the anterior compartment of the leg. They are not involved in the anterior approach to the tibia, but are part of the approachto the anterior compartment and may be seen during the exploration of wounds caused by open tibial fractures. Together with the tibialis anterior muscle, they are implicated in the anterior compartment syndrome (seeFig. l1-25).

Chapter 1I

The Tibia U Fibula

505

POSTEROLATERAL APPROACH TO THE TIBIA

/NCIS/ON The longitudinal incision almost parallels the lines of cleavage the skin, and the resultant scaris not in unduly broad. Cosmesis rarely is a problem with this exposur;it is reservedlargely for cases which in the skin on the anterior aspectof the tibia is unsuitable for surgery. DEEP SURGICAL DISSECTION P".p surgical dissection consists of detaching the flexor hallucis longus muscle from the fibula and the tibialis posterior muscle from the interosseous membrane. Some fibers of the flexor digitorum longus muscle also must be reflected off the posterior surfaceof the tibia to permit access that bone. to Generally, the dissection is carried out sub-

SUPERFICIAL SURGICAL DISSECTION Superficial surgical dissection consists of finding the plane that separates the gastrocnemius and soleus muscles from the peroneus brevis muscle (seeFig. II-291. The fibers of the gastrocnemius are arranged generally longitudinally, giving the muscle the ability to contract a considerable distance at the expenseof muscle strength. The gastrocnemiuscrosses two joints. During quiet walking, plantar flexion of the ankle is carried out largely by the powerful soleus muscle, which crossesonly one joint. The gastrocnemius is capable of acting as a fast plantar flexor of the ankle, but only if the soleus provides po-werto overcome the inertia of the body weight. The gastrocnemius, therefore, comes into pl"y mainly during running and iumping. The major surgical importance of the soleus muscle lies in the numerous plexuses of small veins that it contains. This multipinnate muscle is one of the major pumps involved in venous return from the limb; lack of muscular action (ie, after surgery or fractures) may lead to venous stasis and thrombosis. The percneus brevis tendon, which groovesthe back of the lateral malleolus, is useful in reconstruction of the lateral side of the ankle. On occasion,the peroneus brevis may avulse the styloid processof the fifth metatarsal in association with inversion iniuries of the ankle {Fig. 1l-26, see Fig. lL-291.

The flexor hallucis longusmuscle helps support the longitudinal arch of the foot. In the sole ofthe foot, it sends slips to the flexors of the secondand third toes. It is muscular down to the level of the ankle joint, a characteristic that makes it identifiable at that level. DAAIGERS Neraes and Vessels The posterior tibial aftery and the tibial nerve lie superficial (posterior) to the plane of dissection; they may be damaged if the appropriate surgical plane is not adhered to. The posterior tibial attety, a branch of the popliteal artery, runs under the fibrous arch of the soleus muscle. Its major branch in the calf is the peroneal artery. The tibial nerve, the medial portion of the sciatic nerve, entersthe calf deepunder the fibrous arch of the soleus muscle. It sends branches to all the muscles of the flexor compartment. Passingbehind the medial malleolus, it divides into three branches: a calcaneal branch, a small lateral plantar nerve/ and, finally, a larger medial plantar nerve (see Fig. 1L-271.

APPROACH TO THE FIBULA

LANDMARKS AND INCISION Land:marks and is palpableonly asa resistancefelt on the lateral side of the leg. Incision The longitudinal incision closely parallels the line of cleavage the skin, and the resultant scar is not in broad and unsightly. As is true for the tibia, incisions made directly over the lower and upper ends of

sion. The shaft of the fibula is enclosedin muscles

506

Surgbal Exposures Orthopaedics: AnatomirApproafi in The

mon peroneal . n M e d i a ls u r a l n cutaneous . v S m a l ls a p h e n o u s .

Medial head of gastrocnemius

Lateral head of gastrocnemius Peroneus longus

Soleus

Soleus

brevis Peroneus longus

Figure 11-26. The superficial structures of the posterolateral aspect of the leg.
xor hallucis longus Media malleolus eal artery Lateral malleolus Calcaneus

Gastrocnemius. Origin. Medial head from medial condyle and popliteal surfaceof femut Lateral head from lateral surfaceof lateral femoral condyle. Middle third of posterior aspect. Insertion. Calcaneus. Into Achilles tendon with soleusand plantaris muscles.Achilles tendon then inserts into calcaneus. Action. Plantar flexor of foot. Nerve supply. Tibial nerve. Soleus. Origin. Posterior aspect of upper third of fibula, solealline on tibia, fibrous arch between tibia and fibula.Inseftion Middle third of posterior aspect of calcaneus.(Common tendon with gastrocnemius.! Action. Plantar flexor of foot. Nerve supply. Tibial nerve.

the bone should be closed with special care to ensure sound primary healing. SUPERFICIAL SURGICAL DI SSECTION Superficial surgical dissection consists of mobilizing the common peroneal nerve as it winds around the neck of the fibula and developinga plane between the peroneus and soleus muscles (Fig. I I-291.

The common peroneal nerve is the lateral portion of the tibial nerve; it is palpable at the neck of the fibula (Fig. 11-30). DEEP SURGICAL DISSECTION Deep surgical dissection consists of stripping off those muscles that originate from the fibula: the peroneus longus and peroneus brevis (lateral com-

Chapter 11 The Tibia U Fibula

507

ommon p e r o n e a ln . Lateralhead of gastrocnemius

M e d i a lh e a d o f gastrocnemius

neus
longus Peroneala.

Tibialis posterior

Posterior t i b i a la . T i b i a ln :

F l e x o rh a l l u c i s longus

Flexor digitorum longus

Peroneus revis b

Figure 11-27, The gastrocnemius and soleus muscles have been resectedto reveal the deepflexor compartment and the neurovascularstructures. Flexot Hallucis Longus. Origin. Lower two thirds of posterior surfaceof fibula, interosseous membrane.Insertion. Baseof distal phalanx of hallux. Action. Flexor of hallux and plantar flexor of foot. N ewe supply. Tibial nerve. Flexor Digitorum Longus. Origin. Posteriorsurfaceof middle half of tibia and fascia covering tibialis posterior Insertron. Distal phalanges of lateral four toes. Action. Flexor of toes and dorsiflexor of foot. Nerve supply. Tibial nerve.

Medial malleolus

P e r o n e aa . l teral malleolus

partment); the extensordigitorum longus,peroneus tertius, and extensorhallucis longus (anterior compartment); and the flexor digitorum longus, flexor hallucis longus, and soleus(posteriorcompartment; seeFigs. LI-25 and 11-30). The peroneal afiery arises from the posterior tibial artery soon after it leavesthe popliteaL artery.

Relatively small, it runs through the deep flexor compartment of the leg, close to the fibula. Its brancheswind around the fibula to supply the peroneus longus muscle. The artery is close to the medial surfaceof the lower end of the fibula and may be damaged during operations on that part of the bone (seeFig. LI-271.

508

Surgiral Exposures in Orthopaedics: The Anatomir Approach

Medial head of gastrocnemius Lateral head of gastrocnemius

m o n p e r o n e a ln . lantaris T i b i a ln .

r o n e u sr o n g u s Popliteus leus S o l e a ll i n e T i b i a ln . s t e r i o rt i b i a l a . Peroneala. Flexor digitorum longus F l e x o rh a l l u c i s longus lnterosseous membrane Tibia ibula

Flexor digitorum longus

F l e x o rh a l l u c i s longus oneusbrevis

Achilles tendon

Med

malleolus

n e a la . lral malleolus

Figure 11-28. The flexor hallucis longus, the tibialis posterior, and the flexor digitorum longus have been resected to reveal the posterior aspect of the fibula, interosseousmembrane,and tibia. Tibialis Posterior. Origin. Lateral side of posterior aspect of tibia, upper two thirds of medial surface of fibula, interosseous membrane. Insertion. Tuberosity of navicular and via ligaments to all cuneiforms; second, third, and fourth metatarsals;and cuboid and sustentaculum tali. Action. Plantar flexor and invertor of foot. Nerve supply. Tibial nerve.

Lateral malleolus

SPECIAL AT{ ATIOMIC POINTS Compartment Syndrorne s The muscles of the leg are enclosedin tight fibroosseouscompartments. The fascial layersare tough and unyielding, and swelling within a particular compartment rapidly increasespressure.Pressure,

in turn, leadsto venous stasis,still more intercompartmental pressure/ and, eventualty, arterial ischemia. Increasing pressure alter fractures occurs most commonly in the anterior compartment, even when the fracture is minor and not displaeed, possibly becausethe fascia is so tight. The fascial layers define four distinct muscle

Chapter 1I

The Tibia U Fibula

509

l l i o t i b i ab a n d l

Common peronean. l Lateralhead of gastrocnemius ibialis anterior Extensor digitorum longus

Peroneus longus

roneus brevis

Figure 11-29. The superficial structures of the lateral aspect of the leg. Petoneus Brevis. Origin. Lower two thirds of lateral aspectof fibula. Insertion.Baseof fifth metatarsal.Action. Evertor and plantar flexor of foot. Nerve supply. Superficial peroneal nerve. Peroneus Longus. Origin. Lateral tibial condyle, upper two thirds of lateral surface of fibula. Insefiion. Lateral side of medial cuneiform and baseof first metatarsal.Action. Evertor and plantar flexor of foot. Nerve supply. Superficial peroneal nerve.

F l e x o rh a l l u c i s longus L a t e r a lm a l l e o l u s A c h i l l e st e n d o n

_ The compartment most commonly affected is the anterior compartment. It can be decompressed by inci-sing_thedeep fascia that covers it albng its entire length. All compartments of the leg may be decompressedby excision of the fibula.

510

The in Surgbal Exposures Orthopaedirs: AnatomirApproafi

H e a do f f i b u l a

Lateral head of

gastrocnemi C o m m o n p e r o n e a ln : Tibial tubercle T i b i a lt u b e r c l e

Peroneusongus l

Soleus

i uperfcial p e r o n e a ln . Extensor l digitorumongus

Fibula Tibia

Fibula

Flex hallucis longus Peroneusbrevis T e n d o no f p e r o n e u sl o n g u s L a t e r a lm a l l e o l u s Talus Lateral malleolus Calcaneus

Figure 11-t0. The peroneal muscles have been resected and the soleus and flexor the difitorum longushavebeendetachedpartially from the origin to expose lateral aspect of the fibula.

Chapter 1I

The Tibia Ll Fibula

511

Rcferences
l.

2. 3.
4. 5.

Muurn ME, AncoweRM, Wu,r,rNrcceRH: Manualof lnternal Fixation. New York, Springer-Verlag,1970 Pnnutsren DB: Tieatment of ununited fractures by onlay bone grafts without screw or tie fixation and without breaking down of the fibrous union. I Bonefoint Surg29:946, 1947 PerrtnsoN D, Lrwrs GN, Cess CA: Clinical experience in Australia with an implanted bone growth stimulator 11976-1978).Orthopaedic Tianscripts 3:288, 1979 Henmox PH: A simplified surgical approachto the posterior tibia for bone grafting and fibular transference.I Bone [oint Svg27:496, 1945 |oNEsKG, BanuEn HC: Cancellous-bonegrafting for nonunion of the tibia through the postero-lateral approach.I Bone foint Surg [Am] 37:1250,1955

6 . Hnruny AK: Extensile Exposure,2nded. London, Churchill Livingstone, 1973 7. 8. 9 . SotrNsor.rKH: Treatment of delayedunion and nonunion of the- tibia by fibular resection. Acta Orthop Scand 40:9i, 1959 10. LEecH RE, HauuoNo G, Srrurrn WS: Anterior tibial com_ part-nent syndrome: Acute and chronic. I Bone foint Surg [Am] 49:451, 1967