Anterior Approach to Tibia indications:

The anterior approach to tibia bone offers safe, easy access to the medial (subcutaneous) and lateral (extensor) surfaces of the tibia.

The anterior approach to tibia bone is used for:

  • Open reduction and internal fixation of tibia fractures
  • Bone grafting for nonunion or delayed union
  • Implantation of electrical stimulators
  • Excision or biopsy of bone lesions
  • 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 easier to contour there. Some surgeons prefer to use the lateral surface for plating, however, to avoid the problems of subcutaneous placement.

The anterior approach to Tibia is the preferred approach to the tibia except when the skin is scarred or has draining sinuses in it.

Position of the Patient

  • Place the patient supine on the operating table. The use of a tourniquet is optional.
Anterior Approach to Tibia

Landmarks and Incision

  • Landmarks:
    1. Shaft of the tibia.
  • 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.
Anterior Approach to Tibia

Internervous plane

  • There is No Internervous plane for the anterior approach to tibia bone.
  • Dissection carried epi-periosteal between tibialis anterior muscle and tibia bone.

Superficial dissection

  • Elevate skin flaps to expose the medial (subcutaneous) border of the tibia,
  • Be sure to protect the long saphenous vein when retracting the skin flaps.

Deep dissection

  • Medial subcutaneous surface:
    • Essential to minimize subperiosteal stripping,
    • Incise periosteum longitudinally along the middle of the medial border.
    • Reflect the periosteum anteriorly and posteriorly.
  • Lateral extensor surface:
    • Incise periosteum over anterior border of the tibia.
    • Subperiostally dissect the tibialis anterior muscle and neurovascular bundle and retract laterally.

Approach Extension

Proximal Extension:

  • To extend the approach proximally, continue the skin incision along the medial side of the patella. Deepen the incision through the medial patellar retinaculum to gain access to the knee joint and the patella.
  • Alternatively, extend the wound proximally along the lateral side of the patella. Deepen that wound through the lateral patellar retinaculum to gain access to the lateral compartment of the knee.

Distal Extension:

  • To extend the approach distally, curve the incision over the medial side of the hind part of the foot. Deepening the wound provides access to all the structures that pass behind the medial malleolus. Continue the incision onto the middle and front parts of the foot.
See Also: 
1. Anterior Approach to the Medial Malleolus
2. Posteromedial Approach to Ankle Joint

Dangers

The structures at risk during anterior approach to tibia include:

  1. 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 the anterior approach to tibia 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.

References

  • Surgical Exposures in Orthopaedics book – 4th Edition
  • Campbel’s Operative Orthopaedics book 12th