Introduction Overview primarily a neurovascular approach pathology related to posterolateral and posteromedial corners of the knee should be approached using lateral and medial approaches to knee respectively Indications neurovascular repair in traumatic injury PCL avulsion repair gastrocnemius recession in knee contractures hamstring lengthening Baker's / popliteal cyst excision tibial nerve compression by soleus Key Anatomy Muscles gastrocnemius semimembranosus semitendinosus Nerves medial sural nerve Vessels small saphenous vein popliteal artery and vein genicular vessels (two superior, two inferior, one middle) Internervous Plane The is no true internervous plane Preparation & Positioning Preparation table use radioopaque table when performing fixation (PCL avulsion) tourniquet used in most cases except when a vascular repair is being performed may delay exsanguination until vein is identified Position patient is placed prone Approach Incision identify superficial landmarks gastrocnemius semimembranous semitendinosus biceps femoris make lazy-S incision running from lateral biceps femoris to medial head of gastrocnemius muscle and into calf Superficial Dissection make subcutaneous skin flaps generous skin flaps will facilitate closure identify small saphenous vein and medial sural nerve medial sural nerve runs on lateral side of vein small sapheneous vein can assist in locating the medial sural nerve the medial sural nerve is a branch of the tibial nerve and can be used as a guide and into popliteal fossa incise fascia of popliteal fossa make fascial incision just medial to small saphenous vein disect to apex of popliteal fossa use tibia nerve as a guide to apex of popliteal fossa apex is formed by semimembranous (medial) and biceps femoris (lateral) mobilize common peroneal nerve branches from tibial nerve at apex of popliteal fossa runs along posterior border of biceps femoris mobilize popliteal artery and vein lies deep and medial to tibial nerve popliteal vein lies medial to artery as it enters the fossa, then it curves and lies directly posterior to the artery at the midpoint in the fossa must identify and ligate at least one of the five genicular branches in the posterior knee that include Deep Dissection evaluate posteromedial joint capsule faciliated by detaching medial head of gatrocnemius at origin evaluate posterolateral corner of joint develop plane between lateral head of gastrocnemius and biceps femoris faciliated by detaching lateral head of gatrocnemius at origin Dangers & Complications Medial sural cutaneous nerve injury avoid injury by entering fossa medial medial to small saphenous vein (nerve lies lateral) injury make lead to painful neuroma or anesthesia Tibial nerve injury injury at this level leads to paralysis of foot and toes flexors Common peroneal nerve injury injury at this level leads to paralysis of extensors and evertor of the foot Popliteal artery