Indications Allows visualization of the posterior tibia and popliteal fossa Indications posterior tibial plateau fractures popliteal fossa tumors or foreign bodies nn Plane No true internervous or intermuscular plane Dissection is maintained underneath the gastrocnemius muscle belly Preparation Anesthesia general anesthesia with endotracheal tube Preparation radiolucent table C-arm fluoroscopy Position prone positioning is necessary slightly flex knee via a bump under the ankle Approach Incision inverted L-shaped incision is made horizontal limb is in Langer's lines in the popliteal space vertical limb begins at the medial corner of the popliteal fossa and extends distally S-curve incision above incision can be extended proximally on the lateral side for more extensile exposure Superficial Dissection full thickness fasciocutaneous flaps are created sural nerve and short saphenous vein should be protected Deep Dissection tendon of the gastrocnemius is seen and the muscle is retracted laterally the posterior aspect of the knee capsule is then seen popliteus and soleus are subperiosteally elevated off the posterior tibia this exposes almost all of the posterior tibia Approach extension if additional medial access is necessary, the medial head of the gastrocnemius can be released posterolateral extension should be limited due to risk of common peroneal nerve injury Structures at Risk Popliteal artery risk is minimized with maintenance of access under the gastrocnemius origin before knee a continuation of the superficial femoral artery transition is at hiatus of adductor magnus muscle anchored by insertion of adductor magnus as enters region of posterior knee course in posterior knee relation to anatomy structures of knee lies posterior to the posterior horn of the lateral horn of the lateral meniscus lies directly behind posterior capsule branches within knee at supracondylar ridge gives branches the provide blood supply to the knee above knee joint branches include medial and lateral sural arteries cutaneous branch middle genicular artery at level of knee joint branches include medial genicular artery lateral genicular artery exit of knee anchor as artery exits knee it is anchored by soleus tendon (originates form medial aspect of tibial plateau) distal branches branches into anterior and posterior tibial arteries at distal popliteus muscles Tibial nerve risk is minimized with maintenance of access under the gastrocnemius Sural nerve and short saphenous vein these structures are seen in the superficial dissection and should be protected when possible Intraoperative Images