Posterior longitudinal medial para sural approach of the leg. Techniques - indications.

The medial longitudinal posterior approach of the leg (Farabeuf,Fiolle et Delmas) was described to reach the posterior vessels andnerves, while the proposed approach, presented here, simultaneouslyexposes both vascular-nervous pedicle and tibia.Technique : The entire operation is conducted in ventral decubitus,with no change in position of the patient.The cutaneous incision is more medial, respects the lessersaphenous vein, and peroneal communicating nerve. The gastrocnemiimuscles are dissociated. The soleus muscle is not divided longitudinally,but reclined, thanks to the desinsertion of the medialhead.In addition, the rugination of the deep muscular plane allows thesimultaneous exposure of the tibia and vascular-nervous pedicles,present near the tibial extremity, complicated by ischemia (aclasicaleventuality).Indications: A distinction must be made between acute and chronicsituations.It may be a question of proximal third, open or closed fractures,wherein any previous approach might risk resulting in tegumentarynecrosis, while the fracture is too highly located to allow intramedullarynailing. Major damage of soft tissues often requires afree flap. Vascular repair is performed as soon as the skeleton isstabilized by the use of an epiphyso-metaphyseal T plate.Undesired but inevitable, the situation of these acute conditionstakes into consideration the cases where the skeleton is correctly setand immobilized by external fixation, whereas the vessels arehealthy. At this stage, a free flap covering is required, the reason fortransfer. Our approach is then compatible with the Arnez artifice,which apposes the free flap on the anterior face, and fixes it behind(other team). Consequently, the free flap pedicle has a sagittal passage.Three observations of this exceptional technique are presented.Numerous dissections have been performed at the Laboratory ofAnatomy.