Posterior Surgical Approach to the Knee

Abstract

Posterior knee approaches are reliable techniques to address the treatment of various pathologies of the posterior region of the knee, including Baker cyst excision, tibial plateau fracture fixation, posterior cruciate ligament avulsions and inlay reconstructions, femoral condyle cartilage procedures, posterior meniscal repair and loose body removal among others. Surgery in the posterior knee region can be challenging because of the presence of neurovascular structures including the tibial nerve, popliteal artery and vein, and common peroneal nerve; thus, it is less commonly performed. The purpose of this Technical Note is to describe the posteromedial approach to the knee, its anatomic considerations, and how to avoid complications related to the surgical approach.

Fig 1

Posteromedial approach in a right knee. The semitendinosus tendon, flexion crease, and medial head of the gastrocnemius are used for anatomic reference. The incision begins 12 cm distal to the posterior flexion crease of the knee at the medial border of the gastrocnemius muscle and continues proximally just lateral to the semitendinosus tendon. It is extended laterally as needed, depending on the pathology that is being treated.

Fig 2

View of the subcutaneous tissue immediately following the incision of the dermal tissue in a right knee. Two Senn-Mueller retractors (Marina Medical, Sunrise, FL) are used to separate the skin while the subcutaneous tissue is incised in line with the skin incision. Of note, care must be taken to avoid damage to the fascia and the neurovascular bundle.

Fig 3

View of the fascia layer beneath the subcutaneous tissue in a right knee. The fascia is separated by first isolating the tissue with the forceps and then incising it using the scalpel. This approach ensures the lowest risk of injury to the underlying neurovascular structures.

Fig 4

Posterior approach performed in a right knee. Once the fascia was carefully separated from the subcutaneous tissue, it is incised using a scalpel. To ensure that no neurovascular structures are in contact with the fascia, a hemostatic forceps is placed under the fascia layer and the fascia is carefully released from the adherent tissues.

Fig 5

Image showing the deep posteromedial approach performed in a right knee. Two Kirschner wires are drilled into the tibia and are effectively retracting the medial head of the gastrocnemius. The first Kirschner wire (A) is placed superiorly and is used as a guide for the second Kirschner wire, which is placed slightly distal (B). The neurovascular bundle (not visible) is also retracted, preventing any injury to the region. The surgeon now has clear access to the posterior capsule of the knee.

Fig 6

View of the posterior capsule of a right knee following a posteromedial approach. The white of the capsule is clearly visible beneath the red muscle tissue. A forceps and a scalpel are used to incise the tissue. The specific procedure will determine which portion of the capsule is opened and which structures are exposed.

Fig 7

Following the procedure, the approach should be closed in a layer-by-layer fashion. The subcutaneous tissue can be seen being sutured in the figure above in a right knee (A). Once the subcutaneous layer is closed (B), the skin is closed using an intradermal suturing.