Pearls and Pitfalls for the Direct Posterior Approach to the Proximal Tibia and Knee Joint: A Clinical Experience From a Tertiary Center in Central India

Background The posterior approach to the proximal tibia provides direct access to posterior knee and tibial pathologies, allowing controlled identification and protection of neurovascular structures within the popliteal fossa. Despite these advantages, concerns regarding prone positioning, potential neurovascular injury, wound complications, and limited surgeon familiarity have restricted its widespread use. This study aimed to evaluate indications, perioperative complications, and functional outcomes of the posterior approach to the proximal tibia, highlighting practical pearls and pitfalls. Methods A retrospective review was conducted of 21 patients who underwent surgery using a posterior approach to the proximal tibia between March 2021 and December 2024 at Shri Balaji Institute of Medical Sciences, Raipur, a tertiary care center in Central India. Indications included posterior tibial condyle open reduction and internal fixation or posterior cruciate ligament avulsion fixation in nine of 21 patients (42.9%), popliteal cyst excision in five (23.8%), posterior tibial exostosis with impingement in four (19.0%), and excision or curettage of proximal tibial lesions in three (14.3%). All procedures were performed in the prone position using either a direct posterior or posteromedial approach based on lesion location. Operative duration, complications (graded according to the Clavien-Dindo classification), and functional outcomes were assessed using the Lysholm score. Results The cohort comprised 21 patients (13 males (61.9%) and eight females (38.1%)) with a mean age of 37.4 years (range, 19-62 years). Two of 21 patients (9.5%) developed Clavien-Dindo grade II complications, including one superficial surgical site infection and one transient tibial nerve neuropraxia, both managed conservatively. No vascular injuries, deep infections, anesthesia-related events, or permanent neurological deficits were observed. At a mean follow-up of 12.6 months, three of 21 patients (14.3%) were lost to follow-up. Among the remaining 18 patients, 17 (94.4%) achieved satisfactory functional outcomes, with a mean Lysholm score of 88.4 ± 5.7, and most returned to their preoperative activity levels. Conclusions The posterior approach to the proximal tibia was safe and effective in this cohort, with a low complication rate and favourable functional outcomes. Careful patient selection, meticulous dissection, approach customization based on lesion location, gentle neurovascular handling, maintenance of knee flexion in the prone position, thorough preoperative imaging, and appropriate anesthetic optimization are essential to minimize complications.