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Ankle Approach Indication Position Internervous/ Intermuscular plane Intermuscular: EHL + EDL (deep peroneal N) Incision Superficial dissection Deep dissection Dangers Anterior ORIF pilon # Ankle arthrodesis Total ankle arthroplasty Supine Tourniquet 15cm over anterior ankle Cross joint midway b/w malleoli Incise joint capsule in line w/ incision Subperiosteal + subcapsular dissection of tibia + talus Superficial peroneal N cutaneous branches Neurovascular bundle: deep peroneal N + anterior tibial A running b/w EDL + EHL Supine Tourniquet Internervous: FHL (tibial) Peroneal muscles (superficial peroneal N) Posterior border of fibula centered on # Incise deep fascia in line w/ skin Incise extensor retinaculum – identify plane b/w EDL + EHL + neurovascular bundle medially Retract EDL laterally Dissect down to fibula Posterolateral Posterior malleolus Peroneal tendons Superficial peroneal N Posterior tibial vessels: behind FHL Tibial N: behind FHL Sural N ORIF fibula ORIF syndesmosis supine None Longitudinal over posterior fibula centered on # Elevate skin flaps Look for superficial peroneal N around 10cm proximal to tip of fibula Retract peroneus longus + brevis muscles/tendons posteriorly to access fibula Retract above anteriorly to access posterior malleolus Incise periosteum off subcut surface of fibula Lateral malleolus Anteromedial ORIF medial malleolus ORIF pilon # Deltoid lig repair Supine +/tourniquet None 10cm longitudinal curved 5cm prox to medial mal running across anterior 1/3 Mobilise skin flaps Identify + protect long saphenous vein + nerve anterior to medial mal Expose # Small incision in anterior capsule Split deltoid to allow metalwork to sit down onto bone Sural N Short Saphenous V Terminal branches of peroneal A Superficial peroneal N Saphenous N Long saphenous V Posteromedial ORIF medial malleolus ORIF pilon # ORIF posterior malleolus # Supine tourniquet Intermuscular: Tib post (tibial N) Flexor digitorum (Tibial) 10cm longitudinal curved incision from 5cm above posterior medial malleolus Mobilize skin flaps posterior to long saphenous vein and saphenous nerve Anterolateral ORIF pilon # Supine Tourniquet Internervous: Peroneus tertius (Deep peroneal N) Peroneus brevis (Superficial peroneal N) Centered b/w tibia + fibula Extend across ankle in line w/ 4th ray Full thickness flaps Care of superficial peroneal N running immediately under skin Retract tib post anteriorly Retract neurovascular bundle, FHL + FDL posteriorly Subperiosteal dissection to expose posterior border of tibia Fascia incised proximally Extensor retinaculum excised over ankle Anterior compartment tendons elevated + retracted medially Minimal arthrotomy Tib post muscle FDL tendon FHL tendon Post tib A + V Tibial N Superficial peroneal N Deep peroneal N Anterior tibial A