Download Approaches to the ankle

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