Anterior Approach to Ankle Joint indications:

  • The anterior approach to Ankle Joint provides excellent exposure of the ankle joint for arthrodesis.
  • The anterior approach to Ankle Joint uses include the following:
    1. Open reduction and internal fixation of pilon fractures.
    2. Ankle arthrodesis.
    3. Total ankle arthroplasty.
    4.  Drainage of infections in the ankle joint.
    5. Removal of loose bodies.

Position of the Patient

  • Place the patient supine.

Landmarks and Incision

  • Landmarks:
    • Medial malleolus.
    • Lateral malleolus.
  • Incision:
    • Make a 15 cm incision over anterior ankle:
      • Begin 10 cm proximal to joint.
      • Cross joint midway between malleoli.
      • Stay superficial to avoid injury to superficial peroneal nerve branches.
    • Alternatively, make a 15-cm longitudinal incision with its center overlying the anterior aspect of the medial malleolus.

Internervous plane

  • There is no true internervous plane for the anterior approach to Ankle Joint.
  • Intermuscular plane lies between:
    • Extensor hallucis longus.
    • Extensor digitorum longus.
      • Both are innervated by deep peroneal nerve.

Superficial dissection

  • Incise deep fascia of leg in line with skin incision.
  • Incise extensor retinaculum.
  • Find plane between extensor digitorum longus and extensor hallucis longus a few cm above joint.
  • Identify neurovascular bundle.
    • Mobilizing tibialis anterior artery and deep peroneal nerve.
  • Retract extensor hallucis longus and neurovascular bundle medially.
  • Retract extensor digitorum longus laterally.
  • Remaining joint capsule tissue cleared to expose anterior ankle joint.

Deep dissection

  • Incise capsule of ankle joint in line with incision.
  • Expose full width of ankle joint by subperiosteal and subcapsular dissection of the tibia and talus.

Approach Extension

  • The anterior approach to Ankle Joint can be extended proximally to expose the structures in the anterior compartment.
  • To expose the proximal tibia, use the plane between the tibia and the tibialis anterior muscle.
  • Distal extension to the dorsum of the foot is possible, but rarely is required.

Dangers

  • The structures at risk during the anterior approach to Ankle Joint include:
    1. Superficial peroneal nerve cutaneous branches:
      • at greatest danger during skin incision.
    2. Neurovascular bundle (deep peroneal nerve and anterior tibial artery):
      • above joint runs between extensor digitorum longus and extensor hallucis longus.
      • crosses behind extensor hallucis longus at level of the joint.

References

  • Surgical Exposures in Orthopaedics book – 4th Edition
  • Campbel’s Operative Orthopaedics book 12th