Anterolateral Approach to Ankle Joint indications:

  • The anterolateral approach to ankle joint is used to:
    1. Open reduction and internal fixation of pilon fractures.
    2. Open bone biopsy.
    3. Access to the anterior ankle joint for debridement.

Position of the Patient

  • Place the patient supine on operating table.
  • Place a bump under ipsilateral hip.

Landmarks and Incision

  • Proximally, the incision centered between tibia and fibula bones.
  • Distal extension across the ankle, the incision centered on 4th ray of the foot.

Internervous plane

  • The internervous plane for the anterolateral approach to ankle joint lies between:
    • Peroneus tertius muscle: which is innervated by the deep peroneal nerve.
    • peroneus brevis muscle: which is innervated by the the superficial peroneal nerve.

Superficial dissection

  • Full thickness flaps utilized.
  • Care must be taken to protect superficial peroneal nerve:
    • The superficial peroneal nerve is located in the subcutaneous tissue, immediately under the skin.

Deep dissection

  • Fascia incised proximally and extensor retinaculum incised over ankle.
  • Anterior compartment tendons elevated and retracted medially.
  • Minimal arthrotomy performed:
    • large arthrotomies lead to devascularization of the anterior distal tibia and should be avoided.

Approach Extension

  • Proximal extension of the anterolateral approach to ankle joint:
    • Indications:
      • It’s indicated for proximal plate placement.
    • Dissection is limited proximally by anterior compartment muscle attachments to anterior fibula.
  • Distal extension of the anterolateral approach to ankle joint:
    • Indications:
      • To access talar fractures or talon-avicular injuries.
      • To allow placement of pins for distraction.
    • Dissection:
      • Incision can be extended to talonavicular joint if needed.
      • Extensor digitorum brevis must be elevated.

Dangers

  • The structures at risk during anterolateral approach to ankle joint include:
    1. Superficial peroneal nerve.
    2. Deep peroneal nerve.
    3. Anterior tibial artery.

References

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