Anteromedial Approach to Ankle Joint

Anteromedial Approach to Ankle Joint indications:

  • The Anteromedial Approach to Ankle Joint is used for the following purposes:
    1. Open reduction and internal fixation of medial malleolus fractures.
    2. Open reduction and internal fixation of pilon fractures.
    3. Deltoid ligament repair.

Position of the Patient

  • Supine position.
  • Place foot in slight external rotation to allow better visualization of medial malleolus:
    • if a bump is utilized, it can be removed to allow extremity to externally rotate

Landmarks and Incision

  • Make 10 cm longitudinal, curved incision on medial ankle:
    • begin 5cm proximal to medial malleolus over subcutaneous tibia.
    • continue incision across anterior third of medial mallelous.
      • this can be curved apex anteriorly for improved visualization of the ankle joint.
    • finish 5 cm distal and 5cm anterior to tip of medial malleolus.

Internervous plane

  • There is No internervous plane for the Anteromedial Approach to Ankle Joint.

Superficial dissection

  • Mobilize skin flaps.
  • Identify and protect long saphenous vein just anterior to medial malleolus.
  • Identify and protect long saphenous nerve, if possible, next to vein.
  • Clear remaining tissues down to periosteum.

Deep dissection

  • Expose fracture site for medial malleolus fracture.
  • Make small incision in anterior joint capsule to visualize joint and dome of talus.
  • Split fibers of deltoid ligament to allow hardware to seat directly on bone.
  • Posterior tibial tendon should be visualized to ensure that it remains intact.

Dangers

  • The structures at risk during the Anteromedial Approach to Ankle Joint  include:
    1. Saphenous nerve:
      • prevent injury by protecting and preserving the long saphenous vein.
      • often too small for direct visualization.
      • damage to nerve may cause.
        • formation of painful neuroma.
        • numbness over medial foot.
    2. Long Saphenous vein:
      • prevent injury by mobilizing anterior skin flaps with caution.
      • preservation is ideal so it can be utilized as a vein graft in future.

References

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