Anteromedial Approach to Ankle Joint indications:

The anteromedial approach to Ankle Joint is very useful in many patterns of ankle articular surface fractures particularly the medial malleolus ones.

The Anteromedial Approach to Ankle Joint is used for the following indications:

  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.
Anteromedial Approach to Ankle Joint

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. The Saphenous nerve: prevent its injury by protecting and preserving the long saphenous vein. Often it’s too small for direct visualization. Its damage may cause formation of painful neuroma and numbness over medial foot.
  2. Long Saphenous vein: prevent its 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