Posteromedial Approach to Ankle Joint indications:

  • The posteromedial approach to ankle joint is routinely used for exploring the soft tissues that run around the back of the medial malleolus.
  • The posteromedial approach to the ankle joint other uses include:
    1. Open reduction and internal fixation of medial malleolus fractures.
    2. Open reduction and internal fixation of pilon fractures.
    3. Open reduction and internal fixation of posterior malleolus fractures.
    4. Release of soft tissue around the medial malleolus in the treatment of clubfoot.

Position of the Patient

  •  One of two positions is used in this approach:
    1. Place the patient supine on the operating table. Flex the hip and knee, and place the lateral side of the affected ankle on the anterior surface of the opposite knee.
    2. Place the patient in the lateral position with the affected leg nearest the table. Flex the knee of the opposite limb to get its ankle out of the way.

Landmarks and Incision

  • Landmarks:
    1. Medial malleolus.
    2. Achilles tendon.
  • Incision:
    • Make 10 cm longitudinal curved incision with concavity of incision pointing anterior:
      • Begin 5 cm above the medial maleollus on the posterior border of the tibia.
      • Curve incision distally following the posterior border of the medial malleolus.
      • End incision 5 cm distal to medial malleolus.

Internervous plane

  • There is No internervous plane for posteromedial approach to ankle joint.
  • The approach is carried out between:
    • Tibialis posterior tendon.
    • Flexor digitorum muscle.
      • Both are innervated by the tibial nerve

Superficial dissection

  • Mobilize skin flaps:
    • should be safely posterior to long saphenous vein and saphenous nerve.
  • Incise retinaculum behind medial malleolus in a way that it can be repaired.

Deep dissection

  • Retract tibialis posterior tendon anteriorly.
  • Retract remaining structure posteriorly (neurovascular bundle, flexor hallucis longus, flexor digitorum longus)
  • Perform subperiosteal dissection to expose posterior border of the tibia:
    • Stay on bone to avoid injury to posterior structures.

Approach Extension

  • The posteromedial approach to ankle joint can be extended distally by curving it across the medial border of the ankle, ending over the talonavicular joint.
  • This extension exposes both the talonavicular joint and the master knot of Henry.

Dangers

  • The structures at risk during posteromedial approach to ankle joint include:
    1. Tibialis posterior muscle.
    2. Flexor digitorum longus tendon.
    3. Flexor hallucis longus tendon.
    4. Posterior tibial artery and vein.
    5. Tibial nerve.

References

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