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Figure 11-5. Retract the fat pad with the skin flap. Detach the origins of the
extensor digitorum brevis and retract the muscle distally to expose the dorsal
capsule of the talonavicular joint in the distal end of the wound and the more
lateral dorsal capsule of the calcaneocuboid joint.
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Figure 11-6. Incise the joint capsules of the respective joints.
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Figure 11-7. Reflect the peroneal tendons anteriorly. Incise the joint capsule of
the talocalcaneal joint.
Dangers
Skin Flaps
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Exposures in this area are notorious for producing necrosis of skin flaps.
Therefore, skin flaps should be cut as thickly as possible, stripping and
retraction should be kept to a minimum, and sharp curves in the skin
incision should be avoided.
How to Enlarge the Approach
Local Measures
To open the calcaneocuboid, talonavicular, and subtalar joints, invert the
foot. Note that both the talonavicular joint and the posterior subtalar joint
must be incised before inversion will open either one.
Extensile Measures
To enlarge the approach proximally, continue the incision, curving it along
the posterior border of the fibula. By developing a plane between the
peroneal muscles and the flexor muscles, the entire length of the fibula can
be exposed.1 In practice, however, this extension is required rarely.
The incision also may be extended posteriorly and proximally to reach
the subcutaneous Achilles tendon.
REFERENCE
1. de Boer P, Buckley R, Hoppenfeld S. Posteromedial approach to the
ankle. In: Surgical Exposures in Orthopaedics: The Anatomic Approach.
6th ed. Wolters Kluwer; 2022:681–684.
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12
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Lateral Approach to the Hindfoot
(Posterior Part of Grice)
Position of the Patient
Landmarks and Incision
Internervous Plane
Superficial Surgical Dissection
Deep Surgical Dissection
Dangers
Skin Flaps
Nerve
How to Enlarge the Approach
Introduction
The lateral approach to the hindfoot (posterior part of the Grice
approach1) is used mainly to provide excellent exposure of the
peroneal tubercle. It also gives access to the peroneal tendons and can
be extended both proximally and distally to provide wider exposure of
the structures of the lateral side of the hindfoot, distal fibula, and
Achilles tendon.
Position of the Patient
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Place the patient in a lateral position on the operating table (Fig. 12-1).
Ensure that all bony prominences are carefully protected. Exsanguinate the
limb by elevating it for a few minutes or by applying a rubber tourniquet,
then inflate a pneumatic tourniquet applied to the mid-thigh.
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Figure 12-1. Place the patient in a lateral position on the operating table.
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Landmarks and Incision
Palpate the lateral malleolus at the distal end of the fibula. The lateral wall
of the calcaneum is subcutaneous and lies below the lateral malleolus. The
size of the peroneal tubercle varies. It may be quite prominent and thus
easily palpable somewhat posterior to the line of the fibula. The lateral
process of the talus is felt immediately beneath the distal fibula and
somewhat anterior to it. The peroneal tendons also are visible and palpable.
Make a 2-cm straight incision in line with the long axis of the foot directly
over the peroneal tubercle, distal to the fibula, and lateral process of the
talus (Fig. 12-2).
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Figure 12-2. Make a 2-cm longitudinal incision in line with the long axis of the
foot directly over the peroneal tubercle, distal to the fibula and lateral process of
the talus.
Internervous Plane
There is no true internervous plane with this approach. It is a direct
approach in line with the peroneal tendons. These muscles receive their
nerve supply well proximal to the surgical field.
Superficial Surgical Dissection
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