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Figure 15-3. Extend the capsular incision distally to expose the talar neck and
the articulation between the talus and navicular.
Dangers
Nerves
The saphenous nerve runs with the saphenous vein and is close to the
medial edge of the approach. If cut, it may form a neuroma, causing
numbness on the medial side of the dorsum of the foot. Preserve the nerve
by identifying and preserving the long saphenous vein.
Vessels
The long saphenous vein that runs just anterior to the medial malleolus is at
risk and should be protected.
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How to Enlarge the Approach
Extensile Measures
If problems arise with talar reduction or fixation, a medial malleolar
osteotomy may be necessary, requiring proximal extension of the incision.
Extend the incision proximally, medial to the saphenous vein to allow
subcutaneous exposure of the medial aspect of the distal tibia. Perform a
medial malleolar osteotomy that will allow visualization of the dome of the
talus and the more posterior aspects of the talus (see Figs. 4-3 to 4-5).
The exposure can be extended distally in the line of the original skin
incision to expose the joint between the navicular and cuneiform. The
tendon of the tibialis anterior will remain anterior, and the medial
prominence of the navicular will remain as the landmark medially.
Special Surgical Points
When using two approaches for fixation of a talar neck fracture, two
incisions—the anteromedial approach to the talar neck and the anterolateral
approach to the talar neck—are commonly used together. This allows
visualization of the talar neck in multiple planes and ensures accuracy of
reduction, especially if there is comminution of the fractured neck.
Ensuring that the flaps created are full thickness and are not undermined
allows for preservation of blood supply of the talar neck and reduces the
risk of skin flap necrosis. Preserve whatever soft tissue attachments to the
talus you can identify to reduce the risk of avascular necrosis of the talus
developing postoperatively.
The blood supply to the body of the talus is complex. The major supply
comes from vessels in the sinus tarsi entering the bone from its inferior
surface and from vessels in the talar neck. Nondisplaced fractures of the
talar neck disrupt intraosseous branches of the tarsal canal, but the blood
supply from branches of the dorsalis pedis artery remains intact. In
displaced talar neck fractures, this blood supply is cut off. Inferiorly,
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branches of the posterior tibial artery form an anastomotic sling from which
branches arise to enter the talar neck. Deltoid branches usually arise from
the artery of the tarsal canal and supply the medial third of the body of the
talus. Laterally, there are also branches from the peroneal artery.
2
In instances in which a medial malleolar osteotomy must be performed,
reflect the medial malleolus distally to ensure that the blood supply to the
talus coming via the deltoid ligament branches is preserved. A medial
malleolar osteotomy will compromise the articular surface of the ankle, but
this approach allows for accurate visualization, and accurate reduction and
internal fixation (see Fig. 4-4).
REFERENCES
1. Buckley R, Moran C, Apivatthakakul T. Hindfoot—calcaneus and talus.
In: AO Principles of Fracture Management. 3rd ed. Vol 2. Thieme;
2017.
2. Grear BJ. Review of talus fractures and surgical timing. Orthop Clin
North Am. 2016;47:625–637.
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16
Direct Lateral Approach to the
Lateral Process of Talus
Position of the Patient
Landmarks and Incision
Internervous Plane
Superficial Surgical Dissection
Deep Surgical Dissection
Dangers
Nerves
How to Enlarge the Approach
Introduction
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The lateral approach to the lateral process of talus exposes the
posterior facet of the talocalcaneal joint. Because the exposure is
through a small window, it is mainly used for fixation of lateral
process fractures (“snowboarder’s talus”1) or debridement of this part
of the talocalcaneal joint.
Position of the Patient
Place the patient supine on the operating table with a sandbag under the
buttock of the affected side to bring the lateral malleolus forward (Fig. 16-
1). After exsanguination, apply a tourniquet to the mid-thigh.
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Figure 16-1. Place the patient supine on the operating table with a sandbag
under the buttock of the affected side to bring the lateral malleolus forward.
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Landmarks and Incision
Palpate the lateral malleolus, located at the subcutaneous distal end of the
fibula. The peroneal tubercle is a small protuberance of bone on the lateral
surface of the calcaneum that separates the tendons of the peroneus longus
and the brevis muscles. It lies distal and anterior to the lateral malleolus and
can easily be felt.
Make a 4-cm longitudinal incision from the tip of the lateral malleolus to
the peroneal tubercle (Fig. 16-2). Use of an image intensifier can help
localize the incision.
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Figure 16-2. Make a 4-cm longitudinal incision from the tip of the lateral
malleolus to the peroneal tubercle.
Internervous Plane
There is no internervous plane for this approach. The peroneal muscles,
whose tendons are retracted plantarward, share a nerve supply from the
superficial peroneal nerve. The approach is safe because the muscles
receive their nerve supply at a point well proximal to the surgical field.
Superficial Surgical Dissection
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Deepen the incision through subcutaneous tissue, taking care not to
undermine the skin flaps. Identify the sheath over the peroneus brevis
tendon. Next, incise the deep fascia in line with the skin incision. The
peroneal tendons should remain in their retinacular sheaths lying just
posterior to the approach (Fig. 16-3).
Deep Surgical Dissection
Incise the small fat pad overlying the capsule of the subtalar joint. The joint
itself is difficult to palpate. Incise the subtalar joint capsule for the full
length of the incision to expose the talocalcaneal joint in line with the long
axis of the foot (Fig. 16-4).
Figure 16-3. Incise the deep fascia in line with the skin incision. Make the
incision just distal to the fibula, directly over the talocalcaneal joint.
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Figure 16-4. Incise the joint capsule of the subtalar joint in line with the long
axis of the foot.
Dangers
Nerves
The sural nerve lies distal and posterior to the approach, thus should not be
at risk. The superficial branch of the peroneal nerve runs more anteriorly. A
small incision should not endanger either of these nerves.
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