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5
Posteromedial Approach to the
Ankle
Position of the Patient
Landmarks and Incision
Landmarks
Incision
Superficial Surgical Dissection
Deep Surgical Dissection
Dangers
How to Enlarge the Approach
Extensile Measures
Introduction
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The posteromedial approach to the ankle joint is routinely used for
exploring the soft tissues that run around the back of the medial
malleolus. This approach is used for the release of soft tissue around
the medial malleolus in the treatment of clubfoot.
The approach can also be used to allow access to the posterior
process of the talus or the posterior malleolus of the ankle joint.
Reduction and fixation of posterior malleolar fractures can also be
achieved by using the posterolateral approach to the distal tibia (see
Chapter 6).1,
2
Position of the Patient
Either of two positions is available for this approach. First, 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 (Fig.
5-1). This position will achieve full external rotation of the hip, permitting
better exposure of the medial structures of the ankle. Alternatively, 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.
Exsanguinate the limb by elevating it for 3 to 5 minutes or applying a
soft rubber bandage; then inflate a tourniquet.
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Figure 5-1. Place the patient supine on the operating table with the knee and
the hip flexed to expose the medial structures of the ankle.
Landmarks and Incision
Landmarks
The medial malleolus is the bulbous, distal, subcutaneous end of the tibia.
Palpate the medial border of the Achilles tendon just above the
calcaneum.
Incision
Make an 8- to 10-cm longitudinal incision roughly midway between the
medial malleolus and the Achilles tendon (Fig. 5-2).
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Figure 5-2. Make an 8- to 10-cm longitudinal incision roughly between the
medial malleolus and the Achilles tendon.
Superficial Surgical Dissection
Deepen the incision in line with the skin incision to enter the fat that lies
between the Achilles tendon and those structures that pass around the back
of the medial malleolus. If the Achilles tendon is to be lengthened, identify
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it in the posterior flap of the wound and perform the lengthening now.
Identify a fascial plane in the anterior flap that covers the remaining flexor
tendons. Incise the fascia longitudinally, in the line of the skin incision well
away from the back of the medial malleolus (Figs. 5-3 and 5-4).
Figure 5-3. Incise the deep fascia in line with the skin incision.
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Figure 5-4. Retract the Achilles tendon and the retrotendinous fat laterally,
exposing the fascia of the deeper flexor compartment. Open the compartment
and identify the muscle fibers of the flexor hallucis longus.
Deep Surgical Dissection
There are three different ways to approach the back of the ankle joint.
First, identify the flexor hallucis longus, the only muscle that still has
muscle fibers at this level (see Fig. 5-4). If you wish to access the
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posteromedial aspect of the ankle to reduce and fix a posteromedial
fragment of a posterior malleolar fracture, develop a plane between the
lateral border of the flexor hallucis and the peroneal tendons that lie just
lateral to it (Fig. 5-5). Deepen this plane to expose the posterior aspect of
the ankle joint by retracting the flexor hallucis longus medially (Fig. 5-6).
If you wish to access the ankle joint more anteriorly, identify the flexor
hallucis longus and continue the dissection anteriorly toward the back of the
medial malleolus. Preserve the neurovascular bundle by mobilizing it gently
and retracting it and the flexor hallucis longus laterally to develop a plane
between the bundle and the tendon of the flexor digitorum longus. This
approach brings one onto the posterior aspect of the ankle joint rather more
medially than does the first approach (Fig. 5-7).
When all the tendons that run around the back of the medial malleolus
(the tibialis posterior, flexor digitorum longus, and flexor hallucis longus)
must be lengthened, the back of the ankle can be approached directly,
because the posterior coverings of the tendons must be divided during the
lengthening procedure (Fig. 5-8).
For all three methods, complete the approach by incising the joint
capsule either longitudinally or transversely.
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Figure 5-5. Identify the posterior tibial artery and tibial nerve. Then, incise the
fibro-osseous tunnel over the flexor hallucis longus tendon and the other medial
tendons so that the structures can be mobilized and retracted medially.
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Figure 5-6. Retract the posterior structures medially, exposing the posterior
portion of the ankle joint.
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Figure 5-7. To access the ankle joint more anteriorly, develop a plane between
the neurovascular bundle and the tendon of flexor digitorum longus.
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