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Figure 5-8. If the tendons running behind the medial malleolus need to be
lengthened, the whole of the posteromedial aspect of the medial malleolus is
exposed.
Dangers
The posterior tibial artery and the tibial nerve (the posterior neurovascular
bundle) are vulnerable during the approach. Take care not to apply forceful
retraction to the nerve, as this may lead to neurapraxia. Note that the tibial
nerve is surprisingly large in young children and that the tendon of the
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flexor digitorum longus muscle is extremely small. Take care to identify
positively all structures in the area before dividing any muscle tendons (see
Figs. 10-1 and 10-2).
How to Enlarge the Approach
Extensile Measures
Extend the incision 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. As is true for all long,
curved incisions around the ankle, skin necrosis can result if the skin flaps
are not cut thickly or if forcible retraction is applied. To reach the posterior
talar process, incise the ankle joint capsule and the subtalar joint capsule at
the back of the talus longitudinally in the midline (Fig. 5-9).
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Figure 5-9. To access the posterior process of the talus, use the plane between
the flexor hallucis longus and the Achilles tendon. Incise the capsule of the
ankle longitudinally to expose the posterior aspect of the talus.
REFERENCES
1. Buckley R, Moran C, Apivatthakakul T. Hindfoot—calcaneus and talus.
In: AO Principles of Fracture Management. 3rd ed. Vol. 2. Thieme;
2017.
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2. Meulenkamp B, Louati H, Morellato J, et al. Posterior malleolar
exposure. Orthop Trauma Assoc Int. 2019;2:e021.
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6
Posterolateral Approach to the
Ankle
Position of the Patient
Landmarks and Incision
Landmarks
Incision
Internervous Plane
Superficial Surgical Dissection
Deep Surgical Dissection
Dangers
How to Enlarge the Approach
Extensile Measures
Introduction
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The posterolateral approach is used to treat conditions of the posterior
aspect of the distal tibia and ankle joint. It is well suited for open
reduction and internal fixation of posterior malleolar fractures and
distal fibular fractures. Because the patient is prone, however, it is not
the approach of choice if the fibula and medial malleolus have to be
fixed at the same time. Its other uses include the following:
Excision of sequestra
Removal of benign tumors
Arthrodesis of the posterior facet of the subtalar joint
Posterior capsulotomy and syndesmotomy of the ankle
Elongation of tendons
Position of the Patient
Place the patient prone on the operating table. As always, when the prone
position is being used, place longitudinal pads under the pelvis and chest so
that the center portion of the chest and abdomen are free to move with
respiration. Place a sandbag under the ankle so that it can be extended
during the operation. Next, exsanguinate the limb by elevating it for 3 to 5
minutes or applying a soft rubber bandage; then inflate a tourniquet (Fig. 6-
1).
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Figure 6-1. Position of the patient for the posterolateral approach to the ankle
joint.
Landmarks and Incision
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Landmarks
The lateral malleolus is the subcutaneous distal end of the fibula.
The Achilles tendon is easily palpable as it approaches its insertion into
the calcaneum.
Incision
Make a 10-cm longitudinal incision halfway between the posterior border
of the lateral malleolus and the lateral border of the Achilles tendon. Begin
the incision at the level of the tip of the fibula and extend it proximally (Fig.
6-2).
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Figure 6-2. Make a 10-cm longitudinal incision halfway between the posterior
border of the lateral malleolus and the lateral border of the Achilles tendon.
Internervous Plane
The internervous plane lies between the peroneus brevis muscle (which is
supplied by the superficial peroneal nerve) and the flexor hallucis longus
muscle (which is supplied by the tibial nerve; Fig. 6-3).
Superficial Surgical Dissection
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Mobilize the skin flaps. The short saphenous vein and sural nerves run just
behind the lateral malleolus; they should be well anterior to the incision.
Incise the deep fascia of the leg in line with the skin incision, and identify
the two peroneal tendons as they pass down the leg and around the back of
the lateral malleolus (Fig. 6-4). The tendon of the peroneus brevis muscle is
anterior to that of the peroneus longus muscle at the level of the ankle joint
and, therefore, is closer to the lateral malleolus. Note that the peroneus
brevis is muscular almost down to the ankle, whereas the peroneus longus is
tendinous in the distal third of the leg (see Figs. 25-1 and 25-2).
Incise the peroneal retinaculum to release the tendons, and retract the
muscles laterally and anteriorly to expose the flexor hallucis longus muscle
(Fig. 6-5). The flexor hallucis longus is the most lateral of the deep flexor
muscles of the calf. It is the only one that is still muscular at this level (see
Fig. 25-2).
Deep Surgical Dissection
Make a longitudinal incision through the lateral fibers of the flexor hallucis
longus muscle as they arise from the fibula (Fig. 6-6). Retract the flexor
hallucis longus medially to reveal the periosteum over the posterior aspect
of the tibia (Fig. 6-7). To access the distal tibia, develop an epiperiosteal
plane between the periosteum covering the tibia and the overlying soft
tissues. To enter the ankle joint, follow the posterior aspect of the tibia
down to the posterior ankle joint capsule and incise it transversely.
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