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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_708_Библиотеки_им_академика_М_И_Перельмана
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Figure 7-3. A: Make a 10- to 15-cm incision along the posterior margin of the
fibula all the way to its distal end. From there, curve the incision forward, below
the tip of the lateral malleolus. B: Incise the periosteum on the subcutaneous
surface of the fibula longitudinally. C: Expose the distal fibula subperiosteally.
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Internervous Plane
There is no internervous plane, because the dissection is being performed
down to a subcutaneous bone. For higher fractures of the fibula, the
internervous plane lies between the peroneus tertius muscle (which is
supplied by the deep peroneal nerve) and the peroneus brevis muscle
(which is supplied by the superficial peroneal nerve).
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Superficial Surgical Dissection
Elevate the skin flaps, taking care not to damage the short saphenous vein,
which lies posterior to the lateral malleolus. The sural nerve, which runs
with the short saphenous vein, also should be preserved. If an anterior
incision is used, be aware that the superficial peroneal nerve is close to the
anterior skin flap, especially at the proximal end of the wound.
Deep Surgical Dissection
Incise the periosteum of the subcutaneous surface of the fibula
longitudinally, and strip off just enough of it at the fracture site to expose
the fracture adequately. Take care to keep all dissection strictly
subperiosteal, because the terminal branches of the peroneal artery, which
lie close to the lateral malleolus, may be damaged. Only strip off as much
periosteum as is necessary for accurate reduction; periosteal stripping
markedly reduces the blood supply of the bone in cases of fracture (see Fig.
7-3B, C; see Fig. 25-1).
Dangers
Nerves
The sural nerve is vulnerable when the skin flaps are mobilized. Cutting it
may lead to the formation of a painful neuroma and numbness along the
lateral skin of the foot, which, although it does not bear weight, does come
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in contact with the shoe. The nerve also is valuable as a nerve graft.
Preserve it if possible (see Fig. 10-8). Also, ensure that the nerve is not
inadvertently included in the sutures used in closure. The superficial
peroneal nerve runs close to the anterior margin of the approach if an
anterior skin incision is used. The nerve is especially vulnerable at the
proximal end of the approach and should be identified and preserved.
Vessels
The terminal branches of the peroneal artery lie immediately deep to the
medial surface of the distal fibula. They can be damaged if dissection is
extensive. The damage may not be noticed during surgery because of the
tourniquet, but a hematoma may form after the tourniquet is taken off. That
is why it is best to deflate the tourniquet before closure to ensure
hemostasis; then, the wound can be drained with a suction drain (see Fig.
25-1).
How to Enlarge the Approach
Extensile Measures
Proximal Extension
Extend the incision along the posterior border of the fibula, incising the
deep fascia in line with the skin incision. Develop a new plane between the
peroneal muscles (which are supplied by the superficial peroneal nerve) and
the flexor muscles (which are supplied by the tibial nerve). The upper third
of the fibula can be exposed if the common peroneal nerve can be identified
near the knee and traced down toward the ankle.
Distal Extension
To extend the approach distally, curve the incision down the lateral side of
the foot. Identify the peroneal tendons and incise the peroneal retinacula.
Detach the fat pad in the sinus tarsi and the origin of the extensor digitorum
brevis muscle to expose the calcaneocuboid joint on the lateral side of the
tarsus (see Figs. 10-8 and 10-9).
2
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REFERENCES
1. Brunner CF, Weber BG. The anti-glide plate. In: Special Techniques in
Internal Fixation. Springer-Verlag; 1982:115–133.
2. deBoer P, Buckley R, Hoppenfeld S. The foot and ankle. In: Surgical
Exposures in Orthopaedics: The Anatomic Approach. 6th ed. Wolters
Kluwer; 2022:634–640.
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Anterolateral Approach to the
Ankle and Hind Part of the Foot
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
The full extent of the anterolateral approach to the ankle and hind part
of the foot allows exposure not only of the ankle joint but also of the
talonavicular, calcaneocuboid, and talocalcaneal joints. The approach
is used commonly for ankle fusions, but also can be used for triple
arthrodesis and even pantalar arthrodesis. In addition, it is possible to
view the entire talus through this approach, or to reduce it in cases of
talar dislocation or fracture.1 The superficial part of the approach can
be used for lateral ligament reconstruction.
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Position of the Patient
Place the patient supine on the operating table; place a large sandbag
underneath the affected buttock to rotate the leg internally and bring the
lateral malleolus forward. Exsanguinate the limb either by elevating it for 3
to 5 minutes or by applying a soft rubber bandage; then inflate a tourniquet
(see Fig. 7-1).
Landmarks and Incision
Landmarks
Palpate the lateral malleolus at the distal subcutaneous end of the fibula.
Palpate the base of the fifth metatarsal, a prominent bony mass on the
lateral aspect of the foot.
Incision
Make a 15-cm slightly curved incision on the anterolateral aspect of the
ankle. Begin some 5 cm proximal to the ankle joint, 2 cm anterior to the
anterior border of the fibula. Curve the incision down, crossing the ankle
joint 2 cm medial to the tip of the lateral malleolus, and continue onto the
foot, ending some 2 cm medial to the fifth metatarsal base, over the base of
the fourth metatarsal (Fig. 8-1).
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Figure 8-1. Incision for the anterolateral approach to the ankle. Make a 15-cm
slightly curved incision on the anterolateral aspect of the ankle. Begin
approximately 5 cm proximal to the ankle joint and 2 cm anterior to the anterior
border of the fibula. Curve the incision downward to cross the ankle joint 2 cm
medial to the tip of the lateral malleolus, and continue onto the foot, ending
about 2 cm medial to the fifth metatarsal.
Internervous Plane
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The internervous plane lies between the peroneal muscles (which are
supplied by the superficial peroneal nerve) and the extensor muscles (which
are supplied by the deep peroneal nerve; see Figs. 10-5 and 10-8).
Superficial Surgical Dissection
Incise the fascia in line with the skin incision, cutting through the superior
and inferior extensor retinacula. Do not develop skin flaps. Take care to
identify and preserve the dorsal cutaneous branches of the superficial
peroneal nerve that cross the field of dissection (Fig. 8-2). Identify the
peroneus tertius and extensor digitorum longus muscles, and, in the upper
half of the wound, incise down to bone just lateral to these muscles (Fig. 8-
3).
Deep Surgical Dissection
Retract the extensor musculature medially to expose the anterior aspect of
the distal tibia and the anterior ankle joint capsule. Distally, identify the
extensor digitorum brevis muscle at its origin from the calcaneum (Fig. 8-4)
and detach it by sharp dissection. During dissection, branches of the lateral
tarsal artery will be cut; cauterize (diathermy) them to prevent the formation
of a postoperative hematoma. Reflect the detached extensor digitorum
brevis muscle distally and medially, lifting the muscle fascia and the
subcutaneous fat and skin as one flap. Identify the dorsal capsules of the
calcaneocuboid and talonavicular joints, which lie next to each other across
the foot, forming the clinical midtarsal joint (see Fig. 10-7). Next, identify
the fat in the sinus tarsi and clear it away to expose the talocalcaneal joint,
either by mobilizing the fat pad and turning it downward or by excising it.
Preserving the fat pad prevents the development of a cosmetically ugly
dimple postoperatively. Preserving the pad also helps the wound to heal
(Fig. 8-5).
Finally, incise any or all the capsules that have been exposed. To open
the joints, forcefully flex and invert the foot in a plantar direction (see Fig.
8-5).
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Figure 8-2. Incise the deep fascia and the superior and inferior retinacula in line
with the incision. Take care to preserve the superficial peroneal nerve.
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