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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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Deep Surgical Dissection
Identify the calcaneofibular ligament as it runs from the lateral malleolus
down and back to the lateral surface of the calcaneum. The ligament is
bound closely to the capsule of the talocalcaneal joint. The joint itself is
difficult to palpate and identify, and a small amount of subperiosteal
dissection on the lateral aspect of the calcaneum usually is required before
the joint can be located. Having identified the joint, incise the capsule
transversely to open it up (see Figs. 13-4 and 13-5, and Figs. 10-9 and 10-
10).
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Figure 13-2. Incise the deep fascia in line with the upper part of the skin
incision. Continue the fascial incision distally, following the course of the
tendons. Incise the inferior peroneal retinaculum and expose the peroneal
tendons.
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Figure 13-3. Incise the deep fascia in line with the upper part of the skin
incision. Continue the fascial incision distally, following the course of the
tendons. Incise the inferior peroneal retinaculum and expose the peroneal
tendons.
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Figure 13-4. Mobilize the peroneal tendons and retract them anteriorly over the
distal end of the fibula. Identify the calcaneofibular ligament. Incise it
transversely to open the capsule of the posterior talocalcaneal joint.
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Figure 13-5. Open the joint capsule to expose the posterior talocalcaneal joint.
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 comes in contact with the shoe. The nerve
also is valuable as a nerve graft.
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How to Enlarge the Approach
Local Measures
To expose the bare lateral surface of the calcaneum, incise the periosteum
over its lateral surface and strip it inferiorly by sharp dissection. To see the
talus better, divide the calcaneofibular ligament and the capsule of the
talocalcaneal joint superiorly to uncover its lateral border.
Exposure of the articular surfaces of the joint can be achieved only by
inverting the foot. Note, however, that forcible inversion does not open up
the joint if the anterior part of the talocalcaneal joint remains intact.
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14
Anterolateral Approach to the
Talar Neck
Position of the Patient
Landmarks and Incision
Internervous Plane
Superficial Surgical Dissection
Deep Surgical Dissection
Dangers
How to Enlarge the Approach
Extensile Measures
Introduction
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The full extent of the anterolateral approach to the ankle allows
exposure not only of the ankle joint but also of the talar neck. The
approach is very useful for viewing the talar neck from the
anterolateral side; however, this approach cannot be used in isolation
for fixation of talar neck fractures. The combination of an anterolateral
and anteromedial approach is necessary for fixation of talar neck
fractures to ensure accuracy of reduction.1 The approach can also be
used for surgeries in which the anterolateral portion of the talar neck
needs to be visualized. It could be used to reduce a talar dislocation as
well.
Position of the Patient
Place the patient supine on the operating table (see Fig. 3-1). If the
anterolateral approach is used in isolation, insert a sandbag under the
buttock of the affected side to internally rotate the leg (see Fig. 7-1). If the
patient requires an anterolateral and an anteromedial approach to the talar
neck, do not place a sandbag beneath the buttock. After exsanguination,
apply a tourniquet to the mid-thigh.
Landmarks and Incision
Palpate the lateral malleolus at the distal subcutaneous end of the fibula and
the base of the fifth metatarsal, a prominent bony mass on the lateral aspect
of the foot. Identify the alignment of the fourth ray of the foot by palpating
the subcutaneous surface of the fourth metatarsal bone. Make an 8-cm
straight incision on the anterolateral aspect of the ankle. Begin some 2 cm
proximal to the ankle joint and 2 cm anterior to the anterior border of the
fibula. Extend the incision distally in line with the fourth ray of the foot,
staying medial to the styloid process of the fifth metatarsal (Fig. 14-1).
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Figure 14-1. Make an 8-cm straight incision on the anterolateral aspect of the
ankle. Extend the incision distally in line with the fourth ray of the foot, staying
medial to the styloid process of the fifth metatarsal.
Internervous Plane
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).
Superficial Surgical Dissection
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Incise the fascia in line with the skin incision, cutting through the superior
and inferior extensor retinacula (Fig. 14-2). Do not develop a plane between
the skin and subcutaneous tissues skin flaps. Use full-thickness flaps
consisting of skin and all tissues down to bone as a single unit when
accessing the talus to ensure that the perforating blood supply to the talus is
preserved as much as possible. Such flaps are also much less likely to
necrose than undermined skin flaps. Take care to identify and preserve any
dorsal cutaneous branches of the superficial peroneal nerve that may cross
the field of dissection. Identify the tendons of extensor digitorum longus
and retract them medially (Fig. 14-3).
Deep Surgical Dissection
Retract the extensor musculature medially to expose the anterior aspect of
the ankle joint capsule. Often it is covered with part of the fat pad arising
from the sinus tarsi. Incise the capsule of the ankle longitudinally and
visualize the dome of the talus. Continue to incise the ankle joint capsule in
line with the skin incision and expose the talonavicular joint distally. The
anterolateral aspect of the talus can then be seen (Fig. 14-4). Identify the
cervical ligament running between the talus and the calcaneum. If
necessary, dissect laterally to expose the talocalcaneal joint. Any soft tissue
attachments to the talus should be preserved, as avascular necrosis is always
a concern with approaches to the talus. Often the fat in the sinus tarsi needs
to be cleared away to expose the talocalcaneal joint. Forceful inversion and
plantar flexion of the foot improves visualization of the talus (Fig. 14-5).
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