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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 14-2. Incise the fascia in line with the skin incision, cutting through the
superior and inferior extensor retinacula.
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Figure 14-3. Identify the extensor digitorum longus tendons and retract them
medially.
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Figure 14-4. Incise the capsule of the ankle and visualize the dome of the talus.
Continue to incise the ankle joint capsule in line with the skin incision and
distally expose the talonavicular joint. The anterolateral aspect of the talus can
then be seen.
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Figure 14-5. Forceful inversion and plantar flexion of the foot improves
visualization of the talus.
Dangers
The deep peroneal nerve and anterior tibial artery cross the front of the
ankle joint, medial to the approach. They should be safe if the dissection is
in the proper plane. The superficial branch of the peroneal nerve may be
seen with a proximal extension of the incision, and cutaneous branches of
the nerve crossing the plane of the superficial dissection need to be
carefully protected.
How to Enlarge the Approach
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Extensile Measures
The approach can be extended proximally to explore structures in the
anterior compartment of the leg. Continue the incision over the
compartment and incise the thick deep fascia in line with the skin incision.
The approach can also be extended distally to expose the tarsometatarsal
joints on the lateral half of the foot. Continue the incision over the fourth
metatarsal and expose the subcutaneous tarsal–metatarsal joints.
REFERENCE
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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15
Anteromedial Approach to the
Talar Neck
Position of the Patient
Landmarks and Incision
Internervous Plane
Superficial Surgical Dissection
Deep Surgical Dissection
Dangers
Nerves
Vessels
How to Enlarge the Approach
Extensile Measures
Special Surgical Points
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Introduction
The anteromedial approach to the talar neck offers an excellent view
of the medial side of the talar neck. It also permits inspection of the
anteromedial portion of the ankle joint, dome of the talus, and
talonavicular joint. The anteromedial approach to the talar neck is
usually used in conjunction with the anterolateral approach to the talar
neck to accurately visualize talar neck fractures. It is acknowledged
that using these two incisions is the best approach to deal with this
difficult clinical scenario. The two approaches together provide
excellent visualization of talar neck fractures for reduction and
fixation.
1
Position of the Patient
Place the patient in the supine position on the operating table (see Fig. 7-1).
Place a sandbag beneath the hip on the side undergoing surgery. This will
correct the natural external rotation of the leg and place the foot in a neutral
position, with the toes pointing skyward. After exsanguination, apply a
tourniquet to the mid-thigh.
Landmarks and Incision
Palpate the tendon of the tibialis anterior as it runs over the anteromedial
aspect of the ankle. Trace the tendon distally to its insertion on the
navicular. Identify the ankle joint by passively flexing and extending the
joint. Make an 8-cm-long straight incision on the anteromedial aspect of the
ankle. Begin 2 cm proximal to the junction of the medial edge of the dome
of the talus and the distal tibia. Extend the incision distally to follow the
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medial side of the tibialis anterior tendon, ending at the anteromedial border
of the navicular (Fig. 15-1). The incision may be extended proximally if
access to the medial portion of the ankle is needed. The incision can also be
extended distally for access to the medial portion of the midfoot.
Figure 15-1. Make an 8-cm-long straight incision on the anteromedial aspect of
the ankle. Begin 2 cm proximal to the junction of the medial dome of the talus
and distal tibia. Extend the incision distally to follow the medial side of the
anterior tibial tendon, ending at the anteromedial border of the navicular.
Internervous Plane
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No internervous plane is used. The approach is safe because the incision
cuts down onto bone, which is subcutaneous both proximally and distally.
Superficial Surgical Dissection
Do not mobilize the skin flaps. Take care to identify and preserve the long
saphenous vein medially as it runs just anterior to the medial malleolus. The
flaps should be full thickness without undermining, consisting of skin and
all tissues down to bone. Remember that the anterolateral approach to the
talar neck is commonly used in conjunction with this approach. If both
incisions are used, there should be a full-thickness skin bridge attached to
bone and soft tissue in between the two incisions to avoid skin necrosis.
Identify the extensor retinaculum and incise it in the line of the skin incision
(Fig. 15-2).
Deep Surgical Dissection
Incise the superficial fibers of the deltoid ligament that run anteriorly and
distally downward from the medial malleolus in line with the skin incision
to expose the underlying ankle joint capsule. Finally, incise the ankle joint
capsule in line with the skin incision to reveal the dome and neck of the
talus.
It is easiest to enter the joint where the anteromedial part of the dome of
the talus meets the medial corner of the distal tibia, as accurate landmarks
are easily palpable there. Extend the capsular incision distally to expose the
talar neck and talonavicular joint (Fig. 15-3). By retracting distally and
toward the calcaneum, the subtalar region can be exposed and viewed as
well.
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Figure 15-2. Visualize the extensor retinaculum and incise it in the line of the
skin incision.
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