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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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How to Enlarge the Approach
The approach can be enlarged distally by extending the skin incision
distally, curving it slightly in an anterior direction. This will allow you to
visualize more of the subtalar joint. Posteriorly, this incision can be
extended a few centimeters only before endangering the sural nerve and the
peroneal tendons behind the fibula. To see the talus better, divide the
calcaneofibular ligament and the capsule of the talocalcaneal joint
superiorly to uncover its lateral border.
To expose the articular surfaces of the joint, invert the foot (Fig. 16-5).
Note, however, that forcible inversion does not open up the joint if the
anterior part of the talocalcaneal joint and capsule remains intact.
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Figure 16-5. Invert the foot to expose the articular surfaces of the joint.
REFERENCE
1. Von Knoch F, Rekord U, von Knoch M, et al. Fracture of the lateral
process of the talus in snowboarders. J Bone Joint Surg Br.
2007;89(6):772–777.
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17
Posterolateral Approach to the
Posterior Aspect of the Talus
Position of the Patient
Landmarks and Incision
Internervous Plane
Superficial Surgical Dissection
Deep Surgical Dissection
Dangers
How to Enlarge the Approach
Extensile Measure
Introduction
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The posterolateral approach is used to treat pathology of the posterior
aspect of the talus and ankle joint. It is well suited for open reduction
and internal fixation of posterior talar fractures. Because the patient is
prone, however, it is not the approach of choice if another surgery
requires an anterior approach. In such cases, it is often better to use
either a posteromedial approach or a lateral approach to the fibula.
However, this approach provides the best exposure to the posterior
aspect of the talus; therefore, on occasion, it may be necessary to
change the position of the patient on the table halfway through the
operation to permit the use of an additional anterior approach.
Position of the Patient
Place the patient prone on the operating table (see Fig. 6-1). As always,
when the prone position is used, place longitudinal pads under the pelvis
and chest so that the center portion of the chest and abdomen is free to
move with respiration. Place a sandbag under the ankle so that the ankle
joint is plantarflexed during the operation. Finally, exsanguinate the limb
and apply a tourniquet to the mid-thigh.
Landmarks and Incision
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.
Make a 5-cm longitudinal incision halfway between the posterior border
of the lateral malleolus and lateral border of the Achilles tendon. Begin the
incision 2 cm proximal to the tip of the fibula and extend it distally (Fig.
17-1).
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Figure 17-1. Make a 5-cm longitudinal incision halfway between the posterior
border of the lateral malleolus and lateral border of the Achilles tendon. Begin
the incision 2 cm proximal to the tip of the fibula and extend it distally.
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).
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Superficial Surgical Dissection
Mobilize the skin flaps. The short saphenous vein and sural nerve run just
behind the peroneal tendons; they should be just posterior to the incision
but are in danger during the superficial dissection. 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 around the back of the lateral malleolus (Fig. 17-
2). 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.
Incise the peroneal retinaculum to release the tendons, then retract the
tendons laterally and anteriorly to expose the flexor hallucis longus muscle
(Fig. 17-3). 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.
Deep Surgical Dissection
Continue the longitudinal incision, developing a plane between the flexor
hallucis longus muscle and the peroneus brevis muscle. The back of the
ankle joint is covered by four structures. The posterior inferior tibiofibular
ligament is most proximal. The transverse tibiofibular ligament lies slightly
more distally, and yet more distally lies the posterior joint capsule of the
ankle. The most distal structure is the posterior talofibular ligament running
transversely, covering the back of the ankle joint. Incise transversely
through the posterior joint capsule of the ankle to enter the ankle joint (Fig.
17-4). The ligaments of the ankle joint itself are not incised. The approach,
therefore, provides safe access without creating instability.
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Figure 17-2. 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.
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Figure 17-3. Incise the peroneal retinaculum to release the tendons, then
retract the tendons laterally and anteriorly to expose the flexor hallucis longus
muscle.
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Figure 17-4. Continue the longitudinal incision, developing a plane between the
flexor hallucis longus muscle and the peroneus brevis muscle. Incise
transversely through the posterior joint capsule of the ankle to enter the ankle
joint.
Dangers
The short saphenous vein and the sural nerve run close together just behind
the peroneal tendons. They should be preserved as a unit during the
superficial surgical dissection.
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How to Enlarge the Approach
Extensile Measure
To enlarge the approach proximally, extend the skin incision superiorly and
identify the plane between the muscles of the flexor hallucis longus and the
peroneal muscles. It is an internervous plane (see Fig. 6-5).
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