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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
Extensile Measures
To enlarge both approaches proximally, continue the incision along the
subcutaneous surface of the tibia. Subperiosteal dissection exposes the
subcutaneous and medial surfaces of the tibia along its entire length.
The exposure can be extended distally to expose the deltoid ligaments
and the talocalcaneonavicular joint.
REFERENCES
1. Gatellier J, Chastang P. Access to the fractured malleolus with piece
chipped off at back. J Chir (Paris). 1924;24:5B.
2. Davidovitch RI, Egol KA. The Medial malleolus osteoligamentous
complex and its role in ankle fractures. Bull NYU Hosp Jt Dis.
2009;67(4):318–324.
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4
Approach to the Medial Side of the
Ankle
Position of the Patient
Landmark and Incision
Landmark
Incision
Internervous Plane
Superficial Surgical Dissection
Deep Surgical Dissection
Dangers
Special Surgical Points
How to Enlarge the Approach
Introduction
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The medial approach exposes the medial side of the ankle joint.1 Its
uses include the following:
Arthrodesis of the ankle
Excision or fixation of osteochondral fragments from the medial side
of the talus
Reduction and fixation of fracture dislocations of the talus
Removal of loose bodies from the ankle joint
Position of the Patient
Place the patient supine on the operating table. Exsanguinate the limb either
by elevating it for 5 minutes or by applying a soft rubber bandage firmly;
then inflate a tourniquet. The natural external rotation of the leg exposes the
medial malleolus. The pelvis ordinarily does not have to be tilted to
improve the exposure (see Fig. 3-1).
Landmark and Incision
Landmark
The medial malleolus is the palpable distal end of the tibia.
Incision
Make a 10-cm longitudinal incision on the medial aspect of the ankle joint,
centering it on the tip of the medial malleolus. Begin the incision over the
medial surface of the tibia. Below the malleolus, curve it forward onto the
medial side of the middle part of the foot (Fig. 4-1).
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Figure 4-1. Make a 10-cm longitudinal incision on the medial aspect of the
ankle joint, with its center over the tip of the medial malleolus. Distally, curve the
incision forward onto the medial side of the middle part of the foot.
Internervous Plane
The approach uses no internervous plane. Nevertheless, the surgery is safe
because the tibia is subcutaneous and all dissection stays on bone.
Superficial Surgical Dissection
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Mobilize the skin flaps. Identify the long saphenous vein and the saphenous
nerve, which run together along the anterior border of the medial malleolus
and pass a sling around these structures, retracting them anteriorly (Fig. 4-
2).
Deep Surgical Dissection
To uncover the point at which the medial malleolus joins the shaft of the
tibia, make a small longitudinal incision in the anterior part of the joint
capsule.
Divide the flexor retinaculum just posterior to the medial malleolus and
identify the tendon of the tibialis posterior muscle, which runs immediately
behind the medial malleolus, grooving the bone (see Fig. 4-2). Retract the
tendon posteriorly to expose the posterior surface of the malleolus (Fig. 4-
3A).
Score the bone longitudinally to ensure correct alignment of the
malleolus during closure. Then, drill and tap the medial malleolus so that it
can be reattached (see Fig. 4-3B).
Using an osteotome or oscillating saw, cut through the medial malleolus
obliquely from top to bottom. Do not complete the osteotomy with a saw;
instead, finish by cracking the osteotomy with an osteotome so as not to
damage the articular cartilage. The osteotomy goes laterally and distally
from the junction of the medial malleolus with the shaft of the tibia to enter
the joint at the angle of the joint.2 Check the position of the cut through the
incision in the anterior joint capsule often to be sure it is accurate (see Fig.
4-3).
Retract the medial malleolus (with its attached deltoid ligaments)
downward and forcibly evert the foot, bringing the dome of the talus and
the articulating surface of the tibia into view (Figs. 4-4 and 4-5). Eversion is
limited because of the intact fibula.
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Figure 4-2. Carefully retract the skin flaps to protect the long saphenous vein
and the accompanying saphenous nerve. Incise the flexor retinaculum and
make a small incision into the anterior joint capsule.
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Figure 4-3. A: Retract the tibialis tendon posteriorly. Drill and tap the medial
malleolus, and score the potential osteotomy site for future alignment. B: The
line of the osteotomy and the score marks for the reattachment of the medial
malleolus.
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Figure 4-4. Retract the osteotomized medial malleolus downward.
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Figure 4-5. Forcefully evert the foot to bring the dome of the talus and the
anterior surface of the tibia into view.
Dangers
The saphenous nerve and the long saphenous vein should be preserved as a
unit, largely to prevent damage to the saphenous nerve leading to neuroma
formation.
The tendon of the tibialis posterior muscle is in particular danger during
this approach, because it lies immediately posterior to the medial malleolus.
Preserve the tendon by releasing the flexor retinaculum and retracting the
tendon posteriorly while performing the osteotomy of the malleolus (see
Figs. 4-2 and 4-3A). The tendons of the flexor hallucis longus and flexor
digitorum longus muscle, together with the posterior neurovascular bundle,
lie more posteriorly and laterally. They are in no danger as long as the
osteotomy is performed carefully (see Figs. 10-2 and 10-4).
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Special Surgical Points
In cases of fracture, the interdigitation of the broken ends of bone prevents
rotation between the two fragments when a screw is inserted and tightened.
No such interdigitation exists in an osteotomy. Therefore, two Kirschner
wires should be inserted prior to insertion of the screw to prevent rotation
when the screw is tightened. After the osteotomy has been stabilized with
the screw, the two Kirschner wires can be removed. Tension band fixation
also may be used. Make sure to align the bones correctly by aligning the
score marks made on the bone before the osteotomy was performed.
How to Enlarge the Approach
The approach usually is not enlarged either distally or proximally.
REFERENCES
1. Koenig F, Schaefer P. Osteoplastic surgical exposure of the ankle joint:
41st report of progress in orthopaedic surgery. Chir. 1929;215:196.
2. Ziran BH, Abidi NA, Scheel MJ. Medial malleolar osteotomy for
exposure of complex talar body fractures. J Orthop Trauma.
2001;15(7):513–518.
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