Place a bump under the ipsilateral hip to maintain neutral rotation of the leg

Use a calf or thigh tourniquet (depending on the procedure)

Partial exsanguination can allow better visualization of the neurovascular bundle

Make a 15-cm incision over the anterior ankle

• Begin 10 cm proximal to the joint, lateral to the palpable TA tendon (Fig. 8-37)

• Cross the joint midway between the malleoli

• Dissect carefully in the distal aspect of the incision to avoid injury to the superficial peroneal nerve branches

• For total ankle arthroplasty, the interval between the TA and EHL is typically used; the interval between the EHL and EDL allows for direct visualization of the bundle and medial retraction of the neurovascular structures

Incise the deep fascia of the leg in line with the skin incision (Fig. 8-38)

• Incise the extensor retinaculum over the EHL, maintaining the sheath for the TA

• Retract the EHL laterally and incise the posterior aspect of the EHL sheath to visualize the ankle capsule (Fig. 8-39)

• The anterior tibial artery and deep peroneal nerve should be identified and protected lateral to this interval

Incise the capsule of the ankle joint in line with the incision (Fig. 8-42)

Expose the full width of the ankle joint by subperiosteal and subcapsular dissection of the tibia and talus (Fig. 8-43)

Retractors should be placed on the periosteal layer to avoid excessive pressure on the skin or neurovascular bundle

Attempt to close the ankle capsule prior to layered closure; the extensor retinaculum should also be reapproximated to prevent bow-stringing of tendons

Supine with a sandbag underneath the ipsilateral bump

A 12- to 15-cm incision is made along the anterolateral aspect of the ankle, slightly anterior to the anterior border of the fibula; curve the incision inferiorly, crossing the ankle joint 2 cm medial to the tip of the lateral malleolus (Fig. 8-45)

Incise the fascia in line with the skin incision (Fig. 8-46)

Carefully dissect and protect the medial branch of dorsal cutaneous nerve (superficial peroneal nerve) as it crosses the field

Divide the superior and inferior extensor retinaculum (Fig. 8-49)

• Identify the peroneus tertius and EDL and approach the tibia just lateral to these tendons

• Medial retraction of the extensor muscle group exposes the anterior aspect of the distal tibia and the anterior ankle joint capsule

Proximal extension

• Proximal extension can be performed to explore the anterior compartment

Distal extension

• Distal extension can be used to expose the sinus tarsi, CC joint, and tarsometatarsal (TMT) joint on the lateral half of the foot

The medial branch of dorsal cutaneous nerve (superficial peroneal nerve)

Extensor muscles fall back into place

• Reapproximate the extensor retinaculum to prevent bow-stringing

Standard two-layer closure of skin

Prone position

For acute Achilles tendon ruptures

• A longitudinal incision is made 1 cm medial to the Achilles tendon to improve soft tissue coverage over the tendon after repair (Fig. 8-51); the deep fascia over the Achilles tendon is incised medial to the tendon
In an alternative approach an incision is made just lateral to the Achilles tendon (Fig. 8-52)

In patients with chronic tendinopathy, a midline posterior incision over the tendon is typically used to allow access to the calcaneus (Fig. 8-53)

• The paratenon is incised in the midline so that the paratenon can be closed after the reconstruction

The Achilles tendon is exposed

The deep fascia over the FHL can be incised in the midline to expose the FHL, which passes from lateral to medial if an FHL transfer is planned

The paratenon should be reapproximated to ensure smooth gliding of the Achilles tendon whenever possible

Supine

• Flexion of the hip and knee; place the lateral side of the affected ankle on the opposite knee

• Lateral position with the affected leg nearest the table; flexion of the opposite knee moves its ankle out of the way

• Placing a bump under the contralateral hip allows maximal external rotation of the hip; the retractor should be placed posterior to the FHL to protect the bundle

An 8- to 10-cm incision should be made midway between the medial malleolus and Achilles tendon at the level of the ankle (Fig. 8-55)

See Figs. 8-56 and 8-57

Using blunt dissection, identify the fat plane between the Achilles tendon and FHL (Fig. 8-58)

Retract the Achilles tendon and retrotendinous fat laterally, which exposes the fascia of the deeper flexor compartment (Fig. 8-59)

Identify the fascial plane in the anterior flap that covers the tendons of the flexor retinaculum

• Incise this deep fascia along the length of the incision, and one by one expose and identify the contents of the flexor retinaculum

• The FHL tendon protects the more anterior and medial tibial nerve and the posterior tibial artery/vein

• This procedure facilitates medial retraction of the structures, aiding exposure of the posterior malleolus and the posterior part of the ankle joint

FHL tendon, tibial nerve, and posterior tibial artery/vein

Do not attempt to close the flexor retinaculum

Standard two-layered closure of subcutaneous tissue and skin is performed

Supine with a sandbag under the ipsilateral hip to maintain internal rotation of the ankle to allow access to the fibula

A lateral incision should be centered over the fibula along the distal 8 to 10 cm

• If exposure of the subtalar joint is needed with this incision, the incision may be extended anteriorly toward the base of the fourth metatarsal

The skin and the subcutaneous tissue are incised

The periosteum over the fibula is incised and the fibula is osteotomized obliquely (superolateral to inferomedial), ending approximately 2 cm above the ankle joint (Fig. 8-64); care should be taken not to osteotomize the fibula too proximally, which could disrupt the syndesmotic ligament; the planned location of the osteotomy should be marked provisionally with a Kirschner wire and confirmed on C-arm imaging; a sagittal saw can be used to perform the osteotomy, with cold irrigation to prevent thermal necrosis

The superficial peroneal nerve should be mobilized anteriorly in the proximal aspect of the incision (Fig. 8-65)

• A retractor should be placed posteriorly to protect the peroneal tendons (Fig. 8-66)

The anterior and posterior capsule and ligaments are incised along the fibula, maintaining a sleeve of soft tissue for repair; the distal fibula is hinged distally, maintaining the calcaneofibular ligament to preserve vascularity of the distal fragment

The ankle joint is exposed with inversion of the hind foot; the subtalar joint can be easily accessed via this approach after the distal fibula is mobilized inferiorly (Fig. 8-67)

At the conclusion of the procedure, the fibula is reduced and ORIF is performed to maintain the lateral buttress of the ankle; capsule/ligaments are then repaired in side-to-side fashion

Superficial peroneal nerve and peroneal tendons

Supine; a sandbag or bump is placed under the opposite buttock (Fig. 8-68)

Provides a good view of the medial malleolar fracture

Provides visualization of the anteromedial ankle joint

Provides visualization of the anteromedial dome of the talus

A 10-cm curved incision (longitudinal) is centered over the medial malleolus

Dissect the anterior and posterior flaps

Identify and preserve the great saphenous vein and the saphenous nerve (best preserved together; Fig. 8-70)

Anterior third of the medial malleolus

Preserve soft tissue attachments to the bony fragment

A small incision in the anterior capsule aids in direct visualization of the fracture reduction (Fig. 8-72)

Split the fibers of the deltoid longitudinally, which ensures better purchase of wires and screws and provides soft tissue coverage over hardware

Saphenous nerve

Great saphenous vein

Standard two-layer skin closure (interrupted/continuous)

A direct straight incision is centered over the medial malleolus (Fig. 8-73)

This incision allows anterior access to the ankle joint for visualization of the fracture reduction

Supine

• Place a bump under the opposite buttock to externally rotate the operative extremity

A 10- to 12-cm longitudinal incision is centered over the tip of the medial malleolus (curve the lower half of the incision forward toward the mid part of the foot; Fig. 8-74)

• Make a straight incision (see Fig. 8-72)

Raise the anterior and posterior flaps by blunt dissection, carefully protecting the great saphenous vein and the saphenous nerve under the anterior flap (Fig. 8-75)

Expose the borders of the medial malleolus (Fig. 8-76)

• Incise the ankle joint capsule anterior to the medial malleolus and carefully divide the flexor retinaculum from the posterior border of the malleolus after identifying the tibialis posterior tendon

• Place the retractor behind the medial malleolus to protect the posterior tibial tendon

Leave the attachment of the deltoid ligaments intact

• Osteotomize the medial malleolus (Fig. 8-77)

• First drill and tap the medial malleolus and then make an oblique cut from proximal-medial to distal-lateral; reflect the medial malleolus inferiorly

• This procedure exposes the dome of the talus and the articulating surface of the tibia into view (eversion of the foot improves the exposure further; Fig. 8-78)

Saphenous nerve and great saphenous vein

Tibialis posterior tendon

Secure the medial malleolus osteotomy with screws and modified tension band wiring

Reattach the flexor retinaculum to the posterior border of the medial malleolus

Standard two-layer closure of subcutaneous tissue and skin is performed

Semilateral with an ipsilateral sandbag under the hip or lateral decubitus position

An oblique incision is made beginning at the posterior border of the fibula, 7 to 8 cm proximal to the tip, and coursing distally toward the sinus tarsi, crossing the distal fibula between the approximate origins of the calcaneofibular ligament (CFL) and anterior talofibular ligament (ATFL) (Fig. 8-83)

• The skin and subcutaneous tissue are incised

The superficial peroneal nerve (SPN) and sural nerve in the proximal incision and the SPN in the distal incision; the peroneal tendons should be carefully protected during this approach

If access to the peroneal tendons and posterior fibula/peroneal retinaculum is necessary, extend the proximal incision as needed along the course of the peroneal tendons; the tendon sheath is incised to inspect the peroneal tendons

• For open excision of an os trigonum, the peroneal tendon sheath can be incised to access the posterior ankle

Distally the inferior extensor retinaculum is exposed and the anterior talofibular ligament and the CFL are repaired for instability procedures

• The distal fibula is also exposed in the central portion of the incision

• The incision may be extended distally to explore the peroneal tendons distal to the lateral malleolus