Foot and Ankle

Approaches

 

Ankle

- anterior

- anterolateral

- posterolateral

 

Hindfoot

- lateral

- Ollier's

 

Anterior approach to Ankle

 

Concept

 

Between EHL and EDL

 

Indications 

- drainage of ankle joint

- ankle arthrodesis

- ORIF tibial plafond

- removal of loose bodies

 

Approach

 

Position 

- supine / tourniquet

 

Incision 

- 15cm longitudinal incision over anterior aspect of ankle joint midway between malleolus 

 

Internervous plane

- no true internervous plane

- EHL / EDL define a clear intermuscular plane with anterior tibial vessels / deep peroneal nerve between them

 

Superficial dissection

- incise extensor retinaculum

- dissection in intermuscular plane between EHL / EDL a few cm above ankle joint

- identify anterior tibial vessels / deep peroneal nerve medial to EHL tendon

- retract EHL / NV bundle medially

 

Deep dissection

- incise anterior capsule ankle joint

- detach capsule from tibia or talus by sharp dissection

 

Dangers

- superficial peroneal nerve

- anterior tibial vessels / deep peroneal nerve 

 

Extensile measures 

- extended proximally to expose anterior compartment & proximal tibia between Tibia and T anteror

- distal extension rarely required onto dorsum of foot

 

Anterolateral approach to ankle and hind foot

 

Concept

 

Between Peroneus Tertius and Brevis

Elevate EDB

 

Indications 

- exposes AKJ / STJ / CCJ / STJ

- ankle fusions

- triple arthrodesis & pantalar arthrodesis

- talus excision

- open reduction of talar dislocations

 

Approach

 

Position

- supine with sandbag under hip to IR leg

 

Incision 

- 15cm curved incision on anterolateral aspect of ankle joint.

- begin 5cm proximal to ankle joint 

- 2cm anterior to fibular border

- crossing joint 2cm medial to lateral malleolus tip 

- end over base of 4th MT

 

Internervous plane 

- between peroneus tertius (DPN) and peroneus brevis (SPN)

 

Superficial dissection 

- identify dorsal cutaneous branches of SPN

- incise superior (tibia to fibula) / inferior extensor retinaculum (calcaneum to MM and fascia)

- incise down to bone lateral to peroneus tertius / EDL

 

Deep dissection 

- retract peroneus tertius / EDL medially to expose anterior ankle joint

- distally, expose origin of EDB on dorsum of calcaneus 

- detach EDB by sharp dissection reflecting origin distally and medial

- this will involve division branches of lateral tarsal artery

- identify dorsal capsules of TN / Calcaneo-cuboid joints.

- mobilize fat pad in sinus tarsi to identify subtalar joint (preserve fat pad )

- open joints by forcefully plantar flexing and inverting foot 

 

Dangers

- DPN

- Anterior tibial artery

 

Posterolateral approach Ankle Joint

 

Concept

 

Between Peroneals and T achilles

 

Indications

- treat conditions of posterior aspect of tibia and ankle joint

- ORIF posterior malleolus 

- removal benign tumors

- FHL tendonitis / Os trigonum

 

Approach

 

Position 

- patient prone

 

Incision 

- 10cm longitudinal incision 

- halfway between posterior border of lateral malleolus and lateral border of T achilles

 

Internervous plane

- between PL and FHL tendon

 

Superficial dissection

- mobilize skin flaps

- identify peroneal tendons around back of lateral malleolus

- open peroneal retinaculum to release tendons

- retract them anteriorly to expose FHL muscle at level of ankle joint

- FHL is most lateral of deep calf flexors and is still muscular at this level

 

Deep dissection

- enhance exposure by making a longitudinal incision through lateral fibres of FHL origin on fibula

- retract FHL medially to expose posterior tibia & ankle joint

 

Dangers

- sural nerve and short saphenous vein

 

Extensile measures 

- limited proximally by soleus

 

Lateral approach to STJ

 

Concept

 

Posterior / inferior to peroneal tendons

 

Indications 

- STJ fusion

- ORIF calcaneal fracture

 

Approach

 

Position 

- supine with sandbag under buttock to IR leg and bring hind foot forward

- place a support on opposite iliac crest, tilt table 20 - 30o away from surgeon to improve access

- or put patient on side

 

Incision 

- along line of peroneal tendons

- 10-13cm curved incision, beginning 4cm above tip of lateral malleolus on posterior border of fibula

- follow posterior border of fibula to tip lateral malleolus 

- curve incision forward, passing over peroneal tubercle

 

No Internervous plane

 

Superficial dissection

- avoid sural nerve and short saphenous vein behind lateral malleolus

- sural nerve posterior, superficial peroneal nerve anterior

- incise the separate sheaths of peroneus longus / brevis

- mobilize tendons anteriorly over distal end of fibula.

- ligaments of peroneal retinaculum must be repaired at the end to prevent anterior subluxation of tendons

 

Deep dissection

- identify and divide calcaneofibular ligament (part of STJ capsule)

- open STJ transversely to expose posterior facet of subtalar joint

- divide interosseous ligament for full exposure subtalar joint

 

Dangers

- sural nerve, short saphenous vein

 

Lateral approach to hind foot (Olliers)

 

Concept

 

Incision from lateral malleolus to TNJ

Between P. tertius and Peroneals

 

Indications 

- exposes AKJ / STJ / CCJ / TNJ

- triple arthrodesis

- individual joint arthrodesis 

- excision CN bar

 

Approach

 

Position 

- supine with sandbag under hip to IR leg and bring hind foot forward

 

Incision 

- curved incision 

- commencing distal to lateral malleolus and slightly posterior to it

- continue distally along lateral side of hind foot & over the sinus tarsi 

- curve medially ending over the dorsum of TNJ

 

Internervous plane 

- between peroneal tendons (SPN) and peroneus tertius (DPN)

 

Superficial dissection 

- do not mobilize skin flaps widely as large skin flaps may necrose

- identify and protect SPN

- incise deep fascia along incision

 

Danger 

- Peroneus tertius / EDL tendons cross distal end of wound and retract medially

 

Deep dissection

- EDL and tertius medially, peroneals inferior

- mobilize fat pad in sinus tarsi to identify subtalar joint (preserve fat pad)

- expose origin of EDB on dorsum of calcaneus

- detach by sharp dissection reflecting origin distally and medial

- this will involve division branches of lateral tarsal artery

- identify dorsal capsules of TN medially / Calcaneo-cuboid joints laterally

- open joints by forcefully plantar flexing and inverting foot 

- identify and open posterior talo-calcaneal joint / invert foot

 

Dangers

- skin flaps notorious for producing necrosis

- avoid stripping / retraction and sharp incision curves

- branches of SPN

 

Extensile measures 

 

Proximal 

- continue incision along posterior border of fibula 

- dissect in plane between peroneal & flexor tendons 

- exposing length of fibula (rarely required)

 

Posterior & proximal 

- reach Achilles tendon