Anterolateral Approach to Ankle & Hindfoot

Aims

  • Plane between extensors & peroneal

Indications

  • Exposure of
    • Ankle joint
    • TN joint
    • CC joint
    • TC joint
  • Arthrodesis
    • Ankle
    • Triple
    • Pantalar
  • Reduction talus or excision

Position

  • supine
  • large sandbag under buttock
  • tournique
  • prep & drape

Landmarks

  • Lateral malleolus
  • Base of 5th metatarsal

Incision

  • 15 cm slightly curved longitudinal incision over anterolateral aspect of ankle (2 cm anterior to anterior border of fibula)
  • Start: 5 cm proximal to ankle joint
  • End: base of 4th metatarsal

Internervous Plane

  • Peroneal muscles
    • Superficial peroneal nerves
  • Extensor muscles
    • Deep peroneal nerves

Superficial Dissection

  • Incise fascia (no skin flaps)
    • Taking care to identify & preserve
      • Dorsal cutaneous branches of superficial peroneal nerve
  • Incise superior & inferior extensor retinaculum
  • Identify peroneus tertius & EDL
    • In upper half of wound
      • Incise down to bone just lateral to these muscles

Deep Dissection

  • Retract extensor muscles medially to expose the anterior aspect of the distal tibia & ankle joint capsule
  • Distally
    • Identify EDB at origin from calcaneus
    • Detach by sharp dissection
    • Cauterise branches of lateral tarsal artery to prevent haematoma formation
    • Reflect EDB distally & medially
  • Identify the capsules of CC & TN joints
  • Identify the fat in the sinus tarsi (laterally)
    • Reflect it distally expose the subtalar joint

Dangers

  • Nerves
    • Deep peroneal nerve
  • Vessels
    • Anterior tibial artery