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Introduction
  • Provides exposure to
    • distal tibia
    • ankle joint
    • talar dome
  • Indications include
    • ORIF of pilon fractures
    • ankle arthrodesis
    • total ankle arthroplasty
    • I&D of infected ankles
    • removal of loose bodies
 
Intermuscular plane
  • Intermuscular plane 
    • extensor hallucis longus  (deep peroneal nerve)
    • extensor digitorum longus  (deep peroneal nerve)
 
Preparation
  • Anesthesia
    • general
    • spinal
  • Position
    • supine
  • Tourniquet
    • can elect for partial exsanguination (can allow better visualization of neurovascular bundle)
 
Approach
  • Incision 
    • make15 cm incision over anterior ankle
      • begin 10 cm proximal to joint
      • cross joint midway between malleoli
      • stay superficial to avoid injury to superficial peroneal nerve branches
  • Superficial dissection 
    • incise deep fascia of leg in line with skin incision
    • incise extensor retinaculum
    • find plane between EDL and EHL a few cm above joint
    • identify neurovascular bundle
      • mobilizing tibialis anterior artery and deep peroneal nerve 
    • retract EHL and neurovascular bundle medially
    • retract EDL laterally
    • remaining joint capsule tissue cleared to expose anterior ankle joint
  • Deep dissection
    • incise capsule of ankle joint in line with incision
    • expose full width of ankle joint by subperiosteal and subcapsular dissection of the tibia and talus
  • Medial variation
    • can make 15cm incision anterior to medial malleolus
    • incise deep fascia to medial side of tibialis anterior tendon
    • retract tibialis anterior laterally to expose ankle joint
 






Dangers
  • Superficial peroneal nerve cutaneous branches
    • at greatest danger during skin incision
  • Neurovascular bundle (deep peroneal nerve and anterior tibial artery)
    • above joint runs between EDL and EHL
    • crosses behind EHL at level of the joint
 

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