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