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Introduction
  • Provides exposure to
    • posterior malleolus
    • posterior ankle joint
    • lateral or posterior fibula
    • peroneal tendons and their retinacula
  The patient is placed either in a prone position, in lateral decubitus, or supine with a large bump under the ipsilateral hip.
Internervous plane
  • Internervous plane
    • flexor hallucis longus  (tibial nerve)
    • peroneal muscles  (superficial peroneal nerve)
  Internervous plan is between the flexor hallucis longus (tibial nerve) and the peroneal musculature (superficial peroneal nerve).
Preparation
  • Anesthesia
    • general
    • spinal
  • Position
    • prone
    • lateral
    • supine
      • large bump needed under ipsilateral hip to allow for access
  • Tourniquet
    • if used, exsanguinate leg prior to tourniquet elevation
  incision made along posterior border of fibula, typically centered about fibula fracture.
Approach
  • Incision
    • incision made along posterior border of fibula
      • typically centered about fibula fracture (if present)
      • need to extend almost to tip of fibula to allow deeper access
  • Superficial dissection
    • disect down to fibula
      • access to fibula is done with superficial dissection down to lateral or posterolateral fibula (subcutaneous) 
      • with proximal dissection, care must be taken to minimize risk to the superficial peroneal nerve
  • Deep dissection
    • access fibula
      • access to fibula is obtained with posterior retraction of the peroneus longus and brevis muscles/tendons
    • access the posterior malleolus
      • access to posterior malleolus is obtained with anterior retraction of peroneus longus and brevis muscles/tendons 
      • identify interval between FHL and peroneal tendons and bluntly split areolar tissue
      • elevate the FHL off the distal posterior tibia 
      • retract the FHL medially to allow access to the posterior malleolus
      • care must be taken not to release the PITFL off the fragment
        • devitalizes posterior malleolar fragment
        • can lead to post-fixation syndesmotic instability
  Superficial dissection is made down to deep fascia; the fibula can be accessed anteriorly to the peroneals, and the tibia is accessed posterior to the peroneals.

Deep dissection is carried posterior to the peroneus longus and brevis, and anterior to the FHL, which is retracted medially.
The flexor hallucis longus can be released from the posterior fibula if increased access is required.

The periosteum can be incised to allow access for subperiosteal elevation; interposing periosteum is removed from any fracture site.
The posterior tibia is exposed, with access to all of the posterior tibia except the posteromedial component.  The peroneals are retracted anteriorly and the FHL is retracted posteriorly.
    Clinical Images
   
Dangers
  • Superficial peroneal nerve 
    • at risk with superficial dissection proximally
  • Posterior tibial vessels
    • should remain protected behind FHL
  • Tibial nerve
    • should remain protected behind FHL
  • Sural nerve
    • at risk with further dissection distally
 

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