Introduction Provides exposure to posterior malleolus posterior ankle joint lateral or posterior fibula peroneal tendons and their retinacula Internervous plane Internervous plane flexor hallucis longus (tibial nerve) peroneal muscles (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 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 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