Surgical Approaches to the Ankle

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- See:
    - Anterolateral Approach
    - Kocher approach:
    - Posterolateral Approach to the Ankle: (Gatellier and Chastang)
    - Medial Approach to the Ankle;

- Anterior Approach:
    - allows acces to medial malleolus & medial articular facet of body of talus
    - it is used for   ankle fusion, anterior lip fractures of tibia, for placement of
          percutaneous screws, & for arthrotomy of joint to drain infection or
          remove loose bodies,
    - anterior approach is centered between the malleoli;
    - cutaneous branches of the superficial peroneal nerve should be
          identified and protected;
    - extensor retinaculum & location of anterior neurovascular bundle is identified;
    - usually the approach is developed thru EHL & EDL tendons;
            - retinaculum is split & plane of dissection is either between EDL & EHL
                  tendons w/ medial retraction of EHL & neurovascular bundle;
    - alternatively approach is made medial to tibialis anterior tendon w/ lateral
            retraction of both tibialis anterior tendon and neurovascular bundle;
            - neurovascular bundle is retracted laterally with the extensor tendons
                  of toes, and tibialis anterior tendon is retracted medially;
    - ankle capsule and the joint are then exposed;

- Lateral Approach to the Ankle;
    - used for treatment of lateral collateral ligament injuries, fractures of the fibula ect;
    - incision is either anterolateral or posterolateral to subQ lateral border of fibula,
            and can be curved distally around tip of fibula;
    - short saphenous vein and sural nerve lie posterior & superficial peroneal
            nerve anterior to this incision;
    - proximally dissection proceeds between peroneus tertius & peroneus longus
            and brevis posteriorly;
    - posterior tibia can be exposed by dissection behind and around
          peroneal tendons;
    - it is usually not necessary to remove these tendons from their sheath
          or divide the retinaculuum;

- Posterior Approach to the Ankle:
    - allows acces to distal end of tibia, posterior aspect of ankle joint, posterior
          end of talus, subtalar joint, & posterior part of superior surface of calcaneus;
    - position: pt is prone;
    - make a 12 cm incision along the posteolateral border of the tendocal-
          caneus down to the insertion of the tendon on the calcaneus;
          - alternatively make incision is made on either side of Achilles tendon;
    - retinaculum and tendon sheath are not entered;
    - dissect between peroneal muscles & FHL;
    - if dissection is kept lateral to FHL tendon, posterior tibial vessels
          & tibial nerve, will not be damaged, since this tendon protects them;
    - expose posterior surface of the tibia and the joint capsule;

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