Anterior Approach to Ankle Joint

The anterior approach to ankle joint provides excellent exposure of the ankle joint for joint arthrodesis. The usage of this approach depends on the condition of the skin and the surgical technique to be used.

The ankle anterior approach indications include the following:

1. Open reduction and internal fixation of pilon fractures.
2. Ankle arthrodesis.
3. Total ankle arthroplasty.
4. Drainage of infections in the ankle joint.
5. Removal of loose bodies.

Position of the Patient

The patient is placed supine on the operating table.

Landmarks and Incision

Landmarks:

• Medial malleolus: subcutaneous, distal end of the medial surface of the tibia.
• Lateral malleolus: subcutaneous distal end of the fibula.

Incision:

• Make a 15-cm longitudinal incision over the anterior aspect of the ankle joint.
• Begin about 10 cm proximal to the joint and extend the incision so that it crosses the joint about midway between the malleoli, ending on the dorsum of the foot. Take great care to cut only the skin; the anterior neurovascular bundle and branches of the superficial peroneal nerve cross the ankle joint very close to the line of the skin incision.
• Alternatively, make a 15-cm longitudinal incision with its center overlying the anterior aspect of the medial malleolus.

Internervous plane

• The Anterior Approach to Ankle joint has no true internervous plane.
• The extensor hallucis longus and extensor digitorum longus muscles define a clear intermuscular plane. Both muscles are supplied by the deep peroneal nerve, but the plane may be used because both receive their nerve supplies well proximal to the level of the dissection.
• The plane must be used with great caution, however, because it contains the neurovascular bundle distal to the ankle.

Superficial dissection

• Incise the deep fascia of the leg in line with the skin incision, cutting through the extensor retinaculum.
• Find the plane between the extensor hallucis longus and extensor digitorum longus muscles a few centimeters above the ankle joint, and identify the neurovascular bundle (the anterior tibial artery and the deep peroneal nerve) just medial to the tendon of the extensor hallucis longus.
• Trace the bundle distally until it crosses the front of the ankle joint behind the tendon of the extensor hallucis longus.
• Retract the tendon of the extensor hallucis longus medially, together with the neurovascular bundle.
• Retract the tendon of the extensor digitorum longus laterally. The tendons become mobile after the retinaculum has been cut, but the neurovascular bundle adheres to the underlying tissues and requires mobilization.
• Alternatively, in pillion fractures, incise the deep fascia to the medial side of the tibialis anterior tendon, and expose the underlying surface of the tibia together with the anteromedial ankle joint capsule.

Deep dissection

• For arthrodesis surgery using ankle anterior approach, incise the remaining soft tissues longitudinally to expose the anterior surface of the distal tibia.
• Continue incising down to the ankle joint, then cut through its anterior capsule. Expose the full width of the ankle joint by detaching the anterior ankle capsule from the tibia or the talus by sharp dissection. Some periosteal stripping of the distal tibia may be required.
• Although the periosteal layer usually is thick and easy to define, the plane may be obliterated in cases of infection; the periosteum then must be detached piecemeal by sharp dissection.
• If the approach is used in fracture surgery, take great care to preserve as much soft-tissue attachments to bone as possible.
• Meticulous preoperative planning will allow smaller, precise incisions with consequent reduction in soft tissue damage.

Approach Extension

• The anterior approach to ankle joint can be extended proximally to expose the structures in the anterior compartment.
• To expose the proximal tibia, use the plane between the tibia and the tibialis anterior muscle.
• Distal extension to the dorsum of the foot is possible, but rarely is required.

Dangers

The structures at risk during the ankle anterior approach include:

1. Superficial peroneal nerve cutaneous branches: it’s at greatest danger during skin incision.
2. Neurovascular bundle (deep peroneal nerve and anterior tibial artery): above joint runs between extensor digitorum longus and extensor hallucis longus and crosses behind extensor hallucis longus at level of the joint.

References & More

1. Surgical Exposures in Orthopaedics book – 4th Edition
2. Campbel’s Operative Orthopaedics book 12th
3. Dekker RG 2nd, Kadakia AR. Anterior Approach for Ankle Arthrodesis. JBJS Essent Surg Tech. 2017 Apr 12;7(2):e10. doi: 10.2106/JBJS.ST.15.00066. PMID: 30233945; PMCID: PMC6132605.
4. World J Orthop. 2014 Jan 18;5(1):1-5, Foot Ankle Int. 2011 Oct;32(10):940-7, and Foot Ankle Int. 2009 Jul;30(7):631-9