- Indications: ORIF fractures of the medial malleolus
- Position: Supine on the operating table. Tourniquet with exsanguination of the leg
- Landmark: Medial malleolus palpable distal end tibia
- Incision: One main approach is used but two alternative incisions (anterior and posterior approaches) are described.
(1) The anterior approach consists of a longitudinal curved incision on the medial aspect of the ankle with its midpoint just anterior to the tip of the medial malleolus. The incision begins 5 cm proximal to the medial malleolus and then curves forwards to end anteriorly and distal to the malleolus. The incision should not cross the most prominent portion of the malleolus. The incision permits inspection of the anteromedial ankle joint and the anteromedial part of the dome of the talus.
(2) The posterior approach involves a 10-cm incision on the medial aspect of the ankle, beginning 5 cm above the ankle on the posterior border of the tibia, curving the incision downwards following the posterior border of the medial malleolus. The incision is curved forwards below the medial malleolus to end 5 cm distal to it. The incision allows visualisation of the posterior margin of the tibia.
Alternatively make a 10cm longitudinal incision on the medial aspect of the ankle joint, centered on the tip of the medial malleolus. Begin the incision over the medial surface of the tibia. Below the malleolus, curve it forward onto the medial side of the middle part of the foot.
- Internervous plane: No true internervous plane exists but the approach is safe because the incision cuts down onto subcutaneous bone.
- Superficial surgical dissection: Skin flaps are mobilized. Identify and preserve the saphenous nerve and long saphenous vein, which lie anterior to the medial malleolus.
- Deep surgical dissection: The periosteum of the medial malleolus is incised longitudinally. With an anterior approach a small incision is made in the anterior capsule of the ankle joint so that the joint surfaces can be visualized.
- With a posterior approach the retinaculum behind the medial malleolus is incised. The tibialis posterior (TP) tendon is retracted anteriorly whilst the remaining structures are freed up and retracted posteriorly.
Structures at risk
- Anteriorly the saphenous nerve, which, if cut, may form a painful neuroma and cause numbness over the medial side of the dorsum of the foot.
- Posteriorly all structures that run behind the medial malleolus (TP, FDL posterior tibial artery and vein, tibial nerve and FHL) are at risk.
Anatomy of the medial side of the ankle
- The posterior neurovascular bundle runs behind the medial malleolus between the tendons of FDL and FHL.
- The posterior tibial artery passes behind FDL before entering the sole of the foot where it divides into medial and lateral plantar arteries.
- Tall Doctors Are Never Happy
- Tibialis Posterior
- Flexor Digitorum Longus
- Artery Nerve
- Flexor Hallucis longus
Figure 1. Use a 10cm longitudinal incision over the medial aspect of the ankle joint,with its centre over the tip of the medial malleolus.The saphenous vein and nerve should be preserved to reduce the chance of neuroma formation and troublesome bleeding and possible wound haematoma.