Anterior Approach to the Ankle

What it exposes. The anterior approach gives direct, extensile access to the tibiotalar joint — the anterior tibial plafond and talar dome — through the interval between the tibialis anterior and extensor hallucis longus (EHL) tendons. It exploits the superficial nature of the anterior ankle and the predictable course of the neurovascular bundle, making it the gold-standard exposure for ankle arthrodesis, total ankle arthroplasty (TAR) and ORIF of pilon and talar fractures. Advantages - Direct visualisation of the anterior plafond and talar dome.

• Extensile — proximally to the tibial shaft, distally to the talar neck.
• Relatively safe when the neurovascular bundle is identified systematically.
• Minimal muscle dissection — a true interval between tendons, no muscle divided.
• Good implant access for arthrodesis hardware and arthroplasty components. Disadvantages - No access to the posterior ankle — a separate posterior approach is needed for posterior pathology.
• Superficial peroneal nerve at risk — its variable course makes injury possible.
• Thin anterior soft-tissue envelope — wound-healing concerns, especially after trauma.
• Limited lateral access — cannot extend to the lateral malleolus through the same incision.

Contraindications - Absolute — active infection overlying the surgical site (unless the procedure is debridement for that infection); severe peripheral vascular disease with compromised healing (ankle-brachial index less than 0.5).

• Relative — poor soft-tissue envelope (previous burns, infection, radiation); morbid obesity (BMI greater than 40); severe osteoporosis; active Charcot arthropathy; unrealistic patient expectations. Position & landmarks. Supine on a radiolucent table, with a small bump under the ipsilateral hip to internally rotate the leg and bring the anterior ankle parallel to the floor, and slight knee flexion (10–15 degrees) to relax the gastrocnemius. The foot hangs free off the end of the table or rests on a sterile bolster so it can be manipulated and imaged. Palpate and mark the tibialis anterior tendon (most medial, prominent with dorsiflexion-inversion), the EHL tendon (central, palpated by extending the hallux), the EDL tendons (lateral), the dorsalis pedis pulse between EHL and EDL, and the malleoli — the ankle joint line runs level with the malleolar tips. Tourniquet. Optional. Many experienced surgeons operate without a tourniquet to assess tissue perfusion throughout and avoid ischaemia-reperfusion; if used, a high-thigh cuff at 250–300 mmHg (about 100 mmHg above systolic), deflated before closure, aiming for less than 120 minutes. Anaesthesia & adjuncts. Spinal/epidural or general anaesthesia; tranexamic acid 1 g IV at induction reduces blood loss by 30–50 percent; a popliteal block gives 12–24 hours of analgesia (but blocks motor function, so early nerve assessment is delayed). Skin prep with chlorhexidine 2% in alcohol circumferentially from toes to below knee; image intensifier positioned for AP and lateral views before draping. Global epidemiology. Symptomatic ankle arthritis is most often post-traumatic (about 70 to 80 percent), in contrast to the hip and knee where primary osteoarthritis predominates — so patients presenting for arthrodesis or TAR are typically younger. Ankle arthrodesis is classically a younger, higher-demand, frequently post-traumatic population; TAR volumes are rising worldwide as implants mature and is offered to lower-demand patients with neutral or correctable alignment. Ankle fractures show a bimodal distribution — younger males (high-energy sport and road trauma) and older women (low-energy fragility injuries).

Work down through the layers directly over EHL, protecting the superficial peroneal nerve at the skin, opening and tagging the extensor retinaculum, then identifying the neurovascular bundle lateral to EHL and retracting it medially together with EHL to expose the capsule.

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Structures at risk, by layer

If the neurovascular bundle is injured - Deep peroneal nerve — neurapraxia: release tension, observe (most recover in 3–6 months), AFO to prevent equinus, EMG at 6–8 weeks if not recovering. Complete transection: primary epineural repair with 8-0 or 9-0 nylon. A gap: tag the ends and refer for delayed nerve grafting within 6 months.

• Anterior tibial artery — obtain proximal and distal control. Partial laceration: primary repair with 6-0 or 7-0 Prolene. Complete transection: assess foot perfusion (capillary refill, posterior tibial pulse, handheld Doppler); if perfusion is adequate, ligate both ends — most patients tolerate this when the posterior tibial and peroneal arteries are intact. If perfusion is inadequate, this is an emergency: immediate vascular surgery consultation for vein-graft reconstruction. Monitor with hourly neurovascular checks for 24 hours (compartment-syndrome risk).
• Superficial peroneal nerve — recognised transection: primary repair or bury the proximal stump in muscle to prevent neuroma. Delayed painful neuroma: desensitisation, scar massage and gabapentin/pregabalin; if refractory, excision and burial of the proximal stump. Extensile options. Extend proximally along the EHL border to reach the distal tibial shaft and anterior tibia; extend distally onto the talar neck and head. You cannot extend laterally to the fibula through this incision — a separate lateral incision is required. Variants include the anteromedial approach (between TA and EHL) and the anterolateral approach (between EHL and EDL) for specific lateral pathology. Closure (layer by layer). Deflate the tourniquet (if used) and achieve haemostasis with bipolar cautery — avoid cautery near the deep peroneal nerve — then irrigate with 3–6 L of saline. A drain is optional for TAR (reduces haematoma) but avoided in arthrodesis (interferes with fusion biology) and trauma (infection risk). Close in layers: capsule with 0 or 1 Vicryl; extensor retinaculum (critical) with 0 Vicryl horizontal mattress using the tagged edges; subcutaneous with 2-0 or 3-0 Vicryl inverted sutures to eliminate dead space; skin with 3-0 or 4-0 Monocryl subcuticular plus a Dermabond sealant. Apply a non-circumferential posterior splint with the ankle in neutral dorsiflexion and the hindfoot neutral, from toes to below the knee. Early complications (less than 6 weeks). Superficial wound infection 2–5 percent; deep infection 1–2 percent (higher in trauma and the immunocompromised); wound dehiscence 2–4 percent; DVT/PE under 1 percent with prophylaxis. Late complications (greater than 6 weeks). Arthrodesis nonunion 5–15 percent overall and up to 40 percent in smokers — confirm with CT, and revise with bone graft and augmented fixation (blade plate or nail). TAR loosing/subsidence 10–15 percent at 10 years — revision arthroplasty if bone stock is good, salvage arthrodesis if not. Post-traumatic arthritis in 25–40 percent after pilon fractures despite anatomic reduction. Adjacent-joint arthritis (subtalar, talonavicular) in 20–30 percent at 10 years after arthrodesis, from increased stress on neighbouring joints.

• Ankle arthrodesis — gold-standard access for end-stage post-traumatic or inflammatory arthritis, failed TAR, deformity correction and talar AVN.
• Pilon fracture ORIF — anatomic articular reduction of the tibial plafond; often combined with a posterolateral approach and staged for soft-tissue management.
• Total ankle arthroplasty — strict midline anterior exposure for instrumentation and component implantation.
• Talar neck and body fractures (Hawkins II–IV) — primary anterior access; a medial malleolar osteotomy may be added for the body.
• Osteochondral lesions of the anterior talar dome (greater than 1.5 cm, uncontained), anterior ankle impingement osteophytes, septic washout, synovectomy for inflammatory arthropathy, and loose-body or hardware removal.

Guidelines, registries and global practice National arthroplasty registries provide the most robust real-world implant-survival data and consistently show better survivorship for modern (third-generation) implants, with aseptic loosening and subsidence dominating revision indications across registries. Outcomes also improve with surgeon and centre volume.

Named-society guidance (side by side) - Surgeon and centre volume — AOFAS (US), BOFAS (UK) and other national foot-and-ankle societies recommend that TAR be performed by fellowship-trained foot-and-ankle surgeons in higher-volume centres, with registry participation for surveillance.

• Antibiotic prophylaxis (AAOS / NICE / WHO aligned) — first-generation cephalosporin (cefazolin 2 g IV, 3 g if over 120 kg) within 60 minutes of incision; clindamycin or vancomycin for severe beta-lactam allergy or MRSA risk.
• VTE prophylaxis (AAOS / NICE / ACCP) — mechanical prophylaxis and early mobilisation for all; pharmacological prophylaxis individualised. Foot-and-ankle societies note that routine chemical prophylaxis for isolated below-knee immobilisation is less strongly supported than for hip and knee arthroplasty — guidance genuinely differs and should be risk-stratified.
• Modifiable risk optimisation (universal) — smoking cessation before elective arthrodesis (nonunion rates rise markedly in smokers) and glycaemic optimisation (HbA1c under 7 to 8 percent) before elective surgery. Representative rehabilitation protocols - Arthrodesis — strict non-weight-bearing for 6 to 8 weeks, then protected weight-bearing in a boot, progressing once union is confirmed radiologically (often around 12 weeks).
• Total ankle replacement — implant- and surgeon-dependent, from a short non-weight-bearing period to early weight-bearing as tolerated in a boot, with physiotherapy in the early weeks.
• Fracture ORIF — dictated by fracture configuration and fixation stability; talar and high-energy pilon injuries are kept non-weight-bearing longer (8 to 12 weeks) to mitigate AVN and reduction loss.