Medial Approach to the Talus and Navicular

What it exposes. The medial utility incision gives direct access to the talar neck, the medial talar body and dome, the talonavicular joint and the navicular, with the option of a medial malleolar osteotomy to reach the medial talar dome. It is the workhorse medial exposure for talar neck ORIF, medial talar dome osteochondral lesions, talonavicular arthrodesis and navicular fracture fixation. Why medial. Displaced talar neck fractures commonly have medial comminution and a varus deformity that a lateral approach alone cannot fully control; the medial incision lets you see and buttress the medial neck directly. It is frequently combined with a lateral (Ollier) or anterolateral approach for complete exposure of comminuted patterns. Position & landmarks. Supine with a bump under the ipsilateral hip to internally rotate the foot, the knee slightly flexed (20 to 30 degrees), a tourniquet high on the thigh or below the knee, and the C-arm brought in from the contralateral side. Palpate and mark the medial malleolus, the navicular tuberosity, the tibialis anterior and posterior tibial tendons (the two borders of the incision), and the saphenous vein just anterior to the malleolus — the incision runs midway between the two tendons, from 2 cm proximal to the malleolar tip to the navicular tuberosity.

Work down through the layers between tibialis anterior and tibialis posterior, protecting the saphenous vein and nerve superficially and the artery of the tarsal canal deep, then open the capsule to display the talar neck, body and navicular.

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Structures at risk, by layer

Extensile options. Extend proximally along the medial border of the tibia (2 to 3 cm) to reach the medial tibial plafond and distal tibial metaphysis — useful for combined ankle and talar pathology or medial malleolar fractures. Extend distally along the medial border of the foot toward the first metatarsal base to expose the medial cuneiform and first tarsometatarsal joint for extended talonavicular fusion or midfoot reconstruction, protecting the posterior tibial insertion and medial plantar nerve branches. For comminuted talar neck fractures, combine with a lateral (Ollier or Kocher) or anterolateral approach for complete exposure and varus control. Closure. Closure is layered — repair the capsule and any detached deltoid fibres with absorbable suture, close the fascia and subcutaneous tissue, and close skin. Fix a medial malleolar osteotomy anatomically with two parallel 3.5 mm or 4.0 mm partially threaded cancellous screws directed perpendicular to the osteotomy plane and engaging the far tibial cortex, using washers in osteoporotic bone, and confirm reduction fluoroscopically with no step-off or gap. Apply a posterior splint or boot with the ankle neutral; patients are typically non-weight bearing for 6 to 12 weeks (longer for talar neck fractures and fusions), with serial radiographs to monitor healing and talar vascularity (Hawkins sign).

• Talar neck ORIF — direct visualisation and reduction of medial neck comminution with medial buttress or lag screws; usually combined with a lateral approach for varus control.
• Medial talar dome OCD — microfracture, osteochondral autograft transfer (OATS) or fragment fixation, via a medial malleolar osteotomy.
• Talonavicular arthrodesis — isolated or as part of a triple arthrodesis; cartilage denudation, bone grafting and screw or plate fixation.
• Navicular fracture ORIF — body and tuberosity fractures, protecting the posterior tibial insertion.
• Medial talar body fractures and talar head or neck pathology — including tumour resection and bone grafting of cystic lesions.