Surgical Approaches to the Ankle, Hindfoot and Foot

Useful for: total ankle replacement, open ankle arthrodesis, anterior plafond work, anterior osteophytes and anterior ankle exposure.

1. Supine position, foot at end of table, tourniquet if used, fluoroscopy checked.
2. Mark tibialis anterior, EHL, EDL, superficial peroneal branches if visible, and the planned incision.
3. Use a longitudinal anterior incision centred over the ankle joint and planned implant or fusion surface.
4. Develop full-thickness flaps; avoid thin undermined skin.
5. Identify the interval. Commonly work between tibialis anterior and EHL or between EHL and EDL according to target.
6. Protect the deep peroneal nerve and dorsalis pedis artery in the deep anterior interval.
7. Expose the capsule, open the joint and perform the planned preparation, reduction, fusion or arthroplasty steps.
8. Close capsule and retinacular layers carefully; avoid prominent implants under the incision.

Pitfalls: superficial peroneal neuritis, deep peroneal injury, wound breakdown, extensor tendon irritation and poor access to posterior deformity.

Useful for: posterior malleolus reduction, posterior buttress plating, posterior fibula, peroneal tendon work and selected ankle fracture patterns.

1. Position lateral, prone or supine with appropriate rotation depending the combined approach plan.
2. Mark lateral malleolus, Achilles, peroneal tendons and likely sural nerve zone.
3. Make a longitudinal posterolateral incision between posterior fibula and Achilles region.
4. Protect sural nerve and lesser saphenous vein.
5. Develop the interval between peroneal tendons and FHL region.
6. Retract FHL medially when needed; it helps shield the posterior neurovascular bundle.
7. Expose posterior malleolus, reduce the fragment directly and apply posterior buttress or posterior-to-anterior fixation when indicated.
8. Check posterior fragment reduction, fibular length and syndesmotic stability.

Pitfalls: sural nerve injury, inadequate CT planning, plate too lateral for posterior shear, and failure to reassess syndesmosis after posterior fixation.

Useful for: medial malleolus fixation, deltoid exposure, talar neck/body access, medial gutter work and selected tarsal tunnel or medial hindfoot surgery.

1. Supine position with foot externally rotated or supported for medial access.
2. Mark medial malleolus, tibialis posterior course, saphenous vein and previous scars.
3. Use a longitudinal or gently curved medial incision according to target.
4. Protect saphenous nerve and vein in the superficial layer.
5. For medial malleolus, expose fracture edges subperiosteally only as needed.
6. For deeper medial hindfoot work, identify the relationship to tibialis posterior, FDL, posterior tibial neurovascular bundle and FHL.
7. Avoid uncontrolled posterior dissection unless a tarsal tunnel or deep medial approach is deliberately planned.

Pitfalls: saphenous neuritis, posterior tibial bundle injury, tibialis posterior irritation and medial wound tension.

Useful for: displaced intra-articular calcaneal fractures where the posterior facet can be reduced through a limited lateral window, subtalar joint access and selected lateral hindfoot work.

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1. Lateral position, swelling assessed, fluoroscopy checked for lateral, axial and Broden-type views.
2. Mark lateral malleolus, sinus tarsi, peroneal tendons and sural nerve risk zone.
3. Make an oblique or longitudinal incision over the sinus tarsi region.
4. Protect superficial nerve branches and peroneal tendons.
5. Enter the sinus tarsi and expose posterior facet as required.
6. Reduce facet and tuberosity using percutaneous joysticks, clamps or elevators.
7. Fix with screws or a limited plate according to fracture pattern.
8. Confirm height, width, varus correction, posterior facet reduction and hardware position.

Pitfalls: inadequate view for a complex fracture, missed varus/tuberosity malreduction, sural nerve irritation and relying on the incision when percutaneous reduction tools are needed.

Useful for: complex calcaneal fractures requiring wide lateral wall, posterior facet and tuberosity exposure.

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1. Lateral position with the injured side up.
2. Confirm the skin envelope is ready; do not use the approach through tense swelling.
3. Mark lateral malleolus, Achilles, fifth metatarsal base and calcaneal border.
4. Raise a full-thickness L-shaped lateral flap; do not thin the flap.
5. Protect sural nerve and peroneal tendons.
6. Use temporary wires in talus or cuboid only when safe to support retraction.
7. Reduce tuberosity, posterior facet, anterior process and lateral wall in sequence.
8. Apply plate or screws, confirm reduction and close without tension.

Pitfalls: wound edge necrosis, flap devascularisation, peroneal tendon irritation, prominent lateral hardware and forcing this approach when a limited approach would be enough.

Useful for: Lisfranc reduction and fixation, TMT arthrodesis, medial column work, first-ray reconstruction and selected forefoot procedures.

1. Supine position, bump if needed, foot at table edge.
2. Mark dorsalis pedis, EHL, EDB, first and second TMT joints, and previous scars.
3. Plan one or more dorsal incisions with safe skin bridges.
4. Protect superficial peroneal branches and the deep peroneal nerve/dorsalis pedis bundle.
5. Expose the target column directly: medial, middle or lateral column.
6. Reduce joints anatomically and confirm alignment on AP, oblique and lateral imaging.
7. Place screws, plates or bridge constructs according to injury pattern or fusion plan.
8. Close with swelling control and a clear non-weight-bearing plan.

Pitfalls: narrow skin bridge, dorsal wound breakdown, neurovascular injury, malreduction of the second ray, and fixation prominence under thin dorsal skin.

Useful for: osteochondral lesions of the talus (OLT) and central/posterior talar-dome pathology that cannot be reached through a standard arthrotomy or arthroscopy.

The talar dome is largely covered by the mortise, so the exposure is matched to the lesion's location:

1. Anterocentral / anterolateral lesions — often reachable through an anterior or anterolateral arthrotomy with the ankle plantarflexed, or arthroscopically.
2. Posteromedial lesions (the commonest "deep" OLT) — typically require a medial malleolar osteotomy: a chevron or oblique osteotomy of the medial malleolus that is hinged down to expose the posteromedial dome. Pre-drill and tap the screw holes BEFORE making the osteotomy to guarantee anatomical replacement, protect the posterior tibial tendon and neurovascular bundle, and avoid taking the cut into the weight-bearing plafond.
3. Posterolateral lesions — may need a lateral (fibular) osteotomy or a posterior approach.
4. Posterior lesions generally — posterior hindfoot endoscopy (van Dijk, prone, posterolateral + posteromedial portals) is an increasingly used alternative; FHL is the key landmark — staying lateral to it protects the posteromedial neurovascular bundle.

Pitfalls: intra-articular malreduction of the osteotomy, osteotomy nonunion, taking the cut too far into the plafond, and neurovascular injury during posterior access.

Useful for: posteromedial malleolar fragments, the medial portion of a posterior malleolar fracture, posterior tibial tendon / FDL pathology and deep deltoid access.

The posterior malleolus is not one fragment: the Bartoníček/Mason classification recognises distinct patterns including a posterolateral fragment and a separate posteromedial fragment extending to the medial malleolus. This matters for the approach:

• A posterolateral approach (between peroneals and FHL) reduces the common posterolateral fragment.
• A posteromedial fragment cannot be reduced from posterolateral — it requires a posteromedial approach, working between the tibialis posterior/FDL anteriorly and the posterior tibial neurovascular bundle + FHL posteriorly, to buttress the medial column of the posterior plafond.

1. Position prone or supine with the leg externally rotated.
2. Mark the posteromedial border of the tibia, the posterior tibial tendon and the neurovascular bundle.
3. Protect the posterior tibial neurovascular bundle throughout; identify the interval before deep dissection.
4. Expose and directly reduce the posteromedial fragment, then apply a posterior (antiglide/buttress) plate.

Pitfalls: failing to recognise a posteromedial fragment on CT (so choosing the wrong window), tibial neurovascular injury, and FHL/tibialis posterior entrapment.