Anteromedial approach to medial malleolus

Introduction

• Allows inspection of the anteromedial ankle joint and the anteromedial part of the dome of the talus

Indications

• Used mainly for ORIF of the medial malleolus

Position of patient

• The patient is placed supine on the operating table

Landmarks and incision

Landmark

• Identify the anterior and the posterior borders of the medial malleolus

Incision

• A 10-cm longitudinal curved incision, with its midpoint just anterior to the tip of the medial malleolus
• Begin proximally 5 cm above the malleolus and over the middle of the subcutaneous surface of the tibia, crossing the anterior third of the medial malleolus
• The incision is curved forward to end 5 cm anterior and distal to the malleolus

Internervous plane

• No internervous plane.

Superficial dissection

• Widen the skin flaps
• Identify the long saphenous vein and the accompanying saphenous nerve, which lie just anterior to the medial malleolus

Deep dissection

• Incise the remaining coverings of the medial malleolus longitudinally to expose the fracture site
• Make a small incision in the anterior capsule of the ankle joint to see the articulating surface
• Split the superficial fibers of the deltoid ligament, which run anteriorly and distally downward from the medial malleolus, so that wires or screws will be anchored solidly on bone

Dangers

• Preserve the saphenous nerve by preserving the long saphenous vein
• The long saphenous vein is at risk when the anterior skin flaps are mobilized

How to enlarge the approach

Proximal

• Incision can be extended along the subcutaneous surface of the tibia

Distal

• Incision can be extended to expose the deltoid ligaments and the talocalcaneonavicular joint

Figures