Posteromedial approach to medial malleolus

Introduction

• Allows ORIF of medial malleolar fractures and visualization of posterior margin of the tibia

Position of patient

• Place the patient supine on the operating table

Landmarks and incision

• Identify medial malleolus with its anterior and posterior border and its tip
• Make a 10-cm incision, beginning 5 cm above the ankle on the posterior border of the tibia
• Curve incision downward, following the posterior border of the medial malleolus
• Curve incision forward below the medial malleolus to end 5 cm distal to the malleolus

Internervous plane

• No true internervous plane

Superficial dissection

• Mobilize skin flaps
• Saphaenous vein is not in danger, as it lies anterior

Deep dissection

• Incise the flexor retinaculum behind the medial malleolus longitudinally so that it can be repaired, which permits anterior retraction of the tibialis posterior tendon
• Continue the dissection around the back of the malleolus; deep surgical dissection is carried out close to bone
• Retract other structures that pass behind the medial malleolus posteriorly to reach the posterior margin (or posterior malleolus) of the tibia in case ORIF of the posterior malleolus is the plan
• Leave as much soft tissue as possible attached to the fractured malleolar fragments; complete stripping renders the fragments avascular

Dangers

Structures that run behind the medial malleolus:

• Tibialis posterior muscle
• Flexor digitorum longus muscle
• Posterior tibial artery and vein
• Tibial nerve
• Flexor hallucis longus

How to enlarge the approach

Proximally

• Carry the incision along the subcutaneous surface of the tibia
• Subperiosteal dissection exposes the subcutaneous and lateral surfaces of the tibia along its entire length.

Distally

• Expose deltoid ligaments and talocalcaneonavicular joint

Figures