13.1.1 Principal Indications

• 
  

  Fractures

  
  
• 
  

  Arthrodesis

  
  
• 
  

  Arthroplasty

  
  
• 
  

  Synovectomy

13.1.2 Positioning and Incision

The patient is placed in the supine position. After (optional) application of a tourniquet, the leg is draped in a manner allowing free movement. A pad is placed under the lower leg. The skin incision, approximately 10 cm in length, is straight and passes in the midline over the ankle joint ( Fig. 13.1 ). When transecting the subcutaneous tissue, one should watch for the superficial peroneal nerve, which runs an extrafascial course.

The picture of the anatomical site ( Fig. 13.2 ) shows the oblique course of this nerve, which crosses the operative field in its distal portion. Lying between the tendons of extensor digitorum longus and extensor hallucis longus are the dorsal artery and vein of the foot and the deep peroneal nerve, the sensory terminal branch of which supplies the skin in the first web space.

After exposure of the fascia and its reinforcing bands (superior and inferior extensor retinacula), these are split in line with the skin incision ( Fig. 13.3 ). Medial retraction of extensor hallucis longus and lateral retraction of extensor digitorum longus reveal the neurovascular bundle lying deeply ( Fig. 13.4 ).

13.1.3 Exposure of the Ankle Joint

The entire neurovascular bundle with its connective tissue sheath is dissected free and mobilized laterally. Ligation and transection of the medial anterior malleolar artery and vein are recommended if adequate lateral mobilization is to be achieved ( Fig. 13.5 ). The capsule of the ankle joint behind the neurovascular bundle is split longitudinally. Incision of the capsule is extended proximally into the periosteum of the tibia so that the ankle joint capsule and the periosteum on the lateral surface of the tibia can be medially and laterally mobilized in one layer with a raspatory. This permits anterior opening of the ankle joint. Now Langenbeck retractors may be inserted medially and laterally, uncovering the distal tibia, the anterior portion of the inner malleolus, and the trochlea and neck of the talus ( Fig. 13.6 ).

13.1.4 Wound Closure

After release of the tourniquet and hemostasis, the wound is closed by suture of the capsule and the extensor retinacula.

13.1.5 Note

With this approach, impairment of wound healing is not uncommon. Careful hemostasis and the use of Redon drains are especially important in this procedure.

13.2.1 Principal Indications

• 
  

  Fractures

  
  
• 
  

  Arthrodesis

  
  
• 
  

  Synovectomy

  
  
• 
  

  Arthroplasty

13.2.2 Positioning and Incision

The patient is placed in the supine position. After (optional) application of a tourniquet, the leg is draped so as to allow free movement. A pad is placed under the lower leg, and this is slightly rotated internally. A skin incision approximately 10 cm long is made laterally to the generally readily palpable extensor digitorum longus anterior to the tibiofibular syndesmosis. If necessary, the incision can be extended distally in the direction of the fourth metatarsal bone ( Fig. 13.7 ). After splitting the skin and subcutaneous tissue, the crural fascia is divided with a straight incision, and the inferior extensor retinaculum with an H-shaped incision ( Fig. 13.8 ). Care should be taken not to damage the branches of the superficial peroneal nerve lying medial to this incision. The extensor digitorum longus and peroneus tertius muscles can be medially retracted ( Fig. 13.9 ).

13.2.3 Exposure of the Ankle Joint

The transverse venous branches of the lateral anterior malleolar artery are ligated and transected. With the aid of a raspatory, the neurovascular bundle can be cautiously retracted in a medial direction from the anterior aspect of the ankle joint capsule. Subsequently, a Langenbeck retractor is inserted in the same plane ( Fig. 13.10 ). The capsule of the ankle joint is split longitudinally. For liberal exposure of the ankle joint, the periosteum of the tibia proximal to the capsule also has to be split. It is retracted with a raspatory in the same plane as the capsule. Then Langenbeck retractors are inserted into the joint ( Fig. 13.11 ).

13.2.4 Distal Extension of the Approach

If exposure of the talocalcaneonavicular joint is required, the skin incision is extended distally. After the fascia has been split, extensor digitorum longus and extensor hallucis brevis are detached from their origins ( Fig. 13.12 ). This necessitates transection of the lateral tarsal artery and vein, which course in part beneath these muscles. The muscle flap is retracted distally, and then the medial and lateral Chopart joint is opened with a T-shaped incision ( Fig. 13.13 ). Following transection of the bifurcate ligament, the joint surfaces are well exposed if the forefoot is pushed in a plantar direction ( Fig. 13.14 ). If necessary, the subtalar joint can also be exposed with this approach once the tarsal sinus has been cleared (see Section 13.13, Fig. 13.65 ff.).

13.2.5 Wound Closure

Wound closure is effected by suture of the ankle joint capsule as well as of the fascia and the retinaculum of the inferior extensor muscles.

13.2.6 Note

This approach is especially suitable for arthrodesis of the talocalcaneonavicular and talocrural joints. Impaired wound healing occurs less frequently in this case than with the anterior approach to the ankle joint.

13.3.1 Principal Indications

• 
  

  Correction of talipes equinovarus

  
  
• 
  

  Correction of congenital vertical talus

  
  
• 
  

  Posterior, posteromedial, and posterolateral capsulotomies

13.3.2 Positioning and Incision

The patient is usually placed prone. The extent of the incision depends on the planned operation. If only Achilles tendon elongation and posterior arthrolysis are planned, the incision is posterior, above the transverse skin crease over the heel ( Fig. 13.15a ). If posteromedial arthrolysis is to be performed, the incision is extended medially to in front of the medial malleolus ( Fig. 13.15b ). If complete peritalar arthrolysis is necessary, the incision is continued laterally over the lateral malleolus as far as the calcaneocuboid joint ( Fig. 13.15c ).

13.3.3 Achilles Tendon Lengthening and Exposure of the Posterior Joint Capsule with Posterior Arthrolysis

For posterior arthrolysis, the Achilles tendon, the lateral neurovascular bundle (sural nerve and accompanying vessels), and the medial neurovascular bundle (tibial nerve, posterior tibial artery and vein) are exposed ( Fig. 13.16 ). To lengthen it, the Achilles tendon can be incised in both the frontal and sagittal planes. We prefer elongation in the frontal plane. To expose the posterior joint capsule, the lateral neurovascular bundle and the peroneal tendons (after opening the tendon sheaths), and the flexor hallucis longus and medial neurovascular bundle are retracted.

The flexor hallucis longus points to the talocalcaneonavicular joint. The posterior capsule of the ankle and talocalcaneonavicular joints is exposed together with the posterior fibulotalar ligament ( Fig. 13.16 ).

The capsule is incised transversely, sparing the flexor hallucis longus and posterior fibulotalar ligament ( Figs. 13.17 and 13.18 ). If the flexor hallucis longus tendon is shortened, it can be elongated in a Z-shape through the posterior approach.

13.3.4 Medial Arthrolysis, Elongation of Tibialis Posterior and Flexor Digitorum Longus

To expose the medial series of joints, tibialis posterior, and flexor digitorum longus, the fascia of abductor hallucis is first incised. The medial neurovascular bundle is retracted. Behind the medial malleolus, the tendon sheaths of flexor digitorum longus and tibialis posterior are incised, and the tendons are exposed.

The capsule of the talonavicular joint and the anterior part of the subtalar joint can now be exposed ( Fig. 13.19 ). The flexor digitorum longus tendon can be dissected as far as the plantar flexor chiasm.

A Z-shaped incision is made in the tendon of tibialis posterior. The distal cut tendon end acts as a guide to the talonavicular joint. Arthrolysis of the talonavicular joint and subtalar joint can be performed from the medial side. The extent of the arthrolysis is determined by the severity of the deformity. The talocalcaneal ligament must on no account be divided as this predisposes to pes valgus. If the flexor tendons are contracted, the tendon of flexor digitorum longus can be lengthened by a Z-shaped incision via the medial approach ( Figs. 13.20 and 13.21 ).

13.3.5 Lateral Arthrolysis, Lengthening of the Peroneal Tendons

The fibula with its ligaments, the peroneal tendons, the calcaneus, and the cuboid bone can be exposed through the lateral part of the approach ( Fig. 13.22 ). Lateral arthrolysis is usually performed in the case of very severe deformities. Depending on the severity of the deformity, the arthrolysis can extend from the calcaneocuboid joint via the subtalar joint to the entire gap between the talus, calcaneus, and navicular and cuboid bones ( Figs. 13.23 and 13.24 ). The fibulocalcaneal ligament can be divided from the lateral aspect. If the peroneal tendons are contracted, they can be lengthened through the lateral part of the approach. The sural nerve is exposed posteriorly and must also be dissected laterally and spared.

13.3.6 Wound Closure

The tendons are sutured in a neutral position. Both the Achilles tendon and the tibialis posterior tendon must be sutured with adequate tension. Excessive lengthening results in overcorrection with the development of talipes calcaneus or pes valgus. Wound closure can be continuous with an absorbable intracutaneous suture, but interrupted sutures are preferable for critical wounds. After wound closure, a long-leg case is applied. A short-leg cast is preferable in children over 3 years of age.

13.3.7 Dangers

Since correction is performed during infancy and the site is very small, the neurovascular bundles require special care. Wound closure can be a problem with severe equinovarus deformity. The first postoperative cast is applied with the foot in the equinus position. The equinus is corrected by successive casts that stretch the posterior soft tissues.

13.3.8 Note

Arthrolysis to correct foot deformities in infancy and early childhood must be adjusted to the severity of the deformity. The deformity is corrected “a la carte.” Overextensive arthrolysis leads to overcorrection with the development of even more severe pes valgus.

13.4.1 Principal Indications

• 
  

  Capsulotomy

  
  
• 
  

  Correction of talipes deformities

13.4.2 Positioning and Incision

How the patient is positioned depends on the intended operation. If a purely posterior capsulotomy of the ankle joint with elongation of the Achilles tendon is planned, the patient is placed in the prone position. However, if medial capsulotomy of the talocalcaneonavicular joint is required as well, the supine position with the leg externally rotated is preferable.

The longitudinal incision is made along the medial border of the Achilles tendon and extends to the calcaneal tuberosity. If necessary, the incision may be lengthened anteriorly as far as the insertion of the tibialis anterior tendon ( Fig. 13.25 ). After splitting the fascia over the Achilles tendon, this is dissected free of the underlying fat from below. Depending on the nature of the foot deformity, the Achilles tendon may be transected sagittally or frontally. Sagittal tenotomy with section of the medial half of the Achilles tendon at its attachment is particularly necessary for talipes. In cases of talipes equinus alone, the Achilles tendon is tenotomized frontally ( Fig. 13.26 ). The transection may be either posterior and distal or posterior and proximal. The type of transection performed depends on the length of the muscular portion of the soleus. If the muscular portion of the soleus extends far distally, frontal lengthening is recommended, the proximal transverse incision being made in a posterior direction, and the distal one in an anterior direction. The tenotomized tendon ends are reflected upward from the wound so that the underlying deep crural fascia is revealed ( Fig. 13.27 ). The tendon ends are then covered with moist swabs, and the foot, which is usually in the equinus position, can now be manually set in the neutral position. The deep layer of the crural fascia is incised over the belly of flexor hallucis longus ( Fig. 13.28 ).

13.4.3 Exposure of the Joint Capsule

Flexor hallucis longus is recognizable by its typical muscle belly, which extends far distally and covers the posterior surface of the tibia. The tibial nerve and the posterior tibial artery lie medial to flexor hallucis longus.

For posterior exposure of the distal tibia and the capsule of the ankle joint, flexor hallucis longus has to be proximally detached—sharply in part—from its origin, avoiding damage to the peroneal artery. Distally, the tendon sheath of this muscle is split. At this site, branches of the posterior tibial artery have to be transected ( Fig. 13.29 ). Posterior capsulotomy of the talocrural and talocalcaneonavicular joints can be effected by means of two transverse incisions or by complete detachment of the capsule as shown in Fig. 13.29 . For this purpose, the posterior talofibular and calcaneofibular ligaments need to be transected. When transecting the calcaneofibular ligament, the peroneal tendons have to be protected. Medially, the posterior part of the deltoid ligament is transected directly at its attachment to the calcaneus ( Fig. 13.30 ).

13.4.4 Extension of the Approach with Medial Release

If exposure of the medial portions of the talocalcaneonavicular joint should subsequently prove necessary, the skin incision may be extended anteriorly and distally. The skin is incised approximately as far as the insertion of tibialis anterior on the inner aspect of the first metatarsal joint. Then the crural fascia over the neurovascular bundle is split from proximal to distal, the superficial layer of the flexor retinaculum being opened distally. It is now possible to pass under the neurovascular bundle and retract it laterally with a rubber band ( Fig. 13.31 ). Subsequently, the anterior portion of the flexor retinaculum is split by a curved incision, and now the tendinous compartments of the flexor digitorum longus and tibialis posterior have to be incised ( Fig. 13.32 ). If necessary, the tendons of flexor digitorum longus and tibialis posterior are subjected to a Z-shaped tenotomy and pulled out of the wound ( Fig. 13.33 ). Through manual lateral displacement of the forefoot, the cavities of the subtalar and talonavicular joints can be located with a needle. Complete splitting of the tendon sheath of flexor hallucis longus is necessary to expose the subtalar articulation. Manual eversion of the foot provides a good overview of the talonavicular and talocalcaneal joints ( Fig. 13.34 ).

13.4.5 Wound Closure

Closure of the joint capsule is generally unnecessary after medial and posterior capsulotomy. If conditions warrant, the transected tendons are lengthened by a Z-shaped incision and sutured with interrupted sutures. This incision may entail impaired wound healing owing to skin tension.

13.4.6 Dangers

Transection of the calcaneofibular ligament endangers the peroneal tendons, and transection of the posterior portion of the deltoid ligament endangers the posterior tibial artery and the tibial nerve.