Place the position supine on the operating table (see Fig. 7-1). Place a sandbag beneath the hip on the side undergoing surgery. This will correct the natural external rotation of the leg and place the foot in a neutral position, with the toes pointing skyward. After exsanguination, apply a tourniquet to the mid-thigh.

Palpate the tendon of the tibialis anterior as it runs over the anteromedial aspect of the ankle. Trace the tendon distally to its insertion on the navicular. Identify the ankle joint by passively flexing and extending the joint. Make an 8-cm-long straight incision on the anteromedial aspect of the ankle. Begin 2 cm proximal to the junction of the medial dome of the talus and distal tibia. Extend the incision distally to follow the medial side of the anterior tibial tendon, ending at the anteromedial border of the navicular (Fig. 14-1). The incision may be extended proximally if access to the medial portion of the ankle is needed. The incision can also be extended distally for access to the medial portion of the midfoot.

No internervous plane is used. The approach is safe because the incision cuts down onto bone, which is subcutaneous both proximally and distally.