Lateral Approach to the Ankle with Fibular Osteotomy for Ankle Fusion

The lateral approach to the ankle for ankle fusion with fibular osteotomy is also known as the Royal Air Force (RAF) fusion approach. It offers access to both the fibulotalar and tibiotalar joints. This approach provides access to about 90% of the articular surface of the ankle joint, facilitating the excision of the articular cartilage of the joint needed to perform a successful fusion.

Position of the Patient

Place the patient supine on the operating table with a sandbag under the buttock of the affected limb. The sandbag causes the limb to rotate internally, bringing the lateral malleolus forward and making it accessible (Fig. 2-1). After exsanguination, apply a tourniquet to the mid-thigh.

Landmarks and Incision

Palpate the subcutaneous surface of the fibula and the lateral malleolus, which lies at the fibula’s distal end. Make a 10-cm longitudinal incision along the anterior margin of the fibula extending down to its distal end (Fig. 2-2). The incision may be extended proximally or distally as needed. Be aware that proximal extension may endanger the superficial branch of the peroneal nerve.

Internervous Plane

There is no internervous plane; the dissection is performed down to a subcutaneous bone.

Superficial Surgical Dissection

Elevate the skin flaps, taking care not to damage the short saphenous vein, which lies posterior to the lateral malleolus. The sural nerve runs with the short saphenous vein and must also be preserved. Proximally identify and preserve the superficial branch of the peroneal nerve.