Medial Ankle Instability

Andrew Posner

Kyle Angelicola-Richardson

Andrew J. Rosenbaum

Positioning

Supine
Bump the hip on the operative limb, allowing the foot to remain in neutral.
Place thigh tourniquet.
Use knee holder to support the distal femur, allowing the foot to move freely for arthroscopy before open reconstruction.
Prep and drape in the normal sterile manner, extended proximal to the knee.
After completion of arthroscopy, the knee holder is removed and the foot can rest freely.

Surgical Approach

Ankle arthroscopy

Knee holder used to support the distal femur and get the foot into a hanging position (Figure 18-1)

Figure 18-1. Use knee holder to support the distal femur, allowing the foot to move freely for arthroscopy before open reconstruction. Reprinted with permission from Wiesel SW. Operative Techniques in Orthopaedic Surgery. 1st ed. Philadelphia, PA: Wolters Kluwer, Lippincott Williams & Wilkins; 2010. Figure 104-4b.

Incision
- Anteromedial, longitudinal, curved incision (Figure 18-2)
- Begin 1 cm proximal to medial malleolus. Continue incision across anterior third of medial malleolus, finish 2 to 4 cm distal to the tip of the medial malleolus, heading toward medial aspect of the navicular.

Superficial dissection

Mobilize skin flaps.
Identify and protect great saphenous vein and nerve just anterior to medial malleolus.

Expose periosteum and capsule.

Figure 18-2. Approach for deltoid ligament reconstruction. Reprinted with permission from Wiesel SW. Operative Techniques in Orthopaedic Surgery. 1st ed. Philadelphia, PA: Wolters Kluwer, Lippincott Williams & Wilkins; 2010. Figure 103-2.

Deep dissection (Figure 18-3)
- Posterior tibial tendon should be displaced from the sheath and preserved.
- Incise anterior joint capsule to visualize joint.
- Identify remaining fibers of deltoid ligament.
  - Superficial portion: fan-shaped, commonly torn mid-substance or avulsed from medial malleolus
  - Deep portion: short, heavy, clinically more significant; may be avulsed from the talus (most common), torn from the tip of malleolus, torn mid-substance

Figure 18-3. Medial approach. Posterior tibial tendon (arrow) is retracted posteriorly. Reprinted with permission from Giza E, Wuellner J. Acute deltoid rupture: history, diagnosis, and a repair technique. Tech Foot Ankle Surg. 2014;13(2):73-80. doi:10.1097/BTF.0000000000000045.

Reduction and Fixation Techniques