Medial malleolar osteotomy

This approach may be used to improve visualization of complex talar body fractures, particularly those involving the medial weightbearing dome.

An osteotomy of the medial malleolus exposes the medial aspect of the talar body.

Note: The deltoid branch of the posteromedial vasculature must be preserved when performing this osteotomy as it supplies a majority of the medial talus.

This illustration shows the areas of the talus that are visualized through this surgical approach.

Areas of the talus visible using the Medial malleolar osteotomy

Blood supply to the talus

Note: Ensure not to damage the blood supply to the talus.

Note: Fracture dislocations can easily compromise the blood supply to the body of the talus and lead to avascular necrosis.

The blood supply to the talar body is complex.

These illustrations show the main arteries in the hindfoot and ankle.

$Talar blood supply with major hindfoot and ankle arteries at risk in fractures anterolateral approach$

Anterior view with main arteries

Anterior view of the foot and ankle with main arteries anterolateral approach

The talar neck receives arterial branches from the medial and lateral side (anterior and posterior tibial artery). The body of the talus is supplied almost exclusively from its posteromedial aspect.

The deltoid branches are important to supply blood to the medial talar neck and talar body. Branches from the dorsalis pedis supply the talar head and most of the dorsal talar neck.

The artery of the tarsal canal coming from branches off the posterior tibial artery supplies most of the talar body.

The peroneal artery has the least contribution laterally and is not of concern during a medial malleolar osteotomy.

Artery of the tarsal canal supplying talar body and minimal lateral contribution from peroneal artery

Illustration showing the contribution of arterial blood supply to the talus:

Anterior tibial artery (blue)
Posterior tibial artery (orange) including the deltoid branch
Perforating peroneal artery (green)

Talar arterial blood supply from anterior, posterior tibial, and perforating peroneal arteries

Perform a longitudinal incision over the distal tibia and medial malleolus and extend it distally towards the base of the 1st metatarsal, as necessary.

Medial malleolar osteotomy: Longitudinal incision over distal tibia/medial malleolus, extended toward 1st metatarsal.

Avoid damage to the saphenous nerve. If necessary, coagulate or ligate the saphenous vein.

Incise the periosteum and capsule over the medial distal tibia and malleolus to identify the anatomical landmarks. This can be performed longitudinally or transversely. If undertaken longitudinally, care must be taken distally to avoid damage to the blood supply to the talus.

This allows for accurate positioning of the medial malleolar osteotomy.

Protect saphenous nerve/vein; incise periosteum/capsule to landmark for medial malleolar osteotomy.

The osteotomy must be in such a way that it avoids the distal tibial plafond. The medial malleolus will be stabilized with two lag screws.

Visualize the joint surface before cutting by dissection medial to the anterior colliculus. The tibiotalar joint capsule can be incised to visualize the joint surface during osteotomy preparation.

Predrill and -tap the medial malleolus for two screws, which will be ultimately used to fix the osteotomy. The screws should be placed parallel to each other and perpendicular to the planned osteotomy.

Medial malleolar osteotomy avoids tibial plafond; joint surface visualized; predrill two parallel lag screws.

Cut the bone with an oscillating saw at 90° to the screw position almost to the articular surface.

Pearl: A small K-wire can be used as a guide to correct osteotomy placement.

Medial malleolar osteotomy oscillating saw cut at 90° to screws; small K-wire guide for osteotomy placement.

Insert anterior and posterior small flat retractors around the malleolus into the joint before completing the osteotomy to protect the dome of the talus and the posterior tibialis tendon.

Medial malleolar osteotomy place anterior/posterior flat retractors to protect talar dome and posterior tibialis tendon.

Complete the medial aspect of the osteotomy with an osteotome.

This way, the articular surface can be reapposed without articular loss at the end of the operation.

Medial malleolar osteotomy complete medial osteotomy with osteotome to reappose articular surface without loss.

Reflect the medial malleolar piece distally on its retained soft tissue and blood supply.

Note: Take great care not to retract the medial malleolar fragment excessively as this may damage the deltoid artery branch.

Medial malleolar osteotomy reflect medial malleolus distally; avoid excessive retraction to protect deltoid artery branch.

Once the talar reconstruction is complete, reduce the medial malleolus and fix it with lag screws. This secures stable fixation of the osteotomy.

Tip: In the case of a more vertical osteotomy, an antiglide plate can be used to prevent displacement proximally.

Medial malleolar osteotomy reduce medial malleolus and fix with lag screws; antiglide plate for vertical osteotomy.

This postoperative x-ray shows the fixation of a complex fracture of the talus with an anterolateral approach and an anteromedial approach extended to a medial malleolar osteotomy which was reconstructed with lag screws.

In this case, the osteotomy has been performed more distally. This has the advantage of less bone dissection but may limit the amount of exposure to the talus.

$Medial malleolar osteotomy postop x-ray: talus fracture fixed via anteromedial osteotomy with lag screws.$