Anterior

Indications

  • Open reduction and internal fixation of pilon fractures with anterior or central impaction.
  • Ankle arthrodesis and total ankle replacement.
  • Removal of loose bodies and anterior osteophytes, and drainage of joint sepsis.

Position

  • Supine with a bump under the ipsilateral buttock so the foot points to the ceiling.
  • Thigh tourniquet.

Landmarks and incision

  • Palpate the tibialis anterior and extensor hallucis longus (EHL) tendons and the medial and lateral malleoli.
  • Make a 12 to 15 cm longitudinal incision centred on the joint, just lateral to the tibial crest proximally, then along the line of EHL.
  • In pilon surgery, plan the incision around other incisions and the fracture pattern, keeping wide skin bridges.

Internervous plane

  • The interval lies between tibialis anterior and EHL. Both are supplied by the deep peroneal nerve, so this is an intermuscular plane.

Superficial dissection

  • Identify and protect branches of the superficial peroneal nerve crossing the distal wound.
  • Raise full thickness flaps. Avoid undermining the skin.
  • Divide the superior and inferior extensor retinacula in line with the incision, leaving tissue for repair.
  • Open the EHL sheath and keep tibialis anterior in its own sheath to reduce wound breakdown and bowstringing.

Deep dissection

  • Retract EHL and the neurovascular bundle laterally, and tibialis anterior medially.
  • Incise the periosteum and anterior capsule longitudinally to expose the distal tibia, plafond and talar dome.
  • For pilon fractures, open along the fracture lines to reach the impacted articular fragments and use the talus as a template.

Structures at risk

  • Anterior tibial artery and deep peroneal nerve. The bundle lies between tibialis anterior and EHL above the joint, then crosses deep to EHL to lie lateral to it on the foot.
  • Superficial peroneal nerve branches.
  • Skin edges, which are thin and poorly tolerant of swelling and retraction.

Extensions

  • Proximally along the lateral side of the tibial crest to expose the tibial shaft.
  • Distally onto the dorsum of the foot to expose the talonavicular joint.

Exam traps

  • Define the interval and explain where the bundle is at the joint line.
  • Time definitive pilon fixation to the soft tissues. A staged approach with a spanning external fixator, then fixation when swelling has settled and the skin wrinkles, reduces wound complications.
  • Repair the extensor retinaculum. More approaches are listed under ankle approaches.

References

1. Hoppenfeld S, deBoer P, Buckley R. Surgical exposures in orthopaedics, the anatomic approach. 5th ed. Philadelphia, Wolters Kluwer, 2017.

2. Assal M, Ray A, Stern R. Strategies for surgical approaches in open reduction internal fixation of pilon fractures. J Orthop Trauma. 2015, 29(2), 69-79.

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 17 October 2026.