Anterior Approach to the Ankle Joint

Anterior approach to the ankle joint through the interval between extensor hallucis longus and extensor digitorum longus, with the anterior
Anterior approach to the ankle joint through the interval between extensor hallucis longus and extensor digitorum longus, with the anterior tibial artery lying in the field. Image from Hershfeld B, Krish P, Smith P, Modica A, Krez A, Klein B, Bitterman AD. Total Ankle Arthroplasty, A Comparative Review of Surgical Approaches and Outcomes. JB JS Open Access. 2026, 11(2), e26.00019. CC BY 4.0.

The anterior approach to the ankle joint passes between tibialis anterior and extensor hallucis longus to expose the anterior tibia and talus. It is used for ankle arthrodesis, pilon fracture fixation and joint debridement, protecting the superficial peroneal nerve and the anterior tibial neurovascular bundle.

Gray’s Anatomy illustration of the deep peroneal nerve
Deep nerves of the front of the leg. The deep peroneal nerve and anterior tibial artery cross the front of the ankle beside extensor hallucis longus. Image by Henry Vandyke Carter, Gray’s Anatomy (1918), Wikimedia Commons, public domain.

Indications

Position

  • supine
  • exsanguinate foot (partially)
  • inflate tourniquet

Landmarks

  • medial malleolus
  • lateral malleolus

Incision

  • Start: 15 cm incision centred over anterior aspect of ankle
  • Start 10 cm proximal to joint
  • End: dorsum of foot
  • Cut only skin
    • Bw anterior neurovascular bundle
    • Superficial peroneal nerves

Internervous Plane

  • None
  • Between EHL & ED

Superficial Dissection

  • Incise deep fascia
  • Incise extensor retinaculum
  • Dissect between EHL & ED
  • Identify neurovascular bundle just medial to EHL
    • Anterior tibial artery
    • Deep peroneal nerve
  • Retract EHL & NV bundle medially
  • Retract ED laterally

Deep Dissection

  • Incise ankle joint capsule
  • Perform periosteal stripping if necessary

Dangers

  • Nerves
    • Branches of superficial peroneal nerve
    • Deep peroneal nerve
  • Artery
    • Anterior tibial artery
  • NB
    • Above ankle joint
      • NV bundle lies between EHL & TibAnt
    • At joint
      • EHL tendon crosses NV bundle
  • Proximally
    • Expose structures of anterior compartment
  • Distally
    • Dorsum of Foot

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.