- Posteromedial to the talus
This approach is utilized for posterior fractures of the talar body or posterior process fractures of the talus. This is a difficult-to-reach anatomical area, and medial or lateral osteotomies do not allow visualization here. A posteromedial approach provides an adequate view for fixation of fractures and debridement of debris.
The posteromedial approach is used rarely and would expose a fracture of the posterior process of the talus, but would not give visualization of the talar body, or the subtalar joint. Fractures of the body of the talus most often require, particularly if they are more posterior, an osteotomy of the medial malleolus.
Cases by courtesy of Dr. Steven Steinlauf, Florida, USA.
This rarely-used approach is extremely useful and follows the plane between flexor hallucis longus and the Achilles tendon. The neurovascular structures lie posteromedially behind the medial malleolus and must be protected.
Using the Achilles as the lateral boundary, and the neurovascular structures posteromedially, a skin incision is made centered over the subtalar joint using image intensification.
The structures that run behind the medial malleolus are very important here. The most posterior structure, flexor hallucis longus, is identified so the surgeon can go posterior and lateral to it and medial to the Achilles tendon.
The tendon sheath of the flexor hallucis longus must be opened. This allows the retraction of the tendon together with the neurovascular bundle and gains exposure of the fracture.
Lateral to the tendon sheath of the FHL is the posterior tubercle of the talus.
The surgeon must be careful not to be too proximal and mistake the distal tibia for the talus. Fixation and debridement can now be completed.