THE REGION OF THE ANKLE AND FOOT 487 



occupies the interval between the two malleoli, and contracture 

 of the tendo calcaneus is unlikely to occur. It is wiser to err 

 on the side of inversion rather than eversion, as in the latter 

 case flat-foot may subsequently develop, and to avoid this 

 sequela, care must be exercised to see that the medial margin 

 of the hallux, the medial malleolus and the medial border of the 

 patella are all in the same straight line. 



Surgical Approach to the Ankle - Joint. In 

 arthrotomy, arthrodesis, excision of the joint or removal of the 

 talus, the best approach is obtained by means of Kocher's lateral 

 J-shaped incision, with or without some slight modification. 

 This incision begins behind the fibula and extends below the 

 lateral malleolus to the trochlear process (peroneal tubercle), 

 being placed above the nervus suralis and the small saphenous 

 vein. From this point it curves gently forwards to end a little 

 behind the insertion of the peronseus tertius (p. 471). The flap 

 thus outlined, which consists of skin, fascia and periosteum of 

 the lateral malleolus, is dissected forwards off the peronaei and 

 the malleolus, while below, after division of the cruciate ligament, 

 it is dissected off the anterior talo-fibular ligament (p. 481), the 

 anterior ligament of the ankle and the extensor digitorum 

 brevis. The whole flap is then retracted to the medial side 

 together with the extensor tendons. After the retinacula have 

 been split and the peroneal tendons divided, the three parts of 

 the lateral ligament of the ankle (p. 481), and the weak anterior 

 and posterior ligaments are cut through and the foot is forcibly 

 dislocated by over-inversion. During this process the medial 

 malleolus may break, but this accident is unimportant, as the 

 deltoid ligament remains intact and the surfaces can subsequently 

 be re-opposed. 



By this method, a complete view of the interior of the joint 

 is obtained, and the diseased synovial membrane can be entirely 

 removed along with the anterior and posterior ligaments, but 

 care must be taken not to injure the anterior or posterior tibial 

 arteries as they lie in relation to the joint (pp. 472 and 476). 



Excision of the Talus. If the arthrotomy shows that the 

 disease originated in the talus, this bone may be excised 

 completely. The posterior part of the extensor digitorum 

 brevis is elevated, and the talo-navicular joint is opened. The 

 head of the talus can be drawn upwards, and when the talo- 

 calcanean interosseous ligament is cut through, the bone is 

 held only by the attachment of the deltoid ligament to its medial 



