Where are the incisions made for a Total Ankle Replacement (TAR)?

Incisions for Total Ankle Replacement (TAR)

The standard approach for performing a total ankle replacement is the anterior approach, which provides good direct visualization of the tibiotalar joint, with a complementary posteromedial accessory incision recommended to protect posterior neurovascular structures during bone cuts. 1, 2

Primary Anterior Approach

The anterior approach is the most widely used approach for TAR regardless of implant type 1. This approach offers:

• Direct visualization of the tibiotalar joint
• Access for component placement
• Ability to perform bone cuts and implant positioning

Anterior Incision Technique:

• The incision is placed at the center of the inferior tibial articular surface and curved medially to avoid the medial branch of the superficial peroneal nerve 3
• Care must be taken during soft tissue handling as the anterior incision has historically demonstrated a high incidence of complications, with approximately 19.7% of patients experiencing delayed wound healing greater than 30 days 4

Protective Posteromedial Accessory Approach

A complementary posteromedial approach is recommended to reduce the risk of iatrogenic injury to posterior structures 1, 2. This is critical because:

• Regardless of implant system, bone cuts are typically made in an anterior-to-posterior direction
• These cuts can potentially injure posterior neurovascular structures and tendons running close to the ankle joint
• The pins for bone resection guides, chisels, and saw for distal tibial resection can endanger structures at the posterior aspect of the ankle

Posteromedial Accessory Incision Benefits:

• Allows introduction of a protective instrument that separates posterior anatomical structures from the posterior tibial cortex
• Protects the posterior tibial tendon (PTT), flexor hallucis longus (FHL), flexor digitorum longus (FDL), and neurovascular bundles
• Does not increase complications or surgical duration 1
• Studies have shown no technique-related complications or evidence of injury to posterior structures when this protective approach is used 2

Technical Considerations

When performing TAR, surgeons should consider these technical aspects:

• During resection of the talus, attached ligaments and joint capsule should be debrided prior to osteotomy 3
• When inserting the artificial components, the entire foot should be pulled distally by grasping the heel to avoid excessive plantar flexion 3
• During wound closure, the extensor retinaculum should be repaired to avoid skin bowstringing 3

Potential Complications

The documented complication rate for TAR surgery is up to 15.3% 1. Specific attention should be paid to:

• Wound healing complications, which can occur in nearly 20% of patients 4
• Protection of neurovascular structures, particularly when performing bone cuts
• Careful soft tissue handling to minimize the risk of wound complications

Evolution of Approach

Early TAR designs from the 1970s had unacceptably high failure and complication rates 5. Modern approaches have evolved to address these issues, with newer designs and techniques focusing on:

• Better protection of anatomical structures
• Improved implant design and materials
• More precise surgical techniques

The combination of an anterior approach with a protective posteromedial accessory incision represents the current best practice for performing TAR safely while minimizing the risk of damage to critical posterior structures.