Position of the Posteromedial Ankle Structures in Patients I
The posteromedial ankle structures are at risk during total ankle replacement (TAR). The purpose of our study was to investigate the distance of these structures from the posterior cortex of the tibia and talus in order to determine their anatomy at different levels of bone resection during a TAR and whether plantarflexion of the ankle reliably moved these structures posteriorly.

Ten feet in 10 patients with end-stage tibiotalar arthritis indicated for a TAR were included. Preoperative magnetic resonance images were obtained with the foot in a neutral position as well as in maximum plantarflexion to measure the distance of posteromedial ankle structures to the closest part of the posterior cortex of the tibia or talus. Wilcoxon signed-rank rests were used to investigate differences in these distances.

The mean distance from the posterior tibial cortex to the tibial nerve at 14 and 7 mm above the tibial plafond was 8.7 mm and 6.7 mm, respectively, which represented a statistically significant movement anteriorly. The posterior tibial artery was, on average, 8.0 mm and 7.2 mm from the posterior tibial cortex at 14 and 7 mm above the tibial plafond, respectively. Distal to the tibial plafond, the posterior tibial artery and flexor digitorum longus tendons moved posteriorly by less than 1 mm in plantarflexion (all P < .05); otherwise, plantarflexion of the ankle did not affect the position of the tibial nerve, posterior tibial tendon, or flexor hallucis longus.

In conclusion, in patients with end-stage ankle arthritis, the tibial nerve and posterior tibial artery lie, on average, between 6.5 and 10 mm from the posterior tibial and talar cortices. In some patients, these structures are less than 3 mm away from the bone. Plantarflexing the ankle during the bone cuts for a TAR does not result in the posteromedial structures moving reliably away from the posterior tibial cortex, and therefore, it may be safer to perform the tibial bone cuts in a neutral ankle position. Knowledge of the anatomy of the posteromedial ankle structures may help surgeons avoid iatrogenic injuries to the neurovascular bundle and flexor tendons during TAR.

Source: https://journals.sagepub.com/doi/full/10.1177/2473011420917325