Crenellated Superior Extensor Retinaculum Incision: A Technical Modification to Facilitate Closure in the Anterior Ankle Approach

BACKGROUND: The anterior ankle approach is one of the most commonly used surgical approaches in foot and ankle surgery and requires incision of the superior extensor retinaculum. Traditional longitudinal or Z-shaped retinacular incisions can be challenging to accurately reapproximate when tissues are edematous and retracted following prolonged surgical procedures. We describe a novel crenellated incision technique that creates multiple anatomical landmarks to facilitate accurate retinacular closure. METHODS: The superior extensor retinaculum was incised in a crenellated (battlement) pattern through the standard anterior ankle approach between the tibialis anterior and extensor hallucis longus tendons. The pattern consisted of alternating rectangular notches creating three crenels on each retinacular edge (six total), with each notch measuring approximately 1 cm in depth. During closure, corresponding crenels were matched and repaired using interrupted 1-0 Vicryl sutures. RESULTS: The crenellated technique has been successfully utilized by multiple consultants in our department. This simplifies identification of corresponding edges, ensures even tension distribution, and restores native retinacular anatomy without requiring specialized equipment or increasing operative time. Operating surgeons reported improved confidence in achieving anatomically accurate closure compared to traditional techniques. The technique is easy to adopt and teach and highly reproducible. CONCLUSION: The crenellated retinacular incision is a simple, reproducible technical modification that enhances closure accuracy through creation of multiple anatomical landmarks. This technique can reduce the risk of tibialis anterior tendon bowstringing while maintaining retinacular integrity and may contribute to improved wound healing and reduced wound-related complications.