Because of its high recurrence rate, complete excision with total synovectomy is crucial for diffuse pigmented villonodular synovitis (DPVNS). Regardless of location, surgical approach requires meticulous soft tissue management and full joint exposure to assure complete tumor excision. In the ankle, PVNS can be present in the medial and lateral gutters, as well as extend along the syndesmotic ligament, flexor and peroneal tendon sheaths, and adjacent joints (ie, subtalar and midtarsal joints). The authors describe an open, anterior-posterior technique for excision of DPVNS lesions from the ankle joint with erosive lesions of the tibia and talus, as well as from the flexor hallucis longus and peroneal tendon sheaths. Whereas previously described dual-incision techniques have focused on posteromedial and posterolateral approaches to the ankle, the authors' posterior exposure, in particular, uses a midline skin incision and a longitudinal split of the Achilles tendon. This provides an excellent exposure and minimizes potential wound healing complications.