Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2019 Mar 19;2(2):e021.
doi: 10.1097/OI9.0000000000000021. eCollection 2019 Jun.

Posterior malleolus exposure

Brad Meulenkamp  1   2   3 , Hakim Louati  1   4 , John Morellato  1   2 , Steve Papp  1   2   3 , Karl Andre Lalonde  1   2   3
Affiliations

Posterior malleolus exposure

Brad Meulenkamp et al. OTA Int. .

Abstract

Objectives: Posterior malleolus (PM) fractures are common in rotational ankle injuries, tibial plafond fractures, and distal third tibia fractures. Surgical indications continue to evolve as we improve our understanding of ankle and syndesmotic stability. These fractures remain technically challenging with respect to both exposure and fixation. Our biomechanical cadaveric study compared posterolateral versus modified posteromedial surgical approaches to define the following: maximal surface area exposed, and maximal screw trajectory obtainable for fixation.

Methods: Twelve fresh-frozen cadaver limbs were thawed at room temperature. Posterolateral and modified posteromedial approaches were performed on each limb. Margins of exposure were marked. A 2.5 mm drill was advanced at the extreme medial and lateral extents of each exposure, standardized at 1 cm proximal to the joint line and perpendicular to the bone. Computed tomography (CT) scans were performed to identify the maximal trajectory. Limbs were stripped of soft tissue, and the exposed bony surface area was measured using a validated laser surface-scanning technique.

Results: The modified posteromedial approach allowed for a larger exposed surface area compared to the posterolateral exposure (median 99% vs 64%, respectively; P < .05). The modified posteromedial approach allowed for instrumentation of up to a median of 77% of the posterior distal tibia as opposed to 46% through the posterolateral approach (P < .05).

Conclusion: The modified posteromedial approach allowed for increased exposure and wider access for instrumentation of the PM when compared to the posterolateral approach. We advocate use of this approach when addressing complex PM fractures, in particular the Haraguchi type 2 fracture pattern.

Keywords: Haraguchi; ankle; approach; biomechanical; cadaver; exposure; modified posteromedial; posterior malleolus; posterolateral; screw trajectory.

PubMed Disclaimer

Conflict of interest statement

The authors have no conflicts of interest to disclose.

Figures

Figure 1
Figure 1
Examples of a Haraguchi II type fracture: anteroposterior, lateral and axial CT cut demonstrating extent of fracture line with articular impaction and loose fragments.
Figure 2
Figure 2
Posterolateral approach exposure. AT = Achilles tendon insertion, Fib = distal fibula, P = peroneal tendons.
Figure 3
Figure 3
Modified posteromedial approach exposure. AT = Achilles tendon insertion, MM = medial malleolus, TN = tibial nerve.
Figure 4
Figure 4
Laser-and-camera surface scanning system setup and imaging: (A) distal tibia stripped of soft tissue with burr etchings outlining each exposure; (B) laser-camera surface-scanning system using saw bone as example; (C) digitalized image of specimen depicted in (A).
Figure 5
Figure 5
Example of surface area exposed from the posterolateral, direct posterior and posteromedial view. Yellow depicts surface exposed exclusively through the posterolateral approach. Blue depicts surface exposed exclusively through the modified posteromedial approach. Green depicts surface exposed through both approaches. This example is from specimen 2.
Figure 6
Figure 6
Averaging of perpendicular screw trajectories obtained through the posterolateral and modified posteromedial approaches.
See this image and copyright information in PMC

References

    1. Gardner MJ, Streubel PN, McCormick JJ, et al. Surgeon practices regarding operative treatment of posterior malleolus fractures. Foot Ankle Int. 2011;32:385–393. - PubMed
    1. Haraguchi N, Haruyama H, Toga H, et al. Pathoanatomy of posterior malleolar fractures of the ankle. J Bone Joint Surg Am. 2006;88:1085–1092. - PubMed
    1. Assal M, Ray A, Fasel JHD, et al. A modified posteromedial approach combined with extensile anterior for the treatment of complex tibial pilon fractures (AO/OTA 43-C). J Orthop Trauma. 2014;28:e138–e145. - PubMed
    1. Irwin TA, Lien J, Kadakia AR. Posterior malleolus fracture. J Am Acad Orthop Surg. 2013;21:32–40. - PubMed
    1. Tornetta P, Ricci W, Nork S, et al. The posterolateral approach to the tibia for displaced posterior malleolar injuries. J Orthop Trauma. 2011;25:123–126. - PubMed

LinkOut - more resources