Traditional postero-medial ankle approach for Bartonícek type III in Volkmann Fractures: Is it useful?

Abstract

Introduction: There is evidence that the presence of a posterior malleolus fracture (PMF) worsens the prognosis of ankle fractures, making conservative treatment a poor choice. PMFs include a heterogeneous group of bone injury patterns that are sometimes associated to medial malleolus extensions, as well as fibula fractures or syndesmotic damage. This requires the surgeon to be well-versed in anatomy to choose the appropriate surgical approach. This study examines the relationship between the visualization of the distal posterior tibial surface through a Traditional Postero-Medial (TPM) approach in a simulated fracture pattern equivalent to Bartonícek type III fractures previously studied with axial CT images.

Methods: This is an experimental analytical cross-sectional anatomical study. Twenty fresh-frozen adult cadaveric ankle/foot specimens preserved at - 27 ºC at the University of Barcelona School of Medicine were examined. The traditional posteromedial approach was performed for each specimen, then anatomical measurements were performed. Subsequently, a Bartonícek type III fracture pattern was designed and generated for each of them. Finally, the anatomical view was correlated with axial CT images for each one and the fracture pattern was assessed. Measurements of Anatomical Visualization Surface (AVS), Total width of the Posterior M. (TWPM), Imaging Visualization Surface (IVS) and the Total Imaging Viewing Surface (TIVS) were recorded. Univariate and bivariate analysis was performed. The mean, standard deviation (SD), minimum and maximum values were calculated. The Intraclass Correlation Coefficient (ICC) was calculated.

Results: Of the 20 specimens, 9 were female and 11 male, with 8 right and 12 left specimens, aged between 65 and 95 years. The average Anatomical Visualization Surface (AVS) was 24.1 ± 7.49 mm. The average of the total width of the posterior muscle (TWPM) was 30.55 ± 7.19 mm. While the average visualization was 77 ± 11 %. The average Imaging Visualization Surface was 30.23 ± 6.1 mm. The average Total Imaging Visualization Surface was 37.53 ± 3.45 mm. While the average of visualization in CT was 80 ± 11 %. A degree of agreement (CCI) was obtained with a value of 0.667 CI 95 % (0.1773-0.8672). That is, the CCI is considered good (CCI value between 0.4 and 0.75).

Conclusion: The TPM approach is a valid alternative for surgical access and visualization of the PM, including complex Bartonícek type III fractures. The TPM approach achieves axial visualization of the distal posterior tibial plafond of 77 ± 11 %.

Keywords: Bartonícek type III in Volkmann Fractures; Posterior Tibial malleolus; Posterior malleolar fractures; Posterior surgical approach to the ankle; Traditional posteromedial approach to the ankle.