SLR - May 2017 - Whitney Ellis McConnell

How to Get to the Distal Posterior Tibial Malleolus? A Cadaveric Anatomic Study Defining the Access Corridors Through Three Different Approaches

Reference: Assal M, Dalmau-Pastor M, Ray A, Stern R. How to Get to the Distal Posterior Tibial Malleolus? A Cadaveric Anatomic Study Defining the Access Corridors Through Three Different Approaches. J Orthop Trauma. 2017 Apr;31(4):e127–e129.

Reviewed By: Whitney Ellis McConnell, DPM
Residency Program: Temple University Hospital, Philadelphia, PA

Podiatric Relevance: Trimalleolar ankle fractures and pilon fractures often require fixation of the posterior fragment. When they do, the question arises as to which approach for accessing this fragment reigns superior. This cadaveric study compares posterior approaches by reviewing the anatomy and exposure of the posterior column and posterior malleolus through three approaches: posteromedial, posterolateral and modified posteromedial.

Methods: Twelve cadaveric specimens were dissected by three senior orthopaedic surgeons. Any specimen with a scar or evidence of a previous incision were discarded. Each of the above approaches were utilized four times each by the three surgeons, giving the total of twelve limbs utilized. The specimens were then transversely cut to better demonstrate the exposure percentage and position of the posterior malleolus. The total length of the posterior plafond, from medial to lateral, was measured and compared to the amount exposed in each limb.

Results: The posteromedial approach demonstrated excellent visualization of the medial two-thirds of the posterior malleolus but did not provide exposure and visualization of the lateral one-third, syndesmosis and fibula. The posterolateral approach permits safe exposure of one-half of the posterior plafond, but the achilles tendon and the FHL make more medial access difficult. Finally, the modified posteromedial approach permits exposure of the greatest portion of the distal posterior malleolus, syndesmosis and fibula.  

Conclusions: The decision as to which approach to use should primarily depend on the location and extent of the posterior malleolus fracture. The modified posteromedial approach appears to provide a greater viewing area compared to the other two approaches. In all cases, computed tomography is essential in preoperative planning. 

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