SLR - February 2022 - Logan H. Mitchell
Reference: Campbell ST, DeBaun MR, Kleweno CP, Nork SE. Simultaneous Posterolateral and Posteromedial Approaches for Fractures of the Entire Posterior Tibial Plafond: A Safe Technique for Effective Reduction and Fixation. J Orthop Trauma. 2022 Jan 1;36(1):49-53Level of Evidence: 3
Scientific Literature Review
Reviewed By: Logan H. Mitchell, DPM
Residency Program: Kaiser SF Bay Area Foot and Ankle Residency Program – Oakland, CA
Podiatric Relevance: Posterior fractures of the tibial plafond are a relatively common fracture pattern seen in malleolar trauma. When operating on these fractures, visualization of the entire posterior plafond can be challenging through one incision. This study evaluates the wound healing complications and fracture reduction associated with a combined posteromedial and posterolateral approach to the ankle joint.
Methods: This is a retrospective review from a Level 1 trauma center. They evaluated all patients treated for a posterior tibial plafond fracture from 2000-2019 using dual posterior medial and posterior lateral incisions. The authors collected the following demographic data: age at time of procedure, sex, history of diabetes mellitus, smoking history, or rheumatological illness. They also collected injury characteristics including mechanism of injury, presence of an open injury, fibula fracture pattern, syndesmosis injury, initial ankle dislocation, posterior medial impaction, osteochondral comminution, and extension of the injury into the anteromedial colliculus. The authors also collected surgical variables which included staged management with a spanning external fixator, use of a third incision, and fixation of the syndesmosis. The outcomes assessed were: Accuracy of articular reduction (assessed on postoperative mortise and lateral views), wound healing problems, deep infection, nonunion, removal of symptomatic implants, and unplanned reoperations.
Results: Thirty-three (33) patients were included in the study. Thirty-one of thirty-three (94 percent) patients had articular gaps less than 1 millimeter. Two of thirty-three (6 percent) patients had wound healing problems, with one patient developing a deep space infection. No patients had toe stiffness or paresthesias in the tibial nerve distribution.
Conclusions: The posterior tibial plafond fracture can be assessed by multiple approaches. From an osseous standpoint, this study demonstrates that complex posterior plafond fractures can be well reduced using this dual approach. More importantly, this study demonstrated low wound healing problems using this dual incision approach with a relatively small skin bridge. Lastly, they found no tibial nerve symptoms in their group of patients. Overall, the authors demonstrated an efficacious approach to the entire posterior tibial plafond, and found it to be safe from a wound healing and soft tissue standpoint.