Lateral Malleolar Fractures Research Articles

Arthroscopic anterior talofibular ligament repair with Internal Brace and lasso-loop technique for chronic ankle lateral instability.

To introduce the surgical technique and clinical outcomes of arthroscopic anterior talofibular ligament (ATFL) repair using the Internal Brace and lasso-loop technique for chronic ankle lateral instability. A retrospective study was performed on 29 patients who underwent all-arthroscopic ATFL repair with the Internal Brace and lasso-loop technique from January to August 2020. The patients included 24 males and five females, with a mean age of 30.17years. Through the accessory anterolateral (AAL) portal, we drilled the bone tunnels and fixed the tape with 4.75mm and 3.5mm "SwiveLock" anchors and reattached the torn ligament by the lasso-loop technique. All 29 patients underwent all-arthroscopic procedures smoothly without serious complications, such as infection and important nerve or vessel injuries. There were eight cases of lateral malleolar avulsion fractures and ten cases of talus cartilage injury. The visual analog scale (VAS), Karlsson-Peterson, Tegner, and American Orthopedic Foot and Ankle Society (AOFAS) scores were used to evaluate the clinical consequences. All the patients were followed up for 18.66 ± 4.85months on average. The average pre-operative VAS score was 4.69 ± 1.04, which was significantly higher than the average post-operative VAS score of 1.14 ± 1.56. At the final follow-up appointments, the averages of Karlsson-Peterson, AOFAS, and Tenger scores were 75.83 ± 9.44, 88.31 ± 6.81, and 6.93 ± 1.79, respectively, which was significantly higher than that before the operation. This arthroscopic anterior talofibular ligament repair with the Internal Brace and lasso-loop technique achieves satisfactory clinical outcomes with the benefits of high safety and reliability for chronic ankle lateral instability.

Malleolar Fractures - Indication for Nonoperative and Operative Treatment

Malleolar Fractures - Indication for Nonoperative and Operative Treatment Abstract. In order to understand the trauma mechanism and the expected pattern of injury, malleolar fractures can be classified according to Lauge-Hansen [1]. For isolated lateral malleolar fractures, the Weber classification is also frequently used [2]. For most Weber A fractures and 80% of Weber B fractures conservative treatment is indicated. In all isolated Weber B fractures a supination-external rotation (SER) injury has to be distinguished from a pronation-abduction (PA) injury according to the Lauge-Hansen classification. In SER fractures, stability should be assessed by a gravity stress and a weightbearing radiograph. If the fracture is stable, it can be treated nonoperatively. We recommend surgical treatment for unstable Weber B SER injuries, Weber B PA injuries, and Weber C fractures.

Outcomes of tibial pilon fracture fixation based on four-column theory

ObjectivesTo assess the medium-term functional and radiological outcomes, as well as injury mechanisms, fracture patterns and demographics of typical pilon fractures and pilon variant fractures treated based on the four-column theory in adults. MethodsA retrospective comparative study was performed. Demographics of typical pilon and pilon variant fractures, injury mechanisms, OTA/AO classification, Rüedi-Allgöwer and the four-column classification were analyzed for the cohort. Radiographic ankle arthrosis (modified Kellgren-Lawrence 3/4), Burwell Charnley Score, and AOFAS score were also analyzed. ResultsThere were 142 pilon fractures met the inclusion and exclusion criteria for this study, of which 77(54.23%) were females and 65 (45.77%) were males, with an average of 48 (range, 18-86)years. One hundred twenty-five posterior columns fractured in 142 pilon fractures, and the posterior columns were most prone to fractures. Ninety cases of posterior pilon fractures in 142 pilon fractures were single posterior column fractures with or without medial or lateral malleolar fractures. The average age (51, range, 18-86 years) of low-energy pilon fractures was older than the average age (42, range, 19-66 years) of high-energy pilon fractures significantly. The average time (5, range, 0-17 days) from injury to definitive internal fixation of the low-energy group was shorter than the average time (9, range, 0-21 days) from injury to definitive internal fixation of the high-energy group significantly. The average of AOFAS (87, range, 56-100) of the low-energy group is higher than the average of AOFAS (82, range, 47-100) of the high-energy group significantly. There were more male patients and more die-punch or intercalary fractures in high energy groups significantly. There were more medial and lateral malleolar fractures in low-energy groups. Compared with the non-multiple column group, the multiple-column group had more Rüedi-Allgöwer type III cases, more modified Kellgren-Lawrence 3/4 cases and lower AOFAS score significantly. However, the numbers of Burwell Charnley Score type 1 and 2 cases were not significantly different between the two groups. ConclusionsKinds of pilon variants should be recognized. Outcomes of high-energy pilon fractures were worse than low-energy pilon fractures. The four-column theory can be applied to typical pilon fracture and pilon variants in adults.

Open Reduction and Fixation of Lateral Malleolus and Syndesmosis for Ankle Re-Fracture

Rotational ankle fractures are often accompanied with a syndesmotic injury. Furthermore, malreduction of syndesmosis and fibular shortening are frequent errors observed in these cases and often lead to poor functional outcomes. We present a case of Weber C lateral malleolus fracture and distal tibiofibular syndesmotic injury in an active 23-year-old patient. Various techniques for syndesmotic reduction and restoration of fibular length are discussed and demonstrated.

Ram Janam Sulakshana Gold medal award (2021) Outcome Analysis of Posterior Plating and Lateral Plating for Lateral Malleolus Fracture

Ram Janam Sulakshana Gold medal award (2021) Outcome Analysis of Posterior Plating and Lateral Plating for Lateral Malleolus Fracture

Is the osteosynthesis of lateral malleolar fractures by pin/cerclage effective? A retrospective study

IntroductionLateral malleolar fractures are present in about 90% of ankle fractures. The standard treatment is plate osteosynthesis. Although the plates are thin, the risk of cicatricial complications is not insignificant and can lead to cutaneous or even infectious complications and the latter can cause functional repercussions. We therefore aimed to evaluate a technique consisting of osteosynthesis of the lateral malleolus using two cerclages and two intramedullary pins. HypothesisOur hypothesis is that the use of osteosynthesis by pin/cerclage of the lateral malleolus makes it possible to have objective reduction criteria, similar to the reference treatment. MethodsThis is a retrospective study of patients who had an interligamentous spiral fracture of the lateral malleolus. One group of patients had internal fixation of the lateral malleolus fracture by pins, and the other by plate. Our primary outcome was to compare the reduction of the fracture of the lateral malleolus between the two techniques using the “Dime sign”, the measurement of the talocrural angle and respect for Shenton's line. ResultsA total of 118 lateral malleolar fractures were included: 56 patients (47.5%) in the “pin” group and 62 patients (52.5%) in the “plate” group. The mean age of the patients was 46.6 years (17.4) with an average body mass index of 25.2kg/m2 (4.8) and 55.1% of the patients were women. We found a difference in the reduction criteria between the two groups by looking at Shenton's line: 73.2% (41/56) of postoperative X-rays in the “pin” group respected Shenton's line, compared to 90.3% (56/62) in the “plate” group (p=0.02). We did not find any difference regarding the “Dime sign” and the talocrural angle. ConclusionOur study shows the superiority of plate osteosynthesis for lateral malleolar fractures compared to pin/cerclage osteosynthesis, regarding one of the three radiological criteria for reduction. No significant difference was found in the one-year rates of complications and of hardware removal, between the two groups. Level of evidenceIV, retrospective study.

Assessing the Utility of Deltoid Ligament Repair in Ankle Fracture: A Systematic Review.

Ankle fractures are common injuries treated by orthopedists. Indications for operative repair of deltoid ligament (DL) injuries in ankle fracture patients are debated. The purpose of this review is to determine the indications for operative DL repair.Ovid MEDLINE, CINAHL, and Scopus were searched up to December 2019. Web of Science was searched up to August 2018. Search terms included “Deltoid” and “Ligament” or “Ligaments.” Comparative studies assessing conservative vs operative DL repair were searched for. Articles meeting inclusion criteria were screened in two stages to determine eligibility.Out of 1,542 articles, nine were included in our qualitative synthesis. These nine studies included 449 patients, of which 233 were treated with open reduction internal fixation (ORIF) with or without trans-syndesmotic (TS) screw fixation, and 205 of which were treated with ORIF with DL repair. The remaining 21 patients were managed nonoperatively, had no evidence of DL injury, or were lost to follow-up.There is a lower rate of malreduction associated with DL repair compared to TS screw fixation. Moreover, DL repair may be useful in treating patients with Weber Type C fractures, concomitant DL-syndesmotic disruption, or residual valgus instability following ORIF in isolated lateral malleolar fractures.

Bilateral Talocalcaneal and Talocalcaneocentral Luxation after a Road Traffic Accident in a Dog

AbstractA 4-year-old, 25 kg, male, castrated, crossbreed dog was referred after having been driven over by a trailer 3 days prior. On examination, the dog was unable to ambulate on the pelvic limbs. There was crepitus, soft tissue swelling and pain on manipulation of the tarsi, with bilateral rotational and suspected mild lateral instability. Radiographs identified bilateral talocalcaneal luxation with dorsal displacement of the head of talus and bilateral avulsion fracture of lateral malleolus. A dorsomedial approach to the tarsocrural joint was performed bilaterally and the dorsal luxation of the head of talus was reduced. A 3.5 mm positional cortical screw was placed on both sides from dorsomedial head of talus to plantarolateral distal calcaneus. A temporary calcaneotibial screw was also applied bilaterally. No complications were encountered apart from mild bandage-related dermatitis, and the dog made a complete recovery. No lameness was identified on subjective gait assessment at 14 weeks and 12 months postoperatively; however, mild-to-moderate osteoarthritis affecting the talocalcaneocentral and centrodistal joints was identified at 12 months postoperatively.

Fibula Nailing: A Retrospective Review of 110 Consecutive FibuLock Nails.

To evaluate the treatment of unstable lateral malleolar fractures using a fibula nail with both proximal and distal locking capabilities. Retrospective review of 110 single-surgeon consecutive fibula nails. Single-surgeon, private practice community hospital. One hundred ten fractures, 92 OTA/AO 44B and 18 OTA/AO 44C. FibuLock fibula nail (Arthrex, Naples, FL). Demographic, operative, clinical, and radiographic outcome data. One hundred two patients/102 fractures met criteria. Ninety percent had a f/u of ≥12 months (mean 12.2 months). All fractures healed. There were no superficial or deep infections, no nonunions, or malunions. Two fractures required conversion to plate fixation intraoperatively because of excessive comminution which precluded the use of a nail, while one patient sustained an iatrogenic superficial peroneal nerve neuroma. No patients reported implant irritation, and none have required implant removal. Fibula nails with proximal locking capabilities offer an alternative to plating with the potential for lower complication rates and lower need for implant removal. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Comparison of the WALANT and the PFNB techniques in the surgical treatment of unimalleolar fractures: a prospective study.

The popliteal fossa nerve block (PFNB) technique is one of the most popular anesthesia method in the foot and ankle surgery. The wide awake local anesthesia no tourniquet (WALANT) technique is an local anesthetic method and it has been gaining popularity in orthopedic surgery in recent years. Our aim is to compare the efficacy of the WALANT and the PFNB techniques in pain management. This prospective study included 40 patients with lateral malleolar and medial malleolar fractures. The first group was anesthetized using the WALANT technique; in the second group, PFNB was performed. All patients were evaluated for intrasurgical bleeding amounts, mean arterial pressure, surgery time and VAS scores for presurgical pain, pain during the local anesthetic injection sequence, mean intrasurgical pain, mean postsurgical pain. A total of 40 patients in both groups were successfully operated on with the WALANT and the PFNB techniques. When the two groups were compared, statistically significant differences were observed for mean intrasurgical VAS (p = 0.033), mean postsurgical VAS (p = 0.038) and intrasurgical bleeding (p = 0.006). No significant difference was found in pain scores during anesthetic injection (p = 0.529), mean arterial pressure (p = 0.583) and surgery time (p = 0.277). The PFNB technique is more successful in pain management in the treatment of the unimalleolar fractures. Intrasurgical bleeding amounts were less detected in the WALANT tech- nique. The both techniques are a reliable and suitable anesthetic method in the surgical treatment of uni- malleolar fractures.

Early Return to Daily Life through Immediate Weight-Bearing after Lateral Malleolar Fracture Surgery.

Lateral malleolus fracture is one of the most common fractures. However, there is controversy regarding the rehabilitation protocols used after surgery. In particular, the initiation point for weight-bearing has not been standardized. In the present study, we investigated the prognostic difference between immediate and delayed weight-bearing on lateral malleolus fractures. The medical records of matched patients in the immediate and delayed weight-bearing groups (50 and 50, respectively) were reviewed retrospectively. All patients were treated with open reduction and internal fixation using an anatomical locking compression plate with a lag screw. In the immediate weight-bearing group (IWB), tolerable weight-bearing (i.e., what can be endured immediately after surgery with crutches) was permitted. In the delayed weight-bearing group (DWB), weight-bearing was completely restricted for 4 weeks after surgery. Ankle motion exercise was permitted in both groups, starting from the day after surgery. Radiographic assessment data and clinical outcomes were reviewed between the two groups. No significant differences in radiographic assessments and complications were found between the two groups. Significant differences in terms of a shortened length of hospital stay and time to return to work with the IWB rehabilitation protocol compared with DWB were confirmed (6.0 vs. 9.2 days, p = 0.02 and 6.1 vs. 8.3 weeks, p = 0.02, respectively). A significant difference in sport factor was observed in the Foot and Ankle Outcome Score at 3 months postoperatively (72.3 vs. 67.4, p = 0.02). We found no significant differences between the two groups concerning postoperative radiological outcomes and complications. The benefits of shortening the time to return to work and length of hospital stay associated with the IWB rehabilitation protocol were confirmed. In conclusion, immediate weight-bearing is recommended in patients with lateral malleolus fracture after anatomical reduction and firm fixation by surgery.

Lateral malleolar fractures Weber Type A and B: does percutaneous intramedullary screw confer a solid alternative to the traditional neutralization plate?

PurposeTo compare the clinical results, complication rates, and radiographic outcome between both methods of fixation of lateral malleolar fractures: lateral neutralization plates and intramedullary fully threaded screws.Patients and methodsThis prospective case series study involved 73 patients with fractured lateral malleolus of type A, B according to Weber classification, to whom internal fixation was performed by either lateral plate and screws construct (Group A) or intramedullary screw (Group B). All patients were followed up for 12 months at least, with an average follow-up time of 12.7 months.ResultsThere was no significant difference in the functional outcome score between both groups. The intramedullary screw group had a significantly shorter operative time and time to full union (P<0.001 and =0.006 respectively). There was a relatively higher accuracy of reduction with the plate fixation group, but it was statistically insignificant. There was a relatively fewer complication rate with the use of intramedullary screw fixation compared to plate fixation.ConclusionThe use of intramedullary fixation is a good alternative for plate fixation in low fibular fractures (Weber A and B). Although plate fixation provides an optimal anatomic reconstruction of the fractures, intramedullary fixation may have a lower risk of complications.

Surgical treatment of displaced isolated lateral malleolar fractures: incidence of adverse events requiring revision: a retrospective cohort study

BackgroundRecent systematic reviews support that non-operative management should be the standard treatment for all stable isolated lateral malleolar fractures (ILMFs), regardless of fibular fracture displacement. Surgical fixation of ILMFs carries a risk of adverse events (AEs), and many patients will later require implant removal. We wanted to estimate the incidence of AEs requiring revision after surgical fixation of “potentially stable” displaced ILMFs before non-operative treatment became standard care in our department.Materials and methodsTo identify patients with “potentially stable” ILMFs who had been treated surgically in a historical cohort, we retrospectively applied the stability-based classification system, introduced by Michelson et al., to a cohort of 1006 patients with ankle fractures treated surgically from 2011 to 2016. The primary outcome of this retrospective cohort study was the incidence of AEs that had functionally significant adverse effects on outcome and required revision in the first 12 months after surgery. AEs were graded and categorized using the Orthopedic Surgical Adverse Events Severity (OrthoSAVES) System.ResultsThe study population comprised 108 patients with “potentially stable” displaced ILMFs; 4 patients (3.7% [95% CI (0.1–7.3%]) experienced AEs requiring revision in the first twelve months after surgery. There were 5 additional patients (4.6%) with functionally significant AEs where revision surgery was not indicated within the first twelve months after surgical fixation. A further 5 patients (4.6%) had AEs managed in the outpatient clinic (grade II); 36 patients (33.3%) required secondary implant removal due to implant-related discomfort.ConclusionsSurgical fixation of ILMFs carries a risk of severe AEs, and many patients will subsequently need implant-removal procedures. Further prospective studies are required to ascertain whether non-operative treatment can lower the risk of AEs and the need for additional surgical procedures.

Modified Posterolateral Approach for the Treatment of 2-Part Fractures of the Posterior Malleolus Associated with Medial and Lateral Malleolar Fractures: 1 Incision, 2 Windows, 3 Steel Plates.

BackgroundThe aim of this study was to investigate the effect of the modified posterolateral approach using 1 incision, 2 windows, and 3 plates in the treatment of 2-part posterior malleolus fractures complicated with medial and lateral malleolus fractures.Material/MethodsTwelve patients with 2-part fractures of the posterior malleolus complicated with medial and lateral malleolar fractures and treated by the modified posterolateral approach from January 2018 to January 2021 were studied retrospectively. After surgery, the ankle hindfoot score and visual analog scale (VAS) of the American Orthopedic Foot and Ankle Society (AOFAS) were used for evaluation.ResultsThe average follow-up time of the 12 patients was 18 months (7–30 months). All patients had no infection, and their incisions healed in the first stage. Postoperative radiography showed that the average fracture healing time was 12.5 weeks (10–15 weeks). The average time for patients to walk weight bearing was 13 weeks (11–16 weeks), and there was no obvious pain or discomfort. At the last follow-up, the average AOFAS ankle hindfoot score of the 12 patients was 87.5 (77–95), with 7 excellent and 5 good scores. The VAS score improved from before surgery (average 8.25 points) to after surgery (average 1 point). The curative effect was satisfactory.ConclusionsThe posterolateral approach using 1 incision, 2 windows, and 3 steel plates was effective in the treatment of 2-part posterior malleolus fractures complicated with medial and lateral malleolus fractures.

Fractures of the lateral malleolus \u2013 a retrospective before-and-after study of treatment and resource utilization following the implementation of a structured treatment algorithm

BackgroundIn 2015 a study of isolated lateral malleolar fractures (AO/OTA44-B1) treated at Sahlgrenska University hospital (SU) during two consecutive years revealed large-scale variation in the choice of treatment and planned follow-up. The study resulted in the development of a structured treatment algorithm (TA) for ankle fractures. We investigated the effects of this well-implemented TA on the classification, treatment and follow-up of lateral malleolar fractures.MethodsThe current study is an uncontrolled, non-randomized, retrospective before-and-after study comparing a group of AO/OTA44-B1 fractures treated at SU before the introduction of the TA for ankle fractures (1 April 2012 to 31 March 2014) with a group treated after the introduction of the TA (1 September 2017 to 31 August 2019).ResultsIn all the studied parameters regarding treatment for AO/OTA44-B1 fractures, a statistically significant change was seen after the introduction of the TA. Surgical treatment reduced from 32% (95% CI 27.5 – 36.5) pre-TA to 10% (95% CI 6.9 – 13.1) post-TA, while the number of patients permitted full weight-bearing increased from 41% (95% CI 36.3 – 45.7) to 84% (95% CI 80.1 – 87.9).ConclusionsA thoroughly implemented treatment algorithm can reduce the number of surgical treatments for stable ankle fractures. The current study demonstrates that a structured treatment algorithm can standardize the management of ankle fractures and make decisions less dependent on the surgeon’s discretion.

A prospective observational study of functional outcome of pott’s fracture managed with operative modalities

Introduction: The movement around the ankle joint is very important because of the cultural practices, which involve squatting and sitting cross-legged. Bimalleolar Pott’s fractures are very common in ankle joint injuries because of the increased incidence of road traffic accidents and industrial trauma. Accurate reduction of fractures around the ankle joint is important for a painless ankle joint. AIM: To study the functional outcome of surgically managed closed bimalleolar fractures of the ankle in adults; to evaluate the restoration of the anatomy of malleoli and ankle perfectly by operative treatment with internal fixation; to assess the union of fractures after surgical management; and to achieve stable fixation and early mobilization of the ankle. Materials and Methods: We have evaluated clinical, radiological and functional outcomes of 50 patients treated with different treatment modalities, which include - tension band wiring (TBW), Kirschner (K)-wire, malleolar screw (MS) and cannulated cancellous screws (CCS) for medial malleolus fracture and rush nail, one-third tubular plate, fibular locking plate for lateral malleolus fracture. Results: The present study of 50 patients with ankle fractures treated by open reduction and internal fixation. Excellent results were achieved in 27 (54%) patients, good in 14 (28%), Fair in 5 (10%) and Poor in 4 (8%) patients. The patient with poor results had mild pain with activities of daily living, diminution in the abilities to run and to do work, the reduced motion of the ankle and narrowing of joint space.Conclusion: Closed treatment is often inadequate for restoring the proper biomechanics and anatomical structure of an injured ankle joint, internal fixation is an excellent method. Treating malleolar fractures with the use of anatomic fixation and open reduction was found to be very effective.

Anti-Glide Plate Fixation for Lateral Malleolus Fractures by Minimally Invasive Technique in Geriatric Patients.

The objective was to evaluate the functional outcomes of anti-glide fixation by minimally invasive plate osteosynthesis (MIPPO) in lateral malleolus ankle fractures.The study was a retrospective cohort study conducted at a single trauma center. We reviewed 39 patients >60 years old with either isolated or non-isolated lateral malleolus Weber B ankle fractures.The main outcome measures were postoperative functional assessment performed with the American Orthopaedic Foot and Ankle Society (AOFAS) and Short Musculoskeletal Functional Assessment (SMFA) scores. Our results showed that the mean time to surgery was 1 day. Seventeen patients underwent surgery within 24 hours after sustaining the injury. The mean AOFAS and SMFA scores were 87.8 and 209.7, respectively. No patient developed implant failure or wound complications.It was concluded that the anti-glide plating of the lateral malleolus had better functional outcomes compared to lateral plating by open reduction and internal fixation (ORIF), as shown by the higher AOFAS scores and fewer postoperative complications.

Comparison of Posterior and Lateral Surface Plating for Type B Weber Lateral Malleoli Fractures.

The purpose of this study is to compare the functional outcomes, radiological outcomes, complication rates, and hardware removal between lateral and posterior surface plating in isolated type B Weber lateral malleolus fractures. It was a retrospective study that compared the outcomes of type B Weber lateral malleoli fractures treated by either lateral surface or posterior surface plating. Radiological and functional outcomes were assessed at regular intervals. The follow-up details and the complications and need for implant removal were collected from the hospital records. Our study included 60 patients (male-35 and female-25). The mean age was 41.7 ± 10.5 years. In all, 28 (46.7%) patients received lateral surface plating and 32 (53.3%) patients received posterior surface plating. The mean time gap between the injury and the surgery was significantly more among patients who underwent lateral plate insertion (P < .001). The mean operative time required for both the procedures was comparable, hence nonsignificant (P = .576). The mean American Orthopaedic Foot and Ankle Society score (AOFAS) after 2 years of operation was significantly higher for posterior plate insertion (P = .014). The complication rates as well as the implant removal rates were higher in patients with lateral plating (P < .05). Posterior surface plating can be considered as the procedure of choice for isolated type B Weber lateral malleolus fractures with respect to better functional outcome, lesser complications rates, and need for implant removal. Level III: Economic/decision.

Ankle fractures in Finland: 118,929 operatively treated between 1987 and 2019.

Background and purposeAnkle fractures are one of the most common fractures requiring operative treatment. They occur most commonly in postmenopausal women and younger men and recent studies suggest that the incidence of ankle fractures is increasing. In this registry study, we analyze inpatient data of operatively treated ankle fractures during a period of 33 years from our comprehensive nationwide register data.Patients and methodsThe data on operatively treated ankle fracture patients between January 1, 1987 and December 31, 2019 was collected from the Finnish National Hospital Discharge Register and analyzed.Results118,929 ankle fractures were treated operatively. These included lateral malleolar fractures (33%), bi- or trimalleolar fractures (51%), medial malleolar fractures (7%), and other fractures (9%). Mean age was 53 (SD 17) years for women and 43 (16) for men. The average annual incidence rate was 69 per 100,000 person-years. Over the past 3 decades incidence has leveled off for women and has started to decline for men. However, the incidence is increasing in the elderly women group (over 70 years of age). In the over 50 age group, comorbidities have increased over the years, being more common in men than in women. The incidence of ankle fractures was higher during the winter months (November–March).InterpretationThe number of operatively treated ankle fractures has leveled off during the last 33 years. However, nowadays we operate on more difficult fractures in elderly patients with comorbidities.

Posterior to anterior malleolar extended lateral approach to the ankle (PAMELA): early results of a novel approach

IntroductionIn a previous cadaveric study, we described the Posterior to Anterior Malleolar Extended Lateral Approach (PAMELA) to address complex ankle fractures. It was demonstrated to provide optimal exposure of the posterior and lateral malleoli, and of the anterolateral portion of the ankle through a single incision. The aim of this study is to report the clinical results of this novel approach.MethodsBetween January 2019 and January 2021, all patients presenting with a complex ankle fracture in our institution were assessed by CT scan. Indication to use the PAMELA was determined by the fracture pattern, according to our previous guidelines, including combination of complex lateral and displaced posterior malleolar fractures, associated in most cases with anterolateral fracture avulsion. The approach was performed according to the steps previously described. Intraoperative evaluation included quality of exposure, ease of performing the osteosynthesis, and any complication encountered. The postoperative course was assessed for wound healing, quality of reduction, and the occurrence of any complication.ResultsThe PAMELA was performed in 20 patients (aged 17–73). The most common combination of fractures was a comminuted lateral malleolus fracture associated with a displaced fracture of the posterior malleolus and a Wagstaffe-Le Fort or Chaput avulsion. We encountered no intraoperative complication. X-rays showed anatomical reduction in all cases. Postoperative complications included three delayed wound healing resolved with local treatment and one sural nerve traction injury.ConclusionsThe main potential concern regarding this novel approach was the healing of the flap. Our results reject this concern and are in line with wound healing complications reported following surgical treatment of ankle fractures. This study confirms the safe in vivo feasibility of the PAMELA and opens a new perspective in the optimal management of complex fractures of the ankle. A larger prospective clinical study is ongoing in our institution.