Accessing the Posterior Malleolus: The posterolateral or medial posteromedial approach?

AR Gomaa, R Huynh, M Abdellatif, H Ben Nusir, G Jones, C Kennedy, A Moothoosamy, L Mason

Introduction: The posterolateral (PL) approach to the ankle remains to be commonly used for accessing the posterior malleolus (PM) despite its limitations which include inadequate exposure of the fracture as well as increased risk to peroneal artery. REF As such, the medial posteromedial (MPM) approach has been developed and described to address these two issues. REF The aim of this study is to compare the complications of the two approaches.

Methods: A historic cohort study all operatively treated ankle fractures between August 2022 and March 2024 was undertaken. Comorbidities, injury details, fracture morphology, operative details, clinical and radiographic follow-up were recorded. Complication were classification in line with the modified Clavien-Dindo grading for foot and ankle surgery.[1]

Results: 427 operatively treated ankle fractures were screened, 92 (21.55%) involved surgically treated PMFs. Of these, the MPM approach was used in 68 cases (73.91%), while the PL approach was used in 12 cases (13.19%). Of the 68 MPM approaches, 10 (14.71%) patients developed postoperative complications (Grade 1A: 3, Grade 1B: 1, Grade 2A: 3, Grade 2B: 1, Grade 3A:1, Grade 3B:1). Of the 12 PL approaches, 8 (66.67%) patients developed postoperative complications (Grade 1B: 1, Grade 2A: 4, Grade 2B: 1, Grade 3A: 1, Grade 3B: 1).

Conclusions: In this study, the MPM approach to the ankle was associated with fewer and less severe postoperative complications compared to the PL approach. The MPM approach has greater utility in exposing the posterior tibia and is possibly safer than the PL approach.