SLR - December 2022 - Ben M. Tonsager, DPM
Title: Posterior to Anterior Malleolar Extended Lateral Approach to the Ankle (PAMELA): Early Results of a Novel ApproachReference: Kummer, A., Crevoisier, X. Posterior to anterior malleolar extended lateral approach to the ankle (PAMELA): early results of a novel approach. Archives of Orthopaedic and Trauma Surgery 2022 February 03.
Level of Evidence: Level IV
Reviewed by: Ben M. Tonsager, DPM
Residency Program: Regions Hospital/HealthPartners Institute, Saint Paul, MN
Podiatric Relevance: The healing potential and outcome of an ankle fracture relies heavily on achieving anatomic reduction through either open or closed reduction. Complex ankle fractures involving the posterior malleolus, lateral malleolus, and anterolateral portion of the ankle can complicate anatomic restoration. Historically, restoration would involve multiple incisions, thus increasing the possibility of wound healing complications. This study demonstrates a new incisional approach that allows exposure of both the posterior and lateral malleoli in combination with the anterolateral portion of the ankle with use of a single incision. The goal of this study was to report early results on this incisional approach with an emphasis on cutaneous flap healing.
Methods: Patients presenting to this institution with complex ankle fractures between January 2019 - January 2021 underwent X-ray and CT evaluation. PAMELA indication was determined by fracture pattern followed by validation through the senior author. These primarily consisted of complex lateral and displaced posterior malleolar fractures, often with anterolateral avulsion fractures. Patients were placed in either lateral decubitus or 3/4 supine position with vacuum mattress, depending on the need for medial ankle access. The proposed incisional approach is “L” shaped with the apex located slightly posterior to the distal tip of the fibula. Longitudinal incision is approximately 10 cm long. The distal part of the incision was carried out obliquely to the tip of the lateral malleolus and sinus tarsi. Intraoperative and postoperative course was monitored for quality and complications.
Results: A total of 20 patients were a part of this study with a median follow-up of 21 weeks. No complications were encountered during the procedure while quality of exposure and access for osteosynthesis were optimal in all cases. Anatomical reduction was achieved in all cases. Postoperative complications included three cases of delayed wound healing and one sural nerve traction injury. With local treatment, all complications were resolved, and the surgical flaps of all patient’s went on to heal uneventfully.
Conclusions: The primary focus of this article was to evaluate a novel incisional approach for the treatment of complex ankle fractures with a focus on postsurgical healing potential. Following this study, the authors concluded that the healing rates and complications of the proposed incision were comparable to those of classic ankle fracture surgical treatments. Currently, the same institution is working on a larger prospective study of this incisional approach. If results of this study draw the same conclusion, this new approach would be a viable surgical treatment option of complex ankle fractures that can allow for better open reduction and perhaps more optimal anatomic restoration of these fractures. This would increase patient safety, mobility, and satisfaction throughout the postoperative course.