SLR - December 2023 - Martinez
Title: Posteromedial Surgical Approach for Fixation of Haraguchi 2B Posterior Malleolar FractureReference: Solasz S, Ganta A, Konda SR. Posteromedial Surgical Approach for Fixation of Haraguchi Type 2B Posterior Malleolar Fracture. J Orthop Trauma. 2023 Aug 1;37(8S):S9-S10. doi: 10.1097/BOT.0000000000002634. PMID: 37443437
Level of Evidence: Case report- IV
Reviewed By: Orlando Joshua Martinez
Residency Program: John Peter Smith Hospital. Fort Worth, TX
Podiatric Relevance: Ankle fractures often involve both the medial and lateral aspects of the posterior malleolus leaving the surgeon with question for best incision placement. Traditionally the posterolateral approach has been the standard specifically for ease of dissection and less neurovascular structures to potentially cause iatrogenic injury. This article reviews a case and breaks down steps for a posteromedial approach to these posterior malleoli fractures that may incorporate more of the posterior medial aspect/colliculi which is usually avoided due to the close proximity of the posterior neurovascular bundle.
Methods: Single case report demonstrating follow up of one patient for 3 months.
Results: Posteromedial incision can be helpful for combination posteromedial and posterolateral lip fracture of the posterior tibia. This specific case involved a Haraguchi 2B classification with an associated die punch type fragment that was lodged between fragments and a medial malleolar fracture with extension into posterior colliculi. A prone approach with incision between medial malleolus and Achilles with proximal extension offered great field of view of both posteromedial and posterolateral fragments.Fixation technique and hardware choice did not show any evidence of breakage or loosening at follow up visit after transition to full weight bearing ,which was initiated at 6 weeks post op. Current follow up only at 3 months still demonstrates adequate union with continued ability of patient’s to full weight bear.
Conclusion: This surgical approach can be very helpful for specific fractures involving the medial malleolus with possible extension into posterior colliculus and posterior malleoli. This variant may make the traditional posterolateral incision placement difficult for view and fixation of this fracture pattern.
Historically this posteromedial approach has been avoided due to the fear of damage to neurovascular bundle but this article breaks down the anatomy well to demonstrate appropriate interval between the FHL and FDL which will provide great visualization but protection of these vessels. This approach appears to be a great addition for surgeons to have in their repertoire especially if in need of minimizing number of incisions. If this approach can potentially provide adequate view of the posterolateral fragments as well, this can be extremely helpful to eliminate the need to make an additional posterolateral incision. There are countless limitations with this article as it is only a single case report. The fixation will vary and may not need to be focused on as much compared to data about incision complications or wound healing with this approach. This approach would provide improved chances of healing due to the robust angiosome in this region. This is a technique that is still gaining ground and may not be fully accepted from many surgeons as evident of the paucity of literature available. It will be interesting to see if this approach can be effective for very specific fracture types and one that may be stated more in the literature with longer term follow up results.