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Posterior to anterior malleolar extended lateral approach to the ankle (PAMELA): a cadaveric anatomic study

  • Trauma Surgery
  • Published:
Archives of Orthopaedic and Trauma Surgery Aims and scope Submit manuscript

Abstract

Introduction

The posterolateral approach is used in most cases of surgical treatment of ankle fractures involving the posterior and lateral malleoli. However, this approach does not allow access to the anterolateral structures of the ankle, which represent important landmarks to allow an anatomical reduction in case of complex ankle fracture.

Our objective is to propose a novel surgical approach for optimal management of injuries including both a fracture of the posterior malleolus and a complex lesion of the lateral and/or anterolateral portions of the ankle.

Methods

Cadaveric dissection, including a vascular study, was performed on eight specimens. Assessment included density of the vascular supply around the lateral malleolus, identification of the structures at risk, quality of exposure of the bony structures, and convenience of hardware fixation.

Results

The cutaneous flap benefits from a rich interconnected arterial supply. Structures at risk, including the superficial peroneal and sural nerves, the lesser saphenous vein, and the peroneal artery are easily identified and protected. The interval between the peroneal tendons and the flexor hallucis longus muscle provides optimal access to the posterior malleolus. The lateral malleolus is exposed by retracting the peroneal tendons medially. An anterolateral arthrotomy, respecting the anterior talofibular and tibiofibular ligaments, offers a sharp view on the talo-tibio-fibular junction. Hardware placement can be done with optimal access to any exposed surfaces.

Conclusions

The PAMELA opens a new perspective in the optimal management of complex fractures of the ankle. The approach allows optimal exposure to address fractures of the posterior malleolus, of the lateral malleolus, and of the anterolateral portion of the ankle through a single incision. Application in clinical practice is the subject of a future study in our institution.

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Acknowledgements

The authors thank the UFAM (Université Facultaire d'Anatomie et de Morphologie) of the University of Lausanne directed by Prof. J.-P. Hornung for the dissection facilities.

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Authors and Affiliations

  1. Department of Orthopedics and Traumatology, Lausanne University Hospital (CHUV), and University of Lausanne (UNIL), Pierre-Decker 4, CH 1011, Lausanne, Switzerland

    Anne Kummer & Xavier Crevoisier

  2. Unité Facultaire D’Anatomie Et de Morphologie (UFAM), Centre Universitaire Romand de Médecine Légale (CURML), Lausanne, Switzerland

    Hugues Cadas

Authors
  1. Anne Kummer
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  2. Hugues Cadas
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Contributions

All authors contributed to the study conception and design. Material preparation was performed by HC. Data collection and analysis were performed by XC and AK. The first draft of the manuscript was written by AK and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Xavier Crevoisier.

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This article does not contain any studies with human participants or animals performed by any of the authors.

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Kummer, A., Cadas, H. & Crevoisier, X. Posterior to anterior malleolar extended lateral approach to the ankle (PAMELA): a cadaveric anatomic study. Arch Orthop Trauma Surg 141, 427–435 (2021). https://doi.org/10.1007/s00402-020-03507-2

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  • DOI: https://doi.org/10.1007/s00402-020-03507-2

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