EARLY RESULTS OF A NEW SINGLE APPROACH

“An Extended posteromedial approach of the Ankle”

(through four surgical windows)
for combined Posterior and medial malleolar fractures

Dr N. Purushothama Rao,
MB, MS Orth, MCh Orth (UK), MRCS Ed. MRCS Glas.

Extended Posteromedial approach incision and final healed scar

 Only 4 slides
• abstract
• Methods
• Surgical Procedure
• Results
• Discussion
 Abstract
Aims/ Objectives:
• There has been evolution recently, in the management of unstable fractures of
the ankle, with a trend towards direct fixation of a posterior malleolar
fragment. Hence there is a need for an extensile Posterior approach especially
for those that are difficult reach by a standard posterolateral approach ( Eg.
Haraguchi type 2 fractures, combined PM & MM #s and simple posterior
pilon#s) .
• With this aim, a new surgical approach ‘an extended posteromedial’ approach
been described, to address these fractures and a study been done to assess its
efficacy and safety and its superiority over the PL approach

Patients and Methods: This study involved 8 patients who underwent ORIF thro an Extended Postero medial
approach, for various Posterior Distal tibial #s( a Haraguchi type 2 posterior malleolar fracture, MM &
PMF as separate #s, Posterior pilon # variants)

Results : The median Olerud and Molander score was 72 (IQR 70 to 75), representing a good functional
outcome. No patient had any wound healing/ NV problems.

Conclusion : This new EPM approach is a safe technique that enables good visualisation and reduction of the
individual fracture fragments with promising early outcomes.
Aims/ Objectives
Abstract
 Having established the importance ( esp in the last 2 decades) of ORIF of PM #, there
has been a recent trend towards direct fixation of posterior malleolar fragment.

 Fixation of the PM# therefore has several advantages: restoration of the articular surface
of the tibia; accurate restoration of length of the fibula, helping to avoid malunion
restoration of stability of the syndesmosis with fewer patients requiring its fixation.

 To fix more than one malleoli #s through a single incision, an extensile surgical approach
has been the need of the hour, as the Circumference of the ankle is too small (to leave a
bridge of 4 cm skin between two incisions)

 With this aim, a safe, new surgical approach ‘an extended posteromedial’ approach been
described, to address esp. for those that are difficult reach by a standard posterolateral
approach (PM # with medial extension Eg. Haraguchi type 2 fractures, a combined PM &
MM #s and posterior pilon #s) and a study been done to assess its efficacy and safety and
its superiority over the Posterolateral approach

Patients and Methods: This study involved 8 patients who underwent ORIF thro an Extended Postero medial
approach, for various Posterior Distal tibial #s( a Haraguchi type 2 posterior malleolar fracture, MM & PMF as separate #s,
Posterior pilon # variants)

Results : The median Olerud and Molander score was 72 (IQR 70 to 75), representing a good functional outcome. No patient
had any wound healing/ NV problems.

Conclusion : This new EPM approach is a safe technique that enables good visualisation
and reduction of the individual fracture fragments of PM# with promising early
outcomes.
 Strengths (of this ppt n Study)
• A new single appr with 4 surgical windows
making it most extensile for Unstable/ Difficult
Ankle #
• EPM will easily becomes the workhorse app for
Ankle like PL app till now( less risk of cut.n
damage, such as Sural n.damage, wound healing
problems, better method of fixation possible with
lesser risk of PTA)
• EPM app along with Extended indications been
described there by adding armentorium to Orth
Trauma Surgeon
 Weakness
• thou familiar, most worried abt NV damge
Although, a careful surgeon cud easily get away

• Both “ Opening incision( no flaps) and

closure ( Mad Stich)” require proper attention to
detail

• Lack of POST Op CT to illustrate Anatomical

reduction
 Posterior Distal Tibial fractures
( Haraguchi type 2 posterior malleolar fracture, MM & PMF as separate #s,
Posterior pilon # variants)

• A- Anatomy better studied, the

Attitude is changing so also the
Approach

• B- Better understanding of
Biomechanics of these Post Dist Tib
#s, emerging Bravery of Orthopods
leading to sharpened Surgical skills

• C- Crockery- Surgical Implants/Designs

are evolved to met the ever increasing
demand of Reconstruction of these
difficult Intra Articular #s
 PosteriorMalleolusFracture
• Significant attention focused
recently on fractures of the
posterior malleolus

• Wide range in the reported

prevalence in ankle fractures
7% to 44%

• Relevance and operative

management continues to be a
source of controversy

• Morphology of the fracture has

received far less consideration in
classification & treatment algorithms
 Posterior Pilon Variant
• Increasingly recognized fracture pattern
with posteromedial involvement and
variable articular impaction

• Critical for talar stability and

prevention of posteromedial subluxation

• May change surgical approach

• Current classification systems fail to

account for this pattern

• Relative frequency, associated

characteristics, and reliability of diagnosis
has not been reported in large series in the
literature
 Methods
• A small cohort of 8 patients that met inclusion criteria
(PDF#PMFs HG 2, PPVs)

• Basic demographic data collected

• Fractures involved posterior malleolus

• Represented a posterior pilon variant------------
• defined by **:
A) Medial malleolar double-contour sign 

B) Posterior malleolus fracture in the 

sagittal plane

C) Posterior malleolar impaction 

** switaj PJ, Anish R. Kadakia et al Evaluation of posterior malleolar

fractures and the posterior pilon variant in operatively treated ankle
fractures. Foot Ankle Int. 2014;35(9):886–95
• A posterior pilon variant defined by: **

A)Medial malleolar double-contour sign

B)Posterior malleolus fracture in the

sagittal plane

C)Posterior malleolar impaction

** switaj PJ, et al Evaluation of posterior malleolar fractures and the
posterior pilon variant in operatively treated ankle fractures. Foot
Ankle Int. 2014;35(9):886–95.
• Description of a New Surgical
Purpose Haraguchi’s Posterior
approach Extended Posteromedial Malleolus # Classification
approach to address the Posterior

and Medial malleolar fractures through

a single incision

• (and also report the relative

Importance of the posterior

malleolar fracture and posterior pilon

variants)

• Study and Report on the reliability

this new Surgical approach for

the surgical treatment of the posterior

distal tibia fractures

 PM & MM # are dealt by two approaches ie., Posterolateral and Medial approach seperately, the
purpose of single approach Extended PM approach is both could be done through a single incision, (incl
Haraguchi’s Type II and Mayank’s Type II and also wide range of Posterior Pilon# variants)
 Postero medial approach
( Standard approach) 
• A Curved Incision Behind Medial malleous
• Between FDL& NV bundle (for PM fragment of PMF)

• Between NV and FHL plane is added to this

and been named as Modified PM approach 

Extended Postero Medial approach ( Present Study)

• 1) Anterior to PT tendon ( for MM #)
• 2) Between PT and FDL (for PM fragment of PMF)
• 3) Between FDL& NV bundle(for PM/ PL fragments of PMF)
• 4) Between NV and FHL plane (Modified PM approach)
 Posterior approaches
for the Ankle Trauma
Posterolateral App’ Posteromedial approaches
• PL app’ • Postmedial app’ been so far,

• For AntiGlide plating of • 1) Posteromedial app’

Osteporotic Distal Fibula
# • 2) Modified Posteromedial app’
• As a Single incision app’
for fixation of both
Lateral malleolus and
Posterolateral #
component of Postero • Now, here we are describing a new app’
malleolus # 3)EPM ( Extended Postero Medial Approach ) to
address both #s (ie., Posterior Malleolus # and Medial
Malleolus fractures) and reaching far out posterolateral
component of Posterior Malleolus # so as to enable the
surgeon to fix the more complex # patterns( such as
Posterior Pilon variants etc.,)
 Postero medial approach
( Standard approach) 
• A Curved Incision Behind Medial malleous
• Between FDL& NV bundle (for PM fragment of PMF)

• Between NV and FHL plane is added to this

and been named as Modified PM approach 

Extended Postero Medial approach ( Present Study)

• 1) Anterior to PT tendon ( for MM #)
• 2) Between PT and FDL (for PM fragment of PMF)
• 3) Between FDL& NV bundle(for PM/ PL fragments of PMF)
• 4) Between NV and FHL plane (Modified PM approach)
 Postero Medial approach
(hinges on the tibialis posterior and flexo digitorum
longus on the medial side, and the muscle belly of the
flexor hallucis longus along with NV bundle laterally.

1) Tibialis posterior tendon. 6) Flexor hallucis

(2) Flexor digitorum longus tend longus muscle belly

(3) Posterior tibial artery n veins (4) Tibial nerve (yellow). (5) Tendo Achilles.

• Thus, it provides excellent visualization of the medial two-thirds of the posterior malleolus but cannot provide
visualization and exposure of the lateral one-third, syndesmosis, and fibula. One must avoid overdistraction laterally
with resultant damage to NV structures
 the modified posteromedial approach
( hinges on the tibialis posterior n flexor digitorum longus

medially & the FHL n TA laterally)

(1) Tibialis posterior tendon.

(2) Flexor digitorum longus

(3)Posterior tibial artery n veins

(4) Tibial nerve (yellow).

(5) Flexor hallucis longus

muscle belly and tendon. (6)
Tendo Achilles

• It permits exposure of the greatest portion of the distal posterior malleolus, syndesmosis, and fibula.
• The neurovascular structures are medial
 the modified posteromedial approach
( hinges on the tibialis posterior n flexor digitorum longus

medially & the FHL n TA laterally)

(1) Tibialis posterior tendon.

(2) Flexor digitorum longus

(3)Posterior tibial artery n veins

(4) Tibial nerve (yellow).

It permits exposure of the greatest portion of the distal posterior malleolus, syndesmosis & fibula.(
NV st are Medial)

(5) Flexor hallucis longus

muscle belly and tendon. (6)
Extended PosteroTendo
MedialAchilles
approach ( Present Study)
1) Anterior to PT tendon ( for MM #)
2) Between PT and FDL (for PM fragment of PMF)
3) Between FDL& NV bundle(for PM/ PL fragments of PMF)
4) Between NV and FHL plane (Modified PM approach)
Postero medial approach
( Standard approach) 

•
Extended Postero Medial
approach ( Present Study)

1) Anterior to PT tendon ( for MM #)

2) Between PT and FDL (for PM fragment of PMF)

3) Between FDL& NV bundle(for PM/ PL

fragments of PMF)

4) Between NV and FHL plane (Modified PM

approach to reach- greatest portion of the
distal posterior malleolus, syndesmosis, and
fibula )
 Introduction cont.,
• A Displaced Posterior Malleolar Fracture or A posterior
pilon fracture /a pilon variant are challenging injuries to
treat and can result in poor functional outcomes
• Owing primarily to the difficulty in approaching the fracture, no widely accepted method
Rx. (indirect reduction techniques to direct reduction)

• I am presenting here, a new method of ORIF of the

posterior malleolar # combined with Medial malleolus # /
posterio pilon variants using a single approach called
“Extended PM approach” incl complications, PO rehab the results, along with
extended indications of this approach

• Offering this method as a useful option to treating this difficult fracture pattern there by
adding the armamentarium to ortho trauma surgeon
• Between simple malleolar fractures and more complex pilon injuries, is the
posterior pilon fracture. Involving a variable amount of posterior tibial articular
surface(> 50% of the tibial incisura *) , these injuries may benefit from a posterior
approach to reduce and stabilize the fragments.

• The posterolateral approach can be considered the “workhorse” and allows good
access to the tibia and fibula #.

• The posteromedial approach may be helpful for more complex patterns, but is
closer to the tibial neurovascular bundle.

• These approaches can be performed safely, with low complication rates and
generally favorable outcomes.

*Bartonícek J, et al., Anatomy and classification of the posterior tibial fragment in ankle fractures. Arch Orthop
Trauma Surg 2015;135:506–16
# Wang L, et al . Trimalleolar fracture with involvement of the entire posterior plafond. Foot Ankle Int. 2011;32(8):774–81.
# Forberger J, et al., Posterolateral approach to the displaced posterior malleolus: functional outcome and local morbidity. Foot
Ankle Int. 2009;30(4):309–14.
ROLE OF A SINGLE POSTERO MEDIAL APPROACH

• All these can be done thro’

• A single Extended PM approach,
Surgical approaches
• perhaps only additional
• Lateral approach required
• Postero lateral approach + • to fix Lateral Malleolus #
Medial approach ----
• -----------------------------------
• Haraguchi’s Type II(2006)
• Mayank’s Type II 2016 

• Various Posterior Pilon #s

and its Variants ---
Extended PM approach
Indications ( 10)
1) Posterior malleolus & Medial malleolus as separate #s

2) Haraguchi’s Type II PM#, Mayank’s Type II PM#

3) Posterior Pilon Variants

4) An Extended Posteromedial Approach can be combined w/

extensile Anterior for the Rx of Complex Tibial Pilon Fractures
(AO/OTA 43-C)

5) Talar Body / Neck fractures

6) Retrival Entrapped PM structures ( TP, NV)

Preoperative CT images of a
7) Combination of Posterior Malleolus and Shaft Tibia #s with patient with a posterior pilon
compromised Anterior ST fracture:
8) Occasinally Distal Tibia Fracture with Poor anterior ST cover intercalary fragment and
-------------------------------------------------------- incongruence of the incisura
1) Debridment of the ankle thro Posterior app fibularis tibiae.
axial view (A),
2) Tarsal Tunnel Decompression( those with SOL) sagittal view (S),
coronal view (C).
 ROLE OF A POSTERO LATERAL APPROACH AND DRAW BACKS
• Posterolateral approach in prone position which was initially designed for
posterior malleolus fracture, is the most accepted surgical approach to posterior
pilon variants at present.

• Additional limited posteromedial incision is made only when PM fragments could

not be accessed through the posterolateral incision [6, 11, 12, 14, 16].

• Complications such as sural nueritis and regional pain [12] & recent cadaveric
study [23] showed the potentially high risk
of injuring the perforating branch of peroneal artery were reported using
posterolateral approach

• Based Wang et al on clinical experience, the reduction of PL fragment, can be

achieved through ligamentotaxis, direct visualization is always required reduce PM
fracture. ( Wang et al. BMC Msk Dis’ (2016) 17:328 )
• 6,Tornetta 3rd P, Ricci W, Nork S, Collinge C, Steen B. The posterolateral approach to the tibia for displaced posterior malleolar
injuries. J Orthop Trauma. 2011;25(2):123–6
• 11.Franzone JM, Vosseller JT. Posterolateral approach for ORIF of a posterior malleolus fracture–hinging on an intact PITFL to
disimpact the tibial plafond: a technical note. Foot Ankle Int.2013;34(8):1177–81
• 12. Klammer G, Kadakia AR, Joos DA, Seybold JD, Espinosa N. Posterior pilon fractures: a retrospective case series and proposed
classification system. Foot Ankle Int. 2013;34(2):189–99
• 14. Chen DW, et al ORIF of posterior pilon fractures with buttress plate. Acta Ortop Bras. 2014;22(1):48–53
• 16. Forberger J, et al. Posterolateral approach to the displaced posterior malleolus: functional outcome and local morbidity. Foot
Ankle Int. 2009;30(4):309–14.
• 23. Young KW, Deland JT, Lee KT, Lee YK. Medial approaches to osteochondral lesion of the talus without medial malleolar
osteotomy. Knee Surg Sports Traumatol Arthrosc. 2010;18(5):634–7
This kind of Tri Malleolar #Best dealt with PL app’
 a separate Medial app’ for Medial malleolus #

This kind of Tri Malleolar Fractures

Best dealt with Lateral app’ for Lateral Malleolus # ORIF
 an extended posteromedial EPM app’ for Medial & Post
malleolus #s

This kind of Bi/Tri Malleolar Fractures

Best dealt with Lateral app’ for Lateral Malleolus #
ORIF
 an extended posteromedial EPM app’ for
Bifragmented ( Medial & Lateral Comonents of ) Post
malleolus fracture
 Why a New single surgical approach for
Posterior distal Tibia #
( MM & PM #s, Posterior pilon n its variants)

 Ankle circumference is too small to leave a bride of 4 cm skin between two

incisions on each hemicircumfernce of the ankle.
( to approach Medial, Posterior and Lateral Malleoli individually).

 A safe new surgical approach has been the need of the hour to fix more than one
malleoli through a single incision on each hemicircumfernce of the ankle
(to restore the ankle stability by appropriate fixation)

 The posterolateral approach can be considered the “workhorse” and allows good
access for fixation of distal fibula # and postero lateral half of Tibial planfond
but could not get enough access to reach medial half especially when fractures
extend more anteriorly to the medial malleolus.

 Description of a new single surgical approach called Extended Postero medial

approach to address the complex posterior distal tibial fractures been the
Objective of this presentation/ study
 Why a New single surgical
approach for
Posterior distal Tibia #
( MM & PM #s, Posterior pilon n its
variants)

 Ankle circumference is too small to leave a bride

of 4 cm skin between two incisions on each
hemicircumfernce of the ankle.
( to approach Medial, Posterior and Lateral Malleoli
individually).

 A safe new surgical approach has been the need

of the hour to fix more than one malleoli through
a single incision on each hemicircumfernce of the
ankle
(to restore the ankle stability by appropriate fixation)

 The posterolateral approach can be considered

the “workhorse” and allows good access for
fixation of distal fibula # and postero lateral half
of Tibial planfond
but could not get enough access to reach medial half
especially when fractures extend more anteriorly
to the medial malleolus.

 Description of a new single surgical approach

called Extended Postero medial approach to
address the complex posterior distal tibial
fractures been the Objective of this
presentation/ study
 Introduction
• Ankle fractures comprise approximately 9% of all fractures [1].

• the posterior distal tibia # occurs in about 7 % to 46% of Weber type B or C ankle fracture-
dislocations [2].

• These posterior fractures are usually referred to as posterior malleolar or posterior pilon
fractures [3–6].

• The distinction between posterior malleolar fractures and posterior pilon fractures is a matter
of convention and it was suggested that fragments comprising more than 50% of the tibial
incisura are considered as posterior pilon fractures [7].

• [1] Court-Brown CM, Caesar B. Epidemiology of adul fractures: a review. Injury 2006;37(8):691–7
• [2] Jehlicka D, Bartonicek J, Svatos F, Dobias J. Fracture-dislocations of the ankle joint in adults. Part I: epidemiologic evaluation of patients during a 1-year
period. Luxacni Zlomeniny Hlezna U Dospelych. I. Cast: Epidemiologicke Zhodnoceni Rocniho Souboru 2002;69(4):243–7.
• [3] Gardner MJ, Brodsky A, Briggs SM, Nielson JH, Lorich DG. Fixation of posterior malleolar fractures provides greater syndesmotic stability. Clin Orthop
Relat Res 2006;447:165–71.0
• [4] Müller ME, Nazarian S, Koch P, Schatzker J. The Comprehensive Classification of Fractures of Long Bones. Berlin: Springer; 1987.
• [5] Heim D, Niederhauser K, Simbray N. The Volkmann dogma: a retrospective, long-term, single-center study. Eur J Trauma Emerg Surg 2010;36:515–9.
[6] Klammer G, Kadakia AR, Joos DA, Seybold JD, Espinosa N. Posterior pilon fractures: a retrospective case series and proposed classification system. Foot
Ankle Int 2013;34(2):189–99,
• [7] Bartoní9cek J, Rammelt S, Kostlivý K, Van e9cek V, Klika D, Trešl I. Anatomy and classification of the posterior tibial fragment in ankle fractures. Arch
Orthop Trauma Surg 2015;135:506–16 .
 The indications for fixation of the posterior malleolus
• Controversial.

• The current indications are varied and evolving and include

1) fractures involving >25% to 33% of the articular surface,

2) displacement>2 mm,

3) ankle instability with concomitant syndesmotic injury, and persistent posterior

subluxation of the talus [2, 13 - 16].

• (2)Hong CC, Nashi N, Prosad Roy S, Tan KJ. Impact of trimalleolar ankle fractures: How do patients fare post-operatively?
Foot Ankle Surg 2014; 20(1): 48-51
• 13.Drijfhout van Hooff CC, Verhage SM, Hoogendoorn JM. Influence of fragment size and postoperative joint congruency on
long-term outcome of posterior malleolar fractures. Foot Ankle Int 2015; 36(6): 673-8.
• [14] Mast JW, Teipner WA. A reproducible approach to the internal fixation of adult ankle fractures: Rationale, technique,
and early results. Orthop Clin North Am 1980; 11(3): 661-79.
• [15] Gardner MJ, Streubel PN, McCormick JJ, Klein SE, Johnson JE, Ricci WM. Surgeon practices regarding operative
treatment of posterior malleolus fractures. Foot Ankle Int 2011; 32(4): 385-93.
• [16] Noh KC, Hong DY, Kim YT, Kadakia AR, Park YW, Kim HN. Arthroscopic transfibular approach for removal of bone
fragments in posterior malleolar fracture: technical tip. Foot Ankle Int 2015; 36(1): 108-12.
 Introduction cond.,
• Why the emphasis shifted to Posterior Malleolus #, that to a Direct approach ?

• Ankle coronal stability largely depends on medial, lateral, and posterior structures.

• However, the sagittal stability is mainly provided by the posterior malleolus.

• Therefore, we should restore posterior constraints to maintain sagittal stability

and the articular congruity

• To Sum up – Stability of Syndesmosis & Tibio talar joints and articular conguency of both
these joints largely depends on posterior malleous,

hence is the requisite for anatomic restoration- Posterior malleolar #s fixation

to prevent Post traumatic ankle arthritis ( PTA) following Trimalleolar #s

 Why new concept of Direct Exposure and Internal
fixation ( ORIF) of Post malleolus fractures
i. PMF contributes a great deal to sagittal /axial stability of unstable ankle #s

ii. PMF contributes a great deal to Syndesis stability of unstable ankle #s

iii. Post traumatic arthritis is much more common with poor fixation of PMF

iv. Early / Late Syndesis instability could be avoided by anatomic/ direct Fixation
of PMF

v. Syndesmotic screw fixation (latter it’s removal/ malreduction of Syndesmosis)

could be avoided by good anatomic/ direct Fixation of PMF( bec’ its
attachment with the key stabilizing ligament of syndesmosis-PITFL)

vi. More Physiological fixation of Syndesmosis with a tight rope in subtle laxity is
advisable after fixing PMF
 Why does PMF need a direct ORIF
• The PITFL originates from the fibula and attaches to the PM. This ligament contributes 42% of the
stability that the TFS ligament complex provides.25 Although the PITFL generally remains intact, PM
fractures disrupt the stability of the TFS. Fixation of the PM provides 70% of the TFS stability in
ankle fractures that involve PM fractures, whereas TFSS provides only 40%.

• Open reduction of the PM ensures its proper PITFL length and restores stability of the TFS by
preventing posterior translation of the fibula.8

• In a recent study, Miller et al21 compared the postoperative CT scans of patients who had PM
fixation with those who had fixation of the TFS using a screw and reported that better restoration of
the syndesmosis complex was provided with the PM fixation.

• Jaskulka et al15 stated that poor prognoses were related to even posterior rim fractures of the
tibia. They reported better long-term outcomes for PM fractures larger than 5% of the articular
surface that were operatively treated than those that were not.15

• 8. Gardner MJ, et al., Fixation of posterior malleolar fractures provides greater syndesmotic stability. Clin Orthop
Relat Res. 2006;447:165-171.
• 15. Jaskulka RA, et al., Fractures of the posterior tibial margin: their role in the prognosis of malleolar fractures. J
Trauma. 1989;29(11):1565-1570
• 21. Miller AN, etal., Direct visualization for syndesmotic stabilization of ankle fractures. Foot Ankle Int.
2009;30(5):419-426
• 25.Ogilvie-Harris DJ, et al., Disruption of the ankle syndesmosis: biomechanical study of the ligamentous restraints.
Arthroscopy. 1994;10(5):558-560
 My study is
• A total of eight cases of Unstable ankle fractures which
have been dealt with

• 1) A single Extended Postero medial appraoch for

fixation of both Medial and Posterior Malleoli

• 2) Additional Lateral appraoch for fixation of Lateral

Malleolus # in 4 cases

• 3) No cases where Postero Lateral approach been used

for fixation of PMF
 Demographics of the patients
• Study period – Oct 17 till Dec ‘ 18

• Mode of Injury: RTA : Falls = 6 : 2

• Age distribution : 16 to 20 = 4 Male patients

21 to 40 = 4 Female patients
• Male to Female 50: 50

• Side: Right : Left = 2 : 6

• Types of Fractures Distribution

• Vertical MM and two part PMF in 4 cases all in late teenage males( plus one case
has multiple foot injuries)

• Harguchi’s 2/ Posterior Pilon Variants kind of #s in 4 cases – all in Females between

ages 20 to 40 yrs group
 Description of the Surgical Technique
“Extended Postero Medial approach”
(to address both Medial and Posterior Malleolar # s ORIF)

• Preparation and exposure :The patient was

positioned supine with a tourniquet on the thigh
on a radiolucent table.

• The operative limb was placed in a letter D / Fig of

Four position and the ankle was externally rotated
with a bump placed underneath.

• This position facilitate later steps to access both

PM and PL fragments.

• The skin incision started longitudinally 1 cm

posterior to the medial border of the Tibia, and
then curved at the plane distal to medial
malleolus, following toward the talonavicular
joint.

• The flexor retinaculum was incised lateral to the

flexor hallucis longus tendon (FHL).
 Description of Extended Postero Medial approach
(to address both Medial and Posterior Malleolar # s ORIF)

• A curved incision 1 cm
posterior to medial
margin of tibia,
following the curve of
Medial malleolus
towards Talo navicular
joint
• Fascio cutaneous flaps
raised on either side
Postero-medial ankle
• The flexor retinaculum was incised lateral to the flexor
hallucis longus tendon (FHL) and all 4 the structures
underneath are made freely mobile

• Approach to posterolateral fragment : PL fragment was

approached first through the plane between FHL and
neurovascular (NV) bundle. Care must be taken to protect
the NV bundle, using a hohman retractor gently block it
medially together with Tibialis Posterior tendon (TP) and
flexor digitorum longus tendon (FDL)

• Dissection was continued proximally through this plane.

In cases when comminution or impaction occurs, the
fragments were opened like a book as its lateral hinge
remained .

• Provisional 2.0-mm K-wires were used to stabilize the

fragments before definitive 2.7 mm buttress plate
fixation. The buttress plate was placed in an oblique
fashion for Postero lateral fragment fixation
• Approach to posteromedial fragment : The second plane between
FDL and TP could expose the PM tibial plafond. After the tendon
sheaths were incised in line with its underlying tendon, the FDL
was retracted laterally to protect the NV bundle, while the TP
tendon was mobilized and subluxated medially over the medial
malleolus. Continuing sharp dissection over the floor of the
tendon sheath will expose the PM fragment.

• After reduction, either multiple 4 mm lag screws or low-profile

buttress plate could be used as final fixation according to the
fragment size .

• Further exposure If there were a separate fragment in anterior

colliculus or a complete medial malleolus (MM) fracture, the TP
was put back to its original position making the whole MM under
direct visualization, which constituted the third plane. Lag screw
fixation would be applied if both the anterior and posterior
colliculus were involved. Intraoperative radiographs are evaluated
in each fragment fixation to confirm the correct reduction. Fibular
reduction and fixation were approached last through a lateral
incision with the operative limb turned into neutral position.

• Syndesmotic screws would be placed if the stress test were positive

intraoperatively.

• The tendon sheath and flexor retinaculum were repaired before

wound closure.

• Skin closure in a single layer with a

Modified Allgower-Donati stitches
• Skin incision Flexor retinaculam incision Mob of NV Bundle

Mob of Tendons Exposure of PM # Fixation PM# Fix w/ 2.7 mm T Plate

Medial malleolar # Expo Fixation of MM# w/ Lag screws Repair Periosteum, Tendon sheaths, Flexor Retinaculum

Exposure of MM# anteriorly, PM# Posteriorly Levering Open the MM # Skin closure as single layer w/ MAD stiches
 Case 1
Pre op 3D CT Post Op Radiograph
Post op scars in a couple of patients
 Case 2
Pre op Radiograph Post Op Radiograph
Preop CT
 Case 2
Pre op Radiograph Post Op Radiograph
 Implants used
• Various implants been used for these fracture
patterns
• PM # fixed with PA lag screw with washer – 3 cases
• PM # fixed with Antiglide Plate( 2.7 mm ) – 5 cases
• MM Vertical # fixed with one/ two Horizontal screws
+/_ antiglide plate – 4 cases each

• Addl. fixation – Lateral Malleolar fixation with 3.5

1/3rd tubular plates in 6 cases and 2.7 mm plate in 2
cases
 POST OP PROTOCOL
• Removable Back slab for 2 to 4 weeks

• Active mobilisation exercises started sooner

the wound healing is progressing satisafactory
in about 3 to 5 days time, remain without wt
bearing in all cases till 6 weeks time
 Outcomes

• Olerud & Molander

Score

• Excellent (>90)- 6 cases

• Good (61-90) - 2 cases
• Fair (31-60) -
• Poor (<30) -

Olerud and Molander score

Olerud C, Molander H. A scoring for symptom evaluation
after ankle fracture. Arch Orthop Trauma Surg. 1984;
103(3):190-194
 Follow up
• Study period – Oct 17 till Dec ‘ 18
• Minimum FU = 3 months ( 2 cases)
• Longest FU = 15 months ( 6 cases)
 Complications
• No Major complications( Neither any NV/ Tendon
injuries nor any wound healing problems)

• Two cases of minor wound infections – settled

with a week course of Ab’s without a need for Surgical
intervention-
• Interestingly both these are on lateral incision
area ( for LM# fixation)
Discussion
 Discussion
1) Posterior Malleolus fracture Classifications

2) Posterior Pilon Fractures and its variants

3) Safety of New Surgical approach and its Background –

4) Posteromedial approach(EPM) for the Ankle

5) How EPM approach differs from Modified Postero Medial approach

6) Why Posteromedial approach (esp Extended PM)rather than

Posterolateral app
 Posterior Malleolus fracture Classifications

1. Haraguchi ‘s et al.,( 2006) PMF Classification

2. Bartoníček et al (2015) PMF Classification

3. Mayank’s ( Australia 2016) Classification

4. Mason and Molloy classification (Foot &Ankle Int. 2017)

Classifications of Posterior Malleolus fractures
• Haraguchi ‘s. ( 2006)
Haraguchi N, Haruyama H, Toga
H, et al. Pathoanatomy of
posterior malleolar fractures
of the ankle. J Bone Joint Surg
Am. 2006; 88:1085-92)

• Bartonı´cˇek (2015)
(Anatomy & classification of the
posterior tibial fragment in
ankle fractures
Jan Bartonı´cˇek • Stefan
Rammelt • Karel Kostlivy´
•Va´clav Vaneˇcˇek • Daniel
Klika • Ivo Tresˇl Arch
Orthop Trauma Surg (2015)
135:505–516 ) Vol-2, Issue-
4, 2016 pg 377-84)
 Author Haraguchi et al 2006 Bartoníček et al 2015
• Analysis Axial CT (%) • CT reconstructions (%)

• Type 1 Posterolateral (67) • Extraincisural (8)

• Type 2 Medial extension (19) • Posterolateral (52)

• Type 3 Small shell (14) • Posteromedial (28)

• Type 4 • Large posterolateral (9)

• Type 5 • Irregular osteoporotic (3)

Classifications of Posterior Malleolus fractures

Mayank’s ( Australia 2016)

(Modified Classification of Posterior Malleolus Fracture of Ankle
Dr. Mehul Mayank, Prof Jike Lu, Jac Trappel & Dr. Murray Hyde-Page
John Hunter Hospital, NSW Australia. Imperial Journal Inter -
disciplinary Research (IJIR) Vol-2, Issue-4, 2016 pg 377-84)

• Type I (PL) Postero-lateral with oblique # line

• Type II(PMA) Posteromedial w anterior # line

• Type III (PL+PM) Posterolateral (PL) fracture extending to

Posteromedial (PM), fracture line parallel to trans- malleolar axis,
usually fragment split in the middle

• Type IV (PR) Posterior rim fracture

Mason and Molloy classification (FAI 2017)

• Foot Ankle Int. 2017 Nov;38(11):1229-1235.Epub 2017 Jul 31.
• Pathoanatomy & Associated Injuries of Posterior Malleolus
Fracture of the Ankle.Mason LW1, Molloy AP1.

The pathomechanics that cause the fracture and therefore guides the
surgeon to what fixation will be necessary by which approach.
Methods: The primary posterior malleolar fracture fragments
were characterized into 3 groups. A type 1 fracture was described
as a small extra-articular posterior malleolar primary fragment.
Type 2 fractures consisted of a primary fragment of the
posterolateral triangle of the tibia (Volkmann area). A type 3
primary fragment was characterized by a coronal plane fracture
line involving the whole posterior plafond. Results: In type 1
fractures, the syndesmosis was disrupted in 100% of cases,
although a proportion only involved the posterior syndesmosis. In
type 2 posterior malleolar fractures, there was a variable medial
injury with mixed avulsion/impaction etiology. In type 3 posterior
malleolar fractures, most fibular fractures were either a high
fracture or a long oblique fracture
 Strengths (of this ppt n Study)
• A new single appr with 4 surgical windows
making it most extensile for Unstable/ Difficult
Ankle #
• EPM will easily becomes the workhorse app
for Ankle like PL app till now
• EPM app along with Extended indications
been described there by adding armentorium
to Orth Trauma Surgeon
Classification of PMF according to Mason and Molloy
classification (FAI 2017) based on CT scans obtained
pre-operatively
 Molloy n Mason’s Classification of PMFs “ Pathoanatomy and Associated Injuries of PMF of the
Ankle. FAI July, 2017

•
Classificatio Treatment Approach
n
1 Syndesmotic
fixation
2A ORIF PL
2B ORIF – PM or PL
posteromedial + MPM
fragment first
3 ORIF PM

Treatment algorithm based on

Mason and Molloy classification Figure illustrates approaches on axial CT of lower limb 1cm
above the ankle joint with the different approaches
represented. (ORIF – open reduction internal fixation, PL –
posterolateral approach, PM – posteromedial approach,
MPM – medial posteromedial approach).
Classificatio Treatment Approach
n
1 Syndesmotic fixation
2A ORIF PL
2B ORIF – posteromedial fragment PM or PL + MPM
first
3 ORIF PM
 A new approach incision
• Should take care of two most important things

1) Angiosomes ( Blood supply of the flaps)

2) Cutaneous nerves (to avoid devt. Painful neuromas)

Extended Posteromedial approach incision lies

above the three main branches of Post Tib artery 

Avoids, the possible cutaneous nerve- Saphenous

Why a New single surgical appraoch for both
MM & PM #s

 Ankle circumference is too small to leave a bride of 4

cm skin between two incisions on each
hemicircumfernce of the ankle.

 A safe new surgical approach has been the need of the

hour to fix more than one malleoli through a single
incision on each hemicircumfernce of the ankle

 More healing problems of the incisions

around the ankle are due to our poor
understanding of angiosomes,

 As the incision placement of Extended PM

approach lies above all 3 major branches of
Post tib artery, it is an elegant and staright-
forward way of ORIF both MM n PM #s thro a The angiosomes in the foot and its feeders.
single uncomplicated incision Posterior tibial artery (PTA) feeds medial
rearfoot and entire plantar surface of the
Schematic overview of the vascularization of the soft foot, including 3 angiosomes. The peroneal
tissue envelope surrounding the ankle modified from artery (PA) supplies lateral ankle and plantar
Aubry and Fieve [30]. 1, perfusion area of the anterior heel. The anterior tibial artery (ATA) supplies
tibial artery; 2, perfusion area of the posterior tibial
artery; 3, perfusion area of the peroneal artery; 4, a single angiosome, the dorsum of the foot.
anterior peroneal artery; 5, posterior peroneal artery; The dorsum of the foot is also supplied by
6, posterior tibial artery; 7, anterior tibial artery. the anterior perforating branch of the PA.
branches of PTA. The plantar heel is also supplied by the
medial calcaneal branches of PTA.
 Angiosomes

Schematic overview of the vascularization of the soft tissue envelope

surrounding the ankle modified from Aubry and Fieve ***.
1, perfusion area of the anterior tibial artery;
2, perfusion area of the posterior tibial artery;
3, perfusion area of the peroneal artery;
4, anterior peroneal artery;
5, posterior peroneal artery;
6, posterior tibial artery;
7, anterior tibial artery. branches of PTA
*** Aubry P, Fieve G. Vascularisation osseuse et cutanée du quart
inférieur de la jambe. Rev Chir Orthop 1984;70:589–97. .

The angiosomes in the foot and its feeders.

Posterior tibial artery (PTA) feeds medial rearfoot and entire
plantar surface of the foot, including 3 angiosomes.
The peroneal artery (PA) supplies lateral ankle and plantar heel.
The anterior tibial artery (ATA) supplies a single angiosome, the
dorsum of the foot.
The dorsum of the foot is also supplied by the anterior perforating
branch of the PA. The plantar heel is also supplied by the medial
calcaneal branches of PTA.
 Risk of Damage to Cutaneous nerves
Medial Malleolus and lateral Malleolar exposures
 Postero medial approach
( Standard approach) 
• A Curved Incision Behind Medial malleous
• Thro’ three surgical planes
• 1) Anterior to PT tendon ( for Medial Malleolus #)
• 2) Between PT and FDL (for PM fragment of PM#)
• 3) Between FDL& NV bundle(for PM fragment of PM#)

• 4) Between NV and FHL plane is added to this

and been named as Modified PM approach 
 History of Modified Postero medial approach
• Assal et al. [1] from Switzerland in June 2014, proposed a Modified posteromedial
approach for the treatment of complex pilon tibial fractures, which provides
visualization from medial to lateral and allows access to the entire posterior pilon
and distal fibula.(extensive soft tissue damage is prevented through this approach
since it runs through intermuscular planes instead of the standard internervous
approach.

• Y Wang et al [2] from China in October 2016, described“Modified 

posteromedial approach, an alternative surgical treatment for posterior pilon
variants,with good the short-term outcome ”

• Harm Hoekstraa et al [3] from Belgium March 2017, described Direct  fixation
of fractures of the posterior pilon via a posteromedial approach”

• N. Bali et al [4] from UK in Nov 2017 described “SAFETY AND EFFICACY OF

POSTEROMEDIAL APPROACH FOR HARAGUCHI TYPE 2 POSTERIOR MALLEOLAR
FRACTURES”

1. Assal M, Ray A, Fasel J, Stern R. A modified posteromedial approach combined with extensile anterior for the treatment of complex
tibial pilon fractures (AO/ OTA 43-C). J Orthop Trauma 2014;28:138–45
2. Y Wang et al. BMC Musculoskeletal Disorders (2016) 17:328

3. H. Hoekstra, et al., Direct fixation of fractures of the posterior pilon via a posteromedial approach, Injury J , 2017 Jun;48(6):1269-74

4. N Bali et al JBJS 2017 Nov;99-B(11):1496-1501

Extended Postero Medial approach
differs
from Modified Postero Medial
approach
Modified Postero-medial approach Vs Extended Postero-medial approach
1. Reverse L shaped incision 1. Lazy ‘ J ’shaped incision

2. Right angled incision carries risk of wound 2. Gently curved incision more cosmetic and no
healing problems wound healing problems

3. Incision Placement between PM border and 3. Incision- just a cm behind PM border Tibia,
medial margin of Tendo achilles there by avoiding accidental opening of TA

4. Deeper dissection in any 4 planes 4. Deeper dissection in any 4 planes

5. Careful handling of ST after raising fascio- 5. Careful handling of ST after raising fascio-
cutaneous flaps, respecting NV bundle cutaneous flaps, respecting NV bundle

6. Skin closure as a single layer- Normal 6. Skin single layer-Allgower Donati stich

7. Mainly for PM n MM, PostPilon Variant 7. More extended indications

 Modified Postero-medial Vs Extended Postero-medial approach
Wang et al. BMC Musculoskeletal Disorders (2016) Present Study

“An Extended Postero medial approach of the ankle”to tackle both Medial & Posterior
Malleolar Fractures is different in at least 5 ways from the Modified PM app.

1 Gentle curving of the incision – More cosmetic, lesser/ no healing problems

2 Incision being more closer to posterior border of PM border of the tibia there
by avoiding the risk of accidental opening of TA sheath (for the sake of skin
devascularization and wound healing problems)

3 Apart from raising full thickness Fasciocutaneous flaps, careful handing of NV Standard Postero Medial
bundle and respecting the angiosomes that helps the healing process, the method approach
of wound closure is unique MAD stich ( Mod Allogower Donald )

4. Least/ No risk of damaging Cutaneous nerves in the vicinity

5. Saving/ Respecting the Angiosomes in a better way than Modified PM app

Extended PM approach
Indications ( 10)
1) Posterior malleolus & Medial malleolus as separate #s

2) Haraguchi’s Type II PM#, Mayank’s Type II PM#

3) Posterior Pilon Variants

4) An Extended Posteromedial Approach can be combined w/

extensile Anterior for the Rx of Complex Tibial Pilon Fractures
(AO/OTA 43-C)

5) Talar Body / Neck fractures

6) Retrival Entrapped PM structures ( TP, NV)

Preoperative CT images of a
7) Combination of Posterior Malleolus and Shaft Tibia #s with patient with a posterior pilon
compromised Anterior ST fracture:
8) Occasinally Distal Tibia Fracture with Poor anterior ST cover intercalary fragment and
-------------------------------------------------------- incongruence of the incisura
1) Debridment of the ankle thro Posterior app fibularis tibiae.
axial view (A),
2) Tarsal Tunnel Decompression( those with SOL) sagittal view (S),
coronal view (C).
 Why PM (esp Extended PM)rather than PL app

i. Can be done in Supine, fig of four position (Prone position required for PL
approach, its attended complications avoided)
ii. Sural Nerve injury is a very high risk in PL approach ( bec’ of variable anatomy)
iii. Higher Risk of Damage to PITFL when approaching from PL rather than PM
iv. Larger/ Medium sized Post Medial fragment of Post Mall and medial extension
of PMF ( Harguchi’s 2) or separate Medial malleolar # fixation is not possible
with Postero-lateral approach
• Complications such as sural nueritis and regional pain were reported using
posterolateral approach [12]. Moreover, recent cadaveric study [23] showed the
potentially high risk of injuring the perforating branch of peroneal artery using
posterolateral incision: the safe distance could be as limited as 41 mm. Based on
our clinical experience, we found it hard to manipulate both PL and PM through
the single posterolateral incision, as either the attachment to deltoid ligament or
the entrapment of soft tissue may prevent PM fragment from anatomical
reduction [13, 15, 24]. In comparison to the reduction of PL fragment, which can
be achieved through ligamentotaxis, direct visualization is always required reduce
PM fracture.
 How/ Where, each approach over scores the other

How these ( PM/PL) approaches could be varied, depending on associated

major component ( MM/ LM )

i. Buttress Plating PM is easier from PM app rather than PL app

ii. PL comp of Post malle can be buttressed with an obliquely placed plate
fixation

iii. Biggest advantage of PL app is to retrieve entrapped fracture fragments

from Insisura fibularis by “booking open” the fracture and posterior
antiglide plating of osteoporotic distal fibula thro the same incision
( the former can also be done thro PM approach if a there is split PM n
PL components of PMF or the distal tib art surface can be visualized
through the unreduced MM # or by posteriorly opening the big PMF
fragment)
• Though never reported in posterior pilon variant fracture, the Posteromedial approach may take
advantage in the following Four aspects over posterolateral approach.

• First, the approach has a lower risk of injuring perforator branch of peroneal artery, which was 61 mm to
tibial plafond on average **. The placement of buttress plate was the key step. When using modified
posteromedial approach, the plane developed between FHL and NV bundle allowed buttressing the PL
fragment obliquely, which meant placing the plate proximally medial and distally lateral

• Second, the anatomic safety is further guaranteed by incision design. Modified PM incision curves above
the three main branch of posterior tibial artery, the angiosomes of medial calcaneal and plantar are safe
with meticulous protection of full thickness fasciocutaneous flap $$. Besides, as the whole posterior tibial
plafond could be accessed through the same PM incision, lateral approach to the lateral malleolus is
preferred, leaving a larger skin bridge.

• Third, supine position had less anesthesia related complications and better alignment measurement [28].
As the position facilitates intraoperative fluoroscopic evaluation of lower limb axis as well as joint surface,
it raised efficiency as well.

• Forth, A separate incision for Fixation Medial malleous is not needed.

• ** Lidder S, et al.,. The risk of injury to the peroneal artery in the posterolateral approach to the distal tibia: a cadaver
study. J Orthop Trauma. 2014;28(9):534–7
• $$. Attinger CE, et al.,. Angiosomes of the foot and ankle and clinical implications for limb salvage: reconstruction,
incisions, and revascularization. Plast Reconstr Surg. 2006;117(7 Suppl):261S–93S.
 Why PM (esp Extended PM)rather
than PL app
Postero Medial Approach Postero Lateral Approach
• Supine position – with limb in • Prone position (and its attended
Figure of Four position anaesthetic complictions

• No risk of Damage to Sural n • High Risk of Damage to Sural nerve

• No risk of Damage to PITFL • Moderate risk damage PITFL
• Any size/ any degree of • A large PL( Volkman’s ) &
communited Post Malleolus # Fragments entraped in Insisura
can be stabilised fibularis-best indications for PL
• Although the posteromedial approach is fairly
straightforward, Cronier et al. **cautioned against soft tissue
problems resulting from comprised tendons and
neurovascular bundle by scar tissue **Cronier P, et al” Early • @The major limitation of the posteromedial approach, however
ORIF of pilon fractures.FussSprungg 2012;10:12–26 is the inability to treat fractures of the lateral malleolus or the
distal fibula through the same incision in the presence of
bimalleolar and trimalleolar fractures
• For the PM approach, the main advantage is that the distal tibial articular
surface can be visualized through the unreduced medial malleolar
fracture, which provides direct reduction of the posterior malleolar
fragments.

• Gentle dorsiflexion of the foot make the tibiotalar joint subluxation, which
can easily be reduced without widely stripping the soft tissue attached to
a large posterior fragment.

• There are also some limitations for the PM approach. The neurovascular
bundle is close to the dissection but not usually visualized.
• Overstretching the soft tissues has the potential to result in tibialis posterior nerve or artery
injury. The fixation type in the PM group may also be associated with soft tissue
complications
 Why PM (esp Extended PM)rather than PL app
Postero Medial Approach
Scores over Postero lateral approach by 6 S’ Mnemonic
• Supine position – with limb in Figure of Four position

• Sural nerve damage risk -nil

• Syndesmotic Ligaments saved( PITFL)

• Size/ Shape/ Several fragments Post Malleolus # + MM# can be stabilised

• Surface -the distal tibial articular surface can be visualized through the unreduced
medial malleolar fracture, which provides direct reduction of the posterior malleolar
fragments.

• Stripping the soft tissue widely can be avoided by gentle DF ankle/ Distractor use to
reduce the tibiotalar joint subluxation
 Limitations of this study
• A small series with short follow-up and without post-operative CT scans to confirm
reduction, as this is not our routine practice.

• The outcome measures and clinical and plain radiographic findings suggest this is a
reproducibly safe technique allowing fragment specific visualisation and fixation.

• Further postoperative imaging and longer follow-up would clarify whether

anatomical reduction is achieved and whether this improves the outcome.

• Not included a control group in this study, as the aim was to describe a new
approach to Haraguchi type 2 fractures rather than to compare it with non-
operative, anteroposterior fixation or posterolateral fixation, which is generally
used to address Haraguchi type 1 injuries.
 DRAW BACKS
LIMITATIONS OF THIS STUDY
• CT – NO POST OP CT as that is not our routine
practice

• CONTROL GROUP -
 Conclusion
• This new EPM approach - offers a predictable and easy access and provides excellent
exposure with hardly any serious complications.

• Could be highlighted as a technique that may become as readily used as the posterolateral
approach for the appropriate fracture configuration.

• It provides -- Adequate visualization,

-- Direct reduction,
-- Stable fixation with good short-term outcome

• Superiority of this Postero medial approach over the Posterolateral approach has also been
discussed
 Conclusion

• Based on our study, through our New Single Surgical Approach, so called

Extended Postero medial approach, Direct ORIF that is mandatory (to fix

posteromedial pilon fractures, posterior malleolar fractures with medial

extension and/or intercalary fragments), is possible in a safer and elegant

way to reduce the incidence of Post Traumatic Arthritis, provided routine

pre-op CT scan, Careful surgical technique (raising Fascio cutaneous flaps,

respecting NV bundle) and Post Op Protected Mobilizations are followed.