Department of Orthopaedic Surgery and Traumatology, Hospital Universitario 12 de Octubre, Avda/Córdoba, s/n, 28041, Madrid, Spain.
University Complutense of Madrid (Spain), 28040, Madrid, Spain.
Int Orthop. 2020 Jun;44(6):1177-1185. doi: 10.1007/s00264-020-04481-5. Epub 2020 Feb 4.
The posterior malleolus (PM) is affected in around the 40% of ankle fractures. Anatomical reduction of the articular surface and fibular notch are essential for ankle stability and functional outcomes. These facts justify the increasing interest in the surgical treatment of PM in ankle fractures. Within this context, pre-operative computed tomography (CT) images and posterior approaches to the ankle play a crucial role. The aim of this paper is to make an accurate description of the literature and describe, according to authors' experience, the best surgical approach to the PM based on the CT findings while assessing their advantages and disadvantages.
The fracture pattern of PM is classified according to Haraguchi or Bartoníček classification, both based on pre-operative CT scan images. The posterolateral (PLA) and posteromedial (PMA) approaches to the ankle and their corresponding modifications are described. We propose a decision-making algorithm for posterior malleolus fractures to facilitate treatment selection.
Posterolateral approach should be the election for Haraguchi I or III and Bartoníček 1, 2, or 4 fractures. Percutaneous PLA might be adequate in Haraguchi I and Bartoníček 1 to improve syndesmotic stability. In PL approaches, the fibula fracture may be addressed and fixed with a posterolateral plate or through a subcutaneous window that allows lateral reduction and fixation. Posteromedial approach should be the election for Haraguchi II and Bartoníček 3 fractures. A modified PMA might be the election to reduce and fix any fragment dependent on the anterior inferior tibiofibular ligament (AITFL). The modified PMA is performed in a supine position and allows us to check the articular reduction under direct vision. Both PMA are associated with a lateral fibular approach.
To address the posterior malleolus when treating ankle fractures, surgeons should choose the most adequate approach based on the fracture pattern and their own experience. Anatomical reduction and stable fixation are critical to improve outcomes.
后踝（PM）在约 40%的踝关节骨折中受到影响。关节面和腓骨切迹的解剖复位对于踝关节的稳定性和功能结果至关重要。这些事实证明了人们对踝关节骨折中 PM 的手术治疗越来越感兴趣。在这种情况下，术前计算机断层扫描（CT）图像和踝关节的后入路起着至关重要的作用。本文的目的是对文献进行准确描述，并根据作者的经验，根据 CT 发现描述基于 PM 的最佳手术入路，同时评估其优缺点。
PM 的骨折模式根据 Haraguchi 或 Bartoníček 分类进行分类，两者均基于术前 CT 扫描图像。描述了踝关节的后外侧（PLA）和后内侧（PMA）入路及其相应的改良方法。我们提出了一种后踝骨折的决策算法，以方便治疗选择。
后外侧入路应作为 Haraguchi I 或 III 型和 Bartoníček 1、2 或 4 型骨折的首选。对于 Haraguchi I 和 Bartoníček 1，经皮 PLA 可能足以改善下胫腓联合的稳定性。在 PL 入路中，可以处理和固定腓骨骨折，使用后外侧板或通过允许外侧复位和固定的皮下窗口。后内侧入路应作为 Haraguchi II 和 Bartoníček 3 型骨折的首选。改良的 PMA 可能是用于复位和固定任何依赖于下胫腓前韧带（AITFL）的碎片的选择。改良的 PMA 采用仰卧位进行，并允许我们在直视下检查关节复位。两种 PMA 都与外侧腓骨入路相关。
在治疗踝关节骨折时，外科医生应根据骨折模式和自己的经验选择最合适的入路。解剖复位和稳定固定对于改善结果至关重要。
