Department of Orthopedics and Traumatology, Lausanne University Hospital (CHUV), and University of Lausanne (UNIL), Pierre-Decker 4, 1011, Lausanne, Switzerland.
Arch Orthop Trauma Surg. 2023 Feb;143(2):879-886. doi: 10.1007/s00402-022-04360-1. Epub 2022 Feb 3.
In a previous cadaveric study, we described the Posterior to Anterior Malleolar Extended Lateral Approach (PAMELA) to address complex ankle fractures. It was demonstrated to provide optimal exposure of the posterior and lateral malleoli, and of the anterolateral portion of the ankle through a single incision. The aim of this study is to report the clinical results of this novel approach.
Between January 2019 and January 2021, all patients presenting with a complex ankle fracture in our institution were assessed by CT scan. Indication to use the PAMELA was determined by the fracture pattern, according to our previous guidelines, including combination of complex lateral and displaced posterior malleolar fractures, associated in most cases with anterolateral fracture avulsion. The approach was performed according to the steps previously described. Intraoperative evaluation included quality of exposure, ease of performing the osteosynthesis, and any complication encountered. The postoperative course was assessed for wound healing, quality of reduction, and the occurrence of any complication.
The PAMELA was performed in 20 patients (aged 17-73). The most common combination of fractures was a comminuted lateral malleolus fracture associated with a displaced fracture of the posterior malleolus and a Wagstaffe-Le Fort or Chaput avulsion. We encountered no intraoperative complication. X-rays showed anatomical reduction in all cases. Postoperative complications included three delayed wound healing resolved with local treatment and one sural nerve traction injury.
The main potential concern regarding this novel approach was the healing of the flap. Our results reject this concern and are in line with wound healing complications reported following surgical treatment of ankle fractures. This study confirms the safe in vivo feasibility of the PAMELA and opens a new perspective in the optimal management of complex fractures of the ankle. A larger prospective clinical study is ongoing in our institution.
在之前的一项尸体研究中，我们描述了后向前外踝扩展外侧入路（PAMELA）用于治疗复杂踝关节骨折。该方法通过单一切口即可提供后踝和外踝以及踝关节前外侧部分的最佳暴露。本研究旨在报告该新方法的临床结果。
2019 年 1 月至 2021 年 1 月期间，我们机构所有患有复杂踝关节骨折的患者均通过 CT 扫描进行评估。根据我们之前的指南，根据骨折模式确定使用 PAMELA 的指征，包括复杂外侧和移位后踝骨折的组合，在大多数情况下伴有前外侧骨折撕脱。该方法按照之前描述的步骤进行。术中评估包括暴露质量、进行骨合成的难易程度以及遇到的任何并发症。术后评估包括伤口愈合、复位质量和任何并发症的发生。
PAMELA 在 20 例患者（年龄 17-73 岁）中进行。最常见的骨折组合是粉碎性外踝骨折合并移位的后踝骨折和 Wagstaffe-Le Fort 或 Chaput 撕脱。我们术中未遇到并发症。X 射线显示所有病例均达到解剖复位。术后并发症包括 3 例延迟愈合，经局部治疗后愈合，1 例腓肠神经牵拉伤。
对于这种新方法，主要的潜在关注点是皮瓣的愈合。我们的结果排除了这一担忧，并与踝关节骨折手术治疗后报告的伤口愈合并发症一致。本研究证实了 PAMELA 的体内安全性，并为复杂踝关节骨折的最佳治疗提供了新的视角。我们机构正在进行一项更大的前瞻性临床研究。
