TECHNICAL TRICK The Posterolateral Approach to the Tibia for Displaced Posterior Malleolar Injuries Paul Tornetta, III, MD,* William Ricci, MD,† Sean Nork, MD,‡ Cory Collinge, MD,§ and Brandon Steen, MD* Summary: Fractures involving the posterior malleolus of the tibia can be difficult to manage. Failure to address these fractures can lead to posterior ankle instability and altered ankle reaction forces. The posterolateral approach to the posterior ankle provides access to both the lateral and posterior malleoli. Displaced fractures of the posterior malleolus can be reduced and fixed under direct visualization through a posterolateral incision. We have had excellent results using this technique for management of displaced posterior malleolar fractures with few complications. Surgeons should be aware of the effec- tiveness of this technique for managing displaced fractures of the posterior malleolus. Key Words: posterolateral approach, posterior malleolus, ankle fracture, tibia fracture (J Orthop Trauma 2011;25:123–126) INTRODUCTION The indications to fix posterior malleolar fractures have become more clear with biomechanical studies of stability and joint reaction force. 1–7 Fractures that affect more than 30% of the articular surface and those allowing any instability are generally reduced and fixed. These injuries may be part of an indirect ankle fracture and have also been associated with distal spiral tibial shaft fractures. 8–12 The method of reduction and fixation of these injuries, however, has been given little attention in the literature. The purpose of this study is to report on the use of the posterolateral approach for the reduction and fixation of large displaced posterior malleolar fractures, specifically the ability to reduce and stabilize the fractures and the complications associated with the technique. METHODS Over a 6-year period, 72 patients at four Level I trauma centers with large displaced posterior malleolar fractures were treated using a posterolateral approach to the distal tibia. There were 26 men and 46 women, aged 18 to 91 years (average, 48 years). The fracture was part of a bimalleolar or trimalleolar indirect ankle fracture in 63 cases and associated with a distal spiral tibial shaft fracture in nine cases. Eight patients had associated marginal impaction. Pilon fractures were excluded. The indications for fixation were displace- ment of greater than 30% of the joint surface or evidence of posterior instability of the ankle. Fragment size and presence of subluxation were assessed by plain films and axial computed tomography scans. Surgical Technique The posterolateral approach is performed in the prone position. The leg is slightly flexed at the knee and the foot is positioned off the end of the table or bolstered off the table to allow for maximal dorsiflexion during the reduction. Tourniquet use is optional but not necessary. A longitudinal skin incision is made in the interval between the posterior border of the fibula and the lateral border of the Achilles tendon (Fig. 1). Superficial dissection involves bluntly developing the plane between the peroneal and Achilles tendons. Care must be taken to identify and protect the sural nerve as it courses through the dissection. In the deep dissection, the flexor hallucis longus muscle belly is elevated from the interosseous membrane and lateral tibia and is retracted medially to expose the posterior distal tibia and medial edge of the fibula. Care is taken to avoid injury to the peroneal artery and its branches. The posterior syndesmotic ligaments are preserved by dissecting superficial to the ankle capsule distally. Once the lateral tibia above the fracture is identified, the superior extent of the fracture is visualized. Posterior malleolar fractures are typically displaced more laterally, at the level of the fibular incisura, with a medial hinge. 13 The fracture is cleaned of callus and interposed periosteum by levering the fracture distally and working inside the fracture. In cases with impaction, the impaction is reduced with an osteotome or bone tamp, and allograft is placed as needed. Once the fracture bed is clean, dorsiflexion may aid in gaining length for the reduction. However, in some cases, this may cause posterior translation of the talus and an anteriorly directed translational force may be needed to sit the talus anatomically under the tibia. This is evaluated on perfect lateral fluoroscopic views. An indirect reduction of the joint is performed by keying in the fracture superiorly and applying an Accepted for publication April 23, 2010. From the *Department of Orthopaedic Surgery, Boston University Medical Center, Boston, MA; †Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO; ‡Department of Orthopaedic Surgery, University of Washington School of Medicine, Seattle, WA; and §Harris Methodist Fort Worth Hospital, John Peter Smith Orthopaedic Surgery Residency Program, Fort Worth, TX. No funds were received in support of this work. No benefits in any form have been or will be received from Harris Methodist Fort Worth Hospital John Peter Smith Orthopaedic Surgery Residency Program, a commercial party related directly or indirectly to the subject of this manuscript. Reprints: Paul Tornetta III, MD, Boston Medical Center, Department of Orthopaedic Surgery, 850 Harrison Avenue, Dowling 2 North, Boston, MA 02118 (e-mail: ptornetta@gmail.com). Copyright Ó 2011 by Lippincott Williams & Wilkins J Orthop Trauma  Volume 25, Number 2, February 2011 www.jorthotrauma.com | 123