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

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.