Courtesy: Anish Kadakia and Acumed LLC

Plate Design Features

The Acumed Ankle Plating System (3 plates) is specifically designed to be soft-tissue friendly while providing stable fixation.

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Key Design Characteristics

Low-Profile Distal Segment

• Thinner distal portion
• Minimizes soft tissue irritation

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Screw Configuration

• Distal screw cluster: 2.7 mm locking screws
• Proximal screws: 3.5 mm
  • Available as locking and non-locking options

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Anatomical Contouring

Pre-contoured plates designed for:

• Fibula
• Posterior tibia
• Medial malleolus
• Small avulsion fractures

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Advantages of the System

• Improved anatomical fit
• Reduced soft tissue irritation
• Superior fixation stability compared to traditional 1/3 tubular plates

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Posteromedial Surgical Approach (Posterior Malleolus)

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Surgical Goal

To provide direct access to the posteromedial tibia for accurate reduction and fixation of posterior malleolar fractures.

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Key Anatomical Landmarks

Posteromedial Ankle Structures

• Posterior border of tibia
• Posterior tibial tendon

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Neurovascular Bundle

Contains:

• Posterior tibial artery
• Tibial nerve

Important Principle:
The surgical approach is designed to avoid the neurovascular bundle.

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Skin Incision

Location

The incision is made between:

• Posterior tibial tendon
• Posterior border of tibia

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Advantages

• Maintains a safe distance from the neurovascular bundle
• Provides direct access to the posterior tibial groove

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Incision Length

• Typically short, as posterior malleolar fragments are usually small

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Surgical Technique: Step-by-Step

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Step 1 – Skin Incision

• Make a longitudinal incision just medial to the posterior tibial tendon
• Follow the posterior border of the tibia

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Step 2 – Identify Tendon Sheath

• Expose the posterior tibial tendon sheath

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Step 3 – Open Tendon Sheath

• Carefully incise the sheath

Key Point:
Avoid injury to the posterior tibial tendon

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Step 4 – Tendon Retraction

• Retract the posterior tibial tendon laterally

Exposure Achieved

• Posteromedial tibia
• Posterior malleolar fracture fragment

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Step 5 – Periosteal Incision

• Incise the periosteum over the posterior tibia

Reason

• Posterior malleolar fractures often have thick periosteum

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Step 6 – Fracture Exposure

• Use retractors (e.g., Army-Navy retractors)

Outcome

• Wide exposure of posterior tibia
• Neurovascular bundle remains undisturbed

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Plate Placement

Position

• Along the posterior border of the tibia
• Within the posterior tibial groove

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Advantages

• Anatomical plate fit
• Stable fixation of posterior malleolar fragment

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Closure

Essential Step

• Repair the posterior tibial tendon sheath

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Rationale

• Prevents tendon subluxation

 Although postoperative scarring reduces risk, closure is recommended

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Key Surgical Advantages

• Safe and reliable approach
• Avoids neurovascular structures
• Direct visualization of fracture
• Optimal plate positioning
• Minimal soft tissue disruption

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Anaesthesia & OT Considerations

Patient Positioning

• Prone
• Lateral

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Regional Anaesthesia Options

• Sciatic nerve block (popliteal approach)
• Saphenous nerve block

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Benefits

• Excellent intraoperative and postoperative analgesia
• Ideal for posterior ankle procedures