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Safe Zone for the Placement of Medial Malleolar Screws
John E. Femino, MD1; Brian F. Gruber, MD2; Madhav A. Karunakar, MD2
1 Department of Orthopaedic Surgery, University of Iowa, 200 Hawkins Drive, 01016 JPP, Iowa City, IA 52242-1088
2 Department of Orthopaedic Surgery, University of Michigan, 1500 East Medical Center Drive, Taubman Center 2914, Ann Arbor, MI 48109-0328. E-mail address for M.A. Karunakar: mkarun@umich.edu
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Disclosure: The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2007 Jan 01;89(1):133-138. doi: 10.2106/JBJS.F.00689
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Background: Hardware placement for fracture fixation can put soft-tissue structures at risk for injury or abutment. The prominence of the hardware is a frequent cause of pain after the fixation of ankle fractures. This study was designed to assess the risk of injury or abutment of the posterior tibial tendon with the placement of medial malleolar screws.

Methods: Ten unmatched cadaveric limbs that had been disarticulated at the knee were used, and the medial malleolus was exposed by dissection of the skin. With use of fluoroscopy and direct visualization of the deep fascia, three Kirschner wires were placed through the tip of the medial malleolus and directed parallel to the medial articular surface. The first wire was placed in the center of the anterior colliculus. Two additional wires were placed parallel and posterior to the initial wire at 5-mm intervals. The wires were overdrilled, and 4.0-mm screws were inserted over the Kirschner wires. The specimens were dissected to inspect for trauma and the proximity of the screws to the posterior tibial tendon. The medial malleolus was divided into three zones on the basis of anatomic landmarks. Zone 1 is the anterior colliculus; Zone 2, the intercollicular groove; and Zone 3, the posterior colliculus.

Results: Screws placed in Zone 1 (the anterior colliculus) did not contact the posterior tibial tendon in any specimens. Screws placed in Zone 2 (the intercollicular groove) were, on the average, 2 mm from the posterior tibial tendon. Screws placed in Zone 3 (the posterior colliculus) resulted in tendon abutment in all ten specimens and in tendon injury in five of the ten specimens.

Conclusions: Screws inserted posterior to the anterior colliculus place the posterior tibial tendon at significant risk for injury or abutment.

Clinical Relevance: On the basis of these results, we recommend direct visualization of the posterior tibial tendon prior to the placement of screws in the medial malleolus when they are inserted posterior to the anterior colliculus.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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