title: Radiographic evaluation of the position of implants in the medial malleolus in relation to the ankle joint space: anteroposterior compared with mortise radiographs.
abstract: BACKGROUND
  Displaced transverse fractures of the medial malleolus are commonly treated with open reduction and internal fixation with two screws or wires. A mortise radiograph is often used to verify the position of the implants relative to the joint space. However, because the medial and lateral talomalleolar spaces are normally not parallel, the mortise projection (which is colinear with the lateral space) does not provide an accurate radiograph of the medial joint space.
  
  
  METHODS
  In ten cadaveric ankles, two wires were inserted into the medial malleolus, as is done for fixation of a fracture, and the distance of the wires from the joint space was measured on an anteroposterior radiograph, on mortise radiographs made with the foot in 15 and 30 degrees of internal rotation, and on anatomical cross section.
  
  
  RESULTS
  The measurement on the anteroposterior radiograph exceeded the anatomical measurement in only two specimens, and the discrepancy was 0.5 millimeter in both instances. Measurement of the osseous thickness between the joint surface and the posterior wire on the mortise radiographs always revealed a lower value than the measurements on the anteroposterior radiograph and the anatomical cross section of the same specimen. There was a false appearance of intra-articular placement of the posterior wire on the 15-degree mortise radiographs of four specimens and on the 30-degree mortise radiographs of eight specimens.
  
  
  CONCLUSIONS
  These findings demonstrate that the mortise projection provides an oblique radiograph of the medial joint space that can inaccurately reflect the true position of fixation implants in the medial malleolus. Because an anteroposterior radiograph is made with the articular surface of the medial malleolus tangential to the beam, it provides a more accurate representation of implants in the medial malleolus.
authors: Department of Orthopaedic Surgery, Northwestern University Medical School, Chicago, Illinois, USA. gourineni@hotmail.com
authors: P V
authors: PV
authors: Gourineni
authors: A E
authors: AE
authors: Knuth
authors: G F
authors: GF
authors: Nuber
mesh_terms: D016512:Ankle Injuries / Q000000981:diagnostic imaging* / Q000601:surgery; D000843:Ankle Joint / Q000000981:diagnostic imaging*; D001864:Bone Wires; D001842:Bone and Bones; D002102:Cadaver; D005593:Fracture Fixation, Internal; D050723:Fractures, Bone / Q000000981:diagnostic imaging* / Q000601:surgery; D006801:Humans; D011859:Radiography