[Fracture of the posterior malleolus : A paradigm shift]

Safety of the modified posteromedial approach in complex ankle fractures: Comparative analysis versus posterolateral access

INTRODUCTION

The aim of the study was to evaluate the safety of the modified posteromedial approach (MfPM) in the surgical management of complex ankle fractures in terms of local complications.

METHODS

Retrospective multicenter review of a series of malleolar fractures surgically treated by posterior ankle approaches between 2016 and 2022. Two approaches were used. In the MfPM group patients were placed in a prone position and the incision was made 1 cm medially to the Achilles tendon. In the posterolateral access (PL) group patients were placed in a prone or lateral decubitus position and the incision was made between the lateral malleolus and the Achilles tendon. Complications evaluated were divided into wound complications, infections, neuritis, vascular alterations and others.

RESULTS

81 ankle fractures with a posterior malleolar fragment treated by open reduction and internal fixation were identified. 20 cases were approached through the MfPM approach and 61 through the PL access. The mean follow up was 18.60 months (range 4-78 months). In the MfPM group the local complication rate was 10% (2/10 patients), both corresponding to minor wound problems which required no surgical intervention. No infection or other neural or vascular complications were found. In the PL group a complication rate of 8,19% (5/61 patients) was found, all of them corresponding to minor wound problems which required no surgical intervention. No infection or other neural or vascular complications were found. There were no significant differences between the two approaches regarding postoperative local complications (z score 0.249 - P: 0.803).

CONCLUSION

The MfPM approach is safe and may become as readily used as the PL due to the low incidence of postoperative local complications, especially in fractures with a large fragment and posteromedial extension in which greater access to the posterior pilon can facilitate instrumentation for anatomic reduction and fixation.

Two-staged management of ankle fracture-dislocations with a posterior fragment: computer-tomography-based classification, treatment and its outcome

INTRODUCTION

Trimalleolar fractures are difficult to treat and malreduction can lead to functional impairment. Involvement of the posterior malleolus has a poor predictive value. Current computed-tomography (CT)-based fracture classifications led to an increase in fixation of the posterior malleolus. The aim of this study was to describe the functional outcome after a two-stage stabilisation with direct fixation of the posterior fragment in trimalleolar dislocation fractures.

MATERIALS AND METHODS

In a retrospective study, all patients presenting with a trimalleolar dislocation fracture, an available CT scan, and a two-stage operative stabilisation including the posterior malleolus by a posterior approach were included. All fractures were treated with initial external fixator and delayed definitive stabilisation including fixation of the posterior malleolus. Next to clinical and radiological follow-up, outcome measures (Foot and Ankle Outcome Score (FAOS), Numeric Rating Scale (NRS), Activity of Daily Living (ADL), Hulsmans implant removal score) and complications were analysed.

RESULTS

Between 2008 and 2019, of 320 trimalleolar dislocation fractures, 39 patients were included. Mean follow-up was 49 months (standard deviation (SD) 29.7, range 16-148). Mean age was 60 years (SD 15.3, 17-84) with 69% female patients. The mean FAOS was 93/100 (SD 9.7, 57-100), NRS 2 (interquartile range (IQR) 0-3) and ADL 2 (IQR 1-2). Four patients showed a postoperative infection, three re-operations had to be performed and implants were removed in 24 individuals.

CONCLUSION

A two-stage procedure of trimalleolar dislocation fractures with in-direct reduction and fixation of the posterior tibial fragment through a posterior approach leads to good functional outcome scores with a low rate of complications.

[Ligamentous injuries of the ankle joint : Importance of radiological imaging procedures]

Injuries of the ankle joint show lesions of the lateral ligamentous apparatus with an incidence of 1 in 1000 cases. With a range of 0.3-0.7 in 1000 cases, injuries of the medial ligamentous apparatus occur more frequently than previously thought and are often overlooked. Correct imaging diagnostics of the ankle ligaments are mandatory for the prognosis and treatment planning. In cases of clinically strong suspicion of ligamentous injury or osteochondral lesions of the ankle joint, after primary radiographic evaluation magnetic resonance imaging (MRI) is primarily recommended for a more precise assessment. Additionally, the sensitivity for assessment of the ligaments with ultrasonography is good (91% vs. 97% with MRI) but its specificity is inferior compared to MRI (63% vs. 93% with MRI). Supination trauma is the most common ankle injury and attention should be paid to the anterior tibiofibular ligament and calcaneofibular ligament. In approximately 50%, injuries to the superficial layer of the medial collateral ligament complex are associated with lesions of the posterior tibiotalar ligament.

[Ligamentous injuries of the ankle joint : Importance of radiological imaging procedures]

Injuries of the ankle joint show lesions of the lateral ligamentous apparatus with an incidence of 1 in 1000 cases. With a range of 0.3-0.7 in 1000 cases, injuries of the medial ligamentous apparatus occur more frequently than previously thought and are often overlooked. Correct imaging diagnostics of the ankle ligaments are mandatory for the prognosis and treatment planning. In cases of clinically strong suspicion of ligamentous injury or osteochondral lesions of the ankle joint, after primary radiographic evaluation magnetic resonance imaging (MRI) is primarily recommended for a more precise assessment. Additionally, the sensitivity for assessment of the ligaments with ultrasonography is good (91% vs. 97% with MRI) but its specificity is inferior compared to MRI (63% vs. 93% with MRI). Supination trauma is the most common ankle injury and attention should be paid to the anterior tibiofibular ligament and calcaneofibular ligament. In approximately 50%, injuries to the superficial layer of the medial collateral ligament complex are associated with lesions of the posterior tibiotalar ligament.

Clinical effects of 3D printing-assisted posterolateral incision in the treatment of ankle fractures involving the posterior malleolus

Objective

To explore the clinical outcomes of a 3D printing-assisted posterolateral approach for the treatment of ankle fractures involving the posterior malleolus.

Methods

A total of 51 patients with ankle fractures involving the posterior malleolus admitted to our hospital from January 2018 to December 2019 were selected. The patients were divided into 3D printing group (28 cases) and control group (23 cases). 3D printing was performed for ankle fractures, followed by printing of a solid model and simulation of the operation on the 3D model. The operation was then performed according to the preoperative plan, including open reduction and internal fixation via the posterolateral approach with the patient in the prone position. Routine x-ray and CT examinations of the ankle joint were performed, and ankle function was evaluated using the American Foot and Ankle Surgery Association (AOFAS) ankle-hindfoot score.

Results

All patients underwent x-ray and CT examinations. All fractures healed clinically, without loss of reduction or failure of internal fixation. Good clinical effects were achieved in both groups of patients. The operation time, intraoperative blood loss and intraoperative fluoroscopy frequency in the 3D printing group were significantly less than those in the control group (p < 0.05). There was no significant difference between the two groups in the anatomical reduction rate of fractures or the incidence of surgical complications (p > 0.05).

Conclusion

The 3D printing-assisted posterolateral approach is effective in the treatment of ankle fractures involving the posterior malleolus. The approach can be well planned before the operation, is simple to perform, yields good fracture reduction and fixation, and has good prospects for clinical application.

Intercalary fragments in posterior malleolar fractures: incidence, treatment implications, and distribution within CT-based classification systems

Introduction

Complex ankle fractures frequently include the posterior malleolus (PM). Despite advances in diagnostic and treatment strategies, PM fracture involvement still predisposes to worse outcomes. While not incorporated into the most common PM fracture classifications, the presence of an intercalary fragment (ICF) complicates treatment. This study aims to describe the incidence, morphology, and location of ICFs in PM fractures.

Materials and methods

A total of 135 patients with a mean age of 54.4 (SD ± 18.9) years and PM fractures were analyzed for the presence of an ICF. Patients with an ICF were compared to those without in terms of age, gender, and treatment received. Characteristics of the ICFs in terms of location and size were assessed. Furthermore, the presence of an ICF in relation to the PM fracture classification according to Haraguchi et al., Bartoníček/Rammelt et al., and Mason et al. was investigated.

Results

ICFs presented in 55 (41%) of the 135 patients. Patients with an ICF were younger, and the PM was more often operatively treated when compared to patients without an ICF. A posterolateral approach was used significantly more often in patients with an ICF. Almost all ICFs were found in the posterolateral (58%) and posterocentral (35%) regions. The majority of fragments were found in Bartoníček/Rammelt type 2 fractures, the most common fracture type. Bartoníček/Rammelt type 3 fractures had the highest relative frequency of ICFs.

Conclusion

ICFs are frequently found in PM fractures; however, they are not incorporated into any of the common classifications. They are generally found in younger patients and associated with more complex PM fractures. As they can complicate reduction of the main fragment and may require direct exposure to restore joint congruency, ICFs should be considered in PM fracture classifications. Due to their location, the majority of ICFs are able to be accessed using a posterolateral approach.

The role of the posterior malleolus in the treatment of unstable upper ankle joint injuries - A biomechanical study

BACKGROUND

This biomechanical study aimed to test if the fixation of the posterior malleolus (PM) only with screws inserted from posterior to anterior (PA) restores stability comparable with the natural condition. The extent of stability was also compared with that of anterior to posterior (AP) screw osteosynthesis (OS) with an additional syndesmotic screw (SS).

METHODS

First, the stability of the upper ankle joint in seven pairs of intact lower legs were examined. Subsequently, half of the lower legs were treated with PA screw fixation of a PM fracture without SS and the other half with AP screw fixation with additional tricortical SS.

RESULTS

PA OS without SS showed significantly more diastasis (p = 0.027). The AP OS with an SS revealed a diastasis that was comparable with the intact condition (p = 0.797). The use of SS led to significantly higher stability compared to OS without SS (p = 0.019).

CONCLUSIONS

The Fixation of the PM alone without an additional syndesmotic screw cannot achieve intact upper ankle stability. Fixation of a PM fracture with an SS helps in nearly achieving the natural condition.

[Established classification systems of posterior malleolar fractures : A systematic literature review]

BACKGROUND

Posterior malleolar fractures are found in almost 50% of all ankle fractures. The high clinical relevance of these joint fractures is explained by the significantly worse clinical and functional outcome. There is still a lack of unified opinion regarding the classification and treatment of these fractures.

OBJECTIVE

The aim of this article is to provide a systematic literature review of clinical studies that investigated posterior malleolar fractures and classified them using one of the three established classifications according to Haraguchi, Bartonicek/Rammelt, or Mason.

MATERIAL AND METHODS

PubMed was searched without time limits. The systematic literature search was performed according to the current criteria of Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). The methodological quality of the included studies was quantified using the modified Coleman score.

RESULTS

A total of 27 studies with a total of 2220 patients were included in this systematic literature review. Trimalleolar fractures showed a significantly less favorable prognosis than other ankle fractures. The quality of reduction was the most important prognostic factor for the clinical outcome.

CONCLUSION

None of the three classifications examined has become established in the literature. Most of the classifications are weak or should not be used with respect to a derivable treatment algorithm or a prognosis with respect to the outcome. Only the classification according to Bartonicek/Rammelt is suitable to become established in the literature and in clinical practice due to its derivable treatment algorithm.

Ankle fractures involving the posterior malleolus: patient characteristics and 7-year results in 100 cases

INTRODUCTION

The presence of a posterior malleolar (PM) fragment has a negative prognostic impact in ankle fractures. The best treatment is still subject to debate. The aim of this study was to assess the medium-to-long-term clinical and functional outcome of ankle fractures with a PM fragment in a larger patient population.

MATERIALS AND METHODS

One hundred patients (69 women, 31 men, average age 60 years) with ankle fractures including the PM were evaluated clinically and radiographically. Patients with Bartoníček-Rammelt type 3 and 4 fracture displayed a significant female preponderance. Fixation of the PM was performed in 63% and tailored to the individual fracture pattern.

RESULTS

Internal fixation of the PM fragment was negatively correlated with the need for syndesmotic screw placement at the time of surgery (p = 0.010). At an average follow-up of 7.0 years, the mean Foot Function Index (FFI) was 16.5 (SD: 21.5), the Olerud Molander Ankle Score (OMAS) averaged 80.2 (SD: 24) and the American Orthopedic Foot & Ankle Society (AOFAS) ankle/hindfoot score averaged 87.5 (SD: 19.1). The maximum score of 100 was achieved by 44% of patients. The physical (PCS) and mental health component summary (MCS) scores of the SF-36 averaged 47.7 (SD: 12.51) and 50.5 (SD: 9.36), respectively. Range of motion was within 3.4 (SD: 6.63) degrees of the uninjured side. The size of the PM fragment had no prognostic value. There was a trend to lower outcome scores with slight anterior or posterior shift of the distal fibula within the tibial incisura. Patients who underwent primary internal fixation had significantly superior SF-36 MCS than patients who underwent staged internal fixation (p = 0.031).

CONCLUSIONS

With an individualized treatment protocol, tailored to the CT-based assessment of PM fractures, favorable medium and long-term results can be expected.