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Gao Y, Liu Y, Zhao Y, Shan L, Wang H, Xu X, Zhao B, Zhou J. Comparison between anterior-to-posterior screw fixation versus posterolateral approach plate fixation for posterior malleous fracture: A systematic review and meta-analysis. Foot Ankle Surg 2024; 30:594-602. [PMID: 38824055 DOI: 10.1016/j.fas.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 05/06/2024] [Accepted: 05/07/2024] [Indexed: 06/03/2024]
Abstract
PURPOSE There are two main surgical fixation methods for the posterior malleolar fractures (PMFs), the anterior-to-posterior (AP) screws or via the posterolateral (PL) approach utilizing a buttress plate. This review aims to compare the clinical outcome between the AP screw fixation and the PL plate fixation for treating PMFs. METHODS We searched all relevant publications about PMFs treated with AP screws or PL plates through electronic databases including the PubMed, the Cochrane Library, the Embase, the Wiley online library and the Web of Science. The meta-analysis was conducted to evaluated clinical outcomes including reduction quality, post-operative function and complications. RESULTS Six studies (one single randomized controlled trial and five retrospective cohort studies) were enrolled. 172 patients underwent AP screw fixation and 214 patients underwent PL plate fixation with a total of 386 patients (169 males and 217 females). The PL plating group yielded better AOFAS scores(MD = 6.97, 95 % CI=[4.68, 9.27], P<0.00001, I2 =0 %) and was more likely to achieve excellent anatomical reduction(OR=5.49, 95 % CI=[1.06, 28.42], P = 0.04, I2 =80 %). No differences were found in the bad reduction quality, incidences of complications (arthritis, neuralgia, superficial wound healing problems and implant failure), the walking VAS scores and the dorsiflexion restriction degrees. CONCLUSION We suggest that the PL plate fixation method has the clinical benefit of achieving anatomical reduction and better AOFAS scores over the AP screw fixation for treating PMFs. No differences were found in the incidences of complications ( arthritis, neuralgia, superficial wound healing problems and implant failure), the walking VAS scores and the dorsiflexion restriction degrees. The posterior approach and the direct reduction are recommended for the treatment of the PMFs. LEVEL OF CONFIDENCE Ⅱb.
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Affiliation(s)
- Yuling Gao
- Affiliated Beijing Chaoyang Hospital of Capital Medical University,Bejing, China; Beijing Chaoyang Hospital, Capital Medical University, Gongtinan Road 8#, Beijing 100020, China
| | - Yang Liu
- Affiliated Beijing Chaoyang Hospital of Capital Medical University,Bejing, China; Beijing Chaoyang Hospital, Capital Medical University, Gongtinan Road 8#, Beijing 100020, China
| | - Yanrui Zhao
- Affiliated Beijing Chaoyang Hospital of Capital Medical University,Bejing, China; Beijing Chaoyang Hospital, Capital Medical University, Gongtinan Road 8#, Beijing 100020, China
| | - Lei Shan
- Affiliated Beijing Chaoyang Hospital of Capital Medical University,Bejing, China; Beijing Chaoyang Hospital, Capital Medical University, Gongtinan Road 8#, Beijing 100020, China
| | - Hanzhou Wang
- Affiliated Beijing Chaoyang Hospital of Capital Medical University,Bejing, China; Beijing Chaoyang Hospital, Capital Medical University, Gongtinan Road 8#, Beijing 100020, China
| | - Xiaopei Xu
- Affiliated Beijing Chaoyang Hospital of Capital Medical University,Bejing, China; Beijing Chaoyang Hospital, Capital Medical University, Gongtinan Road 8#, Beijing 100020, China
| | - Binzhi Zhao
- Affiliated Beijing Chaoyang Hospital of Capital Medical University,Bejing, China; Beijing Chaoyang Hospital, Capital Medical University, Gongtinan Road 8#, Beijing 100020, China
| | - Junlin Zhou
- Affiliated Beijing Chaoyang Hospital of Capital Medical University,Bejing, China; Beijing Chaoyang Hospital, Capital Medical University, Gongtinan Road 8#, Beijing 100020, China.
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Chong LSL, Khademi M, Reddy KM, Anderson GH. Ten year outcomes after non-fixation of the smaller posterior malleolar fragment: A retrospective cohort study. Foot (Edinb) 2024; 59:102091. [PMID: 38513374 DOI: 10.1016/j.foot.2024.102091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 02/07/2024] [Accepted: 03/10/2024] [Indexed: 03/23/2024]
Abstract
INTRODUCTION Treatment of posterior malleolar (PM) ankle fractures remains controversial. Despite increasing recommendation for small PM fragment fixation, high quality evidence demonstrating improved clinical outcomes over the unfixated PM is limited. We describe the long term clinical and radiographical outcomes in younger adult patients with PM ankle fractures managed without PM fragment fixation. MATERIAL AND METHODS A retrospective cohort study was performed on PM ankle fracture patients aged 18-55 years old admitted under our orthopaedic unit between 1st of April 2009 and 31st of October 2013. Inclusion criteria were ASA 1 and 2, independent mobility pre-trauma, no pre-existing ankle pathologies, with satisfactory bimalleolar and syndesmotic stabilisation. Open fractures, talar fractures, calcaneal fractures, pilon fractures, subsequent re-injury and major complications were excluded. All PM fragments were unfixated. Clinical outcomes were evaluated using visual analogue scale (VAS) for pain, Foot and Ankle Ability Measure (FAAM) with activities of daily living (ADL) and sports subscale for function, and patient satisfaction ratings. Osteoarthritis was assessed using modified Kellgren-Lawrence scale on follow-up weightbearing ankle radiographs. RESULTS Sixty-one participants were included. Mean follow-up was 10.26 years. Average PM size was 16.2 ± 7.39%. All participants were evaluated for clinical outcomes. Mean score of FAAM-ADL was 95.5 ± 7.13, FAAM-Sports 86.4 ± 15.5, patient satisfaction 86.2 ± 14.4% and pain score 1.13 ± 1.65. Radiographical outcomes were evaluated in 52 participants, showing no-to-minimal osteoarthritis in 36/52 (69%), mild osteoarthritis in 14/52 (27%) and moderate osteoarthritis in 2/52 (4%). Pain and functional scores were independent of PM fragment size, post-reduction step-off, dislocation, malleoli fractured or syndesmotic injury. PM step-off more than 1 mm and traumatic dislocation/subluxation were associated with worse radiographical osteoarthritis. CONCLUSION After controlling for confounders, the unfixated smaller posterior malleolus fragment at 10-year follow-up demonstrated largely satisfactory clinical outcomes with some radiographical progression of osteoarthritis. LEVEL OF EVIDENCE Level III - Retrospective cohort study.
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Affiliation(s)
- Leo Swee Liang Chong
- Department of Orthopaedic Surgery, Palmerston North Hospital, Te Whatu Ora Te Pae Hauora o Ruahine o Tararua / Midcentral, New Zealand.
| | - MohammadAli Khademi
- Department of Orthopaedic Surgery, Palmerston North Hospital, Te Whatu Ora Te Pae Hauora o Ruahine o Tararua / Midcentral, New Zealand
| | - Kundam Murali Reddy
- Department of Orthopaedic Surgery, Palmerston North Hospital, Te Whatu Ora Te Pae Hauora o Ruahine o Tararua / Midcentral, New Zealand
| | - Geoffrey Hunter Anderson
- Department of Orthopaedic Surgery, Palmerston North Hospital, Te Whatu Ora Te Pae Hauora o Ruahine o Tararua / Midcentral, New Zealand
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Shen GD, Bai WB, Zou BL, Lai ZB, Yang KY, Zhang HN, Xu ZQ, Zhu YZ. Advancing treatment strategies for posterior malleolar malunion: The ankle dislocation method. Foot Ankle Surg 2024:S1268-7731(24)00113-9. [PMID: 38789379 DOI: 10.1016/j.fas.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 05/16/2024] [Accepted: 05/19/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND This study aimed to assess the radiological and clinical outcomes of treatment using the ankle dislocation method for posterior malleolar malunion. METHOD Thirty-one patients with posterior malleolar malunion who underwent treatment using the ankle dislocation method from May 2015 to October 2021 were retrospectively analyzed. Key outcome measures were radiographic parameters (articular step-off, tibiofibular clear space, fibular length, tibial lateral surface angle, and ankle osteoarthritis), clinical scores (American Orthopaedic Foot and Ankle Society ankle-hindfoot scale and Visual Analogue Scale), and patient satisfaction rate. RESULT Preoperative computed tomography revealed that Bartoní ček types 3 and 4 accounted for 64.5 % (n = 20) of total cases. Most posterior malleolar malunions were accompanied by depressed intercalary fragments (61.2 % [n = 19]). At the final follow-up, radiographic parameters and clinical scores showed significant improvements postoperatively (P < 0.05), with a high patient satisfaction rate of 77.4 %. Subgroup analysis revealed that the posterior malleolar fracture morphology significantly affected postoperative pain, particularly in more complex fractures (P < 0.001). CONCLUSION The ankle dislocation method effectively exposes the distal tibial articular surface and facilitates the anatomical restoration of joint congruity under direct vision. This approach substantially improves the clinical and imaging outcomes in patients with complex posterior malleolar malunion. LEVELS OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Guo-Dong Shen
- Department of Foot and Ankle Orthopedics, Foshan Hospital of Traditional Chinese Medicine Affiliated to Guangzhou University of Chinese Medicine, Foshan, Guangdong Province 528000, China
| | - Wen-Bo Bai
- Department of Foot and Ankle Orthopedics, Foshan Hospital of Traditional Chinese Medicine Affiliated to Guangzhou University of Chinese Medicine, Foshan, Guangdong Province 528000, China
| | - Bao-Li Zou
- Department of Foot and Ankle Orthopedics, Foshan Hospital of Traditional Chinese Medicine Affiliated to Guangzhou University of Chinese Medicine, Foshan, Guangdong Province 528000, China
| | - Zhi-Bin Lai
- Department of Foot and Ankle Orthopedics, Foshan Hospital of Traditional Chinese Medicine Affiliated to Guangzhou University of Chinese Medicine, Foshan, Guangdong Province 528000, China
| | - Kang-Yong Yang
- Department of Foot and Ankle Orthopedics, Foshan Hospital of Traditional Chinese Medicine Affiliated to Guangzhou University of Chinese Medicine, Foshan, Guangdong Province 528000, China
| | - Hong-Ning Zhang
- Department of Foot and Ankle Orthopedics, Foshan Hospital of Traditional Chinese Medicine Affiliated to Guangzhou University of Chinese Medicine, Foshan, Guangdong Province 528000, China
| | - Zhi-Qiang Xu
- Department of Foot and Ankle Orthopedics, Foshan Hospital of Traditional Chinese Medicine Affiliated to Guangzhou University of Chinese Medicine, Foshan, Guangdong Province 528000, China; Prestigious Chinese Medicine Expert of Guangdong Province Xu Zhiqiang Inheritance Studio, Foshan, Guangdong Province 528000, China.
| | - Yong-Zhan Zhu
- Department of Foot and Ankle Orthopedics, Foshan Hospital of Traditional Chinese Medicine Affiliated to Guangzhou University of Chinese Medicine, Foshan, Guangdong Province 528000, China.
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Warburton C, Perez OF, Cohen JL, Steinlauf SD. Reduction of the Posterior Malleolar Component of Trimalleolar Fractures Using Dry Arthroscopic Visualization and Manipulation by Working Through the Medial Malleolus Fracture. FOOT & ANKLE ORTHOPAEDICS 2024; 9:24730114241258098. [PMID: 38840787 PMCID: PMC11151758 DOI: 10.1177/24730114241258098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Affiliation(s)
| | - Olivia F. Perez
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jacob L. Cohen
- Department of Orthopaedic Surgery, University of Miami/Jackson Health System, Miami, FL, USA
| | - Steven D. Steinlauf
- Department of Orthopaedic Surgery, University of Miami/Jackson Health System, Miami, FL, USA
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Aamir J, Syziu A, Andritsos L, Caldwell R, Mason L. Tibialis posterior tendon entrapment in posterior malleolar and pilon injuries of the ankle: a retrospective analysis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:781-787. [PMID: 37698673 PMCID: PMC10858079 DOI: 10.1007/s00590-023-03714-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 08/22/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND The Tibialis Posterior tendon (TPT) is the only tendon to encounter the distal tibia and is therefore at greatest risk of injury in fractures of the distal tibia. Although TPT injury has been reported rarely with injuries around the ankle, they often have been missed and present late. AIM Our aim was to analyse the rate to TPT entrapment in fractures involving the posterior tibia, i.e. Pilon (PLM) and posterior malleolar fractures (PMF). METHODS A retrospective analysis of PMF and Pilon fractures over an 8-year period was undertaken. Patients who had undergone surgical fixation of their PMF or PLM were identified from 2014 to 2022, using our prospectively collected database. Any fracture which had undergone a preoperative CT was included. Analysis of their pre-operative CT imaging was utilised to identify TPT entrapment, where if < 50% of the tendon cross section was present in the fracture site, this was denoted as a minor entrapment and if ≥ 50% of the tendon was present in the fracture site was denoted as major. RESULTS A total of 363 patients were identified for further analysis, 220 who had a PMF and 143 with PLM injury. The incidence of TPT entrapment was 22% (n = 79) with 64 minor and 15 major entrapments. If the fracture line entered the TPT sheath, there was a 45% rate (72/172) of entrapment as compared to 3.7% (7/190) in fractures not entering the sheath (p < .001). There was no significant difference in TPT entrapment in PMF as compared to PML (p = 0.353). CONCLUSION In our assessment, we found significant prevalence of 22% of TPT entrapment in fractures involving the posterior tibia. PMF and PLF had no statistically significant difference in the rate of TPT entrapment. Additionally, we found that there was a significant risk of TPT entrapment when the CT images display the fracture line entering the tendon sheath. We recommend that surgeons consider taking care assessing pre-operative imaging to seek to identify the TPT and to assess intraoperatively where entrapment does occur.
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Affiliation(s)
- Junaid Aamir
- Liverpool Orthopaedic Trauma Service, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
| | - Anxhela Syziu
- School and Medicine, University of Liverpool, Liverpool, UK
| | - Loukas Andritsos
- Liverpool Orthopaedic Trauma Service, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
| | - Robyn Caldwell
- Liverpool Orthopaedic Trauma Service, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
| | - Lyndon Mason
- Liverpool Orthopaedic Trauma Service, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK.
- School and Medicine, University of Liverpool, Liverpool, UK.
- Department of Trauma and Orthopaedics, Aintree University Hospital, Liverpool, UK.
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Pollard JD, Krcal CE. Considerations with Fractures of the Posterior Malleolus in Ankle Fractures. Clin Podiatr Med Surg 2024; 41:103-117. [PMID: 37951669 DOI: 10.1016/j.cpm.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Foot and ankle surgeons are commonly confronted with the surgical dilemma on when and how to best surgically address trimalleolar ankle fractures with a posterior malleolar component. This may involve either direct fixation of the posterior malleolus or indirect stabilization with the fixation of the medial and lateral malleoli and trans-syndesmotic fixation. Recently there has been a paradigm shift in the management of these injuries with a more thorough understanding of anatomy, stability, and long-term sequela of these injuries. This article aims to evaluate the current literature on posterior malleolar ankle fractures, approaches to fixing the posterior malleolus, and outcomes and complications of these procedures.
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Affiliation(s)
- Jason D Pollard
- Department of Podiatric Surgery, Kaiser Permanente, 3600 Broadway, Suite 17, Oakland, CA 94611, USA.
| | - Craig E Krcal
- The CORE Institute, 18444 North 25th Avenue Suite 320, Phoenix, AZ 85023, USA; Graduate Kaiser San Francisco Bay Area Foot & Ankle Residency, 2023
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Gan TJ, Ma XK, Li YX, Chen Y, Liu X, Li J, Zhang H. Osteoperiosteal Iliac Autograft Transplantation for Unreconstructable Tibial Plafond After Malunions of Pilon Fractures in Young Patients. Foot Ankle Int 2024; 45:33-43. [PMID: 37837388 DOI: 10.1177/10711007231201823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
BACKGROUND Malunion of tibial pilon fracture, especially with a large cartilage loss of the tibial plafond, is a tough clinical conundrum. This study describes a joint-preserving technique that mainly involves corrective intraarticular osteotomy and osteoperiosteal iliac autograft transplantation for treating these generally considered unreconstructable tibial plafond. METHODS Sixteen patients with an average age of 33.6 years who were treated with this joint-preserving method between 2013 and 2020 were retrospectively analyzed. Ankle distraction was applied in all patients. Additional osteochondral autograft transplantation for talus was performed in 4 patients and supramalleolar osteotomy in 2 patients. The visual analog scale (VAS) score, the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, the 36-Item Short Form Health Survey (SF-36) score, and the ankle range of motion (ROM) were used for outcome analysis. Radiographic assessment was conducted, and the complications were recorded. RESULTS At a mean follow-up of 41.1 months, the mean VAS, AOFAS, and SF-36 scores improved from 6.3, 47.6, and 38.0 to 1.7, 84.4, and 70.8, respectively (P < .001 for each). The ankle ROM improved from 27.5 to 32.2 degrees (P = .023). The mean area of ilium blocks was 3.5 cm2, and the mean external fixation time was 94.1 days. Radiographs showed that good osteointegration was found in all patients and no significant progression of osteoarthritis in 15 patients. The major complications included poor incision healing in 2 patients and severe ankle stiffness in 2 patients, with one of them developing considerable varus-type osteoarthritis but reporting no pain. No deep infection, nonunion, or malunion occurred, and no secondary arthrodesis was performed during the final follow-up. CONCLUSION Osteoperiosteal iliac autograft transplantation might be an alternative surgical option for reconstructing unreconstructable malunited pilon fractures with a large cartilage loss of the tibial plafond in young patients. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Ting-Jiang Gan
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Xi-Kun Ma
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Ya-Xing Li
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Yu Chen
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Xi Liu
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Jia Li
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Hui Zhang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
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De Marchi Neto N, Nesello PFT, Bergamasco JM, Costa MT, Christian RW, Severino NR. Importance of computed tomography in posterior malleolar fractures: Added information to preoperative X-ray studies. World J Orthop 2023; 14:868-877. [PMID: 38173804 PMCID: PMC10758590 DOI: 10.5312/wjo.v14.i12.868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/18/2023] [Accepted: 10/16/2023] [Indexed: 12/15/2023] Open
Abstract
BACKGROUND Ankle fractures are common lesions of the lower limbs. Approximately 40% of ankle fractures affect the posterior malleolus (PM). Historically, PM osteosynthesis was recommended when PM size in X-ray images was greater than 25% of the joint. Currently, computed tomography (CT) has been gaining traction in the preoperative evaluation of ankle fractures. AIM To elucidate the similarity in dimensions and to correlate PM size in X-ray images with the articular surface of the affected tibial plafond in the axial view on CT (AXCT) of a PM fracture. METHODS Eighty-one patients (mean age: 39.4 ± 13.5 years) were evaluated (54.3% were male). Two independent examiners measured PM size in profile X-ray images (PMXR) and sagittal CT (SAGCT) slices. The correlation of the measurements between the examiners and the difference in the PM fragment sizes between the two images were compared. Next, the PM size in PMXR was compared with the surface of the tibial plafond involved in the fracture in AXCT according to the Haraguchi classification. RESULTS The correlation rates between the examiners were 0.93 and 0.94 for PMXR and SAGCT, respectively (P < 0.001). Fragments were 2.12% larger in SAGCT than in PMXR (P = 0.018). In PMXR, there were 56 cases < 25% and 25 cases ≥ 25%. When PMXR was < 25%, AXCT corresponded to 10.13% of the tibial plafond. When PMXR was ≥ 25%, AXCT was 24.52% (P < 0.001). According to the Haraguchi classification, fracture types I and II had similar PMXR measurements that were greater than those of type III. When analyzing AXCT, a significant difference was found between the three types, with II > I > III (P < 0.001). CONCLUSION PM fractures show different sizes using X-ray or CT images. CT showed a larger PM in the sagittal plane and allowed the visualization of the real dimensions of the tibial plafond surface.
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Affiliation(s)
- Noé De Marchi Neto
- Department of Orthopedics and Traumatology of the São Paulo Mercy Hospital (Santa Casa de São Paulo)-Fernandinho Simonsen Pavillion, Faculdade de Ciências Médicas da Santa Casa de São Paulo-Brazil, São Paulo 01221-020, Brazil
| | - Pietro Felice Tomazini Nesello
- Department of Orthopedics and Traumatology of the São Paulo Mercy Hospital (Santa Casa de São Paulo)-Fernandinho Simonsen Pavillion, Faculdade de Ciências Médicas da Santa Casa de São Paulo-Brazil, São Paulo 01221-020, Brazil
| | - Jordanna Maria Bergamasco
- Department of Orthopedics and Traumatology of the São Paulo Mercy Hospital (Santa Casa de São Paulo)-Fernandinho Simonsen Pavillion, Faculdade de Ciências Médicas da Santa Casa de São Paulo-Brazil, São Paulo 01221-020, Brazil
| | - Marco Tulio Costa
- Department of Orthopedics and Traumatology of the São Paulo Mercy Hospital (Santa Casa de São Paulo)-Fernandinho Simonsen Pavillion, Faculdade de Ciências Médicas da Santa Casa de São Paulo-Brazil, São Paulo 01221-020, Brazil
| | - Ralph Walter Christian
- Department of Orthopedics and Traumatology of the São Paulo Mercy Hospital (Santa Casa de São Paulo)-Fernandinho Simonsen Pavillion, Faculdade de Ciências Médicas da Santa Casa de São Paulo-Brazil, São Paulo 01221-020, Brazil
| | - Nilson Roberto Severino
- Department of Orthopedics and Traumatology of the São Paulo Mercy Hospital (Santa Casa de São Paulo)-Fernandinho Simonsen Pavillion, Faculdade de Ciências Médicas da Santa Casa de São Paulo-Brazil, São Paulo 01221-020, Brazil
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Faldini C. Osteoarthritis after an ankle fracture: we can't really avoid it. Musculoskelet Surg 2023; 107:375-378. [PMID: 38032524 DOI: 10.1007/s12306-023-00802-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2023] [Indexed: 12/01/2023]
Affiliation(s)
- C Faldini
- 1st Orthopaedic and Traumatologic Department, IRCCS - Rizzoli Orthopedic Institute, Via G.C. Pupilli 1, 40136, Bologna, Italy.
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy.
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Kabelitz M, Kabelitz N, Frima H, Stillhard PF, Sommer C, Michelitsch C. Two-staged management of ankle fracture-dislocations with a posterior fragment: computer-tomography-based classification, treatment and its outcome. Arch Orthop Trauma Surg 2023; 143:6193-6200. [PMID: 37335355 DOI: 10.1007/s00402-023-04949-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 06/11/2023] [Indexed: 06/21/2023]
Abstract
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.
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Affiliation(s)
- Method Kabelitz
- Clinic of Orthopedics, Hand and Trauma Surgery, City Hospital Zurich, Tièchestrasse 99, 8037, Zurich, Switzerland.
| | - Nina Kabelitz
- Department of Trauma Surgery, Kantonsspital Graubünden, Loëstrasse 170, 7000, Chur, Switzerland
| | - Herman Frima
- Department of Trauma Surgery, Noordwest Ziekenhuisgroep, Wilhelminalaan 12, 1815 JD, Alkmaar, Netherlands
| | | | - Christoph Sommer
- Department of Trauma Surgery, Kantonsspital Graubünden, Loëstrasse 170, 7000, Chur, Switzerland
| | - Christian Michelitsch
- Department of Trauma Surgery, Kantonsspital Graubünden, Loëstrasse 170, 7000, Chur, Switzerland
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Sobrón FB, Hernández-Mateo JM, Fernández T, Alonso MB, Parra G, Vaquero J. Locking versus nonlocking plates for the treatment of posterior malleolar ankle fractures: A retrospective cohort study and cost analysis. Foot (Edinb) 2023; 56:102033. [PMID: 37187081 DOI: 10.1016/j.foot.2023.102033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 05/01/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND We hypothesized that, as posterior malleolar ankle fractures usually present one or two main fragments, the buttress plating principle can be successfully achieved either with conventional nonlocking or anatomic locking posterior tibia plates, and no clinical differences should be found. The aim of this study was to evaluate the outcomes of posterior malleolar ankle (PM) fractures treated with conventional nonlocking (CNP) or anatomic locking plates (ALP), and also to compare both constructs in terms of crude costs. METHODS A retrospective cohort study was designed. CNP was used in 22 patients and ALP was used in 11 patients. American Orthopedic Foot and Ankle Society (AOFAS) score was registered at four weeks, 3-6 months, 12 and 24 months to assess all patients' functional status. The primary outcome was ankle and hindfoot AOFAS score at 12 months follow-up visit. All complications, radiographic evaluation and implant construct costs were also registered and compared. The average follow-up was 25.4 (range, 12-42) months. RESULTS No significant difference was observed between both cohorts, in terms of AOFAS score and complication rate (P > .05). We found that ALP construct is 17 times more expensive than CNP construct in our institution (P < .001). CONCLUSION Anatomic locking posterior tibial plates may be an interesting device when poor bone quality is present or when a true multifragmentary pilon fracture is faced. Anatomic locking posterior tibia plate should not become a regular implant for any PM fracture since equivalent clinical and radiological results were obtained in our study using CNP with a significant reduced cost.
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Affiliation(s)
- Francisco Borja Sobrón
- Hospital General Universitario Gregorio Marañón, Calle del Dr. Esquerdo, 46, 28007 Madrid, Spain.
| | | | - Tanya Fernández
- Hospital General Universitario Gregorio Marañón, Calle del Dr. Esquerdo, 46, 28007 Madrid, Spain
| | - María Berta Alonso
- Hospital Universitario La Princesa, Calle Diego de León 62, 28006 Madrid, Spain
| | - Guillermo Parra
- Hospital General Universitario Gregorio Marañón, Calle del Dr. Esquerdo, 46, 28007 Madrid, Spain
| | - Javier Vaquero
- Hospital General Universitario Gregorio Marañón, Calle del Dr. Esquerdo, 46, 28007 Madrid, Spain
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12
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Wang J, Chu XJ, Li LF, Yang ZZ, Zhang TQ, He J. Study on the effect of self-made fracture positioning compression guide device for posterior malleolus fracture surgery: Medical prevention. Prev Med 2023; 174:107648. [PMID: 37507026 DOI: 10.1016/j.ypmed.2023.107648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/03/2023] [Accepted: 07/25/2023] [Indexed: 07/30/2023]
Abstract
To evaluate the effectiveness of a self-designed pressure-guided fracture positioning device, a prospective study was conducted in patients with posterior ankle fractures undergoing surgery using the device. Twenty-seven cases of ankle joint fracture with posterior malleolus fracture were treated by surgery. In the process of fixing posterior malleolus fracture, a self-designed fracture positioning compression guide device was used to fix posterior malleolus bone by anterior and posterior approaches. Postoperative CT images were used to assess the fixation position as well as length of the screw and the compression of the fracture. All patients had healed ankle fractures, and the anterior-posterior screws were fixed in the central area of the posterior malleolus. Posterior malleolus fragment displacement was <2 mm. The screw effectively secured the cortex beyond the length of the posterior malleolus cortex by no more than two threads. The good rate of ankle joint function was 85.16%. Compared to traditional surgical techniques, minimally invasive fixation using the self-designed positioning compression guide device has several advantages, including smaller trauma, faster postoperative recovery, and improved patient satisfaction. The device also provides the surgeon with greater control and precision during the surgical procedure, which can contribute to better surgical outcomes.
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Affiliation(s)
- Jun Wang
- Department of Orthopedics, Shanghai Fifth People's Hospital Affiliated to Fudan University, No. 801, Heqing Road, Minhang District, Shanghai 200240, China
| | - Xiao-Jun Chu
- Department of Orthopedics, Shanghai Fifth People's Hospital Affiliated to Fudan University, No. 801, Heqing Road, Minhang District, Shanghai 200240, China
| | - Ling-Feng Li
- Department of Orthopedics, Shanghai Fifth People's Hospital Affiliated to Fudan University, No. 801, Heqing Road, Minhang District, Shanghai 200240, China
| | - Ze-Zheng Yang
- Department of Orthopedics, Shanghai Fifth People's Hospital Affiliated to Fudan University, No. 801, Heqing Road, Minhang District, Shanghai 200240, China
| | - Tie-Qi Zhang
- Department of Orthopedics, Shanghai Fifth People's Hospital Affiliated to Fudan University, No. 801, Heqing Road, Minhang District, Shanghai 200240, China
| | - Jun He
- Department of Orthopedics, Shanghai Fifth People's Hospital Affiliated to Fudan University, No. 801, Heqing Road, Minhang District, Shanghai 200240, China.
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13
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Miksch RC, Herterich V, Barg A, Böcker W, Polzer H, Baumbach SF. Open Reduction and Internal Fixation of the Posterior Malleolus Fragment in Ankle Fractures Improves the Patient-Rated Outcome: A Systematic Review. Foot Ankle Int 2023; 44:727-737. [PMID: 37125766 PMCID: PMC10394961 DOI: 10.1177/10711007231165771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
BACKGROUND The best treatment strategy for fractures to the posterior malleolus (PM) is still intensively debated. The aim of this systematic review was to compare the patient-rated outcome following open reduction and internal fixation (ORIF) for fractures of the PM to either closed reduction using AP screws (CRIF) or no treatment in bi- or trimalleolar ankle fractures. METHODS Systematic literature research (MEDLINE (PubMed), CINAHL, Scopus, Central and EMBASE) according to the PICOS and PRISMA guidelines. Eligible were studies comparing the outcome following ORIF to any other treatment strategy for fractures to the posterior malleolus in isolated bi- or trimalleolar ankle fractures. RESULTS Twelve studies were eligible for a qualitative analysis and 6 for a quantitative analysis. Overall, a considerable heterogeneity among the studies was observed. The most commonly used outcome score was the American Orthopaedic Foot & Ankle Society ankle-hindfoot score (AOFAS). The final follow-up ranged from 12 to 160 months. Four studies compared ORIF to CRIF of the PM. The quantitative analysis revealed significantly better AOFAS scores for ORIF (90.9 vs 83.4 points; P < .001; I2 = 0%). Three studies compared ORIF to untreated PM fragment. The quantitative analysis again revealed superior AOFAS scores for ORIF (92.0 vs 82.5 points; P < .001; I2 = 99%). A similar trend was observed for the Ankle Fracture Scoring System and American Academy of Orthopaedic Surgeons Foot and Ankle Questionnaire scores as well as the quality of reduction. CONCLUSION Despite a considerable heterogeneity, the data available point to a superior outcome following ORIF for fractures to the PM when compared to CRIF or no treatment.
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Affiliation(s)
- Rainer Christoph Miksch
- Musculoskeletal University Centre Munich (MUM), University Hospital, Ludwig-Maximilians-University Munich (LMU), Germany
| | - Viktoria Herterich
- Musculoskeletal University Centre Munich (MUM), University Hospital, Ludwig-Maximilians-University Munich (LMU), Germany
| | - Alexej Barg
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Böcker
- Musculoskeletal University Centre Munich (MUM), University Hospital, Ludwig-Maximilians-University Munich (LMU), Germany
| | - Hans Polzer
- Musculoskeletal University Centre Munich (MUM), University Hospital, Ludwig-Maximilians-University Munich (LMU), Germany
| | - Sebastian Felix Baumbach
- Musculoskeletal University Centre Munich (MUM), University Hospital, Ludwig-Maximilians-University Munich (LMU), Germany
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14
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Vanderstappen M, Herteleer M, Hoekstra H. Dance Around the Fibula with a Twisted Plate: A Technical Note. Indian J Orthop 2023; 57:1323-1328. [PMID: 37525740 PMCID: PMC10387044 DOI: 10.1007/s43465-023-00941-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 06/17/2023] [Indexed: 08/02/2023]
Abstract
Nowadays, there is a better understanding of the role of the posterior malleolar fragment in trimalleolar ankle fractures. Not fragment size, but rather fragment morphology should guide the management of the posterior malleolar fracture (PMF). Anatomical reduction and fixation of the PMF is important, as an intra-articular step-off will eventually lead to osteoarthritis. Incongruency of the incisura fibularis tibia is associated with fibular dislocation, syndesmotic insufficiency, and poor functional outcomes. Open reduction and internal fixation through a posterior approach leads to ankle joint mobility restriction (i.e., dorsal flexion deficiency) due to arthrofibrosis of the ankle joint, fibrous adhesions and secondary shortening of the flexor muscles. In this technical note, we describe a surgical technique to fixate unstable ankle fractures with a combined PMF and a high supra-syndesmotic fibular fracture through two small surgical windows using a twisted one-third tubular plate. By reducing the size of the posterolateral window, fibrous adhesions and secondary flexor muscle shortening are diminished, favoring ankle joint mobility.
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Affiliation(s)
- Maxim Vanderstappen
- Department of Trauma Surgery, University Hospitals Leuven, Herestraat 39, 3000 Leuven, Belgium
- Department of Orthopaedics, University Hospitals Leuven, Leuven, Belgium
| | - Michiel Herteleer
- Department of Trauma Surgery, University Hospitals Leuven, Herestraat 39, 3000 Leuven, Belgium
- Department of Development and Regeneration, KU Leuven-University of Leuven, Leuven, Belgium
| | - Harm Hoekstra
- Department of Trauma Surgery, University Hospitals Leuven, Herestraat 39, 3000 Leuven, Belgium
- Department of Development and Regeneration, KU Leuven-University of Leuven, Leuven, Belgium
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15
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Yang L, Yin G, Zhu J, Liu H, Zhao X, Xue L, Yin F, Liu J, Liu Z. Posterolateral approach for posterior malleolus fixation in ankle fractures: functional and radiological outcome based on Bartonicek classification. Arch Orthop Trauma Surg 2023; 143:4099-4109. [PMID: 36183274 PMCID: PMC10293422 DOI: 10.1007/s00402-022-04620-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 09/06/2022] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Posterolateral approach has been advocated for the treatment of ankle fractures involving the posterior malleolus and satisfactory results were demonstrated in several studies. The Bartonicek classification based on 3-dimensional CT scanning was commonly used for treatment recommendation of posterior malleolar fracture (PMF). The aim of this retrospective study was to evaluate the clinical effect of the posterolateral approach for the treatment of PMF and present outcomes of patients with different types of Bartonicek classification. METHOD We retrospectively reviewed the clinical outcomes of 72 patients with ankle fractures involving posterior malleolus (PM) from January 2016 to December 2018. Posterior malleolus fractures (PMFs) were all directly reduced and fixed by a posterolateral approach using lag screws and/or buttress plates. AOFAS score and VAS pain score were used as the primary functional outcome measures. The radiographic evaluation included the quality of the reduction and Kellgren-Lawrence (KL) osteoarthritis classification. According to the CT-based Bartonicek classification, all patients were classified into three groups: 42 type II, 18 type III and 12 type IV. Bartonicek type II patients were further divided into subtype IIa 19 cases, subtype IIb 16 cases and subtype IIc 7 cases. The radiological and functional outcomes were analyzed among different types and subtypes of Bartonicek classification. RESULTS Sixty-eight patients (94.5%) achieved good or excellent reduction of PMF after surgery. The mean AOFAS score was 81.35 ± 6.15 at 6 months and 90.56 ± 4.98 at the final follow-up, respectively. The VAS score was 6.62 ± 1.03 one week after surgery, and 1.20 ± 0.92 at the final follow-up. Radiological evaluation at the final follow-up showed that primary bone union was achieved in all patients and 65 patients (88.9%) got no (KL grade 0) or just doubtable (KL grade 1) post-traumatic osteoarthritis. AOFAS scores decreased significantly with the severity of Bartonicek classification at 6 month (p < 0.001) and final follow-up (p < 0.05), while there was no statistical difference of VAS pain score among different types of Bartonicek classification. Reduction quality and the presence of osteoarthritis was not correlated to Bartonicek classification either. Besides, AOFAS scores at the final follow-up were statistically different among three subtypes of Bartonicek type II fractures (p < 0.05), and Bartonicek subtype IIa fractures had the highest AOFAS scores as 93 ± 4.99. Presence and severity of osteoarthritis was lower in patients with subtype IIa PMF compared to other subtype groups, this finding was statistically significant (p < 0.05). CONCLUSION The posterolateral approach could achieve good clinical outcomes in the treatment of posterior malleolus fracture. Patients with a Bartonicek type II fracture had a better functional outcome measured by the AOFAS score compared to other types. Bartonicek type IIa fractures got a higher AOFAS score and a lower incidence of osteoarthritis at the final follow-up than the other two subtypes. Classification of PMFs according to the Bartonicek classification was reliable.
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Affiliation(s)
- Lei Yang
- Department of Orthopedics, Wujin Hospital Affiliated with Jiangsu University, Changzhou, 213017, China
- Department of Orthopedics, The Wujin Clinical College of Xuzhou Medical University, Changzhou, 213017, China
| | - Gang Yin
- Department of Orthopedics, Wujin Hospital Affiliated with Jiangsu University, Changzhou, 213017, China
| | - Jianguo Zhu
- Department of Orthopedics, Wujin Hospital Affiliated with Jiangsu University, Changzhou, 213017, China
| | - Haifeng Liu
- Department of Orthopedics, Wujin Hospital Affiliated with Jiangsu University, Changzhou, 213017, China
| | - Xiaoqiang Zhao
- Department of Orthopedics, Wujin Hospital Affiliated with Jiangsu University, Changzhou, 213017, China
| | - Lei Xue
- Department of Orthopedics, Wujin Hospital Affiliated with Jiangsu University, Changzhou, 213017, China
| | - Fen Yin
- Department of Orthopedics, Wujin Hospital Affiliated with Jiangsu University, Changzhou, 213017, China
| | - Jinbo Liu
- Department of Spinal Surgery, The Third Affiliated Hospital of Soochow University, Changzhou, 213003, China
| | - Zhiyuan Liu
- Department of Orthopedics, Wujin Hospital Affiliated with Jiangsu University, Changzhou, 213017, China.
- Department of Orthopedics, The Wujin Clinical College of Xuzhou Medical University, Changzhou, 213017, China.
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Terstegen J, Weel H, Frosch KH, Rolvien T, Schlickewei C, Mueller E. Classifications of posterior malleolar fractures: a systematic literature review. Arch Orthop Trauma Surg 2023; 143:4181-4220. [PMID: 36469121 PMCID: PMC10293398 DOI: 10.1007/s00402-022-04643-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 09/30/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Complex ankle fractures frequently involve the posterior malleolus. Many classifications describing posterior malleolar fractures (PMF) exist. The aim of this study was to provide a systematic literature review to outline existing PMF classifications and estimate their accuracy. METHODS The databases PubMed and Scopus were searched without time limits. Only specific PMF classifications were included; general ankle and/or pilon fracture classifications were excluded. Selection and data extraction was performed by three independent observers. 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 110 studies with a total of 12.614 patients were included. Four main classifications were identified: Those describing the size of the posterior malleolar fracture (n = 66), Haraguchi (n = 44), Bartoníček/Rammelt (n = 21) and Mason (n = 12). The quality of the studies was moderate to good with a median Coleman-score of 43.5 (14-79) and a weighted median Coleman-score of 42.5 points. All classifications achieved a substantial to perfect score regarding the inter- and intraobserver reliability, with Mason scoring the lowest in comparison. CONCLUSIONS None of the reviewed PMF classifications has been able to establish itself decisively in the literature. Most of the classifications are insufficient in terms of a derivable treatment algorithm or a prognosis with regard to outcome. However, as the Bartoníček/Rammelt classification has the greatest potential due to its treatment algorithm, its reliability in combination with consistent predictive values, its usage in clinical practice and research appears advisable.
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Affiliation(s)
- Julia Terstegen
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Hanneke Weel
- Department of Orthopedics, Bergman Clinics, Arnhem, The Netherlands
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
- Department of Trauma Surgery, Orthopaedics, and Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany
| | - Tim Rolvien
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Carsten Schlickewei
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Elena Mueller
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
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17
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Haws BE, Karnyski S, DiStefano DA, Soin SP, Flemister AS, Ketz JP. Reduction of Posterior Malleolus Fractures With Open Fixation Compared to Percutaneous Treatment. FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231200485. [PMID: 37786607 PMCID: PMC10541751 DOI: 10.1177/24730114231200485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023] Open
Abstract
Background Operative decision making between approaches to posterior malleolus reduction remains a challenge. The purpose of this study is to compare the quality of reduction between percutaneous and open reduction of posterior malleolus fractures and to identify factors associated with malreduction. Methods Operatively managed ankle fractures that included posterior malleolus fixation were reviewed. Fracture characteristics were determined on preoperative CT scans. Initial postoperative radiographs were used to measure reduction of the posterior malleolus articular surface and graded as satisfactory (<2 mm step-off) or malreduced (≥2 mm step-off). Final postoperative PROMIS scores and 1-year complications were compared between percutaneous and open cohorts. A multivariate stepwise regression model was used to evaluate predictors for malreduction. Results A total of 120 patients were included. Open reduction was performed in 91 (75.8%) compared with 29 (24.2%) who underwent percutaneous reduction. Malreduction (≥2-mm articular step-off) occurred in 11.7% of patients. Malreduction rates were significantly higher with percutaneous fixation than open fixation (24.1% vs 7.7%, P = .02). Multiple fragments and those with ≥5 mm of displacement demonstrated higher malreduction rates with percutaneous fixation (P < .05 for both), whereas single fragments and those with <5 mm of displacement experienced similar malreduction rates with percutaneous or open fixation. Initial displacement ≥5 mm (relative risk [RR] = 3.8, 95% CI = 1.2-11.5, P = .02) and percutaneous treatment (RR = 4.1, 95% CI = 1.6-10.5, P < .01) were identified as independent risk factors for malreduction. There were no significant differences in 1-year complication rates or final PROMIS scores between groups. Conclusion Open reduction of the posterior malleolus may lead to improved fracture reduction compared to percutaneous reduction without significant increase in complications. Open fixation improves reduction among fractures with multiple fragments or ≥5 mm of displacement, whereas fractures with a single fragment or <5 mm of displacement achieve similar reductions regardless of approach. Initial displacement ≥5 mm and percutaneous reduction are independent risk factors for malreduction. Level of evidence Level III, therapeutic.
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Affiliation(s)
- Brittany E. Haws
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
| | - Steven Karnyski
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
| | - David A. DiStefano
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
| | - Sandeep P. Soin
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
| | - Adolph S. Flemister
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
| | - John P. Ketz
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
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18
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Zheng H, Xia Y, Ni X, Wu J, Li Y, Zhang P, Wu X, Lu K, Zhao Q. Clinical effects of 3D printing-assisted posterolateral incision in the treatment of ankle fractures involving the posterior malleolus. Front Surg 2023; 10:1176254. [PMID: 37292486 PMCID: PMC10244554 DOI: 10.3389/fsurg.2023.1176254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/03/2023] [Indexed: 06/10/2023] Open
Abstract
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.
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Affiliation(s)
- Hongming Zheng
- Department of Orthopedic Surgery, Affiliated Danyang Hospital of Nantong University, Danyang, China
| | - Yan Xia
- Department of Orthopedic Surgery, Affiliated Danyang Hospital of Nantong University, Danyang, China
| | - Xiaohui Ni
- Department of Orthopedics, Dafeng People’s Hospital, Yancheng, China
| | - Jieshi Wu
- Department of Orthopaedics, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Yankun Li
- Department of Orthopaedics, Guizhou Provincial People's Hospital, Guiyang, China
| | - Pengpeng Zhang
- Department of Orthopaedics, Guizhou Provincial People's Hospital, Guiyang, China
| | - Xinglin Wu
- Department of Orthopaedics, Guizhou Provincial People's Hospital, Guiyang, China
| | - Kaihang Lu
- Department of Orthopaedics, Guizhou Provincial People's Hospital, Guiyang, China
| | - Quanming Zhao
- Department of Orthopaedics, Guizhou Provincial People's Hospital, Guiyang, China
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19
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Stake IK, Douglass BW, Husebye EE, Clanton TO. Methods for Biomechanical Testing of Posterior Malleolar Fractures in Ankle Fractures: A Scoping Review. Foot Ankle Int 2023; 44:348-362. [PMID: 36932661 DOI: 10.1177/10711007231156164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
Abstract
BACKGROUND The treatment of posterior malleolar fractures (PMFs) is debated, including the need for surgery and method of fixation. Recent literature has suggested that fracture pattern, rather than fragment size, may be an important predictor for ankle biomechanics and functional outcome. Biomechanical studies have been conducted to provide evidence-based treatment on the effects of fracture and fixation on contact pressure and stability. The objective of this scoping review is to summarize the methodologies used in biomechanical studies on PMFs and assess whether they are sufficient to test the need for surgery and method of fixation. METHODS A scoping review of publications before January 2022 was performed. PubMed/Medline and Embase Ovid were searched for cadaver or finite element analysis (FEA) studies that created and tested the effects of PMFs in ankle fractures. Both cadaver and FEA studies were included. Data about fragment characteristics, mode of testing, and outcomes were charted by 2 persons from the study group. The data were synthesized when possible and compared. RESULTS We included 25 biomechanical studies, including 19 cadaver studies, 5 FEA studies, and 1 cadaver and FEA study. Aside from the fragment size, few other fragment characteristics were reported. Mode of testing varied with different loads and foot positions. Strong conclusions on the effects of fracture and fixation on contact pressure and stability could not be made. CONCLUSION Biomechanical studies on PMFs demonstrate wide variability in fragment characteristics and mode of testing, which makes it difficult to compare studies and draw conclusions on the need for surgery and method of fixation. Additionally, limited reporting of fragment measurements questions the applicability to clinical practice. The biomechanical literature on PMFs would benefit from the use of a standard classification and universal fragment measurements to match clinical injuries in future biomechanical studies. Based on this review, we recommend the Mason classification, which addresses the pathomechanism, and use of the following fragment measurements in all 3 anatomic planes when creating and describing PMFs: fragment length ratio, axial angle, sagittal angle or fragment height, and interfragmentary angle. The testing protocol needs to reflect the purpose of the study. CLINICAL RELEVANCE This scoping review demonstrates wide methodological diversity of biomechanical studies. Consistency in methodology should enable comparison of study results, leading to stronger evidence-based recommendations to guide surgeons in decision making and offer PMF patients the best treatment.
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Affiliation(s)
- Ingrid K Stake
- Steadman Philippon Research Institute, Vail, CO, USA.,Department of Orthopaedic Surgery, Østfold Hospital Trust, Grålum, Norway
| | | | | | - Thomas O Clanton
- Steadman Philippon Research Institute, Vail, CO, USA.,The Steadman Clinic, Vail, CO, USA
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20
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Fernández-Rojas E, Herrera-Pérez M, Vilá-Rico J. [Translated article] Posterior malleolar fractures: Indications and surgical approaches. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:T160-T169. [PMID: 36574833 DOI: 10.1016/j.recot.2022.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 10/27/2022] [Indexed: 12/25/2022] Open
Abstract
Posterior malleolus fractures are frequent injuries, present in 7-44% of all ankle fractures. The objective of this study is to review the evidence to indicate the fixation of this fracture and to choose the appropriate surgical approach. The classic indications for fixation were fragment size greater than 25-30% of the articular surface and displacement greater than 2mm. However, current evidence suggests that, rather than size, factors such as syndesmotic instability, intra-articular step-off greater than 1-2mm, plafond impaction and the presence of intercalary fragments should be considered. When comparing the different surgical approaches, the literature supports the use of posterior approaches and reserves the recommendation of the traditional approach for exceptional cases. For the treatment of this injury it is essential to know the anatomy of the ankle and to consider all the factors described above, in addition to the presence of concomitant injuries.
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Affiliation(s)
- E Fernández-Rojas
- Equipo de Tobillo y Pie, Servicio de Traumatología y Ortopedia, Hospital Las Higueras, Talcahuano, Chile; Universidad Católica de la Santísima Concepción, Concepción, Chile.
| | - M Herrera-Pérez
- Unidad de Pie y Tobillo, Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Islas Canarias, Spain; Escuela de Medicina, Universidad de La Laguna, Santa Cruz de Tenerife, Islas Canarias, Spain
| | - J Vilá-Rico
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, Spain; Departamento de Cirugía, Universidad Complutense de Madrid, Madrid, Spain
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21
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Fernández-Rojas E, Herrera-Pérez M, Vilá-Rico J. Posterior malleolar fractures: Indications and surgical approaches. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:160-169. [PMID: 36371071 DOI: 10.1016/j.recot.2022.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/10/2022] [Accepted: 10/27/2022] [Indexed: 11/11/2022] Open
Abstract
Posterior malleolus fractures are frequent injuries, present in 7-44% of all ankle fractures. The objective of this study is to review the evidence to indicate the fixation of this fracture and to choose the appropriate surgical approach. The classic indications for fixation were fragment size greater than 25-30% of the articular surface and displacement greater than 2 mm. However, current evidence suggests that, rather than size, factors such as syndesmotic instability, intra-articular step-off greater than 1-2 mm, plafond impaction and the presence of intercalary fragments should be considered. When comparing the different surgical approaches, the literature supports the use of posterior approaches and reserves the recommendation of the traditional approach for exceptional cases. For the treatment of this injury it is essential to know the anatomy of the ankle and to consider all the factors described above, in addition to the presence of concomitant injuries.
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Affiliation(s)
- E Fernández-Rojas
- Equipo de Tobillo y Pie, Servicio de Traumatología y Ortopedia, Hospital Las Higueras, Talcahuano, Chile; Universidad Católica de la Santísima Concepción, Concepción, Chile.
| | - M Herrera-Pérez
- Unidad de Pie y Tobillo, Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Islas Canarias, España; Escuela de Medicina, Universidad de La Laguna, Santa Cruz de Tenerife, Islas Canarias, España
| | - J Vilá-Rico
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, España; Departamento de Cirugía, Universidad Complutense de Madrid, Madrid, España
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22
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Rajan L, Eble S, Kim J, Kukadia S, Kumar P, Day J, Cho D, Drakos M, Ellis S. Risk Factors Associated With Worse Clinical Outcomes of Ankle Fractures Involving the Posterior Malleolus. FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231154217. [PMID: 36860801 PMCID: PMC9969454 DOI: 10.1177/24730114231154217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023] Open
Abstract
Background Ankle fractures involving the posterior malleolus (PM) tend to result in inferior clinical outcomes compared to other ankle fractures. However, it is unclear which specific risk factors and fracture characteristics are associated with negative outcomes in these fractures. The aim of this study was to identify risk factors for poor postoperative patient-reported outcomes in patients with fractures involving the PM. Methods This retrospective cohort study included patients who sustained ankle fractures involving the PM between March 2016 and July 2020 and had preoperative computed tomography (CT) scans. In total, 122 patients were included for analysis. One patient (0.8%) had an isolated PM fracture, 19 (15.6%) had bimalleolar ankle fractures involving the PM, and 102 (83.6%) had trimalleolar fractures. Fracture characteristics including the Lauge-Hansen (LH) and Haraguchi classifications and posterior malleolar fragment size were collected from preoperative CT scans. Patient Reported Outcome Measurement Information System (PROMIS) scores were collected preoperatively and at a minimum of 1 year postoperatively. The association between various demographic and fracture characteristics with postoperative PROMIS scores was assessed. Results Involvement of more malleoli was associated with worse PROMIS Physical Function (P = .04), Global Physical Health (P = .04), and Global Mental Health (P < .001), and Depression scores (P = .001). Elevated BMI was also associated with worse PROMIS Physical Function (P = .0025), Pain Interference (P = .0013), and Global Physical Health (P = .012) scores. Time to surgery, fragment size, Haraguchi classification, and LH classification were not associated with PROMIS scores. Conclusion In this cohort, we found that trimalleolar ankle fractures were associated with inferior PROMIS outcomes compared with bimalleolar ankle fractures involving the PM in multiple domains. Level of Evidence Level III, retrospective cohort study.
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Affiliation(s)
- Lavan Rajan
- Hospital for Special Surgery, New York,
NY, USA,Lavan Rajan, BA, Research Assistant,
Hospital for Special Surgery, 523 East 72nd St, 5th Floor, New York, NY 10021,
USA.
| | | | | | | | | | | | - David Cho
- Hospital for Special Surgery, New York,
NY, USA
| | - Mark Drakos
- Hospital for Special Surgery, New York,
NY, USA
| | - Scott Ellis
- Hospital for Special Surgery, New York,
NY, USA
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23
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Gan TJ, Li YX, Chen Y, Liu X, Zhang H. Open reduction and internal fixation for posterior pilon fracture: Transfibular approach versus posterior approach. Injury 2023; 54:751-760. [PMID: 36404163 DOI: 10.1016/j.injury.2022.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 11/01/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND For posterior pilon fractures, the posterior approach (PA) is widely used but has its limitations. The transfibular approach (TFA) has been adopted to treat posterior malleolar fractures for the advantage of direct visual confirmation of the reduction status intraoperatively, yet the report of its application on posterior pilon fractures is rare. This study aims to compare TFA with PA in terms of their corresponding reduction quality. METHODS Clinical data of 85 posterior pilon fracture patients treated via PA (n = 62) or TFA (n = 23) were retrospectively reviewed. Radiographic and clinical assessments, including articular step-off or gap, syndesmosis reduction quality, signs of ankle arthritis, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, visual analogue scale (VAS), ankle stability, and the active range of motion (ROM) of the ankle, were all evaluated by two readers independently. RESULTS The total incidence of step-off or gap ≥ 1 mm was significantly higher in the PA group (35.5%) than in the TFA group (8.7%, p = 0.015). In all the patients, step-off ≥ 1 mm was identified as an independent risk factor for the development of arthritis and a lower AOFAS score (p < 0.001). No significant difference was found in ROM and complication incidence between the two groups. Ankle instability was found in neither group during the follow-up. CONCLUSION TFA could offer a way to intraoperatively evaluate the reduction status with direct visual confirmation and, thereby, might improve the results of reduction for posterior pilon fractures. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Ting-Jiang Gan
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, China
| | - Ya-Xing Li
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, China; Disaster Medicine Center, Sichuan University, Chengdu, Sichuan Province 610041, China
| | - Yu Chen
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, China
| | - Xi Liu
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, China
| | - Hui Zhang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, China; Disaster Medicine Center, Sichuan University, Chengdu, Sichuan Province 610041, China.
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24
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Lee J, Ryu H, Park JY. Single lateral approach for open reduction and internal fixation of posterior malleolar fragment in Weber B rotational ankle fracture. Medicine (Baltimore) 2023; 102:e32725. [PMID: 36701732 PMCID: PMC9857474 DOI: 10.1097/md.0000000000032725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Ankle fractures involving the posterior malleolus are a relatively common injuries, but various surgical approaches are still being introduced, and the selection of an appropriate surgical method is still controversial. The aim of this study was to introduce the surgical method using a single lateral approach for open reduction and internal fixation for posterior malleolar (PM) fractures associated with Weber B type ankle fractures. In this retrospective study, the single lateral approach was used for osteosynthesis of the PM fracture with Weber B lateral malleolar fractures. A total of 40 patients were followed up at for least 12 months (mean, 23.3; range, 12-88). Clinical assessment was based on the Olerud and Molander score, Foot and Ankle Outcome Score, visual analog scale, and subjective patient satisfaction 1 year after surgery. The accuracy of reduction was evaluated as <1 mm of displacement on the lateral view of the postoperative radiographs. The mean Olerud and Molander ankle score was 85.6 ± 12.7 and the mean Foot and Ankle Outcome Score was 82.7 ± 15.9 at 1-year postoperatively. Acceptable reduction was achieved in 38 of 40 (95%) cases. During the follow-up period, arthritic change was observed in 1 case and limited range of motion was confirmed in 2 cases. There was 1 case of postoperative wound problem and no case of sural nerve injury. The single lateral approach is a relatively simple and convenient method that enables accurate reduction and minimizing complication for fixation of the PM fractures with Weber B lateral malleolar fractures.
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Affiliation(s)
- Jaehyung Lee
- Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang-si, Gyeonggi-do, Republic of Korea
| | - Hwan Ryu
- Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang-si, Gyeonggi-do, Republic of Korea
| | - Jae Yong Park
- Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang-si, Gyeonggi-do, Republic of Korea
- * Correspondence: Jae Yong Park, Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang-si, Gyeonggi-do 14068, Republic of Korea (e-mail: )
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25
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Xie W, Lu H, Zhan S, Liu Y, Xu H, Fu Z, Zhang D, Jiang B. Outcomes of posterior malleolar fractures with intra-articular impacted fragment. Arch Orthop Trauma Surg 2023; 143:141-147. [PMID: 34196772 DOI: 10.1007/s00402-021-04002-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 06/14/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION An intra-articular impacted fragment (IAIF) could lead to articular incongruity and malreduction in ankle fractures with posterior malleolar fractures (PMFs). No studies have been conducted to determine whether the presence of IAIF affects the outcome of ankle fractures with PMF. The aim of our retrospective study was to evaluate the effect of IAIF on postoperative outcomes in PMF and analyze the relationship between area of IAIF and outcomes. MATERIALS AND METHODS We conducted a retrospective study of patients with a posterior malleolar fractures between June 2012 and January 2019 with a minimum follow-up of 2 years. Results of the Olerud-Molander ankle score (OMAS), EuroQol-5D (EQ-5D) index, EQ-5D visual analog scale (VAS), AOFAS (American orthopedic foot and ankle society ankle-hindfoot scale), visual analog scale (VAS) pain score and overall patient satisfaction scale were recorded. Outcomes of the PMF with IAIF group and PMF without IAIF group were compared. Sub-group analysis was given emphasis on the AIAIF > 40 mm2 group and AIAIF < 40 mm2 group in PMF with IAIF. RESULTS A total of 128 patients were included in the study, consisting of 86 patients with IAIF and 42 patients without IAIF. Regarding the osteoarthritis grade (> 1, ≤ 1), the differences werestatistically significant between the two groups (P = 0.044). The risk of articular malreduction was higher in the PMF with IAIF group than in the PMF without IAIF group (P = 0.035). Osteoarthritis grade (> 1, ≤ 1) was closely related to articular malreduction (P < 0.001). There were 51 patients in the AIAIF > 40 mm2 group and 35 patients in the AIAIF < 40 mm2 group of 86 patients in PMF with IAIF. There were statistically significant differences in trimalleolar fracture (P = 0.004), malreduction (P = 0.022), osteoarthritis grade (> 1, ≤ 1; P = 0.027), EQ-5D VAS score (P = 0.031), and AOFAS score (P = 0.047) between the subgroups. CONCLUSION The incidence of IAIF is associated with the area of the posterior malleolar fragment. Articular malreduction can lead to post-traumatic osteoarthritis, while IAIF is an important element for the quality of reduction, which is more likely to lead to articular malreduction. IAIF should be reduced if AIAIF is over 40 mm2. Otherwise, the patient will suffer a poor prognosis and post-traumatic osteoarthritis. Therefore, ankle fractures with PMF should undergo a CT scan preoperatively in order for providers to optimal treatment protocols. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Wenyong Xie
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Hao Lu
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Sizheng Zhan
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Yijun Liu
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Hailin Xu
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China.
| | - Zhongguo Fu
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Dianying Zhang
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Baoguo Jiang
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
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Kummer A, Crevoisier X. Posterior to anterior malleolar extended lateral approach to the ankle (PAMELA): early results of a novel approach. Arch Orthop Trauma Surg 2023; 143:879-886. [PMID: 35113239 PMCID: PMC9925524 DOI: 10.1007/s00402-022-04360-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 01/13/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION In a previous cadaveric study, we described the Posterior to Anterior Malleolar Extended Lateral Approach (PAMELA) to address complex ankle fractures. It was demonstrated to provide optimal exposure of the posterior and lateral malleoli, and of the anterolateral portion of the ankle through a single incision. The aim of this study is to report the clinical results of this novel approach. METHODS Between January 2019 and January 2021, all patients presenting with a complex ankle fracture in our institution were assessed by CT scan. Indication to use the PAMELA was determined by the fracture pattern, according to our previous guidelines, including combination of complex lateral and displaced posterior malleolar fractures, associated in most cases with anterolateral fracture avulsion. The approach was performed according to the steps previously described. Intraoperative evaluation included quality of exposure, ease of performing the osteosynthesis, and any complication encountered. The postoperative course was assessed for wound healing, quality of reduction, and the occurrence of any complication. RESULTS The PAMELA was performed in 20 patients (aged 17-73). The most common combination of fractures was a comminuted lateral malleolus fracture associated with a displaced fracture of the posterior malleolus and a Wagstaffe-Le Fort or Chaput avulsion. We encountered no intraoperative complication. X-rays showed anatomical reduction in all cases. Postoperative complications included three delayed wound healing resolved with local treatment and one sural nerve traction injury. CONCLUSIONS The main potential concern regarding this novel approach was the healing of the flap. Our results reject this concern and are in line with wound healing complications reported following surgical treatment of ankle fractures. This study confirms the safe in vivo feasibility of the PAMELA and opens a new perspective in the optimal management of complex fractures of the ankle. A larger prospective clinical study is ongoing in our institution.
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Affiliation(s)
- Anne Kummer
- Department of Orthopedics and Traumatology, Lausanne University Hospital (CHUV), and University of Lausanne (UNIL), Pierre-Decker 4, 1011 Lausanne, Switzerland
| | - Xavier Crevoisier
- Department of Orthopedics and Traumatology, Lausanne University Hospital (CHUV), and University of Lausanne (UNIL), Pierre-Decker 4, 1011, Lausanne, Switzerland.
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Kleinertz H, Mueller E, Tessarzyk M, Frosch KH, Schlickewei C. Computed tomography-based classifications of posterior malleolar fractures and their inter- and intraobserver reliability: a comparison of the Haraguchi, Bartoníček/Rammelt, and Mason classifications. Arch Orthop Trauma Surg 2022; 142:3895-3902. [PMID: 35094134 DOI: 10.1007/s00402-021-04315-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 12/13/2021] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Complex ankle fractures often include fractures of the posterior malleolus. The most clinically relevant posterior malleolus fracture classifications are computed tomography (CT) based. These classifications aim to enable clear communication and help develop treatment strategies. This study investigates the inter- and intraobserver reliability of the Haraguchi, Bartoníček/Rammelt and Mason posterior malleolar fracture classifications. MATERIALS AND METHODS CT scans of 113 patients with a mean age of 56.2 (SD ± 17.8) years and fractures involving the posterior malleolus were analyzed twice by 4 observers with different levels of training. The posterior malleolar fractures were classified according to Haraguchi et al., Bartoníček/Rammelt et al. and Mason et al. The intraobserver and interobserver reliabilities were determined by calculating Cohen's and Fleiss' kappa values. RESULTS We found substantial multi-rater interobserver agreement for all three classifications. The Haraguchi classification 0.799 (CI 0.744-0.855) showed the highest agreement, followed by the Bartoníček/Rammelt 0.744 (0.695-0.793) and Mason 0.717 (CI 0.666-0.768) classifications. Subgroup analyses showed substantial to perfect agreement for the Haraguchi and substantial agreement for the Bartoníček/Rammelt and Mason classifications independent of observer expertise. The intraobserver reliability was perfect for three and substantial for one of the observers. However, the classifications have certain pitfalls and do not consider the number of fragments, articular surface impressions, or intercalary fragments. CONCLUSION All classifications show substantial, if not perfect inter- and intraobserver reliabilities independent of observer level of expertise.
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Affiliation(s)
- Holger Kleinertz
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Elena Mueller
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Marlon Tessarzyk
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.,Department of Trauma Surgery, Orthopaedics, and Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany
| | - Carsten Schlickewei
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
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Establishment of a finite element model of supination-external rotation ankle joint injury and its mechanical analysis. Sci Rep 2022; 12:20115. [PMID: 36418903 PMCID: PMC9684579 DOI: 10.1038/s41598-022-24705-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 11/18/2022] [Indexed: 11/24/2022] Open
Abstract
By establishing a three-dimensional finite element model of ankle injury arising from supination and external rotation, the stress characteristics of the posterior malleolar surface can be obtained, and analysis of the corresponding stress on the lateral ankle can be conducted. Thin-layer computed tomography images of normal ankle joint in the supination and external rotation nonweight-bearing states was selected, to construct a three-dimensional data model of each ankle joint. A load was applied to examine different ankle joint stress values and pressure distributions on the surface of the posterior ankle joint. A 600 N vertical compressive and 10 Nm internal rotation load was applied in Stage III (removing the anterior tibiofibular ligament and the posterior tibiofibular ligament) of SER (supination-external rotation). When the lateral malleolar was intact, the maximum stress (132.7 MPa) was located at the point of attachment of the posterior tibiofibular ligament to the fibula, and the maximum pressure of the posterior malleolar surface was lower than 4.505 MPa. When a lateral malleolar fracture was present, the maximum stress (82.72 MPa) was located on the fibular fracture surface, and the maximum pressure of the posterior malleolar surface was 8.022 MPa. This study shows that reconstruction of the lateral malleolus in supination-external rotation ankle injuries significantly affects the stress distribution at the posterior malleolar joint surface. Through this reconstruction, the pressure distribution of the posterior malleolar joint surface can be significantly reduced.
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Intercalary fragments in posterior malleolar fractures: incidence, treatment implications, and distribution within CT-based classification systems. Eur J Trauma Emerg Surg 2022; 49:851-858. [PMID: 36331574 PMCID: PMC10175417 DOI: 10.1007/s00068-022-02119-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 09/27/2022] [Indexed: 11/06/2022]
Abstract
Abstract
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.
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30
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Fracture gap of the lateral malleolus via posterolateral approach: Improved visualization of the posterior malleolus fracture. Injury 2022; 53:3849-3852. [PMID: 36127174 DOI: 10.1016/j.injury.2022.08.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 08/19/2022] [Accepted: 08/20/2022] [Indexed: 02/02/2023]
Abstract
The treatment of posterior malleolar fractures is a popular issue. Anatomic reduction of posterior malleolar fractures is critical for re-establishing the stability of the ankle mortise and ligamentous union after trauma. Inappropriate treatment ultimately leads to poorer functional outcomes and lower quality of life. Open reduction and internal fixation through a posterolateral approach are preferred over indirect reduction and anterior-posterior screw fixation. Although the posterolateral approach, which is more common and direct, provides good exposure to the fracture site, it has some limitations. In this report, we describe the posterolateral approach through the lateral ankle fracture gap for the treatment of posterior ankle fractures. Moreover, we discuss the indications, benefits, and limitations of this approach.
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Choi JY, Oh HK, Di Mento L, Hur JW, Suh JS. Operative strategy for tri-malleolar ankle fractures with posteromedial plafond involvement: a review of sixty six cases. INTERNATIONAL ORTHOPAEDICS 2022; 46:2637-2648. [PMID: 35994065 DOI: 10.1007/s00264-022-05554-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 08/12/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE We aimed to summarize the radiographic and clinical outcomes in various conditions of tri-malleolar ankle fractures (TMFs) with posteromedial (PM) plafond involvement (TMF + PM) and determine the factors affecting their subjective clinical outcomes. METHODS Radiographic and clinical findings of 66 patients who underwent operative treatment for TMF + PM were retrospectively reviewed. The patients were classified into three groups according to the PM fracture line location. Type I fractures were defined when the PM fracture line extended medially beyond the PM corner of the distal tibia while type II fractures were those in which the PM fracture line was located laterally to the PM corner. Type III fractures were defined as medial malleolar avulsion fractures when the PM fracture integrated into the medial malleolus. Clinical outcomes were evaluated using a subjective rating scale (excellent, good, fair, poor, and bad). Satisfactory results were defined as excellent, good, and fair. Factors affecting satisfactory clinical outcomes were assessed using a binary logistic regression analysis. Independent variables included demographic, fracture-related, and operation-related factors and radiographic measurements at the final follow-up. RESULTS Satisfactory clinical outcomes were observed in 74.2% of the total patients; of these patients, 75.7% (28/37), 76.5% (13/17), and 66.7% (8/12) had type I, type II, and type III fractures, respectively. The binary logistic regression analysis revealed that age at the time of operation, number of incarcerated fragments (IFs), type of IFs, and postoperative articular step-offs (mm) were related to subjective clinical outcomes (all P < 0.05). A positive value for post-operative articular step-offs represented distal migration of the posterior malleolar fragments. The odds ratios for older age, increased numbers of IFs, rotated IFs, and positive articular step-offs were 0.936, 0.116, 0.020, and 0.295, respectively. CONCLUSION Because TMF + PM is highly unstable, a delicate approach is needed according to each patient's fracture condition. Although it is best to reduce the fractured articular surface, a negative step-off, rather than a positive step-off, would be more likely recommended if accurate reduction is impossible. This could be applied to manage IFs, especially when the IFs are rotated. Dimpling of the articular surface induced by the removal of a small IF was not related to unsatisfactory clinical outcomes.
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Affiliation(s)
- Jun Young Choi
- Department of Orthopedic Surgery, Inje University, Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang-si, Gyeonggi-do, South Korea
| | - Hyoung Keun Oh
- Department of Orthopedic Surgery, Inje University, Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang-si, Gyeonggi-do, South Korea
| | - Lorenzo Di Mento
- Trauma Unit, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - Jae Won Hur
- Department of Orthopedic Surgery, Inje University, Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang-si, Gyeonggi-do, South Korea
| | - Jin Soo Suh
- Department of Orthopedic Surgery, Inje University, Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang-si, Gyeonggi-do, South Korea.
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32
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Swierstra BA, van Enst WA. The prognosis of ankle fractures: a systematic review. EFORT Open Rev 2022; 7:692-700. [PMID: 36287098 PMCID: PMC9619393 DOI: 10.1530/eor-22-0065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The aim of this study was to update the scientific evidence for ankle fracture prognosis by addressing radiographic osteoarthritis, time course and prognostic factors. A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were included if they were randomized controlled trials, controlled trials or observational studies, including case series and case-control studies investigating radiologically confirmed osteoarthritis in adults with a classified ankle fracture, treated with or without surgery, with a minimum follow-up of 1 year. Also included were studies examining prognostic factors predicting radiologically confirmed osteoarthritis. Tibial plafond and talus fractures were excluded. Thirty-four studies were included examining 3447 patients. Extracted data included study type, inclusion and exclusion criteria, age, number of patients, number of fractures according to the author-reported classification method, radiological osteoarthritis, follow-up period, prognostic factors, and treatment. Severe heterogeneity was visible in the analyses (I2 > 90%), reflecting clinical heterogeneity possibly arising from the presence of osteoarthritis at baseline, the classifications used for the fractures and for osteoarthritis. The incidence of osteoarthritis was 25% (95% CI: 18–32) and 34% (95% CI: 23–45) for more severe fractures with involvement of the posterior malleolus. The severity of the trauma, as reflected by the fracture classification, was the most important prognostic factor for the development of radiographic osteoarthritis, but there is also a risk with simpler injuries. The period within which osteoarthritis develops or becomes symptomatic with an indication for treatment could not be specified.
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Affiliation(s)
| | - W Annefloor van Enst
- Medical Guidelines, Amsterdam, The Netherlands,Correspondence should be addressed to W A van Enst;
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Yamamoto N, Iwamoto K, Tomita Y, Iwamoto Y, Kiyono M, Yoshimura M, Noda T, Kawasaki K, Ozaki T. Pre-and postoperative factors associated with functional outcomes in patients with posterior malleolar fractures. Injury 2022; 53:2297-2303. [PMID: 35260245 DOI: 10.1016/j.injury.2022.02.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 02/19/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Recent studies on posterior malleolar fractures mainly focus on the reduction quality and fixation of the posterior fragment since it contributes to ankle stability and articular congruency. However, the association of pre-and postoperative factors considering the whole ankle joint in postoperative functional outcomes remains unclear. Therefore, this study aimed to examine the association between pre-and postoperative variables for postoperative functional outcomes in patients with posterior malleolar fragments (classified as Haraguchi type I or II) and considered the association between reduction and fixation for small posterior malleolar fragments of less than 25% of the intra-articular surface. METHODS This multicenter retrospective cohort study included 110 adult patients who underwent internal fixation for ankle fractures with posterior malleolar fragments. The primary outcome was the American Orthopaedic Foot and Ankle Society (AOFAS) score 12-months postoperatively. As pre-and postoperative variables, the preoperative demographic data, radiographic findings, operative method, postoperative radiographic findings, and complications were evaluated. In addition, univariable and multivariable logistic regression analyses were conducted to examine the association between pre-and postoperative variables and AOFAS scores. RESULTS Twenty-four (21.8%) cases had postoperative complications. Univariate analysis showed that age was significantly according to AOFAS score-stratified groups in patients with Haraguchi type II fractures. Multivariable logistic regression analysis using bootstrapping in the Haraguchi type II group showed that postoperative complications were significantly associated with low AOFAS scores, indicating poor functionality. In both fracture types, postoperative complications had the highest odds ratio among the explanatory variables. In patients with small posterior malleolar fragments, fragment reduction, fixation, and ankle stability were not associated with AOFAS scores. CONCLUSIONS Our results suggest that postoperative complications were associated with AOFAS scores at postoperative 12 months in patients with ankle fractures with posterior malleolar fragments. In patients with small posterior malleolar fragments, reduction and fixation were not associated with AOFAS scores. Therefore, clinical decisions for posterior fragment fixation should be made based on the possible risk of complications related to the surgical procedures in addition to the posterior malleolar fragment size.
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Affiliation(s)
- Norio Yamamoto
- Department of Orthopedic Surgery, Kagawa Prefectural Central Hospital, 1-2-1, Asahi-machi, Takamatsu, Kagawa 760-8557, Japan; Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan.
| | - Kohei Iwamoto
- Department of Emergency Medical Center, Kagawa Prefectural Central Hospital, Kagawa, Japan
| | - Yosuke Tomita
- Department of Physical Therapy, Faculty of Health Care, Takasaki University of Health and Welfare, Gunma, Japan
| | - Yuki Iwamoto
- Department of Orthopedic Surgery, Okayama Saiseikai General Hospital, Okayama, Japan
| | - Masahiro Kiyono
- Department of Orthopedic Surgery, Mitoyo General Hospital, Kagawa, Japan
| | | | - Tomoyuki Noda
- Department of Orthopaedic Surgery and Traumatology, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Keisuke Kawasaki
- Department of Orthopedic Surgery, Kagawa Prefectural Central Hospital, 1-2-1, Asahi-machi, Takamatsu, Kagawa 760-8557, Japan
| | - Toshifumi Ozaki
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
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Müller E, Terstegen J, Kleinertz H, Weel H, Frosch KH, Barg A, Schlickewei C. [Established classification systems of posterior malleolar fractures : A systematic literature review]. Unfallchirurg 2022; 126:387-398. [PMID: 35394158 PMCID: PMC10159979 DOI: 10.1007/s00113-022-01162-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2022] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Elena Müller
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
| | - Julia Terstegen
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Holger Kleinertz
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Hanneke Weel
- Orthopedics Center, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Karl-Heinz Frosch
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
- Abteilung Unfallchirurgie, Orthopädie und Sporttraumatologie, BG Klinikum Hamburg, Hamburg, Deutschland
| | - Alexej Barg
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
- Abteilung Unfallchirurgie, Orthopädie und Sporttraumatologie, BG Klinikum Hamburg, Hamburg, Deutschland
- Orthopädische Universitätsklinik, Universität von Utah, Salt Lake City, UT, USA
| | - Carsten Schlickewei
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
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Beak JS, Kim YT, Lee SH. Predisposing Factors for Posttraumatic Osteoarthritis After Malleolus Fracture Fixation in Patients Younger Than 50 Years. Foot Ankle Int 2022; 43:389-397. [PMID: 34677107 DOI: 10.1177/10711007211050039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to identify the risk factors for posttraumatic osteoarthritis (OA) after surgery for ankle fractures in patients aged ≤50 years. METHODS We performed a retrospective review of consecutive patients who underwent surgery for ankle fractures and were followed up for a minimum period of 5 years. The patients were assigned to 2 groups according to the presence of advanced OA at the last follow-up. Binary logistic regression was used to model the correlation between risk factors and OA. Functional outcomes were assessed using the Foot and Ankle Outcome Score. RESULTS The data of 332 patients who met the inclusion criteria were included in the analysis. The overall rate of posttraumatic arthritis was 27.7% (nonarthritis group: 240 patients, arthritis group: 92 patients). The arthritic change was significantly affected by BMI (95% confidence interval [CI] 1.29-19.76; adjusted odds ratio [OR] ≥ 30, 6.56), fracture-dislocation injury (CI 1.66-11.57; adjusted OR, 4.06), posterior malleolus (PM) fracture (CI 1.92-12.73, adjusted OR > 25% of the articular surface, 5.72), and postoperative articular incongruence (CI 1.52-18.10; adjusted OR, 7.21). The mean scores of the arthritis group were lower than those in the nonarthritis group (P < .05). CONCLUSION Obesity, fracture-dislocation injury, concomitant large PM fracture, and articular incongruence were risk factors of posttraumatic OA after surgery for ankle fractures. Surgeons should be aware that accurate reduction is critical in patients with ankle fractures with associated large PM fractures, especially those with obesity or severe initial injuries such as fracture-dislocation. LEVEL OF EVIDENCE Level III, case control study.
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Affiliation(s)
- Jong Seok Beak
- Department of Orthopedic Surgery, School of Medicine, Wonkwang University Hospital, Iksan, Republic of Korea
| | - Yeong Tae Kim
- Department of Orthopedic Surgery, School of Medicine, Wonkwang University Hospital, Iksan, Republic of Korea
| | - Sung Hyun Lee
- Department of Orthopedic Surgery, School of Medicine, Wonkwang University Hospital, Iksan, Republic of Korea
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Bartoníček J, Rammelt S, Tuček M. Maisonneuve Fractures of the Ankle: A Critical Analysis Review. JBJS Rev 2022; 10:01874474-202202000-00009. [PMID: 35180143 DOI: 10.2106/jbjs.rvw.21.00160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Maisonneuve fractures (MFs), originally described as subcapital (high) fibular fractures with additional injury to the anterior and interosseous tibiofibular ligaments, display a variable injury pattern, ranging from stable to highly unstable fractures. » The high incidence of associated fractures of the posterior malleolus, the medial malleolus, and the anterolateral distal tibia (the "anterior malleolus") as well as the variable position of the fibula in the fibular notch (FN) warrant preoperative examination via computed tomography (CT). » The main goal of treatment is anatomic reduction of the distal fibula into the FN, which requires prior reduction of displaced posterior malleolar fractures, if present, to restore the integrity of the FN. » Open reduction of the distal fibula into the FN and fixation with 2 transsyndesmotic screws or fixation with a screw(s) and suture-button implant, under direct vision, on the lateral aspect of the ankle joint and anterior tibiofibular alignment are preferred over closed reduction to avoid sagittal or rotational malpositioning, which is associated with an inferior outcome. » Intra- or postoperative 3D CT visualization is essential for assessment of the accuracy of the reduction of the distal fibula into the FN.
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Affiliation(s)
- Jan Bartoníček
- Department of Orthopaedics, First Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic
| | - Stefan Rammelt
- University Center for Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Dresden, Germany
| | - Michal Tuček
- Department of Orthopaedics, First Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic
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Seo J, Yang KH, Shim DW, Cho H, Park YC. Marginal impaction associated with posterior malleolar fracture in rotational ankle injury. Injury 2022; 53:756-761. [PMID: 34924191 DOI: 10.1016/j.injury.2021.12.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 12/04/2021] [Indexed: 02/02/2023]
Abstract
AIM This study aimed to introduce the circle drawing method for the evaluation of marginal impaction associated with posterior malleolar fractures (PMFs) on computed tomography (CT) images and evaluate the marginal impaction based on PMF patterns (Bartonícek classification) in rotational ankle fractures. METHODS From January 2014 to December 2019, A total of 299 patients were reviewed retrospectively. The circle drawing method consists of matching the articular surface of the intact tibial plafond with a best-fitted circle on the sagittal CT image. The mismatch gap between the circle and the articular surface indicates the presence of marginal impaction. To validate the circle drawing method, we assessed CT images of 60 ankles without fracture at the medial, central, and lateral parts using the new method. RESULTS Based on the review of the preoperative CT scan, 153 out of 299 patients (51.2%) were identified as having PMFs. Among them, 57 patients (37.3%) had marginal impaction associated with PMFs. For small posterolateral type 2 fractures, 58% of patients (47/81) had marginal impaction, and its incidence was most frequent among all types (P<.01). For posteromedial extended type 3 fractures, 27% of patients (8/30) had marginal impaction. Extraincisural type 1 and large posterolateral triangular type 4 fractures were rarely associated with marginal impaction. Among the 180 zones of 60 ankles without fracture, 171 zones (95%) were perfectly fitted to a best-fitted circle. CONCLUSIONS The marginal impaction associated with PMFs is often observed in rotational ankle fractures, particularly in small posterolateral and posteromedial extended fractures.
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Affiliation(s)
- Jiwoon Seo
- Department of Radiology, Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Kyu-Hyun Yang
- Department of Orthopedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; Department of Orthopedic Surgery, Armed Forces Capital Hospital, Seongnam, Korea
| | - Dong Woo Shim
- Department of Orthopedic Surgery, International ST. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, Republic of Korea
| | - Hyunik Cho
- Department of Orthopedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young-Chang Park
- Department of Orthopedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Evidence-Based Surgical Treatment Algorithm for Unstable Syndesmotic Injuries. J Clin Med 2022; 11:jcm11020331. [PMID: 35054025 PMCID: PMC8780481 DOI: 10.3390/jcm11020331] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 12/26/2021] [Accepted: 01/05/2022] [Indexed: 02/01/2023] Open
Abstract
Background: Surgical treatment of unstable syndesmotic injuries is not trivial, and there are no generally accepted treatment guidelines. The most common controversies regarding surgical treatment are related to screw fixation versus dynamic fixation, the use of reduction clamps, open versus closed reduction, and the role of the posterior malleolus and of the anterior inferior tibiofibular ligament (AITFL). Our aim was to draw important conclusions from the pertinent literature concerning surgical treatment of unstable syndesmotic injuries, to transform these conclusions into surgical principles supported by the literature, and finally to fuse these principles into an evidence-based surgical treatment algorithm. Methods: PubMed, Embase, Google Scholar, The Cochrane Database of Systematic Reviews, and the reference lists of systematic reviews of relevant studies dealing with the surgical treatment of unstable syndesmotic injuries were searched independently by two reviewers using specific terms and limits. Surgical principles supported by the literature were fused into an evidence-based surgical treatment algorithm. Results: A total of 171 articles were included for further considerations. Among them, 47 articles concerned syndesmotic screw fixation and 41 flexible dynamic fixations of the syndesmosis. Twenty-five studies compared screw fixation with dynamic fixations, and seven out of these comparisons were randomized controlled trials. Nineteen articles addressed the posterior malleolus, 14 the role of the AITFL, and eight the use of reduction clamps. Anatomic reduction is crucial to prevent posttraumatic osteoarthritis. Therefore, flexible dynamic stabilization techniques should be preferred whenever possible. An unstable AITFL should be repaired and augmented, as it represents an important stabilizer of external rotation of the distal fibula. Conclusions: The current literature provides sufficient arguments for the development of an evidence-based surgical treatment algorithm for unstable syndesmotic injuries.
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Neumann AP, Rammelt S. Ankle fractures involving the posterior malleolus: patient characteristics and 7-year results in 100 cases. Arch Orthop Trauma Surg 2022; 142:1823-1834. [PMID: 33835195 PMCID: PMC9296426 DOI: 10.1007/s00402-021-03875-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 03/23/2021] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Annika Pauline Neumann
- University Center of Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Stefan Rammelt
- University Center of Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
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Shah P, Dave R, Tank P, Patel N. Posterior malleolus fracture fixation in ankle injuries: A clinical study. MGM JOURNAL OF MEDICAL SCIENCES 2022. [DOI: 10.4103/mgmj.mgmj_142_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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Li Y, Chen Y, Liu X, Chen J, Gan T, Zhang H. Patient Pain and Function After Correction of Posterior Malleolar Malunion. Foot Ankle Int 2021; 42:1536-1546. [PMID: 34210180 DOI: 10.1177/10711007211017831] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The management of an ankle malunion involving the posterior malleolus remains challenging, and only a few published studies described the operative treatment of complex posterior malleolar malunion. A transfibular approach allows for direct visualization of the articular reduction of the posterior malleolus, but the reports of its use for correcting posterior malleolar malunion are rare. This study aims to evaluate the results of the intra-articular osteotomy via a transfibular approach for correcting an ankle malunion involving the posterior malleolus. METHODS We conducted a retrospective review of 26 patients with a symptomatic malunited ankle fracture involving posterior malleolus were treated with the intra-articular osteotomy via a transfibular approach in our department. Radiographic assessments were performed using plain radiographs and computed tomographic (CT) scans. Clinical outcomes were assessed using the AOFAS ankle-hindfoot score, visual analog scale (VAS), active range of motion of ankle, and the 36-Item Short-Form Health Survey score. RESULTS Postoperatively, anatomic correction of articular surface and anatomic reduction of syndesmosis were achieved in all patients as judged by CT scans. No evidence of progression had been found in 18 of 26 patients (69.2%) at final follow-up. The median AOFAS score improved from 42.0 to 81.5 (P < .001). Median pain VAS score decreased from 6.0 to 1.0 (P < .001). A favorable clinical outcome was associated with a short time interval from original injury to correction surgery and a lower grade of preoperative arthritis, but not with the posterior malleolar fragment size. However, time interval, the posterior malleolar fragment size, and the grade of preoperative arthritis showed no correlation with the progression of arthritis grade after surgery. CONCLUSION An intra-articular osteotomy via a transfibular approach demonstrated an improved function and pain after operative treatment of malunited ankle fracture with a displaced posterior malleolar fragment. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Yaxing Li
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China.,Disaster Medicine Center, Sichuan University, Chengdu, Sichuan Province, China
| | - Yu Chen
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Xi Liu
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Jun Chen
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Tingjiang Gan
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Hui Zhang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China.,Disaster Medicine Center, Sichuan University, Chengdu, Sichuan Province, China
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Kho DH, Cho BK, Choi SM. Midterm Outcomes of Unstable Ankle Fractures in Young Patients Treated by Closed Reduction and Fixation With an Intramedullary Fibular Nail vs Open Reduction Internal Fixation Using a Lateral Locking Plate. Foot Ankle Int 2021; 42:1469-1481. [PMID: 34184908 DOI: 10.1177/10711007211017470] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND We aimed to compare midterm radiological and clinical outcomes between closed reduction and internal fixation (CRIF) using the fibular intramedullary nail (IMN) and open reduction and internal fixation (ORIF) using the locking plate for the treatment of unstable ankle fractures in active young patients. METHODS In this retrospective cohort study, 204 patients treated with CRIF using the fibular IMN (94 patients) or ORIF using the locking plate (110 patients) were included after at least 3 years of follow-up. The mean patient age was 41.4 years. Radiographic evaluation included the quality of reduction assessed by plain radiography and 3-dimensional (3D)-reconstructed computed tomography as well as the development of posttraumatic osteoarthritis (PTOA) of the ankle assessed by weightbearing plain radiography. Clinical evaluation included the American Orthopaedic Foot & Ankle Society hindfoot score, Olerud and Molander Score, the Foot and Ankle Outcome Score, and visual analog scale pain score as well as complications. RESULTS At median follow-up greater than 4 years, we found no significant differences in measured clinical outcomes between the 2 groups. There were significantly fewer postoperative complications in the IMN group than in the ORIF group (9.5% vs 39%, P < .001). However, we did find a greater proportion of radiographically fair or poor reductions in the IMN group than in the ORIF group (P < .001). The poor reductions in the IMN group were primarily related to Weber type C, pronation-type injury, and comminuted fibular and trimalleolar fractures (P < .001). PTOA was also more frequently observed in the IMN group than in the ORIF group (21.3% vs 9.1%, P = .024). CONCLUSION Given the current prevailing technologies for fracture fixation, this study suggests that surgeons should consider ORIF for unstable ankle fractures in active young patients with Weber type C, pronation-type injury, and comminuted fibular and trimalleolar fractures. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Duk-Hwan Kho
- Department of Orthopaedic Surgery, Konkuk University Chungju Hospital, Konkuk University School of Medicine, Chungju, Korea
| | - Byung-Ki Cho
- Department of Orthopaedic Surgery, School of Medicine, Chungbuk National University Hospital, Cheongju, Korea
| | - Seung-Myung Choi
- Department of Orthopedic Surgery, Eulji University School of Medicine, Gyeonggi-do, Korea
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Lee SH, Cho HG, Yang JH. Predisposing factors for chronic syndesmotic instability following syndesmotic fixation in ankle fracture: Minimum 5-year follow-up outcomes. Foot Ankle Surg 2021; 27:777-783. [PMID: 34583831 DOI: 10.1016/j.fas.2020.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 09/06/2020] [Accepted: 10/05/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND This study aimed to identify risk factors for chronic syndesmotic instability following syndesmotic fixation. METHODS We performed a retrospective review of consecutive patients who had sustained ankle fractures requiring syndesmotic fixation. Patients available for a minimum 5 years of follow-up were classified into 2 groups according to the presence of syndesmotic instability. Statistical binary logistic regression analyses were performed to investigate the significance of various risk factors. Functional outcomes were assessed using the FAOS. RESULTS In total, 166 patients who met the study inclusion criteria underwent analysis. The overall postoperative instability rate was 20.5%, which was significantly affected due to BMI (p = 0.018; OR 6.72), and concomitant posterior malleolar fracture (p = 0.032, OR 2.77). The mean scores in the syndesmotic instability (SI) group were significantly lower than those in the no syndesmotic instability (NSI) group (p = 0.021). CONCLUSIONS Obesity and concomitant posterior malleolar fracture were significant risk factors for postoperative syndesmotic instability.
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Affiliation(s)
- Sung Hyun Lee
- Department of Orthopedic Surgery, Wonkwang University Hospital, 895, Muwang-Ro, Iksan 54538, Republic of Korea.
| | - Hyung Gyu Cho
- Department of Orthopedic Surgery, Wonkwang University Hospital, 895, Muwang-Ro, Iksan 54538, Republic of Korea
| | - Je Heon Yang
- Department of Orthopedic Surgery, Wonkwang University Hospital, 895, Muwang-Ro, Iksan 54538, Republic of Korea
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Clarke T, Whitworth N, Platt S. Defining a Safe Zone for Percutaneous Screw Fixation of Posterior Malleolar Fractures. J Foot Ankle Surg 2021; 60:929-934. [PMID: 33879359 DOI: 10.1053/j.jfas.2020.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 09/09/2020] [Accepted: 10/05/2020] [Indexed: 02/03/2023]
Abstract
Posterior malleolar fractures require fixation to confer stability to the ankle. Although some have suggested that fractures involving less than 25% of the articular surface require no intervention, estimation of malleolar size on plain imaging is inaccurate. Some posterior malleolar fractures may be particularly suitable for posterior-to-anterior percutaneous screw fixation of the posterior malleolus via a posterolateral approach. We hypothesized that there may be a safe zone in the posterolateral ankle, identifiable with reliable anatomic landmarks, that might allow safe percutaneous screw placement for fracture fixation. The study protocol involved Step 1, in which multiple Kirschner wires were used in a single cadaveric specimen to attempt to identify a safe zone entry point in the posterior ankle, and Step 2, in which a single wire was used in each of six additional cadaveric specimens to test the ability to safely replicate the use of that entry point. In Step 1, a safe zone entry point was identified, located immediately lateral to the Achilles tendon and 1 cm above the level of the tip of the medial malleolus, when visualizing the posterior ankle. In Step 2, using these landmarks and an image intensifier, single wires were then successfully placed in the other six specimens without injury to any significant structure. If confirmed in clinical studies, the safe zone entry point that we have identified could potentially be used to facilitate posterior-to-anterior percutaneous fixation in patients with posterior malleolar fractures for whom open reduction may not be required or may be contraindicated.
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Affiliation(s)
- Thomas Clarke
- Principal House Officer, Department of Musculoskeletal Services - Surgical, Anaesthetics and Procedural Services (SaPS), Gold Coast University Hospital, Gold Coast Health, Southport, Queensland, Australia.
| | - Nicholas Whitworth
- Registrar, Department of Orthopaedics, Cairns Hospital, Cairns and Hinterland Hospital and Health Service, Cairns, Queensland, Australia
| | - Simon Platt
- Senior Staff Specialist, Department of Musculoskeletal Services - Surgical, Anaesthetics and Procedural Services (SaPS), Gold Coast University Hospital, Gold Coast Health, Southport, Queensland, Australia
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Abstract
In patients with ankle fractures, the presence of a posterior malleolar fracture has a negative impact on the prognosis. Computed tomography (CT) scanning is essential for fracture classification and treatment planning, as the indication for surgery depends on the 3-dimensional fragment outline and displacement, incisura involvement, and the presence of joint impaction. Anatomic reduction of a posterior malleolar fragment restores the incisura, facilitating reduction of the distal part of the fibula, and it also restores the integrity of the posterior portion of the syndesmosis, reducing the need for additional syndesmotic stabilization. Direct open reduction and fixation of posterior malleolar fragments from a posterior orientation is biomechanically more stable and provides a more accurate reduction than does indirect reduction and anterior-to-posterior screw fixation. Intra-articular step-off of >=2 mm is an independent risk factor for an inferior outcome and the development of posttraumatic arthritis, irrespective of the fragment size.
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Affiliation(s)
- Stefan Rammelt
- University Center of Orthopaedics and Traumatology, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Jan Bartoníček
- Department of Orthopaedics, First Faculty of Medicine, Charles University and Central Military Hospital Prague, Prague, Czech Republic.,Department of Anatomy, First Faculty of Medicine, Charles University Prague, Prague, Czech Republic
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Ribeiro HM. Response to Letter regarding 'Clinical outcomes and trans-syndesmotic screw frequency after posterior malleolar fracture osteosynthesis'. Injury 2021; 52:2481-2482. [PMID: 34049702 DOI: 10.1016/j.injury.2021.05.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Hugo Marques Ribeiro
- Orthopedic and traumatology, Hospital de São Francisco Xavier, CHLO, Lisboa, Portugal, Estrada do Forte do Alto do Duque, 1449-005 Lisboa, Portugal.
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Management of posterior malleolus fractures: A multicentre cohort study in the United Kingdom. Foot Ankle Surg 2021; 27:629-635. [PMID: 32878722 DOI: 10.1016/j.fas.2020.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 07/13/2020] [Accepted: 08/05/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND There is a need to assess clinical practice in light of increasing literature recommending fixation of posterior malleolus (PM) fractures. This multicentre study examines treatment approaches, within both Major Trauma Centres and District General Hospitals and role of radiographs and CT scanning. METHODS Trauma lists and databases were used to identify patients and data collected from electronic and paper medical records and imaging systems between August 2017-18. Analysis of treatment and outcomes was then conducted. RESULTS One-hundred-and-sixty ankle fractures were included in the study, only 68 ankle fractures underwent CT scanning following initial radiographs and of these, 65 were managed operatively, with 32 undergoing PM fixation. Syndesmotic stabilisation was performed in 9.6% where the PM was fixed. CONCLUSION CT is still under-utilised, PM fractures that appear to be anything other than small avulsion-type injuries should undergo CT scanning. Syndesmotic stabilisation is statistically less likely to be performed with fixation of the PM.
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Fenelon C, Galbraith JG, Fahey T, Kearns SR. The Operative Treatment of Ankle Fractures: A 10-Year Retrospective Study of 1529 Patients. J Foot Ankle Surg 2021; 60:663-668. [PMID: 33509713 DOI: 10.1053/j.jfas.2020.03.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 03/19/2020] [Accepted: 03/29/2020] [Indexed: 02/03/2023]
Abstract
Ankle fractures are the second most common fracture of the lower limb and account for nearly 10% of all fractures. They range from simple to complex injuries and approximately 40% require surgical intervention. The aim of our study was to provide an up-to-date reference of the epidemiology, fracture, and fixation characteristics of operatively treated ankle fractures. We also sought to determine the number of patients undergoing further surgery through revision, implant removal, or ankle fusion. A retrospective observational study was conducted of 1529 consecutive patients that underwent operative intervention for an unstable ankle fracture between 2007 and 2017. Fractures of the distal tibia and pilon injuries were excluded. The mean age of patients was 41.8 years with 50.7% male. Unimalleolar fixation was performed in 60.1%, while bimalleolar and trimalleolar fixation was performed in 31.2% and 5%, respectively. Isolated syndesmotic fixation was performed in 3.8%. A posterior malleolus fracture was present in 28.6%, of which 31.6% underwent fixation. A further procedure was performed in 234 (15.3%) patients. Revision open reduction internal fixation was required in 1.4% and 0.8% underwent future ankle fusion. Treatment of ankle fractures makes up a sizeable part of orthopedic trauma practice with more than 1 in 7 patients requiring a second procedure. More complex fractures were predominantly seen in older females, while patients who suffered trimalleolar fractures have an increased likelihood of requiring future ankle fusion or revision. Despite this the rate of ankle fusion was <1%.
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Affiliation(s)
- Christopher Fenelon
- Orthopaedic Registrar, Department of Orthopaedic Surgery, Galway University Hospital, Galway, Ireland.
| | - John G Galbraith
- Consultant Orthopaedic Surgeon, Department of Orthopaedic Surgery, Galway University Hospital, Galway, Ireland
| | - Tom Fahey
- Professor of General Practice, Department of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Stephen R Kearns
- Professor and Consultant Orthopaedic Surgeon, Department of Orthopaedic Surgery, Galway University Hospital, Galway, Ireland
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Ma Z, Guo S, Gao F, Wang B, Zhou X, Fu B, Xia S. [Comparison of effectiveness between plate and screw internal fixation in treatment of posterior malleolus fractures through posterolateral approach]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:431-438. [PMID: 33855826 DOI: 10.7507/1002-1892.202010030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To compare the effectiveness of posterior malleolus fractures treated by plate and screw internal fixation through posterolateral approach. Methods The clinical data of 95 patients with posterior malleolus fractures who were admitted between January 2016 and December 2019 and met the selection criteria were retrospectively analysed. They were divided into plate group (44 cases, treated with posterolateral plate internal fixation) and screw group (51 cases, treated with posterolateral screw internal fixation) according to different treatment methods. There was no significant difference in general data between the two groups of patients such as age, gender, cause of injury, side of injury, ankle fracture or injury classification, time from injury to operation, and percentage of posterior ankle fracture area to the distal tibia articular surface ( P>0.05). The operation time, hospital stay, fracture healing time, and surgical complications were compared between the two groups. Imaging examinations (X-ray film, CT scan and reconstruction) were used to assess the reduction quality of ankle fracture, articular congruity, and re-displacement in ankle fracture. At last follow-up, the pain visual analogue scale (VAS) score was used to evaluate the patients' pain, and the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was used to evaluate ankle joint function. Results Patients in both groups were followed up 6-30 months, with an average of 18.2 months. The operation time of the plate group was significantly longer than that of the screw group ( U=-2.040, P=0.041); there was no significant difference in hospital stay between the two groups ( U=-1.068, P=0.285). Incision swelling occurred in 2 cases in the plate group, sural nerve injury in 3 cases, and traumatic arthritis in 2 cases during follow-up. In the screw group, there were 1, 2, and 2 cases, respectively. The incidence of complications in the two groups (15.9% vs. 9.8%) was not significantly different ( P=0.372). All patients who underwent tibiofibular screw fixation underwent the removal of the tibiofibular screw before taking full weight bearing at 12 weeks after operation, and there was no screw fracture and retention. During the follow-up, there was no infection, re-displacement of fracture, delayed bone union or nonunion, and there was no significant difference in fracture healing time between the two groups ( t=0.345, P=0.731). There was no significant difference between the two groups of reduction quality of ankle fracture and articular congruity evaluation results ( P>0.05). At last follow-up, there was no significant difference in VAS score, AOFAS ankle-hindfoot score and evaluation grade between the two groups ( P>0.05). Conclusion Both the plate and screw internal fixation through posterolateral approach can achieve satisfied effectiveness in the treatment of posterior ankle fractures with maintenance of fracture reduction, and recovery of ankle joint function. The screw internal fixation has the advantages of minimal invasion and shorter operation time.
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Affiliation(s)
- Ziyuan Ma
- Guizhou Medical University, Guizhou Guiyang, 550004, P.R.China
| | - Shengyang Guo
- Department of Traumatic Orthopaedics, Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai, 201318, P.R.China
| | - Feng Gao
- Department of Traumatic Orthopaedics, Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai, 201318, P.R.China
| | - Bin Wang
- Department of Traumatic Orthopaedics, Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai, 201318, P.R.China
| | - Xiaoxiao Zhou
- Department of Traumatic Orthopaedics, Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai, 201318, P.R.China
| | - Beigang Fu
- Department of Traumatic Orthopaedics, Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai, 201318, P.R.China
| | - Shengli Xia
- Guizhou Medical University, Guizhou Guiyang, 550004, P.R.China.,Department of Traumatic Orthopaedics, Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai, 201318, P.R.China
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Pilskog K, Gote TB, Odland HEJ, Fjeldsgaard KA, Dale H, Inderhaug E, Fevang JM. Traditional Approach vs Posterior Approach for Ankle Fractures Involving the Posterior Malleolus. Foot Ankle Int 2021; 42:389-399. [PMID: 33203272 PMCID: PMC8054166 DOI: 10.1177/1071100720969431] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND In the past, posterior malleolus fragments (PMFs) commonly have been indirectly reduced and fixed when fragments involve 25% or more of the tibial articular surface, while smaller fragments were left unfixed. The posterior approach has become increasingly popular and allows fixation of even smaller fragments. This study compares clinical outcome for the 2 treatment strategies. METHODS Patients with ankle fractures involving a PMF treated from 2014 to 2016 were eligible for inclusion. Patients were allocated to group A (treated with a posterior approach) or group B (treated with the traditional approach) according to the treatment given. A one-to-one matching of patients from each group based on the size of the PMF was performed. Patient charts were reviewed, and outcome evaluation was performed clinically, radiographically, and by patient-reported outcome measures (PROMs; Self-Reported Foot and Ankle Score, RAND-36, visual analog scale [VAS] of pain, and VAS of satisfaction). Forty-three patients from each group were matched. Median follow-up was 26 (interquartile range [IQR], 19-35) months postoperatively. RESULTS The median PMF size was 17% (IQR, 12-24) in both groups, and they reported similar results in terms of PROMs. Fixation of the PMF was performed in 42 of 43 (98%) patients in group A and 7 of 43 (16%) patients in group B (P < .001). The former group more frequently got temporary external fixation (56% vs 12%, P < .01) and less frequently had syndesmotic fixation (14% vs 49%, P < .01), and they had less mechanical irritation and hardware removal but more noninfectious skin problems (28% vs 5%, P < .01). Median time from injury to definitive surgery (8 vs 0 days, P < .001) and median length of stay (12 vs 3 days, P < .001) were longer in group A. CONCLUSION Comparison of treatment strategies for ankle fractures involving the posterior malleolus showed similar results between patients treated with a traditional approach and a posterior approach. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Kristian Pilskog
- Orthopedic Department, Haukeland
University Hospital, Bergen, Norway,Kristian Pilskog, MD, Orthopedic Department,
Haukeland University Hospital, Postbox 1400, 5021, Bergen, Norway.
| | - Teresa Brnic Gote
- Department of Physiotherapy, Haukeland
University Hospital, Bergen, Norway
| | | | | | - Håvard Dale
- Orthopedic Department, Haukeland
University Hospital, Bergen, Norway
| | - Eivind Inderhaug
- Orthopedic Department, Haukeland
University Hospital, Bergen, Norway
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