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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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Baumfeld T, Burgos V, Souza V, Pires RE, Campos T, Baumfeld D. Ankle fractures malreduction rate and its causes in two Brazilian tertiary training hospitals. Injury 2023; 54 Suppl 6:110811. [PMID: 38143130 DOI: 10.1016/j.injury.2023.05.042] [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: 02/26/2023] [Revised: 05/07/2023] [Accepted: 05/11/2023] [Indexed: 12/26/2023]
Abstract
INTRODUCTION Ankle fractures are one of the most frequent injuries managed by any trauma surgeon. Literature has shown that adequate reduction is of utmost importance to achieve satisfactory functional outcomes. However, malreduction rates remain high worldwide. The objective of the present study is to evaluate the quality of ankle fracture reduction in two major trauma centers in a large Brazilian city and to analyze the factors associated with malreduction METHODS: Epidemiologic data of 382 patients (189 men; 193 women) aged between 7 and 87 years who underwent osteosynthesis of the ankle in two trauma centers in a large Brazilian city. Electronic clinical records, preoperative and immediate postoperative radiographs in anteroposterior (AP), lateral and mortise views were evaluated. Pettrone's criteria were used to evaluate the quality of ankle fractures reduction. All radiographs were independently evaluated by two foot and ankle senior surgeons RESULTS: Overall, malreduction rate was 22.2%. Forty-seven (55.2%) fractures classified as malreduced had medial malleolar displacement The results showed three factors that significantly affected the quality of reduction (p<0.05), patients over 60 years, open fractures and fracture-dislocations. Patients aged over 60 years were twice more likely to have poor reduction of ankle fractures than younger ones. The risk of poor fracture reduction among those individuals with open fractures is 2.15 times greater than among patients with closed injuries. Fracture-dislocation imposed a 2.7 higher risk for malreduction DISCUSSION: We found a malreduction rate below most series previously published. Further results agree with the literature. Elderly people aged over 60 years, fracture dislocations and open fractures are associated with worse results, influencing the quality of the reduction, clinical outcomes, and the development of post-traumatic arthrosis CONCLUSION: Ankle fractures malreduction are associated with higher age, open fractures, and fracture-dislocations.
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Affiliation(s)
| | | | | | | | - Túlio Campos
- Universidade Federal de Minas Gerais (UFMG) - Brazil
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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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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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Hoekstra H, Vinckier O, Staes F, Berckmans L, Coninx J, Matricali G, Wuite S, Vanstraelen E, Deschamps K. In Vivo Foot Segmental Motion and Coupling Analysis during Midterm Follow-Up after the Open Reduction Internal Fixation of Trimalleolar Fractures. J Clin Med 2023; 12:jcm12082772. [PMID: 37109109 PMCID: PMC10146606 DOI: 10.3390/jcm12082772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 03/31/2023] [Accepted: 04/05/2023] [Indexed: 04/29/2023] Open
Abstract
PURPOSE Trimalleolar ankle fractures (TAFs) are common traumatic injuries. Studies have described postoperative clinical outcomes in relation to fracture morphology, but less is known about foot biomechanics, especially in patients treated for TAFs. The aim of this study was to analyze segmental foot mobility and joint coupling during the gait of patients after TAF treatment. METHODS Fifteen patients, surgically treated for TAFs, were recruited. The affected side was compared to their non-affected side, as well as to a healthy control subject. The Rizzoli foot model was used to quantify inter-segment joint angles and joint coupling. The stance phase was observed and divided into sub-phases. Patient-reported outcome measures were evaluated. RESULTS Patients treated for TAFs showed a reduced range of motion in the affected ankle during the loading response (3.8 ± 0.9) and pre-swing phase (12.7 ± 3.5) as compared to their non-affected sides (4.7 ± 1.1 and 16.1 ± 3.1) and the control subject. The dorsiflexion of the first metatarsophalangeal joint during the pre-swing phase was reduced (19.0 ± 6.5) when compared to the non-affected side (23.3 ± 8.7). The affected side's Chopart joint showed an increased range of motion during the mid-stance (1.3 ± 0.5 vs. 1.1 ± 0.6). Smaller joint coupling was observed on both the patient-affected and non-affected sides compared to the controls. CONCLUSION This study indicates that the Chopart joint compensates for changes in the ankle segment after TAF osteosynthesis. Furthermore, reduced joint-coupling was observed. However, the minimal case numbers and study power limited the effect size of this study. Nevertheless, these new insights could help to elucidate foot biomechanics in these patients, adjusting rehabilitation programs, thereby lowering the risk of postoperative long-term complications.
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Affiliation(s)
- Harm Hoekstra
- Department of Trauma Surgery, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
- Department of Development and Regeneration, KU Leuven-University of Leuven, 3000 Leuven, Belgium
| | - Olivier Vinckier
- Department of Orthopaedics, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Filip Staes
- Musculoskeletal Rehabilitation Research Group, Department of Rehabilitation Sciences, KU Leuven-University of Leuven, Tervuursevest 101, 3001 Leuven, Belgium
| | - Lisa Berckmans
- Musculoskeletal Rehabilitation Research Group, Department of Rehabilitation Sciences, KU Leuven-University of Leuven, Tervuursevest 101, 3001 Leuven, Belgium
| | - Jolien Coninx
- Musculoskeletal Rehabilitation Research Group, Department of Rehabilitation Sciences, KU Leuven-University of Leuven, Tervuursevest 101, 3001 Leuven, Belgium
| | - Giovanni Matricali
- Department of Development and Regeneration, KU Leuven-University of Leuven, 3000 Leuven, Belgium
- Department of Orthopaedics, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
- Institute for Orthopaedic Research and Training, KU Leuven-University of Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Sander Wuite
- Department of Development and Regeneration, KU Leuven-University of Leuven, 3000 Leuven, Belgium
- Department of Orthopaedics, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
- Institute for Orthopaedic Research and Training, KU Leuven-University of Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Eline Vanstraelen
- Clinical Motion Analysis Laboratory, Campus Pellenberg, University Hospitals Leuven, Weligerveld 1, 3212 Lubbeek, Belgium
| | - Kevin Deschamps
- Musculoskeletal Rehabilitation Research Group, Department of Rehabilitation Sciences, KU Leuven-University of Leuven, Tervuursevest 101, 3001 Leuven, Belgium
- Clinical Motion Analysis Laboratory, Campus Pellenberg, University Hospitals Leuven, Weligerveld 1, 3212 Lubbeek, Belgium
- Division of Podiatry, Institut D'Enseignement Supérieur Parnasse Deux-Alice, Haute Ecole Leonard de Vinci, Avenue e Mounier 84, 1200 Bruxelles, Belgium
- Department of Podiatry, Artevelde University College, Hoogpoort 15, 9000 Gent, Belgium
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Influence of posterior malleolar fragment morphology on the outcomes of trimalleolar fractures: A systematic review and meta-analysis. Foot Ankle Surg 2022; 28:1337-1344. [PMID: 35810125 DOI: 10.1016/j.fas.2022.06.012] [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: 04/12/2022] [Revised: 06/08/2022] [Accepted: 06/21/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Trimalleolar fractures are generally considered to have inferior outcomes among ankle injuries. Historically, emphasis was placed on the size of the posterior malleolar fracture (PMF) to guide surgical decision-making and predict outcomes. Recent studies have suggested that the morphology of the PMF fragment is more important than its size. The aim of this systematic review was to determine if the outcomes of trimalleolar fractures depend on the morphology of the PMF as per the Haraguchi classification system after surgical fixation. METHODS A systematic literature search was conducted in the electronic databases of PubMed, Embase, Scopus, and Ovid. Title and abstracts were screened, and data from eligible studies were extracted. Meta-regression and pooled analysis was performed using appropriate computer software. RESULTS 11 studies with 597 patients were included in the final analysis. Pooled mean AOFAS score was 87.43 (95% CI 84.24-90.62) after a mean follow-up of 31.6 months. Univariate and multivariate meta-regression analysis demonstrated that as the percentage of Haraguchi type 1 patients increased, there was a statistically significant improvement in outcome scores. A similar trend was noted for Haraguchi type 3 fractures, and a reverse trend was observed for Haraguchi type 2 injuries, although neither were statistically significant. CONCLUSION Our review suggests that the outcomes of trimalleolar fractures after surgical fixation may depend on the morphology of the PMF, with Haraguchi type 1 fractures having overall superior functional outcomes than Haraguchi type 2 and 3 injuries. Future studies need to done to conclusively prove or refute these findings.
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Deschamps K, Wouters J, Staes F, Vanstraelen E, Matricali GA, Wuite S, Hoekstra H. Evidence for symmetrically reduced foot mechanics and energetics in patients after trimalleolar fracture repair: A cross-sectional study. Gait Posture 2022; 97:13-20. [PMID: 35849967 DOI: 10.1016/j.gaitpost.2022.07.007] [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: 05/17/2022] [Revised: 06/20/2022] [Accepted: 07/09/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Trimalleolar fractures osteosynthesis is associated with a suboptimal outcome. It is hypothesized that patients with trimalleolar fractures face different ankle joint kinetics at mid- and long-term causing compensations at the distal foot joints. RESEARCH QUESTION Do patients with a history of a trimalleolar fracture demonstrate different foot joint mechanics and energetics (1) between their affected side and their matched controls? (2) between their unaffected side and their matched controls? (3) between their affected side and their unaffected side? METHODS Fifteen patients who sustained a trimalleolar fracture and underwent osteosynthesis for both the lateral, medial and posterior malleolus were compared to a asymptomatic control group which was matched for sex, age and walking speed. Three-dimensional gait analysis was used to quantify kinetic parameters in the Ankle, Chopart, Lisfranc and first metatarsophalangeal joint through a multi-segment kinetic foot model. Statistical analysis was performed using a Univariate Analysis of Covariance and/or a paired t-test. RESULTS The peak internal ankle moment was significantly lower in patients when compared to the control group (p < 0.001). Mean peak power generation and total positive work were significantly lower for the Chopart joint when comparing the patients to the control group (p < 0.001). These results were observed for both the affected and unaffected side of the patients compared to the control group, showing symmetrical changes in the patient group. SIGNIFICANCE Despite adequate radiographic quality of reduction and the fact that all patients were treated according to a fixed postoperative protocol, this study indicates that patients with a history of a trimalleolar fracture demonstrate reduced foot joint kinetics. It is hypothesized that these findings originate from extrinsic and intrinsic foot muscle strength, stiffness and pain. Future research is needed to validate this hypothesis.
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Affiliation(s)
- Kevin Deschamps
- KU Leuven, Department of Rehabilitation Sciences, Musculoskeletal Rehabilitation Research Group, Campus Brugge, Spoorwegstraat 12, 8200 Brugge, Belgium; University Hospitals Leuven, Clinical Motion Analysis Laboratorium, Campus Pellenberg, Weligerveld 1, 3212 Lubbeek, Belgium; Haute Ecole Leonard De Vinci, Institut D'Enseignement Supérieur Parnasse Deux-Alice, Division of Podiatry, Avenue E Mounier 84, 1200 Bruxelles, Belgium; Department of Podiatry, Artevelde University College, Hoogpoort 15, 9000 Gent, Belgium.
| | - Julia Wouters
- KU Leuven, Department of Rehabilitation Sciences, Campus Leuven, Tervuursevest 101, 3000 Leuven, Belgium.
| | - Filip Staes
- KU Leuven, Department of Rehabilitation Sciences, Musculoskeletal Rehabilitation Research Group, Campus Leuven, Tervuursevest 101, 3000 Leuven, Belgium.
| | - Eline Vanstraelen
- University Hospitals Leuven, Clinical Motion Analysis Laboratorium, Campus Pellenberg, Weligerveld 1, 3212 Lubbeek, Belgium.
| | - Giovanni A Matricali
- University Hospitals Leuven, Department of Orthopaedics, Herestraat 49, 3000 Leuven, Belgium; KU Leuven, Institute for Orthopaedic Research & Training, Herestraat 49, 3000 Leuven, Belgium; KU Leuven, Department of Development and Regeneration, Herestraat 49, 3000 Leuven, Belgium.
| | - Sander Wuite
- University Hospitals Leuven, Department of Orthopaedics, Herestraat 49, 3000 Leuven, Belgium; KU Leuven, Institute for Orthopaedic Research & Training, Herestraat 49, 3000 Leuven, Belgium; KU Leuven, Department of Development and Regeneration, Herestraat 49, 3000 Leuven, Belgium.
| | - Harm Hoekstra
- KU Leuven, Department of Development and Regeneration, Herestraat 49, 3000 Leuven, Belgium; University Hospitals Leuven, Department of Trauma Surgery, Herestraat 49, 3000 Leuven, Belgium.
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Neumann AP, Kroker L, Beyer F, Rammelt S. Complications following surgical treatment of posterior malleolar fractures: an analysis of 300 cases. Arch Orthop Trauma Surg 2022; 143:3129-3136. [PMID: 35849187 DOI: 10.1007/s00402-022-04536-9] [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: 04/16/2022] [Accepted: 06/22/2022] [Indexed: 11/26/2022]
Abstract
AIMS The treatment of ankle fractures and fracture-dislocations involving the posterior malleolus (PM) has undergone considerable changes over the past decade. The aim of our study was to identify risk factors related to the occurrence of complications in surgically treated ankle fractures with PM involvement. PATIENTS AND METHODS We retrospectively analyzed 300 patients at a mean age of 57 years with 300 ankle fractures involving the PM treated surgically at our institution over a 12-year period. The following relevant comorbidities were noted: arterial hypertension (43.7%; n = 131), diabetes mellitus (DM) (14.0%; n = 42), thereof insulin-dependent (3.7%; n = 11), peripheral vascular disease (0.7%; n = 2), osteoporosis (12.0%; n = 36), dementia (1.0%; n = 3), and rheumatoid arthritis (2.0%; n = 6). Furthermore, nicotine consumption was recorded in 7.3% (n = 22) and alcohol abuse in 4.0% (n = 12). RESULTS Complications occurred in 41 patients (13.7%). A total of 20 (6.7%) revision surgeries had to be performed. Patients with DM (p < 0.001), peripheral vascular disease (p = 0.003) and arterial hypertension (p = 0.001) had a significantly increased risk of delayed wound healing. Alcohol abuse was associated with a significantly higher overall complication rate (OR 3.40; 95% CI 0.97-11.83; p = 0.043), increased rates of wound healing problems (OR 11.32; 95% CI 1.94-65.60; p = 0.001) and malalignment requiring revision (p = 0.033). The presence of an open fracture was associated with an increased rate of infection and wound necrosis requiring revision (OR 14.25; 95% CI 2.39-84.84; p < 0.001). Multivariate analysis identified BMI (p = 0.028), insulin-dependent DM (p = 0.003), and staged fixation (p = 0.043) as independent risk factors for delayed wound healing. Compared to the traditional lateral approach, using the posterolateral approach for fibular fixation did not lead to increased complication rates. CONCLUSIONS Significant risk factors for the occurrence of complications following PM fracture treatment were identified. An individually tailored treatment regimen that incorporates all risk factors is important for a good outcome.
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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.
| | - Livia Kroker
- University Center of Orthopaedics,Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Franziska Beyer
- 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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Danford NC, Hellwinkel JE, Nocek MJ, Boddapati V, Greisberg JK, Trofa DP. Fractures of the posterior malleolus: a systematic review and analysis of patient-reported outcome scale selection. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2022; 33:1125-1131. [PMID: 35430691 DOI: 10.1007/s00590-022-03261-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 03/28/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Despite the extensive use of PROs in ankle fracture research, no study has quantified which PROs are most commonly used for assessing outcomes of patients who sustain fractures of the posterior malleolus. The purpose of this study was therefore to quantify which PROs are most commonly used for outcome research after posterior malleolus fractures. METHODS A systematic search was performed using the preferred reporting items for systematic reviews and meta-analyses guidelines. Articles were identified through Pubmed, EMBASE, Web of Science, and cochrane central register of controlled trials through May of 2021. Included articles were analyzed for the primary outcome of the most commonly reported PRO. RESULTS The American orthopedic foot and ankle ankle-hindfoot score (AOFAS) was the most commonly used PRO for assessment of posterior malleolus fracture outcomes, used in 37 of 72 studies (51.4%). The second and third most common were the olerud-molander ankle score (OMAS) (22 studies, 30.6%) and the visual analogue score (VAS) (21 studies, 29.2%). Eleven different PROs were used only once. Quality of evidence was graded as low given the percentage of studies that were observational or case series (68 of 72 studies, 94.4%). CONCLUSION Investigators have used many different PROs to assess outcomes for posterior malleolus fractures, the most common of which are the AOFAS, OMAS, and VAS. Future investigators should attempt to unify outcome reporting for these injuries.
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Affiliation(s)
- Nicholas C Danford
- Department of Orthopaedic Surgery, New York-Presbyterian/Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, NY, USA.
| | - Justin E Hellwinkel
- Department of Orthopaedic Surgery, New York-Presbyterian/Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, NY, USA
| | - Michael J Nocek
- Department of Orthopaedic Surgery, New York-Presbyterian/Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, NY, USA
| | - Venkat Boddapati
- Department of Orthopaedic Surgery, New York-Presbyterian/Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, NY, USA
| | - Justin K Greisberg
- Department of Orthopaedic Surgery, New York-Presbyterian/Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, NY, USA
| | - David P Trofa
- Department of Orthopaedic Surgery, New York-Presbyterian/Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, NY, USA
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11
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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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Percutaneous Fixation of Posterior Malleolar Fractures in Patients With Unstable Ankle Fractures Treated With a Fibular Intramedullary Nail: A Description of a Technique and Review of Outcomes. J Orthop Trauma 2022; 36:195-200. [PMID: 34483324 DOI: 10.1097/bot.0000000000002262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/26/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To (1) describe the percutaneous technique used to reduce and fix a posterior malleolar fracture with anteroposterior screws in patients managed with a fibular intramedullary nail, (2) describe the selection of patients to whom this technique can be applied, and (3) report the clinical and patient reported outcome of this intervention. DESIGN Retrospective review. SETTING Academic orthopaedic trauma center. PATIENTS Thirty-two consecutive patients with a mean age of 65 years (range, 39-90) over a thirteen-year period identified from a prospective database. INTERVENTION Unstable ankle fractures managed surgically with a fibular nail and percutaneous fixation of the posterior malleolar component. MAIN OUTCOME MEASUREMENTS The primary short-term outcome was complications related to posterior malleolar fracture fixation. The primary mid-term outcome was the Olerud-Molander Ankle Score. Secondary outcomes included the Manchester-Oxford Foot Questionnaire, EuroQol-5D, health, pain, and satisfaction. RESULTS Thirty of the 32 (94%) posterior malleolar fractures united uneventfully. Postoperative loss of talar reduction occurred in 2 patients (6.3%), which in 1 patient (3.1%) eventually required a hindfoot nail arthrodesis. There were no soft-tissue complications related to the anteroposterior screws or the fibular nail fixation. At a mean follow-up of 3.7 years (range, 1-8), the median Olerud-Molander Ankle Score, Manchester-Oxford Foot Questionnaire, EuroQol-5D, health, pain, and satisfaction scores were 80.0, 23.4, 0.85, 80.0, 85.0, and 87.5, respectively. CONCLUSIONS Percutaneous ankle fracture fixation with a fibular nail and posterior malleolar screws results in reliable fracture stabilization, good patient outcomes, and high treatment satisfaction. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Jeyaseelan L, Bua N, Parker L, Sohrabi C, Trockels A, Vris A, Heidari N, Malagelada F. Outcomes of posterior malleolar fixation in ankle fractures in a major trauma centre. Injury 2021; 52:1023-1027. [PMID: 33376016 DOI: 10.1016/j.injury.2020.12.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 11/11/2020] [Accepted: 12/19/2020] [Indexed: 02/02/2023]
Abstract
AIMS Ongoing controversy exists over the indications and benefits of posterior malleolar fixation in ankle fractures. The aim of this pragmatic study was to evaluate the outcomes of posterior malleolar fracture fixation in ankle fractures in the setting of a major trauma centre. Our hypothesis is that posterior malleolus fixation leads to improved clinical outcomes. METHODS A total of 320 patients were identified with operatively treated ankle fractures involving a posterior malleolus component, at our institution between January 2012 and January 2018, ensuring a minimum 2 year follow-up. Of these patients, 160 had the posterior malleolus fixed as part of their surgery and 160 did not. Patient demographics, surgical details and complications were assessed. The Manchester-Oxford Foot Questionnaire (MOXFQ) was the primary patient outcome measure. RESULTS Fixation of the posterior malleolus was associated with a statistically significant improvement in patient outcomes. Mean MOXFQ score in the unfixed posterior malleolus group was 24.03 (0 - 62), compared to 20.10 (0 - 67) in the fixed posterior malleolus group (p = 0.04). Outcomes were worse with increasing size of posterior malleolar fragment. Metalwork-related issues were higher in the posterior malleolus fixed group (24/160 (15%) versus 10/160 (6.2%)) and re-operation rate was double. CONCLUSION This study demonstrates that in the practical setting of a major trauma unit, fixation of the posterior malleolar fracture leads to improved patient outcomes but with increased metalwork risks and reoperation rates.
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Affiliation(s)
- Luckshmana Jeyaseelan
- Department of Trauma & Orthopaedics, The Royal London Hospital, Bart's Health NHS Trust, Whitechapel Road, London E1 1FR, United Kingdom
| | - Nelson Bua
- Department of Trauma & Orthopaedics, The Royal London Hospital, Bart's Health NHS Trust, Whitechapel Road, London E1 1FR, United Kingdom
| | - Lee Parker
- Department of Trauma & Orthopaedics, The Royal London Hospital, Bart's Health NHS Trust, Whitechapel Road, London E1 1FR, United Kingdom
| | - Catrin Sohrabi
- Department of Trauma & Orthopaedics, The Royal London Hospital, Bart's Health NHS Trust, Whitechapel Road, London E1 1FR, United Kingdom
| | - Amaury Trockels
- Department of Trauma & Orthopaedics, The Royal London Hospital, Bart's Health NHS Trust, Whitechapel Road, London E1 1FR, United Kingdom
| | - Alexandros Vris
- Department of Trauma & Orthopaedics, The Royal London Hospital, Bart's Health NHS Trust, Whitechapel Road, London E1 1FR, United Kingdom
| | - Nima Heidari
- Department of Trauma & Orthopaedics, The Royal London Hospital, Bart's Health NHS Trust, Whitechapel Road, London E1 1FR, United Kingdom
| | - Francesc Malagelada
- Department of Trauma & Orthopaedics, The Royal London Hospital, Bart's Health NHS Trust, Whitechapel Road, London E1 1FR, United Kingdom.
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