The Role of Computed Tomography in Surgical Planning for Trimalleolar Fracture. A Survey of OTA Members

Computed Tomography Scans and Fixation Rates for Trimalleolar Ankle Fractures Over 10 Years at a Level 1 Trauma Center

Background

The posterior malleolus component of the trimalleolar ankle fracture has posed a controversial topic for diagnostic imaging and surgical management. Preoperative computed tomography (CT) scans are used to better appreciate fracture morphology and may affect management techniques. No prior study has investigated the trend in preoperative CT scan use and the rates of posterior and syndesmotic fixation for trimalleolar injuries.

Methods

This retrospective cohort study evaluated the use of preoperative CT scans and the rates of posterior and syndesmotic fixation for trimalleolar ankle fractures over a 10-year period at an adult level 1 trauma center. Patients surgically managed for ankle fractures with OTA/AO classifications of 44B3, 44C3.3, 44C1.3, 44C2.3, and 44A3 were identified and included using Current Procedural Terminology codes and a prospectively collected fracture registry. Demographic information, comorbidities, fixation methods, and use of preoperative CT scan were recorded. Comparative analyses were performed to assess for yearly differences in demographic characteristics along with changes in trends of preoperative CT scans and posterior and syndesmotic fixation.

Results

A total of 1191 patients were included in the analyses. OTA/AO 44B3.2 fractures were the most common injuries (yearly range of 59.4%-80.1%). The rate of posterior fixation did not significantly increase during the study interval (1.4% growth per year [95% CI -0.27, 3.07]). However, the rate of preoperative CT scan use significantly increased by 2.76% (95% CI 1.99, 3.52) per year and the rate of syndesmotic fixation increased by 2.58% (95% CI 1.17, 3.99) per year. Fixation methods for both the syndesmosis and posterior malleolus changed during the study timeline.

Conclusion

Despite a relatively stable rate of posterior fixation, the frequency of preoperative CT scans and use of syndesmotic fixation increased significantly over a 10-year study period.

Level of Evidence

Level IV, descriptive pilot study.

Ankle fractures involving the anterolateral distal tibia: medium-term clinical results of 50 cases

Purpose

The anterolateral distal tibial rim (anterior malleolus, AM) is frequently fractured in malleolar fractures. The aim of this study was to evaluate the medium-term outcomes of malleolar fractures involving the AM.

Methods

Among 100 patients with AM fractures that were treated over a 10-year period, 50 patients were available for follow-up. Outcome was assessed with the Olerud Molander Ankle Score (OMAS), the Foot Function Index (FFI-D), the EuroQol (EQ)-5D-5L Index, the EQ-VAS and the AOFAS Ankle-Hindfoot Score. Type 1 AM fractures (bony syndesmotic avulsions) were fixed surgically with either a suture anchor or a transosseous suture in 11 of 22 cases (50%). Among type 2 AM fractures (with incisura and joint involvement), 68% were treated surgically with screw fixation. All three type 3 AM fractures (anterolateral tibial plafond impaction) were treated surgically with either screw or plate fixation.

Results

At follow-up, the median OMAS was 75, the FFI-D 19, the EQ-5D-5L-Index 0.88, the EQ-VAS 70, and the AOFAS score 93. Assuming that the fracture severity increases from Supination–External Rotation to Pronation–External Rotation and Pronation–Abduction injuries, the AOFAS score (p < 0.001), OMAS score (p = 0.009), and FFI-D (p = 0.041) all showed a significantly inferior clinical outcome with increasing fracture severity. Patients who required surgical revision (n = 5) showed a significantly inferior outcome with the OMAS (p = 0.019).

Conclusions

A differentiated treatment protocol tailored to dislocation, size, incisura involvement and joint impaction leads to favourable outcomes in complex malleolar fractures involving the AM. More data are needed on the outcome of AM fractures that are still commonly underestimated and overlooked.

The Intercalary Fragment in Posterior Malleolus Fractures: Characterization and Significance

Methods of fixation in ankle fractures involving the posterior malleolus have become increasingly scrutinized. With the increase in computed tomography (CT), an intercalary fracture fragment (ICF) adjacent to the posterior malleolus has been oft described. Treatment of the ICF remains controversial and the purpose of this study was to evaluate radiographic and clinical outcomes in patients who had direct reduction and fixation of this fragment compared to those where the ICF was not fixed. This retrospective study included 249 trimalleolar and posterior pilon ankle fractures grouped into those who had the ICF reduced and fixed (n = 74) and those where the ICF was not directly addressed (n = 175). CT scans were evaluated for size and location of the ICF. Demographic, radiographic and intraoperative variables were collected and analyzed. The group which had the ICF reduced and fixed had decreased Kellgren-Lawrence scores (p = .001). There was also a higher rate of repeat surgery in the group who had the ICF fixed, although not meeting statistical significance. There were no differences in size or location of the ICF fragment between groups. We did identify similarities with other studies in regard to size and posterolateral location of the ICF between groups. However, based on worsening radiographic outcomes of the group where the ICF was reduced and fixed, we do not necessarily recommend universal treatment of this fragment. The surgeon's goal should always be a concentric articular reduction and treatment of the ICF should be considered on a case-by-case basis.

Diagnosing Fractures of the Distal Tibial Articular Surface in Tibia Shaft Fractures: Is Computed Tomography Always Necessary?

OBJECTIVES

To identify the incidence of distal articular fractures in a series of distal third tibia shaft fractures and to report the utility of both computed tomography (CT) scans and Radiographic Investigation of the Distal Extension of Fractures into the Articular Surface of the Tibia (RIDEFAST) ratios for identification of articular involvement.

DESIGN

Retrospective cohort.

SETTING

Level 1 trauma center.

PATIENTS

Four hundred seventeen patients with distal third tibia shaft fractures were included in the study.

INTERVENTION

Intramedullary nail or plate fixation.

MAIN OUTCOME MEASURES

Type of articular fracture, time of diagnosis, and RIDEFAST ratios.

RESULTS

One hundred one of the 417 distal third fractures (24%) had a fracture of the distal tibia articular surface. Of these 101 fractures, 41 (41%) represented an extension of the primary fracture line and 60 (59%) were separate malleolar fractures. Of the 101 articular fractures, 95 (94%) were identified preoperatively and 6 (6%) were identified intraoperatively. Of the 95 fractures identified preoperatively, 87 (92%) were identified on plain radiographs and 8 (8%) by CT scan. Thirty-five preoperative CT scans were performed on distal third tibia shaft fractures in search of an intra-articular fracture. In 27 patients (77%), no articular fracture was present, representing an overall yield of 23% among CT scans performed to rule out an articular fracture in distal third tibia shaft fractures. RIDEFAST ratios for all 101 distal tibia shaft fractures with articular involvement and 100 fractures with no articular involvement were not significantly different (P > 0.05) using both coronal and sagittal plane measurements.

CONCLUSIONS

CT scans performed on distal third tibia shaft fractures in search of articular fractures had a low yield (23%). Widespread use of CT scan to diagnose fractures of the distal tibia articular surface in the setting of distal tibia shaft fractures does not seem warranted. No statistically significant differences in RIDEFAST ratios were found between fractures with and without articular involvement, indicating that more work is necessary before RIDEFAST can be used to reliably rule out articular involvement in this setting.

LEVEL OF EVIDENCE

Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Temporary external fixation versus direct ORIF in complete displaced intra-articular radius fractures: a prospective comparative study

PURPOSE

In complex distal radius fractures (DRF), both direct osteosynthesis (one-stage approach) and temporary external fixation as a bridge to definitive osteosynthesis (two-stage approach) are used. Studies directly comparing these two management options are lacking. This study aims to compare the two procedures with regard to complications, and radiological and functional outcomes.

MATERIAL

This prospective observational study included all patients presenting with AO OTA C2 or C3 DRF (1) between January 2011 and January 2018. All patients were categorised into two groups according to received treatment: patients who underwent direct definitive osteosynthesis (Group One Stage) and patients who received an external fixator followed by definitive fixation (Group Two Stage). Primary outcome was the Patient-Rated Wrist Evaluation score (PRWE) measured at 1 year follow-up. Secondary outcomes included complications, range of motion (ROM), and radiologic parameters (ulnar variance, radial inclination and volar tilt).

RESULTS

A total of 187 patients were included in Group One Stage with a mean age of 55.6 years (SD 17.2), of which 67 had a C2 and 120 a C3 fracture. Group Two Stage consisted of 66 patients with a mean age of 53.7 years (SD 20.4 years), of which 6 patients having a C2 and 60 a C3 fracture. There was no significant difference in complications and median PRWE between Group One Stage (12.0, IQR 2.0-20.0) and Group Two Stage (12.2, IQR 5.5-23.4) (p = 0.189), even after correction for differences in baseline characteristics. The ROM and radiologic parameters did not show any significant differences as well.

CONCLUSION

No differences were found in clinical, functional, and radiological outcome between one- and two-staged surgical techniques. It may be concluded that a two-stage approach is a viable and safe alternative.

CT Analysis of the Posteromedial Fragment of the Posterior Malleolar Fracture

BACKGROUND

To date, there have been no studies describing the characteristics of posteromedial fragment in the posterior malleolus fracture. The aim was to investigate the variability of posteromedial fracture fragments to enable better surgical planning.

METHODS

All Mason and Molloy type 2B fractures, defined as fracture of both the posterolateral and the posteromedial fragments of the posterior malleolus, from our database were identified to analyze the preoperative computed tomography scan. The posteromedial fragment was investigated in 47 cases (mean age, 46.6 years; 11 male, 36 female).

RESULTS

Morphologically, the fracture could be divided into 2 subtypes: (1) a large pilon intra-articular fragment (mean of X axis: 33.0 mm, Y: 30.7 mm, Z: 31.7 mm) presented in 29 cases with mean interfragmentary angle of 32.1 and back of tibia angle of 32.7 degrees (this was seen in 25 of 27 cases with supination injury pattern); and (2) a small extra-articular avulsion fragment (mean of X axis: 9.6 mm, Y: 13.2 mm, Z: 11.5 mm) present in 18 cases with a mean interfragmentary angle of 11.0 and back of tibia angle of 10.1 degrees. It was seen in 80% of pronation injuries.

CONCLUSION

The avulsion type of the posteromedial fragment of posterior malleolus fracture was more common in pronation injuries, likely the result of traction by the intermalleolar ligament, and the pilon type was more common in supination injuries, likely the result of the rotating talus impaction. Because of the intra-articular involvement, we believe the pilon type should undergo fixation to achieve articular congruity, unlike the avulsion type which may only function as a secondary syndesmotic stabilizer.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

The Incidence of Posterior Malleolar Involvement in Distal Spiral Tibia Fractures: Is it Higher than We Think?

OBJECTIVES

To investigate the incidence of concomitant posterior malleolar fractures (PMFs) in operative, distal-third, spiral tibia fractures.

DESIGN

Prospective protocol with retrospective review of data.

SETTING

Single, Level 1 trauma center.

PATIENTS/PARTICIPANTS

One hundred ninety-three consecutive, skeletally mature patients with operatively treated fractures of the distal-third, tibial shaft and metaphysis. Pilon fractures were excluded.

INTERVENTION

Computed tomography (CT) scans were obtained in all distal-third, spiral fractures of the tibia to determine fracture morphology and presence of a PMF.

MAIN OUTCOME MEASUREMENTS

The incidence of concurrent PMFs in operative spiral fractures of the distal tibia.

RESULTS

Twenty-six distal-third, spiral fractures were identified with an ipsilateral PMF diagnosed in 92.3% of cases (24 cases). PMFs were over 25 times more likely to occur in distal-third, spiral fractures when compared with other distal-third fracture patterns (relative risk = 25.7, 95% confidence interval, 11.6-56.8). PMFs were treated with supplemental fixation in 23/24 (95.8%) cases.

CONCLUSIONS

There is a high incidence of concomitant, ipsilateral fractures of the posterior malleolus in patients presenting with operative distal-third, spiral fractures of the tibia. A preoperative ankle computed tomography should be strongly considered in all cases with this specific fracture morphology.

LEVEL OF EVIDENCE

Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Repair of syndesmosis injury in ankle fractures: Current state of the art

Conventional treatment of syndesmosis injuries in rotationally unstable ankle fractures is associated with an unacceptably high rate of malreduction, and this has led to a paradigm shift in the approach to a newer concept of anatomical repair.

In the anatomical approach, the principle is to ‘directly fix what is broken and repair what is torn’. The approach is effective in reducing the rate of syndesmosis malreduction, increasing the biomechanical strength of syndesmosis fixation and avoiding the need for trans-syndesmotic fixation and its secondary removal.

The objective of this review article is to compare the conventional treatment of these injuries (accepted usage, general consent, traditional, generally accepted) with a newer anatomical approach to be considered as a shift in thinking.

Cite this article: EFORT Open Rev 2018;3:24-29. DOI: 10.1302/2058-5241.3.170017

Ankle fracture controversies: Do the foot and ankle specialists have a different vision?

OBJECTIVE

To analyse the differences in the management of ankle fractures between orthopaedic/trauma surgeons and foot and ankle specialists.

MATERIAL AND METHOD

An e-mail survey was performed asking some of the country's orthopaedic surgeons controversial questions regarding the analysis of 5 clinical cases of different ankle fractures.

RESULTS

Seventy-two surgeons responded to the questionnaire (response rate of 24.2%): 37 foot and ankle specialists and 35 non-specialist orthopaedic surgeons. For trimalleolar fracture, 40.5% of the specialists would request a computed tomography scan compared to 14% of the non-specialists (P=.01). Ninety-four percent of all the respondents would synthesise the posterior malleolus; 91% of the non-specialists would use an antero-posterior approach, either with a plate or with screws (P=.006). No differences were found between groups in the treatment of syndesmotic injuries (P>.05). For trans-syndesmotic fracture (Weber B) with signs of medial instability, 54% of the non-specialists would revise the internal lateral ligament compared to only 32% of the specialists (P=.06).

CONCLUSIONS

The foot and ankle specialists ask for more complementary tests to diagnose ankle fractures. In turn, they use a greater diversity of surgical techniques in synthesis of the posterior malleolus (posterior plate) and the medial malleolus (cerclage wires). Finally, they indicated a lower revision rate of the internal lateral ligament.