1
|
Andonov Y. Direct fixation of posterior malleolus fractures-posterolateral or posteromedial approach? Acta Orthop Belg 2023; 89:499-506. [PMID: 37935235 DOI: 10.52628/89.3.11914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
Ankle fractures involving the posterior malleolus (PM) generally have worse prognosis. There is a trend towards it's direct fixation, yet the exact indications are a subject of debate. The purpose of our study was to present our treatment protocol and to discuss the advantages and limitations of the direct posterolateral and posteromedial approaches. We present a prospective series of 35 ankle fractures involving the PM, operated for a period of 4 years (2018-2022). Direct posterolateral approach was used in 20 ankles, 15 were operated via a posteromedial approach. Clinical and functional assessment was performed according to the criteria of AOFAS. 14 patients received an excellent score, 16 had good and the rest had an average score. The overall score was 85,4 (54-100). The average range of motion was 50° (15°-55°).Eight patients had superficial skin necrosis along the surgical incision. Thirteen patients need their fibular plates removed due to local irritation. Five patients, operated through a posterolateral approach, had lateral heel numbness suggestive of a sural nerve disfunction. PM is important for normal ankle kinematics. When it's direct fixation is considered appropriate, the safest and shortest route is optimal. It is determined by the preoperative CT. The posterolateral approach is more versatile, but lead to more complications in our study.
Collapse
|
2
|
Solasz S, Ganta A, Konda SR. Posteromedial Surgical Approach for Fixation of Haraguchi Type 2B Posterior Malleolar Fracture. J Orthop Trauma 2023; 37:S9-S10. [PMID: 37443437 DOI: 10.1097/bot.0000000000002634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 07/15/2023]
Abstract
SUMMARY A case of a 26-year-old man with a displaced medial malleolus fracture with extension into the posteromedial aspect of the posterior malleolus is presented. A CT scan of the ankle is obtained demonstrating a Haraguchi type 2B posterior malleolus fracture with a posteromedial and posterolateral fragment. The posteromedial fragment extends into the posterior colliculus of the medial malleolus and has a subchondral impaction fracture. There is also a 1 × 1 cm piece of the articular surface of the posterior malleolus that has flipped 90 degrees and lodged itself between the posterolateral fracture fragment. This video overview and case presentation demonstrates a posteromedial approach with fixation strategy for the posterior malleolus.
Collapse
Affiliation(s)
- Sara Solasz
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY; and
| | - Abhishek Ganta
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY; and
- Department of Orthopaedic Surgery, Jamaica Hospital Medical Center, Richmond Hill, NY
| | - Sanjit R Konda
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY; and
- Department of Orthopaedic Surgery, Jamaica Hospital Medical Center, Richmond Hill, NY
| |
Collapse
|
3
|
Black AT, Stowers JM, Tran S, Mata KDL, Sherman AE, RahnamaVaghef A. Clinical Outcomes for Pilon Variant Posterior Malleolar Fractures: A Multicenter Retrospective Analysis. J Foot Ankle Surg 2022; 61:1303-1307. [PMID: 35595642 DOI: 10.1053/j.jfas.2022.04.007] [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: 10/18/2021] [Revised: 04/07/2022] [Accepted: 04/13/2022] [Indexed: 02/03/2023]
Abstract
Currently, there is no consensus on surgical approach for posterior malleolar fracture fragments with significant posteromedial involvement. The Bartonicek type III/Haraguchi type II posterior malleolar morphologies typically involve large posteromedial fragments, behaving like a pilon injury and have been reported as pilon variant fractures. We performed a retrospective chart review at 2 large healthcare institutions, evaluating patients that underwent surgical management of pilon variant posterior malleolar fractures and determining clinical outcomes including: time to union, union rates, soft tissue complications, infection and time to weight bearing. A total of 68 patients were included (51 females, 17 males). A total of 51 direct (19 posterolateral, 31 posteromedial), 6 indirect, and 11 no-fixation approaches were identified. Significantly different time-to-union was found between direct fixation (mean = 85.1 days), indirect fixation (mean = 74 days) and no-fixation (mean = 174.3 days) (p < .001). A posteromedial approach (mean = 63.0 days, SD = 16.6) was associated with significantly shorter time to union when compared to a posterolateral approach (mean = 124.8 days, SD = 59.4; p < .001). Fixation (direct or indirect) was associated with significantly increased likelihood of union of the overall ankle fracture pattern (52/57 = 91%) when compared to no fixation of the posterior malleolar component (9/14 = 64%), p = .01. Patients who underwent direct fixation had significantly lower incidence of neurovascular damage (6%) when compared to patients who underwent indirect fixation (33%) or no-fixation (29%) (p = .02). There was no significant difference between the groups in terms of tendon damage (p = .54), infection rates (p = .45) and time to weight bearing (p = .66). The authors suggest that surgical management and specifically direct approaches have better outcomes in the short-term follow up.
Collapse
Affiliation(s)
| | - Jered M Stowers
- Fellow, Foot and Ankle Institute Fellowship, Indianapolis, IN
| | - Son Tran
- Resident, Department of Plastic Surgery, Medstar Georgetown University Hospital, Washington, DC
| | - Karla De La Mata
- Resident, Department of Orthopedics, Lenox Hill Hospital Northwell, New York, NY
| | | | - Ali RahnamaVaghef
- Fellowship-Trained Foot and Ankle Surgeon, Assistant Professor, Georgetown University School of Medicine, Washington, DC
| |
Collapse
|
4
|
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.
Collapse
Affiliation(s)
| | - W Annefloor van Enst
- Medical Guidelines, Amsterdam, The Netherlands,Correspondence should be addressed to W A van Enst;
| |
Collapse
|
5
|
Cao MM, Zhang YW, Hu SY, Rui YF. A systematic review of ankle fracture-dislocations: Recent update and future prospects. Front Surg 2022; 9:965814. [PMID: 36017521 PMCID: PMC9398172 DOI: 10.3389/fsurg.2022.965814] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundAnkle fracture-dislocations are one of the most severe types of ankle injuries. Compared to the simple ankle fractures, ankle fracture-dislocations are usually more severely traumatized and can cause worse functional outcomes. The purpose of this study was to review the previous literatures to understand the anatomy, mechanisms, treatment, and functional outcomes associated with ankle fracture-dislocations.MethodsThe available literatures from January 1985 to December 2021 in three main medical databases were searched and analyzed. The detailed information was extracted for each article, such as researchers, age, gender, groups, type of study, type of center research, level of evidence, significant findings, study aim, cause of injury, time from injury to surgery, type of fracture, direction of dislocation, follow-up, postoperative complications and functional evaluation scores.ResultsA total of 15 studies (1,089 patients) met the inclusion criteria. Only one study was a prospective randomized trial. The top-ranked cause of injury was high-energy injury (21.3%). Moreover, the most frequent type of fracture in ankle dislocations was supination-external rotation (SER) ankle fracture (43.8%), while the most common directions of dislocation were lateral (50%) and posterior (38.9%).ConclusionsCollectively, most ankle fracture-dislocations are caused by high-energy injuries and usually have poor functional outcomes. The mechanism of injury can be dissected by the ankle anatomy and Lauge-Hansen's classification. The treatment of ankle fracture-dislocations still requires more detailed and rational solutions due to the urgency of occurrence, the severity of injury, and the postoperative complications.
Collapse
Affiliation(s)
- Mu-Min Cao
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Yuan-Wei Zhang
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Sheng-Ye Hu
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Yun-Feng Rui
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Correspondence: Yun-Feng Rui
| |
Collapse
|
6
|
Jiang Z, Zhang C, Qin JJ, Wang GD, Wang HS. Posterior pilon fracture treated by opening the fibula fracture gap. J Orthop Surg Res 2022; 17:214. [PMID: 35392983 PMCID: PMC8991660 DOI: 10.1186/s13018-022-03106-4] [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] [Received: 11/28/2021] [Accepted: 03/29/2022] [Indexed: 11/10/2022] Open
Abstract
Background Posterior pilon fracture is a relatively common clinical fracture involving the posterior articular surface of the distal tibia. Currently, this form of fracture is receiving increasing attention. The surgical approach and technique for the treatment of posterior pilon fractures are still controversial. The purpose of this retrospective study was to compare the clinical and imaging outcomes of pilon fractures after treatment with the open fibula fracture line (OFFL) surgical technique versus the traditional posterolateral approach (TPL). Methods A retrospective analysis of patients with posterior pilon fractures treated using the open fibula fracture line technique and the traditional posterolateral approach between January 2015 and March 2020. Thirty-one cases were included in the open fibula fracture line technique group and twenty-eight cases were included in the traditional posterolateral approach group. We used the Burwell-Charnley scale to assess the effectiveness of surgical repositioning. The clinical outcomes were evaluated using American Orthopaedic Foot & Ankle Society ankle-hind foot score (AOFAS) and visual analog score (VAS). Results The overall anatomic reduction rate was slightly better in the open fibula fracture line group than in the conventional posterolateral group (81% vs. 71%, p = 0.406), but there was no statistically significant difference between the two groups. There were no statistically significant differences between the two groups in terms of fracture healing time and time to full weight bearing (p > 0.05). At the final follow-up, the AOFAS functional score of the open fibula fracture line group was statistically superior to that of the conventional posterolateral group (p < 0.05). However, there was no statistical difference between the two groups in VAS pain scores at rest, during activity, and under weight bearing (p > 0.05). Conclusion The trans-fibular fracture approach provides a better surgical option for specific types of posterior pilon fractures with a high rate of anatomic repositioning and a good near-term outcome. Trial registration: Retrospective registration.
Collapse
Affiliation(s)
- Zhuang Jiang
- Orthopaedic Department, General Hospital of Central Theater Command of PLA, #627 Wuluo Road, Wuchang District, Wuhan, 430070, China.,Clinical Medicine, Wuhan University of Science and Technology, #2, West Huangjiahu Road, Hongshan District, Wuhan, 430081, China
| | - Chen Zhang
- Orthopaedic Department, General Hospital of Central Theater Command of PLA, #627 Wuluo Road, Wuchang District, Wuhan, 430070, China
| | - Jia-Jun Qin
- Orthopaedic Department, General Hospital of Central Theater Command of PLA, #627 Wuluo Road, Wuchang District, Wuhan, 430070, China
| | - Guo-Dong Wang
- Orthopaedic Department, General Hospital of Central Theater Command of PLA, #627 Wuluo Road, Wuchang District, Wuhan, 430070, China.
| | - Hua-Song Wang
- Orthopaedic Department, General Hospital of Central Theater Command of PLA, #627 Wuluo Road, Wuchang District, Wuhan, 430070, China.
| |
Collapse
|
7
|
Pflüger P, Braun KF, Mair O, Kirchhoff C, Biberthaler P, Crönlein M. Current management of trimalleolar ankle fractures. EFORT Open Rev 2021; 6:692-703. [PMID: 34532077 PMCID: PMC8419795 DOI: 10.1302/2058-5241.6.200138] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
A trimalleolar ankle fracture is considered unstable and treatment is generally performed operatively. Computed tomography is important for the operative planning by providing an elaborated view of the posterior malleolus. Trimalleolar ankle fractures have a rising incidence in the last decade with up to 40 per 100,000 people per year. With a growing number of elderly patients, trimalleolar ankle injuries will become more relevant in the form of fragility fractures, posing a particular challenge for trauma surgeons. In patients with osteoporotic trimalleolar ankle fractures and relevant concomitant conditions, further evidence is awaited to specify indications for open reduction and internal fixation or primary transfixation of the ankle joint. In younger, more demanding patients, arthroscopic-assisted surgery might improve the outcome, but future research is required to identify patients who will benefit from assisted surgical care. This review considers current scientific findings regarding all three malleoli to understand the complexity of trimalleolar ankle injuries and provide the reader with an overview of treatment strategies and research, as well as future perspectives.
Cite this article: EFORT Open Rev 2021;6:692-703. DOI: 10.1302/2058-5241.6.200138
Collapse
Affiliation(s)
- Patrick Pflüger
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Karl-Friedrich Braun
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.,Department of Traumatology and Reconstructive Surgery including Department of Orthopedic Surgery, Charite Universitätsmedizin Berlin, Berlin, Germany
| | - Olivia Mair
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Chlodwig Kirchhoff
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Peter Biberthaler
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Moritz Crönlein
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| |
Collapse
|
8
|
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.
Collapse
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
| |
Collapse
|
9
|
Abo-Elsoud M, Kassem E. Fragment-specific fixation of posterior wall acetabular fractures. INTERNATIONAL ORTHOPAEDICS 2021; 45:3193-3199. [PMID: 34230993 DOI: 10.1007/s00264-021-05110-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 06/10/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Fractures of the posterior wall (PW) of the acetabulum have a wide variety of patterns; treating them as a single entity using the standard ilio-ischial plate would be inappropriate. We are presenting our experience with a fragment-specific fixation technique in which each PW fragment is reduced and fixed with separate buttress/anti-glide plate(s) in a tailored fashion, abandoning the use of the ilio-ischial plate. PATIENTS AND METHODS Fragment-specific fixation was applied to 46 patients with PW fractures (33 simple and 13 associated fracture types) with a mean follow-up of 34.9 ± 20.5 months (range: 12-72). Kocher-Langenbeck approach was utilized for all patients with dissection limited to the fracture site (a limited form of the approach was used in three patients). RESULTS Anatomical reduction of the fracture was achieved in 41 (89.1%) patients, imperfect reduction in four (8.7%), and poor reduction in one (2.2%) patient. Excellent to good radiological and functional results were achieved in 91.3% of cases. A single case had recurrent subluxation which was related to avascular necrosis of the highly comminuted wall fragments. Four patients developed post-traumatic arthritis and required total hip arthroplasty. None of our cases developed clinically significant heterotopic bone formation. CONCLUSION With a versatile yet a strong-enough construct and limited soft tissue dissection, fragment-specific fixation yielded very good results with few complications.
Collapse
Affiliation(s)
- Mohamed Abo-Elsoud
- Pelvic Trauma and Arthroplasty Unit, Department of Orthopaedics and Traumatology, Kasralainy School of Medicine, Cairo University, Cairo, Egypt.
| | - Elsayed Kassem
- Pelvic Trauma and Arthroplasty Unit, Department of Orthopaedics and Traumatology, Kasralainy School of Medicine, Cairo University, Cairo, Egypt
| |
Collapse
|
10
|
Yu T, Ying J, Liu J, Huang D, Yan H, Xiao B, Zhuang Y. Percutaneous posteroanterior screw fixation for Haraguchi type 1 posterior malleolar fracture in tri-malleolar fracture: Operative technique and randomized clinical results. J Orthop Surg (Hong Kong) 2021; 29:2309499021997996. [PMID: 33641534 DOI: 10.1177/2309499021997996] [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] [Indexed: 11/17/2022] Open
Abstract
PURPOSE The study described a novel surgical treatment of Haraguchi type 1 posterior malleolar fracture in tri-malleolar fracture and patient outcomes at intermediate period follow-up. METHODS All patients from January 2015 to December 2017 with tri-malleolar fracture of which posterior malleolar fractures were Haraguchi type 1, were surgically treated in this prospective study. Lateral and medial malleolar fractures were managed by open reduction and internal fixation through dual incision approaches. 36 cases of Haraguchi type 1 posterior malleolar fractures were randomly performed by percutaneous posteroanterior screw fixation with the aid of medial exposure (group 1). And 40 cases were performed by percutaneous anteroposterior screw fixation (group 2). Clinical outcomes, radiographic outcomes and patient-reported outcomes were recorded. RESULTS Seventy-six patients with mean follow-up of 30 months were included. There were no significant differences in the mean operation time (81.0 ± 11.3 vs. 77.2 ± 12.4), ankle function at different periods of follow-up, range of motions and visual analog scale (VAS) at 24 months between the two groups (p > 0.05). However, the rate of severe post-traumatic arthritis (Grade 2 and 3) and the rate of step-off rather than gap in radiological evaluation were lower in group 1 than that in group 2 (p < 0.05). CONCLUSION Using our surgical technique, more patients had good outcome with a lower rate of severe post-traumatic arthritis, compared with the group of percutaneous anteroposterior screw fixation. Percutaneous posteroanterior screw fixation can be a convenient and reliable alternative in treating Haraguchi type 1 posterior malleolar fracture.
Collapse
Affiliation(s)
- Tianming Yu
- Department of Traumatic Orthopedics, 105854Ningbo No. 6 Hospital, Ningbo, Zhejiang, P.R. China
| | - Jichong Ying
- Department of Traumatic Orthopedics, 105854Ningbo No. 6 Hospital, Ningbo, Zhejiang, P.R. China
| | - Jianlei Liu
- Department of Traumatic Orthopedics, 105854Ningbo No. 6 Hospital, Ningbo, Zhejiang, P.R. China
| | - Dichao Huang
- Department of Traumatic Orthopedics, 105854Ningbo No. 6 Hospital, Ningbo, Zhejiang, P.R. China
| | - Hailin Yan
- Department of Traumatic Orthopedics, 105854Ningbo No. 6 Hospital, Ningbo, Zhejiang, P.R. China
| | - Baiping Xiao
- Department of Traumatic Orthopedics, 105854Ningbo No. 6 Hospital, Ningbo, Zhejiang, P.R. China
| | - Yunqiang Zhuang
- Department of Traumatic Orthopedics, 105854Ningbo No. 6 Hospital, Ningbo, Zhejiang, P.R. China
| |
Collapse
|
11
|
Posterior approaches to the ankle - an analysis of 3 approaches for access to the posterior malleolar fracture. Foot (Edinb) 2020; 45:101725. [PMID: 33049427 DOI: 10.1016/j.foot.2020.101725] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 06/18/2020] [Accepted: 08/04/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND An anatomical study to determine what degree of access to the posterior distal tibia could be gained by using 3 different approaches; the posterolateral, the posteromedial and the medial posteromedial approaches. METHODS A comparison study, between the anatomical dissection of 7 fresh frozen cadaveric lower legs and image analysis of CT data of posterior malleolar fractures from a prospectively collected database was conducted. All fractures have been classified using the Mason and Molloy classification. RESULTS In comparing the posterior malleolar fracture fragment width to distal tibia width, the posterolateral fragment encompasses 60.1% (95% CI 56.8, 63.3) of the total width of the tibia. If the posteromedial fragment is included the fragments encompass the entire distal tibia (100%). In type 3 fractures, 81.4% (95% CI 75.5, 87.1) of the distal tibia width is involved. When comparing the fracture width to the approach, no approach achieves a complete exposure of the type 2B or 3 fracture patterns. The overall surface area of the type 2B and 3 fractures, is significantly greater than all the approaches. Considering the lateral to medial extent of the fracture, the posterolateral fragment mean width is 33% greater than what can be exposed by the posterolateral approach (mean 24.9 vs 16.8mm). In type 2B and 3 fractures, the horizontal exposure reduces to 39.8% and 47.6% respectively. In comparison, the PM approach exposes 47.6% of the type 2B fracture pattern and 57.1% of the type 3 fracture pattern and allows a preferable angle for hardware insertion. The MPM approach does not expose any of the posterolateral fragments in this study, however it does expose 92% (mean 21.9 vs. 23.8mm) of the medial to lateral width of a posteromedial fragment of a type 2B fracture. CONCLUSION Each approach allows access to different parts and amounts of the posterior tibia. An understanding of and utilisation of these approaches can lead to adequate exposure for fixation of most posterior malleolus fracture patterns seen.
Collapse
|
12
|
Anwar A, Hu Z, Adnan A, Gao Y, Li B, Nazir MU, Tian C, Wang Y, Lv D, Zhao Z, Zhang Z, Zhang H, Tong C, Lv G. Comprehensive biomechanical analysis of three clinically used fixation constructs for posterior malleolar fractures using cadaveric and finite element analysis. Sci Rep 2020; 10:18639. [PMID: 33122787 PMCID: PMC7596231 DOI: 10.1038/s41598-020-75819-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 09/21/2020] [Indexed: 11/11/2022] Open
Abstract
Different fixation modalities are available for fixation of posterior malleolar fractures (PMFs), but the best method is still unclear. The purpose of this study was to carry out a comparative biomechanical analysis of three commonly used fixation constructs for PMFs using experimental and finite element analysis (FEA). 15 human cadaveric ankle specimens were randomly divided into three groups. Specimens in group-A were fixed with two anteroposterior (AP) lag screws, group-B with two posteroanterior (PA) lag screws, and for group-C, a posterior plate was used. Each model was subjected to axial load. Outcomes included loads for 0.5 mm, 1 mm, 1.5 mm, and 2 mm vertical displacements of posterior fragments were noted. 3D FE models were reconstructed from computed tomography (CT) images and subjected to vertical loads. The model’s stress, fracture step-off, and resultant strains in implants were also studied in 3D FE models. Significantly higher amounts of mean compressive loads were observed to cause the same amount of vertical displacements in plate group (265 ± 60.21 N, 796 ± 57.27 N, 901.18 ± 8.88 N, 977.26 ± 13.04 N) than AP (102.7 ± 16.78 N, 169.5 ± 19.91 N, 225.32 ± 15.92 N, 269.32 ± 17.29 N) and PA (199.88 ± 31.43 N, 362.80 ± 28.46 N, 431.3 ± 28.12 N, 541.86 ± 36.05 N) lag screws respectively (P < 0.05). Simulated micro-motion analysis demonstrated that fracture step-off values in plate group (0.03 ± 0.001 mm, 0.06 ± 0.003 mm and 0.13 ± 0.010 mm) were the lowest among the three groups (P < 0.001). The cancellous bone showed the highest amount of stress in AP and PA lag groups respectively, whereas the lowest stress was noted in the plate-group. This biomechanical study concluded that posterior plating is biomechanically the most stable fixation construct for PMFs fixation. AP and PA lag screws with higher bone stress and fracture step-off values have a high tendency of bone cut-through and loss of fixation respectively.
Collapse
Affiliation(s)
- Adeel Anwar
- Institute of Translational Medicine, China Medical University, No. 77 Puhe Road, North New Area, Shenyang, 110122, Liaoning, People's Republic of China
| | - Zhenwei Hu
- Department of Orthopaedic Surgery, The Second Hospital of Chaoyang City, No 26, Secttion 4 Chaoyang street, Chaoyang, Liaoning, People's Republic of China
| | - Atif Adnan
- Department of Human Anatomy, School of Basic Medical Science, China Medical University, No. 77 Puhe Road, 110122 North New Area, Shenyang, Liaoning, People's Republic of China
| | - Yanming Gao
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Dalian Medical University, 456 Zhong Shan Road, Dalian, 116027, Liaoning, People's Republic of China
| | - Bing Li
- Engineering Research Center of Continuous Extrusion, Ministry of Education, Dalian Jiaotong University, 794 Yellow River Road, Dalian, 116028, Liaoning, People's Republic of China
| | - Muhammad Umar Nazir
- Department of Anesthesia, The Second Affiliated Hospital of Dalian Medical University, 456 Zhong Shan Road, Dalian, 116027, Liaoning, People's Republic of China
| | - Cong Tian
- Department of Railway Vehicle, Ji Lin Railway Technology College, 1 Ji Hua East road, 132200, Ji Lin, People's Republic of China
| | - Yanfeng Wang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of China Medical University, 155 Nanjing street, Shenyang, 110001, Liaoning, People's Republic of China
| | - Decheng Lv
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Dalian Medical University, 222 Zhong shan road, Dalian, Liaoning, 116011, People's Republic of China
| | - Zhi Zhao
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Dalian Medical University, 456 Zhong Shan Road, Dalian, 116027, Liaoning, People's Republic of China
| | - Zhen Zhang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Dalian Medical University, 222 Zhong shan road, Dalian, Liaoning, 116011, People's Republic of China
| | - Hu Zhang
- Department of Orthopaedic Surgery, The 920Th Hospital of Joint Logistics Support Force, Kunming, 650032, Yunnan, People's Republic of China
| | - Changgui Tong
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Dalian Medical University, 456 Zhong Shan Road, Dalian, 116027, Liaoning, People's Republic of China
| | - Gang Lv
- Institute of Translational Medicine, China Medical University, No. 77 Puhe Road, North New Area, Shenyang, 110122, Liaoning, People's Republic of China.
| |
Collapse
|
13
|
A Retrospective Study on the Morphology of Posterior Malleolar Fractures Based on a CT Scan: Whether We Ignore the Importance of Fracture Height. BIOMED RESEARCH INTERNATIONAL 2020; 2020:2903537. [PMID: 32802840 PMCID: PMC7414377 DOI: 10.1155/2020/2903537] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 07/11/2020] [Indexed: 01/31/2023]
Abstract
Objective The aim of this study was to investigate the respective correlation between the height (H) of a posterior malleolar fracture (PMF) and the involved area (S) of an articular surface and the presence of “die-punch.” Methods Patients with closed posterior malleolar fractures admitted to our hospital from January 2015 to December 2017 were selected, with complete X-ray and 3D reconstruction CT imaging data. The gender, age, injured side, and surgical fixation methods of the patients were recorded. A preoperative ankle CT scan was performed, and the images were viewed through the PACS (Picture Archiving and Communication Systems). Simultaneously, the involved joint surface area (S) by the posterior malleolar fracture was measured, as well as the proportion of the fracture area to the total ankle joint area. On the sagittal reconstruction CT images, the height (H) of the posterior malleolar fracture was measured to compare the correlation between the height of the fracture and the area of the fracture, as well as the area ratio. Besides, according to the presence or absence of “die-punch,” patients were divided into two groups: A and B. And each group was further divided into three subgroups according to age (16-39 years old, 40-59 years old, and ≥60 years old). The statistical differences in the height of fracture between the subgroups were compared. Results A total of 48 patients, aged 16-82 years, with an average age of 48.9 years, were included in this study, including 13 males and 35 females. There were 20 cases of left ankle injury and 28 cases of right ankle injury. The average height of the posterior malleolar fractures was 18.19 mm, the average area of the fracture was 202.28 mm2, and the average ratio of the fracture area to the total articular surface area was 17.84%. Besides, die-punch was seen in 27 cases and not in 21 cases. The average height of fractures was 21.33 ± 5.38 mm in group A1, 14.38 ± 9.01 mm in group B1, 18.30 ± 7.95 mm in group A2, 14.48 ± 5.37 mm in group B2, 26.26 ± 6.73 mm in group A3, and 12.77 ± 3.07 mm in group B3. Conclusion The height (H) of the posterior malleolar fractures is positively correlated with the fracture area (S) and the fracture area ratio (FAR). The posterior malleolar fractures with “die-punch” tend to have a greater average height than that without “die-punch.” In clinical work, orthopedic surgeons should not only pay attention to the size of the posterior malleolus fracture but also value its height, which hopefully could provide insight into the treatment and prognosis of PMF patients.
Collapse
|
14
|
Zbeda RM, Friedel SP, Katchis SD, Weiner L. Open Reduction and Internal Fixation of Posterior Malleolus Fractures via a Posteromedial Approach. Orthopedics 2020; 43:e166-e170. [PMID: 32077968 DOI: 10.3928/01477447-20200213-01] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 03/11/2019] [Indexed: 02/03/2023]
Abstract
Ankle fractures with a posterior malleolus component are complex injuries. The most commonly used operative methods include indirect reduction via a percutaneous anterior approach and direct reduction via a posterolateral approach. For large posterior malleolus fractures with medial extension, direct reduction via a posteromedial approach is an alternative operative option. The authors hypothesized that fixation of large posterior malleolus fractures via a posteromedial approach results in anatomic reduction and stable plate fixation. From 2008 to 2015, 22 (9.0%) of 244 consecutive operative ankle fractures were identified as posterior malleolus fractures treated using a posteromedial approach. Patient charts were retrospectively reviewed for demographics, operative details, follow-up time, and any postoperative complications. Postoperative radiographs were reviewed to ensure that anatomic reduction and stable fixation was maintained. Sixteen (72.7%) of 22 patients were female, and the average age at the time of surgery was 54.1 years (range, 26-86 years). The average follow-up time was 13.0 months (range, 2.0-41.4 months). Twenty-one (95.5%) of 22 patients healed on a radiographic and clinical basis. There was an 18.2% (4 of 22) postoperative complication rate: 1 patient had a nonunion, 1 patient had cellulitis, 1 patient had osteomyelitis involving the fibula, and 1 patient had symptomatic heterotopic ossification. Open reduction and internal fixation of posterior malleolus fractures via a posteromedial approach achieved anatomic reduction, stable plate fixation, and complete healing in all but 1 patient. This study demonstrates that the posteromedial approach is a reasonable alternative to other more commonly used methods for treating these fractures. [Orthopedics. 2020;43(3):e166-e170.].
Collapse
|
15
|
How to address the posterior malleolus in ankle fractures? A decision-making model based on the computerised tomography findings. INTERNATIONAL ORTHOPAEDICS 2020; 44:1177-1185. [DOI: 10.1007/s00264-020-04481-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 01/15/2020] [Indexed: 10/25/2022]
|
16
|
Tuček M, Rammelt S, Kostlivý K, Bartoníček J. CT controlled results of direct reduction and fixation of posterior malleolus in ankle fractures. Eur J Trauma Emerg Surg 2020; 47:913-920. [PMID: 32008051 DOI: 10.1007/s00068-020-01309-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 01/20/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE The aim of this study was to present outcomes of operative treatment of the posterior malleolus fractures of type four of the Bartoníček/Rammelt classification. METHODS In 19 patients, direct reduction and fixation of the posterior malleolus was performed from the posterolateral or posteromedial approaches. The accuracy of reduction was assessed with the use of postoperative CT scans. RESULTS The mean size of the avulsed articular surface carried by posterior malleolus amounted to 36%. Reduction of the posterior malleolus fracture was assessed as anatomical in 14 cases and as satisfactory in five cases. Position of the distal fibula was assessed as anatomical in 15 cases. The mean AOFAS score was 89.4 points. All nine patients with anatomical reduction of all lesions achieved the mean AOFAS score of 93.1 points, five patients with malposition of posterior malleolus 89.1 points and five patients with malposition of the fibula in the fibular notch 87.8 points. A total of six patients developed osteoarthritic changes of grades one and two according to the Kellgren and Lawrence classification. CONCLUSIONS Outcomes of the study demonstrated good mid-term results in type four fractures of the posterior malleolus treated by direct reduction from posterior approaches. Postoperative CT examination allowed evaluation of the accuracy of reduction of all fractures and reduction of the distal fibula into the fibular notch. Based on postoperative CT examination, it will be possible to assess the effect of reduction of individual lesions on the functional results.
Collapse
Affiliation(s)
- Michal Tuček
- Department of Orthopaedics, First Faculty of Medicine, Charles University and Military University Hospital Prague, U Vojenské Nemocnice 1200, 169 02, Prague 6, Czech Republic.
| | - Stefan Rammelt
- University Center of Orthopedics and Traumatology, University Hospital Carl Gustav Carus Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Karel Kostlivý
- Surgical Department, Thomayer's Hospital, First Faculty of Medicine, Charles University, Vídeňská 800, 140 59, Prague 4, Czech Republic
| | - Jan Bartoníček
- Department of Orthopaedics, First Faculty of Medicine, Charles University and Military University Hospital Prague, U Vojenské Nemocnice 1200, 169 02, Prague 6, Czech Republic
| |
Collapse
|
17
|
Bergman C, Morin M, Lawson K. Anatomy, Classification, and Management of Ankle Fractures Involving the Posterior Malleolar Fragment: A Literature Review. FOOT & ANKLE ORTHOPAEDICS 2019; 4:2473011419887724. [PMID: 35097350 PMCID: PMC8697079 DOI: 10.1177/2473011419887724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The posterior malleolar fragment is frequently involved in rotational ankle fractures, but diagnosis and definitive management remains controversial. Ankle fractures with a posterior malleolar component that are not identified and treated in a timely manner may contribute significantly to future comorbidities, including continued pain, instability, and the development of arthritis. This article highlights the anatomic features of posterior malleolar ankle fractures, the classification schemes used, and discusses the various nonsurgical and surgical methods currently used.
Collapse
Affiliation(s)
| | - Matthew Morin
- Department of Orthopedic Surgery, Banner University Medical Center, AZ, USA
| | - Kevin Lawson
- Department of Orthopedic Surgery, Banner University Medical Center, AZ, USA
| |
Collapse
|
18
|
Chaparro F, Ahumada X, Urbina C, Lagos L, Vargas F, Pellegrini M, Barahona M, Bastias C. Posterior pilon fracture: Epidemiology and surgical technique. Injury 2019; 50:2312-2317. [PMID: 31630782 DOI: 10.1016/j.injury.2019.10.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 07/12/2019] [Accepted: 10/03/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To review a case series of patients with posterior pilon variant fracture using a novel approach, focusing on demographic data, injury pattern, surgical results based on computed tomography (CT) scan, and short-term complications. DESIGN Consecutive case series. SETTING Level I trauma center. PATIENTS/PARTICIPANTS Twenty-five patients with posterior pilon fracture. INTERVENTION Posterior pilon fracture open reduction and internal fixation. MAIN OUTCOME MEASUREMENTS Parameters measured included age, sex, type of fracture, surgical technique, anatomical reduction, and complications. RESULTS Twenty-five patients sustained a posterior pilon fracture, accounting for 13.4% of all operatively treated ankle fractures with median follow-up of 21.7 months. The average age of patients was 42 years (22-62); 19/25 (76%) were female, and 6/25 (24%) were male. A modified posteromedial approach was used in 18/25 (72%) patients. Persistent syndesmotic instability was present in 11/25 (44%) patients after posterior malleolar stabilization. Quality of reduction was assessed under CT scan in 19 patients, with 15/19 (78.9%) having anatomic reduction. We report 2/25 (8%) patients with early wound problems and 7/25 (20%) with short-term complications during follow-up. CONCLUSION Posterior pilon variant fracture appears to be less common than previously reported. Most fractures can be satisfactorily treated through a modified posteromedial approach. Albeit obtaining posterior malleolar fracture rigid fixation, syndesmotic instability was more prevalent than expected. The short-term complication rate was low. LEVEL OF EVIDENCE Therapeutic level IV.
Collapse
Affiliation(s)
- Felipe Chaparro
- Department of Orthopaedic Surgery, Clinica Universidad de Los Andes, Av. La Plaza 2501, Las Condes, Santiago 7620157, Chile; Department of Orthopaedic Surgery, Hospital Clínico Mutual de Seguridad, Alameda 4848, Estación Central, Santiago 9190015, Chile.
| | - Ximena Ahumada
- Department of Orthopaedic Surgery, Hospital Clínico Mutual de Seguridad, Alameda 4848, Estación Central, Santiago 9190015, Chile
| | - Christian Urbina
- Department of Orthopaedic Surgery, Hospital Clínico Mutual de Seguridad, Alameda 4848, Estación Central, Santiago 9190015, Chile
| | - Leonardo Lagos
- Department of Orthopaedic Surgery, Hospital Clínico Mutual de Seguridad, Alameda 4848, Estación Central, Santiago 9190015, Chile
| | - Fernando Vargas
- Department of Orthopaedic Surgery, Hospital Clínico Mutual de Seguridad, Alameda 4848, Estación Central, Santiago 9190015, Chile
| | - Manuel Pellegrini
- Department of Orthopaedic Surgery, Clinica Universidad de Los Andes, Av. La Plaza 2501, Las Condes, Santiago 7620157, Chile; Department of Orthopaedic Surgery, Hospital Clínico Universidad de Chile, Santos Dumont 999, Independencia, Santiago 7640275, Chile
| | - Maximiliano Barahona
- Department of Orthopaedic Surgery, Hospital Clínico Universidad de Chile, Santos Dumont 999, Independencia, Santiago 7640275, Chile
| | - Christian Bastias
- Department of Orthopaedic Surgery, Hospital Clínico Mutual de Seguridad, Alameda 4848, Estación Central, Santiago 9190015, Chile
| |
Collapse
|
19
|
Meulenkamp B, Louati H, Morellato J, Papp S, Lalonde KA. Posterior malleolus exposure. OTA Int 2019; 2:e021. [PMID: 37662836 PMCID: PMC10473347 DOI: 10.1097/oi9.0000000000000021] [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: 06/29/2018] [Accepted: 11/18/2018] [Indexed: 09/05/2023]
Abstract
Objectives Posterior malleolus (PM) fractures are common in rotational ankle injuries, tibial plafond fractures, and distal third tibia fractures. Surgical indications continue to evolve as we improve our understanding of ankle and syndesmotic stability. These fractures remain technically challenging with respect to both exposure and fixation. Our biomechanical cadaveric study compared posterolateral versus modified posteromedial surgical approaches to define the following: maximal surface area exposed, and maximal screw trajectory obtainable for fixation. Methods Twelve fresh-frozen cadaver limbs were thawed at room temperature. Posterolateral and modified posteromedial approaches were performed on each limb. Margins of exposure were marked. A 2.5 mm drill was advanced at the extreme medial and lateral extents of each exposure, standardized at 1 cm proximal to the joint line and perpendicular to the bone. Computed tomography (CT) scans were performed to identify the maximal trajectory. Limbs were stripped of soft tissue, and the exposed bony surface area was measured using a validated laser surface-scanning technique. Results The modified posteromedial approach allowed for a larger exposed surface area compared to the posterolateral exposure (median 99% vs 64%, respectively; P < .05). The modified posteromedial approach allowed for instrumentation of up to a median of 77% of the posterior distal tibia as opposed to 46% through the posterolateral approach (P < .05). Conclusion The modified posteromedial approach allowed for increased exposure and wider access for instrumentation of the PM when compared to the posterolateral approach. We advocate use of this approach when addressing complex PM fractures, in particular the Haraguchi type 2 fracture pattern.
Collapse
Affiliation(s)
- Brad Meulenkamp
- Division of Orthopaedic Surgery, The Ottawa Hospital
- Department of Surgery, Faculty of Medicine, University of Ottawa
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Hakim Louati
- Division of Orthopaedic Surgery, The Ottawa Hospital
- Orthopaedics Biomechanics Laboratory, University of Ottawa
| | - John Morellato
- Division of Orthopaedic Surgery, The Ottawa Hospital
- Department of Surgery, Faculty of Medicine, University of Ottawa
| | - Steve Papp
- Division of Orthopaedic Surgery, The Ottawa Hospital
- Department of Surgery, Faculty of Medicine, University of Ottawa
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Karl Andre Lalonde
- Division of Orthopaedic Surgery, The Ottawa Hospital
- Department of Surgery, Faculty of Medicine, University of Ottawa
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| |
Collapse
|
20
|
Xing W, Xie P, Wang L, Liu C, Cui J, Zhang Z, Sun L. The application of intraoperative ankle dislocation approach in the treatment of the unstable trimalleolar fractures involving posterior ankle comminuted fracture: a retrospective cohort study. BMC Surg 2018; 18:23. [PMID: 29669542 PMCID: PMC5907374 DOI: 10.1186/s12893-018-0356-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 04/11/2018] [Indexed: 11/21/2022] Open
Abstract
Background The aim of this study was to introduce a novel intraoperative lateral ankle dislocation approach during surgical treatment for patients with unstable trimalleolar fractures involving posterior ankle comminuted fractures and compare its effects and safety with those with conventional approach. Methods From June 2006 to June 2014, 69 patients diagnosed as unstable trimalleolar fractures involving posterior ankle comminuted fracture were included in this study. The patients were divided into intraoperative dislocating ankle group (experimental group) and conventional treatment group (control group) according to surgical modalities. The following parameters including rate of primary healing, healing time, incidence of talus necrosis, incidence of post-traumatic arthritis, functional outcomes according to Baird-Jackson classification system, and any possible complications in two groups were recorded and compared. Results There were no significant differences regarding the rate of primary healing, healing time and the rate of talus necrosis in two groups (P > 0.05). The incidence of post-traumatic arthritis in experimental and control group were 0 and 24.24% (P = 0.0006), respectively. The rate of excellent and good outcomes were achieved in 91.67% in experimental group and 72.73% in control group (P = 0.038), respectively. Conclusions The findings suggest that the intraoperative ankle dislocation approach appears to be a promising surgical option for unstable trimalleolar fractures involving posterior ankle comminuted fracture because it can provide better functional outcomes and lower incidence of post-traumatic arthritis while not compromising primary healing and healing time.
Collapse
Affiliation(s)
- Wenzhao Xing
- Department of Orthopaedics, the Third Hospital of Hebei Medical University, No.139, Ziqiang Road, Shijiazhuang, 050000, People's Republic of China
| | - Peng Xie
- Department of Nuclear Medicine, the Third Hospital of Hebei Medical University, Shijiazhuang, 050000, China
| | - Linjie Wang
- Department of Orthopaedics, Affiliated Hospital of Hebei University, Baoding, 071000, People's Republic of China
| | - Changcheng Liu
- Department of Orthopaedics, the Third Hospital of Hebei Medical University, No.139, Ziqiang Road, Shijiazhuang, 050000, People's Republic of China
| | - Jian Cui
- Department of Orthopaedics, the Third Hospital of Hebei Medical University, No.139, Ziqiang Road, Shijiazhuang, 050000, People's Republic of China
| | - Zhiguo Zhang
- Department of Orthopaedics, the Third Hospital of Hebei Medical University, No.139, Ziqiang Road, Shijiazhuang, 050000, People's Republic of China
| | - Liang Sun
- Department of Orthopaedics, the Third Hospital of Hebei Medical University, No.139, Ziqiang Road, Shijiazhuang, 050000, People's Republic of China.
| |
Collapse
|
21
|
Tosun B, Selek O, Gok U, Ceylan H. Posterior Malleolus Fractures in Trimalleolar Ankle Fractures: Malleolus versus Transyndesmal Fixation. Indian J Orthop 2018; 52:309-314. [PMID: 29887634 PMCID: PMC5961269 DOI: 10.4103/ortho.ijortho_308_16] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND In ankle fractures involving the posterior malleolus, the issue of which types of fractures require posterior malleolus fixation is still controversial. Recent studies have demonstrated that trimalleolar fractures adversely affect the functional outcomes in comparison to bimalleolar fractures of the lateral and medial malleolus. The purpose of this study was to assess the effects of posterior malleolus fixation on the functional and radiological outcomes. MATERIALS AND METHODS Reduction quality, development of posttraumatic ankle osteoarthritis, and functional outcomes in 49 consecutive trimalleolar ankle fractures were evaluated retrospectively in patients with and without posterior malleolus fixation. Group I consisted of 29 patients, in which posterior malleolar fracture was left untreated. Twenty patients in Group II, posterior malleolar fragment was fixed directly by screws alone or plate screw. Twenty-one of these 49 patients were male (43%). The mean age was 47 years (range 20-82 years). RESULTS The mean followup was 12 to 51 months with a mean of 15 months (range 12-51 months). Statistically significant differences were found between Group I and Group II in terms of ankle arthrosis. American Orthopaedic Foot and Ankle Society score was significantly lower in Group I compared to Groups II. CONCLUSIONS These results demonstrate that posterior malleolar fracture fixation is closely related to successful radiological and functional outcomes after trimalleolar fractures. Transyndesmal screw fixation may not be needed in the cases where the posterior malleolar fracture fixated. For these reasons, we recommend that all posterior malleolar fractures have to be fixed regardless of size.
Collapse
Affiliation(s)
- Bilgehan Tosun
- Department of Orthopaedics and Traumatology, School of Medicine, Kocaeli University, Izmit, Turkey,Address for correspondence: Dr. Bilgehan Tosun, Department of Orthopaedics and Traumatology, School of Medicine, Kocaeli University, Uctepeler Mevkii Umuttepe Kampusu, 41380 Izmit, Turkey. E-mail:
| | - Ozgur Selek
- Department of Orthopaedics and Traumatology, School of Medicine, Kocaeli University, Izmit, Turkey
| | - Umit Gok
- Department of Orthopaedics and Traumatology, Izmit Seka State Hospital, Izmit, Turkey
| | - Halil Ceylan
- Department of Orthopaedics and Traumatology, Akademi Hospital, Izmit, Turkey
| |
Collapse
|
22
|
Donohoe S, Alluri RK, Hill JR, Fleming M, Tan E, Marecek G. Impact of Computed Tomography on Operative Planning for Ankle Fractures Involving the Posterior Malleolus. Foot Ankle Int 2017; 38:1337-1342. [PMID: 28954524 DOI: 10.1177/1071100717731568] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [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 (1) Determine the effect of computed tomography (CT) on identification of fractures involving the posterior malleolus, (2) determine its effect on operative indications, and (3) determine its effect on the overall operative plan. METHODS Patients with ankle fractures involving the posterior malleolus were identified. Only injuries with complete preoperative plain radiographs and a CT scan were included. Spiral tibia fractures and pilon variants were excluded. The plain radiographs were deidentified, randomized, and presented to 3 orthopedic surgeons. They were asked 3 questions: (1) Is this fracture simple or complex? (2) Does the injury require direct visualization and reduction? and (3) How would you position the patient and approach the fracture? The same process was repeated for the CT scans. A total of 376 posterior malleolus injuries were identified and 25 met the inclusion criteria. RESULTS A complex fracture pattern was identified on 44% of plain radiographs and 56% of CT scans. The surgeons chose to operate in 84% of cases based on plain radiographs and 92% of cases based on CT scan. The observers changed their operative approach or positioning 44% of the time after reviewing CT images. The interobserver and intraobserver correlation coefficients were moderate. CONCLUSION The use of CT scan changed operative positioning and approach in 44% of cases. There was no significant change in characterization or operative indications when comparing plain radiographs to CT scan. CT scan may be a valuable tool in the management of ankle fractures involving the posterior malleolus. LEVEL OF EVIDENCE Diagnostic Level III, comparative series.
Collapse
Affiliation(s)
- Steven Donohoe
- 1 Department of Orthopaedic Surgery, Keck Medical Center of University of Southern California, 1520 San Pablo Street, Suite 2000, Los Angeles, CA, USA
| | - R Kiran Alluri
- 1 Department of Orthopaedic Surgery, Keck Medical Center of University of Southern California, 1520 San Pablo Street, Suite 2000, Los Angeles, CA, USA
| | - J Ryan Hill
- 1 Department of Orthopaedic Surgery, Keck Medical Center of University of Southern California, 1520 San Pablo Street, Suite 2000, Los Angeles, CA, USA
| | - Mark Fleming
- 2 Navy Trauma Training Center, Los Angeles County + USC Medical Center, Los Angeles, CA, USA
| | - Eric Tan
- 1 Department of Orthopaedic Surgery, Keck Medical Center of University of Southern California, 1520 San Pablo Street, Suite 2000, Los Angeles, CA, USA
| | - Geoffrey Marecek
- 1 Department of Orthopaedic Surgery, Keck Medical Center of University of Southern California, 1520 San Pablo Street, Suite 2000, Los Angeles, CA, USA
| |
Collapse
|
23
|
Bali N, Aktselis I, Ramasamy A, Mitchell S, Fenton P. An evolution in the management of fractures of the ankle. Bone Joint J 2017; 99-B:1496-1501. [DOI: 10.1302/0301-620x.99b11.bjj-2017-0558.r1] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 07/03/2017] [Indexed: 11/05/2022]
Abstract
Aims There has been an evolution recently in the management of unstable fractures of the ankle with a trend towards direct fixation of a posterior malleolar fragment. Within these fractures, Haraguchi type 2 fractures extend medially and often cannot be fixed using a standard posterolateral approach. Our aim was to describe the posteromedial approach to address these fractures and to assess its efficacy and safety. Patients and Methods We performed a review of 15 patients with a Haraguchi type 2 posterior malleolar fracture which was fixed using a posteromedial approach. Five patients underwent initial temporary spanning external fixation. The outcome was assessed at a median follow-up of 29 months (interquartile range (IQR) 17 to 36) using the Olerud and Molander score and radiographs were assessed for the quality of the reduction. Results The median Olerud and Molander score was 72 (IQR 70 to 75), representing a good functional outcome. The reduction was anatomical in ten, with a median step of 1.2 mm (IQR 0.9 to 1.85) in the remaining five patients. One patient had parasthaesiae affecting the medial forefoot, which resolved within three months. Conclusion We found that the posteromedial approach to the ankle for the surgical treatment of Haraguchi type 2 posterior malleolar fractures is a safe technique that enables good visualisation and reduction of the individual fracture fragments with promising early outcomes. Cite this article: Bone Joint J 2017;99-B:1496–1501.
Collapse
Affiliation(s)
- N. Bali
- Royal Devon & Exeter Hospital, Barrack Road, Exeter EX2 5DW, UK
| | - I. Aktselis
- Bristol Royal Infirmary, Marlborough
Street, Bristol BS1 3NU, UK
| | - A. Ramasamy
- The Royal British Legion Centre for Blast
Injury Studies, Imperial College London, SW7
2BW, UK
| | - S. Mitchell
- Bristol Royal Infirmary, Marlborough
Street, Bristol BS1 3NU, UK
| | - P. Fenton
- Queen Elizabeth Hospital, Mindelsohn
Way, Birmingham B15 2TH, UK
| |
Collapse
|
24
|
Zhong S, Shen L, Zhao JG, Chen J, Xie JF, Shi Q, Wu YH, Zeng XT. Comparison of Posteromedial Versus Posterolateral Approach for Posterior Malleolus Fixation in Trimalleolar Ankle Fractures. Orthop Surg 2017; 9:69-76. [PMID: 28371502 DOI: 10.1111/os.12308] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Accepted: 06/05/2016] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVE To compare clinical and radiographic outcomes of posterior malleolar fractures (PMF) treated with lag screws from anterior to posterior versus posterior to anterior approach. METHODS We retrospectively analyzed 48 patients with trimalleolar fractures who underwent open reduction and internal fixation (ORIF) with either posteromedial (PM) or posterolateral (PL) approaches between January 2012 and December 2014. Fixation of the posterior malleolus was made with anteroposterior screws in 20 patients using the PM approach and posteroanterior screws in 28 patients using the PL approach. The American Orthopedic Foot and Ankle Society (AOFAS) scores and range of motion (ROM) of the ankle were used as the main outcome measurements, and results were evaluated at the 6-month, 12-month and final follow-up. Postoperative radiographs and computed tomography scans were used to evaluate the residual gap/step-off. The degree of arthritis was evaluated on final follow-up using Bargon criteria. Other complications were also recorded to compare the clinical outcomes of the two approaches. RESULT The mean duration of follow-up regardless of the approaches was 21.1 months (range, 15-54 months). None of the patients developed delayed union or nonunion. Functional bone healing was obtained in all patients at 10.7 weeks (range, 8-16 weeks). The mean AOFAS scores of the PM group at the postoperative 6-mouth, 12-month, and final follow-up were 91.4 (range, 82-100), 92.5 (range, 84-100), and 92.9 (range, 86-100), respectively. In the PL group, the mean AOFAS scores were 89.9 (range, 72-100), 91.4 (range, 77-100), and 91.9 (range, 77-100), respectively. At the final follow-up, the median loss of range of motion (ROM) for dorsiflexion and plantaflexion were 0°(0°, 5°) and 0°(0°, 0°), respectively, in both groups. There were no significant differences between the two approaches in AOFAS scores and ROM of the ankle in each period postoperatively (P > 0.05). Two patients in the PL group and 1 in the PM group developed Bargon grade 2 or 3 arthritis. We detected a 2-mm and 3-mm step-off in 1 patient in the PM and PL groups, respectively. CONCLUSION Satisfactory results were obtained by using the two approaches for fixation of posterior malleolus, and the approaches have similar clinical and radiographic outcomes. Surgeons should choose the appropriate approach based on their experience.
Collapse
Affiliation(s)
- Sheng Zhong
- Graduate School, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Lin Shen
- Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, China
| | - Jia-Guo Zhao
- Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, China
| | - Jie Chen
- Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, China
| | - Jin-Feng Xie
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Qi Shi
- Spine Institute, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Ying-Hua Wu
- Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, China
| | - Xian-Tie Zeng
- Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, China
| |
Collapse
|
25
|
Sukur E, Akman YE, Gokcen HB, Ozyurek EC, Senel A, Ozturkmen Y. Open reduction in pilon variant posterior malleolar fractures: Radiological and clinical evaluation. Orthop Traumatol Surg Res 2017; 103:703-707. [PMID: 28606840 DOI: 10.1016/j.otsr.2017.05.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 12/23/2016] [Accepted: 05/22/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Pilon variant posterior malleolar (PVPM) fractures significantly disrupt joint congruency and cause tibiotalar instability. They are often underestimated and inadequately treated. PURPOSE This study assessed the outcomes of surgical treatment of this subtype of malleolar fracture, and examined the importance of computed tomography (CT) in diagnosis and surgical treatment. MATERIAL AND METHODS CT images and radiographs of 67 patients with trimalleolar ankle fractures were retrospectively analyzed. Fourteen patients (6 women and 8 men) were studied. The mean age was 37.7 (range, 21-58) years, and mean follow-up period was 17.1 (range, 12-24) months. All patients underwent open reduction. Reconstruction of the joint surface was assessed with postoperative CT images. The outcomes were assessed with the American Academy of Orthopaedic Surgeons (AAOS) and Osteoarthritis (OA) scoring systems. RESULTS The ratio of PVPM fractures to trimalleolar ankle fractures was 20.1%. Postoperative CT images demonstrated that anatomic reconstruction was achieved in 11 patients. The mean AAOS scores were 85.6 in Type 1 and 81.1 in Type 2 cases. The mean OA scores were 1 in Type 1 and 1.1 in Type 2 cases (P>0.05). The only statistically significant difference between the 2 groups was in osteochondral impaction (P<0.05). CONCLUSION CT imaging is essential for the accurate diagnosis and management of PVPM fractures. Posteromedial and posterolateral incisions enable direct exposure, and therefore facilitate joint surface reconstruction. LEVEL OF EVIDENCE Level IV. Retrospective study.
Collapse
Affiliation(s)
- E Sukur
- Sakarya Education and Research Hospital, Department of Orthopedics and Traumatology, 54100 Sakarya, Turkey.
| | - Y E Akman
- M.S. Baltalimani Bone Diseases Training and Research Hospital, Department of Orthopedics and Traumatology, 34470 Istanbul, Turkey
| | - H B Gokcen
- Department of Orthopaedics and Traumotology, Liv Hospital, 34100 Istanbul, Turkey
| | - E C Ozyurek
- Istanbul Research Hospital, Department of Orthopedics and Traumatology, 34050 Istanbul, Turkey
| | - A Senel
- Istanbul Research Hospital, Department of Orthopedics and Traumatology, 34050 Istanbul, Turkey
| | - Y Ozturkmen
- Istanbul Research Hospital, Department of Orthopedics and Traumatology, 34050 Istanbul, Turkey
| |
Collapse
|
26
|
Duan X, Kadakia AR. Operative Treatment of Posterior Malleolar Fractures. Open Orthop J 2017; 11:732-742. [PMID: 28979587 PMCID: PMC5620409 DOI: 10.2174/1874325001711010732] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 07/16/2016] [Accepted: 07/23/2016] [Indexed: 12/11/2022] Open
Abstract
Fractures of the posterior malleolus can occur in conjunction with fibular and medial malleolar fractures or in isolation. The indications for fixation of the posterior malleolus remain controversial except for the fragment sizes. A number of different surgical approaches and techniques for internal fixation of posterior malleolar fractures have been reported. Newer techniques such as direct exposure and plating of the posterior malleolus are chosen more frequently than traditional techniques of indirect reduction and percutaneous screw fixation. These attributes help to minimize the occurrence of postoperative complications.
Collapse
Affiliation(s)
- Xiaojun Duan
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University, Chongqing, 400038, P.R, China
| | - Anish R Kadakia
- Department of Orthopedic Surgery, Northwestern University - Feinberg School of Medicine, Chicago, IL 60611, USA
| |
Collapse
|
27
|
Zhou L, Lin Y, Zhai X, Wang B, Lin J. Finite element analysis of the influence of anterior talofibular ligament injury on Hook test results. Injury 2017; 48:1499-1502. [PMID: 28410754 DOI: 10.1016/j.injury.2017.03.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 03/22/2017] [Accepted: 03/28/2017] [Indexed: 02/02/2023]
Abstract
AIM To determine whether the anterior talofibular ligament injury will influence the Hook test result. METHOD A three-dimensional model of the ankle was established based on CT scan of a healthy volunteer and ligament attachment through references; Four groups (A-D) of operating conditions were set up. In group A, the anterior and posterior ligaments of the inferior tibiofibular joint were cut off and the anterior talofibular ligament was kept intact; in group B, all the anterior and posterior tibiofibular ligaments and the anterior talofibular ligament were cut off; in group C, the medial and lateral ligaments of the ankle joint and the inferior tibiofibular ligament were kept intact; in group D, only the talofibular ligament was cut off and other ligaments were kept intact. The proximal end of the model was restrained in all four groups, an outward pulling force of 100N perpendicular to the fibula was applied, and displacement and rotation of the distal end of the fibula in the four groups was observed. RESULTS When the inferior tibiofibular joint injury was associated with an anterior talofibular ligament injury, the Hook test indicated about 3.19mm of displacement of the distal end of the fibula, and obvious external rotation occurred due to increased activity of the anterior border of the fibula. In the other groups, a single inferior tibiofibular joint injury or a single anterior talofibular ligament injury did not increase displacement or rotation of the distal end of the fibula.
Collapse
Affiliation(s)
- Lin Zhou
- Department of Orthopedic,The First Affiliated Hospital of Jinan University, China.
| | - Yongxin Lin
- Department of Orthopedic,The First Affiliated Hospital of Jinan University, China.
| | - Xu Zhai
- The First Clinical Medical College of Jinan University, China
| | - Bata Wang
- The First Clinical Medical College of Jinan University, China
| | - Jiaming Lin
- The First Clinical Medical College of Jinan University, China
| |
Collapse
|
28
|
Direct fixation of fractures of the posterior pilon via a posteromedial approach. Injury 2017; 48:1269-1274. [PMID: 28336099 DOI: 10.1016/j.injury.2017.03.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Revised: 03/01/2017] [Accepted: 03/15/2017] [Indexed: 02/02/2023]
Abstract
The treatment of fractures of the posterior pilon is a timely issue. Restoration of the integrity of the incisura fibularis and subsequent anatomic reduction of the fibula are essential for reconstruction of the ankle mortise after trauma, and syndesmotic stability. Inappropriate treatment ultimately will lead to a poor functional outcome and quality of life. Open reduction and direct internal fixation through a posterolateral or posteromedial approach are increasingly preferred over indirect reduction and anteroposterior screw fixation. The posteromedial approach, although elegant, straightforward, and offering an excellent exposure of the fracture site, is used less frequently than the posterolateral approach. In this technical note we describe the posteromedial approach for the treatment of posterior pilon fractures in a step-by-step fashion. We will discuss the indications, its benefits and limitations.
Collapse
|
29
|
Bartoníček J, Rammelt S, Tuček M. Posterior Malleolar Fractures: Changing Concepts and Recent Developments. Foot Ankle Clin 2017; 22:125-145. [PMID: 28167058 DOI: 10.1016/j.fcl.2016.09.009] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Injuries to the posterior malleolus are of prognostic relevance in ankle fracture-dislocations. The three-dimensional outline of the fragments as reflected by computed tomography classification, involvement of the fibular notch, and the presence of intercalary fragments seem to be of greater therapeutic relevance than the size of the fragment and amount of the articular surface involved. Operative treatment aims at reconstruction of the posterior tibial plafond, the fibular notch, and the integrity of the posterior inferior tibiofibular syndesmosis. Direct open reduction and fixation of posterior malleolus fragments via posterior approaches is biomechanically more stable than indirect reduction and anteroposterior screw fixation.
Collapse
Affiliation(s)
- Jan Bartoníček
- Department of Orthopaedics, First Faculty of Medicine, Central Military Hospital Prague, Charles University, U Vojenské Nemocnice 1200, Prague 6 169 02, Czech Republic; Department of Anatomy, First Faculty of Medicine, Charles University Prague, U Nemocnice 3, Prague 2 120 00, Czech Republic.
| | - Stefan Rammelt
- University Center of Orthopaedics and Traumatology, University Hospital Carl Gustav Carus Dresden, Fetscherstrasse 74, Dresden 01307, Germany
| | - Michal Tuček
- Department of Orthopaedics, First Faculty of Medicine, Central Military Hospital Prague, Charles University, U Vojenské Nemocnice 1200, Prague 6 169 02, Czech Republic
| |
Collapse
|
30
|
Abstract
Posterior malleolus fractures vary in morphology. A computed tomography scan is imperative to evaluate fragment size, comminution, articular impaction, and syndesmotic disruption. Despite an increasing body of literature regarding posterior malleolus fractures, many questions remain unanswered. Although, historically, fragment size guided surgical fixation, it is becoming evident that fragment size should not solely dictate treatment. Surgical treatment should focus on restoring ankle joint structural integrity, which includes restoring articular congruity, correcting posterior talar translation, addressing articular impaction, removing osteochondral debris, and establishing syndesmotic stability.
Collapse
Affiliation(s)
- Shay Tenenbaum
- Department of Orthopedic Surgery, Chaim Sheba Medical Center Hospital at Tel Hashomer, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, 1 Emek HaEla St, Ramat Gan 52621, Israel.
| | - Nachshon Shazar
- Department of Orthopedic Surgery, Chaim Sheba Medical Center Hospital at Tel Hashomer, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, 1 Emek HaEla St, Ramat Gan 52621, Israel
| | - Nathan Bruck
- Department of Orthopedic Surgery, Chaim Sheba Medical Center Hospital at Tel Hashomer, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, 1 Emek HaEla St, Ramat Gan 52621, Israel
| | - Jason Bariteau
- Department of Orthopaedics, Emory University School of Medicine, 59 Executive Park South, Suite 2000, Atlanta, GA 30306, USA
| |
Collapse
|
31
|
Bartoníček J, Rammelt S, Tuček M, Naňka O. Posterior malleolar fractures of the ankle. Eur J Trauma Emerg Surg 2015; 41:587-600. [DOI: 10.1007/s00068-015-0560-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 07/31/2015] [Indexed: 12/18/2022]
|
32
|
The risk of injury to the peroneal artery in the posterolateral approach to the distal tibia: a cadaver study. J Orthop Trauma 2014; 28:534-7. [PMID: 24662988 DOI: 10.1097/bot.0000000000000089] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The posterolateral approach to the distal tibia allows excellent visualization, direct reduction, and stabilization of posterior malleolar fractures. Concomitant fractures of the lateral malleolus may be internally fixed through the same approach. The approach may also be used for pilon fractures and for bone grafting in nonunions. This study aims to establish the safe zone of proximal dissection to avoid injury to the peroneal vessels when performing the posterolateral approach to the distal tibia. METHODS Twenty-six unpaired adult lower limbs were dissected using the posterolateral approach to the distal tibia. The peroneal artery was identified, as it coursed through the interosseous membrane on deep dissection and the level of its bifurcation was noted over the tibia. Perpendicular measurements were made from these points to the tibial plafond and distal fibula. RESULTS The peroneal artery bifurcated at 83 ± 21 mm (range, 41-115 mm) proximal to the tibial plafond and 103 ± 21 mm (range, 61-136 mm) from the distal fibula. The peroneal artery perforated through the interosseous membrane 64 ± 18 mm (range, 41-96 mm) proximal to the tibial plafond and 81 ± 20 mm (range, 42-113 mm) from the distal fibula. CONCLUSIONS The posterolateral approach to the distal tibia allows direct reduction of posterior malleolus fractures. The peroneal artery may bifurcate and perforate through the interosseous membrane as little as 41 mm from the tibial plafond. Dissection around this region should be performed with care due to the wide variation in vasculature, however, once the peroneal artery is mobilized, a buttress plate can easily be placed beneath it.
Collapse
|
33
|
Chen DW, Li B, Aubeeluck A, Yang YF, Zhou JQ, Yu GR. Open reduction and internal fixation of posterior pilon fractures with buttress plate. ACTA ORTOPEDICA BRASILEIRA 2014; 22:48-53. [PMID: 24644421 PMCID: PMC3952872 DOI: 10.1590/s1413-78522014000100009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Accepted: 07/23/2013] [Indexed: 11/23/2022]
Abstract
Objective: Posterior pilon fractures are rare injuries and have not yet gained well recognition. The purpose of this study was to present the treatment outcome for patients with posterior pilon fractures treated with buttress plate. Method: In this retrospective study we identified patients with posterior pilon fractures of the distal tibia who had undergone open reduction and internal fixation at our institute. Between January 2007 and December 2009, 10 patients (mean age, 46.5 years) who had undergone buttress plating via either a posterolateral approach or a dual posterolateral-posteromedial approach, were selected. All 10 patients were available for follow-up. The clinical outcome was evaluated with the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and the visual analogue scale (VAS). The radiological evaluation was performed using the osteoarthritis-score (OA-score). Results: Satisfactory reduction and stable fixation were accomplished in all patients. At a mean follow-up of 36.2 months, all patients had good radiological results and showed satisfactory clinical recovery. The mean AOFAS sore was 87.8, the mean OA-score was 0.6, and the mean VAS scores during rest, active motion, and weight-bearing walking were 0.6, 0.8, and 1.4, respectively. Conclusion: Buttress plating for posterior pilon fractures gave satisfactory clinical outcomes. It also ensured rigid fixation which in turn enabled earlier postoperative mobilization. Level of Evidence IV, Retrospective Study.
Collapse
|
34
|
Morphologic characteristics of the posterior malleolus fragment: a 3-D computer tomography based study. Arch Orthop Trauma Surg 2014; 134:389-94. [PMID: 24366552 DOI: 10.1007/s00402-013-1844-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Indexed: 02/09/2023]
Abstract
OBJECTIVES The objective of this study was to evaluate the morphological characteristics of the posterior malleolus fragment (PMF) based on 3-D computed tomography scans, and evaluated the variability in different types of injuries (ankle fracture, spiral tibial shaft fracture and pilon fracture). METHODS A retrospective analysis of 3-D computed tomography data of PMF from June 2011 to February 2012 was conducted in a level 1 trauma centre. The cross angle (α), fragment length ratio (FLR), fragment area ratio (FAR), sagittal angle (θ), and fragment height (FH) were measured as morphologic assessments in the Picture Archiving and Communication System (PACS). RESULTS Based on the definition of the PMF, 144 cases were brought into this study. And the PMF was described with a mean α of 25.0°, a mean FAR of 17.66 %, a mean θ of 16.1° and a mean FH of 23.06 mm. Besides, this study showed a significant difference on FAR amongst the three injuries with the FAR was 30.31 % (P < 0.05) in pilon fracture group. Respectively, although the mean θ (16.1°) indicated a vertical fracture pattern, yet no significant difference was shown amongst the three groups. CONCLUSIONS Although the PMFs appear to be highly variable, most of the PMFs were located on the posterolateral of the distal tibia, and showed features with vertical nature. The information obtained from this study will be helpful for fracture models in a future biomechanical study and for determining appropriate surgical approaches.
Collapse
|
35
|
Rammelt S, Zwipp H, Mittlmeier T. [Operative treatment of pronation fracture--dislocations of the ankle]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2013; 25:273-91; quiz 291-3. [PMID: 23756596 DOI: 10.1007/s00064-013-0235-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Early reduction of the dislocation and anatomic reconstruction of axial alignment, ankle mortise and articular congruity with special focus on syndesmotic stability. INDICATIONS Fracture-dislocations resulting from pronation injuries to the ankle with a highly incongruent and unstable mortise and either considerable internal pressure on the soft tissues by the displaced fragments or open soft tissue damage. CONTRAINDICATIONS General contraindications to surgery: closed reduction and cast immobilization or external fixation. SURGICAL TECHNIQUE Early preoperative closed reduction of complete dislocations is achieved through longitudinal traction and movements contrary to the original fracture mechanism. A cast or joint-spanning external fixator is applied temporarily. Ideally, definite anatomic reduction of the posterior tibial fragment, the distal fibula and medial malleolus and stable internal fixation is achieved within the first hours after the injury. Congruity of the ankle mortise and syndesmotic stability is controlled intraoperatively and a syndesmotic screw is inserted if necessary. In these cases, the correct positioning of the distal fibula within the tibial incisura is verified with three-dimensional fluoroscopy or postoperative computed tomography scanning. POSTOPERATIVE MANAGEMENT Early range of motion exercises of the ankle and subtalar joints are initiated the second postoperative day or after soft tissue consolidation and removal of the external fixation. Patients are mobilized with partial weight bearing (20 kg) in a cast or special boot for 6 weeks postoperatively. The syndesmotic screw is then removed in most cases and weight-bearing is rapidly increased. RESULTS The presence of a dislocation at the time of injury represents a negative prognostic factor in malleolar fractures. Higher rates of posttraumatic arthritis are also observed with trimalleolar fracures, especially fractures of the posterior tibial rim, cartilage damage, and syndesmotic disruption. Irrespective of the fracture classsification, good to excellent results can be obtained in 75-89% of cases with anatomic reconstruction of the ankle mortise and the articular surfaces. Proper reduction of the distal fibula into the tibial incisura is of utmost importance in cases of frank syndesmotic diastasis.
Collapse
Affiliation(s)
- S Rammelt
- Klinik und Poliklinik für Unfall- und Wiederherstellungsschirurgie, Universitätsklinikum Carl Gustav Carus der TU Dresden, Fetscherstr. 74, 01307 Dresden, Germany.
| | | | | |
Collapse
|
36
|
Klammer G, Kadakia AR, Joos DA, Seybold JD, Espinosa N. Posterior pilon fractures: a retrospective case series and proposed classification system. Foot Ankle Int 2013; 34:189-99. [PMID: 23413057 DOI: 10.1177/1071100712469334] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Posterior malleolus fractures occur in 7% to 44% of ankle fractures and are associated with worse clinical outcomes. Fractures that involve the posteromedial plafond extending to the medial malleolus have been described previously in small case series. Failure to identify this fracture pattern has led to poor clinical outcomes and persistent talar subluxation. The purpose of this study was to report our outcomes following fixation of this posterior pilon fracture and to describe a novel classification system to help guide operative planning and fixation. METHODS Eleven patients were identified following fixation of a posterior pilon fracture over a 4-year span; 7 returned at minimum 1-year follow-up to complete a physical examination, radiographs, and RAND-36 (health-related quality of life score developed at RAND [Research and Development Corporation] as part of the Medical Outcomes Study) and American Orthopaedic Foot & Ankle Society (AOFAS) ankle/hindfoot questionnaires. Patient records were reviewed to evaluate for secondary complications or operative procedures. RESULTS Our mean postoperative AOFAS ankle/hindfoot score was 82. Anatomical reduction of the plafond was noted radiographically in 7 of 11 patients, with the remainder demonstrating less than 2 mm of articular incongruity. Five of 7 patients demonstrated ankle and hindfoot range of motion within 5 degrees of the uninvolved extremity. Four complications required operative intervention; 2 patients reported continued pain secondary to development of CRPS. CONCLUSION The posterior pilon fracture is a challenging fracture pattern to treat, and it has unique characteristics that require careful attention to operative technique. Our results following fixation of this fracture pattern are comparable with results in the literature. In addition, a novel classification scheme is described to guide recognition and treatment of this fracture pattern. LEVEL OF EVIDENCE Level IV, retrospective case series.
Collapse
Affiliation(s)
- Georg Klammer
- Balgrist Hospital, University of Zurich, Zurich, Switzerland
| | | | | | | | | |
Collapse
|
37
|
Bugler KE, Watson CD, Hardie AR, Appleton P, McQueen MM, Court-Brown CM, White TO. The treatment of unstable fractures of the ankle using the Acumed fibular nail: development of a technique. ACTA ACUST UNITED AC 2012; 94:1107-12. [PMID: 22844054 DOI: 10.1302/0301-620x.94b8.28620] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Techniques for fixation of fractures of the lateral malleolus have remained essentially unchanged since the 1960s, but are associated with complication rates of up to 30%. The fibular nail is an alternative method of fixation requiring a minimal incision and tissue dissection, and has the potential to reduce the incidence of complications. We reviewed the results of 105 patients with unstable fractures of the ankle that were fixed between 2002 and 2010 using the Acumed fibular nail. The mean age of the patients was 64.8 years (22 to 95), and 80 (76%) had significant systemic medical comorbidities. Various different configurations of locking screw were assessed over the study period as experience was gained with the device. Nailing without the use of locking screws gave satisfactory stability in only 66% of cases (4 of 6). Initial locking screw constructs rendered between 91% (10 of 11) and 96% (23 of 24) of ankles stable. Overall, seven patients had loss of fixation of the fracture and there were five post-operative wound infections related to the distal fibula. This lead to the development of the current technique with a screw across the syndesmosis in addition to a distal locking screw. In 21 patients treated with this technique there have been no significant complications and only one superficial wound infection. Good fracture reduction was achieved in all of these patients. The mean physical component Short-Form 12, Olerud and Molander score, and American Academy of Orthopaedic Surgeons Foot and Ankle outcome scores at a mean of six years post-injury were 46 (28 to 61), 65 (35 to 100) and 83 (52 to 99), respectively. There have been no cases of fibular nonunion. Nailing of the fibula using our current technique gives good radiological and functional outcomes with minimal complications, and should be considered in the management of patients with an unstable ankle fracture.
Collapse
Affiliation(s)
- K E Bugler
- Royal Infirmary of Edinburgh, Orthopaedic Trauma Unit, Little France, Edinburgh EH16 4SA, UK.
| | | | | | | | | | | | | |
Collapse
|
38
|
Patzkowski JC, Kirk KL, Orr JD, Waterman BR, Kirby JM, Hsu JR. Quantification of posterior ankle exposure through an achilles tendon-splitting versus posterolateral approach. Foot Ankle Int 2012; 33:900-4. [PMID: 23050716 DOI: 10.3113/fai.2012.0900] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The optimal surgical exposure to the posterior ankle for trauma and reconstruction is a source of debate. We hypothesized that the Achilles tendon-splitting approach would provide greater exposure to the posterior ankle than the posterolateral approach. METHODS Forty surgical approaches were performed from twenty fresh-frozen cadavers. Achilles tendon-splitting and posterolateral approaches were performed using a randomized crossover design for surgical sequence. Six landmarks (medial malleolus, ankle joint, subtalar joint, incisura fibularis, lateral malleolus and medial gutter) were identified by direct visualization or palpation. A calibrated digital photograph was taken and Image J (http://rsb.info.nih.gov/ij/) was used to calculate the surface area of the distal tibia and talus exposed in neutral and dorsiflexion. RESULTS Using a posterolateral approach, the average distal tibia exposed was 11.3cm(2) in neutral and 10.2 cm(2) in dorsiflexion. The average talus exposed was 2.0 cm(2) in neutral and 2.4 cm(2) in dorsiflexion. Using an Achilles tendon-splitting approach, the average exposed distal tibia was 33% more (15.0 cm(2)) in neutral and 43% more (14.6 cm(2)) in dorsiflexion. The average talus exposed was 47% more (3.0 cm(2)) in neutral and 76% more (4.2 cm(2)) in dorsiflexion. All increases in exposure were statistically significant. The medial malleolus was visualized in 19 tendon-splitting and six posterolateral approaches. The medial gutter was visualized in 20 tendon-splitting and 13 posterolateral approaches. These differences were statistically significant. All other landmarks could be visualized through both approaches. CONCLUSION The Achilles tendon-splitting approach provided significantly greater exposure of the posterior distal tibia and talus compared to the posterolateral approach. CLINICAL RELEVANCE Prospective studies will help determine if the tendon-splitting approach is a safe and clinically useful approach for surgeries in which direct access to the entire posterior ankle and subtalar joint are required.
Collapse
Affiliation(s)
- Jeanne C Patzkowski
- San Antonio Military Medical Center, 3851 Roger Brooke Drive, Fort Sam Houston, TX 78234, USA.
| | | | | | | | | | | |
Collapse
|
39
|
Wang L, Shi ZM, Zhang CQ, Zeng BF. Trimalleolar fracture with involvement of the entire posterior plafond. Foot Ankle Int 2011; 32:774-81. [PMID: 22049863 DOI: 10.3113/fai.2011.0774] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND A special type of trimalleolar fracture with the involvement of the entire posterior tibial plafond has been reported recently. Because of the low incidence, the characteristics of the fracture in different studies have not been consistent. We describe our clinical experience with this fracture type. MATERIALS AND METHODS From January 2007 to December 2009, 12 patients were identified with a trimalleolar fracture with involvement of entire posterior tibial plafond. All the fractures were openly reduced and fixed through a combined operative approach (posterolateral and posteromedial). Ten of 12 patients were followed up. The clinical outcome was assessed with the Short Form-36 (SF-36) and standardized AAOS foot and ankle questionnaire, and the radiological evaluation with an osteoarthritis-score (OA-score). RESULTS Based on the pathoanatomy of the posteromedial malleolar fragment, all the fractures could be classified into two types. Using a combined operative approach, anatomical reduction and stable fixation was accomplished in all 12 patients. At a mean followup of 18.9 (range, 12 to 30) months, 10 patients achieved a good radiological result and satisfactory clinical recovery. CONCLUSION This fracture pattern may be classified into two types with different injury mechanisms, which has not been described previously. After anatomic reduction and stable fixation through a combined operative approach, the short-term outcome was good.
Collapse
Affiliation(s)
- Lei Wang
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital, Shanghai Jiaotong University, 600 Yi Shan Road, Shanghai 200233, China
| | | | | | | |
Collapse
|