1
|
Chong LSL, Khademi M, Reddy KM, Anderson GH. Ten year outcomes after non-fixation of the smaller posterior malleolar fragment: A retrospective cohort study. Foot (Edinb) 2024; 59:102091. [PMID: 38513374 DOI: 10.1016/j.foot.2024.102091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 02/07/2024] [Accepted: 03/10/2024] [Indexed: 03/23/2024]
Abstract
INTRODUCTION Treatment of posterior malleolar (PM) ankle fractures remains controversial. Despite increasing recommendation for small PM fragment fixation, high quality evidence demonstrating improved clinical outcomes over the unfixated PM is limited. We describe the long term clinical and radiographical outcomes in younger adult patients with PM ankle fractures managed without PM fragment fixation. MATERIAL AND METHODS A retrospective cohort study was performed on PM ankle fracture patients aged 18-55 years old admitted under our orthopaedic unit between 1st of April 2009 and 31st of October 2013. Inclusion criteria were ASA 1 and 2, independent mobility pre-trauma, no pre-existing ankle pathologies, with satisfactory bimalleolar and syndesmotic stabilisation. Open fractures, talar fractures, calcaneal fractures, pilon fractures, subsequent re-injury and major complications were excluded. All PM fragments were unfixated. Clinical outcomes were evaluated using visual analogue scale (VAS) for pain, Foot and Ankle Ability Measure (FAAM) with activities of daily living (ADL) and sports subscale for function, and patient satisfaction ratings. Osteoarthritis was assessed using modified Kellgren-Lawrence scale on follow-up weightbearing ankle radiographs. RESULTS Sixty-one participants were included. Mean follow-up was 10.26 years. Average PM size was 16.2 ± 7.39%. All participants were evaluated for clinical outcomes. Mean score of FAAM-ADL was 95.5 ± 7.13, FAAM-Sports 86.4 ± 15.5, patient satisfaction 86.2 ± 14.4% and pain score 1.13 ± 1.65. Radiographical outcomes were evaluated in 52 participants, showing no-to-minimal osteoarthritis in 36/52 (69%), mild osteoarthritis in 14/52 (27%) and moderate osteoarthritis in 2/52 (4%). Pain and functional scores were independent of PM fragment size, post-reduction step-off, dislocation, malleoli fractured or syndesmotic injury. PM step-off more than 1 mm and traumatic dislocation/subluxation were associated with worse radiographical osteoarthritis. CONCLUSION After controlling for confounders, the unfixated smaller posterior malleolus fragment at 10-year follow-up demonstrated largely satisfactory clinical outcomes with some radiographical progression of osteoarthritis. LEVEL OF EVIDENCE Level III - Retrospective cohort study.
Collapse
Affiliation(s)
- Leo Swee Liang Chong
- Department of Orthopaedic Surgery, Palmerston North Hospital, Te Whatu Ora Te Pae Hauora o Ruahine o Tararua / Midcentral, New Zealand.
| | - MohammadAli Khademi
- Department of Orthopaedic Surgery, Palmerston North Hospital, Te Whatu Ora Te Pae Hauora o Ruahine o Tararua / Midcentral, New Zealand
| | - Kundam Murali Reddy
- Department of Orthopaedic Surgery, Palmerston North Hospital, Te Whatu Ora Te Pae Hauora o Ruahine o Tararua / Midcentral, New Zealand
| | - Geoffrey Hunter Anderson
- Department of Orthopaedic Surgery, Palmerston North Hospital, Te Whatu Ora Te Pae Hauora o Ruahine o Tararua / Midcentral, New Zealand
| |
Collapse
|
2
|
Shen GD, Bai WB, Zou BL, Lai ZB, Yang KY, Zhang HN, Xu ZQ, Zhu YZ. Advancing treatment strategies for posterior malleolar malunion: The ankle dislocation method. Foot Ankle Surg 2024:S1268-7731(24)00113-9. [PMID: 38789379 DOI: 10.1016/j.fas.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 05/16/2024] [Accepted: 05/19/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND This study aimed to assess the radiological and clinical outcomes of treatment using the ankle dislocation method for posterior malleolar malunion. METHOD Thirty-one patients with posterior malleolar malunion who underwent treatment using the ankle dislocation method from May 2015 to October 2021 were retrospectively analyzed. Key outcome measures were radiographic parameters (articular step-off, tibiofibular clear space, fibular length, tibial lateral surface angle, and ankle osteoarthritis), clinical scores (American Orthopaedic Foot and Ankle Society ankle-hindfoot scale and Visual Analogue Scale), and patient satisfaction rate. RESULT Preoperative computed tomography revealed that Bartoní ček types 3 and 4 accounted for 64.5 % (n = 20) of total cases. Most posterior malleolar malunions were accompanied by depressed intercalary fragments (61.2 % [n = 19]). At the final follow-up, radiographic parameters and clinical scores showed significant improvements postoperatively (P < 0.05), with a high patient satisfaction rate of 77.4 %. Subgroup analysis revealed that the posterior malleolar fracture morphology significantly affected postoperative pain, particularly in more complex fractures (P < 0.001). CONCLUSION The ankle dislocation method effectively exposes the distal tibial articular surface and facilitates the anatomical restoration of joint congruity under direct vision. This approach substantially improves the clinical and imaging outcomes in patients with complex posterior malleolar malunion. LEVELS OF EVIDENCE Level IV, retrospective case series.
Collapse
Affiliation(s)
- Guo-Dong Shen
- Department of Foot and Ankle Orthopedics, Foshan Hospital of Traditional Chinese Medicine Affiliated to Guangzhou University of Chinese Medicine, Foshan, Guangdong Province 528000, China
| | - Wen-Bo Bai
- Department of Foot and Ankle Orthopedics, Foshan Hospital of Traditional Chinese Medicine Affiliated to Guangzhou University of Chinese Medicine, Foshan, Guangdong Province 528000, China
| | - Bao-Li Zou
- Department of Foot and Ankle Orthopedics, Foshan Hospital of Traditional Chinese Medicine Affiliated to Guangzhou University of Chinese Medicine, Foshan, Guangdong Province 528000, China
| | - Zhi-Bin Lai
- Department of Foot and Ankle Orthopedics, Foshan Hospital of Traditional Chinese Medicine Affiliated to Guangzhou University of Chinese Medicine, Foshan, Guangdong Province 528000, China
| | - Kang-Yong Yang
- Department of Foot and Ankle Orthopedics, Foshan Hospital of Traditional Chinese Medicine Affiliated to Guangzhou University of Chinese Medicine, Foshan, Guangdong Province 528000, China
| | - Hong-Ning Zhang
- Department of Foot and Ankle Orthopedics, Foshan Hospital of Traditional Chinese Medicine Affiliated to Guangzhou University of Chinese Medicine, Foshan, Guangdong Province 528000, China
| | - Zhi-Qiang Xu
- Department of Foot and Ankle Orthopedics, Foshan Hospital of Traditional Chinese Medicine Affiliated to Guangzhou University of Chinese Medicine, Foshan, Guangdong Province 528000, China; Prestigious Chinese Medicine Expert of Guangdong Province Xu Zhiqiang Inheritance Studio, Foshan, Guangdong Province 528000, China.
| | - Yong-Zhan Zhu
- Department of Foot and Ankle Orthopedics, Foshan Hospital of Traditional Chinese Medicine Affiliated to Guangzhou University of Chinese Medicine, Foshan, Guangdong Province 528000, China.
| |
Collapse
|
3
|
Sobrón FB, Hernández-Mateo JM, Fernández T, Alonso MB, Parra G, Vaquero J. Locking versus nonlocking plates for the treatment of posterior malleolar ankle fractures: A retrospective cohort study and cost analysis. Foot (Edinb) 2023; 56:102033. [PMID: 37187081 DOI: 10.1016/j.foot.2023.102033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 05/01/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND We hypothesized that, as posterior malleolar ankle fractures usually present one or two main fragments, the buttress plating principle can be successfully achieved either with conventional nonlocking or anatomic locking posterior tibia plates, and no clinical differences should be found. The aim of this study was to evaluate the outcomes of posterior malleolar ankle (PM) fractures treated with conventional nonlocking (CNP) or anatomic locking plates (ALP), and also to compare both constructs in terms of crude costs. METHODS A retrospective cohort study was designed. CNP was used in 22 patients and ALP was used in 11 patients. American Orthopedic Foot and Ankle Society (AOFAS) score was registered at four weeks, 3-6 months, 12 and 24 months to assess all patients' functional status. The primary outcome was ankle and hindfoot AOFAS score at 12 months follow-up visit. All complications, radiographic evaluation and implant construct costs were also registered and compared. The average follow-up was 25.4 (range, 12-42) months. RESULTS No significant difference was observed between both cohorts, in terms of AOFAS score and complication rate (P > .05). We found that ALP construct is 17 times more expensive than CNP construct in our institution (P < .001). CONCLUSION Anatomic locking posterior tibial plates may be an interesting device when poor bone quality is present or when a true multifragmentary pilon fracture is faced. Anatomic locking posterior tibia plate should not become a regular implant for any PM fracture since equivalent clinical and radiological results were obtained in our study using CNP with a significant reduced cost.
Collapse
Affiliation(s)
- Francisco Borja Sobrón
- Hospital General Universitario Gregorio Marañón, Calle del Dr. Esquerdo, 46, 28007 Madrid, Spain.
| | | | - Tanya Fernández
- Hospital General Universitario Gregorio Marañón, Calle del Dr. Esquerdo, 46, 28007 Madrid, Spain
| | - María Berta Alonso
- Hospital Universitario La Princesa, Calle Diego de León 62, 28006 Madrid, Spain
| | - Guillermo Parra
- Hospital General Universitario Gregorio Marañón, Calle del Dr. Esquerdo, 46, 28007 Madrid, Spain
| | - Javier Vaquero
- Hospital General Universitario Gregorio Marañón, Calle del Dr. Esquerdo, 46, 28007 Madrid, Spain
| |
Collapse
|
4
|
Yang L, Yin G, Zhu J, Liu H, Zhao X, Xue L, Yin F, Liu J, Liu Z. Posterolateral approach for posterior malleolus fixation in ankle fractures: functional and radiological outcome based on Bartonicek classification. Arch Orthop Trauma Surg 2023; 143:4099-4109. [PMID: 36183274 PMCID: PMC10293422 DOI: 10.1007/s00402-022-04620-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 09/06/2022] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Posterolateral approach has been advocated for the treatment of ankle fractures involving the posterior malleolus and satisfactory results were demonstrated in several studies. The Bartonicek classification based on 3-dimensional CT scanning was commonly used for treatment recommendation of posterior malleolar fracture (PMF). The aim of this retrospective study was to evaluate the clinical effect of the posterolateral approach for the treatment of PMF and present outcomes of patients with different types of Bartonicek classification. METHOD We retrospectively reviewed the clinical outcomes of 72 patients with ankle fractures involving posterior malleolus (PM) from January 2016 to December 2018. Posterior malleolus fractures (PMFs) were all directly reduced and fixed by a posterolateral approach using lag screws and/or buttress plates. AOFAS score and VAS pain score were used as the primary functional outcome measures. The radiographic evaluation included the quality of the reduction and Kellgren-Lawrence (KL) osteoarthritis classification. According to the CT-based Bartonicek classification, all patients were classified into three groups: 42 type II, 18 type III and 12 type IV. Bartonicek type II patients were further divided into subtype IIa 19 cases, subtype IIb 16 cases and subtype IIc 7 cases. The radiological and functional outcomes were analyzed among different types and subtypes of Bartonicek classification. RESULTS Sixty-eight patients (94.5%) achieved good or excellent reduction of PMF after surgery. The mean AOFAS score was 81.35 ± 6.15 at 6 months and 90.56 ± 4.98 at the final follow-up, respectively. The VAS score was 6.62 ± 1.03 one week after surgery, and 1.20 ± 0.92 at the final follow-up. Radiological evaluation at the final follow-up showed that primary bone union was achieved in all patients and 65 patients (88.9%) got no (KL grade 0) or just doubtable (KL grade 1) post-traumatic osteoarthritis. AOFAS scores decreased significantly with the severity of Bartonicek classification at 6 month (p < 0.001) and final follow-up (p < 0.05), while there was no statistical difference of VAS pain score among different types of Bartonicek classification. Reduction quality and the presence of osteoarthritis was not correlated to Bartonicek classification either. Besides, AOFAS scores at the final follow-up were statistically different among three subtypes of Bartonicek type II fractures (p < 0.05), and Bartonicek subtype IIa fractures had the highest AOFAS scores as 93 ± 4.99. Presence and severity of osteoarthritis was lower in patients with subtype IIa PMF compared to other subtype groups, this finding was statistically significant (p < 0.05). CONCLUSION The posterolateral approach could achieve good clinical outcomes in the treatment of posterior malleolus fracture. Patients with a Bartonicek type II fracture had a better functional outcome measured by the AOFAS score compared to other types. Bartonicek type IIa fractures got a higher AOFAS score and a lower incidence of osteoarthritis at the final follow-up than the other two subtypes. Classification of PMFs according to the Bartonicek classification was reliable.
Collapse
Affiliation(s)
- Lei Yang
- Department of Orthopedics, Wujin Hospital Affiliated with Jiangsu University, Changzhou, 213017, China
- Department of Orthopedics, The Wujin Clinical College of Xuzhou Medical University, Changzhou, 213017, China
| | - Gang Yin
- Department of Orthopedics, Wujin Hospital Affiliated with Jiangsu University, Changzhou, 213017, China
| | - Jianguo Zhu
- Department of Orthopedics, Wujin Hospital Affiliated with Jiangsu University, Changzhou, 213017, China
| | - Haifeng Liu
- Department of Orthopedics, Wujin Hospital Affiliated with Jiangsu University, Changzhou, 213017, China
| | - Xiaoqiang Zhao
- Department of Orthopedics, Wujin Hospital Affiliated with Jiangsu University, Changzhou, 213017, China
| | - Lei Xue
- Department of Orthopedics, Wujin Hospital Affiliated with Jiangsu University, Changzhou, 213017, China
| | - Fen Yin
- Department of Orthopedics, Wujin Hospital Affiliated with Jiangsu University, Changzhou, 213017, China
| | - Jinbo Liu
- Department of Spinal Surgery, The Third Affiliated Hospital of Soochow University, Changzhou, 213003, China
| | - Zhiyuan Liu
- Department of Orthopedics, Wujin Hospital Affiliated with Jiangsu University, Changzhou, 213017, China.
- Department of Orthopedics, The Wujin Clinical College of Xuzhou Medical University, Changzhou, 213017, China.
| |
Collapse
|
5
|
Terstegen J, Weel H, Frosch KH, Rolvien T, Schlickewei C, Mueller E. Classifications of posterior malleolar fractures: a systematic literature review. Arch Orthop Trauma Surg 2023; 143:4181-4220. [PMID: 36469121 PMCID: PMC10293398 DOI: 10.1007/s00402-022-04643-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 09/30/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Complex ankle fractures frequently involve the posterior malleolus. Many classifications describing posterior malleolar fractures (PMF) exist. The aim of this study was to provide a systematic literature review to outline existing PMF classifications and estimate their accuracy. METHODS The databases PubMed and Scopus were searched without time limits. Only specific PMF classifications were included; general ankle and/or pilon fracture classifications were excluded. Selection and data extraction was performed by three independent observers. The systematic literature search was performed according to the current criteria of Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). The methodological quality of the included studies was quantified using the modified Coleman score. RESULTS A total of 110 studies with a total of 12.614 patients were included. Four main classifications were identified: Those describing the size of the posterior malleolar fracture (n = 66), Haraguchi (n = 44), Bartoníček/Rammelt (n = 21) and Mason (n = 12). The quality of the studies was moderate to good with a median Coleman-score of 43.5 (14-79) and a weighted median Coleman-score of 42.5 points. All classifications achieved a substantial to perfect score regarding the inter- and intraobserver reliability, with Mason scoring the lowest in comparison. CONCLUSIONS None of the reviewed PMF classifications has been able to establish itself decisively in the literature. Most of the classifications are insufficient in terms of a derivable treatment algorithm or a prognosis with regard to outcome. However, as the Bartoníček/Rammelt classification has the greatest potential due to its treatment algorithm, its reliability in combination with consistent predictive values, its usage in clinical practice and research appears advisable.
Collapse
Affiliation(s)
- Julia Terstegen
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Hanneke Weel
- Department of Orthopedics, Bergman Clinics, Arnhem, The Netherlands
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
- Department of Trauma Surgery, Orthopaedics, and Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany
| | - Tim Rolvien
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Carsten Schlickewei
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Elena Mueller
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| |
Collapse
|
6
|
Zheng H, Xia Y, Ni X, Wu J, Li Y, Zhang P, Wu X, Lu K, Zhao Q. Clinical effects of 3D printing-assisted posterolateral incision in the treatment of ankle fractures involving the posterior malleolus. Front Surg 2023; 10:1176254. [PMID: 37292486 PMCID: PMC10244554 DOI: 10.3389/fsurg.2023.1176254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/03/2023] [Indexed: 06/10/2023] Open
Abstract
Objective To explore the clinical outcomes of a 3D printing-assisted posterolateral approach for the treatment of ankle fractures involving the posterior malleolus. Methods A total of 51 patients with ankle fractures involving the posterior malleolus admitted to our hospital from January 2018 to December 2019 were selected. The patients were divided into 3D printing group (28 cases) and control group (23 cases). 3D printing was performed for ankle fractures, followed by printing of a solid model and simulation of the operation on the 3D model. The operation was then performed according to the preoperative plan, including open reduction and internal fixation via the posterolateral approach with the patient in the prone position. Routine x-ray and CT examinations of the ankle joint were performed, and ankle function was evaluated using the American Foot and Ankle Surgery Association (AOFAS) ankle-hindfoot score. Results All patients underwent x-ray and CT examinations. All fractures healed clinically, without loss of reduction or failure of internal fixation. Good clinical effects were achieved in both groups of patients. The operation time, intraoperative blood loss and intraoperative fluoroscopy frequency in the 3D printing group were significantly less than those in the control group (p < 0.05). There was no significant difference between the two groups in the anatomical reduction rate of fractures or the incidence of surgical complications (p > 0.05). Conclusion The 3D printing-assisted posterolateral approach is effective in the treatment of ankle fractures involving the posterior malleolus. The approach can be well planned before the operation, is simple to perform, yields good fracture reduction and fixation, and has good prospects for clinical application.
Collapse
Affiliation(s)
- Hongming Zheng
- Department of Orthopedic Surgery, Affiliated Danyang Hospital of Nantong University, Danyang, China
| | - Yan Xia
- Department of Orthopedic Surgery, Affiliated Danyang Hospital of Nantong University, Danyang, China
| | - Xiaohui Ni
- Department of Orthopedics, Dafeng People’s Hospital, Yancheng, China
| | - Jieshi Wu
- Department of Orthopaedics, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Yankun Li
- Department of Orthopaedics, Guizhou Provincial People's Hospital, Guiyang, China
| | - Pengpeng Zhang
- Department of Orthopaedics, Guizhou Provincial People's Hospital, Guiyang, China
| | - Xinglin Wu
- Department of Orthopaedics, Guizhou Provincial People's Hospital, Guiyang, China
| | - Kaihang Lu
- Department of Orthopaedics, Guizhou Provincial People's Hospital, Guiyang, China
| | - Quanming Zhao
- Department of Orthopaedics, Guizhou Provincial People's Hospital, Guiyang, China
| |
Collapse
|
7
|
Hoekstra H, Vinckier O, Staes F, Berckmans L, Coninx J, Matricali G, Wuite S, Vanstraelen E, Deschamps K. In Vivo Foot Segmental Motion and Coupling Analysis during Midterm Follow-Up after the Open Reduction Internal Fixation of Trimalleolar Fractures. J Clin Med 2023; 12:jcm12082772. [PMID: 37109109 PMCID: PMC10146606 DOI: 10.3390/jcm12082772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 03/31/2023] [Accepted: 04/05/2023] [Indexed: 04/29/2023] Open
Abstract
PURPOSE Trimalleolar ankle fractures (TAFs) are common traumatic injuries. Studies have described postoperative clinical outcomes in relation to fracture morphology, but less is known about foot biomechanics, especially in patients treated for TAFs. The aim of this study was to analyze segmental foot mobility and joint coupling during the gait of patients after TAF treatment. METHODS Fifteen patients, surgically treated for TAFs, were recruited. The affected side was compared to their non-affected side, as well as to a healthy control subject. The Rizzoli foot model was used to quantify inter-segment joint angles and joint coupling. The stance phase was observed and divided into sub-phases. Patient-reported outcome measures were evaluated. RESULTS Patients treated for TAFs showed a reduced range of motion in the affected ankle during the loading response (3.8 ± 0.9) and pre-swing phase (12.7 ± 3.5) as compared to their non-affected sides (4.7 ± 1.1 and 16.1 ± 3.1) and the control subject. The dorsiflexion of the first metatarsophalangeal joint during the pre-swing phase was reduced (19.0 ± 6.5) when compared to the non-affected side (23.3 ± 8.7). The affected side's Chopart joint showed an increased range of motion during the mid-stance (1.3 ± 0.5 vs. 1.1 ± 0.6). Smaller joint coupling was observed on both the patient-affected and non-affected sides compared to the controls. CONCLUSION This study indicates that the Chopart joint compensates for changes in the ankle segment after TAF osteosynthesis. Furthermore, reduced joint-coupling was observed. However, the minimal case numbers and study power limited the effect size of this study. Nevertheless, these new insights could help to elucidate foot biomechanics in these patients, adjusting rehabilitation programs, thereby lowering the risk of postoperative long-term complications.
Collapse
Affiliation(s)
- Harm Hoekstra
- Department of Trauma Surgery, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
- Department of Development and Regeneration, KU Leuven-University of Leuven, 3000 Leuven, Belgium
| | - Olivier Vinckier
- Department of Orthopaedics, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Filip Staes
- Musculoskeletal Rehabilitation Research Group, Department of Rehabilitation Sciences, KU Leuven-University of Leuven, Tervuursevest 101, 3001 Leuven, Belgium
| | - Lisa Berckmans
- Musculoskeletal Rehabilitation Research Group, Department of Rehabilitation Sciences, KU Leuven-University of Leuven, Tervuursevest 101, 3001 Leuven, Belgium
| | - Jolien Coninx
- Musculoskeletal Rehabilitation Research Group, Department of Rehabilitation Sciences, KU Leuven-University of Leuven, Tervuursevest 101, 3001 Leuven, Belgium
| | - Giovanni Matricali
- Department of Development and Regeneration, KU Leuven-University of Leuven, 3000 Leuven, Belgium
- Department of Orthopaedics, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
- Institute for Orthopaedic Research and Training, KU Leuven-University of Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Sander Wuite
- Department of Development and Regeneration, KU Leuven-University of Leuven, 3000 Leuven, Belgium
- Department of Orthopaedics, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
- Institute for Orthopaedic Research and Training, KU Leuven-University of Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Eline Vanstraelen
- Clinical Motion Analysis Laboratory, Campus Pellenberg, University Hospitals Leuven, Weligerveld 1, 3212 Lubbeek, Belgium
| | - Kevin Deschamps
- Musculoskeletal Rehabilitation Research Group, Department of Rehabilitation Sciences, KU Leuven-University of Leuven, Tervuursevest 101, 3001 Leuven, Belgium
- Clinical Motion Analysis Laboratory, Campus Pellenberg, University Hospitals Leuven, Weligerveld 1, 3212 Lubbeek, Belgium
- Division of Podiatry, Institut D'Enseignement Supérieur Parnasse Deux-Alice, Haute Ecole Leonard de Vinci, Avenue e Mounier 84, 1200 Bruxelles, Belgium
- Department of Podiatry, Artevelde University College, Hoogpoort 15, 9000 Gent, Belgium
| |
Collapse
|
8
|
Chou TFA, Tzeng YH, Teng MH, Huang YC, Wang CS, Lin CC, Chiang CC. Trimalleolar Fractures Treated by Open Reduction Internal Fixation Compared With Arthroscopically Assisted Reduction and Minimally Invasive Surgery. Foot Ankle Int 2023; 44:431-442. [PMID: 36946569 DOI: 10.1177/10711007231157676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
BACKGROUND Currently, the standard of treatment for trimalleolar (TM) fracture is osteosynthesis through open reduction and internal fixation (ORIF). This study assessed whether arthroscopically assisted reduction and minimally invasive surgery (AARMIS) can be an alternative surgical method for TM fractures. METHODS This retrospective cohort study included 49 patients with TM that were surgically treated. 27 patients received ORIF and 22 patients underwent AARMIS . At baseline, we recorded the patient's demographic features, fracture pattern (AO-OTA and Haraguchi classification), and surgical method. For postoperative results, we examined the patient's radiographic outcome, including time to union, quality of fracture reduction, as well as functional outcomes (American Orthopaedic Foot & Ankle Society ankle hindfoot score, ankle range of motion, and visual analog scale of pain) and perioperative complications. RESULTS At mean follow-up of 46.6±24.6 (ORIF) and 36.4±18.5 months (AARMIS), both groups had comparable radiographic outcomes. No significant difference in rates of early ankle OA were detected. In terms of functional outcome, VAS pain and AOFAS score at postoperative day 3, postoperative month 3, and at final follow-up were not different. In terms of range of motion, we did not find a significant difference in mean range of motion. CONCLUSION Patients with TM fractures treated with AARMIS achieved satisfactory results and was not significantly different in radiographic and functional performance compared with ORIF. LEVEL OF EVIDENCE Level III, retrospective cohort study.
Collapse
Affiliation(s)
- Te-Feng Arthur Chou
- Division of Orthopaedic Trauma, Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Yun-Hsuan Tzeng
- Division of Medical Imaging for Health Management, Cheng-Hsin General Hospital, Taipei
- Department of Radiology, School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Ming-Hung Teng
- Division of Orthopaedic Trauma, Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Yen-Chun Huang
- Division of Orthopaedic Trauma, Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Chien-Shun Wang
- Division of Orthopaedic Trauma, Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Chun-Cheng Lin
- Division of Orthopaedic Trauma, Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Chao-Ching Chiang
- Division of Orthopaedic Trauma, Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei
| |
Collapse
|
9
|
Stake IK, Douglass BW, Husebye EE, Clanton TO. Methods for Biomechanical Testing of Posterior Malleolar Fractures in Ankle Fractures: A Scoping Review. Foot Ankle Int 2023; 44:348-362. [PMID: 36932661 DOI: 10.1177/10711007231156164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
Abstract
BACKGROUND The treatment of posterior malleolar fractures (PMFs) is debated, including the need for surgery and method of fixation. Recent literature has suggested that fracture pattern, rather than fragment size, may be an important predictor for ankle biomechanics and functional outcome. Biomechanical studies have been conducted to provide evidence-based treatment on the effects of fracture and fixation on contact pressure and stability. The objective of this scoping review is to summarize the methodologies used in biomechanical studies on PMFs and assess whether they are sufficient to test the need for surgery and method of fixation. METHODS A scoping review of publications before January 2022 was performed. PubMed/Medline and Embase Ovid were searched for cadaver or finite element analysis (FEA) studies that created and tested the effects of PMFs in ankle fractures. Both cadaver and FEA studies were included. Data about fragment characteristics, mode of testing, and outcomes were charted by 2 persons from the study group. The data were synthesized when possible and compared. RESULTS We included 25 biomechanical studies, including 19 cadaver studies, 5 FEA studies, and 1 cadaver and FEA study. Aside from the fragment size, few other fragment characteristics were reported. Mode of testing varied with different loads and foot positions. Strong conclusions on the effects of fracture and fixation on contact pressure and stability could not be made. CONCLUSION Biomechanical studies on PMFs demonstrate wide variability in fragment characteristics and mode of testing, which makes it difficult to compare studies and draw conclusions on the need for surgery and method of fixation. Additionally, limited reporting of fragment measurements questions the applicability to clinical practice. The biomechanical literature on PMFs would benefit from the use of a standard classification and universal fragment measurements to match clinical injuries in future biomechanical studies. Based on this review, we recommend the Mason classification, which addresses the pathomechanism, and use of the following fragment measurements in all 3 anatomic planes when creating and describing PMFs: fragment length ratio, axial angle, sagittal angle or fragment height, and interfragmentary angle. The testing protocol needs to reflect the purpose of the study. CLINICAL RELEVANCE This scoping review demonstrates wide methodological diversity of biomechanical studies. Consistency in methodology should enable comparison of study results, leading to stronger evidence-based recommendations to guide surgeons in decision making and offer PMF patients the best treatment.
Collapse
Affiliation(s)
- Ingrid K Stake
- Steadman Philippon Research Institute, Vail, CO, USA.,Department of Orthopaedic Surgery, Østfold Hospital Trust, Grålum, Norway
| | | | | | - Thomas O Clanton
- Steadman Philippon Research Institute, Vail, CO, USA.,The Steadman Clinic, Vail, CO, USA
| |
Collapse
|
10
|
Reproducibility of Bartoníček and Haraguchi classifications of the posterior malleolus fractures. Arch Orthop Trauma Surg 2023:10.1007/s00402-023-04823-z. [PMID: 36905426 DOI: 10.1007/s00402-023-04823-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 02/25/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND Two of the most commonly used classifications for the posterior malleolus fracture are Haraguchi and Bartoníček. Both classifications are based on the morphology of the fracture. This study makes an inter- and intra-observer agreement analysis of the mentioned classifications. METHODS 39 patients with ankle fractures who met inclusion criteria were selected. All the fractures were analyzed and classified twice by each of the 20 observers using Bartoníček and Haraguchi's classifications, with a window period of at least 30 days between the two rounds. RESULTS Analysis was made by Kappa coefficient (ƙ). The global intraobserver value was ƙ = 0.627 in the Bartoníček classification and ƙ = 0.644 in the Haraguchi one. The first round global interobserver ƙ = 0.589 (0.574-0.604) on the Bartoníček classification and ƙ = 0.534 (0.517-0.551) on the Haraguchi one. Second round coefficients were ƙ = 0.601 (0.585-0.616) and ƙ = 0.536 (0.519-0.554), respectively. The best agreement was when there was involvement of the posteromedial malleolar zone with ƙ = 0.686 and ƙ = 0.687 in Haraguchi II and ƙ = 0.641 and ƙ = 0.719 in Bartoníček III. No differences were observed in Kappa values when an experience-based analysis was made. CONCLUSION Bartoníček and Haraguchi classifications of the posterior malleolus fracture have both substantial intraobserver agreement but moderate to substantial agreement in interobserver analysis. LEVEL OF EVIDENCE IV.
Collapse
|
11
|
Lee J, Ryu H, Park JY. Single lateral approach for open reduction and internal fixation of posterior malleolar fragment in Weber B rotational ankle fracture. Medicine (Baltimore) 2023; 102:e32725. [PMID: 36701732 PMCID: PMC9857474 DOI: 10.1097/md.0000000000032725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Ankle fractures involving the posterior malleolus are a relatively common injuries, but various surgical approaches are still being introduced, and the selection of an appropriate surgical method is still controversial. The aim of this study was to introduce the surgical method using a single lateral approach for open reduction and internal fixation for posterior malleolar (PM) fractures associated with Weber B type ankle fractures. In this retrospective study, the single lateral approach was used for osteosynthesis of the PM fracture with Weber B lateral malleolar fractures. A total of 40 patients were followed up at for least 12 months (mean, 23.3; range, 12-88). Clinical assessment was based on the Olerud and Molander score, Foot and Ankle Outcome Score, visual analog scale, and subjective patient satisfaction 1 year after surgery. The accuracy of reduction was evaluated as <1 mm of displacement on the lateral view of the postoperative radiographs. The mean Olerud and Molander ankle score was 85.6 ± 12.7 and the mean Foot and Ankle Outcome Score was 82.7 ± 15.9 at 1-year postoperatively. Acceptable reduction was achieved in 38 of 40 (95%) cases. During the follow-up period, arthritic change was observed in 1 case and limited range of motion was confirmed in 2 cases. There was 1 case of postoperative wound problem and no case of sural nerve injury. The single lateral approach is a relatively simple and convenient method that enables accurate reduction and minimizing complication for fixation of the PM fractures with Weber B lateral malleolar fractures.
Collapse
Affiliation(s)
- Jaehyung Lee
- Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang-si, Gyeonggi-do, Republic of Korea
| | - Hwan Ryu
- Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang-si, Gyeonggi-do, Republic of Korea
| | - Jae Yong Park
- Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang-si, Gyeonggi-do, Republic of Korea
- * Correspondence: Jae Yong Park, Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang-si, Gyeonggi-do 14068, Republic of Korea (e-mail: )
| |
Collapse
|
12
|
Quan Y, Lu H, Qi P, Tian S, Liu J, Zhang C, Zhang B, Xu H. Posterior malleolus fracture: a mid-term follow-up. J Orthop Surg Res 2023; 18:10. [PMID: 36600304 PMCID: PMC9814323 DOI: 10.1186/s13018-022-03488-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 12/30/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND The treatment of posterior malleolar fractures is changing rapidly, and the evidence base is still catching up. This study aimed to assess the mid-term prognosis of posterior malleolar fractures based on different morphological types and provides evidence for the treatment of posterior malleolar fractures. METHODS We retrospectively analyzed the data of inpatients with posterior malleolar fractures from 1 January 2012 to 31 December 2019 at one high-volume tertiary trauma center. Fracture morphology was classified into small-shell fragment, single-fragment (small-fragment and large-fragment) and multifragment (double-fragment and compressive-fragment) by computed tomography according to our previous study. All patients were followed up at an average of 5.06 (range, 2.21-8.70) years. The Olerud-Molander Ankle Score (OMAS), EuroQol-5 Dimensions (EQ-5D) and American Orthopedic Foot and Ankle Society (AOFAS) score were recorded. RESULTS Seventy-nine patients were included, and 7 patients were classified into the small-shell group, 52 patients into the single-fragment group and 20 patients into the multifragment group. Of all the patients, the average OMAS, EQ-5D and AOFAS scores were 85.9, 82.8 and 92.5, respectively. In the single-fragment group, patients who underwent surgical fixation in the posterior malleolus had significantly better scores (P = 0.037, 0.033 and 0.027). Among the patients with small fragments, the surgical fixation group also had higher OMAS (93.1 ± 7.5 vs. 83.5 ± 19.5, P = 0.042) and AOFAS scores (98.1 ± 3.1 vs. 91.0 ± 14.1, P = 0.028). The mean OMAS, EQ-5D and AOFAS scores were 85.5, 85.7 and 91.7, respectively, in patients with multiple fragments who underwent surgical fixation. CONCLUSION This study shows that in fractures with a single fragment, surgical fixation of the posterior malleolar fragment led to a better prognosis in the midterm. All single fragments should be fixed regardless of size. Fixation of the posterior region in all single- and multi-fragments in posterior malleolar fractures led to satisfactory outcomes. LEVEL OF EVIDENCE Level III, follow-up study.
Collapse
Affiliation(s)
- Yuan Quan
- grid.411634.50000 0004 0632 4559Orthopaedic and Traumatology, Peking University People’s Hospital, Beijing, 100044 China
| | - Hao Lu
- grid.411634.50000 0004 0632 4559Orthopaedic and Traumatology, Peking University People’s Hospital, Beijing, 100044 China
| | - Peng Qi
- grid.508137.80000 0004 4914 6107Orthopaedic, Qingdao Women and Children’s Hospital, Shandong, China
| | - Songyao Tian
- Orthopaedic, Beijing Daxing District Hospital of Integrated Chinese and Western Medicine, Beijing, China
| | - Jiantao Liu
- Orthopaedic, Luanzhou People’s Hospital, Hebei, China
| | - Chunlong Zhang
- grid.411634.50000 0004 0632 4559Orthopaedic and Traumatology, Peking University People’s Hospital, Beijing, 100044 China
| | - Boyu Zhang
- grid.411634.50000 0004 0632 4559Orthopaedic and Traumatology, Peking University People’s Hospital, Beijing, 100044 China
| | - Hailin Xu
- grid.411634.50000 0004 0632 4559Orthopaedic and Traumatology, Peking University People’s Hospital, Beijing, 100044 China
| |
Collapse
|
13
|
Kroker L, Neumann AP, Beyer F, Rammelt S. Ankle fractures involving the anterolateral distal tibia: medium-term clinical results of 50 cases. Eur J Trauma Emerg Surg 2022; 49:941-949. [PMID: 36414696 PMCID: PMC10175404 DOI: 10.1007/s00068-022-02161-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 11/04/2022] [Indexed: 11/23/2022]
Abstract
Abstract
Purpose
The anterolateral distal tibial rim (anterior malleolus, AM) is frequently fractured in malleolar fractures. The aim of this study was to evaluate the medium-term outcomes of malleolar fractures involving the AM.
Methods
Among 100 patients with AM fractures that were treated over a 10-year period, 50 patients were available for follow-up. Outcome was assessed with the Olerud Molander Ankle Score (OMAS), the Foot Function Index (FFI-D), the EuroQol (EQ)-5D-5L Index, the EQ-VAS and the AOFAS Ankle-Hindfoot Score. Type 1 AM fractures (bony syndesmotic avulsions) were fixed surgically with either a suture anchor or a transosseous suture in 11 of 22 cases (50%). Among type 2 AM fractures (with incisura and joint involvement), 68% were treated surgically with screw fixation. All three type 3 AM fractures (anterolateral tibial plafond impaction) were treated surgically with either screw or plate fixation.
Results
At follow-up, the median OMAS was 75, the FFI-D 19, the EQ-5D-5L-Index 0.88, the EQ-VAS 70, and the AOFAS score 93. Assuming that the fracture severity increases from Supination–External Rotation to Pronation–External Rotation and Pronation–Abduction injuries, the AOFAS score (p < 0.001), OMAS score (p = 0.009), and FFI-D (p = 0.041) all showed a significantly inferior clinical outcome with increasing fracture severity. Patients who required surgical revision (n = 5) showed a significantly inferior outcome with the OMAS (p = 0.019).
Conclusions
A differentiated treatment protocol tailored to dislocation, size, incisura involvement and joint impaction leads to favourable outcomes in complex malleolar fractures involving the AM. More data are needed on the outcome of AM fractures that are still commonly underestimated and overlooked.
Collapse
|
14
|
Neumann AP, Kroker L, Beyer F, Rammelt S. Complications following surgical treatment of posterior malleolar fractures: an analysis of 300 cases. Arch Orthop Trauma Surg 2022; 143:3129-3136. [PMID: 35849187 DOI: 10.1007/s00402-022-04536-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 06/22/2022] [Indexed: 11/26/2022]
Abstract
AIMS The treatment of ankle fractures and fracture-dislocations involving the posterior malleolus (PM) has undergone considerable changes over the past decade. The aim of our study was to identify risk factors related to the occurrence of complications in surgically treated ankle fractures with PM involvement. PATIENTS AND METHODS We retrospectively analyzed 300 patients at a mean age of 57 years with 300 ankle fractures involving the PM treated surgically at our institution over a 12-year period. The following relevant comorbidities were noted: arterial hypertension (43.7%; n = 131), diabetes mellitus (DM) (14.0%; n = 42), thereof insulin-dependent (3.7%; n = 11), peripheral vascular disease (0.7%; n = 2), osteoporosis (12.0%; n = 36), dementia (1.0%; n = 3), and rheumatoid arthritis (2.0%; n = 6). Furthermore, nicotine consumption was recorded in 7.3% (n = 22) and alcohol abuse in 4.0% (n = 12). RESULTS Complications occurred in 41 patients (13.7%). A total of 20 (6.7%) revision surgeries had to be performed. Patients with DM (p < 0.001), peripheral vascular disease (p = 0.003) and arterial hypertension (p = 0.001) had a significantly increased risk of delayed wound healing. Alcohol abuse was associated with a significantly higher overall complication rate (OR 3.40; 95% CI 0.97-11.83; p = 0.043), increased rates of wound healing problems (OR 11.32; 95% CI 1.94-65.60; p = 0.001) and malalignment requiring revision (p = 0.033). The presence of an open fracture was associated with an increased rate of infection and wound necrosis requiring revision (OR 14.25; 95% CI 2.39-84.84; p < 0.001). Multivariate analysis identified BMI (p = 0.028), insulin-dependent DM (p = 0.003), and staged fixation (p = 0.043) as independent risk factors for delayed wound healing. Compared to the traditional lateral approach, using the posterolateral approach for fibular fixation did not lead to increased complication rates. CONCLUSIONS Significant risk factors for the occurrence of complications following PM fracture treatment were identified. An individually tailored treatment regimen that incorporates all risk factors is important for a good outcome.
Collapse
Affiliation(s)
- Annika Pauline Neumann
- University Center of Orthopaedics,Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
| | - Livia Kroker
- University Center of Orthopaedics,Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Franziska Beyer
- University Center of Orthopaedics,Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Stefan Rammelt
- University Center of Orthopaedics,Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| |
Collapse
|
15
|
Effect Evaluation of Perioperative Fast-Track Surgery Nursing for Tibial Fracture Patients with Computerized Tomography Images under Intelligent Algorithm. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:2629868. [PMID: 35845737 PMCID: PMC9249477 DOI: 10.1155/2022/2629868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 05/18/2022] [Accepted: 05/23/2022] [Indexed: 11/23/2022]
Abstract
This study aimed to study the application value of computerized tomography (CT) images under the graph cut algorithm in the effect evaluation of perioperative fast-track surgery (FTS) nursing in tibial fracture. In this study, 80 tibial fracture patients in the perioperative period were selected as the research objects. These objects were randomly divided into two groups according to the examination method. In group A, routine CT examination was performed; in group B, CT examination under the graph cut algorithm was applied. The imaging results showed that there were still 16 cases with collapse of group A and 34 cases with collapse of group B; the difference was statistically significant (P < 0.05). As for 16 cases with collapse in both groups, the average collapse shown in group A was about 2.79 ± 1.31 mm, while that in group B was 5.51 ± 1.88 mm, with a statistically significant difference (P < 0.05). The average broadening in the images of group A was 3.17 ± 1.41 mm and that of group B was 5.72 ± 1.83 mm, suggesting that the difference was statistically significant (P < 0.05). The broadening distance of 3-4 mm was mainly shown in the images of group A and that of 5-8 mm was shown in group B, with a statistical difference (P < 0.05). In terms of the total score, there were 26, 44, 8, and 2 cases that were assessed as excellent, good, common, and bad, respectively, in group A, while 44 cases were assessed as good and 36 cases were assessed as common in group B, which were significantly different (P < 0.05). In summary, the graph cut algorithm not only had a good segmentation effect and segmentation efficiency but also could improve the evaluation of CT images for perioperative FTS nursing effect in patients with tibial fracture.
Collapse
|
16
|
Yamamoto N, Iwamoto K, Tomita Y, Iwamoto Y, Kiyono M, Yoshimura M, Noda T, Kawasaki K, Ozaki T. Pre-and postoperative factors associated with functional outcomes in patients with posterior malleolar fractures. Injury 2022; 53:2297-2303. [PMID: 35260245 DOI: 10.1016/j.injury.2022.02.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 02/19/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Recent studies on posterior malleolar fractures mainly focus on the reduction quality and fixation of the posterior fragment since it contributes to ankle stability and articular congruency. However, the association of pre-and postoperative factors considering the whole ankle joint in postoperative functional outcomes remains unclear. Therefore, this study aimed to examine the association between pre-and postoperative variables for postoperative functional outcomes in patients with posterior malleolar fragments (classified as Haraguchi type I or II) and considered the association between reduction and fixation for small posterior malleolar fragments of less than 25% of the intra-articular surface. METHODS This multicenter retrospective cohort study included 110 adult patients who underwent internal fixation for ankle fractures with posterior malleolar fragments. The primary outcome was the American Orthopaedic Foot and Ankle Society (AOFAS) score 12-months postoperatively. As pre-and postoperative variables, the preoperative demographic data, radiographic findings, operative method, postoperative radiographic findings, and complications were evaluated. In addition, univariable and multivariable logistic regression analyses were conducted to examine the association between pre-and postoperative variables and AOFAS scores. RESULTS Twenty-four (21.8%) cases had postoperative complications. Univariate analysis showed that age was significantly according to AOFAS score-stratified groups in patients with Haraguchi type II fractures. Multivariable logistic regression analysis using bootstrapping in the Haraguchi type II group showed that postoperative complications were significantly associated with low AOFAS scores, indicating poor functionality. In both fracture types, postoperative complications had the highest odds ratio among the explanatory variables. In patients with small posterior malleolar fragments, fragment reduction, fixation, and ankle stability were not associated with AOFAS scores. CONCLUSIONS Our results suggest that postoperative complications were associated with AOFAS scores at postoperative 12 months in patients with ankle fractures with posterior malleolar fragments. In patients with small posterior malleolar fragments, reduction and fixation were not associated with AOFAS scores. Therefore, clinical decisions for posterior fragment fixation should be made based on the possible risk of complications related to the surgical procedures in addition to the posterior malleolar fragment size.
Collapse
Affiliation(s)
- Norio Yamamoto
- Department of Orthopedic Surgery, Kagawa Prefectural Central Hospital, 1-2-1, Asahi-machi, Takamatsu, Kagawa 760-8557, Japan; Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan.
| | - Kohei Iwamoto
- Department of Emergency Medical Center, Kagawa Prefectural Central Hospital, Kagawa, Japan
| | - Yosuke Tomita
- Department of Physical Therapy, Faculty of Health Care, Takasaki University of Health and Welfare, Gunma, Japan
| | - Yuki Iwamoto
- Department of Orthopedic Surgery, Okayama Saiseikai General Hospital, Okayama, Japan
| | - Masahiro Kiyono
- Department of Orthopedic Surgery, Mitoyo General Hospital, Kagawa, Japan
| | | | - Tomoyuki Noda
- Department of Orthopaedic Surgery and Traumatology, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Keisuke Kawasaki
- Department of Orthopedic Surgery, Kagawa Prefectural Central Hospital, 1-2-1, Asahi-machi, Takamatsu, Kagawa 760-8557, Japan
| | - Toshifumi Ozaki
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| |
Collapse
|
17
|
Müller E, Terstegen J, Kleinertz H, Weel H, Frosch KH, Barg A, Schlickewei C. [Established classification systems of posterior malleolar fractures : A systematic literature review]. Unfallchirurg 2022; 126:387-398. [PMID: 35394158 PMCID: PMC10159979 DOI: 10.1007/s00113-022-01162-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Posterior malleolar fractures are found in almost 50% of all ankle fractures. The high clinical relevance of these joint fractures is explained by the significantly worse clinical and functional outcome. There is still a lack of unified opinion regarding the classification and treatment of these fractures. OBJECTIVE The aim of this article is to provide a systematic literature review of clinical studies that investigated posterior malleolar fractures and classified them using one of the three established classifications according to Haraguchi, Bartonicek/Rammelt, or Mason. MATERIAL AND METHODS PubMed was searched without time limits. The systematic literature search was performed according to the current criteria of Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). The methodological quality of the included studies was quantified using the modified Coleman score. RESULTS A total of 27 studies with a total of 2220 patients were included in this systematic literature review. Trimalleolar fractures showed a significantly less favorable prognosis than other ankle fractures. The quality of reduction was the most important prognostic factor for the clinical outcome. CONCLUSION None of the three classifications examined has become established in the literature. Most of the classifications are weak or should not be used with respect to a derivable treatment algorithm or a prognosis with respect to the outcome. Only the classification according to Bartonicek/Rammelt is suitable to become established in the literature and in clinical practice due to its derivable treatment algorithm.
Collapse
Affiliation(s)
- Elena Müller
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
| | - Julia Terstegen
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Holger Kleinertz
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Hanneke Weel
- Orthopedics Center, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Karl-Heinz Frosch
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
- Abteilung Unfallchirurgie, Orthopädie und Sporttraumatologie, BG Klinikum Hamburg, Hamburg, Deutschland
| | - Alexej Barg
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
- Abteilung Unfallchirurgie, Orthopädie und Sporttraumatologie, BG Klinikum Hamburg, Hamburg, Deutschland
- Orthopädische Universitätsklinik, Universität von Utah, Salt Lake City, UT, USA
| | - Carsten Schlickewei
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| |
Collapse
|
18
|
Percutaneous Fixation of Posterior Malleolar Fractures in Patients With Unstable Ankle Fractures Treated With a Fibular Intramedullary Nail: A Description of a Technique and Review of Outcomes. J Orthop Trauma 2022; 36:195-200. [PMID: 34483324 DOI: 10.1097/bot.0000000000002262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/26/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To (1) describe the percutaneous technique used to reduce and fix a posterior malleolar fracture with anteroposterior screws in patients managed with a fibular intramedullary nail, (2) describe the selection of patients to whom this technique can be applied, and (3) report the clinical and patient reported outcome of this intervention. DESIGN Retrospective review. SETTING Academic orthopaedic trauma center. PATIENTS Thirty-two consecutive patients with a mean age of 65 years (range, 39-90) over a thirteen-year period identified from a prospective database. INTERVENTION Unstable ankle fractures managed surgically with a fibular nail and percutaneous fixation of the posterior malleolar component. MAIN OUTCOME MEASUREMENTS The primary short-term outcome was complications related to posterior malleolar fracture fixation. The primary mid-term outcome was the Olerud-Molander Ankle Score. Secondary outcomes included the Manchester-Oxford Foot Questionnaire, EuroQol-5D, health, pain, and satisfaction. RESULTS Thirty of the 32 (94%) posterior malleolar fractures united uneventfully. Postoperative loss of talar reduction occurred in 2 patients (6.3%), which in 1 patient (3.1%) eventually required a hindfoot nail arthrodesis. There were no soft-tissue complications related to the anteroposterior screws or the fibular nail fixation. At a mean follow-up of 3.7 years (range, 1-8), the median Olerud-Molander Ankle Score, Manchester-Oxford Foot Questionnaire, EuroQol-5D, health, pain, and satisfaction scores were 80.0, 23.4, 0.85, 80.0, 85.0, and 87.5, respectively. CONCLUSIONS Percutaneous ankle fracture fixation with a fibular nail and posterior malleolar screws results in reliable fracture stabilization, good patient outcomes, and high treatment satisfaction. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Collapse
|
19
|
Xie W, Lu H, Zhan S, Liu Y, Quan Y, Xu H, Fu Z, Zhang D. Establishment of a finite element model and stress analysis of intra-articular impacted fragments in posterior malleolar fractures. J Orthop Surg Res 2022; 17:186. [PMID: 35346275 PMCID: PMC8961993 DOI: 10.1186/s13018-022-03043-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 03/02/2022] [Indexed: 11/17/2022] Open
Abstract
Background Intra-articular impacted fragments (IAIFs) are considered articular surface fragments resulting from impact and compressive forces. The malreduction of IAIFs in posterior malleolar fractures has been associated with talar subluxation and long-term post-traumatic arthritis. In this study, we establish IAIF defect finite element models of different sizes in posterior malleolar fractures and explored how IAIF defects predict the onset of post-traumatic arthritis. Methods A reliable three-dimensional finite element model of the normal ankle was established. Finite element models with different sizes of IAIF defects were created to calculate ankle joint contact stress. The finite element data were recorded and analyzed. Results There was a linear relationship between the size of the IAIF defect and MCS with IAIF defects in the posterolateral region. The result of Pearson linear correlation analysis was r = 0.963, P = 0.009. The regression equation was MCS = 0.087*AI + 2.951 (AI, area of IAIF) by simple linear regression analysis. When the IAIF defect was in the posteromedial region, there was also a linear relationship between the size of the IAIF defect and MCS. The result of Pearson linear correlation analysis was r = 908, P = 0.033. The regression equation was MCS = 0.065*AI + 1.841. The MCS was increased mainly in the border of the IAIF defect. Conclusions A small IAIF defect in the posterior malleolus will result in a high MCS, and the MCS in the posterolateral region is larger than the MCS in the posteromedial region when the size of the IAIF defect is the same. We obtain the regression equation of MCS and area of IAIF defect. This indicates that patients are more prone to post-trauma arthritis when the size of IAIF defects is more than 17.8 mm2 in the posterolateral region and more than 40.9 mm2 in the posteromedial region. Trial registration Retrospectively registered.
Collapse
|
20
|
Xie W, Lu H, Yuan Y, Xu H. A new finite element model of intra-articular impacted fragment in posterior malleolar fractures: A technical note. Injury 2022; 53:784-788. [PMID: 34972564 DOI: 10.1016/j.injury.2021.12.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 12/17/2021] [Indexed: 02/02/2023]
Abstract
Intra-articular impacted fragment (IAIF) was considered as the articular surface fragment resulting from impact and compressive forces. Malreduction of IAIF in posterior malleolar fractures was associated with the cause of talus subluxation and long-term arthritis. The effect of IAIF on ankle pressure and stress has not been studied, and it's difficult to do this in cadaver bone. So we established IAIF defect finite element model in posterior malleolar fractures and explored the effect of IAIF defect in ankle joint. We also discussed the relation between IAIF defect and post-traumatic arthritis.
Collapse
Affiliation(s)
- Wenyong Xie
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, China, 100044
| | - Hao Lu
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, China, 100044
| | - Yusong Yuan
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, China, 100044
| | - Hailin Xu
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, China, 100044.
| |
Collapse
|
21
|
Neumann AP, Rammelt S. Ankle fractures involving the posterior malleolus: patient characteristics and 7-year results in 100 cases. Arch Orthop Trauma Surg 2022; 142:1823-1834. [PMID: 33835195 PMCID: PMC9296426 DOI: 10.1007/s00402-021-03875-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 03/23/2021] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The presence of a posterior malleolar (PM) fragment has a negative prognostic impact in ankle fractures. The best treatment is still subject to debate. The aim of this study was to assess the medium-to-long-term clinical and functional outcome of ankle fractures with a PM fragment in a larger patient population. MATERIALS AND METHODS One hundred patients (69 women, 31 men, average age 60 years) with ankle fractures including the PM were evaluated clinically and radiographically. Patients with Bartoníček-Rammelt type 3 and 4 fracture displayed a significant female preponderance. Fixation of the PM was performed in 63% and tailored to the individual fracture pattern. RESULTS Internal fixation of the PM fragment was negatively correlated with the need for syndesmotic screw placement at the time of surgery (p = 0.010). At an average follow-up of 7.0 years, the mean Foot Function Index (FFI) was 16.5 (SD: 21.5), the Olerud Molander Ankle Score (OMAS) averaged 80.2 (SD: 24) and the American Orthopedic Foot & Ankle Society (AOFAS) ankle/hindfoot score averaged 87.5 (SD: 19.1). The maximum score of 100 was achieved by 44% of patients. The physical (PCS) and mental health component summary (MCS) scores of the SF-36 averaged 47.7 (SD: 12.51) and 50.5 (SD: 9.36), respectively. Range of motion was within 3.4 (SD: 6.63) degrees of the uninjured side. The size of the PM fragment had no prognostic value. There was a trend to lower outcome scores with slight anterior or posterior shift of the distal fibula within the tibial incisura. Patients who underwent primary internal fixation had significantly superior SF-36 MCS than patients who underwent staged internal fixation (p = 0.031). CONCLUSIONS With an individualized treatment protocol, tailored to the CT-based assessment of PM fractures, favorable medium and long-term results can be expected.
Collapse
Affiliation(s)
- Annika Pauline Neumann
- University Center of Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Stefan Rammelt
- University Center of Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| |
Collapse
|
22
|
Schoenmakers S, Houben M, van Hoeve S, Willems P, Meijer K, Poeze M. The influence of size and comminution of the posterior malleolus fragment on gait in trimalleolar ankle fractures. Clin Biomech (Bristol, Avon) 2022; 91:105550. [PMID: 34922095 DOI: 10.1016/j.clinbiomech.2021.105550] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 11/22/2021] [Accepted: 12/08/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Ankle fractures involving the posterior malleolus generally lead to worse outcome. However, no studies on gait in trimalleolar ankle fractures have evaluated the influence of size and comminution of the posterior malleolar fragment. METHODS We expected patients with more severely comminuted posterior malleolus, more severe fracture type and larger posterior fragment to have reduced gait kinematics and poorer patient-reported outcomes. 26 trimalleolar ankle fracture patients were compared with 14 healthy controls and kinematically analyzed using the Oxford Foot Model. Functional outcome was based on 4 patient reported outcome questionnaires. Effects of posterior fragment size, comminution and Haraguchi fracture classification were determined on conventional and 3D CT-scans. FINDINGS Trimalleolar patients had lower walking speed and reduced range of motion between the hindfoot and tibia in both loading and push-off phases in the sagittal and transverse planes. The range between the hindfoot and tibia in the sagittal plane in the push-off phase correlated significantly with patient reported outcomes. The absolute and relative surface area of the posterior fragment on conventional CT-scans and 3D CT-scans, correlated significantly with range of motion. Patients with a posterior malleolus size >10% of the posterior malleolus had lower flexion-extension between forefoot and hindfoot during loading phase than patients with a size ≤10%. INTERPRETATION Trimalleolar fractures reduce walking speed and range of motion in the talocrural joint. Reduced range in the talocrural joint is associated with poorer outcomes. Posterior fragment size correlated significantly with range of motion in talocrural and midfoot joints and with patient reported outcomes. LEVEL OF EVIDENCE Level 3, retrospective study.
Collapse
Affiliation(s)
- S Schoenmakers
- Department of Surgery, Division of Trauma surgery, Maastricht University Medical Center, P. Debyelaan 25, PO Box 5800, 6202 AZ Maastricht, the Netherlands.
| | - M Houben
- Department of Surgery, Division of Trauma surgery, Maastricht University Medical Center, P. Debyelaan 25, PO Box 5800, 6202 AZ Maastricht, the Netherlands.
| | - S van Hoeve
- Department of Surgery, Division of Trauma surgery, Maastricht University Medical Center, P. Debyelaan 25, PO Box 5800, 6202 AZ Maastricht, the Netherlands
| | - P Willems
- Department of Movement Sciences, Maastricht University Medical Center, P. Debyelaan 25, PO Box 616, 6200 MD Maastricht, the Netherlands; NUTRIM, School for Nutrition and Translational Research in Metabolism, PO Box 616, 6200 MD Maastricht, the Netherlands.
| | - K Meijer
- Department of Movement Sciences, Maastricht University Medical Center, P. Debyelaan 25, PO Box 616, 6200 MD Maastricht, the Netherlands; NUTRIM, School for Nutrition and Translational Research in Metabolism, PO Box 616, 6200 MD Maastricht, the Netherlands.
| | - M Poeze
- Department of Surgery, Division of Trauma surgery, Maastricht University Medical Center, P. Debyelaan 25, PO Box 5800, 6202 AZ Maastricht, the Netherlands; NUTRIM, School for Nutrition and Translational Research in Metabolism, PO Box 616, 6200 MD Maastricht, the Netherlands.
| |
Collapse
|
23
|
Xie W, Lu H, Xu H, Quan Y, Liu Y, Fu Z, Zhang D, Jiang B. Morphological analysis of posterior malleolar fractures with intra-articular impacted fragment in computed tomography scans. J Orthop Traumatol 2021; 22:52. [PMID: 34890022 PMCID: PMC8664919 DOI: 10.1186/s10195-021-00615-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 11/17/2021] [Indexed: 11/22/2022] Open
Abstract
Background Intraarticular impacted fragment (IAIF) of posterior malleolar fractures has been reported by a few studies. However its location, morphology, and the correlation of posterior malleolar fractures have not been described in detail. The aim of this study was to describe the morphology of IAIF in posterior malleolar fractures, to analyze the related factors between IAIF and posterior malleolar fragments, and explore the treatment of IAIF. Materials and methods Between January 2013 and December 2018, 108 consecutive patients with unilateral posterior malleolar fractures were managed in our hospital. Basic demographic and computed tomography (CT) data were collected and classified by Lauge–Hansen, OTA/AO, Haraguchi, and Mason classification. Additional radiographic data, including the length and area of posterior malleolar fragment, IAIF, and stable tibial plafond were measured. The location of IAIF was described, and involvement of the fibular notch and medial malleolus was also observed. Statistics were analyzed based on univariate analysis (Chi-square test, t-test, Mann–Whitney U test, Fisher’s test) and Spearman’s correlation test. Results Among the 108 cases of posterior malleolar fractures, 75 (69.4%) were with IAIF and 33 (30.6%) cases were without. There were 74 (68.5%) females and 34 (31.5%) males, and the average age of the patients was 49 years (18–89 years). The average LIFN/(LIFN + LSFN) [length of involving fibular notch/(length of involving fibular + length of stable notch fibular notch)] was 32.9% (11.6–64.9%). The APMF/(APMF + ASTP + AIAIF) [area of posterior malleolar fragment/(area of posterior malleolar fragment + area of IAIF + area of stable tibial plafond)] and AIAIF/APMF (area of IAIF/area of posterior malleolar fragment) were 13.1% (0.8–39.7%) and 52.6% (1.2–235.4%), respectively. Involvement of medial malleolus (fracture line extended to medial malleolus, P = 0.022), involvement of fibular notch (P = 0.021), LIFN/(LIFN + LSFN) (P = 0.037), LMPMF (P = 0.004), and APMF were significantly related to the occurrence of IAIF. Conclusion Our research indicates a high incidence of IAIF in posterior malleolar fractures. All IAIFs were found in posterior malleolar, and the most common location was within the lateral area A. Posterior malleolar fracture lines that extend to medial malleolus or fibular notch herald the incidence of IAIF. LIFN/(LIFN + LSFN), LMPMF and APMF are also associated with the incidence of IAIF. CT scans are useful for posterior malleolar fractures to determine the occurrence of IAIF and make operational plans. Operation approach selection should be based on the morphology of posterior malleolar fragments and the location of IAIF. Level of evidence Level III, retrospective case analysis.
Collapse
Affiliation(s)
- Wenyong Xie
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Hao Lu
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Hailin Xu
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Yuan Quan
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Yijun Liu
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Zhongguo Fu
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Dianying Zhang
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Baoguo Jiang
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China. .,Trauma Center, National Center for Trauma Medicine, Beijing, 100044, China. .,Key Laboratory of Trauma and Neural Regeneration, Peking University People's Hospital, Beijing, 100044, China.
| |
Collapse
|
24
|
Li Y, Chen Y, Liu X, Chen J, Gan T, Zhang H. Patient Pain and Function After Correction of Posterior Malleolar Malunion. Foot Ankle Int 2021; 42:1536-1546. [PMID: 34210180 DOI: 10.1177/10711007211017831] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The management of an ankle malunion involving the posterior malleolus remains challenging, and only a few published studies described the operative treatment of complex posterior malleolar malunion. A transfibular approach allows for direct visualization of the articular reduction of the posterior malleolus, but the reports of its use for correcting posterior malleolar malunion are rare. This study aims to evaluate the results of the intra-articular osteotomy via a transfibular approach for correcting an ankle malunion involving the posterior malleolus. METHODS We conducted a retrospective review of 26 patients with a symptomatic malunited ankle fracture involving posterior malleolus were treated with the intra-articular osteotomy via a transfibular approach in our department. Radiographic assessments were performed using plain radiographs and computed tomographic (CT) scans. Clinical outcomes were assessed using the AOFAS ankle-hindfoot score, visual analog scale (VAS), active range of motion of ankle, and the 36-Item Short-Form Health Survey score. RESULTS Postoperatively, anatomic correction of articular surface and anatomic reduction of syndesmosis were achieved in all patients as judged by CT scans. No evidence of progression had been found in 18 of 26 patients (69.2%) at final follow-up. The median AOFAS score improved from 42.0 to 81.5 (P < .001). Median pain VAS score decreased from 6.0 to 1.0 (P < .001). A favorable clinical outcome was associated with a short time interval from original injury to correction surgery and a lower grade of preoperative arthritis, but not with the posterior malleolar fragment size. However, time interval, the posterior malleolar fragment size, and the grade of preoperative arthritis showed no correlation with the progression of arthritis grade after surgery. CONCLUSION An intra-articular osteotomy via a transfibular approach demonstrated an improved function and pain after operative treatment of malunited ankle fracture with a displaced posterior malleolar fragment. LEVEL OF EVIDENCE Level IV, retrospective case series.
Collapse
Affiliation(s)
- Yaxing Li
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China.,Disaster Medicine Center, Sichuan University, Chengdu, Sichuan Province, China
| | - Yu Chen
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Xi Liu
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Jun Chen
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Tingjiang Gan
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Hui Zhang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China.,Disaster Medicine Center, Sichuan University, Chengdu, Sichuan Province, China
| |
Collapse
|
25
|
Ræder BW, Andersen MR, Madsen JE, Jacobsen SB, Frihagen F, Figved W. Prognostic value of the Haraguchi classification in posterior malleolar fractures in A0 44-C type ankle fractures. Injury 2021; 52:3150-3155. [PMID: 34362561 DOI: 10.1016/j.injury.2021.07.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 07/24/2021] [Accepted: 07/28/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND PURPOSE Incidence of posterior malleolar fractures (PMFs) associated with ankle fractures is historically based on plain radiographs. Several classification systems for PMF are currently in use, but the reliability of the Haraguchi classification is not reported. The aim of this diagnostic cohort study was to assess incidence of PMF in patients with AO 44-C fractures, and test the reliability of the Haraguchi fracture classification based on CT. In addition, to evaluate the clinical outcome in patients with PMF. METHODS 210 patients with an AO 44-C type fracture treated with syndesmotic fixation between 2011 and 2017 were included. Presence of PMF was registered, morphology was assessed and classified according to the Haraguchi classification. Interobserver agreement for the Haraguchi classification was evaluated. Patient assessment was conducted at 6 weeks, 6 months, 1 and 2 years. The American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Score (AOFAS) was the primary outcome measure. Secondary outcome measures included presence of osteoarthritis. RESULTS 125 of 210 patients (60%) had a PMF. 34% of the PMFs were missed on plain radiographs compared to CT. The interobserver agreement was 0.797, (95% CI: 0.705 to 0.889, p < 0.001), for the Haraguchi classification. The 2-year follow-up rate was 86%. Haraguchi type II fractures had a lower AOFAS compared with the no-fracture group at 6 weeks (mean difference -7.5 (95% CI; -15.0 to -0.2), p = 0.04) and 6 months (mean difference -8.4 (95% CI; -15.3 to -1.5), p = 0.01). Presence of osteoarthritis was higher in patients with Haraguchi type II PMF compared to the no PMF group, this finding was not significant (relative risk (RR) 1.6(95% CI 1.1 to 2.4, p = 0.059)). CONCLUSIONS Plain radiographs underestimated PMF. Patients with a Haraguchi type II fracture had a poorer outcome measured by the AOFAS score compared to no PMF up until 6 months. Classification of PMF according to the Haraguchi classification was reliable.
Collapse
Affiliation(s)
- Benedikte Wendt Ræder
- Orthopaedic surgeon, Department of Orthopaedic Surgery, Baerum Hospital, Vestre Viken Hospital Trust, Norway.
| | - Mette Renate Andersen
- Orthopaedic surgeon, Department of Orthopaedic Surgery, Baerum Hospital, Vestre Viken Hospital Trust, Norway; Orthopaedic surgeon, Aleris Hospital, Tromsø, Norway
| | - Jan Erik Madsen
- Orthopaedic Surgeon, Division of Orthopaedic Surgery, Oslo University Hospital, Norway and Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Norway.
| | - Silje Berild Jacobsen
- Radiologist, Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Frede Frihagen
- Orthopaedic surgeon, Department of Orthopaedic Surgery, Østfold Hospital Trust, Grålum, Norway and Division of Clinical Medicine, Univeristy og Oslo, Oslo, Norway
| | - Wender Figved
- Orthopaedic surgeon, Department of Orthopaedic Surgery, Baerum Hospital, Vestre Viken Hospital Trust, Norway.
| |
Collapse
|
26
|
Bouche PA, Gaujac N, Corsia S, Leclerc P, Anract P, Auberger G. Ankle CT scan allows better management of posterior malleolus fractures than X-rays. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:1301-1309. [PMID: 34468840 DOI: 10.1007/s00590-021-03104-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 08/23/2021] [Indexed: 01/23/2023]
Abstract
PURPOSE Undiagnosed and undertreated posterior malleolus fractures lead to early ankle instability and arthritis. A preoperative CT scan could improve the management of those fractures. This study assessed the benefits of a systematic ankle CT scanner to diagnose and manage posterior malleolus fracture. METHODS A monocentric retrospective cohort study was conducted. Sixty consecutive patients with bimalleolar fractures were operated and underwent a preoperative CT scan. The mean age was 50.0 years old (18.6 years old) with a mean body mass index of 20.3 (kg/m2) (11.4 kg/m2) and 71.7% (43/60) of women. The primary outcome was the rate of posterior malleolus fragment diagnosed on X-rays and on CT scan. Secondly, interobserver and interobserver's agreement were compared between conventional X-rays and CT scan. RESULTS Thirty-five (58.3%) posterior fragment fractures were observed on X-rays and 53 (88.3%) on the preoperative CT scan (p < 0.01). The intraobserver reproducibility for X-rays was low (0.02 [- 0.23; 0.27]) and moderate for CT scan (0.45 [0.0; 0.84]). The interobserver reproducibility for X-rays was moderate (0.39 [0.15; 0.60]) and excellent for CT scan (0.78 [0.0; 1.0]). CONCLUSION A wide proportion of bimalleolar fractures are associated with posterior malleolus fractures and undiagnosed with standard X-rays. We advocate a systematic preoperative CT scan in the management of bimalleolar fractures. LEVEL OF EVIDENCE Level IV, retrospective cohort study. TRIAL REGISTRATION NUMBER 2218999v0, date of registration: 11/08/2020 (retrospectively registered).
Collapse
Affiliation(s)
- Pierre-Alban Bouche
- Orthopaedic Department, Cochin University Hospital, APHP Paris, Paris Descartes University, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France.
| | - Nicolas Gaujac
- Orthopaedic Department, Cochin University Hospital, APHP Paris, Paris Descartes University, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Simon Corsia
- Orthopaedic Department, Cochin University Hospital, APHP Paris, Paris Descartes University, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Philippe Leclerc
- Orthopaedic Department, Croix St Simon Hospital, 125 rue d'Avron, 75020, Paris, France
| | - Philippe Anract
- Orthopaedic Department, Cochin University Hospital, APHP Paris, Paris Descartes University, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Guillaume Auberger
- Orthopaedic Department, Croix St Simon Hospital, 125 rue d'Avron, 75020, Paris, France
| |
Collapse
|
27
|
Chen F, An Z, Zhou F, Fan J, Gao W, Chen Z. [Comparison of the effectiveness of the posterior malleolus fixed or not on treatment of different Haraguchi's classification of posterior malleolus fractures]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:722-728. [PMID: 34142499 DOI: 10.7507/1002-1892.202012114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To investigate the effectiveness of fixation the posterior malleolus or not to treat different Haraguchi's classification of posterior malleolus fractures. Methods The clinical data of 86 trimalleolar fracture patients who were admitted between January 2015 and September 2019 and met the selection criteria were retrospectively reviewed. There were 29 males and 57 females; the age ranged from 26 to 82 years with a mean age of 55.2 years. According to Haraguchi's classification, 38 patients were in type Ⅰ group, 30 patients in type Ⅱ group, and 18 patients in type Ⅲ group. There was no significant difference in the general data such as gender, age, and fracture location among the 3 groups ( P>0.05). The fixation of the posterior malleolus was performed in 23, 21, and 5 patients in type Ⅰ, Ⅱ, and Ⅲ groups, respectively. The operation time, fracture healing time, full weight-bearing time, postoperative joint flatness, and joint degeneration degree of the patients in each group were recorded and compared. The American Orthopedic Foot and Ankle Society (AOFAS) ankle and hindfoot score was used to evaluate ankle function, including pain, quality of daily life, joint range of motion, and joint stability. The AOFAS scores were compared between fixation and non-fixation groups in each group. Results The procedure was successfully completed by all patients in each group, and there was no significant difference in operation time ( F=3.677, P=0.159). All patients were followed up 12-36 months with a mean time of 16.8 months. At last follow-up, 6 patients were found to have suboptimal ankle planarity, including 2 patients (5.3%) in the type Ⅰ group and 4 patients (13.3%) in the type Ⅱ group, with no significant difference between groups ( χ 2=6.566, P=0.161). The ankle joints of all the patients in each group showed mild degeneration; the fractures all healed well and no delayed union or nonunion occurred. There was no significant difference in the fracture healing time and full weight-bearing time between groups ( P>0.05). No complications such as incision infection, fracture displacement, or plate screw loosening and fracture occurred during follow-up. At last follow-up, the total scores and pain scores of the AOFAS scores in the type Ⅱ group were significantly lower than those in the type Ⅰand Ⅲ groups ( P<0.05), there was no significant difference between groups in the scores for the quality of daily life, joint range of motion, and joint stability between groups ( P>0.05). There was no significant difference in any of the scores between the unfixed and fixed groups, except for the pain and quality of daily life scores, which were significantly lower ( P<0.05) in the unfixed group of type Ⅱ group than the fixed group. Conclusion Haraguchi type Ⅱ posterior malleolus fractures have a worse prognosis than types Ⅰ and Ⅲ fractures, especially in terms of postoperative pain, which can be significantly improved by fixing the posterior malleolus; the presence or absence of posterior malleolus fixation in types Ⅰ and Ⅲ has less influence on prognosis.
Collapse
Affiliation(s)
- Feng Chen
- The Second Clinical College of Zhejiang Chinese Medical University, Hangzhou Zhejiang, 310000, P.R.China
| | - Zhongcheng An
- Department of Spinal Surgery, the Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou Zhejiang, 310000, P.R.China
| | - Fang Zhou
- The Second Clinical College of Zhejiang Chinese Medical University, Hangzhou Zhejiang, 310000, P.R.China
| | - Jiajun Fan
- The Second Clinical College of Zhejiang Chinese Medical University, Hangzhou Zhejiang, 310000, P.R.China
| | - Wei Gao
- The Second Clinical College of Zhejiang Chinese Medical University, Hangzhou Zhejiang, 310000, P.R.China
| | - Zhe Chen
- Department of Spinal Surgery, the Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou Zhejiang, 310000, P.R.China
| |
Collapse
|
28
|
Ma Z, Guo S, Gao F, Wang B, Zhou X, Fu B, Xia S. [Comparison of effectiveness between plate and screw internal fixation in treatment of posterior malleolus fractures through posterolateral approach]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:431-438. [PMID: 33855826 DOI: 10.7507/1002-1892.202010030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To compare the effectiveness of posterior malleolus fractures treated by plate and screw internal fixation through posterolateral approach. Methods The clinical data of 95 patients with posterior malleolus fractures who were admitted between January 2016 and December 2019 and met the selection criteria were retrospectively analysed. They were divided into plate group (44 cases, treated with posterolateral plate internal fixation) and screw group (51 cases, treated with posterolateral screw internal fixation) according to different treatment methods. There was no significant difference in general data between the two groups of patients such as age, gender, cause of injury, side of injury, ankle fracture or injury classification, time from injury to operation, and percentage of posterior ankle fracture area to the distal tibia articular surface ( P>0.05). The operation time, hospital stay, fracture healing time, and surgical complications were compared between the two groups. Imaging examinations (X-ray film, CT scan and reconstruction) were used to assess the reduction quality of ankle fracture, articular congruity, and re-displacement in ankle fracture. At last follow-up, the pain visual analogue scale (VAS) score was used to evaluate the patients' pain, and the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was used to evaluate ankle joint function. Results Patients in both groups were followed up 6-30 months, with an average of 18.2 months. The operation time of the plate group was significantly longer than that of the screw group ( U=-2.040, P=0.041); there was no significant difference in hospital stay between the two groups ( U=-1.068, P=0.285). Incision swelling occurred in 2 cases in the plate group, sural nerve injury in 3 cases, and traumatic arthritis in 2 cases during follow-up. In the screw group, there were 1, 2, and 2 cases, respectively. The incidence of complications in the two groups (15.9% vs. 9.8%) was not significantly different ( P=0.372). All patients who underwent tibiofibular screw fixation underwent the removal of the tibiofibular screw before taking full weight bearing at 12 weeks after operation, and there was no screw fracture and retention. During the follow-up, there was no infection, re-displacement of fracture, delayed bone union or nonunion, and there was no significant difference in fracture healing time between the two groups ( t=0.345, P=0.731). There was no significant difference between the two groups of reduction quality of ankle fracture and articular congruity evaluation results ( P>0.05). At last follow-up, there was no significant difference in VAS score, AOFAS ankle-hindfoot score and evaluation grade between the two groups ( P>0.05). Conclusion Both the plate and screw internal fixation through posterolateral approach can achieve satisfied effectiveness in the treatment of posterior ankle fractures with maintenance of fracture reduction, and recovery of ankle joint function. The screw internal fixation has the advantages of minimal invasion and shorter operation time.
Collapse
Affiliation(s)
- Ziyuan Ma
- Guizhou Medical University, Guizhou Guiyang, 550004, P.R.China
| | - Shengyang Guo
- Department of Traumatic Orthopaedics, Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai, 201318, P.R.China
| | - Feng Gao
- Department of Traumatic Orthopaedics, Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai, 201318, P.R.China
| | - Bin Wang
- Department of Traumatic Orthopaedics, Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai, 201318, P.R.China
| | - Xiaoxiao Zhou
- Department of Traumatic Orthopaedics, Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai, 201318, P.R.China
| | - Beigang Fu
- Department of Traumatic Orthopaedics, Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai, 201318, P.R.China
| | - Shengli Xia
- Guizhou Medical University, Guizhou Guiyang, 550004, P.R.China.,Department of Traumatic Orthopaedics, Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai, 201318, P.R.China
| |
Collapse
|
29
|
Ochman S, Raschke MJ. [Ankle fractures in older patients : What should we do differently?]. Unfallchirurg 2021; 124:200-211. [PMID: 33566120 DOI: 10.1007/s00113-021-00953-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2021] [Indexed: 02/07/2023]
Abstract
As a result of the demographic developments ankle fractures in older patients are part of routine trauma surgery. Due to comorbidities, such as diabetes mellitus, reduced bone quality and limited compliance in follow-up treatment, these fractures are prone to complications. The primary goal in the treatment of older patients with ankle fractures is to maintain mobility. In contrast to young patients most fractures are unstable pronation-abduction injuries. In the diagnostics the recognition and optimization of factors influencing the outcome, such as the blood perfusion and the generous use of computed tomography (CT) are recommended. As in the case of younger patients, conservative treatment is reserved for stable fracture forms and, if there are contraindications, should also be initiated in the case of unstable injuries. The choice of approaches is different for surgical treatment, which is adapted to the soft tissues, if necessary minimally invasive and increasingly carried out by a posterolateral approach. The initial transfixation can reduce soft tissue problems. Special surgical techniques and implants that provide a high level of stability, such as dorsal plate positioning, hook plates, angular stable plate systems and intramedullary systems as well as additional options, such as tibia pro fibula constructs are used. Primary retrograde nail arthrodesis is reserved as a salvage procedure only for exceptional cases. As part of the follow-up treatment, an interdisciplinary approach with respect for and optimization of concomitant diseases seems to make sense.
Collapse
Affiliation(s)
- Sabine Ochman
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert Schweitzer Campus 1, Gebäude W1, Waldeyerstr. 1, 48149, Münster, Deutschland.
| | - Michael J Raschke
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert Schweitzer Campus 1, Gebäude W1, Waldeyerstr. 1, 48149, Münster, Deutschland
| |
Collapse
|