Open Reduction and Internal Fixation of Posterior Malleolus Fractures via a Posteromedial Approach

Direct fixation of posterior malleolus fractures-posterolateral or posteromedial approach?

Ankle fractures involving the posterior malleolus (PM) generally have worse prognosis. There is a trend towards it's direct fixation, yet the exact indications are a subject of debate. The purpose of our study was to present our treatment protocol and to discuss the advantages and limitations of the direct posterolateral and posteromedial approaches. We present a prospective series of 35 ankle fractures involving the PM, operated for a period of 4 years (2018-2022). Direct posterolateral approach was used in 20 ankles, 15 were operated via a posteromedial approach. Clinical and functional assessment was performed according to the criteria of AOFAS. 14 patients received an excellent score, 16 had good and the rest had an average score. The overall score was 85,4 (54-100). The average range of motion was 50° (15°-55°).Eight patients had superficial skin necrosis along the surgical incision. Thirteen patients need their fibular plates removed due to local irritation. Five patients, operated through a posterolateral approach, had lateral heel numbness suggestive of a sural nerve disfunction. PM is important for normal ankle kinematics. When it's direct fixation is considered appropriate, the safest and shortest route is optimal. It is determined by the preoperative CT. The posterolateral approach is more versatile, but lead to more complications in our study.

Posteromedial Surgical Approach for Fixation of Haraguchi Type 2B Posterior Malleolar Fracture

SUMMARY

A case of a 26-year-old man with a displaced medial malleolus fracture with extension into the posteromedial aspect of the posterior malleolus is presented. A CT scan of the ankle is obtained demonstrating a Haraguchi type 2B posterior malleolus fracture with a posteromedial and posterolateral fragment. The posteromedial fragment extends into the posterior colliculus of the medial malleolus and has a subchondral impaction fracture. There is also a 1 × 1 cm piece of the articular surface of the posterior malleolus that has flipped 90 degrees and lodged itself between the posterolateral fracture fragment. This video overview and case presentation demonstrates a posteromedial approach with fixation strategy for the posterior malleolus.

Fracture gap of the lateral malleolus via posterolateral approach: Improved visualization of the posterior malleolus fracture

The treatment of posterior malleolar fractures is a popular issue. Anatomic reduction of posterior malleolar fractures is critical for re-establishing the stability of the ankle mortise and ligamentous union after trauma. Inappropriate treatment ultimately leads to poorer functional outcomes and lower quality of life. Open reduction and internal fixation through a posterolateral approach are preferred over indirect reduction and anterior-posterior screw fixation. Although the posterolateral approach, which is more common and direct, provides good exposure to the fracture site, it has some limitations. In this report, we describe the posterolateral approach through the lateral ankle fracture gap for the treatment of posterior ankle fractures. Moreover, we discuss the indications, benefits, and limitations of this approach.

Clinical Outcomes for Pilon Variant Posterior Malleolar Fractures: A Multicenter Retrospective Analysis

Currently, there is no consensus on surgical approach for posterior malleolar fracture fragments with significant posteromedial involvement. The Bartonicek type III/Haraguchi type II posterior malleolar morphologies typically involve large posteromedial fragments, behaving like a pilon injury and have been reported as pilon variant fractures. We performed a retrospective chart review at 2 large healthcare institutions, evaluating patients that underwent surgical management of pilon variant posterior malleolar fractures and determining clinical outcomes including: time to union, union rates, soft tissue complications, infection and time to weight bearing. A total of 68 patients were included (51 females, 17 males). A total of 51 direct (19 posterolateral, 31 posteromedial), 6 indirect, and 11 no-fixation approaches were identified. Significantly different time-to-union was found between direct fixation (mean = 85.1 days), indirect fixation (mean = 74 days) and no-fixation (mean = 174.3 days) (p < .001). A posteromedial approach (mean = 63.0 days, SD = 16.6) was associated with significantly shorter time to union when compared to a posterolateral approach (mean = 124.8 days, SD = 59.4; p < .001). Fixation (direct or indirect) was associated with significantly increased likelihood of union of the overall ankle fracture pattern (52/57 = 91%) when compared to no fixation of the posterior malleolar component (9/14 = 64%), p = .01. Patients who underwent direct fixation had significantly lower incidence of neurovascular damage (6%) when compared to patients who underwent indirect fixation (33%) or no-fixation (29%) (p = .02). There was no significant difference between the groups in terms of tendon damage (p = .54), infection rates (p = .45) and time to weight bearing (p = .66). The authors suggest that surgical management and specifically direct approaches have better outcomes in the short-term follow up.

The Association Between Lateral Radiographs and Axial Computed Tomography of Posterior Malleolar Fractures as a Tool for Predicting Medial Malleolar Extension: A Multi-Center Retrospective Analysis

Posterior malleolar fractures are often part of complex ankle fracture patterns. Radiographs and computed tomography are often obtained in the preoperative setting. In this study, we compared measurements from lateral ankle radiographs with measurements on axial computed tomography. We hypothesize that there is an association between measurements taken on lateral XR and certain fracture morphology such as medial extension and that measurements taken on lateral XR can be used to predict likelihood of medial extension type fractures. A multi-center retrospective analysis was performed involving patients with trimalleolar ankle fractures treated at two large urban healthcare systems ranging from January 1, 2010 to November 1, 2019. A total of 279 patients met criteria including 186 females and 93 males aged 18 to 90 with an average age 55. Four reviewers measured continuous variables on lateral radiograph and axial computed tomography: posterior malleolus fracture height, articular surface length, medial-lateral width, and anterior-posterior depth and then agreement was assessed via intraclass correlation coefficient. Pearson correlations were calculated for all pairwise combinations of measurements. Two fracture classification systems were then evaluated for association with the continuous variables. Lateral height was divided into quartiles and analyzed for the degree of association. Positive correlation was found between lateral height and axial depth/axial width. Taller lateral height values were statistically associated with medial extension type fractures. Lateral height 24.5mm-29.5mm is 3.1x higher, and lateral height >29.5mm is 8.6x more likely to have medial extension when compared to shorter lateral heights(<20.5mm). Based on these findings we suggest increased usage of pre-operative CT and evaluation for the use of posteromedial approaches in the setting of taller lateral height fracture patterns(>24.5mm) as seen on lateral XR.

Trimalleolar fracture: The endless posterior malleolus fracture debate, to repair or not to repair?

Ankle fracture is one of the most common fractures presenting in the emergency department. The fracture varies from unimalleolar, bimalleolar or trimalleolar. Involvement of the posterior malleolus is common and ranges from small avulsions to large intraarticular fragments causing subluxation of the talus. If left untreated, the resulting step-off, comminution or posterior talar subluxation may lead to osteoarthritis and further disability. To date, no consensus exists regarding the management of posterior malleolus fractures in the set-up of trimalleolar fractures. In this review we provide an overview of the literature on the available treatment options for posterior malleolar fracture in the set-up of trimalleolar fractures.