Complications following surgical treatment of posterior malleolar fractures: an analysis of 300 cases

Posterior Malleolus Fracture Fixation In Lateral Decubitus Position: Surgical Technique and Results in 60 Patients

The present study shows how posterior malleolus fractures (PMFs) and distal fibular fractures were fixed using the posterolateral approach with the patient in lateral decubitus position, not previously described in the literature. This technique has been used in 60 consecutive patients (42 women and 18 men; mean age 54.7; range 21-92 years), 33 of which presented as fracture dislocations from March, 2021 to December, 2023. After PMFs fixation in lateral decubitus position, release of the sacral support allowed patients to be placed supine (without de-sterilizing the operative field), in order to proceed with medial malleolus or posteromedial fragment fixation. Fractures were classified according to the Lauge Hansen classification as SER4 (n = 50), PER4 (n = 7), SAD (n = 1), and PAB (n = 2). Fractures were classified according to Rammelt & Bartonicek, as type B (n = 40), C (n = 13), and D (n = 7). During the same period of time 14 fractures involving the PM, classified as type A, were treated with indirect fixation, whilst 6 geriatric and/or poor mobility patients with fracture dislocations were treated with retrograde hindfoot nail fixation. Follow-up period ranged from 4-36 months (mean = 14.4; SD = 8.8). Complications occurred in 5 patients (8.3%; 3 had delayed (medial) wound healing, one developed CRPS and one required implants removal and arthroscopy because of metal irritation and stiffness). No deep infections, thromboembolic events, fracture malreductions or malunions were recorded and all patients returned to the preinjury mobilization status. In conclusion, PM fracture fixation was feasible and safely performed with patients in lateral decubitus position.

Comparison between anterior-to-posterior screw fixation versus posterolateral approach plate fixation for posterior malleous fracture: A systematic review and meta-analysis

PURPOSE

There are two main surgical fixation methods for the posterior malleolar fractures (PMFs), the anterior-to-posterior (AP) screws or via the posterolateral (PL) approach utilizing a buttress plate. This review aims to compare the clinical outcome between the AP screw fixation and the PL plate fixation for treating PMFs.

METHODS

We searched all relevant publications about PMFs treated with AP screws or PL plates through electronic databases including the PubMed, the Cochrane Library, the Embase, the Wiley online library and the Web of Science. The meta-analysis was conducted to evaluated clinical outcomes including reduction quality, post-operative function and complications.

RESULTS

Six studies (one single randomized controlled trial and five retrospective cohort studies) were enrolled. 172 patients underwent AP screw fixation and 214 patients underwent PL plate fixation with a total of 386 patients (169 males and 217 females). The PL plating group yielded better AOFAS scores(MD = 6.97, 95 % CI=[4.68, 9.27], P＜0.00001, I2 =0 %) and was more likely to achieve excellent anatomical reduction(OR=5.49, 95 % CI=[1.06, 28.42], P = 0.04, I2 =80 %). No differences were found in the bad reduction quality, incidences of complications (arthritis, neuralgia, superficial wound healing problems and implant failure), the walking VAS scores and the dorsiflexion restriction degrees.

CONCLUSION

We suggest that the PL plate fixation method has the clinical benefit of achieving anatomical reduction and better AOFAS scores over the AP screw fixation for treating PMFs. No differences were found in the incidences of complications ( arthritis, neuralgia, superficial wound healing problems and implant failure), the walking VAS scores and the dorsiflexion restriction degrees. The posterior approach and the direct reduction are recommended for the treatment of the PMFs.

LEVEL OF CONFIDENCE

Ⅱb.

Ankle fracture surgery in patients experiencing homelessness: a national evaluation of one-year rates of reoperation

Objectives

To evaluate the impact of homelessness on surgical outcomes following ankle fracture surgery.

Design

Retrospective cohort study.

Setting

Mariner claims database.

Patients/Participants

Patients older than 18 years who underwent open reduction and internal fixation (ORIF) of ankle fractures between 2010 and 2021. A total of 345,759 patients were included in the study.

Intervention

Study patients were divided into two cohorts (homeless and nonhomeless) based on whether their patient record contained International Classification of Disease (ICD)-9 or ICD-10 codes for homelessness/inadequate housing.

Main Outcome Measures

One-year rates of reoperation for amputation, irrigation and debridement, repeat ORIF, repair of nonunion/malunion, and implant removal in isolation.

Results

Homeless patients had significantly higher odds of undergoing amputation (adjusted odds ratio [aOR] 1.59, 95% confidence interval [CI] 1.08-2.27, P = 0.014), irrigation and debridement (aOR 1.22, 95% CI 1.08-1.37, P < 0.001), and repeat ORIF (aOR 1.16, 95% CI 1.00-1.35, P = 0.045). Implant removal was less common in homeless patients (aOR 0.65, 95% CI 0.59-0.72, P < 0.001). There was no significant difference between homeless and nonhomeless patients in the rate of nonunion/malunion repair (aOR 0.87, 95% CI 0.63-1.18, P = 0.41).

Conclusions

Homelessness is a significant risk factor for worse surgical outcomes following ankle fracture surgery. The findings of this study warrant future research to identify gaps in surgical fracture care for patients with housing insecurity and underscore the importance of developing interventions to advance health equity for this vulnerable patient population.

Level of Evidence

Prognostic Level III.

Joint-Preserving Osteotomy of the Lateral Tibial Plafond for Posttraumatic Osteonecrosis: A Prospective Cohort Study

BACKGROUND

Posttraumatic osteonecrosis (ON) of the lateral distal tibia is a rare but severe complication of malleolar fractures. Treatment options include ankle fusion, arthroplasty, osteotomy, and drilling but clinical data on outcomes are limited to single case reports. The aim of this study was to prospectively evaluate the outcome following joint-preserving reconstruction.

METHODS

Over a 10-year period, 10 patients (8 females and 2 males, average age 36 years; range, 27-68 years) with posttraumatic ON were treated with intra-articular osteotomy of the distal tibia and bone grafting. All patients initially sustained a closed pronation injury, 7 with initial tibiotalar subluxation. Chronic syndesmotic instability following initial treatment was present in 4 patients and 5 were smokers. All patients were followed for a median of 68 (range, 12-103) months, 7 returned in person for clinical and radiographic follow-up.

RESULTS

No immediate postoperative complications were seen. Secondary ankle fusion was necessary in 1 case (10%) because of progressive osteoarthritis. At the time of follow-up, anterior ankle arthritis leading to impingement and requiring cheilectomy was noted in 4 cases, partial graft necrosis, and secondary syndesmotic instability requiring revision surgery was seen in 1 case each. Compared with the preoperative values, significant improvement in the Olerud-Molander Ankle Score (P = .012), EuroQuol-5 Score (P = .008), and Foot Function Index (FFI-D pain, P = .028; FFI-D restriction, P = .038) was seen. Average range of motion at the ankle was 45 degrees.

CONCLUSION

In our limited series of patients with posttraumatic ON of the lateral distal tibia, we found that joint-preserving reconstruction using an intra-articular distal tibial osteotomy with autologous bone grafting usually provided significant functional improvement and pain relief. In our cohort secondary fusions by a median 5.5-year follow-up were rare, but secondary, joint-sparing surgeries were common.

LEVEL OF EVIDENCE

Level III, prospective study.

Incidence and Risk Factors for Surgical Site Infection in Ankle Fractures: An Observational Study of 480 Patients in Sweden

INTRODUCTION

Surgical site infection (SSI) is a frequently reported complication after ankle fracture surgery. To our knowledge, no study has been conducted on its incidence in Sweden. The present study aimed to determine the incidence of, risk factors for, and most common causative pathogen of SSI.

METHODS

Patients who underwent primary surgery for an ankle fracture between 1 September 2017 and 31 August 2019 at the Sahlgrenska University Hospital were identified. Data on potential SSI risk factors and clinical outcome (infected/non-infected) were retrieved from medical records. Cox regression analysis and descriptive statistics were used.

RESULTS

Of the 480 reviewed patients, 49 developed SSI (10.2%), of which 35 (7.3%) were superficial and 14 (2.9%) were deep. Open fractures (p < 0.001) and age (p = 0.016) were statistically significant risk factors for SSI in the univariate analysis. In the multivariable analysis, only open fracture was statistically significant (HR = 3.0; 95% C.I. = 1.3-6.9, p = 0.013). Cases of Staphylococcus aureus (S. aureus) were most common (n = 12, 24.5%). Methicillin resistance was uncommon (n = 2, 4.1%).

CONCLUSIONS

An incidence of 10.2% was established, which is comparable to international findings. Infection monitoring is an important part of tackling the global challenge of antibiotic resistance. Future prospective studies to further establish risk factors are warranted to decrease the incidence of SSI.

Current concepts in ankle fractures

Ankle fractures are among the most common orthopaedic injuries. Operative management is performed in unstable ankle fracture patterns to restore the stability and native kinematics of the ankle mortise and minimize the risk of post-traumatic degenerative changes. In this study, we review current concepts in ankle fracture management, including posterior malleolus fixation, syndesmosis fixation, deltoid ligament repair, fibular nailing, and early weightbearing, from both a biomechanical and clinical perspective.

Ankle Fractures in Diabetic Patients: A Critical Analysis

»

Patients with diabetes are at higher risk for complications after surgical fixation of unstable fractures due to impaired neurovascular functioning and wound-healing capabilities.

»

Patients with uncontrolled diabetes have higher rates of complications when compared with patients with controlled diabetes.

»

Despite higher rates of complications, operative fixation of unstable ankle fractures in diabetic patients reliably leads to a functional lower extremity with an overall lower rate of complications than nonoperative management.

»

Operatively and nonoperatively managed ankle fractures in patients with diabetes should remain non-weight-bearing for an extended period of time.

»

Discussion of risk of poor outcomes including deep infection, loss of reduction, return to the operating room, and risk of arthrodesis or amputation should be explicitly discussed with patients and families when managing unstable ankle fractures in diabetic patients.