Posterior Malleolar Fractures: Changing Concepts and Recent Developments

Computed tomography changes diagnosis, management and surgical planning of ankle fractures

PURPOSE

To demonstrate how the use of adjunctive Computed Tomography (CT) can modify diagnosis, treatment options, and operative planning of ankle fractures in comparison with conventional radiographs (CR) in isolation.

MATERIALS AND METHODS

A total of 53 patients diagnosed with an ankle fracture between 2011 and 2016, were assessed with CT and CR. Evaluations of the fractures using CR in isolation and CR combined with CT were compared using different readers. Fractures were assessed in terms of type, displacement, size, associated injuries, treatment, patient position and surgical planning.

RESULTS

The medial malleolus fractures characteristics (posteromedial fragment and anterior colliculus), the presence of posterior malleolus fracture and its characteristics (displacement, size, posteromedial or posterolateral segment) (ps < 0.042), syndesmosis injury (p < 0.001), and the absence of deltoid ligament lesion (p < 0.001), were more evident with the combination of CT and radiographs. There was an increase in operative indication (p = 0.007), prone positioning (p = 0.002), posterior malleolus surgical treatment (p < 0.001), posterolateral approach for the lateral malleolus (p = 0.003), and syndesmosis fixation (p = 0.020) with the association of CT and CR, among all groups of expertise, with a high interobserver reliability (> 0.75).

CONCLUSIONS

The CR may fail to demonstrate subtle lesions, such as posterior malleolus fractures and syndesmotic injuries. The CT evaluation increases the diagnostic precision and improves the quality of information the surgeon receives, what might positively affect patient care.

LEVEL OF EVIDENCE III

Retrospective Comparative Study.

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.

Advancing treatment strategies for posterior malleolar malunion: The ankle dislocation method

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.

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

Background

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

Methods

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

Results

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

Conclusion

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

Level of Evidence

Level IV, descriptive pilot study.

Importance of computed tomography in posterior malleolar fractures: Added information to preoperative X-ray studies

BACKGROUND

Ankle fractures are common lesions of the lower limbs. Approximately 40% of ankle fractures affect the posterior malleolus (PM). Historically, PM osteosynthesis was recommended when PM size in X-ray images was greater than 25% of the joint. Currently, computed tomography (CT) has been gaining traction in the preoperative evaluation of ankle fractures.

AIM

To elucidate the similarity in dimensions and to correlate PM size in X-ray images with the articular surface of the affected tibial plafond in the axial view on CT (AXCT) of a PM fracture.

METHODS

Eighty-one patients (mean age: 39.4 ± 13.5 years) were evaluated (54.3% were male). Two independent examiners measured PM size in profile X-ray images (PMXR) and sagittal CT (SAGCT) slices. The correlation of the measurements between the examiners and the difference in the PM fragment sizes between the two images were compared. Next, the PM size in PMXR was compared with the surface of the tibial plafond involved in the fracture in AXCT according to the Haraguchi classification.

RESULTS

The correlation rates between the examiners were 0.93 and 0.94 for PMXR and SAGCT, respectively (P < 0.001). Fragments were 2.12% larger in SAGCT than in PMXR (P = 0.018). In PMXR, there were 56 cases < 25% and 25 cases ≥ 25%. When PMXR was < 25%, AXCT corresponded to 10.13% of the tibial plafond. When PMXR was ≥ 25%, AXCT was 24.52% (P < 0.001). According to the Haraguchi classification, fracture types I and II had similar PMXR measurements that were greater than those of type III. When analyzing AXCT, a significant difference was found between the three types, with II > I > III (P < 0.001).

CONCLUSION

PM fractures show different sizes using X-ray or CT images. CT showed a larger PM in the sagittal plane and allowed the visualization of the real dimensions of the tibial plafond surface.

Plain X-ray is insufficient for correct diagnosis of tibial shaft spiral fractures: a prospective trial

PURPOSE

Tibial shaft spiral fractures and fractures of the distal third of the tibia (AO:42A/B/C and 43A) frequently occur with non-displaced posterior malleolus fractures (PM). This study investigated the hypothesis that plain X-ray is not sufficient for a reliable diagnosis of associated non-displaced PM fractures in tibial shaft spiral fractures.

METHODS

50 X-rays showing 42A/B/C and 43A fractures were evaluated by two groups of physicians, each group was comprised of a resident and a fellowship-trained traumatologist or radiologist. Each group was tasked to make a diagnosis and/or suggest if further imaging was needed. One group was primed with the incidence of PM fractures and asked to explicitly assess the PM.

RESULTS

Overall, 9.13/25 (SD ± 5.77) PM fractures were diagnosed on X-ray. If the posterior malleolus fracture was named or a CT was requested, the fracture was considered "detected". With this in mind, 14.8 ± 5.95 posterior malleolus fractures were detected. Significantly more fractures were diagnosed/detected (14 vs. 4.25/25; p < 0.001/14.8 vs. 10.5/25; p < 0.001) in the group with awareness. However, there were significantly more false positives in the awareness group (2.5 vs. 0.5; p = 0.024). Senior physicians recognized slightly more fractures than residents (residents: 13.0 ± 7.79; senior physicians: 16.5 ± 3.70; p = 0.040). No significant differences were demonstrated between radiologists and trauma surgeons. The inner-rater reliability was high with 91.2% agreement. Inter-rater reliability showed fair agreement (Fleiss-Kappa 0.274, p < 0.001) across all examiners and moderate agreement (Fleiss-Kappa 0.561, p < 0.001) in group 2.

CONCLUSION

Only 17% of PM fractures were identified on plain X-ray and awareness of PM only improved diagnosis by 39%. While experiencing improved accuracy, CT imaging should be included in a comprehensive examination of tibial shaft spiral fractures.

LEVEL OF EVIDENCE

II. Diagnostic prospective cohort study.

TRAIL REGISTRATION NUMBER

DRKS00030075.

Enhancing Consistency in Posterior Malleolus Fracture Classification: A Comprehensive Interobserver Reliability Study With 20 Raters Using the Mason & Molloy Classification

INTRODUCTION

Over the past decade, there has been a growing interest in the identification and treatment of posterior malleolus fragments, driven by a better understanding of their significance. The Mason & Molloy (M&M) classification system has emerged as a valuable tool for systematically categorizing these fractures and assisting clinicians in formulating treatment. We aim to assess the interobserver reliability of the M&M classification for posterior malleolus fracture by using 20 raters.

METHODOLOGY

The study was conducted at a major foot and ankle referral center in Wythenshawe, Manchester, UK. Thirty-eight Computed Tomography (CT) scans were evaluated by 20 independent raters: 15 general orthopedic and trauma surgeons plus five foot and ankle surgeons. Each rater classified the posterior malleolus fracture according to M&M classification into type 1, 2A, 2B, 3, or not classifiable. Statistical analysis was done with the R software package and SPSS (v26; IBM Corp., Armonk, NY). Fleiss kappa (κ) coefficient with a 95% confidence interval (CI) was applied.

RESULTS

The interobserver agreement was moderate with a global κ value of 0.531 (95% CI: 0.518, 0.544). There were good agreements for identifying type 3 M&M (κ=0.785) and those that are not applicable for M&M classification (κ=0.785). There was a strong correlation between all raters in using M&M classification (Tb=0.53-0.59) except for Rater 12.

CONCLUSION

M&M classification remains a valuable tool to guide the management of patients with these subsets of ankle fractures.

Safety of the modified posteromedial approach in complex ankle fractures: Comparative analysis versus posterolateral access

INTRODUCTION

The aim of the study was to evaluate the safety of the modified posteromedial approach (MfPM) in the surgical management of complex ankle fractures in terms of local complications.

METHODS

Retrospective multicenter review of a series of malleolar fractures surgically treated by posterior ankle approaches between 2016 and 2022. Two approaches were used. In the MfPM group patients were placed in a prone position and the incision was made 1 cm medially to the Achilles tendon. In the posterolateral access (PL) group patients were placed in a prone or lateral decubitus position and the incision was made between the lateral malleolus and the Achilles tendon. Complications evaluated were divided into wound complications, infections, neuritis, vascular alterations and others.

RESULTS

81 ankle fractures with a posterior malleolar fragment treated by open reduction and internal fixation were identified. 20 cases were approached through the MfPM approach and 61 through the PL access. The mean follow up was 18.60 months (range 4-78 months). In the MfPM group the local complication rate was 10% (2/10 patients), both corresponding to minor wound problems which required no surgical intervention. No infection or other neural or vascular complications were found. In the PL group a complication rate of 8,19% (5/61 patients) was found, all of them corresponding to minor wound problems which required no surgical intervention. No infection or other neural or vascular complications were found. There were no significant differences between the two approaches regarding postoperative local complications (z score 0.249 - P: 0.803).

CONCLUSION

The MfPM approach is safe and may become as readily used as the PL due to the low incidence of postoperative local complications, especially in fractures with a large fragment and posteromedial extension in which greater access to the posterior pilon can facilitate instrumentation for anatomic reduction and fixation.

Syndesmosis dislocation and ankle ligament stress in the posterior malleolus fracture fixated - "in vitro analysis"

PURPOSE

The objectives of this study were to compare syndesmosis dislocation and ankle ligament stress after the fixation of the posterior malleolus fracture (PMF) with four different techniques by Finite Element Analysis (FEM).

METHODS

Four internal fixation techniques used for fixation of PMF were assessed by FEM: posterior one-third tubular 3.5 mm buttress plate (PP) with one screw (PP 1 screw), PP with two screws (PP 2 screws), two cannulated 3.5 mm lag screws in the anteroposterior (AP) direction (AP lag screws), and two posteroanterior (PA) cannulated 3.5 mm lag screws (PA lag screws). PMF with 30% fragment size was simulated through computational processing reconstructed from computed tomography (CT). The simulated loads of 700 N and 1200 N were applied to the proximal tibial end. The FEM evaluated the syndesmosis dislocation (mm) and stress values of the posterior tibiofibular ligament (PTFL) (in Kpa) and deltoid ligament (in Kpa) in the four mentioned subgroups.

RESULTS

We found that with a load of 700 N, syndesmosis dislocation varied from 6.5 to 7.9 mm, being the lowest and greatest for PA lag screw and PP 1 screw, respectively. In all groups was observed a greater dislocation in the syndesmosis at 1200 N of load. We observed that the stress values on the PTFL were lower for AP lag screws and PP 2 screws with 700 N and 1200 N, respectively. For both loads, PP 1 screw presented the greatest stress. Regarding the stress in the deltoid ligament, the AP lag screws presented the lowest stress for 700 N and PP 1 screw for 1200 N. For all fixation techniques, the syndesmosis displacement and ligament stresses were higher when 1200 N were imposed.

CONCLUSION

This study demonstrated that PMF fixed with lag screws presents greater stability in the distal tibiofibular syndesmosis and higher joint loadings promoted greater displacement and ligaments stress, regardless of the fixation technique. Besides, lower stress in the syndesmosis is accompanied by a greater load on the deltoid ligament.

Locking versus nonlocking plates for the treatment of posterior malleolar ankle fractures: A retrospective cohort study and cost analysis

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.

Posterolateral approach for posterior malleolus fixation in ankle fractures: functional and radiological outcome based on Bartonicek classification

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.

Classifications of posterior malleolar fractures: a systematic literature review

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.

Ligament Ruptures in Ankle Fractures-Was Lauge-Hansen Right?

The contribution of Lauge-Hansen to the understanding and treatment of ankle fractures cannot be underestimated, an unquestionable merit being the analysis of the ligamentous component of these injuries that are considered as equivalent to the respective malleolar fractures. In numerous clinical and biomechanical studies, the lateral ankle ligaments are ruptured either together with or instead of the syndesmotic ligaments, as predicted by the Lauge-Hansen stages. A ligament-based view on malleolar fractures may deepen the understanding of the mechanism of injury and lead to a stability-based evaluation and treatment of the 4 osteoligamentous pillars (malleoli) at the ankle.

Clinical effects of 3D printing-assisted posterolateral incision in the treatment of ankle fractures involving the posterior malleolus

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.

Instability of the distal tibiofibular syndesmosis

The distal tibiofibular syndesmosis (DTFS) is more frequently injured than previously thought. Early diagnosis and appropriate treatment is essential to avoid long term complications like chronic instability, early osteoarthritis and residual pain. Management of these injuries require a complete understanding of the anatomy of DTFS, and the role played by the ligaments stabilizing the DTFS and ankle. High index of suspicion, appreciating the areas of focal tenderness and utilizing the provocative maneuvers help in early diagnosis. In pure ligamentous injuries radiographs with stress of weight bearing help to detect subtle instability. If these images are inconclusive, then further imaging with MRI, CT scan, stress examination under anesthesia, and arthroscopic examination facilitate diagnosis. An injury to syndesmosis frequently accompanies rotational fractures and all ankle fractures need to be stressed intra-operatively under fluoroscopy after fixation of the osseous components to detect syndesmotic instability. Non-operative treatment is appropriate for stable injuries. Unstable injuries should be treated operatively. Anatomic reduction of the syndesmosis is critical, and currently both trans-syndesmotic screws and suture button fixation are commonly used for syndesmotic stabilization. Chronic syndesmotic instability (CSI) requires debridement of syndesmosis, restoration of ankle mortise with or without syndesmotic stabilization. Arthrodesis of ankle is used a last resort in the presence of significant ankle arthritis. This article reviews anatomy and biomechanics of the syndesmosis, the mechanism of pure ligamentous injury and injury associated with ankle fractures, clinical, radiological and arthroscopic diagnosis and surgical treatment.

[Translated article] Posterior malleolar fractures: Indications and surgical approaches

Posterior malleolus fractures are frequent injuries, present in 7-44% of all ankle fractures. The objective of this study is to review the evidence to indicate the fixation of this fracture and to choose the appropriate surgical approach. The classic indications for fixation were fragment size greater than 25-30% of the articular surface and displacement greater than 2mm. However, current evidence suggests that, rather than size, factors such as syndesmotic instability, intra-articular step-off greater than 1-2mm, plafond impaction and the presence of intercalary fragments should be considered. When comparing the different surgical approaches, the literature supports the use of posterior approaches and reserves the recommendation of the traditional approach for exceptional cases. For the treatment of this injury it is essential to know the anatomy of the ankle and to consider all the factors described above, in addition to the presence of concomitant injuries.

Posterior malleolar fractures: Indications and surgical approaches

Posterior malleolus fractures are frequent injuries, present in 7-44% of all ankle fractures. The objective of this study is to review the evidence to indicate the fixation of this fracture and to choose the appropriate surgical approach. The classic indications for fixation were fragment size greater than 25-30% of the articular surface and displacement greater than 2 mm. However, current evidence suggests that, rather than size, factors such as syndesmotic instability, intra-articular step-off greater than 1-2 mm, plafond impaction and the presence of intercalary fragments should be considered. When comparing the different surgical approaches, the literature supports the use of posterior approaches and reserves the recommendation of the traditional approach for exceptional cases. For the treatment of this injury it is essential to know the anatomy of the ankle and to consider all the factors described above, in addition to the presence of concomitant injuries.

Plate versus screws fixation for the posterior malleolar fragment in trimalleolar ankle fractures

BACKGROUND

The fixation methods of posterior malleolar fracture (PMF) in trimalleolar ankle fractures is still controversial. We aim to compare clinical and radiological outcomes between plate fixation and screws fixation for PMF in trimalleolar ankle fractures.

METHODS

Literature search was performed through PubMed, EMBASE, Cochrane Library and CNKI database from databases inception to May 2022 to identify randomized controlled trial (RCT) and comparative clinical study in English or Chinese. A meta-analysis was performed using RevMan 5.1 software, and systematic review was performed when the data extracted from included studies could not be synthesized.

RESULTS

Two RCTs and six cohort studies were included. The meta-analysis results showed that articular step-off or gap in plate fixation was superior to antero-posterior screws fixation (RR = 0.28; 95%CI: 0.11, 0.76; P = 0.01). there were no significant differences in American Orthopaedic Foot & Ankle Society scores (MD = -0.19; 95%CI: -2.43, 2.05; P = 0.87), arthritis (RR = 1.67; 95%CI: 0.61, 4.55; P = 0.32), infection and total complication (RR = 1.42; 95%CI: 0.89, 2.25; P = 0.14).

CONCLUSION

Plate fixation might have better articular step-off or gap, compared with "A to P" screws fixation for the posterior malleolus in trimalleolar ankle fractures. Screw fixation could achieve shorter surgical time than plate fixation. However, no significant differences were found in AOFAS scores, arthritis, infection, sural nerve injury and total complication during the comparisons.

Variation in posterior fragment fixation in the Netherlands: a nationwide study

PURPOSE

The treatment of the posterior fragment in trimalleolar fractures differs from hospital to hospital in the Netherlands. A nationwide survey was performed to evaluate the fixation criteria and practice variation.

METHODS

An online cross-sectional survey amongst (orthopaedic) trauma surgeons was performed in the Netherlands. It consisted of three sections: a general section, a section showing preoperative images of six cases and a section with postoperative images of nine cases.

RESULTS

A total of 151 surgeons completed the online survey. 45% of the respondents indicated that they fixated the posterior fragment if smaller than 25% of the intra-articular surface. 48% preferred an open posterior approach to fixate the posterior fragment. There was good consensus in treatment for the two cases with Bartonicek type 4 fractures (operative treatment in 73 and 72% respectively). Little consensus was found for Bartonicek type 2 and 3 fractures (88% opted for operative treatment in one case, but 89% for conservative treatment in the second case). Reoperation was mostly considered in cases with a step-off of more than 1 mm (by 33-38% of the respondents). There was great variation in the choice of treatment if only the size of the posterior fragment was considered. Other fixation criteria such as postoperative step-off or instability after fixation of the lateral and medial malleoli are taken into account. In cases where fixation was needed, a percutaneous approach and an open posterolateral approach were equally preferred.

CONCLUSIONS

There is much variation in treatment of the posterior malleolar fracture amongst orthopaedic and trauma surgeons in the Netherlands. The percutaneous approach and open posterolateral approach to fixate the posterior malleolar fracture seem to be equally used in the Netherlands. Still, there is no uniformity in treatment of posterior malleolar fracture, especially for Bartonicek 2 and Bartonicek 3 fractures. Reoperation is considered by less than half of the surgeons in case of postoperative persistent step-off of more than 1 mm.

Single lateral approach for open reduction and internal fixation of posterior malleolar fragment in Weber B rotational ankle fracture

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.

Posterior to anterior malleolar extended lateral approach to the ankle (PAMELA): early results of a novel approach

INTRODUCTION

In a previous cadaveric study, we described the Posterior to Anterior Malleolar Extended Lateral Approach (PAMELA) to address complex ankle fractures. It was demonstrated to provide optimal exposure of the posterior and lateral malleoli, and of the anterolateral portion of the ankle through a single incision. The aim of this study is to report the clinical results of this novel approach.

METHODS

Between January 2019 and January 2021, all patients presenting with a complex ankle fracture in our institution were assessed by CT scan. Indication to use the PAMELA was determined by the fracture pattern, according to our previous guidelines, including combination of complex lateral and displaced posterior malleolar fractures, associated in most cases with anterolateral fracture avulsion. The approach was performed according to the steps previously described. Intraoperative evaluation included quality of exposure, ease of performing the osteosynthesis, and any complication encountered. The postoperative course was assessed for wound healing, quality of reduction, and the occurrence of any complication.

RESULTS

The PAMELA was performed in 20 patients (aged 17-73). The most common combination of fractures was a comminuted lateral malleolus fracture associated with a displaced fracture of the posterior malleolus and a Wagstaffe-Le Fort or Chaput avulsion. We encountered no intraoperative complication. X-rays showed anatomical reduction in all cases. Postoperative complications included three delayed wound healing resolved with local treatment and one sural nerve traction injury.

CONCLUSIONS

The main potential concern regarding this novel approach was the healing of the flap. Our results reject this concern and are in line with wound healing complications reported following surgical treatment of ankle fractures. This study confirms the safe in vivo feasibility of the PAMELA and opens a new perspective in the optimal management of complex fractures of the ankle. A larger prospective clinical study is ongoing in our institution.

Intercalary fragments in posterior malleolar fractures: incidence, treatment implications, and distribution within CT-based classification systems

Introduction

Complex ankle fractures frequently include the posterior malleolus (PM). Despite advances in diagnostic and treatment strategies, PM fracture involvement still predisposes to worse outcomes. While not incorporated into the most common PM fracture classifications, the presence of an intercalary fragment (ICF) complicates treatment. This study aims to describe the incidence, morphology, and location of ICFs in PM fractures.

Materials and methods

A total of 135 patients with a mean age of 54.4 (SD ± 18.9) years and PM fractures were analyzed for the presence of an ICF. Patients with an ICF were compared to those without in terms of age, gender, and treatment received. Characteristics of the ICFs in terms of location and size were assessed. Furthermore, the presence of an ICF in relation to the PM fracture classification according to Haraguchi et al., Bartoníček/Rammelt et al., and Mason et al. was investigated.

Results

ICFs presented in 55 (41%) of the 135 patients. Patients with an ICF were younger, and the PM was more often operatively treated when compared to patients without an ICF. A posterolateral approach was used significantly more often in patients with an ICF. Almost all ICFs were found in the posterolateral (58%) and posterocentral (35%) regions. The majority of fragments were found in Bartoníček/Rammelt type 2 fractures, the most common fracture type. Bartoníček/Rammelt type 3 fractures had the highest relative frequency of ICFs.

Conclusion

ICFs are frequently found in PM fractures; however, they are not incorporated into any of the common classifications. They are generally found in younger patients and associated with more complex PM fractures. As they can complicate reduction of the main fragment and may require direct exposure to restore joint congruency, ICFs should be considered in PM fracture classifications. Due to their location, the majority of ICFs are able to be accessed using a posterolateral approach.

Arthroscopic handlebar technique for the treatment of posterior malleolar fractures

Treating posterior malleolar fractures of the ankle remains a challenge. The arthroscopic handlebar technique is our novel surgical method used for reduction and fixation of posterior malleolar fractures and involves the restoration of posterior malleolar fractures under anterior arthroscopic guidance and the use of Kirschner wires that penetrates the fractured posterior malleolus. Arthroscopy enables visualization of the intra-articular fracture of the posterior malleolus, and a handlebar reduction bar is used to control the fractured posterior malleolus. The arthroscopic handlebar technique is a promising procedure for reduction and internal fixation of the posterior malleolar fractures.

A retrospective study of deltoid ligament repair versus syndesmotic fixation in lateral malleolus fracture combined with both deltoid ligament injury and inferior tibiofibular syndesmotic disruption

Background

To compare clinical outcomes of deltoid ligament repair versus syndesmotic fixation in lateral malleolus fracture combined with both deltoid ligament injury and inferior tibiofibular syndesmotic disruption.

Methods

Patients diagnosed with lateral malleolus fracture combined with both deltoid ligament injury and inferior tibiofibular syndesmotic disruption who received open reduction and internal fixation (ORIF) were retrospectively reviewed. Seventy-eight patients were enrolled into the study, including 40 patients treated with lateral malleolus fracture ORIF and trans-syndesmotic fixation, and 38 patients treated with lateral malleolus fracture ORIF and deltoid ligament repair. Basic information and pre- and postoperative radiological materials were reviewed. Visual analog pain scale (VAS) score, Olerud-Molander score, and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale were used for evaluating pain control and functional recovery postoperatively at different time points.

Results

No complication was reported in both groups. In the trans-syndesmotic fixation group, all patients received syndesmotic screw removal 6-8 weeks postoperatively. The Olerud-Molander score and AOFAS Ankle-Hindfoot Scale in the deltoid ligament repair group were higher than the trans-syndesmotic fixation group 3 months after operation. No statistical difference was found between the two groups in VAS score from 1 to 12 months postoperatively.

Conclusions

Lateral malleolus fracture ORIF and deltoid ligament repair is an effective method for lateral malleolus fracture combined with both deltoid ligament injury and inferior tibiofibular syndesmotic disruption. Compared with trans-syndesmotic fixation, deltoid ligament repair holds the advantage of not needing surgical removal of inferior tibiofibular screws postoperatively.

Treatment and outcome of a patient with low-energy 'Logsplitter' injury

The low-energy ‘Logsplitter’ fracture, caused by a sprain or fall, is characterized by an intact or slightly separated inferior tibiofibular joint. Compared with the high-energy ‘Logsplitter’ fracture, this atypical subtype is rarely seen and is easily missed. Here, the case of a 33-year-old male patient with a fractured right ankle as a result of a sprain during walking is reported. The patient initially received routine surgical treatment comprising internal fixation of the fibular, medial and posterior malleoli. Unexpectedly, post-surgery imaging examinations revealed that the medial clear space of the right ankle had widened to 6 mm, due to incomplete reduction of the lateral malleolus, shortening and rotation of the fibula, and an unreduced avulsion fracture block of the anterior malleolus. A revision surgery was then performed to anatomically reduce and fix the lateral malleolus, as well as the anterior malleolus avulsion fracture. During 5 months following surgery, the patient achieved good fracture union and functional restoration of the right ankle. For this rare injury, the present case demonstrates that complete restoration of the fracture is required to achieve good clinical efficacy.

The role of the posterior malleolus in the treatment of unstable upper ankle joint injuries - A biomechanical study

BACKGROUND

This biomechanical study aimed to test if the fixation of the posterior malleolus (PM) only with screws inserted from posterior to anterior (PA) restores stability comparable with the natural condition. The extent of stability was also compared with that of anterior to posterior (AP) screw osteosynthesis (OS) with an additional syndesmotic screw (SS).

METHODS

First, the stability of the upper ankle joint in seven pairs of intact lower legs were examined. Subsequently, half of the lower legs were treated with PA screw fixation of a PM fracture without SS and the other half with AP screw fixation with additional tricortical SS.

RESULTS

PA OS without SS showed significantly more diastasis (p = 0.027). The AP OS with an SS revealed a diastasis that was comparable with the intact condition (p = 0.797). The use of SS led to significantly higher stability compared to OS without SS (p = 0.019).

CONCLUSIONS

The Fixation of the PM alone without an additional syndesmotic screw cannot achieve intact upper ankle stability. Fixation of a PM fracture with an SS helps in nearly achieving the natural condition.

The Intercalary Fragment in Posterior Malleolus Fractures: Characterization and Significance

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

Unstable Rotational Ankle Fractures Treated With Anatomic Mortise Repair and Direct Posterior Malleolus Fixation

Introduction: The purpose of this study was to evaluate patient outcomes following a standardized algorithmic approach to ankle mortise stabilization, following rotational fracture, utilizing direct repair of the posterior malleolus in the prone position. Methods: Eighty consecutive patients with unstable rotational ankle fractures that involved the posterior malleolus were analyzed. All underwent direct repair of the posterior malleolus regardless of size through a posterolateral approach. Electronic records were retrospectively reviewed for demographic information, initial injury and operation details, healing status, and complications. Preoperative and postoperative radiographs were obtained to assess the initial injury and healing was determined both by radiographic and clinical progress at follow-up visits. Results: Average posterior malleolus fragment width was 8.1 ± 3.7 mm (range = 2.1-19.9 mm) and percentage of the articular surface was 23.6% (range = 7.1%-56.7%) on the lateral radiograph. Overall, 80/80 (100%) patients healed their ankle fractures by a mean 2.9 ± 1.1 months. Only 1 (1.3%) patient required transsyndesmotic fixation following posterior malleolus repair. Mean range of ankle motion was as follows: dorsiflexion 20° ± 10°, plantarflexion 34° ± 10°, inversion 8° ± 4°, and eversion 7° ± 4°. Seventy-nine patients (98.8%) had an anatomic mortise reduction. Nine patients (11.3%) had a superficial wound complication, 3 patients (3.8%) had dysesthesia in the sural nerve distribution, and 1 patient (1.3%) lost reduction of the medial malleolus. Conclusion: Patients who undergo direct repair of the posterior malleolus in the prone position can expect a high rate of healing with superficial wound breakdown being the biggest problem, which was associated with an ankle fracture dislocation. Posterior malleolus fixation may obviate the need of transsyndesmotic stabilization.Levels of Evidence: Retrospective Level IV.

Comparison of results of three different patient-based assessment scales in surgically treated adult ankle fractures

Purpose: The aim of this study was to evaluate the post-operative clinical and radiological results of ankle fractures, using three different patient-reported outcome measurements (PROM) and to analyze the results and compatibility of the PROMs. Materials and Methods: A total of 77 patients were followed up prospectively. Demographic data, fracture side, trauma mechanisms, fracture types, post-operative splint times, initiation of full weight bearing time, and complications were recorded. All patients were evaluated according to the AOFAS, Ankle-Hindfoot Rating Scale, Weber Scoring and Freiburg Scale, at the first-year follow-ups. Results: The results were good in 57 patients (74%) and poor in 20 patients (26%), according to the AOFAS Scale; excellent in 51 patients (66.2%), good in 12 patients (15.6%) and poor in 14 patients (18.2%) according to the Weber Scoring, and excellent in 50 patients (64.9%), good in 12 patients (15.6%) and poor in 15 patients (19.5%) according to the Freiburg Scale. The results of the PROMs were found to be compatible with each other. Significant relationship was found between the development of complications and the AOFAS Scale and Weber Scoring, and between older age and Weber Scoring. Conclusion: The results of the AOFAS Scale, Weber Score and Freiburg Scales are compatible with each other and can be safely used in the evaluation of ankle fractures. Development of complications and older age are associated with poor clinical outcomes.

Open reduction and internal fixation of the posterior malleolus fragment via the posterolateral approach is radiologically superior to 'A to P' screw fixation

PURPOSE

Functional outcome in trimalleolar fractures is largely correlated to the reduction of the posterior fragment. Until recently, fixation was mainly performed for large fragments, by percutaneous anterior to posterior ('A to P') screw placement after closed reduction. Nowadays, ORIF via a posterolateral approach seems to gain in popularity. The aim of this study was to compare the postoperative photographs of operated trimalleolar fractures after either fracture treatment method, for fracture diastasis and step-off.

MATERIAL AND METHODS

All consecutive patients with trimalleolar fractures, including posterior fragments of >5% of the articular surface and operated between 2007-2013 were analysed on size of posterior fragment, post-operative gap and step-off by three observers. The patients were divided into three groups; A to P screw fixation, ORIF via the posterolateral approach and no posterior fragment fixation at all.

RESULTS

180 patients with trimalleolar ankle fractures were included for analyses. Twenty five posterior fragments were fixated percutaneously from anterior to posterior (group 1) and 51 underwent open reduction and internal fixation through a posterolateral approach (group 2). 104 patients underwent no posterior malleolus fixation (group 3). The average size of posterior fragment was 34% in group 1, 27% in group 2 and 16% in group 3. A postoperative step-off >1 mm was found in 40% (group 1), 9% (group 2) or 34% respectively (group 3).

CONCLUSIONS

Fixation of the posterior malleolus through an open posterolateral approach leads to better radiological results as compared to percutaneous 'A to P' screw fixation or no fixation at all.

Direct Fixation of Fractures of the Posterior Malleolus Through a Postero-Medial Approach

Background and objective: Fractures of the posterior malleolus have long been neglected in the past. The decision for their fixation should be based on plain lateral radiographs. Recent studies have emphasized the important biomechanical function of the posterior tibial ridge. This has caused a trend towards more aggressive surgical treatment. The aim of this study was to present our experience with the direct fixation of complex ankle fractures engaging the posterior malleolus. We also tried to clarify the advantages and limitations of the posterior-medial surgical approach.

Materials and Methods: For a period of 1,5 years we have operated 14 patients with posterior malleolus fractures. Their average age was 51 years. Eight of the patients were male, the rest 6 were females. Fractures were classified according to Bartoníček classification system. All patients had type 3 fractures. Direct open reduction was performed in all cases. Posterior buttress plate was used for the fixation of the fracture. Bone grafting was found necessary in one case. Functional assessment was done according to the criteria of the AOFAS (American Orthopedic Foot and ankle score). Follow up was done for an average period of 10 months.

Results: All fractures united for an average period of 9 weeks (8-10 weeks). Six patients achieved an excellent functional result, 5 – a good one and 3 had an average result. The average AOFAS rating score was 84,02 (54-100). The average range of motion was 38° (15°-50°). There were no deep infections or septic arthritis. Three ankles had superficial skin necrosis that healed without any additional procedures. One patient had prolonged and substantial swelling of the leg, despite of the routine antithrombotic prophylaxis. Five patients needed their fibular plates removed due to local irritation.

Conclusion: The direct reduction and fixation of the posterior malleolus fractures allow anatomical restoration of the ankle mortise. This is a prerequisite for an optimal functional recovery and appears to be a safe treatment strategy.

How the Direction of Screws Affects the Primary Stability of a Posterior Malleolus Osteosynthesis under Torsional Loading: A Biomechanical Study

Insufficient fixation of a posterior malleolus fracture (PM) can lead to posttraumatic complications such as osteoarthritis and chronic pain. The purpose of this biomechanical study was to test the hypothesis of whether the direction of PM screw fixation has an impact on the primary stability of osteosynthesis of a PM under torsional loading. PM fractures of 7 pairs human cadaveric lower leg specimens were stabilized with posterior to anterior (p.a.) or anterior to posterior (a.p.) screw fixation. Stability of the osteosynthesis was biomechanically tested using cyclic external torsional loading levels, in 2 Nm steps from 2 Nm up to 12 Nm, under constant monitoring with 3D ultrasonic marker (Zebris). The primary stability does not differ between both stabilizations (p = 0.378) with a medium effect size (η2p = 0.065). The movement of the PM tends to be marginally greater for the osteosynthesis with a.p. screws than with p.a. screws. Whether a.p. screws or the alternative p.a. screw fixation is performed does not seem to have an influence on the primary stability of the osteosynthesis of the PM fixation under torsional loading. Although osteosynthesis from posterior seems to be more stable, the biomechanical results in the torsional test show quite equivalent stabilities. If there is no significant dislocation of the PM, a.p. screw fixation could be a minimally invasive but stable surgical strategy.

Evaluation of ankle fracture classification systems in 193 trimalleolar ankle fractures

Purpose

Different classification systems have been developed for ankle fractures. In recent years, the posterior malleolus has gained in importance and led to computed tomography (CT)-based classification systems. The aim of the study was to analyse their reliability, fracture patterns and influence on treatment strategy.

Methods

Patients with a trimalleolar ankle fracture treated between 2011 and 2020 with preoperative radiographs and CT images were included. The blinded images were independently classified by three reviewers according to the AO/OTA, Herscovici, Bartoníček, Mason and Haraguchi classifications. The interobserver reliability was calculated by Fleiss' kappa (κ). CT images were analysed to determine the dimensions of the posterior malleolus fragments. Patient registries were reviewed regarding the treatment data.

Results

A total of 193 patients were included. The AO/OTA classification showed almost perfect inter- and intraobserver reliability (Fleiss’ κ = 0.86, 95% CI 0.82–0.90). Regarding the posterior malleolus, the Bartoníček classification demonstrated the highest reliability (Fleiss’ κ = 0.78, 95% CI 0.73–0.83). The Herscovici classification only reached moderate reliability for medial malleolus fractures (Fleiss' κ = 0.59, 95% CI 0.54–0.65). There was a trend towards direct fixation of the posterior malleolus in the last 3 years of the observation period (OR: 2.49, 95% CI 1.03–5.99).

Conclusion

In trimalleolar ankle fractures, the AO/OTA classification is a reliable system to characterize the type of fracture, but it fails to provide solid information about the posterior malleolus. Nowadays, treatment recommendations for trimalleolar ankle fractures focus on the configuration of the posterior malleolus; therefore, the results of this study advocate the use of the Bartoníček classification as a reliable tool to guide treatment.

Peroneal artery safe zone in the posterolateral approach to the distal tibia: A CT angiogram based anatomical study

OBJECTIVES

The posterolateral approach to the distal tibia is commonly used for stabilisation of ankle fractures as it allows good visualisation and direct reduction of the posterior distal tibia and malleolar fragments. This approach can also be used for internal fixation of an associated lateral malleolus fracture. The aim of our study is to describe the surgical anatomy of the peroneal artery (PA) in relation to the tibial plafond and the distal fibula; thereby suggesting a safe zone during proximal dissection of posterolateral approach.

METHODS

Using Computed Tomography Angiographic (CTA) study, the course of the PA in relation to the tibial plafond and distal fibula was analysed in 142 lower limbs (bilateral limbs of 71 adult patients; 43 males and 28 females). Axial, coronal, and sagittal CT sections were cross-linked to specify the position of the PA. The PA course was identified and the level of its distal bifurcation over the tibia was marked. Perpendicular measurements were made from this point to the tibial plafond and tip of distal fibula.

RESULTS

The PA bifurcated distally at mean 58.3±24.2mm (SD) (range: 37.0-115.0mm) proximal to the right tibial plafond and mean 81.9±24.4mm (range: 54.0-137.0mm) from the right distal fibular tip. In the contralateral side, the PA bifurcated at mean 57.9±23.3mm (range: 36.0-125.0mm) proximal to the left tibial plafond and 81.8±23.9mm (range: 54.0-147.0mm) from the left distal fibular tip. The difference between the right and the left side of distal bifurcation point diameter of the same patient was assessed, range (0.0-58.0mm) with median 2.0mm and IQR 10.0mm. Three different PA vasculature patterns were identified.

CONCLUSIONS

It is important for surgeons to be aware of the surgical anatomy of PA to avoid inadvertent injury during posterolateral approach to distal tibia. The PA may bifurcate as close as 36mm from the tibial plafond with possible variation bilaterally. Therefore, special attention needs to be considered by the operating surgeon while dissecting in this region due to the wide anatomical variation in vasculature. However, once the PA is mobilised, any fixation modality including posterior buttress plate could be safely performed.

Anatomic Structures at Risk During Posterior to Anterior Percutaneous Screw Fixation of Posterior Malleolar Fractures: A Cadaveric Study

Background. There are no established guidelines for fixation of posterior malleolus fractures (PMFs). However, fixation of PMFs appears to be increasing with growing evidence demonstrating benefits for stability, alignment, and early functional outcomes. The purpose of this study was to determine the risk to anatomic structures utilizing a percutaneous technique for posterior to anterior (PA) screw fixation of PMFs. Methods. Percutaneous PA screw placement was carried out on 10 fresh frozen cadaveric ankles followed by dissection to identify soft tissue and neurovascular structures at risk. The distance from the guidewire to each anatomic structure of interest was measured. The correlation between the mean distances from the guidewire to each structure was calculated. Results. The sural nerve was directly transected in 1/10 specimens (10%) and in contact with the wire in a second specimen (10%). There was a significant correlation between the proximity of the guidewire to the apex of Volkmann's tubercle and its proximity to the sural nerve. The flexor hallucis longus (FHL) muscle belly was perforated by the guidewire 40% of the time but was not tethered or entrapped by the screw. Conclusions. Percutaneous PA screw placement is a safe technique which can be improved with several modifications. A mini-open technique is recommended to protect the sural nerve. There may be potential for tethering of the FHL with use of a washer or large screw head. Risk to the anterior and posterior neurovascular bundles is minimal.Levels of Evidence: Level V.

Accompanying injuries in tibial shaft fractures: how often is there an additional violation of the posterior malleolus and which factors are predictive? A retrospective cohort study

Introduction

An undislocated fracture of the posterior malleolus is a common concomitant injury in tibial shaft spiral fractures. Nevertheless, these accompanying injuries cannot always be reliably assessed using conventional X-rays. Thus, the aim of the study is to evaluate how often a fracture of the posterior malleolus occurs with tibial shaft fractures (AO:42A/B/C and AO:43A) and which factors—identifiable in conventional X-rays—are predictive.

Methods

Retrospective evaluation of X-ray and CT images revealed a total of 103 patients with low-energy tibial shaft fractures without direct joint involvement. Proximal fractures and fractures involving the knee were excluded. Basic data on injury, the trauma mechanism, the path of the fracture, bony avulsions of the posterior syndesmosis and the procedures performed were evaluated.

Results

Thirty-nine fractures were located in the middle third of the tibia, 64 in the distal third. In 65 cases, a spiral fracture (simple or wedge fracture) was found. In 31/103 fractures, an additional osseous avulsion of the posterior syndesmosis could be detected, 5 (16.1%) of them were not recognized preoperatively due to an absence of CT imaging. In three of these patients, a fracture of the posterior malleolus was only recognized postoperatively, and an additional surgery was necessary. The spiral fractures were classified in the a.p. X-ray according to their path from lateral proximal to medial distal (Type A) or from medial proximal to lateral distal (Type B).

A Pearson chi-square test and Fisher’s exact test showed a highly significant accumulation of accompanying posterior malleolus fractures for type A fractures (p = 0.001), regardless of the location of the fracture. In addition, the fractures with involvement of the posterior malleolus had a significantly higher proportion in the fractures of the distal third (p = 0.003).

There was no statistically significant relationship between the height of the fracture and the path of the fracture (type A or B). These two factors seem to be independent factors for participation of the posterior malleolus.

Conclusion

In 40.6% of the tibial shaft fractures in the distal third, in 56.9% of the type A spiral fractures and in 67.6% of the type A fractures in the distal third, the ankle joint is involved with bony avulsion of the posterior syndesmosis, which is not always recognized in conventional X-rays. To avoid complications such as additional operations, instability and post-traumatic arthrosis, we recommend preoperative imaging of the ankle using CT for these fractures.

Level of evidence

III, retrospective cohort study.

Trail registration number

DRKS00024536.

Posterior Locking Plate Fixation of Bartoníček Type IV Posterior Malleolar Fracture: A Focus on Die-Punch Fragment Size

Die-punch fragments refer to articular cartilage and subchondral bone embedded in cancellous bone as part of an intra-articular fracture. Bartoníček type IV posterior malleolar fractures with associated die-punch fragments are rare, and the appropriate surgical approach remains unclear. We determined outcomes, and the effect of die-punch fragment size on outcomes, for 32 patients with Bartoníček type IV posterior malleolar fractures with die-punch fragments between January 2015 and December 2017. Mean follow-up for all patients was 23.8 (range 20.0-30.0) months. At the final follow-up visit, mean ankle dorsal extension was 24.6° and plantar flexion was 40.0°; American Orthopaedic Foot and Ankle Society ankle-hindfoot score was 88.6 ± 4.3; visual analog scale weightbearing pain score was 1.5 ± 0.6; and Bargon traumatic arthritis score was 0.8 ± 0.4. There were no severe complications. We divided patients into a small-fragment (≤3 mm) group (n = 12) and large-fragment (>3 mm) group (n = 20). The Bargon scores at final follow-up were 0.5 and 1, respectively (P=.02). There were no statistically significant differences between the 2 groups for the other outcome scores at various time intervals. The posterolateral approach with distal locking plate internal fixation for Bartoníček type IV posterior malleolar fractures with die-punch fragments can result in excellent anatomical reduction of the collapsed articular surface and the displaced fragment from the tibial plafond, recovery of articular surface congruity, and maintenance of joint stability. Die-punch fragment size may not impact clinical and functional outcomes but may contribute to post-traumatic arthritis.

Evidence-Based Surgical Treatment Algorithm for Unstable Syndesmotic Injuries

Background: Surgical treatment of unstable syndesmotic injuries is not trivial, and there are no generally accepted treatment guidelines. The most common controversies regarding surgical treatment are related to screw fixation versus dynamic fixation, the use of reduction clamps, open versus closed reduction, and the role of the posterior malleolus and of the anterior inferior tibiofibular ligament (AITFL). Our aim was to draw important conclusions from the pertinent literature concerning surgical treatment of unstable syndesmotic injuries, to transform these conclusions into surgical principles supported by the literature, and finally to fuse these principles into an evidence-based surgical treatment algorithm. Methods: PubMed, Embase, Google Scholar, The Cochrane Database of Systematic Reviews, and the reference lists of systematic reviews of relevant studies dealing with the surgical treatment of unstable syndesmotic injuries were searched independently by two reviewers using specific terms and limits. Surgical principles supported by the literature were fused into an evidence-based surgical treatment algorithm. Results: A total of 171 articles were included for further considerations. Among them, 47 articles concerned syndesmotic screw fixation and 41 flexible dynamic fixations of the syndesmosis. Twenty-five studies compared screw fixation with dynamic fixations, and seven out of these comparisons were randomized controlled trials. Nineteen articles addressed the posterior malleolus, 14 the role of the AITFL, and eight the use of reduction clamps. Anatomic reduction is crucial to prevent posttraumatic osteoarthritis. Therefore, flexible dynamic stabilization techniques should be preferred whenever possible. An unstable AITFL should be repaired and augmented, as it represents an important stabilizer of external rotation of the distal fibula. Conclusions: The current literature provides sufficient arguments for the development of an evidence-based surgical treatment algorithm for unstable syndesmotic injuries.

Ankle fractures involving the posterior malleolus: patient characteristics and 7-year results in 100 cases

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.

Evaluation of Ankle Fractures in 228 Patients From a Single Center Using Three-Dimensional Computed Tomography Mapping

Purpose: The ankle joint has a complex anatomy structure with many causative factors and various injury mechanisms, and the clinical presentation of ankle fractures is diverse. This study aimed to analyze the characteristics of ankle fractures by applicating three-dimensional fracture line mapping technique. Methods: A retrospective study was conducted on 228 patients with ankle fractures. Three-dimensional reconstruction was performed by CT images and the fracture reconstruction model was superimposed onto a standard model of the tibiofibula for fracture line drawing. Then the fracture lines were converted into a three-dimensional coordinate point data set. And the fracture line maps as well as the fracture line heat maps were generated in 3-Matic software and Unigraphics NX software, respectively. Results: The dense area of the fibular fracture lines was located above the tibiofibular joint ligament and wrapped obliquely around the distal fibula from the anterior edge of the fibular neck. The fibular fracture line could be divided into three categories according to the degree of denseness. The dense area of the tibial fracture line is located within the anterior tibial fornix, the anterolateral corner, and the fibular notch. The tibial fracture lines can be classified into four categories according to the density of the fracture lines. The combined medial malleolus + posterior malleolar fracture line situation was found to be not encompassed by the existing AO and Lauge-Hansen (LH) classification systems according to this classification. Conclusion: The 3D fracture line mapping technique can better reflect the distribution of ankle fracture lines and could help to establish a new ankle fracture typing system in the future.

Can treatment of posterior malleolus fractures with tibio-fibular instability be usefully addressed by Bartonicek classification?

INTRODUCTION

Ankle fractures account for 4% of all fractures and treatment of those involving the Posterior Malleolus remains controversial. Clinical and radiological outcomes in a cohort of patients with Posterior Malleolus fractures conservatively treated were retrospectively evaluated; furthermore, a treatment algorithm was suggested.

METHODS

Patients were divided according to Bartoníček classification. The clinical evaluation was made with OMAS/AOFAS scores; the radiological evaluation with Van Dijk classification for post-traumatic arthritis.

RESULTS

Clinical outcome worsened with the severity of Bartoníček classification, but early degenerative changes were not correlated neither to the clinical outcome nor to the injury pattern. Clinical and radiological outcomes depended on the damage of the syndesmosis as articular step-offs and tibio-fibular notch involvement.

DISCUSSION

We recommend conservative treatment for Bartoníček type I, type II and type III fractures, the latter when undisplaced and without tibial plafond depression. We suggest surgical treatment for type IV and displaced type III fractures.

Results From an All Wales Trainee Led Collaborative Prospective Audit on Management of Ankle Fractures

Aim The purpose of this all Wales national audit was to compare compliance against British Orthopedic Association Standards for Trauma (BOAST) guidelines on the management of ankle fractures. Methods A multi-center prospective audit of the management of adult ankle fractures was conducted between February 2, 2020, and February 17, 2020, via the Welsh Orthopedic Research Collaborative (WORC). Regional leads were recruited in nine NHS hospitals across six university health boards, and recruited collaborators in their respective hospitals. Questionnaires for the data collection on both surgical and conservative management were made available via a password-protected website (walesortho.co.uk). We defined early weight-bearing (EWB) as unrestricted weight-bearing on the affected leg within three weeks of injury or surgery and delayed weight-bearing (DWB) as unrestricted weight-bearing after three weeks of injury or surgery. Results A total of 28 collaborators contributed data for 238 ankle fractures. Poor documentation at the time of injury was noted. Less than 50% of patients with posterior malleolus fracture had a CT scan for further evaluation. Eighty-four percent of the non-operatively treated patients did not have a weight-bearing X-ray (WBXR). Patients who had a WBXR were more likely to be allowed EWB but this was not statistically significant. EWB was allowed in 59.43% and 10% of the non-operatively and operatively treated patients, respectively. DWB was higher in patients who had fixation of the posterior malleolus or syndesmosis. Conclusion There is poor compliance with BOAST guidelines on the management of ankle fractures across Wales. We need to improve documentation and also consider performing a CT scan when the posterior malleolus is fractured. A weight-bearing X-ray should be performed more often to ascertain the stability of an ankle fracture, and those that are deemed stable should be treated with early weight-bearing. The guidelines need to be clearer regarding weight-bearing after fixation especially when posterior malleolus and/or syndesmosis are fixed.

Anatomic and Radiographic Safe Zone for Posterior Malleolar Screw Placement

BACKGROUND

The most appropriate treatment and management of posterior malleolar fractures (PMFs) lacks consensus. Indirect reduction and fixation with posterior to anterior (PA) screw shows promise by avoiding the risks associated with direct reduction or indirect anterior to posterior approaches. Some authors have raised concerns about potential risk to nearby structures with the PA technique, including hardware prominence into the syndesmosis. This study highlights use of the posteromedial vertical syndesmotic line (PVSL) as a fluoroscopic landmark, helping surgeons avoid intrasyndesmotic placement. Study aims are to evaluate PVSL correspondence with posterior border of the incisura tibialis and to define a safe zone between this line and flexor hallucis longus tendon.

METHODS

Indirect PA screw placement was completed on 10 cadaveric specimens, followed by fluoroscopy in mortise and lateral views. Dissection was performed to assess screw placement relative to the posteromedial border of the syndesmosis. The posterior border of the syndesmosis was marked with a radiopaque wire. Repeat imaging was completed to validate the fluoroscopic PVSL is representative of the posteromedial border of the tibial incisura.

RESULTS

On dissection, 9 out of 10 cadavers had accurate screw placement with no penetration into the syndesmosis. Corresponding imaging showed the screw head to be medial to the marker on mortise view. For the specimen with penetration into the syndesmosis, imaging confirmed that the screw head was lateral to the marker on mortise views. The radiopaque marker correlated with the PVSL for all specimens when comparing anatomic to radiographic findings. A radiographic safe zone is defined for the PA screw 12 mm medial to the PVSL to ensure no iatrogenic injury to the flexor hallucis longus tendon.

CONCLUSION

This study demonstrated that a posterior incisura tibialis fluoroscopic landmark is unambiguous in localizing the posterior syndesmotic border and that screws medial to this line are safely out of the syndesmosis, while screws placed lateral are either in or at risk of intrasyndesmotic placement. A safe zone is defined for screw placement.

CLINICAL RELEVANCE

This article describes a radiographic and clinical safe zone for fixation and hardware placement during open reduction internal fixation (ORIF) of PMFs. This information will assist surgeons in avoiding intrasyndesmotic hardware placement as well as injury to deep soft tissue structures.

Patient Pain and Function After Correction of Posterior Malleolar Malunion

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.

Distribution of posterior malleolus fracture lines in ankle fracture of supination-external rotation

INTRODUCTION

Supination-external rotation ankle fracture is one of the most common fractures. Studies on the fracture line distribution of this fracture type are limited. The purpose of this study is to explore the distribution characteristics of intra-articular posterior malleolus fracture lines in supination-external rotation.

HYPOTHESIS

Most of the fracture lines are concentrated in a particular area.

MATERIAL AND METHODS

Computed tomography scans of a consecutive series of 70 ankle fractures of supination-external rotation were used for this study. The DICOM files were loaded into Mimics 16.0 for 3D reconstruction of the distal tibial articular surface. The intra-articular posterior malleolus fracture lines were identified after virtual fracture reduction. All the fracture lines were drawn on one picture of the distal tibial articular surface after standardization before a heat map was created based on the frequency of fracture lines.

RESULTS

Although the distribution of posterior malleolus intra-articular fracture lines varied, most of them were concentrated in an arcuate zone. The ratios of the area of posterior fracture fragment to the total area of articular surface averaged 14.96% (range, from 2.23% to 38.45%). They were most likely to enter the articular surface at 20.4% of the tangent of the posterior edge in a standardized image and exit at 58.7% of the tangent of the lateral edge.

CONCLUSIONS

In ankle fractures of supination-external rotation, most intra-articular posterior malleolus fracture lines may be distributed regularly in an arcuate zone of the articular surface.

LEVEL OF PROOF

V; Descriptive research.

Current management of trimalleolar ankle fractures

A trimalleolar ankle fracture is considered unstable and treatment is generally performed operatively. Computed tomography is important for the operative planning by providing an elaborated view of the posterior malleolus.

Trimalleolar ankle fractures have a rising incidence in the last decade with up to 40 per 100,000 people per year. With a growing number of elderly patients, trimalleolar ankle injuries will become more relevant in the form of fragility fractures, posing a particular challenge for trauma surgeons.

In patients with osteoporotic trimalleolar ankle fractures and relevant concomitant conditions, further evidence is awaited to specify indications for open reduction and internal fixation or primary transfixation of the ankle joint.

In younger, more demanding patients, arthroscopic-assisted surgery might improve the outcome, but future research is required to identify patients who will benefit from assisted surgical care.

This review considers current scientific findings regarding all three malleoli to understand the complexity of trimalleolar ankle injuries and provide the reader with an overview of treatment strategies and research, as well as future perspectives.

Cite this article: EFORT Open Rev 2021;6:692-703. DOI: 10.1302/2058-5241.6.200138

Ankle CT scan allows better management of posterior malleolus fractures than X-rays

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).

Posterior Malleolar Fractures: A Critical Analysis Review

In patients with ankle fractures, the presence of a posterior malleolar fracture has a negative impact on the prognosis. Computed tomography (CT) scanning is essential for fracture classification and treatment planning, as the indication for surgery depends on the 3-dimensional fragment outline and displacement, incisura involvement, and the presence of joint impaction. Anatomic reduction of a posterior malleolar fragment restores the incisura, facilitating reduction of the distal part of the fibula, and it also restores the integrity of the posterior portion of the syndesmosis, reducing the need for additional syndesmotic stabilization. Direct open reduction and fixation of posterior malleolar fragments from a posterior orientation is biomechanically more stable and provides a more accurate reduction than does indirect reduction and anterior-to-posterior screw fixation. Intra-articular step-off of >=2 mm is an independent risk factor for an inferior outcome and the development of posttraumatic arthritis, irrespective of the fragment size.

The level of bifurcation of peroneal artery and its implications for posterolateral approach to the ankle: a CT angiography study

PURPOSE

This study aims to provide data, with the use of computed tomography angiography, regarding the level of bifurcation of the peroneal artery to the anterior perforating branch and the lateral calcaneal branch, in relation to the osseous anatomic structures of the tibial plafond, the medial malleolus and the lateral malleolus.

METHODS

The study included patients who underwent diagnostic computed tomography angiography of the lower extremities. Measurements were performed in two-dimensional reconstructions and included the perpendicular distance from peroneal artery bifurcation into anterior perforating branch and lateral calcaneal branch to the lowest level of tibial plafond (D1), medial malleolus (D2) and lateral malleolus (D3). The distances were also normalized to the length of the tibia.

RESULTS

Sixty patients and a total of 115 limbs were enrolled in this study. The mean distance ± standard deviation from peroneal artery bifurcation to tibial plafond (D1) was 4.33 ± 1.12 cm (normalized 0.12 ± 0.03) (range 2.54-8.26 cm), to medial malleolus (D2) was 5.53 ± 1.18 cm (normalized 0.16 ± 0.03) (range 3.27-9.5 cm) and to lateral malleolus (D3) was 6.53 ± 1.17 cm (normalized 0.18 ± 0.03) (range 4.71-10.2 cm), respectively. There was no significant difference between right and left limb measurements (p > 0.05). Females presented lower, but not statistically significant (p > 0.05), D1, D2 and D3 measurements compared to males.

CONCLUSION

The bifurcation of the peroneal artery takes place at lower level compared to previously published studies and consequently extreme caution should be exercised when performing the posterolateral approach to the ankle. This study adds to the understanding of the relevant vascular anatomy of the region and assists in performing the posterolateral approach to the ankle with safety.