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Chong LSL, Khademi M, Reddy KM, Anderson GH. Ten year outcomes after non-fixation of the smaller posterior malleolar fragment: A retrospective cohort study. Foot (Edinb) 2024; 59:102091. [PMID: 38513374 DOI: 10.1016/j.foot.2024.102091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 02/07/2024] [Accepted: 03/10/2024] [Indexed: 03/23/2024]
Abstract
INTRODUCTION Treatment of posterior malleolar (PM) ankle fractures remains controversial. Despite increasing recommendation for small PM fragment fixation, high quality evidence demonstrating improved clinical outcomes over the unfixated PM is limited. We describe the long term clinical and radiographical outcomes in younger adult patients with PM ankle fractures managed without PM fragment fixation. MATERIAL AND METHODS A retrospective cohort study was performed on PM ankle fracture patients aged 18-55 years old admitted under our orthopaedic unit between 1st of April 2009 and 31st of October 2013. Inclusion criteria were ASA 1 and 2, independent mobility pre-trauma, no pre-existing ankle pathologies, with satisfactory bimalleolar and syndesmotic stabilisation. Open fractures, talar fractures, calcaneal fractures, pilon fractures, subsequent re-injury and major complications were excluded. All PM fragments were unfixated. Clinical outcomes were evaluated using visual analogue scale (VAS) for pain, Foot and Ankle Ability Measure (FAAM) with activities of daily living (ADL) and sports subscale for function, and patient satisfaction ratings. Osteoarthritis was assessed using modified Kellgren-Lawrence scale on follow-up weightbearing ankle radiographs. RESULTS Sixty-one participants were included. Mean follow-up was 10.26 years. Average PM size was 16.2 ± 7.39%. All participants were evaluated for clinical outcomes. Mean score of FAAM-ADL was 95.5 ± 7.13, FAAM-Sports 86.4 ± 15.5, patient satisfaction 86.2 ± 14.4% and pain score 1.13 ± 1.65. Radiographical outcomes were evaluated in 52 participants, showing no-to-minimal osteoarthritis in 36/52 (69%), mild osteoarthritis in 14/52 (27%) and moderate osteoarthritis in 2/52 (4%). Pain and functional scores were independent of PM fragment size, post-reduction step-off, dislocation, malleoli fractured or syndesmotic injury. PM step-off more than 1 mm and traumatic dislocation/subluxation were associated with worse radiographical osteoarthritis. CONCLUSION After controlling for confounders, the unfixated smaller posterior malleolus fragment at 10-year follow-up demonstrated largely satisfactory clinical outcomes with some radiographical progression of osteoarthritis. LEVEL OF EVIDENCE Level III - Retrospective cohort study.
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Affiliation(s)
- Leo Swee Liang Chong
- Department of Orthopaedic Surgery, Palmerston North Hospital, Te Whatu Ora Te Pae Hauora o Ruahine o Tararua / Midcentral, New Zealand.
| | - MohammadAli Khademi
- Department of Orthopaedic Surgery, Palmerston North Hospital, Te Whatu Ora Te Pae Hauora o Ruahine o Tararua / Midcentral, New Zealand
| | - Kundam Murali Reddy
- Department of Orthopaedic Surgery, Palmerston North Hospital, Te Whatu Ora Te Pae Hauora o Ruahine o Tararua / Midcentral, New Zealand
| | - Geoffrey Hunter Anderson
- Department of Orthopaedic Surgery, Palmerston North Hospital, Te Whatu Ora Te Pae Hauora o Ruahine o Tararua / Midcentral, New Zealand
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Pollard JD, Krcal CE. Considerations with Fractures of the Posterior Malleolus in Ankle Fractures. Clin Podiatr Med Surg 2024; 41:103-117. [PMID: 37951669 DOI: 10.1016/j.cpm.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Foot and ankle surgeons are commonly confronted with the surgical dilemma on when and how to best surgically address trimalleolar ankle fractures with a posterior malleolar component. This may involve either direct fixation of the posterior malleolus or indirect stabilization with the fixation of the medial and lateral malleoli and trans-syndesmotic fixation. Recently there has been a paradigm shift in the management of these injuries with a more thorough understanding of anatomy, stability, and long-term sequela of these injuries. This article aims to evaluate the current literature on posterior malleolar ankle fractures, approaches to fixing the posterior malleolus, and outcomes and complications of these procedures.
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Affiliation(s)
- Jason D Pollard
- Department of Podiatric Surgery, Kaiser Permanente, 3600 Broadway, Suite 17, Oakland, CA 94611, USA.
| | - Craig E Krcal
- The CORE Institute, 18444 North 25th Avenue Suite 320, Phoenix, AZ 85023, USA; Graduate Kaiser San Francisco Bay Area Foot & Ankle Residency, 2023
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Baumfeld T, Burgos V, Souza V, Pires RE, Campos T, Baumfeld D. Ankle fractures malreduction rate and its causes in two Brazilian tertiary training hospitals. Injury 2023; 54 Suppl 6:110811. [PMID: 38143130 DOI: 10.1016/j.injury.2023.05.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/07/2023] [Accepted: 05/11/2023] [Indexed: 12/26/2023]
Abstract
INTRODUCTION Ankle fractures are one of the most frequent injuries managed by any trauma surgeon. Literature has shown that adequate reduction is of utmost importance to achieve satisfactory functional outcomes. However, malreduction rates remain high worldwide. The objective of the present study is to evaluate the quality of ankle fracture reduction in two major trauma centers in a large Brazilian city and to analyze the factors associated with malreduction METHODS: Epidemiologic data of 382 patients (189 men; 193 women) aged between 7 and 87 years who underwent osteosynthesis of the ankle in two trauma centers in a large Brazilian city. Electronic clinical records, preoperative and immediate postoperative radiographs in anteroposterior (AP), lateral and mortise views were evaluated. Pettrone's criteria were used to evaluate the quality of ankle fractures reduction. All radiographs were independently evaluated by two foot and ankle senior surgeons RESULTS: Overall, malreduction rate was 22.2%. Forty-seven (55.2%) fractures classified as malreduced had medial malleolar displacement The results showed three factors that significantly affected the quality of reduction (p<0.05), patients over 60 years, open fractures and fracture-dislocations. Patients aged over 60 years were twice more likely to have poor reduction of ankle fractures than younger ones. The risk of poor fracture reduction among those individuals with open fractures is 2.15 times greater than among patients with closed injuries. Fracture-dislocation imposed a 2.7 higher risk for malreduction DISCUSSION: We found a malreduction rate below most series previously published. Further results agree with the literature. Elderly people aged over 60 years, fracture dislocations and open fractures are associated with worse results, influencing the quality of the reduction, clinical outcomes, and the development of post-traumatic arthrosis CONCLUSION: Ankle fractures malreduction are associated with higher age, open fractures, and fracture-dislocations.
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Affiliation(s)
| | | | | | | | - Túlio Campos
- Universidade Federal de Minas Gerais (UFMG) - Brazil
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Theyvan Balakrishnan T, Bilal A, Fitzpatrick N, Dahiya R, Soelar SA, Khalid K, Pillai A. Enhancing Consistency in Posterior Malleolus Fracture Classification: A Comprehensive Interobserver Reliability Study With 20 Raters Using the Mason & Molloy Classification. Cureus 2023; 15:e48586. [PMID: 38024046 PMCID: PMC10655162 DOI: 10.7759/cureus.48586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2023] [Indexed: 12/01/2023] Open
Abstract
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.
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Affiliation(s)
| | - Ahmad Bilal
- Trauma and Orthopedics, Wythenshawe Hospital, Manchester, GBR
| | - Niall Fitzpatrick
- Trauma and Orthopedics, Manchester NHS Foundation Trust, Manchester, GBR
| | - Rohan Dahiya
- Orthopedics and Traumatology, Wythenshawe Hospital, Manchester, GBR
| | | | - Karniza Khalid
- Biochemistry, Institute for Medical Research, National Institutes of Health, Kuala Lumpur, MYS
| | - Anand Pillai
- Trauma and Orthopedics, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, GBR
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Li Y, Zhou H, Xia J, Li B, Zhao Y, He W, Li Z, Yang Y. Quantitative Evaluation of the Influence of Posterior Malleolus Fracture and Fixation on the Rotational Stability of the Ankle. Indian J Orthop 2023; 57:1461-1472. [PMID: 37609030 PMCID: PMC10441913 DOI: 10.1007/s43465-023-00951-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/06/2023] [Indexed: 08/24/2023]
Abstract
Background This study aimed to analyze quantitative correlation between the posterior malleolus fracture and fixation and the rotational stability of the ankle and to explore supplementary surgical indications for posterior malleolus fracture. Methods Twenty fresh frozen cadaver specimens were selected and dissected. Based on the tibial insertion of the ligament complex, the model for the supination external rotation stage 3 ankle fracture with a posterior malleolar fragment and syndesmosis diastasis was created. The area threshold of the posterior tibial insertion of posterior malleolus fracture was biomechanically assessed and the difference of the antirotating ability stiffness of the ankle between simple posterior malleolus fixation and simple syndesmotic fixation was analyzed statistically. Results The tibial insertion of posterior inferior tibiofibular ligament and inferior transverse tibiofibular ligament complex was relatively broad, and its width decreased as the distance from the joint line increased. Biomechanical analysis showed that: the threshold of posterior area of posterior malleolus fracture was 1/4S; posterior malleolus fixation provided better rotational stability than syndesmotic fixation (P < 0.01). Conclusion The surgical indications for posterior malleolus fracture should consider simultaneously the restoration of the axial and rotational stability of the ankle. Simple posterior malleolus fracture fixation is recommended when the syndesmosis is unstable and the area ratio of posterior tibial insertion of posterior malleolus fracture is greater than or equal to 1/4. Syndesmotic fixation is proposed to restore and maintain the rotational stability of the ankle when the syndesmosis is unstable and the area ratio is less than 1/4. Regardless of the area ratio, the surgical indication only depends on the impact of the posterior malleolus fracture on the axial stability of tibiotalar joint, the involved articular surface area, and the displacement degree of posterior malleolus fragment, when the syndesmosis is stable.
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Affiliation(s)
- Yongqi Li
- Department of Orthopedics, Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065 China
- Department of Orthopedics, Karamay Central Hospital, Karamay, 834000 China
| | - Haichao Zhou
- Department of Orthopedics, Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065 China
| | - Jiang Xia
- Department of Orthopedics, Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065 China
| | - Bing Li
- Department of Orthopedics, Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065 China
| | - Youguang Zhao
- Department of Orthopedics, Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065 China
| | - Wenbao He
- Department of Orthopedics, Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065 China
| | - Zhendong Li
- Department of Orthopedics, Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065 China
| | - Yunfeng Yang
- Department of Orthopedics, Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065 China
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Koh D, Mehta K. Anterior Displacement of a Posterior Malleolar Fragment Through the Syndesmosis: A Case Report. Cureus 2023; 15:e42451. [PMID: 37637621 PMCID: PMC10449562 DOI: 10.7759/cureus.42451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2023] [Indexed: 08/29/2023] Open
Abstract
Ankles are the most common site of injury in lower limb fractures. Despite this, the classification of the Maisonneuve fracture is still highly controversial, perhaps due to its low incidence. Typically described as a proximal fibular fracture with associated injury to the syndesmosis and medial structures secondary to an external rotation mechanism, the injury often necessitates surgical intervention to restore joint stability for good functional outcomes. A 32-year-old lady sustained a pronation external rotation injury resulting in a proximal fibula fracture with disruption of the distal tibiofibular syndesmosis as well as an associated posterior malleolar fracture with displacement of the fragment anteriorly through the syndesmosis to the ventral aspect of the ankle joint. The patient underwent surgical fixation of the posterior malleolar fracture as well as repair of the syndesmosis with a screw. This report aims to highlight the details of a Maisonneuve fracture with the rarer associated posterior malleolar fracture, and its anterior displacement through the syndesmosis, as well as provide a narrative review of the current literature.
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Affiliation(s)
- Don Koh
- Orthopaedics, Changi General Hospital, Singapore, SGP
| | - Kinjal Mehta
- Orthopaedics, Changi General Hospital, Singapore, SGP
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Rashid MS, Islam R, Marsden S, Trompeter A, Teoh KH. Validation of three classification systems for posterior malleolus fractures of the ankle. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-023-03476-3. [PMID: 36723774 DOI: 10.1007/s00590-023-03476-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 01/18/2023] [Indexed: 02/02/2023]
Abstract
PURPOSE A number of classification systems exist for posterior malleolar ankle fractures. The user reliability of these classification systems remains unclear. The primary aim of this study was to evaluate the reliability of three commonly utilised classification systems for fractures of the posterior malleolus. METHODS Imaging of 60 patients across 2 hospitals with ankle fractures including a posterior malleolar fragment was identified. All patients had undergone plain radiographs and computed tomography of their injured ankle as part of their normal standard of care. 9 surgeons including pre-resident/registrar level, resident/registrar level, and attending/consultant level applied the Haraguchi, Bartoníček, and Mason classifications to these fractures, at two timepoints, at least 4 weeks apart. The order was randomised between assessments. Inter-rater reliability was assessed using Fleiss' κ and standard error (SE). Intra-rater reliability was assessed using Cohen's κ and standard error (SE). RESULTS Inter-rater reliability (Fleiss' κ) was calculated for the Haraguchi classification as 0.588 (SE 0.023), for the Bartoníček classification as 0.626 (SE 0.019), and the Mason classification as 0.541 (SE 0.098). Intra-rater reliability (Cohen's κ) was 0.761 (SE 0.098) for the Haraguchi classification, 0.761 (SE 0.091) for the Bartoníček, classification, and 0.724 (SE 0.096) for the Mason classification. CONCLUSIONS This study reports the inter-rater and intra-rater reliability for three classification systems for posterior malleolus fractures. Based on definitions by Landis and Koch (Biometrics 33:159-174, 1977), inter-rater reliability was rated as 'moderate' for the Haraguchi and Mason classifications and 'substantial' for the Bartoníček classification. Similarly, the intra-rater reliability was rated as 'substantial' for all three classifications.
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Affiliation(s)
- Mustafa S Rashid
- St George's University Hospital, St. George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, England, UK.
| | - Raisa Islam
- The Princess Alexandra Hospital NHS Trust, Harlow, UK
| | - Samuel Marsden
- St George's University Hospital, St. George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, England, UK
| | - Alexander Trompeter
- St George's University Hospital, St. George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, England, UK
| | - Kar Hao Teoh
- The Princess Alexandra Hospital NHS Trust, Harlow, UK
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Quan Y, Lu H, Qi P, Tian S, Liu J, Zhang C, Zhang B, Xu H. Posterior malleolus fracture: a mid-term follow-up. J Orthop Surg Res 2023; 18:10. [PMID: 36600304 PMCID: PMC9814323 DOI: 10.1186/s13018-022-03488-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 12/30/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND The treatment of posterior malleolar fractures is changing rapidly, and the evidence base is still catching up. This study aimed to assess the mid-term prognosis of posterior malleolar fractures based on different morphological types and provides evidence for the treatment of posterior malleolar fractures. METHODS We retrospectively analyzed the data of inpatients with posterior malleolar fractures from 1 January 2012 to 31 December 2019 at one high-volume tertiary trauma center. Fracture morphology was classified into small-shell fragment, single-fragment (small-fragment and large-fragment) and multifragment (double-fragment and compressive-fragment) by computed tomography according to our previous study. All patients were followed up at an average of 5.06 (range, 2.21-8.70) years. The Olerud-Molander Ankle Score (OMAS), EuroQol-5 Dimensions (EQ-5D) and American Orthopedic Foot and Ankle Society (AOFAS) score were recorded. RESULTS Seventy-nine patients were included, and 7 patients were classified into the small-shell group, 52 patients into the single-fragment group and 20 patients into the multifragment group. Of all the patients, the average OMAS, EQ-5D and AOFAS scores were 85.9, 82.8 and 92.5, respectively. In the single-fragment group, patients who underwent surgical fixation in the posterior malleolus had significantly better scores (P = 0.037, 0.033 and 0.027). Among the patients with small fragments, the surgical fixation group also had higher OMAS (93.1 ± 7.5 vs. 83.5 ± 19.5, P = 0.042) and AOFAS scores (98.1 ± 3.1 vs. 91.0 ± 14.1, P = 0.028). The mean OMAS, EQ-5D and AOFAS scores were 85.5, 85.7 and 91.7, respectively, in patients with multiple fragments who underwent surgical fixation. CONCLUSION This study shows that in fractures with a single fragment, surgical fixation of the posterior malleolar fragment led to a better prognosis in the midterm. All single fragments should be fixed regardless of size. Fixation of the posterior region in all single- and multi-fragments in posterior malleolar fractures led to satisfactory outcomes. LEVEL OF EVIDENCE Level III, follow-up study.
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Affiliation(s)
- Yuan Quan
- grid.411634.50000 0004 0632 4559Orthopaedic and Traumatology, Peking University People’s Hospital, Beijing, 100044 China
| | - Hao Lu
- grid.411634.50000 0004 0632 4559Orthopaedic and Traumatology, Peking University People’s Hospital, Beijing, 100044 China
| | - Peng Qi
- grid.508137.80000 0004 4914 6107Orthopaedic, Qingdao Women and Children’s Hospital, Shandong, China
| | - Songyao Tian
- Orthopaedic, Beijing Daxing District Hospital of Integrated Chinese and Western Medicine, Beijing, China
| | - Jiantao Liu
- Orthopaedic, Luanzhou People’s Hospital, Hebei, China
| | - Chunlong Zhang
- grid.411634.50000 0004 0632 4559Orthopaedic and Traumatology, Peking University People’s Hospital, Beijing, 100044 China
| | - Boyu Zhang
- grid.411634.50000 0004 0632 4559Orthopaedic and Traumatology, Peking University People’s Hospital, Beijing, 100044 China
| | - Hailin Xu
- grid.411634.50000 0004 0632 4559Orthopaedic and Traumatology, Peking University People’s Hospital, Beijing, 100044 China
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Kummer A, Crevoisier X. Posterior to anterior malleolar extended lateral approach to the ankle (PAMELA): early results of a novel approach. Arch Orthop Trauma Surg 2023; 143:879-886. [PMID: 35113239 PMCID: PMC9925524 DOI: 10.1007/s00402-022-04360-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 01/13/2022] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Anne Kummer
- Department of Orthopedics and Traumatology, Lausanne University Hospital (CHUV), and University of Lausanne (UNIL), Pierre-Decker 4, 1011 Lausanne, Switzerland
| | - Xavier Crevoisier
- Department of Orthopedics and Traumatology, Lausanne University Hospital (CHUV), and University of Lausanne (UNIL), Pierre-Decker 4, 1011, Lausanne, Switzerland.
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Influence of posterior malleolar fragment morphology on the outcomes of trimalleolar fractures: A systematic review and meta-analysis. Foot Ankle Surg 2022; 28:1337-1344. [PMID: 35810125 DOI: 10.1016/j.fas.2022.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/08/2022] [Accepted: 06/21/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Trimalleolar fractures are generally considered to have inferior outcomes among ankle injuries. Historically, emphasis was placed on the size of the posterior malleolar fracture (PMF) to guide surgical decision-making and predict outcomes. Recent studies have suggested that the morphology of the PMF fragment is more important than its size. The aim of this systematic review was to determine if the outcomes of trimalleolar fractures depend on the morphology of the PMF as per the Haraguchi classification system after surgical fixation. METHODS A systematic literature search was conducted in the electronic databases of PubMed, Embase, Scopus, and Ovid. Title and abstracts were screened, and data from eligible studies were extracted. Meta-regression and pooled analysis was performed using appropriate computer software. RESULTS 11 studies with 597 patients were included in the final analysis. Pooled mean AOFAS score was 87.43 (95% CI 84.24-90.62) after a mean follow-up of 31.6 months. Univariate and multivariate meta-regression analysis demonstrated that as the percentage of Haraguchi type 1 patients increased, there was a statistically significant improvement in outcome scores. A similar trend was noted for Haraguchi type 3 fractures, and a reverse trend was observed for Haraguchi type 2 injuries, although neither were statistically significant. CONCLUSION Our review suggests that the outcomes of trimalleolar fractures after surgical fixation may depend on the morphology of the PMF, with Haraguchi type 1 fractures having overall superior functional outcomes than Haraguchi type 2 and 3 injuries. Future studies need to done to conclusively prove or refute these findings.
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Percutaneous Fixation of Posterior Malleolar Fractures in Patients With Unstable Ankle Fractures Treated With a Fibular Intramedullary Nail: A Description of a Technique and Review of Outcomes. J Orthop Trauma 2022; 36:195-200. [PMID: 34483324 DOI: 10.1097/bot.0000000000002262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/26/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To (1) describe the percutaneous technique used to reduce and fix a posterior malleolar fracture with anteroposterior screws in patients managed with a fibular intramedullary nail, (2) describe the selection of patients to whom this technique can be applied, and (3) report the clinical and patient reported outcome of this intervention. DESIGN Retrospective review. SETTING Academic orthopaedic trauma center. PATIENTS Thirty-two consecutive patients with a mean age of 65 years (range, 39-90) over a thirteen-year period identified from a prospective database. INTERVENTION Unstable ankle fractures managed surgically with a fibular nail and percutaneous fixation of the posterior malleolar component. MAIN OUTCOME MEASUREMENTS The primary short-term outcome was complications related to posterior malleolar fracture fixation. The primary mid-term outcome was the Olerud-Molander Ankle Score. Secondary outcomes included the Manchester-Oxford Foot Questionnaire, EuroQol-5D, health, pain, and satisfaction. RESULTS Thirty of the 32 (94%) posterior malleolar fractures united uneventfully. Postoperative loss of talar reduction occurred in 2 patients (6.3%), which in 1 patient (3.1%) eventually required a hindfoot nail arthrodesis. There were no soft-tissue complications related to the anteroposterior screws or the fibular nail fixation. At a mean follow-up of 3.7 years (range, 1-8), the median Olerud-Molander Ankle Score, Manchester-Oxford Foot Questionnaire, EuroQol-5D, health, pain, and satisfaction scores were 80.0, 23.4, 0.85, 80.0, 85.0, and 87.5, respectively. CONCLUSIONS Percutaneous ankle fracture fixation with a fibular nail and posterior malleolar screws results in reliable fracture stabilization, good patient outcomes, and high treatment satisfaction. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Bouche PA, Gaujac N, Corsia S, Leclerc P, Anract P, Auberger G. Ankle CT scan allows better management of posterior malleolus fractures than X-rays. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:1301-1309. [PMID: 34468840 DOI: 10.1007/s00590-021-03104-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 08/23/2021] [Indexed: 01/23/2023]
Abstract
PURPOSE Undiagnosed and undertreated posterior malleolus fractures lead to early ankle instability and arthritis. A preoperative CT scan could improve the management of those fractures. This study assessed the benefits of a systematic ankle CT scanner to diagnose and manage posterior malleolus fracture. METHODS A monocentric retrospective cohort study was conducted. Sixty consecutive patients with bimalleolar fractures were operated and underwent a preoperative CT scan. The mean age was 50.0 years old (18.6 years old) with a mean body mass index of 20.3 (kg/m2) (11.4 kg/m2) and 71.7% (43/60) of women. The primary outcome was the rate of posterior malleolus fragment diagnosed on X-rays and on CT scan. Secondly, interobserver and interobserver's agreement were compared between conventional X-rays and CT scan. RESULTS Thirty-five (58.3%) posterior fragment fractures were observed on X-rays and 53 (88.3%) on the preoperative CT scan (p < 0.01). The intraobserver reproducibility for X-rays was low (0.02 [- 0.23; 0.27]) and moderate for CT scan (0.45 [0.0; 0.84]). The interobserver reproducibility for X-rays was moderate (0.39 [0.15; 0.60]) and excellent for CT scan (0.78 [0.0; 1.0]). CONCLUSION A wide proportion of bimalleolar fractures are associated with posterior malleolus fractures and undiagnosed with standard X-rays. We advocate a systematic preoperative CT scan in the management of bimalleolar fractures. LEVEL OF EVIDENCE Level IV, retrospective cohort study. TRIAL REGISTRATION NUMBER 2218999v0, date of registration: 11/08/2020 (retrospectively registered).
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Affiliation(s)
- Pierre-Alban Bouche
- Orthopaedic Department, Cochin University Hospital, APHP Paris, Paris Descartes University, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France.
| | - Nicolas Gaujac
- Orthopaedic Department, Cochin University Hospital, APHP Paris, Paris Descartes University, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Simon Corsia
- Orthopaedic Department, Cochin University Hospital, APHP Paris, Paris Descartes University, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Philippe Leclerc
- Orthopaedic Department, Croix St Simon Hospital, 125 rue d'Avron, 75020, Paris, France
| | - Philippe Anract
- Orthopaedic Department, Cochin University Hospital, APHP Paris, Paris Descartes University, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Guillaume Auberger
- Orthopaedic Department, Croix St Simon Hospital, 125 rue d'Avron, 75020, Paris, France
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