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Lassiter EM, Brown KJ, Patel D, Sparks A, Liu J, Elattar O. A systematic review of posterior pilon variant fractures. J Orthop 2024; 53:73-81. [PMID: 38476677 PMCID: PMC10926286 DOI: 10.1016/j.jor.2024.02.035] [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: 02/14/2024] [Accepted: 02/19/2024] [Indexed: 03/14/2024] Open
Abstract
Posterior pilon variant ankle fractures (PPVF) are a unique subtype of posterior malleolar fractures which have been a source of controversy and confusion in recent years. There has not been a thorough literature review previously written on the topic. Database searches of PubMed and Embase were conducted from inception until June 2023. The key words included "pilon variant," "posterior pilon variant," and "posterior pilon" fractures. Outcomes were evaluated by union time, rates of delayed union, nonunion, malunion, and complication. A total of 15 articles relevant to surgical repair of pilon variant fractures were included in the literature review. The unique mechanism of injury has been reported to involve both rotational and axial forces, leading to involvement of the posterior and medial aspects of the distal tibia. Pilon variant fractures can be suspected by several characteristics on radiographs and have a high confirmation rate via CT images. Multiple systems have been proposed to classify this fracture pattern, but there is no consensus on the ideal classification system. Surgically, direct fixation has shown better short-term clinical outcomes versus indirect fixation or no fixation. PPVF have a distinct fracture pattern involving the posterior and medial columns of the distal tibial plafond, and results from a mechanism intermediate to rotational and axial forces. These fractures are more severe than tri-malleolar fractures due to increased rates of articular impaction and incongruity. Future classification systems should focus on joint surface area and the tibial pilon column involved to avoid confusion with less severe posterior malleolar fractures.
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Affiliation(s)
- Eric M. Lassiter
- Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, OH, 43614, United States
| | - Kevin J. Brown
- Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, OH, 43614, United States
| | - Devon Patel
- Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, OH, 43614, United States
| | - Addison Sparks
- Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, OH, 43614, United States
| | - Jiayong Liu
- Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, OH, 43614, United States
| | - Osama Elattar
- Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, OH, 43614, United States
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Patel S, Dionisopoulos SB. Current Concepts in Ankle Fracture Management. Clin Podiatr Med Surg 2024; 41:519-534. [PMID: 38789168 DOI: 10.1016/j.cpm.2024.01.008] [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: 05/26/2024]
Abstract
Ankle fractures are one of the more common musculoskeletal injuries that are treated by foot and ankle specialists. A thorough understanding of managing these injuries requires the ability to differentiate between stable and unstable fractures. The current literature supports the nonoperative management of stable Weber B ankle fractures, whereas unstable fractures have much better outcomes with surgical intervention. Specifically, we review the fixation strategies for the lateral, medial, and posterior malleolar fractures respectively. Finally, we discuss the current trends in postoperative management of some of the more common fracture patterns, and the safety in early weight-bearing protocols.
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Affiliation(s)
- Sandeep Patel
- The Permanente Medical Group Diablo Service Area, Department of Orthopedics and Podiatry, San Francisco Bay Area Foot and Ankle Residency, 1425 S. Main Street, Walnut Creek, CA 94596, USA.
| | - Shontal Behan Dionisopoulos
- The Permanente Medical Group Diablo Service Area, Department of Orthopedics and Podiatry, San Francisco Bay Area Foot and Ankle Residency, 1425 S. Main Street, Walnut Creek, CA 94596, USA
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Massri-Pugin J, Morales S, Serrano J, Mery P, Filippi J, Villa A. Percutaneous Fixation of Posterior Malleolar Fractures: A Contemporary Review. FOOT & ANKLE ORTHOPAEDICS 2024; 9:24730114241256371. [PMID: 38840784 PMCID: PMC11151760 DOI: 10.1177/24730114241256371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Affiliation(s)
- Jafet Massri-Pugin
- Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Sergio Morales
- Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Javier Serrano
- Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Pablo Mery
- Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jorge Filippi
- Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Andrés Villa
- Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
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Zhu G, Cao S, Zhu J, Yuan C, Wang Z, Huang J, Ma X, Wang X. Combined vertical and external rotational force in plantarflexion position produces posterior pilon fracture: A preliminary cadaveric study. Foot Ankle Surg 2024:S1268-7731(24)00037-7. [PMID: 38431488 DOI: 10.1016/j.fas.2024.02.010] [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: 10/25/2023] [Revised: 12/09/2023] [Accepted: 02/22/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Posterior pilon fracture is speculated to occur by a combination of rotation and axial load, which makes it different from rotational posterior malleolar fracture or pilon fracture, but is not validated in vitro. The aim of the current study is to investigate the injury mechanisms of posterior pilon fracture on cadaveric specimens. METHODS Eighteen cadaveric specimens were mounted to a loading device to undergo solitary vertical loading, solitary external rotational loading, and combined vertical and external rotational loading until failure, in initial position of plantarflexion with or without varus. The fracture characteristics were documented for each specimen. RESULTS Vertical loading force combined with external rotation force diversified the fracture types resulting in pilon fracture, tibial spiral fracture, rotational malleolar fracture, talar fracture or calcaneal fracture. Vertical violence combined with external rotational loading in position of 45° of plantarflexion and 0° of varus produced posterior pilon fracture in specimens No. 13 and 14. CONCLUSION Combination of vertical and external rotational force in plantarflexion position on cadaveric specimens produce posterior pilon fracture.
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Affiliation(s)
- Genrui Zhu
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Shengxuan Cao
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Jun Zhu
- Yiwu Research Institute, Fudan University, Shanghai, China; Academy for Engineering and Technology, Fudan University, Shanghai, China
| | - Chengjie Yuan
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Zhifeng Wang
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Jiazhang Huang
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Xin Ma
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China; Academy for Engineering and Technology, Fudan University, Shanghai, China; Shanghai Sixth People's Hospital, Shanghai, China
| | - Xu Wang
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China.
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Fisher ND, Nwakoby E, Hernandez H, McLaurin TM. Electric scooter injuries: Incidence and injury patterns at a level I trauma center. Chin J Traumatol 2023; 26:334-338. [PMID: 36922264 PMCID: PMC10755772 DOI: 10.1016/j.cjtee.2023.02.003] [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: 04/30/2022] [Revised: 01/31/2023] [Accepted: 02/20/2023] [Indexed: 03/18/2023] Open
Abstract
PURPOSE Electric scooters (e-scooters) have become an increasingly popular mode of public transportation in recent years. As the incidence of related injuries rises, it is important to understand specific fracture patterns unique to e-scooters and electric bikes (e-bikes) to help guide management. The purpose of this study was to review the prevalence and describe specific fracture patterns of e-scooter and e-bike related injuries at the busiest level 1 trauma center in the borough of Manhattan. METHODS Chart review to determine mechanism of injury was performed on all patients for whom an orthopedic consult was requested from 1/1/2021 to 12/31/2021. All patients whose injuries were sustained due to an e-scooter or e-bike were further reviewed for demographics, injury characteristics including fracture pattern, and definitive injury management. Any patients who had an orthopedic consult placed for a reason other than an acute injury were excluded. Descriptive statistics are reported as frequency (percentage) for categorical variables and means for continuous variables. RESULTS Of the 1815 orthopedic consults requested, 1357 (74.8%) were for acute injury management. Of those with acute injuries, 119 (8.8%) sustained 136 e-scooter or e-bike related injuries. There were 92 (77.3%) males at an average age of (33.8 ± 15.7) years. Approximately one-fifth of all patients presented in June 2021 (26, 21.8%). There was a 9.2% rate of open fractures. The 136 injuries were evenly split between the upper and lower extremities, with 57 (47.9%) upper extremity, 57 (47.9%) lower extremity injuries, and 5 (4.2%) concomitant upper and lower extremity injuries. The most common fracture patterns were ankle fractures (16, 11.7%), followed by tibial shaft (14, 10.2%), tibial plateau (13, 9.5%), and radial head fractures (11, 8.0%). There was a 33.3% incidence of associated posterior malleolar fractures in the spiral tibial shaft fractures, 31.0% of posterior malleolar involvement and 18.8% of isolated vertical medial malleolar fractures in the ankle fractures, and 61.5% of posterior comminution in the tibial plateau fractures. CONCLUSION E-scooter and e-bike related injuries have a high incidence of tibial shaft fractures, ankle fractures, tibial plateau fractures, and radial head fractures. There should be a high index of suspicion for posterior and medial involvement in lower extremity fractures sustained due to e-scooter or e-bikes. Identifying specific fracture patterns seen in e-scooter and e-bike related mechanisms will help guide management of these injuries.
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Affiliation(s)
- Nina D Fisher
- Department of Orthopedic Surgery, Langone Orthopedic Hospital, New York University, New York, United States.
| | - Ekenedilichukwu Nwakoby
- Department of Orthopedic Surgery, Langone Orthopedic Hospital, New York University, New York, United States
| | - Hunter Hernandez
- Department of Orthopedic Surgery, Langone Orthopedic Hospital, New York University, New York, United States
| | - Toni M McLaurin
- Department of Orthopedic Surgery, Langone Orthopedic Hospital, New York University, New York, United States; Department of Orthopedic Surgery, Health+Hospitals/Bellevue New York City, New York, United States
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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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Qing S, Zhang Y, Qin X. The treatment of a malunited posterior pilon fracture with talar dislocation: A staged surgical treatment protocol. Injury 2023; 54:110934. [PMID: 37478691 DOI: 10.1016/j.injury.2023.110934] [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: 03/23/2023] [Revised: 06/25/2023] [Accepted: 07/10/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND Malunited posterior pilon fractures with talus dislocation (mPPFtd) are rare and there are no appropriate treatment strategies. The purpose of this study was to introduce a stepped strategy featuring preliminary soft tissue management according to the Ilizarov principle and delayed open reduction and internal fixation (ORIF) through a modified posteromedial approach to overcome rigid soft tissue contracture. METHOD From February 2015 to August 2021, 12 selected patients with mPPFtd who were treated with the staged protocol (Group A) were retrospectively analysed. The clinical and radiographic outcomes were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, the visual analogue scale (VAS) score, and the Burwell-Charnley score. Moreover, this case series was compared with some cases of fresh fracture (Group B) in patients that had the same baseline data from our previous study. RESULTS In Group A, the average length of time between the date of injury and the date of surgery was 4.8 ± 3.3 months. The average time to external fixator distraction, as the first-stage treatment, was 13.4 ± 1.0 days. In the second stage of ORIF, the posterosuperior dislocation of the talus was corrected with osteotomy and leverage manoeuvres. According to the Burwell-Charnley score system, the reduction quality was excellent in 9 cases and good in 3 cases. After a mean follow-up of 3.8 ± 2.1 years, there were no infections, wound healing problems, or nerve injuries in our cohort, and union was observed in all fractures without a loss of reduction. The baseline data of the two groups were not significantly different (p>0.05). The mean AOFAS score in Group A was 85.0 ± 10.5 and that in Group B was 95.4 ± 6.1 (p<0.05). The mean VAS score in Group A was 1.7 ± 1.4 and that in Group B was 0.7 ± 0.9 (p<0.05). CONCLUSION A staged surgical treatment strategy characterized by soft tissue management will improve the treatment of mPPFtd and produce satisfactory clinical outcomes. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Siyuan Qing
- Department of Trauma, the First Affifiliating Hospital of Nanjing Medical University & Jiangsu Province Hospital, China
| | - Yu Zhang
- Department of Trauma, the First Affifiliating Hospital of Nanjing Medical University & Jiangsu Province Hospital, China.
| | - Xiaodong Qin
- Department of Trauma, the First Affifiliating Hospital of Nanjing Medical University & Jiangsu Province Hospital, China.
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Xie W, Lu H, Liu Y, Quan Y, Xu H, Fu Z, Zhang D, Jiang B. Morphological analysis and classification of posterior malleolar fractures based on CT scans. Injury 2023; 54:111006. [PMID: 37643538 DOI: 10.1016/j.injury.2023.111006] [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: 04/11/2023] [Revised: 08/03/2023] [Accepted: 08/19/2023] [Indexed: 08/31/2023]
Abstract
OBJECTIVES The aim of the study was to propose a classification system of posterior malleolar fractures by fracture lines with the use of CT scans, including 3D CT reconstruction, which can better understand morphological characteristics, analyze the mechanism and guide the surgeon to choose the optimal approach and fixation. METHODS Patients with OTA/AO type 44 fractures involving the posterior malleolus and preoperative CT scans were included. We retrospectively analyzed 128 consecutive patients with posterior malleolar fractures from January 2013 to December 2019 at our institution. CT data were loaded into Mimics software (V20.0, Materialize), in which 3D CT reconstruction, morphological analysis and data measurements were made. RESULTS Based on the number of fracture lines in 128 consecutive patients, posterior malleolar fractures were classified into three types: type 1 with a single fracture line, type 2 with double fracture lines and type 3 with multiple fracture lines. According to the distribution of the fracture line, type 1 was divided into types 1A, 1B and 1C, and type 2 was divided into types 2A, 2B and 2C. The fracture line from the fibular notch to the posterior rim of the distal tibia was defined as type 1A, and the fracture line to the medial malleolus was defined as type 1B. Type 1C was a small fragment in the posterior rim of the distal tibia. Type 2A was regarded as type 1A with type 1C. It was considered type 2B because another fracture line started from the fracture line of type 1A and extended to the medial malleolus. In type 2C, we could see that the double fracture lines were all from the fibular notch to the posterior rim of the distal tibia and did not cross. Type 3 fractures were comminuted fractures with multiple fracture lines. CONCLUSION The morphology of posterior malleolar fractures, involvement of the fibular notch, or the medial malleolus can be obviously assessed by our classification system. We found the relation of the injury mechanism between type 1 and type 2 by comparing the area of the fragment. We have indicated that each type of fracture corresponds to its associated injury mechanism and which surgical approach and fixation can be chosen.
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Affiliation(s)
- Wenyong Xie
- Department of Orthopedics and Trauma, Peking University People's Hospital, 100044, Beijing, China; Beijing Jishuitan Hospital, 100035, Beijing, China
| | - Hao Lu
- Department of Orthopedics and Trauma, Peking University People's Hospital, 100044, Beijing, China
| | - Yijun Liu
- Department of Foot and Ankle Surgery, Center for Orthopaedic Surgery, the Third Affiliated Hospital of Southern Medical University, Guangzhou, China; Orthopaedic Hospital of Guangdong Province, Guangzhou, China
| | - Yuan Quan
- Department of Orthopedics and Trauma, Peking University People's Hospital, 100044, Beijing, China
| | - Hailin Xu
- Department of Orthopedics and Trauma, Peking University People's Hospital, 100044, Beijing, China.
| | - Zhongguo Fu
- Department of Orthopedics and Trauma, Peking University People's Hospital, 100044, Beijing, China
| | - Dianying Zhang
- Department of Orthopedics and Trauma, Peking University People's Hospital, 100044, Beijing, China
| | - Baoguo Jiang
- Department of Orthopedics and Trauma, Peking University People's Hospital, 100044, Beijing, China; Trauma Center, National Center for Trauma Medicine, 100044, Beijing, China; Key Laboratory of Trauma and Neural Regeneration, Peking University People's Hospital Beijing, 100044, China
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Terstegen J, Weel H, Frosch KH, Rolvien T, Schlickewei C, Mueller E. Classifications of posterior malleolar fractures: a systematic literature review. Arch Orthop Trauma Surg 2023; 143:4181-4220. [PMID: 36469121 PMCID: PMC10293398 DOI: 10.1007/s00402-022-04643-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 09/30/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Complex ankle fractures frequently involve the posterior malleolus. Many classifications describing posterior malleolar fractures (PMF) exist. The aim of this study was to provide a systematic literature review to outline existing PMF classifications and estimate their accuracy. METHODS The databases PubMed and Scopus were searched without time limits. Only specific PMF classifications were included; general ankle and/or pilon fracture classifications were excluded. Selection and data extraction was performed by three independent observers. The systematic literature search was performed according to the current criteria of Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). The methodological quality of the included studies was quantified using the modified Coleman score. RESULTS A total of 110 studies with a total of 12.614 patients were included. Four main classifications were identified: Those describing the size of the posterior malleolar fracture (n = 66), Haraguchi (n = 44), Bartoníček/Rammelt (n = 21) and Mason (n = 12). The quality of the studies was moderate to good with a median Coleman-score of 43.5 (14-79) and a weighted median Coleman-score of 42.5 points. All classifications achieved a substantial to perfect score regarding the inter- and intraobserver reliability, with Mason scoring the lowest in comparison. CONCLUSIONS None of the reviewed PMF classifications has been able to establish itself decisively in the literature. Most of the classifications are insufficient in terms of a derivable treatment algorithm or a prognosis with regard to outcome. However, as the Bartoníček/Rammelt classification has the greatest potential due to its treatment algorithm, its reliability in combination with consistent predictive values, its usage in clinical practice and research appears advisable.
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Affiliation(s)
- Julia Terstegen
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Hanneke Weel
- Department of Orthopedics, Bergman Clinics, Arnhem, The Netherlands
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
- Department of Trauma Surgery, Orthopaedics, and Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany
| | - Tim Rolvien
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Carsten Schlickewei
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Elena Mueller
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
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Wang C, Chen C, Zhou Y, Pan ZE. Morphological study of CT image of posterior pilon variant fracture and its possible clinical significance. Arch Orthop Trauma Surg 2023; 143:1203-1215. [PMID: 34705073 DOI: 10.1007/s00402-021-04224-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 10/11/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The incidence of posterior pilon variant fractures has been underestimated. The purpose was to study the characteristics of posteromedial (PM) and posterolateral (PL) fragments in CT imaging of posterior pilon variant fractures, and to provide help for clinical diagnosis and treatment. METHODS CT imaging data of 109 cases of posterior pilon variant fractures in our hospital from January 2013 to December 2020 were retrospectively analyzed. According to Mason and Molloy classification, PM fragments were further divided into pilon subtypes and avulsed subtypes. The largest actual area of fragments in axial and sagittal were selected as the study plane, and the maximum axial lengths of X, Y and Z, α angle, β angle, fragment area (S1-7) and fragment area ratio (FAR1-4), interfragmentary (IF) angle, and back of tibia (BT) angle were measured. RESULTS A total of 109 cases were included in this study, 61 of whom were pilon subtypes [90.16% were supination-external rotation (SER) injuries]. 48 cases were avulsed subtypes [81.25% were pronation-external rotation (PER) injuries]. Pilon subtypes were larger than avulsed subtypes in X, Y, Z, α2 Angle, β2 Angle, fragment area and ratio, and IF and BT angle (P < 0.05). There was no difference between α1 and β1 angle (P > 0.05). CONCLUSION The morphology of pilon subtype was larger than that of avulsion subtype. According to fragment size, morphology, and injury mechanism, two fragments of pilon subtype should be anatomic reduction and fixation. However, the PL fragment of avulsion subtype should to be fixed, while PM fragment may only need conservative treatment.
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Affiliation(s)
- Chenglong Wang
- Department of Orthopaedics, Taizhou Hospital of Zhejiang Province, Taizhou, 318000, Zhejiang, People's Republic of China
| | - Chengwei Chen
- Department of Orthopaedics, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, People's Republic of China
| | - Yeli Zhou
- Department of Orthopaedics, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, People's Republic of China
| | - Zhe-Er Pan
- Department of Orthopaedics, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, People's Republic of China.
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Lee BG, Lee GS, Kim SB, Lee JK, Lee SH, Song JH, Kang C, Song JH. Difference in Joint Stability Between Small Posterior Malleolar Fragments With Fixation and Those Without Fixation: A Biomechanical Cadaver Study. J Foot Ankle Surg 2023:S1067-2516(23)00015-7. [PMID: 36872103 DOI: 10.1053/j.jfas.2023.01.006] [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: 12/30/2021] [Revised: 10/26/2022] [Accepted: 01/21/2023] [Indexed: 03/07/2023]
Abstract
The indication for the surgical treatment of ankle fractures that involve a posterior malleolar fragment remains controversial. This cadaver study assessed the biomechanical results of rotation stiffness of Haraguchi type 1 posterior malleolar fragments with or without cannulated screw fixation. Twelve anatomic lower-extremity specimens from 6 cadavers were tested. Six right legs were subjected to posterior malleolus osteotomy (Haraguchi type I) followed with (group A; n = 3) or without (group B; n = 3) fixation using a cannulated screw. Ankle joint stability was measured under both external rotation force and axial loading, and the passive resistive torque was measured in both groups. The mean torque value in group A was 0.1093 Nm/º, while that in group B was 0.0537 Nm/º. There was a significant intergroup difference (p = .004). In group B, the torque value was further increased in the latter rotation period (about 40-60 degrees). Group A proved more stable under experimental conditions than group B. Fixation in type I posterior malleolar fragments produced improved stability in ankle rotation, even for posterior malleolar fragments involving <25% of the articular surface, and has been considered an effective aid in treatment.
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Affiliation(s)
- Byoung-Gu Lee
- Department of Orthopedics, Chungnam National University Sejong hospital, Sejong-si, Republic of Korea
| | - Gi-Soo Lee
- Department of Orthopedics, Chungnam National University Sejong hospital, Sejong-si, Republic of Korea.
| | - Sang-Bum Kim
- Department of Orthopedics, Chungnam National University Sejong hospital, Sejong-si, Republic of Korea
| | - Jeong-Kil Lee
- Department of Orthopedics, Chungnam National University Sejong hospital, Sejong-si, Republic of Korea
| | - Seung Hoo Lee
- Department of Orthopedics, Chungnam National University Sejong hospital, Sejong-si, Republic of Korea
| | - Ju-Ho Song
- Department of Orthopedics, Chungnam National University Sejong hospital, Sejong-si, Republic of Korea
| | - Chan Kang
- Department of Orthopedics, Chungnam National University hospital, Jung-gu, Daejeon, Republic of Korea
| | - Jae-Hwang Song
- Department of Orthopedics, Konyang University hospital, Seo-gu, Daejeon, Republic of Korea
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Gan TJ, Li YX, Chen Y, Liu X, Zhang H. Open reduction and internal fixation for posterior pilon fracture: Transfibular approach versus posterior approach. Injury 2023; 54:751-760. [PMID: 36404163 DOI: 10.1016/j.injury.2022.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 11/01/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND For posterior pilon fractures, the posterior approach (PA) is widely used but has its limitations. The transfibular approach (TFA) has been adopted to treat posterior malleolar fractures for the advantage of direct visual confirmation of the reduction status intraoperatively, yet the report of its application on posterior pilon fractures is rare. This study aims to compare TFA with PA in terms of their corresponding reduction quality. METHODS Clinical data of 85 posterior pilon fracture patients treated via PA (n = 62) or TFA (n = 23) were retrospectively reviewed. Radiographic and clinical assessments, including articular step-off or gap, syndesmosis reduction quality, signs of ankle arthritis, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, visual analogue scale (VAS), ankle stability, and the active range of motion (ROM) of the ankle, were all evaluated by two readers independently. RESULTS The total incidence of step-off or gap ≥ 1 mm was significantly higher in the PA group (35.5%) than in the TFA group (8.7%, p = 0.015). In all the patients, step-off ≥ 1 mm was identified as an independent risk factor for the development of arthritis and a lower AOFAS score (p < 0.001). No significant difference was found in ROM and complication incidence between the two groups. Ankle instability was found in neither group during the follow-up. CONCLUSION TFA could offer a way to intraoperatively evaluate the reduction status with direct visual confirmation and, thereby, might improve the results of reduction for posterior pilon fractures. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Ting-Jiang Gan
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, China
| | - Ya-Xing Li
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, China; Disaster Medicine Center, Sichuan University, Chengdu, Sichuan Province 610041, China
| | - Yu Chen
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, China
| | - Xi Liu
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, China
| | - Hui Zhang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, China; Disaster Medicine Center, Sichuan University, Chengdu, Sichuan Province 610041, China.
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13
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Posterior Malleolar Fracture Assessment: An Independent Interobserver and Intraobserver Validation of Three Computed Tomography-Based Classifications. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202301000-00004. [PMID: 36622849 PMCID: PMC9831157 DOI: 10.5435/jaaosglobal-d-22-00258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/06/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Posterior malleolus fractures occur in up to 50% of all ankle fractures. Several classification systems exist for their characterization, especially under CT. However, those classifications do not report the level of agreement or do it incompletely. This study aims to independently assess three posterior malleolus fracture classifications (Haraguchi, Bartoníček/Rammelt, and Mason). METHODS This study was designed according to the Guidelines for Reporting Reliability and Agreement Studies. Ninety-four CT scans of patients with ankle fractures that had posterior malleolus fractures were included. Posterior malleolus fractures were assessed by six evaluators (three attending foot and ankle surgeons and three orthopaedic surgery residents) according to Haraguchi, Bartoníček/Rammelt, and Mason classifications. All images were reassessed by the same evaluators in a random sequence 3 weeks later. The kappa (k) coefficient was used to determine the interobserver and intraobserver agreement. Statistical significance was established using P < 0.05 with a 95% confidence interval (CI). RESULTS The interobserver agreement was moderate for Haraguchi, Bartoníček/Rammelt, and Mason classifications with a global k value of 0.52 (95% CI, 0.43 to 0.60), 0.53 (95% CI, 0.46 to 0.61), and 0.54 (95% CI, 0.47 to 0.62), respectively. The intraobserver agreement was substantial for Haraguchi, Bartoníček/Rammelt, and Mason classifications, with an overall k value of 0.70 (95% CI, 0.64 to 0.74), 0.73 (95% CI, 0.68 to 0.78), and 0.73 (95% CI, 0.69 to 0.78), respectively. Interobserver and intraobserver agreement among orthopaedic surgeons and residents had no significant difference. CONCLUSION The current classifications for posterior malleolus fractures showed a substantial intraobserver agreement. Nevertheless, the interobserver agreement obtained was just moderate for all classifications, independent of the level of expertise of the evaluators.
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Liang W, Zhou M, Jiang Z, Mao X, Zhou X. Treatment outcomes of posterior pilon fractures using a simple single lateral approach via stretching fibular fracture line. Front Surg 2023; 10:1141606. [PMID: 37066001 PMCID: PMC10097982 DOI: 10.3389/fsurg.2023.1141606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/06/2023] [Indexed: 04/18/2023] Open
Abstract
Purpose The aim of this study was to explore the treatment outcomes of a novel single lateral approach via fibular fracture line for patients with posterior pilon fractures. Patients and methods From January 2020 to December 2021, a total of 41 patients with posterior pilon fractures who received surgical treatment in our hospital were retrospectively reviewed. Twenty patients (Group A) were treated with open reduction and internal fixation (ORIF) via posterolateral approach. Twenty-one patients (Group B) were treated with ORIF using a simple single lateral approach via stretching fibular fracture line. Clinical assessments, including operation time, intraoperative blood loss, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, visual analogue scale (VAS), and the active range of motion (ROM) of the ankle at the final follow-up visit after surgery, were performed in all patients. Radiographic outcome was evaluated by using the criteria proposed by Burwell and Charnley. Results The mean follow-up time was 21 months (range 12-35). The average operation time and intraoperative blood loss in the Group B were significantly less than those in the Group A. Moreover, the AOFAS score and ankle ROM in the Group B were significantly higher than those in the Group A at the final follow-up visit. Eighteen cases (90%) in Group A and 19 cases (90.5%) in Group B achieved anatomical reduction of the fracture. Conclusion The single lateral approach via stretching fibular fracture line is a simple and effective technique for reduction and fixation of posterior pilon fractures.
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Affiliation(s)
- Wei Liang
- Department of Orthopaedics, Lishui People's Hospital, The Sixth Affiliated Hospital of Wenzhou Medical University, The First Affiliated Hospital of Lishui University, Lishui, China
| | - Mingping Zhou
- Department of Orthopaedics, Lishui People's Hospital, The Sixth Affiliated Hospital of Wenzhou Medical University, The First Affiliated Hospital of Lishui University, Lishui, China
| | - Zhongting Jiang
- Department of Orthopaedics, Lishui People's Hospital, The Sixth Affiliated Hospital of Wenzhou Medical University, The First Affiliated Hospital of Lishui University, Lishui, China
| | - Xuanyu Mao
- Department of Orthopaedics, Lishui People's Hospital, The Sixth Affiliated Hospital of Wenzhou Medical University, The First Affiliated Hospital of Lishui University, Lishui, China
| | - Xiang Zhou
- Department of Orthopaedics, Longquan People’s Hospital, Longquan, China
- Correspondence: Xiang Zhou
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15
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Guo C, Zhu Y, Li C, Li X, Yang C, Xu X. Comparison of prone-supine versus supine position for the treatment of pilon fractures via modified posteromedial approach combined with anterolateral approach. Foot Ankle Surg 2023; 29:79-85. [PMID: 36270884 DOI: 10.1016/j.fas.2022.10.004] [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: 02/26/2022] [Revised: 09/30/2022] [Accepted: 10/08/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Most of modified posteromedial approaches require prone position for the treatment of pilon fractures. We describe the technique of modified posteromedial approach under supine position. The goal of the study was to compare the radiographic and clinical outcomes of prone-supine versus supine position for the treatment of pilon fractures via modified posteromedial approach combined with anterolateral approach. METHODS A total of 50 retrospectively consecutive pilon fractures that underwent open reduction internal fixation via modified posteromedial approach combined with anterolateral approach from 2016 to 2019 were reviewed at least a two-year follow up. The positions of patients were divided into two groups: prone-supine versus supine position (26 vs 24, respectively). The operation time, radiographic outcomes including bone union time and ratio of congruent articular reduction were evaluated. The post-operative function was evaluated using the Manchester Oxford score (MOXFQ) and the visual analogue score (VAS). The motion of ankle joint and complications and were also compared. RESULTS The mean follow-up was 42.2(24.7-73.0) months in the prone-supine group and 42.7(37.3-56.5) months in the supine group (P = .87). The mean operation time was 141.9 ± 10.1 min in the prone-supine group and 107.5 ± 18.9 min in the supine group (P = .00). There was no significant difference in the bone union time and ratio of congruent articular reduction between the two groups. There was no significant difference in the final MOXFQ score, VAS score, and the mean range of ankle motion between the two groups (P > .05). The total incidence of complications was 11.5% in the prone-supine group and 16.6% in the supine group (P = .66). CONCLUSION The patient in the prone-supine position versus supine position for pilon fractures via modified posteromedial approach combined with anterolateral approach contributed comparable quality of reduction, bone union time functional outcomes and complications. The supine technique was significantly shorter in terms of operation time.
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Affiliation(s)
- Changjun Guo
- Department of Orthopaedics, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 20025, China.
| | - Yuan Zhu
- Department of Orthopaedics, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 20025, China.
| | - Chunguang Li
- Department of Orthopaedics, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 20025, China.
| | - Xingchen Li
- Department of Orthopaedics, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 20025, China.
| | - Chonglin Yang
- Department of Orthopaedics, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 20025, China.
| | - Xiangyang Xu
- Department of Orthopaedics, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 20025, China.
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Kleinertz H, Mueller E, Tessarzyk M, Frosch KH, Schlickewei C. Computed tomography-based classifications of posterior malleolar fractures and their inter- and intraobserver reliability: a comparison of the Haraguchi, Bartoníček/Rammelt, and Mason classifications. Arch Orthop Trauma Surg 2022; 142:3895-3902. [PMID: 35094134 DOI: 10.1007/s00402-021-04315-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 12/13/2021] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Complex ankle fractures often include fractures of the posterior malleolus. The most clinically relevant posterior malleolus fracture classifications are computed tomography (CT) based. These classifications aim to enable clear communication and help develop treatment strategies. This study investigates the inter- and intraobserver reliability of the Haraguchi, Bartoníček/Rammelt and Mason posterior malleolar fracture classifications. MATERIALS AND METHODS CT scans of 113 patients with a mean age of 56.2 (SD ± 17.8) years and fractures involving the posterior malleolus were analyzed twice by 4 observers with different levels of training. The posterior malleolar fractures were classified according to Haraguchi et al., Bartoníček/Rammelt et al. and Mason et al. The intraobserver and interobserver reliabilities were determined by calculating Cohen's and Fleiss' kappa values. RESULTS We found substantial multi-rater interobserver agreement for all three classifications. The Haraguchi classification 0.799 (CI 0.744-0.855) showed the highest agreement, followed by the Bartoníček/Rammelt 0.744 (0.695-0.793) and Mason 0.717 (CI 0.666-0.768) classifications. Subgroup analyses showed substantial to perfect agreement for the Haraguchi and substantial agreement for the Bartoníček/Rammelt and Mason classifications independent of observer expertise. The intraobserver reliability was perfect for three and substantial for one of the observers. However, the classifications have certain pitfalls and do not consider the number of fragments, articular surface impressions, or intercalary fragments. CONCLUSION All classifications show substantial, if not perfect inter- and intraobserver reliabilities independent of observer level of expertise.
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Affiliation(s)
- Holger Kleinertz
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Elena Mueller
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Marlon Tessarzyk
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.,Department of Trauma Surgery, Orthopaedics, and Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany
| | - Carsten Schlickewei
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
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Gerlach R, Toepfer A, Jacxsens M, Zdravkovic V, Potocnik P. Temporizing cast immobilization is a safe alternative to external fixation in ankle fracture-dislocation while posterior malleolar fragment size predicts loss of reduction: a case control study. BMC Musculoskelet Disord 2022; 23:698. [PMID: 35869482 PMCID: PMC9306170 DOI: 10.1186/s12891-022-05646-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 07/08/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
To determine if temporizing cast immobilization is a safe alternative to external fixator (ex-fix) in ankle fracture-dislocations with delayed surgery or moderate soft-tissue injury, we analysed the early complications and re-dislocation rates of cast immobilization in relation to ex-fix in patients sustaining these injuries.
Methods
All skeletally mature patients with a closed ankle fracture-dislocation and a minimum 6-months follow-up treated between 2007 and 2017 were included. Baseline demographics, comorbidities, injury description, treatment history and complications were assessed.
Results
In 160 patients (94 female; mean age 50 years) with 162 ankle fracture-dislocations, 35 underwent primary ex-fix and 127 temporizing cast immobilizations. Loss of reduction (LOR) was observed in 25 cases (19.7%) and 19 (15.0%) were converted to ex-fix. The rate of surgical site infections (ex-fix: 11.1% vs cast: 4.6%) and skin necrosis (ex-fix: 7.4% vs cast: 6.5%) did not differ significantly between groups (p = 0.122 and p = 0.825). Temporizing cast immobilization led to an on average 2.7 days earlier definite surgery and 5.0 days shorter hospitalization when compared to ex-fix (p < 0.001). Posterior malleolus fragment (PMF) size predicted LOR with ≥ 22.5% being the threshold for critical PMF-size (p < 0.001).
Conclusion
Temporizing cast immobilization was a safe option for those ankle fracture-dislocations in which immediate definite treatment was not possible. Those temporized in a cast underwent definite fixation earlier than those with a fix-ex and had a complication rate no worse than the ex-fix patients. PMF-size was an important predictor for LOR. Primary ex-fix seems appropriate for those with ≥ 22.5% PMF-size.
Trial registration
The study does not meet the criteria of a prospective, clinical trial. There was no registration.
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Choi JY, Oh HK, Di Mento L, Hur JW, Suh JS. Operative strategy for tri-malleolar ankle fractures with posteromedial plafond involvement: a review of sixty six cases. INTERNATIONAL ORTHOPAEDICS 2022; 46:2637-2648. [PMID: 35994065 DOI: 10.1007/s00264-022-05554-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 08/12/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE We aimed to summarize the radiographic and clinical outcomes in various conditions of tri-malleolar ankle fractures (TMFs) with posteromedial (PM) plafond involvement (TMF + PM) and determine the factors affecting their subjective clinical outcomes. METHODS Radiographic and clinical findings of 66 patients who underwent operative treatment for TMF + PM were retrospectively reviewed. The patients were classified into three groups according to the PM fracture line location. Type I fractures were defined when the PM fracture line extended medially beyond the PM corner of the distal tibia while type II fractures were those in which the PM fracture line was located laterally to the PM corner. Type III fractures were defined as medial malleolar avulsion fractures when the PM fracture integrated into the medial malleolus. Clinical outcomes were evaluated using a subjective rating scale (excellent, good, fair, poor, and bad). Satisfactory results were defined as excellent, good, and fair. Factors affecting satisfactory clinical outcomes were assessed using a binary logistic regression analysis. Independent variables included demographic, fracture-related, and operation-related factors and radiographic measurements at the final follow-up. RESULTS Satisfactory clinical outcomes were observed in 74.2% of the total patients; of these patients, 75.7% (28/37), 76.5% (13/17), and 66.7% (8/12) had type I, type II, and type III fractures, respectively. The binary logistic regression analysis revealed that age at the time of operation, number of incarcerated fragments (IFs), type of IFs, and postoperative articular step-offs (mm) were related to subjective clinical outcomes (all P < 0.05). A positive value for post-operative articular step-offs represented distal migration of the posterior malleolar fragments. The odds ratios for older age, increased numbers of IFs, rotated IFs, and positive articular step-offs were 0.936, 0.116, 0.020, and 0.295, respectively. CONCLUSION Because TMF + PM is highly unstable, a delicate approach is needed according to each patient's fracture condition. Although it is best to reduce the fractured articular surface, a negative step-off, rather than a positive step-off, would be more likely recommended if accurate reduction is impossible. This could be applied to manage IFs, especially when the IFs are rotated. Dimpling of the articular surface induced by the removal of a small IF was not related to unsatisfactory clinical outcomes.
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Affiliation(s)
- Jun Young Choi
- Department of Orthopedic Surgery, Inje University, Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang-si, Gyeonggi-do, South Korea
| | - Hyoung Keun Oh
- Department of Orthopedic Surgery, Inje University, Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang-si, Gyeonggi-do, South Korea
| | - Lorenzo Di Mento
- Trauma Unit, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - Jae Won Hur
- Department of Orthopedic Surgery, Inje University, Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang-si, Gyeonggi-do, South Korea
| | - Jin Soo Suh
- Department of Orthopedic Surgery, Inje University, Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang-si, Gyeonggi-do, South Korea.
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Black AT, Stowers JM, Tran S, Mata KDL, Sherman AE, RahnamaVaghef A. Clinical Outcomes for Pilon Variant Posterior Malleolar Fractures: A Multicenter Retrospective Analysis. J Foot Ankle Surg 2022; 61:1303-1307. [PMID: 35595642 DOI: 10.1053/j.jfas.2022.04.007] [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: 10/18/2021] [Revised: 04/07/2022] [Accepted: 04/13/2022] [Indexed: 02/03/2023]
Abstract
Currently, there is no consensus on surgical approach for posterior malleolar fracture fragments with significant posteromedial involvement. The Bartonicek type III/Haraguchi type II posterior malleolar morphologies typically involve large posteromedial fragments, behaving like a pilon injury and have been reported as pilon variant fractures. We performed a retrospective chart review at 2 large healthcare institutions, evaluating patients that underwent surgical management of pilon variant posterior malleolar fractures and determining clinical outcomes including: time to union, union rates, soft tissue complications, infection and time to weight bearing. A total of 68 patients were included (51 females, 17 males). A total of 51 direct (19 posterolateral, 31 posteromedial), 6 indirect, and 11 no-fixation approaches were identified. Significantly different time-to-union was found between direct fixation (mean = 85.1 days), indirect fixation (mean = 74 days) and no-fixation (mean = 174.3 days) (p < .001). A posteromedial approach (mean = 63.0 days, SD = 16.6) was associated with significantly shorter time to union when compared to a posterolateral approach (mean = 124.8 days, SD = 59.4; p < .001). Fixation (direct or indirect) was associated with significantly increased likelihood of union of the overall ankle fracture pattern (52/57 = 91%) when compared to no fixation of the posterior malleolar component (9/14 = 64%), p = .01. Patients who underwent direct fixation had significantly lower incidence of neurovascular damage (6%) when compared to patients who underwent indirect fixation (33%) or no-fixation (29%) (p = .02). There was no significant difference between the groups in terms of tendon damage (p = .54), infection rates (p = .45) and time to weight bearing (p = .66). The authors suggest that surgical management and specifically direct approaches have better outcomes in the short-term follow up.
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Affiliation(s)
| | - Jered M Stowers
- Fellow, Foot and Ankle Institute Fellowship, Indianapolis, IN
| | - Son Tran
- Resident, Department of Plastic Surgery, Medstar Georgetown University Hospital, Washington, DC
| | - Karla De La Mata
- Resident, Department of Orthopedics, Lenox Hill Hospital Northwell, New York, NY
| | | | - Ali RahnamaVaghef
- Fellowship-Trained Foot and Ankle Surgeon, Assistant Professor, Georgetown University School of Medicine, Washington, DC
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Neumann AP, Kroker L, Beyer F, Rammelt S. Complications following surgical treatment of posterior malleolar fractures: an analysis of 300 cases. Arch Orthop Trauma Surg 2022; 143:3129-3136. [PMID: 35849187 DOI: 10.1007/s00402-022-04536-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 06/22/2022] [Indexed: 11/26/2022]
Abstract
AIMS The treatment of ankle fractures and fracture-dislocations involving the posterior malleolus (PM) has undergone considerable changes over the past decade. The aim of our study was to identify risk factors related to the occurrence of complications in surgically treated ankle fractures with PM involvement. PATIENTS AND METHODS We retrospectively analyzed 300 patients at a mean age of 57 years with 300 ankle fractures involving the PM treated surgically at our institution over a 12-year period. The following relevant comorbidities were noted: arterial hypertension (43.7%; n = 131), diabetes mellitus (DM) (14.0%; n = 42), thereof insulin-dependent (3.7%; n = 11), peripheral vascular disease (0.7%; n = 2), osteoporosis (12.0%; n = 36), dementia (1.0%; n = 3), and rheumatoid arthritis (2.0%; n = 6). Furthermore, nicotine consumption was recorded in 7.3% (n = 22) and alcohol abuse in 4.0% (n = 12). RESULTS Complications occurred in 41 patients (13.7%). A total of 20 (6.7%) revision surgeries had to be performed. Patients with DM (p < 0.001), peripheral vascular disease (p = 0.003) and arterial hypertension (p = 0.001) had a significantly increased risk of delayed wound healing. Alcohol abuse was associated with a significantly higher overall complication rate (OR 3.40; 95% CI 0.97-11.83; p = 0.043), increased rates of wound healing problems (OR 11.32; 95% CI 1.94-65.60; p = 0.001) and malalignment requiring revision (p = 0.033). The presence of an open fracture was associated with an increased rate of infection and wound necrosis requiring revision (OR 14.25; 95% CI 2.39-84.84; p < 0.001). Multivariate analysis identified BMI (p = 0.028), insulin-dependent DM (p = 0.003), and staged fixation (p = 0.043) as independent risk factors for delayed wound healing. Compared to the traditional lateral approach, using the posterolateral approach for fibular fixation did not lead to increased complication rates. CONCLUSIONS Significant risk factors for the occurrence of complications following PM fracture treatment were identified. An individually tailored treatment regimen that incorporates all risk factors is important for a good outcome.
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Affiliation(s)
- Annika Pauline Neumann
- University Center of Orthopaedics,Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
| | - Livia Kroker
- University Center of Orthopaedics,Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Franziska Beyer
- University Center of Orthopaedics,Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Stefan Rammelt
- University Center of Orthopaedics,Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
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21
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Jiang Z, Zhang C, Qin JJ, Wang GD, Wang HS. Posterior pilon fracture treated by opening the fibula fracture gap. J Orthop Surg Res 2022; 17:214. [PMID: 35392983 PMCID: PMC8991660 DOI: 10.1186/s13018-022-03106-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 03/29/2022] [Indexed: 11/10/2022] Open
Abstract
Background Posterior pilon fracture is a relatively common clinical fracture involving the posterior articular surface of the distal tibia. Currently, this form of fracture is receiving increasing attention. The surgical approach and technique for the treatment of posterior pilon fractures are still controversial. The purpose of this retrospective study was to compare the clinical and imaging outcomes of pilon fractures after treatment with the open fibula fracture line (OFFL) surgical technique versus the traditional posterolateral approach (TPL). Methods A retrospective analysis of patients with posterior pilon fractures treated using the open fibula fracture line technique and the traditional posterolateral approach between January 2015 and March 2020. Thirty-one cases were included in the open fibula fracture line technique group and twenty-eight cases were included in the traditional posterolateral approach group. We used the Burwell-Charnley scale to assess the effectiveness of surgical repositioning. The clinical outcomes were evaluated using American Orthopaedic Foot & Ankle Society ankle-hind foot score (AOFAS) and visual analog score (VAS). Results The overall anatomic reduction rate was slightly better in the open fibula fracture line group than in the conventional posterolateral group (81% vs. 71%, p = 0.406), but there was no statistically significant difference between the two groups. There were no statistically significant differences between the two groups in terms of fracture healing time and time to full weight bearing (p > 0.05). At the final follow-up, the AOFAS functional score of the open fibula fracture line group was statistically superior to that of the conventional posterolateral group (p < 0.05). However, there was no statistical difference between the two groups in VAS pain scores at rest, during activity, and under weight bearing (p > 0.05). Conclusion The trans-fibular fracture approach provides a better surgical option for specific types of posterior pilon fractures with a high rate of anatomic repositioning and a good near-term outcome. Trial registration: Retrospective registration.
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Affiliation(s)
- Zhuang Jiang
- Orthopaedic Department, General Hospital of Central Theater Command of PLA, #627 Wuluo Road, Wuchang District, Wuhan, 430070, China.,Clinical Medicine, Wuhan University of Science and Technology, #2, West Huangjiahu Road, Hongshan District, Wuhan, 430081, China
| | - Chen Zhang
- Orthopaedic Department, General Hospital of Central Theater Command of PLA, #627 Wuluo Road, Wuchang District, Wuhan, 430070, China
| | - Jia-Jun Qin
- Orthopaedic Department, General Hospital of Central Theater Command of PLA, #627 Wuluo Road, Wuchang District, Wuhan, 430070, China
| | - Guo-Dong Wang
- Orthopaedic Department, General Hospital of Central Theater Command of PLA, #627 Wuluo Road, Wuchang District, Wuhan, 430070, China.
| | - Hua-Song Wang
- Orthopaedic Department, General Hospital of Central Theater Command of PLA, #627 Wuluo Road, Wuchang District, Wuhan, 430070, China.
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22
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Mousa AEM, Mousa M, Singisetti K. Peroneal artery safe zone in the posterolateral approach to the distal tibia: A CT angiogram based anatomical study. Injury 2022; 53:1268-1275. [PMID: 34600733 DOI: 10.1016/j.injury.2021.09.021] [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: 09/07/2021] [Accepted: 09/14/2021] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Adham E M Mousa
- Queen Elizabeth Hospital, Gateshead Health NHS Foundation Trust, Gateshead, UK, NE9 6SX; MBBCh, MCh (T&O), MRCS-England, PGCert MedEd. T&O Registrar and Clinical Teaching Fellow. .
| | - Mohamed Mousa
- Queen Elizabeth Hospital, Gateshead Health NHS Foundation Trust, Gateshead, UK, NE9 6SX; MBBCh. T&O clinical attaché.
| | - Kiran Singisetti
- Queen Elizabeth Hospital, Gateshead Health NHS Foundation Trust, Gateshead, UK, NE9 6SX; MBBS, MS, MFST Ed, FRCS (T&O), Consultant Orthopaedic Surgeon.
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23
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Zhang ZC, He WB, Lin H. Analysis of the efficacy of a modified posteromedial approach for Klammer III posterior Pilon fractures. Chin J Traumatol 2022; 25:83-89. [PMID: 35177289 PMCID: PMC9039846 DOI: 10.1016/j.cjtee.2022.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/23/2021] [Accepted: 12/10/2021] [Indexed: 02/04/2023] Open
Abstract
PURPOSE To analyze the curative effect and technical points of a modified posteromedial approach in the treatment of Klammer III posterior Pilon fracture. METHODS A retrospective analysis of patients with Klammer III posterior Pilon fractures were conducted in our department from January 2018 to December 2019. Before the surgery, the patients were fully relieved of swelling and pain, and a comprehensive examination was carried out. The posteromedial approach exposed the posterior and medial fracture block of the distal tibia. According to the fracture of external malleolus, it is determined whether to combine a lateral incision and protect tendons and vascular nerves by a retractor, and then perform a fracture reduction and internal fixation. Postoperatively, the patients were treated with analgesia, detumescence, anticoagulation and rehabilitation exercise. The American orthopaedic foot and ankle society (AOFAS) score and visual analogue score were recorded at regular follow-up after surgery. A t-test was used for the comparison of the preoperative and final AOFAS score. RESULTS There were 7 male and 13 female (n = 20) included in the study, aged 22 to 88 years (average age 54.2 years). The injury mechanisms were falling from a height (n = 7), traffic accident (n = 6), walking injury (n = 2) and heavy injury (n = 5). The postoperative follow-up duration was 12-24 months (mean 16.95 months). The AOFAS score of the 20 patients before and after surgery were compared. The preoperative AOFAS score was 38.90 ± 3.91, and the final AOFAS score was 80.55 ± 4.20, (p < 0.001). The mean final visual analogue scores at rest, active and weight-bearing walking were 0.30, 0.85 and 1.70, respectively. One patient reported poor postoperative wound healing and required a return to hospital for debridement and anti-infection treatment. CONCLUSION In the treatment of Klammer III posterior Pilon fractures, the modified posteromedial approach can fully expose the fracture block and the collapsed articular surface of the medial malleolus, achieve good reduction and internal fixation with limited injury of the tendon and vascular nerves, and have a better prognosis.
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Affiliation(s)
- Zheng-Chao Zhang
- Department of Emergency Surgery, Fujian Provincial Hospital, Fuzhou, 350001, China,Provincial Clinical Medical College of Fujian Medical University, Fuzhou, 350001, China
| | - Wu-Bing He
- Department of Emergency Surgery, Fujian Provincial Hospital, Fuzhou, 350001, China,Provincial Clinical Medical College of Fujian Medical University, Fuzhou, 350001, China
| | - Hao Lin
- Department of Emergency Surgery, Fujian Provincial Hospital, Fuzhou, 350001, China,Provincial Clinical Medical College of Fujian Medical University, Fuzhou, 350001, China,Corresponding author. Department of Emergency Surgery, Fujian Provincial Hospital, Fuzhou, 350001, China.
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24
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Neumann AP, Rammelt S. Ankle fractures involving the posterior malleolus: patient characteristics and 7-year results in 100 cases. Arch Orthop Trauma Surg 2022; 142:1823-1834. [PMID: 33835195 PMCID: PMC9296426 DOI: 10.1007/s00402-021-03875-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 03/23/2021] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The presence of a posterior malleolar (PM) fragment has a negative prognostic impact in ankle fractures. The best treatment is still subject to debate. The aim of this study was to assess the medium-to-long-term clinical and functional outcome of ankle fractures with a PM fragment in a larger patient population. MATERIALS AND METHODS One hundred patients (69 women, 31 men, average age 60 years) with ankle fractures including the PM were evaluated clinically and radiographically. Patients with Bartoníček-Rammelt type 3 and 4 fracture displayed a significant female preponderance. Fixation of the PM was performed in 63% and tailored to the individual fracture pattern. RESULTS Internal fixation of the PM fragment was negatively correlated with the need for syndesmotic screw placement at the time of surgery (p = 0.010). At an average follow-up of 7.0 years, the mean Foot Function Index (FFI) was 16.5 (SD: 21.5), the Olerud Molander Ankle Score (OMAS) averaged 80.2 (SD: 24) and the American Orthopedic Foot & Ankle Society (AOFAS) ankle/hindfoot score averaged 87.5 (SD: 19.1). The maximum score of 100 was achieved by 44% of patients. The physical (PCS) and mental health component summary (MCS) scores of the SF-36 averaged 47.7 (SD: 12.51) and 50.5 (SD: 9.36), respectively. Range of motion was within 3.4 (SD: 6.63) degrees of the uninjured side. The size of the PM fragment had no prognostic value. There was a trend to lower outcome scores with slight anterior or posterior shift of the distal fibula within the tibial incisura. Patients who underwent primary internal fixation had significantly superior SF-36 MCS than patients who underwent staged internal fixation (p = 0.031). CONCLUSIONS With an individualized treatment protocol, tailored to the CT-based assessment of PM fractures, favorable medium and long-term results can be expected.
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Affiliation(s)
- Annika Pauline Neumann
- University Center of Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Stefan Rammelt
- University Center of Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
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25
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Simultaneous Posterolateral and Posteromedial Approaches for Fractures of the Entire Posterior Tibial Plafond: A Safe Technique for Effective Reduction and Fixation. J Orthop Trauma 2022; 36:49-53. [PMID: 34924545 DOI: 10.1097/bot.0000000000002144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the short-term results of surgical treatment with dual posterolateral and posteromedial approaches for fractures of the entire posterior tibial plafond and secondarily to identify common fracture characteristics. DESIGN Retrospective. SETTING Single academic Level 1 trauma center. PATIENTS Thirty-five patients with posterior pilon fractures followed until fracture union (minimum 3 months). INTERVENTION Surgical treatment using simultaneous combined posterolateral and posteromedial exposures for fracture reduction and internal fixation. MAIN OUTCOME MEASUREMENT (1) Surgical outcomes including rate of wound complications and accuracy of the articular reduction. (2) Fracture characteristics including the incidence of articular impaction, comminution interfering with reduction, syndesmosis injury, and the type of fibula fracture. RESULTS The rate of wound problems was low (6%), and 94% of patients had an articular reduction with less than 1 mm of step or gap. There were high rates of articular comminution (83%) and posteromedial articular impaction (63%) and a 17% rate of syndesmosis injury requiring repair. CONCLUSIONS Surgical fixation using simultaneous, combined posterolateral and posteromedial approaches for posterior pilon fractures had a low rate of wound complications and was an effective strategy for obtaining an accurate reduction. The rate of syndesmotic instability requiring fixation was lower than previous work reporting on fixation using a single approach. This may be a useful technique for surgeons who treat these injuries. Careful assessment of the preoperative imaging is required in patients with posterior pilon fractures. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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26
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Abstract
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.
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Affiliation(s)
- Stefan Rammelt
- University Center of Orthopaedics and Traumatology, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Jan Bartoníček
- Department of Orthopaedics, First Faculty of Medicine, Charles University and Central Military Hospital Prague, Prague, Czech Republic.,Department of Anatomy, First Faculty of Medicine, Charles University Prague, Prague, Czech Republic
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27
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Guo H, Huang W, Zeng C. Ankle Fracture with a Complex Injury Mechanism and Misleading Hook Test Result: A Case Report. J Foot Ankle Surg 2021; 59:1275-1278. [PMID: 32830018 DOI: 10.1053/j.jfas.2019.10.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 06/26/2019] [Accepted: 10/01/2019] [Indexed: 02/03/2023]
Abstract
Ankle fractures and their mechanisms of injury can be complex. We report a case of a patient with an uncertain mechanism of injury and an uncommon combination of lower extremity fractures, which fit the criteria for a Lauge-Hansen classification pronation-external-rotation fracture, Maisonneuve fracture, Wagstaffe fracture, and posterior pilon fracture. Plain radiographs and computed tomography scan revealed Chaput tubercle avulsion fractures, an anterior distal fibular fracture fragment, multiple lateral malleolar fractures, a posterior malleolar fracture fragment with proximal displacement, a die-punch fragment between the posterior malleolar fragment and the tibia, a proximal fibular fracture, and possible ankle syndesmotic diastasis. Intraoperative hook test was negative after fixation of the fractures, so syndesmotic fixation was not performed. At 3-month follow-up, plain radiographs showed obvious syndesmotic diastasis. At 1-year follow-up, symptoms persisted and syndesmotic fusion was recommended but declined by the patient. This case demonstrates that both ankle fractures and their mechanisms of injury can be remarkably complex and confusing, posterior pilon fractures can occur along with pronation-external-rotation ankle fractures, syndesmotic fixation should be considered for all patients with Maisonneuve fractures, reliance on the hook test for surgical management decisions may not always be reliable, and there exists a need for a more accurate and reliable intraoperative test to determine the presence of ankle syndesmotic injury.
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Affiliation(s)
- Hao Guo
- Resident, Department of Foot and Ankle Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou, P.R. China; Member, Chinese Orthopedic Foot and Ankle Society, Beijing, P.R. China
| | - Weiqi Huang
- Attending, Department of Foot and Ankle Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou, P.R. China
| | - Canjun Zeng
- Director, Department of Foot and Ankle Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou, P.R. China; Vice Chairman, Youth Committee of Chinese Orthopedic Foot and Ankle Society, Beijing, P.R. China; International Member, American Orthopaedic Foot & Ankle Society, Rosemont, IL.
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28
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Smith SE, Chang EY, Ha AS, Bartolotta RJ, Bucknor M, Chandra T, Chen KC, Gorbachova T, Khurana B, Klitzke AK, Lee KS, Mooar PA, Ross AB, Shih RD, Singer AD, Taljanovic MS, Thomas JM, Tynus KM, Kransdorf MJ. ACR Appropriateness Criteria® Acute Trauma to the Ankle. J Am Coll Radiol 2020; 17:S355-S366. [PMID: 33153549 DOI: 10.1016/j.jacr.2020.09.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 09/01/2020] [Indexed: 02/07/2023]
Abstract
Acute injuries to the ankle are frequently encountered in the setting of the emergency room, sport, and general practice. This ACR Appropriateness Criteria defines best practices for imaging evaluation for several variants of patients presenting with acute ankle trauma. The variants include scenarios when Ottawa Rules can be evaluated, when there are exclusionary criteria, when Ottawa Rules cannot be evaluated, as well as specific injuries. Clinical scenarios are followed by the imaging choices and their appropriateness with an accompanying narrative explanation to help physicians to order the most appropriate imaging test. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Stacy E Smith
- Brigham & Women's Hospital & Harvard Medical School, Boston, Massachusetts.
| | - Eric Y Chang
- Panel Chair, VA San Diego Healthcare System, San Diego, California
| | - Alice S Ha
- Panel Vice-Chair, University of Washington, Seattle, Washington
| | | | - Matthew Bucknor
- University of California San Francisco, San Francisco, California
| | | | - Karen C Chen
- VA San Diego Healthcare System, San Diego, California
| | | | | | - Alan K Klitzke
- Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Kenneth S Lee
- University of Wisconsin Hospital & Clinics, Madison, Wisconsin
| | - Pekka A Mooar
- Temple University Hospital, Philadelphia, Pennsylvania; American Academy of Orthopaedic Surgeons
| | - Andrew B Ross
- University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin
| | - Richard D Shih
- Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, American College of Emergency Physicians
| | - Adam D Singer
- Emory University School of Medicine, Atlanta, Georgia
| | | | - Jonelle M Thomas
- Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Katherine M Tynus
- Northwestern Memorial Hospital, Chicago, Illinois; American College of Physicians
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29
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Anwar A, Hu Z, Adnan A, Gao Y, Li B, Nazir MU, Tian C, Wang Y, Lv D, Zhao Z, Zhang Z, Zhang H, Tong C, Lv G. Comprehensive biomechanical analysis of three clinically used fixation constructs for posterior malleolar fractures using cadaveric and finite element analysis. Sci Rep 2020; 10:18639. [PMID: 33122787 PMCID: PMC7596231 DOI: 10.1038/s41598-020-75819-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 09/21/2020] [Indexed: 11/11/2022] Open
Abstract
Different fixation modalities are available for fixation of posterior malleolar fractures (PMFs), but the best method is still unclear. The purpose of this study was to carry out a comparative biomechanical analysis of three commonly used fixation constructs for PMFs using experimental and finite element analysis (FEA). 15 human cadaveric ankle specimens were randomly divided into three groups. Specimens in group-A were fixed with two anteroposterior (AP) lag screws, group-B with two posteroanterior (PA) lag screws, and for group-C, a posterior plate was used. Each model was subjected to axial load. Outcomes included loads for 0.5 mm, 1 mm, 1.5 mm, and 2 mm vertical displacements of posterior fragments were noted. 3D FE models were reconstructed from computed tomography (CT) images and subjected to vertical loads. The model’s stress, fracture step-off, and resultant strains in implants were also studied in 3D FE models. Significantly higher amounts of mean compressive loads were observed to cause the same amount of vertical displacements in plate group (265 ± 60.21 N, 796 ± 57.27 N, 901.18 ± 8.88 N, 977.26 ± 13.04 N) than AP (102.7 ± 16.78 N, 169.5 ± 19.91 N, 225.32 ± 15.92 N, 269.32 ± 17.29 N) and PA (199.88 ± 31.43 N, 362.80 ± 28.46 N, 431.3 ± 28.12 N, 541.86 ± 36.05 N) lag screws respectively (P < 0.05). Simulated micro-motion analysis demonstrated that fracture step-off values in plate group (0.03 ± 0.001 mm, 0.06 ± 0.003 mm and 0.13 ± 0.010 mm) were the lowest among the three groups (P < 0.001). The cancellous bone showed the highest amount of stress in AP and PA lag groups respectively, whereas the lowest stress was noted in the plate-group. This biomechanical study concluded that posterior plating is biomechanically the most stable fixation construct for PMFs fixation. AP and PA lag screws with higher bone stress and fracture step-off values have a high tendency of bone cut-through and loss of fixation respectively.
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Affiliation(s)
- Adeel Anwar
- Institute of Translational Medicine, China Medical University, No. 77 Puhe Road, North New Area, Shenyang, 110122, Liaoning, People's Republic of China
| | - Zhenwei Hu
- Department of Orthopaedic Surgery, The Second Hospital of Chaoyang City, No 26, Secttion 4 Chaoyang street, Chaoyang, Liaoning, People's Republic of China
| | - Atif Adnan
- Department of Human Anatomy, School of Basic Medical Science, China Medical University, No. 77 Puhe Road, 110122 North New Area, Shenyang, Liaoning, People's Republic of China
| | - Yanming Gao
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Dalian Medical University, 456 Zhong Shan Road, Dalian, 116027, Liaoning, People's Republic of China
| | - Bing Li
- Engineering Research Center of Continuous Extrusion, Ministry of Education, Dalian Jiaotong University, 794 Yellow River Road, Dalian, 116028, Liaoning, People's Republic of China
| | - Muhammad Umar Nazir
- Department of Anesthesia, The Second Affiliated Hospital of Dalian Medical University, 456 Zhong Shan Road, Dalian, 116027, Liaoning, People's Republic of China
| | - Cong Tian
- Department of Railway Vehicle, Ji Lin Railway Technology College, 1 Ji Hua East road, 132200, Ji Lin, People's Republic of China
| | - Yanfeng Wang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of China Medical University, 155 Nanjing street, Shenyang, 110001, Liaoning, People's Republic of China
| | - Decheng Lv
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Dalian Medical University, 222 Zhong shan road, Dalian, Liaoning, 116011, People's Republic of China
| | - Zhi Zhao
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Dalian Medical University, 456 Zhong Shan Road, Dalian, 116027, Liaoning, People's Republic of China
| | - Zhen Zhang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Dalian Medical University, 222 Zhong shan road, Dalian, Liaoning, 116011, People's Republic of China
| | - Hu Zhang
- Department of Orthopaedic Surgery, The 920Th Hospital of Joint Logistics Support Force, Kunming, 650032, Yunnan, People's Republic of China
| | - Changgui Tong
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Dalian Medical University, 456 Zhong Shan Road, Dalian, 116027, Liaoning, People's Republic of China
| | - Gang Lv
- Institute of Translational Medicine, China Medical University, No. 77 Puhe Road, North New Area, Shenyang, 110122, Liaoning, People's Republic of China.
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30
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Yang Y, He W, Zhou H, Xia J, Li B, Yu T. Combined Posteromedial and Posterolateral Approaches for 2-Part Posterior Malleolar Fracture Fixation. Foot Ankle Int 2020; 41:1234-1239. [PMID: 32683981 DOI: 10.1177/1071100720937637] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study investigated the clinical efficacy of combined posteromedial and posterolateral approaches for repair of 2-part posterior malleolar fractures associated with medial and lateral malleolar fractures. METHODS This case series report included 27 Weber B with Haraguchi type II patients with medial and lateral malleolar fractures combined with 2-part posterior malleolar fractures. Patients were treated with open reduction and internal fixation through a combination of posteromedial and posterolateral approaches from January 2015 to January 2018. There were 11 males and 16 females, with an average age of 61.5 years (range, 53-67 years). The procedures were performed on prone patients under spinal anesthesia. The medial, lateral, and posterior malleolar fractures were exposed through posteromedial and posterolateral approaches performed at the same time. The lateral malleolar fracture was fixed using a plate, the medial malleolar fracture was fixed using screws, and the posterior malleolar fracture was fixed using a plate or cannulated screws according to the size of the fragments. We performed follow-up on 22 patients for an average of 30 months (range, 18-48 months). RESULTS Primary healing of the incisions was achieved in all cases, and no infection was found. The mean time of bone union was 12.5 weeks (range, 10-15 weeks). The mean time from the operation to full weightbearing was 13 weeks (range, 11-16 weeks). We used the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scale to score patient outcomes; the mean score was 85.4 (range, 80-92) at the final follow-up. No significant pain was found at the final follow-up. CONCLUSION This study showed that satisfactory outcomes were achieved with combined posteromedial and posterolateral approaches. Therefore, we believe this approach was a good alternative strategy to repair 2-part posterior malleolar fractures associated with medial and lateral malleolar fractures. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Yunfeng Yang
- Department of Orthopedics, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wenbao He
- Department of Orthopedics, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Haichao Zhou
- Department of Orthopedics, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jiang Xia
- Department of Orthopedics, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Bing Li
- Department of Orthopedics, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Tao Yu
- Department of Orthopedics, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
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31
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Wang J, Wang X, Xie L, Zheng W, Chen H, Cai L. Comparison of radiographs and CT features between posterior Pilon fracture and posterior malleolus fracture: a retrospective cohort study. Br J Radiol 2020; 93:20191030. [PMID: 32233930 PMCID: PMC10993212 DOI: 10.1259/bjr.20191030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 03/24/2020] [Accepted: 03/26/2020] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES This study explored the morphological differences between posterior Pilon fracture and posterior malleolus fracture from radiographs and CT to provide detail for diagnosis and treatment of them. METHODS Radiographs and CT imaging data of 174 patients with distal posterior tibial fractures who were treated from January 2013 to January 2019 were retrospectively analyzed. Based on the operation and imaging examination, the fractures were classified into posterior Pilon fractures and posterior malleolus fractures. Radiographic parameters including the width, height, depth, α angle, β angle, γ angle, fragment area ratio 1 (FAR1), δ angle and fragment area ratio 2 (FAR2) of ankle mortise were measured. RESULTS There were 96 posterior Pilon fractures (Type I: 30, Type II: 22 and Type III: 44) and 78 posterior malleolus fractures (Type I: 40 and Type II: 38). The ankle depth, α angle, γ angle, FAR1 and FAR2 of posterior Pilon fractures were larger than these of posterior malleolus fractures (p < 0.05). In addition, FAR1 and FAR2 of Type II and Type III posterior Pilon fractures were significantly larger than these of Type I (p < 0.05). FAR1 and FAR2 of Type I posterior malleolus fractures were significantly smaller than these of Type II (p < 0.05). CONCLUSION Radiographs combined with CT analysis is an effective method to accurately distinguish morphological features between posterior Pilon fracture and posterior malleolus fracture. ADVANCES IN KNOWLEDGE Radiographs combined with CT distinguished the fracture of posterior malleolus and posterior Pilon rapidly and accurately, instead of operation.
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Affiliation(s)
- Jinwu Wang
- Department of Orthopaedics, The Second Affiliated Hospital and
Yuying Children’s Hospital of Wenzhou Medical University, 109 Xue
Yuan Xi Road, Wenzhou, Zhejiang
325000, China
| | - Xingyu Wang
- Department of Orthopaedics, The Second Affiliated Hospital and
Yuying Children’s Hospital of Wenzhou Medical University, 109 Xue
Yuan Xi Road, Wenzhou, Zhejiang
325000, China
| | - Linzhen Xie
- Department of Orthopaedics, The Second Affiliated Hospital and
Yuying Children’s Hospital of Wenzhou Medical University, 109 Xue
Yuan Xi Road, Wenzhou, Zhejiang
325000, China
| | - Wenhao Zheng
- Department of Orthopaedics, The Second Affiliated Hospital and
Yuying Children’s Hospital of Wenzhou Medical University, 109 Xue
Yuan Xi Road, Wenzhou, Zhejiang
325000, China
| | - Hua Chen
- Department of Orthopaedics, The Second Affiliated Hospital and
Yuying Children’s Hospital of Wenzhou Medical University, 109 Xue
Yuan Xi Road, Wenzhou, Zhejiang
325000, China
| | - Leyi Cai
- Department of Orthopaedics, The Second Affiliated Hospital and
Yuying Children’s Hospital of Wenzhou Medical University, 109 Xue
Yuan Xi Road, Wenzhou, Zhejiang
325000, China
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Zbeda RM, Friedel SP, Katchis SD, Weiner L. Open Reduction and Internal Fixation of Posterior Malleolus Fractures via a Posteromedial Approach. Orthopedics 2020; 43:e166-e170. [PMID: 32077968 DOI: 10.3928/01477447-20200213-01] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 03/11/2019] [Indexed: 02/03/2023]
Abstract
Ankle fractures with a posterior malleolus component are complex injuries. The most commonly used operative methods include indirect reduction via a percutaneous anterior approach and direct reduction via a posterolateral approach. For large posterior malleolus fractures with medial extension, direct reduction via a posteromedial approach is an alternative operative option. The authors hypothesized that fixation of large posterior malleolus fractures via a posteromedial approach results in anatomic reduction and stable plate fixation. From 2008 to 2015, 22 (9.0%) of 244 consecutive operative ankle fractures were identified as posterior malleolus fractures treated using a posteromedial approach. Patient charts were retrospectively reviewed for demographics, operative details, follow-up time, and any postoperative complications. Postoperative radiographs were reviewed to ensure that anatomic reduction and stable fixation was maintained. Sixteen (72.7%) of 22 patients were female, and the average age at the time of surgery was 54.1 years (range, 26-86 years). The average follow-up time was 13.0 months (range, 2.0-41.4 months). Twenty-one (95.5%) of 22 patients healed on a radiographic and clinical basis. There was an 18.2% (4 of 22) postoperative complication rate: 1 patient had a nonunion, 1 patient had cellulitis, 1 patient had osteomyelitis involving the fibula, and 1 patient had symptomatic heterotopic ossification. Open reduction and internal fixation of posterior malleolus fractures via a posteromedial approach achieved anatomic reduction, stable plate fixation, and complete healing in all but 1 patient. This study demonstrates that the posteromedial approach is a reasonable alternative to other more commonly used methods for treating these fractures. [Orthopedics. 2020;43(3):e166-e170.].
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Mechanism of posterior malleolar fracture of the ankle: A cadaveric study. OTA Int 2020; 3:e060. [PMID: 33937695 PMCID: PMC8022911 DOI: 10.1097/oi9.0000000000000060] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 12/08/2019] [Indexed: 12/26/2022]
Abstract
Objectives: Ankle fracture treatment involves reduction of the bone fragments and stabilization of the joint by reversing the mechanics of injury. For posterior malleolar fracture however, the true mechanism is not understood, leading to a lack of consistent guidance on how to best treat this injury. Methods: Fifteen cadaver ankles were subjected to fracture loading that replicated the Lauge-Hansen pronation-external rotation mechanism. An axial load was applied to each specimen, which was mounted on a materials testing machine, and the foot was rotated externally to failure. Digital video cameras recorded the failure sequence of specific anatomic structures. Results: Posterior malleolar fracture occurred in 7 specimens. Of these, 1 was an intra-articular fracture, another was a fracture involving the entire posterior tibial margin consisting of 2 fragments: that of the posterior tubercle and that of the posteromedial margin of the tibial plafond, with the former judged to be a consequence of avulsion by the posterior inferior tibiofibular ligament and the latter a consequence of axial loading from the talus. In the remaining 5 specimens, the posterior malleolar fracture was a small extra-articular avulsion fracture. Conclusions: Fractures at the posterolateral corner of the distal tibia were shown to be avulsion fractures attributed to the posterior inferior tibiofibular ligament and produced by external rotation of the talus. A fracture involving the entire posterior tibial margin consisting of 2 fragments can be produced by a combination of avulsion by the posterior inferior tibiofibular ligament and axial loading from the talus.
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Bergman C, Morin M, Lawson K. Anatomy, Classification, and Management of Ankle Fractures Involving the Posterior Malleolar Fragment: A Literature Review. FOOT & ANKLE ORTHOPAEDICS 2019; 4:2473011419887724. [PMID: 35097350 PMCID: PMC8697079 DOI: 10.1177/2473011419887724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The posterior malleolar fragment is frequently involved in rotational ankle fractures, but diagnosis and definitive management remains controversial. Ankle fractures with a posterior malleolar component that are not identified and treated in a timely manner may contribute significantly to future comorbidities, including continued pain, instability, and the development of arthritis. This article highlights the anatomic features of posterior malleolar ankle fractures, the classification schemes used, and discusses the various nonsurgical and surgical methods currently used.
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Affiliation(s)
| | - Matthew Morin
- Department of Orthopedic Surgery, Banner University Medical Center, AZ, USA
| | - Kevin Lawson
- Department of Orthopedic Surgery, Banner University Medical Center, AZ, USA
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Chaparro F, Ahumada X, Urbina C, Lagos L, Vargas F, Pellegrini M, Barahona M, Bastias C. Posterior pilon fracture: Epidemiology and surgical technique. Injury 2019; 50:2312-2317. [PMID: 31630782 DOI: 10.1016/j.injury.2019.10.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 07/12/2019] [Accepted: 10/03/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To review a case series of patients with posterior pilon variant fracture using a novel approach, focusing on demographic data, injury pattern, surgical results based on computed tomography (CT) scan, and short-term complications. DESIGN Consecutive case series. SETTING Level I trauma center. PATIENTS/PARTICIPANTS Twenty-five patients with posterior pilon fracture. INTERVENTION Posterior pilon fracture open reduction and internal fixation. MAIN OUTCOME MEASUREMENTS Parameters measured included age, sex, type of fracture, surgical technique, anatomical reduction, and complications. RESULTS Twenty-five patients sustained a posterior pilon fracture, accounting for 13.4% of all operatively treated ankle fractures with median follow-up of 21.7 months. The average age of patients was 42 years (22-62); 19/25 (76%) were female, and 6/25 (24%) were male. A modified posteromedial approach was used in 18/25 (72%) patients. Persistent syndesmotic instability was present in 11/25 (44%) patients after posterior malleolar stabilization. Quality of reduction was assessed under CT scan in 19 patients, with 15/19 (78.9%) having anatomic reduction. We report 2/25 (8%) patients with early wound problems and 7/25 (20%) with short-term complications during follow-up. CONCLUSION Posterior pilon variant fracture appears to be less common than previously reported. Most fractures can be satisfactorily treated through a modified posteromedial approach. Albeit obtaining posterior malleolar fracture rigid fixation, syndesmotic instability was more prevalent than expected. The short-term complication rate was low. LEVEL OF EVIDENCE Therapeutic level IV.
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Affiliation(s)
- Felipe Chaparro
- Department of Orthopaedic Surgery, Clinica Universidad de Los Andes, Av. La Plaza 2501, Las Condes, Santiago 7620157, Chile; Department of Orthopaedic Surgery, Hospital Clínico Mutual de Seguridad, Alameda 4848, Estación Central, Santiago 9190015, Chile.
| | - Ximena Ahumada
- Department of Orthopaedic Surgery, Hospital Clínico Mutual de Seguridad, Alameda 4848, Estación Central, Santiago 9190015, Chile
| | - Christian Urbina
- Department of Orthopaedic Surgery, Hospital Clínico Mutual de Seguridad, Alameda 4848, Estación Central, Santiago 9190015, Chile
| | - Leonardo Lagos
- Department of Orthopaedic Surgery, Hospital Clínico Mutual de Seguridad, Alameda 4848, Estación Central, Santiago 9190015, Chile
| | - Fernando Vargas
- Department of Orthopaedic Surgery, Hospital Clínico Mutual de Seguridad, Alameda 4848, Estación Central, Santiago 9190015, Chile
| | - Manuel Pellegrini
- Department of Orthopaedic Surgery, Clinica Universidad de Los Andes, Av. La Plaza 2501, Las Condes, Santiago 7620157, Chile; Department of Orthopaedic Surgery, Hospital Clínico Universidad de Chile, Santos Dumont 999, Independencia, Santiago 7640275, Chile
| | - Maximiliano Barahona
- Department of Orthopaedic Surgery, Hospital Clínico Universidad de Chile, Santos Dumont 999, Independencia, Santiago 7640275, Chile
| | - Christian Bastias
- Department of Orthopaedic Surgery, Hospital Clínico Mutual de Seguridad, Alameda 4848, Estación Central, Santiago 9190015, Chile
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Rammelt S, Boszczyk A. Computed Tomography in the Diagnosis and Treatment of Ankle Fractures: A Critical Analysis Review. JBJS Rev 2019; 6:e7. [PMID: 30562210 DOI: 10.2106/jbjs.rvw.17.00209] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Stefan Rammelt
- University Center for Orthopaedics & Traumatology, University Hospital Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Andrzej Boszczyk
- Department of Traumatology and Orthopaedics, Centre of Postgraduate Medical Education, Prof. Adam Gruca Clinical Hospital, Otwock, Poland
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Wright DJ, Bariteau JT, Hsu AR. Advances in the Surgical Management of Ankle Fractures. FOOT & ANKLE ORTHOPAEDICS 2019; 4:2473011419888505. [PMID: 35097351 PMCID: PMC8697288 DOI: 10.1177/2473011419888505] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Ankle fractures are one of the most common injuries treated by orthopedic surgeons worldwide. However, operative indications, techniques, and reported outcomes following operative fixation vary widely in the literature. This evidence-based review focuses on recent advances in the operative management of ankle fractures including arthroscopic-assisted surgery, deltoid ligament complex repair, expanded indications for posterior malleolus fixation, fibula intramedullary nailing, and dynamic syndesmosis repair. LEVEL OF EVIDENCE Level V, expert opinion.
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Affiliation(s)
- David J Wright
- Department of Orthopaedic Surgery, University of California-Irvine, Orange, CA, USA
| | - Jason T Bariteau
- Department of Orthopedics, University School of Medicine Emory, Atlanta, GA, USA
| | - Andrew R Hsu
- Department of Orthopaedic Surgery, University of California-Irvine, Orange, CA, USA
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38
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Thacher RR, Garner MR, Warner SJ, Lorich DG. Clinical Outcomes of Hyperplantarflexion Variant Compared With Supination External Rotation Ankle Fractures: A Matched-Cohort Analysis. J Foot Ankle Surg 2019; 58:669-673. [PMID: 30962109 DOI: 10.1053/j.jfas.2018.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Indexed: 02/03/2023]
Abstract
Recent literature has reported an uncategorized hyperplantarflexion variant ankle fracture characterized by a posteromedial fragment separate from the posterior or medial malleolar fragments. The current study sought to determine whether the outcomes for surgically treated hyperplantarflexion variant fractures are similar to the more common supination external rotation (SER) IV fractures. A prospective registry of operatively treated ankle fractures was queried to create 2 age- and gender-matched cohorts: hyperplantarflexion variant and SER IV fractures. Each cohort had 23 patients (18 females), and matched pairs were within 2 years of age at the date of surgery. Patient demographics, comorbidities, and Foot and Ankle Outcomes Scores at minimum 12 months after the index surgery were compared. The cohorts were similar with respect to body mass index, the length of the clinical follow-up, medical comorbidities, dislocation rate, and postoperative articular incongruity (p > .05). Patient-reported outcomes demonstrated no statistically or clinically significant differences within any domain and were as follows: symptoms (70.8 versus 77.8, p = .11), pain (80.7 versus 85.0, p = .33), activities of daily living (83.7 versus 89.2, p = .23), sports (67.4 versus 73.4, p = .33), and quality of life (57.3 versus 63.9, p = .24) for the hyperplantarflexion and SER IV groups, respectively. No significant differences were found in the rang`e of motion for dorsiflexion (17.7° versus 18.1°, p = .52) or for plantarflexion (48.6° versus 47.1°, p = .71). Patients treated surgically for hyperplantarflexion variant ankle fractures have similar 1-year clinical outcomes when compared with the more common SER IV fracture patterns, provided that the injury is correctly identified preoperatively and treated appropriately.
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Affiliation(s)
- Ryan R Thacher
- Medical Student, Columbia University College of Physicians and Surgeons, New York, NY.
| | - Matthew R Garner
- Assistant Professor, Division of Orthopaedic Trauma, Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA
| | - Stephen J Warner
- Assistant Professor, University of Texas Health Science Center at Houston, Houston, TX
| | - Dean G Lorich
- Associate Director, Orthopedic Trauma Service, Hospital for Special Surgery and Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY
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Gao M, Liu N, Cheng Y, Shi W, Yang H. Treatment outcomes of the posterolateral approach of plate fixation for posterior pilon fractures. Exp Ther Med 2019; 17:4267-4272. [PMID: 31007756 DOI: 10.3892/etm.2019.7458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 02/21/2019] [Indexed: 11/05/2022] Open
Abstract
Posterior pilon fracture is a common type of intraarticular fracture encountered in clinical practice. The treatment of this fracture pattern has been increasingly reported. However, methods for minimizing the associated surgical trauma and achieve effective fixation still require to be established. The present study involved 23 patients with posterior pilon fracture treated at the First Affiliated Hospital of Soochow University (Suzhou, China) between March 2013 and October 2017. Klammer's classification system was used to divide the posterior pilon fractures into 3 types. The surgical procedure, reduction of post-operative fracture, peri-operative complications and post-operative functional recovery were reviewed and analyzed. The reduction in post-operative fractures was evaluated by determining the Burwell-Charnley scores at the last follow-up. Anatomical reduction was confirmed in 17 patients, and an acceptable reduction was reported in 6 patients. The American Orthopedic Foot and Ankle Score was used to assess ankle function recovery; the average score was 82.3 points (range, 44-97 points). In conclusion, the posterolateral approach is able to achieve anatomical exposure of the operative field. In addition, the posterior fracture fragment of the tibia may be fully exposed through the fibula fracture gap by retraction. Posterior placement of the plate may serve a definitive role in the fixation of the posterior fracture fragment and maintain stability in the anatomical reduction of the fracture, which is helpful in early functional rehabilitation.
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Affiliation(s)
- Maofeng Gao
- Department of Orthopaedics, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215000, P.R. China
| | - Naicheng Liu
- Department of Orthopaedics, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215000, P.R. China
| | - Yu Cheng
- Department of Orthopaedics, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215000, P.R. China
| | - Weidong Shi
- Department of Orthopaedics, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215000, P.R. China
| | - Huilin Yang
- Department of Orthopaedics, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215000, P.R. China
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Yi Y, Chun DI, Won SH, Park S, Lee S, Cho J. Morphological characteristics of the posterior malleolar fragment according to ankle fracture patterns: a computed tomography-based study. BMC Musculoskelet Disord 2018; 19:51. [PMID: 29439685 PMCID: PMC5811968 DOI: 10.1186/s12891-018-1974-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Accepted: 02/08/2018] [Indexed: 12/16/2022] Open
Abstract
Background The posterior malleolar fragment (PMF) of an ankle fracture can have various shapes depending on the injury mechanism. The purpose of this study was to evaluate the morphological characteristics of the PMF according to the ankle fracture pattern described in the Lauge-Hansen classification by using computed tomography (CT) images. Methods We retrospectively analyzed CT data of 107 patients (107 ankles) who underwent surgery for trimalleolar fracture from January 2012 to December 2014. The patients were divided into two groups: 76 ankles in the supination-external rotation (SER) stage IV group and 31 ankles in the pronation-external rotation (PER) stage IV group. The PMF type of the two groups was assessed using the Haraguchi and Jan Bartonicek classification. The cross angle (α), fragment length ratio (FLR), fragment area ratio (FAR), sagittal angle (θ), and fragment height (FH) were measured to assess the morphological characteristics of the PMF. Results The PMF in the SER group mainly had a posterolateral shape, whereas that in the PER group mainly had a posteromedial two-part shape or a large posterolateral triangular shape (P = 0.02). The average cross angle was not significantly different between the two groups (SER group = 19.4°, PER group = 17.6°). The mean FLR and FH were significantly larger in the PER group than in the SER group (P = 0.024, P = 0.006). The mean fragment sagittal angle in the PER group was significantly smaller than that in the SER group (P = 0.017). Conclusions With regard to the articular involvement, volume, and vertical nature, the SER-type fracture tends to have a smaller fragment due to the rotational force, whereas the PER-type fracture tends to have a larger fragment due to the combination of rotational and axial forces.
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Affiliation(s)
- Young Yi
- Seoul Foot and Ankle Center, Inje University Seoul Paik Hospital, Seoul, Republic of Korea
| | - Dong-Il Chun
- Department of Orthopedic Surgery, Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Sung Hun Won
- Department of Orthopedic Surgery, Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Suyeon Park
- Department of Biostatistics, Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Sanghyeon Lee
- Department of Orthopaedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University, 77, Sakju-ro, Chuncheoni-si, Gangwon-do, 200-704, Republic of Korea
| | - Jaeho Cho
- Department of Orthopaedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University, 77, Sakju-ro, Chuncheoni-si, Gangwon-do, 200-704, Republic of Korea.
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Donohoe S, Alluri RK, Hill JR, Fleming M, Tan E, Marecek G. Impact of Computed Tomography on Operative Planning for Ankle Fractures Involving the Posterior Malleolus. Foot Ankle Int 2017; 38:1337-1342. [PMID: 28954524 DOI: 10.1177/1071100717731568] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to (1) Determine the effect of computed tomography (CT) on identification of fractures involving the posterior malleolus, (2) determine its effect on operative indications, and (3) determine its effect on the overall operative plan. METHODS Patients with ankle fractures involving the posterior malleolus were identified. Only injuries with complete preoperative plain radiographs and a CT scan were included. Spiral tibia fractures and pilon variants were excluded. The plain radiographs were deidentified, randomized, and presented to 3 orthopedic surgeons. They were asked 3 questions: (1) Is this fracture simple or complex? (2) Does the injury require direct visualization and reduction? and (3) How would you position the patient and approach the fracture? The same process was repeated for the CT scans. A total of 376 posterior malleolus injuries were identified and 25 met the inclusion criteria. RESULTS A complex fracture pattern was identified on 44% of plain radiographs and 56% of CT scans. The surgeons chose to operate in 84% of cases based on plain radiographs and 92% of cases based on CT scan. The observers changed their operative approach or positioning 44% of the time after reviewing CT images. The interobserver and intraobserver correlation coefficients were moderate. CONCLUSION The use of CT scan changed operative positioning and approach in 44% of cases. There was no significant change in characterization or operative indications when comparing plain radiographs to CT scan. CT scan may be a valuable tool in the management of ankle fractures involving the posterior malleolus. LEVEL OF EVIDENCE Diagnostic Level III, comparative series.
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Affiliation(s)
- Steven Donohoe
- 1 Department of Orthopaedic Surgery, Keck Medical Center of University of Southern California, 1520 San Pablo Street, Suite 2000, Los Angeles, CA, USA
| | - R Kiran Alluri
- 1 Department of Orthopaedic Surgery, Keck Medical Center of University of Southern California, 1520 San Pablo Street, Suite 2000, Los Angeles, CA, USA
| | - J Ryan Hill
- 1 Department of Orthopaedic Surgery, Keck Medical Center of University of Southern California, 1520 San Pablo Street, Suite 2000, Los Angeles, CA, USA
| | - Mark Fleming
- 2 Navy Trauma Training Center, Los Angeles County + USC Medical Center, Los Angeles, CA, USA
| | - Eric Tan
- 1 Department of Orthopaedic Surgery, Keck Medical Center of University of Southern California, 1520 San Pablo Street, Suite 2000, Los Angeles, CA, USA
| | - Geoffrey Marecek
- 1 Department of Orthopaedic Surgery, Keck Medical Center of University of Southern California, 1520 San Pablo Street, Suite 2000, Los Angeles, CA, USA
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Mason LW, Marlow WJ, Widnall J, Molloy AP. Pathoanatomy and Associated Injuries of Posterior Malleolus Fracture of the Ankle. Foot Ankle Int 2017; 38:1229-1235. [PMID: 28758439 DOI: 10.1177/1071100717719533] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND We present a classification system that progresses in severity, indicates the pathomechanics that cause the fracture and therefore guides the surgeon to what fixation will be necessary by which approach. METHODS The primary posterior malleolar fracture fragments were characterized into 3 groups. A type 1 fracture was described as a small extra-articular posterior malleolar primary fragment. Type 2 fractures consisted of a primary fragment of the posterolateral triangle of the tibia (Volkmann area). A type 3 primary fragment was characterized by a coronal plane fracture line involving the whole posterior plafond. RESULTS In type 1 fractures, the syndesmosis was disrupted in 100% of cases, although a proportion only involved the posterior syndesmosis. In type 2 posterior malleolar fractures, there was a variable medial injury with mixed avulsion/impaction etiology. In type 3 posterior malleolar fractures, most fibular fractures were either a high fracture or a long oblique fracture in the same fracture alignment as the posterior shear tibia fragment. Most medial injuries were Y-type or posterior oblique fractures. This fracture pattern had a low incidence of syndesmotic injury. CONCLUSION The value of this approach was that by following the pathomechanism through the ankle, it demonstrated which other structures were likely to be damaged by the path of the kinetic energy. With an understanding of the pattern of associated injuries for each category, a surgeon may be able to avoid some pitfalls in treatment of these injuries. LEVEL OF EVIDENCE Level III, retrospective comparative series.
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Affiliation(s)
- Lyndon W Mason
- 1 University Hospital Aintree, Lower Lane, Liverpool, United Kingdom
| | - William J Marlow
- 1 University Hospital Aintree, Lower Lane, Liverpool, United Kingdom
| | - James Widnall
- 1 University Hospital Aintree, Lower Lane, Liverpool, United Kingdom
| | - Andrew P Molloy
- 1 University Hospital Aintree, Lower Lane, Liverpool, United Kingdom
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Sukur E, Akman YE, Gokcen HB, Ozyurek EC, Senel A, Ozturkmen Y. Open reduction in pilon variant posterior malleolar fractures: Radiological and clinical evaluation. Orthop Traumatol Surg Res 2017; 103:703-707. [PMID: 28606840 DOI: 10.1016/j.otsr.2017.05.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 12/23/2016] [Accepted: 05/22/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Pilon variant posterior malleolar (PVPM) fractures significantly disrupt joint congruency and cause tibiotalar instability. They are often underestimated and inadequately treated. PURPOSE This study assessed the outcomes of surgical treatment of this subtype of malleolar fracture, and examined the importance of computed tomography (CT) in diagnosis and surgical treatment. MATERIAL AND METHODS CT images and radiographs of 67 patients with trimalleolar ankle fractures were retrospectively analyzed. Fourteen patients (6 women and 8 men) were studied. The mean age was 37.7 (range, 21-58) years, and mean follow-up period was 17.1 (range, 12-24) months. All patients underwent open reduction. Reconstruction of the joint surface was assessed with postoperative CT images. The outcomes were assessed with the American Academy of Orthopaedic Surgeons (AAOS) and Osteoarthritis (OA) scoring systems. RESULTS The ratio of PVPM fractures to trimalleolar ankle fractures was 20.1%. Postoperative CT images demonstrated that anatomic reconstruction was achieved in 11 patients. The mean AAOS scores were 85.6 in Type 1 and 81.1 in Type 2 cases. The mean OA scores were 1 in Type 1 and 1.1 in Type 2 cases (P>0.05). The only statistically significant difference between the 2 groups was in osteochondral impaction (P<0.05). CONCLUSION CT imaging is essential for the accurate diagnosis and management of PVPM fractures. Posteromedial and posterolateral incisions enable direct exposure, and therefore facilitate joint surface reconstruction. LEVEL OF EVIDENCE Level IV. Retrospective study.
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Affiliation(s)
- E Sukur
- Sakarya Education and Research Hospital, Department of Orthopedics and Traumatology, 54100 Sakarya, Turkey.
| | - Y E Akman
- M.S. Baltalimani Bone Diseases Training and Research Hospital, Department of Orthopedics and Traumatology, 34470 Istanbul, Turkey
| | - H B Gokcen
- Department of Orthopaedics and Traumotology, Liv Hospital, 34100 Istanbul, Turkey
| | - E C Ozyurek
- Istanbul Research Hospital, Department of Orthopedics and Traumatology, 34050 Istanbul, Turkey
| | - A Senel
- Istanbul Research Hospital, Department of Orthopedics and Traumatology, 34050 Istanbul, Turkey
| | - Y Ozturkmen
- Istanbul Research Hospital, Department of Orthopedics and Traumatology, 34050 Istanbul, Turkey
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44
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Duan X, Kadakia AR. Operative Treatment of Posterior Malleolar Fractures. Open Orthop J 2017; 11:732-742. [PMID: 28979587 PMCID: PMC5620409 DOI: 10.2174/1874325001711010732] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 07/16/2016] [Accepted: 07/23/2016] [Indexed: 12/11/2022] Open
Abstract
Fractures of the posterior malleolus can occur in conjunction with fibular and medial malleolar fractures or in isolation. The indications for fixation of the posterior malleolus remain controversial except for the fragment sizes. A number of different surgical approaches and techniques for internal fixation of posterior malleolar fractures have been reported. Newer techniques such as direct exposure and plating of the posterior malleolus are chosen more frequently than traditional techniques of indirect reduction and percutaneous screw fixation. These attributes help to minimize the occurrence of postoperative complications.
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Affiliation(s)
- Xiaojun Duan
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University, Chongqing, 400038, P.R, China
| | - Anish R Kadakia
- Department of Orthopedic Surgery, Northwestern University - Feinberg School of Medicine, Chicago, IL 60611, USA
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45
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Zhou Y, Cai L, Lu X, Yu Y, Hong J. The correlation of the morphological changes of ankle point and ankle joint function after surgery on the Ruedi-Allgouer type III Pilon fracture: A case series study. Int J Surg 2017. [PMID: 28629769 DOI: 10.1016/j.ijsu.2017.06.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND To analyze the relationship between imaging findings and postoperative curative effect by measuring the morphology of the ankle mortise in patients with the Ruedi-Allgouer type III Pilon fractures. MATERIAL AND METHODS Forty-seven patients with Ruedi-Allgouer type III Pilon fractures who underwent surgical treatment from January 2011 to January 2015 were retrospectively analyzed. At the last follow-up, x-rays of the affected ankle and the healthy side were measured. According to the Kitaoka score of ankle joint function at the last follow-up. RESULTS All patients were followed up for 18-24 months (mean 21 months). This study demonstrated that compared with the healthy side, the index of the width, depth, and coronal/sagittal angles of the ankle mortise were significantly different (P < 0.05) in the 47 patients except for the index of height (P > 0.05). According to the Kitaoka score, the difference between the affected and the healthy sides of each index of the ankle mortise was compared between the 3 groups. That is, the intraoperative treatment of the width and depth of the ankle mortise as well as the coronal and sagittal angles of the ankle mortise were significantly correlated with the postoperative curative effect. CONCLUSION The intraoperative treatment of ankle mortise width, depth, and ankle coronal/sagittal angle in patients with severe Pilon fractures has a significant impact on postoperative efficacy. In order to prevent the occurrence of traumatic arthritis, the anatomical morphology of the ankle should be restored as much as possible in the course of surgery.
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Affiliation(s)
- Yifei Zhou
- The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, China
| | - Leyi Cai
- The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, China
| | - Xiaolang Lu
- The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, China
| | - Yang Yu
- The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, China
| | - Jianjun Hong
- The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, China.
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The Role of Computed Tomography in Surgical Planning for Trimalleolar Fracture. A Survey of OTA Members. J Orthop Trauma 2017; 31:e116-e120. [PMID: 27984443 DOI: 10.1097/bot.0000000000000763] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Does the additional information provided by computed tomography (CT) alter surgeons' treatment plans for trimalleolar ankle fracture? DESIGN Prospective. SETTING Electronic survey. PATIENTS/PARTICIPANTS Members of the OTA. INTERVENTION Compare management of trimalleolar ankle fracture before and after CT. MAIN OUTCOME MEASUREMENTS Compare types of fixation used, indication for fixation, and approach need for fixation before and after CT. RESULTS Overall, OTA members' operative technique changed in 430 of the 1710 (25.1%) cases after review of the CT images. Of the 430 observations in which the operative technique was altered, the surgeon had initially stated that they would not have requested a CT in 51.2% incidences. When analyzing if CT affected whether or not operative fixation was indicated, a total of 16.3% responses changed. Surgeons were significantly more likely to change from no fixation to fixation (11.5%) than vice versa (4.8%) after reviewing CT imaging. A total of 17.8% of responses changed operative approach after reviewing the CT; 11.7% changed to open reduction internal fixation, whereas 6.1% changed away from open reduction internal fixation. CONCLUSION A consensus on the ideal treatment of trimalleolar fractures remains elusive, evidenced by a high variation in treatment preference, both before and after CT review. Our results demonstrate with the additional information delineated on CT, a surgeons' operative plan, technique, and approach often change. With greater than 25% of respondents changing their treatment strategy after seeing CT imaging, radiographs alone limited surgeon understanding of fracture pattern. Because of difficulty understanding the posterior fracture fragment, we recommend preoperative CT on all trimalleolar fractures. LEVEL OF EVIDENCE Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.
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Wang X, Zhang C, Yin JW, Wang C, Huang JZ, Ma X, Wang CW, Wang X. Treatment of Medial Malleolus or Pure Deltoid Ligament Injury in Patients with Supination-External Rotation Type IV Ankle Fractures. Orthop Surg 2017; 9:42-48. [PMID: 28296225 DOI: 10.1111/os.12318] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 11/23/2016] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To investigate the effect of internal fixation on postoperative ankle function in patients with supination-external rotation type IV ankle fractures, including medial malleolus fractures and deltoid ligament injury. METHODS Between January 2012 and June 2014, patients with medial structure injuries were enrolled in this study and assigned to the medial malleolus fracture group or the deltoid ligament group. The surgical procedures for the two groups were documented. The follow-up endpoint was the time point when the steel plate or screw was removed from the lateral ankle. The Olerud-Molander ankle scoring system was used to assess ankle function. RESULTS A total of 84 patients with supination-external rotation type IV ankle fractures had complete medical records and were included in this study. The average age of the patients was 44.16 years (range, 15-75). The patient sample included 39 males and 45 females. Overall, 49 patients (19 males and 30 females) suffered a medial malleolus fracture. The average age of these patients was 40.20 years (range, 15-75). Patients with a posterior malleolar fracture fragment >25% of the articular surface accounted for 81.6% (40 patients) of these patients. Overall, 35 patients (20 males and 15 females) experienced a deltoid ligament injury. The average age of these patients was 44.21 years (range, 17-73). Patients with a posterior malleolar fracture fragment >25% of the articular surface accounted for 11.5% (four patients) of these patients. Open reduction was performed in patients with medial malleolus fractures, and two 4.0-mm cannulated screws were used to fixate the posterior malleolus and the medial malleolus. The suture-anchor technique was used to repair the ligaments in patients with deltoid ligament injuries. The follow-up endpoint was the time point when the steel plate and screws were removed from the lateral ankle in patients. The average follow-up period was 13.4 months (range, 11-17). The Olerud-Molander ankle scoring system was used to assess postoperative ankle function. The average score for the patients in the medial malleolus fracture group was 90.3 points (range, 85-95). The average score for the patients in the deltoid ligament injury group was 87.7 points (range, 80-95). No significant differences were found in the scores between the two groups. CONCLUSION Medial malleolus fracture and deltoid ligament injury are two different presentations of supination-external rotation type IV ankle fractures. Anatomic reduction of the articular surface concurrent with restoration of ankle stability can achieve favorable results for these two injuries.
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Affiliation(s)
- Xu Wang
- Department of Orthopaedic Surgery, Huashan Hospital of Fudan University, Shanghai, China
| | - Chao Zhang
- Department of Orthopaedic Surgery, Huashan Hospital of Fudan University, Shanghai, China
| | - Jian-Wen Yin
- Department of Orthopaedic Surgery, Huashan Hospital of Fudan University, Shanghai, China
| | - Chen Wang
- Department of Orthopaedic Surgery, Huashan Hospital of Fudan University, Shanghai, China
| | - Jia-Zhang Huang
- Department of Orthopaedic Surgery, Huashan Hospital of Fudan University, Shanghai, China
| | - Xin Ma
- Department of Orthopaedic Surgery, Huashan Hospital of Fudan University, Shanghai, China
| | - Cheng-Wei Wang
- Department of Orthopaedic Surgery, The Sixth Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Xue Wang
- Department of Orthopaedic Surgery, The Sixth Affiliated Hospital of Xinjiang Medical University, Urumqi, China
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Bartoníček J, Rammelt S, Tuček M. Posterior Malleolar Fractures: Changing Concepts and Recent Developments. Foot Ankle Clin 2017; 22:125-145. [PMID: 28167058 DOI: 10.1016/j.fcl.2016.09.009] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Injuries to the posterior malleolus are of prognostic relevance in ankle fracture-dislocations. The three-dimensional outline of the fragments as reflected by computed tomography classification, involvement of the fibular notch, and the presence of intercalary fragments seem to be of greater therapeutic relevance than the size of the fragment and amount of the articular surface involved. Operative treatment aims at reconstruction of the posterior tibial plafond, the fibular notch, and the integrity of the posterior inferior tibiofibular syndesmosis. Direct open reduction and fixation of posterior malleolus fragments via posterior approaches is biomechanically more stable than indirect reduction and anteroposterior screw fixation.
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Affiliation(s)
- Jan Bartoníček
- Department of Orthopaedics, First Faculty of Medicine, Central Military Hospital Prague, Charles University, U Vojenské Nemocnice 1200, Prague 6 169 02, Czech Republic; Department of Anatomy, First Faculty of Medicine, Charles University Prague, U Nemocnice 3, Prague 2 120 00, Czech Republic.
| | - Stefan Rammelt
- University Center of Orthopaedics and Traumatology, University Hospital Carl Gustav Carus Dresden, Fetscherstrasse 74, Dresden 01307, Germany
| | - Michal Tuček
- Department of Orthopaedics, First Faculty of Medicine, Central Military Hospital Prague, Charles University, U Vojenské Nemocnice 1200, Prague 6 169 02, Czech Republic
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Wang Y, Wang J, Luo CF. Modified posteromedial approach for treatment of posterior pilon variant fracture. BMC Musculoskelet Disord 2016; 17:328. [PMID: 27496169 PMCID: PMC4974710 DOI: 10.1186/s12891-016-1182-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Accepted: 07/27/2016] [Indexed: 11/30/2022] Open
Abstract
Background Posterior pilon variant fracture is a recently described posterior malleolus fracture characterized by the involvement of both posterolateral and posteromedial malleolar fragment. The associated surgical approach remains controversial. The aim of this study was to present the application of modified posteromedial approach in the treatment for posterior pilon variant fracture. Methods Sixteen patients were identified with posterior pilon variant fractures. All fractures were operated via modified posteromedial approach. Fragment length ratio, area ratio and height were measured as morphologic assessments. The clinical outcome was evaluated with American Orthopaedic Foot & Ankle Society ankle-hind foot score and visual analogue scale. Radiological images were evaluated using osteoarthritis-score. Results According to the radiological measurements, the average fragment length ratio of posteromedial and posterolateral fragment was 25.3 and 31.5 % respectively. All fractures healed within a mean period of 13.1 weeks without malalignment or articular step-off. Fourteen patients were followed up, and all achieved good or excellent ankle function. The average score of American Orthopaedic Foot & Ankle Society and visual analogue scale at rest, motion and weight bearing walking was 85.6 and 0.25, 0.81, 1.31 respectively. Conclusion Modified posteromedial approach provides an alternative surgical treatment for posterior pilon variant fractures, and the short-term outcome was good. Electronic supplementary material The online version of this article (doi:10.1186/s12891-016-1182-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yukai Wang
- Trauma Service III, Shanghai Sixth People's Hospital, affiliated with Shanghai Jiaotong University, N. 600 Yishan R. d, Xuhui Distict, Shanghai, China
| | - Jianwei Wang
- Trauma Service III, Shanghai Sixth People's Hospital, affiliated with Shanghai Jiaotong University, N. 600 Yishan R. d, Xuhui Distict, Shanghai, China.
| | - Cong Feng Luo
- Trauma Service III, Shanghai Sixth People's Hospital, affiliated with Shanghai Jiaotong University, N. 600 Yishan R. d, Xuhui Distict, Shanghai, China
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Abstract
The ankle represents the most commonly injured weightbearing joint in the human body. They are typically the result of low-energy, rotational injury mechanisms. However, ankle fractures represent a spectrum of injury patterns from simple to very complex, with varying incidence of posttraumatic arthritis. Stable injury patterns can be treated nonoperatively; unstable injury patterns are typically treated operatively given that they could lead to severe arthritis if not properly addressed.
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Affiliation(s)
- Cristián A Ortiz
- Orthopaedic Department, Clínica Alemana de Santiago, Universidad del Desarrollo, Vitacura 5957, Santiago, Chile 7650568.
| | - Pablo Wagner
- Orthopaedic Department, Clínica Alemana de Santiago, Universidad del Desarrollo, Vitacura 5957, Santiago, Chile 7650568
| | - Emilio Wagner
- Orthopaedic Department, Clínica Alemana de Santiago, Universidad del Desarrollo, Vitacura 5957, Santiago, Chile 7650568
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