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Hunt AA, Maschhoff C, Van Rysselberghe N, Gonzalez CA, Goodnough H, Gardner M, Bishop JA. Historic indications for fixation of posterior malleolus fractures- where did they come from and where are we now? Injury 2024; 55:111537. [PMID: 38657283 DOI: 10.1016/j.injury.2024.111537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 03/14/2024] [Accepted: 04/01/2024] [Indexed: 04/26/2024]
Abstract
INTRODUCTION The indications for reduction and fixation of the posterior malleolus component of rotational ankle fractures have been controversial for nearly a century. This study aims to identify the historical basis for surgical intervention and trace trends in management strategies over time. METHODS In March 2023, a systematic review of full-text, English-language articles providing indications for surgical fixation of the posterior malleolus component of rotational ankle fractures was performed. Articles underwent title and abstract screening before undergoing full-text review. RESULTS Historical indications for surgical fixation were size-dependent, with fractures comprising 25 % to 33 % of the plafond recommended for internal fixation. Modern studies suggest that nonoperative management of posterior malleolus fractures below this threshold results in residual malreduction of the articular surface, syndesmotic instability, and an increased need for independent fixation of the syndesmosis. CONCLUSIONS Size-based indications for posterior malleolus fracture fixation are based on Level V evidence from small retrospective case series published nearly one century ago and should be retired. While the size of the posterior malleolus component cannot be ignored, additional factors like fracture morphology and location within the plafond should guide modern surgical indications. Contemporary studies indicate that reduction and fixation of small posterior malleolus fractures (comprising less than 25 % of the articular surface) are associated with improved articular reductions, tibiotalar contact pressures, syndesmotic stability with decreased need for independent fixation of the syndesmosis, and superior postoperative outcomes.
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Affiliation(s)
- Anastasia A Hunt
- Stanford University, Department of Orthopedic Surgery, 300 Pasteur Drive, Edwards Bldg, R144, Stanford, CA USA.
| | - Clayton Maschhoff
- University of Illinois at Chicago School of Medicine, Chicago, IL USA
| | - Noelle Van Rysselberghe
- Stanford University, Department of Orthopedic Surgery, 300 Pasteur Drive, Edwards Bldg, R144, Stanford, CA USA
| | | | - Henry Goodnough
- Stanford University, Department of Orthopedic Surgery, 300 Pasteur Drive, Edwards Bldg, R144, Stanford, CA USA
| | - Michael Gardner
- Stanford University, Department of Orthopedic Surgery, 300 Pasteur Drive, Edwards Bldg, R144, Stanford, CA USA
| | - Julius A Bishop
- Stanford University, Department of Orthopedic Surgery, 300 Pasteur Drive, Edwards Bldg, R144, Stanford, CA USA
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Chong LSL, Khademi M, Reddy KM, Anderson GH. Ten year outcomes after non-fixation of the smaller posterior malleolar fragment: A retrospective cohort study. Foot (Edinb) 2024; 59:102091. [PMID: 38513374 DOI: 10.1016/j.foot.2024.102091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 02/07/2024] [Accepted: 03/10/2024] [Indexed: 03/23/2024]
Abstract
INTRODUCTION Treatment of posterior malleolar (PM) ankle fractures remains controversial. Despite increasing recommendation for small PM fragment fixation, high quality evidence demonstrating improved clinical outcomes over the unfixated PM is limited. We describe the long term clinical and radiographical outcomes in younger adult patients with PM ankle fractures managed without PM fragment fixation. MATERIAL AND METHODS A retrospective cohort study was performed on PM ankle fracture patients aged 18-55 years old admitted under our orthopaedic unit between 1st of April 2009 and 31st of October 2013. Inclusion criteria were ASA 1 and 2, independent mobility pre-trauma, no pre-existing ankle pathologies, with satisfactory bimalleolar and syndesmotic stabilisation. Open fractures, talar fractures, calcaneal fractures, pilon fractures, subsequent re-injury and major complications were excluded. All PM fragments were unfixated. Clinical outcomes were evaluated using visual analogue scale (VAS) for pain, Foot and Ankle Ability Measure (FAAM) with activities of daily living (ADL) and sports subscale for function, and patient satisfaction ratings. Osteoarthritis was assessed using modified Kellgren-Lawrence scale on follow-up weightbearing ankle radiographs. RESULTS Sixty-one participants were included. Mean follow-up was 10.26 years. Average PM size was 16.2 ± 7.39%. All participants were evaluated for clinical outcomes. Mean score of FAAM-ADL was 95.5 ± 7.13, FAAM-Sports 86.4 ± 15.5, patient satisfaction 86.2 ± 14.4% and pain score 1.13 ± 1.65. Radiographical outcomes were evaluated in 52 participants, showing no-to-minimal osteoarthritis in 36/52 (69%), mild osteoarthritis in 14/52 (27%) and moderate osteoarthritis in 2/52 (4%). Pain and functional scores were independent of PM fragment size, post-reduction step-off, dislocation, malleoli fractured or syndesmotic injury. PM step-off more than 1 mm and traumatic dislocation/subluxation were associated with worse radiographical osteoarthritis. CONCLUSION After controlling for confounders, the unfixated smaller posterior malleolus fragment at 10-year follow-up demonstrated largely satisfactory clinical outcomes with some radiographical progression of osteoarthritis. LEVEL OF EVIDENCE Level III - Retrospective cohort study.
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Affiliation(s)
- Leo Swee Liang Chong
- Department of Orthopaedic Surgery, Palmerston North Hospital, Te Whatu Ora Te Pae Hauora o Ruahine o Tararua / Midcentral, New Zealand.
| | - MohammadAli Khademi
- Department of Orthopaedic Surgery, Palmerston North Hospital, Te Whatu Ora Te Pae Hauora o Ruahine o Tararua / Midcentral, New Zealand
| | - Kundam Murali Reddy
- Department of Orthopaedic Surgery, Palmerston North Hospital, Te Whatu Ora Te Pae Hauora o Ruahine o Tararua / Midcentral, New Zealand
| | - Geoffrey Hunter Anderson
- Department of Orthopaedic Surgery, Palmerston North Hospital, Te Whatu Ora Te Pae Hauora o Ruahine o Tararua / Midcentral, New Zealand
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Patel P, Little Z, Beak P, Williams R, Trompeter A. The Effect of Prone and Supine Limb Positioning on the Radiographic Evaluation of Posterolateral Plate Fixation of the Posterior Malleolus. Indian J Orthop 2024; 58:250-256. [PMID: 38425831 PMCID: PMC10899138 DOI: 10.1007/s43465-023-01066-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 11/15/2023] [Indexed: 03/02/2024]
Abstract
Aim To facilitate the posterolateral approach to the posterior malleolus patients are often positioned prone initially, then turned supine to complete fixation at the medial malleolus. We sought to define observed differences in the radiographic appearance of implants relative to the joint line, in prone and supine positions. Methods A 3.5 mm tubular plate and a 3.5 mm posterior distal tibial periarticular plate were applied sequentially to 3 individual cadaveric legs, via a posterolateral approach. The tubular plate was positioned to simulate buttress fixation and the posterolateral plate placed more distally. Each limb was secured on a custom jig and radiographs were taken on a mobile c-arm fluoroscopy machine with a calibration ball. A series of prone AP, supine PA and mortise radiographs were taken. Prone radiographs were also taken in different degrees of caudal tilt to simulate knee flexion which occurs in practice, during intraoperative positioning. Plate tip-joint line distances were measured and Mann-Whitney U tests performed. Results There was no statistically significant difference in plate tip-joint line distance when comparing equivalent prone and supine views (PA/AP or mortise). However, significant differences in apparent implant position were noted with alterations in caudal tilt. When taking a prone image, when the knee is flexed to 20 degrees, the plate tip will appear 6.5-8.5 mm more proximal than in the equivalent supine image where the knee is extended and the fluoroscopy beam is orthogonal to the anatomic axis of the tibia. Conclusion Observed differences in radiographic appearance of metalwork in the prone and supine position are most likely due to knee flexion and the resulting variation in the angle of the fluoroscopy beam, rather than projectional differences between supine and prone views. Surgeons should be alert to this when analysing intraoperative images.
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Affiliation(s)
- Preemal Patel
- Department of Trauma and Orthopaedics, St George’s University Hospital NHS Foundation Trust, St George’s University, London, UK
| | - Zoe Little
- Department of Trauma and Orthopaedics, St George’s University Hospital NHS Foundation Trust, St George’s University, London, UK
| | - Phillip Beak
- Trauma and Orthopaedics, Kingston Hospital, London, UK
| | - Rachel Williams
- Department of Radiology, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Alex Trompeter
- Department of Trauma and Orthopaedics, St George’s University Hospital NHS Foundation Trust, St George’s University, London, UK
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Bartoníček J, Rammelt S, Naňka O. Early history of posterior malleolus fractures in ankle fractures. Int Orthop 2023:10.1007/s00264-023-06080-6. [PMID: 38157040 DOI: 10.1007/s00264-023-06080-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 12/20/2023] [Indexed: 01/03/2024]
Abstract
INTRODUCTION No comprehensive treatise on the early history of fractures of posterior malleolus (PM) has yet been published, and many substantial discoveries have fallen into oblivion-particularly if not having been published in English originally. MATERIALS AND METHODS Literature search was performed in original publications and historical sources. RESULTS Early history of PM fractures from their first description up to the beginnings of their operative treatment may be divided into three basic periods, covering the era between 1828 and 1940. In the pre-radiological period (1828-1895), description of PM injuries was based merely on the autopsy findings in deceased patients. The first mentions of this injury were published by the British authors. In the radiologic period (1899-1916), the x-ray examination started a revolution also in diagnostics of ankle fractures, with the first radiographs performed as early as in 1899. Radiographic examination had subsequently become an integral part of the diagnostics of these injuries and initiated a number of significant studies of PM fractures. The first detailed mention of a PM injury may be found in the French and German literature. The period of early operative treatment (1918-1940), i.e., open reduction and internal fixation of PM, was started by the younger post-WWI generation, primarily the French surgeons, represented by Gaston Picot. His operative technique and the first six cases treated operatively between 1918 and 1921 were described in 1921 by Edouard Huc. Picot himself published his technique in great detail in 1923. CONCLUSION The early history of diagnostics and treatment of PM fractures witnesses the remarkable body of knowledge gathered about that topic by numerous visionary surgeons predominantly French and German surgeons immediately before and after World War I. They substantially contributed to the radiological examination and operative treatment of this injury.
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Affiliation(s)
- Jan Bartoníček
- Department of Orthopaedics, First Faculty of Medicine, Charles University and the Central Military Hospital, U Vojenské nemocnice 1200, Prague 6, Czech Republic
- Institute of Anatomy, First Faculty of Medicine, Charles University, U Nemocnice 3, 128 00, Prague 2, Czech Republic
| | - Stefan Rammelt
- University Center of Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstraße 74, DE-01307, Dresden, Germany
| | - Ondřej Naňka
- Institute of Anatomy, First Faculty of Medicine, Charles University, U Nemocnice 3, 128 00, Prague 2, Czech Republic.
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Tuček M, Bartoníček J, Fojtík P, Kamin K, Rammelt S. Injury to the posterior malleolus in Maisonneuve fractures. Eur J Trauma Emerg Surg 2023:10.1007/s00068-023-02394-7. [PMID: 38041703 DOI: 10.1007/s00068-023-02394-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 11/03/2023] [Indexed: 12/03/2023]
Abstract
PURPOSE The aim of this study was to describe the incidence and a complex pathoanatomy of posterior malleolus fractures in a Maisonneuve fracture. METHODS The study included 100 prospectively collected patients with a complete clinical and radiological documentation of an ankle fracture or fracture-dislocation including a fracture of the proximal quarter of the fibula. RESULTS A posterior malleolus fracture was identified in 74 patients, and in 27% of these cases it carried more than one quarter of the fibular notch. Displacement of the posterior fragment by more than 2 mm was shown by scans in 72% of cases. Small intercalary fragments were identified in 43% of cases. Fractures of the Tillaux-Chaput tubercle were identified in 20 patients. CONCLUSION Our study has proved a high rate of posterior malleolus fractures associated with a Maisonneuve fracture, and documented their considerable variability in terms of involvement of the fibular notch, tibiotalar contact area, direction of displacement and frequency of intercalary fragments. Of no less importance is a combination of Tillaux-Chaput fractures with a Maisonneuve fracture.
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Affiliation(s)
- Michal Tuček
- Department of Orthopaedics, First Faculty of Medicine, Charles University and Military University Hospital Prague, U Vojenské Nemocnice 1200, Prague 6, 169 02, Czech Republic.
| | - Jan Bartoníček
- Department of Orthopaedics, First Faculty of Medicine, Charles University and Military University Hospital Prague, U Vojenské Nemocnice 1200, Prague 6, 169 02, Czech Republic
| | - Petr Fojtík
- Department of Orthopaedics, First Faculty of Medicine, Charles University and Military University Hospital Prague, U Vojenské Nemocnice 1200, Prague 6, 169 02, Czech Republic
| | - Konrad Kamin
- University Center for Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Stefan Rammelt
- University Center for Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
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Vanderstappen M, Herteleer M, Hoekstra H. Dance Around the Fibula with a Twisted Plate: A Technical Note. Indian J Orthop 2023; 57:1323-1328. [PMID: 37525740 PMCID: PMC10387044 DOI: 10.1007/s43465-023-00941-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 06/17/2023] [Indexed: 08/02/2023]
Abstract
Nowadays, there is a better understanding of the role of the posterior malleolar fragment in trimalleolar ankle fractures. Not fragment size, but rather fragment morphology should guide the management of the posterior malleolar fracture (PMF). Anatomical reduction and fixation of the PMF is important, as an intra-articular step-off will eventually lead to osteoarthritis. Incongruency of the incisura fibularis tibia is associated with fibular dislocation, syndesmotic insufficiency, and poor functional outcomes. Open reduction and internal fixation through a posterior approach leads to ankle joint mobility restriction (i.e., dorsal flexion deficiency) due to arthrofibrosis of the ankle joint, fibrous adhesions and secondary shortening of the flexor muscles. In this technical note, we describe a surgical technique to fixate unstable ankle fractures with a combined PMF and a high supra-syndesmotic fibular fracture through two small surgical windows using a twisted one-third tubular plate. By reducing the size of the posterolateral window, fibrous adhesions and secondary flexor muscle shortening are diminished, favoring ankle joint mobility.
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Affiliation(s)
- Maxim Vanderstappen
- Department of Trauma Surgery, University Hospitals Leuven, Herestraat 39, 3000 Leuven, Belgium
- Department of Orthopaedics, University Hospitals Leuven, Leuven, Belgium
| | - Michiel Herteleer
- Department of Trauma Surgery, University Hospitals Leuven, Herestraat 39, 3000 Leuven, Belgium
- Department of Development and Regeneration, KU Leuven-University of Leuven, Leuven, Belgium
| | - Harm Hoekstra
- Department of Trauma Surgery, University Hospitals Leuven, Herestraat 39, 3000 Leuven, Belgium
- Department of Development and Regeneration, KU Leuven-University of Leuven, Leuven, Belgium
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Karaismailoglu B, Yıldırım O, Aslan L, Yontar NS, Guven MF, Kaynak G, Ogut T. Middle-sized posterior malleolus fractures: Fixed versus non-fixed - A prospective randomized study. Foot Ankle Surg 2023; 29:329-333. [PMID: 37062618 DOI: 10.1016/j.fas.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 04/04/2023] [Accepted: 04/08/2023] [Indexed: 04/18/2023]
Abstract
PURPOSE This study aimed to assess the impact of fixation on functional and radiological outcomes of ankle fractures involving the posterior malleolus. We hypothesized that fixation of the posterior malleolus would be associated with improved radiological and functional outcome. METHODS A prospective randomized controlled study was planned and 40 consecutive ankle fractures involving middle-sized (10-25%) posterior fragment were included. Posterior fragments in Group 1 were not fixated while Group 2 underwent posterior malleolus fixation. The patients were evaluated both functionally and radiologically at minimum 2-years. RESULTS Demographics and fracture type distributions were similar between the groups. Despite the slightly better functional outcome in Group 2, no significant functional or radiological outcome difference could be detected. Articular step-off> 1 mm was more common in Group 1 (p = 0.04) and the patients with articular step-off showed significantly worse functional outcome in all functional parameters (p < 0.05). Radiological and functional outcome parameters were positively correlated when all patients were evaluated together. Lateral radiographs caused an overestimation in the size of posterior fragment compared to CT (p < 0.001). CONCLUSION Although there was a slightly better clinical outcome in patients with fixed posterior fragments, it was not significant at short to mid-term follow-up. However, posterior fragment fixation contributed to functional outcomes by decreasing the incidence of articular step-off> 1 mm, which was found to be a negative prognostic factor. LEVEL OF EVIDENCE Level I; prospective randomized controlled study.
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Affiliation(s)
- Bedri Karaismailoglu
- Istanbul University - Cerrahpasa, Cerrahpasa Medical Faculty, Department of Orthopaedics and Traumatology, Istanbul, Turkey; Foot & Ankle Research and Innovation Laboratory (FARIL), Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, MA, USA; CAST (Cerrahpasa Research, Simulation and Design Laboratory), Istanbul University-Cerrahpasa, Istanbul, Turkey.
| | - Onur Yıldırım
- Istanbul University - Cerrahpasa, Cerrahpasa Medical Faculty, Department of Orthopaedics and Traumatology, Istanbul, Turkey
| | - Lercan Aslan
- Koc University Hospital, Department of Orthopaedics and Traumatology, Istanbul, Turkey
| | - Necip Selcuk Yontar
- Nisantasi Orthopaedics Center, Foot and Ankle Surgery Clinic, Istanbul, Turkey
| | - Mehmet Fatih Guven
- Istanbul University - Cerrahpasa, Cerrahpasa Medical Faculty, Department of Orthopaedics and Traumatology, Istanbul, Turkey
| | - Gokhan Kaynak
- Istanbul University - Cerrahpasa, Cerrahpasa Medical Faculty, Department of Orthopaedics and Traumatology, Istanbul, Turkey
| | - Tahir Ogut
- Nisantasi Orthopaedics Center, Foot and Ankle Surgery Clinic, Istanbul, Turkey
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Sugrañes J, Lopez-Hervas S, Alvarez C, Gamba C. Reproducibility of Bartoníček and Haraguchi classifications of the posterior malleolus fractures. Arch Orthop Trauma Surg 2023. [PMID: 36905426 DOI: 10.1007/s00402-023-04823-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 02/25/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND Two of the most commonly used classifications for the posterior malleolus fracture are Haraguchi and Bartoníček. Both classifications are based on the morphology of the fracture. This study makes an inter- and intra-observer agreement analysis of the mentioned classifications. METHODS 39 patients with ankle fractures who met inclusion criteria were selected. All the fractures were analyzed and classified twice by each of the 20 observers using Bartoníček and Haraguchi's classifications, with a window period of at least 30 days between the two rounds. RESULTS Analysis was made by Kappa coefficient (ƙ). The global intraobserver value was ƙ = 0.627 in the Bartoníček classification and ƙ = 0.644 in the Haraguchi one. The first round global interobserver ƙ = 0.589 (0.574-0.604) on the Bartoníček classification and ƙ = 0.534 (0.517-0.551) on the Haraguchi one. Second round coefficients were ƙ = 0.601 (0.585-0.616) and ƙ = 0.536 (0.519-0.554), respectively. The best agreement was when there was involvement of the posteromedial malleolar zone with ƙ = 0.686 and ƙ = 0.687 in Haraguchi II and ƙ = 0.641 and ƙ = 0.719 in Bartoníček III. No differences were observed in Kappa values when an experience-based analysis was made. CONCLUSION Bartoníček and Haraguchi classifications of the posterior malleolus fracture have both substantial intraobserver agreement but moderate to substantial agreement in interobserver analysis. LEVEL OF EVIDENCE IV.
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Fernández-Rojas E, Herrera-Pérez M, Vilá-Rico J. [Translated article] Posterior malleolar fractures: Indications and surgical approaches. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:T160-T169. [PMID: 36574833 DOI: 10.1016/j.recot.2022.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 10/27/2022] [Indexed: 12/25/2022] Open
Abstract
Posterior malleolus fractures are frequent injuries, present in 7-44% of all ankle fractures. The objective of this study is to review the evidence to indicate the fixation of this fracture and to choose the appropriate surgical approach. The classic indications for fixation were fragment size greater than 25-30% of the articular surface and displacement greater than 2mm. However, current evidence suggests that, rather than size, factors such as syndesmotic instability, intra-articular step-off greater than 1-2mm, plafond impaction and the presence of intercalary fragments should be considered. When comparing the different surgical approaches, the literature supports the use of posterior approaches and reserves the recommendation of the traditional approach for exceptional cases. For the treatment of this injury it is essential to know the anatomy of the ankle and to consider all the factors described above, in addition to the presence of concomitant injuries.
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Affiliation(s)
- E Fernández-Rojas
- Equipo de Tobillo y Pie, Servicio de Traumatología y Ortopedia, Hospital Las Higueras, Talcahuano, Chile; Universidad Católica de la Santísima Concepción, Concepción, Chile.
| | - M Herrera-Pérez
- Unidad de Pie y Tobillo, Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Islas Canarias, Spain; Escuela de Medicina, Universidad de La Laguna, Santa Cruz de Tenerife, Islas Canarias, Spain
| | - J Vilá-Rico
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, Spain; Departamento de Cirugía, Universidad Complutense de Madrid, Madrid, Spain
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Fernández-Rojas E, Herrera-Pérez M, Vilá-Rico J. Posterior malleolar fractures: Indications and surgical approaches. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:160-169. [PMID: 36371071 DOI: 10.1016/j.recot.2022.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/10/2022] [Accepted: 10/27/2022] [Indexed: 11/11/2022] Open
Abstract
Posterior malleolus fractures are frequent injuries, present in 7-44% of all ankle fractures. The objective of this study is to review the evidence to indicate the fixation of this fracture and to choose the appropriate surgical approach. The classic indications for fixation were fragment size greater than 25-30% of the articular surface and displacement greater than 2 mm. However, current evidence suggests that, rather than size, factors such as syndesmotic instability, intra-articular step-off greater than 1-2 mm, plafond impaction and the presence of intercalary fragments should be considered. When comparing the different surgical approaches, the literature supports the use of posterior approaches and reserves the recommendation of the traditional approach for exceptional cases. For the treatment of this injury it is essential to know the anatomy of the ankle and to consider all the factors described above, in addition to the presence of concomitant injuries.
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Affiliation(s)
- E Fernández-Rojas
- Equipo de Tobillo y Pie, Servicio de Traumatología y Ortopedia, Hospital Las Higueras, Talcahuano, Chile; Universidad Católica de la Santísima Concepción, Concepción, Chile.
| | - M Herrera-Pérez
- Unidad de Pie y Tobillo, Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Islas Canarias, España; Escuela de Medicina, Universidad de La Laguna, Santa Cruz de Tenerife, Islas Canarias, España
| | - J Vilá-Rico
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, España; Departamento de Cirugía, Universidad Complutense de Madrid, Madrid, España
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Rashid MS, Islam R, Marsden S, Trompeter A, Teoh KH. Validation of three classification systems for posterior malleolus fractures of the ankle. Eur J Orthop Surg Traumatol 2023:10.1007/s00590-023-03476-3. [PMID: 36723774 DOI: 10.1007/s00590-023-03476-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 01/18/2023] [Indexed: 02/02/2023]
Abstract
PURPOSE A number of classification systems exist for posterior malleolar ankle fractures. The user reliability of these classification systems remains unclear. The primary aim of this study was to evaluate the reliability of three commonly utilised classification systems for fractures of the posterior malleolus. METHODS Imaging of 60 patients across 2 hospitals with ankle fractures including a posterior malleolar fragment was identified. All patients had undergone plain radiographs and computed tomography of their injured ankle as part of their normal standard of care. 9 surgeons including pre-resident/registrar level, resident/registrar level, and attending/consultant level applied the Haraguchi, Bartoníček, and Mason classifications to these fractures, at two timepoints, at least 4 weeks apart. The order was randomised between assessments. Inter-rater reliability was assessed using Fleiss' κ and standard error (SE). Intra-rater reliability was assessed using Cohen's κ and standard error (SE). RESULTS Inter-rater reliability (Fleiss' κ) was calculated for the Haraguchi classification as 0.588 (SE 0.023), for the Bartoníček classification as 0.626 (SE 0.019), and the Mason classification as 0.541 (SE 0.098). Intra-rater reliability (Cohen's κ) was 0.761 (SE 0.098) for the Haraguchi classification, 0.761 (SE 0.091) for the Bartoníček, classification, and 0.724 (SE 0.096) for the Mason classification. CONCLUSIONS This study reports the inter-rater and intra-rater reliability for three classification systems for posterior malleolus fractures. Based on definitions by Landis and Koch (Biometrics 33:159-174, 1977), inter-rater reliability was rated as 'moderate' for the Haraguchi and Mason classifications and 'substantial' for the Bartoníček classification. Similarly, the intra-rater reliability was rated as 'substantial' for all three classifications.
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Affiliation(s)
- Mustafa S Rashid
- St George's University Hospital, St. George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, England, UK.
| | - Raisa Islam
- The Princess Alexandra Hospital NHS Trust, Harlow, UK
| | - Samuel Marsden
- St George's University Hospital, St. George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, England, UK
| | - Alexander Trompeter
- St George's University Hospital, St. George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, England, UK
| | - Kar Hao Teoh
- The Princess Alexandra Hospital NHS Trust, Harlow, UK
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13
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Verhage SM, Hoogendoorn JM, Krijnen P, Schipper IB. Variation in posterior fragment fixation in the Netherlands: a nationwide study. Eur J Trauma Emerg Surg 2023; 49:317-26. [PMID: 36018372 DOI: 10.1007/s00068-022-02066-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 07/16/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE The treatment of the posterior fragment in trimalleolar fractures differs from hospital to hospital in the Netherlands. A nationwide survey was performed to evaluate the fixation criteria and practice variation. METHODS An online cross-sectional survey amongst (orthopaedic) trauma surgeons was performed in the Netherlands. It consisted of three sections: a general section, a section showing preoperative images of six cases and a section with postoperative images of nine cases. RESULTS A total of 151 surgeons completed the online survey. 45% of the respondents indicated that they fixated the posterior fragment if smaller than 25% of the intra-articular surface. 48% preferred an open posterior approach to fixate the posterior fragment. There was good consensus in treatment for the two cases with Bartonicek type 4 fractures (operative treatment in 73 and 72% respectively). Little consensus was found for Bartonicek type 2 and 3 fractures (88% opted for operative treatment in one case, but 89% for conservative treatment in the second case). Reoperation was mostly considered in cases with a step-off of more than 1 mm (by 33-38% of the respondents). There was great variation in the choice of treatment if only the size of the posterior fragment was considered. Other fixation criteria such as postoperative step-off or instability after fixation of the lateral and medial malleoli are taken into account. In cases where fixation was needed, a percutaneous approach and an open posterolateral approach were equally preferred. CONCLUSIONS There is much variation in treatment of the posterior malleolar fracture amongst orthopaedic and trauma surgeons in the Netherlands. The percutaneous approach and open posterolateral approach to fixate the posterior malleolar fracture seem to be equally used in the Netherlands. Still, there is no uniformity in treatment of posterior malleolar fracture, especially for Bartonicek 2 and Bartonicek 3 fractures. Reoperation is considered by less than half of the surgeons in case of postoperative persistent step-off of more than 1 mm.
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14
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Aravindan S, Tucker NJ, Prusick PJ, Mauffrey C, Parry JA. Open fixation of the posterior malleolus increases the morbidity of trimalleolar ankle fracture fixation. Eur J Orthop Surg Traumatol 2022. [PMID: 36581699 DOI: 10.1007/s00590-022-03455-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 12/01/2022] [Indexed: 12/31/2022]
Abstract
PURPOSE To assess the morbidity of open reduction internal fixation (ORIF) of posterior malleolus fractures (PMFs) in the setting of trimalleolar ankle fractures. METHODS A retrospective review of 79 trimalleolar ankle fractures was performed to identify need for syndesmotic fixation, blood loss, operative/tourniquet time, complications, and reoperations. Patients with PMF ORIF (n = 38) were compared to those with no fixation (n = 41). A subanalysis of patients with small PMFs (< 25%) was performed. RESULTS The PMF ORIF group required less syndesmosis fixation (proportional difference (PD) - 44.6%, 95% confidence interval (CI) - 61.8 to - 23.0%), had more blood loss (MD 20 ml, CI 0-40), longer operative times (MD 53.0 min, CI 35.9-70.1), longer tourniquet times (MD 26 min, CI 4-33), and had no difference in postoperative joint step-off or concentrically reduced joints. The PMF ORIF group had more postoperative complications (PD 26.9%, CI 6.3-44.8%) and a trend for more reoperations (PD 13.6%, CI -3.4 to 29.6%). Wound complications were more common in the PMF ORIF group (PD 26.5%, CI 6.9-43.6%), resulting in 5 (16.1%) irrigation and debridement procedures. On analysis of patients with small PMFs (n = 42), PMF ORIF (n = 15) resulted in longer operative/tourniquet times and had no observed difference in postoperative joint step-off, concentrically reduced joints, need for syndesmotic fixation, blood loss, or complications/reoperations. CONCLUSION PMF ORIF in the setting of trimalleolar ankle fractures was associated with increased operative/tourniquet times, blood loss, wound complications, and did not eliminate the need for syndesmosis fixation.
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15
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Patel S, Baburaj V, Sharma S, Mason LW, Dhillon MS. Influence of posterior malleolar fragment morphology on the outcomes of trimalleolar fractures: A systematic review and meta-analysis. Foot Ankle Surg 2022; 28:1337-44. [PMID: 35810125 DOI: 10.1016/j.fas.2022.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/08/2022] [Accepted: 06/21/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Trimalleolar fractures are generally considered to have inferior outcomes among ankle injuries. Historically, emphasis was placed on the size of the posterior malleolar fracture (PMF) to guide surgical decision-making and predict outcomes. Recent studies have suggested that the morphology of the PMF fragment is more important than its size. The aim of this systematic review was to determine if the outcomes of trimalleolar fractures depend on the morphology of the PMF as per the Haraguchi classification system after surgical fixation. METHODS A systematic literature search was conducted in the electronic databases of PubMed, Embase, Scopus, and Ovid. Title and abstracts were screened, and data from eligible studies were extracted. Meta-regression and pooled analysis was performed using appropriate computer software. RESULTS 11 studies with 597 patients were included in the final analysis. Pooled mean AOFAS score was 87.43 (95% CI 84.24-90.62) after a mean follow-up of 31.6 months. Univariate and multivariate meta-regression analysis demonstrated that as the percentage of Haraguchi type 1 patients increased, there was a statistically significant improvement in outcome scores. A similar trend was noted for Haraguchi type 3 fractures, and a reverse trend was observed for Haraguchi type 2 injuries, although neither were statistically significant. CONCLUSION Our review suggests that the outcomes of trimalleolar fractures after surgical fixation may depend on the morphology of the PMF, with Haraguchi type 1 fractures having overall superior functional outcomes than Haraguchi type 2 and 3 injuries. Future studies need to done to conclusively prove or refute these findings.
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16
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Chen DL, Liu P, Zheng LX, Zhu ZH, Zhang ZF. Fracture gap of the lateral malleolus via posterolateral approach: Improved visualization of the posterior malleolus fracture. Injury 2022; 53:3849-52. [PMID: 36127174 DOI: 10.1016/j.injury.2022.08.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 08/19/2022] [Accepted: 08/20/2022] [Indexed: 02/02/2023]
Abstract
The treatment of posterior malleolar fractures is a popular issue. Anatomic reduction of posterior malleolar fractures is critical for re-establishing the stability of the ankle mortise and ligamentous union after trauma. Inappropriate treatment ultimately leads to poorer functional outcomes and lower quality of life. Open reduction and internal fixation through a posterolateral approach are preferred over indirect reduction and anterior-posterior screw fixation. Although the posterolateral approach, which is more common and direct, provides good exposure to the fracture site, it has some limitations. In this report, we describe the posterolateral approach through the lateral ankle fracture gap for the treatment of posterior ankle fractures. Moreover, we discuss the indications, benefits, and limitations of this approach.
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17
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Kohler FC, Schenk P, Koehler P, Hofmann GO, Biedermann U, Wildemann B, Graul I, Hallbauer J. The role of the posterior malleolus in the treatment of unstable upper ankle joint injuries - A biomechanical study. Foot Ankle Surg 2022; 28:979-985. [PMID: 35177329 DOI: 10.1016/j.fas.2022.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 01/28/2022] [Accepted: 02/09/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND This biomechanical study aimed to test if the fixation of the posterior malleolus (PM) only with screws inserted from posterior to anterior (PA) restores stability comparable with the natural condition. The extent of stability was also compared with that of anterior to posterior (AP) screw osteosynthesis (OS) with an additional syndesmotic screw (SS). METHODS First, the stability of the upper ankle joint in seven pairs of intact lower legs were examined. Subsequently, half of the lower legs were treated with PA screw fixation of a PM fracture without SS and the other half with AP screw fixation with additional tricortical SS. RESULTS PA OS without SS showed significantly more diastasis (p = 0.027). The AP OS with an SS revealed a diastasis that was comparable with the intact condition (p = 0.797). The use of SS led to significantly higher stability compared to OS without SS (p = 0.019). CONCLUSIONS The Fixation of the PM alone without an additional syndesmotic screw cannot achieve intact upper ankle stability. Fixation of a PM fracture with an SS helps in nearly achieving the natural condition.
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Affiliation(s)
- F C Kohler
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747 Jena, Germany.
| | - P Schenk
- Reseaserch Executive Department, BG Klinikum Bergmannstrost, 06112 Halle, Germany
| | - P Koehler
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747 Jena, Germany
| | - G O Hofmann
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747 Jena, Germany; Department of Trauma and Reconstructive Surgery, BG Klinikum Bergmannstrost, 06112 Halle, Germany
| | - U Biedermann
- Institute of Anatomy I, Jena University Hospital, Friedrich Schiller University Jena, 07743 Jena, Germany
| | - B Wildemann
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747 Jena, Germany
| | - I Graul
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747 Jena, Germany
| | - J Hallbauer
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747 Jena, Germany
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18
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Verhage SM, Leijdesdorff A, Schipper IB, Hoogendoorn JM. Open reduction and internal fixation of the posterior malleolus fragment via the posterolateral approach is radiologically superior to 'A to P' screw fixation. Foot (Edinb) 2022; 51:101894. [PMID: 35255401 DOI: 10.1016/j.foot.2021.101894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 11/18/2021] [Accepted: 12/21/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Functional outcome in trimalleolar fractures is largely correlated to the reduction of the posterior fragment. Until recently, fixation was mainly performed for large fragments, by percutaneous anterior to posterior ('A to P') screw placement after closed reduction. Nowadays, ORIF via a posterolateral approach seems to gain in popularity. The aim of this study was to compare the postoperative photographs of operated trimalleolar fractures after either fracture treatment method, for fracture diastasis and step-off. MATERIAL AND METHODS All consecutive patients with trimalleolar fractures, including posterior fragments of >5% of the articular surface and operated between 2007-2013 were analysed on size of posterior fragment, post-operative gap and step-off by three observers. The patients were divided into three groups; A to P screw fixation, ORIF via the posterolateral approach and no posterior fragment fixation at all. RESULTS 180 patients with trimalleolar ankle fractures were included for analyses. Twenty five posterior fragments were fixated percutaneously from anterior to posterior (group 1) and 51 underwent open reduction and internal fixation through a posterolateral approach (group 2). 104 patients underwent no posterior malleolus fixation (group 3). The average size of posterior fragment was 34% in group 1, 27% in group 2 and 16% in group 3. A postoperative step-off >1 mm was found in 40% (group 1), 9% (group 2) or 34% respectively (group 3). CONCLUSIONS Fixation of the posterior malleolus through an open posterolateral approach leads to better radiological results as compared to percutaneous 'A to P' screw fixation or no fixation at all.
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Affiliation(s)
- Samuel Marinus Verhage
- Haaglanden Medical Center, Department of Surgery, The Hague, The Netherlands; Leiden University Medical Center, Department of Trauma Surgery, Leiden, The Netherlands.
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Danford NC, Hellwinkel JE, Nocek MJ, Boddapati V, Greisberg JK, Trofa DP. Fractures of the posterior malleolus: a systematic review and analysis of patient-reported outcome scale selection. Eur J Orthop Surg Traumatol 2022; 33:1125-1131. [PMID: 35430691 DOI: 10.1007/s00590-022-03261-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 03/28/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Despite the extensive use of PROs in ankle fracture research, no study has quantified which PROs are most commonly used for assessing outcomes of patients who sustain fractures of the posterior malleolus. The purpose of this study was therefore to quantify which PROs are most commonly used for outcome research after posterior malleolus fractures. METHODS A systematic search was performed using the preferred reporting items for systematic reviews and meta-analyses guidelines. Articles were identified through Pubmed, EMBASE, Web of Science, and cochrane central register of controlled trials through May of 2021. Included articles were analyzed for the primary outcome of the most commonly reported PRO. RESULTS The American orthopedic foot and ankle ankle-hindfoot score (AOFAS) was the most commonly used PRO for assessment of posterior malleolus fracture outcomes, used in 37 of 72 studies (51.4%). The second and third most common were the olerud-molander ankle score (OMAS) (22 studies, 30.6%) and the visual analogue score (VAS) (21 studies, 29.2%). Eleven different PROs were used only once. Quality of evidence was graded as low given the percentage of studies that were observational or case series (68 of 72 studies, 94.4%). CONCLUSION Investigators have used many different PROs to assess outcomes for posterior malleolus fractures, the most common of which are the AOFAS, OMAS, and VAS. Future investigators should attempt to unify outcome reporting for these injuries.
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Affiliation(s)
- Nicholas C Danford
- Department of Orthopaedic Surgery, New York-Presbyterian/Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, NY, USA.
| | - Justin E Hellwinkel
- Department of Orthopaedic Surgery, New York-Presbyterian/Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, NY, USA
| | - Michael J Nocek
- Department of Orthopaedic Surgery, New York-Presbyterian/Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, NY, USA
| | - Venkat Boddapati
- Department of Orthopaedic Surgery, New York-Presbyterian/Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, NY, USA
| | - Justin K Greisberg
- Department of Orthopaedic Surgery, New York-Presbyterian/Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, NY, USA
| | - David P Trofa
- Department of Orthopaedic Surgery, New York-Presbyterian/Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, NY, USA
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20
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Maluta T, Samaila EM, Amarossi A, Dorigotti A, Ricci M, Vecchini E, Magnan B. Can treatment of posterior malleolus fractures with tibio-fibular instability be usefully addressed by Bartonicek classification? Foot Ankle Surg 2022; 28:126-133. [PMID: 33685829 DOI: 10.1016/j.fas.2021.02.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/12/2021] [Accepted: 02/19/2021] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Ankle fractures account for 4% of all fractures and treatment of those involving the Posterior Malleolus remains controversial. Clinical and radiological outcomes in a cohort of patients with Posterior Malleolus fractures conservatively treated were retrospectively evaluated; furthermore, a treatment algorithm was suggested. METHODS Patients were divided according to Bartoníček classification. The clinical evaluation was made with OMAS/AOFAS scores; the radiological evaluation with Van Dijk classification for post-traumatic arthritis. RESULTS Clinical outcome worsened with the severity of Bartoníček classification, but early degenerative changes were not correlated neither to the clinical outcome nor to the injury pattern. Clinical and radiological outcomes depended on the damage of the syndesmosis as articular step-offs and tibio-fibular notch involvement. DISCUSSION We recommend conservative treatment for Bartoníček type I, type II and type III fractures, the latter when undisplaced and without tibial plafond depression. We suggest surgical treatment for type IV and displaced type III fractures.
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Affiliation(s)
- T Maluta
- Department of Orthopedics and Trauma Surgery, University of Verona, Italy
| | - E M Samaila
- Department of Orthopedics and Trauma Surgery, University of Verona, Italy
| | - A Amarossi
- Department of Orthopedics and Trauma Surgery, University of Verona, Italy
| | - A Dorigotti
- Department of Orthopedics and Trauma Surgery, University of Verona, Italy
| | - M Ricci
- Department of Orthopedics and Trauma Surgery, University of Verona, Italy
| | - E Vecchini
- Department of Orthopedics and Trauma Surgery, University of Verona, Italy
| | - B Magnan
- Department of Orthopedics and Trauma Surgery, University of Verona, Italy.
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Xie W, Lu H, Xu H, Quan Y, Liu Y, Fu Z, Zhang D, Jiang B. Morphological analysis of posterior malleolar fractures with intra-articular impacted fragment in computed tomography scans. J Orthop Traumatol 2021; 22:52. [PMID: 34890022 PMCID: PMC8664919 DOI: 10.1186/s10195-021-00615-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 11/17/2021] [Indexed: 11/22/2022] Open
Abstract
Background Intraarticular impacted fragment (IAIF) of posterior malleolar fractures has been reported by a few studies. However its location, morphology, and the correlation of posterior malleolar fractures have not been described in detail. The aim of this study was to describe the morphology of IAIF in posterior malleolar fractures, to analyze the related factors between IAIF and posterior malleolar fragments, and explore the treatment of IAIF. Materials and methods Between January 2013 and December 2018, 108 consecutive patients with unilateral posterior malleolar fractures were managed in our hospital. Basic demographic and computed tomography (CT) data were collected and classified by Lauge–Hansen, OTA/AO, Haraguchi, and Mason classification. Additional radiographic data, including the length and area of posterior malleolar fragment, IAIF, and stable tibial plafond were measured. The location of IAIF was described, and involvement of the fibular notch and medial malleolus was also observed. Statistics were analyzed based on univariate analysis (Chi-square test, t-test, Mann–Whitney U test, Fisher’s test) and Spearman’s correlation test. Results Among the 108 cases of posterior malleolar fractures, 75 (69.4%) were with IAIF and 33 (30.6%) cases were without. There were 74 (68.5%) females and 34 (31.5%) males, and the average age of the patients was 49 years (18–89 years). The average LIFN/(LIFN + LSFN) [length of involving fibular notch/(length of involving fibular + length of stable notch fibular notch)] was 32.9% (11.6–64.9%). The APMF/(APMF + ASTP + AIAIF) [area of posterior malleolar fragment/(area of posterior malleolar fragment + area of IAIF + area of stable tibial plafond)] and AIAIF/APMF (area of IAIF/area of posterior malleolar fragment) were 13.1% (0.8–39.7%) and 52.6% (1.2–235.4%), respectively. Involvement of medial malleolus (fracture line extended to medial malleolus, P = 0.022), involvement of fibular notch (P = 0.021), LIFN/(LIFN + LSFN) (P = 0.037), LMPMF (P = 0.004), and APMF were significantly related to the occurrence of IAIF. Conclusion Our research indicates a high incidence of IAIF in posterior malleolar fractures. All IAIFs were found in posterior malleolar, and the most common location was within the lateral area A. Posterior malleolar fracture lines that extend to medial malleolus or fibular notch herald the incidence of IAIF. LIFN/(LIFN + LSFN), LMPMF and APMF are also associated with the incidence of IAIF. CT scans are useful for posterior malleolar fractures to determine the occurrence of IAIF and make operational plans. Operation approach selection should be based on the morphology of posterior malleolar fragments and the location of IAIF. Level of evidence Level III, retrospective case analysis.
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Affiliation(s)
- Wenyong Xie
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Hao Lu
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Hailin Xu
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Yuan Quan
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Yijun Liu
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Zhongguo Fu
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Dianying Zhang
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Baoguo Jiang
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China. .,Trauma Center, National Center for Trauma Medicine, Beijing, 100044, China. .,Key Laboratory of Trauma and Neural Regeneration, Peking University People's Hospital, Beijing, 100044, China.
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22
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Kašper Š, Bartoníček J, Rammelt S, Kamin K, Tuček M. "Double Maisonneuve fracture": an unknown fracture pattern. Eur J Trauma Emerg Surg 2021. [PMID: 34519863 DOI: 10.1007/s00068-021-01786-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 08/30/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The aim of this study was to describe pathoanatomy and to raise awareness of a fracture of the lateral malleolus combined with a high subcapital fracture of the fibula caused by a dislocation mechanism. METHODS The study comprised 11 patients, 5 men and 6 women, with the mean age of 57 years (range, 21-87), with a "Double Maisonneuve fracture". Individual lesions of ankle structures were described on the basis of radiographs, CT, and intraoperative findings. RESULTS The distal fibular fracture was classified as Weber type B in 1 case and Weber type C in 10 cases. The proximal fibular fracture was described as a subcapital oblique spiral fracture with metadiaphyseal involvement in nine cases and a high short oblique fracture with fibular head involvement in two cases. Injury to the deltoid ligament was revealed in six cases; a bicollicular fracture of the medial malleolus was found in five patients. Posterior malleolar fractures were classified as type 1 in eight cases and type 2 in three cases. Avulsion of the Chaput tubercle was detected in four cases. Injury to the interosseous tibiofibular ligament was assessed in nine patients. CONCLUSION Double Maisonneuve fracture is a rare but probably underreported injury that must be taken into consideration during examination, as it may be easily overlooked. The essential part of diagnosis is a careful clinical examination and radiological assessment of the lower leg with additional CT examination of the ankle.
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23
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Bouche PA, Gaujac N, Corsia S, Leclerc P, Anract P, Auberger G. Ankle CT scan allows better management of posterior malleolus fractures than X-rays. Eur J Orthop Surg Traumatol 2021; 32:1301-1309. [PMID: 34468840 DOI: 10.1007/s00590-021-03104-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 08/23/2021] [Indexed: 01/23/2023]
Abstract
PURPOSE Undiagnosed and undertreated posterior malleolus fractures lead to early ankle instability and arthritis. A preoperative CT scan could improve the management of those fractures. This study assessed the benefits of a systematic ankle CT scanner to diagnose and manage posterior malleolus fracture. METHODS A monocentric retrospective cohort study was conducted. Sixty consecutive patients with bimalleolar fractures were operated and underwent a preoperative CT scan. The mean age was 50.0 years old (18.6 years old) with a mean body mass index of 20.3 (kg/m2) (11.4 kg/m2) and 71.7% (43/60) of women. The primary outcome was the rate of posterior malleolus fragment diagnosed on X-rays and on CT scan. Secondly, interobserver and interobserver's agreement were compared between conventional X-rays and CT scan. RESULTS Thirty-five (58.3%) posterior fragment fractures were observed on X-rays and 53 (88.3%) on the preoperative CT scan (p < 0.01). The intraobserver reproducibility for X-rays was low (0.02 [- 0.23; 0.27]) and moderate for CT scan (0.45 [0.0; 0.84]). The interobserver reproducibility for X-rays was moderate (0.39 [0.15; 0.60]) and excellent for CT scan (0.78 [0.0; 1.0]). CONCLUSION A wide proportion of bimalleolar fractures are associated with posterior malleolus fractures and undiagnosed with standard X-rays. We advocate a systematic preoperative CT scan in the management of bimalleolar fractures. LEVEL OF EVIDENCE Level IV, retrospective cohort study. TRIAL REGISTRATION NUMBER 2218999v0, date of registration: 11/08/2020 (retrospectively registered).
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Affiliation(s)
- Pierre-Alban Bouche
- Orthopaedic Department, Cochin University Hospital, APHP Paris, Paris Descartes University, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France.
| | - Nicolas Gaujac
- Orthopaedic Department, Cochin University Hospital, APHP Paris, Paris Descartes University, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Simon Corsia
- Orthopaedic Department, Cochin University Hospital, APHP Paris, Paris Descartes University, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Philippe Leclerc
- Orthopaedic Department, Croix St Simon Hospital, 125 rue d'Avron, 75020, Paris, France
| | - Philippe Anract
- Orthopaedic Department, Cochin University Hospital, APHP Paris, Paris Descartes University, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Guillaume Auberger
- Orthopaedic Department, Croix St Simon Hospital, 125 rue d'Avron, 75020, Paris, France
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Stringfellow TD, Walters ST, Nash W, Ahluwalia R; Posterior Malleolus Study Group. Management of posterior malleolus fractures: A multicentre cohort study in the United Kingdom. Foot Ankle Surg 2021; 27:629-35. [PMID: 32878722 DOI: 10.1016/j.fas.2020.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 07/13/2020] [Accepted: 08/05/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND There is a need to assess clinical practice in light of increasing literature recommending fixation of posterior malleolus (PM) fractures. This multicentre study examines treatment approaches, within both Major Trauma Centres and District General Hospitals and role of radiographs and CT scanning. METHODS Trauma lists and databases were used to identify patients and data collected from electronic and paper medical records and imaging systems between August 2017-18. Analysis of treatment and outcomes was then conducted. RESULTS One-hundred-and-sixty ankle fractures were included in the study, only 68 ankle fractures underwent CT scanning following initial radiographs and of these, 65 were managed operatively, with 32 undergoing PM fixation. Syndesmotic stabilisation was performed in 9.6% where the PM was fixed. CONCLUSION CT is still under-utilised, PM fractures that appear to be anything other than small avulsion-type injuries should undergo CT scanning. Syndesmotic stabilisation is statistically less likely to be performed with fixation of the PM.
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Jeyaseelan L, Bua N, Parker L, Sohrabi C, Trockels A, Vris A, Heidari N, Malagelada F. Outcomes of posterior malleolar fixation in ankle fractures in a major trauma centre. Injury 2021; 52:1023-1027. [PMID: 33376016 DOI: 10.1016/j.injury.2020.12.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 11/11/2020] [Accepted: 12/19/2020] [Indexed: 02/02/2023]
Abstract
AIMS Ongoing controversy exists over the indications and benefits of posterior malleolar fixation in ankle fractures. The aim of this pragmatic study was to evaluate the outcomes of posterior malleolar fracture fixation in ankle fractures in the setting of a major trauma centre. Our hypothesis is that posterior malleolus fixation leads to improved clinical outcomes. METHODS A total of 320 patients were identified with operatively treated ankle fractures involving a posterior malleolus component, at our institution between January 2012 and January 2018, ensuring a minimum 2 year follow-up. Of these patients, 160 had the posterior malleolus fixed as part of their surgery and 160 did not. Patient demographics, surgical details and complications were assessed. The Manchester-Oxford Foot Questionnaire (MOXFQ) was the primary patient outcome measure. RESULTS Fixation of the posterior malleolus was associated with a statistically significant improvement in patient outcomes. Mean MOXFQ score in the unfixed posterior malleolus group was 24.03 (0 - 62), compared to 20.10 (0 - 67) in the fixed posterior malleolus group (p = 0.04). Outcomes were worse with increasing size of posterior malleolar fragment. Metalwork-related issues were higher in the posterior malleolus fixed group (24/160 (15%) versus 10/160 (6.2%)) and re-operation rate was double. CONCLUSION This study demonstrates that in the practical setting of a major trauma unit, fixation of the posterior malleolar fracture leads to improved patient outcomes but with increased metalwork risks and reoperation rates.
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Affiliation(s)
- Luckshmana Jeyaseelan
- Department of Trauma & Orthopaedics, The Royal London Hospital, Bart's Health NHS Trust, Whitechapel Road, London E1 1FR, United Kingdom
| | - Nelson Bua
- Department of Trauma & Orthopaedics, The Royal London Hospital, Bart's Health NHS Trust, Whitechapel Road, London E1 1FR, United Kingdom
| | - Lee Parker
- Department of Trauma & Orthopaedics, The Royal London Hospital, Bart's Health NHS Trust, Whitechapel Road, London E1 1FR, United Kingdom
| | - Catrin Sohrabi
- Department of Trauma & Orthopaedics, The Royal London Hospital, Bart's Health NHS Trust, Whitechapel Road, London E1 1FR, United Kingdom
| | - Amaury Trockels
- Department of Trauma & Orthopaedics, The Royal London Hospital, Bart's Health NHS Trust, Whitechapel Road, London E1 1FR, United Kingdom
| | - Alexandros Vris
- Department of Trauma & Orthopaedics, The Royal London Hospital, Bart's Health NHS Trust, Whitechapel Road, London E1 1FR, United Kingdom
| | - Nima Heidari
- Department of Trauma & Orthopaedics, The Royal London Hospital, Bart's Health NHS Trust, Whitechapel Road, London E1 1FR, United Kingdom
| | - Francesc Malagelada
- Department of Trauma & Orthopaedics, The Royal London Hospital, Bart's Health NHS Trust, Whitechapel Road, London E1 1FR, United Kingdom.
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Nasrallah K, Einal B, Shtarker H. Trimalleolar fracture: The endless posterior malleolus fracture debate, to repair or not to repair? Orthop Rev (Pavia) 2021; 13:8784. [PMID: 33897988 PMCID: PMC8054658 DOI: 10.4081/or.2021.8784] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 10/24/2020] [Indexed: 01/18/2023] Open
Abstract
Ankle fracture is one of the most common fractures presenting in the emergency department. The fracture varies from unimalleolar, bimalleolar or trimalleolar. Involvement of the posterior malleolus is common and ranges from small avulsions to large intraarticular fragments causing subluxation of the talus. If left untreated, the resulting step-off, comminution or posterior talar subluxation may lead to osteoarthritis and further disability. To date, no consensus exists regarding the management of posterior malleolus fractures in the set-up of trimalleolar fractures. In this review we provide an overview of the literature on the available treatment options for posterior malleolar fracture in the set-up of trimalleolar fractures.
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Affiliation(s)
- Khalil Nasrallah
- Galilee Medical Center, Department of Orthopedics, Nahariya, Israel
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Philpott MDG, Jayatilaka MLT, Millward G, Molloy A, Mason L. Posterior approaches to the ankle - an analysis of 3 approaches for access to the posterior malleolar fracture. Foot (Edinb) 2020; 45:101725. [PMID: 33049427 DOI: 10.1016/j.foot.2020.101725] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 06/18/2020] [Accepted: 08/04/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND An anatomical study to determine what degree of access to the posterior distal tibia could be gained by using 3 different approaches; the posterolateral, the posteromedial and the medial posteromedial approaches. METHODS A comparison study, between the anatomical dissection of 7 fresh frozen cadaveric lower legs and image analysis of CT data of posterior malleolar fractures from a prospectively collected database was conducted. All fractures have been classified using the Mason and Molloy classification. RESULTS In comparing the posterior malleolar fracture fragment width to distal tibia width, the posterolateral fragment encompasses 60.1% (95% CI 56.8, 63.3) of the total width of the tibia. If the posteromedial fragment is included the fragments encompass the entire distal tibia (100%). In type 3 fractures, 81.4% (95% CI 75.5, 87.1) of the distal tibia width is involved. When comparing the fracture width to the approach, no approach achieves a complete exposure of the type 2B or 3 fracture patterns. The overall surface area of the type 2B and 3 fractures, is significantly greater than all the approaches. Considering the lateral to medial extent of the fracture, the posterolateral fragment mean width is 33% greater than what can be exposed by the posterolateral approach (mean 24.9 vs 16.8mm). In type 2B and 3 fractures, the horizontal exposure reduces to 39.8% and 47.6% respectively. In comparison, the PM approach exposes 47.6% of the type 2B fracture pattern and 57.1% of the type 3 fracture pattern and allows a preferable angle for hardware insertion. The MPM approach does not expose any of the posterolateral fragments in this study, however it does expose 92% (mean 21.9 vs. 23.8mm) of the medial to lateral width of a posteromedial fragment of a type 2B fracture. CONCLUSION Each approach allows access to different parts and amounts of the posterior tibia. An understanding of and utilisation of these approaches can lead to adequate exposure for fixation of most posterior malleolus fracture patterns seen.
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Weigelt L, Hasler J, Flury A, Dimitriou D, Helmy N. Clinical and radiological mid- to long-term results after direct fixation of posterior malleolar fractures through a posterolateral approach. Arch Orthop Trauma Surg 2020; 140:1641-1647. [PMID: 31982927 DOI: 10.1007/s00402-020-03353-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Direct fixation of posterior malleolar fractures has been shown to lead to higher accuracy of fracture reduction compared to an indirect anterior to posterior fixation but lacks long-term clinical results. This study shows the mid- to long-term clinical and radiological outcome after direct fixation of the posterior malleolus through a posterolateral approach. MATERIALS AND METHODS Thirty-six patients with an ankle fracture including a posterior malleolar fragment (23 × AO-44C, 12 × AO-44B, 1 × unclassifiable) treated with direct fixation of the fragment through a posterolateral approach were retrospectively evaluated. There were 24 females (67%) with a mean age of 63 (range 34-80) years and a BMI of 28 (range 19-41) kg/m2 at the time of surgery. An initial fracture-dislocation was seen in 67%. The clinical outcome was assessed with the Visual Analog Scale (VAS, 0-10 points) and the American Foot and Ankle Society (AOFAS, 0-100 points) score. Posttraumatic osteoarthritis was recorded with the Van Dijk Classification (grade 0-III). Subgroup analyses of patient- and fracture-associated risk factors (age, BMI, smoking, fracture-dislocation, postoperative articular step-off) were assessed to reveal possible negative prognostic predictors. RESULTS After a mean follow-up of 7.9 (range 3-12) years, the median VAS was 1 (IQR 0-2) point, and the median AOFAS score was 96 (IQR 88-100) points. Ankle range of motion measurements showed a significant, but clinically irrelevant, difference in plantar- and dorsiflexion between the affected and unaffected ankle. 92% of the patients were very satisfied or satisfied with the postoperative course. 89% had no preoperative signs of ankle osteoarthritis. Osteoarthritis progression was seen in 72%, with 50% showing grade II or III osteoarthritis at the final follow-up. No significant negative prognostic factors for a worse clinical outcome could be detected. CONCLUSION Direct fixation of posterior malleolar fractures through a posterolateral approach showed good clinical mid- to long-term results with a high satisfaction rate but substantial development of posttraumatic ankle osteoarthritis. Further studies should include CT analysis of the preoperative fracture morphology and even, perhaps, the postoperative reduction accuracy to evaluate the benefit of posterior malleolar fracture reduction in preventing ankle osteoarthritis in the long term. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for authors for a complete description of levels of evidence.
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Affiliation(s)
- Lizzy Weigelt
- Department of Orthopaedics and Traumatology, Bürgerspital Solothurn, Solothurn, Switzerland.
- Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - Julian Hasler
- Department of Orthopaedics and Traumatology, Bürgerspital Solothurn, Solothurn, Switzerland
| | - Andreas Flury
- Department of Orthopaedics and Traumatology, Bürgerspital Solothurn, Solothurn, Switzerland
| | - Dimitris Dimitriou
- Department of Orthopaedics and Traumatology, Bürgerspital Solothurn, Solothurn, Switzerland
| | - Naeder Helmy
- Department of Orthopaedics and Traumatology, Bürgerspital Solothurn, Solothurn, Switzerland
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Abstract
AIMS The primary aim of this study was to address the hypothesis that fracture morphology might be more important than posterior malleolar fragment size in rotational type posterior malleolar ankle fractures (PMAFs). The secondary aim was to identify clinically important predictors of outcome for each respective PMAF-type, to challenge the current dogma that surgical decision-making should be based on fragment size. METHODS This observational prospective cohort study included 70 patients with operatively treated rotational type PMAFs, respectively: 23 Haraguchi Type I (large posterolateral-oblique), 22 Type II (two-part posterolateral and posteromedial), and 25 (avulsion-) Type III. There was no standardized protocol on how to address the PMAFs and CT-imaging was used to classify fracture morphology and quality of postoperative syndesmotic reduction. Quantitative 3D-CT (Q3DCT) was used to assess the quality of fracture reduction, respectively: the proportion of articular involvement; residual intra-articular: gap, step-off, and 3D-displacement; and residual gap and step-off at the fibular notch. These predictors were correlated with the Foot and Ankle Outcome Score (FAOS) at two-years follow-up. RESULTS Bivariate analyses revealed that fracture morphology (p = 0.039) as well as fragment size (p = 0.007) were significantly associated with the FAOS. However, in multivariate analyses, fracture morphology (p = 0.001) (but not fragment size (p = 0.432)) and the residual intra-articular gap(s) (p = 0.009) were significantly associated. Haraguchi Type-II PMAFs had poorer FAOS scores compared with Types I and III. Multivariate analyses identified the following independent predictors: step-off in Type I; none of the Q3DCT-measurements in Type II, and quality of syndesmotic reduction in small-avulsion Type III PMAFs. CONCLUSION PMAFs are three separate entities based on fracture morphology, with different predictors of outcome for each PMAF type. The current debate on whether or not to fix PMAFs needs to be refined to determine which morphological subtype benefits from fixation. In PMAFs, fracture morphology should guide treatment instead of fragment size. Cite this article: Bone Joint J 2020;102-B(9):1229-1241.
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Affiliation(s)
- Robin P Blom
- Department of Orthopaedic Surgery, Amsterdam UMC, Amsterdam, Netherlands.,Amsterdam Movement Sciences, Amsterdam, Netherlands
| | - Batur Hayat
- Department of Orthopaedic Surgery, Amsterdam UMC, Amsterdam, Netherlands
| | - Rami M A Al-Dirini
- College of Science and Engineering, Flinders University, Adelaide, Australia
| | - Inger Sierevelt
- Specialized Center of Orthopaedic Research and Education (SCORE), Amsterdam, Netherlands
| | - Gino M M J Kerkhoffs
- Department of Orthopaedic Surgery, Amsterdam UMC, Amsterdam, Netherlands.,University of Amsterdam, Amsterdam, Netherlands.,Academic Centre for Evidence based Sports medicine (ACES), Amsterdam, Netherlands.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), Amsterdam, Netherlands.,IOC Research Centre, Amsterdam, Netherlands
| | - J Carel Goslings
- University of Amsterdam, Amsterdam, Netherlands.,Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Ruurd L Jaarsma
- Department of Orthopaedic Surgery, Flinders Medical Centre, Adelaide, Australia.,Flinders University, Adelaide, Australia
| | - Job N Doornberg
- Department of Orthopaedic Surgery, Amsterdam UMC, Amsterdam, Netherlands.,Flinders Medical Centre, Adelaide Australia
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He JQ, Ma XL, Xin JY, Cao HB, Li N, Sun ZH, Wang GX, Fu X, Zhao B, Hu FK. Pathoanatomy and Injury Mechanism of Typical Maisonneuve Fracture. Orthop Surg 2020; 12:1644-1651. [PMID: 32896104 PMCID: PMC7767678 DOI: 10.1111/os.12733] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/22/2020] [Accepted: 06/01/2020] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE Maisonneuve fracture is a special type of injury which are rare in clinic. The manifestation of such fractures is variable. The aim of this study is to describe the pathoanatomical features of typical Maisonneuve fracture on the basis of radiographs, computed tomography (CT) scans, magnetic resonance imaging (MRI), and intraoperative exploration findings, and to investigate the injury mechanism of this variety. METHODS The data of 41 patients with Maisonneuve fracture from April 2014 to September 2019 were retrospectively analyzed. There were 32 males and nine females, the average age was 37.9 years (range, 18 to 61 years), the fractures occurred on the left side in 20 patients and on the right side in 21 patients. The cause of injuries were traffic accident in five patients, sprain injury in 20 patients, and falling injury from height in 16 patients. All patients underwent posteroanterior and lateral X-ray examinations of the ankle and calf. CT scan of the ankle was performed in 38 patients, including three-dimensional reconstruction in 33 patients. MRI examination of the ankle and calf was performed in 28 and five patients, respectively. Forty patients were treated with open reduction and internal fixation. The features of proximal fibular fracture, injuries of the medial and posterior structures of the ankle, injuries of the anterior inferior tibiofibular ligament and the interosseous membrane were recorded and analyzed. RESULTS Forty-one patients had proximal one-third fractures of the fibula including six patients with fracture involving the fibular neck, 30 with proximal one-third fractures of the fibular shaft, and five with proximal-medial one-third junction fracture of the fibular shaft. Thirty-five patients (35/41, 85.37%) with injury of posterior structures, 34 patients had posterior malleolar fracture (34/41, 82.93%), and one patient had posterior inferior tibiofibular ligament rupture (1/41, 2.44%). There were 20 patients with type I fracture, four patients with type II fracture, and 10 patients with type III fracture according to the Haraguchi classification of posterior malleolus fracture. The fracture of the medial malleolus was in 30 patients (30/41, 73.17%), rupture of the deltoid ligament was in 10 patients (10/41, 24.39%), and medial structures intact were in one patient (1/41, 2.44%). All 41 patients had injury of the anterior inferior tibiofibular ligament. CONCLUSIONS Maisonneuve fracture is characterized by fractures of the proximal fibula and the complete rupture of the anterior inferior tibiofibular ligament. Pronation-external rotation is the main injury mechanism. The manifestations of typical Maisonneuve fracture including that the fibular fracture located in proximal one-third diaphysis and the fracture line was from anterosuperior to posteroinferior.
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Affiliation(s)
- Jin-Quan He
- The First Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, China
| | - Xin-Long Ma
- The First Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, China
| | - Jing-Yi Xin
- The First Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, China
| | - Hong-Bin Cao
- The First Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, China
| | - Nan Li
- The First Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, China
| | - Zhen-Hui Sun
- The First Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, China
| | - Gui-Xin Wang
- The First Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, China
| | - Xin Fu
- The First Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, China
| | - Bin Zhao
- The First Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, China
| | - Fang-Ke Hu
- The First Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, China
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Sheikh HQ, Mills EJ, McGregor-Riley JC, Chadwick C, Davies MB. The effect of computerised tomography on operative planning in posterior malleolus ankle fractures. Foot Ankle Surg 2020; 26:676-680. [PMID: 31515200 DOI: 10.1016/j.fas.2019.08.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 08/07/2019] [Accepted: 08/19/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim of this project was to analyse whether a CT influences surgical planning in ankle fracture involving the posterior malleolus. METHODS Twenty consecutive patients with fractures involving the posterior malleolus were retrospectively selected and had their plain radiographs and CT scan anonymised. Initially, radiographs alone were presented to nine trauma surgeons to formulate a surgical plan individually. After a minimum of 6 weeks, the same process was repeated with CT scans available. RESULTS The surgical approach for ankle fracture fixation changed in 32.7% of cases following CT scan review. A CT scan altered the decision to stabilise the posterior malleolus in 25.6% and the decision of whether to stabilise the syndesmosis in 16.6% of cases. CONCLUSIONS This study demonstrates that a pre-operative CT scan changes the surgical approach in 32.7% of cases and therefore we recommend use of CT scanning in this subset of ankle injuries.
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Affiliation(s)
- Hassaan Q Sheikh
- Trauma and Orthopaedic Unit, Sheffield Teaching Hospitals, Herries Road, Sheffield, S5 7AU, United Kingdom.
| | - Edward J Mills
- Trauma and Orthopaedic Unit, Sheffield Teaching Hospitals, Herries Road, Sheffield, S5 7AU, United Kingdom.
| | - Jonathan C McGregor-Riley
- Trauma and Orthopaedic Unit, Sheffield Teaching Hospitals, Herries Road, Sheffield, S5 7AU, United Kingdom.
| | - Carolyn Chadwick
- Trauma and Orthopaedic Unit, Sheffield Teaching Hospitals, Herries Road, Sheffield, S5 7AU, United Kingdom.
| | - Mark B Davies
- Trauma and Orthopaedic Unit, Sheffield Teaching Hospitals, Herries Road, Sheffield, S5 7AU, United Kingdom.
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Abstract
AIM The aim of this study was to determine the most appropriate approaches for fixation of each type and fragment of posterior malleolar fractures. MATERIALS AND METHODS A retrospective analysis of a prospectively collected database was performed on 141 posterior malleolar fractures. On the CT scan axial slice, a clock face was drawn using the posterolateral corner of the tibia as the centre and the Achilles tendon as the 6 o'clock axis. A box was then drawn from the fracture plane, with 90-degree lines corresponding to the medial perpendicular line (MPL) and lateral perpendicular line (LPL) extremity of the fracture and a central perpendicular line (CPL) (i.e. orthogonal central plane, for optimum screw placement). It was recorded where the MPL, LPL and CPL exited the clock face. All fracture patterns were further assessed by both senior authors regarding their choice of approach based on CPL and all variances resolved by discussion. RESULTS The LPL was equivalent across the groups (except for the 2B medial fragments), indicating a consistent posterolateral corner fragment throughout the posterior malleolar sub types (p = 0.25). The medial aspect (MPL) of the type 1, type 2A and posterolateral fragments of type 2B were equivalent. The MPL of type 3 fractures was significantly more medial than type 1 and 2A fractures (p < 0.05), with the medial extremes of the type 2B posteromedial fragment being further medial. The majority of type 2B fractures (2/3rds) were determined to be best accessed through a combined posterolateral and medial posteromedial approach, with the other third via the posteromedial approach. Almost all type 3 fractures could be appropriately accessed through the PM approach. CONCLUSION This study concludes that the extent of each subtype of posterior malleolar fractures are consistent. To fully expose each fracture differing incisions are necessary and should be in the skill mix for surgeons treating these fractures. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Surya Gandham
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Graham Millward
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Andrew P Molloy
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK; University of Liverpool, Liverpool, UK
| | - Lyndon W Mason
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK; University of Liverpool, Liverpool, UK.
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McHale S, Williams M, Ball T. Retrospective cohort study of operatively treated ankle fractures involving the posterior malleolus. Foot Ankle Surg 2020; 26:138-145. [PMID: 30709682 DOI: 10.1016/j.fas.2019.01.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 11/20/2018] [Accepted: 01/02/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Direct fixation of the posterior malleolus through a posterolateral approach is increasing in popularity. However, data is limited, and no studies have stratified results by posterior malleolus size. METHODS A retrospective cohort study of patients with posterior malleolus (PM) fractures undergoing internal fixation over an 18-month period was conducted. Radiographic and patient reported outcomes measures (PROMs) were assessed. 75 patients were included, and 31 returned Manchester-Oxford Foot and Ankle (MOXFQ), EQ-5D-3 L, 5-point Likert satisfaction questionnaires. Mean age was 56.2 years, 68% were female, mean ASA was 1.72, 6.7% were diabetic, and average surgical time was 75.7 min (±40.9). RESULTS Overall, the MOXFQ summary score was 26.9 (±25.8), with the pain domain showing the most severe score 32.4 (±24.0). The EQ-5D VAS index was 0.75 (±0.24). Larger PM size was associated with more anatomical reduction (58.8%, n = 20 of <10% vs. 90.9%, n = 10 of >30%) and larger sized fragments were more likely to be fixed posteriorly. Best PROMs were observed in PM fragments <10%, and the worst in fragments 10-20%. A tendency towards more secondary surgery was observed with posterior subluxation 21.9% (n = 7) vs. 7.0% (n = 3) (p = 0.06). CONCLUSIONS Patients with fragments >10% have an intra-articular injury. We recommend direct anatomic reduction and rigid internal fixation. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Stephen McHale
- Department of Trauma and Orthopaedics, Torbay and South Devon NHS Foundation Trust, Torbay Hospital, Torquay, TQ2 7AA, UK.
| | - Mark Williams
- Department of Trauma and Orthopaedics, Torbay and South Devon NHS Foundation Trust, Torbay Hospital, Torquay, TQ2 7AA, UK
| | - Thomas Ball
- Department of Trauma and Orthopaedics, Torbay and South Devon NHS Foundation Trust, Torbay Hospital, Torquay, TQ2 7AA, UK
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Tuček M, Rammelt S, Kostlivý K, Bartoníček J. CT controlled results of direct reduction and fixation of posterior malleolus in ankle fractures. Eur J Trauma Emerg Surg 2020; 47:913-920. [PMID: 32008051 DOI: 10.1007/s00068-020-01309-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 01/20/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE The aim of this study was to present outcomes of operative treatment of the posterior malleolus fractures of type four of the Bartoníček/Rammelt classification. METHODS In 19 patients, direct reduction and fixation of the posterior malleolus was performed from the posterolateral or posteromedial approaches. The accuracy of reduction was assessed with the use of postoperative CT scans. RESULTS The mean size of the avulsed articular surface carried by posterior malleolus amounted to 36%. Reduction of the posterior malleolus fracture was assessed as anatomical in 14 cases and as satisfactory in five cases. Position of the distal fibula was assessed as anatomical in 15 cases. The mean AOFAS score was 89.4 points. All nine patients with anatomical reduction of all lesions achieved the mean AOFAS score of 93.1 points, five patients with malposition of posterior malleolus 89.1 points and five patients with malposition of the fibula in the fibular notch 87.8 points. A total of six patients developed osteoarthritic changes of grades one and two according to the Kellgren and Lawrence classification. CONCLUSIONS Outcomes of the study demonstrated good mid-term results in type four fractures of the posterior malleolus treated by direct reduction from posterior approaches. Postoperative CT examination allowed evaluation of the accuracy of reduction of all fractures and reduction of the distal fibula into the fibular notch. Based on postoperative CT examination, it will be possible to assess the effect of reduction of individual lesions on the functional results.
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Affiliation(s)
- Michal Tuček
- Department of Orthopaedics, First Faculty of Medicine, Charles University and Military University Hospital Prague, U Vojenské Nemocnice 1200, 169 02, Prague 6, Czech Republic.
| | - Stefan Rammelt
- University Center of Orthopedics and Traumatology, University Hospital Carl Gustav Carus Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Karel Kostlivý
- Surgical Department, Thomayer's Hospital, First Faculty of Medicine, Charles University, Vídeňská 800, 140 59, Prague 4, Czech Republic
| | - Jan Bartoníček
- Department of Orthopaedics, First Faculty of Medicine, Charles University and Military University Hospital Prague, U Vojenské Nemocnice 1200, 169 02, Prague 6, Czech Republic
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Kostlivý K, Bartoníček J, Rammelt S. Posterior malleolus fractures in Bosworth fracture-dislocations. A combination not to be missed. Injury 2020; 51:537-41. [PMID: 31703958 DOI: 10.1016/j.injury.2019.10.088] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 10/29/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Posterior malleolar fractures (PM) have been linked to inferior outcome in malleolar fractures. This study aims to analyze the prevalence and pathoanatomy of PM fractures in Bosworth fracture-dislocations (BF). MATERIALS & METHODS Radiographs and computed tomography (CT) scans of 13 patients treated at our institution and 97 cases published between 1947 and 2018, identified in a systematic literature search, were evaluated with respect to the pathoanatomy of BF. In all 13 cases from the present study and in 10 cases from the literature, axial CT scans were performed. RESULTS All 13 patients (100%) with BF from the present series and 61 of 97 documented cases (63%) of BF from the literature were associated with a PM fracture. In patients with a complete CT analysis, dislocation of the fibula behind the posterior tibial rim was associated with extraincisural (Bartoníček / Rammelt type 1) PM fractures. Displacement of the fibula between the displaced PM fragment and the tibia was associated with Bartoníček / Rammelt types 2 and 3 PM fractures. CONCLUSIONS Seventy prevent of all reported BF are associated with a PM fracture. The true prevalence may be even higher because of the historically infrequent use of CT imaging. The pathoanatomy of the PM fragment is highly variable as is the kind of fibular displacement in BF. Therefore, CT scanning should be performed routinely in BF. Displaced PM fractures in BF involving the incisura should be treated operatively via a direct posterolateral approach.
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Abstract
Posterior malleolus fractures and pilon variants refer to a pattern of fractures involving the posterior weightbearing surface of the tibial plafond. The surgical indications for fixation of posterior malleolus fractures varies considerably throughout the literature, based on the size and/or displacement. There is controversy on how to best address fracture fixation, with the main workhorses being either the posterior-lateral approach or indirect anterior-posterior-directed screws. We present an alternative technique for posterior malleolus fracture fixation using a direct posterior arthroscopic-assisted reduction internal fixation method. With this method, posterior malleolus fractures are reduced arthroscopically and percutaneous fixation is placed through the arthroscopic portals. Level of Evidence: Level V, expert opinion.
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Won Y, Lee GS, Hwang JM, Park IY, Song JH, Kang C, Hwang DS. Improved functional outcome after early reduction in Bosworth fracture-dislocation. Foot Ankle Surg 2019; 25:798-803. [PMID: 30578159 DOI: 10.1016/j.fas.2018.10.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 10/04/2018] [Accepted: 10/16/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Bosworth described an unusual fracture-dislocation of the ankle with fixed posterior fracture-dislocation of the fibula. Previous epidemiological data on the prevalence and characteristics of patients with Bosworth ankle fractures have been limited. Bosworth fracture-dislocations are often missed in patients with ankle fractures. We investigated the outcomes of missed diagnosis and the prevalence of Bosworth fracture-dislocation in patients with ankle fractures. METHODS We conducted a retrospective analysis of inpatients aged 15 years and older with an ankle fracture, who underwent surgery between 2007 and 2016 in 4 Korean hospitals. The patient demographics, risk factors, fracture characteristics, treatment data, outcomes, and complications were analyzed. RESULTS We reviewed 3405 hospital admissions for ankle fractures. During the study period, Bosworth fracture-dislocations were diagnosed in 51 cases. The prevalence of Bosworth fracture-dislocations (n=51) was 1.62% among patients with ankle fractures who were enrolled in this study (n=3140). Emergency surgery was performed within 24h of injury in 36 cases (group A) and delayed surgery was performed in 15 cases (group B). The mean patient age at admission was 35.97 (standard deviation [SD], 1.643) years in group A and 34.33 (SD, 2.296) years in group B. Men were more commonly affected than women, with a 32:19 ratio. Most of the patients with Bosworth fracture-dislocations were young adults with high-energy trauma. The most frequent mechanism of trauma was falling down stairs (n=27, 52.94%), followed by traffic accidents. Patient outcomes were significantly better in group A than in group B. CONCLUSION The prevalence of Bosworth fracture-dislocations was higher than expected. If unrecognized, it can result in inappropriate treatment and permanent disability. With accurate diagnosis and prompt treatment, excellent results can usually be obtained. LEVEL OF CLINICAL SIGNIFICANCE 4.
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Affiliation(s)
- Yougun Won
- Department of Orthopaedic Surgery, Chungnam National University School of Medicine, Korea; Department of Orthopedic Surgery, Konyang University College of Medicine, Korea
| | - Gi-Soo Lee
- Department of Orthopaedic Surgery, Chungnam National University School of Medicine, Korea.
| | - Jung-Mo Hwang
- Department of Orthopaedic Surgery, Chungnam National University School of Medicine, Korea
| | - Il-Young Park
- Department of Orthopaedic Surgery, Chungnam National University School of Medicine, Korea
| | - Jae-Hwang Song
- Department of Orthopaedic Surgery, Chungnam National University School of Medicine, Korea; Department of Orthopedic Surgery, Konyang University College of Medicine, Korea
| | - Chan Kang
- Department of Orthopaedic Surgery, Chungnam National University School of Medicine, Korea
| | - Deuk-Soo Hwang
- Department of Orthopaedic Surgery, Chungnam National University School of Medicine, Korea
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Abarquero-Diezhandino A, Luengo-Alonso G, Alonso-Tejero D, Sánchez-Morata EJ, Olaya-Gonzalez C, Vilá Y Rico J. Study of the relation between the posterior malleolus fracture and the development of osteoarthritis. Rev Esp Cir Ortop Traumatol (Engl Ed) 2019; 64:41-49. [PMID: 31676414 DOI: 10.1016/j.recot.2019.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 07/04/2019] [Accepted: 09/01/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND AIMS At least 10% of ankle fractures involve the posterior malleolus of the tibia, which has been related to poorer long-term prognosis. Our aim was to analyse the clinical and functional outcomes of ankle fractures involving the posterior edge, treated surgically without direct reduction of the third malleolus. MATERIAL AND METHODS We performed a retrospective study of 45 patients aged under 60, who we classified into three groups in terms of the percentage of joint involvement of the posterior fragment (<10%, 10%-25% and >25%) assessing the functional outcomes using the visual analogue pain scale (VAS), the AOFAS scale (American Orthopedic Foot and Ankle Society) of the ankle and hindfoot and the global health questionnaire SF-36; we also analysed the degree of osteoarthritis with weight-bearing radiography, at least one year following the injury. RESULTS The mean VAS pain score of the sample was 1.1 (0-5) at rest and 3 (0-8) on exercise; 88.4±10.1 on the AOFAS scale, and 68.5±19.3 points on the SF-36. Up to 18% of the patients developed radiographically significant osteoarthritis in the short and medium term (between 12 and 73months, with a mean of 33months). Of the patients, 55.6% had involvement of between 19% and 25% of the joint surface. We found that a larger posterior fragment size related to a greater degree of early-onset osteoarthritis (P<.03) and poorer AOFAS scores (P<.01). CONCLUSION Ankle fractures involving the posterior malleolus seem to contribute to the development of early-onset osteoarthritis with functional limitation in young adults.
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Affiliation(s)
- A Abarquero-Diezhandino
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, España.
| | - G Luengo-Alonso
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, España
| | - D Alonso-Tejero
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, España
| | - E J Sánchez-Morata
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, España
| | - C Olaya-Gonzalez
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, España
| | - J Vilá Y Rico
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, España; Universidad Complutense de Madrid, Madrid, España
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Testa G, Ganci M, Amico M, Papotto G, Giardina SMC, Sessa G, Pavone V. Negative prognostic factors in surgical treatment for trimalleolar fractures. Eur J Orthop Surg Traumatol 2019; 29:1325-1330. [PMID: 30968203 DOI: 10.1007/s00590-019-02430-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 04/02/2019] [Indexed: 12/30/2022]
Abstract
PURPOSE Trimalleolar fractures are a common injury of the ankle that require surgical treatment to obtain an anatomic reduction of both malleoli and stabilization of the syndesmosis. This study aims to report the outcomes of surgical treatment for trimalleolar fractures, identifying the risk factors determining a worse result. MATERIALS AND METHODS Between January 2013 and December 2016, 48 patients with trimalleolar fracture treated with open reduction and internal fixation were retrospectively analyzed. The mean age was 44.69 years, and average body mass index (BMI) was 29.04. According to the Danis-Weber classification, 30 (62.5%) fractures were type B and 18 (37.5%) were type C. Clinical and radiographic evaluations at 3, 6, and 12 months were assessed. The functional results of Visual Analogue Staircases and Olerud-Molander (O&M) ankle score were reported. RESULTS No significant difference was found among the size of the PM in patients with and without ankle dislocation (p = 0.364). Therefore, there is no correlation between the size of the posterior fragment and the ankle dislocation and the size of the posterior malleolus and syndesmosis stability (p = 0.328). Age over 61 years, BMI > 40, ASA > 1, type C fracture, and fracture dislocation were considered as negative prognostic fractures. CONCLUSIONS Surgical treatment for trimalleolar fractures needs accurate preoperative planning. Age over 61 years, BMI > 40, ASA > 1, type C fracture, and fracture dislocation were considered as negative prognostic fractures.
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Affiliation(s)
- Gianluca Testa
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, A.O.U. Policlinico - Vittorio Emanuele, University of Catania, Via Santa Sofia, 78, 95123, Catania, Italy.
| | - Marco Ganci
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, A.O.U. Policlinico - Vittorio Emanuele, University of Catania, Via Santa Sofia, 78, 95123, Catania, Italy
| | - Mirko Amico
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, A.O.U. Policlinico - Vittorio Emanuele, University of Catania, Via Santa Sofia, 78, 95123, Catania, Italy
| | - Giacomo Papotto
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, A.O.U. Policlinico - Vittorio Emanuele, University of Catania, Via Santa Sofia, 78, 95123, Catania, Italy
| | - Serena Maria Chiara Giardina
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, A.O.U. Policlinico - Vittorio Emanuele, University of Catania, Via Santa Sofia, 78, 95123, Catania, Italy
| | - Giuseppe Sessa
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, A.O.U. Policlinico - Vittorio Emanuele, University of Catania, Via Santa Sofia, 78, 95123, Catania, Italy
| | - Vito Pavone
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, A.O.U. Policlinico - Vittorio Emanuele, University of Catania, Via Santa Sofia, 78, 95123, Catania, Italy
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Baumbach SF, Herterich V, Damblemont A, Hieber F, Böcker W, Polzer H. Open reduction and internal fixation of the posterior malleolus fragment frequently restores syndesmotic stability. Injury 2019; 50:564-570. [PMID: 30600086 DOI: 10.1016/j.injury.2018.12.025] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 12/03/2018] [Accepted: 12/17/2018] [Indexed: 02/02/2023]
Abstract
AIM Comparison of unfixed, CRIF, and ORIF of the posterior malleolus fragment (PMF) regarding the frequency of trans-syndesmotic fixation and quality of reduction in trimalleolar (equivalent) fractures. MATERIAL AND METHODS Retrospective registry study. Patients with a trimalleolar (equivalent) ankle fractures were identified within the departments' fracture database. General demographics, treatment details, and fracture specific details (CT-scans) were assessed. Patients were grouped per the PMF treatment: not addressed, CRIF, ORIF. RESULTS 236 patients (53.0 ± 18.3 (range: 18-100) years), 58.1% female were eligible. The mean size of the PMF was 21.4 ± 10.4% (range: 2.7-55.9%), 71.6% were ≤25% of the tibial plafond. PMF fixation: Untreated 48.3%, CRIF 18.6%, ORIF 33.1%. ORIF of the PMF significantly (p < 0.001) reduced the frequency of trans-syndesmotic fixation (25%) compared to CRIF (61%) or untreated PMF (63%) with no significant influence of the PMF size (≤25%/>25%). ORIF resulted in a significantly (p < 0.001) better quality of reduction (1.2 ± 1.1 mm (range: 0-5 mm)) compared to CRIF (2.5 ± 2.1 mm (range: 0-8 mm)) and untreated PMF (2.5 ± 2.3 mm (range: 0-20 mm)). Neither the frequency of trans-syndesmotic fixation nor the quality of reduction differed significantly between untreated PMF and CRIF. CONCLUSION All posterior malleolus fragments, independent of their size, should be treated by ORIF, as this restores syndesmotic stability significantly more often than untreated PMF or CRIF.
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Affiliation(s)
- S F Baumbach
- University Hospital, LMU Munich, Department of General, Trauma and Reconstructive Surgery, Nussbaumstr. 20, 80336 Munich, Germany
| | - V Herterich
- University Hospital, LMU Munich, Department of General, Trauma and Reconstructive Surgery, Nussbaumstr. 20, 80336 Munich, Germany
| | - A Damblemont
- University Hospital, LMU Munich, Department of General, Trauma and Reconstructive Surgery, Nussbaumstr. 20, 80336 Munich, Germany
| | - F Hieber
- University Hospital, LMU Munich, Department of General, Trauma and Reconstructive Surgery, Nussbaumstr. 20, 80336 Munich, Germany
| | - W Böcker
- University Hospital, LMU Munich, Department of General, Trauma and Reconstructive Surgery, Nussbaumstr. 20, 80336 Munich, Germany
| | - H Polzer
- University Hospital, LMU Munich, Department of General, Trauma and Reconstructive Surgery, Nussbaumstr. 20, 80336 Munich, Germany.
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Abstract
The diagnosis and treatment of ankle fractures has evolved considerably over the past two decades. Recent topics of interest have included indications for operative treatment of isolated lateral malleolus fractures, need for fixation of the posterior malleolus, utilization of the posterolateral approach, treatment of the syndesmosis, and the potential role of fibular nailing. In this update, we concisely review these topics and what to expect in the future literature.
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Affiliation(s)
- Matthew J Toth
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJ Barnabas Health, Jersey City, NJ, United States
| | - Richard S Yoon
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJ Barnabas Health, Jersey City, NJ, United States
| | - Frank A Liporace
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJ Barnabas Health, Jersey City, NJ, United States
| | - Kenneth J Koval
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJ Barnabas Health, Jersey City, NJ, United States.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Hoekstra H, Rosseels W, Rammelt S, Nijs S. Direct fixation of fractures of the posterior pilon via a posteromedial approach. Injury 2017; 48:1269-74. [PMID: 28336099 DOI: 10.1016/j.injury.2017.03.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Revised: 03/01/2017] [Accepted: 03/15/2017] [Indexed: 02/02/2023]
Abstract
The treatment of fractures of the posterior pilon is a timely issue. Restoration of the integrity of the incisura fibularis and subsequent anatomic reduction of the fibula are essential for reconstruction of the ankle mortise after trauma, and syndesmotic stability. Inappropriate treatment ultimately will lead to a poor functional outcome and quality of life. Open reduction and direct internal fixation through a posterolateral or posteromedial approach are increasingly preferred over indirect reduction and anteroposterior screw fixation. The posteromedial approach, although elegant, straightforward, and offering an excellent exposure of the fracture site, is used less frequently than the posterolateral approach. In this technical note we describe the posteromedial approach for the treatment of posterior pilon fractures in a step-by-step fashion. We will discuss the indications, its benefits and limitations.
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44
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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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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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