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Xie RZ, Li XS, Wei-Qiang Zhao, Liang YF, Huang JF. Fluoroscopic visualization in ankle surgery: Evaluating the effects of lateral malleolus fixation order. J Foot Ankle Surg 2025:S1067-2516(25)00055-9. [PMID: 40054599 DOI: 10.1053/j.jfas.2025.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2024] [Revised: 01/25/2025] [Accepted: 03/01/2025] [Indexed: 03/07/2025]
Abstract
Ankle fractures, particularly those involving the lateral and posterior malleolus, are complex injuries requiring careful surgical management. This study investigates how the sequence of lateral malleolus fixation affects the intraoperative visualization of the posterior malleolus fracture during fluoroscopy. A retrospective and prospective approach was used, comparing outcomes in patients who underwent surgery for combined lateral and posterior malleolar fractures. In the retrospective group, lateral malleolus fixation with a plate often obstructed fluoroscopic visualization of the posterior malleolus, complicating fracture reduction. The prospective group was adjusted to prioritize posterior malleolar fracture visualization before lateral malleolus fixation, using temporary Kirschner wires if necessary. The study aimed to determine if the initial fixation strategy influenced surgical outcomes, including fracture healing and functional recovery. Results showed that for fractures involving the visible posterior malleolar area, no significant differences in outcomes were observed between the two groups. However, for fractures extending into the obstructed region, the prospective approach provided clearer visualization, potentially leading to more accurate reduction and fixation. This study concludes that the appropriate fixation strategy should be based on the extent of the posterior malleolar fracture. For fractures involving the visible area, traditional fixation of the lateral malleolus can be used. For those involving the obstructed area, a more cautious approach with temporary fixation or prior reduction of the posterior malleolus is recommended. This study emphasizes the importance of preoperative assessment to guide surgical planning and optimize patient outcomes.
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Affiliation(s)
- Rong-Zhen Xie
- Department of Orthopaedics & Traumatology, The First Affiliated Hospital of Zhejiang Chinese Medical University, 54 Youdian Road, Shangcheng District, Hangzhou, 310006, PR China; The First Clinical College, Zhejiang Chinese Medical University, Hangzhou, 310006, Zhejiang, PR China
| | - Xu-Song Li
- Department of Orthopaedics and Traumatology, Zhongshan Hospital of Traditional Chinese Medicine, Zhongshan, 528401, Guangdong, PR China
| | - Wei-Qiang Zhao
- Department of Orthopaedics & Traumatology, The First Affiliated Hospital of Zhejiang Chinese Medical University, 54 Youdian Road, Shangcheng District, Hangzhou, 310006, PR China; The First Clinical College, Zhejiang Chinese Medical University, Hangzhou, 310006, Zhejiang, PR China
| | - Yu-Feng Liang
- Department of Orthopaedics & Traumatology, The First Affiliated Hospital of Zhejiang Chinese Medical University, 54 Youdian Road, Shangcheng District, Hangzhou, 310006, PR China; The First Clinical College, Zhejiang Chinese Medical University, Hangzhou, 310006, Zhejiang, PR China
| | - Jie-Feng Huang
- Department of Orthopaedics & Traumatology, The First Affiliated Hospital of Zhejiang Chinese Medical University, 54 Youdian Road, Shangcheng District, Hangzhou, 310006, PR China; The First Clinical College, Zhejiang Chinese Medical University, Hangzhou, 310006, Zhejiang, PR China.
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Lambert LA, Stringer H, Weigelt L, Duncan L, Cowen J, Mason L. 2B or not 2B, should this not be the question? Comparison of 3D Surface Rendering CT to Plain Radiographs for Characterization of Posterior Malleolar Fracture Morphology. FOOT & ANKLE ORTHOPAEDICS 2025; 10:24730114241311879. [PMID: 40092621 PMCID: PMC11909655 DOI: 10.1177/24730114241311879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2025] Open
Abstract
Background The aim of this study was to compare plain lateral radiographs and 3D surface rendering (SR) CT imaging, in the characterization of posterior malleolar fracture (PMF) morphology using the Mason and Molloy classification. The null hypothesis was that there was no difference in characterization of morphology between plain radiographs and 3D SR CT. Methods Morphology of the PMF was categorized initially by the CT scan as classified by Mason and Molloy on 180 trimalleolar ankle fractures. PM fracture fragment size on the lateral radiograph were compared to their respective 3D surface rendering CT reconstructions, by two independent observers. Morphology of the PMF was assessed using all preoperative radiographs as compared to 3D SR CT. Results On comparison of fracture fragment morphology, all fractures had poor categorization by plain radiographs although rotational pilon fractures (type 2A and 2B fractures) had the worse sensitivity and specificity (below 33% and below 50%, respectively). Radiographs underestimated joint involvement in type 2B fracture patterns because of the underappreciation of the posteromedial fragment. Conclusion This study shows that the use of plain radiographs to categorize morphology of PMFs is poor. The study adds to the ever-growing body of evidence on the inaccuracy of using plain radiographs in PMFs to plan treatment. Additional CT imaging is imperative to allow for appropriate treatment planning in the management of PMF. Smaller fracture fragments are more susceptible to inaccuracies, especially the rotational pilon subtypes (2A and 2B) because of the obliquity of the posteromedial fragment to the plane of the X-ray source. Level of Evidence Level III, retrospective comparative study.
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Affiliation(s)
- Laura-Ann Lambert
- Trauma and Orthopaedic Department, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Howard Stringer
- Trauma and Orthopaedic Department, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
- University of Liverpool, Liverpool, United Kingdom
| | - Lizzy Weigelt
- Trauma and Orthopaedic Department, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
- Trauma and Orthopaedic Department, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Lois Duncan
- University of Liverpool, Liverpool, United Kingdom
| | - Jake Cowen
- Trauma and Orthopaedic Department, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Lyndon Mason
- Trauma and Orthopaedic Department, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
- University of Liverpool, Liverpool, United Kingdom
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Thomas A, Fredette R, Han G, Curtin P, Swart E. Can Lateral X-Rays Reliably Determine Which Posterior Malleolus Ankle Fractures Need a CT? Foot Ankle Spec 2024; 17:585-591. [PMID: 36217982 DOI: 10.1177/19386400221128159] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND For rotational ankle fractures with a posterior malleolus fracture (PMF), the decision to further evaluate the ankle injury with computed tomography (CT) is challenging. The objective of this study is to determine how well PMF fracture size on x-rays correlates with size on CT, and how well x-rays can predict which patients receive PMF fixation after CT review. METHODS This is a retrospective study of adult ankle fractures with PMFs that had preoperative radiographs and CT imaging over a 5-year period. PMF x-ray and CT measurements were recorded, and relationships between x-ray measurements and final PMF fixation plan after CT review were evaluated. RESULTS A total of 98 patients were identified with both x-rays and preoperative CT imaging. Pearson's rank correlation demonstrated a strong relation between PMF width percentage measured on x-ray and CT (r = 0.724). Of the 45 patients with a PMF size under 20% on x-ray, only one patient (with an apparent incarcerated fragment) underwent PMF fixation after review of the CT. CONCLUSIONS PMF width on lateral x-ray correlates well with CT size and is sensitive for predicting the need for dedicated posterior malleolus based on one institutional practice pattern. Below 20% fracture width on lateral x-ray, a dedicated CT rarely leads to a decision to perform PMF fixation. Limiting pre-operative CT to those with PMF width >20% could reduce CT utilization by as much as 45% without negatively affecting patient care. LEVELS OF EVIDENCE Level III: Diagnostic.
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Affiliation(s)
- Ayush Thomas
- Department of Orthopaedic Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Ryan Fredette
- Department of Orthopaedic Surgery, University of Massachusetts, Worcester, Massachusetts
| | - George Han
- Department of Orthopaedic Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Patrick Curtin
- Department of Orthopaedic Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Eric Swart
- Department of Orthopaedic Surgery, Lahey Hospital & Medical Center, Burlington, Massachusetts
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Simske NM, Kotchman H, Pennacchio C, Dorney I, Vallier HA. Frequent Sural Nerve Injury with Posterior Approach for Ankle Fracture Fixation. J Am Acad Orthop Surg 2024; 32:747-753. [PMID: 38723261 DOI: 10.5435/jaaos-d-23-00577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/28/2023] [Indexed: 08/03/2024] Open
Abstract
INTRODUCTION The purpose of this study was to report the incidence of iatrogenic sural nerve injury in a large, consecutive sample of surgically managed ankle fractures and to identify factors associated with sural nerve injury and subsequent recovery. We hypothesize that a direct posterior approach may be associated with higher risk of iatrogenic sural nerve injury. METHODS A retrospective cohort study of 265 skeletally mature patients who sustained ankle fractures over a 2-year period was done. All were treated with open reduction and internal fixation of fractured malleoli. Patient, injury, and treatment features were documented. The presence (n = 26, 9.8%) of sural nerve injury and recovery of sural nerve function were noted. RESULTS All 26 sural nerve injuries were iatrogenic, occurring postoperatively after open reduction and internal fixation. Patients who sustained sural nerve injuries had more ankle fractures secondary to motor vehicle collisions (23.1% versus 9.2%), more associated trimalleolar fractures (69.2% versus 33.9%), and more Orthopaedic Trauma Association/AO 44B3 fractures (57.7% versus 25.1%), all P < 0.05. A posterior approach to the posterior malleolus through the prone position was used in 20.4% of patients. All 26 of the sural nerve injuries (100%) occurred when the patient was placed prone for a posterior approach, P < 0.001. Therefore, 26 of the 54 patients (48%) treated with a posterior approach sustained an iatrogenic sural nerve injury. 62% of patients had full recovery of sural nerve function with no residual numbness, and patients with nerve recovery had fewer associated fracture-dislocations (23.1% versus 100%, P = 0.003). CONCLUSIONS A posterior approach for posterior malleolus fixation was associated with a 48% iatrogenic sural nerve injury rate, with 62% recovering full function within 6 months of injury. Morbidity of this approach should be considered, and surgeons should be cautious with nerve handling. LEVEL OF EVIDENCE Level III, Therapeutic.
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Affiliation(s)
- Natasha M Simske
- From the MetroHealth Medical Center, affiliated with Case Western Reserve University, Cleveland, OH
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Chong LSL, Khademi M, Reddy KM, Anderson GH. Ten year outcomes after non-fixation of the smaller posterior malleolar fragment: A retrospective cohort study. Foot (Edinb) 2024; 59:102091. [PMID: 38513374 DOI: 10.1016/j.foot.2024.102091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 02/07/2024] [Accepted: 03/10/2024] [Indexed: 03/23/2024]
Abstract
INTRODUCTION Treatment of posterior malleolar (PM) ankle fractures remains controversial. Despite increasing recommendation for small PM fragment fixation, high quality evidence demonstrating improved clinical outcomes over the unfixated PM is limited. We describe the long term clinical and radiographical outcomes in younger adult patients with PM ankle fractures managed without PM fragment fixation. MATERIAL AND METHODS A retrospective cohort study was performed on PM ankle fracture patients aged 18-55 years old admitted under our orthopaedic unit between 1st of April 2009 and 31st of October 2013. Inclusion criteria were ASA 1 and 2, independent mobility pre-trauma, no pre-existing ankle pathologies, with satisfactory bimalleolar and syndesmotic stabilisation. Open fractures, talar fractures, calcaneal fractures, pilon fractures, subsequent re-injury and major complications were excluded. All PM fragments were unfixated. Clinical outcomes were evaluated using visual analogue scale (VAS) for pain, Foot and Ankle Ability Measure (FAAM) with activities of daily living (ADL) and sports subscale for function, and patient satisfaction ratings. Osteoarthritis was assessed using modified Kellgren-Lawrence scale on follow-up weightbearing ankle radiographs. RESULTS Sixty-one participants were included. Mean follow-up was 10.26 years. Average PM size was 16.2 ± 7.39%. All participants were evaluated for clinical outcomes. Mean score of FAAM-ADL was 95.5 ± 7.13, FAAM-Sports 86.4 ± 15.5, patient satisfaction 86.2 ± 14.4% and pain score 1.13 ± 1.65. Radiographical outcomes were evaluated in 52 participants, showing no-to-minimal osteoarthritis in 36/52 (69%), mild osteoarthritis in 14/52 (27%) and moderate osteoarthritis in 2/52 (4%). Pain and functional scores were independent of PM fragment size, post-reduction step-off, dislocation, malleoli fractured or syndesmotic injury. PM step-off more than 1 mm and traumatic dislocation/subluxation were associated with worse radiographical osteoarthritis. CONCLUSION After controlling for confounders, the unfixated smaller posterior malleolus fragment at 10-year follow-up demonstrated largely satisfactory clinical outcomes with some radiographical progression of osteoarthritis. LEVEL OF EVIDENCE Level III - Retrospective cohort study.
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Affiliation(s)
- Leo Swee Liang Chong
- Department of Orthopaedic Surgery, Palmerston North Hospital, Te Whatu Ora Te Pae Hauora o Ruahine o Tararua / Midcentral, New Zealand.
| | - MohammadAli Khademi
- Department of Orthopaedic Surgery, Palmerston North Hospital, Te Whatu Ora Te Pae Hauora o Ruahine o Tararua / Midcentral, New Zealand
| | - Kundam Murali Reddy
- Department of Orthopaedic Surgery, Palmerston North Hospital, Te Whatu Ora Te Pae Hauora o Ruahine o Tararua / Midcentral, New Zealand
| | - Geoffrey Hunter Anderson
- Department of Orthopaedic Surgery, Palmerston North Hospital, Te Whatu Ora Te Pae Hauora o Ruahine o Tararua / Midcentral, New Zealand
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Pollard JD, Krcal CE. Considerations with Fractures of the Posterior Malleolus in Ankle Fractures. Clin Podiatr Med Surg 2024; 41:103-117. [PMID: 37951669 DOI: 10.1016/j.cpm.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Foot and ankle surgeons are commonly confronted with the surgical dilemma on when and how to best surgically address trimalleolar ankle fractures with a posterior malleolar component. This may involve either direct fixation of the posterior malleolus or indirect stabilization with the fixation of the medial and lateral malleoli and trans-syndesmotic fixation. Recently there has been a paradigm shift in the management of these injuries with a more thorough understanding of anatomy, stability, and long-term sequela of these injuries. This article aims to evaluate the current literature on posterior malleolar ankle fractures, approaches to fixing the posterior malleolus, and outcomes and complications of these procedures.
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Affiliation(s)
- Jason D Pollard
- Department of Podiatric Surgery, Kaiser Permanente, 3600 Broadway, Suite 17, Oakland, CA 94611, USA.
| | - Craig E Krcal
- The CORE Institute, 18444 North 25th Avenue Suite 320, Phoenix, AZ 85023, USA; Graduate Kaiser San Francisco Bay Area Foot & Ankle Residency, 2023
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De Marchi Neto N, Nesello PFT, Bergamasco JM, Costa MT, Christian RW, Severino NR. Importance of computed tomography in posterior malleolar fractures: Added information to preoperative X-ray studies. World J Orthop 2023; 14:868-877. [PMID: 38173804 PMCID: PMC10758590 DOI: 10.5312/wjo.v14.i12.868] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/18/2023] [Accepted: 10/16/2023] [Indexed: 12/15/2023] Open
Abstract
BACKGROUND Ankle fractures are common lesions of the lower limbs. Approximately 40% of ankle fractures affect the posterior malleolus (PM). Historically, PM osteosynthesis was recommended when PM size in X-ray images was greater than 25% of the joint. Currently, computed tomography (CT) has been gaining traction in the preoperative evaluation of ankle fractures. AIM To elucidate the similarity in dimensions and to correlate PM size in X-ray images with the articular surface of the affected tibial plafond in the axial view on CT (AXCT) of a PM fracture. METHODS Eighty-one patients (mean age: 39.4 ± 13.5 years) were evaluated (54.3% were male). Two independent examiners measured PM size in profile X-ray images (PMXR) and sagittal CT (SAGCT) slices. The correlation of the measurements between the examiners and the difference in the PM fragment sizes between the two images were compared. Next, the PM size in PMXR was compared with the surface of the tibial plafond involved in the fracture in AXCT according to the Haraguchi classification. RESULTS The correlation rates between the examiners were 0.93 and 0.94 for PMXR and SAGCT, respectively (P < 0.001). Fragments were 2.12% larger in SAGCT than in PMXR (P = 0.018). In PMXR, there were 56 cases < 25% and 25 cases ≥ 25%. When PMXR was < 25%, AXCT corresponded to 10.13% of the tibial plafond. When PMXR was ≥ 25%, AXCT was 24.52% (P < 0.001). According to the Haraguchi classification, fracture types I and II had similar PMXR measurements that were greater than those of type III. When analyzing AXCT, a significant difference was found between the three types, with II > I > III (P < 0.001). CONCLUSION PM fractures show different sizes using X-ray or CT images. CT showed a larger PM in the sagittal plane and allowed the visualization of the real dimensions of the tibial plafond surface.
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Affiliation(s)
- Noé De Marchi Neto
- Department of Orthopedics and Traumatology of the São Paulo Mercy Hospital (Santa Casa de São Paulo)-Fernandinho Simonsen Pavillion, Faculdade de Ciências Médicas da Santa Casa de São Paulo-Brazil, São Paulo 01221-020, Brazil
| | - Pietro Felice Tomazini Nesello
- Department of Orthopedics and Traumatology of the São Paulo Mercy Hospital (Santa Casa de São Paulo)-Fernandinho Simonsen Pavillion, Faculdade de Ciências Médicas da Santa Casa de São Paulo-Brazil, São Paulo 01221-020, Brazil
| | - Jordanna Maria Bergamasco
- Department of Orthopedics and Traumatology of the São Paulo Mercy Hospital (Santa Casa de São Paulo)-Fernandinho Simonsen Pavillion, Faculdade de Ciências Médicas da Santa Casa de São Paulo-Brazil, São Paulo 01221-020, Brazil
| | - Marco Tulio Costa
- Department of Orthopedics and Traumatology of the São Paulo Mercy Hospital (Santa Casa de São Paulo)-Fernandinho Simonsen Pavillion, Faculdade de Ciências Médicas da Santa Casa de São Paulo-Brazil, São Paulo 01221-020, Brazil
| | - Ralph Walter Christian
- Department of Orthopedics and Traumatology of the São Paulo Mercy Hospital (Santa Casa de São Paulo)-Fernandinho Simonsen Pavillion, Faculdade de Ciências Médicas da Santa Casa de São Paulo-Brazil, São Paulo 01221-020, Brazil
| | - Nilson Roberto Severino
- Department of Orthopedics and Traumatology of the São Paulo Mercy Hospital (Santa Casa de São Paulo)-Fernandinho Simonsen Pavillion, Faculdade de Ciências Médicas da Santa Casa de São Paulo-Brazil, São Paulo 01221-020, Brazil
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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: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 09/30/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Complex ankle fractures frequently involve the posterior malleolus. Many classifications describing posterior malleolar fractures (PMF) exist. The aim of this study was to provide a systematic literature review to outline existing PMF classifications and estimate their accuracy. METHODS The databases PubMed and Scopus were searched without time limits. Only specific PMF classifications were included; general ankle and/or pilon fracture classifications were excluded. Selection and data extraction was performed by three independent observers. The systematic literature search was performed according to the current criteria of Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). The methodological quality of the included studies was quantified using the modified Coleman score. RESULTS A total of 110 studies with a total of 12.614 patients were included. Four main classifications were identified: Those describing the size of the posterior malleolar fracture (n = 66), Haraguchi (n = 44), Bartoníček/Rammelt (n = 21) and Mason (n = 12). The quality of the studies was moderate to good with a median Coleman-score of 43.5 (14-79) and a weighted median Coleman-score of 42.5 points. All classifications achieved a substantial to perfect score regarding the inter- and intraobserver reliability, with Mason scoring the lowest in comparison. CONCLUSIONS None of the reviewed PMF classifications has been able to establish itself decisively in the literature. Most of the classifications are insufficient in terms of a derivable treatment algorithm or a prognosis with regard to outcome. However, as the Bartoníček/Rammelt classification has the greatest potential due to its treatment algorithm, its reliability in combination with consistent predictive values, its usage in clinical practice and research appears advisable.
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Affiliation(s)
- Julia Terstegen
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Hanneke Weel
- Department of Orthopedics, Bergman Clinics, Arnhem, The Netherlands
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
- Department of Trauma Surgery, Orthopaedics, and Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany
| | - Tim Rolvien
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Carsten Schlickewei
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Elena Mueller
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
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Stake IK, Douglass BW, Husebye EE, Clanton TO. Methods for Biomechanical Testing of Posterior Malleolar Fractures in Ankle Fractures: A Scoping Review. Foot Ankle Int 2023; 44:348-362. [PMID: 36932661 DOI: 10.1177/10711007231156164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
Abstract
BACKGROUND The treatment of posterior malleolar fractures (PMFs) is debated, including the need for surgery and method of fixation. Recent literature has suggested that fracture pattern, rather than fragment size, may be an important predictor for ankle biomechanics and functional outcome. Biomechanical studies have been conducted to provide evidence-based treatment on the effects of fracture and fixation on contact pressure and stability. The objective of this scoping review is to summarize the methodologies used in biomechanical studies on PMFs and assess whether they are sufficient to test the need for surgery and method of fixation. METHODS A scoping review of publications before January 2022 was performed. PubMed/Medline and Embase Ovid were searched for cadaver or finite element analysis (FEA) studies that created and tested the effects of PMFs in ankle fractures. Both cadaver and FEA studies were included. Data about fragment characteristics, mode of testing, and outcomes were charted by 2 persons from the study group. The data were synthesized when possible and compared. RESULTS We included 25 biomechanical studies, including 19 cadaver studies, 5 FEA studies, and 1 cadaver and FEA study. Aside from the fragment size, few other fragment characteristics were reported. Mode of testing varied with different loads and foot positions. Strong conclusions on the effects of fracture and fixation on contact pressure and stability could not be made. CONCLUSION Biomechanical studies on PMFs demonstrate wide variability in fragment characteristics and mode of testing, which makes it difficult to compare studies and draw conclusions on the need for surgery and method of fixation. Additionally, limited reporting of fragment measurements questions the applicability to clinical practice. The biomechanical literature on PMFs would benefit from the use of a standard classification and universal fragment measurements to match clinical injuries in future biomechanical studies. Based on this review, we recommend the Mason classification, which addresses the pathomechanism, and use of the following fragment measurements in all 3 anatomic planes when creating and describing PMFs: fragment length ratio, axial angle, sagittal angle or fragment height, and interfragmentary angle. The testing protocol needs to reflect the purpose of the study. CLINICAL RELEVANCE This scoping review demonstrates wide methodological diversity of biomechanical studies. Consistency in methodology should enable comparison of study results, leading to stronger evidence-based recommendations to guide surgeons in decision making and offer PMF patients the best treatment.
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Affiliation(s)
- Ingrid K Stake
- Steadman Philippon Research Institute, Vail, CO, USA
- Department of Orthopaedic Surgery, Østfold Hospital Trust, Grålum, Norway
| | | | | | - Thomas O Clanton
- Steadman Philippon Research Institute, Vail, CO, USA
- The Steadman Clinic, Vail, CO, USA
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Variation in posterior fragment fixation in the Netherlands: a nationwide study. Eur J Trauma Emerg Surg 2023; 49:317-326. [PMID: 36018372 DOI: 10.1007/s00068-022-02066-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [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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Posterior Malleolar Fracture Assessment: An Independent Interobserver and Intraobserver Validation of Three Computed Tomography-Based Classifications. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202301000-00004. [PMID: 36622849 PMCID: PMC9831157 DOI: 10.5435/jaaosglobal-d-22-00258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/06/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Posterior malleolus fractures occur in up to 50% of all ankle fractures. Several classification systems exist for their characterization, especially under CT. However, those classifications do not report the level of agreement or do it incompletely. This study aims to independently assess three posterior malleolus fracture classifications (Haraguchi, Bartoníček/Rammelt, and Mason). METHODS This study was designed according to the Guidelines for Reporting Reliability and Agreement Studies. Ninety-four CT scans of patients with ankle fractures that had posterior malleolus fractures were included. Posterior malleolus fractures were assessed by six evaluators (three attending foot and ankle surgeons and three orthopaedic surgery residents) according to Haraguchi, Bartoníček/Rammelt, and Mason classifications. All images were reassessed by the same evaluators in a random sequence 3 weeks later. The kappa (k) coefficient was used to determine the interobserver and intraobserver agreement. Statistical significance was established using P < 0.05 with a 95% confidence interval (CI). RESULTS The interobserver agreement was moderate for Haraguchi, Bartoníček/Rammelt, and Mason classifications with a global k value of 0.52 (95% CI, 0.43 to 0.60), 0.53 (95% CI, 0.46 to 0.61), and 0.54 (95% CI, 0.47 to 0.62), respectively. The intraobserver agreement was substantial for Haraguchi, Bartoníček/Rammelt, and Mason classifications, with an overall k value of 0.70 (95% CI, 0.64 to 0.74), 0.73 (95% CI, 0.68 to 0.78), and 0.73 (95% CI, 0.69 to 0.78), respectively. Interobserver and intraobserver agreement among orthopaedic surgeons and residents had no significant difference. CONCLUSION The current classifications for posterior malleolus fractures showed a substantial intraobserver agreement. Nevertheless, the interobserver agreement obtained was just moderate for all classifications, independent of the level of expertise of the evaluators.
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Schiedo R, Jo J, Marin A, Fredette R, Thomas A, Siegel J, Swart E. What Is the Rate of Displacement of Occult Posterior Malleolus Fractures in Nailed Tibial Shaft Fractures? J Orthop Trauma 2022; 36:652-657. [PMID: 36399678 DOI: 10.1097/bot.0000000000002435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To describe the radiographic consequences of posterior malleolus fractures (PMF) present with tibial shaft fractures fixed with intramedullary nails. DESIGN Retrospective cohort study. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS Seven hundred thirty-three patients with tibial shaft fractures. INTERVENTION Intramedullary nail fixation and prophylactic articular fixation. MAIN OUTCOME MEASURE Displacement of PMF with intramedullary nail insertion. RESULTS Seven hundred thirty-three patients were identified with tibial shaft fractures treated with intramedullary nail fixation at a Level 1 trauma center without a uniform preoperative computed tomography protocol. One hundred thirty-three patients had an identifiable PMF appreciated on preoperative imaging. Of the 600 remaining patients without a known PMF, 29 had PMF identified after nail insertion: 24 patients with nondisplaced fractures that all healed radiographically at final follow-up, 3 patients had fractures <30% of the articular surface displaced 1-2 mm, and 2 patients had fractures >30% of the joint surface that displaced 1-2 mm. CONCLUSIONS The incidence of radiographically observable PMF associated with tibial shaft fractures is high, even without a preoperative computed tomography screening protocol in place. In patients without an appreciable PMF on injury films, less than 1% (2/600) had displacement of a large, clinically significant PMF with nail placement. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ryan Schiedo
- University of Massachusetts, Department of Orthopaedic Surgery, Worcester, MA
| | - Jacob Jo
- University of Massachusetts, Department of Orthopaedic Surgery, Worcester, MA
| | - Arden Marin
- University of Massachusetts, Department of Orthopaedic Surgery, Worcester, MA
| | - Ryan Fredette
- University of Massachusetts, Department of Orthopaedic Surgery, Worcester, MA
| | - Ayush Thomas
- University of Massachusetts, Department of Orthopaedic Surgery, Worcester, MA
| | - Jodi Siegel
- University of North Carolina, Department of Orthopaedic Surgery, Chapel Hill, NC; and
| | - Eric Swart
- Lahey Hospital and Medical Center, Department of Orthopaedic Surgery, Burlington, MA
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Myers DM, Kelley JA, Taylor BC, Umbel B, Buchan J, Melaragno A. The Intercalary Fragment in Posterior Malleolus Fractures: Characterization and Significance. J Foot Ankle Surg 2022; 61:1060-1064. [PMID: 35197223 DOI: 10.1053/j.jfas.2022.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 07/06/2021] [Accepted: 01/11/2022] [Indexed: 02/03/2023]
Abstract
Methods of fixation in ankle fractures involving the posterior malleolus have become increasingly scrutinized. With the increase in computed tomography (CT), an intercalary fracture fragment (ICF) adjacent to the posterior malleolus has been oft described. Treatment of the ICF remains controversial and the purpose of this study was to evaluate radiographic and clinical outcomes in patients who had direct reduction and fixation of this fragment compared to those where the ICF was not fixed. This retrospective study included 249 trimalleolar and posterior pilon ankle fractures grouped into those who had the ICF reduced and fixed (n = 74) and those where the ICF was not directly addressed (n = 175). CT scans were evaluated for size and location of the ICF. Demographic, radiographic and intraoperative variables were collected and analyzed. The group which had the ICF reduced and fixed had decreased Kellgren-Lawrence scores (p = .001). There was also a higher rate of repeat surgery in the group who had the ICF fixed, although not meeting statistical significance. There were no differences in size or location of the ICF fragment between groups. We did identify similarities with other studies in regard to size and posterolateral location of the ICF between groups. However, based on worsening radiographic outcomes of the group where the ICF was reduced and fixed, we do not necessarily recommend universal treatment of this fragment. The surgeon's goal should always be a concentric articular reduction and treatment of the ICF should be considered on a case-by-case basis.
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Affiliation(s)
- Devon M Myers
- Department of Orthopaedic Surgery, OhioHealth Grant Medical Center, Columbus, OH; Ohio University Heritage College of Osteopathic Medicine, Athens, OH.
| | - Justin A Kelley
- Department of Orthopaedic Surgery, OhioHealth Grant Medical Center, Columbus, OH; Ohio University Heritage College of Osteopathic Medicine, Athens, OH
| | - Benjamin C Taylor
- Department of Orthopaedic Surgery, OhioHealth Grant Medical Center, Columbus, OH; Ohio University Heritage College of Osteopathic Medicine, Athens, OH
| | - Benjamin Umbel
- Department of Orthopaedic Surgery, OhioHealth Grant Medical Center, Columbus, OH; Ohio University Heritage College of Osteopathic Medicine, Athens, OH
| | - John Buchan
- Department of Orthopaedic Surgery, OhioHealth Grant Medical Center, Columbus, OH; Ohio University Heritage College of Osteopathic Medicine, Athens, OH
| | - Anthony Melaragno
- Department of Orthopaedic Surgery, OhioHealth Grant Medical Center, Columbus, OH; Ohio University Heritage College of Osteopathic Medicine, Athens, OH
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Can we predict size, Haraguchi type and preoperative displacement of posterior malleolar fractures in association with tibial shaft fractures? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03327-7. [PMID: 35794425 DOI: 10.1007/s00590-022-03327-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 06/20/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE To (1) determine if any injury characteristics or radiographic parameters of tibial shaft fractures (TSFs) could predict posterior malleolar fracture (PMF) size, and (2) identify characteristics of PMFs that were fixed versus those that were not in a cohort of ipsilateral TSFs that underwent intramedullary nailing. METHODS A cross-sectional radiographic study was performed at a single academic institution. Demographic and radiographic parameters of TSFs were recorded, including fracture obliquity angle (FOA) and distance from distal extent of fracture to plafond (DFP). Using CT, the PMFs were evaluated for Haraguchi classification, size measurements, and preoperative displacement. Multivariate regression analysis was used to identify independent predictors of PMF Harachuchi classification, size parameters, and preoperative displacement. Univariate differences between PMF that were fixed and not fixed were identified. RESULTS 47 (50%) PMF underwent surgical fixation with 47 treated conservatively. There were no demographic differences between groups. Multivariate linear regression demonstrated increasing DFP and high energy injury mechanism as independent variables correlated with plafond surface area involvement, PMF height and width on sagittal CT cuts. Increasing DFP alone was correlated with PMF width on axial CT cuts and extent > 50% into incisura. Haraguchi type II fractures were associated with high energy injury mechanism (OR = 4.2 [95% CI = 1.3-14.5]; p = 0.02). Odds of Haraguchi type 3 fractures increased 9% per increased year of age (OR = 1.09 [95% CI = 1.04-1.16]; p = 0.006) and decreased 13% per 1% increase in relative DFP (OR = 0.87 [95% CI = 0.75-0.98]; p = 0.04). CONCLUSIONS An increasing DFP of TSFs and high energy injury mechanism were independent predictors of PMF size, and high energy injury mechanism was also correlated with Haraguchi type II fracture patterns. Increasing age and decreasing DFP of TSFs predict Haraguchi type III PMF patterns. These radiographic parameters should prompt surgeons to plan for fixation in scenarios in which CT scan is not available. LEVEL OF EVIDENCE Diagnostic Level III.
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Müller E, Terstegen J, Kleinertz H, Weel H, Frosch KH, Barg A, Schlickewei C. [Established classification systems of posterior malleolar fractures : A systematic literature review]. Unfallchirurg 2022; 126:387-398. [PMID: 35394158 PMCID: PMC10159979 DOI: 10.1007/s00113-022-01162-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Posterior malleolar fractures are found in almost 50% of all ankle fractures. The high clinical relevance of these joint fractures is explained by the significantly worse clinical and functional outcome. There is still a lack of unified opinion regarding the classification and treatment of these fractures. OBJECTIVE The aim of this article is to provide a systematic literature review of clinical studies that investigated posterior malleolar fractures and classified them using one of the three established classifications according to Haraguchi, Bartonicek/Rammelt, or Mason. MATERIAL AND METHODS PubMed was searched without time limits. 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 27 studies with a total of 2220 patients were included in this systematic literature review. Trimalleolar fractures showed a significantly less favorable prognosis than other ankle fractures. The quality of reduction was the most important prognostic factor for the clinical outcome. CONCLUSION None of the three classifications examined has become established in the literature. Most of the classifications are weak or should not be used with respect to a derivable treatment algorithm or a prognosis with respect to the outcome. Only the classification according to Bartonicek/Rammelt is suitable to become established in the literature and in clinical practice due to its derivable treatment algorithm.
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Affiliation(s)
- Elena Müller
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
| | - Julia Terstegen
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Holger Kleinertz
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Hanneke Weel
- Orthopedics Center, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Karl-Heinz Frosch
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
- Abteilung Unfallchirurgie, Orthopädie und Sporttraumatologie, BG Klinikum Hamburg, Hamburg, Deutschland
| | - Alexej Barg
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
- Abteilung Unfallchirurgie, Orthopädie und Sporttraumatologie, BG Klinikum Hamburg, Hamburg, Deutschland
- Orthopädische Universitätsklinik, Universität von Utah, Salt Lake City, UT, USA
| | - Carsten Schlickewei
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
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Comparison of routine computed tomography and plain X-ray imaging for malleolar fractures-How much do we miss? Foot Ankle Surg 2022; 28:263-268. [PMID: 33832814 DOI: 10.1016/j.fas.2021.03.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 03/27/2021] [Accepted: 03/30/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Most patients with ankle arthrosis have a history of ankle fracture. Evaluation of malleolar fractures solely on X-ray may be insufficient to identify many pathologies that potentially contribute to ankle arthrosis, with a consequent poor prognosis. We investigated the pathologies that may be overlooked in malleolar fractures evaluated solely on plain X-ray. METHODS During 2012-2019, 65,479 patients attended our Emergency Department, of which 6508 complained of an ankle joint problem. X-rays indicated a fracture in 454 of these patients. Patients with isolated, simple fracture of the lateral or medial malleolus, or talus, or a history of surgery to this area were excluded; finally, 67 patients were enrolled (31 males, 36 females; mean age: 51,2 years (range: 9-83 years). Patients underwent X-ray imaging of both ankles in anterio-posterior, lateral, and Mortise views, as well as CT scans. Three independent observers with varied experience in diagnostic imaging (orthopaedic resident, experienced orthopaedic surgeon, and musculoskeletal radiologist) evaluated X-ray images blinded to CT scans. Their diagnoses were subsequently compared with CT findings. RESULTS Modeling results indicated that about 40% [95% CI: 32%, 50%] of pathologies may be overlooked based on X-ray evaluation, regardless of evaluator experience. The most frequently overlooked injuries were: Tillaux fracture, Pillon fracture, loose bodies and syndesmosis injury. All of that missed pathologies required dedicated treatment and could be easily missed with standard surgical approach. CONCLUSION Evaluation of malleolar fractures by X-ray only inevitably results in overlooking of many pathologies, despite the clinician's experience. Routine CT scan can help to improve the accuracy of diagnosis, and thereby reduce the risk of ankle osteoarthrosis.
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Schoenmakers S, Houben M, van Hoeve S, Willems P, Meijer K, Poeze M. The influence of size and comminution of the posterior malleolus fragment on gait in trimalleolar ankle fractures. Clin Biomech (Bristol, Avon) 2022; 91:105550. [PMID: 34922095 DOI: 10.1016/j.clinbiomech.2021.105550] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 11/22/2021] [Accepted: 12/08/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Ankle fractures involving the posterior malleolus generally lead to worse outcome. However, no studies on gait in trimalleolar ankle fractures have evaluated the influence of size and comminution of the posterior malleolar fragment. METHODS We expected patients with more severely comminuted posterior malleolus, more severe fracture type and larger posterior fragment to have reduced gait kinematics and poorer patient-reported outcomes. 26 trimalleolar ankle fracture patients were compared with 14 healthy controls and kinematically analyzed using the Oxford Foot Model. Functional outcome was based on 4 patient reported outcome questionnaires. Effects of posterior fragment size, comminution and Haraguchi fracture classification were determined on conventional and 3D CT-scans. FINDINGS Trimalleolar patients had lower walking speed and reduced range of motion between the hindfoot and tibia in both loading and push-off phases in the sagittal and transverse planes. The range between the hindfoot and tibia in the sagittal plane in the push-off phase correlated significantly with patient reported outcomes. The absolute and relative surface area of the posterior fragment on conventional CT-scans and 3D CT-scans, correlated significantly with range of motion. Patients with a posterior malleolus size >10% of the posterior malleolus had lower flexion-extension between forefoot and hindfoot during loading phase than patients with a size ≤10%. INTERPRETATION Trimalleolar fractures reduce walking speed and range of motion in the talocrural joint. Reduced range in the talocrural joint is associated with poorer outcomes. Posterior fragment size correlated significantly with range of motion in talocrural and midfoot joints and with patient reported outcomes. LEVEL OF EVIDENCE Level 3, retrospective study.
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Affiliation(s)
- S Schoenmakers
- Department of Surgery, Division of Trauma surgery, Maastricht University Medical Center, P. Debyelaan 25, PO Box 5800, 6202 AZ Maastricht, the Netherlands.
| | - M Houben
- Department of Surgery, Division of Trauma surgery, Maastricht University Medical Center, P. Debyelaan 25, PO Box 5800, 6202 AZ Maastricht, the Netherlands.
| | - S van Hoeve
- Department of Surgery, Division of Trauma surgery, Maastricht University Medical Center, P. Debyelaan 25, PO Box 5800, 6202 AZ Maastricht, the Netherlands
| | - P Willems
- Department of Movement Sciences, Maastricht University Medical Center, P. Debyelaan 25, PO Box 616, 6200 MD Maastricht, the Netherlands; NUTRIM, School for Nutrition and Translational Research in Metabolism, PO Box 616, 6200 MD Maastricht, the Netherlands.
| | - K Meijer
- Department of Movement Sciences, Maastricht University Medical Center, P. Debyelaan 25, PO Box 616, 6200 MD Maastricht, the Netherlands; NUTRIM, School for Nutrition and Translational Research in Metabolism, PO Box 616, 6200 MD Maastricht, the Netherlands.
| | - M Poeze
- Department of Surgery, Division of Trauma surgery, Maastricht University Medical Center, P. Debyelaan 25, PO Box 5800, 6202 AZ Maastricht, the Netherlands; NUTRIM, School for Nutrition and Translational Research in Metabolism, PO Box 616, 6200 MD Maastricht, the Netherlands.
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O'Callaghan WB, Nielsen DEA, Hope MJ, Whitehouse SL, Tan SLE. Ankle fracture management using smartphone multimedia messaging service (MMS) imaging - How reliable and to what point? Foot Ankle Surg 2022; 28:20-24. [PMID: 33500217 DOI: 10.1016/j.fas.2021.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/27/2020] [Accepted: 01/07/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND The use of smartphones and multimedia messaging service (MMS) continues to increase in day to day orthopaedic clinical practice. However, there is limited evidence to support the safe utilisation of MMS. OBJECTIVES The aim of this study was to correlate the performance of MMS imaging to picture archiving and communication systems (PACS) imaging within the setting of diagnosis and management of ankle fractures. METHODS The ankle fracture radiograph series of 82 consecutive patients were evaluated by five orthopaedic consultant specialists. A questionnaire regarding diagnosis and preferred management was completed separately for each patient using smartphone and PACS images. Statistical analysis was performed using Intraclass Correlation Coefficient (ICC). RESULTS Ankle fracture diagnosis showed strong to excellent correlation both inter- and intraobserver MMS vs PACS when using the Weber (0.815, 0.988), Anatomical (0.858, 0.988), and AO classification systems (0.855, 0.985). MMS was less reliable than PACS in determining many management options. CONCLUSION The reliability of ankle fracture classification using MMS image viewing was not significantly different to interpretation on PACS workstations. Smartphone use in ankle fracture classification is supported by this study. Smartphone use was less accurate than PACS in devising management plans and future use should be limited to making only initial plans that must be corroberated with PACS and intraoperative findings prior to definitive fixation.
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Affiliation(s)
| | - David E A Nielsen
- Department of Orthopaedics, Pindara Private Hospital, Gold Coast, Queensland, Australia
| | - Matthew J Hope
- Department of Orthopaedics, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Sarah L Whitehouse
- Orthopaedic Research Unit, Queensland University of Technology, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - S L Ezekiel Tan
- Department of Orthopaedics, Gold Coast University Hospital, Gold Coast, Queensland, Australia
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Kho DH, Cho BK, Choi SM. Midterm Outcomes of Unstable Ankle Fractures in Young Patients Treated by Closed Reduction and Fixation With an Intramedullary Fibular Nail vs Open Reduction Internal Fixation Using a Lateral Locking Plate. Foot Ankle Int 2021; 42:1469-1481. [PMID: 34184908 DOI: 10.1177/10711007211017470] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND We aimed to compare midterm radiological and clinical outcomes between closed reduction and internal fixation (CRIF) using the fibular intramedullary nail (IMN) and open reduction and internal fixation (ORIF) using the locking plate for the treatment of unstable ankle fractures in active young patients. METHODS In this retrospective cohort study, 204 patients treated with CRIF using the fibular IMN (94 patients) or ORIF using the locking plate (110 patients) were included after at least 3 years of follow-up. The mean patient age was 41.4 years. Radiographic evaluation included the quality of reduction assessed by plain radiography and 3-dimensional (3D)-reconstructed computed tomography as well as the development of posttraumatic osteoarthritis (PTOA) of the ankle assessed by weightbearing plain radiography. Clinical evaluation included the American Orthopaedic Foot & Ankle Society hindfoot score, Olerud and Molander Score, the Foot and Ankle Outcome Score, and visual analog scale pain score as well as complications. RESULTS At median follow-up greater than 4 years, we found no significant differences in measured clinical outcomes between the 2 groups. There were significantly fewer postoperative complications in the IMN group than in the ORIF group (9.5% vs 39%, P < .001). However, we did find a greater proportion of radiographically fair or poor reductions in the IMN group than in the ORIF group (P < .001). The poor reductions in the IMN group were primarily related to Weber type C, pronation-type injury, and comminuted fibular and trimalleolar fractures (P < .001). PTOA was also more frequently observed in the IMN group than in the ORIF group (21.3% vs 9.1%, P = .024). CONCLUSION Given the current prevailing technologies for fracture fixation, this study suggests that surgeons should consider ORIF for unstable ankle fractures in active young patients with Weber type C, pronation-type injury, and comminuted fibular and trimalleolar fractures. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Duk-Hwan Kho
- Department of Orthopaedic Surgery, Konkuk University Chungju Hospital, Konkuk University School of Medicine, Chungju, Korea
| | - Byung-Ki Cho
- Department of Orthopaedic Surgery, School of Medicine, Chungbuk National University Hospital, Cheongju, Korea
| | - Seung-Myung Choi
- Department of Orthopedic Surgery, Eulji University School of Medicine, Gyeonggi-do, Korea
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Yu T, Zhang Y, Zhou H, Yang Y. Distribution of posterior malleolus fracture lines in ankle fracture of supination-external rotation. Orthop Traumatol Surg Res 2021; 107:103000. [PMID: 34216839 DOI: 10.1016/j.otsr.2021.103000] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 06/03/2020] [Accepted: 07/06/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Supination-external rotation ankle fracture is one of the most common fractures. Studies on the fracture line distribution of this fracture type are limited. The purpose of this study is to explore the distribution characteristics of intra-articular posterior malleolus fracture lines in supination-external rotation. HYPOTHESIS Most of the fracture lines are concentrated in a particular area. MATERIAL AND METHODS Computed tomography scans of a consecutive series of 70 ankle fractures of supination-external rotation were used for this study. The DICOM files were loaded into Mimics 16.0 for 3D reconstruction of the distal tibial articular surface. The intra-articular posterior malleolus fracture lines were identified after virtual fracture reduction. All the fracture lines were drawn on one picture of the distal tibial articular surface after standardization before a heat map was created based on the frequency of fracture lines. RESULTS Although the distribution of posterior malleolus intra-articular fracture lines varied, most of them were concentrated in an arcuate zone. The ratios of the area of posterior fracture fragment to the total area of articular surface averaged 14.96% (range, from 2.23% to 38.45%). They were most likely to enter the articular surface at 20.4% of the tangent of the posterior edge in a standardized image and exit at 58.7% of the tangent of the lateral edge. CONCLUSIONS In ankle fractures of supination-external rotation, most intra-articular posterior malleolus fracture lines may be distributed regularly in an arcuate zone of the articular surface. LEVEL OF PROOF V; Descriptive research.
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Affiliation(s)
- Tao Yu
- Department of Orthopedic Surgery, Tongji Hospital, Tongji University School of Medicine, 200065 Shanghai, China
| | - Yingqi Zhang
- Department of Orthopedic Surgery, Tongji Hospital, Tongji University School of Medicine, 200065 Shanghai, China
| | - Haichao Zhou
- Department of Orthopedic Surgery, Tongji Hospital, Tongji University School of Medicine, 200065 Shanghai, China
| | - Yunfeng Yang
- Department of Orthopedic Surgery, Tongji Hospital, Tongji University School of Medicine, 200065 Shanghai, China.
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Ræder BW, Andersen MR, Madsen JE, Jacobsen SB, Frihagen F, Figved W. Prognostic value of the Haraguchi classification in posterior malleolar fractures in A0 44-C type ankle fractures. Injury 2021; 52:3150-3155. [PMID: 34362561 DOI: 10.1016/j.injury.2021.07.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 07/24/2021] [Accepted: 07/28/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND PURPOSE Incidence of posterior malleolar fractures (PMFs) associated with ankle fractures is historically based on plain radiographs. Several classification systems for PMF are currently in use, but the reliability of the Haraguchi classification is not reported. The aim of this diagnostic cohort study was to assess incidence of PMF in patients with AO 44-C fractures, and test the reliability of the Haraguchi fracture classification based on CT. In addition, to evaluate the clinical outcome in patients with PMF. METHODS 210 patients with an AO 44-C type fracture treated with syndesmotic fixation between 2011 and 2017 were included. Presence of PMF was registered, morphology was assessed and classified according to the Haraguchi classification. Interobserver agreement for the Haraguchi classification was evaluated. Patient assessment was conducted at 6 weeks, 6 months, 1 and 2 years. The American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Score (AOFAS) was the primary outcome measure. Secondary outcome measures included presence of osteoarthritis. RESULTS 125 of 210 patients (60%) had a PMF. 34% of the PMFs were missed on plain radiographs compared to CT. The interobserver agreement was 0.797, (95% CI: 0.705 to 0.889, p < 0.001), for the Haraguchi classification. The 2-year follow-up rate was 86%. Haraguchi type II fractures had a lower AOFAS compared with the no-fracture group at 6 weeks (mean difference -7.5 (95% CI; -15.0 to -0.2), p = 0.04) and 6 months (mean difference -8.4 (95% CI; -15.3 to -1.5), p = 0.01). Presence of osteoarthritis was higher in patients with Haraguchi type II PMF compared to the no PMF group, this finding was not significant (relative risk (RR) 1.6(95% CI 1.1 to 2.4, p = 0.059)). CONCLUSIONS Plain radiographs underestimated PMF. Patients with a Haraguchi type II fracture had a poorer outcome measured by the AOFAS score compared to no PMF up until 6 months. Classification of PMF according to the Haraguchi classification was reliable.
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Affiliation(s)
- Benedikte Wendt Ræder
- Orthopaedic surgeon, Department of Orthopaedic Surgery, Baerum Hospital, Vestre Viken Hospital Trust, Norway.
| | - Mette Renate Andersen
- Orthopaedic surgeon, Department of Orthopaedic Surgery, Baerum Hospital, Vestre Viken Hospital Trust, Norway; Orthopaedic surgeon, Aleris Hospital, Tromsø, Norway
| | - Jan Erik Madsen
- Orthopaedic Surgeon, Division of Orthopaedic Surgery, Oslo University Hospital, Norway and Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Norway.
| | - Silje Berild Jacobsen
- Radiologist, Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Frede Frihagen
- Orthopaedic surgeon, Department of Orthopaedic Surgery, Østfold Hospital Trust, Grålum, Norway and Division of Clinical Medicine, Univeristy og Oslo, Oslo, Norway
| | - Wender Figved
- Orthopaedic surgeon, Department of Orthopaedic Surgery, Baerum Hospital, Vestre Viken Hospital Trust, Norway.
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22
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Black AT, Stowers JM, Tenley J, Hu CY, Eshetu T, Spielfogel WD, Katchis SD, RahnamaVaghef A, Weiner LS. The Association Between Lateral Radiographs and Axial Computed Tomography of Posterior Malleolar Fractures as a Tool for Predicting Medial Malleolar Extension: A Multi-Center Retrospective Analysis. J Foot Ankle Surg 2021; 60:897-901. [PMID: 33785238 DOI: 10.1053/j.jfas.2021.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 03/01/2021] [Accepted: 03/03/2021] [Indexed: 02/03/2023]
Abstract
Posterior malleolar fractures are often part of complex ankle fracture patterns. Radiographs and computed tomography are often obtained in the preoperative setting. In this study, we compared measurements from lateral ankle radiographs with measurements on axial computed tomography. We hypothesize that there is an association between measurements taken on lateral XR and certain fracture morphology such as medial extension and that measurements taken on lateral XR can be used to predict likelihood of medial extension type fractures. A multi-center retrospective analysis was performed involving patients with trimalleolar ankle fractures treated at two large urban healthcare systems ranging from January 1, 2010 to November 1, 2019. A total of 279 patients met criteria including 186 females and 93 males aged 18 to 90 with an average age 55. Four reviewers measured continuous variables on lateral radiograph and axial computed tomography: posterior malleolus fracture height, articular surface length, medial-lateral width, and anterior-posterior depth and then agreement was assessed via intraclass correlation coefficient. Pearson correlations were calculated for all pairwise combinations of measurements. Two fracture classification systems were then evaluated for association with the continuous variables. Lateral height was divided into quartiles and analyzed for the degree of association. Positive correlation was found between lateral height and axial depth/axial width. Taller lateral height values were statistically associated with medial extension type fractures. Lateral height 24.5mm-29.5mm is 3.1x higher, and lateral height >29.5mm is 8.6x more likely to have medial extension when compared to shorter lateral heights(<20.5mm). Based on these findings we suggest increased usage of pre-operative CT and evaluation for the use of posteromedial approaches in the setting of taller lateral height fracture patterns(>24.5mm) as seen on lateral XR.
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Affiliation(s)
- Alexandra T Black
- Chief Resident Physician, Department of Orthopedics, Lenox Hill Hospital Northwell, New York, NY.
| | - Jered M Stowers
- Senior Resident Physician, Department of Plastic Surgery, Medstar Georgetown University Hospital, Washington, DC
| | - Jonathan Tenley
- Resident Physician, Department of Plastic Surgery, Medstar Georgetown University Hospital, Washington, DC
| | - Charles Y Hu
- Resident Physician, Department of Plastic Surgery, Medstar Georgetown University Hospital, Washington, DC
| | - Tefera Eshetu
- Biostatistician, Medstar Health Research Institute, Washington, DC
| | - William D Spielfogel
- Chief of Podiatry, Department of Orthopedics, Lenox Hill Hospital Northwell, New York, NY
| | - Stuart D Katchis
- Section Chief, Foot and Ankle, Department of Orthopedics, Lenox Hill Hospital Northwell, New York, NY
| | - Ali RahnamaVaghef
- Fellowship Trained Foot and Ankle Surgeon, Assistant Professor, Georgetown University, School of Medicine, Washington, DC
| | - Lon S Weiner
- Program Director, Department of Orthopedics, Lenox Hill Hospital Northwell, New York, NY
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23
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Clarke T, Whitworth N, Platt S. Defining a Safe Zone for Percutaneous Screw Fixation of Posterior Malleolar Fractures. J Foot Ankle Surg 2021; 60:929-934. [PMID: 33879359 DOI: 10.1053/j.jfas.2020.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 09/09/2020] [Accepted: 10/05/2020] [Indexed: 02/03/2023]
Abstract
Posterior malleolar fractures require fixation to confer stability to the ankle. Although some have suggested that fractures involving less than 25% of the articular surface require no intervention, estimation of malleolar size on plain imaging is inaccurate. Some posterior malleolar fractures may be particularly suitable for posterior-to-anterior percutaneous screw fixation of the posterior malleolus via a posterolateral approach. We hypothesized that there may be a safe zone in the posterolateral ankle, identifiable with reliable anatomic landmarks, that might allow safe percutaneous screw placement for fracture fixation. The study protocol involved Step 1, in which multiple Kirschner wires were used in a single cadaveric specimen to attempt to identify a safe zone entry point in the posterior ankle, and Step 2, in which a single wire was used in each of six additional cadaveric specimens to test the ability to safely replicate the use of that entry point. In Step 1, a safe zone entry point was identified, located immediately lateral to the Achilles tendon and 1 cm above the level of the tip of the medial malleolus, when visualizing the posterior ankle. In Step 2, using these landmarks and an image intensifier, single wires were then successfully placed in the other six specimens without injury to any significant structure. If confirmed in clinical studies, the safe zone entry point that we have identified could potentially be used to facilitate posterior-to-anterior percutaneous fixation in patients with posterior malleolar fractures for whom open reduction may not be required or may be contraindicated.
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Affiliation(s)
- Thomas Clarke
- Principal House Officer, Department of Musculoskeletal Services - Surgical, Anaesthetics and Procedural Services (SaPS), Gold Coast University Hospital, Gold Coast Health, Southport, Queensland, Australia.
| | - Nicholas Whitworth
- Registrar, Department of Orthopaedics, Cairns Hospital, Cairns and Hinterland Hospital and Health Service, Cairns, Queensland, Australia
| | - Simon Platt
- Senior Staff Specialist, Department of Musculoskeletal Services - Surgical, Anaesthetics and Procedural Services (SaPS), Gold Coast University Hospital, Gold Coast Health, Southport, Queensland, Australia
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24
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Bouche PA, Gaujac N, Corsia S, Leclerc P, Anract P, Auberger G. Ankle CT scan allows better management of posterior malleolus fractures than X-rays. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:1301-1309. [PMID: 34468840 DOI: 10.1007/s00590-021-03104-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 08/23/2021] [Indexed: 01/23/2023]
Abstract
PURPOSE Undiagnosed and undertreated posterior malleolus fractures lead to early ankle instability and arthritis. A preoperative CT scan could improve the management of those fractures. This study assessed the benefits of a systematic ankle CT scanner to diagnose and manage posterior malleolus fracture. METHODS A monocentric retrospective cohort study was conducted. Sixty consecutive patients with bimalleolar fractures were operated and underwent a preoperative CT scan. The mean age was 50.0 years old (18.6 years old) with a mean body mass index of 20.3 (kg/m2) (11.4 kg/m2) and 71.7% (43/60) of women. The primary outcome was the rate of posterior malleolus fragment diagnosed on X-rays and on CT scan. Secondly, interobserver and interobserver's agreement were compared between conventional X-rays and CT scan. RESULTS Thirty-five (58.3%) posterior fragment fractures were observed on X-rays and 53 (88.3%) on the preoperative CT scan (p < 0.01). The intraobserver reproducibility for X-rays was low (0.02 [- 0.23; 0.27]) and moderate for CT scan (0.45 [0.0; 0.84]). The interobserver reproducibility for X-rays was moderate (0.39 [0.15; 0.60]) and excellent for CT scan (0.78 [0.0; 1.0]). CONCLUSION A wide proportion of bimalleolar fractures are associated with posterior malleolus fractures and undiagnosed with standard X-rays. We advocate a systematic preoperative CT scan in the management of bimalleolar fractures. LEVEL OF EVIDENCE Level IV, retrospective cohort study. TRIAL REGISTRATION NUMBER 2218999v0, date of registration: 11/08/2020 (retrospectively registered).
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Affiliation(s)
- Pierre-Alban Bouche
- Orthopaedic Department, Cochin University Hospital, APHP Paris, Paris Descartes University, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France.
| | - Nicolas Gaujac
- Orthopaedic Department, Cochin University Hospital, APHP Paris, Paris Descartes University, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Simon Corsia
- Orthopaedic Department, Cochin University Hospital, APHP Paris, Paris Descartes University, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Philippe Leclerc
- Orthopaedic Department, Croix St Simon Hospital, 125 rue d'Avron, 75020, Paris, France
| | - Philippe Anract
- Orthopaedic Department, Cochin University Hospital, APHP Paris, Paris Descartes University, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Guillaume Auberger
- Orthopaedic Department, Croix St Simon Hospital, 125 rue d'Avron, 75020, Paris, France
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25
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Management of posterior malleolus fractures: A multicentre cohort study in the United Kingdom. Foot Ankle Surg 2021; 27:629-635. [PMID: 32878722 DOI: 10.1016/j.fas.2020.08.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [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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26
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Fenelon C, Galbraith JG, Fahey T, Kearns SR. The Operative Treatment of Ankle Fractures: A 10-Year Retrospective Study of 1529 Patients. J Foot Ankle Surg 2021; 60:663-668. [PMID: 33509713 DOI: 10.1053/j.jfas.2020.03.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 03/19/2020] [Accepted: 03/29/2020] [Indexed: 02/03/2023]
Abstract
Ankle fractures are the second most common fracture of the lower limb and account for nearly 10% of all fractures. They range from simple to complex injuries and approximately 40% require surgical intervention. The aim of our study was to provide an up-to-date reference of the epidemiology, fracture, and fixation characteristics of operatively treated ankle fractures. We also sought to determine the number of patients undergoing further surgery through revision, implant removal, or ankle fusion. A retrospective observational study was conducted of 1529 consecutive patients that underwent operative intervention for an unstable ankle fracture between 2007 and 2017. Fractures of the distal tibia and pilon injuries were excluded. The mean age of patients was 41.8 years with 50.7% male. Unimalleolar fixation was performed in 60.1%, while bimalleolar and trimalleolar fixation was performed in 31.2% and 5%, respectively. Isolated syndesmotic fixation was performed in 3.8%. A posterior malleolus fracture was present in 28.6%, of which 31.6% underwent fixation. A further procedure was performed in 234 (15.3%) patients. Revision open reduction internal fixation was required in 1.4% and 0.8% underwent future ankle fusion. Treatment of ankle fractures makes up a sizeable part of orthopedic trauma practice with more than 1 in 7 patients requiring a second procedure. More complex fractures were predominantly seen in older females, while patients who suffered trimalleolar fractures have an increased likelihood of requiring future ankle fusion or revision. Despite this the rate of ankle fusion was <1%.
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Affiliation(s)
- Christopher Fenelon
- Orthopaedic Registrar, Department of Orthopaedic Surgery, Galway University Hospital, Galway, Ireland.
| | - John G Galbraith
- Consultant Orthopaedic Surgeon, Department of Orthopaedic Surgery, Galway University Hospital, Galway, Ireland
| | - Tom Fahey
- Professor of General Practice, Department of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Stephen R Kearns
- Professor and Consultant Orthopaedic Surgeon, Department of Orthopaedic Surgery, Galway University Hospital, Galway, Ireland
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27
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Black AT, Stowers JM, Bohm AR, Katchis SD, Spielfogel W, Weiner LS. Reconciliation Between Lateral X-ray and Axial Computed Tomography Regarding Posterior Malleolus Fracture Anatomy and Medial Malleolus Involvement: A Pilot Study. J Foot Ankle Surg 2021; 60:507-511. [PMID: 33509715 DOI: 10.1053/j.jfas.2020.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 05/01/2020] [Accepted: 07/31/2020] [Indexed: 02/03/2023]
Abstract
Configuration of a posterior malleolus fracture has significant variation based on mechanism of injury and concomitant ankle injuries. Radiographs obtained during early workup of ankle trauma play a pivotal role in closed reduction, surgical planning and preoperative management. Preoperative computed tomography helps distinguish fracture pathoanatomy. The purpose of this study is to relate measurements from traditional lateral radiographs with measurements on axial computed tomography. Imaging from a total of 22 patients treated at our institution from January 2008 to 2018 were evaluated. Two raters measured posterior malleolus fracture height and articular surface length on lateral radiographs, as well as medial-lateral width and anterior-posterior depth on axial computed tomography using calibrated imaging software. Posterior malleolar fractures with medial extension were recorded. Pearson correlations were calculated for all pairwise combinations of measurements. Lateral height and axial width were positively correlated. There was found to be an association between taller lateral height, and separately, wider axial width with presence of medial extension. Based on the correlations found between the measurements as well as the independent associations found with presence of medial extension, we suggest posterior-medial incision be evaluated as a potential approach in taller fractures as noted on lateral radiograph.
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Affiliation(s)
- Alexandra T Black
- Resident Physician, Department of Orthopedics, Lenox Hill Hospital Northwell Health, New York, NY.
| | - Jered M Stowers
- Resident Physician, Department of Podiatric Surgery, Medstar Georgetown University Hospital, Washington, DC
| | - Andrew R Bohm
- Biostatistician, Department of Orthopedics, Lenox Hill Hospital Northwell Health, New York, NY
| | - Stuart D Katchis
- Attending Physician, Department of Orthopedics, Lenox Hill Hospital Northwell Health, New York, NY
| | - William Spielfogel
- Chief, Division of Podiatry, Department of Orthopedics, Lenox Hill Hospital Northwell Health, New York, NY
| | - Lon S Weiner
- Director, Department of Orthopedics, Lenox Hill Hospital Northwell Health, New York, NY
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28
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Pilskog K, Gote TB, Odland HEJ, Fjeldsgaard KA, Dale H, Inderhaug E, Fevang JM. Traditional Approach vs Posterior Approach for Ankle Fractures Involving the Posterior Malleolus. Foot Ankle Int 2021; 42:389-399. [PMID: 33203272 PMCID: PMC8054166 DOI: 10.1177/1071100720969431] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND In the past, posterior malleolus fragments (PMFs) commonly have been indirectly reduced and fixed when fragments involve 25% or more of the tibial articular surface, while smaller fragments were left unfixed. The posterior approach has become increasingly popular and allows fixation of even smaller fragments. This study compares clinical outcome for the 2 treatment strategies. METHODS Patients with ankle fractures involving a PMF treated from 2014 to 2016 were eligible for inclusion. Patients were allocated to group A (treated with a posterior approach) or group B (treated with the traditional approach) according to the treatment given. A one-to-one matching of patients from each group based on the size of the PMF was performed. Patient charts were reviewed, and outcome evaluation was performed clinically, radiographically, and by patient-reported outcome measures (PROMs; Self-Reported Foot and Ankle Score, RAND-36, visual analog scale [VAS] of pain, and VAS of satisfaction). Forty-three patients from each group were matched. Median follow-up was 26 (interquartile range [IQR], 19-35) months postoperatively. RESULTS The median PMF size was 17% (IQR, 12-24) in both groups, and they reported similar results in terms of PROMs. Fixation of the PMF was performed in 42 of 43 (98%) patients in group A and 7 of 43 (16%) patients in group B (P < .001). The former group more frequently got temporary external fixation (56% vs 12%, P < .01) and less frequently had syndesmotic fixation (14% vs 49%, P < .01), and they had less mechanical irritation and hardware removal but more noninfectious skin problems (28% vs 5%, P < .01). Median time from injury to definitive surgery (8 vs 0 days, P < .001) and median length of stay (12 vs 3 days, P < .001) were longer in group A. CONCLUSION Comparison of treatment strategies for ankle fractures involving the posterior malleolus showed similar results between patients treated with a traditional approach and a posterior approach. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Kristian Pilskog
- Orthopedic Department, Haukeland
University Hospital, Bergen, Norway,Kristian Pilskog, MD, Orthopedic Department,
Haukeland University Hospital, Postbox 1400, 5021, Bergen, Norway.
| | - Teresa Brnic Gote
- Department of Physiotherapy, Haukeland
University Hospital, Bergen, Norway
| | | | | | - Håvard Dale
- Orthopedic Department, Haukeland
University Hospital, Bergen, Norway
| | - Eivind Inderhaug
- Orthopedic Department, Haukeland
University Hospital, Bergen, Norway
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29
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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: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [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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30
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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: 3.2] [Reference Citation Analysis] [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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31
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Blom RP, Hayat B, Al-Dirini RMA, Sierevelt I, Kerkhoffs GMMJ, Goslings JC, Jaarsma RL, Doornberg JN. Posterior malleolar ankle fractures. Bone Joint J 2020; 102-B:1229-1241. [PMID: 32862684 DOI: 10.1302/0301-620x.102b9.bjj-2019-1660.r1] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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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Wang Z, Sun J, Yan J, Gao P, Zhang H, Yang Y, Jin Q. Comparison of the efficacy of posterior-anterior screws, anterior-posterior screws and a posterior-anterior plate in the fixation of posterior malleolar fractures with a fragment size of ≥ 15 and < 15. BMC Musculoskelet Disord 2020; 21:570. [PMID: 32828121 PMCID: PMC7443295 DOI: 10.1186/s12891-020-03594-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 08/17/2020] [Indexed: 01/22/2023] Open
Abstract
Background Different fixation methods have been used to treat posterior malleolar fractures (PMFs), but the clinical efficacy of different fixation methods in the treatment of PMF with different fragmentation has rarely been reported. The purpose of this study was to investigate the efficacy of posterior-anterior (PA), anterior-posterior (AP) screws and PA plate in the fixation of PMFs with a fragment size of ≥15 and < 15%. Methods This is a retrospective study of the clinical data of 243 patients with a unilateral ankle fracture involving the posterior malleolar ankle fracture. All patients were divided into two groups based on their fragment size, ≥15% (n = 136) and < 15% (n = 107). After reduction of PMF under direct vision via a posterolateral approach, posterior-anterior (PA), anterior-posterior (AP) screws and PA plate were used for fixation of PMF in the two groups. Briefly, for fixation of PMF with PA screw, two to three 3.5-mm (Depuy Synthes, Switzerland) cannulated screws were placed from the posterior to anterior direction; for fixation with PA plate, a 3.5-mm reconstruction plate (Depuy Synthes, Switzerland) was placed from the posterior to anterior direction, and for fixation of PMF with an AP screw, two to three 3.5-mm screws were placed from the anterior to posterior direction. All patients were followed up at 1, 3, 6, and 12 months after surgery and thereafter at 6-month intervals. The primary outcomes were AOFAS and ROM, which were recorded at the final follow-up. Results The average follow-up time for all patients was 18.9 months (range 12–36 months), and all fractures healed. In fragment size ≥15% group, the average AOFAS score of patients treated with PA, AP screws and posterior plate were 91.5, 91.8, and 90.8, respectively, and the average limited ankle-dorsiflexion ROM was 5.0 °, 5.4 ° and 5.6°, respectively, at the last follow-up, there was no significant difference between the three fixation methods in terms of AOFAS scores and ankle ROM (P > 0.05). In fragment size < 15% group, the average AOFAS score of patients treated with PA, AP screws and posterior plate were 92.3, 91.9, and 84.1, respectively, the average limited ankle-dorsiflexion ROM were 5.1 °, 4.7 °, and 6.3 °, respectively, at the last follow-up. There were statistically significant differences in AOFAS scores and ankle ROM between posterior plate fixation and PA, AP screw fixation (P < 0.05); while no significant difference was found between PA and AP screw fixation (P > 0.05). Conclusion For PMFs with fragment size ≥15%, there was no significant difference in the outcomes between the three fixation methods. For PMF with fragmentation < 15%, the PA and AP screws both provided good fixation.
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Affiliation(s)
- Zheng Wang
- Department of Orthopaedic, General Hospital of Ningxia Medical University, Yinchuan, 750004, Ningxia, China
| | - Jianbin Sun
- Department of Orthopaedic, General Hospital of Ningxia Medical University, Yinchuan, 750004, Ningxia, China
| | - Jun Yan
- Department of Orthopaedic, General Hospital of Ningxia Medical University, Yinchuan, 750004, Ningxia, China
| | - Pengcheng Gao
- Department of Orthopaedic, General Hospital of Ningxia Medical University, Yinchuan, 750004, Ningxia, China
| | - Hao Zhang
- Department of Orthopaedic, General Hospital of Ningxia Medical University, Yinchuan, 750004, Ningxia, China
| | - Yong Yang
- Department of Orthopaedic, General Hospital of Ningxia Medical University, Yinchuan, 750004, Ningxia, China
| | - Qunhua Jin
- Department of Orthopaedic, General Hospital of Ningxia Medical University, Yinchuan, 750004, Ningxia, China.
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Lee SH, Kim MB, Lee W, Kang HJ, Lee YH. Quantitative evaluation of posterior talar subluxation in posterior malleolar fractures: A preliminary study. Injury 2020; 51:1669-1675. [PMID: 32360088 DOI: 10.1016/j.injury.2020.03.064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 03/17/2020] [Accepted: 03/30/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUNDS Although ankle posterior subluxation is one of the major mechanisms by which posterior malleolar fractures (PMF) contribute to a worse prognosis, there is no parameter to address it quantitatively. So, we suggest a method that can evaluate posterior talar subluxation quantitatively in PMF. METHODS We retrospectively analyzed 37 patients with posterior malleolar fractures. The patients were divided into two groups: PMF without posterior talar subluxation (n = 18) and with posterior talar subluxation (n = 19). We measured the distance between the arc center of the talus and the anterior tibia (TAD), the percentage of articular involvement of the fracture fragment, the inter-fragment distance (IFD) and articular step-off. We analyzed significant differences and the correlations between the two groups for each index. The estimated area of the receiver operating characteristic (ROC) curve was calculated, and cutoff values were suggested to discriminate posterior talar subluxation. RESULTS TAD, IFD, and articular step-off were significantly greater in patients with posterior talar subluxation. (TAD: 14.3 vs. 2.8 mm, p < 0.001, IFD: 7.8 vs. 4.0 mm, p < 0.001, articular step-off: 3.6 vs. 2.0 mm, p = 0.004). The ROC curve showed that TAD was most useful to determine cutoff values for posterior talar subluxation. The area under the curve for TAD was 1.000, and the appropriate cutoff value was 5 mm. When a TAD of > 5 mm was used as a threshold, a sensitivity of 100% and a specificity of 100% were achieved in determining the presence of posterior talar subluxation. Also, higher TAD was correlated with IFD and articular step-off. CONCLUSIONS TAD can be a useful parameter for evaluating the posterior talar subluxation in PMF. It can reflect not only the degree of fracture displacement but also posterior talar subluxation quantitatively.
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Affiliation(s)
- Seung Hoo Lee
- Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Center, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea
| | - Min Bom Kim
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, South Korea.
| | - Wonik Lee
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, South Korea
| | - Hyo-Jin Kang
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, South Korea
| | - Young Ho Lee
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, South Korea
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ALTUN G, REİS HÇ, BAYRAM B, SAKA G. Comparison of two plain radiographic and 3D-based measurement methods for posterior malleolar fragment size in trimalleol ankle fractures. ARCHIVES OF CLINICAL AND EXPERIMENTAL MEDICINE 2020. [DOI: 10.25000/acem.641188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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How to address the posterior malleolus in ankle fractures? A decision-making model based on the computerised tomography findings. INTERNATIONAL ORTHOPAEDICS 2020; 44:1177-1185. [DOI: 10.1007/s00264-020-04481-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 01/15/2020] [Indexed: 10/25/2022]
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Quantitative Evaluation of Articular Involvement of Posterior Malleolus Associated with Operative Indication: A Comparative Study of Six Methods Based on Radiography and CT. BIOMED RESEARCH INTERNATIONAL 2020; 2020:6745626. [PMID: 31998795 PMCID: PMC6970486 DOI: 10.1155/2020/6745626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 12/09/2019] [Accepted: 12/13/2019] [Indexed: 11/18/2022]
Abstract
The aim of this study was to compare the values of six methods in measuring the involvement of posterior malleolus and to demonstrate the reliability and reproducibility of each method. Three independent orthopaedic surgeons, retrospectively, measured 106 cases. The difference between the six methods was analyzed using Bonferroni-corrected paired t-tests after one-way ANOVA. The agreement between the six methods was analyzed using Bland-Altman analysis. The intraclass correlation coefficient (ICC) was used to assess intraobserver reproducibility and interobserver reliability. Significant differences were observed between values of any two of the six measurement methods (P < 0.0033), except between any two of the plane radiograph linear, axial CT linear, sagittal CT linear, and 3D CT linear. The Bland-Altman plots demonstrated poor agreement between values of any two of the six methods. The lowest intraobserver reproducibility was 0.46 (moderate) for resident surgeon using plain radiographs. The intraobserver reproducibility for three surgeons using two-dimensional (2D) and 3D images was almost perfect (ICC, 0.82-0.96). The lowest interobserver reliability was 0.41 (moderate) between chief and attending surgeon using plain radiographs, and it improved to almost perfect (ICC, 0.81-0.95) with the use of 3D CT images. The standard error of measurement showed almost the same results as ICC values. The existing operative indications which were determined based on plain radiography are neither reliable nor suitable for other measurement methods. Both 3D linear and 3D surface measurement methods are reliable and reproducible in measuring posterior fragment involvement, and experience is not so crucial. Operative indications for posterior malleolar fractures need to be redefined based on the 3D measurement method.
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Guan M, Zhao J, Kuang Y, Li G, Tan J. Finite element analysis of the effect of sagittal angle on ankle joint stability in posterior malleolus fracture: A cohort study. Int J Surg 2019; 70:53-59. [PMID: 31430548 DOI: 10.1016/j.ijsu.2019.08.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/30/2019] [Accepted: 08/12/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Aim of this study was to establish three-dimensional finite element model of the posterolateral-oblique type of posterior malleolus fracture with different sagittal angle and to explore the effect of sagittal angle on ankle joint stability. METHODS CT data of ankle were collected from a normal male volunteer.Established finite element model of the normal ankle and verified its reliability. Five posterior malleolus fracture models with different sagittal angles were established. Finite element analysis(FEA)was carried out to simulate the conditions of vertical loading in neutral position with a total weight of 600 N.Recorded the data and did statistical analyses. RESULTS (1) The contact area was 483.55 mm2 and the maximum contact stress was 3.793 MPa in the model of the normal ankle joint. (2) There was a positive correlation between the sagittal angle(SA)and the contact area(CA)(r = 0.925,P < 0.05). Regression equation was CA = 316.755 + 1.749* SA. The correlation between the sagittal angle and the maximum contact stress(MCS)was negative (r = -0.988,P < 0.01). Regression equation was MCS = 5.214-0.018*SA. There was a negative correlation between the sagittal angle of fracture and relative displacement(RD)(r = -0.950,P < 0.05). Regression equation was RD = 1.388-0.009*SA. CONCLUSION The greater the sagittal angle of fracture was, The more stable the ankle joint was. The sagittal angle of fracture could be used as a relative index to reflect ankle stability for posterior malleolus fracture.
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Affiliation(s)
- Ming Guan
- Department of Spine surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200120, China
| | - Jing Zhao
- Department of Nursing, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200120, China
| | - Yong Kuang
- Department of Orthopedics, Shanghai Artemed Hospital, Shanghai, 200131, China
| | - Guang Li
- Department of Traumatology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200120, China.
| | - Jun Tan
- Department of Spine surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200120, China.
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Quantification of Postoperative Posterior Malleolar Fragment Reduction Using 3-Dimensional Computed Tomography (Q3DCT) Determines Outcome in a Prospective Pilot Study of Patients With Rotational Type Ankle Fractures. J Orthop Trauma 2019; 33:404-410. [PMID: 31116137 DOI: 10.1097/bot.0000000000001486] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To correlate Q3DCT measurements of residual step-off, gap, and 3D multidirectional displacement of postoperative posterior malleolar fracture fragment reduction in patients with rotational type ankle fractures, with patients' clinical outcome using standardized patient- and physician-based outcome measures. DESIGN Prospective cohort study. SETTING Level-I Trauma Center. PATIENTS Thirty-one patients with ankle fractures including a posterior malleolar fracture (OTA/AO type 44) were included. INTERVENTION All patients underwent open reduction internal fixation of their ankle fracture, of which 18 patients (58%) had direct fixation of the posterior malleolar fragment. Decision of (direct) fixation of the posterior malleolar fragment was not standardized and guided by surgeons' preference. MAIN OUTCOME MEASUREMENTS Quality of postoperative reduction was quantified using Q3DCT: posterior fragment size (% of joint surface), residual step-off (mm), postoperative gaps (mm), and overall multidirectional displacement were quantified. Foot and Ankle Outcome Score pain and symptoms subscales and quality of life (Short Form-36) at 1 year postoperatively were included as the main outcome measures. RESULTS Step-off (mean 0.6 mm, range 0.0-2.7, SD 0.8) showed a significant correlation with worse Foot and Ankle Outcome Score pain and symptoms subscales. Residual fracture gap (mean 12.6 mm, range 0.0-68.8, SD 19.5) and 3D multidirectional displacement (mean 0.96 mm, range 0.0-2.8, SD 0.8) showed no correlation. CONCLUSIONS In patients with rotational type ankle fractures involving a posterior malleolar fracture, contemporary Q3DCT measurements of posterior fragment size and residual intra-articular step-off-but not gap-show significant correlation with patient-reported pain and symptoms. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Blom RP, Meijer DT, de Muinck Keizer RJO, Stufkens SAS, Sierevelt IN, Schepers T, Kerkhoffs GMMJ, Goslings JC, Doornberg JN. Posterior malleolar fracture morphology determines outcome in rotational type ankle fractures. Injury 2019; 50:1392-1397. [PMID: 31176480 DOI: 10.1016/j.injury.2019.06.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 05/23/2019] [Accepted: 06/02/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Rotational type ankle fractures with a concomitant fracture of the posterior malleolus are associated with a poorer clinical outcome as compared to ankle fractures without. However, clinical implications of posterior malleolar (PM) fracture morphology and pattern have yet to be established. Many studies on this subject report on fragment size, rather than fracture morphology based on computed tomography (CT). The overall purpose of the current study was to elucidate the correlation of PM fracture morphology and functional outcome, assessed with CT imaging and not with -unreliable- plain radiographs. METHODS Between January 2010 and May 2014, 194 patients with an operatively (ORIF) treated ankle fracture, were prospectively included in the randomized clinical EF3X-trial at our Level-I trauma center. The current study retrospectively included 73 patients with rotational type ankle fractures and concomitant fractures of the posterior malleolus. According to the CT-based Haraguchi fracture morphology, all patients were divided into three groups: 20 Type I (large posterolateral-oblique), 21 Type II (transverse medial-extension) and 32 Type III (small-shell fragment). At 12 weeks, 1 year and 2 years postoperatively the Foot and Ankle Outcome Scores (FAOS) and SF-36 scores were obtained, with the FAOS domain scores at two years postoperative as primary study outcome. Statistical analysis included a multivariate regression and secondary a mixed model analysis. RESULTS Haraguchi Type II PM ankle fractures demonstrated significantly poorer outcome scores at two years follow-up compared to Haraguchi Types I and III. Mean FAOS domain scores at two years follow-up showed to be significantly worse in Haraguchi Type II as compared to Type III, respectively: Symptoms 48.2 versus 61.7 (p = 0.03), Pain 58.5 versus 84.4 (p < 0.01), Activities of Daily Living (ADL) 64.1 versus 90.5 (p < 0.01). CONCLUSION Posterior malleolar ankle fractures with medial extension of the fracture line (i.e. Haraguchi Type II) are associated with significantly poorer functional outcomes. The current dogma to fix PM fractures that involve at least 25-33% of the tibial plafond may be challenged, as posterior malleolar fracture pattern and morphology - rather than fragment size - seem to determine outcome.
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Affiliation(s)
- R P Blom
- Department of Orthopaedic Surgery, Amsterdam UMC, location AMC. University of Amsterdam. Amsterdam, the Netherlands; Amsterdam Movement Sciences, Amsterdam, the Netherlands; Academic Center for Evidence-based Sports medicine (ACES).
| | - D T Meijer
- Department of Orthopaedic Surgery, Amsterdam UMC, location AMC. University of Amsterdam. Amsterdam, the Netherlands; Trauma Unit, Department of Surgery, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - R-J O de Muinck Keizer
- Trauma Unit, Department of Surgery, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - S A S Stufkens
- Department of Orthopaedic Surgery, Amsterdam UMC, location AMC. University of Amsterdam. Amsterdam, the Netherlands; Amsterdam Movement Sciences, Amsterdam, the Netherlands; Academic Center for Evidence-based Sports medicine (ACES)
| | - I N Sierevelt
- Specialized Centre of Orthopedic Research and Education (SCORE). Amsterdam, the Netherlands
| | - T Schepers
- Trauma Unit, Department of Surgery, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - G M M J Kerkhoffs
- Department of Orthopaedic Surgery, Amsterdam UMC, location AMC. University of Amsterdam. Amsterdam, the Netherlands; Amsterdam Movement Sciences, Amsterdam, the Netherlands; Academic Center for Evidence-based Sports medicine (ACES); Amsterdam Collaboration for Health and Safety in Sports (ACHSS), Amsterdam UMC IOC Research Center, Amsterdam, the Netherlands
| | - J C Goslings
- Trauma Unit, Department of Surgery, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, the Netherlands
| | - J N Doornberg
- Department of Orthopaedic Surgery, Amsterdam UMC, location AMC. University of Amsterdam. Amsterdam, the Netherlands; Department of Orthopaedics and Trauma Surgery, Flinders Medical Centre and Flinders University. Adelaide, South Australia, Australia
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Verhage SM, Krijnen P, Schipper IB, Hoogendoorn JM. Persistent postoperative step-off of the posterior malleolus leads to higher incidence of post-traumatic osteoarthritis in trimalleolar fractures. Arch Orthop Trauma Surg 2019; 139:323-329. [PMID: 30430238 PMCID: PMC6394475 DOI: 10.1007/s00402-018-3056-0] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Traditionally, size of the posterior fragment is considered the most important indicator for fixation in trimalleolar fractures. It remains unclear which factors contribute to worse functional and radiological outcome. This study was designed to determine predictors for the development of posttraumatic osteoarthritis and worse functional outcome in trimalleolar fractures. METHODS This retrospective cohort study evaluated outcomes of 169 patients with a trimalleolar fracture treated between 1996 and 2013 in a level-1 trauma hospital in the Netherlands after a mean follow-up of 6.3 (range 2.4 to 15.9) years. The average fragment size was 17%. Twenty patients had a posterior fragment smaller than 5% of the intra-articular surface, 119 patients a fragment of 5-25% and 30 patients a posterior fragment larger than 25%. In total, 39 patients (23%) underwent fixation of the posterior fragment. RESULTS Clinical union was achieved in all 169 patients. The median AOFAS score after follow-up was 93 (interquartile range 76-100) and the median AAOS score was 92 (interquartile range 81-98). A persistent postoperative step-off larger than 1 mm was found in 65 patients (39%) and osteoarthritis was present in 49 patients (30%). Higher age and postoperative step-off > 1 mm were independent, significant risk factors for the development of osteoarthritis. Osteoarthritis and BMI were independent, significant risk factors for worse functional outcome. CONCLUSION It is advisable to correct intra-articular step-off of intraarticular posterior malleolar fragments to reduce the risk of developing osteoarthritis and, consequently, the risk of worse functional outcome after long-term follow-up. LEVEL OF EVIDENCE Level IIB.
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Affiliation(s)
- Samuel Marinus Verhage
- 0000 0004 0395 6796grid.414842.fDepartment of Surgery, Haaglanden Medical Center, Lijnbaan 32, The Hague, VA 2512 The Netherlands ,0000000089452978grid.10419.3dDepartment of Traumatology Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Pieta Krijnen
- 0000000089452978grid.10419.3dDepartment of Traumatology Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Inger Birgitta Schipper
- 0000000089452978grid.10419.3dDepartment of Traumatology Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Jochem Maarten Hoogendoorn
- 0000 0004 0395 6796grid.414842.fDepartment of Surgery, Haaglanden Medical Center, Lijnbaan 32, The Hague, VA 2512 The Netherlands
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Verhage SM, Hoogendoorn JM, Krijnen P, Schipper IB. When and how to operate the posterior malleolus fragment in trimalleolar fractures: a systematic literature review. Arch Orthop Trauma Surg 2018; 138:1213-1222. [PMID: 29752537 DOI: 10.1007/s00402-018-2949-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Whether or not and how to fixate the posterior malleolus fracture seems to depend on the fracture fragment size and its amount of dislocation, but clear guidelines for daily practice are lacking. In this review, we summarize the literature on preferred treatment of the posterior fragment in trimalleolar fractures. METHODS A systematic review of publications between January 1995 and April 30 2017 on this topic in the PubMed, Embase, and Cochrane databases was performed according to the PRISMA statement. RESULTS Seventeen (2 prospective and 15 retrospective) of the 180 identified studies were included. Six studies report on indications for fixation of posterior malleolus fracture fragments. Eleven studies compare different fixation approaches and techniques for the posterior fragment. Meta-analysis was not possible due to varying fixation criteria and outcomes. There was no clear association between posterior fragment size and functional outcome or development of osteoarthritis. The non-anatomical reduction of the fragment was of more influence on outcome. Radiological and functional outcome was better after open reduction and internal fixation via the posterolateral approach than after percutaneous anterior-to-posterior screw fixation. CONCLUSION The posterior fragment size is not a clear indication for its fixation. A step-off, however, seems an important indicator for developing posttraumatic osteoarthritis and worse functional outcome. Posterior fragments involving the intra-articular surface need to be reduced and fixated to prevent postoperative persisting step-off. Furthermore, fixation of the posterior malleolus via an open posterolateral approach seems superior to percutaneous anterior-to-posterior fixation. However, these results need to be confirmed in a prospective comparative trial. LEVEL OF EVIDENCE Therapeutic level II.
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Affiliation(s)
- Samuel Marinus Verhage
- Department of Surgery, HMC Westeinde, Secretariaat Heelkunde F1.31, Lijnbaan 12, 2512 VA, The Hague, The Netherlands. .,Department of Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands.
| | - Jochem Maarten Hoogendoorn
- Department of Surgery, HMC Westeinde, Secretariaat Heelkunde F1.31, Lijnbaan 12, 2512 VA, The Hague, The Netherlands
| | - Pieta Krijnen
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands
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Boffeli TJ, Collier RC, Gervais SJ. Two-View Gravity Stress Imaging Protocol for Nondisplaced Type II Supination External Rotation Ankle Fractures: Introducing the Gravity Stress Cross-Table Lateral View. J Foot Ankle Surg 2018. [PMID: 28633800 DOI: 10.1053/j.jfas.2017.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Assessing ankle stability in nondisplaced Lauge-Hansen supination external rotation type II injuries requires stress imaging. Gravity stress mortise imaging is routinely used as an alternative to manual stress imaging to assess deltoid integrity with the goal of differentiating type II from type IV injuries in cases without a posterior or medial fracture. A type II injury with a nondisplaced fibula fracture is typically treated with cast immobilization, and a type IV injury is considered unstable and often requires operative repair. The present case series (two patients) highlights a standardized 2-view gravity stress imaging protocol and introduces the gravity stress cross-table lateral view. The gravity stress cross-table lateral view provides a more thorough evaluation of the posterior malleolus owing to the slight external rotation and posteriorly directed stress. External rotation also creates less bony overlap between the tibia and fibula, allowing for better visualization of the fibula fracture. Gravity stress imaging confirmed medial-sided injury in both cases, confirming the presence of supination external rotation type IV or bimalleolar equivalent fractures. Open reduction and internal fixation was performed, and both patients achieved radiographic union. No further treatment was required at 21 and 33 months postoperatively.
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Affiliation(s)
- Troy J Boffeli
- Director, Foot & Ankle Surgery Residency Program, Regions Hospital/HealthPartners Institute for Education & Research, St. Paul, MN
| | - Rachel C Collier
- Attending Surgeon, Foot and Ankle Surgery, Regions Hospital/HealthPartners Institute for Education & Research, St. Paul, MN
| | - Samuel J Gervais
- Chief Resident, Foot and Ankle Surgery, Regions Hospital/HealthPartners Institute for Education & Research, St. Paul, MN.
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Donohoe S, Alluri RK, Hill JR, Fleming M, Tan E, Marecek G. Impact of Computed Tomography on Operative Planning for Ankle Fractures Involving the Posterior Malleolus. Foot Ankle Int 2017; 38:1337-1342. [PMID: 28954524 DOI: 10.1177/1071100717731568] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to (1) Determine the effect of computed tomography (CT) on identification of fractures involving the posterior malleolus, (2) determine its effect on operative indications, and (3) determine its effect on the overall operative plan. METHODS Patients with ankle fractures involving the posterior malleolus were identified. Only injuries with complete preoperative plain radiographs and a CT scan were included. Spiral tibia fractures and pilon variants were excluded. The plain radiographs were deidentified, randomized, and presented to 3 orthopedic surgeons. They were asked 3 questions: (1) Is this fracture simple or complex? (2) Does the injury require direct visualization and reduction? and (3) How would you position the patient and approach the fracture? The same process was repeated for the CT scans. A total of 376 posterior malleolus injuries were identified and 25 met the inclusion criteria. RESULTS A complex fracture pattern was identified on 44% of plain radiographs and 56% of CT scans. The surgeons chose to operate in 84% of cases based on plain radiographs and 92% of cases based on CT scan. The observers changed their operative approach or positioning 44% of the time after reviewing CT images. The interobserver and intraobserver correlation coefficients were moderate. CONCLUSION The use of CT scan changed operative positioning and approach in 44% of cases. There was no significant change in characterization or operative indications when comparing plain radiographs to CT scan. CT scan may be a valuable tool in the management of ankle fractures involving the posterior malleolus. LEVEL OF EVIDENCE Diagnostic Level III, comparative series.
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Affiliation(s)
- Steven Donohoe
- 1 Department of Orthopaedic Surgery, Keck Medical Center of University of Southern California, 1520 San Pablo Street, Suite 2000, Los Angeles, CA, USA
| | - R Kiran Alluri
- 1 Department of Orthopaedic Surgery, Keck Medical Center of University of Southern California, 1520 San Pablo Street, Suite 2000, Los Angeles, CA, USA
| | - J Ryan Hill
- 1 Department of Orthopaedic Surgery, Keck Medical Center of University of Southern California, 1520 San Pablo Street, Suite 2000, Los Angeles, CA, USA
| | - Mark Fleming
- 2 Navy Trauma Training Center, Los Angeles County + USC Medical Center, Los Angeles, CA, USA
| | - Eric Tan
- 1 Department of Orthopaedic Surgery, Keck Medical Center of University of Southern California, 1520 San Pablo Street, Suite 2000, Los Angeles, CA, USA
| | - Geoffrey Marecek
- 1 Department of Orthopaedic Surgery, Keck Medical Center of University of Southern California, 1520 San Pablo Street, Suite 2000, Los Angeles, CA, USA
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Smeeing DPJ, Houwert RM, Kruyt MC, Hietbrink F. The isolated posterior malleolar fracture and syndesmotic instability: A case report and review of the literature. Int J Surg Case Rep 2017; 41:360-365. [PMID: 29149741 PMCID: PMC5695917 DOI: 10.1016/j.ijscr.2017.10.062] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 10/16/2017] [Accepted: 10/22/2017] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION Ankle fractures are among the most common type of fractures in the lower extremity. A posterior malleolar fracture is frequently part of a more complex ankle fracture and only in rare cases it occurs as isolated injury. Posterior malleolar fractures often occur with associated injuries, such as a Maisonneuve fracture or with bi- or trimalleolar ligamentous injuries. Knowledge about these associated injuries is essential to prevent missed diagnoses. The aim of this article is to describe the isolated posterior malleolar fracture, the possible associated injuries, the diagnostic work-up and therapeutic consequences. PRESENTATION OF CASE We present a case of a 26-year-old male patient who sustained an isolated posterior malleolar fracture with 4.5 years follow-up. DISCUSSION Isolated fractures of the posterior malleolus are uncommon injuries. Diagnosis, treatment and outcome can seldom be extracted from large series. However, several cases have been described in literature, which we have summarized. CONCLUSION This case report and literature review shows that isolated posterior malleolar fractures might occur as part of a more complex ankle injury, in combination with a fracture of the lower leg or after high energy trauma. Physicians should be aware of these associated injuries. Diagnostic work-up should include X-rays of the knee and lower leg and a CT scan of the ankle. If diagnosed and treated properly, isolated posterior malleolar fractures have a good long-term functional outcome.
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Affiliation(s)
- Diederik P J Smeeing
- Traumacenter Utrecht, Utrecht, The Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Roderick M Houwert
- Traumacenter Utrecht, Utrecht, The Netherlands; Department of Surgery, St Antonius Hospital Nieuwegein, The Netherlands.
| | - Moyo C Kruyt
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
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Mason LW, Marlow WJ, Widnall J, Molloy AP. Pathoanatomy and Associated Injuries of Posterior Malleolus Fracture of the Ankle. Foot Ankle Int 2017; 38:1229-1235. [PMID: 28758439 DOI: 10.1177/1071100717719533] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND We present a classification system that progresses in severity, indicates the pathomechanics that cause the fracture and therefore guides the surgeon to what fixation will be necessary by which approach. METHODS The primary posterior malleolar fracture fragments were characterized into 3 groups. A type 1 fracture was described as a small extra-articular posterior malleolar primary fragment. Type 2 fractures consisted of a primary fragment of the posterolateral triangle of the tibia (Volkmann area). A type 3 primary fragment was characterized by a coronal plane fracture line involving the whole posterior plafond. RESULTS In type 1 fractures, the syndesmosis was disrupted in 100% of cases, although a proportion only involved the posterior syndesmosis. In type 2 posterior malleolar fractures, there was a variable medial injury with mixed avulsion/impaction etiology. In type 3 posterior malleolar fractures, most fibular fractures were either a high fracture or a long oblique fracture in the same fracture alignment as the posterior shear tibia fragment. Most medial injuries were Y-type or posterior oblique fractures. This fracture pattern had a low incidence of syndesmotic injury. CONCLUSION The value of this approach was that by following the pathomechanism through the ankle, it demonstrated which other structures were likely to be damaged by the path of the kinetic energy. With an understanding of the pattern of associated injuries for each category, a surgeon may be able to avoid some pitfalls in treatment of these injuries. LEVEL OF EVIDENCE Level III, retrospective comparative series.
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Affiliation(s)
- Lyndon W Mason
- 1 University Hospital Aintree, Lower Lane, Liverpool, United Kingdom
| | - William J Marlow
- 1 University Hospital Aintree, Lower Lane, Liverpool, United Kingdom
| | - James Widnall
- 1 University Hospital Aintree, Lower Lane, Liverpool, United Kingdom
| | - Andrew P Molloy
- 1 University Hospital Aintree, Lower Lane, Liverpool, United Kingdom
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Abstract
The posterior malleolus component of a fracture of the ankle is important, yet often overlooked. Pre-operative CT scans to identify and classify the pattern of the fracture are not used enough. Posterior malleolus fractures are not difficult to fix. After reduction and fixation of the posterior malleolus, the articular surface of the tibia is restored; the fibula is out to length; the syndesmosis is more stable and the patient can rehabilitate faster. There is therefore considerable merit in fixing most posterior malleolus fractures. An early post-operative CT scan to ensure that accurate reduction has been achieved should also be considered. Cite this article: Bone Joint J 2017;99-B:1413–19.
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Affiliation(s)
- M. C. Solan
- Royal Surrey County Hospital, Egerton
Road, Guildford, Surrey
GU2 7XX, UK
| | - A. Sakellariou
- Frimley Park Hospital, Portsmouth
Road, Frimley, Surrey
GU16 7UJ, UK
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Bali N, Aktselis I, Ramasamy A, Mitchell S, Fenton P. An evolution in the management of fractures of the ankle. Bone Joint J 2017; 99-B:1496-1501. [DOI: 10.1302/0301-620x.99b11.bjj-2017-0558.r1] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 07/03/2017] [Indexed: 11/05/2022]
Abstract
Aims There has been an evolution recently in the management of unstable fractures of the ankle with a trend towards direct fixation of a posterior malleolar fragment. Within these fractures, Haraguchi type 2 fractures extend medially and often cannot be fixed using a standard posterolateral approach. Our aim was to describe the posteromedial approach to address these fractures and to assess its efficacy and safety. Patients and Methods We performed a review of 15 patients with a Haraguchi type 2 posterior malleolar fracture which was fixed using a posteromedial approach. Five patients underwent initial temporary spanning external fixation. The outcome was assessed at a median follow-up of 29 months (interquartile range (IQR) 17 to 36) using the Olerud and Molander score and radiographs were assessed for the quality of the reduction. Results The median Olerud and Molander score was 72 (IQR 70 to 75), representing a good functional outcome. The reduction was anatomical in ten, with a median step of 1.2 mm (IQR 0.9 to 1.85) in the remaining five patients. One patient had parasthaesiae affecting the medial forefoot, which resolved within three months. Conclusion We found that the posteromedial approach to the ankle for the surgical treatment of Haraguchi type 2 posterior malleolar fractures is a safe technique that enables good visualisation and reduction of the individual fracture fragments with promising early outcomes. Cite this article: Bone Joint J 2017;99-B:1496–1501.
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Affiliation(s)
- N. Bali
- Royal Devon & Exeter Hospital, Barrack Road, Exeter EX2 5DW, UK
| | - I. Aktselis
- Bristol Royal Infirmary, Marlborough
Street, Bristol BS1 3NU, UK
| | - A. Ramasamy
- The Royal British Legion Centre for Blast
Injury Studies, Imperial College London, SW7
2BW, UK
| | - S. Mitchell
- Bristol Royal Infirmary, Marlborough
Street, Bristol BS1 3NU, UK
| | - P. Fenton
- Queen Elizabeth Hospital, Mindelsohn
Way, Birmingham B15 2TH, UK
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Shi HF, Xiong J, Chen YX, Wang JF, Qiu XS, Huang J, Gui XY, Wen SY, Wang YH. Comparison of the direct and indirect reduction techniques during the surgical management of posterior malleolar fractures. BMC Musculoskelet Disord 2017; 18:109. [PMID: 28292290 PMCID: PMC5351253 DOI: 10.1186/s12891-017-1475-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Accepted: 03/06/2017] [Indexed: 12/13/2022] Open
Abstract
Background The optimal method for the reduction and fixation of posterior malleolar fracture (PMF) remains inconclusive. Currently, both of the indirect and direct reduction techniques are widely used. We aimed to compare the reduction quality and clinical outcome of posterior malleolar fracture managed with the direct reduction technique through posterolateral approach or the indirect reduction technique using ligamentotaxis. Methods Patients with a PMF involving over 25% of the articular surface were recruited and assigned to the direct reduction (DR) group or the indirect reduction (IR) group. Following reduction and fixation of the fracture, the quality of fracture reduction was evaluated in post-operative CT images. Clinical and radiological follow-ups were performed at 6 weeks, 3 months, 6 months, 12 months, and then at 6 month-intervals postoperatively. Functional outcome (AOFAS score), ankle range of motion, and Visual Analog Scale (VAS) were evaluated at the last follow-up. Statistical differences were compared between the DR and IR groups considering the patient demographics, quality of fracture reduction, AOFAS score, and VAS. Results Totally 116 patients were included, wherein 64 cases were assigned to the DR group and 52 cases were assigned to the IR group. The quality of fracture reduction was significant higher in the DR group (P = 0.038). In the patients who completed a minimum of 12 months’ follow-up, a median AOFAS score of 87 was recorded in the DR group, which was significantly higher than that recorded in the IR group (a median score of 80). The ankle range of motion was slightly better in the DR group, with the mean dorsiflexion restriction recorded to be 5.2° and 6.1° in the DR and IR group respectively (P = 0.331). Similar VAS score was observed in the two groups (P = 0.419). Conclusions The direct reduction technique through a posterolateral approach provide better quality of fracture reduction and functional outcome in the management of PMF over 25% of articular surface, as compared with the indirect reduction technique using ligamentotaxis. Trial registration NCT02801474 (retrospectively registered, June 2016, ClinicalTrails.gov).
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Affiliation(s)
- Hong-Fei Shi
- Department of Orthopaedics, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, China
| | - Jin Xiong
- Department of Orthopaedics, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, China.
| | - Yi-Xin Chen
- Department of Orthopaedics, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, China.
| | - Jun-Fei Wang
- Department of Orthopaedics, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, China
| | - Xu-Sheng Qiu
- Department of Orthopaedics, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, China
| | - Jie Huang
- Nanjing Medical University, Nanjing, China
| | | | - Si-Yuan Wen
- Nanjing University Medical School, Nanjing, China
| | - Yin-He Wang
- Department of Orthopaedics, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, China
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Verhage S, van der Zwaal P, Bronkhorst M, van der Meulen H, Kleinveld S, Meylaerts S, Rhemrev S, Krijnen P, Schipper I, Hoogendoorn J. Medium-sized posterior fragments in AO Weber-B fractures, does open reduction and fixation improve outcome? the POSTFIX-trial protocol, a multicenter randomized clinical trial. BMC Musculoskelet Disord 2017; 18:94. [PMID: 28231779 PMCID: PMC5324206 DOI: 10.1186/s12891-017-1445-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 02/07/2017] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Guidelines for treatment of the posterior fracture fragment in trimalleolar fractures are scarce and show varying advices. Did the increasing size of the posterior fragment seem to relate to worse outcome in the past, nowadays this has changed to the amount of dislocation of the posterior fragment post-operatively. Despite many retrospective cohort studies and some prospective cohort studies, no consistent guideline could be derived from the current literature. METHODS The POSTFIX-study is designed as a multicenter randomized clinical trial to analyse the effects of anatomical reduction and fixation of the posterior fragment in AO 44-B3 fractures with medium-sized posterior fragment. A total of 84 patients will be included and online allocated to either anatomical reduction and fixation of the posterior fragment via the posterolateral approach (n = 42) or no fixation of the posterior fragment (n = 42). The concomitant fractured medial and lateral malleoli are treated according to the AO-principles. Functionality of the ankle as measured by the AAOS-questionnaire (American Association of Orthopaedic Surgeons) 1 year post-operatively was set as primary outcome. Main secondary outcome measures are the AAOS-questionnaire 5 years postoperatively and osteoarthritis as measured on plain radiographs 1 year and 5 years post-operatively. The Olerud and Molander score, the AOFAS-score, the VAS-pain, the Euroqol-5D and Range of Motion by physical examination will also be evaluated during the follow-up period. DISCUSSION The POSTFIX-trial is the first high quality multicenter randomized clinical trial worldwide to analyse the effects of anatomical fixation of the posterior fragment in trimalleolar fractures. New guidelines on anatomical reduction and fixation of the posterior fragment can in future be based on the results of this trial. TRIAL REGISTRATION This trial is registered on ClinicalTrials.gov with reference number: NCT02596529 . Registered 3 November 2015, retrospectively registered.
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Affiliation(s)
| | | | | | | | - Sanne Kleinveld
- Department of Traumasurgery, Haga Ziekenhuis, The Hague, The Netherlands
| | | | | | - Pieta Krijnen
- Department of Traumasurgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Inger Schipper
- Department of Traumasurgery, Leiden University Medical Center, Leiden, The Netherlands
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Abstract
Posterior malleolus fractures vary in morphology. A computed tomography scan is imperative to evaluate fragment size, comminution, articular impaction, and syndesmotic disruption. Despite an increasing body of literature regarding posterior malleolus fractures, many questions remain unanswered. Although, historically, fragment size guided surgical fixation, it is becoming evident that fragment size should not solely dictate treatment. Surgical treatment should focus on restoring ankle joint structural integrity, which includes restoring articular congruity, correcting posterior talar translation, addressing articular impaction, removing osteochondral debris, and establishing syndesmotic stability.
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Affiliation(s)
- Shay Tenenbaum
- Department of Orthopedic Surgery, Chaim Sheba Medical Center Hospital at Tel Hashomer, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, 1 Emek HaEla St, Ramat Gan 52621, Israel.
| | - Nachshon Shazar
- Department of Orthopedic Surgery, Chaim Sheba Medical Center Hospital at Tel Hashomer, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, 1 Emek HaEla St, Ramat Gan 52621, Israel
| | - Nathan Bruck
- Department of Orthopedic Surgery, Chaim Sheba Medical Center Hospital at Tel Hashomer, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, 1 Emek HaEla St, Ramat Gan 52621, Israel
| | - Jason Bariteau
- Department of Orthopaedics, Emory University School of Medicine, 59 Executive Park South, Suite 2000, Atlanta, GA 30306, USA
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