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Tatum M, Kern A, Goetz JE, Thomas G, Anderson DD. A Novel System for Markerless Intra-Operative Bone and Bone Fragment Tracking. COMPUTER METHODS IN BIOMECHANICS AND BIOMEDICAL ENGINEERING. IMAGING & VISUALIZATION 2025; 13:2463327. [PMID: 39991594 PMCID: PMC11845215 DOI: 10.1080/21681163.2025.2463327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 02/01/2025] [Indexed: 02/25/2025]
Abstract
Fluoroscopic guidance is an integral tool in modern orthopedic surgery often used to track bones and/or bone fragments during a surgical procedure. However, relying upon this intra-operative 2D projective imaging modality for this purpose can challenge a surgeon's ability to interpret 3D position and orientation of any but the simplest bony anatomy. A number of object-tracking technologies have been developed to aid surgeons, but they have failed to be generalizable to a wider array of procedures, have required an unrealistic amount of time and effort to implement, or have unacceptably changed the flow of the surgery. This work describes a novel, general-purpose system for markerless, intra-operative bone tracking that seamlessly integrates into a surgical setting. The system uses a unique calibration object placed next to the patient, which provides a common reference for aligning multiple fluoroscopic images. This approach enables robust and expedient 3D object registration from only two semi-orthogonal 2D fluoroscopic images.
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Affiliation(s)
- Marcus Tatum
- Department of Orthopedics and Rehabilitation, The University of Iowa
- Department of Industrial and Systems Engineering, The University of Iowa
| | - Andrew Kern
- Department of Orthopedics and Rehabilitation, The University of Iowa
- Department of Biomedical Engineering, The University of Iowa
| | - Jessica E. Goetz
- Department of Orthopedics and Rehabilitation, The University of Iowa
- Department of Biomedical Engineering, The University of Iowa
| | - Geb Thomas
- Department of Orthopedics and Rehabilitation, The University of Iowa
- Department of Industrial and Systems Engineering, The University of Iowa
| | - Donald D. Anderson
- Department of Orthopedics and Rehabilitation, The University of Iowa
- Department of Industrial and Systems Engineering, The University of Iowa
- Department of Biomedical Engineering, The University of Iowa
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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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Gao Y, Liu Y, Zhao Y, Shan L, Wang H, Xu X, Zhao B, Zhou J. Comparison between anterior-to-posterior screw fixation versus posterolateral approach plate fixation for posterior malleous fracture: A systematic review and meta-analysis. Foot Ankle Surg 2024; 30:594-602. [PMID: 38824055 DOI: 10.1016/j.fas.2024.05.004] [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: 01/25/2024] [Revised: 05/06/2024] [Accepted: 05/07/2024] [Indexed: 06/03/2024]
Abstract
PURPOSE There are two main surgical fixation methods for the posterior malleolar fractures (PMFs), the anterior-to-posterior (AP) screws or via the posterolateral (PL) approach utilizing a buttress plate. This review aims to compare the clinical outcome between the AP screw fixation and the PL plate fixation for treating PMFs. METHODS We searched all relevant publications about PMFs treated with AP screws or PL plates through electronic databases including the PubMed, the Cochrane Library, the Embase, the Wiley online library and the Web of Science. The meta-analysis was conducted to evaluated clinical outcomes including reduction quality, post-operative function and complications. RESULTS Six studies (one single randomized controlled trial and five retrospective cohort studies) were enrolled. 172 patients underwent AP screw fixation and 214 patients underwent PL plate fixation with a total of 386 patients (169 males and 217 females). The PL plating group yielded better AOFAS scores(MD = 6.97, 95 % CI=[4.68, 9.27], P＜0.00001, I2 =0 %) and was more likely to achieve excellent anatomical reduction(OR=5.49, 95 % CI=[1.06, 28.42], P = 0.04, I2 =80 %). No differences were found in the bad reduction quality, incidences of complications (arthritis, neuralgia, superficial wound healing problems and implant failure), the walking VAS scores and the dorsiflexion restriction degrees. CONCLUSION We suggest that the PL plate fixation method has the clinical benefit of achieving anatomical reduction and better AOFAS scores over the AP screw fixation for treating PMFs. No differences were found in the incidences of complications ( arthritis, neuralgia, superficial wound healing problems and implant failure), the walking VAS scores and the dorsiflexion restriction degrees. The posterior approach and the direct reduction are recommended for the treatment of the PMFs. LEVEL OF CONFIDENCE Ⅱb.
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Affiliation(s)
- Yuling Gao
- Affiliated Beijing Chaoyang Hospital of Capital Medical University,Bejing, China; Beijing Chaoyang Hospital, Capital Medical University, Gongtinan Road 8#, Beijing 100020, China
| | - Yang Liu
- Affiliated Beijing Chaoyang Hospital of Capital Medical University,Bejing, China; Beijing Chaoyang Hospital, Capital Medical University, Gongtinan Road 8#, Beijing 100020, China
| | - Yanrui Zhao
- Affiliated Beijing Chaoyang Hospital of Capital Medical University,Bejing, China; Beijing Chaoyang Hospital, Capital Medical University, Gongtinan Road 8#, Beijing 100020, China
| | - Lei Shan
- Affiliated Beijing Chaoyang Hospital of Capital Medical University,Bejing, China; Beijing Chaoyang Hospital, Capital Medical University, Gongtinan Road 8#, Beijing 100020, China
| | - Hanzhou Wang
- Affiliated Beijing Chaoyang Hospital of Capital Medical University,Bejing, China; Beijing Chaoyang Hospital, Capital Medical University, Gongtinan Road 8#, Beijing 100020, China
| | - Xiaopei Xu
- Affiliated Beijing Chaoyang Hospital of Capital Medical University,Bejing, China; Beijing Chaoyang Hospital, Capital Medical University, Gongtinan Road 8#, Beijing 100020, China
| | - Binzhi Zhao
- Affiliated Beijing Chaoyang Hospital of Capital Medical University,Bejing, China; Beijing Chaoyang Hospital, Capital Medical University, Gongtinan Road 8#, Beijing 100020, China
| | - Junlin Zhou
- Affiliated Beijing Chaoyang Hospital of Capital Medical University,Bejing, China; Beijing Chaoyang Hospital, Capital Medical University, Gongtinan Road 8#, Beijing 100020, China.
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Datta S, Bandyopadhyay B, Tahir M, Bose G, Khadilkar S. A Comprehensive Review of Recent Trends in Posterior Malleolus Fracture Management. Cureus 2024; 16:e72081. [PMID: 39575057 PMCID: PMC11580813 DOI: 10.7759/cureus.72081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2024] [Indexed: 11/24/2024] Open
Abstract
Posterior malleolus fractures (PMFs) are challenging injuries around the ankle that can lead to poor clinical outcomes as they can compromise ankle stability. Although there has been an evolution in the principles of management of PMFs, their optimal treatment remains controversial. This review article aims to provide an in-depth account of the management of PMF, thereby providing a better understanding of these complex cases hence resulting in improving patient outcomes.
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Affiliation(s)
- Sunandan Datta
- Trauma and Orthopaedics, East Kent Hospitals University NHS Foundation Trust, Margate, GBR
| | | | - Muhammad Tahir
- Trauma and Orthopaedics, East Kent Hospitals University NHS Foundation Trust, Margate, GBR
| | - Gourab Bose
- Trauma and Orthopaedics, North West Anglia NHS Foundation Trust, Peterborough, GBR
| | - Siddharth Khadilkar
- Trauma and Orthopaedics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, GBR
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Massri-Pugin J, Morales S, Serrano J, Mery P, Filippi J, Villa A. Percutaneous Fixation of Posterior Malleolar Fractures: A Contemporary Review. FOOT & ANKLE ORTHOPAEDICS 2024; 9:24730114241256371. [PMID: 38840784 PMCID: PMC11151760 DOI: 10.1177/24730114241256371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Affiliation(s)
- Jafet Massri-Pugin
- Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Sergio Morales
- Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Javier Serrano
- Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Pablo Mery
- Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jorge Filippi
- Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Andrés Villa
- Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
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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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Lisitano L, Röttinger T, Wiedl A, Rau K, Helling S, Cifuentes J, Jehs B, Härting M, Feitelson LM, Gleich J, Kiesl S, Pfeufer D, Neuerburg C, Mayr E, Förch S. Plain X-ray is insufficient for correct diagnosis of tibial shaft spiral fractures: a prospective trial. Eur J Trauma Emerg Surg 2023; 49:2339-2345. [PMID: 37269304 PMCID: PMC10728229 DOI: 10.1007/s00068-023-02285-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/20/2023] [Indexed: 06/05/2023]
Abstract
PURPOSE Tibial shaft spiral fractures and fractures of the distal third of the tibia (AO:42A/B/C and 43A) frequently occur with non-displaced posterior malleolus fractures (PM). This study investigated the hypothesis that plain X-ray is not sufficient for a reliable diagnosis of associated non-displaced PM fractures in tibial shaft spiral fractures. METHODS 50 X-rays showing 42A/B/C and 43A fractures were evaluated by two groups of physicians, each group was comprised of a resident and a fellowship-trained traumatologist or radiologist. Each group was tasked to make a diagnosis and/or suggest if further imaging was needed. One group was primed with the incidence of PM fractures and asked to explicitly assess the PM. RESULTS Overall, 9.13/25 (SD ± 5.77) PM fractures were diagnosed on X-ray. If the posterior malleolus fracture was named or a CT was requested, the fracture was considered "detected". With this in mind, 14.8 ± 5.95 posterior malleolus fractures were detected. Significantly more fractures were diagnosed/detected (14 vs. 4.25/25; p < 0.001/14.8 vs. 10.5/25; p < 0.001) in the group with awareness. However, there were significantly more false positives in the awareness group (2.5 vs. 0.5; p = 0.024). Senior physicians recognized slightly more fractures than residents (residents: 13.0 ± 7.79; senior physicians: 16.5 ± 3.70; p = 0.040). No significant differences were demonstrated between radiologists and trauma surgeons. The inner-rater reliability was high with 91.2% agreement. Inter-rater reliability showed fair agreement (Fleiss-Kappa 0.274, p < 0.001) across all examiners and moderate agreement (Fleiss-Kappa 0.561, p < 0.001) in group 2. CONCLUSION Only 17% of PM fractures were identified on plain X-ray and awareness of PM only improved diagnosis by 39%. While experiencing improved accuracy, CT imaging should be included in a comprehensive examination of tibial shaft spiral fractures. LEVEL OF EVIDENCE II. Diagnostic prospective cohort study. TRAIL REGISTRATION NUMBER DRKS00030075.
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Affiliation(s)
- Leonard Lisitano
- Department for Trauma, Orthopedics, Hand and Plastic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany.
| | - Timon Röttinger
- Department for Trauma, Orthopedics, Hand and Plastic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Andreas Wiedl
- Department for Trauma, Orthopedics, Hand and Plastic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Kim Rau
- Department for Trauma, Orthopedics, Hand and Plastic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Sönke Helling
- Department for Trauma, Orthopedics, Hand and Plastic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Jairo Cifuentes
- Department for Trauma, Orthopedics, Hand and Plastic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Bertram Jehs
- Department for Diagnostic and Interventional Radiology, University Hospital Augsburg, Augsburg, Germany
| | - Mark Härting
- Department for Diagnostic and Interventional Radiology, University Hospital Augsburg, Augsburg, Germany
| | - Laura-Marie Feitelson
- Department for Diagnostic and Interventional Radiology, University Hospital Augsburg, Augsburg, Germany
| | - Johannes Gleich
- Department for Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital LMU Munich, Munich, Germany
| | - Sophia Kiesl
- Department of Radiology, University Hospital LMU Munich, Munich, Germany
| | - Daniel Pfeufer
- Department for Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital LMU Munich, Munich, Germany
| | - Carl Neuerburg
- Department for Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital LMU Munich, Munich, Germany
| | - Edgar Mayr
- Department for Trauma, Orthopedics, Hand and Plastic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Stefan Förch
- Department for Trauma, Orthopedics, Hand and Plastic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
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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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Haws BE, Karnyski S, DiStefano DA, Soin SP, Flemister AS, Ketz JP. Reduction of Posterior Malleolus Fractures With Open Fixation Compared to Percutaneous Treatment. FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231200485. [PMID: 37786607 PMCID: PMC10541751 DOI: 10.1177/24730114231200485] [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: 10/04/2023] Open
Abstract
Background Operative decision making between approaches to posterior malleolus reduction remains a challenge. The purpose of this study is to compare the quality of reduction between percutaneous and open reduction of posterior malleolus fractures and to identify factors associated with malreduction. Methods Operatively managed ankle fractures that included posterior malleolus fixation were reviewed. Fracture characteristics were determined on preoperative CT scans. Initial postoperative radiographs were used to measure reduction of the posterior malleolus articular surface and graded as satisfactory (<2 mm step-off) or malreduced (≥2 mm step-off). Final postoperative PROMIS scores and 1-year complications were compared between percutaneous and open cohorts. A multivariate stepwise regression model was used to evaluate predictors for malreduction. Results A total of 120 patients were included. Open reduction was performed in 91 (75.8%) compared with 29 (24.2%) who underwent percutaneous reduction. Malreduction (≥2-mm articular step-off) occurred in 11.7% of patients. Malreduction rates were significantly higher with percutaneous fixation than open fixation (24.1% vs 7.7%, P = .02). Multiple fragments and those with ≥5 mm of displacement demonstrated higher malreduction rates with percutaneous fixation (P < .05 for both), whereas single fragments and those with <5 mm of displacement experienced similar malreduction rates with percutaneous or open fixation. Initial displacement ≥5 mm (relative risk [RR] = 3.8, 95% CI = 1.2-11.5, P = .02) and percutaneous treatment (RR = 4.1, 95% CI = 1.6-10.5, P < .01) were identified as independent risk factors for malreduction. There were no significant differences in 1-year complication rates or final PROMIS scores between groups. Conclusion Open reduction of the posterior malleolus may lead to improved fracture reduction compared to percutaneous reduction without significant increase in complications. Open fixation improves reduction among fractures with multiple fragments or ≥5 mm of displacement, whereas fractures with a single fragment or <5 mm of displacement achieve similar reductions regardless of approach. Initial displacement ≥5 mm and percutaneous reduction are independent risk factors for malreduction. Level of evidence Level III, therapeutic.
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Affiliation(s)
- Brittany E. Haws
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
| | - Steven Karnyski
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
| | - David A. DiStefano
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
| | - Sandeep P. Soin
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
| | - Adolph S. Flemister
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
| | - John P. Ketz
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
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Qi H, Li Z, Ma T, Ren C, Xu Y, Huang Q, Feng H, Zhang K, Lu Y, Li M. One quick and simple fixation method: posterior malleolus fractures in spiral tibial fractures. BMC Musculoskelet Disord 2023; 24:244. [PMID: 36997965 PMCID: PMC10061987 DOI: 10.1186/s12891-023-06319-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 03/14/2023] [Indexed: 04/01/2023] Open
Abstract
OBJECTIVE Spiral fracture of tibia combined with posterior malleolar fracture (PMF) is a special and regular injury. There is no uniform fixation method for PMF in this kind of injury. Intramedullary nail is the first choice for the treatment of tibial spiral fracture. We proposed a minimally invasive percutaneous screw combined with intramedullary nail technology to fix the PMF in the tibial spiral fracture. This study aims to explore the effectiveness and advantages of this technology. MATERIALS AND METHODS From January 2017 to February 2020, 116 cases of spiral fracture of tibia combined with PMF who were operated in our hospital were divided into Fixation Group (FG) and No Fixation Group (NG) according to whether PMF was fixed. After minimally invasive percutaneous screw fixation of ankle fracture in FG patients, the tibial intramedullary nail was inserted to fix the fracture. Collected the operation and postoperative recovery of the two groups of patients, including the operation time, intraoperative blood loss, AOFAS score, VAS score and dorsiflexion restriction of ankle joint at the last follow-up, and compared whether there is any difference between the two groups of patients. RESULTS The fracture of both groups healed.2 patients in NG had secondary displacement of PMF during operation, and the fracture finally healed after fixation. There were statistical differences between the two groups in terms of operation time, AOFAS score and weight bearing time. The operation time of FG was 67.9±11.2 min, and that of NG was 60.8±9.4 min; The weight bearing time of FG was 57.35±34.72 days, and that of NG was 69.17±21.43 days; The AOFAS score of FG was 92.50±3.46, and that of NG was 91.00±4.16. There were no significant difference in blood loss, VAS and dorsiflexion restriction of ankle joint between the two groups. The blood loss of FG was 66.8±12.3 ml, the blood loss of NG was 65.6±11.7 ml, the VAS score of FG was 1.37±0.47, the VAS score of NG was 1.43±0.51, the dorsiflexion restriction of FG was 5.8±4.1; the NG was 6.1±5.7. CONCLUSION For the injury of tibial spiral fracture combined with PMF, our fixation technology can achieve minimally invasive fixation of PMF with percutaneous screws on the basis of intramedullary nail fixation of tibial fracture, promoting early functional exercise of ankle joint and early weight bearing of patients. This fixation technology is also characterized by simple and fast operation.
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Affiliation(s)
- Hongfei Qi
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, No. 555, East Youyi Road, Xi'an, 710000, Shaanxi, People's Republic of China
| | - Zhong Li
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, No. 555, East Youyi Road, Xi'an, 710000, Shaanxi, People's Republic of China.
| | - Teng Ma
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, No. 555, East Youyi Road, Xi'an, 710000, Shaanxi, People's Republic of China
| | - Cheng Ren
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, No. 555, East Youyi Road, Xi'an, 710000, Shaanxi, People's Republic of China
| | - Yibo Xu
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, No. 555, East Youyi Road, Xi'an, 710000, Shaanxi, People's Republic of China
| | - Qiang Huang
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, No. 555, East Youyi Road, Xi'an, 710000, Shaanxi, People's Republic of China
| | - Haoxuan Feng
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, No. 555, East Youyi Road, Xi'an, 710000, Shaanxi, People's Republic of China
| | - Kun Zhang
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, No. 555, East Youyi Road, Xi'an, 710000, Shaanxi, People's Republic of China
| | - Yao Lu
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, No. 555, East Youyi Road, Xi'an, 710000, Shaanxi, People's Republic of China
| | - Ming Li
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, No. 555, East Youyi Road, Xi'an, 710000, Shaanxi, People's Republic of China.
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12
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Willey MC, Kern AM, Goetz JE, Marsh JL, Anderson DD. Biomechanical guidance can improve accuracy of reduction for intra-articular tibia plafond fractures and reduce joint contact stress. J Orthop Res 2023; 41:546-554. [PMID: 35672888 PMCID: PMC9726992 DOI: 10.1002/jor.25393] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/15/2022] [Accepted: 05/26/2022] [Indexed: 02/04/2023]
Abstract
Articular fracture malreduction increases posttraumatic osteoarthritis (PTOA) risk by elevating joint contact stress. A new biomechanical guidance system (BGS) that provides intraoperative assessment of articular fracture reduction and joint contact stress based solely on a preoperative computed tomography (CT) and intraoperative fluoroscopy may facilitate better fracture reduction. The objective of this proof-of-concept cadaveric study was to test this premise while characterizing BGS performance. Articular tibia plafond fractures were created in five cadaveric ankles. CT scans were obtained to provide digital models. Indirect reduction was performed in a simulated operating room once with and once without BGS guidance. CT scans after fixation provided models of the reduced ankles for assessing reduction accuracy, joint contact stresses, and BGS accuracy. BGS was utilized 4.8 ± 1.3 (mean ± SD) times per procedure, increasing operative time by 10 min (39%), and the number of fluoroscopy images by 31 (17%). Errors in BGS reduction assessment compared to CT-derived models were 0.45 ± 0.57 mm in translation and 2.0 ± 2.5° in rotation. For the four ankles that were successfully reduced and fixed, associated absolute errors in computed mean and maximum contact stress were 0.40 ± 0.40 and 0.96 ± 1.12 MPa, respectively. BGS reduced mean and maximum contact stress by 1.1 and 2.6 MPa, respectively. BGS thus improved the accuracy of articular fracture reduction and significantly reduced contact stress. Statement of Clinical Significance: Malreduction of articular fractures is known to lead to PTOA. The BGS described in this work has potential to improve quality of articular fracture reduction and clinical outcomes for patients with a tibia plafond fracture.
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Affiliation(s)
- Michael C Willey
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, USA
| | - Andrew M Kern
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, USA
| | - Jessica E Goetz
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, USA
| | - John Lawrence Marsh
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, USA
| | - Donald D Anderson
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, USA
- Department of Biomedical Engineering, University of Iowa, Iowa City, Iowa, USA
- Department of Industrial and Systems Engineering, University of Iowa, Iowa City, Iowa, USA
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13
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Wang C, Chen C, Zhou Y, Pan ZE. Morphological study of CT image of posterior pilon variant fracture and its possible clinical significance. Arch Orthop Trauma Surg 2023; 143:1203-1215. [PMID: 34705073 DOI: 10.1007/s00402-021-04224-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 10/11/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The incidence of posterior pilon variant fractures has been underestimated. The purpose was to study the characteristics of posteromedial (PM) and posterolateral (PL) fragments in CT imaging of posterior pilon variant fractures, and to provide help for clinical diagnosis and treatment. METHODS CT imaging data of 109 cases of posterior pilon variant fractures in our hospital from January 2013 to December 2020 were retrospectively analyzed. According to Mason and Molloy classification, PM fragments were further divided into pilon subtypes and avulsed subtypes. The largest actual area of fragments in axial and sagittal were selected as the study plane, and the maximum axial lengths of X, Y and Z, α angle, β angle, fragment area (S1-7) and fragment area ratio (FAR1-4), interfragmentary (IF) angle, and back of tibia (BT) angle were measured. RESULTS A total of 109 cases were included in this study, 61 of whom were pilon subtypes [90.16% were supination-external rotation (SER) injuries]. 48 cases were avulsed subtypes [81.25% were pronation-external rotation (PER) injuries]. Pilon subtypes were larger than avulsed subtypes in X, Y, Z, α2 Angle, β2 Angle, fragment area and ratio, and IF and BT angle (P < 0.05). There was no difference between α1 and β1 angle (P > 0.05). CONCLUSION The morphology of pilon subtype was larger than that of avulsion subtype. According to fragment size, morphology, and injury mechanism, two fragments of pilon subtype should be anatomic reduction and fixation. However, the PL fragment of avulsion subtype should to be fixed, while PM fragment may only need conservative treatment.
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Affiliation(s)
- Chenglong Wang
- Department of Orthopaedics, Taizhou Hospital of Zhejiang Province, Taizhou, 318000, Zhejiang, People's Republic of China
| | - Chengwei Chen
- Department of Orthopaedics, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, People's Republic of China
| | - Yeli Zhou
- Department of Orthopaedics, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, People's Republic of China
| | - Zhe-Er Pan
- Department of Orthopaedics, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, People's Republic of China.
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14
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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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15
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Kleinertz H, Mueller E, Tessarzyk M, Frosch KH, Schlickewei C. Computed tomography-based classifications of posterior malleolar fractures and their inter- and intraobserver reliability: a comparison of the Haraguchi, Bartoníček/Rammelt, and Mason classifications. Arch Orthop Trauma Surg 2022; 142:3895-3902. [PMID: 35094134 DOI: 10.1007/s00402-021-04315-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 12/13/2021] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Complex ankle fractures often include fractures of the posterior malleolus. The most clinically relevant posterior malleolus fracture classifications are computed tomography (CT) based. These classifications aim to enable clear communication and help develop treatment strategies. This study investigates the inter- and intraobserver reliability of the Haraguchi, Bartoníček/Rammelt and Mason posterior malleolar fracture classifications. MATERIALS AND METHODS CT scans of 113 patients with a mean age of 56.2 (SD ± 17.8) years and fractures involving the posterior malleolus were analyzed twice by 4 observers with different levels of training. The posterior malleolar fractures were classified according to Haraguchi et al., Bartoníček/Rammelt et al. and Mason et al. The intraobserver and interobserver reliabilities were determined by calculating Cohen's and Fleiss' kappa values. RESULTS We found substantial multi-rater interobserver agreement for all three classifications. The Haraguchi classification 0.799 (CI 0.744-0.855) showed the highest agreement, followed by the Bartoníček/Rammelt 0.744 (0.695-0.793) and Mason 0.717 (CI 0.666-0.768) classifications. Subgroup analyses showed substantial to perfect agreement for the Haraguchi and substantial agreement for the Bartoníček/Rammelt and Mason classifications independent of observer expertise. The intraobserver reliability was perfect for three and substantial for one of the observers. However, the classifications have certain pitfalls and do not consider the number of fragments, articular surface impressions, or intercalary fragments. CONCLUSION All classifications show substantial, if not perfect inter- and intraobserver reliabilities independent of observer level of expertise.
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Affiliation(s)
- Holger Kleinertz
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Elena Mueller
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Marlon Tessarzyk
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.,Department of Trauma Surgery, Orthopaedics, and Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany
| | - Carsten Schlickewei
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
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16
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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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Jiang Z, Zhang C, Qin JJ, Wang GD, Wang HS. Posterior pilon fracture treated by opening the fibula fracture gap. J Orthop Surg Res 2022; 17:214. [PMID: 35392983 PMCID: PMC8991660 DOI: 10.1186/s13018-022-03106-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 03/29/2022] [Indexed: 11/10/2022] Open
Abstract
Background Posterior pilon fracture is a relatively common clinical fracture involving the posterior articular surface of the distal tibia. Currently, this form of fracture is receiving increasing attention. The surgical approach and technique for the treatment of posterior pilon fractures are still controversial. The purpose of this retrospective study was to compare the clinical and imaging outcomes of pilon fractures after treatment with the open fibula fracture line (OFFL) surgical technique versus the traditional posterolateral approach (TPL). Methods A retrospective analysis of patients with posterior pilon fractures treated using the open fibula fracture line technique and the traditional posterolateral approach between January 2015 and March 2020. Thirty-one cases were included in the open fibula fracture line technique group and twenty-eight cases were included in the traditional posterolateral approach group. We used the Burwell-Charnley scale to assess the effectiveness of surgical repositioning. The clinical outcomes were evaluated using American Orthopaedic Foot & Ankle Society ankle-hind foot score (AOFAS) and visual analog score (VAS). Results The overall anatomic reduction rate was slightly better in the open fibula fracture line group than in the conventional posterolateral group (81% vs. 71%, p = 0.406), but there was no statistically significant difference between the two groups. There were no statistically significant differences between the two groups in terms of fracture healing time and time to full weight bearing (p > 0.05). At the final follow-up, the AOFAS functional score of the open fibula fracture line group was statistically superior to that of the conventional posterolateral group (p < 0.05). However, there was no statistical difference between the two groups in VAS pain scores at rest, during activity, and under weight bearing (p > 0.05). Conclusion The trans-fibular fracture approach provides a better surgical option for specific types of posterior pilon fractures with a high rate of anatomic repositioning and a good near-term outcome. Trial registration: Retrospective registration.
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Affiliation(s)
- Zhuang Jiang
- Orthopaedic Department, General Hospital of Central Theater Command of PLA, #627 Wuluo Road, Wuchang District, Wuhan, 430070, China.,Clinical Medicine, Wuhan University of Science and Technology, #2, West Huangjiahu Road, Hongshan District, Wuhan, 430081, China
| | - Chen Zhang
- Orthopaedic Department, General Hospital of Central Theater Command of PLA, #627 Wuluo Road, Wuchang District, Wuhan, 430070, China
| | - Jia-Jun Qin
- Orthopaedic Department, General Hospital of Central Theater Command of PLA, #627 Wuluo Road, Wuchang District, Wuhan, 430070, China
| | - Guo-Dong Wang
- Orthopaedic Department, General Hospital of Central Theater Command of PLA, #627 Wuluo Road, Wuchang District, Wuhan, 430070, China.
| | - Hua-Song Wang
- Orthopaedic Department, General Hospital of Central Theater Command of PLA, #627 Wuluo Road, Wuchang District, Wuhan, 430070, China.
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Seo J, Yang KH, Shim DW, Cho H, Park YC. Marginal impaction associated with posterior malleolar fracture in rotational ankle injury. Injury 2022; 53:756-761. [PMID: 34924191 DOI: 10.1016/j.injury.2021.12.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 12/04/2021] [Indexed: 02/02/2023]
Abstract
AIM This study aimed to introduce the circle drawing method for the evaluation of marginal impaction associated with posterior malleolar fractures (PMFs) on computed tomography (CT) images and evaluate the marginal impaction based on PMF patterns (Bartonícek classification) in rotational ankle fractures. METHODS From January 2014 to December 2019, A total of 299 patients were reviewed retrospectively. The circle drawing method consists of matching the articular surface of the intact tibial plafond with a best-fitted circle on the sagittal CT image. The mismatch gap between the circle and the articular surface indicates the presence of marginal impaction. To validate the circle drawing method, we assessed CT images of 60 ankles without fracture at the medial, central, and lateral parts using the new method. RESULTS Based on the review of the preoperative CT scan, 153 out of 299 patients (51.2%) were identified as having PMFs. Among them, 57 patients (37.3%) had marginal impaction associated with PMFs. For small posterolateral type 2 fractures, 58% of patients (47/81) had marginal impaction, and its incidence was most frequent among all types (P<.01). For posteromedial extended type 3 fractures, 27% of patients (8/30) had marginal impaction. Extraincisural type 1 and large posterolateral triangular type 4 fractures were rarely associated with marginal impaction. Among the 180 zones of 60 ankles without fracture, 171 zones (95%) were perfectly fitted to a best-fitted circle. CONCLUSIONS The marginal impaction associated with PMFs is often observed in rotational ankle fractures, particularly in small posterolateral and posteromedial extended fractures.
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Affiliation(s)
- Jiwoon Seo
- Department of Radiology, Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Kyu-Hyun Yang
- Department of Orthopedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; Department of Orthopedic Surgery, Armed Forces Capital Hospital, Seongnam, Korea
| | - Dong Woo Shim
- Department of Orthopedic Surgery, International ST. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, Republic of Korea
| | - Hyunik Cho
- Department of Orthopedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young-Chang Park
- Department of Orthopedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Lisitano L, Mayr E, Rau K, Wiedl A, Reuter J, Foerch S. Accompanying injuries in tibial shaft fractures: how often is there an additional violation of the posterior malleolus and which factors are predictive? A retrospective cohort study. Eur J Trauma Emerg Surg 2022; 48:3171-3176. [PMID: 35076729 PMCID: PMC9360070 DOI: 10.1007/s00068-021-01866-y] [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] [Received: 06/28/2021] [Accepted: 12/26/2021] [Indexed: 11/29/2022]
Abstract
Introduction An undislocated fracture of the posterior malleolus is a common concomitant injury in tibial shaft spiral fractures. Nevertheless, these accompanying injuries cannot always be reliably assessed using conventional X-rays. Thus, the aim of the study is to evaluate how often a fracture of the posterior malleolus occurs with tibial shaft fractures (AO:42A/B/C and AO:43A) and which factors—identifiable in conventional X-rays—are predictive. Methods Retrospective evaluation of X-ray and CT images revealed a total of 103 patients with low-energy tibial shaft fractures without direct joint involvement. Proximal fractures and fractures involving the knee were excluded. Basic data on injury, the trauma mechanism, the path of the fracture, bony avulsions of the posterior syndesmosis and the procedures performed were evaluated. Results Thirty-nine fractures were located in the middle third of the tibia, 64 in the distal third. In 65 cases, a spiral fracture (simple or wedge fracture) was found. In 31/103 fractures, an additional osseous avulsion of the posterior syndesmosis could be detected, 5 (16.1%) of them were not recognized preoperatively due to an absence of CT imaging. In three of these patients, a fracture of the posterior malleolus was only recognized postoperatively, and an additional surgery was necessary. The spiral fractures were classified in the a.p. X-ray according to their path from lateral proximal to medial distal (Type A) or from medial proximal to lateral distal (Type B). A Pearson chi-square test and Fisher’s exact test showed a highly significant accumulation of accompanying posterior malleolus fractures for type A fractures (p = 0.001), regardless of the location of the fracture. In addition, the fractures with involvement of the posterior malleolus had a significantly higher proportion in the fractures of the distal third (p = 0.003). There was no statistically significant relationship between the height of the fracture and the path of the fracture (type A or B). These two factors seem to be independent factors for participation of the posterior malleolus. Conclusion In 40.6% of the tibial shaft fractures in the distal third, in 56.9% of the type A spiral fractures and in 67.6% of the type A fractures in the distal third, the ankle joint is involved with bony avulsion of the posterior syndesmosis, which is not always recognized in conventional X-rays. To avoid complications such as additional operations, instability and post-traumatic arthrosis, we recommend preoperative imaging of the ankle using CT for these fractures. Level of evidence III, retrospective cohort study. Trail registration number DRKS00024536.
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Affiliation(s)
- Leonard Lisitano
- Universitätsklinikum Augsburg, Klinik Für Unfallchirurgie, Orthopädie, Plastische und Handchirurgie, Stenglinstr. 2, 86156, Augsburg, Germany.
| | - Edgar Mayr
- Universitätsklinikum Augsburg, Klinik Für Unfallchirurgie, Orthopädie, Plastische und Handchirurgie, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Kim Rau
- Universitätsklinikum Augsburg, Klinik Für Unfallchirurgie, Orthopädie, Plastische und Handchirurgie, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Andreas Wiedl
- Universitätsklinikum Augsburg, Klinik Für Unfallchirurgie, Orthopädie, Plastische und Handchirurgie, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Jan Reuter
- Universitätsklinikum Augsburg, Klinik Für Unfallchirurgie, Orthopädie, Plastische und Handchirurgie, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Stefan Foerch
- Universitätsklinikum Augsburg, Klinik Für Unfallchirurgie, Orthopädie, Plastische und Handchirurgie, Stenglinstr. 2, 86156, Augsburg, Germany
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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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21
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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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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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Behlmer RJ, Simske NM, Graf RM, Kliethermes SA, Lang GJ, Whiting PS. Diagnosing Fractures of the Distal Tibial Articular Surface in Tibia Shaft Fractures: Is Computed Tomography Always Necessary? J Orthop Trauma 2021; 35:485-489. [PMID: 33840735 DOI: 10.1097/bot.0000000000002135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/29/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To identify the incidence of distal articular fractures in a series of distal third tibia shaft fractures and to report the utility of both computed tomography (CT) scans and Radiographic Investigation of the Distal Extension of Fractures into the Articular Surface of the Tibia (RIDEFAST) ratios for identification of articular involvement. DESIGN Retrospective cohort. SETTING Level 1 trauma center. PATIENTS Four hundred seventeen patients with distal third tibia shaft fractures were included in the study. INTERVENTION Intramedullary nail or plate fixation. MAIN OUTCOME MEASURES Type of articular fracture, time of diagnosis, and RIDEFAST ratios. RESULTS One hundred one of the 417 distal third fractures (24%) had a fracture of the distal tibia articular surface. Of these 101 fractures, 41 (41%) represented an extension of the primary fracture line and 60 (59%) were separate malleolar fractures. Of the 101 articular fractures, 95 (94%) were identified preoperatively and 6 (6%) were identified intraoperatively. Of the 95 fractures identified preoperatively, 87 (92%) were identified on plain radiographs and 8 (8%) by CT scan. Thirty-five preoperative CT scans were performed on distal third tibia shaft fractures in search of an intra-articular fracture. In 27 patients (77%), no articular fracture was present, representing an overall yield of 23% among CT scans performed to rule out an articular fracture in distal third tibia shaft fractures. RIDEFAST ratios for all 101 distal tibia shaft fractures with articular involvement and 100 fractures with no articular involvement were not significantly different (P > 0.05) using both coronal and sagittal plane measurements. CONCLUSIONS CT scans performed on distal third tibia shaft fractures in search of articular fractures had a low yield (23%). Widespread use of CT scan to diagnose fractures of the distal tibia articular surface in the setting of distal tibia shaft fractures does not seem warranted. No statistically significant differences in RIDEFAST ratios were found between fractures with and without articular involvement, indicating that more work is necessary before RIDEFAST can be used to reliably rule out articular involvement in this setting. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Richard J Behlmer
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, WI
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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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Abstract
In patients with ankle fractures, the presence of a posterior malleolar fracture has a negative impact on the prognosis. Computed tomography (CT) scanning is essential for fracture classification and treatment planning, as the indication for surgery depends on the 3-dimensional fragment outline and displacement, incisura involvement, and the presence of joint impaction. Anatomic reduction of a posterior malleolar fragment restores the incisura, facilitating reduction of the distal part of the fibula, and it also restores the integrity of the posterior portion of the syndesmosis, reducing the need for additional syndesmotic stabilization. Direct open reduction and fixation of posterior malleolar fragments from a posterior orientation is biomechanically more stable and provides a more accurate reduction than does indirect reduction and anterior-to-posterior screw fixation. Intra-articular step-off of >=2 mm is an independent risk factor for an inferior outcome and the development of posttraumatic arthritis, irrespective of the fragment size.
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Affiliation(s)
- Stefan Rammelt
- University Center of Orthopaedics and Traumatology, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Jan Bartoníček
- Department of Orthopaedics, First Faculty of Medicine, Charles University and Central Military Hospital Prague, Prague, Czech Republic.,Department of Anatomy, First Faculty of Medicine, Charles University Prague, Prague, Czech Republic
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26
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Quan Y, Lu H, Xu H, Liu Y, Xie W, Zhang B, Zhang D, Jiang B. The Distribution of Posterior Malleolus Fracture Lines. Foot Ankle Int 2021; 42:959-966. [PMID: 33745344 DOI: 10.1177/1071100721996700] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The morphology and classification of posterior malleolus (PM) fractures remain controversial. An increasing number of studies have found that merely focusing on the fragment size does not lead to a satisfactory prognosis. This study aimed to demonstrate the fracture line and comminution zones of PM fractures using computed tomography (CT), in order to provide insights into the injury mechanism of PM fractures. METHODS We retrospectively reviewed the data of 95 patients with PM fractures between 2013 and 2018 at a level 1 trauma center. The CT data of the PM of the patients were reconstructed using software. Images of all patients were superimposed together, and drawn as a heat map of the fragments and line distributions of PM fractures. RESULTS Our study included 66 type I, 19 type II, and 10 type III PM fractures according to the classification of Haraguchi. In the single-fragment fracture group, the fracture lines were mainly concentrated in the posterolateral tibial tubercle area (Volkmann's tubercle) and a larger tubercle area involving the tibialis posterior groove. In the multifragment fracture group, there were 10 (43.5%) patients with a 2-fragment pattern and 13 (56.5%) patients with a compressive-fragment pattern. CONCLUSION According to the fracture map and previous studies on the syndesmosis, our study provides a different understanding of the pathomechanisms of ankle injuries compared with previous classifications of PM fractures. LEVEL OF EVIDENCE Level III, retrospective study.
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Affiliation(s)
- Yuan Quan
- Orthopaedic and Traumatology, Peking University People's Hospital, Beijing, China.,Key Laboratory of Trauma and Neural Regeneration (Peking University), Ministry of Education, Beijing, China
| | - Hao Lu
- Orthopaedic and Traumatology, Peking University People's Hospital, Beijing, China
| | - Hailin Xu
- Orthopaedic and Traumatology, Peking University People's Hospital, Beijing, China
| | - Yijun Liu
- Orthopaedic and Traumatology, Peking University People's Hospital, Beijing, China
| | - Wenyong Xie
- Orthopaedic and Traumatology, Peking University People's Hospital, Beijing, China
| | - Boyu Zhang
- Orthopaedic and Traumatology, Peking University People's Hospital, Beijing, China
| | - Dianying Zhang
- Orthopaedic and Traumatology, Peking University People's Hospital, Beijing, China
| | - Baoguo Jiang
- Orthopaedic and Traumatology, Peking University People's Hospital, Beijing, China
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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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Wang Z, Chen W, Zhu Y, Tian S, Zhao K, Guo J, Hou Z, Zhang Q, Zhang Y. Incidence and missed diagnosis risk of occult posterior malleolar fractures associated with the tibial shaft fractures: a systematic review. J Orthop Surg Res 2021; 16:355. [PMID: 34074309 PMCID: PMC8167951 DOI: 10.1186/s13018-021-02502-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 05/23/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Tibial shaft fractures (TSFs) combined with occult posterior malleolar fractures (PMFs) are becoming widely recognized in the field of orthopedics. The purpose of this study was to determine the clinical incidence, missed diagnosis rate, and treatment strategies of this combined injury. METHODS PubMed, Cochrane, and MEDLINE Ovid databases were searched for articles of English language from 1988 to 2020, identifying 1549 papers. RESULTS Twenty-one of the 1278 identified studies were eligible for inclusion. Each study reported on the incidence of this combined injury, and 12 studies documented the missed diagnosis rate. Seventeen studies reported surgical intervention strategies for PMFs. In the present review, PMFs frequently occurred in spiral TSFs (70%), especially distal third spiral TSFs (70.4%), based on CT scans or additional MRI. Based on the original X-ray detection, approximately 50% of PMFs were missed in patients with a combined injury. In addition, the treatment strategies for PMFs were inconsistent. Most studies (11/17) believe that specific surgical management needs to be developed based on the fragment size, displacement, and stability of the PMF. CONCLUSIONS For patients with TSFs, spiral TSFs, especially distal third spiral TSFs, are closely related to PMFs and are often not sufficiently diagnosed by X-ray alone. Advanced CT and MRI examinations can significantly reduce the missed diagnosis rate of occult PMFs. According to available literature, the treatment strategy for PMFs associated with TSFs is questionable without convincing evidence of benefit.
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Affiliation(s)
- Zhongzheng Wang
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Qiaoxi District, Shijiazhuang, 050051, Hebei Province, People's Republic of China
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, People's Republic of China
| | - Wei Chen
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Qiaoxi District, Shijiazhuang, 050051, Hebei Province, People's Republic of China
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, People's Republic of China
- NHC Key Laboratory of Intelligent Orthopaedic Equipment, Shijiazhuang, 050051, People's Republic of China
| | - Yanbin Zhu
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Qiaoxi District, Shijiazhuang, 050051, Hebei Province, People's Republic of China
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, People's Republic of China
- NHC Key Laboratory of Intelligent Orthopaedic Equipment, Shijiazhuang, 050051, People's Republic of China
| | - Siyu Tian
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Qiaoxi District, Shijiazhuang, 050051, Hebei Province, People's Republic of China
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, People's Republic of China
| | - Kuo Zhao
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Qiaoxi District, Shijiazhuang, 050051, Hebei Province, People's Republic of China
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, People's Republic of China
| | - Jialiang Guo
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Qiaoxi District, Shijiazhuang, 050051, Hebei Province, People's Republic of China
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, People's Republic of China
| | - Zhiyong Hou
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Qiaoxi District, Shijiazhuang, 050051, Hebei Province, People's Republic of China
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, People's Republic of China
- NHC Key Laboratory of Intelligent Orthopaedic Equipment, Shijiazhuang, 050051, People's Republic of China
| | - Qi Zhang
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Qiaoxi District, Shijiazhuang, 050051, Hebei Province, People's Republic of China.
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, People's Republic of China.
- NHC Key Laboratory of Intelligent Orthopaedic Equipment, Shijiazhuang, 050051, People's Republic of China.
| | - Yingze Zhang
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Qiaoxi District, Shijiazhuang, 050051, Hebei Province, People's Republic of China.
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, People's Republic of China.
- NHC Key Laboratory of Intelligent Orthopaedic Equipment, Shijiazhuang, 050051, People's Republic of China.
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29
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Pogliacomi F, De Filippo M, Casalini D, Longhi A, Tacci F, Perotta R, Pagnini F, Tocco S, Ceccarelli F. Acute syndesmotic injuries in ankle fractures: From diagnosis to treatment and current concepts. World J Orthop 2021; 12:270-291. [PMID: 34055585 PMCID: PMC8152437 DOI: 10.5312/wjo.v12.i5.270] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 04/14/2021] [Accepted: 04/28/2021] [Indexed: 02/06/2023] Open
Abstract
A stable and precise articulation of the distal tibiofibular syndesmosis maintains the tibiofibular relationship, and it is essential for normal motion of the ankle joint. The disruption of this joint is frequently accompanied by rotational ankle fracture, such as pronation-external rotation, and rarely occurs without ankle fracture. The diagnosis is not simple, and ideal management of the various presentations of syndesmotic injury remains controversial to this day. Anatomical restoration and stabilization of the disrupted tibiofibular syndesmosis is essential to improve functional outcomes. In such an injury, including inadequately treated, misdiagnosed and correctly diagnosed cases, a chronic pattern characterized by persistent ankle pain, function disability and early osteoarthritis can result. This paper reviews anatomical and biomechanical characteristics of this syndesmosis, the mechanism of its acute injury associated to fractures, radiological and arthroscopic diagnosis and surgical treatment.
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Affiliation(s)
| | - Massimo De Filippo
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy
| | - Daniele Casalini
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy
| | - Alberto Longhi
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy
| | - Fabrizio Tacci
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy
| | - Rocco Perotta
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy
| | - Francesco Pagnini
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy
| | - Silvio Tocco
- Centro Riabilitativo della Mano e Arto Superiore, Parma 43121, Italy
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30
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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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Nasrallah K, Einal B, Shtarker H. Trimalleolar fracture: The endless posterior malleolus fracture debate, to repair or not to repair? Orthop Rev (Pavia) 2021; 13:8784. [PMID: 33897988 PMCID: PMC8054658 DOI: 10.4081/or.2021.8784] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 10/24/2020] [Indexed: 01/18/2023] Open
Abstract
Ankle fracture is one of the most common fractures presenting in the emergency department. The fracture varies from unimalleolar, bimalleolar or trimalleolar. Involvement of the posterior malleolus is common and ranges from small avulsions to large intraarticular fragments causing subluxation of the talus. If left untreated, the resulting step-off, comminution or posterior talar subluxation may lead to osteoarthritis and further disability. To date, no consensus exists regarding the management of posterior malleolus fractures in the set-up of trimalleolar fractures. In this review we provide an overview of the literature on the available treatment options for posterior malleolar fracture in the set-up of trimalleolar fractures.
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Affiliation(s)
- Khalil Nasrallah
- Galilee Medical Center, Department of Orthopedics, Nahariya, Israel
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Liu B, Jin R, Rai S, Liu R, Hong P. Additional table for easier access to ankle fracture: A retrospective study of traditional positioning versus modified positioning. Medicine (Baltimore) 2020; 99:e23146. [PMID: 33157997 PMCID: PMC7647510 DOI: 10.1097/md.0000000000023146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
An interest in the fixation of posterior malleolus via the posterolateral approach has gained popularity recently. Most surgeons choose prone or lateral position during the surgery, and this study proposes an additional radiolucent table for easier access to the posterolateral anatomic structure of ankle joint, and compares it with traditional positioning.From September 2014 to September 2018, 21 patients with trimalleolar fractures and 28 patients with posterior malleolus and fibular fractures receiving open reduction and internal fixation (ORIF) using the posterolateral approach with the utilization of an additional radiolucent table were included in Additional Table group. Patients of matched sex, age, and injury type using the same surgical approach with the traditional positioning were selected from the hospital database and included in the Traditional group. Baseline information and clinical parameters were recorded.No significant differences existed concerning age, sex, or operative side between the 2 groups in patients with trimalleolar fractures. The time for positioning was significantly longer in the Traditional group (20.5 ± 6.45 minutes) than the Additional Table group (12 ± 3.5 minutes) (P < .001). Besides, the operative time in the Traditional group (75.28 ± 5.45 minutes) was significantly longer than the Additional Table group (58 ± 5.95 minutes) (P < .001). There was no case of nonunion and malunion in both groups. At 12-month follow-up, the American Orthopedic Foot and Ankle Society Scale (AOFAS) score showed no significant difference between the 2 groups (P = .46). In patients with fibular fracture and posterior malleolus fracture, no significant differences existed concerning age, sex, operative side between the 2 groups. The time for positioning was significantly longer in the Traditional group (16.5 ± 3.45 minutes) than the Additional Table group (11 ± 3.5 minutes) (P < .001). Besides, the operative time in the Traditional group (55.28 ± 8.45 minutes) was significantly longer than the Additional Table group (44 ± 7.95 minutes) (P < .001). There was no case of nonunion and malunion in both groups. At the 12-month follow-up, the AOFAS score showed no significant difference between the 2 groups (P = .26).The novel positioning with an additional table is an excellent choice for trimalleolar fracture, posterior malleolus fracture, with/without distal fibular fracture.
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Affiliation(s)
- Bo Liu
- Department of Orthopaedics, Chongqing High-tech Zone People's Hospital, Chongqing
| | - Rui Jin
- Department of Thyroid and Breast Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Saroj Rai
- Department of Orthopaedics and Trauma Surgery, National Trauma Center, National Academy of Medical Sciences, Mahankal, Kathmandu, Nepal
| | - Ruikang Liu
- First School of Clinical Medicine, Tongji Medical College
| | - Pan Hong
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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A Retrospective Study on the Morphology of Posterior Malleolar Fractures Based on a CT Scan: Whether We Ignore the Importance of Fracture Height. BIOMED RESEARCH INTERNATIONAL 2020; 2020:2903537. [PMID: 32802840 PMCID: PMC7414377 DOI: 10.1155/2020/2903537] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 07/11/2020] [Indexed: 01/31/2023]
Abstract
Objective The aim of this study was to investigate the respective correlation between the height (H) of a posterior malleolar fracture (PMF) and the involved area (S) of an articular surface and the presence of “die-punch.” Methods Patients with closed posterior malleolar fractures admitted to our hospital from January 2015 to December 2017 were selected, with complete X-ray and 3D reconstruction CT imaging data. The gender, age, injured side, and surgical fixation methods of the patients were recorded. A preoperative ankle CT scan was performed, and the images were viewed through the PACS (Picture Archiving and Communication Systems). Simultaneously, the involved joint surface area (S) by the posterior malleolar fracture was measured, as well as the proportion of the fracture area to the total ankle joint area. On the sagittal reconstruction CT images, the height (H) of the posterior malleolar fracture was measured to compare the correlation between the height of the fracture and the area of the fracture, as well as the area ratio. Besides, according to the presence or absence of “die-punch,” patients were divided into two groups: A and B. And each group was further divided into three subgroups according to age (16-39 years old, 40-59 years old, and ≥60 years old). The statistical differences in the height of fracture between the subgroups were compared. Results A total of 48 patients, aged 16-82 years, with an average age of 48.9 years, were included in this study, including 13 males and 35 females. There were 20 cases of left ankle injury and 28 cases of right ankle injury. The average height of the posterior malleolar fractures was 18.19 mm, the average area of the fracture was 202.28 mm2, and the average ratio of the fracture area to the total articular surface area was 17.84%. Besides, die-punch was seen in 27 cases and not in 21 cases. The average height of fractures was 21.33 ± 5.38 mm in group A1, 14.38 ± 9.01 mm in group B1, 18.30 ± 7.95 mm in group A2, 14.48 ± 5.37 mm in group B2, 26.26 ± 6.73 mm in group A3, and 12.77 ± 3.07 mm in group B3. Conclusion The height (H) of the posterior malleolar fractures is positively correlated with the fracture area (S) and the fracture area ratio (FAR). The posterior malleolar fractures with “die-punch” tend to have a greater average height than that without “die-punch.” In clinical work, orthopedic surgeons should not only pay attention to the size of the posterior malleolus fracture but also value its height, which hopefully could provide insight into the treatment and prognosis of PMF patients.
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Zbeda RM, Friedel SP, Katchis SD, Weiner L. Open Reduction and Internal Fixation of Posterior Malleolus Fractures via a Posteromedial Approach. Orthopedics 2020; 43:e166-e170. [PMID: 32077968 DOI: 10.3928/01477447-20200213-01] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 03/11/2019] [Indexed: 02/03/2023]
Abstract
Ankle fractures with a posterior malleolus component are complex injuries. The most commonly used operative methods include indirect reduction via a percutaneous anterior approach and direct reduction via a posterolateral approach. For large posterior malleolus fractures with medial extension, direct reduction via a posteromedial approach is an alternative operative option. The authors hypothesized that fixation of large posterior malleolus fractures via a posteromedial approach results in anatomic reduction and stable plate fixation. From 2008 to 2015, 22 (9.0%) of 244 consecutive operative ankle fractures were identified as posterior malleolus fractures treated using a posteromedial approach. Patient charts were retrospectively reviewed for demographics, operative details, follow-up time, and any postoperative complications. Postoperative radiographs were reviewed to ensure that anatomic reduction and stable fixation was maintained. Sixteen (72.7%) of 22 patients were female, and the average age at the time of surgery was 54.1 years (range, 26-86 years). The average follow-up time was 13.0 months (range, 2.0-41.4 months). Twenty-one (95.5%) of 22 patients healed on a radiographic and clinical basis. There was an 18.2% (4 of 22) postoperative complication rate: 1 patient had a nonunion, 1 patient had cellulitis, 1 patient had osteomyelitis involving the fibula, and 1 patient had symptomatic heterotopic ossification. Open reduction and internal fixation of posterior malleolus fractures via a posteromedial approach achieved anatomic reduction, stable plate fixation, and complete healing in all but 1 patient. This study demonstrates that the posteromedial approach is a reasonable alternative to other more commonly used methods for treating these fractures. [Orthopedics. 2020;43(3):e166-e170.].
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Gupta S, Virk JS, Malhotra A, Garg SK. Fragment-specific fixation of trimalleolar fractures utilizing the posterolateral approach: A preliminary experience. J Orthop Surg (Hong Kong) 2020; 27:2309499019842289. [PMID: 31079568 DOI: 10.1177/2309499019842289] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Ankle fractures involving posterior malleolus are disabling injuries if not managed properly. Clinical and functional outcome of ankle fractures involving posterior tibial plafond is significantly worse. Although the surgical approach and techniques to reduce and fix this fracture are well described in the literature, there still seems to be divided consensus among orthopedic surgeons regarding the same. METHODS In this case series of eight patients with trimalleolar fractures, a posterolateral approach was used for fixation of posterior malleolus in all the cases. A preoperative computed tomography scan formed an integral part of management of such injuries. The Olerud and Molendar scoring system was employed at 12 months of follow-up to assess the functional outcome. Weight-bearing X-rays were taken to assess for any ankle arthritis. RESULTS The average age of patients was 48.8 years. The most common mode of sustaining injury was twisting of the ankle joint ( n = 5). The average time to union and full weight-bearing was 12.8 weeks (range 10-16 weeks). An excellent functional outcome in four patients and a good outcome in the rest of the four patients were obtained at the end of 12 months of follow-up. No significant ankle arthritis or complications were encountered. CONCLUSION Appropriate preoperative imaging evaluation is an integral part of planning for these complex injuries. The posterolateral approach provides good exposure for appropriate visualization. Stable fixation of posterior malleolus in trimalleolar fractures plays a vital role in obtaining a positive clinical and functional outcome.
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Affiliation(s)
- Sandeep Gupta
- Department of Orthopaedics, Government Medical College Hospital, Chandigarh, India
| | - Jagandeep Singh Virk
- Department of Orthopaedics, Government Medical College Hospital, Chandigarh, India
| | - Anubhav Malhotra
- Department of Orthopaedics, Government Medical College Hospital, Chandigarh, India
| | - Sudhir Kumar Garg
- Department of Orthopaedics, Government Medical College Hospital, Chandigarh, India
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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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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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Su QH, Liu J, Zhang Y, Tan J, Yan MJ, Zhu K, Zhang J, Li C. Three-dimensional computed tomography mapping of posterior malleolar fractures. World J Clin Cases 2020; 8:29-37. [PMID: 31970167 PMCID: PMC6962073 DOI: 10.12998/wjcc.v8.i1.29] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 11/28/2019] [Accepted: 11/30/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Posterior malleolar fractures have been reported to occur in < 40% of ankle fractures.
AIM To reveal the recurrent patterns and characteristics of posterior malleolar fractures by creating fracture maps of the posterior malleolar fractures through the use of computed tomography mapping.
METHODS A consecutive series of posterior malleolar fractures was used to create three-dimensional reconstruction images, which were oriented and superimposed to fit an ankle model template by both aligning specific biolandmarks and reducing reconstructed fracture fragments. Fracture lines were found and traced in order to generate an ankle fracture map.
RESULTS This study involved 112 patients with a mean age of 49, comprising 32 pronation-external rotation grade IV fractures and 80 supination-external rotation grade IV fractures according to the Lauge-Hansen classification system. Three-dimensional maps showed that the posterior ankle fracture fragments in the supination-external rotation grade IV group were relatively smaller than those in the pronation-external rotation grade IV group after posterior malleolus fracture. In addition, the distribution analyses on posterior malleolus fracture lines indicated that the supination-external rotation grade IV group tended to have higher linear density but more concentrated and orderly distribution fractures compared to the pronation-external rotation grade IV group.
CONCLUSION Fracture maps revealed the fracture characteristics and recurrent patterns of posterior malleolar fractures, which might help to improve the understanding of ankle fracture as well as increase opportunities for follow-up research and aid clinical decision-making.
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Affiliation(s)
- Qi-Hang Su
- Department of Orthopedics, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Juan Liu
- Department of the First Clinical Medical School, Shanxi Medical University, Taiyuan 030000, Shanxi Province, China
| | - Yan Zhang
- Department of Orthopedics, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Jun Tan
- Department of Orthopedics, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
- Department of Orthopedics, Pinghu Second People’s Hospital, Pinghu 314200, Zhejiang Province, China
| | - Mei-Jun Yan
- Department of Orthopedics, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Kai Zhu
- Department of Orthopedics, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Jin Zhang
- Department of Orthopedics, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Cong Li
- Department of Trauma Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
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Bergman C, Morin M, Lawson K. Anatomy, Classification, and Management of Ankle Fractures Involving the Posterior Malleolar Fragment: A Literature Review. FOOT & ANKLE ORTHOPAEDICS 2019; 4:2473011419887724. [PMID: 35097350 PMCID: PMC8697079 DOI: 10.1177/2473011419887724] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The posterior malleolar fragment is frequently involved in rotational ankle fractures, but diagnosis and definitive management remains controversial. Ankle fractures with a posterior malleolar component that are not identified and treated in a timely manner may contribute significantly to future comorbidities, including continued pain, instability, and the development of arthritis. This article highlights the anatomic features of posterior malleolar ankle fractures, the classification schemes used, and discusses the various nonsurgical and surgical methods currently used.
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Affiliation(s)
| | - Matthew Morin
- Department of Orthopedic Surgery, Banner University Medical Center, AZ, USA
| | - Kevin Lawson
- Department of Orthopedic Surgery, Banner University Medical Center, AZ, USA
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Chaparro F, Ahumada X, Urbina C, Lagos L, Vargas F, Pellegrini M, Barahona M, Bastias C. Posterior pilon fracture: Epidemiology and surgical technique. Injury 2019; 50:2312-2317. [PMID: 31630782 DOI: 10.1016/j.injury.2019.10.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 07/12/2019] [Accepted: 10/03/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To review a case series of patients with posterior pilon variant fracture using a novel approach, focusing on demographic data, injury pattern, surgical results based on computed tomography (CT) scan, and short-term complications. DESIGN Consecutive case series. SETTING Level I trauma center. PATIENTS/PARTICIPANTS Twenty-five patients with posterior pilon fracture. INTERVENTION Posterior pilon fracture open reduction and internal fixation. MAIN OUTCOME MEASUREMENTS Parameters measured included age, sex, type of fracture, surgical technique, anatomical reduction, and complications. RESULTS Twenty-five patients sustained a posterior pilon fracture, accounting for 13.4% of all operatively treated ankle fractures with median follow-up of 21.7 months. The average age of patients was 42 years (22-62); 19/25 (76%) were female, and 6/25 (24%) were male. A modified posteromedial approach was used in 18/25 (72%) patients. Persistent syndesmotic instability was present in 11/25 (44%) patients after posterior malleolar stabilization. Quality of reduction was assessed under CT scan in 19 patients, with 15/19 (78.9%) having anatomic reduction. We report 2/25 (8%) patients with early wound problems and 7/25 (20%) with short-term complications during follow-up. CONCLUSION Posterior pilon variant fracture appears to be less common than previously reported. Most fractures can be satisfactorily treated through a modified posteromedial approach. Albeit obtaining posterior malleolar fracture rigid fixation, syndesmotic instability was more prevalent than expected. The short-term complication rate was low. LEVEL OF EVIDENCE Therapeutic level IV.
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Affiliation(s)
- Felipe Chaparro
- Department of Orthopaedic Surgery, Clinica Universidad de Los Andes, Av. La Plaza 2501, Las Condes, Santiago 7620157, Chile; Department of Orthopaedic Surgery, Hospital Clínico Mutual de Seguridad, Alameda 4848, Estación Central, Santiago 9190015, Chile.
| | - Ximena Ahumada
- Department of Orthopaedic Surgery, Hospital Clínico Mutual de Seguridad, Alameda 4848, Estación Central, Santiago 9190015, Chile
| | - Christian Urbina
- Department of Orthopaedic Surgery, Hospital Clínico Mutual de Seguridad, Alameda 4848, Estación Central, Santiago 9190015, Chile
| | - Leonardo Lagos
- Department of Orthopaedic Surgery, Hospital Clínico Mutual de Seguridad, Alameda 4848, Estación Central, Santiago 9190015, Chile
| | - Fernando Vargas
- Department of Orthopaedic Surgery, Hospital Clínico Mutual de Seguridad, Alameda 4848, Estación Central, Santiago 9190015, Chile
| | - Manuel Pellegrini
- Department of Orthopaedic Surgery, Clinica Universidad de Los Andes, Av. La Plaza 2501, Las Condes, Santiago 7620157, Chile; Department of Orthopaedic Surgery, Hospital Clínico Universidad de Chile, Santos Dumont 999, Independencia, Santiago 7640275, Chile
| | - Maximiliano Barahona
- Department of Orthopaedic Surgery, Hospital Clínico Universidad de Chile, Santos Dumont 999, Independencia, Santiago 7640275, Chile
| | - Christian Bastias
- Department of Orthopaedic Surgery, Hospital Clínico Mutual de Seguridad, Alameda 4848, Estación Central, Santiago 9190015, Chile
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Rammelt S, Boszczyk A. Computed Tomography in the Diagnosis and Treatment of Ankle Fractures: A Critical Analysis Review. JBJS Rev 2019; 6:e7. [PMID: 30562210 DOI: 10.2106/jbjs.rvw.17.00209] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Stefan Rammelt
- University Center for Orthopaedics & Traumatology, University Hospital Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Andrzej Boszczyk
- Department of Traumatology and Orthopaedics, Centre of Postgraduate Medical Education, Prof. Adam Gruca Clinical Hospital, Otwock, Poland
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Jeyaseelan L, Malagelada F, Parker L, Panagopoulos A, Heidari N, Vris A. Intra-Operative 3-Dimensional Imaging (O-arm) in Foot and Ankle Trauma Surgery: Report of 2 Cases and Review of the Literature. Open Orthop J 2019. [DOI: 10.2174/1874325001913010189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
Background:
Intraoperative two-dimensional (2D) fluoroscopy is the standard imaging modality available to orthopaedic surgeons worldwide. It is well-accepted, however, multiplanar 3 dimensional (3D) CT scanning is superior to 2D imaging for visualising joint surfaces and is now a fundamental feature of the pre-operative planning of intra-articular fractures.
Objective:
We present two cases in which the use of 3D intraoperative imaging and the O-arm® (Medtronic, Minneapolis, USA) led to immediate intraoperative revision to optimise fixation and articular congruity. A review of the current literature is also provided.
Methods:
During the trial period of the O-arm at our major trauma centre, intra-operative imaging was used in the lower limb trauma setting. The O-arm was used intra-operatively in a comminuted pilon fracture and a displaced talus fracture. We recorded all the intra-operative events, including quality of reduction, implant positioning and operation time. Each patient was followed-up for 12 months post-operation and was finally assessed with x-rays and the AOFAS score.
Results:
In both the cases, either fracture reduction or the implant position/usage that was observed with 2D fluoroscopy was revised following a 3D intra-operative scan. No postoperative complications were noted and the healing process was uneventful. X-rays at the final follow-up were excellent and acceptable for the talus and pilon fracture, respectively, with corresponding clinical results and AOFAS score.
Conclusion:
Although frequently used in spinal surgery, to the best of our knowledge, the use of intra-operative 3D techniques in lower limb trauma is sparse and sporadically reported. We present our cases in which the most current innovative imaging techniques influenced intra-operative outcomes without compromising patient safety. We feel that this is a real example of how innovation can positively influence patient care.
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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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44
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Meulenkamp B, Louati H, Morellato J, Papp S, Lalonde KA. Posterior malleolus exposure. OTA Int 2019; 2:e021. [PMID: 37662836 PMCID: PMC10473347 DOI: 10.1097/oi9.0000000000000021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 11/18/2018] [Indexed: 09/05/2023]
Abstract
Objectives Posterior malleolus (PM) fractures are common in rotational ankle injuries, tibial plafond fractures, and distal third tibia fractures. Surgical indications continue to evolve as we improve our understanding of ankle and syndesmotic stability. These fractures remain technically challenging with respect to both exposure and fixation. Our biomechanical cadaveric study compared posterolateral versus modified posteromedial surgical approaches to define the following: maximal surface area exposed, and maximal screw trajectory obtainable for fixation. Methods Twelve fresh-frozen cadaver limbs were thawed at room temperature. Posterolateral and modified posteromedial approaches were performed on each limb. Margins of exposure were marked. A 2.5 mm drill was advanced at the extreme medial and lateral extents of each exposure, standardized at 1 cm proximal to the joint line and perpendicular to the bone. Computed tomography (CT) scans were performed to identify the maximal trajectory. Limbs were stripped of soft tissue, and the exposed bony surface area was measured using a validated laser surface-scanning technique. Results The modified posteromedial approach allowed for a larger exposed surface area compared to the posterolateral exposure (median 99% vs 64%, respectively; P < .05). The modified posteromedial approach allowed for instrumentation of up to a median of 77% of the posterior distal tibia as opposed to 46% through the posterolateral approach (P < .05). Conclusion The modified posteromedial approach allowed for increased exposure and wider access for instrumentation of the PM when compared to the posterolateral approach. We advocate use of this approach when addressing complex PM fractures, in particular the Haraguchi type 2 fracture pattern.
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Affiliation(s)
- Brad Meulenkamp
- Division of Orthopaedic Surgery, The Ottawa Hospital
- Department of Surgery, Faculty of Medicine, University of Ottawa
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Hakim Louati
- Division of Orthopaedic Surgery, The Ottawa Hospital
- Orthopaedics Biomechanics Laboratory, University of Ottawa
| | - John Morellato
- Division of Orthopaedic Surgery, The Ottawa Hospital
- Department of Surgery, Faculty of Medicine, University of Ottawa
| | - Steve Papp
- Division of Orthopaedic Surgery, The Ottawa Hospital
- Department of Surgery, Faculty of Medicine, University of Ottawa
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Karl Andre Lalonde
- Division of Orthopaedic Surgery, The Ottawa Hospital
- Department of Surgery, Faculty of Medicine, University of Ottawa
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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45
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Baumbach SF, Herterich V, Damblemont A, Hieber F, Böcker W, Polzer H. Open reduction and internal fixation of the posterior malleolus fragment frequently restores syndesmotic stability. Injury 2019; 50:564-570. [PMID: 30600086 DOI: 10.1016/j.injury.2018.12.025] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 12/03/2018] [Accepted: 12/17/2018] [Indexed: 02/02/2023]
Abstract
AIM Comparison of unfixed, CRIF, and ORIF of the posterior malleolus fragment (PMF) regarding the frequency of trans-syndesmotic fixation and quality of reduction in trimalleolar (equivalent) fractures. MATERIAL AND METHODS Retrospective registry study. Patients with a trimalleolar (equivalent) ankle fractures were identified within the departments' fracture database. General demographics, treatment details, and fracture specific details (CT-scans) were assessed. Patients were grouped per the PMF treatment: not addressed, CRIF, ORIF. RESULTS 236 patients (53.0 ± 18.3 (range: 18-100) years), 58.1% female were eligible. The mean size of the PMF was 21.4 ± 10.4% (range: 2.7-55.9%), 71.6% were ≤25% of the tibial plafond. PMF fixation: Untreated 48.3%, CRIF 18.6%, ORIF 33.1%. ORIF of the PMF significantly (p < 0.001) reduced the frequency of trans-syndesmotic fixation (25%) compared to CRIF (61%) or untreated PMF (63%) with no significant influence of the PMF size (≤25%/>25%). ORIF resulted in a significantly (p < 0.001) better quality of reduction (1.2 ± 1.1 mm (range: 0-5 mm)) compared to CRIF (2.5 ± 2.1 mm (range: 0-8 mm)) and untreated PMF (2.5 ± 2.3 mm (range: 0-20 mm)). Neither the frequency of trans-syndesmotic fixation nor the quality of reduction differed significantly between untreated PMF and CRIF. CONCLUSION All posterior malleolus fragments, independent of their size, should be treated by ORIF, as this restores syndesmotic stability significantly more often than untreated PMF or CRIF.
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Affiliation(s)
- S F Baumbach
- University Hospital, LMU Munich, Department of General, Trauma and Reconstructive Surgery, Nussbaumstr. 20, 80336 Munich, Germany
| | - V Herterich
- University Hospital, LMU Munich, Department of General, Trauma and Reconstructive Surgery, Nussbaumstr. 20, 80336 Munich, Germany
| | - A Damblemont
- University Hospital, LMU Munich, Department of General, Trauma and Reconstructive Surgery, Nussbaumstr. 20, 80336 Munich, Germany
| | - F Hieber
- University Hospital, LMU Munich, Department of General, Trauma and Reconstructive Surgery, Nussbaumstr. 20, 80336 Munich, Germany
| | - W Böcker
- University Hospital, LMU Munich, Department of General, Trauma and Reconstructive Surgery, Nussbaumstr. 20, 80336 Munich, Germany
| | - H Polzer
- University Hospital, LMU Munich, Department of General, Trauma and Reconstructive Surgery, Nussbaumstr. 20, 80336 Munich, Germany.
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Klumpp R, Compagnoni R, Zeppieri M, Trevisan CL. The Cunéo and Picot fracture-dislocation of the ankle: A case report and review of the literature. Foot (Edinb) 2018; 37:11-15. [PMID: 30321853 DOI: 10.1016/j.foot.2018.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 04/29/2018] [Accepted: 06/13/2018] [Indexed: 02/05/2023]
Abstract
The Cunéo and Picot fracture-dislocation is an atypical trimalleolar fracture-dislocation of the ankle with unique anatomopathologic and radiographic features, which has not been reported in English literature. We report a case of a 42-year-old woman that was diagnosed with a trimalleolar fracture-dislocation and treated surgically with an open reduction and osteosynthesis of the lateral and medial malleolus. At one-month follow-up, X-rays showed secondary displacement of the medial malleolus requiring revision surgery. The patient complained of persisting pain, with X-rays showing no signs of apparent fracture displacement. A CT scan performed after hardware removal 10 months after trauma showed severe ankle arthritis and fracture malunion at the level of the syndesmosis. The patient was retrospectively diagnosed with a Cunéo and Picot fracture-dislocation. The treatment of trimalleolar fractures is discussed, especially regarding the correct indication of synthesis of the posterior malleolus. Cunéo and Picot fractures are usually inherently unstable even if the posterior malleolar fragment may be small and can easily be recognized from standard X-rays. Whenever this type of fracture is not correctly recognized and managed by osteosynthesis of only the medial and lateral malleolus, clinical outcomes and radiographic follow-ups tend to be unsatisfactory. Fixation of the posterior malleolus is indicated in the management of Cunéo and Picot fractures. Level of clinical evidence: 4.
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Affiliation(s)
- Raymond Klumpp
- ASST Bergamo Est, Ospedale "Bolognini", Seriate, Bergamo, Italy.
| | | | - Marco Zeppieri
- Azienda Ospedaliero-Universitaria "Santa Maria della Misericordia", Udine, Italy
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47
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Arthroscopy assisted fixation of posterior malleolar fractures: case series for novel approach. CURRENT ORTHOPAEDIC PRACTICE 2018. [DOI: 10.1097/bco.0000000000000616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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48
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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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Yi Y, Chun DI, Won SH, Park S, Lee S, Cho J. Morphological characteristics of the posterior malleolar fragment according to ankle fracture patterns: a computed tomography-based study. BMC Musculoskelet Disord 2018; 19:51. [PMID: 29439685 PMCID: PMC5811968 DOI: 10.1186/s12891-018-1974-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Accepted: 02/08/2018] [Indexed: 12/16/2022] Open
Abstract
Background The posterior malleolar fragment (PMF) of an ankle fracture can have various shapes depending on the injury mechanism. The purpose of this study was to evaluate the morphological characteristics of the PMF according to the ankle fracture pattern described in the Lauge-Hansen classification by using computed tomography (CT) images. Methods We retrospectively analyzed CT data of 107 patients (107 ankles) who underwent surgery for trimalleolar fracture from January 2012 to December 2014. The patients were divided into two groups: 76 ankles in the supination-external rotation (SER) stage IV group and 31 ankles in the pronation-external rotation (PER) stage IV group. The PMF type of the two groups was assessed using the Haraguchi and Jan Bartonicek classification. The cross angle (α), fragment length ratio (FLR), fragment area ratio (FAR), sagittal angle (θ), and fragment height (FH) were measured to assess the morphological characteristics of the PMF. Results The PMF in the SER group mainly had a posterolateral shape, whereas that in the PER group mainly had a posteromedial two-part shape or a large posterolateral triangular shape (P = 0.02). The average cross angle was not significantly different between the two groups (SER group = 19.4°, PER group = 17.6°). The mean FLR and FH were significantly larger in the PER group than in the SER group (P = 0.024, P = 0.006). The mean fragment sagittal angle in the PER group was significantly smaller than that in the SER group (P = 0.017). Conclusions With regard to the articular involvement, volume, and vertical nature, the SER-type fracture tends to have a smaller fragment due to the rotational force, whereas the PER-type fracture tends to have a larger fragment due to the combination of rotational and axial forces.
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Affiliation(s)
- Young Yi
- Seoul Foot and Ankle Center, Inje University Seoul Paik Hospital, Seoul, Republic of Korea
| | - Dong-Il Chun
- Department of Orthopedic Surgery, Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Sung Hun Won
- Department of Orthopedic Surgery, Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Suyeon Park
- Department of Biostatistics, Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Sanghyeon Lee
- Department of Orthopaedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University, 77, Sakju-ro, Chuncheoni-si, Gangwon-do, 200-704, Republic of Korea
| | - Jaeho Cho
- Department of Orthopaedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University, 77, Sakju-ro, Chuncheoni-si, Gangwon-do, 200-704, Republic of Korea.
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50
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Miller MA, McDonald TC, Graves ML, Spitler CA, Russell GV, Jones LC, Replogle W, Wise JA, Hydrick J, Bergin PF. Stability of the Syndesmosis After Posterior Malleolar Fracture Fixation. Foot Ankle Int 2018; 39:99-104. [PMID: 29058951 DOI: 10.1177/1071100717735839] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND We sought to define the rate of syndesmotic instability after anatomic reduction of the posterior malleolus when posterior stabilization of a trimalleolar or trimalleolar equivalent ankle fracture was chosen vs when a supine position and initially conservative management of the posterior elements was chosen. METHODS The types of syndesmotic and posterior malleolar fixation used to treat adult patients with ankle fractures involving the posterior malleolus at our level I trauma center were retrospectively assessed (N = 198). Specifically, both bimalleolar and trimalleolar fractures were included. Exclusion criteria included pilon fractures, trimalleolar fractures with Chaput fragments, and neurologic injury. Demographics, fracture classification, initial operative position, medial clear space, and posterior malleolar fragment size were recorded for each fracture. RESULTS In total, 151 patients (76.3%) were initially positioned supine, 27.2% of whom had syndesmotic instability requiring operative stabilization. Almost 25% of supine patients also underwent posterior malleolar stabilization for posterior instability. Overall, 73 (48.3%) patients who were initially treated in the supine position needed some form of additional stabilization. Forty-seven patients (23.7%) were initially positioned prone. Syndesmotic stability was restored in 97.9% of these patients. This 2.1% rate of instability vastly differs from the 13-fold higher syndesmotic instability rate observed in the supine group ( P < .001). CONCLUSION Our data demonstrate that the rate of syndesmotic instability was reduced in trimalleolar and trimalleolar equivalent fractures when prone positioning and direct fixation of the posterior malleolus were first performed. Using traditional preoperative estimates of posterior stability to determine the need for posterior malleolar fixation may be inadequate since almost a quarter of patients treated supine received posterior stabilization. LEVEL OF EVIDENCE Level III, retrospective comparative series.
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Affiliation(s)
- Matthew A Miller
- 1 Department of Orthopedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, MS, USA
| | - Tyler C McDonald
- 1 Department of Orthopedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, MS, USA
| | - Matthew L Graves
- 1 Department of Orthopedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, MS, USA
| | - Clay A Spitler
- 1 Department of Orthopedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, MS, USA
| | - George V Russell
- 1 Department of Orthopedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, MS, USA
| | - LaRita C Jones
- 1 Department of Orthopedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, MS, USA
| | - William Replogle
- 1 Department of Orthopedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jeremy A Wise
- 1 Department of Orthopedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, MS, USA
| | - Josie Hydrick
- 1 Department of Orthopedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, MS, USA
| | - Patrick F Bergin
- 1 Department of Orthopedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, MS, USA
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