Abstract
IntroductionAnkle fractures are commonly treated by open reduction and internal fixation with plate and screws. Unplanned return to theatre is common, in many cases to extract prominent osteosynthesis material from the lateral malleolus as swelling subsides. We hypothesised that patients operated with a posterolateral plate placement on the lateral malleolus would have fewer reoperations, and fewer complications, compared to patients with a lateral plate placement. Materials and MethodsFrom a prospectively collected database of all orthopaedic surgery performed at our institution, we identified 664 ankle fractures undergoing plate fixation between 2008-01-01 and 2012-04-30. Radiographs were analysed to only include AO/OTA 44-B-fractures (n = 453), and to define study groups based on plate positioning. Hospital files were assessed to identify possible confounding factors, and any unplanned reoperation or complication. Complications were classified according to Dindo-Clavien. ResultsThe risk of reoperation was 13% after posterolateral plating, compared with 24% after lateral plating; absolute risk reduction 10% (95% CI: 2.5–18), p = 0.02. After adjusting for possible confounders, the odds ratio of undergoing reoperation after lateral plating was 2.2 (95% CI: 1.17–4.1), p = 0.01. The two surgical methods did not differ with regard to complication frequency: 31% vs 34%, p = 0.6, but complications following lateral plate fixation were more serious, p = 0.03. Plate positioning depended on surgeon preference. DiscussionThe two studied methods are both considered standard treatment of ankle fractures, and relatively simple surgical procedures. High rates of secondary surgery after plate fixation have been reported, but no study comparing plate positioning has been previously published to our knowledge. AO Sweden has recently switched to teaching posterolateral plating in group exercises during the AO Basic Fracture Surgery course, based on the belief that it may be safer than lateral plating. Our findings support this change in practice. ConclusionsPosterolateral plate positioning on the lateral malleolus in AO/OTA 44-B-fractures may be preferential to lateral plate positioning, due to a large difference in unplanned secondary surgery.
Highlights
Ankle fractures are commonly treated by open reduction and internal fixation with plate and screws
The primary aim of this study was to compare the rate of unplanned reoperations after posterolateral plate fixation with lateral plate fixation, in patients operated for a fracture of the lateral malleolus at the syndesmotic level (AO/OTA 44-B)
Fractures treated with lateral plate positioning were more often open, were less often treated with syndesmosis staple, occurred more often in patients with diabetes, and had a higher risk of reoperation (Table 1)
Summary
Ankle fractures are commonly treated by open reduction and internal fixation with plate and screws. Unplanned return to theatre is common, in many cases to extract prominent osteosynthesis material from the lateral malleolus as swelling subsides. We hypothesised that patients operated with a posterolateral plate placement on the lateral malleolus would have fewer reoperations, and fewer complications, compared to patients with a lateral plate placement. Three quarters of all ankle fractures in Sweden undergo open reduction internal fixation [4]. Plate and screw fixation is the most common surgical method globally [5]. Plates can be positioned in two principal ways on the lateral malleolus: either laterally, acting as a neutralisation plate for a lag screw [5], or posterolaterally, acting as an anti-glide plate [6]
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