Fixation Of Posterior Malleolus Research Articles

Frequent Sural Nerve Injury with Posterior Approach for Ankle Fracture Fixation

Introduction: The purpose of this study was to report the incidence of iatrogenic sural nerve injury in a large, consecutive sample of surgically managed ankle fractures and to identify factors associated with sural nerve injury and subsequent recovery. We hypothesize that a direct posterior approach may be associated with higher risk of iatrogenic sural nerve injury. Methods: A retrospective cohort study of 265 skeletally mature patients who sustained ankle fractures over a 2-year period was done. All were treated with open reduction and internal fixation of fractured malleoli. Patient, injury, and treatment features were documented. The presence (n = 26, 9.8%) of sural nerve injury and recovery of sural nerve function were noted. Results: All 26 sural nerve injuries were iatrogenic, occurring postoperatively after open reduction and internal fixation. Patients who sustained sural nerve injuries had more ankle fractures secondary to motor vehicle collisions (23.1% versus 9.2%), more associated trimalleolar fractures (69.2% versus 33.9%), and more Orthopaedic Trauma Association/AO 44B3 fractures (57.7% versus 25.1%), all P < 0.05. A posterior approach to the posterior malleolus through the prone position was used in 20.4% of patients. All 26 of the sural nerve injuries (100%) occurred when the patient was placed prone for a posterior approach, P < 0.001. Therefore, 26 of the 54 patients (48%) treated with a posterior approach sustained an iatrogenic sural nerve injury. 62% of patients had full recovery of sural nerve function with no residual numbness, and patients with nerve recovery had fewer associated fracture-dislocations (23.1% versus 100%, P = 0.003). Conclusions: A posterior approach for posterior malleolus fixation was associated with a 48% iatrogenic sural nerve injury rate, with 62% recovering full function within 6 months of injury. Morbidity of this approach should be considered, and surgeons should be cautious with nerve handling. Level of Evidence: Level III, Therapeutic.

Early history of posterior malleolus fractures in ankle fractures.

No comprehensive treatise on the early history of fractures of posterior malleolus (PM) has yet been published, and many substantial discoveries have fallen into oblivion-particularly if not having been published in English originally. Literature search was performed in original publications and historical sources. Early history of PM fractures from their first description up to the beginnings of their operative treatment may be divided into three basic periods, covering the era between 1828 and 1940. In the pre-radiological period (1828-1895), description of PM injuries was based merely on the autopsy findings in deceased patients. The first mentions of this injury were published by the British authors. In the radiologic period (1899-1916), the x-ray examination started a revolution also in diagnostics of ankle fractures, with the first radiographs performed as early as in 1899. Radiographic examination had subsequently become an integral part of the diagnostics of these injuries and initiated a number of significant studies of PM fractures. The first detailed mention of a PM injury may be found in the French and German literature. The period of early operative treatment (1918-1940), i.e., open reduction and internal fixation of PM, was started by the younger post-WWI generation, primarily the French surgeons, represented by Gaston Picot. His operative technique and the first six cases treated operatively between 1918 and 1921 were described in 1921 by Edouard Huc. Picot himself published his technique in great detail in 1923. The early history of diagnostics and treatment of PM fractures witnesses the remarkable body of knowledge gathered about that topic by numerous visionary surgeons predominantly French and German surgeons immediately before and after World War I. They substantially contributed to the radiological examination and operative treatment of this injury.

Comparison of American orthopedic foot and ankle society score between anterior to posterior lag screws versus posterior buttress plating for posterior malleolus fixation in tri-malleolar ankle fracture

Background: Posterior malleolar fractures are frequent, occurring in up to 44% of all ankle fractures. Surgical management typically involves anterior to posterior (AP) lag screws or posterior buttress plates. This study aimed to compare the AOFAS (American orthopedic foot and ankle society) score between AP lag screw and posterior buttress plating for posterior malleolus fixation in tri-malleolar ankle fracture. Methods: This quasi-experimental study was conducted at the department of orthopedics and traumatology, Chittagong medical college hospital, Chattogram, Bangladesh, from November 2020 to October 2021. It involved 28 patients with ankle fractures, equally divided into two groups. Group A received AP lag screw fixation, and group B underwent posterior buttress plating. Data analysis was performed using MS office tools and SPSS version 23.0. Results: The posterior plating group demonstrated superior postoperative AOFAS scores compared with the AP screw group with statistically significant differences (88 versus 81, p=0.008). Significant differences were noted in the AOFAS pain score (p=0.045) and function score (p=0.019) at the final follow-up between the two groups. Conclusions: Patients with tri-malleolar ankle fractures in whom the posterior malleolus is treated with posterior buttress plating show superior postoperative AOFAS scores at follow-up compared to those treated with AP screws.

A Prospective Randomized Study Comparing the Outcomes of Fixed vs Non-Fixed Middle-Sized Posterior Malleolus Fractures

Category: Ankle; Trauma Introduction/Purpose: The controversy surrounding the indications for fixation of posterior malleolar fractures remains unresolved, particularly in cases of middle-sized fragments that make up between 10-25% of the joint surface. Although several studies have been conducted, the evidence to support the need for fixation of such fragments is limited, with a lack of level 1 evidence. This study aimed to assess patients with ankle fractures involving middle-sized posterior fragments and compare those who received posterior malleolus fixation to those who did not. The hypothesis was that fixation of middle-sized (10-25%) posterior malleolar fractures would result in superior functional and radiological outcomes in the short to mid-term follow-up. Methods: A prospective randomized-controlled study was conducted to assess the effects of posterior malleolus fixation in patients with acute rotational ankle fractures involving a middle-sized fragment. Eligible patients were included and randomly allocated into two groups, Group 1 receiving open reduction and internal fixation without posterior malleolus fixation, and Group 2 receiving the same procedure with posterior malleolus fixation, following informed consent. Prior to the study, a power analysis was conducted, indicating that a minimum of 16 patients in each group would be necessary to achieve 80% power and a 5% significance level. The randomization was conducted using an even/odd numbers technique, resulting in 20 patients in each group. Patient clinical and functional status was evaluated annually postoperatively, utilizing the VAS pain scale, AOFAS and SMFA scales. Radiological evaluations were conducted through direct radiographs, utilizing articular step-off evaluation and the Kellgren Lawrence osteoarthritis grading system. Results: The groups were comparable in terms of age, BMI, gender, and fracture type distribution. There were no significant differences in average follow-up times, posterior malleolus size, or height values. However, articular step-off greater than 1mm was more common in Group 1 (p=0.04). Despite slightly better functional outcomes in Group 2, there were no significant differences between the two groups in terms of VAS pain, AOFAS, or SMFA scores (functional, bothersome, and total). However, there was a trend towards significance in the SMFA Function score difference (p=0.07). Multivariate analysis showed that Haraguchi type 1 fractures had better functional outcomes in only the SMFA Bothersome parameter (p=0.03). Patients with articular step-off greater than 1 mm had significantly worse outcomes in all SMFA and AOFAS parameters (p < 0.05). Conclusion: In patients with closed rotational ankle fractures involving medium-sized (10-25%) posterior fragments, there was no significant improvement in functional or radiological outcomes with posterior fragment fixation at short to mid-term follow-up. Patients without posterior fixation were more likely to have articular step-off greater than 1 mm, which was associated with poorer functional outcomes. Despite similar outcomes in both groups, posterior fragment fixation may decrease the incidence of articular step-off and contribute to improved functional outcomes.

Quantitative Evaluation of the Influence of Posterior Malleolus Fracture and Fixation on the Rotational Stability of the Ankle

BackgroundThis study aimed to analyze quantitative correlation between the posterior malleolus fracture and fixation and the rotational stability of the ankle and to explore supplementary surgical indications for posterior malleolus fracture.MethodsTwenty fresh frozen cadaver specimens were selected and dissected. Based on the tibial insertion of the ligament complex, the model for the supination external rotation stage 3 ankle fracture with a posterior malleolar fragment and syndesmosis diastasis was created. The area threshold of the posterior tibial insertion of posterior malleolus fracture was biomechanically assessed and the difference of the antirotating ability stiffness of the ankle between simple posterior malleolus fixation and simple syndesmotic fixation was analyzed statistically.ResultsThe tibial insertion of posterior inferior tibiofibular ligament and inferior transverse tibiofibular ligament complex was relatively broad, and its width decreased as the distance from the joint line increased. Biomechanical analysis showed that: the threshold of posterior area of posterior malleolus fracture was 1/4S; posterior malleolus fixation provided better rotational stability than syndesmotic fixation (P < 0.01).ConclusionThe surgical indications for posterior malleolus fracture should consider simultaneously the restoration of the axial and rotational stability of the ankle. Simple posterior malleolus fracture fixation is recommended when the syndesmosis is unstable and the area ratio of posterior tibial insertion of posterior malleolus fracture is greater than or equal to 1/4. Syndesmotic fixation is proposed to restore and maintain the rotational stability of the ankle when the syndesmosis is unstable and the area ratio is less than 1/4. Regardless of the area ratio, the surgical indication only depends on the impact of the posterior malleolus fracture on the axial stability of tibiotalar joint, the involved articular surface area, and the displacement degree of posterior malleolus fragment, when the syndesmosis is stable.

Reduction of Posterior Malleolus Fractures With Open Fixation Compared to Percutaneous Treatment.

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. 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. 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. 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 III, therapeutic.

Middle-sized posterior malleolus fractures: Fixed versus non-fixed – A prospective randomized study

PurposeThis study aimed to assess the impact of fixation on functional and radiological outcomes of ankle fractures involving the posterior malleolus. We hypothesized that fixation of the posterior malleolus would be associated with improved radiological and functional outcome. MethodsA prospective randomized controlled study was planned and 40 consecutive ankle fractures involving middle-sized (10–25%) posterior fragment were included. Posterior fragments in Group 1 were not fixated while Group 2 underwent posterior malleolus fixation. The patients were evaluated both functionally and radiologically at minimum 2-years. ResultsDemographics and fracture type distributions were similar between the groups. Despite the slightly better functional outcome in Group 2, no significant functional or radiological outcome difference could be detected. Articular step-off> 1 mm was more common in Group 1 (p = 0.04) and the patients with articular step-off showed significantly worse functional outcome in all functional parameters (p < 0.05). Radiological and functional outcome parameters were positively correlated when all patients were evaluated together. Lateral radiographs caused an overestimation in the size of posterior fragment compared to CT (p < 0.001). ConclusionAlthough there was a slightly better clinical outcome in patients with fixed posterior fragments, it was not significant at short to mid-term follow-up. However, posterior fragment fixation contributed to functional outcomes by decreasing the incidence of articular step-off> 1 mm, which was found to be a negative prognostic factor. Level of evidenceLevel I; prospective randomized controlled study.

The 2-Window Posterolateral vs Single-Window Approach for Ankle Fracture Fixation.

The posterolateral approach to the ankle allows for reduction and fixation of the posterior and lateral malleoli through the same surgical incision. This can be accomplished via 1 or 2 surgical "windows." The purpose of this study is to compare outcomes including wound complications following direct fixation of unstable rotational ankle fracture through the posterolateral approach using either 1 or 2 surgical windows. One hundred sixty-four patients with bi- or trimalleolar ankle fractures treated using the single-window posterolateral approach (between the peroneal tendons and the flexor hallucis longus [FHL]) or the 2-window technique (between the peroneal tendons and the FHL for posterior malleolus fixation; lateral to the peroneal tendons for fibula fixation) were reviewed for demographics, radiographic details, and clinical outcomes. We were able to review these 164 at the 3-month follow-up and a subset of 104 at a minimum of 12-month follow-up. One hundred eight ankles had the single-window approach; 56 had the 2-window approach. These 2 cohorts did not differ in demographic or injury characteristics. Ankles in the 2-window group experienced a greater number of early (3 months postsurgery) wound complications (32% vs 12%, P < .01). Two-window patients had more wound complications among ankles treated later than 1 week after injury (44% vs 16%, P < .01). There was no difference in surgical site infection, with low rates in both cohorts. Single-window patients had greater plantarflexion (35 ± 10 vs 30 ± 11 degrees, P = .025) and dorsiflexion after 12 months (21 ± 10 vs 16 ± 11 degrees, P = .021). We did not find a significant difference in nerve complications for these 2 cohorts. In our study, we found the single-window posterolateral approach to be associated with fewer wound complications and better postoperative range of ankle motion when compared to the 2-window approach. Level III, retrospective cohort study.

Effect of Posterior Malleolar Fixation on Syndesmotic Stability

Background: Transsyndesmotic fixation with suture buttons (SBs), posterior malleolar fixation with screws, and anterior inferior tibiofibular ligament (AITFL) augmentation using suture tape (ST) have all been suggested as potential treatments in the setting of a posterior malleolar fracture (PMF). However, there is no consensus on the optimal treatment for PMFs. Purpose: To determine which combination of (1) transsyndesmotic SBs, (2) posterior malleolar screws, and (3) AITFL augmentation using ST best restored native tibiofibular and ankle joint kinematics after 25% and 50% PMF. Study Design: Controlled laboratory study. Methods: Twenty cadaveric lower-leg specimens were divided into 2 groups (25% or 50% PMF) and underwent biomechanical testing using a 6 degrees of freedom robotic arm in 7 states: intact, syndesmosis injury with PMF, transsyndesmotic SBs, transsyndesmotic SBs + AITFL augmentation, transsyndesmotic SBs + AITFL augmentation + posterior malleolar screws, posterior malleolar screws + AITFL augmentation, and posterior malleolar screws. Four biomechanical tests were performed at neutral and 30° of plantarflexion: external rotation, internal rotation, posterior drawer, and lateral drawer. The position of the tibia, fibula, and talus were recorded using a 5-camera motion capture system. Results: With external rotation, posterior malleolar screws with AITFL augmentation resulted in best stability of the fibula and ankle joint. With internal rotation, all repairs that included posterior malleolar screws stabilized the fibula and ankle joint. Posterior and lateral drawer resulted in only small differences between the intact and injured states. No differences were found in the efficacy of treatments between 25% and 50% PMFs. Conclusion: Posterior malleolar screws resulted in higher syndesmotic stability when compared with transsyndesmotic SBs. AITFL augmentation provided additional external rotational stability when combined with posterior malleolar screws. Transsyndesmotic SBs did not provide any additional stability and tended to translate the fibula medially. Clinical Relevance: Posterior malleolar fixation with AITFL augmentation using ST may be the preferred surgical method when treating patients with acute ankle injury involving an unstable syndesmosis and a PMF ≥25%.

Impact of Posterior Malleolus Fixation on Clinical and Functional Results.

Clinical studies have shown that posterior malleolar fractures treated with a posterior buttress plate have improved outcomes compared to anterior-to-posterior screw fixation. The aim of this study was to evaluate the impact of posterior malleolus fixation on clinical and functional results. The patients with posterior malleolar fractures who were treated between January of 2014 and April of 2018 at our hospital were investigated retrospectively. Fifty-five patients included in the study were divided into three groups according to the fixation preferences of fractures (group I, posterior buttress plate; group II, anterior-to-posterior screw; and group III, nonfixated). The groups consisted of 20, nine, and 26 patients, respectively. These patients were analyzed according to demographic data, fixation preferences of fractures, mechanism of injury, hospitalization length of stay, surgical time, syndesmosis screw use, follow-up time, complications, Haraguchi fracture classification, van Dijk classification, American Orthopaedic Foot and Ankle Society score, and plantar pressure analysis. There were no statistically significant differences between the groups in terms of gender, operation side, injury mechanism, length of stay, anesthesia types, and syndesmotic screw usage. However, when the age, follow-up time, operation time, complications, Haraguchi classification, van Dijk classification, and American Orthopaedic Foot and Ankle Society scores were evaluated, statistically significant differences were observed between the groups. Plantar pressure analysis data showed that group I yielded balanced pressure distribution between both feet compared to the other study groups. The posterior buttress plating of posterior malleolar fractures yielded better clinical and functional outcomes compared to the anterior-to-posterior screw fixation and nonfixated groups.

Direct versus indirect posterior malleolar fixation in the treatment of trimalleolar ankle fractures: Is there a difference in outcomes?

The purpose of this study was to examine the differences in functional outcomes between direct and indirect surgical fixation methods of the posterior malleolus in the setting of trimalleolar fractures and identify any variables affecting patient outcomes. Primary outcomes were evaluated by PROMIS scores for short-term outcomes regarding total pain (TP) and total function (TF) comparing 40 patients with direct fixation with 77 with indirect fixation. Continuous variables were analyzed using t tests for parametric variables and the Mann-Whitney U test for nonparametric variables. Categorical variables were analyzed using a χ2 test. Univariate and multivariate linear regression models were performed to analyze factors that affect outcomes of TP and TF. There was no difference in TP or TF between groups (P = 0.65 vs. P = 0.19). On univariate linear regression for TP, BMI, incidence of complication, tobacco use, and open injury showed significance in increasing pain levels with open injuries providing the greatest effect (coef = 11.8). On multivariate analysis, BMI, incidence of complication, open injury, and tourniquet time all significantly increased pain. For TF, univariate analysis showed age, BMI, incidence of complication, and diabetes to decrease function, and use of external fixator and tourniquet time increased function. In the multivariate model, increased BMI, open injuries, and increasing tourniquet time all decreased TF while use of an external fixator increased TF. This study showed no difference in TP and TF using the PROMIS outcome scores when comparing direct fixation versus indirect fixation under univariate and multivariate models. Therapeutic III.

Relevance of posterior malleolar fracture fixation to ankle syndesmotic reduction, a comparative study

&lt;p&gt;&lt;strong&gt;Background:&lt;/strong&gt;&lt;strong&gt; &lt;/strong&gt;Appropriate distal tibiofibular syndesmotic reduction is crucial to restore ankle stability, guard against future arthrosis with worse functional outcome. Optimal technique for syndesmotic reduction has been a matter of debate. This study aimed at radiological evaluation of syndesmotic integrity following two methods of reduction (posterior malleolar fixation and trans-syndesmotic screw fixation), additionally, correlating the posterior malleolus size to the radiological results of both techniques.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;Syndesmotic integrity was compared after each technique as per translational and rotational fibular positions. Utilizing, preoperative and postoperative computed tomography scans of injured ankle, the fibular antero-posterior and Medio-lateral translation distances were measured. Additionally, the fibular rotation angle was calibrated. Incidence of inadequate reduction in each group was reported. Preoperative and postoperative radiological findings were compared and correlated to posterior malleolus size in relation to tibial articular distance.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results:&lt;/strong&gt; A significant difference between both techniques was noted in term of fibular rotation. In patients with PM ˂ 10% of tibial articular surface, a significant difference was obvious in postoperative AP-translational and rotational findings between both techniques. Overall malreduction incidence rate of 68.9% was reported in this study, with 84.7% rate in patients managed with SS-fixation, whilst 51.2% rate in those managed via PM-fixation.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt;&lt;strong&gt; &lt;/strong&gt;Posterior malleolar fixation could limit syndesmotic malreduction risk whatsoever it’s size. Approaching CT reference values for syndesmotic reduction might benefit preoperative planning and detect intraoperative malreduction. Further future clinical studies correlating these findings to clinical outcome would be more helpful.&lt;/p&gt;

Unstable Rotational Ankle Fractures Treated With Anatomic Mortise Repair and Direct Posterior Malleolus Fixation.

Introduction: The purpose of this study was to evaluate patient outcomes following a standardized algorithmic approach to ankle mortise stabilization, following rotational fracture, utilizing direct repair of the posterior malleolus in the prone position. Methods: Eighty consecutive patients with unstable rotational ankle fractures that involved the posterior malleolus were analyzed. All underwent direct repair of the posterior malleolus regardless of size through a posterolateral approach. Electronic records were retrospectively reviewed for demographic information, initial injury and operation details, healing status, and complications. Preoperative and postoperative radiographs were obtained to assess the initial injury and healing was determined both by radiographic and clinical progress at follow-up visits. Results: Average posterior malleolus fragment width was 8.1 ± 3.7 mm (range = 2.1-19.9 mm) and percentage of the articular surface was 23.6% (range = 7.1%-56.7%) on the lateral radiograph. Overall, 80/80 (100%) patients healed their ankle fractures by a mean 2.9 ± 1.1 months. Only 1 (1.3%) patient required transsyndesmotic fixation following posterior malleolus repair. Mean range of ankle motion was as follows: dorsiflexion 20° ± 10°, plantarflexion 34° ± 10°, inversion 8° ± 4°, and eversion 7° ± 4°. Seventy-nine patients (98.8%) had an anatomic mortise reduction. Nine patients (11.3%) had a superficial wound complication, 3 patients (3.8%) had dysesthesia in the sural nerve distribution, and 1 patient (1.3%) lost reduction of the medial malleolus. Conclusion: Patients who undergo direct repair of the posterior malleolus in the prone position can expect a high rate of healing with superficial wound breakdown being the biggest problem, which was associated with an ankle fracture dislocation. Posterior malleolus fixation may obviate the need of transsyndesmotic stabilization.Levels of Evidence: Retrospective Level IV.

Poster 267: The Impact of Posterior Malleolar Fixation on Syndesmotic Stability

Objectives:Trans-syndesmotic fixation with suture buttons, posterior malleolar fixation (PMF) with screws and anterior inferior tibiofibular ligament (AITFL) augmentation with suture tape have all been suggested as potential treatments in the setting of a malleolar fracture. However, there is no consensus on the optimal treatment for small vs. large malleolar fractures. The purpose of this study was to determine which combination of: 1) posterior malleolar screw fixation, 2) syndesmotic fixation with suture button (SB), and 3) AITFL augmentation with suture tape (ST) best restored native tibio-fibular and ankle joint kinematics following a small and large posterior malleolar fracture.Methods:Twenty fresh frozen cadaveric lower leg specimens were divided into two groups and underwent biomechanical testing using a 6-degrees-of-freedom robotic arm in 7 states: 1) Native, 2) Syndesmosis Injury + Malleolar Fracture (Group 1: small fracture, Group 2: large fracture) 3) Screw fixation, 4) Screw + Suture Tape Augmentation, 5) Screw + Suture Tape Augmentation + Suture Button, 6) Suture Button + Suture Tape Augmentation, 7) Suture Button. Four biomechanical tests were performed at neutral and at 30 degrees of plantarflexion: 1) Internal Rotation, 2) External Rotation, 3) Lateral Drawer, 4) Posterior Drawer. The position of the tibia, fibula and talus were continuously recorded using a 5-camera motion capture system.Results:No differences were found in the efficacy of treatments between the small fracture and large fracture groups. In the external rotation test, screws with ST augmentation resulted in best stability of the fibula and ankle joint. In the internal rotation test, all repairs that included posterior malleolar screws stabilized the fibula and ankle. Posterior and lateral drawer of the foot resulted in only small differences between the intact and malleolar fracture states.Conclusions:Posterior malleolar fixation resulted in higher syndesmotic stability compared to trans-syndesmotic fixation with SBs. AITFL augmentation with ST provided additional external rotation stability when combined with screw fixation. Posterior malleolar screw fixation with AITFL augmentation using ST may be the preferred surgical method when treating patients with acute ankle injury involving an unstable syndesmosis injury and a posterior malleolar fragment.Figure 1.Sample of Syndesmosis Injury With Repair.Figure 2.Experimental Specimen Set-Up With the 6 D.O.F.Robotic Arm.

Analysis of the Effect of Posterior Lateral Malleolus Plate Fixation on the Curative Effect and Mechanical Stability of Complex Ankle Fractures.

This paper investigates the effect of lateral and posterior 1/3 tubular plate bone plate fixation on the curative effect, wound healing, and mechanical stability of complex ankle fracture. 80 patients with complex ankle fractures treated in our hospital from January 2018 to July 2020 are selected for the study, and 80 patients are randomly divided into posterior fixation group and lateral fixation group according to the number table method, with 40 patients in each group. Patients in the posterior malleolus fixation group are treated with posterior lateral malleolus plate fixation, and patients in the lateral malleolus fixation group are treated with lateral malleolus plate fixation. The differences in efficacy, mechanical stability, wound healing, visual analog scale (VAS) pain score, and American Association of Foot and Ankle Surgery (AOFAS) ankle function are compared. The subjects are followed up for 6 months until January 2022. In patients with complex ankle fracture, 1/3 tubular plate osteoplate fixation in the posterior lateral malleolus can improve clinical efficacy and mechanical stability, which is helpful to promote incision healing and reduce the risk of complications. The 1/3 tubular plate osteoplate fixation in the posterior lateral malleolus is worthy of clinical promotion and application.

TRIMALLEOLARFRACTURES :- FRAGMENT SPECIFIC FIXATION AND ITS FUNCTIONAL OUTCOMES

Trimalleolar fractures are disabling injuries if not managed properly. Clinical and functional outcomes oftrimalleolar fracture are worse as compared to bimalleolar fractures not involving the posterior malleolus. Various surgical approaches and techniques to reduce and fix these fractures described in the literature.In this case study of 11 patients with trimalleolar fractures, a posterolateral approach was used for fixation of posterior malleolus as well as lateral malleolus in all the cases. A preoperative CT scan was done in all the cases. The Olerud and Molendar scoring system was used to assess the functional outcome.The average age of patients was 52.6 years. The most common mode of sustaining injury was twisting of the ankle joint (n = 7). The average time to union and full weight-bearing was 12 weeks (range 10–14 weeks). An excellent functional outcome in 6 patients and a good outcome in 5 patients were obtained at the end of 12 months of follow-up. No significant complications were encountered. The posterolateral approach provides good exposure to fix both posterior and lateral malleolus via single incision. Stable fixation of posterior malleolus plays a vital role in obtaining good clinical and functional outcomes.

Outcomes of Posterior Malleolar Fixation in Ankle Fractures in A Major Trauma Centre

Category:Ankle; TraumaIntroduction/Purpose:Ongoing controversy exists over the indications and benefits of posterior malleolar fixation in ankle fractures. These injuries require careful evaluation of the bony and ligamentous structures with theoretical benefits of posterior malleolar fixation now widely accepted as restoration of articular congruity, restoration of fibular length and stabilisation of the syndesmosis. Surgical and patient report outcomes are varied in the literature with analysis limited by the lack of standardisation in functional outcomes and small patient populations. Posterior malleolar fixation does extend operative time and potentially increases complication rate. The aim of this pragmatic study was to evaluate the outcomes of posterior malleolar fracture fixation 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, between January 2012 and January 2018, with minimum 2 year follow-up. Patient electronic records were assessed for demographic data including age, gender, mechanism of injury, co-morbidities and smoking status. Pre-operative imaging, including CT was used to evaluate the nature of the injury and classify the posterior malleolar fracture according to the Mason classification. One hundred and sixty patients underwent posterior malleolus fixation as part of their surgery and 160 patients did not. The Manchester-Oxford Foot Questionnaire (MOXFQ) at final follow-up, was the primary patient outcome measure.Complications were noted to be minor (superficial infection or delayed wound healing) or major (DVT/PE, deep infection, chronic regional pain syndrome (CRPS), arthrofibrosis, further intervention for post-traumatic arthritis, hardware failure or irritation). All cause reoperation rates were also noted.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. When compared with either posterior malleolus fixation alone or syndesmotic stabilisation alone, poorer outcomes were seen when the posterior malleolus fixed with additional syndesmotic stabilisation, with mean MOXFQ scores of 21.73 (0-60), p =0.057. Metalwork-related issues were higher in the posterior malleolus fixed group (24/160 (15%) versus 10/160 (6.2%), p=0.03). Re-operation rate was double (34/160 (21.2%) vs 16/160 (10%), p = 0.03). The main cause of this was hardware related issues.Conclusion:This pragmatic study is one of the largest published series that assesses patient reported outcomes in posterior malleolar fixation. The key finding is that posterior malleolar fixation is associated with a statistically significant improvement in patient reported outcome scores. However, the overall complication rate was 10.7% higher in the fixation group and the risk of reoperation was over double. Further research should focus on high quality randomised controlled trials with long term follow-up to assess long term impacts of this complex ankle injury pattern.

Cost of Operative Fixation of Ankle Fractures: Comparing Orthopaedics and Podiatry

Category:Trauma; OtherIntroduction/Purpose:Ankle fractures pose a unique situation as both podiatrists and orthopaedic surgeons are licensed to treat them. Despite increasing emphasis on value-based medical care, there are few cost analyses focused on the treatment of ankle fractures. The goal of this study is to determine if there are cost differences between an orthopaedic surgeon and podiatrist to operatively manage an ankle fracture.Methods:Retrospective cohort study of patients who underwent ankle fracture fixation over a 22 month period at an academic level 1 trauma center. Patient data was subcategorized by surgeon type and treatment groups. Four treatment groups were included: lateral malleolus open reduction and internal fixation (ORIF), bimalleolar/trimalleolar ORIF (no posterior malleolus fixation), lateral malleolus ORIF with syndesmotic fixation, bimalleolar/trimalleolar ORIF (no posterior malleolus fixation) with syndesmotic fixation. Primary outcome was total (OR time cost + Implant cost) cost per case.Results:A total of 134 cases met criteria. Eighty-five cases were treated by a total of 4 orthopaedic surgeons while 49 were treated by 8 podiatrists. There was significantly longer OR time (minutes) for lateral malleolus ORIF (111 vs 134.92), lateral malleolus ORIF with syndesmotic fixation (130.53 vs 156.7), and bimalleolar/trimalleolar ORIF (no posterior malleolus fixation) with syndesmotic fixation (162.13 vs 208) when podiatry was the treating team. Average total cost per case was significantly more for lateral malleolus ORIF (+$1188.45), lateral malleolus ORIF with syndesmotic fixation (+$2259.16), and bimalleolar/trimalleolar ORIF with syndesmotic fixation (+$2837.29) when podiatry was the treating team.Conclusion:Lateral malleolus ORIF, lateral malleolus ORIF with syndesmotic fixation, and bimalleolar/trimalleolar ORIF with syndesmotic fixation costs less per case when performed by an orthopaedic surgeon based on OR time costs and implant costs.

Posterior malleolus fracture fixation in ankle injuries: A clinical study

Introduction: Posterior Malleolar fractures are relatively rare and a part of complex ankle injuries. Trimalleolar fractures affect the stability of the weight-bearing ankle joint. Management of posterior malleolar fractures is a challenge. Aims: This study aimed to examine the radiological and clinical outcomes of the management of posterior malleolar fractures in adults. Settings and Design: This is an original research retrospective studyMaterials and Methods: Eleven patients underwent fixation of ankle fractures with fixation of posterior malleolus as needed using screws or plates. Surgical outcomes were examined in follow-up with an average follow-up of 21 months using the American Orthopedic Foot and Ankle Score (AOFAS) score and with radiological correlation at each follow-up. Results: In our series, 27% of patients had 44B type injury and 73% of patients had 44C type injury as per AO/OTA classification. The average AOFAS score was 90.45 for the series and the score for patients treated with direct reduction of the fragment was better than for those treated with indirect reduction. The average score for patients managed with screws was better than for those treated with plates in our series. 82% of patients showed excellent to good outcomes with one patient having an infection and one patient having moderate to severe pain. Conclusion: Anatomical reduction of posterior malleolar fragment leads to better long-term functional outcomes and a stable ankle joint with early mobilization.

Ankle Fractures Involving the Posterior Malleolus: 7-Year Results in 100 Cases

Category:Ankle; TraumaIntroduction/Purpose:The presence of a posterior malleolar (PM) fragment has a negative prognostic impact in ankle fractures. The best treatment is still subject to debate and new concepts continue to emerge. The aim of this study was to assess the medium- to long-term clinical and functional outcome of ankle fractures with a PM fragment in a larger patient population treated with an individualized treatment approach.Methods:One hundred patients with ankle fractures involving the PM were identified retrospectively and reevaluated at an average follow-up of 7.0 years. Fixation of the PM was tailored to the individual fracture pattern. Bartoníček-Rammelt type I PM fractures (extraincisural shell-like fragments) were not fixed surgically. Displaced Type II (posterolateral fragments) and type III PM fractures (two-part with medial extension) were mostly fixed with direct posterior screw or plate fixation. Intercalary joint fragments were fixed with lost K-wires or resorbable pins. Type IV PM fractures (large triangular fragments) were treated with either posterior screw / plate fixation or indirect anteroposterior screw fixation with direct transfibular control of reduction, if feasible.Results:Internal PM fragment fixation was negatively correlated with the need for syndesmotic screw placement at the time of surgery (p=0.010). At 7 years, the mean Foot Function Index was 16.5, the Olerud Molander Ankle Score averaged 80.2 and the American Orthopaedic Foot & Ankle Society ankle/hindfoot score averaged 87.5. The physical (PCS) and mental health component summary (MCS) scores of the SF-36 averaged 47.7 and 50.5, respectively. Range of motion was within 3.4 degrees of the uninjured side. The size of the PM fragment had no prognostic value. There was a trend to lower outcome scores with anterior or posterior shift of the distal fibula of 1 mm within the tibial incisura. Patients who underwent primary internal fixation had significantly superior SF-36 MCS than patients who underwent staged internal fixation (p=0.031). Two patients (2%) needed secondary ankle fusion following deep infection.Conclusion:With an individualized treatment protocol, tailored to the CT-based assessment of PM fractures, favorable medium and long-term results can be expected. The mere size of the PM fragment is just one of the factors guiding treatment, other important criteria are fragment displacement, impaction of the tibial plafond and incisura involvement. PM fixation provides direct bone-to-bone fixation of the syndesmosis and significantly reduces the need for additional transsyndesmotic fixation with a screw or flexible implant.