Posterior Malleolar Fractures Research Articles

Should all Small Shell Posterior Malleolar Fractures be Considered for Fixation? Results from a 3D Fracture Mapping Study

Category: Ankle; Trauma Introduction/Purpose: Approximately 10-15% of posterior malleolar fractures (PMFs) are "small shell," extra-articular fragments. Current classification systems present difficulties to perform a uniform typification of PMFs and contain no consensus on whether they should be fixed. Anatomical studies have identified two distinct components of the posterior inferior tibiofibular ligament (PITFL); the superficial band is thought to be more important than its deep counterpart in imparting syndesmotic stability. However, the involvement of one or both bands of the PITFL by small shell PMFs has not been evaluated so far. Hence, we conducted this study to perform 3D mapping of small shell PMFs and to determine whether surgeons should fix these routinely. Methods: Ankle fracture patients with a ‘small shell’ PMF (Haraguchi 3/Mason 1/Bartoníček 1 or 2) were included. Demographics, radiological features, treatment, and outcomes were recorded. 3D models of the fractured tibiae were generated from CT scans and superimposed on a statistical shape model of the right tibia, which served as a template. Fracture lines along with footprints of superficial and deep PITFL were marked on the template. 3D fracture heat maps were generated. Size of the fracture fragments and involvement of the superficial and deep PITFL footprints were quantified using a custom MATLAB script (Figure 1). Sparing of the footprint was defined as an overlap of < 1% between the fracture line and the footprint areas. Odds ratios (OR) with 95% confidence intervals (CI) were determined to determine which variables correlated with sparing of the PITFL footprint; P-values of < 0.05 were considered significant. Results: Thirty-nine patients were included. The superficial PITFL footprint was spared in 15 (38%), deep PITFL in 10 (26%), and both in 4 cases (10%). Males and Weber C fractures had a higher likelihood of sparing the superficial and deep PITFL footprints, respectively (P = 0.04). Supination external rotation (SER) patterns were less likely to demonstrate syndesmotic widening if either PITFL footprint was spared. Direct fixation of the PMF was done in 1 case; syndesmotic fixation in 25 cases and in 14 cases, no syndesmotic fixation was done. Of these, 11 were SER injuries where stability was achieved after fixation of medial and lateral malleoli. In 1 SER and pronation external rotation (PER) injury case, the syndesmosis was stable after fixation of a large Chaput fragment. Conclusion: This study demonstrated that 48% of small shell PMFs spare either the superficial or deep footprint of the PITFL; in 10% both PITFL footprints were spared. Hence, 58 % of small-shell PMFs may not benefit from direct fixation. Additionally, SER injuries with small shell PMFs that spare either PITFL footprint may not demonstrate radiographic instability and may not need direct or indirect fixation after addressing other components of the ankle fracture. However, given the fact that syndesmotic stability is not dictated by the PITFL alone, it remains prudent to stress the syndesmosis per-operatively to determine if syndesmotic fixation is needed.

Tibialis Posterior Tendon Entrapment in Posterior Malleolar and Pilon Injuries of the Ankle: A Retrospective Analysis

Category: Ankle; Trauma Introduction/Purpose: The Tibialis Posterior tendon (TPT) is the only tendon to come into contact with the distal tibia and is therefore at greatest risk of injury in fractures of the distal tibia. Although TPT injury has been reported rarely with injuries around the ankle they often have been missed and present late. Aim Our aim was to analyse the rate to TPT entrapment in fractures involving the posterior tibia i.e. Pilon (PLM) and posterior malleolar fractures (PMF). Methods: A retrospective analysis of PMF and Pilon fractures over an 8-year period was undertaken. Patients who had undergone surgical fixation of their PMF or PLM were identified from 2014 to 2022, using our prospectively collected database. Any fracture which had undergone a preoperative CT was included. Analysis of their pre-operative CT imaging was utilised to identify TPT entrapment, where if < 50% of the tendon cross section was present in the fracture site this was denoted as a minor entrapment and if ≥50% of the tendon was present in the fracture site was denoted as major. Results: A total of 363 patients were identified for further analysis, 220 who had a PMF and posterior 143 with Pilon injury. The incidence of TPT entrapment was 22% (n = 79) with 64 minor and 15 major entrapments. If the fracture entered the TPT sheath, there was a 45% (72/172) of entrapment as compared to 3.7% (7/190) in fractures not entering the sheath p <.001). There was no significant difference in TPT entrapment in PMF as compared to PML (p=0.353). Conclusion: In our assessment, there was a significant risk of TPT entrapment when the CT images display the fracture line entering the tendon sheath. We recommend that surgeons consider care pre-operative imaging and seek to identify the TPT intraoperatively where entrapment does occur.

The Role of Computed Tomography with External Rotation and Dorsiflexion in Decision Making for Acute Isolated Posterior Malleolar Fractures Bartoníček and Rammelt Type II: A Cross-Sectional Study

Category: Ankle; Sports Introduction/Purpose: A ligament-centered analysis is currently incorporated in the assessment of joint stability in malleolar fractures. Although several imaging tests are available, in the setting of acute isolated non-displaced posterior malleolar fractures Bartoníček/Rammelt types II and IV diagnosing syndesmotic instability remains challenging. The objective of this multi-center cross- sectional study was to evaluate the syndesmotic and fracture instability using conventional ankle CT with external rotation and dorsiflexion in the setting of acute, isolated non-displaced Bartoníček and Rammelt type II posterior malleolar fractures. Methods: Between March 2018 and September 2022, a consecutive sample of 123 individuals with an ankle sprain were assessed for eligibility. In total, 33 participants met the inclusion criteria. All participants underwent a CT scan (CTSM), comprising a first phase with the ankles in a neutral position, then a stress phase with the ankles in external rotation and dorsiflexion and semiflexed knees. Investigators used the patterns of ligament tear found at MRI and instability at CTSM to classify all participants into West Point grades I, IIA, IIB, or III. Mann-Whitney test was used to test the differences in the numerical variables between injured and uninjured syndesmoses. The Spearman correlation tested the strength of the association between the tibial joint surface involved in posterior malleolus fracture and syndesmotic instability. Results: In MRI reading parameters two patterns of syndesmotic ligament injury predominated. A completely torn AITF and IO ligaments and a completely torn AITF was combined with a partially torn IO. Regarding the deep layer of the deltoid ligament, participants were classified as normal, strained and partially torn. In CT scan reading parameters in the neutral phase, the median difference of 0.2 mm in d measurements between injured and uninjured syndesmoses was not statistically significant (P = 0.057). During the stress phase, the injured and uninjured syndesmoses had distinct behavior, and the 2.3 mm median difference for d measurement was statistically significant (P < 0.0001). Conclusion: The conventional computed tomography with external rotation and dorsiflexion represent a reproducible and accurate diagnostic option for the detection of syndesmosis instability and fracture instability in acute isolated posterior malleolar fractures Bartonícek and Rammelt type II.

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.

A Systematic Review of Tibialis Posterior Tendon Entrapment in Pilon and Trimalleolar Injuries

Category: Ankle; Trauma Introduction/Purpose: The tibialis posterior tendon (TPT) entrapment is an uncommon complication associated with posterior malleolar and pilon fractures. If undiagnosed, TPT entrapment is associated with significant morbidity. Our aim was to perform a systematic review of all reported TPT entrapments in the literature to further understand its risks and outcomes. Methods: The electronic databases Scopus, PubMed, and Medline was utilised to identify the relevant publications regarding TPT entrapment in pilon and ankle fractures. Inclusion criteria: all adult studies published in English language reporting the outcome of TPT entrapment in patients with ankle injuries. To critically appraise the papers, CASP clinical appraisal tool was used. Results: Four retrospective studies and eight case reports were accepted in this review. Collectively there were, 489 Pilon fractures, 77 of which presented with TP entrapment (15.75%). There were 28 Tri-malleolar fractures, 12 of which presented with TP entrapment (42.86%). All the case report studies reported inability to reduce the fracture at initial presentation. The diagnosis of TPT entrapment was made in the early period in 25% of cases and delayed diagnosis in 75% of cases reported. Utilising modified Clavien-Dindo complication classification, 67% of the injuries reported GRADE IIIA complications, and the rest GRADE IIIB complications. Conclusion: In conclusion, TPT tendon was the commonest tendon injury associated with Pilon and Tri-malleolar ankle fractures. Early identification, utilising a clinical suspicion and CT imaging, could lead to early management of TP entrapment in these injuries which could potentially lead to better patient outcomes and reduced morbidity.

Epidemiology, Pathoanatomy and Clinicoradiologic Correlations of Quadrimalleolar Ankle Fractures: A Cross-Sectional Study

Category: Ankle; Trauma Introduction/Purpose: The term ‘quadrimalleolar fracture’ (QMF) describes a trimalleolar (TM) ankle fracture with an associated Chaput or Wagstaffe fracture. Optimal fixation of these injuries not only allows for bone-to-bone healing but also facilitates syndesmotic reduction. However, this is a relatively new concept, and the literature on QMFs is limited to a few case series. Hence, we conducted this study to determine the epidemiology, patterns, and clinicoradiologic correlations of QMFs. The primary objective of this study was to describe the prevalence and patterns of QMFs. The secondary objective was to determine if certain clinical or radiological parameters were associated with different types and patterns of QMFs. Methods: A retrospective analysis of ankle fractures presenting to three tertiary referral hospitals was undertaken. Adult patients (≥18 years) presenting with an acute, traumatic TM ankle fracture over 3 years (July 2018 to July 2021) were included. Isolated medial and lateral malleolar fractures, bimalleolar ankle fractures, pediatric patients, pilon fractures, pathological fractures, and those with delayed presentation or (≥3 weeks of injury) were excluded. Clinical demographic variables were obtained from the patients’ medical records. AP, lateral, and mortise ankle radiographs, and CT scans, (axial, coronal, and sagittal sections along with 3D volume reconstructed models) whenever available, were evaluated in detail. Demographics and radiological parameters were compared between TM and QMF, as well as between different types of QMFs. Odds ratios with 95% confidence intervals were determined to test the strength of association. Results: A total of 876 adult patients with ankle fractures were included after the screening, of which 323 had a TM ankle fracture for which a CT scan had been performed. A total of 159 AITFL avulsions were identified, yielding a prevalence of 18.2% amongst all ankle fractures and 26.1% in ankle fractures where a CT scan had been performed. TMFs had the significantly highest proportion of CT-confirmed AITFL avulsions (44.4%) in comparison to unimalleolar (4.4%) and bimalleolar fractures (6.4%) (P < 0.0001). Age and osteoporosis were significant associations of QMFs. Avulsion of the medial malleolus, Weber B fibular fracture, and supination external rotation mechanism were significantly associated with Wagstaffe fractures. Size of the Chaput fracture was inversely related to that of the posterior malleolar fracture. Conclusion: Quadrimalleolar ankle fractures account for a significant proportion of ankle fractures. The strengths of this study include a large sample size, which was derived from three different hospitals, consecutive inclusion (or exclusion) of cases, strict adherence to the STROBE guidelines, and the fact that only CT-confirmed cases were used to determine clinic-radiological associations. Wagstaffe and Chaput fractures have distinct clinical and radiological correlations. However, further research is needed to determine the optimal fixation protocols for these injuries.

Ligamentous Injuries in Stable Ankle Fractures

Category: Ankle; Trauma Introduction/Purpose: When considering ankle fractures requiring fixation, it has been shown that stability is the key determinant. Lauge-Hansen supination external rotation (SER) 2 injuries are by definition stable and has been shown to be successfully managed non-operatively. SER 3 and SER 4 ankle fractures are unstable with complete syndesmosis disruption and the majority are managed operatively. We hypothesise that a percentage of radiologically stable injuries involve more structures than previously thought. The primary aim is to determine the prevalence of SER3 and SER4 ankle injuries amongst radiographically SER 2 injuries. Methods: This cross-sectional study uses baseline data from a longitudinal study at Gold Coast University Hospital and Health Service (GCHHS). Patients attending the GCHHS fracture clinic were invited to participate provided they had a radiographically stable SER 2 fracture. Those meeting the eligibility criteria were referred for ankle magnetic resonance imaging (MRI) to assess the integrity of the syndesmotic and ankle ligaments. Results: To date, this study has recruited 33 participants. Following MRI, 23 were determined to have true SER 2 injuries. Nine participants were however reclassified as SER 3 and one participant was reclassified as having an SER 4 injury. Of the SER 3 injuries six included a non-displaced posterior malleolus fracture, while the remaining three were purely ligamentous. Conclusion: This study demonstrates that a portion of radiographically stable ankle injuries involve more structures than previously thought. When radiographic SER 2 injuries were further evaluated with MRI, nearly half were reclassified as SER 3 and 4 injuries. This may suggest that some SER 3 and 4 injuries are functionally stable and can be managed successfully non-operatively.

Tibialis posterior tendon entrapment in posterior malleolar and pilon injuries of the ankle: a retrospective analysis

BackgroundThe Tibialis Posterior tendon (TPT) is the only tendon to encounter the distal tibia and is therefore at greatest risk of injury in fractures of the distal tibia. Although TPT injury has been reported rarely with injuries around the ankle, they often have been missed and present late.AimOur aim was to analyse the rate to TPT entrapment in fractures involving the posterior tibia, i.e. Pilon (PLM) and posterior malleolar fractures (PMF).MethodsA retrospective analysis of PMF and Pilon fractures over an 8-year period was undertaken. Patients who had undergone surgical fixation of their PMF or PLM were identified from 2014 to 2022, using our prospectively collected database. Any fracture which had undergone a preoperative CT was included. Analysis of their pre-operative CT imaging was utilised to identify TPT entrapment, where if < 50% of the tendon cross section was present in the fracture site, this was denoted as a minor entrapment and if ≥ 50% of the tendon was present in the fracture site was denoted as major.ResultsA total of 363 patients were identified for further analysis, 220 who had a PMF and 143 with PLM injury. The incidence of TPT entrapment was 22% (n = 79) with 64 minor and 15 major entrapments. If the fracture line entered the TPT sheath, there was a 45% rate (72/172) of entrapment as compared to 3.7% (7/190) in fractures not entering the sheath (p < .001). There was no significant difference in TPT entrapment in PMF as compared to PML (p = 0.353).ConclusionIn our assessment, we found significant prevalence of 22% of TPT entrapment in fractures involving the posterior tibia. PMF and PLF had no statistically significant difference in the rate of TPT entrapment. Additionally, we found that there was a significant risk of TPT entrapment when the CT images display the fracture line entering the tendon sheath. We recommend that surgeons consider taking care assessing pre-operative imaging to seek to identify the TPT and to assess intraoperatively where entrapment does occur.

The reliability of posterior malleolar ankle fracture assessment: a unique perspective.

This study aims to elucidate the pathology of PMFs in the South African population, establish correlations between fracture patterns and international classification guidelines and evaluate the interobserver reliability of current classifications. A retrospective review was conducted in a multicentre analysis over a one-year period from January 2019 to December 2019 at our institution. Computer tomography scans for foot and ankle injuries were reviewed, and posterior malleolus fractures were included. Pathoanatomical data was collected and analysed according to known classification systems and subsequent treatment modalities evaluated. A panel of observers individually reviewed radiographic data to determine interobserver reliability. A total of 71 patients were included with a mean age of 41 ± 13.4years (range 18-78) and a female predominant population (69%). A greater proportion of injuries were high energy (23.9%), with significant fragment comminution (53.5%), and half (52.1%) of all injuries were subluxated/dislocated at presentation. A total of 93% of injuries were managed operatively, despite theatre access limitations resulting in significant delays to fixation (19.1days). Despite good pathoanatomical agreement with most international classifications, interobserver reliability was poor (Krippendorff α-coefficient < 0.667). Inconsistent treatment patterns in operative and non-operative strategies are reported. A unique patient population of younger, female individuals incurred posterior malleolar fractures due to higher energy mechanisms of injury. Whilst injury patterns were mostly comparable, significant interobserver variability was noted. Resource limitations, diagnostic challenges, poorly defined and inconsistent treatment strategies, inevitably impact outcomes within the South African population. Level III.

Morphological analysis and classification of posterior malleolar fractures based on CT scans

ObjectivesThe aim of the study was to propose a classification system of posterior malleolar fractures by fracture lines with the use of CT scans, including 3D CT reconstruction, which can better understand morphological characteristics, analyze the mechanism and guide the surgeon to choose the optimal approach and fixation. MethodsPatients with OTA/AO type 44 fractures involving the posterior malleolus and preoperative CT scans were included. We retrospectively analyzed 128 consecutive patients with posterior malleolar fractures from January 2013 to December 2019 at our institution. CT data were loaded into Mimics software (V20.0, Materialize), in which 3D CT reconstruction, morphological analysis and data measurements were made. ResultsBased on the number of fracture lines in 128 consecutive patients, posterior malleolar fractures were classified into three types: type 1 with a single fracture line, type 2 with double fracture lines and type 3 with multiple fracture lines. According to the distribution of the fracture line, type 1 was divided into types 1A, 1B and 1C, and type 2 was divided into types 2A, 2B and 2C. The fracture line from the fibular notch to the posterior rim of the distal tibia was defined as type 1A, and the fracture line to the medial malleolus was defined as type 1B. Type 1C was a small fragment in the posterior rim of the distal tibia. Type 2A was regarded as type 1A with type 1C. It was considered type 2B because another fracture line started from the fracture line of type 1A and extended to the medial malleolus. In type 2C, we could see that the double fracture lines were all from the fibular notch to the posterior rim of the distal tibia and did not cross. Type 3 fractures were comminuted fractures with multiple fracture lines. ConclusionThe morphology of posterior malleolar fractures, involvement of the fibular notch, or the medial malleolus can be obviously assessed by our classification system. We found the relation of the injury mechanism between type 1 and type 2 by comparing the area of the fragment. We have indicated that each type of fracture corresponds to its associated injury mechanism and which surgical approach and fixation can be chosen.

Morphology of Fibular Incisura is a Deciding Factor Between Posterior Malleolus Avulsion Fracture or Syndesmotic Ligament Injury in Ankle Fractures

The bone anatomy of tibiofibular syndesmosis has been a topic of interest. Fibular incisura morphology has been analyzed on cadaver specimens, plain radiographs, or CT images. The aim of this study is to examine the effects of fibula incisura features and fibula morphology in ankle injuries, especially involving posterior malleolus and posteroinferior tibiofibular ligament injuries. From 2017 through 2022, A total of 59 patients with isolated lateral malleolar fracture, Mason-Malloy type 1 posterior malleolar fracture, syndesmosis injury in those without posterior malleolar fracture, supination external rotation type 3 injuries according to Lauge-Hansen classification, and preoperative bilateral ankle computed tomography images were included in the study. Fibula morphologies and syndesmosis measurements were made from preoperative computed tomography images using axial CT images from 1 cm proximal to the tibial plafond. The diagnosis of posterior malleolar fractures was made using the CT classification system of Mason and Malloy, and the diagnosis of syndesmosis injury was made with a cotton test during surgery. Age, gender, fractured side, incisura type, incisor depth, width, anterior and posterior facet lengths, incisor version (antevert-retrovert), the angle between the anterior and posterior facets, and fibula type were recorded. There was a statistically significant difference between the groups in posterior facet length and incisura width. Morphological features of fibular incisura may be the determinant of PITFL injury or PMA injury in fibular fractures caused by an external rotation mechanism.

Study on the effect of self-made fracture positioning compression guide device for posterior malleolus fracture surgery: Medical prevention

To evaluate the effectiveness of a self-designed pressure-guided fracture positioning device, a prospective study was conducted in patients with posterior ankle fractures undergoing surgery using the device. Twenty-seven cases of ankle joint fracture with posterior malleolus fracture were treated by surgery. In the process of fixing posterior malleolus fracture, a self-designed fracture positioning compression guide device was used to fix posterior malleolus bone by anterior and posterior approaches. Postoperative CT images were used to assess the fixation position as well as length of the screw and the compression of the fracture. All patients had healed ankle fractures, and the anterior-posterior screws were fixed in the central area of the posterior malleolus. Posterior malleolus fragment displacement was <2 mm. The screw effectively secured the cortex beyond the length of the posterior malleolus cortex by no more than two threads. The good rate of ankle joint function was 85.16%. Compared to traditional surgical techniques, minimally invasive fixation using the self-designed positioning compression guide device has several advantages, including smaller trauma, faster postoperative recovery, and improved patient satisfaction. The device also provides the surgeon with greater control and precision during the surgical procedure, which can contribute to better surgical outcomes.

Analysis of the epidemiological characteristics of posterior malleolus fracture in adults

BackgroundThis study explores the latest epidemiological characteristics of posterior malleolus fracture and compares the epidemiological differences of posterior malleolus fracture in different periods, regions, and adult age groups.MethodsClinical information of inpatients with posterior malleolus fracture in Shanghai Tongji Hospital and Karamay Central Hospital from January 2014 to February 2022 was reviewed and collected. The imaging data of patients were acquired using the Picture Archiving and Communication Systems. A statistical analysis was performed as to gender, current age, year of admission, injury mechanism, fracture type, and posterior malleolus fracture classification. Moreover, a comparative analysis was conducted on the injury mechanisms and morphological differences of posterior malleolus fracture at different periods, regions, and age groups.ResultsA total of 472 patients (210 patients from Shanghai Tongji Hospital and 262 patients from Karamay Central Hospital) with posterior malleolus fracture and an average age of 48.7 ± 15.6 were included in this study. The peak of posterior malleolus fracture occurs in the age group of 50–59. The injury mechanisms mainly involve low-energy fall and sprain (411 cases, 87.1%), followed by traffic accidents (52 cases, 11.0%), and fall injury from height (9 cases, 1.9%). With aging, the number of fall and sprain cases increases and reaches the peak at the age of 50–59, followed by progressive decline. Traffic accidents presents a relatively flat small peak in the age group of 40–59. The number of cases according to different fracture types shows the following ascending order: trimalleolar fracture-supination external rotation (335 cases, 71.0%) > bimalleolar fracture (60 cases, 12.7%) > trimalleolar fracture-pronation extorsion (43 cases, 9.1%) > posterior malleolus + tibial shaft fracture (19 cases, 4.0%) > simple posterior malleolus fracture (15 cases, 3.2%). The numbers of cases corresponding to the Haraguchi I Type, II Type, and III Type of posterior malleolus fractures were 369 (78.2%), 49 (10.4%), and 54 (11.4%), respectively. The Tongji IIA Type represented the highest number of cases (249 cases, 52.8%), followed by the IIB Type (120 cases, 25.4%), I Type (54 cases, 11.4%), IIIB Type (36 cases, 7.6%), and IIIA type (13 cases, 2.8%). The trimalleolar fracture-supination external rotation, Haraguchi I Type and Tongji IIA Type of posterior malleolus fractures all presented an obvious peak of incidence in the age group of 50–59. However, no obvious statistical difference was observed in the injury mechanism, Haraguchi classification, and Tongji classification of posterior malleolus fractures among different years and regions in recent years (P > 0.05).ConclusionsThe injury mechanism of posterior malleolus fracture mainly involves low-energy fall and sprain cases. The trimalleolar fracture-supination external rotation, Haraguchi I type and Tongji IIA type of posterior malleolus fracture are predilection fracture types, and all present an obvious incidence peak in the age group of 50–59. Elderly patients have high risks of falling and their bones are more fragile, conditions which are potential risk factors of posterior malleolus fracture. Early positive control has important significance. This study provides references for relevant basic and clinical studies of posterior malleolus fracture.

Patient-reported outcomes and prognostic factors in ankle fracture-dislocation: A systematic review

Objectives Ankle fractures have an incidence of around 90,000 per year in the United Kingdom. They affect younger patients following high energy trauma and, in the elderly, following low energy falls. Younger patients with pre-existing comorbidities including raised BMI or poor bone quality are also at risk of these injuries which impact the bony architecture of the joint and the soft tissues leading to a highly unstable fracture pattern, resulting in dislocation. At present, there is no literature exploring what effect ankle fracture-dislocations have on patients’ quality of life and activities of daily living, with only ankle fractures being explored. Methods Relevant question formatting was utilised to generate a focused search. This was limited to studies specifically mentioning ankle injuries with a focus on ankle fracture-dislocations. The number of patients, fracture-dislocation type, length of follow up, prognostic factors, complications and outcome measures were recorded. Results Nine hundred and thirty-nine fractures were included within the studies. Eight studies looked at previously validated foot and ankle scores, two primarily focused on the American Orthopaedic Foot and Ankle Society score (AOFAS), three on the foot and ankle outcome score (FAOS), and one study on the Olerud–Molander score (OMAS). Patient, injury, and management factors were identified as being associated with poorer clinical outcomes. Conclusions Not only are age and BMI a risk factor for posttraumatic osteoarthritis but they were also identified as prognostic indicators for functional outcome in this review. Patients sustaining a concurrent fracture-dislocation were found to have poorer clinical outcomes, and the timing and success of reduction further influenced outcomes. This review found that the quality of reduction was directly related to the patients’ functional outcomes post-follow up, and the risk of developing posttraumatic osteoarthritis, which was more frequent in patients sustaining Bosworth fractures, posterior malleolar fractures, and in patients with increasing age. Level of evidence IV.

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.

Dance Around the Fibula with a Twisted Plate: A Technical Note.

Nowadays, there is a better understanding of the role of the posterior malleolar fragment in trimalleolar ankle fractures. Not fragment size, but rather fragment morphology should guide the management of the posterior malleolar fracture (PMF). Anatomical reduction and fixation of the PMF is important, as an intra-articular step-off will eventually lead to osteoarthritis. Incongruency of the incisura fibularis tibia is associated with fibular dislocation, syndesmotic insufficiency, and poor functional outcomes. Open reduction and internal fixation through a posterior approach leads to ankle joint mobility restriction (i.e., dorsal flexion deficiency) due to arthrofibrosis of the ankle joint, fibrous adhesions and secondary shortening of the flexor muscles. In this technical note, we describe a surgical technique to fixate unstable ankle fractures with a combined PMF and a high supra-syndesmotic fibular fracture through two small surgical windows using a twisted one-third tubular plate. By reducing the size of the posterolateral window, fibrous adhesions and secondary flexor muscle shortening are diminished, favoring ankle joint mobility.

Intraobserver and Interobserver Reliability of the Computed Tomography-Based Classifications Used in Posterior Malleolar Fractures: The Haraguchi and Bartoníček-Rammelt Classifications.

Three main computed tomography (CT)-based classification systems have been defined and used for posterior malleolar fractures. The intraobserver and interobserver reliability of two of these systems has never been investigated. The aim of this study was to investigate the intraobserver and interobserver reliability of the Haraguchi (HC) and Bartoníček-Rammelt (BRC) classifications. Axial and sagittal CT sections and three-dimensional reconstruction images of 60 fractures were evaluated twice by six observers at a 6-week interval. Cohen κ values for intraobserver reliability and Fleiss κ values for interobserver reliability were calculated. The interobserver reliability of the HC was fair in both assessments (Fleiss κ: 0.263 and 0.249 for the first and second evaluations, respectively). The interobserver reliability of the BRC was moderate in both evaluations (Fleiss κ: 0.535 and 0.447, respectively). The intraobserver reliability values (Cohen κ) of the HC were determined to be between 0.532 and 0.927 for the six observers. These values indicated moderate agreement for one observer, substantial for four, and very good for one. Intraobserver reliability values for the BRC were determined to be between Cohen κ of 0.626 and 0.884. Based on these values, the BRC's intraobserver reliability indicated substantial agreement for two observers and very good for four observers. Intraobserver and interobserver reliability values of the BRC were higher than those of the HC.

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.

Plain X-ray is insufficient for correct diagnosis of tibial shaft spiral fractures: a prospective trial

PurposeTibial 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.Methods50 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.ResultsOverall, 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.ConclusionOnly 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 evidenceII. Diagnostic prospective cohort study.Trail registration numberDRKS00030075.

The Influence of Sagittal Angle of Posterior Malleolus Fracture on Ankle Joint Stability: A Retrospective Study of 120 Cases.

Due to the different force exerted during the posterior malleolus fracture (PMF), the difference in sagittal angle (SA) between the fracture fragments may affect ankle stability. But this aspect is less well studied and the aim of this study was to investigate the relationship between SA and the stability of PMF. The imaging data of 120 patients with PMFs from January 2014 to November 2022 were collected retrospectively and reconstructed. We first measured SA, posterior fragment area (PFA) and fragment area ratio (FAR), reanalyzing the correlation of SA with PFA and FAR, respectively. To better describe the morphological characteristics of the fracture fragments, we further measured the fragment width diameter ratio (FWR), the fragment length ratio (FLR), fragment height (FH), contact area (CA), and finally carried these data into the regression model of SA versus FAR to conduct the intermediary role. SA was negatively correlated with PFA(s) (r = -0.583, P < 0.001), with regression equation s = -0.063SA + 3.066; SA was negatively correlated with FAR (r = -0.204, P < 0.05), with regression equation FAR = -0.002SA + 0.198; A significant correlation was found between FWR, FLR, FH, CA and SA (P < 0.05), as well as between FWR, FLR, FH and FAR (P < 0.05); Further intermediary role analysis showed that FWR, FLR, FH had a partial intermediary role between SA and FAR. As SA increased, PFA and FAR decreased, so the larger the SA was due to the effect of vertical shear force, reflecting higher ankle stability, meanwhile, FWR, FLR and FH should also be considered on the fixation method of fracture fragments.