Posterior Malleolus Research Articles

The role of computed tomography with external rotation and dorsiflexion in decision making for acute isolated non-displaced posterior malleolar fractures Bartoníček and Rammelt type II: a prospective study.

Our objective was to evaluate the syndesmotic and fracture instability using conventional ankle computed tomography (CT) with stress maneuvers. A consecutive sample of 123 individuals with an ankle sprain was assessed for eligibility. In total, 33 patients met the inclusion criteria. All patients underwent a magnetic resonance imaging (MRI) and CT scan with stress maneuvers (CTSM). The patterns of ligament tears f were classified using West Point grades I, IIA, IIB, 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. In MRI, two patterns of syndesmotic ligament injury predominated. A completely torn anterior inferior tibiofibular (AITFL) and interosseous tibiofibular ligaments (ITFL) and a completely torn AITFL were combined with a partially torn ITFL. In the neutral phase CTSM and during the stress phase the median difference of the narrowest tibiofibular distance between injured and uninjured syndesmoses was 0.2mm (P = 0.057) and 2.3mm (P < 0.0001), respectively. There was no association between the percentage of involvement of the posterior tibial joint surface in the posterior malleolar fracture and syndesmotic instability as measured with CTSM. The conventional computed tomography with external rotation and dorsiflexion represents a reproducible and accurate diagnostic option for detecting syndesmosis instability and fracture instability in acute isolated non-displaced posterior malleolar fractures Bartoníček and Rammelt type II. Prospective study among consecutive patients (Diagnosis); Level of evidence, 2.

Prediction of Short-Term Postoperative Complications Following Open Reduction Internal Fixation of Acute Ankle Fractures

Introduction/Purpose: Acute ankle fractures are a common injury and represent a significant financial burden to the healthcare system. Reimbursement following ankle fractures is complicated by bundled payments within the 90-day global period which do not account for unpredictable complications. Comorbidity indices, such as the American Society of Anesthesiologists (ASA) classification, are often correlated with complications; however, the positive predictive value of these metrics have not been investigated. As insurers continue to transition towards bundled reimbursements, greater attentiveness towards providing efficient care is paramount. The purpose of this investigation is to develop a machine learning (ML) model that is predictive of complications following operative management of acute ankle fractures. This study will also compare ML algorithms to legacy indices to assess the predictive value in predicting complications. Methods: The American College of Surgeons-National Surgical Quality Improvement Program database was queried via Current Procedural Terminology (CPT) from 2015-2018 for open reduction internal fixation (ORIF) cases for ankle fractures, including ORIF of the medial malleolus, posterior malleolus, lateral malleolus, bimalleolar, trimalleolar, syndesmosis. Training and validation sets were created by randomly assigning 80% and 20% of the data set. Included variables were age, body mass index (BMI), operative time, smoking status, comorbidities, diagnosis, and preoperative hematocrit and albumin. Complications included any adverse event, transfusion, surgical site infection, return to the operating room, deep vein thrombosis or pulmonary embolism, pneumonia, urinary tract infection, cerebrovascular accident, cardiac arrest, myocardial infarction. Each ML algorithm was compared with one another and to a baseline model using American Society of Anesthesiologists (ASA) classification. Model strength was evaluated by calculating the area under the curve (AUC) for receiver operating characteristic (ROC) of any adverse event. Results: We identified a total of 28,736 ORIF cases. Mean age and BMI were 32.2 ± 18.6 years, 30.8 ± 7.6 kg/m^2, respectively. The overall incidence of any medical complication was 3.4% (n=975) with surgical site infection (1.3%, n=386) and return to operating room (1.3%, n=367) being the most common. Percentage hematocrit, BMI, operative time, and age were of highest importance in outcome prediction. Logistic regression (AUC: 72%) and gradient boosting (AUC: 72%) ML algorithms outperformed ASA classification (AUC: 69%) for predicting any adverse event following ORIF of ankle fractures. Conclusion: Legacy comorbidity indices are simple metrics that can be easily constructed from patient demographic variables and past medical history. However, the predictive power is limited as they have shown a low positive predictive value for predicting complications. Machine learning algorithms can calculate patient-specific risk for postoperative complications which may adjust perioperative care and site of surgery. These models have the capability to optimize utilization of healthcare resources and minimize excessive expenditure by providing patient-specific care. Receiver Operating Curve-Area under the Curve Analysis for Adverse Events Following ORIF of Ankle Fractures

Ten year outcomes after non-fixation of the smaller posterior malleolar fragment: A retrospective cohort study

IntroductionTreatment of posterior malleolar (PM) ankle fractures remains controversial. Despite increasing recommendation for small PM fragment fixation, high quality evidence demonstrating improved clinical outcomes over the unfixated PM is limited. We describe the long term clinical and radiographical outcomes in younger adult patients with PM ankle fractures managed without PM fragment fixation. Material and methodsA retrospective cohort study was performed on PM ankle fracture patients aged 18–55 years old admitted under our orthopaedic unit between 1st of April 2009 and 31st of October 2013. Inclusion criteria were ASA 1 and 2, independent mobility pre-trauma, no pre-existing ankle pathologies, with satisfactory bimalleolar and syndesmotic stabilisation. Open fractures, talar fractures, calcaneal fractures, pilon fractures, subsequent re-injury and major complications were excluded. All PM fragments were unfixated. Clinical outcomes were evaluated using visual analogue scale (VAS) for pain, Foot and Ankle Ability Measure (FAAM) with activities of daily living (ADL) and sports subscale for function, and patient satisfaction ratings. Osteoarthritis was assessed using modified Kellgren-Lawrence scale on follow-up weightbearing ankle radiographs. ResultsSixty-one participants were included. Mean follow-up was 10.26 years. Average PM size was 16.2 ± 7.39%. All participants were evaluated for clinical outcomes. Mean score of FAAM-ADL was 95.5 ± 7.13, FAAM-Sports 86.4 ± 15.5, patient satisfaction 86.2 ± 14.4% and pain score 1.13 ± 1.65. Radiographical outcomes were evaluated in 52 participants, showing no-to-minimal osteoarthritis in 36/52 (69%), mild osteoarthritis in 14/52 (27%) and moderate osteoarthritis in 2/52 (4%). Pain and functional scores were independent of PM fragment size, post-reduction step-off, dislocation, malleoli fractured or syndesmotic injury. PM step-off more than 1 mm and traumatic dislocation/subluxation were associated with worse radiographical osteoarthritis. ConclusionAfter controlling for confounders, the unfixated smaller posterior malleolus fragment at 10-year follow-up demonstrated largely satisfactory clinical outcomes with some radiographical progression of osteoarthritis. Level of evidenceLevel III – Retrospective cohort study

Computed tomography changes diagnosis, management and surgical planning of ankle fractures.

To demonstrate how the use of adjunctive Computed Tomography (CT) can modify diagnosis, treatment options, and operative planning of ankle fractures in comparison with conventional radiographs (CR) in isolation. A total of 53 patients diagnosed with an ankle fracture between 2011 and 2016, were assessed with CT and CR. Evaluations of the fractures using CR in isolation and CR combined with CT were compared using different readers. Fractures were assessed in terms of type, displacement, size, associated injuries, treatment, patient position and surgical planning. The medial malleolus fractures characteristics (posteromedial fragment and anterior colliculus), the presence of posterior malleolus fracture and its characteristics (displacement, size, posteromedial or posterolateral segment) (ps < 0.042), syndesmosis injury (p < 0.001), and the absence of deltoid ligament lesion (p < 0.001), were more evident with the combination of CT and radiographs. There was an increase in operative indication (p = 0.007), prone positioning (p = 0.002), posterior malleolus surgical treatment (p < 0.001), posterolateral approach for the lateral malleolus (p = 0.003), and syndesmosis fixation (p = 0.020) with the association of CT and CR, among all groups of expertise, with a high interobserver reliability (> 0.75). The CR may fail to demonstrate subtle lesions, such as posterior malleolus fractures and syndesmotic injuries. The CT evaluation increases the diagnostic precision and improves the quality of information the surgeon receives, what might positively affect patient care. Retrospective Comparative Study.

Percutaneous posterior to anterior screw fixation through achilles tendon for posterior malleolus fractures: technique description and case series.

Posterior malleolus fractures (PMFs) (OTA 43B1.1) are frequently seen in combination with fractures of the fibula, medial malleolus, and distal tibia; they can rarely be seen in isolation. PMFs affect the alignment of the ankle mortise and the stability of syndesmosis. Techniques described for fixation of PMFs include open reduction internal fixation through a posterolateral or posteromedial approach or anterior-to-posterior screw fixation. For selected minimally displaced or nondisplaced fractures of the posterior malleolus, we developed a percutaneous technique through the Achilles tendon for the insertion of a posterior-to-anterior cannulated screw. The technique is described, and a clinical series is reviewed.

Trauma

The February 2024 Trauma Roundup360 looks at: Posterior malleolus fractures: what about medium-sized fragments?; Acute or delayed total hip arthroplasty after acetabular fracture fixation?; Intrawound antibiotics reduce the risk of deep infections in fracture fixation; Does the VANCO trial represent real world patients?; Can a restrictive transfusion protocol be effective beyond initial resuscitation?; What risk factors result in avascular necrosis of the talus?; Pre-existing anxiety and mood disorders have a role to play in complex regional pain syndrome; Three- and four-part proximal humeral fractures at ten years.

The Effect of Prone and Supine Limb Positioning on the Radiographic Evaluation of Posterolateral Plate Fixation of the Posterior Malleolus.

To facilitate the posterolateral approach to the posterior malleolus patients are often positioned prone initially, then turned supine to complete fixation at the medial malleolus. We sought to define observed differences in the radiographic appearance of implants relative to the joint line, in prone and supine positions. A 3.5mm tubular plate and a 3.5mm posterior distal tibial periarticular plate were applied sequentially to 3 individual cadaveric legs, via a posterolateral approach. The tubular plate was positioned to simulate buttress fixation and the posterolateral plate placed more distally. Each limb was secured on a custom jig and radiographs were taken on a mobile c-arm fluoroscopy machine with a calibration ball. A series of prone AP, supine PA and mortise radiographs were taken. Prone radiographs were also taken in different degrees of caudal tilt to simulate knee flexion which occurs in practice, during intraoperative positioning. Plate tip-joint line distances were measured and Mann-Whitney U tests performed. There was no statistically significant difference in plate tip-joint line distance when comparing equivalent prone and supine views (PA/AP or mortise). However, significant differences in apparent implant position were noted with alterations in caudal tilt. When taking a prone image, when the knee is flexed to 20 degrees, the plate tip will appear 6.5-8.5mm more proximal than in the equivalent supine image where the knee is extended and the fluoroscopy beam is orthogonal to the anatomic axis of the tibia. Observed differences in radiographic appearance of metalwork in the prone and supine position are most likely due to knee flexion and the resulting variation in the angle of the fluoroscopy beam, rather than projectional differences between supine and prone views. Surgeons should be alert to this when analysing intraoperative images.

Operative vs Nonoperative Management of Unstable Medial Malleolus Fractures

Unstable ankle fractures are routinely managed operatively. However, because of soft tissue and implant-related complications, recent literature has reported on the nonoperative management of well-reduced medial malleolus fractures after fibular stabilization, but with limited evidence supporting the routine application. To assess the superiority of internal fixation of well-reduced (displacement ≤2 mm) medial malleolus fractures compared with nonfixation after fibular stabilization. This superiority, pragmatic, parallel, prospective randomized clinical trial was conducted from October 1, 2017, to August 31, 2021. A total of 154 adult participants (≥16 years) with a closed, unstable bimalleolar or trimalleolar ankle fracture requiring surgery at an academic major trauma center in the UK were assessed. Exclusion criteria included injuries with no medial-sided fracture, open fractures, neurovascular injury, and the inability to comply with follow-up. Data analysis was performed in July 2022 and confirmed in September 2023. Once the lateral (and where appropriate, posterior) malleolus had been fixed and satisfactory intraoperative reduction of the medial malleolus fracture was confirmed by the operating surgeon, participants were randomly allocated to fixation (n = 78) or nonfixation (n = 76) of the medial malleolus. Olerud-Molander Ankle Score (OMAS) 1 year after randomization (range, 0-100 points, with 0 indicating worst possible outcome and 100 indicating best possible outcome). Among 154 randomized participants (mean [SD] age, 56.5 [16.7] years; 119 [77%] female), 144 (94%) completed the trial. At 1 year, the median OMAS was 80.0 (IQR, 60.0-90.0) in the fixation group compared with 72.5 (IQR, 55.0-90.0) in the nonfixation group (P = .17). Complication rates were comparable. Significantly more patients in the nonfixation group developed a radiographic nonunion (20% vs 0%; P < .001), with 8 of 13 clinically asymptomatic; 1 patient required surgical reintervention for this. Fracture type and reduction quality appeared to influence fracture union and patient outcome. In this randomized clinical trial comparing internal fixation of well-reduced medial malleolus fractures with nonfixation, after fibular stabilization, fixation was not superior according to the primary outcome. However, 1 in 5 patients developed a radiographic nonunion after nonfixation, and although the reintervention rate to manage this was low, the future implications are unknown. These results support selective nonfixation of anatomically reduced medial malleolar fractures after fibular stabilization. ClinicalTrials.gov Identifier: NCT03362229.

Fixation of Posterior Malleolus in Trimalleolar Ankle Fractures: Anteroposterior Screw or Posterolateral Plate?

Background: The treatment of the third malleolus has evolved in recent years, and surgical treatment can be carried out with traditional percutaneous osteosynthesis using anteroposterior screws or ORIF with a posterolateral plate. Methods: Our study included 54 patients divided into two groups based on the intervention type (screw or plate). Instrumental assessments comprised pre- and post-operative X-rays and pre-operative CT scans to evaluate joint step-off. The mean follow-up duration was 1 year and 9 months. Results: Radiographic control revealed no loss of reduction or mobilization of the synthesis devices, and all patients achieved fracture healing. Articular step-off &gt; 2 mm was observed in 21 patients (38.9%), including 4 in the plate group and 17 in the screw group, with a statistically significant likelihood of step-off presence in the latter. The mean AOFAS score was 90 points, negatively correlated with age, and lower in patients with joint step-off and a 15° reduction in ROM. Conclusions: The management of posterior malleolus fractures has changed with anatomical studies and an understanding of ankle stability through CT scans. ORIF with a posterior plate is advantageous for anatomical reduction of the tibial plafond but is disadvantageous in terms of surgical invasiveness and technical difficulty.

Clinical Effect of Screw Internal Fixation on Fracture Healing and Ankle Alignment in Patients with Posterior Malleolar Fracture.

To examine the clinical impact of screw internal fixation on the process of fracture healing and ankle alignment in individuals diagnosed with posterior malleolar (PM) fracture, specifically those with a fracture involving less than 25% of the articular surface (ASR) area. A total of 120 patients diagnosed and treated for PM fracture, encompassing less than 25% of the distal tibial ASR area, were selected from our hospital's records spanning from September 2021 to June 2023. These people were subsequently divided into two groups, namely the control group (group A) and the observation group (group B), based on the distinct treatment methods employed, with each group consisting of 60 patients. The people in the group A were treated with posterior malleolus non internal fixation, while the patients in the group B were treated with posterior malleolus screw internal fixation. The visual analog scores, peak plantar pressure and AOFAS scores of the two groups were subjected to comparison. The visual analog scores in the observation group at 6 months and 12 months after operation were reduced than the group A. Three months after operation, the peak plantar pressure of the affected foot (full foot, hind foot) in the group B was reduced than that of the healthy foot; There was a lack of statistically significant variation observed in the peak plantar pressure (full foot, hind foot) between the affected foot and the healthy foot 12 months after operation in the group B, and the plantar pressure tended to be balanced. Three months after operation, the peak plantar pressure of the affected foot (full foot, hind foot) in the group A was reduced than that of the healthy foot; After a period of 12 months following the surgical procedure, no notable disparity in the maximum pressure exerted on the sole of the foot was observed between the foot that underwent the operation and the unaffected foot in the group A, but the peak plantar pressure of the whole foot was reduced than that of the healthy foot, and the plantar pressure did not tend to be balanced. At the intervals of 6 months and 12 months following the surgical procedure, AOFAS ankle hind foot score in the group B was increased than the group A. The utilization of screw internal fixation demonstrates favorable clinical outcomes in patients presenting with PM fracture encompassing less than 25% of the articular surface area, which is conducive to promoting fracture healing, maintaining good ankle alignment, and promoting patient rehabilitation. screw internal fixation, posterior ankle fracture, articular surface of distal tibia, fracture healing, ankle joint alignment.

Computed Tomography Scans and Fixation Rates for Trimalleolar Ankle Fractures Over 10 Years at a Level 1 Trauma Center.

The posterior malleolus component of the trimalleolar ankle fracture has posed a controversial topic for diagnostic imaging and surgical management. Preoperative computed tomography (CT) scans are used to better appreciate fracture morphology and may affect management techniques. No prior study has investigated the trend in preoperative CT scan use and the rates of posterior and syndesmotic fixation for trimalleolar injuries. This retrospective cohort study evaluated the use of preoperative CT scans and the rates of posterior and syndesmotic fixation for trimalleolar ankle fractures over a 10-year period at an adult level 1 trauma center. Patients surgically managed for ankle fractures with OTA/AO classifications of 44B3, 44C3.3, 44C1.3, 44C2.3, and 44A3 were identified and included using Current Procedural Terminology codes and a prospectively collected fracture registry. Demographic information, comorbidities, fixation methods, and use of preoperative CT scan were recorded. Comparative analyses were performed to assess for yearly differences in demographic characteristics along with changes in trends of preoperative CT scans and posterior and syndesmotic fixation. A total of 1191 patients were included in the analyses. OTA/AO 44B3.2 fractures were the most common injuries (yearly range of 59.4%-80.1%). The rate of posterior fixation did not significantly increase during the study interval (1.4% growth per year [95% CI -0.27, 3.07]). However, the rate of preoperative CT scan use significantly increased by 2.76% (95% CI 1.99, 3.52) per year and the rate of syndesmotic fixation increased by 2.58% (95% CI 1.17, 3.99) per year. Fixation methods for both the syndesmosis and posterior malleolus changed during the study timeline. Despite a relatively stable rate of posterior fixation, the frequency of preoperative CT scans and use of syndesmotic fixation increased significantly over a 10-year study period. Level IV, descriptive pilot study.

Minimally-invasive lag screw fixation technique for posterior malleolus fractures: A cadaveric study

Anatomical reduction and lag screw fixation of posterior malleolar (PM) ankle fractures typically involves an open posterolateral approach. The aim of this anatomical study was to assess whether a minimally-invasive, percutaneous posterior-to-anterior lag screw fixation technique is safe to perform. Eighteen cadaveric ankle specimens were used. A transverse incision was made at the lateral border of the Tendo Achilles (TA). Windows were made lateral to and through the substance of the TA and simulated reduction and placement of a single lag screw performed. Specimens were then fully dissected to ascertain proximity and damage to anatomical structures. Lag screw fixation was placed appropriately in all ankles. No injury to the neurovascular structures, ankle joint or syndesmotic ligaments was observed. The mean distance from the soft tissue window to sural nerve was 10.0 mm (range 5–16), and 9.5 mm to short saphenous vein (4–14). Whilst the muscle belly of flexor hallucis longus (FHL) was pierced in six specimens, no injuries to the FHL tendon were observed. The mean distance from screw to syndesmosis was 9.3 mm (range 3–15) and 12.7 mm to the ankle joint (7–17). This study demonstrates that posterior percutaneous lag screw fixation is both safe and accurate. Further work is required to evaluate the precision of reduction and the biomechanical stability of this fixation technique. This novel minimally-invasive technique may be beneficial in avoiding the wound complications associated with open posterolateral ankle approaches and also offer a functional advantage due to minimal soft tissue disruption.

Trans-syndesmotic fixation in supination external rotation type 4 injuries: Are intraoperative tests reliable?

Ankle fractures occur due to a rotational mechanism. According to the Lauge-Hansen classification, supination-external rotation (SER) injuries are the most common type. Following osseous fixation, the evaluation and treatment of syndesmotic injuries in these injuries are controversial. This study aimed to evaluate the clinical, functional, and radiological results of trans-syndesmotic fixation using intraoperative tests in SER type 4 ankle injuries. Ankle syndesmosis was intraoperatively evaluated using cotton/hook and manual external rotation stress tests in 64 patients with SER type 4 fracture dislocation injuries. These patients were divided into two groups: those treated with and without trans-syndesmotic fixation in addition to open reduction and internal fixation of the fractures. Ankle range of motion (ROM), American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score, and Olerud-Molander Ankle Score (OMAS), tibiofibular overlap, tibiofibular clear space, and joint arthritis based on the Kellgren-Lawrence (K-L) scale were evaluated. Median values of OMAS (Z=-3.92, p<0.001), AOFAS (Z=-4.31, p<0.001), and ROM (Z=-2.95, p=0.003) were higher in Group 1. There were no differences between the groups regarding tibiofibular overlap median values (Z=-0.59, p=0.0554), tibiofibular clear space (Z=-1.13, p=0.258), and Kellgren-Lawrence arthritis scale. Lack of posterior malleolus fixation was found to increase the risk of arthritis by 18.197 times, despite having trans-syndesmotic fixation, which was statistically significant (Confidence Interval, CI: 2.482-133.417, p=0.004) (Table 4). Median values of OMAS, AOFAS, and ROM in patients without trans-syndesmotic fixation were lower. These results indicate that intraoperative tests may not provide entirely accurate results in SER type 4 injuries. Failure to detect a syndesmotic injury timely can result in instability. Therefore, we think that routine trans-syndesmotic fixation, as well as posterior malleolus fixation in SER type 4 ankle injuries, may improve outcomes.

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.

Results of Surgical Treatment of Ankle and Posterior Malleolus Fractures Using Different Surgical Techniques

Background. Almost half of the patients with ankle fractures have fracture of the posterior malleolus. Conclusions of the existing studies are contradictory and do not provide a decisive answer to the question of the need for fixation of the posterior tibial fragment.&#x0D; Aim of the study — to compare the radiologic and functional outcomes of osteosynthesis of the posterior tibial fragment in unstable ankle fractures using closed reduction and minimally invasive technique and direct open reduction using posterolateral and posteromedial surgical approaches.&#x0D; Methods. Prospective multicenter study enrolled 132 patients with complex ankle and posterior malleolus fractures. They were divided into three groups depending on the technique of fixation of posterior tibia. Functional and radiologic results of treatment were assessed at 12, 24, and 48 weeks after osteosynthesis. The AOFAS and Neer scales were used.&#x0D; Results. Bone union occurred in all patients at an average of 8.3±0.8 weeks after surgery. Analysis of postoperative CT scans showed that the use of posterior approaches provided statistically significantly more precise reduction of the fragments of posterior tibia. Functional results of patients of the second (posterolateral approach) and third (posteromedial approach) groups at 24 and 48 weeks of follow-up were statistically significantly superior to those of the first group. The median AOFAS score at 48 weeks of follow-up was 86 for group 2 patients and 90 — for group 3. The median scores on the Neer scale were 88 and 94 points respectively.&#x0D; Conclusion. Posterior approaches in the surgical treatment of patients with complex ankle and posterior malleolus fractures allow for more precise fragment open reduction compared to closed one. These patients also show better mid-term functional outcomes.

Importance of computed tomography in posterior malleolar fractures: Added information to preoperative X-ray studies.

Ankle fractures are common lesions of the lower limbs. Approximately 40% of ankle fractures affect the posterior malleolus (PM). Historically, PM osteosynthesis was recommended when PM size in X-ray images was greater than 25% of the joint. Currently, computed tomography (CT) has been gaining traction in the preoperative evaluation of ankle fractures. To elucidate the similarity in dimensions and to correlate PM size in X-ray images with the articular surface of the affected tibial plafond in the axial view on CT (AXCT) of a PM fracture. Eighty-one patients (mean age: 39.4 ± 13.5 years) were evaluated (54.3% were male). Two independent examiners measured PM size in profile X-ray images (PMXR) and sagittal CT (SAGCT) slices. The correlation of the measurements between the examiners and the difference in the PM fragment sizes between the two images were compared. Next, the PM size in PMXR was compared with the surface of the tibial plafond involved in the fracture in AXCT according to the Haraguchi classification. The correlation rates between the examiners were 0.93 and 0.94 for PMXR and SAGCT, respectively (P < 0.001). Fragments were 2.12% larger in SAGCT than in PMXR (P = 0.018). In PMXR, there were 56 cases < 25% and 25 cases ≥ 25%. When PMXR was < 25%, AXCT corresponded to 10.13% of the tibial plafond. When PMXR was ≥ 25%, AXCT was 24.52% (P < 0.001). According to the Haraguchi classification, fracture types I and II had similar PMXR measurements that were greater than those of type III. When analyzing AXCT, a significant difference was found between the three types, with II > I > III (P < 0.001). PM fractures show different sizes using X-ray or CT images. CT showed a larger PM in the sagittal plane and allowed the visualization of the real dimensions of the tibial plafond surface.

Does Flipping From Prone to Supine for Medial Malleolar Fixation of Trimalleolar Ankle Fractures Improve Results?

There has been a paradigm shift towards fixing the posterior malleolus in trimalleolar ankle fractures. This study evaluated whether a surgeon's preference to intraoperatively flip or not flip patients from prone to supine for medial malleolar fixation following repair of fibular and posterior malleoli impacted surgical outcomes. A retrospective patient cohort treated at a large urban academic center and level 1 trauma center was reviewed to identify all operative trimalleolar ankle fractures initially positioned prone. One hundred and forty-seven patients with mean 12-month follow-up were included and divided based on positioning for medial malleolar fixation, prone or supine (following closure, flip and re-prep, and drape). Data was collected on patient demographics, injury mechanism, perioperative variables, and complication rates. Postoperative reduction films were reviewed by orthopedic traumatologists to grade the accuracy of anatomic fracture reduction. Overall, 74 (50.3%) had the medial malleolus fixed prone, while 73 (49.7%) were flipped and fixed supine. No differences in demographics, injury details, and fracture type existed between the groups. The supine group had a higher rate of initial external fixation (p = .047), longer operative time in minutes (p < .001), and a higher use of plate and screw constructs for medial malleolar fixation (p = .019). There were no differences in clinical and radiographic outcomes and complication rates. This study demonstrated that intraoperative change in positioning for improved medial malleolar visualization in trimalleolar ankle fractures results in longer operative times but similar radiographic and clinical results. The decision of operative position should be based on surgeon comfort.

Injury to the posterior malleolus in Maisonneuve fractures

PurposeThe aim of this study was to describe the incidence and a complex pathoanatomy of posterior malleolus fractures in a Maisonneuve fracture.MethodsThe study included 100 prospectively collected patients with a complete clinical and radiological documentation of an ankle fracture or fracture-dislocation including a fracture of the proximal quarter of the fibula.ResultsA posterior malleolus fracture was identified in 74 patients, and in 27% of these cases it carried more than one quarter of the fibular notch. Displacement of the posterior fragment by more than 2 mm was shown by scans in 72% of cases. Small intercalary fragments were identified in 43% of cases. Fractures of the Tillaux–Chaput tubercle were identified in 20 patients.ConclusionOur study has proved a high rate of posterior malleolus fractures associated with a Maisonneuve fracture, and documented their considerable variability in terms of involvement of the fibular notch, tibiotalar contact area, direction of displacement and frequency of intercalary fragments. Of no less importance is a combination of Tillaux–Chaput fractures with a Maisonneuve fracture.

Trauma

The December 2023 Trauma Roundup360 looks at: Distal femoral arthroplasty: medical risks under the spotlight; Quads repair: tunnels or anchors?; Complex trade-offs in treating severe tibial fractures: limb salvage versus primary amputation; Middle-sized posterior malleolus fractures – to fix?; Bone transport through induced membrane: a randomized controlled trial; Displaced geriatric femoral neck fractures; Risk factors for reoperation to promote union in 1,111 distal femur fractures; New versus old – reliability of the OTA/AO classification for trochanteric hip fractures; Risk factors for fracture-related infection after ankle fracture surgery.