Size Of Posterior Malleolar Fragment Research Articles

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

MEDIUM- TO LONG-TERM OUTCOMES AFTER NON-FIXATION OF THE SMALLER POSTERIOR MALLEOLAR FRAGMENT: A RETROSPECTIVE COHORT STUDY

Treatment of posterior malleolar (PM) ankle fractures remain 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 medium-to-long term clinical and radiographical outcomes in younger adult patients with PM ankle fractures managed without PM fragment fixation.A retrospective cohort study of patients aged 18-55 years old admitted under our orthopaedic unit between 1st of April 2009 and 31st of October 2013 with PM ankle fractures was performed. Inclusion criteria were that all patients must mobilise independently pre-trauma, have no pre-existing ankle pathologies, and had 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 Foot and Ankle Ability Measure (FAAM) with activities of daily living (ADL) and sports subscale, visual analogue scale (VAS) and patient satisfaction ratings. Osteoarthrosis was assessed using modified Kellgren-Lawrence scale on updated weightbearing ankle radiographs.61 participants were included. Mean follow-up was 10.26 years. Average PM size was 16.19±7.39%. All participants were evaluated for clinical outcomes, demonstrating good functional outcomes (FAAM-ADL 95.48±7.13; FAAM-Sports 86.39±15.52) and patient satisfaction (86.16±14.42%), with minimal pain (VAS 1.13±1.65). Radiographical outcomes were evaluated in 52 participants, showing no-to-minimal osteoarthrosis in 36/52 (69.23%), mild osteoarthrosis in 14/52 (26.92%) and moderate osteoarthrosis in 2/52 (3.85%). Clinical outcomes were not associated with PM fragment size, post-reduction step-off, dislocation, malleoli fractured or syndesmotic injury. PM step-off and dislocation were associated with worse radiographical osteoarthrosis. Other published medium-to-long term studies reported overall good outcomes, with no differences after small fragment fixation.The unfixated smaller posterior malleolus fragment demonstrated overall satisfactory clinical and radiographical outcomes at 10-year follow-up and may be considered a valid treatment strategy.

Risk Factors Associated With Worse Clinical Outcomes of Ankle Fractures Involving the Posterior Malleolus.

Ankle fractures involving the posterior malleolus (PM) tend to result in inferior clinical outcomes compared to other ankle fractures. However, it is unclear which specific risk factors and fracture characteristics are associated with negative outcomes in these fractures. The aim of this study was to identify risk factors for poor postoperative patient-reported outcomes in patients with fractures involving the PM. This retrospective cohort study included patients who sustained ankle fractures involving the PM between March 2016 and July 2020 and had preoperative computed tomography (CT) scans. In total, 122 patients were included for analysis. One patient (0.8%) had an isolated PM fracture, 19 (15.6%) had bimalleolar ankle fractures involving the PM, and 102 (83.6%) had trimalleolar fractures. Fracture characteristics including the Lauge-Hansen (LH) and Haraguchi classifications and posterior malleolar fragment size were collected from preoperative CT scans. Patient Reported Outcome Measurement Information System (PROMIS) scores were collected preoperatively and at a minimum of 1 year postoperatively. The association between various demographic and fracture characteristics with postoperative PROMIS scores was assessed. Involvement of more malleoli was associated with worse PROMIS Physical Function (P = .04), Global Physical Health (P = .04), and Global Mental Health (P < .001), and Depression scores (P = .001). Elevated BMI was also associated with worse PROMIS Physical Function (P = .0025), Pain Interference (P = .0013), and Global Physical Health (P = .012) scores. Time to surgery, fragment size, Haraguchi classification, and LH classification were not associated with PROMIS scores. In this cohort, we found that trimalleolar ankle fractures were associated with inferior PROMIS outcomes compared with bimalleolar ankle fractures involving the PM in multiple domains. Level III, retrospective cohort study.

Temporizing cast immobilization is a safe alternative to external fixation in ankle fracture-dislocation while posterior malleolar fragment size predicts loss of reduction: a case control study

BackgroundTo determine if temporizing cast immobilization is a safe alternative to external fixator (ex-fix) in ankle fracture-dislocations with delayed surgery or moderate soft-tissue injury, we analysed the early complications and re-dislocation rates of cast immobilization in relation to ex-fix in patients sustaining these injuries.MethodsAll skeletally mature patients with a closed ankle fracture-dislocation and a minimum 6-months follow-up treated between 2007 and 2017 were included. Baseline demographics, comorbidities, injury description, treatment history and complications were assessed.ResultsIn 160 patients (94 female; mean age 50 years) with 162 ankle fracture-dislocations, 35 underwent primary ex-fix and 127 temporizing cast immobilizations. Loss of reduction (LOR) was observed in 25 cases (19.7%) and 19 (15.0%) were converted to ex-fix. The rate of surgical site infections (ex-fix: 11.1% vs cast: 4.6%) and skin necrosis (ex-fix: 7.4% vs cast: 6.5%) did not differ significantly between groups (p = 0.122 and p = 0.825). Temporizing cast immobilization led to an on average 2.7 days earlier definite surgery and 5.0 days shorter hospitalization when compared to ex-fix (p < 0.001). Posterior malleolus fragment (PMF) size predicted LOR with ≥ 22.5% being the threshold for critical PMF-size (p < 0.001).ConclusionTemporizing cast immobilization was a safe option for those ankle fracture-dislocations in which immediate definite treatment was not possible. Those temporized in a cast underwent definite fixation earlier than those with a fix-ex and had a complication rate no worse than the ex-fix patients. PMF-size was an important predictor for LOR. Primary ex-fix seems appropriate for those with ≥ 22.5% PMF-size.Trial registrationThe study does not meet the criteria of a prospective, clinical trial. There was no registration.

Pre-and postoperative factors associated with functional outcomes in patients with posterior malleolar fractures

IntroductionRecent studies on posterior malleolar fractures mainly focus on the reduction quality and fixation of the posterior fragment since it contributes to ankle stability and articular congruency. However, the association of pre-and postoperative factors considering the whole ankle joint in postoperative functional outcomes remains unclear. Therefore, this study aimed to examine the association between pre-and postoperative variables for postoperative functional outcomes in patients with posterior malleolar fragments (classified as Haraguchi type I or II) and considered the association between reduction and fixation for small posterior malleolar fragments of less than 25% of the intra-articular surface. MethodsThis multicenter retrospective cohort study included 110 adult patients who underwent internal fixation for ankle fractures with posterior malleolar fragments. The primary outcome was the American Orthopaedic Foot and Ankle Society (AOFAS) score 12-months postoperatively. As pre-and postoperative variables, the preoperative demographic data, radiographic findings, operative method, postoperative radiographic findings, and complications were evaluated. In addition, univariable and multivariable logistic regression analyses were conducted to examine the association between pre-and postoperative variables and AOFAS scores. ResultsTwenty-four (21.8%) cases had postoperative complications. Univariate analysis showed that age was significantly according to AOFAS score-stratified groups in patients with Haraguchi type II fractures. Multivariable logistic regression analysis using bootstrapping in the Haraguchi type II group showed that postoperative complications were significantly associated with low AOFAS scores, indicating poor functionality. In both fracture types, postoperative complications had the highest odds ratio among the explanatory variables. In patients with small posterior malleolar fragments, fragment reduction, fixation, and ankle stability were not associated with AOFAS scores. ConclusionsOur results suggest that postoperative complications were associated with AOFAS scores at postoperative 12 months in patients with ankle fractures with posterior malleolar fragments. In patients with small posterior malleolar fragments, reduction and fixation were not associated with AOFAS scores. Therefore, clinical decisions for posterior fragment fixation should be made based on the possible risk of complications related to the surgical procedures in addition to the posterior malleolar fragment size.

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.

Patient Pain and Function After Correction of Posterior Malleolar Malunion.

The management of an ankle malunion involving the posterior malleolus remains challenging, and only a few published studies described the operative treatment of complex posterior malleolar malunion. A transfibular approach allows for direct visualization of the articular reduction of the posterior malleolus, but the reports of its use for correcting posterior malleolar malunion are rare. This study aims to evaluate the results of the intra-articular osteotomy via a transfibular approach for correcting an ankle malunion involving the posterior malleolus. We conducted a retrospective review of 26 patients with a symptomatic malunited ankle fracture involving posterior malleolus were treated with the intra-articular osteotomy via a transfibular approach in our department. Radiographic assessments were performed using plain radiographs and computed tomographic (CT) scans. Clinical outcomes were assessed using the AOFAS ankle-hindfoot score, visual analog scale (VAS), active range of motion of ankle, and the 36-Item Short-Form Health Survey score. Postoperatively, anatomic correction of articular surface and anatomic reduction of syndesmosis were achieved in all patients as judged by CT scans. No evidence of progression had been found in 18 of 26 patients (69.2%) at final follow-up. The median AOFAS score improved from 42.0 to 81.5 (P < .001). Median pain VAS score decreased from 6.0 to 1.0 (P < .001). A favorable clinical outcome was associated with a short time interval from original injury to correction surgery and a lower grade of preoperative arthritis, but not with the posterior malleolar fragment size. However, time interval, the posterior malleolar fragment size, and the grade of preoperative arthritis showed no correlation with the progression of arthritis grade after surgery. An intra-articular osteotomy via a transfibular approach demonstrated an improved function and pain after operative treatment of malunited ankle fracture with a displaced posterior malleolar fragment. Level IV, retrospective case series.

Outcomes of posterior malleolar fixation in ankle fractures in a major trauma centre

Ongoing controversy exists over the indications and benefits of posterior malleolar fixation in ankle fractures. The aim of this pragmatic study was to evaluate the outcomes of posterior malleolar fracture fixation in ankle fractures in the setting of a major trauma centre. Our hypothesis is that posterior malleolus fixation leads to improved clinical outcomes. A total of 320 patients were identified with operatively treated ankle fractures involving a posterior malleolus component, at our institution between January 2012 and January 2018, ensuring a minimum 2 year follow-up. Of these patients, 160 had the posterior malleolus fixed as part of their surgery and 160 did not. Patient demographics, surgical details and complications were assessed. The Manchester-Oxford Foot Questionnaire (MOXFQ) was the primary patient outcome measure. Fixation of the posterior malleolus was associated with a statistically significant improvement in patient outcomes. Mean MOXFQ score in the unfixed posterior malleolus group was 24.03 (0 - 62), compared to 20.10 (0 - 67) in the fixed posterior malleolus group (p = 0.04). Outcomes were worse with increasing size of posterior malleolar fragment. Metalwork-related issues were higher in the posterior malleolus fixed group (24/160 (15%) versus 10/160 (6.2%)) and re-operation rate was double. This study demonstrates that in the practical setting of a major trauma unit, fixation of the posterior malleolar fracture leads to improved patient outcomes but with increased metalwork risks and reoperation rates.

Fracture Type, Postoperative Articular Congruency and Obesity of Patients Influenced on Long to Midterm Outcome of Posterior Malleolar Fractures in Ankle Injury

Category:Trauma; ArthroscopyIntroduction/Purpose:One of the factors contributing to outcome of posterior malleolar (PM) fractures is the development of osteoarthritis. Previous studies suggested that fragment size of PM and postoperative articular congruency were influenced on generative ankle arthritis. Haraguchi et al. classify PM fractures according to pathoanatomy of injury. However, there was no study to investigate possible risk factors including the type of PM fracture for degenerative arthritis in ankle fractures including PM. The purpose of this study was to identify the risk factors for degenerative arthritis in ankle fractures including PM. We hypothesized that risk factors for posttraumatic arthritis could be identified from patient demographic and the extent of the pathologic condition associated with fractures.Methods:We performed a retrospective review between 2004 and 2015 of consecutive patients who underwent operation with ankle fractures and available at minimum 5 years of follow up. The exclusion criteria included diabetic neuropathy, skeletal immaturity, tibial pilon fractures, polytrauma, open fracture. Patients were sorted into 2 groups according to the presence of arthritis change more than grade 2 at last follow up. Furthermore, the statistical analysis by binary logistic regression analysis included the significance of various risk factors including age at surgery, sex, diabetes, smoking, body mass index (BMI), dominant side, time interval between the trauma and surgery, type of PM fracture, PM fragment size and postoperative joint congruency, The functional outcomes were assessed with the Foot and Ankle Outcome Score (FAOS).Results:A total 332 patients with mean follow up of 8.2+-2.4 years met the study inclusion criteria and underwent analysis. The overall rate of posttraumatic arthritic change was 31.3% (non-arthritis group: 228 patients, arthritis group: 104). It was significantly affected by the BMI (p=0.021; adjusted odds ratio, OR, >= 30, 7.23), Mason classification type 3 PM fracture (p=0.031, adjusted OR 4.23), >25% of articular surface of PM, and postoperative articular incongruence (p=0.029, adjusted OR 5.13). The other variables were not found to be significant risk factors. The mean scores in the group with arthritis were significantly lower than those in the group without arthritis (p=0.001)Conclusion:The overall results suggest that articular congruency should be considered during surgery along with meticulous attention to anatomic reduction of large fragment posterior malleolar fracture, especially in obese patients.

Posterior malleolar ankle fractures.

The primary aim of this study was to address the hypothesis that fracture morphology might be more important than posterior malleolar fragment size in rotational type posterior malleolar ankle fractures (PMAFs). The secondary aim was to identify clinically important predictors of outcome for each respective PMAF-type, to challenge the current dogma that surgical decision-making should be based on fragment size. This observational prospective cohort study included 70 patients with operatively treated rotational type PMAFs, respectively: 23 Haraguchi Type I (large posterolateral-oblique), 22 Type II (two-part posterolateral and posteromedial), and 25 (avulsion-) Type III. There was no standardized protocol on how to address the PMAFs and CT-imaging was used to classify fracture morphology and quality of postoperative syndesmotic reduction. Quantitative 3D-CT (Q3DCT) was used to assess the quality of fracture reduction, respectively: the proportion of articular involvement; residual intra-articular: gap, step-off, and 3D-displacement; and residual gap and step-off at the fibular notch. These predictors were correlated with the Foot and Ankle Outcome Score (FAOS) at two-years follow-up. Bivariate analyses revealed that fracture morphology (p = 0.039) as well as fragment size (p = 0.007) were significantly associated with the FAOS. However, in multivariate analyses, fracture morphology (p = 0.001) (but not fragment size (p = 0.432)) and the residual intra-articular gap(s) (p = 0.009) were significantly associated. Haraguchi Type-II PMAFs had poorer FAOS scores compared with Types I and III. Multivariate analyses identified the following independent predictors: step-off in Type I; none of the Q3DCT-measurements in Type II, and quality of syndesmotic reduction in small-avulsion Type III PMAFs. PMAFs are three separate entities based on fracture morphology, with different predictors of outcome for each PMAF type. The current debate on whether or not to fix PMAFs needs to be refined to determine which morphological subtype benefits from fixation. In PMAFs, fracture morphology should guide treatment instead of fragment size. Cite this article: Bone Joint J 2020;102-B(9):1229-1241.

Trimalleoller ayak bileği kırıklarında posterior malleol fragmanın ölçümü için 3D temelli ölçüm metodlarıyla ile iki boyutlu radyoragrafi metodunun karşılaştırılması

Aim: The aim of this study is, to compare the posterior malleolar fragment (PMF) sizing between lateral ankle radiography measurement and computer assistted 3D modelling (CA3DM) methods Methods: Fifty-one patients between january 2015 and november 2018 with posterior malleolar fractured were included in this study. The rate of PMF to the articular surface at the distal end of the tibia was calculated by two different imaging methods by two surgeons. According to posterior fragment size, patients were separated into two groups. Group 1 was consisted of posterior fragment size smaller than 15% and group 2 was bigger than 15% due to CA3DM. Results: The interobserver correlation (IOC) between two observers and CA3DM was 44.3%. Also the IOC between first observer and CA3DM was 35.7% (p&amp;lt;0.05), second observer and CA3DM were 46.6% (p&amp;lt;0.01) and observers was 51.6% (p&amp;lt;0.01). For group 1, IOC between two observers and CA3DM was 41.2% (p&amp;lt;0.05), first observer and CA3DM was 30.6% (p&amp;gt;0.05), second observer and CA3DM was 51.6% (p&amp;lt;0.05) and two observers were 45.8% (p&amp;lt;0.05). For group 2, IOC between two observers and CA3DM was 27.9% (p&amp;gt;0.05), first and CA3DM was 18.6% (p&amp;gt;0.05), second observer and CA3DM was 7.1% (p&amp;gt;0.05) and two observers was 49% (p&amp;lt;0.05).Conclusion: Our study shows that posterior malleolar fragment size measuring on plain radiography is not a safe method for bigger fragments and CA3DM method may be a more reliable to assess correct fragment size and also to analyze fracture morphology. But for fragments ≤15% CA3DM and plain radiographic measures are not statistically different.

The Clinical, Radiologic Outcomes of Indirect Anteroposterior Screw Fixation for Posterior Malleolar Fracture in Rotational Ankle Fractures: Comparison with Syndesmosis Fixation

Category:AnkleIntroduction/Purpose:The posterior malleolus is an important soft tissue attachment for the posterior inferior syndesmosis ligament. Recent studies suggested that direct fixation of a sizable posterior malleolar (PM) fracture through posterolateral approach would act to stabilize the syndesmosis and minimize or eliminate the need for trans-syndesmotic fixation. Indirect anteroposterior (AP) screw fixation was an alternative method, which represent relatively low complication. However, there were few studies to evaluate the stability of syndesmosis after indirect anteroposterior screw. The purpose of this study was to define the rate of syndesmotic instability after anteroposterior screw fixation and to compare to the clinical and anatomical outcomes with indirect reduction without fixation.Methods:We performed a retrospective review between 2009 and 2015 of consecutive patients who underwent surgery with sustained rotational ankle fractures including PM fractures. The exclusion criteria included age <18 years, diabetic neuropathy, tibial pilon fractures, previous ankle fracture repair and not available at minimum 1 year follow up. After the fibula and medial malleolar fracture fixation, the PM was fixed with an AP screw, leaving some of relatively smaller and indirect reduced PM fractures unfixed. Patients were sorted into 2 groups according to the presence (group F) or absence (group N) of AP screw fixation of PM. Then, both groups were divided according to the intraoperative necessity of syndesmotic fixation. The demographics, PM fragment size and syndesmosis widening comparing intact ankle on CT at 1 year postoperatively were recorded for each fracture. The functional outcomes were assessed with the Foot and Ankle Outcome Score (FAOS).Results:A total 126 patients met the study inclusion criteria and underwent analysis. Syndesmotic fixation was required in 17 of 78 (21.8%) and 24 of 88 (72.7%) in group F and N, respectively (p=0.012). Postoperative and follow-up FAOS scores were similar in the four subgroups. The tibiofibular distance on CT was greater in the patients without syndesmotic screw fixation in group F and N (p=0.036 and 0.021, respectively).Conclusion:Indirect AP screw fixation of the PM fracture in rotational ankle fractures might be support syndesmotic stability and, thus, lower the rate of syndesmotic fixation. Also, these patients have functional outcomes at least equivalent to outcomes for patients having syndesmotic screw fixation. However, in AP screw fixation group, syndesmosis widening was evaluated without syndesmosis fixation, which could be resulted in degenerative arthritis change. Therefore, our data demonstrate that indirect AP screw fixation of PM fracture alone could not restore syndesmotic stability perfectly.

The role of a small posterior malleolar fragment in trimalleolar fractures: a biomechanical study.

The aim of this study was to investigate the effect of a posterior malleolar fragment (PMF), with < 25% ankle joint surface, on pressure distribution and joint-stability. There is still little scientific evidence available to advise on the size of PMF, which is essential to provide treatment. To date, studies show inconsistent results and recommendations for surgical treatment date from 1940. A total of 12 cadaveric ankles were assigned to two study groups. A trimalleolar fracture was created, followed by open reduction and internal fixation. PMF was fixed in Group I, but not in Group II. Intra-articular pressure was measured and cyclic loading was performed. Contact area decreased following each fracture, while anatomical fixation restored it nearly to its intact level. Contact pressure decreased significantly with fixation of the PMF. In plantarflexion, the centre of force shifted significantly posteriorly in Group II and anteriorly in Group I. Load to failure testing showed no difference between the groups. Surgical reduction of a small PMF with less than 25% ankle joint surface improves pressure distribution but does not affect ankle joint stability. Cite this article: Bone Joint J 2018;100-B:95-100.

Stability of the Syndesmosis After Posterior Malleolar Fracture Fixation.

We sought to define the rate of syndesmotic instability after anatomic reduction of the posterior malleolus when posterior stabilization of a trimalleolar or trimalleolar equivalent ankle fracture was chosen vs when a supine position and initially conservative management of the posterior elements was chosen. The types of syndesmotic and posterior malleolar fixation used to treat adult patients with ankle fractures involving the posterior malleolus at our level I trauma center were retrospectively assessed (N = 198). Specifically, both bimalleolar and trimalleolar fractures were included. Exclusion criteria included pilon fractures, trimalleolar fractures with Chaput fragments, and neurologic injury. Demographics, fracture classification, initial operative position, medial clear space, and posterior malleolar fragment size were recorded for each fracture. In total, 151 patients (76.3%) were initially positioned supine, 27.2% of whom had syndesmotic instability requiring operative stabilization. Almost 25% of supine patients also underwent posterior malleolar stabilization for posterior instability. Overall, 73 (48.3%) patients who were initially treated in the supine position needed some form of additional stabilization. Forty-seven patients (23.7%) were initially positioned prone. Syndesmotic stability was restored in 97.9% of these patients. This 2.1% rate of instability vastly differs from the 13-fold higher syndesmotic instability rate observed in the supine group ( P < .001). Our data demonstrate that the rate of syndesmotic instability was reduced in trimalleolar and trimalleolar equivalent fractures when prone positioning and direct fixation of the posterior malleolus were first performed. Using traditional preoperative estimates of posterior stability to determine the need for posterior malleolar fixation may be inadequate since almost a quarter of patients treated supine received posterior stabilization. Level III, retrospective comparative series.

Results of Syndesmotic Screw Fixation versus Posterior Malleolus Fixation in Syndesmotic Injury at Pronation External Rotation Stage IV Ankle Fracture with Posterior Malleolus Fracture: Postoperative One Year Follow-up

Purpose: The purpose of this study is to compare the radiologic and clinical results of syndesmotic screw fixation and posterior malleolar fixation for syndesmotic injury in Lauge-Hansen classification pronation-external rotation (PER) stage IV ankle fractures with posterior malleolus fracture. Materials and Methods: We designed a retrospective study that included patients with Lauge-Hansen classification PER stage IV ankle fracture with posterior malleolus fracture. Of 723 patients who underwent ankle fracture surgery from March 2005 to November 2012, 29 were included in this study. In this study, syndesmotic injury was treated with syndesmotic screw fixation or posterior malleolus fixation. There were 15 cases of syndesmotic screw fixation and 14 cases of posterior malleolar fixation. We compared the radiologic and clinical results at one year postoperatively. Posterior malleolus fragment size on a pre-operative computed tomographic image, and tibiofibular overlap, medial clear space, articular step-off, Kellgren-Lawrence grade, and Takakura classification on a postoperative one year followup radiograph were used for comparison of the radiologic results. The clinical results were assessed using the American Orthopaedic Foot and Ankle Society score, visual analogue scale score, and patient subjective satisfaction score. Results: Posterior malleolar fragment size was 12.62%±3.01% of the joint space in the syndesmotic screw fixation group and 27.04%±4.34% in the posterior malleolar fixation group. A statistical difference was observed between the two groups. However, other results, including tibiofibular overlap, medial clear space, articular step-off, Kellgren-Lawrence grade, Takakura classification, and clinical scores showed no statistical difference. Conclusion: In the Lauge-Hansen classification PER stage IV ankle fracture with posterior malleolus fracture, if the posterior malleolus fracture can be reduced anatomically and fixated rigidly, syndesmotic screw fixation, which can cause several complications, is usually not required for achievement of a satisfactory syndesmotic stability; this would be a recommendable option for treatment of syndesmotic injury.

Impact of trimalleolar ankle fractures: How do patients fare post-operatively?

We aim to evaluate the clinical and functional outcome of trimalleolar fractures and the ability of patients to return to sporting activities. A retrospective review of 31 patients with operatively managed trimalleolar fractures was conducted. Their Olerud and Molander scores and ability to return to sports was analyzed at 1 year postoperatively. Dislocations were more likely to result from trimalleolar fractures (p<0.001). 11 (52.4%) of our patients had residual pain at 1 year. 13 (61.9%) and 10 (47.6%) had persistent ankle stiffness and swelling. Out of 12 patients who were involved in sports pre-operatively, only 4 (33.3%) patients were able to return to sports. 3 (25%) patients were unable to do sports at all. Increasing posterior malleolar fragment size correlates with poorer functional outcome. Patients have poorer functional outcome with increasing posterior malleolar fragment size in trimalleolar fractures. Residual deficits affect the majority of our patients and a notable proportion was unable to return to sporting activities.