Treatment Of Posterior Malleolar Fractures Research Articles

Treatment of Syndesmotic Instability: The Importance of Malleolar Fixation

A significant proportion of syndesmotic injuries often occur simultaneously with malleolar fractures. The existing literature emphasizes that even slight misalignments in the malleolar structures can lead to altered talar motion, ultimately resulting in post-traumatic ankle arthritis. Rotational ankle fractures with syndesmotic injury can manifest with isolated or a combination of lateral, medial, and/or posterior malleolar fractures, and an accurate anatomic restoration of malleolar fractures has been emphasized. One such reason for anatomic reduction is that the fracture fragment may have an important attachment site for ligaments that contributes to the stability of the ankle and syndesmotic joints. While the biomechanical impact of malreduction of the lateral and medial malleolus osteoligamentous complex has been well documented and understood, controversy persists regarding the optimal surgical treatment of posterior malleolar fractures in the context of syndesmosis instability. Advanced imaging and biomechanical studies have shed new light on the role of the posterior malleolus in syndesmosis stability, suggesting that anatomic reduction of the posterior malleolar fragment could decrease the necessity of transfixation of the syndesmosis, lowering the risk of malreduction. As a result, there is growing advocacy for anatomically reducing and fixing the posterior malleolus in ankle fractures with syndesmotic injuries. This review focuses on the critical role of malleolar fixation in the management of syndesmotic injuries. Level of Evidence : Diagnostic Level V—expert opinion. See Instructions for Authors for a complete description of levels of evidence.

ANATOMY OF THE INSERTION OF THE POSTERIOR INFERIOR TIBIOFIBULAR LIGAMENT AND ITS RELEVANCE TO POSTERIOR MALLEOLAR ROTATIONAL PILON FRACTURES

IntroductionThe treatment of posterior malleolar fractures is developing. Mason and Molloy (Foot Ankle Int. 2017 Nov;38(11):1229-1235) identified only 49% of posterior malleolar rotational pilon type fractures had syndesmotic instabilities. This was against general thinking that fixation of such a fragment would stabilize the syndesmosis.MethodsWe examined 10 cadaveric lower limbs that had been preserved for dissection at the Human Anatomy and Resource Centre at Liverpool University in a solution of formaldehyde. The lower limbs were carefully dissected to identify the ligamentous structures on the posterior aspect of the ankle. To compare the size to the rotational pilon posterior malleolar fracture (Mason and Molloy 2A and B) we gathered information from our posterior malleolar fracture database. 3D CT imaging was analysed using our department PACS system.ResultsThe PITFL insertion on the posterior aspect of the tibia is very large. The average size of insertion was 54.9×47.1mm across the posterior aspect of the tibia. Medially the PITFL blends into the sheath of tibialis posterior and laterally into the peroneal tendon sheath.78 posterior lateral and 35 posterior medial fragments were measured. On average, the lateral to medial size of the posteromalleolar fragment was 24.5mm in the posterolateral fragment, and 43mm if there is a posteromedial fragment present also. The average distal to proximal size of the posterolateral fragment was 24.5mm and 18.5mm for the posteromedial fragment.ConclusionThe PITFL insertion on the tibia is broad. In comparison to the average size of the posterior malleolar fragments, the PITFL insertion is significantly bigger. Therefore, for a posterior malleolar fracture to cause posterior syndesmotic instability, a ligamentous injury will also have to occur. This explains the finding by Mason and Molloy that only 49% of type 2 injuries had a syndesmotic injury on testing.

Morphological Analysis of Intraarticular Fragments in AO/OTA 44 Category Posterior Malleolar Fractures

Category: Ankle; Trauma Introduction/Purpose: Intraarticular fragments (IAFs) associated with posterior malleolar fractures are a major obstacle in the treatment of ankle fractures. However, their frequency, location, and morphology, as well as their relationship with the classification of ankle posterior malleolar fractures, are poorly understood and unresolved. The Purpose of this study is to clarify the frequency and morphology of IAFs in posterior malleolar ankle fractures. Methods: This study was conducted at a single institution and included 104 consecutive patients with trimalleolar ankle fractures treated between 2015 and 2022. The inclusion criteria were 1) acute fracture within 2 weeks after injury and 2) cases with computed tomography (CT) images at the time of injury. The exclusion criteria were 1) previous ipsilateral ankle fracture, 2) pathological fracture, and 3) younger age with open physis. CT images at the time of injury were reviewed and each posterior malleolar fracture was classified using the Mason classification. Frequency of occurrence, size (long diameter × short diameter), and angle (the angle between the long diameter and fracture surface of the posterior malleolar fracture) of the IAF. The location of the IAF was described from CT axial images The dislocated distance of the IAF from the articular surface was measured on the sagittal CT view. Results: The patient’s mean age was 54.6 years. 46 cases were Type 1, 32 cases were Type 2A, 9 cases were Type 2B, and 17 cases were Type 3 according to the Mason’s classification. In Mason Type 2 and 3 cases, the IAF was present in 32 (78.0%) and 12 (70.6%) cases, respectively. The IAF was more frequently observed laterally in type 2 (22 cases) and medially in type 3 (7 cases). The long × short diameter of the IAF averaged 11.2 × 4.9 mm and 9.0 × 3.7 mm for Types 2 and 3, respectively. The angle of IAF was 10.5 ± 13.4° and 8.5 ± 7.8°, the distance of displacement was 3.0 ± 2.6 mm and 2.4 ± 1.2 mm, respectively. Conclusion: This study revealed a high incidence of IAFs in posterior malleolar ankle fractures. The IAF has a long medial to lateral shape, as well as the direction of the posterior malleolus fracture, occurs more often laterally in Mason Type 2 and medially in type 3. These findings suggest a pathophysiology in which the axial force causes secondary intraarticular impingement after the main fracture of the posterior malleolus. resulting in the development of an IAF. Handling IAFs is one of the keys in the treatment of posterior malleolar fractures and the surgical approach should be also selected based on the IAF.

Posterior malleolus fracture: a mid-term follow-up

BackgroundThe treatment of posterior malleolar fractures is changing rapidly, and the evidence base is still catching up. This study aimed to assess the mid-term prognosis of posterior malleolar fractures based on different morphological types and provides evidence for the treatment of posterior malleolar fractures.MethodsWe retrospectively analyzed the data of inpatients with posterior malleolar fractures from 1 January 2012 to 31 December 2019 at one high-volume tertiary trauma center. Fracture morphology was classified into small-shell fragment, single-fragment (small-fragment and large-fragment) and multifragment (double-fragment and compressive-fragment) by computed tomography according to our previous study. All patients were followed up at an average of 5.06 (range, 2.21–8.70) years. The Olerud-Molander Ankle Score (OMAS), EuroQol-5 Dimensions (EQ-5D) and American Orthopedic Foot and Ankle Society (AOFAS) score were recorded.ResultsSeventy-nine patients were included, and 7 patients were classified into the small-shell group, 52 patients into the single-fragment group and 20 patients into the multifragment group. Of all the patients, the average OMAS, EQ-5D and AOFAS scores were 85.9, 82.8 and 92.5, respectively. In the single-fragment group, patients who underwent surgical fixation in the posterior malleolus had significantly better scores (P = 0.037, 0.033 and 0.027). Among the patients with small fragments, the surgical fixation group also had higher OMAS (93.1 ± 7.5 vs. 83.5 ± 19.5, P = 0.042) and AOFAS scores (98.1 ± 3.1 vs. 91.0 ± 14.1, P = 0.028). The mean OMAS, EQ-5D and AOFAS scores were 85.5, 85.7 and 91.7, respectively, in patients with multiple fragments who underwent surgical fixation.ConclusionThis study shows that in fractures with a single fragment, surgical fixation of the posterior malleolar fragment led to a better prognosis in the midterm. All single fragments should be fixed regardless of size. Fixation of the posterior region in all single- and multi-fragments in posterior malleolar fractures led to satisfactory outcomes.Level of EvidenceLevel III, follow-up study.

Posterolateral approach for posterior malleolus fixation in ankle fractures: functional and radiological outcome based on Bartonicek classification

IntroductionPosterolateral approach has been advocated for the treatment of ankle fractures involving the posterior malleolus and satisfactory results were demonstrated in several studies. The Bartonicek classification based on 3-dimensional CT scanning was commonly used for treatment recommendation of posterior malleolar fracture (PMF). The aim of this retrospective study was to evaluate the clinical effect of the posterolateral approach for the treatment of PMF and present outcomes of patients with different types of Bartonicek classification.MethodWe retrospectively reviewed the clinical outcomes of 72 patients with ankle fractures involving posterior malleolus (PM) from January 2016 to December 2018. Posterior malleolus fractures (PMFs) were all directly reduced and fixed by a posterolateral approach using lag screws and/or buttress plates. AOFAS score and VAS pain score were used as the primary functional outcome measures. The radiographic evaluation included the quality of the reduction and Kellgren–Lawrence (KL) osteoarthritis classification.According to the CT-based Bartonicek classification, all patients were classified into three groups: 42 type II, 18 type III and 12 type IV. Bartonicek type II patients were further divided into subtype IIa 19 cases, subtype IIb 16 cases and subtype IIc 7 cases. The radiological and functional outcomes were analyzed among different types and subtypes of Bartonicek classification.ResultsSixty-eight patients (94.5%) achieved good or excellent reduction of PMF after surgery. The mean AOFAS score was 81.35 ± 6.15 at 6 months and 90.56 ± 4.98 at the final follow-up, respectively. The VAS score was 6.62 ± 1.03 one week after surgery, and 1.20 ± 0.92 at the final follow-up. Radiological evaluation at the final follow-up showed that primary bone union was achieved in all patients and 65 patients (88.9%) got no (KL grade 0) or just doubtable (KL grade 1) post-traumatic osteoarthritis. AOFAS scores decreased significantly with the severity of Bartonicek classification at 6 month (p < 0.001) and final follow-up (p < 0.05), while there was no statistical difference of VAS pain score among different types of Bartonicek classification. Reduction quality and the presence of osteoarthritis was not correlated to Bartonicek classification either. Besides, AOFAS scores at the final follow-up were statistically different among three subtypes of Bartonicek type II fractures (p < 0.05), and Bartonicek subtype IIa fractures had the highest AOFAS scores as 93 ± 4.99. Presence and severity of osteoarthritis was lower in patients with subtype IIa PMF compared to other subtype groups, this finding was statistically significant (p < 0.05).ConclusionThe posterolateral approach could achieve good clinical outcomes in the treatment of posterior malleolus fracture. Patients with a Bartonicek type II fracture had a better functional outcome measured by the AOFAS score compared to other types. Bartonicek type IIa fractures got a higher AOFAS score and a lower incidence of osteoarthritis at the final follow-up than the other two subtypes. Classification of PMFs according to the Bartonicek classification was reliable.

Fracture gap of the lateral malleolus via posterolateral approach: Improved visualization of the posterior malleolus fracture

The treatment of posterior malleolar fractures is a popular issue. Anatomic reduction of posterior malleolar fractures is critical for re-establishing the stability of the ankle mortise and ligamentous union after trauma. Inappropriate treatment ultimately leads to poorer functional outcomes and lower quality of life. Open reduction and internal fixation through a posterolateral approach are preferred over indirect reduction and anterior-posterior screw fixation. Although the posterolateral approach, which is more common and direct, provides good exposure to the fracture site, it has some limitations. In this report, we describe the posterolateral approach through the lateral ankle fracture gap for the treatment of posterior ankle fractures. Moreover, we discuss the indications, benefits, and limitations of this approach.

Variation in posterior fragment fixation in the Netherlands: a nationwide study.

The treatment of the posterior fragment in trimalleolar fractures differs from hospital to hospital in the Netherlands. A nationwide survey was performed to evaluate the fixation criteria and practice variation. An online cross-sectional survey amongst (orthopaedic) trauma surgeons was performed in the Netherlands. It consisted of three sections: a general section, a section showing preoperative images of six cases and a section with postoperative images of nine cases. A total of 151 surgeons completed the online survey. 45% of the respondents indicated that they fixated the posterior fragment if smaller than 25% of the intra-articular surface. 48% preferred an open posterior approach to fixate the posterior fragment. There was good consensus in treatment for the two cases with Bartonicek type 4 fractures (operative treatment in 73 and 72% respectively). Little consensus was found for Bartonicek type 2 and 3 fractures (88% opted for operative treatment in one case, but 89% for conservative treatment in the second case). Reoperation was mostly considered in cases with a step-off of more than 1mm (by 33-38% of the respondents). There was great variation in the choice of treatment if only the size of the posterior fragment was considered. Other fixation criteria such as postoperative step-off or instability after fixation of the lateral and medial malleoli are taken into account. In cases where fixation was needed, a percutaneous approach and an open posterolateral approach were equally preferred. There is much variation in treatment of the posterior malleolar fracture amongst orthopaedic and trauma surgeons in the Netherlands. The percutaneous approach and open posterolateral approach to fixate the posterior malleolar fracture seem to be equally used in the Netherlands. Still, there is no uniformity in treatment of posterior malleolar fracture, especially for Bartonicek 2 and Bartonicek 3 fractures. Reoperation is considered by less than half of the surgeons in case of postoperative persistent step-off of more than 1mm.

Treatment of Posterior Malleolar Fractures in Elderly Individuals with Kirschner Wire Tension Band Fixation.

Generally, posterior malleolar fragments are fixed either with percutaneous anteroposterior screws or through a posterolateral approach using screws and/or a buttress plate. Both surgical methods have some shortcomings, and the use of anteroposterior screws to fix osteoporotic posterior malleolar fractures carries a risk of failure. Nine elderly patients (average age, 67 years) with posterior malleolar fractures were treated with transfibular Kirschner wire tension band fixation. According to the Lauge-Hansen classification, all fractures were of the supination-external rotation type. The operative duration, intraoperative blood loss, and wound healing outcome were recorded. During the follow-up period, clinical outcomes were measured using the American Orthopaedic Foot and Ankle Society ankle-hindfoot score, and the occurrence of complications was observed. The patients were followed up for 12 to 18 months (mean, 15 months). The operative duration ranged from approximately 30 to 95 minutes, with an average of 70 minutes. Anatomical reduction was achieved in nine cases, and there were no complications, such as skin necrosis, wound infection, or skin sensory disturbance. There was one case of delayed wound healing caused by fat liquefaction, which was cured by a dressing change. The functional scores were excellent in four cases, good in four cases, fair in one case, and poor in zero cases. The rate of excellent and good results was 88.89% (eight of nine), with an average of 78.78 points. Kirschner wire tension band fixation through a transfibular approach for the treatment of posterior malleolar fractures does not require a change in patient posture. It facilitates the reduction and internal fixation of the posterior malleolar fragment; furthermore, it is easier to remove internal fixation after fracture healing, which provides a new surgical method for elderly patients with posterior malleolus fracture. Thus, this has potential as a new surgical method for elderly patients with posterior malleolar fractures.

History of ankle fractures in the German-speaking literature

Starting with Lorenz Heister, ankle fractures are dealt within German textbooks since the early 18th century. The Austrian surgeon Hönigschmied, in 1877, published a landmark series of biomechanical studies on the mechanism of fractures and avulsions around the ankle that are still valid today. German-speaking authors contributed particularly to the recognition and treatment of posterior malleolar fractures and fractures of the anterolateral distal tibia. The term “Volkmann Triangle”, however, is historically incorrect, as Volkmann most likely was the first to treat an anterolateral distal tibial fracture by resection but never described a posterior malleolar fracture. The founding of the AO (Arbeitsgemeinschaft für Osteosynthesefragen) by Swiss surgeons and engineers profoundly influenced evaluation and treatment of fractures worldwide. Proponents like Weber and Heim coined the modern principles of the treatment of malleolar and pilon fractures that are still in use and continue to evolve.

Outcomes of Posterior Arthroscopic Reduction and Internal Fixation (PARIF) for the Posterior Malleolar Fragment in Trimalleolar Ankle Fractures

Category:Arthroscopy; TraumaIntroduction/Purpose:The treatment of posterior malleolar fractures within a trimalleolar ankle fracture pattern can be challenging to manage. Due to anatomical constraints that inhibit visualization of the articular surface, reduction of the posterior malleolus relies on cortical read and/or intraoperative fluoroscopy. Posterior ankle arthroscopy is a tool that may address this shortfall by providing a means to assess the intra-articular and syndesmotic reductions, while removing any loose bodies. The purpose of this study was to determine the radiographic and patient reported outcomes of posterior arthroscopic reduction and internal fixation (PARIF) for the posterior malleolar fragment in trimalleolar ankle fractures.Methods:From November 2015 to May 2019, we prospectively enrolled consecutive trimalleolar ankle fractures that underwent PARIF for the posterior malleolar fragment by a single surgeon. Patient demographics, surgical details, and fracture characteristics, as determined by computed tomography (CT) scan, were obtained. At final follow-up the main outcome measures collected were: The Foot and Ankle Disability Index (FADI), American Orthopaedic Foot & Ankle Society (AOFAS) ankle score, Olerud and Molander Ankle Score (OSMA), the Visual Analog Score (VAS), and surgical complications. Preoperative and postoperative CT scans were interpreted and compared by two blinded musculoskeletal radiologists for articular congruity, syndesmosis congruity, and presence of loose bodies.Results:A total of 29 trimalleolar ankle fractures were treated with PARIF, including 15 fracture-dislocations. Mean patient age was 36 (range, 19-69) years. Mean prone tourniquet time was 58 (range, 35-79) minutes. Preoperative CT scans demonstrated intra-articular loose bodies in 53% of fractures and syndesmosis incongruity in 80% of fractures. Postoperative CT scans showed one ankle with a retained loose body and residual syndesmosis incongruity in 17% of fractures. 100% of fractures healed and demonstrated intra-articular reduction within 2mm. There were 2 complications (hardware irritation and sural nerve numbness). 2-year patient reported outcomes were available in 13 patients. These included mean VAS 1 (range 0-4), mean AOFAS score 84 (range, 63-100), mean FADI 85 (range, 59-100), and mean OSMA 76 (range, 40-100).Conclusion:Posterior ankle arthroscopic reduction and internal fixation (PARIF) is a safe and effective option for management of posterior malleolar fractures. The technique results in improved intra-articular and syndesmosis congruity, while removing loose bodies. Future studies are needed that compare this technique with current practices.

Comparison of the efficacy of posterior-anterior screws, anterior-posterior screws and a posterior-anterior plate in the fixation of posterior malleolar fractures with a fragment size of\u2009\u2265\u200915 and\u2009

BackgroundDifferent fixation methods have been used to treat posterior malleolar fractures (PMFs), but the clinical efficacy of different fixation methods in the treatment of PMF with different fragmentation has rarely been reported. The purpose of this study was to investigate the efficacy of posterior-anterior (PA), anterior-posterior (AP) screws and PA plate in the fixation of PMFs with a fragment size of ≥15 and < 15%.MethodsThis is a retrospective study of the clinical data of 243 patients with a unilateral ankle fracture involving the posterior malleolar ankle fracture. All patients were divided into two groups based on their fragment size, ≥15% (n = 136) and < 15% (n = 107). After reduction of PMF under direct vision via a posterolateral approach, posterior-anterior (PA), anterior-posterior (AP) screws and PA plate were used for fixation of PMF in the two groups. Briefly, for fixation of PMF with PA screw, two to three 3.5-mm (Depuy Synthes, Switzerland) cannulated screws were placed from the posterior to anterior direction; for fixation with PA plate, a 3.5-mm reconstruction plate (Depuy Synthes, Switzerland) was placed from the posterior to anterior direction, and for fixation of PMF with an AP screw, two to three 3.5-mm screws were placed from the anterior to posterior direction. All patients were followed up at 1, 3, 6, and 12 months after surgery and thereafter at 6-month intervals. The primary outcomes were AOFAS and ROM, which were recorded at the final follow-up.ResultsThe average follow-up time for all patients was 18.9 months (range 12–36 months), and all fractures healed. In fragment size ≥15% group, the average AOFAS score of patients treated with PA, AP screws and posterior plate were 91.5, 91.8, and 90.8, respectively, and the average limited ankle-dorsiflexion ROM was 5.0 °, 5.4 ° and 5.6°, respectively, at the last follow-up, there was no significant difference between the three fixation methods in terms of AOFAS scores and ankle ROM (P > 0.05). In fragment size < 15% group, the average AOFAS score of patients treated with PA, AP screws and posterior plate were 92.3, 91.9, and 84.1, respectively, the average limited ankle-dorsiflexion ROM were 5.1 °, 4.7 °, and 6.3 °, respectively, at the last follow-up. There were statistically significant differences in AOFAS scores and ankle ROM between posterior plate fixation and PA, AP screw fixation (P < 0.05); while no significant difference was found between PA and AP screw fixation (P > 0.05).ConclusionFor PMFs with fragment size ≥15%, there was no significant difference in the outcomes between the three fixation methods. For PMF with fragmentation < 15%, the PA and AP screws both provided good fixation.

A modified posterolateral approach for lateral and posterior malleolar fractures: a preliminary report

Objective To observe the clinical efficacy of internal fixation through a modified posterolateral approach in the treatment of lateral and posterior malleolar fractures. Methods From January 2015 to January 2018, 25 patients with fracture involving the lateral and posterior malleolus were treated at Department of Orthopedics, The Second Affiliated Hospital to Wenzhou Medical University. They were 13 males and 12 females, aged from 18 to 70 years (mean, 43.1 years). By the Lauge-Hansen classification for ankle injury, 9 cases belonged to supination-supination type of degree Ⅲ, 11 to supination-supination type of degree Ⅳ, and 5 to pronation-supination type of degree Ⅳ. By the Haraguchi classification, all the posterior malleolar fractures in this series belonged to type Ⅰ. Internal fixation through a modified posterolateral approach was performed for all the lateral and posterior malleolar fractures. Their operation time, fracture healing time and postoperative complications were observed. At the last follow-up, ankle joint function was assessed by the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale. Results In the 25 patients, the operation time ranged from 50 to 100 min (mean, 70 min). Of this group, 21 patients were followed up for 12 to 18 months (mean, 14 months). Bony union was achieved after 3 to 5 months after operation. Superficial wound infection was observed in 3 cases. No such complications occurred like postoperative adhesion, deep infection, contracture of flexor hallucis longus tendon, or loosening or breakage of implants. By the AOFAS ankle-hindfoot scale at the last follow-up, the ankle function was excellent in 13 cases, good in 6 and fair in 2. Conclusion The modified posterolateral approach is worth popularizing in clinic because it provides possibilities of fixating the lateral and posterior malleolar fractures by the same incision, not stripping the muscular origins of the flexor hallucis longus and reducing postoperative adhesion of the flexor hallucis longus. Key words: Fractures, bone; Ankle joint; Fracture fixation, internal; Approach

Third Place Award: Characterization and incidence of occult posterior malleolar fractures

Background: Occult fractures of the posterior malleolus are often missed by primary care providers and radiologists. Delayed treatment of posterior malleolar fractures can be problematic because of the potential for malunion, arthritis, or instability. The incidence and characterization of missed posterior malleolar fractures has not been reported in the literature. Methods: A retrospective review was performed of all ankle fractures with CT scans from 2005 to 2015 at a single institution. Inclusion criteria included age older than 18 yr and posterior malleolar fracture as seen on CT scan. Exclusion criteria included distal tibial shaft fractures and pilon fractures. Forty-six patients were identified with the above criteria. Data collected included whether a fracture was missed on initial radiographs by a board-certified radiologist, and the size and angle of the posterior malleolar fragment. Results: Of the 46 patients with posterior malleolar fractures, nine (19.5%) were missed on the radiology report. Seven of 46 (15.2%) were not described on all plain films prior to the CT scan. Two of seven (28.6%) radiographically occult fractures underwent open reduction and internal fixation of the posterior malleolar fragment. The average angle of occult posterior malleolar fractures relative to the transmalleolar axis was quite variable, with an average of 17 degrees (SD 11 degrees, range −20 degrees to 50 degrees). Conclusions: With a 15% incidence of occult posterior malleolar fractures, a CT scan or multiple orthogonal views can be helpful to avoid missed fractures. Given the wide variability of fracture angle, a single external rotation view is unlikely to prevent all missed fractures on initial radiographic interpretations. Level of Evidence: Level III, retrospective cohort study.

Treatment of posterior malleolar two-part fractures complicated with medial and lateral malleolar fractures via posterolateral and posteromedial approaches

Objective To evaluate the treatment of posterior malleolar two-part fractures complicated with medial and lateral malleolar fractures via a combination of posterolateral and posteromedial approaches. Methods From January 2014 to January 2017, 26 patients were operatively treated at Department of Or-thopaedics, Tongji Hospital for posterior malleolar two-part fractures complicated with medial and lateral malleolar fractures via a combination of posterolateral and posteromedial approaches.They were 10 men and 16 women, aged from 53 to 67 years (average, 61.5 years).The surgery was conducted in prone position via the posterolateral and posteromedial approaches to expose simultaneously the fractures ends at medial, lateral and posterior malleoli for open reduction.The lateral malleolar fractures were fixated with plate, the medial malleolar fractures with screws and posterior malleolar fractures with plate or cannulated screws depending on the size of the fracture blocks.The outcomes were assessed using the ankle-hindfoot scores of American Or-thopaedic Foot and Ankle Society (AOFAS) and the visual analogue scale (VAS). Results Of this co-hort, 22 were followed up for 30 months on average (range, from 18 to 48 months).All the cases healed by the first intension without any infection.Their postoperative X-ray showed bone union after an average of 12.5 weeks (range, from 10 to 15 weeks).No nonunion, loosening or breakage of implants was found.The mean time for walking with full weight-bearing was 13 weeks (range, from 11 to 16 weeks).Their AOFAS ankle-hindfoot scores at the final follow-ups were 85.4 (range, from 80 to 92), yielding 13 excellent and 9 good cases with a good to excellent rate of 100%.Their mean VAS scores were decreased significantly from preoperative 8.6±0.6 to postoperative 1.7±0.3 (t=153.000, P=0.000). Conclusion In treatment of posterior malleolar two-part fractures complicated with medial and lateral malleolar fractures, a combination of pos-terolateral and posteromedial approaches in prone position can expose and reduce simultaneously the fractures ends at medial, lateral and posterior malleoli, leading to satisfactory clinical outcomes. Key words: Ankle joint; Posterior malleolus; Fracture; Surgical treatment

Surgical Treatment of Posterior Malleolus Fractures and Posterior Fixation

Posterior malleolar fractures (PMFs) have been demonstrated to result in poorer outcomes than other types of ankle fractures with a higher incidence of posttraumatic arthritis. Accordingly, there has been a recent surge in interest in reduction and fixation of PMFs. Operative criteria for PMFs have been based on size, step-off, ankle joint instability, and syndesmotic injury, though universally accepted criteria have yet to be defined. Anatomically, the posterior malleolus is important as an insertion point of the posterior inferior tibiofibular ligament and thereby may play a role in syndesmotic stability. However, the important lateral ankle ligament complex is also important in governing stability of the talus within the ankle mortise. PMFs have been classified by the Haraguchi system based on morphology and extent. Radiographs, although always appropriate to perform as the initial diagnostic imaging study, are likely insufficient to evaluate the size and displacement; computed tomography scan is recommended for optimal evaluation for preoperative planning. When treating the posterior malleolus by a posterolateral approach, prone and lateral positioning of the patient facilitates exposure, although it can also be performed in the supine position with a large bump and with a leg that can be safely passively internally rotated sufficiently, or externally rotated if a posteromedial approach is used. Fixation can be performed with lag screw fixation alone versus buttress or standard plating techniques. Wound complications and posttraumatic arthritis are relatively common complications encountered in the treatment of PMFs. Level of Evidence: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.

Anatomy of the Insertion of the Posterior Inferior Tibiofibular Ligament and the Posterior Malleolar Fracture

Category: Ankle Introduction/Purpose: The treatment of posterior malleolar fractures is developing. Our previous study on the anatomy of the posterior malleolar fracture identified only 49% of rotational push off fractures of the posterior malleolus had syndesmotic instabilities. This was against general thinking that fixation of such a fragment would stabilize the syndesmosis. Our aim in this study was to identify the extent of the posterior inferior tibiofibular ligament insertion on the posterior tibia and its relation to push off fractures. Methods: We examined 10 cadaveric lower limbs that had been preserved for dissection at the Human Anatomy and Resource Centre at Liverpool University in a solution of formaldehyde. The lower limbs were carefully dissected to identify the ligamentous structures on the posterior aspect of the ankle. Results: In all specimens, the tibial insertion of the PITFL encompassed 1/3 of the distal posterior tibia. In addition, the posterior intermalleolar ligament inserted onto the posterior tibia just medial to the tibialis posterior groove. Thus a rotational push off fracture would only cause syndesmotic injury if greater than a 3 rd of the posterior tibia was injured or occurred in combination with a ligamentous injury. This is in keeping with the clinical findings of only 49% syndesmotic instabilities with Haraguchi type 1 posterior malleolar fractures. Conclusion: Haraguchi type 1 posterior malleolar fractures (less than a 3 rd of the width of the posterior tibia) are unlikely to cause syndesmotic instabilities without the addition of a ligamentous injury.

Posterior Malleolus Fractures in Athletes

Ankle injuries are the most common sports-related injuries in athletes, the most of which are sprains or partial ligament tears. They most often occur in basketball and soccer, but essentially no sports are immune to ankle injuries. Ankle fractures occur less commonly than sprains, and are typically because of higher energy mechanisms. When dealing specifically with fractures of the posterior malleolus, these occur most often from a rotational injury, and are typically associated with fractures of one or both the other malleoli. The anatomy of the posterior ligaments, their osseous attachments, the weight bearing surface, and buttress effect of the posterior malleolus, make this a critical area of the ankle. There has been considerable debate as to the appropriate treatment of posterior malleolar fractures in the literature. In general, treatment has evolved from simple closed reduction and casting, to open reduction and internal fixation in most cases for reliable healing, restoration of anatomy, and expeditious return to play.

Longterm outcome of 886 posterior malleolar fractures: A systematic review of the literature

The objective of the present study was to review the current data on the long-term outcomes of posterior malleolar fractures, with special emphasis on the role of the type of treatment, surgical approach, and reduction and internal fixation. The search was limited to skeletally mature patients. Major databases were searched from 1978 to 2014 to identify studies relating to functional outcome, subjective outcome, and radiographic evaluation at least 2 years after either surgical or conservative treatment of posterior malleolar fractures. Of 68 initially relevant studies, 19 met our inclusion criteria. A total of 886 fractures were identified in 885 patients. The mean sample size-weighted follow-up period was 3.7 years. Comparable results are achieved when comparing open reduction and internal fixation to conservative treatment for posterior malleolar fractures. Current consensus suggests posterior malleolar fragments comprising of >25% of the distal tibial plafond as seen on a true lateral radiograph and fragments with more than 2mm dislocation require open reduction and internal fixation of the fragment. The current consensus on treatment of posterior malleolar fractures is neither supported nor disapproved by the available evidence.

Operative indications for posterior malleolar fractures

Objective To explore the operative indications for posterior malleolar fractures. Methods A retrospective study was conducted to analyze the clinical data of the whole year of 2011 of 298 combined fractures of ankle joint and posterior malleolus. They were 143 males and 155 females, 14 to 85 years of age (average, 43 years). Laterality: 152 right sides and 146 left sides. Associations of surgical fixation were analyzed respectively with dislocation of the tibiotalar joint, Danis-Weber classification of the ankle fracture, Haraguchi classification of posterior malleolar fracture, and fragmental size of posterior malleolar fracture. Results Significantly more posterior malleolar fractures combined with dislocation of the tibiotalar joint (57. 0% ) were subjected to surgical fixation than those without (34. 0% ) (P 0. 05). Conclusion In clinical treatment of posterior malleolar fractures, the factors influencing operative decision include combined dislocation of the tibiotalar joint, Haraguchi type Ⅱ, and fragmental size more than 15% of the total joint area. Key words: Ankle joint; Fractures, bone; Fracture fixation, internal; Indication

Approaches for surgical treatment of posterior malleolar fracture

Objective To compare the approaches for surgical treatment of posterior malleolar fracture in terms of their effect on the fracture prognosis.Methods We analyzed retrospectively the 69 patients with posterior malleolar fracture who had been treated by surgery from July 2000 to June 2013.They were 24 males and 45 females,14 to 80 years of age (average,46.2 years).By AO classification,there were 8 cases of type 44A,49 cases of type 44B and 12 cases of type 44C.American Orthopaedic Foot and Ankle Society (AOFAS) and visual analogue scale (VAS) scores were compared between the 27 patients with ≥25％ fragments which were fixated from the anterior to the posterior and the 15 ones with ≥25％ fragments which were fixated from the posterior to the anterior,as well as between the 15 patients with ＜ 25％ fragments which were fixated from the anterior to the posterior and the 12 ones with ＜ 25％ fragments which were fixated from the posterior to the anterior.Results This cohort obtained follow-up from 12 to 126 months (average,52.0 months).When the fragments ≥25％,there was no significant difference in AOFAS or VAS score between those fixated from the anterior to the posterior (94.4 ± 5.0 and 0.2 ± 0.4 respectively) and those fixated from the posterior to the anterior (94.1 ±7.0 and 0.4 ±0.8 respectively) (P ＞ 0.05).When the fragments ＜ 25％,those fixated from the anterior to the posterior had a significantly lower AOFAS score (93.2 ± 5.4) than those fixated from the posterior to the anterior (98.3 ± 3.9) (P =0.009),but there was no significant difference in VAS score between the 2 groups (0.1 ± 0.4 versus 0) (P =0.058).Conclusions In the treatment of posterior malleolar fracture with a ≥ 25％ fragment,as the operative approaches may exert little impact on the fracture prognosis,the approach from anterior to posterior may be a priority choice due to its simplicity and smaller incision.When a posterior malleolar fragment is less than 25％,it may be better to choose the approach from posterior to anterior. Key words: Ankle; Fractures, bone; Prognosis; Approach for surgical treatment