Treatment Of Posterior Malleolar Fractures Research Articles

Improper screw fixation in the treatment of posterior malleolar fractures

Objective To explore the problem of improper screw fixation in the treatment of posterior malleolar fractures.Methods We performed a retrospective analysis of the X-ray films and CT scans of the 421 ankle fractures in 417 patients that had been treated in our department from 1 January 2011 through 31 December 2011.219 fractures occurred in 217 male patients and 202 fractures in 200 females.Their ages ranged from 14 to 85 years,averaging 41 years.223 fractures were at the right side and 198 fractures at the left side.Among the 368 ankle fractures that had been examined by CT scan,there were 299 posterior malleolar fractures,131 of which were fixated by screws.Improper screw fixations of the posterior malleolar fragments were identified and characterized.Results The improper screw fixation was manifested as intrusion of the screw head and shaft into the interspace of distal tibiofibular syndesmosis in the CT scans and as location of the screw head at the lateral side of the posterior margin of the tibiofibular notch in the X-ray films.In the 131 posterior malleolar fractures that had screw fixation,CT confirmed 7 cases of improper screw fixation and X-ray examination 6 cases,giving a rate of improper screw fixation of 9.9％ (13/131).Of the 13cases 9 belonged to percutaneous fixation (69.2％,9/13).Conclusion Although improper screw fixation may likely occur in the treatment of posterior malleolar fractures,it can be reduced by careful fluoroscopy to ensure that the screw is positioned at the tibial side of the posterior tubercle of the tibia. Key words: Ankle joint; Fracture; Fracture fixation, internal; Bone nails; Postoperative complications

The indication for surgical treatment of posterior malleolar fracture

Objective To explore the indication for surgical treatment of posterior malleolar fracture by observing the effects of bone fragment size and fixation on the fracture healing.Methods We retrospectively analyzed 73 patients with posterior malleolar fracture who had undergone surgical treatment from January 2004 to December 2011.By AO classification,there were 19 cases of type 44A,37 cases of type 44B and 17 cases of type 44C.Fixation of the posterior malleolus was conducted in 30 cases (45.2％) and not in 43 cases (54.8％).American Orthopaedic Foot and Ankle Society (AOFAS) score and the Mos 36-item Short Form Health Survey (SF-36 score) were used for functional evaluation.Articular smoothness and degeneration in the X-ray films were considered as image evaluation criteria.The AOFAS and SF-36 scores were compared between the fixation and non-fixation groups as well as between the ≥25％ bone fragments and the ＜ 25％ones.Results Sixty-five patients completed the follow-ups which ranged from 2 to 84 months (average,44.3 months).Irregular articular surface was observed in 4 cases and mild to moderate degeneration in 5 cases.Infective infection of the lateral malleolar skin occurred early in 2 cases and poor internal implantation in one,but their functional recovery was not affected.The AOFAS and SF-36 scores for patients with ≥25％bone fragments in the fixation group were respectively 94.2 ± 9.8 and 107.5 ± 11.8 points,significantly higher than those in the non-fixation group (87.4 ± 6.7 and 92.8 ± 18.5 respectively) (P ＜ 0.05).The AOFAS and SF-36 scores for patients with ＜ 25％ bone fragments in the fixation group were respectively 91.3 ± 13.2 and 104.2 ± 14.2 points,with no significant differences from those in the non-fixation group (91.8 ± 10.9 and 102.3 ± 16.6 respectively) (P ＞ 0.05).Conclusions When a posterior fragment is larger than 25％ of the articular surface,open reduction and internal fixation should be considered.When a posterior fragment is less than 25％ of the articular surface,conservative treatment may be a better choice. Key words: Ankle; Fracture; Prognosis

Surgeon Practices regarding Operative Treatment of Posterior Malleolus Fractures

Operative indications for surgical treatment of posterior malleolar fractures associated with fractures of the distal fibula and tibia are not currently well defined. The purpose of the present study was to determine the current practice among orthopaedic surgeons regarding the management of posterior malleolus fractures. Web-based questionnaires were emailed to members of the Orthopaedic Trauma Association (OTA) and American Orthopaedic Foot and Ankle Society (AOFAS). Requested information included demographics and treatment preferences for five clinical scenarios with different fracture characteristics. Four hundred one respondents completed the survey (20% response rate). Ninety eight (24%) subjects had received specialty training in orthopaedic trauma, 199 (50%) in foot and ankle (F&A) surgery and six (2%) in both orthopaedic trauma and F&A surgery. Ninety five (24%) had either no or other specialty training. The most frequently reported indication for fixation was not based on a fragment size threshold, but rather was ``depends on stability and other factors'' (56%). Trauma surgeons, those with less than 10 years experience, and those who treated more than five ankles fractures per month were significantly more likely to use factors other than size for indications (p = 0.026, <0.01, and <0.01, respectively). Despite this general response, fragment size still affected treatment decisions. A fragment comprising 50% of the articular surface was indicated for fixation by 97% of respondents, while a size of 10% would be treated by only 9% of respondents. For a posterior fragment with 20% articular involvement and a small free osteochondral fragment, fixation was deemed necessary by 44% of respondents. There were no differences in fellowship training, years of experience in practice, or ankle fracture volume per month in these three situations. A larger proportion of trauma trained surgeons considered fixation necessary compared to F&A trained surgeons in this case (p = 0.028). When posterior malleolus fixation was indicated for a large fragment, direct open reduction using the flexor hallucis longus -peroneal tendon interval was the most commonly selected approach in all cases. Trauma-trained surgeons were significantly more likely to choose antiglide plate fixation compared to screw-only fixation (p < 0.05). In this survey study of trauma and F&A surgeons, significant variation existed regarding most aspects of posterior malleolar ankle fracture treatment. Most notably, factors other than fragment size most impacted surgical indications. Newer techniques such as direct exposure and plating of the posterior malleolus are chosen more frequently than traditional techniques of indirect reduction and percutaneous screw fixation.

Location of the Sural Nerve During Posterolateral Approach to the Ankle

There is no consensus regarding the most appropriate surgical approach for the treatment of posterior malleolar fractures. The posterolateral approach facilitates more accurate reduction, but the sural nerve is potentially at risk during the approach. The location of this nerve in relation to this approach has not been clearly described in the literature. We performed cadaveric dissection of 12 legs using the posterolateral approach, a 10-cm incision midway between the tendo-achilles and the lateral malleolus, commencing at the tip of the lateral malleolus and extending proximally. The horizontal distances of the sural nerve and the short saphenous vein to the incision were measured at the proximal and distal ends and at the mid-point of the incision (positive towards the Achilles and negative towards the lateral malleolus). In ten of the 12 cases, the sural nerve and short saphenous vein crossed the incision at an average of 56.7 mm and 61.0 mm along the incision, respectively. The median distances from the proximal end of the wound were -9.9 mm and -12.7 mm, 0.9 mm and -1.7 mm from the midpoint, and 6.3 mm and 7.7 mm from the distal end of the incision, respectively. The sural nerve and saphenous vein are at risk of iatrogenic injury over the whole length of the incision for the posterolateral approach for posterior malleolar fractures. When performing a posterolateral approach to the ankle, particular care should be taken at the midpoint of the incision.

Treatment of posterior malleolar fractures by means of limited open reduction, poking reduction and QWIX cannulated screw internal fixation

Objective To evaluate the clinical effect of limited open reduction, poking reduction and QWIX cannulated screw internal fixation in treatment of posterior malleolar fracture. Methods A total of 14 patients with posterior malleolar fracture were treated by limited open reduction, poking reduction and QWIX cannulated screw internal fixation. Injury causes included traffic accidents in five patients, fall from height injury in four and inversion sprain in five. According to fracture type classification methods of Weber and Danis, there were two patients with type A3, seven with type B3 and five with type C3. Func-tional exercise was carried out based on postoperative exercise plan. Regular follow-up was performed to e-valuate the functional recovery of the ankle joint. Results All patients were followed up for 6-18 months (average 9.5 months). One patient with sural nerve injury returned to normal after six months. Twelve pa-tients showed excellent range of motion of the ankle joint and normal gait three months after operation. In 12 patients, dorsiflexion of the ankle joint was > 20° and plantar flexion > 40° six months after operation, which was approximately similar to contralateral normal ankle joint. The ankle joint function of all patients returned to normal six months after operation. According to Baird-Jackson ankle joint function evaluation, the result was excellent in 12 patients, good in one and fair in one, with excellence rate of 93%. Con-clusion The limited open reduction, poking reduction and internal fixation of QWIX caunulated screw are effective method for treatment of posterior malleolar fractures. Key words: Hind limb; Ankle injuries; Fracture fixation, internal

Radiologic Analysis and Treatment of Posterior Malleolar Fractures of the Ankle

98 통신저자:강 수 용 서울시 용산구 한강로 3가 65-207 중앙대학교 용산병원 정형외과학교실 Tel:02-748-9848ᆞFax:02-793-6634 E-mail:sooykang@hitel.net 접수: 2008. 8. 1 심사 (수정): 2008. 10. 27 게재확정: 2009. 2. 27 Address reprint requests to:Soo Yong Kang, M.D. Department of Orthopaedic Surgery, Yong-San Hospital, Chung-Ang University College of Medicine, 65-207, Hangang-ro 3ga, Yongsan-gu, Seoul 140-757, Korea Tel:82-2-748-9848ᆞFax:82-2-793-6634 E-mail:sooykang@hitel.net 족근관절 후과 골절의 방사선학적 분석과 치료

Treatment of posterior malleolar fractures by fixation with minimally invaslve percutaneous cannulated screws

Objective To discuss clinical results and techniques of treatment of posterior malleolar fractures by fixation with minimally invasive percutaneous cannulated screws. Methods A total of 18posterior malleolar fractures were treated with percutaneous cannulated screws (4.0 ram) between March 2004 and September 2006. According to Lauge-Hansen system, 14 were diagnosed as supination external rotation stage Ⅳ, and 4 as pronation external rotation stage Ⅳ. In all cases, the size of fragment exceeded 25% of the articular surface with displacement of more than 2 mm on the lateral radiograph. We studied the preoperative CT to determine the size of the posterior fragment, displacement and the angle between the bimalleolar axis and the major fracture line of the posterior malleolus. After ORIF of outer and medial malleoli, the posterior malleolus was treated by minimally invasive osteosynthesis. Results Follow-ups of 16.5 (range, 6-35) months on average revealed that all cases healed. According to the Ankle Hindfoot Clinical Rating System of the American Orthopaedic Foot & Ankle Society (AOFAS), the results were rated as excellent in 11 cases, good in 5 cases,moderate in 1 case, and poor in 1 case, with the good-excellent rate being 88.9%. Conclusions Fixation with minimally invasive percutaneous cannulated screws is a good method with advantages of mini-invasion and rigid fixation. Careful preoperative plan according to CT scan is a prerequisite for good results. Key words: Posterior malleolar; Fracture; Fracture fixation,internal

POSTERIOR MALLEOLAR FRACTURES

1. A method of treatment of posterior malleolar fracture is described which restores the proximal surface of the ankle joint to its normal position. 2. Reduction is achieved with a special clamp and the position held with a strong plate. Early ankle movements may therefore be encouraged without fear of redisplacing the fracture. 3. Perfect reduction is necessary to avoid the later onset of arthritis, and this was achieved in five of six patients reported.