CT controlled results of direct reduction and fixation of posterior malleolus in ankle fractures (original) (raw)
Related papers
Archives of Orthopaedic and Trauma Surgery
Introduction The presence of a posterior malleolar (PM) fragment has a negative prognostic impact in ankle fractures. The best treatment is still subject to debate. The aim of this study was to assess the medium-to-long-term clinical and functional outcome of ankle fractures with a PM fragment in a larger patient population. Materials and methods One hundred patients (69 women, 31 men, average age 60 years) with ankle fractures including the PM were evaluated clinically and radiographically. Patients with Bartoníček–Rammelt type 3 and 4 fracture displayed a significant female preponderance. Fixation of the PM was performed in 63% and tailored to the individual fracture pattern. Results Internal fixation of the PM fragment was negatively correlated with the need for syndesmotic screw placement at the time of surgery (p = 0.010). At an average follow-up of 7.0 years, the mean Foot Function Index (FFI) was 16.5 (SD: 21.5), the Olerud Molander Ankle Score (OMAS) averaged 80.2 (SD: 24) a...
Surgical Treatment of Posterior Malleolus Fractures and Posterior Fixation
Techniques in Foot & Ankle Surgery, 2018
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.
The Management of Posterior Malleolus Fractures in Unstable Ankle Injuries: Where Do We Stand Now?
Cureus
The evaluation and treatment of the posterior malleolus fracture in unstable ankle injuries remain a topic of controversy. The main objective of this systematic review was to examine the available literature and identify the variables that affect the management of posterior malleolar fractures and how these are related to the outcomes. To that end, a systematic review was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search of MEDLINE, Embase, and Cochrane Library was conducted. The search terms used were as follows: "posterior malleolar", "ankle fractures", "trimalleolar fractures", "ORIF", "surgery", "operative", and "conservative". The available studies were screened against the inclusion and exclusion criteria. Based on the review of the available literature, we have concluded that the size of the posterior malleolar fragment is not an accurate indicator, and clinicians should consider other factors such as fracture configuration and articular surface congruity. Also, the risk for the development of post-traumatic arthritis increases when the joint surface is not restored regardless of the surgical intervention and fragment size. The complications of posterior malleolus fractures necessitate evidence-based management. The assessment and the final treatment of these injuries in unstable ankle fractures should not be based on the traditional fragment-size parameters. Clinicians should assess the fracture configuration through imaging modalities and try to preserve the articular surface congruity so as to achieve optimal outcomes. Finally, more studies with high-level evidence are required in order to determine the most appropriate management pathway for these patients.
Management of Posterior Malleolar Fractures: A Systematic Review
The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons, 2015
Posterior malleolar fractures are relatively common and usually result from rotational ankle injuries. Although treatment of associated lateral and medial structures is well established, several controversies exist in the management of posterior malleolus fractures. We performed a systematic review of the current published data with regard to the diagnosis, management, and prognosis of posterior malleolus fractures. A total of 33 studies (8 biomechanical and 25 clinical) with >950 patients were reviewed. The outcome of ankle fractures with posterior malleolar involvement was poor; however, the evidence was not enough to prove that the size of the posterior malleolus affects the outcome. Significant heterogeneity was noted in the cutoff size of the posterior malleolar fragment in determining management. The outcome was related to other factors, such as fracture displacement, congruency of the articular surface, and residual tibiotalar subluxation. Indirect evidence showed that lar...
Journal of Orthopaedic Surgery and Research, 2020
Background: A proper reduction and internal fixation of posterior malleolar fractures can be challenging, as intraoperative fluoroscopy often underestimates the extent of the fracture. Our aim was to assess the value of a modified classification system for posterior malleolar fractures, which is based on computed tomography (CT) images, optimizing screw trajectory during fluoroscopic-guided surgery, and to compare it to the Lauge-Hansen classification system to the CT-based classification. Methods: A retrospective review of all ankle fracture operations from January 2014 to December 2016 was performed. Fractures were included if a CT scan was performed within 1 week of the surgery, and the posterior malleolar fragment occupied one third or more of the antero-posterior talar surface or jeopardize the ankle stability. Eighty-five adult ankle fractures with posterior malleolar fragments were included in this study. Fractures were categorized into one of three types, namely "postero-lateral," "postero-medial," or "postero-central," according to the location of the fracture fragment on axial CT image. An optimal trajectory angle for a single-lag screw fixation was measured on the CT cut between a central antero-posterior line and the line intersecting the posterior fragment perpendicular to the major fracture line. Mean trajectory angles were calculated for each fracture type. Fractures were also categorized according to the Lauge-Hansen system. Results: The mean trajectory angle was 21°lateral for "postero-lateral" fragments, 7°lateral for "postero-central" fragments, and 28°medial for "postero-medial" fragments (p < 0.01 for comparisons among the groups). The range of trajectory angles within each group was about 10°, as compared to about 20°within each Lauge-Hansen type. There were no differences in trajectory angle among the Lauge-Hansen groups (p > 0.05 for all comparisons). Conclusions: There are 3 distinct anatomic subgroups of posterior malleolar fragments, each with an ideal screw trajectory that needs to be used in order to achieve an optimal reduction and fixation.
The effect of computerised tomography on operative planning in posterior malleolus ankle fractures
Foot and Ankle Surgery, 2019
Background: The aim of this project was to analyse whether a CT influences surgical planning in ankle fracture involving the posterior malleolus. Methods: Twenty consecutive patients with fractures involving the posterior malleolus were retrospectively selected and had their plain radiographs and CT scan anonymised. Initially, radiographs alone were presented to nine trauma surgeons to formulate a surgical plan individually. After a minimum of 6 weeks, the same process was repeated with CT scans available. Results: The surgical approach for ankle fracture fixation changed in 32.7% of cases following CT scan review. A CT scan altered the decision to stabilise the posterior malleolus in 25.6% and the decision of whether to stabilise the syndesmosis in 16.6% of cases. Conclusions: This study demonstrates that a pre-operative CT scan changes the surgical approach in 32.7% of cases and therefore we recommend use of CT scanning in this subset of ankle injuries.
Foot & Ankle International, 2015
Background: Up to 44% of ankle fractures have involvement of the posterior tibial margin. Fracture size and morphology are important factors to guide treatment of these fragments, but reliability of plain radiography in estimating size is low. The aim of the current study was to evaluate the accuracy of 2-dimensional computed tomography (2DCT) in the assessment of posterior malleolar fractures. Additionally, the diagnostic accuracy of 2DCT and its value in preoperative planning was evaluated. Methods: Thirty-one patients with 31 ankle fractures including a posterior malleolar fragment were selected. Preoperative CT scans were analyzed by 50 observers from 23 countries. Quantitative 3-dimensional CT (Q3DCT) reconstructions were used as a reference standard. Results: Articular involvement of the posterior fragment was overestimated on 2DCT by factors 1.6, 1.4, and 2.2 for Haraguchi types I, II, and III, respectively. Interobserver agreement on operative management (“to fix, or not to ...
International Journal of Orthopaedics Sciences, 2017
To study the functional outcome of surgically managed malleolar fractures at ankle and to assess the results of complication. Introduction: Ankle fracture is a common injury with potentially significant morbidity associated with it. Regardless of the method of the intervention, main goal is to restore normal anatomy. Complications associated with both conservative and operative management are an important consideration in decision making. Patient selection is very important in deciding the type of management. This paper provides an update to surgical management of ankle fractures. Methodology: Medical records of 96 patients were studied and data was collected which includes the demographic data, fracture details, intraoperative and postoperative details. Then patients were called up for follow-up. The functional outcome of these patients was assessed subjectively using OLERUD MOLANDER ANKLE SCORE (OMA) score. Objective and radiological outcome was assessed using cedell's criteria. Results: Among the 96 patients we achieved excellent and good subjective results in 60 (62.5%) patients; Good objective result in 72 (75%) patients; Good radiographic results in 80 (83.4%) patients. In our study, patients with unimalleolar fractures had the best outcome. Trimalleolar fractures had the worst outcome. Bimalleolar fracture had intermediate outcome. With regards to lateral malleolar fracture fixation modality, patients with rush nail achieved good to fair radiological and objective outcome with no poor outcomes With regards to medial malleolar fracture fixation modality, patients with Tension band achieved good objective and radiological outcome and there were no poor outcomes. In patients with malleolar screw fixation 62.5 % patients achieved good objective and 75 % patients achieved good radiological outcome. Patients with complications has poorer outcome. In patients with superficial infection the outcome was poorer.
Open Reduction and Internal Fixation of Bi -Malleolar Fractures of Ankle
IOSR Journals , 2019
Introduction: The ideal management of a fracture accomplishes a solidly united fracture in the perfect alignment, restored length and freely mobile joint by normal musculature all with in a shortest possible time.Several aspects in the management of malleolar fractures pose technical problems to the surgeon. The present clinical study of internal fixation of bi-malleolar fractures using malleolar screws, K-wires, one-third tubular plates is done to assess results. Materials and methods : The study was carried-out inthe department of the orthopaedics, SVRR Government General Hospital, Tirupati, from December 2007 to October 2009. The study consisted of 25 patients , 10 cases representing the cross-sectional population reported in detail. Clinical examination and x rays were done and fractures classified based on Lauge-Hansen's classification. Internal fixation of both malleoli in 25 patients. Medial malleolus fixed with malleolar screws in 18 cases and k-wires in 7 cases. Lateral malleolus was held with plate in 12 cases and intramedullary device like K-wire or Rush nail in 11 cases, in two cases it was fixed with interfragmentary screws. Results : The present study consists of 25 cases of bimalleolar fractures treated by open reduction and internal fixation. Among these 5 (20%) were females and 20 (80%) were males. Right ankle involved in 9 cases (36%) and left ankle in16 cases (64%). Based on Lauge-Hansen's classification 15 cases(60%) grouped under supination and external rotation injuries,6(24%)cases under pronation external rotation injury and 4(16%) cases under pronation abduction injury. 3 cases were compound(2 are type 3 b and 1 is type 2 compound)in nature. Medial malleolus stabilized with malleolar screws in 18 cases, and k-wire in 7 cases. Lateral malleolus with plate in 12 cases and interfragmentary screws in 2 cases and intramedullary device (k-wires, rush nail, ulna nail) in 11 cases. All cases were followed for 12 months, 6 months on an average. Cast was removed after 6 weeks and active mobilisation started. Full weight bearing allowed after 3 months. Last case was done in the month of May 2009 and followed upto October 2009. Subjective evaluation was asymptomatic in 48%cases, minimal in 40%cases and moderate in 12%cases. Objective evaluation normal in 24%, minimal in 32%, and moderate in 32% cases, severe in 8%. The results were poor when number of deranged structures were increased. Conclusion : we conclude that all unstable bimalleolar fractures needs to be fixed by open reduction and internal fixation, for faster rehabilitation and better functional outcome.