Pathoanatomy and Associated Injuries of Posterior Malleolus Fracture of the Ankle

Mason, Lyndon; Marlow, William J; Widnall, James; Molloy, Andy

doi:10.1177/1071100717719533

Cited by 118 publications

(117 citation statements)

References 30 publications

(23 reference statements)

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“…The use of an additional buttress plate is advised in case of a large posterior fragment (> 25%) and long proximal extension. Recently, three CT-based classification systems of posterior malleolar fractures were developed [14–16]. With increasing stage the need for anatomical reduction and fixation increases to restore intra-articular unevenness.…”

Section: Introductionmentioning

confidence: 99%

Persistent postoperative step-off of the posterior malleolus leads to higher incidence of post-traumatic osteoarthritis in trimalleolar fractures

Verhage

Krijnen

Schipper

et al. 2018

Arch Orthop Trauma Surg

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Background Traditionally, size of the posterior fragment is considered the most important indicator for fixation in trimalleolar fractures. It remains unclear which factors contribute to worse functional and radiological outcome. This study was designed to determine predictors for the development of posttraumatic osteoarthritis and worse functional outcome in trimalleolar fractures. Methods This retrospective cohort study evaluated outcomes of 169 patients with a trimalleolar fracture treated between 1996 and 2013 in a level-1 trauma hospital in the Netherlands after a mean follow-up of 6.3 (range 2.4 to 15.9) years. The average fragment size was 17%. Twenty patients had a posterior fragment smaller than 5% of the intra-articular surface, 119 patients a fragment of 5–25% and 30 patients a posterior fragment larger than 25%. In total, 39 patients (23%) underwent fixation of the posterior fragment. Results Clinical union was achieved in all 169 patients. The median AOFAS score after follow-up was 93 (interquartile range 76–100) and the median AAOS score was 92 (interquartile range 81–98). A persistent postoperative step-off larger than 1 mm was found in 65 patients (39%) and osteoarthritis was present in 49 patients (30%). Higher age and postoperative step-off > 1 mm were independent, significant risk factors for the development of osteoarthritis. Osteoarthritis and BMI were independent, significant risk factors for worse functional outcome. Conclusion It is advisable to correct intra-articular step-off of intraarticular posterior malleolar fragments to reduce the risk of developing osteoarthritis and, consequently, the risk of worse functional outcome after long-term follow-up. Level of evidence Level IIB.

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Section: Introductionmentioning

confidence: 99%

Persistent postoperative step-off of the posterior malleolus leads to higher incidence of post-traumatic osteoarthritis in trimalleolar fractures

Verhage

Krijnen

Schipper

et al. 2018

Arch Orthop Trauma Surg

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“…In addition, the authors include in the analysis pilon fractures, which have a very different pathomechanism. Mason et al [25] divided the fractures into 3 groups based on severity and pathomechanics. Type 1 is an extra-articular posterior malleolar fragment, type 2 involves a primary fragment of the Volkman area with or without a medial injury, and type 3 is a fracture in the coronal plane that includes all the plafond.…”

Section: Discussionmentioning

confidence: 99%

Preoperative planning and surgical technique for optimizing internal fixation of posterior malleolar fractures: CT versus standard radiographs

et al. 2020

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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.

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“…Mason et al have suggested a classification system of posterior malleolar fractures that progresses in severity, indicating the pathomechanics of the fracture and then guides surgical fixation. 17 Attempting to address the syndesmosis without reduction and stabilisation of the posterior malleolus often results in malreduction of the syndesmosis.…”

Section: Discussionmentioning

confidence: 99%

A survey of the management of posterior malleolar ankle fractures in South Africa

2019

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Background: Posterior malleolus fractures are associated with poorer functional outcomes compared to simpler malleolar fractures. Traditional teaching states that if a posterior malleolus fracture involves less than 25% of the distal tibia, it can be managed without fixation. Current literature has shown that fixation should not be based on the size of the posterior fragment but rather on the fracture pattern, instability and awareness that reduction and fixation is biomechanically advantageous. We hypothesised that current management of ankle fractures with posterior malleolus involvement in South Africa is not evidence-based and is suboptimal. We sought to assess the training, experience and decision-making of surgeons and trainees who are involved in the management of ankle fractures. Another aim was to develop evidence-based algorithms for the management of posterior malleolus and complex ankle fractures. Methods: An email survey consisting of questions related to the management of ankle fractures was sent to specialists, registrars and medical officers who voluntarily completed an online survey. Results: A total of 103 out of 456 emails sent drew responses to the survey. Responses included 28% from consultants, 54% from registrars and 18% from medical officers. Forty-six per cent of responders believed that posterior malleolus fractures can be managed non-operatively if less than 20% of the tibial plafond is involved. Only 49% would CT scan a posterior malleolus prior to operating. Thirty-eight per cent of the responders were not familiar or comfortable with the posterior-lateral approach used for fixation of the posterior malleolus directly. Conclusion: Understanding of ankle fractures has progressed. A significant proportion of responders to the survey are not following best practice and current literature. Posterior malleolus fractures are not benign and have poorer outcomes compared to bi-malleolar or lateral malleolus ankle fractures. All patients with posterior malleolus fractures should receive pre-operative CT scan. All posterior malleolar fractures that can be held with a plate or screws should be fixed.

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Pathoanatomy and Associated Injuries of Posterior Malleolus Fracture of the Ankle

Abstract: Level III, retrospective comparative series.

Cited by 118 publications

References 30 publications

Persistent postoperative step-off of the posterior malleolus leads to higher incidence of post-traumatic osteoarthritis in trimalleolar fractures

Persistent postoperative step-off of the posterior malleolus leads to higher incidence of post-traumatic osteoarthritis in trimalleolar fractures

Preoperative planning and surgical technique for optimizing internal fixation of posterior malleolar fractures: CT versus standard radiographs

A survey of the management of posterior malleolar ankle fractures in South Africa

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