Surgical Fixation of Quadrimalleolar Fractures of the Ankle

Rammelt, Stefan; Bartoníček, Jan; Kroker, Livia; Neumann, Annika Pauline

doi:10.1097/bot.0000000000001915

Cited by 25 publications

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References 38 publications

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“…With pronation-type fracture-dislocations or forced abduction, impaction of the anterolateral articular surface may be observed 12,13,23 , as seen in 11.4% of our cases. The prevalence of PA fractures was more than twice as high in AM type-3 fractures (50%) than in AM type-1 fractures (20.3%).…”

Section: Discussionmentioning

confidence: 50%

“…Second, we cannot report on outcomes. From the few available clinical studies, it appears that favorable functional short-term results can be expected after surgical fixation of simple, displaced AM fractures 7,12,41,47,48 , while impaction of the anterolateral tibial plafond potentially leads to posttraumatic arthritis and osteonecrosis of the distal tibia 13,14,49 .…”

Section: Discussionmentioning

confidence: 99%

“…1). Fixation of dislocated anterolateral tibial fragments facilitates fibular reduction by reestablishing the tibial incisura 12 . This is analogous to the posterior tibial rim (posterior malleolus), which has gained considerable attention over the past decade particularly with the consequent use of computed tomography (CT) imaging [19][20][21] .…”

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confidence: 99%

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Pathoanatomy of the Anterolateral Tibial Fragment in Ankle Fractures

Rammelt¹,

Bartoníček²,

Kroker³

2021

Journal of Bone and Joint Surgery

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Background: The anterior distal tibial tubercle provides attachment to the anterior tibiofibular syndesmosis. It may be considered a fourth, or anterior, malleolus (AM). Fractures of the AM may extend into the tibial incisura and tibial plafond. The purpose of this study was to analyze the pathoanatomy of AM fractures and associated ankle injuries.Methods: One hundred and forty patients (median age, 61.0 years) with a total of 140 acute malleolar fractures (OTA/AO 44) involving the anterolateral distal tibial rim were analyzed with computed tomography (CT) imaging. All components of the malleolar fractures were analyzed and classified. Fracture patterns were compared with those of all patients with malleolar fractures treated during the same 9-year period. Patients with fractures of the tibial pilon (OTA/AO 43) and patients <18 years of age were excluded.Results: Of the 140 AM fractures, 52.9% were classified as type 1 (extra-articular avulsion); 35.7%, type 2 (incisura and plafond involvement); and 11.4%, type 3 (impaction of the anterolateral plafond). The fibula was fractured in 87.1%; the medial malleolus, in 66.4%; and the posterior malleolus, in 68.6%. An isolated AM fracture was seen in 4.3%. The size of the AM fractures correlated negatively with that of the posterior malleolar fractures. The proportion of pronation-abduction fractures increased and the proportion of supination-external rotation fractures decreased as the type of AM fracture increased. A fracture involving the AM occurred in 12.6% of all ankle fractures and occurred significantly more frequently in pronation-type injuries and elderly patients. No supination-adduction fractures with AM involvement were seen. The intraclass correlation coefficient for the proposed classification of the AM fractures was 0.961 (95% confidence interval [CI] = 0.933 to 0.980) for interobserver agreement and 0.941 (95% CI = 0.867 to 0.974) for intraobserver agreement.Conclusions: Knowledge of the 3D pathoanatomy of AM fractures and associated malleolar fractures may help with surgical decision-making and planning. CT imaging should be employed generously in the diagnosis of complex ankle fractures, in particular with pronation-type injuries.Clinical Relevance: Depending on the individual 3D fracture pattern, fixation of displaced anterolateral distal tibial fragments potentially contributes to the restoration of joint congruity, tibiofibular alignment, and syndesmotic stability in complex malleolar fractures.Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G774).

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Section: Discussionmentioning

confidence: 50%

Section: Discussionmentioning

confidence: 99%

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Pathoanatomy of the Anterolateral Tibial Fragment in Ankle Fractures

Rammelt¹,

Bartoníček²,

Kroker³

2021

Journal of Bone and Joint Surgery

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“…Of 100 ankle fractures with a PM fragment, 12% were bimalleolar fractures, 57% were trimalleolar fractures (Fig. 1 ) and 31% were quadrimalleolar fractures [ 23 ]: 13% trimalleolar fractures with an additional tubercule de Tillaux–Chaput fragment, 16% trimalleolar fractures with an additional Wagstaffe–LeFort fragment and 2% trimalleolar fractures with both a tubercule de Tillaux–Chaput and Wagstaffe–LeFort fragment. The right ankle was affected in 49% and the left ankle in 51%.…”

Section: Methodsmentioning

confidence: 99%

Ankle fractures involving the posterior malleolus: patient characteristics and 7-year results in 100 cases

Neumann

Rammelt

2021

Arch Orthop Trauma Surg

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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) and the American Orthopedic Foot & Ankle Society (AOFAS) ankle/hindfoot score averaged 87.5 (SD: 19.1). The maximum score of 100 was achieved by 44% of patients. The physical (PCS) and mental health component summary (MCS) scores of the SF-36 averaged 47.7 (SD: 12.51) and 50.5 (SD: 9.36), respectively. Range of motion was within 3.4 (SD: 6.63) degrees of the uninjured side. The size of the PM fragment had no prognostic value. There was a trend to lower outcome scores with slight anterior or posterior shift of the distal fibula within the tibial incisura. Patients who underwent primary internal fixation had significantly superior SF-36 MCS than patients who underwent staged internal fixation (p = 0.031). Conclusions With an individualized treatment protocol, tailored to the CT-based assessment of PM fractures, favorable medium and long-term results can be expected.

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“…The prognosis of ankle fractures depends largely on obtaining an anatomical reduction [1], and particular attention to the posterior malleolus is currently recognized to achieve this goal [2,3]. Furthermore, recent literature highlights the importance of considering and anatomically restoring the anterolateral portion of the ankle, such as the anterior syndesmosis [4,5] or a Chaput or Wagstaffe-Le Fort fracture avulsion [6][7][8]. In case of complex ankle fracture, to restore the anatomical relationship and congruency of the anterolateral portion of the ankle is, thus, of great importance.…”

Section: Introductionmentioning

confidence: 99%

Posterior to anterior malleolar extended lateral approach to the ankle (PAMELA): early results of a novel approach

Kummer

Crevoisier

2022

Arch Orthop Trauma Surg

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Introduction In a previous cadaveric study, we described the Posterior to Anterior Malleolar Extended Lateral Approach (PAMELA) to address complex ankle fractures. It was demonstrated to provide optimal exposure of the posterior and lateral malleoli, and of the anterolateral portion of the ankle through a single incision. The aim of this study is to report the clinical results of this novel approach. Methods Between January 2019 and January 2021, all patients presenting with a complex ankle fracture in our institution were assessed by CT scan. Indication to use the PAMELA was determined by the fracture pattern, according to our previous guidelines, including combination of complex lateral and displaced posterior malleolar fractures, associated in most cases with anterolateral fracture avulsion. The approach was performed according to the steps previously described. Intraoperative evaluation included quality of exposure, ease of performing the osteosynthesis, and any complication encountered. The postoperative course was assessed for wound healing, quality of reduction, and the occurrence of any complication. Results The PAMELA was performed in 20 patients (aged 17–73). The most common combination of fractures was a comminuted lateral malleolus fracture associated with a displaced fracture of the posterior malleolus and a Wagstaffe-Le Fort or Chaput avulsion. We encountered no intraoperative complication. X-rays showed anatomical reduction in all cases. Postoperative complications included three delayed wound healing resolved with local treatment and one sural nerve traction injury. Conclusions The main potential concern regarding this novel approach was the healing of the flap. Our results reject this concern and are in line with wound healing complications reported following surgical treatment of ankle fractures. This study confirms the safe in vivo feasibility of the PAMELA and opens a new perspective in the optimal management of complex fractures of the ankle. A larger prospective clinical study is ongoing in our institution.

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Surgical Fixation of Quadrimalleolar Fractures of the Ankle

Cited by 25 publications

References 38 publications

Pathoanatomy of the Anterolateral Tibial Fragment in Ankle Fractures

Pathoanatomy of the Anterolateral Tibial Fragment in Ankle Fractures

Ankle fractures involving the posterior malleolus: patient characteristics and 7-year results in 100 cases

Posterior to anterior malleolar extended lateral approach to the ankle (PAMELA): early results of a novel approach

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