Percutaneous fixation of posterior malleolar fractures in patients with unstable ankle fractures treated with a fibular intramedullary nail

Background Lateral malleolar fractures (Weber type B or OTA 44-B) account for 60% of all ankle fractures. To achieve anatomic restoration, surgical stabilization provides better results than conservative treatment. Various fixation methods are available to treat these fractures; however, the best method is still unknown. Our objectives were to present a new, useful, and efficient surgical technique for stabilizing lateral malleolar fractures and to analyze the outcomes of patients treated with the compression cerclage system. Methods The surgical technique consists of a Kirschner wire that is passed percutaneously and perpendicular to the fracture line, and a cerclage wire that is passed in a semi-circular fashion over the ends of the Kirschner wire on the lateral side of the bone, leaving loops on each side to allow bilateral compression while twisting both wires. We retrospectively evaluated patients treated with this technique, with or without additional fractures. Follow-up of <24 months and bilateral ankle fractures were the exclusion criteria. Fractures were examined clinically and radiologically in comparison to the uninjured side and were rated according to the criteria reported by McLennon and Ungersma. Olerud and Molander ankle score was used to evaluate functional outcome. Results At the final follow-up, 15 out of 21 patients (9 women and 6 men; mean age, 48.2 years [range, 19–78 years]) were evaluated. The mean follow-up was 5.16 years (28–129 months). Five patients had an isolated lateral malleolar fracture; eight had lateral and medial malleolar fractures; and two had trimalleolar fractures. At the final follow-up, 11 patients were rated good functionally and four were fair, and all patients were rated good radiographically according to the criteria by McLennon and Ungersma. Mean Olerud and Molander ankle score was 93.3 (range, 80–100). Conclusions The compression cerclage system provides good functional and radiological outcomes in patients with lateral malleolus fractures. This method is useful, safe, and efficient with minimum hardware. It can be applied through limited soft-tissue stripping, which is especially important in patients with a high risk for wound complications.

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

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00347 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0034

Author(s):

Kevin D. Martin ◽

Jeannie Huh

Keyword(s):

Internal Fixation ◽

Patient Reported Outcomes ◽

Articular Surface ◽

Ankle Fractures ◽

Ct Scans ◽

Loose Bodies ◽

Arthroscopic Reduction ◽

Malleolar Fractures ◽

Posterior Malleolus ◽

Patient Reported

Category: Arthroscopy; Trauma Introduction/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.

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

Foot & Ankle International ◽

10.1177/1071100720955149 ◽

2020 ◽

pp. 107110072095514

Author(s):

Kevin D. Martin ◽

Courtney T. Tripp ◽

Jeannie Huh

Keyword(s):

Internal Fixation ◽

Soft Tissues ◽

Case Series ◽

Ankle Fractures ◽

Ct Scans ◽

Loose Bodies ◽

Level Of Evidence ◽

Arthroscopic Reduction ◽

Malleolar Fractures ◽

Patient Reported

Background: Posterior malleolar fractures within a trimalleolar ankle fracture pattern are challenging to manage. Posterior ankle arthroscopy provides a means to assess the intra-articular and syndesmotic reductions, while removing loose bodies. The purpose of this study was to determine the radiographic and patient reported outcomes of posterior arthroscopic reduction and internal fixation (PARIF) in trimalleolar ankle fractures. Methods: From November 2015 to March 2019, we prospectively enrolled consecutive trimalleolar ankle fractures that underwent PARIF by a single surgeon. Preoperative and postoperative computed tomography (CT) scans were interpreted by 2 blinded musculoskeletal radiologists for articular reduction, syndesmosis congruity, and presence of ossific loose bodies. Patient outcomes were assessed using the Foot and Ankle Disability Index (FADI), American Orthopaedic Foot & Ankle Society (AOFAS) ankle score, Olerud-Molander Ankle Score (OMAS), and visual analog scale (VAS). A total of 28 trimalleolar ankle fractures were treated with PARIF. Mean patient age was 36 years (range, 19-69). Results: Preoperative CT identified 18 intra-articular loose bodies (range, 0-4) in 36% of ankles and 75% (n = 21) syndesmosis incongruity. Postoperative CT scans demonstrated anatomic intra-articular reduction in all fractures, 41.7% (5/12) syndesmosis incongruity without fixation, and 0% (0/9) with suture-button fixation. At mean 2-year follow-up, the results were good to excellent with mean VAS score 1 (range, 0-4), AOFAS score 84 (range, 63-100), FADI 85 (range, 59-100), and OMAS 76 (range, 40-100). Conclusion: The PARIF technique for displaced posterior malleolar fractures was effective in achieving anatomic intra-articular reduction, syndesmosis congruity, and intra-articular loose body removal, while safely preserving the soft tissues. Level of Evidence: Level IV, prospective case series.

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MALLEOLAR ANKLE FRACTURES IN ADULTS: FUNCTIONAL OUTCOME AND COMPLICATIONS AFTER OPEN DECREASE AND INTERNAL FIXATION

International Journal of Medical and Biomedical Studies ◽

10.32553/ijmbs.v4i3.1443 ◽

2020 ◽

Vol 4 (3) ◽

Author(s):

Chetan Laljibhai Rathod

Keyword(s):

Internal Fixation ◽

Functional Outcome ◽

Open Reduction ◽

External Rotation ◽

Ankle Fractures ◽

Ankle Injuries ◽

Excellent Outcome ◽

Malleolar Fractures ◽

Supination External Rotation ◽

Type Of Injury

Background: Ankle injuries may result from high energy as well as low energy rotational forces sustained during sports or a misstep during routine daily activities.3 Young and middle aged are more prone for this type of injury. Population-based studies suggest that the incidence of the ankle fractures has increased dramatically since the early 1960s. Objective: To evaluate the functional outcome and complications following open reduction and internal fixation of malleolar fractures of ankle in adults. Methodology: The study was a descriptive observational study conducted involving all the adult patients of malleolar fractures. Total of 35 subjects of malleolar fractures undergoing open reduction and internal fixation and fulfilling the eligibility criteria were selected for the study. Results: 31.4% subjects each were from 31-40 and 41-50 years age group with mean age of 39.32 +/- 4.16 years. 37.1% patients had Supination External Rotation and 34.3% patients had Pronation External Rotation type of injury. 82.9% patients had Bi-malleolar fracture. 11(31.4%) patients had excellent outcome. Post-operative complications included superficial skin infections in 17.1% and Ankle stiffness in 5.7% cases. Conclusion: At the end of 6 months, 11(31.4%) patients had excellent outcome, 19(54.3%) had good results, 3 (8.6%) patients had fair outcome while 2 (5.7%) had poor results according to Baird and Jackson score. Weber type B was the commonest type of fracture while supination external rotation injury was the most common mechanism of injury. Keywords: Malleolar fractures, ankle, adults, functional outcome, complications, open reduction and internal fixation.

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Polyglycolide Bioabsorbable Screws in the Treatment of Ankle Fractures

Foot & Ankle International ◽

10.1177/107110079701800303 ◽

1997 ◽

Vol 18 (3) ◽

pp. 128-131 ◽

Cited By ~ 47

Author(s):

W. David Hovis ◽

Robert W. Bucholz

Keyword(s):

Functional Results ◽

Sinus Tract ◽

Ankle Fractures ◽

Medial Malleolus ◽

Wound Infections ◽

Inflammatory Reactions ◽

Malleolar Fractures ◽

Metallic Implants ◽

Bioabsorbable Screws

Twenty-one patients with unstable medial malleolar, bimalleolar, or trimalleolar ankle fractures underwent open reduction and internal fixation of the medial malleolus with 4.5-mm polyglycolide screws. All lateral malleolar fractures were internally fixed with standard metallic implants. Radiographic and clinical follow-up results were available on 16 of 21 patients. All fractures healed at an average of 3.4 months (range, 3–6 months), and there were no medial wound infections. Eight of 16 patients developed an inflammatory reaction to the biodegradable polyester at 3 to 4 months after implantation, including one who developed a sterile draining sinus tract. No surgical or nonsurgical treatment was required in those eight patients. We conclude that whereas polyester screws yield union rates and functional results similar to those of metallic screws in the treatment of medial malleolar fractures, the use of polyglycolide screws is associated with an unacceptable rate of inflammatory reactions.

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Comparing Functional Outcomes After Injury-Specific Fixation of Posterior Malleolar Fractures and Equivalent Ligamentous Injuries in Rotational Ankle Fractures

Journal of Orthopaedic Trauma ◽

10.1097/bot.0000000000001104 ◽

2018 ◽

Vol 32 (4) ◽

pp. e123-e128 ◽

Cited By ~ 11

Author(s):

Ashley E. Levack ◽

Stephen J. Warner ◽

Elizabeth B. Gausden ◽

David L. Helfet ◽

Dean G. Lorich

Keyword(s):

Functional Outcomes ◽

Ankle Fractures ◽

Malleolar Fractures ◽

Specific Fixation

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Diagnosis of tibiofibular syndesmosis instability in Weber type B malleolar fractures

Journal of International Medical Research ◽

10.1177/0300060520939752 ◽

2020 ◽

Vol 48 (7) ◽

pp. 030006052093975

Author(s):

Qiang Huang ◽

Yongxing Cao ◽

Chonglin Yang ◽

Xingchen Li ◽

Yangbo Xu ◽

...

Keyword(s):

Ankle Fractures ◽

Preoperative Imaging ◽

Diagnostic Efficiency ◽

Tibiofibular Syndesmosis ◽

Type B ◽

X Ray ◽

Malleolar Fractures ◽

Distal Tibiofibular Syndesmosis ◽

Arthroscopic Findings ◽

Weber Type

Objective This study was performed to analyze the clinical value of X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) examinations for the diagnosis of distal tibiofibular syndesmosis injuries in Weber type B ankle fractures with reference to the ankle arthroscopic findings. Methods This retrospective clinical study involved 52 patients with type B ankle fractures from August 2014 to January 2018. We analyzed the patients’ preoperative imaging data and judged the stability of the distal tibiofibular syndesmosis using X-ray, CT, and MRI examinations. We also evaluated the syndesmosis stability with arthroscopy both statically and dynamically. Results With the arthroscopic findings as the standard, the sensitivity of X-ray for diagnosing syndesmosis instability was 52.8%, the specificity was 100%, and the diagnostic efficiency was 67.3%. The sensitivity of CT for diagnosing syndesmosis instability was 77.8%, the specificity was 100%, and the diagnostic efficiency was 84.6%. The sensitivity of MRI for diagnosing syndesmosis instability was 100%, the specificity was 81.3%, and the diagnostic efficiency was 94.2%. Conclusion This study suggests that an arthroscopic examination may be recommended when the X-ray or CT features are different from the MRI findings while diagnosing tibiofibular syndesmosis instability in Weber type B malleolar fractures.

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Are Orthopaedic Surgeons Being Adequately Compensated for Ankle Fractures? An Analysis of Relative Value Units (RVUs)

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00052 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0005

Author(s):

Azeem Tariq Malik ◽

Safdar N. Khan ◽

Laura Phieffer ◽

Thuan V. Ly ◽

Carmen E. Quatman

Keyword(s):

Internal Fixation ◽

Open Reduction ◽

Operative Time ◽

Open Reduction Internal Fixation ◽

Ankle Fractures ◽

Reimbursement Rate ◽

Total Operative Time ◽

Orthopaedic Surgeons ◽

Malleolar Fractures ◽

The Mean

Category: Ankle, Trauma Introduction/Purpose: Tri-malleolar fractures, as compared to simple uni-malleolar fractures, are technically more challenging cases, have longer operative times and require a higher effort. The current RVU-based system is built to reflect the varying presentation of ankle fractures (uni-malleolar vs. bi-malleolar vs. tri-malleolar) by assigning individual RVUs to different fracture complexities. However, no study has evaluated whether the current RVUs reflect an appropriate compensation per unit time following open reduction internal fixation (ORIF) for uni-malleolar vs. bi-malleolar vs. tri-malleolar ankle fractures. Methods: The 2012-2017 American College of Surgeons – National Surgical Quality Improvement Program (ACS-NSQIP) files were queried using CPT codes for patients undergoing open reduction internal fixation (ORIF) for uni-malleolar (CPT-27766, CPT- 27769, CPT-27792), bi-malleolar (CPT-27814) and tri-malleolar (CPT-27822, CPT-27823) ankle fractures. A total of 7,830 (37.2%) uni-malleolar, 7,826 (37.2%) bi-malleolar and 5,391 (25.6%) tri-malleolar ankle fractures were retrieved. Total RVUs were calculated for each case. Mean RVU/minute was derived by dividing the total RVU of each case by the total operative time. Reimbursement rate ($/min) was calculated by multiplying the mean RVU/min of each procedure by a preset CMS-defined rate of $35.8887/RVU. Mean Reimbursement/case was calculated by multiplying the reimbursement rate by the operative time of each procedure. Kruskal-Wallis tests were used to compare RVUs, operative time and reimbursements between the three fracture groups. Results: The mean total RVU for each fracture type was as follows:- 1) Uni-malleolar: 9.99, 2) Bi-malleolar=11.71 and 3) Tri- malleolar=12.87 (p<0.001). A statistically significant difference was noted in mean operative time (uni-malleolar=63.2 vs. bi- malleolar=78.6 vs. tri-malleolar=95.5; p<0.001) between the two groups. Reimbursement rates ($/min) decreased significantly as fracture complexity increased (uni-malleolar=$7.21/min vs. bi-malleolar=$6.75/min vs. tri-malleolar=$6.10; p<0.001). The average reimbursement/case was $358, $420 and $462 for uni-malleolar, bi-malleolar and tri-malleolar fractures respectively. Based on a hypothetical scenario, an orthopaedic surgeon spent 190 minutes fixing two tri-malleolar fractures and earning $924 in the process. Within a total operative time of 190 minutes, three uni-malleolar ankle fractures and two bi-malleolar ankle fractures could be managed completely with an associated earning of $1,074 and $840 respectively. Conclusion: Orthopaedic surgeons are reimbursed at a higher rate ($/min) for treating a simple uni-malleolar fracture as compared to bi-malleolar and tri-malleolar fractures, despite the higher complexity and longer operative times seen in the latter. The study highlights the need of a change in the RVUs for bi-malleolar and tri-malleolar ankle fractures to ensure that surgeons are adequately reimbursed per unit time for treating a more complex fracture case.

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