A Retrospective Study on the Morphology of Posterior Malleolar Fractures Based on a CT Scan: Whether We Ignore the Importance of Fracture Height

Objective. The aim of this study was to investigate the respective correlation between the height (H) of a posterior malleolar fracture (PMF) and the involved area (S) of an articular surface and the presence of “die-punch.” Methods. Patients with closed posterior malleolar fractures admitted to our hospital from January 2015 to December 2017 were selected, with complete X-ray and 3D reconstruction CT imaging data. The gender, age, injured side, and surgical fixation methods of the patients were recorded. A preoperative ankle CT scan was performed, and the images were viewed through the PACS (Picture Archiving and Communication Systems). Simultaneously, the involved joint surface area (S) by the posterior malleolar fracture was measured, as well as the proportion of the fracture area to the total ankle joint area. On the sagittal reconstruction CT images, the height (H) of the posterior malleolar fracture was measured to compare the correlation between the height of the fracture and the area of the fracture, as well as the area ratio. Besides, according to the presence or absence of “die-punch,” patients were divided into two groups: A and B. And each group was further divided into three subgroups according to age (16-39 years old, 40-59 years old, and ≥60 years old). The statistical differences in the height of fracture between the subgroups were compared. Results. A total of 48 patients, aged 16-82 years, with an average age of 48.9 years, were included in this study, including 13 males and 35 females. There were 20 cases of left ankle injury and 28 cases of right ankle injury. The average height of the posterior malleolar fractures was 18.19 mm, the average area of the fracture was 202.28 mm2, and the average ratio of the fracture area to the total articular surface area was 17.84%. Besides, die-punch was seen in 27 cases and not in 21 cases. The average height of fractures was 21.33±5.38 mm in group A1, 14.38±9.01 mm in group B1, 18.30±7.95 mm in group A2, 14.48±5.37 mm in group B2, 26.26±6.73 mm in group A3, and 12.77±3.07 mm in group B3. Conclusion. The height (H) of the posterior malleolar fractures is positively correlated with the fracture area (S) and the fracture area ratio (FAR). The posterior malleolar fractures with “die-punch” tend to have a greater average height than that without “die-punch.” In clinical work, orthopedic surgeons should not only pay attention to the size of the posterior malleolus fracture but also value its height, which hopefully could provide insight into the treatment and prognosis of PMF patients.

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Percutaneous posteroanterior screw fixation for Haraguchi type 1 posterior malleolar fracture in tri-malleolar fracture: Operative technique and randomized clinical results

Journal of Orthopaedic Surgery ◽

10.1177/2309499021997996 ◽

2021 ◽

Vol 29 (1) ◽

pp. 230949902199799

Author(s):

Tianming Yu ◽

Jichong Ying ◽

Jianlei Liu ◽

Dichao Huang ◽

Hailin Yan ◽

...

Keyword(s):

Screw Fixation ◽

Malleolar Fracture ◽

Malleolar Fractures ◽

Posterior Malleolar Fracture ◽

Post Traumatic ◽

Group 2 ◽

Traumatic Arthritis ◽

Group 1

Purpose: The study described a novel surgical treatment of Haraguchi type 1 posterior malleolar fracture in tri-malleolar fracture and patient outcomes at intermediate period follow-up. Methods: All patients from January 2015 to December 2017 with tri-malleolar fracture of which posterior malleolar fractures were Haraguchi type 1, were surgically treated in this prospective study. Lateral and medial malleolar fractures were managed by open reduction and internal fixation through dual incision approaches. 36 cases of Haraguchi type 1 posterior malleolar fractures were randomly performed by percutaneous posteroanterior screw fixation with the aid of medial exposure (group 1). And 40 cases were performed by percutaneous anteroposterior screw fixation (group 2). Clinical outcomes, radiographic outcomes and patient-reported outcomes were recorded. Results: Seventy-six patients with mean follow-up of 30 months were included. There were no significant differences in the mean operation time (81.0 ± 11.3 vs. 77.2 ± 12.4), ankle function at different periods of follow-up, range of motions and visual analog scale (VAS) at 24 months between the two groups ( p > 0.05). However, the rate of severe post-traumatic arthritis (Grade 2 and 3) and the rate of step-off rather than gap in radiological evaluation were lower in group 1 than that in group 2 ( p < 0.05). Conclusion: Using our surgical technique, more patients had good outcome with a lower rate of severe post-traumatic arthritis, compared with the group of percutaneous anteroposterior screw fixation. Percutaneous posteroanterior screw fixation can be a convenient and reliable alternative in treating Haraguchi type 1 posterior malleolar fracture.

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Concurrent ipsilateral Tillaux fracture and medial malleolar fracture in adolescence: management and outcome

10.21203/rs.3.rs-27907/v1 ◽

2020 ◽

Author(s):

quanwen yuan ◽

Zhixiong Guo ◽

Xiaodong Wang ◽

Jin Dai ◽

Fuyong Zhang ◽

...

Keyword(s):

Computerized Tomography ◽

Articular Surface ◽

High Energy ◽

Fracture Pattern ◽

Malleolar Fracture ◽

Malleolar Fractures ◽

Ankle Stability ◽

Anatomic Reduction ◽

The Mean ◽

Tillaux Fracture

Abstract Background The concurrent ipsilateral Tillaux fracture with medial malleolar fracture in adolescence commonly suffer from high-energy injury, making treatment more difficult. The aim of this study was to discuss the mechanism on injury, diagnosis and treatment of this complex fracture pattern. Methods The charts and radiographs of six patients were reviewed. The functional was assessed by the American Orthopedic Foot and Ankle Society ankle-hindfoot scores. Results The mean age at operation was 12.8 years. The mean interval from injury to operation was 7.7 days. Five Tillaux fractures and all medial malleolar fractures were shown on AP plain radiographs. One Tillaux fracture and two cases with avulsion of posterolateral tibial aspect were confirmed in axial computerized tomography. Talar subluxation laterally with medial space widening in three, and syndesmotic disruption in one. There were five patients sustaining ipsilateral distal fibular fractures. All fractures, except nonunion in two medial malleolar fractures and in one Tillaux fracture, healed within 6–8 weeks. There was one case of osteoarthritis of ankle joint. The average AOFAS score was 88.7. Conclusions Computerized tomography is helpful in identifying the fracture pattern. Anatomic reduction and internal fixation of Tillaux and medial malleolar fracture was recommended to restore the articular surface congruity and ankle stability.

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Concurrent ipsilateral Tillaux fracture and medial malleolar fracture in adolescents: management and outcome

Journal of Orthopaedic Surgery and Research ◽

10.1186/s13018-020-01961-7 ◽

2020 ◽

Vol 15 (1) ◽

Author(s):

Quanwen Yuan ◽

Zhixiong Guo ◽

Xiaodong Wang ◽

Jin Dai ◽

Fuyong Zhang ◽

...

Keyword(s):

Computerized Tomography ◽

Articular Surface ◽

High Energy ◽

Fracture Pattern ◽

Malleolar Fracture ◽

Malleolar Fractures ◽

Ankle Stability ◽

Anatomic Reduction ◽

The Mean ◽

Tillaux Fracture

Abstract Background The concurrent ipsilateral Tillaux fracture with medial malleolar fracture in adolescents commonly suffer from high-energy injury, making treatment more difficult. The aim of this study was to discuss the mechanism on injury, diagnosis, and treatment of this complex fracture pattern. Methods The charts and radiographs of six patients were reviewed. The function was assessed by the American Orthopedic Foot and Ankle Society ankle-hindfoot scores. Results The mean age at operation was 12.8 years. The mean interval from injury to operation was 7.7 days. Five Tillaux fractures and all medial malleolar fractures were shown on AP plain radiographs. One Tillaux fracture and two cases with avulsion of posterolateral tibial aspect were confirmed in axial computerized tomography. There was talar subluxation laterally with medial space widening in three and syndesmotic disruption in one. There were five patients sustaining ipsilateral distal fibular fractures. All fractures, except nonunion in two medial malleolar fractures and in one Tillaux fracture, healed within 6–8 weeks. There was one case of osteoarthritis of ankle joint. The average AOFAS score was 88.7. Conclusions Computerized tomography is helpful in identifying the fracture pattern. Anatomic reduction and internal fixation of Tillaux and medial malleolar fracture was recommended to restore the articular surface congruity and ankle stability.

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Anatomy of the Insertion of the Posterior Inferior Tibiofibular Ligament and the Posterior Malleolar Fracture

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00341 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0034

Author(s):

Lyndon Mason ◽

Lara Jayatilaka ◽

Andrew Fisher ◽

Lauren Fisher ◽

Andrew Molloy

Keyword(s):

Lower Limbs ◽

Human Anatomy ◽

Tibialis Posterior ◽

Ligamentous Injury ◽

Malleolar Fracture ◽

Malleolar Fractures ◽

Tibiofibular Ligament ◽

Posterior Malleolar Fracture ◽

Posterior Malleolus

Category: Ankle Introduction/Purpose: The treatment of posterior malleolar fractures is developing. Our previous study on the anatomy of the posterior malleolar fracture identified only 49% of rotational push off fractures of the posterior malleolus had syndesmotic instabilities. This was against general thinking that fixation of such a fragment would stabilize the syndesmosis. Our aim in this study was to identify the extent of the posterior inferior tibiofibular ligament insertion on the posterior tibia and its relation to push off fractures. Methods: We examined 10 cadaveric lower limbs that had been preserved for dissection at the Human Anatomy and Resource Centre at Liverpool University in a solution of formaldehyde. The lower limbs were carefully dissected to identify the ligamentous structures on the posterior aspect of the ankle. Results: In all specimens, the tibial insertion of the PITFL encompassed 1/3 of the distal posterior tibia. In addition, the posterior intermalleolar ligament inserted onto the posterior tibia just medial to the tibialis posterior groove. Thus a rotational push off fracture would only cause syndesmotic injury if greater than a 3 rd of the posterior tibia was injured or occurred in combination with a ligamentous injury. This is in keeping with the clinical findings of only 49% syndesmotic instabilities with Haraguchi type 1 posterior malleolar fractures. Conclusion: Haraguchi type 1 posterior malleolar fractures (less than a 3 rd of the width of the posterior tibia) are unlikely to cause syndesmotic instabilities without the addition of a ligamentous injury.

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The Lateral Trans-Malleolar approach for Posterior Malleolar Fracture of the Ankle: A Clinical and Computed Tomography Evaluation

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00463 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0046

Author(s):

Masanori Taki ◽

Naohiro Hio

Keyword(s):

Computed Tomography ◽

External Rotation ◽

Articular Surface ◽

Clinical Results ◽

Direct Visualization ◽

Malleolar Fracture ◽

Aofas Score ◽

Posterior Malleolar Fracture ◽

Posterior Malleolus

Category: Ankle; Trauma Introduction/Purpose: Posterior malleolar fracture reduction including the articular surface of trimalleolar ankle fracture has been reported to be an important prognostic factor. The lateral trans-malleolar approach (LTA) is a surgical approach that provides direct visualization of the articular surface of the posterior malleolus. We herein report the clinical results and computed tomography (CT) findings for the articular reduction status after LTA for posterior malleolar fracture of the ankle. Methods: Sixteen patients (9 men, 7 women, mean age 52.6+-18.1 years old) who underwent the LTA for posterior malleolar fracture of the ankle and were followed for at least 1 year were evaluated retrospectively. The types of ankle malleolar fracture according to the Lauge-Hansen classification were Supination-External rotation (SER) in 13 patients and Pronation-External rotation (PER) in 3 patients. The CT classifications of posterior malleolus fracture by Haraguchi were Type 1 in 6 cases, Type 2 in 10 cases and Type 3 in 0 cases. The AOFAS score, post-surgical complications and reduction status of the posterior malleolus on CT were investigated. Results: The mean follow-up period was 15.5 months. The AOFAS score was 93.0+-5.2 points. Postoperative complications were seen in one case of superficial infection; however, delayed union, nonunion and fibular necrosis were not observed. The articular step-off in CT improved significantly after surgery (5.9+-2.9 mm preoperatively vs. 0.6+-0.8 mm postoperatively). The 2 patients who showed an articular step-off exceeding 1 mm were both Haraguchi type 2 posterior malleolar fracture. Conclusion: Several approaches for managing posterior malleolus of the ankle have been reported. However, few provide direct visualization to the articular surface. The LTA requires relatively substantial invasion, but it can facilitate surgery in the supine position and thereby reduce the articular surface directly. In our experience, the LTA provided favorable clinical results and fracture reductions. Even when utilizing the LTA, it remains difficult to confirm the fracture reduction of medial articular surface for Haraguchi type 2 medial extension fractures. Therefore, it remains important to also perform appropriate intraoperative X-ray controls.

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Concurrent ipsilateral Tillaux fracture and medial malleolar fracture in adolescents: management and outcome

10.21203/rs.3.rs-27907/v3 ◽

2020 ◽

Author(s):

quanwen yuan ◽

Zhixiong Guo ◽

Xiaodong Wang ◽

Jin Dai ◽

Fuyong Zhang ◽

...

Keyword(s):

Computerized Tomography ◽

Articular Surface ◽

High Energy ◽

Fracture Pattern ◽

Malleolar Fracture ◽

Malleolar Fractures ◽

Ankle Stability ◽

Anatomic Reduction ◽

The Mean ◽

Tillaux Fracture

Abstract Background: The concurrent ipsilateral Tillaux fracture with medial malleolar fracture in adolescents commonly suffer from high-energy injury, making treatment more difficult. The aim of this study was to discuss the mechanism on injury, diagnosis and treatment of this complex fracture pattern. Methods: The charts and radiographs of six patients were reviewed. The function was assessed by the American Orthopedic Foot and Ankle Society ankle-hindfoot scores. Results: The mean age at operation was 12.8 years. The mean interval from injury to operation was 7.7 days. Five Tillaux fractures and all medial malleolar fractures were shown on AP plain radiographs. One Tillaux fracture and two cases with avulsion of posterolateral tibial aspect were confirmed in axial computerized tomography. Talar subluxation laterally with medial space widening in three, and syndesmotic disruption in one. There were five patients sustaining ipsilateral distal fibular fractures. All fractures, except nonunion in two medial malleolar fractures and in one Tillaux fracture, healed within 6-8 weeks. There was one case of osteoarthritis of ankle joint. The average AOFAS score was 88.7. Conclusions: Computerized tomography is helpful in identifying the fracture pattern. Anatomic reduction and internal fixation of Tillaux and medial malleolar fracture was recommended to restore the articular surface congruity and ankle stability.

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Combined Posteromedial and Posterolateral Approaches for 2-Part Posterior Malleolar Fracture Fixation

Foot & Ankle International ◽

10.1177/1071100720937637 ◽

2020 ◽

Vol 41 (10) ◽

pp. 1234-1239 ◽

Cited By ~ 1

Author(s):

Yunfeng Yang ◽

Wenbao He ◽

Haichao Zhou ◽

Jiang Xia ◽

Bing Li ◽

...

Keyword(s):

Case Series ◽

Good Alternative ◽

Retrospective Case ◽

Malleolar Fracture ◽

Level Of Evidence ◽

Malleolar Fractures ◽

Posterior Malleolar Fracture ◽

The Mean ◽

Mean Time

Background: This study investigated the clinical efficacy of combined posteromedial and posterolateral approaches for repair of 2-part posterior malleolar fractures associated with medial and lateral malleolar fractures. Methods: This case series report included 27 Weber B with Haraguchi type II patients with medial and lateral malleolar fractures combined with 2-part posterior malleolar fractures. Patients were treated with open reduction and internal fixation through a combination of posteromedial and posterolateral approaches from January 2015 to January 2018. There were 11 males and 16 females, with an average age of 61.5 years (range, 53-67 years). The procedures were performed on prone patients under spinal anesthesia. The medial, lateral, and posterior malleolar fractures were exposed through posteromedial and posterolateral approaches performed at the same time. The lateral malleolar fracture was fixed using a plate, the medial malleolar fracture was fixed using screws, and the posterior malleolar fracture was fixed using a plate or cannulated screws according to the size of the fragments. We performed follow-up on 22 patients for an average of 30 months (range, 18-48 months). Results: Primary healing of the incisions was achieved in all cases, and no infection was found. The mean time of bone union was 12.5 weeks (range, 10-15 weeks). The mean time from the operation to full weightbearing was 13 weeks (range, 11-16 weeks). We used the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scale to score patient outcomes; the mean score was 85.4 (range, 80-92) at the final follow-up. No significant pain was found at the final follow-up. Conclusion: This study showed that satisfactory outcomes were achieved with combined posteromedial and posterolateral approaches. Therefore, we believe this approach was a good alternative strategy to repair 2-part posterior malleolar fractures associated with medial and lateral malleolar fractures. Level of Evidence: Level IV, retrospective case series.

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Marginal Impaction Associated with Posterior Malleolar Fracture in Rotational Ankle Injury

Injury ◽

10.1016/j.injury.2021.12.013 ◽

2021 ◽

Author(s):

Jiwoon Seo ◽

Kyu-Hyun Yang ◽

Dong Woo Shim ◽

Hyunik Cho ◽

Young-Chang Park

Keyword(s):

Ankle Injury ◽

Malleolar Fracture ◽

Posterior Malleolar Fracture ◽

Marginal Impaction

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Screw fixation of the posterior malleolar fracture

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00306 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0030

Author(s):

Gi-Soo Lee ◽

Chan Kang ◽

Byung-Ki Cho ◽

Yougun Won

Keyword(s):

Clinical Outcome ◽

Screw Fixation ◽

Cannulated Screw ◽

Joint Surface ◽

Functional Score ◽

Malleolar Fracture ◽

Malleolar Fractures ◽

Posterior Malleolar Fracture ◽

Group A

Category: Trauma Introduction/Purpose: Posterior malleolar fracture is known to be an indication for surgery when the size of the fragment is greater than 25% to 30% of the joint surface. The purpose of this study was to compare the results of cannulated screw fixation and early joint motion in patients with ankle fracture with posterior malleolar fracture of less than 25%, and we do cadaver experiments. Methods: The clinical portion of the study evaluated 70 patients with fracture of the posterior malleolus that comprised less than 25% of the articular surface. After fixation for lateral and/or medial malleolar fractures, cannulated screw fixation was performed for posterior malleolar fractures in 34 cases. (A group) In other 36 cases, fixation was not performed for posterior malleolar fractures. (B group) One week after the operation, ankle range of motion exercise was performed. Cadaver studies were evaluated both cannulated screw fixed and non-fixed in less than 25% fractures of the posterior malleolar. The stability of the ankle joint was measured in 12 cases. In 6 cases, the posterior malleolar was fixed and the other 6 cases were not fixed. Results: There was no significant difference in clinical outcome between Group A and B and functional score at 2 years follow up. However, the ankle function score at 6 months and 1 year after the follow - up was significantly higher in group A than in group B. In the cadaver study, the group with screw fixation was significantly stable in external rotation. Conclusion: In case of less than 25% posterior fracture, screw fixation is considered to have a significant effect on recovery and clinical outcome in the short term due to stability.

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