Impact of Computed Tomography on Operative Planning for Ankle Fractures Involving the Posterior Malleolus

A trimalleolar ankle fracture is considered unstable and treatment is generally performed operatively. Computed tomography is important for the operative planning by providing an elaborated view of the posterior malleolus. Trimalleolar ankle fractures have a rising incidence in the last decade with up to 40 per 100,000 people per year. With a growing number of elderly patients, trimalleolar ankle injuries will become more relevant in the form of fragility fractures, posing a particular challenge for trauma surgeons. In patients with osteoporotic trimalleolar ankle fractures and relevant concomitant conditions, further evidence is awaited to specify indications for open reduction and internal fixation or primary transfixation of the ankle joint. In younger, more demanding patients, arthroscopic-assisted surgery might improve the outcome, but future research is required to identify patients who will benefit from assisted surgical care. This review considers current scientific findings regarding all three malleoli to understand the complexity of trimalleolar ankle injuries and provide the reader with an overview of treatment strategies and research, as well as future perspectives. Cite this article: EFORT Open Rev 2021;6:692-703. DOI: 10.1302/2058-5241.6.200138

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Stability in ankle fractures

EFORT Open Reviews ◽

10.1302/2058-5241.3.170057 ◽

2018 ◽

Vol 3 (5) ◽

pp. 294-303 ◽

Cited By ~ 10

Author(s):

Vasileios Lampridis ◽

Nikolaos Gougoulias ◽

Anthony Sakellariou

Keyword(s):

Computed Tomography ◽

Weight Bearing ◽

Ct Scanning ◽

Ankle Fractures ◽

Deltoid Ligament ◽

Contact Pressure Distribution ◽

Distal Fibula ◽

Posterior Malleolus ◽

Surgical Fixation ◽

The Stability

Medial column (deltoid ligament) integrity is of key importance when considering the stability of isolated lateral malleolus ankle fractures. Weight-bearing radiographs are the best method of evaluating stability of isolated distal fibula fractures. Computed tomography (CT) scanning is mandatory for the assessment of complex ankle fractures, especially those involving the posterior malleolus. Most isolated trans-syndesmotic fibular fractures (Weber-B, SER, AO 44-B) are stable and can safely be treated non-operatively. Posterior malleolus fractures, regardless of size, should be considered for surgical fixation to restore stability, reduce the need for syndesmosis fixation, and improve contact pressure distribution. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170057

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The effect of computerised tomography on operative planning in posterior malleolus ankle fractures

Foot and Ankle Surgery ◽

10.1016/j.fas.2019.08.007 ◽

2020 ◽

Vol 26 (6) ◽

pp. 676-680

Author(s):

Hassaan Q. Sheikh ◽

Edward J. Mills ◽

Jonathan C. McGregor-Riley ◽

Carolyn Chadwick ◽

Mark B. Davies

Keyword(s):

Ankle Fractures ◽

Computerised Tomography ◽

Posterior Malleolus ◽

Operative Planning

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Three-dimensional ultrasound for knee osteophyte depiction: a comparative study to computed tomography

International Journal of Computer Assisted Radiology and Surgery ◽

10.1007/s11548-021-02456-4 ◽

2021 ◽

Author(s):

Valeria Vendries ◽

Tamas Ungi ◽

Jordan Harry ◽

Manuela Kunz ◽

Jana Podlipská ◽

...

Keyword(s):

Computed Tomography ◽

Automatic Segmentation ◽

Three Dimensional ◽

3D Ultrasound ◽

Surgical Interventions ◽

Structured Light Scanner ◽

Joint Surfaces ◽

Operative Planning ◽

Rms Error ◽

Tissue Characteristics

Abstract Purpose Osteophytes are common radiographic markers of osteoarthritis. However, they are not accurately depicted using conventional imaging, thus hampering surgical interventions that rely on pre-operative images. Studies have shown that ultrasound (US) is promising at detecting osteophytes and monitoring the progression of osteoarthritis. Furthermore, three-dimensional (3D) ultrasound reconstructions may offer a means to quantify osteophytes. The purpose of this study was to compare the accuracy of osteophyte depiction in the knee joint between 3D US and conventional computed tomography (CT). Methods Eleven human cadaveric knees were pre-screened for the presence of osteophytes. Three osteoarthritic knees were selected, and then, 3D US and CT images were obtained, segmented, and digitally reconstructed in 3D. After dissection, high-resolution structured light scanner (SLS) images of the joint surfaces were obtained. Surface matching and root mean square (RMS) error analyses of surface distances were performed to assess the accuracy of each modality in capturing osteophytes. The RMS errors were compared between 3D US, CT and SLS models. Results Average RMS error comparisons for 3D US versus SLS and CT versus SLS models were 0.87 mm ± 0.33 mm (average ± standard deviation) and 0.95 mm ± 0.32 mm, respectively. No statistical difference was found between 3D US and CT. Comparative observations of imaging modalities suggested that 3D US better depicted osteophytes with cartilage and fibrocartilage tissue characteristics compared to CT. Conclusion Using 3D US can improve the depiction of osteophytes with a cartilaginous portion compared to CT. It can also provide useful information about the presence and extent of osteophytes. Whilst algorithm improvements for automatic segmentation and registration of US are needed to provide a more robust investigation of osteophyte depiction accuracy, this investigation puts forward the potential application for 3D US in routine diagnostic evaluations and pre-operative planning of osteoarthritis.

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Predisposing Factors for Posttraumatic Osteoarthritis After Malleolus Fracture Fixation in Patients Younger Than 50 Years

Foot & Ankle International ◽

10.1177/10711007211050039 ◽

2021 ◽

pp. 107110072110500

Author(s):

Jong Seok Beak ◽

Yeong Tae Kim ◽

Sung Hyun Lee

Keyword(s):

Risk Factors ◽

Articular Surface ◽

Binary Logistic Regression ◽

Ankle Fractures ◽

Fracture Dislocation ◽

Posttraumatic Arthritis ◽

Level Of Evidence ◽

Posttraumatic Osteoarthritis ◽

Posterior Malleolus

Background: The purpose of this study was to identify the risk factors for posttraumatic osteoarthritis (OA) after surgery for ankle fractures in patients aged ≤50 years. Methods: We performed a retrospective review of consecutive patients who underwent surgery for ankle fractures and were followed up for a minimum period of 5 years. The patients were assigned to 2 groups according to the presence of advanced OA at the last follow-up. Binary logistic regression was used to model the correlation between risk factors and OA. Functional outcomes were assessed using the Foot and Ankle Outcome Score. Results: The data of 332 patients who met the inclusion criteria were included in the analysis. The overall rate of posttraumatic arthritis was 27.7% (nonarthritis group: 240 patients, arthritis group: 92 patients). The arthritic change was significantly affected by BMI (95% confidence interval [CI] 1.29-19.76; adjusted odds ratio [OR] ≥ 30, 6.56), fracture-dislocation injury (CI 1.66-11.57; adjusted OR, 4.06), posterior malleolus (PM) fracture (CI 1.92-12.73, adjusted OR > 25% of the articular surface, 5.72), and postoperative articular incongruence (CI 1.52-18.10; adjusted OR, 7.21). The mean scores of the arthritis group were lower than those in the nonarthritis group ( P < .05). Conclusion: Obesity, fracture-dislocation injury, concomitant large PM fracture, and articular incongruence were risk factors of posttraumatic OA after surgery for ankle fractures. Surgeons should be aware that accurate reduction is critical in patients with ankle fractures with associated large PM fractures, especially those with obesity or severe initial injuries such as fracture-dislocation. Level of Evidence: Level III, case control study.

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ONE OR TWO SCREWS IN THE FRACTURE OF THE ODONTOID PROCESS? EVALUATION USING COMPUTED TOMOGRAPHY

Coluna/Columna ◽

10.1590/s1808-185120151403147309 ◽

2015 ◽

Vol 14 (3) ◽

pp. 210-213

Author(s):

Carlos Alexandre Botelho do Amaral ◽

Edgar Taira Nakagawa ◽

Leonardo Ternis Ferreira ◽

José Sergio Franco ◽

Robinson Esteves Santos Pires ◽

...

Keyword(s):

Computed Tomography ◽

Process Evaluation ◽

Odontoid Process ◽

T Test ◽

Ct Scans ◽

Transverse Diameter ◽

Bone Area ◽

Men And Women ◽

Male And Female ◽

Operative Planning

Objective:To evaluate the bone area of the odontoid process through computed tomography and its relation with the area of one and two screws in the male and female subjects.Methods:188 CT scans of adults were analyzed. The isthmus area was selected and the transverse diameter was measured at 1.2 mm from the base of odontoid.Results:After placement of a screw, the odontoid area remains with 82% of free bone for both men and women. With two screws, 45.6% of women, had a free bone area of the odontoid process between 50% and 75% and 54.4% were above 75%. 26.6% men had percentage from 50% to 75% of free bone area and 73.4% above 75% (p=0.07). After the placement of two screws, the bone area was, in average, 77.3% in men and 75.4% in women. Using the Student t-test, the differences between the average of percentage of free bone area in men and women are significantly lower in women (p=0.0012).Conclusion:The pre-operative planning through CT can help to choose the number of screws in the odontoid process. The choice should be particularly careful when using two screws in women.

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Factors Affecting the Clinical Outcomes of Surgically Treated Ankle Fractures Associated with the Posterior Malleolar Fragment

Journal of the American Podiatric Medical Association ◽

10.7547/18-184 ◽

2021 ◽

Vol 111 (5) ◽

Author(s):

Mehmet Kuyumcu ◽

Emre Bilgin ◽

Hasan Bombacı

Keyword(s):

Clinical Outcomes ◽

Fragment Size ◽

Statistical Significance ◽

Ankle Fractures ◽

Foot And Ankle ◽

Ankle Osteoarthritis ◽

Posterior Malleolus ◽

Significant Difference ◽

Functional Scores ◽

The Mean

Background This study was performed to determine the factors that influence the clinical outcomes of surgically treated ankle fractures associated with the posterior malleolus (PM). Methods We evaluated 42 fractures of 42 patients. Posterior malleolus fracture size was calculated using computed tomography. Posterior malleolar fractures with a size less than 10% were left nonfixated. The decision for larger fragments was performed using fluoroscopy following the fixation of other components. If the joint was found to be congruent, the PM was left nonfixated. Otherwise, the PM was reduced and fixated. Clinical outcomes were evaluated based on Weber, Freiburg, and American Orthopaedic Foot and Ankle Society scores. Ankle osteoarthritis was determined according to the Canadian Orthopaedic Foot and Ankle Society classification. The effect of PM fixation, age, PM fragment size, waiting period before surgery, presence of ankle dislocation, and number of injured malleoli on clinical outcomes were assessed. Statistical significance was set at a value of P < .05. Results The mean patients age was 48.5 ± 14.9 years (range, 20–84 years) and the mean follow-up was 23.7 ± 8.6 months (range, 12–56 months). Fixation of the PM was performed solely in 12 patients. Postoperative displacement of the PM and articular step were less than 2 mm in all fractures. Statistically significant worse outcomes were demonstrated based on functional scores in the patients with a PM size greater than or equal to 25% (P = .042, P = .038, and P = .048, respectively) and in patients aged 60 years or older (P = .005, P = .007, and P = .018, respectively). However, there was no significant difference between functional scores and the other factors. Ankle osteoarthritis was observed at a higher rate in patients with PM size greater than or equal to 25% and in patients aged 60 years or older. Conclusions Clinical outcomes of the patients are mainly influenced by the patient's age and PM fragment size. However, if the tibiotalar joint is congruent, comparable results can be obtained in PM fixated or nonfixated patients.

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Three-dimensional computed tomography reconstruction for operative planning in robotic segmentectomy: a pilot study

Journal of Thoracic Disease ◽

10.21037/jtd.2017.11.144 ◽

2018 ◽

Vol 10 (1) ◽

pp. 196-201 ◽

Cited By ~ 3

Author(s):

Julien Le Moal ◽

Christophe Peillon ◽

Jean-Nicolas Dacher ◽

Jean-Marc Baste

Keyword(s):

Computed Tomography ◽

Pilot Study ◽

Three Dimensional ◽

Operative Planning ◽

Tomography Reconstruction ◽

Computed Tomography Reconstruction

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Screw Fixation of the Posterior Malleolus Fragment in Ankle Fracture: Cadaveric and Clinical Studies

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00267 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0026

Author(s):

Gisoo Lee ◽

Chan Kang ◽

Yougun Won ◽

Jae Hwang Song ◽

Byungki Cho

Keyword(s):

Clinical Outcomes ◽

Ankle Fracture ◽

Screw Fixation ◽

Articular Surface ◽

Cannulated Screw ◽

Ankle Fractures ◽

Neutral Position ◽

Early Recovery ◽

Malleolar Fracture ◽

Posterior Malleolus

Category: Ankle, Trauma Introduction/Purpose: Previously, a posterior malleolus fragment (PMF) covering 25–30% of the articular surface was a known indication for surgical fixation for ankle fractures. This study aimed to compare the outcomes of screw fixation for PMF comprising <25% of the articular surface and to evaluate the results of cadaver experiments. Methods: The clinical study enrolled ankle fracture patients with PMFs who planned to undergo surgery between March 2014 and February 2017. Among them, 62 with type 1 PMF comprising <25% of the articular surface were included: 32 patients underwent cannulated screw fixation for PMF after fixation for lateral and/or medial malleolar fracture (A group), whereas the other 30 patients underwent internal fixation for lateral and/or medial malleolar fracture but no screw fixation (B group). Clinical outcomes were determined at the 3-, 6-, 12-, and 18-month visits. Additionally, cadaver studies were conducted to evaluate cannulated screw fixation or no fixation in cases of PMFs comprising <25% of the articular surface and >1 mm displacement. Ankle joint stability was measured under external torque on the ankle in the neutral position. The level of significance was set at P < .05. Results: Clinical outcomes at 6 and 12 months after surgery were significantly higher in group A than in group B. However, there was no significant intergroup difference in clinical outcomes at 18 months of follow-up. In the cadaver study, PMF screw fixations were significantly more stable under external rotation force. Conclusion: Screw fixation was significantly useful during early recovery and in short-term clinical outcomes owing to stabilization of ankle fractures with PMF involving <25% of the articular surface.

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