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

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.

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

2019 ◽  
Vol 40 (11) ◽  
pp. 1319-1324 ◽  
Author(s):  
Malwattage Lara Tania Jayatilaka ◽  
Matthew D. G. Philpott ◽  
Andrew Fisher ◽  
Lauren Fisher ◽  
Andrew Molloy ◽  
...  
Keyword(s):  
Transverse Component ◽  
Lower Limbs ◽  
Ligamentous Injury ◽  
Malleolar Fracture ◽  
Posterior Aspect ◽  
Tibiofibular Ligament ◽  
Posterior Malleolar Fracture ◽  
Posterior Malleolus ◽  
Average Size

Background: Our aim in this study was to identify the extent of the posterior inferior tibiofibular ligament (PITFL) insertion on the posterior tibia and its relation to intra-articular posterior malleolar fractures. Methods: Careful dissection was undertaken on 10 cadaveric lower limbs to identify the ligamentous structures on the posterior aspect of the ankle. The ligamentous anatomy was further compared with our ankle fracture database, specifically posterior malleolar fracture patterns, demonstrating a rotational pilon etiology (Mason and Molloy type 2A and B). Computed tomography imaging was used to measure the dimensions of the fracture fragments. Results: The superficial PITFL was found to have a transverse component and an oblique component. The average size of the tibial insertion was 54.9 mm (95% CI, 51.8, 58.0) from joint line and 47.1 mm (95% CI, 43.0, 51.2) transverse. From our database of ankle fractures involving the posterior malleolus, 80 Mason and Molloy type 2 fractures were identified for analysis. Of these, 33 were type 2A and 47 were type 2B. The posterolateral fragments had an average size of 26.3 mm (95% CI, 25.0, 27.7) height and 22.1 mm (95% CI, 21.1, 23.1) width. The posteromedial fragments had an average size of 22.0 (95% CI, 18.9, 25.1) height and 19.8 (95% CI, 17.5, 22.0) width. Conclusion: The superficial PITFL insertion on the tibia is broad. In comparison with the average size of the posterior malleolar fragments, the PITFL insertion is significantly larger. Therefore, for a posterior malleolar fracture to cause posterior syndesmotic instability, a ligamentous injury must also occur. Clinical Relevance: Posterior syndesmotic instability results from injury to the PITFL. It has been widely reported that a posterior malleolar fracture will also give rise to posterior syndesmotic instability due to the insertion of the deep PITFL on the posterior tibia. On the contrary, in this paper, we have shown that the superficial PITFL insertion on the tibia is very large, much greater than the average size of the posterior malleolar fragments. Therefore, for a posterior malleolar fracture to cause posterior syndesmotic instability, a ligamentous injury will also have to occur.

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

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.

scholarly journals Trimalleolar fracture: The endless posterior malleolus fracture debate, to repair or not to repair?

2021 ◽  
Vol 13 (1) ◽  
Author(s):  
Khalil Nasrallah ◽  
Bathish Einal ◽  
Haim Shtarker
Keyword(s):  
Emergency Department ◽  
Ankle Fracture ◽  
Treatment Options ◽  
Malleolar Fracture ◽  
Posterior Malleolar Fracture ◽  
Posterior Malleolus ◽  
Trimalleolar Fractures ◽  
Trimalleolar Fracture ◽  
Set Up

Ankle fracture is one of the most common fractures presenting in the emergency department. The fracture varies from unimalleolar, bimalleolar or trimalleolar. Involvement of the posterior malleolus is common and ranges from small avulsions to large intraarticular fragments causing subluxation of the talus. If left untreated, the resulting step-off, comminution or posterior talar subluxation may lead to osteoarthritis and further disability. To date, no consensus exists regarding the management of posterior malleolus fractures in the set-up of trimalleolar fractures. In this review we provide an overview of the literature on the available treatment options for posterior malleolar fracture in the set-up of trimalleolar fractures.

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

2020 ◽  
Vol 2020 ◽  
pp. 1-8
Author(s):  
Zhifeng Wang ◽  
Chengjie Yuan ◽  
Genrui Zhu ◽  
Xiang Geng ◽  
Chao Zhang ◽  
...  
Keyword(s):  
Ct Scan ◽  
Surface Area ◽  
Articular Surface ◽  
Area Ratio ◽  
Ankle Injury ◽  
Average Height ◽  
Malleolar Fracture ◽  
Malleolar Fractures ◽  
Posterior Malleolar Fracture ◽  
Fracture Area

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.

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

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.

scholarly journals Posterior Approaches to the Ankle: An Analysis of 3 Approaches for Access to the Posterior Distal Tibia

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0021
Author(s):  
Gavin Heyes ◽  
Matthew Philpott ◽  
Lara Jayatilaka ◽  
Andrew P. Molloy ◽  
Lyndon W Mason
Keyword(s):  
Fragment Size ◽  
Distal Tibia ◽  
Lower Limbs ◽  
Posterolateral Approach ◽  
Surgical Approaches ◽  
Tibialis Posterior ◽  
Flexor Hallucis Longus ◽  
Fracture Fragment ◽  
Malleolar Fractures ◽  
Fracture Patterns

Category: Ankle, Trauma Introduction/Purpose: With the increase in the use of CT scanning and fragment specific fixation for complex ankle fractures, utilisation of multiple surgical approaches has increased. The posterolateral approach has been advocated by many, however in our experience, a large proportion of these fractures are not attainable by this approach. Our aim in this study was to analyse three posterior ankle approaches to find their use and efficacy in accessing the posterior tibia in the fixation of posterior malleolar fractures. Methods: We examined 5 fresh frozen cadaveric lower limbs. Three posterior ankle approaches (posterolateral (PL), posteromedial (PM) and medial posteromedial (MPM) approaches were performed, using a consistent repeatable incision of 7 cm extended proximal from the palpable distal extent of the medial malleolus. In both the PL and PM approaches, the flexor hallucis longus (FHL) was taken medially. In the MPM approach, the access was anterior to tibialis posterior (TP). K-wires were then placed parallel to one another at the 4 extremities of the approach. The ankles were imaged using an image intensifier and the distances measured. Our database of 172 consecutively treated posterior malleolar fractures in our department, was used to analyse the fracture fragment size and compare these fracture patterns to the approaches. The fractures were categorised using the Mason and Molloy classification. Only type 2 and 3 fractures were included, leaving 101 in the study. Results: On radiographic analysis, the type 2B and type 3 fractures incorporate 100% and 83% of the posterior width of the tibia respectively. Considering the PL approach only allows access to 40% of the posterior width of the tibia, another approach is required for these fracture patterns. Only 65% of fractures could be adequately exposed using the PL incision. In comparison, 78% of fractures could be exposed using the PM incision. The MPM incision gave the largest area for access to the posterior tibia, however it did not allow access to the constant posterolateral fragment. Only 35% of patients had posteromedial fractures that could be dealt with using the MPM incision, thus its usage is primarily as a supplementary incision, in conjunction with the PL incision. Conclusion: We conclude that the most commonly used approach (the PL approach) gives the least amount of access to the posterior tibia. In comparison to fracture fragment size, almost half of fractures would not be adequately exposed through the PL approach, and if fixing such fractures the surgeon should be comfortable with multiple approaches.

CT Analysis of the Posteromedial Fragment of the Posterior Malleolar Fracture

2019 ◽  
Vol 40 (6) ◽  
pp. 648-655 ◽  
Author(s):  
Amir Reza Vosoughi ◽  
Malwattage Lara Tania Jayatilaka ◽  
Benjamin Fischer ◽  
Andrew P. Molloy ◽  
Lyndon W. Mason
Keyword(s):  
Computed Tomography ◽  
Surgical Planning ◽  
Injury Pattern ◽  
Computed Tomography Scan ◽  
Malleolar Fracture ◽  
Level Of Evidence ◽  
Posterior Malleolar Fracture ◽  
Posterior Malleolus ◽  
Ct Analysis ◽  
Tomography Scan

Background: To date, there have been no studies describing the characteristics of posteromedial fragment in the posterior malleolus fracture. The aim was to investigate the variability of posteromedial fracture fragments to enable better surgical planning. Methods: All Mason and Molloy type 2B fractures, defined as fracture of both the posterolateral and the posteromedial fragments of the posterior malleolus, from our database were identified to analyze the preoperative computed tomography scan. The posteromedial fragment was investigated in 47 cases (mean age, 46.6 years; 11 male, 36 female). Results: Morphologically, the fracture could be divided into 2 subtypes: (1) a large pilon intra-articular fragment (mean of X axis: 33.0 mm, Y: 30.7 mm, Z: 31.7 mm) presented in 29 cases with mean interfragmentary angle of 32.1 and back of tibia angle of 32.7 degrees (this was seen in 25 of 27 cases with supination injury pattern); and (2) a small extra-articular avulsion fragment (mean of X axis: 9.6 mm, Y: 13.2 mm, Z: 11.5 mm) present in 18 cases with a mean interfragmentary angle of 11.0 and back of tibia angle of 10.1 degrees. It was seen in 80% of pronation injuries. Conclusion: The avulsion type of the posteromedial fragment of posterior malleolus fracture was more common in pronation injuries, likely the result of traction by the intermalleolar ligament, and the pilon type was more common in supination injuries, likely the result of the rotating talus impaction. Because of the intra-articular involvement, we believe the pilon type should undergo fixation to achieve articular congruity, unlike the avulsion type which may only function as a secondary syndesmotic stabilizer. Level of Evidence: Level III, retrospective comparative series.

scholarly journals The Plantar Support of the Navicular-Cunieform Joint

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0033
Author(s):  
Lyndon Mason ◽  
Eric Swanton ◽  
Lauren Fisher ◽  
Andrew Fisher ◽  
Andrew Molloy
Keyword(s):  
Lower Limbs ◽  
Human Anatomy ◽  
Tibialis Posterior ◽  
Posterior Tibial Tendon ◽  
Medial Longitudinal Arch ◽  
Average Width ◽  
Posterior Tibial ◽  
Spring Ligament ◽  
Longitudinal Arch ◽  
Medial Cuneiform

Category: Midfoot/Forefoot Introduction/Purpose: Weight-bearing radiographic analysis of pes planus deformities shows, with varying degree of severity, a break in Meary’s line, uncovering of the talar head and an increase in talar-first metatarsal angle. Work by Alsousou (BOFAS 2016) has shown the break in Meary’s line to occur not only at the talonavicular joint (2/3rds of cases) but also at the navicular-cuneiform joint (1/3 rd of cases), distal to the spring ligament and reported posterior tibial tendon insertion. There are currently no anatomical studies analysing the medial longitudinal arch distal to the spring ligament insertion. We aimed to examine this area and assess the anatomy supporting the distal medial longitudinal arch. Methods: We examined 11 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 plantar aspect of the medial longitudinal arch Results: In all specimens, the posterior tibial tendon inserted into the plantar medial aspect of the navicular with separate slips to the intermediate and lateral cuneiform. Following insertion, on the navicular, a tendon-like structure extended from this navicular insertion point to the medial cuneiform. This tendon-like structure is statically inserted between the navicular and medial cuneiform allowing the pull of tibialis posterior to act on the navicular and medial cuneiform in tandem. The average width of this ligament (15.2 mm) is much greater than that of the tibialis posterior tendon (9.5 mm). A separate smaller plantar ligament is also present between the navicular and medial cuneiform. Conclusion: The posterior tibialis tendon inserts into the navicular, and what is likely an anthropological remnant, extends onto the medial cuneiform as the navicular cuneiform ligament. This provides a static restraint between two bony insertions and increases the lever arm of the posterior tibial tendon. The major support of the distal aspect of the medial longitudinal arch (i.e. the navicular-cuneiform joint) is provided by the substantial navicular cuneiform ligament.

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

2020 ◽  
Vol 41 (10) ◽  
pp. 1234-1239 ◽  
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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