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

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.

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

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.

A Modified Posterolateral Approach for the Treatment of Posterior Malleolar Fracture

Background: To observe the clinical effect of a modified posterolateral approach internal fixation in the treatment of posterior malleolar fracture. Method: From January 2015 to October 2018, 30 cases involving lateral and posterior malleolar fracture patient data were treated in our department. we observed operation time, fracture healing time and postoperative complications. At the time of the last follow-up, we evaluated ankle joint function by the American Orthopedic Foot Ankle Society (AOFAS) ankle- hindfoot scale, the Short Form-36 (SF-36) outcome Tools and the American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle Questionnaire. Result: In this group of 30 patients, the operation time of the patients was 80-120min (median 90min). The 25 patients were followed up for more than 1 year. 3 ~ 5 months after the operation, all the patients had bony healing. 3 cases with superficial wound infection. No other complication was found. The mean AOFAS scores at the postoperative 6-month, 12-month, and final follow-up were 78.4 (range, 72–90), 89.4 (range, 80–96), and 90.8 (range, 84–96), respectively. The mean SF-36 scores at the postoperative 12-month and final follow-up were 82.4 (range, 77.6–90.6) and 84.6 (range, 77.8–92.6), the mean AAOS scores at the postoperative 12-month and final follow-up were87.8 (range, 79–95), 90.6 (range, 82–96). Conclusion: Modified posterolateral approach avoided stripping the muscular origins of flexor hallucis longus, reduced the adhesion, and can fix the lateral and posterior malleolar fracture in the same incision, is worth popularizing in clinical.

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

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.