Clinical outcomes and trans-syndesmotic screw frequency after posterior malleolar fracture osteosynthesis

Ribeiro, Hugo; Silva, J.; Teixeira, Raquel; Fernandes, Pedro; Sobral, Larissa Lemos; Rosa, Isabel

doi:10.1016/j.injury.2020.10.021

Cited by 14 publications

(21 citation statements)

References 23 publications

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“…Furthermore, Verhage et al [2] showed that persistent intraarticular step-off of posterior malleolar fragment was a risk factor for development of osteoarthritis after a mean follow-up of 6 years. The importance of an anatomical reduction of the posterior malleolus in the clinical outcomes was also demonstrated in several other studies [17][18][19]. Moreover, the fixation of the posterior malleolus reduced the need for trans-syndesmotic screw [16,18].…”

Section: Discussionmentioning

confidence: 70%

“…The importance of an anatomical reduction of the posterior malleolus in the clinical outcomes was also demonstrated in several other studies [ 17 – 19 ]. Moreover, the fixation of the posterior malleolus reduced the need for trans-syndesmotic screw [ 16 , 18 ]. Thus, even if the fixation of posterior malleolar fragment was controverted in the past, it is now well recognized, regardless of the size of the fragment.…”

Section: Discussionmentioning

confidence: 99%

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Posterior to anterior malleolar extended lateral approach to the ankle (PAMELA): early results of a novel approach

Kummer

Crevoisier

2022

Arch Orthop Trauma Surg

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Introduction In a previous cadaveric study, we described the Posterior to Anterior Malleolar Extended Lateral Approach (PAMELA) to address complex ankle fractures. It was demonstrated to provide optimal exposure of the posterior and lateral malleoli, and of the anterolateral portion of the ankle through a single incision. The aim of this study is to report the clinical results of this novel approach. Methods Between January 2019 and January 2021, all patients presenting with a complex ankle fracture in our institution were assessed by CT scan. Indication to use the PAMELA was determined by the fracture pattern, according to our previous guidelines, including combination of complex lateral and displaced posterior malleolar fractures, associated in most cases with anterolateral fracture avulsion. The approach was performed according to the steps previously described. Intraoperative evaluation included quality of exposure, ease of performing the osteosynthesis, and any complication encountered. The postoperative course was assessed for wound healing, quality of reduction, and the occurrence of any complication. Results The PAMELA was performed in 20 patients (aged 17–73). The most common combination of fractures was a comminuted lateral malleolus fracture associated with a displaced fracture of the posterior malleolus and a Wagstaffe-Le Fort or Chaput avulsion. We encountered no intraoperative complication. X-rays showed anatomical reduction in all cases. Postoperative complications included three delayed wound healing resolved with local treatment and one sural nerve traction injury. Conclusions The main potential concern regarding this novel approach was the healing of the flap. Our results reject this concern and are in line with wound healing complications reported following surgical treatment of ankle fractures. This study confirms the safe in vivo feasibility of the PAMELA and opens a new perspective in the optimal management of complex fractures of the ankle. A larger prospective clinical study is ongoing in our institution.

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Section: Discussionmentioning

confidence: 70%

Section: Discussionmentioning

confidence: 99%

Posterior to anterior malleolar extended lateral approach to the ankle (PAMELA): early results of a novel approach

Kummer

Crevoisier

2022

Arch Orthop Trauma Surg

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“…Four studies, compromising of 5 groups, compared ORIF vs CRIF AP screws (0 randomized controlled trials, 1 prospective study, 3 retrospective studies). 17,22,34,35 Per the individual studies, 3 studies (4 groups) reported significantly better AOFAS scores for the ORIF group 17,34,35 and 1 retrospective study found no significant differences 22 (Figure 2): No study reported significantly better AOFAS scores for the CRIF AP screw group. Taken together in the quantitative analysis (Figure 2), 142 patients treated by ORIF and 108 treated by CRIF were included.…”

Section: Orif Vs Crifmentioning

confidence: 93%

“…Two studies assessed the American Academy of Orthopaedic Surgeons Foot and Ankle Questionnaire. 18,22 One of these reported significantly better results (P = .037) for ORIF compared to the untreated PM group, 18 and the second study found no significant differences (P = .35) comparing ORIF to CRIF. 22 Two studies assessed the health-related quality of life using the EQ-5D reporting.…”

Section: Other Promsmentioning

confidence: 95%

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Open Reduction and Internal Fixation of the Posterior Malleolus Fragment in Ankle Fractures Improves the Patient-Rated Outcome: A Systematic Review

et al. 2023

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Background: The best treatment strategy for fractures to the posterior malleolus (PM) is still intensively debated. The aim of this systematic review was to compare the patient-rated outcome following open reduction and internal fixation (ORIF) for fractures of the PM to either closed reduction using AP screws (CRIF) or no treatment in bi- or trimalleolar ankle fractures. Methods: Systematic literature research (MEDLINE (PubMed), CINAHL, Scopus, Central and EMBASE) according to the PICOS and PRISMA guidelines. Eligible were studies comparing the outcome following ORIF to any other treatment strategy for fractures to the posterior malleolus in isolated bi- or trimalleolar ankle fractures. Results: Twelve studies were eligible for a qualitative analysis and 6 for a quantitative analysis. Overall, a considerable heterogeneity among the studies was observed. The most commonly used outcome score was the American Orthopaedic Foot & Ankle Society ankle-hindfoot score (AOFAS). The final follow-up ranged from 12 to 160 months. Four studies compared ORIF to CRIF of the PM. The quantitative analysis revealed significantly better AOFAS scores for ORIF (90.9 vs 83.4 points; P < .001; I2 = 0%). Three studies compared ORIF to untreated PM fragment. The quantitative analysis again revealed superior AOFAS scores for ORIF (92.0 vs 82.5 points; P < .001; I2 = 99%). A similar trend was observed for the Ankle Fracture Scoring System and American Academy of Orthopaedic Surgeons Foot and Ankle Questionnaire scores as well as the quality of reduction. Conclusion: Despite a considerable heterogeneity, the data available point to a superior outcome following ORIF for fractures to the PM when compared to CRIF or no treatment.

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Evaluation of ankle fracture classification systems in 193 trimalleolar ankle fractures

Pflüger

Harder

Müller

et al. 2022

Eur J Trauma Emerg Surg

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Purpose Different classification systems have been developed for ankle fractures. In recent years, the posterior malleolus has gained in importance and led to computed tomography (CT)-based classification systems. The aim of the study was to analyse their reliability, fracture patterns and influence on treatment strategy. Methods Patients with a trimalleolar ankle fracture treated between 2011 and 2020 with preoperative radiographs and CT images were included. The blinded images were independently classified by three reviewers according to the AO/OTA, Herscovici, Bartoníček, Mason and Haraguchi classifications. The interobserver reliability was calculated by Fleiss' kappa (κ). CT images were analysed to determine the dimensions of the posterior malleolus fragments. Patient registries were reviewed regarding the treatment data. Results A total of 193 patients were included. The AO/OTA classification showed almost perfect inter- and intraobserver reliability (Fleiss’ κ = 0.86, 95% CI 0.82–0.90). Regarding the posterior malleolus, the Bartoníček classification demonstrated the highest reliability (Fleiss’ κ = 0.78, 95% CI 0.73–0.83). The Herscovici classification only reached moderate reliability for medial malleolus fractures (Fleiss' κ = 0.59, 95% CI 0.54–0.65). There was a trend towards direct fixation of the posterior malleolus in the last 3 years of the observation period (OR: 2.49, 95% CI 1.03–5.99). Conclusion In trimalleolar ankle fractures, the AO/OTA classification is a reliable system to characterize the type of fracture, but it fails to provide solid information about the posterior malleolus. Nowadays, treatment recommendations for trimalleolar ankle fractures focus on the configuration of the posterior malleolus; therefore, the results of this study advocate the use of the Bartoníček classification as a reliable tool to guide treatment.

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Clinical outcomes and trans-syndesmotic screw frequency after posterior malleolar fracture osteosynthesis

Cited by 14 publications

References 23 publications

Posterior to anterior malleolar extended lateral approach to the ankle (PAMELA): early results of a novel approach

Posterior to anterior malleolar extended lateral approach to the ankle (PAMELA): early results of a novel approach

Open Reduction and Internal Fixation of the Posterior Malleolus Fragment in Ankle Fractures Improves the Patient-Rated Outcome: A Systematic Review

Evaluation of ankle fracture classification systems in 193 trimalleolar ankle fractures

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