Comparison of the direct and indirect reduction techniques during the surgical management of posterior malleolar fractures

Abstract

BackgroundThe optimal method for the reduction and fixation of posterior malleolar fracture (PMF) remains inconclusive. Currently, both of the indirect and direct reduction techniques are widely used. We aimed to compare the reduction quality and clinical outcome of posterior malleolar fracture managed with the direct reduction technique through posterolateral approach or the indirect reduction technique using ligamentotaxis.MethodsPatients with a PMF involving over 25% of the articular surface were recruited and assigned to the direct reduction (DR) group or the indirect reduction (IR) group. Following reduction and fixation of the fracture, the quality of fracture reduction was evaluated in post-operative CT images. Clinical and radiological follow-ups were performed at 6 weeks, 3 months, 6 months, 12 months, and then at 6 month-intervals postoperatively. Functional outcome (AOFAS score), ankle range of motion, and Visual Analog Scale (VAS) were evaluated at the last follow-up. Statistical differences were compared between the DR and IR groups considering the patient demographics, quality of fracture reduction, AOFAS score, and VAS.ResultsTotally 116 patients were included, wherein 64 cases were assigned to the DR group and 52 cases were assigned to the IR group. The quality of fracture reduction was significant higher in the DR group (P = 0.038). In the patients who completed a minimum of 12 months’ follow-up, a median AOFAS score of 87 was recorded in the DR group, which was significantly higher than that recorded in the IR group (a median score of 80). The ankle range of motion was slightly better in the DR group, with the mean dorsiflexion restriction recorded to be 5.2° and 6.1° in the DR and IR group respectively (P = 0.331). Similar VAS score was observed in the two groups (P = 0.419).ConclusionsThe direct reduction technique through a posterolateral approach provide better quality of fracture reduction and functional outcome in the management of PMF over 25% of articular surface, as compared with the indirect reduction technique using ligamentotaxis.Trial registration NCT02801474 (retrospectively registered, June 2016, ClinicalTrails.gov).

Comparison of the Efficacy of Posterior-Anterior Screws, Anterior-Posterior Screws and a Posterior-Anterior Plate in the Fixation of Posterior Malleolar Fractures with a Fragment Size of ≥15% and <15%

“…In recent years, more attention has been paid to the importance of anatomical reduction and internal fixation of PMF [23][24][25]. Anatomical reduction and fixation of posterior ankle fractures can be achieved under direct vision using a posterolateral approach, which is highly accepted [10,21,26,27]. In this study, we chose the posterolateral approach to reduce posterior ankle fractures under direct vision.…”

“…Therefore, to prevent poor function of the ankle joint and the occurrence of post-traumatic arthritis, more attention should be paid to PMF [9]. At present, the reduction of PMF directly through a posterior approach is the most effective technique [10]. Different fixation methods have been used to treat PMF, but the preferred fixation method remains controversial.…”

Numerical Simulation of the Posterior Malleolus Fracture with the Finite Element Method

“…These types of fractures classically include the Volkmann tubercle of the posteromedial tibial plafond [18,19]. Biomechanical studies suggest that the posterior malleolus serves as an important contributor to the stability of ankle joint, while the indication of surgical treatment remains controversial [20]. The decision about surgical treatment of the posterior malleolus is traditionally based on the amount of joint involvement and articular step-off.…”

“…The decision about surgical treatment of the posterior malleolus is traditionally based on the amount of joint involvement and articular step-off. Larger fragments involving >25% of the tibial plafond with >2 mm of articular step-off require surgical treatment in order to prevent joint instability and post-traumatic arthritis of the ankle joint [20].…”

Cómo sintetizar el maléolo posterior. ¿La mejor opción es la síntesis directa?

“…La síntesis del mismo puede realizarse de forma directa o indirecta. Vía indirecta (15)(16)(17) Se realiza de manera percutánea, en dirección AP y con el paciente en decúbito supino. La reducción del peroné favorece la reducción del MP a través de la inserción del LTFPI.…”