Fixation of anterolateral distal tibial fractures: the anterior malleolus

Rammelt, Stefan; Bartoníček, Jan; Schepers, Tim; Kroker, Livia

doi:10.1007/s00064-021-00703-0

Cited by 23 publications

(34 citation statements)

References 40 publications

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“…Another reason is the overlap of the contours of the AM and the distal fibula on anteroposterior and mortise radiographs. Therefore, a generous use of CT imaging is advised with unclear fracture patterns or when the presence of an AM fracture is suspected in order to make an appropriate treatment plan 21,23 , specifically with pronation fractures as these are associated with a high prevalence of AM and posterior malleolar fractures in general and tibial plafond impaction (type-3 AM) fractures in particular.…”

Section: Discussionmentioning

confidence: 99%

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Pathoanatomy of the Anterolateral Tibial Fragment in Ankle Fractures

Rammelt¹,

Bartoníček²,

Kroker³

2021

Journal of Bone and Joint Surgery

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Background: The anterior distal tibial tubercle provides attachment to the anterior tibiofibular syndesmosis. It may be considered a fourth, or anterior, malleolus (AM). Fractures of the AM may extend into the tibial incisura and tibial plafond. The purpose of this study was to analyze the pathoanatomy of AM fractures and associated ankle injuries.Methods: One hundred and forty patients (median age, 61.0 years) with a total of 140 acute malleolar fractures (OTA/AO 44) involving the anterolateral distal tibial rim were analyzed with computed tomography (CT) imaging. All components of the malleolar fractures were analyzed and classified. Fracture patterns were compared with those of all patients with malleolar fractures treated during the same 9-year period. Patients with fractures of the tibial pilon (OTA/AO 43) and patients <18 years of age were excluded.Results: Of the 140 AM fractures, 52.9% were classified as type 1 (extra-articular avulsion); 35.7%, type 2 (incisura and plafond involvement); and 11.4%, type 3 (impaction of the anterolateral plafond). The fibula was fractured in 87.1%; the medial malleolus, in 66.4%; and the posterior malleolus, in 68.6%. An isolated AM fracture was seen in 4.3%. The size of the AM fractures correlated negatively with that of the posterior malleolar fractures. The proportion of pronation-abduction fractures increased and the proportion of supination-external rotation fractures decreased as the type of AM fracture increased. A fracture involving the AM occurred in 12.6% of all ankle fractures and occurred significantly more frequently in pronation-type injuries and elderly patients. No supination-adduction fractures with AM involvement were seen. The intraclass correlation coefficient for the proposed classification of the AM fractures was 0.961 (95% confidence interval [CI] = 0.933 to 0.980) for interobserver agreement and 0.941 (95% CI = 0.867 to 0.974) for intraobserver agreement.Conclusions: Knowledge of the 3D pathoanatomy of AM fractures and associated malleolar fractures may help with surgical decision-making and planning. CT imaging should be employed generously in the diagnosis of complex ankle fractures, in particular with pronation-type injuries.Clinical Relevance: Depending on the individual 3D fracture pattern, fixation of displaced anterolateral distal tibial fragments potentially contributes to the restoration of joint congruity, tibiofibular alignment, and syndesmotic stability in complex malleolar fractures.Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G774).

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Section: Discussionmentioning

confidence: 99%

“…Fractures of the AM were classified into 3 distinct types (Fig. 2) 23 . Type 1 represents an extra-articular avulsion of the AITFL.…”

Section: Methodsmentioning

confidence: 99%

Pathoanatomy of the Anterolateral Tibial Fragment in Ankle Fractures

Rammelt¹,

Bartoníček²,

Kroker³

2021

Journal of Bone and Joint Surgery

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“…Avulsions or fractures of the CTT are typically reduced and fixed last, following tibiofibular stabilization 97 . However, they should be visualized before fibular reduction into the FN as fragments, particularly smaller ones, may displace into the tibiofibular clear space and prevent anatomic reduction 16,52,96 . The exact sequence of reduction may vary depending on the individual injury pattern as well as surgeon preference and experience.…”

Section: Surgical Techniquementioning

confidence: 99%

Maisonneuve Fractures of the Ankle

2022

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Maisonneuve fractures (MFs), originally described as subcapital (high) fibular fractures with additional injury to the anterior and interosseous tibiofibular ligaments, display a variable injury pattern, ranging from stable to highly unstable fractures.The high incidence of associated fractures of the posterior malleolus, the medial malleolus, and the anterolateral distal tibia (the “anterior malleolus”) as well as the variable position of the fibula in the fibular notch (FN) warrant preoperative examination via computed tomography (CT).The main goal of treatment is anatomic reduction of the distal fibula into the FN, which requires prior reduction of displaced posterior malleolar fractures, if present, to restore the integrity of the FN.Open reduction of the distal fibula into the FN and fixation with 2 transsyndesmotic screws or fixation with a screw(s) and suture-button implant, under direct vision, on the lateral aspect of the ankle joint and anterior tibiofibular alignment are preferred over closed reduction to avoid sagittal or rotational malpositioning, which is associated with an inferior outcome.Intra- or postoperative 3D CT visualization is essential for assessment of the accuracy of the reduction of the distal fibula into the FN.

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“…The suture technique can adjust the direction of the suture by controlling the direction of the bone tunnel and the outlet position of the bone tunnel joint above the epiphyseal line, which helps to enhance the accuracy and stability of the reduction, and ensures the firm fixation of the bone block. And it can adjust the tension of the ligament twice to reduce the occurrence of surgical complications[ 16 , 17 ]. Some scholars reported that in the fixation of anterior cruciate ligament fractures, the second band-line anchor was first fixed on both sides of the central slightly deviated back of the tibial bone bed by suture technique, and the outer row of one anchor was fixed to the anterior and lateral sides of the bone bed.…”

Section: Discussionmentioning

confidence: 99%

Therapeutic effect of two methods on avulsion fracture of tibial insertion of anterior cruciate ligament

Niu¹,

Wang²,

Sun³

2022

WJCC

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BACKGROUND The tibial stop of anterior cruciate ligament (ACL) is fan-shaped and attached to the medial groove in front of the intercondylar spine, which is located between the anterior horn of the medial and lateral meniscus. The incidence of this fracture is low previously reported, which is common in children and adolescents. With the increase of sports injury and traffic injury and the deepening of under-standing, it is found that the incidence of the disease is high at present. AIM To explore the difference between open reduction and internal fixation with small incision and high-intensity non-absorbable suture under arthroscopy in the treatment of tibial avulsion fracture of ACL. METHODS Seventy-six patients with tibial avulsion fracture of anterior cruciate ligament diagnosed and treated in Guanyun County People's Hospital from April 2018 to June 2020 were retrospectively analyzed. According to the surgical methods, they were divided into group A (40 cases) and group B (36 cases). Patients in group A were treated with arthroscopic high-strength non-absorbable suture, and patients in group B were treated with small incision open reduction and internal fixation. The operation time, fracture healing time, knee joint activity and functional score before and after operation, and surgical complications of the two groups were compared. RESULTS The operation time of group A was higher than that of group B, and the difference was statistically significant ( P < 0.05); the fracture healing time of group A was compared with that of group B, and the difference was not statistically significant ( P > 0.05); The knee joint function activity was compared between two groups before operation, 3 mo and 6 mo after operation, and the difference was not statistically significant ( P > 0.05); the knee joint function activity of group A and group B at 3 mo and 6 mo after operation was significantly higher than that before operation ( P < 0.05); the limp, support, lock, instability, swelling, upstairs, squatting, pain and Lysholm score were compared between the two groups before and 6 mo after operation, and the difference was not statistically significant ( P > 0.05); the scores of limp, support, lock, instability, swelling, upstairs, squatting, pain and Lysholm in group A and group B at 6 mo after operation were significantly higher than those before operation ( P > 0.05); the surgical complication rate of group A was 2.63%, which was lower than 18.42% of group B, and the difference was statistically significant ( P > 0.05). CONCLUSION Both small incision open reduction and internal fixation and arthroscopic high-strength non-absorbable sutures can achieve good results in the treatment of anterior cruciate ligam...

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Fixation of anterolateral distal tibial fractures: the anterior malleolus

Cited by 23 publications

References 40 publications

Pathoanatomy of the Anterolateral Tibial Fragment in Ankle Fractures

Pathoanatomy of the Anterolateral Tibial Fragment in Ankle Fractures

Maisonneuve Fractures of the Ankle

Therapeutic effect of two methods on avulsion fracture of tibial insertion of anterior cruciate ligament

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