Fragment-specific fixation of trimalleolar fractures utilizing the posterolateral approach: A preliminary experience

Abstract

Introduction: Ankle fractures involving posterior malleolus are disabling injuries if not managed properly. Clinical and functional outcome of ankle fractures involving posterior tibial plafond is significantly worse. Although the surgical approach and techniques to reduce and fix this fracture are well described in the literature, there still seems to be divided consensus among orthopedic surgeons regarding the same. Methods: In this case series of eight patients with trimalleolar fractures, a posterolateral approach was used for fixation of posterior malleolus in all the cases. A preoperative computed tomography scan formed an integral part of management of such injuries. The Olerud and Molendar scoring system was employed at 12 months of follow-up to assess the functional outcome. Weight-bearing X-rays were taken to assess for any ankle arthritis. Results: The average age of patients was 48.8 years. The most common mode of sustaining injury was twisting of the ankle joint (n ¼ 5). The average time to union and full weight-bearing was 12.8 weeks (range 10-16 weeks). An excellent functional outcome in four patients and a good outcome in the rest of the four patients were obtained at the end of 12 months of follow-up. No significant ankle arthritis or complications were encountered. Conclusion: Appropriate preoperative imaging evaluation is an integral part of planning for these complex injuries. The posterolateral approach provides good exposure for appropriate visualization. Stable fixation of posterior malleolus in trimalleolar fractures plays a vital role in obtaining a positive clinical and functional outcome.

Use of an aiming drill guide and ankle arthroscopy for reduction of depressed articular surface in posterior malleolar fractures

“…[16][17][18][19][20][21] However, the posterior malleolar fracture is sometimes associated with a depressed articular fragment between the posterior tibia and the fractured posterior malleolus, which is difficult to approach and reduce. 2,[4][5][6] Accurate intraoperative evaluation of the joint surface using fluoroscopic radiographs may sometimes be limited because of the overlap between the posterior malleolus and the lateral malleolus on lateral radiographs. 16,22,23 The use of intraoperative cone-beam CT can significantly improve intraoperative assessment of the fractured fragment and joint surface.…”

“…Posterior malleolar fractures involving the weight-bearing articular surface can be associated with depressed articular fragments between the posterior tibia and the fractured posterior malleolus, which are sometimes difficult to approach and reduce unless the fractured posterior malleolus is opened (Figure 1). [1][2][3][4][5][6] When the large osteochondral fragment is not reduced, it may block anatomic reduction and prevent the restoration of normal joint relationship and stability. 6 Weber 6 described a method to reduce osteochondral fragments that are proximally dislocated and impacted between the posterior tibia and the fractured posterior malleolus.…”

Fractura trimaleolar

“…Assal y colaboradores compararon el porcentaje de exposición del extremo distal y posterior de la tibia utilizando tres técnicas quirúrgicas distintas; con el abordaje posterolateral se logró visualizar 40% de superficie, mientras que, con los abordajes posteromedial y posteromedial modificado, se obtuvo 64% y 91% respectivamente (17). Pese a lo anterior, la selección de la técnica quirúrgica va a depender del tamaño, la localización y orientación del fragmento posterior (18). Zhong y colaboradores realizaron un estudio para comparar la efectividad del abordaje posteromedial y el posterolateral, obteniéndose como resultado que ambas técnicas tienen resultados clínicos y radiográficos similares (19).…”

“…Deben mantenerse por seis semanas sin apoyar la extremidad afectada, además, de seguir un protocolo de ejercicios para la movilidad del tobillo. Idealmente, se debe asignar una cita de seguimiento a las 6 semanas postoperatorias, con radiografías control; en ese momento se puede considerar comenzar el apoyo de la extremidad con equipo de apoyo (18,25). Cuando se observa una consolidación clínica y radiológica se puede apoyar la extremidad con libertad, dicha consolidación ocurre en 12-16 semanas en promedio, según las observaciones realizadas por Gawali y colaboradores (34).…”

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

“…8 Generally, Haraguchi type 1 posterior malleolar fracture can be fixed either with percutaneous anteroposterior screws or through a posterolateral approach using screws and/or a buttress plate. [9][10][11] Anterior indirect reduction relies upon ligamentotaxis for the reduction 12 but fixation with percutaneous anterior to posterior screws may lack fixation strength. 13 However, direct reduction of the fracture through a posterolateral approach requires more extensive exposure and may require a position change during the operation.…”