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

Abstract

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.

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

“…Nine cases with a depressed articular surface in a posterior malleolar fracture were associated with supination-external rotation fracture and two were associated with pronation-external rotation fracture, according to the Lauge-Hansen classification system. 3,15 On preoperative CT scans, the depressed articular fragment was associated with type I posterior malleolar fracture (posterolateral-oblique fracture) in six cases and with type II posterior malleolar fracture (medialextension fracture) in five cases, according to the classification of Haraguchi. 16 Six cases were approached through the lateral malleolar fracture.…”

“…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.…”

Insights into optimal surgical fixation for posterior malleolar fractures

“…The trials involved P-A screw fixation (11 trials), 2,[8][9][10][11][12][15][16][17]29,30 A-P screw fixation (six trials), 2,[11][12][13][14]29 and plate fixation (11 trials). 2,[8][9][10][12][13][14][15][16][17]30 Four studies analyzed trimalleolar fractures, 2,11,13,29 while the remaining nine included a combination of various fracture patterns, [8][9][10]12,[14][15][16][17]30 such as trimalleolar fractures, concurrent posterior and lateral malleolar fractures, and/or isolated posterior malleolar fractures. Concerning the fractured posterior malleolus size, six studies included cases with PM ≥ 25%, [8][9][10]16,29,30 one study addressed PM ≥ 20%, 15 and the...…”

“…However, the indirect reduction manoeuvres may impede complete anatomical reduction because the fracture fragments are not directly observable during the reduction process. 2,[11][12][13][14] In contrast, P-A screws facilitate direct anatomical reduction through a posterolateral incision and manipulation of minute fragments. 2,15 However, the technique necessitates additional soft-tissue release, and the extent to which it yields superior clinical outcomes compared to A-P screws remains inconclusive.…”

“…Presently, three principal methods are employed for the fixation of PMFs, encompassing anteroposterior (A-P) screws, posteroanterior (P-A) screws, and plate fixation. [8][9][10][11][12] A-P screws are deemed less invasive due to the reduced extent of soft-tissue dissection required. However, the indirect reduction manoeuvres may impede complete anatomical reduction because the fracture fragments are not directly observable during the reduction process.…”