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Archives of Orthopaedic and Trauma Surgery

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Open Access 01-03-2019 | Trauma Surgery

Persistent postoperative step-off of the posterior malleolus leads to higher incidence of post-traumatic osteoarthritis in trimalleolar fractures

Authors: Samuel Marinus Verhage, Pieta Krijnen, Inger Birgitta Schipper, Jochem Maarten Hoogendoorn

Published in: Archives of Orthopaedic and Trauma Surgery | Issue 3/2019

Abstract

Background

Traditionally, size of the posterior fragment is considered the most important indicator for fixation in trimalleolar fractures. It remains unclear which factors contribute to worse functional and radiological outcome. This study was designed to determine predictors for the development of posttraumatic osteoarthritis and worse functional outcome in trimalleolar fractures.

Methods

This retrospective cohort study evaluated outcomes of 169 patients with a trimalleolar fracture treated between 1996 and 2013 in a level-1 trauma hospital in the Netherlands after a mean follow-up of 6.3 (range 2.4 to 15.9) years. The average fragment size was 17%. Twenty patients had a posterior fragment smaller than 5% of the intra-articular surface, 119 patients a fragment of 5–25% and 30 patients a posterior fragment larger than 25%. In total, 39 patients (23%) underwent fixation of the posterior fragment.

Results

Clinical union was achieved in all 169 patients. The median AOFAS score after follow-up was 93 (interquartile range 76–100) and the median AAOS score was 92 (interquartile range 81–98). A persistent postoperative step-off larger than 1 mm was found in 65 patients (39%) and osteoarthritis was present in 49 patients (30%). Higher age and postoperative step-off > 1 mm were independent, significant risk factors for the development of osteoarthritis. Osteoarthritis and BMI were independent, significant risk factors for worse functional outcome.

Conclusion

It is advisable to correct intra-articular step-off of intraarticular posterior malleolar fragments to reduce the risk of developing osteoarthritis and, consequently, the risk of worse functional outcome after long-term follow-up.

Level of evidence

Level IIB.

De Vries JS, Wijgman AJ, Sierevelt IN, Schaap GR (2005) Longterm results of ankle fractures with a posterior malleolar fragment. J Foot Ankle Surg 44(3):211–217CrossRefPubMed

Broos PL, Bisschop AP (1991) Operative treatment of ankle fractures in adults: correlation between types of fracture and final results. Injury 22(5):403–406CrossRefPubMed

McDaniel WJ, Wilson FC (1977) Trimalleolar fractures of the ankle. An end result study. Clin Orthop Relat Res 122:37–45

Lindsjo U (1985) Operative treatment of ankle fracture-dislocations. A follow-up study of 306/321 consecutive cases. Clin Orthop Relat Res 199:28–38

Fitzpatrick DC, Otto JK, McKinley TO, Marsh JL, Brown TD (2004) Kinematic and contact stress analysis of posterior malleolus fractures of the ankle. J Orthop Trauma 18(5):271–278CrossRefPubMed

Hartford JM, Gorczyca JT, McNamara JL, Mayor MB (1995) Tibiotalar contact area. Contribution of posterior malleolus and deltoid ligament. Clin Orthop Relat Res 320:182–187

Jaskulka RA, Ittner G, Schedl R (1989) Fractures of the posterior tibial margin: their role in the prognosis of malleolar fractures. J Trauma 29(11):1565–1570CrossRefPubMed

Langenhuijsen JF, Heetveld MJ, Ultee JM, Steller EP, Butzelaar RM (2002) Results of ankle fractures with involvement of the posterior tibial margin. J Trauma 53(1):55–60CrossRefPubMed

Macko VW, Matthews LS, Zwirkoski P, Goldstein SA (1991) The joint-contact area of the ankle. The contribution of the posterior malleolus. J Bone Joint Surg Am 73(3):347–351CrossRefPubMed

10.

Vrahas M, Fu F, Veenis B (1994) Intraarticular contact stresses with simulated ankle malunions. J Orthop Trauma 8(2):159–166CrossRefPubMed

11.

Drijfhout van Hooff CC, Verhage SM, Hoogendoorn JM (2015 Jun) Influence of fragment size and postoperative joint congruency on long-term outcome of posterior malleolar fractures. Foot Ankle Int 36(6):673–678CrossRef

12.

Shi H, Xiong J, Chen Y et al (2017) Comparison of the direct and indirect reduction techniques during the surgical management of posterior malleolar fractures. BMC Musculoskelet Disord 14(1):109 18(CrossRef

13.

Xu HL, Li X, Zhang DY et al (2012) A retrospective study of posterior malleolus fractures. Int Orthop 36(9):1929–1936CrossRefPubMedPubMedCentral

14.

Bartonicek J, Rammelt S, Kostlivy K, Vanecek V, Klika D, Tresi I (2015) Anatomy and classification of the posterior tibial fragment in ankle fractures. Arch Orthop Trauma Surg 135(4):505–516CrossRefPubMed

15.

Haraguchi N, Harayuma H, Toga H, Kato F (2006) Pathoanatomy of posterior malleolar fractures of the ankle. J Bone Joint Surg Am 88(5):1085–1092CrossRefPubMed

16.

Mason LW, Marlow WJ, Widnall J, Molloy AP (2017) Pathoanatomy and associated injuries of posterior malleolus fracture of the ankle. Foot Ankle Int 38(11):1229–1235CrossRefPubMed

17.

Huber M, Stutz PM, Gerber C (1996) Open reduction and internal fixation of the posterior malleolus with a posterior antiglide using a posterolateral approach, a preliminary report. Foot Ankle Surg 2(2):95–103CrossRef

18.

O’Connor TJ, Mueller B, Ly TV et al (2015) “A to P” screw versus posterolateral plate for posterior malleolus fixation in trimalleolar fractures. J Orthop Trauma 29(4):151–156CrossRef

19.

Domsic ST (1998) Ankle osteoarthritis scale. Foot Ankle Int 19:466–471CrossRefPubMed

20.

Johanson NA, Liang MH, Daltroy L, Rudicel S, Richmond J (2004) American academy of orthopaedic surgeons lower limb outcomes assessment instruments. Reliability, validity, and sensitivity to change. J Bone Joint Surg Am 86-A(5):902–909CrossRef

21.

Kitaoka HB, Alexander IJ, Adelaar RS et al (1994) Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int 15(7):349–353CrossRef

22.

Mangnus L, Meijer DT, Stufkens SA, Mellema JJ, Steller EP, Kerkhoffs GM, Doornberg JN (2015) Posterior malleolar fracture patterns. J Orthop Trauma 29(9):428–435CrossRefPubMed

23.

Meijer DT, Doornberg JN, Sierevelt IN, Mallee WH, van Dijk CN, Kerkhoffs GM, Stufkens SA (2015) Ankle platform study collaborative—science of variation group. Guesstimation of posterior malleolar fractures on lateral plain radiographs. Injury 46(10):2024–2029CrossRefPubMed

24.

Verhage SM, Boot F, Schipper IB et al (2016) Open reduction and internal fixation of posterior malleolar fractures using the posterolateral approach. Bone Joint J. 2016 98-B(6):812–817

25.

Hoogendoorn JM (2017) Posterior Malleolar open reduction and internal fixation through a posterolateral approach for trimalleolar fractures. JBJS Essent Surg Tech 7(4):e31CrossRefPubMedPubMedCentral

26.

Berkes MB, Little MT, Lazaro LE, Pardee NC, Schottel PC, Helfet DL, Lorich DG (2013) Articular congruity is associated with short-term clinical outcomes of operatively treated SER IV ankle fractures. J Bone Joint Surg Am ;95(19):1769–1775CrossRefPubMed

27.

Mingo-Robinet J, Lopez-Duran L, Galeote JE, MartinezCervell C (2011) Ankle fractures with posterior malleolar fragment: management and results. J Foot Ankle Surg 50(2):141–145CrossRefPubMed

28.

Tejwani NC, Pahk B, Egol KA (2010) Effect of posterior malleolus fracture on outcome after unstable ankle fracture. J Trauma 69:666–669CrossRefPubMed

29.

Ferries JS, DeCoster TA, Firoozbakhsh KK, Garcia JF, Miller RA (1994) Plain radiographic interpretation in trimalleolar ankle fractures poorly assesses posterior fragment size. J Orthop Trauma 8(4):328–331CrossRefPubMed

30.

Verhage SM, Rhemrev SJ, Keizer SB, Quarles van Ufford HM, Hoogendoorn JM (2015) Interobserver variation in classification of malleolar fractures. Skeletal Radiol 44(10):1435–1439CrossRefPubMed

31.

Bartonicek J, Rammelt S, Tucek M (2017) Posterior malleolar fractures: changing concepts and recent developments. Foot Ankle Clin 22(1):125–145CrossRefPubMed

32.

Solan MC, Sakkelariou A (2017) Posterior malleolus fractures: worth fixing. Bone Joint J 99-B(11):1413–1419

33.

Papachristou G, Efstathopoulos N, Levidiotis C, Chronopoulos E (2003) Early weight bearing after posterior malleolar fractures: an experimental and prospective clinical study. J Foot Ankle Surg 42(2):99–104CrossRefPubMed

34.

Verhage SM, van der Zwaal P, Bronkhorst M, van der Meulen H, Kleinveld S, Meylaerts S, Rhemrev S, Krijnen P, Schipper I, Hoogendoorn J (2017) Medium-sized posterior fragments in AO Weber-B fractures, does open reduction and internal fixation improve outcome? The POSTIX-trial protocol, a multicenter randomized clinical trial. BMC Musculoskel Disord 18(1):94CrossRef

Title: Persistent postoperative step-off of the posterior malleolus leads to higher incidence of post-traumatic osteoarthritis in trimalleolar fractures
Authors: Samuel Marinus Verhage
Pieta Krijnen
Inger Birgitta Schipper
Jochem Maarten Hoogendoorn
Publication date: 01-03-2019
Publisher: Springer Berlin Heidelberg
Published in: Archives of Orthopaedic and Trauma Surgery / Issue 3/2019
Print ISSN: 0936-8051
Electronic ISSN: 1434-3916
DOI: https://doi.org/10.1007/s00402-018-3056-0

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Persistent postoperative step-off of the posterior malleolus leads to higher incidence of post-traumatic osteoarthritis in trimalleolar fractures

Abstract

Background

Methods

Results

Conclusion

Level of evidence

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

Level of evidence

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