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

Hong-Fei Shi, Jin Xiong, Yi-Xin Chen, Jun-Fei Wang, Xu-Sheng Qiu, Jie Huang, Xue-Yang Gui, Si-Yuan Wen, Yin-He Wang, Hong-Fei Shi, Jin Xiong, Yi-Xin Chen, Jun-Fei Wang, Xu-Sheng Qiu, Jie Huang, Xue-Yang Gui, Si-Yuan Wen, Yin-He Wang

Abstract

Background: The 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.

Methods: Patients 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.

Results: Totally 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).

Conclusions: The 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).

Keywords: Buttress plate; Ligamentotaxis; Posterior malleolar fracture; Posterolateral approach.

Figures

Fig. 1
Fig. 1
For the patient presented in Fig. 4, a distal radius plate was applied spanning the fracture in a buttress mode to fix the PMF. The postoperative sagittal reconstruction of CT images confirmed an excellent (anatomical) reduction of the posterior fragment
Fig. 2
Fig. 2
For the patient presented in Fig. 4, the AOFAS score was 94 at the last follow-up (24 months postoperatively). Satisfied ankle range of motion were achieved
Fig. 3
Fig. 3
For the patient presented in Fig. 5, the AOFAS score was 88 at the last follow-up (12 months postoperatively). Satisfied ankle range of motion were achieved
Fig. 4
Fig. 4
The 56-year-old female patient treated using direct reduction technique. Preoperative AP and lateral radiograph showed a pilon-type PMF. Preoperative 3D and sagittal reconstruction of CT images provided more precise determination of the morphology and size of the posterior fragments
Fig. 5
Fig. 5
The 55-year-old male patient treated using indirect reduction technique. Preoperative radiographs and CT images showed a displaced PMF
Fig. 6
Fig. 6
For the patient presented in Fig. 5, the PMF was reduced using ligamentotaxis following ORIF of lateral and medial malleoli. Percutaneous screw fixation of PMF was achieved through a stab incision. The postoperative sagittal reconstruction of CT images provided more precise determination of residual articular step-off of the posterior malleolus which could be easily ignored in radiographs

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