Traditional Approach vs Posterior Approach for Ankle Fractures Involving the Posterior Malleolus

Kristian Pilskog, Teresa Brnic Gote, Heid Elin Johannessen Odland, Knut Andreas Fjeldsgaard, Håvard Dale, Eivind Inderhaug, Jonas Meling Fevang, Kristian Pilskog, Teresa Brnic Gote, Heid Elin Johannessen Odland, Knut Andreas Fjeldsgaard, Håvard Dale, Eivind Inderhaug, Jonas Meling Fevang

Abstract

Background: In the past, posterior malleolus fragments (PMFs) commonly have been indirectly reduced and fixed when fragments involve 25% or more of the tibial articular surface, while smaller fragments were left unfixed. The posterior approach has become increasingly popular and allows fixation of even smaller fragments. This study compares clinical outcome for the 2 treatment strategies.

Methods: Patients with ankle fractures involving a PMF treated from 2014 to 2016 were eligible for inclusion. Patients were allocated to group A (treated with a posterior approach) or group B (treated with the traditional approach) according to the treatment given. A one-to-one matching of patients from each group based on the size of the PMF was performed. Patient charts were reviewed, and outcome evaluation was performed clinically, radiographically, and by patient-reported outcome measures (PROMs; Self-Reported Foot and Ankle Score, RAND-36, visual analog scale [VAS] of pain, and VAS of satisfaction). Forty-three patients from each group were matched. Median follow-up was 26 (interquartile range [IQR], 19-35) months postoperatively.

Results: The median PMF size was 17% (IQR, 12-24) in both groups, and they reported similar results in terms of PROMs. Fixation of the PMF was performed in 42 of 43 (98%) patients in group A and 7 of 43 (16%) patients in group B (P < .001). The former group more frequently got temporary external fixation (56% vs 12%, P < .01) and less frequently had syndesmotic fixation (14% vs 49%, P < .01), and they had less mechanical irritation and hardware removal but more noninfectious skin problems (28% vs 5%, P < .01). Median time from injury to definitive surgery (8 vs 0 days, P < .001) and median length of stay (12 vs 3 days, P < .001) were longer in group A.

Conclusion: Comparison of treatment strategies for ankle fractures involving the posterior malleolus showed similar results between patients treated with a traditional approach and a posterior approach.

Level of evidence: Level III, retrospective comparative study.

Keywords: PROM; SEFAS; ankle fracture; fixation; operative; outcome; posterior malleolus; posterolateral.

Conflict of interest statement

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. ICMJE forms for all authors are available online.

Figures

Figure 1.
Figure 1.
Search results, exclusion criteria, and inclusion criteria. In total, 130 patients met for a follow-up visit. To compare patients who received the traditional treatment (group B, n = 76 patients) to those operated through a posterior approach (group A, n = 54 patients), we matched patients one by one from each group according to the size of the posterior malleolus fragment. This rendered 86 patients, 43 in each group, for analysis. Due to too large discrepancies in the size of the posterior malleolus fragments (PMFs), 11 patients from group A and 33 patients from group B could not be matched.
Figure 2.
Figure 2.
The size of the posterior malleolus fracture was measured as percentage joint involvement (B) of the anteroposterior length of the distal tibial articular surface (A + B) on lateral radiographs of the ankles ((B/(A + B)) *100 = % size of the distal tibial articulate surface).
Figure 3.
Figure 3.
The Kellgren-Lawrence classification of grading of osteoarthritis.
Figure 4.
Figure 4.
Boxplot (upper half) and density plot (lower half) showing the distribution of the Self-Reported Foot and Ankle Score (SEFAS, score from 0-48) in the 2 groups. n = 43 patients in each group. Each point in the boxplot graph represents a patient. The points are scattered for better visualization of the variation among the patients.

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