A retrospective study on manual reduction combined with Chinese Orthopaedic ankle external fixator in the treatment of trimalleolar fracture / 中国骨伤

OBJECTIVE@#To evaluate the needle puncture safety and clinical efficacy of manual reduction combined with external fixation of ankle frame in the treatment of trimalleolar fracture under the guidance of Chinese Osteosynthesis (CO) theory.@*METHODS@#The clinical data of 118 patients with trimalleolar fractures admitted from December 2010 to December 2021 were retrospectively analyzed. Fifty-three patients were treated with manual reduction combined with external fixation of ankle frame(observation group). Sixty-five patients were treated with open reduction and internal fixation with plate and screws(control group). The operation time, hospitalization days, non-weight-bearing time of the affected limb, clinical healing time of fracture, incidence of complications, visual analogue scale (VAS) before and 1 month after operation, and American Orthopedic Foot and Ankle Society(AOFAS) score of ankle joint before and 1 year after operation were compared between the two groups.@*RESULTS@#Patients in both groups were followed up for more than 1 year. All patients were followed up, and the duration ranged from 14 to 70 months, with an average of(35.28±14.66) months. There were statistically significant in operation time, hospitalization days, non-load-bearing time of affected limbs, clinical healing time of fractures and VAS score one month after operation between the two groups. One month after operation, the VAS score of the observation group was lower than that of the control group(t=3.343, P=0.001). The operation time of the observation group was significantly shorter than that of the control group(t=9.091, P=0.000). The hospitalization days in the observation group were significantly less than those in the control group(t=5.034, P=0.000). The non-load-bearing time of the affected limb in the observation group was significantly shorter than that in the control group(t=11.960, P=0.000). The clinical healing time of fracture in the observation group was significantly shorter than that in the control group(t=4.007, P=0.000). There was no significant difference in AOFAS score between the two groups one year after operation(t=0.417, P=0.678). In the observation group, there were 2 cases of pinhole infection and 3 cases of loss of reduction less than 2 mm. There were 3 cases of surgical incision infection in the control group. There was no significant difference in the incidence of complications between the two groups(χ2=0.446, P=0.504).@*CONCLUSION@#Manual reduction combined with external fixation is safe and effective in the treatment of trimalleolar fracture under the guidance of CO theory, and the function of ankle joint recovers well after operation. This therapy has good clinical value.

Plantar Pressure Features under Different Walking Conditions in Patients after Trimalleolar Fracture Surgery / 医用生物力学

Objective To analyze plantar pressure features of patients in injured and healthy sides of the lower limbs under different walking conditions after the trimalleolar fracture surgery, and compare these characteristics with healthy subjects. Methods Twelve Trimalleolar fracture patients and twenty-three healthy subjects were recruited and their plantar pressure characteristics under different walking conditions were tested, including peak pressure, contact area and contact time percentage. Results Comparison between injured and healthy sides: during level walking, peak pressure of the 3rd-5th toe in the injured feet were smaller than those in the healthy sides; in inversion position, peak pressure and contact area of the 3rd-5th toe area in the injured feet were smaller than those in the healthy side; in eversion position, peak pressure, contact area and contact time of the 3rd-5th toe in the injured feet were smaller than those in the healthy sides, and peak pressures of the hindfoot area were larger than those in the healthy sides. Comparison between patients and healthy subjects: under three kinds of walking conditions, peak pressures of the 2nd and 3rd metatarsus bones, the 2nd toe, the 3rd-5th toe, contact area of the 1st-5th toe and contact time percentage of the 2nd toe, the 3rd-5th toe area were all smaller than those of healthy subjects, while contact time of the hindfoot and mid-foot area were all smaller than those of healthy subjects. Conclusions The plantar pressure characteristics of Trimalleolar fracture patients were asymmetrical. Compared with healthy subjects, the plantar pressure features of patients were abnormal during stance phase. Compared with healthy subjects, the motor control ability and stability of patients in eversion positions were decreased. The plantar pressure characteristics at ankle eversion can be used to evaluate ankle joint function.

Outcomes of Immediate Operative Treatment of Ankle Trimalleolar Open Fractures / 대한족부족관절학회지

PURPOSE: Generally, the treatment of ankle trimalleolar open fractures is divided into two stages: external fixation and debridement; and secondary internal fixation. On the other hand, this two-stage operation takes considerable treatment time and is challenging in procedures requiring reduction. The purpose of this study was to evaluate the radiologic and clinical results of an immediate one-stage internal fixation operation considering the wound conditions to overcome two stage operation disadvantages.MATERIALS AND METHODS: From September 2009 to January 2018, 24 cases of ankle trimalleolar open fractures, who underwent immediate internal fixation and were followed up for at least one year, were studied retrospectively. The open wound was divided into the Gustilo-Anderson classification. Open reduction and internal fixation were performed on every medial and lateral malleolar fracture. On the other hand, with posterior malleolar fractures, surgical or conservative treatment was performed depending on the fragment size. The radiologic outcome was evaluated using the Burwell and Charnley criteria and American Orthopaedic Foot and Ankle Society (AOFAS) scores, and complications, such as infection and posttraumatic arthritis, were used for the clinical evaluation.RESULTS: The wound was classified into eight cases (33.3%) of type I, 11 cases (45.8%) of type II, and five cases (20.8%) of type IIIa. The degree of reduction was anatomical, fair, and poor in 16 cases (66.7%), six cases (25.0%), and two cases (8.3%), respectively. The mean AOFAS score was 79 points, and there were complications, such as infection in three cases (12.5%) and post-traumatic arthritis in two cases (8.3%).CONCLUSION: Satisfactory results were obtained through immediate surgical treatment in ankle trimalleolar open fractures of types I, II, and IIIa.

Management of trimalleolar fracture in Sanglah hospital: a case series

Trimalleolar fractures are one of the most complex fracture around ankle. This study aims to assess the functional outcome and result of the surgical treatment for trimalleolar fracture. Case 1: A 49-years-old male experience closed fracture left ankle Lauge-Hansen PER type IV caused by traffic accident. Patient present with swollen and painful around ankle with an inability to bear weight on the affected extremity. Case 2: A 36-years-old female sustained closed fracture at right trimalleolar ankle, closed fracture at right talus nondisplace Hawkins I, and closed fracture at second, third, and fourth metatarsal. Case 3: A 57-years-old female came with history the left ankle twisted after got slipped and fell down at the yard. Patient was diagnosed by closed fracture left ankle Lauge Hansen SER type IV. Ankle fracture mostly happen in young men and older women during sporting activities or even bicycle or car accidents. The Lauge-Hansen system classify the fracture based on the postion and the direction of the ankle when trauma happen. The AOFAS was use for evaluation patient-relevant outcomes in patients operated on with anatomical ankle injury. In or present study of 3 patients with ankle fractures that were unstable, displaced or both treated surgically by open reduction with internal fixation in accordance with Lauge-Hansen classification. The result in our series confirm that all of 3 patients have a good result based on AOFAS scoring for evaluation the treatment and it means the management approve the good functional outcomes for the patients with ankle fractures.

Finite Element Analysis on Manual Reduction with Inverse Shift for Pronation-Extorsion Trimalleolar Fracture / 医用生物力学

Objective To investigate the feasibility of manual reduction with inverse shift for pronation-extorsion trimalleolar fracture by applying the finite element method combined with clinical experience. Methods Based on CT images and anatomical features of bone, ligaments and other tissues as well as material parameters, a normal ankle model with completed muscles and bones for a Chinese young male was established. According to the related characteristics of the pronation-extorsion trimalleolar fractures, fracture was simulated in the proper position to make osteotomy model. The finite element model of pronation-extorsion trimalleolar fractures was thus established and then applied with mechanical loading to simulate manual reduction with inverse shift. Results The established finite element model of pronation-extorsion trimalleolar fractures was effectively restored by the displacement loading. Conclusions The finite element analysis on pronation-extorsion trimalleolar fractures by inverse shift maneuver could further prove the feasibility, effectiveness and scientificity of manual reduction with inverse shift based on clinical experience.

Treatment of trimalleolar factures through posteromedial combined with lateral surgical approach / 中国基层医药

Objective To evaluate the effect of posteromedial combined with lateral surgical approach in treatment of trimalleolar factures.Methods The clinical data of 37 patients with trimalleolar factures underwent open reduction and internal fixation through posteromedial combined with lateral surgical approach were retrospectively ana-lyzed.There were 21 males and 16 females with average age of 55.0 years (ranged 35 -80).Complications such as infection,nonunion,fixation failures were observed.All patients were followed up at 6 months and 12 months after sur-gery and assessed functionally with American Orthopaedic Foot and Ankle Society Scores (AOFAS).After the 12 month follow up,the patients were also called for a radiological examination.Results Average follow -up time was 18.8 months (12 -27 months).All cases had no complications such as incision infection,skin necrosis,internal fixator loosening or rupture and bone nonunion.Using AOFAS,the scores were 82.9 and 89.7 respectively at the 6 month and 12 month follow up.The degree of arthrosis was grades Ⅰ in 2 ankles,Ⅱ in 1 ankle,and Ⅲ in 1 ankle according to Kellgren&Lawrence.Conclusion Posteromedial combined with lateral surgical approach for the treat-ment of trimalleolar factures has leaded to an satisfactory clinic outcomes.It is minimally invasive and has less compli-cations and cost.

Two-Year Follow-up Results of Anteroposterior Cannulated Screw Fixation of Posterior Malleolar Fragment in the Trimalleolar Fracture / 대한족부족관절학회지

PURPOSE: The purpose of this study was to assess the 2-year follow-up results of patients with a trimalleolar fracture, who had undergone an anterior incision cannulated screw fixation of the posterior malleolar fragment, which had more than 25% of articular involvement or had no cortical continuity with the distal tibia. MATERIALS AND METHODS: Among 28 patients with a trimalleolar fracture who had undergone fixation of the posterior malleolar fragment between February 2005 and February 2010, 14 patients, who underwent an anterior incision cannulated screw fixation of posterior malleolar fragment and were followed-up for more than 2 years, were selected. The postoperative clinical and radiological findings immediately and at the 1- and 2-year follow-up were compared. The clinical findings were evaluated as American Orthopaedic Foot and Ankle Society (AOFAS) score. The radiological assessment was evaluated as the maintenance of reduction, period to bone union, and the presence of nonunion, malunion, and complications. RESULTS: The clinical outcome by mean AOFAS score revealed 83.0 points in the group with preoperative displacement below 2 mm and 80.7 points in the group with preoperative displacement above 2 mm postoperatively. The mean AOFAS score was 91.7 and 93.1 points in the group with preoperative displacement below 2 mm on 1- and 2-year follow-up, respectively, and 89.8 and 91.7 points in group with the preoperative displacement above 2 mm on 1- and 2-year follow-up, respectively. After a 2-year follow-up among 14 cases selected for this study, 13 cases showed an excellent reduction state and only 1 case (7.1%) showed a displacement of more than 2 mm. No complication were encountered in the group with preoperative displacement below 2 mm. On the other hand, among 8 patients in the group with preoperative displacement above 2 mm, there were 3 with limitations of the range of motion of the ankle joint (37.5%) and 1 post-traumatic arthritis (12.5%) at the 2-year follow-up. CONCLUSION: Anterior incision cannulated screw fixation of the posterior malleolar fragment could be a valuable method for the treatment of trimalleolar fractures that provides satisfactory results.

Treatment of the Trimalleolar Fracture Using Posterolateral Approach: Minimum 2-year Follow Up Results

PURPOSE: To analyze the long term follow up results of treatment with posterolateral approach and to investigate its usefulness in the patients of trimalleolar fracture with posterior fragment which is above 25% of articular involvement. MATERIALS AND METHODS: There were 34 cases of trimalleolar fracture in our hospital from May 2004 to April 2008. We investigated 20 patients who underwent operation with the posterolateral approach and over-2 years follow up cases. The mean follow up period was 34 (24~58) months. Preoperative posterior malleolar fragment involved above 25% of articular surface in all cases and displaced more than 2 mm in 11 cases. We analyzed the radiologic type of posterior malleolar fragments and evaluated the function and pain through AOFAS score and complications. RESULTS: All cases showed primary union at mean 13.1 weeks. The complications are that partial ankylosis result of soft tissue contracture is seen in 2 cases (10%) and post-traumatic arthritis is seen in 1 cases (5%) and 17 cases (85%) of all patients are showed excellent AOFAS score. CONCLUSION: The posterolateral approach is a valuable method because that it enables us to easily reduction and internal fixation of the posterior malleolus and lateral malleolus at one time and the results are satisfied for a long time follow up.

Treatment of the Posterior Malleolar Fragment of Trimalleolar Fracture Using Posterolateral Approach: Preliminary Report / 대한정형외과학회잡지

PURPOSE: We wanted to evaluate the effectiveness of posterolateral approach for open reduction and internal fixation of posterior malleolar fragment with trimalleolar fracture of ankle joint. MATERIALS AND METHODS: There were 27 cases of trimalleolar fracture in our hospital from Jan. 2005 to Dec. 2007. We investigated 10 patients who underwent operation with the posterolateral approach. The mean follow up period was 20 (6-36) months. Preoperative posterior malleolar fragment involved above 25% of articular surface in 10 cases and displaced more than 2 mm in 4 cases. We analyzed the radiologic type of posterior malleolar fragments and complications, and evaluated the AOFAS score. RESULTS: All cases showed primary union mean 11.8 (8-14) weeks. The complication focal skin necrosis in one case and all patients showed excellent AOFAS score. CONCLUSION: The posterolateral approach may be a useful for open reduction and internal fixation of posterior malleolar fragment with trimalleolar fracture, especially simultaneous management of lateral malleolar fracture.

Peroneus Longus Dislocation associated with Trimalleolar Fracture: A Case Report / 대한족부족관절학회지

Traumatic dislocation of the peroneus longus tendon is an often unrecognized injury which has been reported to occur most commonly during sports activity. Most acute cases with early detection can be treated by simple repair of the tendon or retinaculum using one of several procedures available. Accurate treatment through a comprehensive evaluation of the ankle injury prevents suboptimal and sometimes unrecorrectable outcomes. The authors experienced concomitantly the peroneus longus tendon dislocation associated with a trimalleolar fracture of the ankle. We report this case a brief review of the literature.

The Treatment of Posterolateral Malleolar Fractures using Percutaneous Reduction Technique

PURPOSE: To evaluate the usefullness of the percutaneous reduction technique with K-wire that could reduce the displaced posterolateral fracture fragment which persisted even after an anatomical reduction of the lateral malleolar fracture. MATERIALS AND METHODS: From January 2004 to December 2006, we reviewed 72 patients who underwent surgical treatment for their trimalleolar fractures. We estimated the clinical and radiological results of 5 cases treated by percutaneous reduction technique with K-wire when more than the distal tibial articular step-off was left after reduction of the lateral malleolar fracture. The method of reduction starts with temporary fixation of lateral malleolar fracture followed by checking ankle radiographic image to confirm the accuracy of reduction. In case of incomplete reduction of the posterior fragment, a K-wire is inserted into the posterior fragment and pushed downward to the ankle joint level, and then lag screws were inserted. RESULTS: The average articular involvement by the posterolateral fracture fragment was 30.2%. The average step-off after reduction of the lateral malleolar fracture was 3.7 mm. At the final follow up, step-off was less than 2 mm in all cases. In clinical results by Baird and Jackson score, 3 out of 5 cases were excellent, other 2 were good. CONCLUSION: Percutaneous reduction technique for posterolateral fragment using the K-wire is relatively easy. This technique may be useful when the posterolateral fragment is large (more the 25% of articular surface) and not severely comminuted.

Comparative Study for the Results of Ankle Fracture Depending onthe Extension of the Posterior Malleolus Fracture / 대한정형외과학회잡지

PURPOSE: Posterior malleolus fractures of the ankle involve the articular surface of the distal tibia, and are related to the axis of weight bearing, which often causes difficulty in reduction and fixation. It was assumed that patients with ankle fractures combined with posterior malleolus fractures would be more prone to arthritis than those without such fractures. The main aim of this article was to define the relationship between early arthritis and an ankle fracture with a concomitant trimalleolar fracture or bimalleolar fracture. MATERIALS AND METHODS: Among the patients who had undergone an open reduction and internal fixation of the ankle joint between Nov. 2000 and Sep. 2005, 52 patients had a bimalleolar fracture or a trimalleolar fracture, and underwent metal removal. A retrospective clinical and radiological analysis was performed on the 52 patients. The mean follow up period was 25 months. Thirty-six patients had a bimalleolar fracture without a posterior malleolus fracture, and 16 patients had a trimalleolar fracture with internal fixation. The mean ages of the two groups were 36 and 43 years of age, and there were no significant differences in the gender distribution, route of trauma, and smoking between the two groups. The post operational rehabilitation treatment was applied equally to both groups. RESULTS: The VAS score of thebimalleolar fracture and trimalleolar fracture was 8.8 and 8.6, respectively. The AOFAS score of the bimalleolar fracture and trimalleolar fracture was 84.0 and 83.5, respectively, showing no significant difference. Only the patients who underwent metal removal were included because of the radiological analysis. The Kellgren-Lawrence scale of the bimalleolar fracture and trimalleolar fracture was 1.00 and 1.31, respectively, showing no significant difference. CONCLUSION: This study showed that patients with ankle fractures concomitant with posterior malleolus fractures had equally favorable outcomes to those patients with ankle fractures without a concomitant posterior malleolus fracture. Studies with more cases, a longer follow up, and prospective approaches will be needed to confirm these results.

Irreducible Ankle Fractures by Locked Posterior Malleolar Fragment: Case Report / 대한족부족관절학회지

Irreducible fracture dislocation of the ankle associated with comminuted displaced fracture of posterior malleolus is rare. Locked posterior malleolar fragments interfere with reduction of fibula or talus in ankle fractures. Prompt recognition and appropriate surgical approaches are necessary to achieve anatomical reduction of the ankle fractures.

Comparison between X-ray and Three Dimensional Computed Tomography in Trimalleolar Ankle Fractures

PURPOSE: To evaluate the accuracy of X-ray evaluation in classification, displacement and size of posterior malleolar fragment, comparing with three dimensional computed tomography (3D CT) in trimallelar ankle fractures. MATERIALS AND METHODS: 20 cases of trimalleolar ankle fractures evaluated with preoperative 3D CT, and followed up periods were at least 2 years. All cases were classified according to the Danis-Weber and Lauge-Hansen classification. Displacement and size of posterior malleolar fragment were measured using PACS. The reliability between simple X-ray and 3D CT was evaluated in the Danis-Weber and Lauge-Hansen classification (kappa analysis). The correlation between simple X-ray and 3D CT was evaluated in displacement and size of posterior malleolar fragment (correlation analysis). RESULTS: Degree of agreement of Danis-Weber classification in simple X-ray and 3D CT was 0.700 kappa value, and that of Lauge-Hansen was 0.605 kappa value. Measurement of simple X-ray and 3D CT about displaced status of posterior malleolar fragment showed statistically significant positive linear correlation (p= 0.000), but correlation of measurement of size in simple X-ray and CT was not statistically significant (p=0.102). CONCLUSION: CT or operative field will be more accurate than simple X-ray to select the method of treatment and operation, especially when the displacement and size of posterior malleolar fragment are important to decide.

Comparison of the Results after the Surgical Treatments of the Trimalleolar Ankle Fractures / 대한족부족관절학회지

PURPOSE: To evaluate the methods and results of the surgical treatment in the trimalleolar fracture of the ankle. MATERIALS AND METHODS: We analysed the results of the ankle trimalleolar fracture which were treated with open reduction and internal fixation from January 1999 till September 2003. There were 45 patients who had at least six months follow up, 16 men, and 29 women. We have analysed the mechanism of injury, methods of operation and postoperative complications. RESULTS: The results were assessed on ankle AP, lateral and mortise X-rays and retrospective chart review. There were 30 supination-external rotation, 13 pronation-external rotation, 2 pronation-abduction in the mechanism of injury by Lauge-Hansen classification. Cases of the posterior malleolar fracture which involved more than 25% of the weight bearing surface were 7 (15.6%). Medial malleolar mono-fixation was done in 5 cases, fibular mono-fixation in 2 cases, bimalleolar fixation in 32 cases, trimalleolar fixation in 6 cases. 38 cases (84.4%) were good or excellent in clincal assessment and 39 cases (86.7%) were good or excellent in radiological assessment according to the criteria of the Meyer. There was no difference of results among the surgical treatment methods. CONCLUSION: The results of our study indicate that the rigid fixation with early ankle motion and weight bearing is needed in ankle trimalleolar fracture. But minimal fixation is not bad in slight displaced fracture. Both anterior approach and posterior approach were useful methods to stabilization the posterior malleolar fracture. And pre-operative evaluation to detect the hidden soft tissue injuries and fracture mechanism is very important to avoid the failure.