SLR - December 2022 - Gabriella A. Ley, DPM
Title: Complications following surgical treatment of posterior malleolar fractures: an analysis of 300 casesReference: Neumann AP, Kroker L, Beyer F, Rammelt S. Complications following surgical treatment of posterior malleolar fractures: an analysis of 300 cases. Arch Orthop Trauma Surg. 2022 Jul 18. doi: 10.1007/s00402-022-04536-9
Level of Evidence: III
Reviewed by: Gabriella A. Ley, DPM
Residency Program: Regions Hospital/HealthPartners Institute – St. Paul, MN
Podiatric Relevance: Ankle fractures are among the most common lower extremity injuries treated in podiatric medicine. Posterior Malleolar (PM) ankle fractures, often seen in bimalleolar or trimalleolar ankle injuries, have poorer outcomes due to challenges with fixation, anatomic reduction, and involvement of articular surface. Treatment for these types of fractures have been controversial with regard to fixation and approach. The goal of this study is to identify risks factors associated with complications in surgical treatment ankle fractures with posterior malleolus involvement.
Methods: A retrospective chart review was performed including 300 patients with ankle fractures involving the posterior malleolus treated at a single institution between 2003 and 2015. Fracture types included bimalleolar, trimalleolar with or without additional Tillaux-chaput or Wagstaff fragments, and isolated posterior malleolar fractures. Open ankle fractures and fracture dislocations were also included. Different fixation methods were utilized including one-stage open reduction internal fixation, staged surgeries with primary external fixation and secondary internal fixation, and open approach with direct fixation to posterior malleolar fragment. Relevant comorbidities were also noted including hypertension, diabetes mellitus, peripheral vascular disease, osteoporosis, rheumatoid arthritis, nicotine abuse, and alcohol abuse. Multivariate statistical analysis was conducted to identify independent risk factors for complications.
Results: Complications occurred in 13.7% of the patients included, the most prevalent being superficial wound healing problems. Infection rate in the study was 2%. Secondary ankle fusion occurred in 2% of patients with average follow up of 9 years. BMI, insulin-dependent diabetes mellitus, and staged fixation were found to be independent risks factors for delayed wound healing. Peripheral vascular disease, alcohol abuse, and use of syndesmotic positional screw were found to be independent risk factors for mechanical problems requiring revision surgery.
Conclusions: Several significant independent risk factors for infections were identified in this study including diabetes mellitus, peripheral vascular disease, alcohol abuse, and dementia. High BMI and insulin dependent diabetes were found to be independent risk factors for wound healing problems. The authors noted limitations in study to do its retrospective nature, possibility leading to underreporting of factors such as sensory disorders, late ankle fusion, nicotine consumption or alcohol abuse. Although further studies are needed, the authors recommend treatment of posterior malleolar fractures be based individual pathoanatomy and known risk factors. They also note that a posterolateral approach is associated with minimal morbidity for fixation of fibular fracture and PM fragment.