SLR - February 2023 - John Seha, DPM
Title: Posterior Malleous Fixation In Trimalleolar Ankle Fractures Using Anterior To Posterior Screw Versus Posterolateral PlateReference: Deendayal, Sharma R, Aggarwal S, Shekhawat V. Posterior Malleous Fixation In Trimalleolar Ankle Fractures Using Anterior To Posterior Screw Versus Posterolateral Plate. International Journal of Orthopaedics Sciences 2022; 8(1):135-138. doi:10.22271/ortho.2022.v8.i1b.3000
Level of Evidence: Level 1
Scientific Literature Review
Reviewed By: John Seha, DPM
Residency Program: Hoboken University Medical Center – Hoboken, NJ
Podiatric Relevance: Posterior malleolar fractures (PMFs) account for about 7 to 44% of all ankle fractures. Although such a common presentation, there is no consensus on the indications of surgical treatment, how to approach different fracture patterns, or the clinical efficacy of different fixation methods. It is widely accepted that if the PMF involves more than 25% of the articular surface and if the fragment is displaced more than 2 mm, that surgical treatment is required. This study aimed to investigate the efficacy of posterolateral plate fixation versus the anterior to posterior screw fixation for the PMF in trimalleolar ankle fracture.
Method: This study is a prospective randomized comparative study that included a total of forty-six patients with trimalleolar ankle fractures. Patients underwent surgical stabilization of all three malleolar fragments in a tertiary-level health care center in Rajasthan, India, by the same orthopedic surgeon from April 2017 to November 2018. Exclusion criteria included patients who had additional ipsilateral or contralateral lower extremity injury, Pilon fracture, trimalleolar fracture, or had a history of a lower extremity fracture. Patients underwent computerized randomization and were allocated into two groups, group A was fixated with anterior to posterior screw, and group B was fixated with posterolateral plate fixation. Patients were examined for clinical and radiological signs of union, deformity correction, pain level, and range of motion at 2 weeks, 6 weeks, and 6 months.
Results: Forty-six patients with ages ranging from 18-60 years old, the mean age in group A was 39.08±10.02 years, and in group B was 36.44±6.95 years. The type of fracture difference between both groups was statistically insignificant. In terms of functional results, Group A had 28% excellent results, 58% good results, and the remaining 14% poor results. On the other hand, group B had 40% excellent results, 50% good results, and the remaining 10% poor results. Statistically significant mean weight-bearing time difference was noted between both groups, with mean weight-bearing time after surgery in group A being 7.04±0.73 weeks and in group B being 12.02±1.50 weeks. Also, statistically significant evidence of union in X-ray was seen after 18.80±1.92 weeks of operation in group A and 20.16±2.01 weeks in group B.
Conclusions: The findings of this study demonstrate better overall functional outcomes with the posterolateral plate fixation of the posterior malleolus fracture but point out that mean weight-bearing time and radiographical signs of healing were delayed. The author proposes that the fixation of even smaller posterior malleolar fractures may adequately restore the congruency and ligamentous tension of the PITFL and stabilize the syndesmosis, with no need for syndesmotic fixation after stressing the joint intraoperatively, confirming the results of Gardner et al. (2006), who found that 70% stiffness of the distal tibiofibular articulation was restored by reducing and stabilizing the posterior malleolus compared to 40% through the use of a syndesmotic screw. There is still no consensus on when or how to fixate posterior malleolar fractures, but a careful interpretation of case-specific parameters is required to reach this critical decision.