Vol 35 | Issue 1 | Jan-April 2020 | page: 12-16 | Ravi Garg, Rohit Nath, Tushar Chaurasia, Devendra Kumar
Authors: Ravi Garg , Rohit Nath , Tushar Chaurasia , Devendra Kumar 
¹Department of Orthopaedic Surgery, GSVM Medical College & LLR Hospital Kanpur, Uttarpradesh, India,
Address of Correspondence:
Dr. Rohit Nath,
GSVM Medical College & LLR Hospital Kanpur, Uttarpradesh, India.
Objectives: This prospective study has been done to evaluate the clinical and radiological outcome of open reduction and direct internal fixation of posterior malleolus in trimalleolar ankle fracture through posterolateral approach in prone position.
Methods: This study is a prospective study of 12 cases of trimalleolar ankle fracture with posterior malleolus fracture treated with open reduction and direct internal fixation technique through posterolateral approach, admitted in the department of orthopaedics, L.L.R. Hospital, Kanpur from June 2017 to June 2019. All cases of posterior malleolus fracture were directly fixed with antiglide/buttress plate in prone position. All patients were assessed using American Orthopedic Foot and Ankle Society (AOFAS) score clinically and post traumatic arthritic score radiologically. Ankle joint mobility was also compared with unaffected side.
Results: Mean follow-up period was 21 months (range: 18-24 months). There were 8 male patients and 4 female patients between 20 and 65 years of age (mean: 44 years). Average time to surgery was 7.5 days (4-21days). According to AOFAS assessment, result was excellent in 8 patients and good in 4 patients. When compared with uninjured side, there was no significant difference in plantar flexion of ankle (p=0.325) but there was significant difference in dorsiflexion of ankle joint (p<0.001).
Conclusion: Open reduction and direct internal fixation of small posterior malleolus provides satisfactory clinical and functional outcomes and facilitates rehabilitation by creating more stable construction. Posterolateral approach to ankle gives adequate access to the posterior malleolus allowing its anatomical reduction and stable fixation to maintain articular congruency without any step.
Keywords: Ankle fracture, Posterior malleolus, Trimalleolar fracture, Post traumatic arthritic score, AOFAS score.
1. Srivastava DC, Yadav S, Singh A, Gupta A. The Functional Outcome of Fixation of Trimalleolar Fracture, through Fixation of Lateral Malleolus by Plating, Medial Malleolus by Tension Band Wiring and Percutaneous Screw Fixation of Posterior Malleolus: A Prospective Study. Journal of Bone and Joint Diseases Aug-Dec 2016; 31(2):30-32.
2. Orthopaedic Trauma Association (September 2007). “Ankle Fractures”. AAOS.
3. Bucholz R, Court-Brown C, Rockwood C. Rockwood and Green’S Fracture in Adult. New York: Lippincott; 2015.p2541-86.
4. Jaskulka RA, Ittner G, Schedl R. Fractures of the posterior tibial margin: their role in the prognosis of malleolar fractures. J Trauma 1989; 29:1565–70.
5. Court-Brown CM, McBirnie J, Wilson G. Adult ankle fractures–an increasing problem? Acta Orthop Scand 1998; 69:43–7.
6. Neumaier Probst E, Maas R, Meenen NM. Isolated fracture of the postero-lateral tibial lip (Volkmann’s triangle). Acta Radiol 1997;38:359–62.
7. Marsh JL, Saltzman CL. Ankle fractures. Rockwood and Green’s Fractures in Adults. In: Bucholz RW, Heckman JD, Court-Brown CM, editors. 6th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2005. pp. 2147–235. [Google Scholar]
8. De Vries JS, Wijgman AJ, Sierevelt IN, Schaap GR. Long term results of ankle fractures with a posterior malleolar fragment. J Foot Ankle Surg. 2005;44:211–7. [PubMed] [Google Scholar]
9. Langenhuijsen JF, Heetveld MJ, Ultee JM, Steller EP, Butzelaar RM. Results of ankle fractures with involvement of the posterior tibial margin. J Trauma. 2002;53:55–60. [PubMed] [Google Scholar]
10. Lindsjö U. Operative treatment of ankle fracture-dislocations. A followup study of 306/321 consecutive cases. Clin Orthop Relat Res. 1985;199:28–38. [PubMed] [Google Scholar]
11. McDaniel WJ, Wilson FC. Trimalleolar fractures of the ankle. An end result study. Clin Orthop Relat Res. 1977;122:37–45. [PubMed] [GoogleScholar]
12. Borg T, Larsson S, Lindsjö U. Percutaneous plating of distal tibial fractures. Preliminary results in 21 patients. Injury. 2004;35:608–14. [PubMed] [Google Scholar]
13. Macko VW, Matthews LS, Zwirkoski P, Goldstein SA. The joint-contact area of the ankle. The contribution of the posterior malleolus. J Bone Joint Surg Am. 1991;73:347–51. [PubMed] [Google Scholar]
14. Domsic RT, Saltzman CL. Ankle osteoarthritis scale. Foot Ankle Int 1998;19:466–71.
15. Rodrigues RC, Masiero D, Mizusaki JM, Imoto AM, Cohen M.Translation, cultural adaptation and validity of the American orthopaedic foot and ankle society(AOFAS) ankle-hindfoot scale.Acta Ortop Bras.(serial on internet).2008;16(2):107-111.
16. McDaniel WJ, Wilson FC. Trimalleolar fractures of the ankle. An end result study. Clin Orthop Relat Res 1977;122:37–45.
17. Mingo-Robinet J, López-Durán L, Galeote JE, Martinez-Cervell C. Ankle fractures with posterior malleolar fragment: management and results. J Foot Ankle Surg 2011;50:141–145.
18. Berkes MB, Little MTM, Lazaro LE, et al. Articular congruity is associated with short-term clinical outcomes of operatively treated SER IV ankle fractures. J Bone Joint Surg [Am] 2013;95-A:1769–1775.
19. Gardner MJ, Brodsky A, Briggs SM, Nielson JH, Lorich DG. Fixation of Posterior malleolar fractures provides greater syndesmotic stability. Clin Orthop Relat Res 2006;447:165–171.
20. Miller AN, Carroll EA, Parker RJ, Helfet DL, Lorich DG. Posterior malleolar stabilization of syndesmotic injuries is equivalent to screw fixation. Clin Orthop Relat Res2010 Apr;468:1129–1135.
21. van den Bekerom MP, Haverkamp D, Kloen P. Biomechanical and clinical evaluation of posterior malleolar fractures. A systematic review of the literature. J Trauma 2009;66:279–284.
22. Fitzpatrick DC, Otto JK, McKinley TO, Marsh JL, Brown TD. Kinematic and contact stress analysis of posterior malleolus fractures of the ankle. J Orthop Trauma 2004;18:271–278.
23. No authors listed. AO Foundation. www2.aofoundation.org (date last accessed 04May 2016).
24. De Vries JS, Wijgman AJ, Sierevelt IN, Schaap GR. Long-term results of ankle fractures with a posterior malleolar fragment. J Foot Ankle Surg 2005;44:211–217.
25. Langenhuijsen JF, Heetveld MJ, Ultee JM, Steller EP, Butzelaar RM. Results of ankle fractures with involvement of the posterior tibial margin. J Trauma 2002;53:55–60.
26. Mingo-Robinet J, López-Durán L, Galeote JE, Martinez-Cervell C. Ankle fractureswith posterior malleolar fragment: management and results. J Foot Ankle Surg 2011;50:141–145.
27. Harper MC. Talar shift. The stabilizing role of the medial, lateral, and posterior ankle structures. Clin Orthop Relat Res 1990;257:177–83.
28. Hartford JM, Gorczyca JT, McNamara JL, Mayor MB. Tibiotalar contact area. Contribution of posterior malleolus and deltoid ligament. Clin Orthop Relat Res 1995;320:182–7.
29. Verhage SM, Boot F, Schipper IB, Hoogendoorn JM. Open reduction and internal fixation of posterior malleolar fractures using the posterolateral approach. The bone & joint journal. 2016 Jun;98(6):812-7.
30. Karaca S, Enercan M, Ozdemir G, Kahraman S, Çobanoğlu M, Küçükkaya M. Importance of fixation of posterior malleolus fracture in trimalleolar fractures: A retrospective study.
|How to Cite this Article: Garg R, Nath R, Chaurasia T, Kumar D| Prospective analysis of clinicoradiological outcome of direct internal Fixation of posterior malleolus in
trimalleolar ankle fractures through posterolateral approach in prone position | Journal of Bone and Joint Diseases Jan-April 2020; 35(1):12- 16.