Complications following surgical treatment of posterior malleolar fractures: an analysis of 300 cases.

AIMS: The treatment of ankle fractures and fracture-dislocations involving the posterior malleolus (PM) has undergone considerable changes over the past decade. The aim of our study was to identify risk factors related to the occurrence of complications in surgically treated ankle fractures with PM involvement. PATIENTS AND METHODS: We retrospectively analyzed 300 patients at a mean age of 57 years with 300 ankle fractures involving the PM treated surgically at our institution over a 12-year period. The following relevant comorbidities were noted: arterial hypertension (43.7%; n = 131), diabetes mellitus (DM) (14.0%; n = 42), thereof insulin-dependent (3.7%; n = 11), peripheral vascular disease (0.7%; n = 2), osteoporosis (12.0%; n = 36), dementia (1.0%; n = 3), and rheumatoid arthritis (2.0%; n = 6). Furthermore, nicotine consumption was recorded in 7.3% (n = 22) and alcohol abuse in 4.0% (n = 12). RESULTS: Complications occurred in 41 patients (13.7%). A total of 20 (6.7%) revision surgeries had to be performed. Patients with DM (p < 0.001), peripheral vascular disease (p = 0.003) and arterial hypertension (p = 0.001) had a significantly increased risk of delayed wound healing. Alcohol abuse was associated with a significantly higher overall complication rate (OR 3.40; 95% CI 0.97-11.83; p = 0.043), increased rates of wound healing problems (OR 11.32; 95% CI 1.94-65.60; p = 0.001) and malalignment requiring revision (p = 0.033). The presence of an open fracture was associated with an increased rate of infection and wound necrosis requiring revision (OR 14.25; 95% CI 2.39-84.84; p < 0.001). Multivariate analysis identified BMI (p = 0.028), insulin-dependent DM (p = 0.003), and staged fixation (p = 0.043) as independent risk factors for delayed wound healing. Compared to the traditional lateral approach, using the posterolateral approach for fibular fixation did not lead to increased complication rates. CONCLUSIONS: Significant risk factors for the occurrence of complications following PM fracture treatment were identified. An individually tailored treatment regimen that incorporates all risk factors is important for a good outcome.

Ankle fractures involving the anterolateral distal tibia: medium-term clinical results of 50 cases.

PURPOSE: The anterolateral distal tibial rim (anterior malleolus, AM) is frequently fractured in malleolar fractures. The aim of this study was to evaluate the medium-term outcomes of malleolar fractures involving the AM. METHODS: Among 100 patients with AM fractures that were treated over a 10-year period, 50 patients were available for follow-up. Outcome was assessed with the Olerud Molander Ankle Score (OMAS), the Foot Function Index (FFI-D), the EuroQol (EQ)-5D-5L Index, the EQ-VAS and the AOFAS Ankle-Hindfoot Score. Type 1 AM fractures (bony syndesmotic avulsions) were fixed surgically with either a suture anchor or a transosseous suture in 11 of 22 cases (50%). Among type 2 AM fractures (with incisura and joint involvement), 68% were treated surgically with screw fixation. All three type 3 AM fractures (anterolateral tibial plafond impaction) were treated surgically with either screw or plate fixation. RESULTS: At follow-up, the median OMAS was 75, the FFI-D 19, the EQ-5D-5L-Index 0.88, the EQ-VAS 70, and the AOFAS score 93. Assuming that the fracture severity increases from Supination-External Rotation to Pronation-External Rotation and Pronation-Abduction injuries, the AOFAS score (p < 0.001), OMAS score (p = 0.009), and FFI-D (p = 0.041) all showed a significantly inferior clinical outcome with increasing fracture severity. Patients who required surgical revision (n = 5) showed a significantly inferior outcome with the OMAS (p = 0.019). CONCLUSIONS: A differentiated treatment protocol tailored to dislocation, size, incisura involvement and joint impaction leads to favourable outcomes in complex malleolar fractures involving the AM. More data are needed on the outcome of AM fractures that are still commonly underestimated and overlooked.

Ankle fractures involving the posterior malleolus: patient characteristics and 7-year results in 100 cases.

INTRODUCTION: The presence of a posterior malleolar (PM) fragment has a negative prognostic impact in ankle fractures. The best treatment is still subject to debate. The aim of this study was to assess the medium-to-long-term clinical and functional outcome of ankle fractures with a PM fragment in a larger patient population. MATERIALS AND METHODS: One hundred patients (69 women, 31 men, average age 60 years) with ankle fractures including the PM were evaluated clinically and radiographically. Patients with Bartonícek-Rammelt type 3 and 4 fracture displayed a significant female preponderance. Fixation of the PM was performed in 63% and tailored to the individual fracture pattern. RESULTS: Internal fixation of the PM fragment was negatively correlated with the need for syndesmotic screw placement at the time of surgery (p = 0.010). At an average follow-up of 7.0 years, the mean Foot Function Index (FFI) was 16.5 (SD: 21.5), the Olerud Molander Ankle Score (OMAS) averaged 80.2 (SD: 24) and the American Orthopedic Foot & Ankle Society (AOFAS) ankle/hindfoot score averaged 87.5 (SD: 19.1). The maximum score of 100 was achieved by 44% of patients. The physical (PCS) and mental health component summary (MCS) scores of the SF-36 averaged 47.7 (SD: 12.51) and 50.5 (SD: 9.36), respectively. Range of motion was within 3.4 (SD: 6.63) degrees of the uninjured side. The size of the PM fragment had no prognostic value. There was a trend to lower outcome scores with slight anterior or posterior shift of the distal fibula within the tibial incisura. Patients who underwent primary internal fixation had significantly superior SF-36 MCS than patients who underwent staged internal fixation (p = 0.031). CONCLUSIONS: With an individualized treatment protocol, tailored to the CT-based assessment of PM fractures, favorable medium and long-term results can be expected.