The additional value of weight-bearing radiographs in assessing stability of isolated type B fibular fractures.

INTRODUCTION: In isolated type B fibular fractures, the decision whether to operate or treat conservatively is principally based on congruency and stability of the ankle joint. The purpose of the current study is to examine the additional diagnostic value of the weight-bearing radiograph (WBR) in assessing stability of potentially unstable type B fibular fractures. MATERIALS AND METHODS: In this retrospective cohort study, patients were selected based on who presented an isolated type B fracture of the fibula. Unstable fractures were directly planned for surgery. Other patients underwent additional weight-bearing imaging 4-7 days after initial trauma, on which definitive treatment was based. The medial clear space (MCS) was compared between the WBR and the conventional radiograph. RESULTS: A total of 70 patients were included in the period January 2018-December 2021. The average MCS on conventional mortise radiograph was 3.56 mm compared to 3.02 mm on the WBR(p<0.05). The superior clear space (SCS) was equal between both groups (respectively 3.12 mm and 3.08 mm, p = 0.44). All 70 patients were initially treated conservatively with immediate weight-bearing in a brace or soft cast. One patient had the need for open repair and internal fixation due to non-union. DISCUSSION: Different techniques for the assessment of deep deltoid ligament integrity exist, such as the MRI, the ultrasonography and different kinds of stress test radiographs. As fractured ankles don't need direct fixation and operative treatment can be postponed, a stepped approach for the assessment of deep deltoid ligament (DDL) integrity can be of assistance in assessing ankle stability. In isolated type B fibular fractures a stepped approach, using the weight-bearing radiograph can be of additional value in assessing the stability. It is a low cost, prevents unnecessary surgery and contributes to a quick weight-bearing non-operative treatment.

The role of fibula fixation in combined distal-third tibia and fibula fractures: a systematic literature review.

OBJECTIVE: The role of concomitant fibula fracture fixation in distal-third tibia fractures regarding alignment, union, and functional outcome is still a topic of debate. In this review, we summarize the available comparative literature regarding fibula fixation in distal third lower leg fractures. MATERIALS AND METHODS: A systematic literature review of articles published between January 2000 and January 2022 in the PubMed, Cochrane, and EMBASE databases about this topic was performed. RESULTS: 746 unique studies were identified of which four randomized-controlled trials and six retrospective studies were included. Nine studies compared alignment after tibia fixation with or without fibula fixation, six studies reported on tibial union, and three studies reported on functional outcome between groups. Pooling of data was not possible due to varying outcome measures and inclusion criteria. Fibula fixation was associated with less rotational malalignment, while there does not seem to be consensus regarding the effect on sagittal and coronal alignment. Six studies reported on the effect of fibula fixation on tibial union. None of these studies found a significant difference between treatment modalities. Furthermore, one out of three studies reporting functional outcome described a marginal beneficial functional outcome after fibula fixation. Ultimately, no differences in complication rates between treatment modalities were described. CONCLUSION: Fixation of the fibula in distal-third lower leg fractures does not seem to have a significant effect on coronal and sagittal tibial alignment. Furthermore, fibula fixation is associated with significantly less rotational malalignment, although the clinical importance of this finding is questionable as true differences in rotational alignment between treatment modalities are small. Finally, fibula fixation does not affect union, functional outcome, or complication rate as adjuvant to tibia fixation. LEVEL OF EVIDENCE: II.

Variation in posterior fragment fixation in the Netherlands: a nationwide study.

PURPOSE: The treatment of the posterior fragment in trimalleolar fractures differs from hospital to hospital in the Netherlands. A nationwide survey was performed to evaluate the fixation criteria and practice variation. METHODS: An online cross-sectional survey amongst (orthopaedic) trauma surgeons was performed in the Netherlands. It consisted of three sections: a general section, a section showing preoperative images of six cases and a section with postoperative images of nine cases. RESULTS: A total of 151 surgeons completed the online survey. 45% of the respondents indicated that they fixated the posterior fragment if smaller than 25% of the intra-articular surface. 48% preferred an open posterior approach to fixate the posterior fragment. There was good consensus in treatment for the two cases with Bartonicek type 4 fractures (operative treatment in 73 and 72% respectively). Little consensus was found for Bartonicek type 2 and 3 fractures (88% opted for operative treatment in one case, but 89% for conservative treatment in the second case). Reoperation was mostly considered in cases with a step-off of more than 1 mm (by 33-38% of the respondents). There was great variation in the choice of treatment if only the size of the posterior fragment was considered. Other fixation criteria such as postoperative step-off or instability after fixation of the lateral and medial malleoli are taken into account. In cases where fixation was needed, a percutaneous approach and an open posterolateral approach were equally preferred. CONCLUSIONS: There is much variation in treatment of the posterior malleolar fracture amongst orthopaedic and trauma surgeons in the Netherlands. The percutaneous approach and open posterolateral approach to fixate the posterior malleolar fracture seem to be equally used in the Netherlands. Still, there is no uniformity in treatment of posterior malleolar fracture, especially for Bartonicek 2 and Bartonicek 3 fractures. Reoperation is considered by less than half of the surgeons in case of postoperative persistent step-off of more than 1 mm.

Open reduction and internal fixation of the posterior malleolus fragment via the posterolateral approach is radiologically superior to 'A to P' screw fixation.

PURPOSE: Functional outcome in trimalleolar fractures is largely correlated to the reduction of the posterior fragment. Until recently, fixation was mainly performed for large fragments, by percutaneous anterior to posterior ('A to P') screw placement after closed reduction. Nowadays, ORIF via a posterolateral approach seems to gain in popularity. The aim of this study was to compare the postoperative photographs of operated trimalleolar fractures after either fracture treatment method, for fracture diastasis and step-off. MATERIAL AND METHODS: All consecutive patients with trimalleolar fractures, including posterior fragments of >5% of the articular surface and operated between 2007-2013 were analysed on size of posterior fragment, post-operative gap and step-off by three observers. The patients were divided into three groups; A to P screw fixation, ORIF via the posterolateral approach and no posterior fragment fixation at all. RESULTS: 180 patients with trimalleolar ankle fractures were included for analyses. Twenty five posterior fragments were fixated percutaneously from anterior to posterior (group 1) and 51 underwent open reduction and internal fixation through a posterolateral approach (group 2). 104 patients underwent no posterior malleolus fixation (group 3). The average size of posterior fragment was 34% in group 1, 27% in group 2 and 16% in group 3. A postoperative step-off >1 mm was found in 40% (group 1), 9% (group 2) or 34% respectively (group 3). CONCLUSIONS: Fixation of the posterior malleolus through an open posterolateral approach leads to better radiological results as compared to percutaneous 'A to P' screw fixation or no fixation at all.

Weight-bearing or non-weight-bearing after surgical treatment of ankle fractures: a multicenter randomized controlled trial.

PURPOSE: The goal of this study was to assess if unprotected weight-bearing as tolerated is superior to protected weight-bearing and unprotected non-weight-bearing in terms of functional outcome and complications after surgical fixation of Lauge-Hansen supination external rotation stage 2-4 ankle fractures. METHODS: A multicentered randomized controlled trial was conducted in patients ranging from 18 to 65 years of age without severe comorbidities. Patients were randomized to unprotected non-weight-bearing, protected weight-bearing, and unprotected weight-bearing as tolerated. The primary endpoint of the study was the Olerud Molander Ankle Score (OMAS) 12 weeks after randomization. The secondary endpoints were health-related quality of life using the SF-36v2, time to return to work, time to return to sports, and the number of complications. RESULTS: The trial was terminated early as advised by the Data and Safety Monitoring Board after interim analysis. A total of 115 patients were randomized. The O'Brien-Fleming threshold for statistical significance for this interim analysis was 0.008 at 12 weeks. The OMAS was higher in the unprotected weight-bearing group after 6 weeks c(61.2 ± 19.0) compared to the protected weight-bearing (51.8 ± 20.4) and unprotected non-weight-bearing groups (45.8 ± 22.4) (p = 0.011). All other follow-up time points did not show significant differences between the groups. Unprotected weight-bearing showed a significant earlier return to work (p = 0.028) and earlier return to sports (p = 0.005). There were no differences in the quality of life scores or number of complications. CONCLUSIONS: Unprotected weight-bearing and mobilization as tolerated as postoperative care regimen improved short-term functional outcomes and led to earlier return to work and sports, yet did not result in an increase of complications.

Persistent postoperative step-off of the posterior malleolus leads to higher incidence of post-traumatic osteoarthritis in trimalleolar fractures.

BACKGROUND: Traditionally, size of the posterior fragment is considered the most important indicator for fixation in trimalleolar fractures. It remains unclear which factors contribute to worse functional and radiological outcome. This study was designed to determine predictors for the development of posttraumatic osteoarthritis and worse functional outcome in trimalleolar fractures. METHODS: This retrospective cohort study evaluated outcomes of 169 patients with a trimalleolar fracture treated between 1996 and 2013 in a level-1 trauma hospital in the Netherlands after a mean follow-up of 6.3 (range 2.4 to 15.9) years. The average fragment size was 17%. Twenty patients had a posterior fragment smaller than 5% of the intra-articular surface, 119 patients a fragment of 5-25% and 30 patients a posterior fragment larger than 25%. In total, 39 patients (23%) underwent fixation of the posterior fragment. RESULTS: Clinical union was achieved in all 169 patients. The median AOFAS score after follow-up was 93 (interquartile range 76-100) and the median AAOS score was 92 (interquartile range 81-98). A persistent postoperative step-off larger than 1 mm was found in 65 patients (39%) and osteoarthritis was present in 49 patients (30%). Higher age and postoperative step-off > 1 mm were independent, significant risk factors for the development of osteoarthritis. Osteoarthritis and BMI were independent, significant risk factors for worse functional outcome. CONCLUSION: It is advisable to correct intra-articular step-off of intraarticular posterior malleolar fragments to reduce the risk of developing osteoarthritis and, consequently, the risk of worse functional outcome after long-term follow-up. LEVEL OF EVIDENCE: Level IIB.

When and how to operate the posterior malleolus fragment in trimalleolar fractures: a systematic literature review.

OBJECTIVES: Whether or not and how to fixate the posterior malleolus fracture seems to depend on the fracture fragment size and its amount of dislocation, but clear guidelines for daily practice are lacking. In this review, we summarize the literature on preferred treatment of the posterior fragment in trimalleolar fractures. METHODS: A systematic review of publications between January 1995 and April 30 2017 on this topic in the PubMed, Embase, and Cochrane databases was performed according to the PRISMA statement. RESULTS: Seventeen (2 prospective and 15 retrospective) of the 180 identified studies were included. Six studies report on indications for fixation of posterior malleolus fracture fragments. Eleven studies compare different fixation approaches and techniques for the posterior fragment. Meta-analysis was not possible due to varying fixation criteria and outcomes. There was no clear association between posterior fragment size and functional outcome or development of osteoarthritis. The non-anatomical reduction of the fragment was of more influence on outcome. Radiological and functional outcome was better after open reduction and internal fixation via the posterolateral approach than after percutaneous anterior-to-posterior screw fixation. CONCLUSION: The posterior fragment size is not a clear indication for its fixation. A step-off, however, seems an important indicator for developing posttraumatic osteoarthritis and worse functional outcome. Posterior fragments involving the intra-articular surface need to be reduced and fixated to prevent postoperative persisting step-off. Furthermore, fixation of the posterior malleolus via an open posterolateral approach seems superior to percutaneous anterior-to-posterior fixation. However, these results need to be confirmed in a prospective comparative trial. LEVEL OF EVIDENCE: Therapeutic level II.

Influence of fragment size and postoperative joint congruency on long-term outcome of posterior malleolar fractures.

BACKGROUND: One of the factors contributing to long-term outcome of posterior malleolar fractures is the development of osteoarthritis. Based on biomechanical, cadaveric, and small population studies, fixation of posterior malleolar fracture fragments (PMFFs) is usually performed when fragment size exceeds 25-33%. However, the influence of fragment size on long-term clinical and radiological outcome size remains unclear. METHODS: A retrospective cohort study of 131 patients treated for an isolated ankle fracture with involvement of the posterior malleolus was performed. Mean follow-up was 6.9 (range, 2.5-15.9) years. Patients were divided into groups depending on size of the fragment, small (<5%, n = 20), medium (5-25%, n = 86), or large (>25%, n = 25), and presence of step-off after operative treatment. We have compared functional outcome measures (AOFAS, AAOS), pain (VAS), and dorsiflexion restriction compared to the contralateral ankle and the incidence of osteoarthritis on X-ray. RESULTS: There were no nonunions, 56% of patients had no radiographic osteoarthritis, VAS was 10 of 100, and median clinical score was 90 of 100. More osteoarthritis occurred in ankle fractures with medium and large PMFFs compared to small fragments (small 16%, medium 48%, large 54%; P = .006). Also when comparing small with medium-sized fragments (P = .02), larger fragment size did not lead to a significantly decreased function (median AOFAS 95 vs 88, P = .16). If the PMFF size was >5%, osteoarthritis occurred more frequently when there was a postoperative step-off ≥1 mm in the tibiotalar joint surface (41% vs 61%, P = .02) (whether the posterior fragment had been fixed or not). In this group, fixing the PMFF did not influence development of osteoarthritis. However, in 42% of the cases with fixation of the fragment a postoperative step-off remained (vs 45% in the group without fixation). CONCLUSION: Osteoarthritis is 1 component of long-term outcome of malleolar fractures, and the results of this study demonstrate that there was more radiographic osteoarthritis in patients with medium and large posterior fragments than in those with small fragments. Radiographic osteoarthritis also occurred more frequently when postoperative step-off was 1 mm or more, whether the posterior fragment was fixed or not. However, clinical scores were not different for these groups. LEVEL OF EVIDENCE: Level IV, retrospective case series.