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A Novel Classification for Medial Malleolar Fracture Based on the 3-D Reconstruction CT Fangke Hu1, Guoyun Bu1, Jun Liang2, Haijing Huang2 and Jinquan He2*

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A Novel Classification for Medial Malleolar Fracture Based on the 3-D Reconstruction CT Fangke Hu1, Guoyun Bu1, Jun Liang2, Haijing Huang2 and Jinquan He2* Hu et al. Journal of Orthopaedic Surgery and Research (2021) 16:538 https://doi.org/10.1186/s13018-021-02688-9 RESEARCH ARTICLE Open Access A novel classification for medial malleolar fracture based on the 3-D reconstruction CT Fangke Hu1, Guoyun Bu1, Jun Liang2, Haijing Huang2 and Jinquan He2* Abstract Background: Fracture of the medial malleolus is one of the most frequent injuries treated surgically; however, the classification of the fracture has not attracted much attention and a good classification system is still lacking. Methods: Consecutive cases of medial malleolus fractures were prospectively enrolled. Based on the 3-D reconstruction CT morphology and centered on the posterior colliculus of the medial malleolus, we classified the fractures into 4 types: type 1 with no involvement of the posterior colliculus, type 2 with partial involvement of posterior colliculus, type 3 with the entire involvement of posterior colliculus, and type 4 with the fracture line 4 vertically extended from the intercollicular groove to the comminuted fracture of the posterior malleolus. Statistical analyses were performed to evaluate the clinical significance of the classification. Results: There were 273 cases prospectively enrolled. The distribution of the cases was type 1 of 12.1%, type 2 of 41.0%, type 3 of 30.0%, and type 4 of 16.8%. Statistics showed that the new classification had significant associations but did not totally depend on the classical ankle fracture classifications. Results showed that the new classification had implications in the severity of ankle fractures. From type 1 to type 4, the ankle joint was more and more unstable. Furthermore, comminuted medial malleolar fractures could be subdivided, and the new classification could provide useful information for surgical decision-making. Conclusions: The novel classification was a useful system to describe the 3-D geometry of the fractured medial malleolus. Keywords: Medial malleolus, Fracture, 3-D reconstruction CT, Classification Introduction Fractures of the ankle joint are commonly classified Fracture of the medial malleolus is one of the most fre- according to the Danis-Weber [4–6] and Lauge-Hansen quent injuries treated by the orthopedic surgeon [1]. Ei- systems [7]. However, all the two classifications were ther in isolation or in conjunction with fractures of the centered on the injury of the lateral malleolus, and the lateral and posterior malleolus, displaced medial malleo- fracture morphology of medial malleolus was little men- lar fracture has been recommended for operative man- tioned [8]. There have been attempts at introducing clas- agement [2, 3]; however, the classification of the fracture sification systems for the medial malleolar fracture. The has not been paid much attention by the orthopedic Pankovich system [9, 10] and the modified Pankovich surgeon. system [11] are based on the location of the medial mal- leolar fracture and the competency of the deltoid liga- ment and divided the fractures into 6 groups. The * Correspondence: [email protected] 2Orthopedic Trauma Department of Foot and Ankle Surgery I, Tianjin Ebraheim system [12, 13] is based on the level and loca- Hospital, Tianjin 300211, China tion of the medial malleolar fracture and classified into 4 Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Hu et al. Journal of Orthopaedic Surgery and Research (2021) 16:538 Page 2 of 10 groups: transverse, oblique, comminuted, and vertical Herscovici classification [14] based on the standard X- fractures. The Herscovici system [14] is based on the rays. As shown in Fig. 1a, the modified Pankovich classifi- level of medial malleolar fracture and classified into 4 cation includes 4 types of type A with no or avulsion frac- groups: avulsion fractures, between the tip and plafond, ture, type B with anterior colliculus fracture, type C with at the level of the plafond, and vertical fractures. Unfor- posterior colliculus fracture, and type D with supra- tunately, all the above classifications were mostly used collicular fracture [11].AsshowninFig.1b, the for the descriptions of fracture morphology based on X- Herscovici system includes 4 fracture lines of type A ray film while the clinical significance was unclear. with avulsion fracture of the tip, type B occurs be- The medial malleolus is composed of the anterior col- tween the tip and the level of the plafond, type C at liculus, the intercollicular groove, and the posterior col- the level of the plafond, and type D extends vertically liculus. In the latest years, the posterior colliculus has above this level [14]. been considered to be the primary stabilizer of the med- Considering the importance of the posterior colliculus ial ankle [1, 15]. Considering the great clinical signifi- in the stability of medial ankle fracture, we raised a new cance of fracture line direction and the comminuted fracture line classification centered on the integrity of morphology for the lateral malleolus, we proposed that the posterior colliculus (Fig. 2). Fracture line 1 (type 1) it also had clinical significance for the medial malleolus. extended from the anterior of the medial malleolus to According to the theory, we raised a posterior the intercollicular groove with no involvement of the colliculus-centric classification system based on the 3-D posterior colliculus. Fracture line 2 (type 2) extended reconstruction CT of medial malleolar fracture. The from the anterior of the medial malleolus to the poster- present study was performed to describe the novel clas- ior colliculus or the distal groove for posterior tibial ten- sification system and to evaluate the clinical significance don with the partial involvement of posterior colliculus. of the classification. Fracture line 3 (type 3) obliquely horizontally extended from the upper anterior of the medial malleolus to the Materials and methods proximal groove for the posterior tibial tendon with the We prospectively enrolled all consecutive patients with entire involvement of the posterior colliculus. Fracture medial malleolar fractures according to inclusion and ex- line 4 (type 4) vertically extended from the intercollicu- clusion criteria from January 1, 2018, to October 31, lar groove or the posterior colliculus to the distal tibia 2019, at our department of foot and ankle surgery. The which was always combined with other 3 fracture lines inclusion criteria were patients with medial malleolar with the comminuted fracture of the posterior colliculus. fractures enrolled at our department. In order to predict Notably, all the comminuted cases with fracture line 4 the association of medial malleolar fracture with lateral were included in type 4. and posterior malleolar fractures as well as to simplify The presence or absence of distal tibiofibular syndes- the statistical analysis, we excluded cases of isolated motic injury was recorded, with the distance of syndes- medial malleolar fractures and cases of avulsion malleo- mosis between the tibia and fibula <4mm of no lar fractures of the tip. Other exclusion criteria were syndesmotic injury, 4–7mm of syndesmotic injury, and open fractures, Pilon fractures, multiple fractures in the >7mm of syndesmotic separation measured on the same foot, old fractures more than 3 weeks, pathologic mortise view. The lateral displacement of the talus was fractures, fractures treated by conservative therapy, pa- measured by the lateral border of the talus versus the tients younger than 18 years, and patients who refused lateral border of the distal tibial plafond on the coronal to join in the study. The 3-D reconstruction CT was CT images at the middle level of the medial malleolus. routinely performed for all the patients after closed re- The joint surface involvement of the distal tibial plafond duction and radiography was prospectively collected and the angle between the major fracture line and distal from the radiology department. With the approval of tibial plafond was also measured on the coronal CT im- our institutional review board, all the information was ages at the middle level of the medial malleolus. The pres- collected in accordance with the World Medical Associ- ence of Maisonneuve fractures, the separation of the ation Declaration of Helsinki and written consents were anterior and posterior colliculus, and the comminuted obtained from all the patients. fractures of medial malleolar were determined on the 3-D All the classifications
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