Posterior Malleolus Fractures / Posterior Pilon Variants
STEVEN STEINLAUF, MD THE ORTHOPAEDIC FOOT AND ANKLE INSTITUTE OF SOUTH FLORIDA CLINICAL ASSISTANT PROFESSOR THE UNIVERSITY OF MIAMI CLINICAL ASSISTANT PROFESSOR NOVA SOUTHEASTERN SCHOOL OF MEDICINE Disclosures
Wright Medical – Design surgeon , royalties Smith & Nephew – Design surgeon, royalties Goals
To understand how to assess the posterior malleolus fracture To understand why we fix them Learn how to fix them Learn new concepts –
The posterior malleolus needs to be reduced at the articular surface and the incisura
The posterior malleolar fracture and syndesmotic stability are intimately related To understand that we do not understand everything Classification
By size? Old rules – fix if >20% or 25%
Are X-rays enough? Lateral X-rays are unreliable ?% NO, NO, NO CT is much better Hassaan Q., et. al. JFAS, 2019. Xray vs. CT for surg plan The surgical approach for ankle fracture fixation changed in 32.7%
• Case – 43 y.o. woman - fall off a bike • Is this a posterior pilon variant??? • Does it matter??? Magnus, L., et. al. JOT 2015 Classification
Haraguchi, N., et. al. JBJS Am 2006 I – 67%, (12% artic.), II – 19% (30% artic. ), III - 14% (Shell) Mason LW., et. al. FAI 2017 Mason LW, et. al. , JB JS OpAc. 2019 Progresses in severity I – syndesmosis 100% (Posterior only?) II III – “posterior pilon” – syndesmosis 20% Pathomechanics Guides fixation and approach. Bartoníček J, et. al., Arch Orthop Trauma Surg., 2015 Importance of fibular notch involvement Classification – Posterior Medial Fragment
Vosoughi AR, et. al. , FAI 2019 Jun;40(6):648-655. Avulsion type (smaller) – pronation injuries (may not need surgery) Pilon type - Larger – supination injuries (Fix) Does the Classification Matter?
Blom RP, et. al. , Injury. 2019
73 pts. (2 year outcome data)
Haraguchi Type II - significantly poorer outcome scores
Pattern and morphology are important
Magnus, L., et. al. JOT 2015 Posterior Pilon Fractures Vs. Posterior Malleolar Fractures?
I think there is a difference Switaj PJ, et. al., FAI 2014 Mostly semantics 270 PTS. Posterior Pilon – Posterior pilon variant More extensive medial malleolar double contour sign, More axial load posterior malleolus fracture in the sagittal plane More damage to the articular surface Joint impaction Posterior malleolus - 50%. Posterior pilon variant was 40% of all PM fxs Older, female, diabetic OTA and Lauge-Hansen classifications do not correlate Surgical Planning - Approach
• Lateral Approaches • Supine • Little MT, et. al. FAI 2013
True Posterior lateral Posterior border of fibula EORIF.com Sural nerve
Medial NV structures Surgical Planning Approach
Posterior Medial
Supine
External rotation
Interval posterior tib and tibia
Bali N., et. al., Bone Joint J., 2017
https://musculoskeletal key.com/wp- content/uploads/2016 /09/DA1C3FF1.jpg Surgical Planning - Approach
Both posterior medial and posterior lateral
Prone JOT 2014 Alternative Position
Lateral Decubitus -
Can expose anterior and posterior ankle at the same time Little MT, et. al. FAI 45 y.o woman s/p MVA 2013 • Good access • Minimal wound complications • Good outcomes How Should We Fix Them? Screws Vs. Plates
Plates
Biomechanically better Anwar A, et. al., Injury. 2017 Simulation Plates better especially in bigger Are they necessary? PMs Complex comminuted Wang X, et. al. FAI 2017 Cadaver, Haragucci I – 2 P to A screws vs. fractures plates No difference Osteopaenia Kalem M, et. al., Acta Orthop Belg. 2018 More soft tissue stripping 67 pts., PA screws and plates were better No difference in ROM Loss of dorsiflexion Zhao H, et .al. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2013 Screws Posterior to anterior better The Emerging Role of arthroscopy in Managing ankle fractures Case study
DS 19 year old man Fell of an all terrain vehicle Case study
Tibia Tibia
Fibula
Talus Case study
• First gain fibular length with bone clamp • Next pin fibula to tibia • Next reduce the posterior malleolus • Use arthroscopy for the incarcerated fragments • Use manipulation with wires for the larger posterior fragment Tibia Tibia Fibula
Talus Case Study
Incarcerated Fragments were Medial clear space (gutter) and adequately reduced with syndesmosis are anatomically arthroscopic manipulation reduced and stable to external rotation stress
Talus Medial Tibia malleol us
Fibula Talus Technical Trick Why is all of this important?
Trimalleolar fractures have a poorer prognosis than lateral mal and bimal fractures Hong CC, et. Al., FAS . 2014 More severe posterior malleolar fractures do worse 52% - residual pain at 1 year Articular incongruity on follow-up leads to worse 61.9% and 47.6% - ankle stiffness and outcomes swelling Syndesmotic fixation through the posterior 2/3 unable to return to sports malleolus and PITFL equivalent to syndesmotic Increasing posterior malleolar screw fixation. fragment size - poorer functional outcome. Berkes MB, et. Al. JBJS 2013 Articular incongruity – worse clinical outcome Mason LW, et. al. , JB JS Open Access. 2019 Miller AN, et. al. CORR 2010 Miller MA, et. al., FAI 2018 Summary
You need a CT on all ankle fractures with a posterior malleolus fracture Important details Size Location Morphology – How much of the articular surface is trully involved? Is the fibular notch involved Surgical approach is determined by the pattern Posterior to anterior fixation is better There is a role for arthroscopy The better the reduction = Likely a better outcome Posterior stripping may have consequences There is still a lot that we do not Know How does the fracture affect deep deltoid and syndesmotic stability? Thank you Literature Review Magnus, L, et.al., JOT 2015 J Bone Joint Surg Am. 2006 May;88(5):1085-92. Pathoanatomy of posterior malleolar fractures of the ankle. Haraguchi N1, Haruyama H, Toga H, Kato F. Between 1999 and 2003, fifty-seven consecutive patients The fifty-seven fractures were categorized into three types: (1) the posterolateral-oblique type (thirty-eight fractures; 67%), (2) the medial-extension type (eleven fractures; 19%), and (3) the small-shell type (eight fractures; 14%). ] The average area of the fragment comprised 11.7% of the cross-sectional area of the tibial plafond for posterolateral-oblique fractures and 29.8% for medial-extension fractures. In the cases of seven of the nine fractures that comprised >25% of the tibial plafond, the fracture line extended to the medial malleolus. The fracture lines associated with posterior malleolar fractures appear to be highly variable. A large fragment extending to the medial malleolus existed in almost 20% of the posterior malleolar fractures in the current study, and some fragments involved almost the entire medial malleolus. Because of the great variation in fracture configurations, preoperative use of computed tomography may be justified. Mason LW., et. al. FAI 2017 Pathoanatomy and Associated Injuries of Posterior Malleolus Fracture of the Ankle.
progresses in severity, indicates the pathomechanics that cause the fracture, guides the surgeon to what fixation will be necessary by which approach.
METHODS:
The primary posterior malleolar fracture fragments were characterized into 3 groups. A type 1 fracture was described as a small extra-articular posterior malleolar primary fragment. Type 2 fractures consisted of a primary fragment of the posterolateral triangle of the tibia (Volkmann area). A type 3 primary fragment was characterized by a coronal plane fracture line involving the whole posterior plafond.
RESULTS:
In type 1 fractures, the syndesmosis was disrupted in 100% of cases, although a proportion only involved the posterior syndesmosis. In type 2 posterior malleolar fractures, there was a variable medial injury with mixed avulsion/impaction etiology. In type 3 posterior malleolar fractures, most fibular fractures were either a high fracture or a long oblique fracture in the same fracture alignment as the posterior shear tibia fragment. Most medial injuries were Y-type or posterior oblique fractures. This fracture pattern had a low incidence of syndesmotic injury.
CONCLUSION:
The value of this approach was that by following the pathomechanism through the ankle, it demonstrated which other structures were likely to be damaged by the path of the kinetic energy. With an understanding of the pattern of associated injuries for each category, a surgeon may be able to avoid some pitfalls in treatment of these injuries. Blom RP, et. al. , Injury. 2019 Jul;50(7):1392-1397
Posterior malleolar fracture morphology determines outcome in rotational type ankle fractures.
METHODS:
Between January 2010 and May 2014, 194 patients with an operatively (ORIF) treated ankle fracture, were prospectively included in the randomized clinical EF3X-trial at our Level-I trauma center. The current study retrospectively included 73 patients with rotational type ankle fractures and concomitant fractures of the posterior malleolus. According to the CT-based Haraguchi fracture morphology, all patients were divided into three groups: 20 Type I (large posterolateral-oblique), 21 Type II (transverse medial-extension) and 32 Type III (small-shell fragment). At 12 weeks, 1 year and 2 years postoperatively the Foot and Ankle Outcome Scores (FAOS) and SF-36 scores were obtained, with the FAOS domain scores at two years postoperative as primary study outcome.
Haraguchi Type II PM ankle fractures demonstrated significantly poorer outcome scores at two years follow-up compared to Haraguchi Types I and III. Mean FAOS domain scores at two years follow-up showed to be significantly worse in Haraguchi Type II as compared to Type III, respectively: Symptoms 48.2 versus 61.7 (p = 0.03), Pain 58.5 versus 84.4 (p <