Posterior Fractures / Posterior Pilon Variants

STEVEN STEINLAUF, MD THE ORTHOPAEDIC AND 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 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

 Bali N., et. al., 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, 1year 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<0.01), Activities of Daily Living (ADL) 64.1 versus 90.5 (p<0.01).

 CONCLUSION:

 Posterior malleolar ankle fractures with medial extension of the fracture line (i.e. Haraguchi Type II) are associated with significantly poorer functional outcomes. The current dogma to fix PM fractures that involve at least 25-33% of the tibial plafond may be challenged, as posterior malleolar fracture pattern and morphology - rather than fragment size - seem to determine outcome.  Vosoughi AR, et. al. , FAI 2019 Jun;40(6):648-655.

 CT Analysis of the Posteromedial Fragment of the Posterior Malleolar Fracture.

 All Mason and Molloy type 2B fractures, defined as fracture of both the posterolateral and the posteromedial fragments of the posterior malleolus, from our database were identified to analyze the preoperative computed tomography scan. The posteromedial fragment was investigated in 47 cases (mean age, 46.6 years; 11 male, 36 female).

 RESULTS:

 Morphologically, the fracture could be divided into 2 subtypes: (1) a large pilon intra-articular fragment (mean of X axis: 33.0 mm, Y: 30.7 mm, Z: 31.7 mm) presented in 29 cases with mean interfragmentary angle of 32.1 and back of tibia angle of 32.7 degrees (this was seen in 25 of 27 cases with supination injury pattern); and (2) a small extra-articular avulsion fragment (mean of X axis: 9.6 mm, Y: 13.2 mm, Z: 11.5 mm) present in 18 cases with a mean interfragmentary angle of 11.0 and back of tibia angle of 10.1 degrees. It was seen in 80% of pronation injuries.

 CONCLUSION:

 The avulsion type of the posteromedial fragment of posterior malleolus fracture was more common in pronation injuries, likely the result of traction by the intermalleolar ligament, and the pilon type was more common in supination injuries, likely the result of the rotating talus impaction. Because of the intra- articular involvement, we believe the pilon type should undergo fixation to achieve articular congruity, unlike the avulsion type which may only function as a secondary syndesmotic stabilizer.  Bartoníček J, et. al., Arch Orthop Trauma Surg., 2015 Apr;135(4):505- 16  Anatomy and classification of the posterior tibial fragment in ankle fractures.  141 pts, CT with 3D reconstructions  type 1: extraincisural fragment with an intact fibular notch, type 2: posterolateral fragment extending into the fibular notch, type 3: posteromedial two-part fragment involving the medial malleolus, type 4: large posterolateral triangular fragment.  type 5 (irregular, osteoporotic fragments).  size, shape and location of the fragment, stability of the tibio-talar joint and the integrity of the fibular notch. The effect of computerised tomography on operative planning in posterior malleolus ankle fractures⋆ Author links open overlay panel Hassaan Q., et. al. j.fas.2019.

Methods Twenty consecutive patients with fractures involving the posterior malleolus were retrospectively selected and had their plain radiographs and CT scan anonymised. Initially, radiographs alone were presented to nine trauma surgeons to formulate a surgical plan individually. After a minimum of 6 weeks, the same process was repeated with CT scans available.

Results The surgical approach for ankle fracture fixation changed in 32.7% of cases following CT scan review. A CT scan altered the decision to stabilise the posterior malleolus in 25.6% and the decision of whether to stabilise the syndesmosis in 16.6% of cases.

Conclusions This study demonstrates that a pre-operative CT scan changes the surgical approach in 32.7% of cases and therefore we recommend use of CT scanning in this subset of ankle injuries.  Sukur E, et. al., Orthop Traumatol Surg Res. 2017 Sep;103(5):703-707.  Open reduction in pilon variant posterior malleolar fractures: Radiological and clinical evaluation.  CT images and radiographs of 67 patients with trimalleolar ankle fractures were retrospectively analyzed. Fourteen patients (6 women and 8 men) were studied. The mean age was 37.7 (range, 21-58) years, and mean follow-up period was 17.1 (range, 12-24) months. All patients underwent open reduction. Reconstruction of the joint surface was assessed with postoperative CT images. The outcomes were assessed with the American Academy of Orthopaedic Surgeons (AAOS) and Osteoarthritis (OA) scoring systems.  RESULTS:  The ratio of PVPM fractures to trimalleolar ankle fractures was 20.1%. Postoperative CT images demonstrated that anatomic reconstruction was achieved in 11 patients. The mean AAOS scores were 85.6 in Type 1 and 81.1 in Type 2 cases. The mean OA scores were 1 in Type 1 and 1.1 in Type 2 cases (P>0.05). The only statistically significant difference between the 2 groups was in osteochondral impaction (P<0.05).  CONCLUSION:  CT imaging is essential for the accurate diagnosis and management of PVPM fractures. Posteromedial and posterolateral incisions enable direct exposure, and therefore facilitate joint surface reconstruction.  Foot Ankle Int. 2014 Sep;35(9):886-95. doi: 10.1177/1071100714537630. Epub 2014 Jun 18.

 Evaluation of posterior malleolar fractures and the posterior pilon variant in operatively treated ankle fractures. The posterior pilon variant pattern was

 Switaj PJ1, Weatherford B2, Fuchs D3, Rosenthal B3, Pang E3, Kadakia AR3. defined by the presence of a medial  METHODS: malleolar doublecontour sign,40 a  We retrospectively identified 270 patients who met our inclusion criteria. Basic demographic data were collected. The fractures were classified according to Lauge-Hansen and AO/OTA. Additional radiographic posterior malleolus fracture in the sagittal data included whether the fracture involved the posterior malleolus and whether the fracture represented a posterior pilon variant. Univariate statistical methods, chi-square analysis, and interobserver reliability were assessed. plane (split posterior malleolus),37 or

 RESULTS: posterior malleolar impaction (Figure 1).

 The relative frequency of posterior malleolus fracture was 50%. The relative frequency of the posterior pilon variant was 20%. No significant difference was noted with respect to the frequency of posterior malleolar or posterior pilon variant between the subgroups of the AO/OTA and Lauge- Hansen classification systems when compared to the overall fracture distribution. Patients with posterior malleolar fractures and posterior pilon variants were significantly older. Females were significantly more likely than men to sustain posterior malleolar fractures and posterior pilon variants. Patients with diabetes trended toward a greater risk of both types of fractures. Interobserver reliability data revealed substantial agreement for posterior malleolar fractures and posterior pilon variants.

 CONCLUSION:

 These data represent the highest reported rate of posterior malleolar involvement in operatively treated ankle fractures and is the first to describe the percentage of the posterior pilon variant in such a large series. The interobserver reliability data demonstrate substantial agreement in identification of posterior malleolar fractures and the posterior pilon variant based on plain radiographs. Certain patient characteristics such as age, sex, and diabetes may be associated with these fractures.  Foot Ankle Int. 2017 Oct;38(10):1132-1138. doi: 10.1177/1071100717719531. Epub 2017 Jul 31.

 Biomechanical Study of Screw Fixation and Plate Fixation of a Posterior Malleolar Fracture in a Simulation of the Normal Gait Cycle.

 Wang X, et. al. FAI 2017

 Haragucci I – 2 Pto A scews vs. plates

 Nodifference

 Thirty-six below-knee specimens with a single posterolateral fragment (Haraguchi I) type posterior malleolar fracture models were randomly divided into 2 groups. Two parallel-placed 3.5-mm partially threaded P to A titanium alloy screws were used in Group A to fix the fractures, while anatomical plates were used in Group B. According to the ratio (S) of the area between the fracture and the total articular surface, each group was subdivided into 3 subgroups. In group A1 and B1, S=1/4; in A2 and B2, S=1/3; and in A3 and B3, S=1/2. To simulate the gait cycle, each specimen was subjected to mechanical loading in 4 different ankle positions. A fatigue loading system was used for repeated loading. A spatial motion capture system was used to measure the displacement in the final loading stage.

 RESULTS:

 Despite the limited sample size and relatively low power, no significant difference was observed between A1 and B1, A2 and B2, and A3 and B3 in all 4 ankle positions after repeated loading.

 CONCLUSION:

 For a Haraguchi type I posterior malleolar fracture with an average height of 19 mm, fixation with a posterior malleolar anatomical plate failed to demonstrate a stronger strength than 2 parallel-placed 3.5-mm partially threaded screws, which indicates that plates may not be absolutely necessary for standard rehabilitation after posterior malleolar internal fixation.  Kalem M, et. al., Acta Orthop Belg. 2018 Jun;84(2):203-212.  Comparison of three posterior malleolar fixation methods in trimalleolar ankle fractures.  104 trimalleolar fracture cases treated surgically between October 2011 and January 2014 were extracted from hospital records.  A total of 67 patients met the study inclusion criteria; 20 cases in the AP screw, 13 cases in the PA screw and 34 cases in the plate group. The mean follow-up period was 14.4 ± 2.23 months in AP, 16.3 ± 2.56 months in PA and 17.1 ± 3.01 months in the plate group.  Better AOFAS scores were obtained in the PA group and the plate group compared to the AP screw group (p < 0.001).  No statistically significant difference was found between the groups in respect of VAS scores during walking and dorsiflexion restriction. Better radiological reduction was observed in the PA screw group and the plate group (p < 0.001).  PMID:  Injury. 2017 Apr;48(4):825-832. doi: 10.1016/j.injury.2017.02.012. Epub 2017 Feb 20.

 Finite element analysis of the three different posterior malleolus fixation strategies in relation to different fracture sizes.

 Anwar A1, Lv D2, Zhao Z3, Zhang Z4, Lu M5, Nazir MU6, Qasim W7.

 Author information

 Abstract

 PURPOSE:

 Appropriate fixation method for the posterior malleolar fractures (PMF) according to the fracture size is still not clear. Aim of this study was to evaluate the outcomes of the different fixation methods used for fixation of PMF by finite element analysis (FEA) and to compare the effect of fixation constructs on the size of the fracture computationally.

 MATERIALS AND METHODS:

 Three dimensional model of the tibia was reconstructed from computed tomography (CT) images. PMF of 30%, 40% and 50% fragment sizes were simulated through computational processing. Two antero-posterior (AP) lag screws, two postero-anterior (PA) lag screws and posterior buttress plate were analysed for three different fracture volumes. The simulated loads of 350N and 700N were applied to the proximal tibial end. Models were fixed distally in all degrees of freedom.

 RESULTS:

 In single limb standing condition, the posterior plate group produced the lowest relative displacement (RD) among all the groups (0.01, 0.03 and 0.06mm). Further nodal analysis of the highest RD fracture group showed a higher mean displacement of 4.77mm and 4.23mm in AP and PA lag screws model (p=0.000). The amounts of stress subjected to these implants, 134.36MPa and 140.75MPa were also significantly lower (p=0.000). There was a negative correlation (p=0.021) between implant stress and the displacement which signifies a less stable fixation using AP and PA lag screws.

 CONCLUSION:

 Progressively increasing fracture size demands more stable fixation construct because RD increases significantly. Posterior buttress plate produces superior stability and lowest RD in PMF models irrespective of the fragment size.  Bali N., et. al., Bone Joint J., 2017  An evolution in the management of fractures of the ankle: safety and efficacy of posteromedial approach for Haraguchi type 2 posterior malleolar fractures.  We performed a review of 15 patients with a Haraguchi type 2 posterior malleolar fracture which was fixed using a posteromedial approach. Five patients underwent initial temporary spanning external fixation. The outcome was assessed at a median follow-up of 29 months (interquartile range (IQR) 17 to 36) using the Olerud and Molander score and radiographs were assessed for the quality of the reduction.  RESULTS:  The median Olerud and Molander score was 72 (IQR 70 to 75), representing a good functional outcome. The reduction was anatomical in ten, with a median step of 1.2 mm (IQR 0.9 to 1.85) in the remaining five patients. One patient had parasthaesiae affecting the medial forefoot, which resolved within three months.  CONCLUSION:  We found that the posteromedial approach to the ankle for the surgical treatment of Haraguchi type 2 posterior malleolar fractures is a safe technique that enables good visualisation and reduction of the individual fracture fragments with promising early outcomes. Cite this article: Case Study #2

Syndesmosis screw removal at 5 months Is There a Role for Arthoscopy

 Martin KD, FAI 2020  Posterior Arthroscopic Reduction and Internal Fixation for Treatment of Posterior Malleolus Fractures.  Posterior malleolus fractures and pilon variants refer to a pattern of fractures involving the posterior weightbearing surface of the tibial plafond. The surgical indications for fixation of posterior malleolus fractures varies considerably throughout the literature, based on the size and/or displacement. There is controversy on how to best address fracture fixation, with the main workhorses being either the posterior- lateral approach or indirect anterior-posterior-directed screws. We present an alternative technique for posterior malleolus fracture fixation using a direct posterior arthroscopic-assisted reduction internal fixation method. With this method, posterior malleolus fractures are reduced arthroscopically and percutaneous fixation is placed through the arthroscopic portals. Level of Evidence: Level V, expert opinion. Articular congruity is associated with short-term clinical outcomes of operatively treated SER IV ankle fractures

 Berkes MB, et. Al. JBJS 2013  108 SER IV ankle fractures, Postoperative computed tomography (CT) scans  F/U - 21 months.  72 patients (67%) had a congruent ankle joint (< 2 mm step off or gap)  36 (33%) - articular surface incongruity  Articular incongruity – worse clinical outcome  Orthopaedic surgeons – should strive for perfection to allow for the best possible clinical outcome. [Effectiveness and biomechanical analysis of three fixation methods in treatment of posterior Pilon fractures].

 Zhao H, et .al. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2013  Fifteen fresh-frozen cadavers  Fracture was fixed :  plate (n = 5), AP screw (n = 5), PA sc rew (n = 5).  56 patients with posterior

 AP screw - 11 cases

 PA screw - 26 cases

 Plate - 19 cases.  Fixation failure was caused by cancellous bone compression.  The instantaneous loads of 1 mm and 2 mm steps were the largest in BPF group, larger in SPAF group, and smallest in SAPF group,  Fixation failure was found in 2 cases of AP group only  AOFAS score was significantly lower in AP group and VAS scores higher  no significant difference was found between SPAF and BPF groups Complications following treatment of supination external rotation ankle fractures through the posterolateral approach

 Little MT, et. al. FAI 2013  Good access to:

 Apex of the fibula fracture for posterior antiglide plating

 Posterior malleolus for fixation

 Posterior inferior tibiofibular ligament for repair  Minimal major wound complications  Good functional outcomes  Minimal need for reoperation. Posterior malleolar stabilization of syndesmotic injuries is equivalent to screw fixation.

 Miller AN, et. al. CORR 2010  31 patients with unstable ankle fractures treated with (1) open posterior malleolus fixation whenever the posterior malleolus was fractured, regardless of fragment size (PM group; n = 9); (2) locked syndesmotic screws in the absence of a posterior malleolar fracture (S group; n = 14); or (3) combined fixation in fracture-dislocations and more severe soft tissue injury (C group; n = 8).

 Syndesmotic fixation through the posterior malleolus and PITFL is maintained at followup, and these patients have functional outcomes at least equivalent to outcomes for patients having syndesmotic screw fixation. Outcomes

 Mason LW, et. al. , JB JS Open Access. 2019 Posterior Malleolar Ankle Fractures: An Effort at Improving Outcomes.  Type-1 fractures underwent syndesmotic fixation. Type-2A fractures underwent open reduction and internal fixation through a posterolateral incision, type-2B fractures underwent open reduction and internal fixation through either a posteromedial incision or a combination of a posterolateral with a medial-posteromedial incision, and type-3 fractures underwent open reduction and internal fixation through a posteromedial incision.  Patient-related outcome measures were obtained in 50 patients with at least 1-year follow-up. According to the Mason and Molloy classification, there were 17 type-1 fractures, 12 type- 2A fractures, 10 type-2B fractures, and 11 type-3 fractures. The mean Olerud- Molander Ankle Score was 75.9 points (95% confidence interval [CI], 66.4 to 85.3 points) for patients with type-1 fractures, 75.0 points (95% CI, 61.5 to 88.5 points) for patients with type- 2A fractures, 74.0 points (95% CI, 64.2 to 83.8 points) for patients with type-2B fractures, and 70.5 points (95% CI, 59.0 to 81.9 points) for patients with type-3 fractures.  CONCLUSIONS:  We have been able to demonstrate an improvement in the Olerud-Molander Ankle Score for all posterior malleolar fractures with the treatment algorithm applied using the Mason and Molloy classification. Mason classification type-3 fractures have marginally poorer outcomes, which correlates with a more severe injury; however, this did not reach significance.  Miller MA, et. al., FAI 2018 Jan;39(1):99-104. doi: 10.1177/1071100717735839. Epub 2017 Oct 23.

 Stability of the Syndesmosis After Posterior Malleolar Fracture Fixation.

 We sought to define the rate of syndesmotic instability after anatomic reduction of the posterior malleolus when posterior stabilization of a trimalleolar or trimalleolar equivalent ankle fracture was chosen vs when a supine position and initially conservative management of the posterior elements was chosen.

 METHODS:

 The types of syndesmotic and posterior malleolar fixation used to treat adult patients with ankle fractures involving the posterior malleolus at our level I trauma center were retrospectively assessed (N = 198). Specifically, both bimalleolar and trimalleolar fractures were included. Exclusion criteria included pilon fractures, trimalleolar fractures with Chaput fragments, and neurologic injury. Demographics, fracture classification, initial operative position, medial clear space, and posterior malleolar fragment size were recorded for each fracture.

 RESULTS:

 In total, 151 patients (76.3%) were initially positioned supine, 27.2% of whom had syndesmotic instability requiring operative stabilization. Almost 25% of supine patients also underwent posterior malleolar stabilization for posterior instability. Overall, 73 (48.3%) patients who were initially treated in the supine position needed some form of additional stabilization. Forty-seven patients (23.7%) were initially positioned prone. Syndesmotic stability was restored in 97.9% of these patients. This 2.1% rate of instability vastly differs from the 13-fold higher syndesmotic instability rate observed in the supine group ( P < .001).

 CONCLUSION:

 Our data demonstrate that the rate of syndesmotic instability was reduced in trimalleolar and trimalleolar equivalent fractures when prone positioning and direct fixation of the posterior malleolus were first performed. Using traditional preoperative estimates of posterior stability to determine the need for posterior malleolar fixation may be inadequate since almost a quarter of patients treated supine received posterior stabilization. Case Studies Case 2 – Pre-op

• 52 y.o. laborer s/p fall Case 2 – Post-op

• ORIF of posterior malleolus • Syndesmosis still unstable • My bias for rigid fixation in an axial unstable situation • There are proponents for an endobutton is this setting Case Study – Posterior Malleolus Fracture

• 30 y.o. PA s/p slip and fall • Closed Reduction • How do you want to treat? • Additional work up? Case Study – Posterior Malleolus Fracture Case Study – Posterior Malleolus Fracture

•Syndesmosis was stable Fixation – Screws Vs. Plates

 Case 1 Zhao H, et .al. Zhongguo Xiu  50 y.o. maintenance worker s/p fall from ladder Fu Chong Jian Wai Ke Za  Large open medial wound with posterior tibial tendon Zhi. 2013 dislocation • cadavers  Position? • Posterior to anterior  Approach? screws or plate better than anterior to posterior screws Case Study Technical Aspects: • Use Minfragment plates on fibula and posterior medial • Less Irritation of tendons and soft tissues