Posterior Malleolus Fracture Displacement Is Associated with Rotational Ankle Fracture Stability in Patients Without Medial Malleolar Fractures

Background

The optimal method for the determination of ankle stability remains controversial in rotational ankle fractures without medial bony injury.

Questions/Purposes

The purposes of this study were to (1) evaluate whether posterior malleolar (PM) fracture displacement is associated with deltoid ligament injury in supination-external rotation (SER) ankle fractures and (2) compare the diagnostic accuracy of PM displacement and magnetic resonance imaging (MRI) evaluation of the deep deltoid ligament in identifying fractures with deltoid ligament incompetence.

Methods

Patients with rotational bimalleolar injuries containing lateral malleolar and PM fractures without bony medial injury were included. After operative lateral and PM fixation, an external rotation stress test was performed to evaluate deltoid ligament stability. Operative dictations were reviewed to confirm injury pattern, stability on stress test, and visual inspection of the deltoid ligament. Maximum PM displacement was assessed on lateral X-ray. Pre-operative MRI of the ankle was performed following closed reduction and splinting.

Results

The final cohort consisted of 13 trimalleolar equivalent fractures (torn deltoid ligament) and 20 bimalleolar fractures (medial malleolus and deltoid ligament intact). Average PM displacement was significantly higher for SER trimalleolar equivalent patterns when measured on lateral X-ray. The sensitivity of detecting trimalleolar equivalent fracture was higher on all reported X-ray findings than the sensitivity obtained by the reported MRI findings of deltoid ligament injury.

Conclusion

PM displacement on X-ray is a useful adjuvant along with external rotation stress radiography and MRI evaluation of deep deltoid integrity to distinguish between stable and unstable fracture patterns and thus helps facilitate treatment decisions.

     

A clinical evaluation of alternative fixation techniques for medial malleolus fractures

Background

Medial malleolus fractures have traditionally been managed using partially threaded screws and/or Kirschner wire fixation. Using these conventional techniques, a non-union rate of as high as 20% has been reported. In addition too many patients complaining of prominent hardware as a source of pain post-fixation. This study was designed to assess the outcomes of medial malleolar fixation using a headless compression screw in terms of union rate, the need for hardware removal, and pain over the hardware site.

Setting

Saint Louis University and Mercy Medical Center, Level 1 Trauma Centers, St. Louis, MO.

Methods

After IRB approval, we used billing records to identify all patients with ankle fractures involving the medial malleolus. Medical records and radiographs were reviewed to identify patients with medial malleolar fractures treated with headless compression screw fixation. Our inclusion criteria included follow-up until full weight bearing and a healed fracture. Follow-up clinical records and radiographs were reviewed to determine union, complication rate and perception of pain over the site of medial malleolus fixation. Sixty-four ankles were fixed via headless compression screws and 44 had adequate follow-up for additional evaluation.

Results

Seven patients had isolated medial malleolar fractures, 23 patients had bimalleolar fractures, and 14 patients had trimalleolar fractures. One patient (2%) required hardware removal due to cellulitis. One patient (2%) had a delayed union, which healed without additional intervention. Ten patients (23%) reported mild discomfort to palpation over the medial malleolus. The median follow-up was 35 weeks (range: 12–208 weeks). There were no screw removals for painful hardware and no cases of non-union.

Conclusions

Headless compression screws provide effective compression of medial malleolus fractures and result in good clinical outcomes. The headless compression screw is a beneficial alternative to the conventional methods of medial malleolus fixation.     

Nonunion of a medial malleolar stress fracture in an adolescent athlete secondary to lateral ankle instability: A case report

IntroductionMedial malleolar stress fractures are relatively uncommon. This report describes the successful treatment of nonunion of a medial malleolar stress fracture due to chronic lateral ankle instability.Presentation of caseA 13-year-old middle school student who belonged to a football club presented to our clinic with chronic medial left ankle pain lasting over a year. He had sprained his left ankle several times 6 years earlier. A plain anteroposterior ankle radiograph showed a vertical fracture line in the medial malleolus involving the epiphyseal plate, and computed tomography demonstrated the vertical fracture seen on the plain radiographs and bone sclerosis at the fracture site. We performed internal fixation for nonunion of the medial malleolar stress fracture with arthroscopic modified Broström for lateral ankle instability. Two years after surgery, the Self-Administered Foot Evaluation Questionnaire improved in all parameters, and both the anterior drawer and varus stress tests were negative.DiscussionEarly diagnosis of medial malleolar stress fracture is important for a rapid return to sports. Magnetic resonance imaging is helpful for early diagnosis. Because lateral ankle instability can cause medial malleolar stress fracture, arthroscopic modified Broström procedure is meaningful for medial malleolar stress fracture with lateral ankle instability.ConclusionInternal fixation and the arthroscopic modified Broström procedure could achieve good clinical outcomes for medial malleolar stress fractures with lateral ankle instability.     

Does functional outcome depend on the quality of the fracture fixation? Mid to long term outcomes of ankle fractures at two university teaching hospitals

BackgroundThe aim of our study was to assess the adequacy of reduction and internal fixation of ankle fractures and the long-term functional outcomes of patients treated in two university teaching hospitals by general orthopaedic surgeons.MethodWe performed a retrospective study involving two large trauma units in the UK, reviewing all operatively treated unstable ankle fractures performed in one centre between 1st October 2006 and 31st December 2007 and another centre between 1st January 2009 and 31st December 2009. All patients were contacted by postal follow up at a minimum of 6-years using the Olerud–Molander Ankle Score (OMAS).Results261 patients underwent operative treatment for ankle fractures during the study period at the two hospitals. 107 patients responded to the questionnaire. Analysis of patients’ functional outcome by fracture type reveals that the outcome scores decrease as the complexity of the ankle fracture increases. A significant finding within subgroup analysis found that trimalleolar fractures (B3) have worse outcomes than bimalleolar fractures (B2 and C); which in turn have worse outcomes than isolated lateral malleolar fractures (B1). Analyzing the outcome of patients based on the severity of malreduction revealed that Pettrone’s value was inversely proportional to the OMAS.ConclusionWe have found a significant reduction in patient reported function in patients whose fractures were malreduced at time of surgery.     

The association between medial malleolar fracture geometry,injury mechanism,and syndesmotic disruption

BackgroundPrecise correlations between medial malleolar fracture geometry and fracture mechanism have not been thoroughly described. This study sought to determine the prevalence of different medial malleolar fracture types and to elucidate the association between fracture geometry and fracture mechanism.MethodsThe records of 112 medial malleolar ankle fractures were reviewed. For each fracture, the direction of the fracture line in the medial malleolus (transverse, oblique, vertical, or comminuted), the Lauge-Hansen classification, and the presence or absence of syndesmotic injury was recorded. Bivariate correlation analysis was performed to determine if correlations existed.ResultsTransverse fractures were the most prevalent type of medial malleolar fracture [n = 64 (57%)], and they correlated with supination-external rotation injuries. These were followed by oblique fractures [29 (26)], which correlated with pronation-external rotation injuries [29 (26)], and vertical fractures [7 (6)], which correlated with supination-adduction injuries [9 (8)]. Comminuted fractures [12 (11)] and pronation-abduction injuries [22 (20)] did not correlate with any other categories. Syndesmotic injuries were correlated with transverse fractures, bimalleolar fractures, and pronation-external rotation injuries.ConclusionMedial malleolar fractures can be divided into four fracture types: transverse fractures, which correlated with supination-external rotation injuries; oblique fractures, which correlated with pronation-external rotation injuries; vertical fractures, which correlated with supination-adduction injuries; and comminuted fractures, which did not correlate with a particular type of injury. Syndesmotic injury was positively correlated with transverse fractures of the medial malleolus, bimalleolar fractures, and pronation-external rotation injuries. These findings suggest that medial malleolar fracture geometry can provide valuable information for the clinician when classifying and managing ankle fractures.     

Malleolar fractures. Predictive factors for secondary osteoarthritis. Retrospective study of 32 cases

The authors report a series of 32 ankle fractures treated by internal fixation and reviewed with a follow-up of more than 15 years. The series includes 12 fibular, 14 bimalleolar and 6 trimalleolar fractures. Following Weber's classification, there were 4 type A, 18 type B and 10 type C fractures. The postoperative x-ray showed 28 anatomy reductions; shortening of the fibula from 3 to 5 mm was noted in 4 cases. Clinical results were evaluated according to Kitaoka's criteria, and radiological results according to Magnusson's criteria. Statistical analysis was made with a Chi-square test. The retrospective review at an average follow-up of 15 years showed 19 painfree ankles, normal mobility in 22 cases, absence of edema in 18. The shoe-wear was normal in 30 cases. Walking had returned to normal in 23 cases but radiography showed narrowing of the tibiotalar joint line in 12 cases and lengthening of the medial malleolus in 16. Narrowing of the tibiotalar joint space was associated with lengthening of the medial malleolus in 10 cases. The objective results were rated as follows: 23 good, 8 fair, and 1 poor. With a follow-up of 15 years, we noted degenerative changes in the ankle in 37% of cases in spite of an anatomic reconstruction which had been perfect in 28. Shortening of the fibula, observed in 4 cases, was associated with subsequent ossification below the medial malleolus corresponding to avulsion of the non sutured medial collateral ligament. Nevertheless, degenerative changes of the ankle were clinically well-tolerated. The long term result of internal fixation of malleolar fractures was good. This was achieved only through perfect restoration of the joint anatomy. Contrary to other series, non-operative repair of the medial collateral ligament was associated with long team degenerative changes and reduced mobility of the joint. We therefore now advocate surgical repair of the medial collateral ligament.     

Radiographic effects observed in the coronal view after medial malleolar osteotomy at total ankle arthroplasty in rheumatoid arthritis cases

BackgroundWhen soft tissue balance is not acceptable at total ankle arthroplasty (TAA) for rheumatoid varus deformity, medial malleolar osteotomy has been performed. At the same time, the shape of the ankle joint changes after soft tissue balancing with such an osteotomy, however there is few information for the radiographic findings after the osteotomy. Thus, radiographic changes in the coronal view of such cases were investigated.MethodsJSSF-RA foot and ankle scale and SAFE-Q scores were determined along with pre/postoperative radiographic parameters of the ankle joint in 70 ankles (65 patients) with rheumatoid arthritis followed for a mean of 7.9 years (range, 2–16 years) after TAA. Seven ankles were excluded because those underwent lateral or lateral/medial malleolar osteotomy. Twenty-seven ankles underwent medial malleolar osteotomy, and compared with 36 ankles without osteotomy.ResultsAll ankles achieved bone union after medial malleolar osteotomy, and the tibial medial malleolus (TMM) angle was significantly decreased [30.3°–19.1°] following significant valgus correction [TC angle: −2.7° to 0.5°]. The gap due to medial soft tissue tightness was significantly improved by medial malleolar osteotomy [4.95° to 0.7°]. Lateral malleolar fractures sometimes occurred (19%: 5/27 ankles) at valgus correction, but they healed completely without any internal fixation.ConclusionMedial malleolar osteotomy was useful in rheumatoid varus ankle for not only controlling the soft tissue balance, but also providing a stabilized shape of the ankle joint. Lateral malleolar fractures were caused by valgus correction following medial malleolar osteotomy in some cases, but all fractures were completely healed without any internal fixation.     

Arthroscopically Assisted Treatment of Complex Ankle Fractures: Intra-articular Findings and 1-Year Follow-Up

Especially after complex ankle fractures, patients regularly suffer from residual symptoms, presumably due to occult intra-articular injuries. The aim of this study was to evaluate the intra-articular lesions, identify fractures specifically at risk for these, and assess the results after arthroscopically assisted open reduction and internal fixation of complex ankle fractures after 1 year. The primary outcome was the American Orthopedic Foot and Ankle Society (AOFAS) hindfoot score. Secondary outcome parameters were the Olerud and Molander Ankle Score (OMAS), Tegner activity scale, arthroscopic findings, functional assessment, and complications. Thirty-two patients (56% female) were enrolled. Chondral lesions were detected in 91%. Full-thickness lesions treated by microfracturing were observed in 0% of unimalleolar, 43% of bimalleolar, and 40% of trimalleolar fractures. After 1 year, the median (interquartile range) AOFAS was 94 (9) and OMAS was 90 (10) for all patients. When analyzing factors possibly influencing the outcome, age, sex, smoking, grading for surgical procedures according to the American Society of Anesthesiologists, fracture type (uni-, bi-, or trimalleolar), severity of chondral lesions graded according to the International Cartilage Repair Society (grade <4 versus grade 4), and syndesmotic instability had no significant influence on the outcome. The only variable significantly influencing the AOFAS (p = .004) and OMAS (p < .001) was body mass index (BMI; r_s = –0.522 and –0.606, respectively), with a higher BMI resulting in inferior outcome scores. Complications were observed in 3 patients, 2 with superficial skin necrosis at the posterolateral incision and 1 nonunion of the medial malleolus. Taken together, these data show that intra-articular injuries were common in ankle fractures. Bi- and trimalleolar fractures were particularly at risk for full-thickness lesions. A higher BMI tended to result in inferior outcome scores. Arthroscopically assisted open reduction and internal fixation led to good to excellent results in all but 1 patient.     

Competence of the deltoid ligament in bimalleolar ankle fractures after medial malleolar fixation

BACKGROUND: The stability of the ankle joint is provided by the medial and lateral malleoli and ligaments. Recent studies of cadaveric ankles have demonstrated that injury to the medial structures of the ankle is necessary to allow lateral subluxation of the talus after fracture. However, cadaveric models are limited by the fracture pattern chosen for the model. We sought to investigate the competency of the deltoid ligament in vivo in patients with an operatively treated bimalleolar ankle fracture. METHODS: Twenty-seven patients with a bimalleolar ankle fracture were evaluated. In each patient, the medial malleolus was anatomically reduced and fixed. A radiograph of the ankle was then made with application of an external rotation load to the joint. All lateral malleolar injuries were then reduced and fixed. The radiographs were evaluated for restoration of the competence of the deltoid ligament according to established criteria. RESULTS: Seven (26 percent) of the twenty-seven patients had radiographically evident incompetence of the deltoid ligament after medial malleolar fixation. This finding was associated with a small medial malleolar fragment. CONCLUSIONS: In bimalleolar fractures, the medial injury may be an osseous avulsion, leaving the deltoid intact on the displaced fragment, or it may be a combination of ligamentous and osseous injury with disruption of the deep portion of the deltoid ligament.     

Outcomes of posterior malleolar fixation in ankle fractures in a major trauma centre

AimsOngoing controversy exists over the indications and benefits of posterior malleolar fixation in ankle fractures. The aim of this pragmatic study was to evaluate the outcomes of posterior malleolar fracture fixation in ankle fractures in the setting of a major trauma centre. Our hypothesis is that posterior malleolus fixation leads to improved clinical outcomes.MethodsA total of 320 patients were identified with operatively treated ankle fractures involving a posterior malleolus component, at our institution between January 2012 and January 2018, ensuring a minimum 2 year follow-up. Of these patients, 160 had the posterior malleolus fixed as part of their surgery and 160 did not. Patient demographics, surgical details and complications were assessed. The Manchester-Oxford Foot Questionnaire (MOXFQ) was the primary patient outcome measure.ResultsFixation of the posterior malleolus was associated with a statistically significant improvement in patient outcomes. Mean MOXFQ score in the unfixed posterior malleolus group was 24.03 (0 - 62), compared to 20.10 (0 - 67) in the fixed posterior malleolus group (p = 0.04). Outcomes were worse with increasing size of posterior malleolar fragment. Metalwork-related issues were higher in the posterior malleolus fixed group (24/160 (15%) versus 10/160 (6.2%)) and re-operation rate was double.ConclusionThis study demonstrates that in the practical setting of a major trauma unit, fixation of the posterior malleolar fracture leads to improved patient outcomes but with increased metalwork risks and reoperation rates.     

An evaluation of the Weber classification of ankle fractures

This retrospective study over a 3 year follow-up was designed to establish the significance of the Weber classification of ankle fractures with regards to functional and radiographic outcome. One hundred and seven patients were available for follow-up, of which 88 ankles could be classified with the Weber system. Medial malleolar fractures alone and pilon fractures could not be classified with this system. A correlation was found between the type of Weber fracture and the overall ankle score. This held true for unimalleolar fractures alone. More complex bimalleolar and trimalleolar fractures did not follow this convention. Logistical regression analysis was used to evaluate other predictors of outcome. Bimalleolar and trimalleolar fractures were statistically significant predictors of a poorer outcome (P = 0.033, P = 0.021). The initial degree of displacement was also determined to be a predictor of outcome (P = 0.0133) as was the operative reduction (P = 0.0113). Using linear regression, older age (> 62 years) was also established as a predictor of a poorer outcome (P < 0.05). The Weber classification was found to be a predictor of outcome in unimalleloar ankle fractures and not for multimalleolar fractures. We have identified further predictors of a poorer outcome in ankle fractures as the degree of initial injury, the number of malleoli fractured and older age. These factors were found to have greater significance in predicting outcome than the level of fibular fracture alone. We have identified a deficiency of the Weber system in excluding these criteria and have addressed this by modifying the existing system to include the number of malleoli involved, thus providing a more useful prognostic tool.     

Bicortical fixation of medial malleolar fractures: a review of 23 cases at risk for complicated bone healing

Several methods have been described for fixation of unstable medial malleolar fractures. Certain patient populations, including the elderly, those with osteoporosis and osteopenia, and patients with diabetes mellitus, are generally known to be susceptible to complications associated with ankle fracture healing. The goal of the present retrospective investigation was to review the outcomes of a series of patients who had undergone medial malleolar fracture repair using fully threaded bicortical interfragmental compression screw fixation. Patients were included in the present series if they had undergone bicortical fixation of an unstable ankle fracture with a medial malleolar fracture component, in addition to having at least 1 of the following comorbidities: age 55 years or older, osteoporosis or osteopenia, diabetes mellitus, peripheral arterial disease, end-stage renal disease, chronic kidney disease, previous kidney transplantation, peripheral neuropathy, or current tobacco use. A total of 23 ankle fractures in 22 consecutive patients met the inclusion criteria. The mean age of the patients was 69.52 (range 45 to 89) years; 17 were female (77.27%) and 5 were male (22.73%). Of the 23 medial malleolar fractures, 21 (91.3%) achieved complete, uncomplicated healing. The mean interval to union was 62.6 (range 42 to 156) days. A total of 4 complications (17.39%) were noted, including 1 nonunion (4.35%), 1 malunion (4.35%), and 2 cases of painful retained hardware (8.7%). From our experience with this series of patients, bicortical screw fixation for medial malleolus fractures appears to be an acceptable alternative for fixation that provides a stable construct for patients at greater risk of bone healing complications.     

Do type B malleolar fractures need a positioning screw?

Type B malleolar fractures (AO/ASIF classification) are usually stable ankle joint fractures. Nonetheless, some show a residual instability after internal fixation requiring further stabilization. How often does such a situation occur and can these unstable fractures be recognized beforehand?From 1995 to 1997, 111 malleolar fractures (three type A, 90 type B, 18 type C) were operated on. Seventeen out of 90 patients (19%) with a type B fracture showed residual instability after internal fixation (one unilateral, four bimalleolar and 12 trimalleolar fractures). Five of these patients showed a dislocation in the sagittal plane (anteroposterior) clinically or on the radiographs, five a dislocation in the coronal plane with dislocation of the tibia on the medial aspect of the ankle joint, and four an incongruency on the medial aspect of the joint. In three cases, no preoperative abnormality indicating instability was found. The fractures were all fixed using an additional positioning screw. In 11 patients, the positioning screw was removed after 8-12 weeks, in six patients removal was performed after 1 year along with removal of the plate. All 17 patients were reviewed 1 year after internal fixation, 16/17 showed a good or excellent result with identical or only minor impairment of range of motion of the ankle joint. CONCLUSION: Unstable ankle joints after internal fixation of type B malleolar fractures exist. Residual instability most often occurs after trimalleolar fractures with initial joint dislocation. Treatment with an additional positioning screw generally produced a satisfactory result.     

Medial malleolar osteotomy for the correction of varus deformity during total ankle arthroplasty: results in 15 ankles

BACKGROUND: Preoperative deformity in the frontal plane in the arthritic ankle is a risk factor for failure after total ankle arthroplasty. Medial malleolar lengthening osteotomy was developed to correct varus malalignment. MATERIALS AND METHODS: From 1998 to 2005 total ankle arthroplasty combined with medial malleolar lengthening osteotomy was done in 15 ankles (13 patients) with a mean preoperative varus deformity of 14.9 (SD, 7.8) degrees. Diagnosis was arthritis with instability in 11 ankles (9 patients) and inflammatory joint disease in 4 ankles. Two mobile-bearing designs were used. Osteosynthesis of the osteotomy was done in 2 ankles; for the remaining 13 osteotomies, no fixation was used. RESULTS: Followup was 5 (range 2 to 8) years. Neutral alignment was obtained in all ankles. In 3 patients residual hindfoot varus remained, for which a second-stage hindfoot correction was done. Two rheumatoid ankles developed a symptom-free nonunion of the medial malleolus, all other malleolar osteotomies united. One tibial component, implanted with too much anterior slope, developed early aseptic loosening and was revised. Debridement for talar-malleolar arthritis was done in two ankles. Of the 14 ankles in followup, 12 were rated as excellent or good, one as fair. One ankle with subsidence of the talar component was rated as unsatisfactory. AOFAS score increased from 30.8 preoperative to 81.0 at followup (p < 0.01). CONCLUSION: Medial malleolar lengthening osteotomy is an easy technique for the realignment of the varus ankle at the time of total ankle arthroplasty, and served as an alternative to medial ligament release or lateral ligament reconstruction.     

Operative treatment of ankle fractures in adults: correlation between types of fracture and final results.

By means of a simple and easy classification, namely uni, bi- and trimalleolar ankle fractures, and the localization of the fracture at the level of the fibula; all of the 612 ankle fractures that were surgically treated at the Leuven University Hospital were easily classified. In 590 cases the results were collected 1 year after the operation by means of an evaluation system based on symptoms, clinical findings and radiographic findings. The influence of the type of fracture was analysed and led to the following conclusion: 1. Unimalleolar fractures have a better prognosis than trimalleolar fractures. 2. An isolated medial malleolar fracture gives a worse final result than an isolated lateral malleolar fracture. 3. Multimalleolar fractures, including the medial malleolus, have a worse prognosis than multimalleolar fractures without medial malleolar fractures. 4. Even after perfect internal fixation, the presence of a posterior fragment larger than one-third of the articular surface leads to a worse final result than a small unfixed fragment. 5. Weber's classification may not be useful for prognosis.     

胫骨远端后内侧解剖接骨板固定后踝治疗三踝骨折

目的探讨胫骨远端后内侧解剖接骨板固定后踝治疗三踝骨折的临床效果。方法2007年2月至2009年1月采用胫骨远端后内侧解剖接骨板固定后踝治疗三踝骨折患者11例,男7例,女4例;年龄23～58岁,平均41岁;左踝5例,右踝6例;开放骨折2例,闭合骨折9例。根据Lauge-Hansen分型均为旋前外旋型Ⅳ度,后踝骨折均超过关节面的25%。结果全部获得随访,随访时间为11～26个月,平均15.8个月。伤口均一期愈合,无一例发生感染。骨折愈合时间为10～15周,平均11.6周。术后采用AOFAS踝关节-后足评分标准,评分为83～100分,平均87.2分。结论胫骨远端后内侧解剖接骨板固定后踝是治疗三踝骨折的有效方法之一。     

Ankle fractures resulting from rotational injuries

Ankle fractures are among the most common skeletal injuries; selection of an optimal management method depends on ankle stability. Stable fractures (eg, isolated lateral malleolar) generally are managed nonsurgically; unstable fractures (eg, bimalleolar, bimalleolar equivalent) usually are managed with open reduction and internal fixation. Stress radiographs may aid in the management of incomplete deltoid injury in which there is medial swelling and tenderness without radiographic talar shift. A posterior malleolar fracture should be reduced and stabilized if it comprises >30% of the articular surface and remains displaced after fibular stabilization. Ankle fractures with syndesmotic injury have additional tibiofibular instability that can be controlled by screw fixation. However, the choice between metal and bioabsorbable screws, screw size, number of cortices fixed, and indications for screw removal remain controversial. Conditions such as diabetes or advanced age are no longer contraindications to usual management recommendations.     

三角韧带深层损伤是否影响旋前外旋型踝关节骨折的中期临床疗效

目的了解三角韧带深层损伤对PER型踝关节骨折中期临床疗效的影响。方法回顾性研究2013年1月至2014年12月北京积水潭医院创伤骨科手术治疗的50例PERⅢ度或Ⅳ度骨折患者。其中男37例,女13例;年龄16~68岁,平均30.2岁。根据踝关节内侧损伤类型分为两组:未修复组为内踝三角韧带深层损伤且无内踝骨折患者,未行三角韧带修复手术,共28例;对照组为内踝丘上骨折且三角韧带深层完整患者,行内踝丘上骨折切开复位内固定,共22例。两组患者均行腓骨骨折切开复位内固定和下胫腓螺钉固定。比较两组患者术后6个月以上影像学检查的内踝间隙和下胫腓间隙,以及中期随访的美国足踝外科协会的(AOFAS)的踝-后足评分和疼痛视觉模拟评分(VAS)。结果两组患者的性别、年龄、出现踝关节半脱位或脱位时的表现方式差异有统计学意义(P<0.05)。两组患者在损伤暴力程度、腓骨骨折线高度、是否完全脱位、后踝骨折率、后踝固定率、内固定物取出率、手术时间等差异均无统计学意义(P>0.05)。38例完成术后6个月影像学检查,21例未修复组的内踝间隙为3.7 mm,下胫腓间隙为4.5 mm;17例对照组的内踝间隙为3.4 mm;下胫腓间隙为4.4 mm。术后约3年时随访,未修复组和对照组的平均AOFAS评分分别为98.3分和94.6分,平均VAS评分分别为0.4分和1.5分。术后约5年时随访,未修复组和对照组的平均AOFAS评分分别为97.1分和93.6分,平均VAS评分分别为0.5分和1.2分。对于年龄<45岁的患者,术后约3、5年时随访的AOFAS评分、VAS评分与三角韧带完整与否均无相关性(P>0.05)。年龄与术后5年随访时AOFAS评分(P=0.021)相关。结论对于PER型Ⅲ、Ⅳ度踝关节骨折,在腓骨骨折及下胫腓螺钉固定后,残留三角韧带深层损伤不会影响45岁以内患者的中期疗效。     

Instability of the distal tibiofibular syndesmosis after bimalleolar and trimalleolar ankle fractures

We studied the late results after bimalleolar and trimalleolar ankle fractures in thirty-four patients after an average follow-up of four years. Twenty-one patients had had open reduction and internal fixation of the medial malleolus only and thirteen, internal fixation of both the medial malleolus and the lateral malleolus. Twenty-four lesions were supination-external rotation fractures; six, pronation-external rotation; and four, supination-adduction fractures. All initial and post-reduction roentgenograms were evaluated, and the patients were re-evaluated two to seven years after fracture. Re-evaluation included physical examination as well as standardized and stress roentgenograms of both ankles. Criteria were developed for measuring the width of the syndesmosis and assessing the late roentgenographic, subjective, and objective results, as well as any late instability of the syndesmosis and osteoarthritis. Significant correlations were found between: (1) the adequacy of the reduction of the syndesmosis and late arthritis, (2) the adequacy of the initial reduction of the syndesmosis and the late stability of the syndesmosis, (3) the late stability of the syndesmosis and the final outcome, and (4) the adequacy of the reduction of the lateral malleolus and that of the syndesmosis. Based on the findings in this small series and on the evidence published in the literature, we concluded that adequate reduction of the syndesmosis is necessary to achieve a stable ankle following supination-external rotation and pronation-external rotation fractures of the ankle, and that the reduction of the syndesmosis will be unsatisfactory if the lateral malleolus is not well reduced.