Operative strategy for tri-malleolar ankle fractures with posteromedial plafond involvement: a review of sixty six cases,International Orthopaedics

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Operative strategy for tri-malleolar ankle fractures with posteromedial plafond involvement: a review of sixty six cases
International Orthopaedics ( IF 2.0 ) Pub Date : 2022-08-22 , DOI: 10.1007/s00264-022-05554-3
Jun Young Choi ₁ , Hyoung Keun Oh ₁ , Lorenzo Di Mento ₂ , Jae Won Hur ₁ , Jin Soo Suh ₁

Affiliation

Purpose

We aimed to summarize the radiographic and clinical outcomes in various conditions of tri-malleolar ankle fractures (TMFs) with posteromedial (PM) plafond involvement (TMF + PM) and determine the factors affecting their subjective clinical outcomes.

Methods

Radiographic and clinical findings of 66 patients who underwent operative treatment for TMF + PM were retrospectively reviewed. The patients were classified into three groups according to the PM fracture line location. Type I fractures were defined when the PM fracture line extended medially beyond the PM corner of the distal tibia while type II fractures were those in which the PM fracture line was located laterally to the PM corner. Type III fractures were defined as medial malleolar avulsion fractures when the PM fracture integrated into the medial malleolus. Clinical outcomes were evaluated using a subjective rating scale (excellent, good, fair, poor, and bad). Satisfactory results were defined as excellent, good, and fair. Factors affecting satisfactory clinical outcomes were assessed using a binary logistic regression analysis. Independent variables included demographic, fracture-related, and operation-related factors and radiographic measurements at the final follow-up.

Results

Satisfactory clinical outcomes were observed in 74.2% of the total patients; of these patients, 75.7% (28/37), 76.5% (13/17), and 66.7% (8/12) had type I, type II, and type III fractures, respectively. The binary logistic regression analysis revealed that age at the time of operation, number of incarcerated fragments (IFs), type of IFs, and postoperative articular step-offs (mm) were related to subjective clinical outcomes (all P < 0.05). A positive value for post-operative articular step-offs represented distal migration of the posterior malleolar fragments. The odds ratios for older age, increased numbers of IFs, rotated IFs, and positive articular step-offs were 0.936, 0.116, 0.020, and 0.295, respectively.

Conclusion

Because TMF + PM is highly unstable, a delicate approach is needed according to each patient’s fracture condition. Although it is best to reduce the fractured articular surface, a negative step-off, rather than a positive step-off, would be more likely recommended if accurate reduction is impossible. This could be applied to manage IFs, especially when the IFs are rotated. Dimpling of the articular surface induced by the removal of a small IF was not related to unsatisfactory clinical outcomes.

中文翻译：

后内侧平台受累三踝踝骨折的手术策略：附66例回顾

目的

我们旨在总结后内侧 (PM) 平台受累 (TMF + PM) 的各种情况下的三踝踝骨折 (TMF) 的影像学和临床结果，并确定影响其主观临床结果的因素。

方法

对 66 例接受 TMF + PM 手术治疗的患者的影像学和临床结果进行了回顾性分析。根据PM骨折线位置将患者分为三组。I型骨折定义为PM骨折线向内侧延伸超过胫骨远端PM角，而II型骨折是PM骨折线位于PM角外侧的骨折。Ⅲ型骨折定义为PM骨折与内踝融合时的内踝撕脱骨折。使用主观评分量表（优秀、良好、一般、差和差）评估临床结果。令人满意的结果被定义为优秀、良好和一般。使用二元逻辑回归分析评估影响令人满意的临床结果的因素。

结果

在 74.2% 的患者中观察到令人满意的临床结果；在这些患者中，分别有 75.7%（28/37）、76.5%（13/17）和 66.7%（8/12）有 I 型、II 型和 III 型骨折。二元逻辑回归分析显示，手术时的年龄、嵌顿碎片（IFs）数量、IFs类型和术后关节脱位（mm）与主观临床结果相关（均P <0.05）。术后关节脱位的正值表示后踝碎片的远端迁移。高龄、增加的 IF 数量、旋转的 IF 和正关节步进的优势比分别为 0.936、0.116、0.020 和 0.295。