Comparison of the effectiveness of the posterior malleolus fixed or not on treatment of different Haraguchi’s classification of posterior malleolus fractures_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

CHEN Feng ¹ , AN Zhongcheng ² , ZHOU Fang ¹ , FAN Jiajun ¹ , GAO Wei ¹ ,  CHEN Zhe ²

1. The Second Clinical College of Zhejiang Chinese Medical University, Hangzhou Zhejiang, 310000, P.R.China;
2. Department of Spinal Surgery, the Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou Zhejiang, 310000, P.R.China;

Corresponding?author：

CHEN Zhe, Email: 3153949565@qq.com

Keywords：

Trimalleolar fracture; posterior malleolus; internal fixation; Haraguchi classification

DOI：

10.7507/1002-1892.202012114

Video：

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Objective To investigate the effectiveness of fixation the posterior malleolus or not to treat different Haraguchi’s classification of posterior malleolus fractures.Methods The clinical data of 86 trimalleolar fracture patients who were admitted between January 2015 and September 2019 and met the selection criteria were retrospectively reviewed. There were 29 males and 57 females; the age ranged from 26 to 82 years with a mean age of 55.2 years. According to Haraguchi’s classification, 38 patients were in type Ⅰ group, 30 patients in type Ⅱ group, and 18 patients in type Ⅲ group. There was no significant difference in the general data such as gender, age, and fracture location among the 3 groups (P>0.05). The fixation of the posterior malleolus was performed in 23, 21, and 5 patients in type Ⅰ, Ⅱ, and Ⅲ groups, respectively. The operation time, fracture healing time, full weight-bearing time, postoperative joint flatness, and joint degeneration degree of the patients in each group were recorded and compared. The American Orthopedic Foot and Ankle Society (AOFAS) ankle and hindfoot score was used to evaluate ankle function, including pain, quality of daily life, joint range of motion, and joint stability. The AOFAS scores were compared between fixation and non-fixation groups in each group.Results The procedure was successfully completed by all patients in each group, and there was no significant difference in operation time (F=3.677, P=0.159). All patients were followed up 12-36 months with a mean time of 16.8 months. At last follow-up, 6 patients were found to have suboptimal ankle planarity, including 2 patients (5.3%) in the type Ⅰ group and 4 patients (13.3%) in the type Ⅱ group, with no significant difference between groups (χ²=6.566, P=0.161). The ankle joints of all the patients in each group showed mild degeneration; the fractures all healed well and no delayed union or nonunion occurred. There was no significant difference in the fracture healing time and full weight-bearing time between groups (P>0.05). No complications such as incision infection, fracture displacement, or plate screw loosening and fracture occurred during follow-up. At last follow-up, the total scores and pain scores of the AOFAS scores in the type Ⅱ group were significantly lower than those in the type Ⅰand Ⅲ groups (P<0.05), there was no significant difference between groups in the scores for the quality of daily life, joint range of motion, and joint stability between groups (P>0.05). There was no significant difference in any of the scores between the unfixed and fixed groups, except for the pain and quality of daily life scores, which were significantly lower (P<0.05) in the unfixed group of type Ⅱ group than the fixed group.Conclusion Haraguchi type Ⅱ posterior malleolus fractures have a worse prognosis than types Ⅰ and Ⅲ fractures, especially in terms of postoperative pain, which can be significantly improved by fixing the posterior malleolus; the presence or absence of posterior malleolus fixation in types Ⅰ and Ⅲ has less influence on prognosis.

Citation： CHEN Feng, AN Zhongcheng, ZHOU Fang, FAN Jiajun, GAO Wei, CHEN Zhe. Comparison of the effectiveness of the posterior malleolus fixed or not on treatment of different Haraguchi’s classification of posterior malleolus fractures. Chinese Journal of Reparative and Reconstructive Surgery, 2021, 35(6): 722-728. doi: 10.7507/1002-1892.202012114 Copy

1.	Kortekangas T, Haapasalo H, Flinkkil? T, et al. Three week versus six week immobilisation for stable Weber B type ankle fractures: randomised, multicentre, non-inferiority clinical trial. BMJ, 2019, 364: k5432.
2.	許騰飛, 龍毅. 微型鋼板內固定與螺釘內固定治療后踝關節骨折患者的療效比較. 創傷外科雜志, 2020, 22(7): 547-550.
3.	Evers J, Fischer M, Raschke M, et al. Leave it or fix it? How fixation of a small posterior malleolar fragment neutralizes rotational forces in trimalleolar fractures. Arch Orthop Trauma Surg, 2021. doi: 10.1007/s00402-021-03772-9.
4.	Ochman S, Raschke MJ. Ankle fractures in older patients: What should we do differently? Unfallchirurg, 2021, 124(3): 200-211.
5.	李庭, 孫志堅, 柴益民, 等. ERAS理念下踝關節骨折診療方案優化的專家共識. 中華骨與關節外科雜志, 2019, 12(1): 3-12.
6.	龔曉峰, 武勇, 呂艷偉, 等. 后踝骨折手術治療的指征. 中華創傷骨科雜志, 2015, 17(3): 232-237.
7.	McHale S, Williams M, Ball T. Retrospective cohort study of operatively treated ankle fractures involving the posterior malleolus. Foot Ankle Surg, 2020, 26(2): 138-145.
8.	戴坤權, 姚粵峰, 熊奡, 等. 不同大小后踝骨折塊的手術選擇及療效分析. 中華骨與關節外科雜志, 2020, 13(4): 304-308.
9.	Blom RP, Hayat B, Al-Dirini RMA, et al. Posterior malleolar ankle fractures. Bone Joint J, 2020, 102-B(9): 1229-1241.
10.	廖明新, 王巖. 后踝骨折的治療與研究進展. 骨科臨床與研究雜志, 2019, 4(1): 50-54.
11.	Haraguchi N, Haruyama H, Toga H, et al. Pathoanatomy of posterior malleolar fractures of the ankle. J Bone Joint Surg (Am), 2006, 88(5): 1085-1092.
12.	Domsic RT, Saltzman CL. Ankle osteoarthritis scale. Foot Ankle Int, 1998, 19(7): 466-471.
13.	Hasenstein T, Greene T, Meyr AJ. A 5-year review of clinical outcome measures published in the Journal of the American Podiatric Medical Association and the Journal of Foot and Ankle Surgery. J Am Podiatr Med Assoc, 2017, 107(3): 176-179.
14.	Evers J, Barz L, W?hnert D, et al. Size matters: The influence of the posterior fragment on patient outcomes in trimalleolar ankle fractures. Injury, 2015, 46 Suppl 4: S109-113.
15.	Tenenbaum S, Shazar N, Bruck N, et al. Posterior malleolus fractures. Orthop Clin North Am, 2017, 48(1): 81-89.
16.	Mak MF, Stern R, Assal M. Repair of syndesmosis injury in ankle fractures: Current state of the art. EFORT Open Rev, 2018, 3(1): 24-29.
17.	Blom RP, Meijer DT, de Muinck Keizer RO, et al. Posterior malleolar fracture morphology determines outcome in rotational type ankle fractures. Injury, 2019, 50(7): 1392-1397.
18.	Verhage SM, Boot F, Schipper IB, et al. Open reduction and internal fixation of posterior malleolar fractures using the posterolateral approach. Bone Joint J, 2016, 98-B(6): 812-817.
19.	Lambert LA, Falconer L, Mason L. Ankle stability in ankle fracture. J Clin Orthop Trauma, 2020, 11(3): 375-379.
20.	Liu J, Smith CD, White E, et al. A systematic review of the role of surgical approaches on the outcomes of the tibia pilon fracture. Foot Ankle Spec, 2016, 9(2): 163-168.
21.	Zhang J, Wang H, Pen C, et al. Characteristics and proposed classification system of posterior pilon fractures. Medicine (Baltimore), 2019, 98(3): e14133. doi: 10.1097/MD.0000000000014133.
22.	何錦泉, 馬信龍, 馬寶通, 等. 后踝骨折分型及治療的研究進展. 中華骨科雜志, 2016, 36(13): 863-870.
23.	Yi Y, Chun DI, Won SH, et al. Morphological characteristics of the posterior malleolar fragment according to ankle fracture patterns: a computed tomography-based study. BMC Musculoskelet Disord, 2018, 19(1): 51. doi: 10.1186/s12891-018-1974-1.
24.	Mangnus L, Meijer DT, Stufkens SA, et al. Posterior malleolar fracture patterns. J Orthop Trauma, 2015, 29(9): 428-435.
25.	Klammer G, Kadakia AR, Joos DA, et al. Posterior pilon fractures: a retrospective case series and proposed classification system. Foot Ankle Int, 2013, 34(2): 189-199.
26.	張光明, 阮志勇, 丁聲龍, 等. Pilon變異的后踝骨折的形態分析和損傷機制的三維有限元分析. 中華實驗外科雜志, 2018, 35(11): 2035-2038.
27.	Goost H, Wimmer MD, Barg A, et al. Fractures of the ankle joint: investigation and treatment options. Dtsch Arztebl Int, 2014, 111(21): 377-388.
28.	Solan MC, Sakellariou A. Posterior malleolus fractures: worth fixing. Bone Joint J, 2017, 99-B(11): 1413-1419.
29.	Bartoní?ek J, Rammelt S, Tu?ek M. Posterior malleolar fractures: Changing concepts and recent developments. Foot Ankle Clin, 2017, 22(1): 125-145.
30.	Baumbach SF, Herterich V, Damblemont A, et al. Open reduction and internal fixation of the posterior malleolus fragment frequently restores syndesmotic stability. Injury, 2019, 50(2): 564-570.

1. Kortekangas T, Haapasalo H, Flinkkil? T, et al. Three week versus six week immobilisation for stable Weber B type ankle fractures: randomised, multicentre, non-inferiority clinical trial. BMJ, 2019, 364: k5432.
2. 許騰飛, 龍毅. 微型鋼板內固定與螺釘內固定治療后踝關節骨折患者的療效比較. 創傷外科雜志, 2020, 22(7): 547-550.
3. Evers J, Fischer M, Raschke M, et al. Leave it or fix it? How fixation of a small posterior malleolar fragment neutralizes rotational forces in trimalleolar fractures. Arch Orthop Trauma Surg, 2021. doi: 10.1007/s00402-021-03772-9.
4. Ochman S, Raschke MJ. Ankle fractures in older patients: What should we do differently? Unfallchirurg, 2021, 124(3): 200-211.
5. 李庭, 孫志堅, 柴益民, 等. ERAS理念下踝關節骨折診療方案優化的專家共識. 中華骨與關節外科雜志, 2019, 12(1): 3-12.
6. 龔曉峰, 武勇, 呂艷偉, 等. 后踝骨折手術治療的指征. 中華創傷骨科雜志, 2015, 17(3): 232-237.
7. McHale S, Williams M, Ball T. Retrospective cohort study of operatively treated ankle fractures involving the posterior malleolus. Foot Ankle Surg, 2020, 26(2): 138-145.
8. 戴坤權, 姚粵峰, 熊奡, 等. 不同大小后踝骨折塊的手術選擇及療效分析. 中華骨與關節外科雜志, 2020, 13(4): 304-308.
9. Blom RP, Hayat B, Al-Dirini RMA, et al. Posterior malleolar ankle fractures. Bone Joint J, 2020, 102-B(9): 1229-1241.
10. 廖明新, 王巖. 后踝骨折的治療與研究進展. 骨科臨床與研究雜志, 2019, 4(1): 50-54.
11. Haraguchi N, Haruyama H, Toga H, et al. Pathoanatomy of posterior malleolar fractures of the ankle. J Bone Joint Surg (Am), 2006, 88(5): 1085-1092.
12. Domsic RT, Saltzman CL. Ankle osteoarthritis scale. Foot Ankle Int, 1998, 19(7): 466-471.
13. Hasenstein T, Greene T, Meyr AJ. A 5-year review of clinical outcome measures published in the Journal of the American Podiatric Medical Association and the Journal of Foot and Ankle Surgery. J Am Podiatr Med Assoc, 2017, 107(3): 176-179.
14. Evers J, Barz L, W?hnert D, et al. Size matters: The influence of the posterior fragment on patient outcomes in trimalleolar ankle fractures. Injury, 2015, 46 Suppl 4: S109-113.
15. Tenenbaum S, Shazar N, Bruck N, et al. Posterior malleolus fractures. Orthop Clin North Am, 2017, 48(1): 81-89.
16. Mak MF, Stern R, Assal M. Repair of syndesmosis injury in ankle fractures: Current state of the art. EFORT Open Rev, 2018, 3(1): 24-29.
17. Blom RP, Meijer DT, de Muinck Keizer RO, et al. Posterior malleolar fracture morphology determines outcome in rotational type ankle fractures. Injury, 2019, 50(7): 1392-1397.
18. Verhage SM, Boot F, Schipper IB, et al. Open reduction and internal fixation of posterior malleolar fractures using the posterolateral approach. Bone Joint J, 2016, 98-B(6): 812-817.
19. Lambert LA, Falconer L, Mason L. Ankle stability in ankle fracture. J Clin Orthop Trauma, 2020, 11(3): 375-379.
20. Liu J, Smith CD, White E, et al. A systematic review of the role of surgical approaches on the outcomes of the tibia pilon fracture. Foot Ankle Spec, 2016, 9(2): 163-168.
21. Zhang J, Wang H, Pen C, et al. Characteristics and proposed classification system of posterior pilon fractures. Medicine (Baltimore), 2019, 98(3): e14133. doi: 10.1097/MD.0000000000014133.
22. 何錦泉, 馬信龍, 馬寶通, 等. 后踝骨折分型及治療的研究進展. 中華骨科雜志, 2016, 36(13): 863-870.
23. Yi Y, Chun DI, Won SH, et al. Morphological characteristics of the posterior malleolar fragment according to ankle fracture patterns: a computed tomography-based study. BMC Musculoskelet Disord, 2018, 19(1): 51. doi: 10.1186/s12891-018-1974-1.
24. Mangnus L, Meijer DT, Stufkens SA, et al. Posterior malleolar fracture patterns. J Orthop Trauma, 2015, 29(9): 428-435.
25. Klammer G, Kadakia AR, Joos DA, et al. Posterior pilon fractures: a retrospective case series and proposed classification system. Foot Ankle Int, 2013, 34(2): 189-199.
26. 張光明, 阮志勇, 丁聲龍, 等. Pilon變異的后踝骨折的形態分析和損傷機制的三維有限元分析. 中華實驗外科雜志, 2018, 35(11): 2035-2038.
27. Goost H, Wimmer MD, Barg A, et al. Fractures of the ankle joint: investigation and treatment options. Dtsch Arztebl Int, 2014, 111(21): 377-388.
28. Solan MC, Sakellariou A. Posterior malleolus fractures: worth fixing. Bone Joint J, 2017, 99-B(11): 1413-1419.
29. Bartoní?ek J, Rammelt S, Tu?ek M. Posterior malleolar fractures: Changing concepts and recent developments. Foot Ankle Clin, 2017, 22(1): 125-145.
30. Baumbach SF, Herterich V, Damblemont A, et al. Open reduction and internal fixation of the posterior malleolus fragment frequently restores syndesmotic stability. Injury, 2019, 50(2): 564-570.

Chinese Journal of Reparative and Reconstructive Surgery

Comparison of the effectiveness of the posterior malleolus fixed or not on treatment of different Haraguchi’s classification of posterior malleolus fractures

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