The aim of this study was to analyze the pathoanatomy of the posterior fragment on the basis of a comprehensive CT examination, including 3D reconstructions, in a large patient cohort. One hundred and forty one consecutive individuals with an ankle fracture or fracture-dislocation of types Weber B or Weber C and evidence of a posterior tibial fragment in standard radiographs were included in the study. The mean patient age was 49 years (range 19–83 years). The exclusion criteria were patients below 18 years of age, inability to provide written consent, fractures of the tibial pilon, posttraumatic arthritis and pre-existing deformities. In all patients, post-injury radiographs were obtained in anteroposterior, mortise and lateral views. All patients underwent CT scanning in transverse, sagittal and frontal planes. 3D CT reconstruction was performed in 91 patients. We were able to classify 137 cases into one of the following four types with constant pathoanatomic features: 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. In the 4 cases it was not possible to classify the type of the posterior tibial fragment. These were collectively termed type 5 (irregular, osteoporotic fragments). It is impossible to assess the shape and size of the posterior malleolar fragment, involvement of the fibular notch, or the medial malleolus, on the basis of plain radiographs. The system that we propose for classification of fractures of the posterior malleolus is based on CT examination and takes into account the size, shape and location of the fragment, stability of the tibio-talar joint and the integrity of the fibular notch. It may be a useful indication for surgery and defining the most useful approach to these injuries.

Anatomy and classification of the posterior tibial fragment in ankle fractures

Injuries to the posterior malleolus are of prognostic relevance in ankle fracture-dislocations. The three-dimensional outline of the fragments as reflected by computed tomography classification, involvement of the fibular notch, and the presence of intercalary fragments seem to be of greater therapeutic relevance than the size of the fragment and amount of the articular surface involved. Operative treatment aims at reconstruction of the posterior tibial plafond, the fibular notch, and the integrity of the posterior inferior tibiofibular syndesmosis. Direct open reduction and fixation of posterior malleolus fragments via posterior approaches is biomechanically more stable than indirect reduction and anteroposterior screw fixation.

Posterior Malleolar Fractures: Changing Concepts and Recent Developments.

Despite an increasing awareness of injuries to PM in ankle fracture-dislocations, there are still many open questions. The mere presence of a posterior fragment leads to significantly poorer outcomes. Adequate diagnosis, classification and treatment require preoperative CT examination, preferably with 3D reconstructions. The indication for surgical treatment is made individually on the basis of comprehensive assessment of the three-dimensional outline of the PM fracture and all associated injuries to the ankle including syndesmotic instability. Anatomic fixation of the avulsed posterior tibiofibular ligament will contribute to syndesmotic stability and restore the integrity of the incisura tibiae thus facilitating anatomic reduction of the distal fibula. A necessary prerequisite is mastering of posterolateral and posteromedial approaches and the technique of direct reduction and internal fixation. Further clinical studies with higher numbers of patients treated by similar methods and evaluation of pre- and postoperative CT scans will be necessary to determine reliable prognostic factors associated with certain types of PM fractures and associated injuries to the ankle.

Posterior malleolar fractures of the ankle.

To diagnose chronic ankle instability, clinicians frequently use manual anterior drawer test and stress radiography. However, both exams can yield incorrect results and do not reveal the extent of ankle instability. The use of stress ultrasound during a manual anterior drawer stress procedure might enable the diagnosis of chronic ankle instability. Seventy-three patients with chronic ankle pain or laxity after remote ankle sprain were included. The study population included 41 males and 32 females. The mean age of the patients at the time of the operation was 29 years. A standardized physical examination (manual anterior drawer test), stress radiography and stress ultrasonography were performed to assess the anterior talofibular ligament (ATFL). Ultrasound images were taken in the resting position and the maximal anterior drawer position. The statistical significance of stress ultrasound among the three groups according to manual anterior drawer test and a specific degree (5 mm) of anterior translation of stress radiography were analysed. Correlation coefficients between stress ultrasound, stress radiography and manual anterior drawer test were calculated. There was a significant difference for ATFL length (ATFL stress) and ATFL ratio (ATFL stress/ATFL resting) among the three groups (both p < 0.001). However, there was no significant difference for anterior translation of stress radiography among three groups according to manual anterior drawer test (p = 0.159). There was a significant difference for ATFL length (ATFL stress) and ATFL ratio between two groups with 5-mm anterior translation of stress radiography (p = 0.002 and p = 0.011, respectively). The mean value of grade of manual anterior drawer test between the two groups also differed (p = 0.021). There was a moderately positive linear relationship between stress ultrasound and manual anterior drawer test. Also, there was a positive linear relationship between stress ultrasound and stress radiography. The results suggest that the value of ATFL length (ATFL stress) and ATFL ratio of stress ultrasound could be used for diagnosis of chronic ankle instability in addition to manual anterior drawer test and stress radiography. III.

New method of diagnosis for chronic ankle instability: comparison of manual anterior drawer test, stress radiography and stress ultrasound

Background:Substantial attention has recently been placed on fractures of the posterior malleolus. Fracture extension to the posteromedial rim (“posterior pilon variant”) may result in articular incongruity and talar subluxation. Current classification systems fail to account for these fractures. The relative frequency of this fracture, its associated patient characteristics, and the reliability of its diagnosis have never been reported in such a large series.Methods: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 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.Results:The relative frequency of posterior malleolus fracture was 50%. The relative frequency of the posterior p...

Evaluation of Posterior Malleolar Fractures and the Posterior Pilon Variant in Operatively Treated Ankle Fractures

Peroneal Tendon Disorders

Chronic Ankle Instability

Thank you very much for your interest and comments on our article published in the February 2013 issue of Foot & Ankle International. We agree that articular impaction is a component of this injury and clearly will negatively affect the function of patients. However, when one is considering this injury pattern, the presence of articular comminution should not play a role in determining the need for fixation. The surgical approach does require addressing the impacted fragments. Primarily, we have noted that articular impaction will preclude indirect reduction of the posterolateral fracture as has been historically described. As described in the article, the fragments are either reduced from a cranial to caudal direction or excised if reduction cannot be achieved. The use of the fracture lines to determine the need for fixation is based on the consideration that joint stability is the critical factor of this injury. Amorosa et al describe fixation for fracture with a minimum of 20% involvement of the posterior plafond. We believe that the size of the fragment does not play a critical role in determining the need for fixation. The importance of anatomic reduction and fixation of the posterolateral and posteromedial fragment to prevent late subluxation with associated degenerative changes is what we have chosen to emphasize. All cases in our series did not have articular impaction as that was not a factor in determining the need for operative intervention. In the experience described by Weber, restoration of joint congruity with an osteotomy resulted in improved clinical outcomes, despite inability to correct articular impaction. Therefore, we believe that it is appropriate to consider posterior plafond fracture without articular comminution a “posterior pilon” to emphasize the importance of the injury and the need to restore joint congruity to minimize arthrosis. This is similar to a traditional pilon fracture that involves the articular surface without articular comminution; the presence of comminution does not alter the need for operative reduction and stabilization to restore joint congruity and minimize arthrosis. Reduction of the involved articular impaction is difficult, as you have described. In this fracture pattern and in our experience, there has not been the need for bone grafting proximal to the articular fragment. The computed tomography scans that we presented in the article are representative of the size of the involved articular fragments in our series and that described by Weber without the presence of a significant bone void following reduction. The use of K-wires to stabilize the fragments is described in the article by Wang et al, as you have referenced. However, in their description, the fragments were reduced indirectly via the posterolateral approach and assessed by fluoroscopy. The secondary posteromedial approach they described was for visualization of reduction of the large posteromedial fragment and fixation and not for assessment of the reduction of the articular fragments. This critique regarding our described technique for reduction applies to their technique as well. This is expected as one cannot directly visualize the reduction given the anatomical structure of the distal tibia. Stabilization of the fragments with a K-wire is an excellent suggestion, although given the small fragment sizes noted in our series, such stabilization may be difficult to achieve. Your described technique would be excellent for larger fragments that are amenable to fixation. The classification system was based on our experience of low-energy injuries that did not involve a known axial loading mechanism, which was not explicitly stated, as you have pointed out. No patient had a fracture pattern in which the posterior colliculus was persistently attached to the anterior colliculus of the medial malleolus. As we continue to collect data on this injury, we may encounter that pattern. In the article by Wang et al, a type II injury is described in 5 patients in whom the posterior malleolus and the anterior aspect were one piece: 3 of these cases were electric bike accidents that would not be considered in our series because this situation imparts a higher energy mechanism. Given the limited number of patients, we may not have encountered this pattern in our specific cohort. This variation exists, as you have stated, and the classification can be modified for our type I patient to state that a single posteromedial fragment is present. This will include the specific variation you describe and would not alter the surgical approach that we describe for type I. Thank you for comments regarding the syndesmotic disruption. We agree that Amorosa et al have described this additional injury and this was not noted in our review of the literature. Our diagnosis of instability, however, is determined by preoperative imaging as opposed to intraoperative determination of instability via fluoroscopy. We do routinely perform intraoperative stress testing; however, are we concerned that with direct stabilization of the posterior lateral malleolus, instability may not be detected via stress testing. Therefore, preoperative 3-D imaging is important to determine disruption of the anterior tibiofibular ligament and interosseus ligament with clear widening of the tibiofibular joint and should be performed when one encounters these injuries, as we now routinely perform following the review of our experience. 487177 FAIXXX10.1177/1071100713487177Foot & Ankle InternationalResponse research-article2013

Foot & ankle international

Achilles Tendon Disorders

Ligamentous Injuries of the Foot

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