ABSTARCT patients was 60 weeks. Results: In this series

ABSTARCT

Introduction: One
of the most common fractures an orthopaedic surgeon encounters is Malleolar
fractures. As with all intra articular fractures accurate reduction and stable
internal fixation of malleolar fractures is desirable. The present study aimed
at analyzing the factors influencing the outcome of operative management of
malleolar fractures.

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Materials and methods:
In this prospective study 25 patients with Malleolar fractures who were
surgically treated between 2014 to 2016 were included.  All patients were treated in accordance with
A.O. principles. Patients aged above 18 years, with unstable fractures were
included in this study. Post op protocol was below knee POP cast with a dorsal
window for ankle mobilization and non-weight bearing walking with walker for 4
weeks post operatively. Baird and Jackson ankle scoring system was used to
analyze the results. The follow up period for all patients was 60 weeks.

Results:  In this series of fixation of malleolar
fractures with various techniques had Fair results in 84% and poor results in
16% as per Baird and Jackson Score. The average time to union was 12 weeks. The
complications leading poor result were instability, Pain at rest, arthritic
changes.

Conclusion:
Open reduction and internal fixation guaranty high standard of reduction
besides eliminating the chances of loss of reduction. In our study, the Extent
of anatomical reduction achieved in the surgery and Post-operative ankle
mobilization and patients’ compliance influenced the outcome. Restoration of
fibular length and rotation is critical in re-establishing a stable ankle
mortise and perfect talar alignment.  We
conclude tension band wiring is the preferred method for small fracture
fragments and osteoporotic bones of both medial and lateral malleolus

Key Words:
Malleolar fractures, Anatomical reduction, Baird and Jackson score              

 

 

 

 

 

 

 

 

INTRODUCTION:

One
of the most common fractures an orthopaedic surgeon encounters is Malleolar
fractures.  The annual incidence of ankle
fracture is between 107 and 184 per 100,000 perssons1-3. Ankle
fractures usually affect young men and elderly females4. As with all
intra articular fractures accurate reduction and stable internal fixation of
malleolar fractures is desirable. The results of inaccurately reduced malleolar
fractures are post traumatic painful restriction of motion or osteoarthritis of
ankle or both. The superiority of Open Reduction and Internal Fixation over
closed treatment has been thoroughly demonstrated in literature. However all
studies in operative treatment have not obtained good results in cases of
malleolar fractures.

A
rewarding outcome for the patient and surgeon which is a proper anatomical
alignment and stability of ankle joint can be achieved only with open reduction
and internal fixation technique for malleolar fractures.

                The purpose of this study is to analyze
the factors influencing the outcome of operative management of malleolar
fractures.

MATERIALS AND METHODS:

In this prospective
study twenty five patients with malleolar fractures of ankle presenting to
BALAJI INSTITUTE OF SURGERY RESEARCH, AND REHABILITATION FOR THE DISABLED
BIRRD Hospital, Tirupati, Andhra Pradesh
from SEPTEMBER 2014 to DECEMBER 2016 were operated with open reduction and
internal fixation by various methods. The ethical committee approval was
acquired to conduct the study.. The inclusion criteria were patients with
unstable malleolar fracture, skeletally matured, closed type, type I and type
II compound fractures, acute fractures (seen within 72 hrs of the injury).

 Indications for surgery were fractures of the
articular surface of the ankle, displacement 
greater  than 2 mm at the lateral,
medial malleolus, in  the  absence 
of  medial  malleolar 
fracture,  widening  of the medial clear space  greater 
than  2 mm, posterior malleolar
fracture with >2 mm displacement or fracture fragment >25% of the tibial
articular surface. Exclusion criteria were skeletally immature, compound
fractures of type III A, B and C, fractures associated with pilon or plafond
fractures of tibia, previous ankle fracture, polytrauma, associated with bilateral
lower limb fractures and any concomitant painful or disabling disease of lower
limb that could interfere with evaluation of the affected ankle.

Out
of 25 there were 16 males and 9 females, In 16 patients (64 %) right ankle was
involved and in 9 patients (36%) it was left ankle. Patients were aged between
18 to 65 with an average of 40.9yrs. The majority were in the 4th
decade. 13 52% patients presented to us with the history of Road Traffic
Accidents, in 8 32% patients fracture was due to slipping and tumbling.  Fall from height was the cause of fracture in
the rest 4 16% patients. (Table 1). As per Lauge- Hansen’s classification In
14 (56%) patients sustained fracture due to supination external rotation,
followed by pronation external rotation type in 6 (24%) patients, supination
adduction type in 4 (16%) and only in 1 (4%) patient sustained injury by
pronator abduction type (Table 2). The majority of the fractures 16 64% were of
Bimalleolar type, followed by 8 24% were Unimalleolar type. Three 12%
patients sustained Trimalleolar fracture.

Detailed
history pertaining to mode of injury, chronicity of the injury to the time of
presentation was obtained at the time of admission and a detailed examination
was done. Ankle trauma radiographs (i.e. anteroposterior, lateral and mortise
view) were taken. After all investigations and after surgical fitness from anesthesiologist
the cases were   taken up   for surgery.  

Under
spinal anesthesia and tourniquet, open reduction and internal fixation of the
malleolar fracture were performed as per AO principles. Fibular fractures were
fixed first. Fibula fractures were fixed with Dynamic compression plate(DCP) in
14 (56%) cases, DCP with lag screw in 7(28%) cases, DC buttress plate, DCP with
syndesmotic screw, tension band wiring and lag screw alone in one case each
(4%). Medial malleolar fractures were fixed with malleolar screw with k wire in
15 (60%) patients, malleolar screw alone in 4(16%) patient, tension band wiring
in 3(12%) patients and 3(12%) patients with Buttress plate. (Table 3 & 4)

After
suture removal on the 12th post-operative day, a below knee POP cast
with a dorsal window was applied, to facilitate passive dorsiflexion movement
of the foot. Non Weight- bearing mobilization was allowed for 4 weeks. After 4
weeks, cast was discontinued and active range of motion was started with
partial weight bearing.

Full
weight bearing was allowed after 12 weeks.
Regular follow ups of the patients were done for every six weeks, by
assessing functional parameters and x-rays in all three views, until bony union
on x-rays. 

Table 1:
Mode of injury

Mode of injury

Number of Patients

Percentage

Road
traffic accident

13

52%

Fall
from height

4

16%

Slipping
and tumbling

8

32%

 

 

 

 

 

 

 

 

Table 2: Mechanism of injury

Lauge-Hansen fracture
classification type

Number of patients

Percentage

Supination
–adduction

4

16%

Supination-external
rotation

14

56%

Pronation
abduction

1

4%

Pronation
external rotation

6

24%

Pronation
dorsiflexion

0

0%

Table 3:
Implants used for medial malleolus

Type of implant

Number of patients

Percentage

Malleolar
screws

4

16%

Malleolar
screw + K- Wire

15

60%

Tension band wiring

3

12%

Buttress plate

3

12%

Table
4:
Implants used for lateral malleolus

Type of implant

Number  of patients

Percentage

Dynamic
compression plate

14

56%

Lag
screw +
Dynamic
compression plate

7

28%

DC
Buttress plate

1

4%

Syndesmotic
screw + Dynamic compression screw

1

4%

Tension
band wiring

1

4%

Lag
screw alone

1

4%

 

RESULTS:

                All 25 patients were followed up
for a period of 60 weeks. The duration between 
occurrence  of  the 
injury  and   internal fixation  in 
fresh  cases varied  from  5
to 7 days  and  in 
late  cases  from 
10 days to 15 days.

BAIRD and JACKSON5ankle
scoring system was used to analyze the results of functional and radiological
outcome. The evaluation was based on a questionnaire and clinical, radiological
examination. The range of plantar flexion and dorsiflexion was measured with
the patient seated and the knee extended, using a Goniometer. The difference
between injured and the uninjured side was recorded. Radiologically the medial
clear space, superior joint space and talar tilt was measured. These scores
were evaluated and noted for the each follow up of the patient; each visit of
being 6 weeks interval up to 10th visit.

In this study, 17 68%
patients had no pain and 2 8% patients had mild pain after strenuous
activity, 2 8% patients complained pain on activity of daily living and 2
8% had pain only on weight bearing on the affected side and only 2 8% patients
complained pain at rest at the time of final follow up.

At the final follow-up,
only one patient 4% had clinical instability, 14 64% patients could walk
desired distances without limp or pain; 6 24% patients were able to walk  desired distance with mild pain,  3 12% had moderately restricted ability to
walk,  2 8% could walk only short
distances and 1 4% patient remained with inability to walk.

In our series, 16 64%
patients were able to do their usual occupation without any restrictions at
their final follow up, 5 20% had restrictions in certain strenuous
activities, while 2 8% could perform their usual occupation with substantial
restriction, 2 8% patients could do only selected jobs and only one 4%
patient had shown her inability to perform any of the work. At final follow-up only
four patients lacked more than 100 of dorsiflexion.

At the final follow up
all fractures were healed radiologically, 23 (92%) patients showed anatomical
reduction and maintenance of reduction and fixation at final follow-up. Only 2
(8%) patients had mild reactive changes at the joint margins.

As per Baird and Jackson5
scoring system, Fair and poor results were found in 21 84% and 4 16%
patients respectively in this series.

Complications were
divided into Major (Deep infections or Osteomyelitis,   Loss
of reduction and fixation) and Minor (Superficial infections, wound sloughs,
superficial skin dehiscence and stitch abscess)

 

 

 

 

 

 

 

 

 

 

Case1:   FAIR Result.                        

 

 

                                                                                                                                               

                                                                               

 

 

 

 

 

Pre-op Radiographs                                                                            post-op
radiographs at 60 weeks follow up

               

 

                                                                               

 

 

 

 

 

Dorsiflexion                                                                Neutral                                                             Plantar
Flexion

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Case
2: Poor Result

 

 

 

                                               

                                                                                                                               

 

                               

 

 

 

Pre-op radiographs                                                              post-op
radiographs at 60 weeks follow up

 

 

 

 

 

 

 

 

 

Neutral                                                                                  Plantar
Flexion                                                  Dorsiflexion

 

 

DISCUSSION:

 

Increased knowledge
about the normal and post traumatic anatomy and function of the ankle joint has
led to demands for exact reduction and rigid fixation of the ankle fractures. The
displaced ankle fractures necessitates   prompt operative treatment to ensure good functional
outcome and decreased morbidity.

            The treatment of malleolar
fractures with accurate open reduction and stable internal fixation using AO
method and principle was found to give a high percentage of excellent and good
results.6

Mean age of patients in
our study was 40.92 years (range 18 to 65 years). This finding was similar to
Roberts RS7 (40), Beris et al.6 (43), but in
Baird and Jackson5 study the average age was found to be 30 years.

                There
was male preponderance in this series with 16 64% males and 9 36% were
females. Where as in Roberts et al and Beri et al there was female
preponderance.

Lauge-Hansens classification
system was used to classify the injuries in the present study. The most common
type of injury was Supination External Rotation and least common was Pronation
Abduction. This finding was similar to observation with Baird and Jackson5,
Beris et al6 and Roberts SR7.

Burnwell & charnley7,
Baird and Jackson5, Beris et al6and Roberts RS 7 achieved
more than 75% of good to excellent results in their studies. Where as In our study  at final
follow up, we obtained 21 fair results as per Baird and Jackson5
scoring system and none in the good to excellent , most probably because we
limited our follow up period for 60 weeks only and no patient was allowed to
run in that period. In all other studies the follow up period varied between 5
to 12 years and all patients running ability was evaluated at final follow up.

The ankle joint is
subject to enormous forces across a relatively small surface area of contact,
with up to 1.5 times body weight with gait and greater than 5.5 times body
weight with more strenuous activity. Maintaining congruency of the ankle joint
is therefore critical to the long term viability of the ankle. Decreased
surface contact area leads to an abnormal distribution of joint stresses, which
leads to post traumatic arthritis. Thordarson and colleagues8 showed
that 2 mm of shortening or lateral shift of fibula or external rotation greater
than or equal to 50 increases contact forces in the ankle joint,
which may predispose to ankle arthritis.

In our study, after
surgery, only 2 patients had superior joint space of more than 2 mm and talar
tilt more than 2 mm. The cause of the inadequate reduction in these two
patients is due to excessive comminution and poor bone quality.

Observation in this
study support the contention of Yablon et al9 that lateral malleolus
is key to anatomical reduction of the malleolar fractures, because the
displacement of the talus faithfully followed that of the lateral malleolus.
Poor reduction of distal part of fibula would result in persistent lateral
displacement or residual shortening. This does not necessarily lessen the
importance of the medial malleolus in contributing to the congruity of the
medial aspect of the ankle, but it does serves to emphasize that the lateral
malleolus should no longer be ignored in the treatment of ankle injuries.

The size of the
posterior malleolar fragment plays a significant role in the post traumatic
arthritis, with large fragment (those involving area more than 25% of the
tibial articular surface) having poorer outcomes. The present study had three patients
with posterior malleolar fracture (size less than 25% of the tibial articular
surface), none of these patients were treated by fixing the posterior malleolus
and at the final follow up 2 patients showed good results and one patient had
poor result.

A number of different post-operative
protocols are in practice. Burnwell and Charnley7 series followed joint
mobility exercises in bed until motion was restored followed by full weight
bearing in a cast. Lund–Kristensen et al10 either used no cast or
applied one for a few days postoperatively and then allowed full joint
mobilization out of the cast. Crutches were used to maintain a non-weight
bearing status. Meyer and Kumler11 series had a post- operative cast
but only for an average of 3.8 weeks followed by non –weight bearing
mobilization until fracture union. Whereas in our series a below knee POP cast
was applied with a dorsal window, to facilitate passive dorsiflexion movement
of the foot. Non Weight- bearing mobilization was allowed for 4 weeks. After 4
weeks, cast was discontinued and active range of motion was started with
partial weight bearing. Full weight bearing was allowed after 12 weeks.

            Our study suggests that
a ruptured deltoid ligament can be left unexplored, thereby reducing the soft
tissue manipulation and surgery time. all ankle fractures after fixation  treated by early mobilization and gradually
increased weight bearing. Protected mobilization in slab or cast with dorsal
window for 6 weeks allows soft tissues to heal adequately. In our study only
one patient had clinical instability at final follow-up.

CONCLUSION:

                Malleolar fractures of ankle
have a varied presentation. They can range from isolated fibular fractures with
no displacement to a trimalleolar fracture with dislocation and vascular
compromise. A broad understanding of all aspects of mechanism of injury,
pathoanatomy and treatment options coupled with training experience is required
before any attempt should be made to treat these injuries. With thorough
understanding of injury patterns, repair of the damaged ankle joint can lead to
rewarding outcomes for the patient and physician.

We conclude that anatomical reduction is
essential in all malleolar fractures of ankle as it is a weight bearing joint.
Open reduction and internal fixation guaranty high standard of reduction
besides eliminating the chances of loss of reduction. Restoration of fibular
length and rotation is critical in re-establishing a stable ankle mortise and
perfect talar alignment. Tension band wiring is the preferred method for small
fracture fragments and osteoporotic bones of both medial and lateral
malleolus. 

Application of plaster slab and cast for
6 weeks allows the soft tissues around the ankle to heal adequately, thereby
reducing clinical instability. And dorsal window facilitates the early passive
mobilisation of the ankle, preventing ankle stiffness postoperatively.

                Perfect Anatomical reduction and
good internal fixation, post- operative ankle mobilization is directly
proportional to the final result.

 

 

 

 

 

 

 

 

 

REFERENCES:

1 Court-Brown, C.M.,
McBirnie, J. and Wilson, G. (1998) Adult Ankle Fractures—An Increasing Problem?
Acta Orthopaedica Scandinavica, 69, 43-47.
http://dx.doi.org/10.3109/17453679809002355

2 Daly, P.J.,
Fitzgerald Jr., R.H., Melton, L.J, and Ilstrup, D.M. (1987) Epidemiology of
Ankle Fractures in Rochester, Minnesota. Acta Orthopaedica Scandinavica, 58,
539-544. http://dx.doi.org/10.3109/17453678709146395

3 Jensen, S.L.,
Andresen, B.K., Mencke, S. and Nielsen, P.T. (1998) Epidemiology of Ankle
Fractures: A Prospective Population-Based Study of 212 Cases in Aalborg,
Denmark. Acta Orthopaedica Scandinavica, 69, 48-50. http://dx.doi.org/10.3109/17453679809002356

4
Donken, C.C.M.A., Al-Khateeb, H., Verhofstad, M.H.J. and van Laarhoven,
C.J.H.M. (2012) Surgical versus Conservative Interventions for Treating Ankle Fractures
in Adults. The Cochrane Database of Systematic Reviews, Published Online. http://dx.doi.org/10.1002/14651858.CD008470

5
Fracture of the distal part of fibula with associated disruption of deltoid
ligament. Baird RA and Jackson ST; JBJS, 1987; 69A:1346-52.

6
Surgical treatment of malleolar fractures-a review of 144 patients. Beris AE,
Kabbani KT, Xenakis TA, Mitsionis G, Soucacos PN. Clinical Orthopaedic Related
Research, 1997 Aug; 341:90- 98.

7
The treatment of displaced fractures at the ankle by rigid internal fixation
and early joint movement. Burnwell HD &Charnley AD; JBJS, 1965; 47 B;
643-660

8
Thordarson DB, Motamed S, Hedman T, Ebramzadeh E, Bakshian S. The effect of
fibular malreduction on contact pressures in an ankle fracture malunion model.
J Bone Joint Surg Am 1997; 79: 1809-1815.

9
The key role of the lateral malleolus in displaced fractures of ankle. Yablon
IG, Heller FG, Shouse L. JBJS, 1977; 57A: 169-173

10
Lundberg A, Goldie I, Kalin B, Selvik G. Kinematics of the ankle/foot complex:
Plantar flexion and dorsiflexion foot and ankle. 1989;9:194-200

11
Meyer TL, Kumler KN. ASIF technique and ankle fractures, Clin Orthop,
1980;150:211-216.