ABSTARCTIntroduction: Oneof the most common fractures an orthopaedic surgeon encounters is Malleolarfractures. As with all intra articular fractures accurate reduction and stableinternal fixation of malleolar fractures is desirable. The present study aimedat analyzing the factors influencing the outcome of operative management ofmalleolar fractures.Materials and methods:In this prospective study 25 patients with Malleolar fractures who weresurgically treated between 2014 to 2016 were included.
All patients were treated in accordance withA.O. principles. Patients aged above 18 years, with unstable fractures wereincluded in this study. Post op protocol was below knee POP cast with a dorsalwindow for ankle mobilization and non-weight bearing walking with walker for 4weeks post operatively. Baird and Jackson ankle scoring system was used toanalyze the results.
The follow up period for all patients was 60 weeks.Results: In this series of fixation of malleolarfractures with various techniques had Fair results in 84% and poor results in16% as per Baird and Jackson Score. The average time to union was 12 weeks. Thecomplications leading poor result were instability, Pain at rest, arthriticchanges.Conclusion:Open reduction and internal fixation guaranty high standard of reductionbesides eliminating the chances of loss of reduction. In our study, the Extentof anatomical reduction achieved in the surgery and Post-operative anklemobilization and patients’ compliance influenced the outcome. Restoration offibular length and rotation is critical in re-establishing a stable anklemortise and perfect talar alignment. Weconclude tension band wiring is the preferred method for small fracturefragments and osteoporotic bones of both medial and lateral malleolusKey Words:Malleolar fractures, Anatomical reduction, Baird and Jackson score INTRODUCTION:Oneof the most common fractures an orthopaedic surgeon encounters is Malleolarfractures.
The annual incidence of anklefracture is between 107 and 184 per 100,000 perssons1-3. Anklefractures usually affect young men and elderly females4. As with allintra articular fractures accurate reduction and stable internal fixation ofmalleolar fractures is desirable. The results of inaccurately reduced malleolarfractures are post traumatic painful restriction of motion or osteoarthritis ofankle or both. The superiority of Open Reduction and Internal Fixation overclosed treatment has been thoroughly demonstrated in literature. However allstudies in operative treatment have not obtained good results in cases ofmalleolar fractures.
Arewarding outcome for the patient and surgeon which is a proper anatomicalalignment and stability of ankle joint can be achieved only with open reductionand internal fixation technique for malleolar fractures. The purpose of this study is to analyzethe factors influencing the outcome of operative management of malleolarfractures.MATERIALS AND METHODS:In this prospectivestudy twenty five patients with malleolar fractures of ankle presenting toBALAJI INSTITUTE OF SURGERY RESEARCH, AND REHABILITATION FOR THE DISABLEDBIRRD Hospital, Tirupati, Andhra Pradeshfrom SEPTEMBER 2014 to DECEMBER 2016 were operated with open reduction andinternal fixation by various methods. The ethical committee approval wasacquired to conduct the study.
. The inclusion criteria were patients withunstable malleolar fracture, skeletally matured, closed type, type I and typeII compound fractures, acute fractures (seen within 72 hrs of the injury). Indications for surgery were fractures of thearticular 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 malleolarfracture with >2 mm displacement or fracture fragment >25% of the tibialarticular surface. Exclusion criteria were skeletally immature, compoundfractures of type III A, B and C, fractures associated with pilon or plafondfractures of tibia, previous ankle fracture, polytrauma, associated with bilaterallower limb fractures and any concomitant painful or disabling disease of lowerlimb that could interfere with evaluation of the affected ankle. Outof 25 there were 16 males and 9 females, In 16 patients (64 %) right ankle wasinvolved and in 9 patients (36%) it was left ankle. Patients were aged between18 to 65 with an average of 40.9yrs.
The majority were in the 4thdecade. 13 52% patients presented to us with the history of Road TrafficAccidents, in 8 32% patients fracture was due to slipping and tumbling. Fall from height was the cause of fracture inthe rest 4 16% patients. (Table 1). As per Lauge- Hansen’s classification In14 (56%) patients sustained fracture due to supination external rotation,followed by pronation external rotation type in 6 (24%) patients, supinationadduction type in 4 (16%) and only in 1 (4%) patient sustained injury bypronator abduction type (Table 2). The majority of the fractures 16 64% were ofBimalleolar type, followed by 8 24% were Unimalleolar type. Three 12%patients sustained Trimalleolar fracture.
Detailedhistory pertaining to mode of injury, chronicity of the injury to the time ofpresentation was obtained at the time of admission and a detailed examinationwas done. Ankle trauma radiographs (i.e. anteroposterior, lateral and mortiseview) were taken. After all investigations and after surgical fitness from anesthesiologistthe cases were taken up for surgery.
Underspinal anesthesia and tourniquet, open reduction and internal fixation of themalleolar fracture were performed as per AO principles. Fibular fractures werefixed first. Fibula fractures were fixed with Dynamic compression plate(DCP) in14 (56%) cases, DCP with lag screw in 7(28%) cases, DC buttress plate, DCP withsyndesmotic screw, tension band wiring and lag screw alone in one case each(4%). Medial malleolar fractures were fixed with malleolar screw with k wire in15 (60%) patients, malleolar screw alone in 4(16%) patient, tension band wiringin 3(12%) patients and 3(12%) patients with Buttress plate. (Table 3 & 4)Aftersuture removal on the 12th post-operative day, a below knee POP castwith a dorsal window was applied, to facilitate passive dorsiflexion movementof the foot. Non Weight- bearing mobilization was allowed for 4 weeks. After 4weeks, cast was discontinued and active range of motion was started withpartial weight bearing. Fullweight bearing was allowed after 12 weeks.
Regular follow ups of the patients were done for every six weeks, byassessing functional parameters and x-rays in all three views, until bony unionon 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% Table4: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 upfor a period of 60 weeks. The duration between occurrence of the injury and internal fixation in fresh cases varied from 5to 7 days and in late cases from 10 days to 15 days.
BAIRD and JACKSON5anklescoring system was used to analyze the results of functional and radiologicaloutcome. The evaluation was based on a questionnaire and clinical, radiologicalexamination. The range of plantar flexion and dorsiflexion was measured withthe patient seated and the knee extended, using a Goniometer. The differencebetween injured and the uninjured side was recorded. Radiologically the medialclear space, superior joint space and talar tilt was measured. These scoreswere evaluated and noted for the each follow up of the patient; each visit ofbeing 6 weeks interval up to 10th visit.In this study, 17 68%patients had no pain and 2 8% patients had mild pain after strenuousactivity, 2 8% patients complained pain on activity of daily living and 28% had pain only on weight bearing on the affected side and only 2 8% patientscomplained 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 walkdesired distances without limp or pain; 6 24% patients were able to walk desired distance with mild pain, 3 12% had moderately restricted ability towalk, 2 8% could walk only shortdistances 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 attheir final follow up, 5 20% had restrictions in certain strenuousactivities, while 2 8% could perform their usual occupation with substantialrestriction, 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 onlyfour patients lacked more than 100 of dorsiflexion.At the final follow upall fractures were healed radiologically, 23 (92%) patients showed anatomicalreduction 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 Jackson5scoring system, Fair and poor results were found in 21 84% and 4 16%patients respectively in this series.Complications weredivided into Major (Deep infections or Osteomyelitis, Lossof reduction and fixation) and Minor (Superficial infections, wound sloughs,superficial skin dehiscence and stitch abscess) Case1: FAIR Result. Pre-op Radiographs post-opradiographs at 60 weeks follow up Dorsiflexion Neutral PlantarFlexion Case2: Poor Result Pre-op radiographs post-opradiographs at 60 weeks follow up Neutral PlantarFlexion Dorsiflexion DISCUSSION: Increased knowledgeabout the normal and post traumatic anatomy and function of the ankle joint hasled to demands for exact reduction and rigid fixation of the ankle fractures. Thedisplaced ankle fractures necessitates prompt operative treatment to ensure good functionaloutcome and decreased morbidity.
The treatment of malleolarfractures with accurate open reduction and stable internal fixation using AOmethod and principle was found to give a high percentage of excellent and goodresults.6Mean age of patients inour study was 40.92 years (range 18 to 65 years). This finding was similar toRoberts RS7 (40), Beris et al.6 (43), but inBaird and Jackson5 study the average age was found to be 30 years.
Therewas male preponderance in this series with 16 64% males and 9 36% werefemales. Where as in Roberts et al and Beri et al there was femalepreponderance.Lauge-Hansens classificationsystem was used to classify the injuries in the present study. The most commontype of injury was Supination External Rotation and least common was PronationAbduction. 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 achievedmore than 75% of good to excellent results in their studies. Where as In our study at finalfollow up, we obtained 21 fair results as per Baird and Jackson5scoring system and none in the good to excellent , most probably because welimited our follow up period for 60 weeks only and no patient was allowed torun in that period. In all other studies the follow up period varied between 5to 12 years and all patients running ability was evaluated at final follow up.The ankle joint issubject 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 bodyweight with more strenuous activity.
Maintaining congruency of the ankle jointis therefore critical to the long term viability of the ankle. Decreasedsurface contact area leads to an abnormal distribution of joint stresses, whichleads to post traumatic arthritis. Thordarson and colleagues8 showedthat 2 mm of shortening or lateral shift of fibula or external rotation greaterthan or equal to 50 increases contact forces in the ankle joint,which may predispose to ankle arthritis.In our study, aftersurgery, only 2 patients had superior joint space of more than 2 mm and talartilt more than 2 mm. The cause of the inadequate reduction in these twopatients is due to excessive comminution and poor bone quality.
Observation in thisstudy support the contention of Yablon et al9 that lateral malleolusis key to anatomical reduction of the malleolar fractures, because thedisplacement of the talus faithfully followed that of the lateral malleolus.Poor reduction of distal part of fibula would result in persistent lateraldisplacement or residual shortening. This does not necessarily lessen theimportance of the medial malleolus in contributing to the congruity of themedial aspect of the ankle, but it does serves to emphasize that the lateralmalleolus should no longer be ignored in the treatment of ankle injuries. The size of theposterior malleolar fragment plays a significant role in the post traumaticarthritis, with large fragment (those involving area more than 25% of thetibial articular surface) having poorer outcomes.
The present study had three patientswith posterior malleolar fracture (size less than 25% of the tibial articularsurface), none of these patients were treated by fixing the posterior malleolusand at the final follow up 2 patients showed good results and one patient hadpoor result.A number of different post-operativeprotocols are in practice. Burnwell and Charnley7 series followed jointmobility exercises in bed until motion was restored followed by full weightbearing in a cast. Lund–Kristensen et al10 either used no cast orapplied one for a few days postoperatively and then allowed full jointmobilization out of the cast. Crutches were used to maintain a non-weightbearing status. Meyer and Kumler11 series had a post- operative castbut only for an average of 3.8 weeks followed by non –weight bearingmobilization until fracture union. Whereas in our series a below knee POP castwas applied with a dorsal window, to facilitate passive dorsiflexion movementof the foot.
Non Weight- bearing mobilization was allowed for 4 weeks. After 4weeks, cast was discontinued and active range of motion was started withpartial weight bearing. Full weight bearing was allowed after 12 weeks. Our study suggests thata ruptured deltoid ligament can be left unexplored, thereby reducing the softtissue manipulation and surgery time. all ankle fractures after fixation treated by early mobilization and graduallyincreased weight bearing.
Protected mobilization in slab or cast with dorsalwindow for 6 weeks allows soft tissues to heal adequately. In our study onlyone patient had clinical instability at final follow-up.CONCLUSION: Malleolar fractures of anklehave a varied presentation. They can range from isolated fibular fractures withno displacement to a trimalleolar fracture with dislocation and vascularcompromise. A broad understanding of all aspects of mechanism of injury,pathoanatomy and treatment options coupled with training experience is requiredbefore any attempt should be made to treat these injuries. With thoroughunderstanding of injury patterns, repair of the damaged ankle joint can lead torewarding outcomes for the patient and physician.
We conclude that anatomical reduction isessential in all malleolar fractures of ankle as it is a weight bearing joint.Open reduction and internal fixation guaranty high standard of reductionbesides eliminating the chances of loss of reduction. Restoration of fibularlength and rotation is critical in re-establishing a stable ankle mortise andperfect talar alignment. Tension band wiring is the preferred method for smallfracture fragments and osteoporotic bones of both medial and lateralmalleolus. Application of plaster slab and cast for6 weeks allows the soft tissues around the ankle to heal adequately, therebyreducing clinical instability. And dorsal window facilitates the early passivemobilisation of the ankle, preventing ankle stiffness postoperatively.
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