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

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Abstract

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.

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Data availability

All data generated or analyzed during this study are included in this published article.

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Authors and Affiliations

  1. Department of Orthopedic Surgery, Inje University, Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang-si, Gyeonggi-do, South Korea

    Jun Young Choi, Hyoung Keun Oh, Jae Won Hur & Jin Soo Suh

  2. Trauma Unit, Humanitas Clinical and Research Center, Rozzano, Milan, Italy

    Lorenzo Di Mento

Authors
  1. Jun Young Choi
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  2. Hyoung Keun Oh
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  3. Lorenzo Di Mento
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  4. Jae Won Hur
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  5. Jin Soo Suh
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Contributions

JY Choi wrote the article with organizing the data, participated in the design of the study, and performed the statistical analysis. HK Oh participated in the writing the article in English. L Di Mento participated in the revision process. JW Hur sorted the involved patients with a review of medial record. JS Suh conceived the study and participated in its design and coordination and helped to draft the manuscript.

Corresponding author

Correspondence to Jin Soo Suh.

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Ethics approval

This study was approved by the appropriate institutional ethics review committee and performed according to the tenets of the Declaration of Helsinki.

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Written informed consent was obtained from all enrolled patients.

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The authors declare no competing interests.

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Level of Evidence: 4, Retrospective case series.

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Choi, J.Y., Oh, H.K., Di Mento, L. et al. Operative strategy for tri-malleolar ankle fractures with posteromedial plafond involvement: a review of sixty six cases. International Orthopaedics (SICOT) 46, 2637–2648 (2022). https://doi.org/10.1007/s00264-022-05554-3

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