Comparison of posterolateral approach and combined approach in treatment of Mason type 2B posterior malleolar fracture_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

LU Xinghua , JI Renchen , ZHAO Wenzhi ,  ZHANG Lu

Department of Trauma Orthopaedics, the Second Affiliated Hospital of Dalian Medical University, Dalian Liaoning, 116081, P. R. China;

Corresponding?author：

ZHANG Lu, Email: zhanglu_dalian@163.com

Keywords：

Posterior malleolar fracture; Mason 2B avulsion subtype; Mason 2B Pilon subtype; posterolateral approach; combined approach

DOI：

10.7507/1002-1892.202307049

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Objective To compare the effectiveness between the posterolateral approach and the posterolateral combined posteromedial approaches in the treatment of Mason type 2B posterior malleolar fracture. Methods A retrospective analysis was performed on the clinical data of 79 patients with posterior ankle fracture who met the selection criteria between January 2015 and January 2022. There were 62 cases of Mason 2B Pilon subtype and 17 cases of avulsion subtype. Among Mason 2B Pilon subtype patients, 35 were treated with posterolateral approach (group A), 27 patients were treated with combined approach (group B). There was no significant difference in gender, age, injured side, cause of injury, time from injury to operation, preoperative hospital stay, preoperative visualanalogue scale (VAS) score, and intraoperative internal fixation between the two groups (P>0.05). All patients with Mason 2B avulsion subtype were treated by posterolateral approach, including 7 males and 10 females, aged from 25 to 68 years, with an average of 46.1 years. The operation time, intraoperative blood loss, postoperative hospital stay, and complications were recorded. The reduction quality was evaluated by Ovadia deals radiographic score, and the ankle function and pain were evaluated by VAS score, American Orthopaedic Foot and Ankle Society (AOFAS) score, and ankle range of motion. Results Mason 2B Pilon subtype: There was no significant difference in operation time, intraoperative blood loss, postoperative hospital stay, and follow-up time between the two groups (P>0.05). The radiological evaluation of Ovadia deals in group A was significantly worse than that in group B (P<0.05). The VAS score in the two groups significantly improved at each time point after operation, and the VAS score and AOFAS score further improved with the extension of time after operation, and the differences were significant (P<0.05). Except that the AOFAS score of group A was significantly lower than that of group B at last follow-up (P<0.05), there was no significant difference in VAS score and AOFAS score between the two groups at other time points (P>0.05). At last follow-up, the ankle range of motion in group A was significantly less than that in group B (P<0.05). There was no significant difference in the incidence of sural nerve injury, deep tissue infection, limitation of toe movement, and traumatic ankle arthritis between the two groups (P>0.05). Mason 2B avulsion subtype: The operation time was (119.47±20.61) minutes and the intraoperative blood loss was 50 (35, 55) mL. Seventeen patients were followed up 13-25 months, with an average of 18 months. The Ovadia deals score was excellent in 10 cases, good in 6 cases, and poor in 1 case at 1 week after operation, and the excellent and good rate was 94.1%. All fractures healed in 8-18 weeks with an average of 12.35 weeks. There were 1 case of sural nerve injury and 3 cases of traumatic ankle arthritis after operation. No deep tissue infection or limitation of toe movement occurred. The VAS score decreased significantly and AOFAS score increased significantly with time, and the differences were significant between different time points before and after operation (P<0.05). The ankle range of motion at last follow-up was (56.71±2.47)°. Conclusion Compared with the posterolateral approach, the combined approach is a better choice for the treatment of Mason 2B Pilon subtype. If the posteromedial bone block does not affect the reduction of the medial malleolus, the posterolateral approach can achieve good effectiveness for Mason 2B avulsion subtype.

Citation： LU Xinghua, JI Renchen, ZHAO Wenzhi, ZHANG Lu. Comparison of posterolateral approach and combined approach in treatment of Mason type 2B posterior malleolar fracture. Chinese Journal of Reparative and Reconstructive Surgery, 2023, 37(11): 1353-1360. doi: 10.7507/1002-1892.202307049 Copy

1.	Yip G, Hay D, Stringfellow T, et al. Assessment and management of adult ankle fractures: understanding the evidence. Br J Hosp Med (Lond), 2021, 82(5): 1-9.
2.	Jeyaseelan L, Bua N, Parker L, et al. Outcomes of posterior malleolar fixation in ankle fractures in a major trauma centre. Injury, 2021, 52(4): 1023-1027.
3.	Stringfellow TD, Walters ST, Nash W, et al. Management of posterior malleolus fractures: A multicentre cohort study in the United Kingdom. Foot Ankle Surg, 2021, 27(6): 629-635.
4.	Mason LW, Marlow WJ, Widnall J, et al. Pathoanatomy and associated injuries of posterior malleolus fracture of the ankle. Foot Ankle Int, 2017, 38(11): 1229-1235.
5.	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.
6.	Mangnus L, Meijer DT, Stufkens SA, et al. Posterior Malleolar Fracture Patterns. J Orthop Trauma, 2015, 29(9): 428-435.
7.	Vosoughi AR, Jayatilaka MLT, Fischer B, et al. CT analysis of the posteromedial fragment of the posterior malleolar fracture. Foot Ankle Int, 2019, 40(6): 648-655.
8.	Fernández-Rojas E, Herrera-Pérez M, Vilá-Rico J. Posterior malleolar fractures: Indications and surgical approaches. Rev Esp Cir Ortop Traumatol, 2023, 67(2): 160-169.
9.	Yang L, Yin G, Zhu J, et al. Posterolateral approach for posterior malleolus fixation in ankle fractures: functional and radiological outcome based on Bartonicek classification. Arch Orthop Trauma Surg, 2023, 143(7): 4099-4109.
10.	Patel S, Baburaj V, Sharma S, et al. Influence of posterior malleolar fragment morphology on the outcomes of trimalleolar fractures: A systematic review and meta-analysis. Foot Ankle Surg, 2022, 28(8): 1337-1344.
11.	Gan TJ, Li YX, Chen Y, et al. Open reduction and internal fixation for posterior pilon fracture: Transfibular approach versus posterior approach. Injury, 2023, 54(2): 751-760.
12.	趙波, 高青鳳, 鄧長康. 改良踝關節后外側、前內側聯合入路治療三踝骨折的臨床療效分析. 中國現代藥物應用, 2020, 14(14): 11-13.
13.	陳偉, 鄭金鑫, 侯曉斌, 等. 聯合入路開放復位內固定HaraguchiⅡ型后踝骨折. 中國矯形外科雜志, 2023, 31(4): 369-372.
14.	Lee J, Ryu H, Park JY. Single lateral approach for open reduction and internal fixation of posterior malleolar fragment in Weber B rotational ankle fracture. Medicine (Baltimore), 2023, 102(3): e32725.
15.	Evers J, Fischer M, Zderic I, et al. The role of a small posterior malleolar fragment in trimalleolar fractures: a biomechanical study. Bone Joint J, 2018, 100-B(1): 95-100.
16.	Bartoní?ek J, Rammelt S, Tu?ek M, et al. Posterior malleolar fractures of the ankle. Eur J Trauma Emerg Surg, 2015, 41(6): 587-600.
17.	van den Bekerom MP, Haverkamp D, Kloen P. Biomechanical and clinical evaluation of posterior malleolar fractures. A systematic review of the literature. J Trauma, 2009, 66(1): 279-284.
18.	Tenenbaum S, Shazar N, Bruck N, et al. Posterior malleolus fractures. Orthop Clin North Am, 2017, 48(1): 81-89.
19.	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.
20.	Heyes GJ, Khashkhusha TR, Mason L. Posterolateral approach to posterior malleolar fractures: A literature review. Foot Ankle Spec, 2023, 16(2): 149-158.
21.	Gandham S, Millward G, Molloy AP, et al. Posterior malleolar fractures: A CT guided incision analysis. Foot (Edinb), 2020, 43: 101662.
22.	Roberts V, Mason LW, Harrison E, et al. Does functional outcome depend on the quality of the fracture fixation? Mid to long term outcomes of ankle fractures at two university teaching hospitals. Foot Ankle Surg, 2019, 25(4): 538-541.
23.	Shi HF, Xiong J, Chen YX, et al. Comparison of the direct and indirect reduction techniques during the surgical management of posterior malleolar fractures. BMC Musculoskelet Disord, 2017, 18(1): 109.
24.	Howard JL, Agel J, Barei DP, et al. A prospective study evaluating incision placement and wound healing for tibial plafond fractures. J Orthop Trauma, 2008, 22(5): 299-305.
25.	Bali N, Aktselis I, Ramasamy A, et al. An evolution in the management of fractures of the ankle: safety and efficacy of posteromedial approach for Haraguchi type 2 posterior malleolar fractures. Bone Joint J, 2017, 99-B(11): 1496-1501.
26.	Yang Y, He W, Zhou H, et al. Combined posteromedial and posterolateral approaches for 2-part posterior malleolar fracture fixation. Foot Ankle Int, 2020, 41(10): 1234-1239.
27.	Stake IK, Bryniarski AR, Brady AW, et al. Effect of posterior malleolar fixation on syndesmotic stability. Am J Sports Med, 2023, 51(4): 997-1006.
28.	俞光榮, 趙宏謀. 足踝部急性損傷的治療要點與最新進展. 中國修復重建外科雜志, 2011, 25(7): 769-773.
29.	Rosenberg ZS, Cheung YY, Beltran J, et al. Posterior intermalleolar ligament of the ankle: normal anatomy and MR imaging features. AJR Am J Roentgenol, 1995, 165(2): 387-390.

1. Yip G, Hay D, Stringfellow T, et al. Assessment and management of adult ankle fractures: understanding the evidence. Br J Hosp Med (Lond), 2021, 82(5): 1-9.
2. Jeyaseelan L, Bua N, Parker L, et al. Outcomes of posterior malleolar fixation in ankle fractures in a major trauma centre. Injury, 2021, 52(4): 1023-1027.
3. Stringfellow TD, Walters ST, Nash W, et al. Management of posterior malleolus fractures: A multicentre cohort study in the United Kingdom. Foot Ankle Surg, 2021, 27(6): 629-635.
4. Mason LW, Marlow WJ, Widnall J, et al. Pathoanatomy and associated injuries of posterior malleolus fracture of the ankle. Foot Ankle Int, 2017, 38(11): 1229-1235.
5. 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.
6. Mangnus L, Meijer DT, Stufkens SA, et al. Posterior Malleolar Fracture Patterns. J Orthop Trauma, 2015, 29(9): 428-435.
7. Vosoughi AR, Jayatilaka MLT, Fischer B, et al. CT analysis of the posteromedial fragment of the posterior malleolar fracture. Foot Ankle Int, 2019, 40(6): 648-655.
8. Fernández-Rojas E, Herrera-Pérez M, Vilá-Rico J. Posterior malleolar fractures: Indications and surgical approaches. Rev Esp Cir Ortop Traumatol, 2023, 67(2): 160-169.
9. Yang L, Yin G, Zhu J, et al. Posterolateral approach for posterior malleolus fixation in ankle fractures: functional and radiological outcome based on Bartonicek classification. Arch Orthop Trauma Surg, 2023, 143(7): 4099-4109.
10. Patel S, Baburaj V, Sharma S, et al. Influence of posterior malleolar fragment morphology on the outcomes of trimalleolar fractures: A systematic review and meta-analysis. Foot Ankle Surg, 2022, 28(8): 1337-1344.
11. Gan TJ, Li YX, Chen Y, et al. Open reduction and internal fixation for posterior pilon fracture: Transfibular approach versus posterior approach. Injury, 2023, 54(2): 751-760.
12. 趙波, 高青鳳, 鄧長康. 改良踝關節后外側、前內側聯合入路治療三踝骨折的臨床療效分析. 中國現代藥物應用, 2020, 14(14): 11-13.
13. 陳偉, 鄭金鑫, 侯曉斌, 等. 聯合入路開放復位內固定HaraguchiⅡ型后踝骨折. 中國矯形外科雜志, 2023, 31(4): 369-372.
14. Lee J, Ryu H, Park JY. Single lateral approach for open reduction and internal fixation of posterior malleolar fragment in Weber B rotational ankle fracture. Medicine (Baltimore), 2023, 102(3): e32725.
15. Evers J, Fischer M, Zderic I, et al. The role of a small posterior malleolar fragment in trimalleolar fractures: a biomechanical study. Bone Joint J, 2018, 100-B(1): 95-100.
16. Bartoní?ek J, Rammelt S, Tu?ek M, et al. Posterior malleolar fractures of the ankle. Eur J Trauma Emerg Surg, 2015, 41(6): 587-600.
17. van den Bekerom MP, Haverkamp D, Kloen P. Biomechanical and clinical evaluation of posterior malleolar fractures. A systematic review of the literature. J Trauma, 2009, 66(1): 279-284.
18. Tenenbaum S, Shazar N, Bruck N, et al. Posterior malleolus fractures. Orthop Clin North Am, 2017, 48(1): 81-89.
19. 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.
20. Heyes GJ, Khashkhusha TR, Mason L. Posterolateral approach to posterior malleolar fractures: A literature review. Foot Ankle Spec, 2023, 16(2): 149-158.
21. Gandham S, Millward G, Molloy AP, et al. Posterior malleolar fractures: A CT guided incision analysis. Foot (Edinb), 2020, 43: 101662.
22. Roberts V, Mason LW, Harrison E, et al. Does functional outcome depend on the quality of the fracture fixation? Mid to long term outcomes of ankle fractures at two university teaching hospitals. Foot Ankle Surg, 2019, 25(4): 538-541.
23. Shi HF, Xiong J, Chen YX, et al. Comparison of the direct and indirect reduction techniques during the surgical management of posterior malleolar fractures. BMC Musculoskelet Disord, 2017, 18(1): 109.
24. Howard JL, Agel J, Barei DP, et al. A prospective study evaluating incision placement and wound healing for tibial plafond fractures. J Orthop Trauma, 2008, 22(5): 299-305.
25. Bali N, Aktselis I, Ramasamy A, et al. An evolution in the management of fractures of the ankle: safety and efficacy of posteromedial approach for Haraguchi type 2 posterior malleolar fractures. Bone Joint J, 2017, 99-B(11): 1496-1501.
26. Yang Y, He W, Zhou H, et al. Combined posteromedial and posterolateral approaches for 2-part posterior malleolar fracture fixation. Foot Ankle Int, 2020, 41(10): 1234-1239.
27. Stake IK, Bryniarski AR, Brady AW, et al. Effect of posterior malleolar fixation on syndesmotic stability. Am J Sports Med, 2023, 51(4): 997-1006.
28. 俞光榮, 趙宏謀. 足踝部急性損傷的治療要點與最新進展. 中國修復重建外科雜志, 2011, 25(7): 769-773.
29. Rosenberg ZS, Cheung YY, Beltran J, et al. Posterior intermalleolar ligament of the ankle: normal anatomy and MR imaging features. AJR Am J Roentgenol, 1995, 165(2): 387-390.

Chinese Journal of Reparative and Reconstructive Surgery

Comparison of posterolateral approach and combined approach in treatment of Mason type 2B posterior malleolar fracture

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