Department of Orthopaedics and Traumatology, Bürgerspital Solothurn, Solothurn, Switzerland.
Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland.
Arch Orthop Trauma Surg. 2020 Nov;140(11):1641-1647. doi: 10.1007/s00402-020-03353-2. Epub 2020 Jan 25.
Direct fixation of posterior malleolar fractures has been shown to lead to higher accuracy of fracture reduction compared to an indirect anterior to posterior fixation but lacks long-term clinical results. This study shows the mid- to long-term clinical and radiological outcome after direct fixation of the posterior malleolus through a posterolateral approach.
Thirty-six patients with an ankle fracture including a posterior malleolar fragment (23 × AO-44C, 12 × AO-44B, 1 × unclassifiable) treated with direct fixation of the fragment through a posterolateral approach were retrospectively evaluated. There were 24 females (67%) with a mean age of 63 (range 34-80) years and a BMI of 28 (range 19-41) kg/m at the time of surgery. An initial fracture-dislocation was seen in 67%. The clinical outcome was assessed with the Visual Analog Scale (VAS, 0-10 points) and the American Foot and Ankle Society (AOFAS, 0-100 points) score. Posttraumatic osteoarthritis was recorded with the Van Dijk Classification (grade 0-III). Subgroup analyses of patient- and fracture-associated risk factors (age, BMI, smoking, fracture-dislocation, postoperative articular step-off) were assessed to reveal possible negative prognostic predictors.
After a mean follow-up of 7.9 (range 3-12) years, the median VAS was 1 (IQR 0-2) point, and the median AOFAS score was 96 (IQR 88-100) points. Ankle range of motion measurements showed a significant, but clinically irrelevant, difference in plantar- and dorsiflexion between the affected and unaffected ankle. 92% of the patients were very satisfied or satisfied with the postoperative course. 89% had no preoperative signs of ankle osteoarthritis. Osteoarthritis progression was seen in 72%, with 50% showing grade II or III osteoarthritis at the final follow-up. No significant negative prognostic factors for a worse clinical outcome could be detected.
Direct fixation of posterior malleolar fractures through a posterolateral approach showed good clinical mid- to long-term results with a high satisfaction rate but substantial development of posttraumatic ankle osteoarthritis. Further studies should include CT analysis of the preoperative fracture morphology and even, perhaps, the postoperative reduction accuracy to evaluate the benefit of posterior malleolar fracture reduction in preventing ankle osteoarthritis in the long term.
Therapeutic Level IV. See Instructions for authors for a complete description of levels of evidence.
与间接前向后固定相比，直接固定后踝骨折可提高骨折复位的准确性，但缺乏长期的临床结果。本研究通过后外侧入路展示了直接固定后踝骨折的中期至长期临床和影像学结果。
回顾性评估了 36 例踝关节骨折患者，其中包括后踝骨折块（23×AO-44C，12×AO-44B，1×无法分类），通过后外侧入路直接固定骨折块。24 名女性（67%），平均年龄 63 岁（范围 34-80 岁），BMI 为 28（范围 19-41）kg/m2。初次骨折脱位占 67%。临床结果采用视觉模拟评分（VAS，0-10 分）和美国足踝外科协会（AOFAS，0-100 分）评分进行评估。创伤后骨关节炎采用范迪克分类（0-III 级）记录。对患者和骨折相关危险因素（年龄、BMI、吸烟、骨折脱位、术后关节台阶）的亚组分析，以揭示可能的负面预后预测因素。
平均随访 7.9（范围 3-12）年后，中位 VAS 为 1（IQR 0-2）分，AOFAS 评分为 96（IQR 88-100）分。踝关节活动度测量显示，患侧和健侧的跖屈和背屈有显著但临床无意义的差异。92%的患者对术后过程非常满意或满意。89%的患者术前无踝关节骨关节炎迹象。89%的患者术后发生骨关节炎进展，最终随访时 50%的患者出现 II 级或 III 级骨关节炎。未发现临床结果较差的显著负面预后因素。
通过后外侧入路直接固定后踝骨折可获得良好的中期至长期临床效果，患者满意度高，但创伤后踝关节骨关节炎发展显著。进一步的研究应包括术前骨折形态的 CT 分析，甚至可能包括术后复位准确性，以评估后踝骨折复位在预防踝关节骨关节炎方面的长期益处。
治疗 IV 级。有关证据水平的完整描述，请参见作者说明。
