Hunt Anastasia A, Maschhoff Clayton, Van Rysselberghe Noelle, Gonzalez Christian A, Goodnough Henry, Gardner Michael, Bishop Julius A
Stanford University, Department of Orthopedic Surgery, 300 Pasteur Drive, Edwards Bldg, R144, Stanford, CA USA.
University of Illinois at Chicago School of Medicine, Chicago, IL USA.
Injury. 2024 Jun;55(6):111537. doi: 10.1016/j.injury.2024.111537. Epub 2024 Apr 6.
The indications for reduction and fixation of the posterior malleolus component of rotational ankle fractures have been controversial for nearly a century. This study aims to identify the historical basis for surgical intervention and trace trends in management strategies over time.
In March 2023, a systematic review of full-text, English-language articles providing indications for surgical fixation of the posterior malleolus component of rotational ankle fractures was performed. Articles underwent title and abstract screening before undergoing full-text review.
Historical indications for surgical fixation were size-dependent, with fractures comprising 25 % to 33 % of the plafond recommended for internal fixation. Modern studies suggest that nonoperative management of posterior malleolus fractures below this threshold results in residual malreduction of the articular surface, syndesmotic instability, and an increased need for independent fixation of the syndesmosis.
Size-based indications for posterior malleolus fracture fixation are based on Level V evidence from small retrospective case series published nearly one century ago and should be retired. While the size of the posterior malleolus component cannot be ignored, additional factors like fracture morphology and location within the plafond should guide modern surgical indications. Contemporary studies indicate that reduction and fixation of small posterior malleolus fractures (comprising less than 25 % of the articular surface) are associated with improved articular reductions, tibiotalar contact pressures, syndesmotic stability with decreased need for independent fixation of the syndesmosis, and superior postoperative outcomes.
近一个世纪以来，旋后型踝关节骨折后踝骨折块的复位与固定指征一直存在争议。本研究旨在确定手术干预的历史依据，并追溯管理策略随时间的发展趋势。
2023年3月，对提供旋后型踝关节骨折后踝骨折块手术固定指征的英文全文文章进行了系统综述。文章在进行全文审查之前先进行标题和摘要筛选。
手术固定的历史指征取决于骨折块大小，当骨折块占关节面25%至33%时建议进行内固定。现代研究表明，低于此阈值的后踝骨折采用非手术治疗会导致关节面残余复位不良、下胫腓联合不稳定，以及增加下胫腓联合单独固定的需求。
基于骨折块大小的后踝骨折固定指征是基于近一个世纪前发表的小型回顾性病例系列的V级证据，应予以摒弃。虽然后踝骨折块的大小不容忽视，但骨折形态和在关节面内的位置等其他因素应指导现代手术指征。当代研究表明，小型后踝骨折（占关节面不到25%）的复位与固定与改善关节复位、胫距接触压力、下胫腓联合稳定性、减少下胫腓联合单独固定的需求以及更好的术后结果相关。
