Comparison of effectiveness between plate and screw internal fixation in treatment of posterior malleolus fractures through posterolateral approach_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

MA Ziyuan ¹ , GUO Shengyang ² , GAO Feng ² , WANG Bin ² , ZHOU Xiaoxiao ² , FU Beigang ² ,  XIA Shengli ^1,2

1. Guizhou Medical University, Guizhou Guiyang, 550004, P.R.China;
2. Department of Traumatic Orthopaedics, Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai, 201318, P.R.China;

Corresponding author：

XIA Shengli, Email: victorxia@126.com

Keywords：

Posterior malleolus fracture; posterolateral approach; plate; screw; internal fixation

DOI：

10.7507/1002-1892.202010030

Video：

Export PDF Favorites Scan Get Citation

Abstract Full text Figures/Tables Video References Cited by

Objective To compare the effectiveness of posterior malleolus fractures treated by plate and screw internal fixation through posterolateral approach.Methods The clinical data of 95 patients with posterior malleolus fractures who were admitted between January 2016 and December 2019 and met the selection criteria were retrospectively analysed. They were divided into plate group (44 cases, treated with posterolateral plate internal fixation) and screw group (51 cases, treated with posterolateral screw internal fixation) according to different treatment methods. There was no significant difference in general data between the two groups of patients such as age, gender, cause of injury, side of injury, ankle fracture or injury classification, time from injury to operation, and percentage of posterior ankle fracture area to the distal tibia articular surface (P>0.05). The operation time, hospital stay, fracture healing time, and surgical complications were compared between the two groups. Imaging examinations (X-ray film, CT scan and reconstruction) were used to assess the reduction quality of ankle fracture, articular congruity, and re-displacement in ankle fracture. At last follow-up, the pain visual analogue scale (VAS) score was used to evaluate the patients’ pain, and the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was used to evaluate ankle joint function.Results Patients in both groups were followed up 6-30 months, with an average of 18.2 months. The operation time of the plate group was significantly longer than that of the screw group (U=−2.040, P=0.041); there was no significant difference in hospital stay between the two groups (U=−1.068, P=0.285). Incision swelling occurred in 2 cases in the plate group, sural nerve injury in 3 cases, and traumatic arthritis in 2 cases during follow-up. In the screw group, there were 1, 2, and 2 cases, respectively. The incidence of complications in the two groups (15.9% vs. 9.8%) was not significantly different (P=0.372). All patients who underwent tibiofibular screw fixation underwent the removal of the tibiofibular screw before taking full weight bearing at 12 weeks after operation, and there was no screw fracture and retention. During the follow-up, there was no infection, re-displacement of fracture, delayed bone union or nonunion, and there was no significant difference in fracture healing time between the two groups (t=0.345, P=0.731). There was no significant difference between the two groups of reduction quality of ankle fracture and articular congruity evaluation results (P>0.05). At last follow-up, there was no significant difference in VAS score, AOFAS ankle-hindfoot score and evaluation grade between the two groups (P>0.05).Conclusion Both the plate and screw internal fixation through posterolateral approach can achieve satisfied effectiveness in the treatment of posterior ankle fractures with maintenance of fracture reduction, and recovery of ankle joint function. The screw internal fixation has the advantages of minimal invasion and shorter operation time.

Citation： MA Ziyuan, GUO Shengyang, GAO Feng, WANG Bin, ZHOU Xiaoxiao, FU Beigang, XIA Shengli. Comparison of effectiveness between plate and screw internal fixation in treatment of posterior malleolus fractures through posterolateral approach. Chinese Journal of Reparative and Reconstructive Surgery, 2021, 35(4): 431-438. doi: 10.7507/1002-1892.202010030 Copy

1.	Gardner MJ, Brodsky A, Briggs SM, et al. Fixation of posterior malleolar fractures provides greater syndesmotic stability. Clin Orthop Relat Res, 2006, 447: 165-171.
2.	Yi Y, Chun DI, Won SH, et al. Morphological characteristics of the posterior malleolar fragment according to ankle fracture patterns: a computed tomography-based study. BMC Musculoskelet Disord, 2018, 19(1): 51.
3.	Bartoníček J, Rammelt S, Tuček M. Posterior malleolar fractures: Changing concepts and recent developments. Foot Ankle Clin, 2017, 22(1): 125-145.
4.	Wang X, Yin J, Zhang C, et al. Biomechanical study of screw fixation and plate fixation of a posterior malleolar fracture in a simulation of the normal gait cycle. Foot Ankle Int, 2017, 38(10): 1132-1138.
5.	Verhage SM, Krijnen P, Schipper IB, et al. Persistent postoperative step-off of the posterior malleolus leads to higher incidence of post-traumatic osteoarthritis in trimalleolar fractures. Arch Orthop Trauma Surg, 2019, 139(3): 323-329.
6.	Velleman J, Nijs S, Hoekstra H. Operative management of AO type 44 ankle fractures: Determinants of outcome. J Foot Ankle Surg, 2018, 57(2): 247-253.
7.	Kang C, Hwang DS, Lee JK, et al. Screw fixation of the posterior malleolus fragment in ankle fracture. Foot Ankle Int, 2019, 40(11): 1288-1294.
8.	Yammine K, Karam K, Assi C. Cortical versus cancellous screws in treating medial malleolar fractures: A systematic review of comparative clinical and biomechanical studies. Foot (Edinb), 2019, 40: 81-86.
9.	Mchale S, Williams M, Ball T. Retrospective cohort study of operatively treated ankle fractures involving the posterior malleolus. Foot Ankle Surg, 2020, 26(2): 138-145.
10.	Ovadia DN, Beals RK. Fractures of the tibial plafond. J Bone Joint Surg (Am), 1986, 68(4): 543-551.
11.	Ketz J, Sanders R. Staged posterior tibial plating for the treatment of Orthopaedic Trauma Association 43C2 and 43C3 tibial pilon fractures. J Orthop Trauma, 2012, 26(6): 341-347.
12.	Briet JP, Hietbrink F, Smeeing DP, et al. Ankle fracture classification: An innovative system for describing ankle fractures. J Foot Ankle Surg, 2019, 58(3): 492-496.
13.	Alonso-Rasgado T, Jimenez-Cruz D, Karski M. 3-D computer modelling of malunited posterior malleolar fractures: effect of fragment size and offset on ankle stability, contact pressure and pattern. J Foot Ankle Res, 2017, 10. doi: 10.1186/s13047-017-0194-5.
14.	Toth MJ, Yoon RS, Liporace FA, et al. What’s new in ankle fractures. Injury, 2017, 48(10): 2035-2041.
15.	Odak S, Ahluwalia R, Unnikrishnan P, et al. Management of posterior malleolar fractures: A systematic review. J Foot Ankle Surg, 2016, 55(1): 140-145.
16.	尹建文, 王旭, 王成伟, 等. 后踝骨折内固定方法的选择. 中华创伤骨科杂志, 2016, 18(6): 545-549.
17.	Duan X, Kadakia AR. Operative treatment of posterior malleolar fractures. Open Orthop J, 2017, 11: 732-742.
18.	俞光荣, 赵宏谋, 杨云峰, 等. 切开复位内固定治疗后踝骨折的疗效分析. 中国修复重建外科杂志, 2011, 25(7): 774-777.
19.	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.
20.	Karaca S, Enercan M, Özdemir G, et al. Importance of fixation of posterior malleolus fracture in trimalleolar fractures: A retrospective study. Ulus Travma Acil Cerrahi Derg, 2016, 22(6): 553-558.
21.	Tosun B, Selek O, Gok U, et al. Posterior malleolus fractures in trimalleolar ankle fractures: Malleolus versus transyndesmal fixation. Indian J Orthop, 2018, 52(3): 309-314.
22.	Verhage SM, Hoogendoorn JM, Krijnen P, et al. When and how to operate the posterior malleolus fragment in trimalleolar fractures: a systematic literature review. Arch Orthop Trauma Surg, 2018, 138(9): 1213-1222.
23.	Blom RP, Hayat B, Al-Dirini RMA, et al. Posterior malleolar ankle fractures. Bone Joint J, 2020, 102-B(9): 1229-1241.
24.	Fitzpatrick E, Goetz JE, Sittapairoj T, et al. Effect of posterior malleolus fracture on syndesmotic reduction: A cadaveric study. J Bone Joint Surg (Am), 2018, 100(3): 243-248.
25.	Tenenbaum S, Shazar N, Bruck N, et al. Posterior malleolus fractures. Orthop Clin North Am, 2017, 48(1): 81-89.
26.	柴浩, 吴婷, 舒莉, 等. 螺钉与钢板固定治疗后踝骨折的 Meta 分析. 中国组织工程研究, 2018, 22(27): 4423-4428.
27.	Gupta S, Virk JS, Malhotra A, et al. Fragment-specific fixation of trimalleolar fractures utilizing the posterolateral approach: A preliminary experience. J Orthop Surg (Hong Kong), 2019, 27(2): 2309499019842289.
28.	Vidović D, Elabjer E, Muskardin I, et al. Posterior fragment in ankle fractures: anteroposterior vs posteroanterior fixation. Injury, 2017, 48 Suppl 5: S65-S69.
29.	Erdem MN, Erken HY, Burc H, et al. Comparison of lag screw versus buttress plate fixation of posterior malleolar fractures. Foot Ankle Int, 2014, 35(10): 1022-1030.
30.	Wang Z, Sun J, Yan J, et al. Comparison of the efficacy of posterior-anterior screws, anterior-posterior screws and a posterior-anterior plate in the fixation of posterior malleolar fractures with a fragment size of ≥15 and <15%. BMC Musculoskelet Disord, 2020, 21(1): 570.
31.	Mak MF, Stern R, Assal M, et al. Repair of syndesmosis injury in ankle fractures: Current state of the art. EFORT Open Rev, 2018, 3(1): 24-29.
32.	von Rüden C, Hackl S, Woltmann A, et al. The postero-lateral approach—an alternative to closed anterior-posterior screw fixation of a dislocated postero-lateral fragment of the distal tibia in complex ankle fractures. Z Orthop Unfall, 2015, 153(3): 289-295.
33.	O’Connor TJ, Mueller B, Ly TV, et al. “A to p” screw versus posterolateral plate for posterior malleolus fixation in trimalleolar ankle fractures. J Orthop Trauma, 2015, 29(4): e151-e156.
34.	Kalem M, Şahin E, Songür M, et al. Comparison of three posterior malleolar fixation methods in trimalleolar ankle fractures. Acta Orthop Belg, 2018, 84(2): 203-212.
35.	Bennett C, Behn A, Daoud A, et al. Buttress plating versus anterior-to-posterior lag screws for fixation of the posterior malleolus: A biomechanical study. J Orthop Trauma, 2016, 30(12): 664-669.
36.	Anwar A, Zhang Z, Lv D, et al. Biomechanical efficacy of AP, PA lag screws and posterior plating for fixation of posterior malleolar fractures: a three dimensional finite element study. BMC Musculoskelet Disord, 2018, 19(1): 73.
37.	Mehta SS, Rees K, Cutler L, et al. Understanding risks and complications in the management of ankle fractures. Indian J Orthop, 2014, 48(5): 445-452.
38.	彭义, 曲家富, 曹立海. 钢板与螺钉内固定对后踝关节骨折患者的疗效及 IL-6、IL-8 和 CRP 的影响. 中国临床研究, 2017, 30(6): 816-818.

1. Gardner MJ, Brodsky A, Briggs SM, et al. Fixation of posterior malleolar fractures provides greater syndesmotic stability. Clin Orthop Relat Res, 2006, 447: 165-171.
2. Yi Y, Chun DI, Won SH, et al. Morphological characteristics of the posterior malleolar fragment according to ankle fracture patterns: a computed tomography-based study. BMC Musculoskelet Disord, 2018, 19(1): 51.
3. Bartoníček J, Rammelt S, Tuček M. Posterior malleolar fractures: Changing concepts and recent developments. Foot Ankle Clin, 2017, 22(1): 125-145.
4. Wang X, Yin J, Zhang C, et al. Biomechanical study of screw fixation and plate fixation of a posterior malleolar fracture in a simulation of the normal gait cycle. Foot Ankle Int, 2017, 38(10): 1132-1138.
5. Verhage SM, Krijnen P, Schipper IB, et al. Persistent postoperative step-off of the posterior malleolus leads to higher incidence of post-traumatic osteoarthritis in trimalleolar fractures. Arch Orthop Trauma Surg, 2019, 139(3): 323-329.
6. Velleman J, Nijs S, Hoekstra H. Operative management of AO type 44 ankle fractures: Determinants of outcome. J Foot Ankle Surg, 2018, 57(2): 247-253.
7. Kang C, Hwang DS, Lee JK, et al. Screw fixation of the posterior malleolus fragment in ankle fracture. Foot Ankle Int, 2019, 40(11): 1288-1294.
8. Yammine K, Karam K, Assi C. Cortical versus cancellous screws in treating medial malleolar fractures: A systematic review of comparative clinical and biomechanical studies. Foot (Edinb), 2019, 40: 81-86.
9. Mchale S, Williams M, Ball T. Retrospective cohort study of operatively treated ankle fractures involving the posterior malleolus. Foot Ankle Surg, 2020, 26(2): 138-145.
10. Ovadia DN, Beals RK. Fractures of the tibial plafond. J Bone Joint Surg (Am), 1986, 68(4): 543-551.
11. Ketz J, Sanders R. Staged posterior tibial plating for the treatment of Orthopaedic Trauma Association 43C2 and 43C3 tibial pilon fractures. J Orthop Trauma, 2012, 26(6): 341-347.
12. Briet JP, Hietbrink F, Smeeing DP, et al. Ankle fracture classification: An innovative system for describing ankle fractures. J Foot Ankle Surg, 2019, 58(3): 492-496.
13. Alonso-Rasgado T, Jimenez-Cruz D, Karski M. 3-D computer modelling of malunited posterior malleolar fractures: effect of fragment size and offset on ankle stability, contact pressure and pattern. J Foot Ankle Res, 2017, 10. doi: 10.1186/s13047-017-0194-5.
14. Toth MJ, Yoon RS, Liporace FA, et al. What’s new in ankle fractures. Injury, 2017, 48(10): 2035-2041.
15. Odak S, Ahluwalia R, Unnikrishnan P, et al. Management of posterior malleolar fractures: A systematic review. J Foot Ankle Surg, 2016, 55(1): 140-145.
16. 尹建文, 王旭, 王成伟, 等. 后踝骨折内固定方法的选择. 中华创伤骨科杂志, 2016, 18(6): 545-549.
17. Duan X, Kadakia AR. Operative treatment of posterior malleolar fractures. Open Orthop J, 2017, 11: 732-742.
18. 俞光荣, 赵宏谋, 杨云峰, 等. 切开复位内固定治疗后踝骨折的疗效分析. 中国修复重建外科杂志, 2011, 25(7): 774-777.
19. 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.
20. Karaca S, Enercan M, Özdemir G, et al. Importance of fixation of posterior malleolus fracture in trimalleolar fractures: A retrospective study. Ulus Travma Acil Cerrahi Derg, 2016, 22(6): 553-558.
21. Tosun B, Selek O, Gok U, et al. Posterior malleolus fractures in trimalleolar ankle fractures: Malleolus versus transyndesmal fixation. Indian J Orthop, 2018, 52(3): 309-314.
22. Verhage SM, Hoogendoorn JM, Krijnen P, et al. When and how to operate the posterior malleolus fragment in trimalleolar fractures: a systematic literature review. Arch Orthop Trauma Surg, 2018, 138(9): 1213-1222.
23. Blom RP, Hayat B, Al-Dirini RMA, et al. Posterior malleolar ankle fractures. Bone Joint J, 2020, 102-B(9): 1229-1241.
24. Fitzpatrick E, Goetz JE, Sittapairoj T, et al. Effect of posterior malleolus fracture on syndesmotic reduction: A cadaveric study. J Bone Joint Surg (Am), 2018, 100(3): 243-248.
25. Tenenbaum S, Shazar N, Bruck N, et al. Posterior malleolus fractures. Orthop Clin North Am, 2017, 48(1): 81-89.
26. 柴浩, 吴婷, 舒莉, 等. 螺钉与钢板固定治疗后踝骨折的 Meta 分析. 中国组织工程研究, 2018, 22(27): 4423-4428.
27. Gupta S, Virk JS, Malhotra A, et al. Fragment-specific fixation of trimalleolar fractures utilizing the posterolateral approach: A preliminary experience. J Orthop Surg (Hong Kong), 2019, 27(2): 2309499019842289.
28. Vidović D, Elabjer E, Muskardin I, et al. Posterior fragment in ankle fractures: anteroposterior vs posteroanterior fixation. Injury, 2017, 48 Suppl 5: S65-S69.
29. Erdem MN, Erken HY, Burc H, et al. Comparison of lag screw versus buttress plate fixation of posterior malleolar fractures. Foot Ankle Int, 2014, 35(10): 1022-1030.
30. Wang Z, Sun J, Yan J, et al. Comparison of the efficacy of posterior-anterior screws, anterior-posterior screws and a posterior-anterior plate in the fixation of posterior malleolar fractures with a fragment size of ≥15 and <15%. BMC Musculoskelet Disord, 2020, 21(1): 570.
31. Mak MF, Stern R, Assal M, et al. Repair of syndesmosis injury in ankle fractures: Current state of the art. EFORT Open Rev, 2018, 3(1): 24-29.
32. von Rüden C, Hackl S, Woltmann A, et al. The postero-lateral approach—an alternative to closed anterior-posterior screw fixation of a dislocated postero-lateral fragment of the distal tibia in complex ankle fractures. Z Orthop Unfall, 2015, 153(3): 289-295.
33. O’Connor TJ, Mueller B, Ly TV, et al. “A to p” screw versus posterolateral plate for posterior malleolus fixation in trimalleolar ankle fractures. J Orthop Trauma, 2015, 29(4): e151-e156.
34. Kalem M, Şahin E, Songür M, et al. Comparison of three posterior malleolar fixation methods in trimalleolar ankle fractures. Acta Orthop Belg, 2018, 84(2): 203-212.
35. Bennett C, Behn A, Daoud A, et al. Buttress plating versus anterior-to-posterior lag screws for fixation of the posterior malleolus: A biomechanical study. J Orthop Trauma, 2016, 30(12): 664-669.
36. Anwar A, Zhang Z, Lv D, et al. Biomechanical efficacy of AP, PA lag screws and posterior plating for fixation of posterior malleolar fractures: a three dimensional finite element study. BMC Musculoskelet Disord, 2018, 19(1): 73.
37. Mehta SS, Rees K, Cutler L, et al. Understanding risks and complications in the management of ankle fractures. Indian J Orthop, 2014, 48(5): 445-452.
38. 彭义, 曲家富, 曹立海. 钢板与螺钉内固定对后踝关节骨折患者的疗效及 IL-6、IL-8 和 CRP 的影响. 中国临床研究, 2017, 30(6): 816-818.

Chinese Journal of Reparative and Reconstructive Surgery

Comparison of effectiveness between plate and screw internal fixation in treatment of posterior malleolus fractures through posterolateral approach

Abstract Full text Figures/Tables Video References Cited by

Previous Article

Next Article

Format

Content