Surgical Outcomes of Indirect Reduction and Anterior to Posterior Fixation for Posterior Fragment in Trimalleolar Ankle Fracture

Transcription

1 Surgical Outcomes of Indirect Reduction and Anterior to Posterior Fixation for Posterior Fragment in Trimalleolar Ankle Fracture Ki-Sun Sung M.D., PhD., Yong-Serk Park M.D., Tae-Hwan Chun M.D., Sung-shan Lee M.D., Keun-ho Lee M.D. Department of Orthopedic Surgery, Samsung Medical Center, College of Medicine, Sungkyunkwan University, Seoul, Korea

2 Surgical Outcomes of Indirect Reduction and Anterior to Posterior Fixation for Posterior Fragment in Trimalleolar Ankle Fracture Ki-Sun Sung M.D., PhD., Yong-Serk Park M.D., Tae-Hwan Chun M.D., Sung-shan Lee M.D., Keun-ho Lee M.D. My disclosure is in the Final AOFAS Program Book. I have no potential conflicts with this presentation.

3 Introduction Trimalleolar Fracture 7~40 % of Ankle Fracture Incidence of Ankle Fracture : 0.01~0.02%/year High Rate of Post-Traumatic Ankle OA Controversies for Post. Malleolar Fragment Indications for Operative Treatment Suggestion of Some Clinical Studies 25~33% of articular surface Fixation Methods Ant. To Post. Screws / Post. Plate / Post. To Ant. Screws Reduction Techniques Direct Open / Indirect (Ligamentotaxis, Percutaneous by Clamp or Others)

4 Purpose To evaluate & compare the results of post. Malleolar fragment whether it is fixed Ant. to Post. or Not fixed To evaluate & compare the outcomes according to the articular surface congruency Study Design Retrospective comparative study Period : March 2004 ~ July 2010 Single Surgeon Series Exclusion Criteria Pathologic Fx. / Open Fx. / Pilon Fx. Post. Ant. Fixation of Post. Malleolar Fragment

5 Materials and methods Patients Demographics 28 Males / 24 Females Mean Age : 54.4 years (20~86) Mean F/U : 54.7 months (12~89) 20 Post. Fragment 25% Ant. Post. Fixated 160 Ankle Fx. 58 Trimalleolar Fx. Operative Technique Anatomical Reduction & Stable Fixation of Med. & Lat. Malleolar Fragment Post. Malleolar Fragment Reduction Indirect Reduction (Ligamentotaxis or Percutaneous) Cannulated Screw Insertion from Ant. to Post. 32 Post. Fragment < 25% Non-Fixated

6 Materials and methods Clinical Evaluations American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot-ankle score Olerud & Molander (O&M) score Recovery Time to Pre-Injury State Subjective Satisfaction Excellent/Good/Fair/Poor Radiologic Evaluations Post. Malleolar Fragment Size (%) Reduction Status Displace 2mm Congruent OsteoArthritis (OA) score 1. Osteophytes 2. Joint Space Narrowing 3. Deformity Statistical Analysis SAS version 9.1 (SAS Institute Inc, Cary, NC, USA) Mann-Whitney U-test P < 0.05 Statistically Significant

7 Results Clinical results of the patients for fixated group (A) and non-fixated (B). Parameter Group A Group B p-value(<0.05) AOFAS hind-foot Score Pain score (20~40) (20~40) Function score (30~50) (32~50) Total score (65~100) (62~100) Olerud & Molander Score (55~100) (25~100) Osteoarthritis Score 0.85 (0~2) 0.78 (0~2) Recovery Time (weeks) (8~48) (8~48) 0.214

8 Results Subjective satisfaction of the patients for fixated group (A), non-fixated (B). Parameter Group A (n=20) Group B (n=32) Total Excellent Good Fair Poor Clinical results of the patients according to the postoperative reduction status Postoperative reduction < 2mm (n=41) 2mm (n=11) p-value(<0.05) Group A 16 4 Group B 25 7 AOFAS hind-foot Score (62~100) (70~100) Olerud & Molander Score (25~100) (55~100) Osteoarthritis Score 0.73 (0~2) 1.09 (0~2) Fragment size (%) (7.27~55.56) (17.63~48.93) Recovery Time (weeks) (8~48) (12~48) 0.048

9 Discussion Posterolateral Approach, Direct Reduction, & Buttress Plate Good Anatomic Reduction, But, No Clinical Outcomes Abdgelgawad et al. JFAS, 2011 Increasing trend to direct ORIF of Post. Malleolar fractures Focus on Anatomic Reductions of all Periarticular fragments Restore Med. & Lat. Constraints > Articular Surface Provide the Majority of Ankle Stability Gardner et al. FAI, 2011 Van den Berkerome et al. J trauma, 2009 Stiehl et al. J trauma, 1993 Harper et al. JBJS Am, 1988 Anatomic reduction patients did not have better clinical results than non-anatomic reduction patients Mingo-Robinet et al. JFAS, 2011 Anatomic reduction & rigid fixation of posterior malleolar fragment did not entirely return the dynamic contact stress distribution to normal Fitzpatrick et al. JOT, 2004

10 Conclusion After Less Invasive Indirect Reduction, Ant. to post. fixation might be sufficient fixation method for significant posterior malleolar fragment. Clinical outcomes were not affected by the reduction status of post. malleolar fragments.

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