Abstract
Trimalleolar fractures account for 7%-11% of ankle fractures and are generally caused by high-energy trauma. They are unstable fractures that require surgical repair in most cases as it is associated with a better functional outcome, so it should be considered in all patients, even those with comorbidities. In this type of fracture, the posterior malleolus compromise has the highest complexity, and it is associated with a worse prognosis. The management is still controversial, especially regarding the order in which malleolus should be repaired and the fixation materials to be used.
Key words: ankle fractures;
Keywords
References
Stead TS, Pomerantz LH, Ganti L. Acute Management of Trimalleolar Fracture. Cureus. 2021; 13(1): e12536. https://doi.org/10.7759/cureus.12536
Putra FD, Pili M. Management and clinical outcome of trimalleolar fractures of ankle: a case report. The Orthopaedic Journal of Sports Medicine. 2019; 7(11): 6. https://doi.org/10.1177/2325967119S00473
Bartonicek J, Rammelt S, Kostlivy K, et al. Anatomy and classification of the posterior tibial fragment in ankle fractures. Arch Orthop Trauma Surg. 2015; 135: 505–516. https://doi.org/10.1007/s00402-015-2171-4
Neumann A, Rammelt S. Ankle fractures involving the posterior malleolus: patient characteristics and 7‑year results in 100 cases. Archives of Orthopaedic and Trauma Surgery. 2021. https://doi.org/10.1007/s00402-021-03875-3
Nasrallah K, Einal B, Shtarker H. Trimalleolar fracture: The endless posterior malleolus fracture debate, to repair or not to repair?. Orthop Rev (Pavia). 2021; 13(1): 8784. https://doi.org/10.4081/or.2021.8784
Goost H, Wimmer MD, Barg A, et al. Fractures of the ankle joint: investigation and treatment options. Dtsch Arztebl Int. 2014; 111(21): 377-88. https://doi.org/10.3238/arztebl.2014.0377
Bartonicek J, Rammelt S, Tucek M. Posterior Malleolar Fractures: Changing concepts and recent developments. Foot Ankle Clin N am. 2016; 22(1):125-145. https://doi.org/10.1016/j.fcl.2016.09.009
Bartonícek J. Anatomy of the tibiofibular syndesmosis and its clinical relevance. Surg Radiol Anat. 2003; 25 (5-6): 379-386. https://doi.org/10.1007/s00276-003-0156-4
Van den Berg JC. Angiosome Perfusion Of The Foot: An Old Theory Or A New Issue? Seminars in Vascular Surgery. 2018; 31: 56-65. https://doi.org/10.1053/j.semvascsurg.2018.12.002
Attinger CE, Evans KK, Bulan E, et al. Angiosomes of the foot and ankle and clinical implications for limb salvage: reconstruction, incisions, and revascularization. Plast Reconstr Surg. 2006; 117(7): 261-293.
https://doi.org/10.1097/01.prs.0000222582.84385.54
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. https://doi.org/10.1177/1071100717719533
Haraguchi N, Haruyama H, Toga H, et al. Pathoanatomy of posterior malleolar fractures of the ankle. J Bone Joint Surg Am. 2006; 88(5): 1085-92. https://doi.org/10.2106/JBJS.E.00856
Badawy A, El Ghaffar T, Boteen A. Operative Management of Trimalleolar Fractures. The Egyptian Orthopedic Journal. 2019; 54: 41-48. URL del artículo: https://www.researchgate.net/publication/343917821_Operative_Management_of_Trimalleolar_Fractures_Operative_Management_of_Trimalleolar_Fractures
Mangnus L, Meijer DT, Stufkens SA, et al. Posterior Malleolar Fracture Patterns. J Orthop Trauma. 2015; 29(9): 428-435. https://doi.org/10.1097/BOT.0000000000000330
Toth MJ, Yoon RS, Liporace FA, et al. What's new in ankle fractures. Injury. 2017; 48(10): 2035-2041. https://doi.org/10.1016/j.injury.2017.08.016
Kumar A, Mishra P, Tandon A, et al. Effect of CT on Management Plan in Malleolar Ankle Fractures. Foot Ankle Int. 2018; 39(1): 59-66. https://doi.org/10.1177/1071100717732746
Assal M, Dalmau-Pastor M, Ray A, et al. How to Get to the Distal Posterior Tibial Malleolus? A Cadaveric Anatomic Study Defining the Access Corridors Through 3 Different Approaches. J Orthop Trauma. 2017; 31(4): 127-129. https://doi.org/10.1097/BOT.0000000000000774
Gupta S, Virk J, Malhotra A, et al. Fragment-specific fixation of trimalleolar fractures utilizing the posterolateral approach: A preliminary experience. J Orthop Surg. 2019; 27(2): 1-7. https://doi.org/10.1177/2309499019842289
Zhong S, Shen L, Zhao JG, et al. Comparison of Posteromedial Versus Posterolateral Approach for Posterior Malleolus Fixation in Trimalleolar Ankle Fractures. Orthop Surg. 2017; 9(1): 69-76. https://doi.org/10.1111/os.12308
Arrondo GM, Joannas G. Complex Ankle Fractures: Practical Approach for Surgical Treatment. Foot Ankle Clin. 2020; 25(4): 587-595. https://doi.org/10.1016/j.fcl.2020.08.002
Herring M, Yoon P. Surgical Treatment of Posterior Malleolus Fractures and Posterior Fixation. Techniques in Foot & Ankle Surgery. 2018; 17(3):141–150. https://doi.org/10.1097/BTF.0000000000000207
Mason LW, Kaye A, Widnall J, et al. Posterior Malleolar Ankle Fractures: An Effort at Improving Outcomes. JB JS Open Access. 2019; 4(2): e0058. https://doi.org/10.2106/JBJS.OA.18.00058
Mingo-Robinet J, Abril JM, Valle JA. El abordaje posterolateral en las fracturas trimaleolares de tobillo. Técnica quirúrgica [Posterolateral approach in trimalleolar ankle fractures: surgical technique]. Rev Esp Cir Ortop Traumatol. 2012; 56(4): 313-318. https://doi.org/10.1016/j.recot.2012.02.003
Hoogendoorn JM. Posterior Malleolar Open Reduction and Internal Fixation Through a Posterolateral Approach for Trimalleolar Fractures. JBJS Essent Surg Tech. 2017; 7(4): e31. https://doi.org/10.2106/JBJS.ST.17.00016
Dhillon MS, Dureja K, Patel S. How We do It. Trimalleolar Fractures: Fixing the Posterior Malleolus by Posterolateral Approach. J Foot Ankle Surg (AsiaPacific) 2017; 4(2): 63-68. https://doi.org/10.5005/jp-journals-10040-1073
Carter TH, Duckworth AD, White TO. Medial malleolar fractures: current treatment concepts. Bone Joint J. 2019; 101-B(5): 512-521. https://doi.org/10.1302/0301-620x.101B5.BJJ-2019-0070
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. https://doi.org/10.1302/0301-620X.99B11.BJJ-2017-0558.R1
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. https://doi.org/10.1177/1071100720937637
Assal M, Ray A, Fasel J, et al. A modified posteromedial approach combined with extensile anterior for the treatment of complex tibial pilon fractures (AO/OTA 43-C). J Orthop Trauma. 2014; 28(6): 138-145. https://doi.org/10.1097/01.bot.0000435628.79017.c5
Meulenkamp B, Louati H, Morellato J, et al. Posterior malleolus exposure. OTA International. 2019; 2(2): e021. https://doi.org/10.1097/OI9.0000000000000021
O´Connor T, Mueller B, Ly T, et al. “A to P” Screw Versus Posterolateral Plate for Posterior Malleolus Fixation in Trimalleolar Ankle Fractures. J Orthop Trauma. 2015; 29 (24): 151–156. https://doi.org/10.1097/BOT.0000000000000230
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. Disponible en: https://www.researchgate.net/publication/329126077_Comparison_of_three_posterior_malleolar_fixation_methods_in_trimalleolar_ankle_fractures
Xu HL, Li X, Zhang DY, et al. A retrospective study of posterior malleolus fractures. Int Orthop. 2012; 36 (9): 1929-1936. https://doi.org/10.1007/s00264-012-1591-9
Gawali SR, Toshniwal RO, Kukale SB, et al. Management of fracture of Posterior Malleolus, Trimalleolar Fracture, Fracture Dislocations, and Syndesmosis Injury of Ankle Joint. Journal of Foot and Ankle Surgery (Asia Pacific). 2017; 4(2): 90-96. https://doi.org/10.5005/jp-journals-10040-1077
Sahin A, Agar A, Gulabi D, et al. The Surgical Outcomes of Unstable Ankle Fractures in Patients Aged >65 Years. Geriatr Orthop Surg Rehabil. 2021; 12: 1-6. https://doi.org/10.1177/2151459321997765
Pina G, Fonseca F, Vaz A, et al. Unstable malleolar ankle fractures: evaluation of prognostic factors and sports return. Arch Orthop Trauma Surg. 2021; 141(1): 99-104. https://doi.org/10.1007/s00402-020-03650-w
Testa G, Ganci M, Amico M, et al. Negative prognostic factors in surgical treatment for trimalleolar fractures. Eur J Orthop Surg Traumatol. 2019; 29(6): 1325-1330. https://doi.org/10.1007/s00590-019-02430-6
Nilsson G, Jonsson K, Ekdahl C, et al. Outcome and quality of life after surgically treated ankle fractures in patients 65 years or older. BMC Musculoskelet Disord. 2007; 8: 127. https://doi.org/10.1186/1471-2474-8-127
D’souza JJ. American Orthopedic Foot-and-Ankle Society Score, Where Are We Now? – A Narrative Review of Quality of Life Measures in Foot-and-Ankle Surgery. Open Access Macedonian Journal of Medical Sciences. 2020; 8(F): 133-136. https://doi.org/10.3889/oamjms.2020.3914
McKeown R, Parsons H, Ellard DR, et al. An evaluation of the measurement properties of the Olerud Molander Ankle Score in adults with an ankle fracture. Physiotherapy. 2021; 112: 1-8. https://doi.org/10.1016/j.physio.2021.03.015
Hong CC, Roy SP, Nashi N, et al. Functional outcome and limitation of sporting activities after bimalleolar and trimalleolar ankle fractures. Foot Ankle Int. 2013; 34(6): 805-810. https://doi.org/10.1177/1071100712472490
Netzahualcóyotl B, Gutiérrez M, Makkozzay P. Resultado clínico-radiológico del tratamiento quirúrgico de las fracturas intra-articulares del calcáneo. Acta Ortop Mex. 2004; 18(1): 21-24. Disponible en: https://www.medigraphic.com/cgi-bin/new/resumen.cgi?IDARTICULO=1100
Trapote AR, Matilla E, Gallego L, et al. Lesiones de la articulación de Lisfranc: e
xperiencia en el tratamiento quirúrgico. Rev Pie Tobillo. 2020; 34(2):116-124. https://doi.org/10.24129/j.rpt.3402.fs1906013
Hasani I, Kaftandziev I, Stojmenski S, et al. Two Stage Minimally Invasive Method with Locking Plate Application on Distal Tibia Fractures - Our Experience. Open Access Maced J Med Sci. 2017; 5(5): 630-634.
https://doi.org/10.3889/oamjms.2017.099
Gowda BN, Kumar JM. Outcome of ankle arthrodesis in posttraumatic arthritis. Indian J Orthop. 2012; 46(3): 317-320. https://doi.org/10.4103/0019-5413.96392
Kleweno C, Rodriguez EK. Trimalleolar Ankle Fractures. In: Sethi M, Obremskey W, Jahangir A, eds. Orthopedic Traumatology. 2nd ed. Springer; 2018: 323-334. https://doi.org/10.1007/978-3-319-73392-0_25
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. https://doi.org/10.5505/tjtes.2016.44844
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. https://doi.org/10.4103/0019-5413.139829
Ewalefo SO, Dombrowski M, Hirase T, et al. Management of Posttraumatic Ankle Arthritis: Literature Review. Curr Rev Musculoskelet Med. 2018; 11(4): 546-557. https://doi.org/10.1007/s12178-018-9525-9
Abarquero-Diezhandino A, Luengo-Alonso G, Alonso-Tejero D, et al. Study of the relation between the posterior malleolus fracture and the development of osteoarthritis. Rev Esp Cir Ortop Traumatol (Engl Ed). 2020; 64(1): 41-49. https://doi.org/10.1016/j.recot.2019.09.002
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Copyright (c) 2022 Array