Original article
Long-Term Results of Ankle Fractures With a Posterior Malleolar Fragment

https://doi.org/10.1053/j.jfas.2005.02.002Get rights and content

The aim of this study was to evaluate 1) long-term results of ankle fractures with a posterior malleolar fragment, and 2) the need for fixation of fragments smaller than 25%. Forty-five patients with ankle fractures and a posterior malleolar fragment were evaluated. Mean follow-up was 13 years (range, 2–24). The size and fixation of the fragment were registered. Outcome was assessed using an Ankle Fracture Scoring System (maximum: 150 points), a 10-point Numeric Scale for Pain (1 = no pain, 10 = unbearable pain) and an OsteoArthritis Score (0 = no osteoarthritis, 3 = severe osteoarthritis). The mean Ankle Fracture Scoring System, Numeric Scale for Pain and Osteoarthritis-score were 124, 2.5, and 1.2, respectively. The mean size of fixated fragments was significantly larger than that of nonfixated fragments (30% versus 16%). Those patients in which the posterior malleolar fragment was fixated did not have a statistically significant better outcome than those patients in which the fragments were not fixated (Ankle Fracture Scoring System: 119 versus 126, Numeric Scale for Pain: 2.6 versus 2.4, Osteoarthritis-score: 1.0 versus 1.2). There was no significant correlation between outcome and size of unfixated fragments. Fracture-dislocation was seen more often in combination with larger fragments (24% versus 15%) and resulted in statistically significant worse long-term outcome than nondislocated fractures, except for pain (Ankle Fracture Scoring System: 115 versus 134, Osteoarthritis-score: 1.7 versus 0.8). In conclusion, patients showed good results after 13 years follow-up and there was no evidence for the need for fixation of fragments smaller than 25%.

Section snippets

Materials and Methods

A retrospective analysis was performed on all adult patients who sustained an ankle fracture with a posterior malleolar fragment and were treated in the Academic Medical Center (Amsterdam, The Netherlands) between 1975 and 1996. Exclusion criteria were open epiphysial plates, pathologic fractures, open fractures, a second ankle fracture, pilon fractures, and patients not being able to bear weight for reasons other than posttraumatic complications of the affected ankle. The patients were seen at

Results

According to the AO-classification, 34 fractures were classified as type 44B and 11 as type 44C. None of the patients was treated nonoperatively. A fracture-dislocation was seen in 20 of the 45 patients. The means of the outcome measures for the evaluated population are presented in Table 1. The mean size of the posterior malleolar fragment was 19.4% (range, 3%–49%). Thirteen of the 45 patients had posterior malleolar fragments that comprised more than 25% of the joint surface. Eleven of the 45

Discussion

The majority of our patients showed good results after a mean follow-up of 13 years, regarding both functional and osteoarthritic scores. The AFSS score used in the current study was introduced by Phillips et al for the comparison of conservative treatment and internal fixation of severe ankle fractures in a randomized controlled trial (13). According to this score, the group that underwent internal fixation showed better results. The ankle fractures in our population were considered to be of

Conclusion

Patients with posterior malleolar fractures showed good results after a mean of 13 years follow-up. Fracture-dislocation was seen more often in combination with larger fragments and resulted in worse long-term outcome than nondislocated fractures. Outcome was not affected by size or fixation of the posterior tibial fragment. This study supports that posterior malleolar fragments smaller than 25% do not require fixation.

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