Exclusion and Inclusion Criteria
This study reviewed a case series of ankle fracture involving posterior malleolar fracture and laternal malleolar fracture from January 2015 to October 2018. The inclusion criteria were:(i) The age older than 18 years; (ii) patients with ankle fractures involve lateral malleolar and posterior malleolar; (iii) posterior malleolar fractures were fixed by the modified posterolateral approach;(iv) posterior malleolar fracture is type 1 according to the Haraguchi classification23, the size should be more than 10% in percentage of the tibial plafond. The exclusion criteria were: (i) pathologic fractures and open fractures; (ii) tibial pilon fractures; (iii) Patients with lower limb infections, tumors, congenital malformations and other diseases affecting lower limb function.
Demographic Data of Patients
From January 2015 to October 2018, thirty patients meeting the above criteria, admitted to our hospital. All patients had unilateral ankle fracture, with 19 fractures on the left and 11 on the right ankle. The mean age of the patients was 46.0±13.2 years (range, 19–68 years). In our series , the causes of injury were motor vehicle accident for 12 patients, ground-level fall for 16 patients, and falling from height for 2 patients. According to the Lauge-Hansen classification, 22 cases were supination external rotation (SER) stage III or IV fractures, 8 cases were pronation external rotation(PER) stage IV fractures. The size of the posterior malleolar fragment was 20.2%±9.5%.
Surgical Techniques
The injured ankle joint was fixed by a brace which can help reduce swelling and alleviate pain. If combined with ankle subluxation or dislocation, and reduction was difficult to maintain, calcaneal traction will be given. When the swelling goes down, and the “wrinkle” sign appears, open reduction and internal fixation will take place. After anesthesia, the patient was placed in a lateral prone position with the injured side facing up. Along with the posterior edge of the lateral malleolus and the middle point of the outer edge of the Achilles tendon , we make a longitudinal incision parallel to the outer edge of the Achilles tendon to the anterolateral arc of the lateral malleolus(figure1). Take care to protect the small saphenous vein and sural nerve. Exposing the underside of the Achilles tendon, the fascia on the surface of flexor hallucis longus will be found. Cut the fascia and pull the flexor hallucis longus to outside(figure2), posterior malleolus fracture will be found under the flexor hallucis longus. The fracture lines can guide reduction of the posterior malleolar fragments, especially the medial fracture line and the top of the fracture line. After reduction, buttress plate was placed close to the joint line. Laternal malleolus fracture was fixed by lateral anatomical plate, and medial malleolus fracture was fixed by hollow screw.
Postoperative Protocol
In the first 2 weeks postoperatively, the injured ankle joint was fixed by a brace. Patients were advised to raise the limb and encouraged to activate the toes and the knee to help reduce swelling. The patients started ROM exercises after the brace was removed, and kept non-weight-bearing for 2 months. Patients begined partial weight bearing at 2 months after operation, with full weight bearing by 3 months. Operative time, fracture healing time and postoperative complications were recorded, Postoperative X-rays were performed at the first week after surgery, 1-month, 3-month, 6-month, 12-month to Judge fracture healing. We evaluated the functions of all patients using American Orthopedic Foot and Ankle Society (AOFAS) scores at the 6-month, 12-month and final follow-up[24], using the Short Form-36 (SF-36) outcome
Tools and the American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle Questionnaire at the 12-month and final follow-up visits[25-26] ,