SLR - September 2011 - Jennifer Miller
Reference: Heim, D., Niederhasuer, K., and N. Simbrey. Eur J Trauma Emer Surg. (2010) 36:515-519
Scientific Literature Review
Reviewed by: Jennifer Miller, DPM
Residency Program: St. John Hospital & Medical Center, Detroit MI
Podiatric Relevance:
The question of whether fixation is indicated for bi-malleolar or tri-malleolar ankle fractures with concomitant posterior malleolar Volkmann’s fragment is controversial. The hallmark recommendation is for fixation of those posterior malleolar fractures that involve more that 25% of the tibial plafond. Concepts supporting a better prognostic outcome for larger Volkmann’s fragments are based on the premises of talar subluxation, articular incongruency, and overall instability of the ankle mortise. Talar subluxation laterally shifts contact stresses anteromedially within the tibial plafond. Larger involvement of the posterior malleolus causes further incongruity of the articular surfaces in question leading to further ankle joint instability post-trauma. This article proposes a retrospective review of a prospective database to question and determine radiologic and clinic results of malleolar fractures with an added focus on the relationship between the Volkmann fragment and post-trauma arthrosis.
Methods:
Beginning in 1995, malleolar fractures admitted to the author’s institution that underwent surgical reduction with either internal or external fixation were entered into a prospective database and followed post- operatively by their respective surgeon for one year. Inclusive to this study were all patients whom incurred a dislocated malleolar fracture of at minimum 4 years follow-up. Physical and clinical findings were obtained by a party other than the first author. Radiographic films were also obtained and evaluated by an independent radiologist. Fractures were classified via the Danis-Weber classification. Also for comparison, the level of arthrosis was graded at 7.1 years post trauma per a modified Knirk and Jupiter classification for ever progressing arthritic findings radiographically ( 0= no arthrosis, 1=articular scerosis, 2= cystic and osteophytic changes , 3=joint narrowing, and 4= ankylosis). If a Volkmann fragment was identified, the fragment was further detailed as: shell like fragment, involvement less that 25% of the tibial plafond, and greater than 25% of the tibial plafond. Subjectively, the Olerud-Molander score was obtained at an average of 7.1 years. No computerized tomography was obtained. Comparisons of cartilaginous damage versus level arthrosis, level of arthrosis versus percent or size of Volkmann fragment, and OM score versus level of arthrosis, percent of plafond involvement and presence or absence of cartilage damage were performed.
Results:
Provisionally, 56 patients were considered with 13 excluded due to inadequate follow-up (deceased, out of geographic region, refusal to participate). Forty-three patients were analyzed: 15 men and 28 women with average age of e53 and 63 years respectively. Nine bi-malleolar fractures and 34 tri-malleolar fractures were categorized via the Weber classification (23: B; 20:C). Four fractures were classified as open (3 Gustillo-Anderson grade 1; 1 Gustillo-Anderson grade 2.) Sixteen intra-operatively were found to have osteochondral defects. Seven fractures had absence of a Volkmann fragment. Eight were classified as “shell-like”, and 18 fractures involved less than 25% of the plafond. Eight fractures involved greater than 25% of the plafond and all were fixated ( 4 AP lag screw, 1 PA lag screw, and 3 posterotibial antiglide plates) with 1 malunion and 2 fixated with greater than 1 mm step off. If after fixation, the mortise was found to be unstable, a further “positioning” screw was utilized for improved stability. Of those fractures involving less than 25% of the plafond, after fixation of the malleoli, 8 were anatomically reduced and 10 did not return to original anatomic position via ligamentotaxis. Shell-like Volkmann’s fractures were disregarded intra–operatively.
Olereud-Molander scores were: 94 with cartilage damage vs. 97.2 without cartilage damage; 95.5 for no Volkmann fragment, 98.5 for Volkmann fragment <25%, and 90.5 for Volkmann fragment >25% of the tibial plafond. Grade 0 arthrosis included 4 cases without Volkmann fragment, 6 shell like fragments, 7 <25% tibial plafond, and 1 >25% of the tibial plafond. Grade 1 arthrosis included two instances without Volkmann fracture, 2 shell like fragments, 10 Volkmann fragments <25% of the plafond and 4 > 25% of the plafond. Two instances of grade 2 arthrosis were noted one for <25% and >25% plafond involvement. One instance of grade 3 arthrosis was noted with >25% plafond involvement.
Conclusions:
No relationship was found between level of joint arthrosis and size of Volkmann fragment. Prognostically, any presence of cartilaginous disruption, no matter the presence or absence of a Volkmann fragment, resulted in poor clinical outcomes. No difference was noted whether or not fixation of the Volkmann fragment occurred. More long term and more largely populated studies are needed.