SLR-September 2023-Abbaszadeh
Title: Posterolateral Approach for Posterior Malleolus Fixation in Ankle Fractures: Functional and Radiological Outcome Based on Bartonicek ClassificationReference: Yang, L., Yin, G., Zhu, J. et al. Posterolateral approach for posterior malleolus fixation in ankle fractures: functional and radiological outcome based on Bartonicek classification. Arch Orthop Trauma Surg 143, 4099–4109 (2023). https://doi.org/10.1007/s00402-022-04620-0
Level of Evidence: III
Scientific Literature Review
Reviewed By: Marall Abbaszadeh, DPM
Residency Program: Boston University Medical Center, Boston, MA
Podiatric Relevance: Posterior malleolus fractures (PMFs) occur in 7-44% of all ankle fractures. The posterolateral surgical approach has been advocated for treating ankle fractures when there is posterior malleolar involvement. Several studies have demonstrated satisfactory results, particularly with the Bartonicek classification, based on 3-dimensional CT scanning, offering treatment recommendations for the posterior malleolar fracture (PMF). This study attempts to evaluate the clinical effect of the posterolateral approach for treating PMFs, while presenting outcomes of different types of PMF per the Bartonicek classification.
Methods: The authors performed a level III therapeutic retrospective study involving 72 patients with ankle fractures involving the posterior malleolus over a two and a half year period. All PMFs were directly reduced and fixated by the posterolateral approach, using lag screws and/or buttress plates. AOFAS and VAS pain scores were used as the primary functional outcome measures. Furthermore, radiographic evaluation was utilized, evaluating the reduction and using the Kellgren-Lawrence osteoarthritis classification. The patients were divided into three groups: Type II (n=42), Type III (n=18), and Type IV (n=12). Within the Bartonicek Type II sample, patients were subdivided into subtypes IIa (n=19), IIb (n=16), and IIc (n=7). Outcome measures were evaluated for these three groups and with the Type II subgroups. All cases took place at the same trauma center.
Results: After surgery, 68 patients (94.5%) achieved a good or excellent reduction of PMFs per radiographic evaluation. Clinically, the mean AOFAS score was 81.35+/-6.15 at 6 months and 90.56 +/- 4.98 at the final follow-up. The VAS score was 6.62 +/- 1.03 one week after surgery, and 1.20 +/- 0.92 at the final follow-up. Radiographic evaluation at the final follow-up showed successful primary bone union in all patients (n=72) with a 0% rate of mal- or non-union. 88.9% received a KL grade of 0 or 1 for post-traumatic arthritis. Bartonicek Type II fractures, particularly subtype IIa, had the highest AOFAS scores, and the severity of osteoarthritis was lower in patients within this group compared to other subtype groups, with a statistically significant finding (p<0.05).
Conclusions: There is value in exploring the posterolateral approach in treating posterior malleolar fractures, as this approach could achieve promising clinical and radiographic results. Patients with a Bartonicek type II fracture had a superior functional outcome, as measured by the AOFAS score, measuring functionality, pain, and alignment. Within the type II group, the IIa subtype group achieved a higher AOFAS score and a lower incidence of post-traumatic arthritis at the final follow-up compared to the other two subtypes. For the Foot and Ankle Surgeon, the classification of PMFs according to the Bartonicek classification could be a reliable asset in predicting outcomes when treating posterior malleolar fractures. Perhaps when presented with the Bartonicek IIa subtype, the posterolateral approach could become a standard choice during surgically planning. More studies at a variety of trauma centers, would be valuable to confirm this conclusion, and to determine if other subtypes could be standardized with the posterolateral approach as well.