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Minerva Ortopedica e Traumatologica 2020 December;71(4):177-84

DOI: 10.23736/S0394-3410.20.03983-1


lingua: Inglese

Use of the posterolateral approach in the treatment of trimalleolar fractures: indications, pros and cons

Federico CHIODINI 1, Massimo G. LOMBARDO 2, Luca BUSNELLI 3 , Lorenzo LEINARDI 3, Andrea CONTINI 3, Domenico PRESTAMBURGO 1

1 Unit of Orthopedics and Trauma Surgery, New Hospital of Legnano, ASST Ovest Milanese, Legnano, Milan, Italy; 2 Unit of Orthopedics and Trauma Surgery, Santissima Trinità Hospital, Cagliari, Italy; 3 Orthopedic Clinic, Marino Hospital, University of Cagliari, Cagliari, Italy

BACKGROUND: Trimalleolar fractures have a worse prognosis compared to bimalleolar fractures. Even if it is clear that the posterior malleolus has a fundamental role in the outcome of these fractures until now there is no consensus on the best way to treat it. When treated surgically the third malleolus can be approached indirectly from anterior or through a direct posterolateral approach. Aim of this study was to analyze indications, strengths and weaknesses of the posterolateral ankle approach to fix the posterior malleolus.
METHODS: This is a retrospective case series study conducted in two Italian orthopedic trauma departments over a three-year period. All the patients with a trimalleolar fracture who received surgical stabilization of the third malleolus were included. They were divided into two groups according to the approach chosen for the third fragment stabilization. In group A, percutaneous anterior fixation was performed while in group B fixation through a posterolateral approach was preferred. Patients were followed up clinically by the AOFAS and OMAS score and radiographically until consolidation. Attention was paid to the specific fracture pattern or patient features that led the surgeon to choose one approach in respect to the other with the intent to define indications for the use of the posterolateral approach.
RESULTS: Thirty out of 114 patients with a trimalleolar fracture (26%) were treated surgically for the posterior malleolus. There were 13 patients in group A and 17 in group B. Group B showed a higher incidence of acute soft tissue problems; most of the patients of this group received an external fixator in emergency and had skin or wound postoperative problems. CT scan showed to be fundamental for surgical planning and for the choice of the appropriate approach. All the patient in group B had one or more of these CT findings: a big posterior fragment, posterior talar subluxation, an articular fragment interposed in the fracture or involvement of the fibular notch. Despite the different complexity of the fracture pattern and soft tissue involvement, at the final follow up between group A and group B no clinical differences were found.
CONCLUSIONS: Posterolateral approach to the ankle is a useful tool in the hands of the trauma surgeon for the treatment of trimalleolar fractures. Major indications are related to soft tissue sufferance and specific fracture pattern. Results have shown to be comparable in terms of complications and clinical scores to the standard anterior approach used for the treatment of less complex fractures. This makes the posterolateral approach safer and to be preferred in these selected cases.

KEY WORDS: Ankle fractures; Orthopedics; Traumatology

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