Outcomes of Immediate Operative Treatment of Ankle Trimalleolar Open Fractures

Jun-Young Lee; Yong-Jin Cho; Sin-Wook Kang; Yung-Min Cho; Hyun-Bai Choi

doi:10.14193/jkfas.2020.24.1.25

Journal List > J Korean Foot Ankle Soc > v.24(1) > 1144010

Go to TopGo to Top Go to BottomGo to Bottom

TOOLS

Lee, Cho, Kang, Cho, and Choi: Outcomes of Immediate Operative Treatment of Ankle Trimalleolar Open Fractures

Original Article

J Korean Foot Ankle Soc 2020;24(1):25-30.

Published online: 20 March 2020

DOI: https://doi.org/10.14193/jkfas.2020.24.1.25

Outcomes of Immediate Operative Treatment of Ankle Trimalleolar Open Fractures

Jun-Young Lee, Yong-Jin Cho, Sin-Wook Kang, Yung-Min Cho, Hyun-Bai Choi

Department of Orthopaedic Surgery, College of Medicine, Chosun University, Gwangju, Korea

Corresponding Author: Jun-Young Lee Department of Orthopaedic Surgery, Chosun University Hospital, 365 Pilmun-daero, Dong-gu, Gwangju 61453, Korea Tel: 82-62-220-3147, Fax: 82-62-226-3379, E-mail: leejy88@chosun.ac.kr ORCID: https://orcid.org/0000-0002-9764-339X

Received 14 October 2020 Revised 3 January 2020 Accepted 7 January 2020

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

Generally, the treatment of ankle trimalleolar open fractures is divided into two stages: external fixation and debridement; and secondary internal fixation. On the other hand, this two-stage operation takes considerable treatment time and is challenging in procedures requiring reduction. The purpose of this study was to evaluate the radiologic and clinical results of an immediate one-stage internal fixation operation considering the wound conditions to overcome two stage operation disadvantages.

Materials and Methods

From September 2009 to January 2018, 24 cases of ankle trimalleolar open fractures, who underwent immediate internal fixation and were followed up for at least one year, were studied retrospectively. The open wound was divided into the Gusti-lo-Anderson classification. Open reduction and internal fixation were performed on every medial and lateral malleolar fracture. On the other hand, with posterior malleolar fractures, surgical or conservative treatment was performed depending on the fragment size. The radiologic outcome was evaluated using the Burwell and Charnley criteria and American Orthopaedic Foot and Ankle Society (AOFAS) scores, and complications, such as infection and posttraumatic arthritis, were used for the clinical evaluation.

Results

The wound was classified into eight cases (33.3%) of type I, 11 cases (45.8%) of type II, and five cases (20.8%) of type IIIa. The degree of reduction was anatomical, fair, and poor in 16 cases (66.7%), six cases (25.0%), and two cases (8.3%), respectively. The mean AOFAS score was 79 points, and there were complications, such as infection in three cases (12.5%) and post-traumatic arthritis in two cases (8.3%).

Conclusion

Satisfactory results were obtained through immediate surgical treatment in ankle trimalleolar open fractures of types I, II, and IIIa.

Keywords: Ankle, Open, Trimalleolar fracture, Immediate internal fixation

References

1. Hulsker CC, Kleinveld S, Zonnenberg CB, Hogervorst M, van den Bekerom MP. Evidence-based treatment of open ankle fractures. Arch Orthop Trauma Surg. 2011; 131:1545–53. doi:. DOI: 10.1007/s00402-011-1349-7.

2. Bray TJ, Endicott M, Capra SE. Treatment of open ankle fractures. Immediate internal fixation versus closed immobilization and delayed fixation. Clin Orthop Relat Res. 1989; 240:47–52.

3. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976; 58:453–8. doi:. DOI: 10.2106/00004623-197658040-00004.

4. De Vries JS, Wijgman AJ, Sierevelt IN, Schaap GR. Long-term results of ankle fractures with a posterior malleolar fragment. J Foot Ankle Surg. 2005; 44:211–7. doi:. DOI: 10.1053/j.jfas.2005.02.002.

5. McDaniel WJ, Wilson FC. Trimalleolar fractures of the ankle. An end result study. Clin Orthop Relat Res. 1977; 122:37–45.

6. Sachs W, Kanat IO, McLaughlin E, Burns DE. A surgical approach to a displaced ankle fracture. J Foot Surg. 1984; 23:302–7.

7. Talbot M, Steenblock TR, Cole PA. Posterolateral approach for open reduction and internal fixation of trimalleolar ankle fractures. Can J Surg. 2005; 48:487–90.

8. Lee GC, Lee JY, Ha SH, You JW, Lee SH, Sohn HM, et al. Treatment of the trimalleolar fracture using posterolateral approach: minimum 2-year follow up results. J Korean Fract Soc. 2011; 24:328–34. doi:. DOI: 10.12671/jkfs.2011.24.4.328.

9. Burwell HN, Charnley AD. The treatment of displaced fractures at the ankle by rigid internal fixation and early joint movement. J Bone Joint Surg Br. 1965; 47:634–60.

10. Toolan BC, Wright Quinones VJ, Cunningham BJ, Brage ME. An evaluation of the use of retrospectively acquired preoperative AOFAS clinical rating scores to assess surgical outcome after elective foot and ankle surgery. Foot Ankle Int. 2001; 22:775–8. doi:. DOI: 10.1177/107110070102201002.

11. Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int. 1994; 15:349–53. doi:. DOI: 10.1177/107110079401500701.

12. Roberts CS, Pape HC, Jones AL, Malkani AL, Rodriguez JL, Giannoudis PV. Damage control orthopaedics: evolving concepts in the treatment of patients who have sustained orthopaedic trauma. Instr Course Lect. 2005; 54:447–62.

13. Melvin JS, Dombroski DG, Torbert JT, Kovach SJ, Esterhai JL, Mehta S. Open tibial shaft fractures: I. Evaluation and initial wound management. J Am Acad Orthop Surg. 2010; 18:10–9. doi:. DOI: 10.5435/00124635-201001000-00003.

14. Scharfenberger AV, Alabassi K, Smith S, Weber D, Dulai SK, Bergman JW, et al. Primary wound closure after open fracture: a prospective cohort study examining nonunion and deep infection. J Orthop Trauma. 2017; 31:121–6. doi:. DOI: 10.1097/BOT.0000000000000751.

15. Franklin JL, Johnson KD, Hansen ST Jr. Immediate internal fixation of open ankle fractures. Report of thirty-eight cases treated with a standard protocol. J Bone Joint Surg Am. 1984; 66:1349–56.

16. Ovaska MT, Madanat R, Honkamaa M, Mäkinen TJ. Contemporary demographics and complications of patients treated for open ankle fractures. Injury. 2015; 46:1650–5. doi:. DOI: 10.1016/j.injury.2015.04.015.

17. Tho KS, Chiu PL, Krishnamoorthy S. Grade III open ankle fractures: a review of the outcome of treatment. Singapore Med J. 1994; 35:57–8.

18. Joshi D, Singh D, Ansari J, Lal Y. Immediate open reduction and internal fixation in open ankle fractures. J Am Podiatr Med Assoc. 2006; 96:120–4. doi:. DOI: 10.7547/0960120.

19. Johnson EE, Davlin LB. Open ankle fractures. The indications for immediate open reduction and internal fixation. Clin Orthop Relat Res. 1993; 292:118–27.

Figure 1.

(A) The initial film shows a trimalleolar fracture of the tibia with medial open wound. (B) Gustilo-Anderson II exposition. (C) Postoperative radiograph shows satisfactory position of plate and 4.0 mm cannulated screws.

Figure 2.

(A) A 55-year-old male sustained a right trimalleolar fracture with medial open wound after traffic accident. (B) First, lateral malleolar fracture was fixed using 1/3 semitubular plate, and 4.0 mm cannulated screws were applied. After 2 weeks, Wound infection was observed. (C) After 5 weeks, incision and debridement was done on medial malleolar infective wound.

Table 1.

Patient Data

Case	Age (yr)/Sex	Wound		G-A	Fixation device			B-C	Union time (wk)	AOFAS	Complications
Case	Age (yr)/Sex	Location	Size (cm)	G-A	Med.	Lat.	Post.	B-C	Union time (wk)	AOFAS	Complications
1	51/male	Med.	2	Type II	Screw	Plate	Screw	Anatomical	16	91	No
2	74/female	Med.	0.5	Type I	Screw	Plate	Conservation	Fair	19	95	No
3	68/female	Med.	1	Type I	Screw	Plate	Screw	Anatomical	16	100	No
4	64/male	Lat.	11	Type IIIa	Screw	Rush pin cannulated screw	Screw	Poor	20	83	Arthritis
5	31/male	Med.	3	Type II	Screw	Plate	Conservation	Anatomical	20	97	No
6	73/male	Lat.	0.5	Type I	Screw	Plate	Screw	Anatomical	15	98	No
7	74/female	Lat.	2	Type II	Screw	Plate	Screw	Anatomical	17	83	No
8	55/male	Med.	13	Type IIIa	Screw	Plate	Screw	Fair	16	87	Infection
9	72/female	Med.	5	Type II	Screw	Plate	Screw	Anatomical	16	93	No
10	48/female	Lat.	10	Type IIIa	Screw	Rush pin cannulated screw	Screw	Anatomical	15	86	Infection
11	24/female	Med.	2	Type II	Screw	Plate	Screw	Fair	16	88	No
12	33/male	Med.	2	Type II	Screw	Plate	Screw	Anatomical	20	88	No
13	57/female	Lat.	1	Type I	Screw	Plate	Conservation	Anatomical	17	97	No
14	58/female	Lat.	2	Type II	Screw	Plate	Screw	Anatomical	19	90	No
15	43/male	Med.	12	Type IIIa	Screw	Plate	Screw	Fair	18	84	Infection
16	59/female	Med.	0.5	Type I	Screw	Plate	Screw	Anatomical	17	100	No
17	31/female	Lat.	0.5	Type I	Screw	Plate	Screw	Anatomical	18	95	No
18	56/female	Med.	4	Type II	Screw	Plate	Screw	Fair	16	90	No
19	56/female	Med.	5	Type II	Screw	Plate	Conservation	Anatomical	18	90	No
20	55/female	Lat.	5	Type II	Screw	Plate	Screw	Anatomical	16	88	No
21	60/female	Med.	2	Type II	Screw	Plate	Screw	Anatomical	20	91	No
22	75/female	Lat.	13	Type IIIa	Screw	Rush pin cannulated screw	Screw	Poor	18	84	Arthritis
23	39/female	Med.	0.5	Type I	Screw	Plate	Screw	Anatomical	17	90	No
24	65/female	Med.	1	Type I	Screw	Plate	Screw	Fair	16	98	No

G-A: Gustillo-Anderson classification, B-C: Burwell-Charnley classification, AOFAS: American Orthopaedic Foot and Ankle Society score, Med.: medial malleolar side, Lat.: lateral malleolar side, Screw: 4.0 mm cannulated screw.

Table 2.

Comparison with Other Open Ankle Fracture Article

Study	Open ankle fracture case	Infection	Post traumatic QA
Ovaska et al. (2015)¹⁶⁾	134	23 (17.2)	15 (11.2)
Franklin et al. (1984)¹⁵⁾	38	6 (15.8)	13 (34.2)
Tho et al. (1994)¹⁷⁾	15	6 (40.0)	7 (46.7)
Our study (I, II, IIIa)	24	3 (12.5)	2 (8.3)
Our study (II, IIIa)	16	3 (18.8)	2 (12.5)

Values are presented as number only or number (%). OA: osteoarthritis.

TOOLS

Similar articles