Yüksek Risk Faktörlü Trimalleolar Kırık Hastalarında Posterolateral Yaklaşımın Güvenliği

Year 2024, Volume: 15 Issue: 2, 279 - 286, 01.07.2024

Ekin Kaya Şimşek , Bahtiyar Haberal , Orçun Şahin , Yüksel Uğur Yaradılmış

https://doi.org/10.18663/tjcl.1484575

Abstract

Amaç: Bu çalışmanın amacı, yara iyileşmesi açısından risk faktörleri taşıyan hastalarda posterior malleol fragmanının tespitinde posterolateral yaklaşım (PLY) ve minimal invaziv perkütan anterior-posterior (AP) yaklaşımın sonuçlarını karşılaştırmaktır.
Gereç ve Yöntemler: 66 hasta, 2 çalışma grubunda analiz edildi. Grup 1: PLY (29 hasta), Grup 2: AP (37 hasta). Hasta demografik özellikleri, yara iyileşmesi için risk faktörleri, sindezmotik yaralanma varlığı, kırık tipi, ameliyat sonrası yara iyileşmesi komplikasyonları ve Amerikan Ortopedik Ayak ve Ayak Bileği Derneği ayak bileği-arka ayak skoru (AOFAS) kaydedildi.
Bulgular: Yara iyileşme sorunları açısından çalışma grupları arasında fark yoktu. Obez ve sigara içenlerin, cerrahi yaklaşımdan bağımsız olarak yara iyileşmesi sorunları anlamlı derecede daha fazlaydı. AOFAS açısından çalışma grupları arasında istatistiksel olarak anlamlı bir fark yoktu.
Sonuçlar: Trimalleolar kırıklarda obezite ve sigara kullanımı dışında yara iyileşmesi sorunları açısından risk faktörleri olan hastalarda dahi PLA güvenle düşünülebilir.

Keywords

Posterolateral yaklaşım, trimalleolar kırık, yüksek riskli hasta, sigara, obezite

Ethical Statement

Bu çalışmanın, özgün bir çalışma olduğunu; çalışmanın hazırlık, veri toplama, analiz ve bilgilerin sunumu olmak üzere tüm aşamalarından bilimsel etik ilke ve kurallarına uygun davrandığımı; bu çalışma kapsamında elde edilmeyen tüm veri ve bilgiler için kaynak gösterdiğimi ve bu kaynaklara kaynakçada yer verdiğimi; kullanılan verilerde herhangi bir değişiklik yapmadığımı, çalışmanın Committee on Publication Ethics (COPE)' in tüm şartlarını ve koşullarını kabul ederek etik görev ve sorumluluklara riayet ettiğimi beyan ederim. Herhangi bir zamanda, çalışmayla ilgili yaptığım bu beyana aykırı bir durumun saptanması durumunda, ortaya çıkacak tüm ahlaki ve hukuki sonuçlara razı olduğumu bildiririm.

Supporting Institution

Bu çalışma Başkent Üniversitesi Tıp ve Sağlık Bilimleri Araştırma Kurulu tarafından onaylanmış (Proje no: KA20/269) ve Başkent Üniversitesi Araştırma Fonunca desteklenmiştir.

Project Number

KA20/269

Safety of Posterolateral Approach in High-Risk Patients with Trimalleolar Fractures

Abstract

Aim: Purpose of this study is to compare the outcomes of posterolateral approach (PLA) and minimal-invasive percutaneous anteroposterior (AP) approach for the fixation of posterior malleolar fragment in patients who have risk factors for wound healing.
Material and Methods: 66 patients were analyzed in 2 study groups. Group 1: PLA (29 patients), Group 2: AP (37 patients). Patient demographics, risk factors for wound healing, presence of syndesmotic injury, fracture type, postoperative wound-healing complications and American Orthopedic Foot and Ankle Society ankle-hindfoot score (AOFAS) were recorded.
Results: There was no difference between the study groups in regard to wound-healing problems. Obese and smokers had significantly more wound-healing problems regardless of the surgical approach. There was no statistically significant difference between the study groups in regard to AOFAS.
Conclusion: In trimalleolar fractures, PLA can be safely considered even for the patients who have risk factors for wound-healing problems other than obesity and smoking.

Keywords

Posterolateral approach, trimalleolar fracture, high risk patients, smoking, obesity

Project Number

KA20/269

References

• Court-Brown CM, McBirnie J, Wilson G. Adult ankle fractures--an increasing problem? Acta Orthop Scand. 1998;69(1):43-7. doi: 10.3109/17453679809002355.
• Elsoe R, Ostgaard SE, Larsen P. Population-based epidemiology of 9767 ankle fractures. Foot Ankle Surg. 2018;24(1):34-39. doi: 10.1016/j.fas.2016.11.002.
• Jaskulka RA, Ittner G, Schedl R. Fractures of the posterior tibial margin: Their role in the prognosis of malleolar fractures. J Trauma. 1989;29(11):1565-70. doi: 10.1097/00005373-198911000-00018.
• Koval KJ, Lurie J, Zhou W, et al. Ankle fractures in the elderly: What you get depends on where you live and who you see. J Orthop Trauma. 2005;19(9):635-9. doi: 10.1097/01.bot.0000177105.53708.a9.
• Broos PL, Bisschop AP. Operative treatment of ankle fractures in adults: Correlation between types of fracture and final results. Injury. 1991;22(5):403-6. doi: 10.1016/0020-1383(91)90106-o.
• Heim D, Niederhauser K, Simbrey N. The volkmann dogma: A retrospective, long-term, single-center study. Eur J Trauma Emerg Surg. 2010;36(6):515-9. doi: 10.1007/s00068-010-0061-6.
• Odak S, Ahluwalia R, Unnikrishnan P, Hennessy M, Platt S. Management of posterior malleolar fractures: A systematic review. J Foot Ankle Surg. 2016;55(1):140-5. doi: 10.1053/j.jfas.2015.04.001.
• Liu Z, Tang G, Guo S, Cai B, Li Q. Therapeutic effects of internal fixation with support plates and cannulated screws via the posterolateral approach on supination external rotation stage iv ankle fracture. Pak J Med Sci. 2020;36(3):438-44. doi: 10.12669/pjms.36.3.1671.
• O'Connor TJ, Mueller B, Ly TV, et al. "A to p" screw versus posterolateral plate for posterior malleolus fixation in trimalleolar ankle fractures. J Orthop Trauma. 2015;29(4):e151-6. doi: 10.1097/BOT.0000000000000230.
• Shi HF, Xiong J, Chen YX, et al. Comparison of the direct and indirect reduction techniques during the surgical management of posterior malleolar fractures. BMC Musculoskelet Disord. 2017;18(1):109. doi: 10.1186/s12891-017-1475-7.
• Vidovic D, Elabjer E, Muskardin IVA, et al. Posterior fragment in ankle fractures: Anteroposterior vs posteroanterior fixation. Injury. 2017;48 Suppl 5(S65-S69. doi: 10.1016/S0020-1383(17)30743-X.
• Jowett AJ, Sheikh FT, Carare RO, Goodwin MI. Location of the sural nerve during posterolateral approach to the ankle. Foot Ankle Int. 2010 Oct;31(10):880-3. doi: 10.3113/FAI.2010.0880. PMID: 20964966.
• Saleh H, Konda S, Driesman A, et al. Wound-healing issues following rotational ankle fracture surgery: Predictors and local management options. Foot Ankle Spec. 2019;12(5):409-17. doi: 10.1177/1938640018810422.
• Lee HJ, Kang KS, Kang SY, Lee JS. Percutaneous reduction technique using a kirschner wire for displaced posterior malleolar fractures. Foot Ankle Int. 2009;30(2):157-9. doi: 10.3113/FAI.2009.0157 10.3113/FAI-2009-0157.
• Strenge KB, Idusuyi OB. Technique tip: Percutaneus screw fixation of posterior malleolar fractures. Foot Ankle Int. 2006;27(8):650-2. doi: 10.1177/107110070602700818.
• Gardner MJ, Graves ML, Higgins TF, Nork SE. Technical considerations in the treatment of syndesmotic injuries associated with ankle fractures. J Am Acad Orthop Surg. 2015;23(8):510-8. doi: 10.5435/JAAOS-D-14-00233.
• Van Heest TJ, Lafferty PM. Injuries to the ankle syndesmosis. J Bone Joint Surg Am. 2014;96(7):603-13. doi: 10.2106/JBJS.M.00094.
• Fidan F, Polat A, Cetin MU, et al. Fixation of posterior malleolar fractures with posterior plating through a posterolateral approach. J Am Podiatr Med Assoc. 2021;111(2):doi: 10.7547/20-100.
• Verhage SM, Hoogendoorn JM, Krijnen P, Schipper IB. When and how to operate the posterior malleolus fragment in trimalleolar fractures: A systematic literature review. Arch Orthop Trauma Surg. 2018;138(9):1213-22. doi: 10.1007/s00402-018-2949-2.
• Weigelt L, Hasler J, Flury A, Dimitriou D, Helmy N. Clinical and radiological mid- to long-term results after direct fixation of posterior malleolar fractures through a posterolateral approach. Arch Orthop Trauma Surg. 2020;doi: 10.1007/s00402-020-03353-2.
• Clanton TO, Williams BT, Backus JD, et al. Biomechanical analysis of the individual ligament contributions to syndesmotic stability. Foot Ankle Int. 2017;38(1):66-75. doi: 10.1177/1071100716666277.
• Miller MA, McDonald TC, Graves ML, et al. Stability of the syndesmosis after posterior malleolar fracture fixation. Foot Ankle Int. 2018;39(1):99-104. doi: 10.1177/1071100717735839.
• Nair AV, Shamsuddin K, John PS, Hamalainen JA, Kurien MA. Correlation of visual analogue scale foot and ankle (vas-fa) to aofas score in malleolar fractures using indian language questionnare. Foot Ankle Surg. 2015;21(2):125-31. doi: 10.1016/j.fas.2014.10.006.
• Erdem MN, Erken HY, Burc H, et al. Comparison of lag screw versus buttress plate fixation of posterior malleolar fractures. Foot Ankle Int. 2014;35(10):1022-30. doi: 10.1177/1071100714540893.
• Mingo-Robinet J, Lopez-Duran L, Galeote JE, Martinez-Cervell C. Ankle fractures with posterior malleolar fragment: Management and results. J Foot Ankle Surg. 2011;50(2):141-5. doi: 10.1053/j.jfas.2010.12.013.
• Choi JY, Kim JH, Ko HT, Suh JS. Single oblique posterolateral approach for open reduction and internal fixation of posterior malleolar fractures with an associated lateral malleolar fracture. J Foot Ankle Surg. 2015;54(4):559-64. doi: 10.1053/j.jfas.2014.09.043.
• Gonzalez TA, Watkins C, Drummond R, et al. Transfibular approach to posterior malleolus fracture fixation: Technique tip. Foot Ankle Int. 2016;37(4):440-5. doi: 10.1177/1071100715617760.
• Hirose C. Corr insights(r): What factors are associated with outcomes scores after surgical treatment of ankle fractures with a posterior malleolar fragment. Clin Orthop Relat Res. 2019;477(4):870-71. doi: 10.1097/CORR.0000000000000671.
• Little MT, Berkes MB, Lazaro LE, et al. Complications following treatment of supination external rotation ankle fractures through the posterolateral approach. Foot Ankle Int. 2013;34(4):523-9. doi: 10.1177/1071100713477626.
• Ovaska MT, Makinen TJ, Madanat R, et al. Risk factors for deep surgical site infection following operative treatment of ankle fractures. J Bone Joint Surg Am. 2013;95(4):348-53. doi: 10.2106/JBJS.K.01672.
• Su J, Cao X. Risk factors of wound infection after open reduction and internal fixation of calcaneal fractures. Medicine (Baltimore). 2017;96(44):e8411. doi: 10.1097/MD.0000000000008411.
• Ovaska MT, Makinen TJ, Madanat R, et al. Predictors of poor outcomes following deep infection after internal fixation of ankle fractures. Injury. 2013;44(7):1002-6. doi: 10.1016/j.injury.2013.02.027.
• Berkes M, Obremskey WT, Scannell B, et al. Maintenance of hardware after early postoperative infection following fracture internal fixation. J Bone Joint Surg Am. 2010;92(4):823-8. doi: 10.2106/JBJS.I.00470.
• Hoiness P, Engebretsen L, Stromsoe K. Soft tissue problems in ankle fractures treated surgically. A prospective study of 154 consecutive closed ankle fractures. Injury. 2003;34(12):928-31. doi: 10.1016/s0020-1383(02)00309-1.
• Zaghloul A, Haddad B, Barksfield R, Davis B. Early complications of surgery in operative treatment of ankle fractures in those over 60: A review of 186 cases. Injury. 2014;45(4):780-3. doi: 10.1016/j.injury.2013.11.008.
• Schepers T, De Vries MR, Van Lieshout EM, Van der Elst M. The timing of ankle fracture surgery and the effect on infectious complications; a case series and systematic review of the literature. Int Orthop. 2013;37(3):489-94. doi: 10.1007/s00264-012-1753-9.