A Comparison of the Long-Term Outcome after Fixed and Non-Fixed Volkmann Fractures

Category: Trauma; Ankle Introduction/Purpose: Our first aim was to compare the long term clinical and radiological outcome of patients sustaining a trimalleolar fracture with a posterior malleolar fragment (PMF) between the patients who had a fixation of the PMF and those who did not. Our secondary aims were to compare the postoperative complication rate, to identify independent risk factors associated with worse clinical and radiological outcome and to assess if the indication of PMF fixation was correlated with the fragment size. Methods: For this monocentric retrospective comparative study, we included 69 consecutive patients who were operated on for a trimalleolar fracture between 2008 to 2013. They completed the SF-12 and the EFAS score at least 10 years after surgery. The radiological osteoarthritis was assessed according to the Kellgren and Lawrence classification. Their demographics (BMI, sex, annual income, smoking status and presence of diabetes) were taken from the chart. The postoperative complications were evaluated according to the Sink classification. The size of the PMF was measured in the preoperative x-ray and the CT and classified according to the Haraguchi classification. 69 patients (49 female (71% /20 male (29%)) with tri-malleolar fractures were included at mean follow-up of 11.3 years. Mean age was 51.4 y.o. Results: 21 (30.4%) of them had a fixation of the PMF by plate and 48 (69.6%) of them not. 9patients (13.04%) had diabetes and 20 patients (29.4%) were smokers. There was no difference between the two groups in the long-term clinical PROMS (EFAS, EFAS Sports, MCS, PCS) nor in degree of osteoarthritis (p=0.05501). Patients in the fixated PMF group had a higher complications rate (p=0.0004527). In the linear regression analysis diabetes was a predictor of negative outcome for the PCS (p=0.007798) and malreduction of syndesmosis was a predictor of negative outcome for the EFAS-score (p=0.0310) and osteoarthritis (p< 0.0001). The PMF size was significantly higher in the fixated group and wasn't correlated to the long-term clinical outcome, except for the mental part of the SF-12 (p=0.0288). Conclusion: Fixation of PMF does not change the clinical and radiological outcome in the long term if the ankle joint is congruent. In contrast the posterolateral approach presents more complications. Surgeons must be aware of this during their design making.