BACKGROUND: Bosworth fractures (BFs) with entrapment of a fibular fragment behind the posterior malleolus (PM) are rare but potentially serious injuries to the ankle. Despite an increased awareness through a more regular use of computed tomography (CT) scanning, there is still a scarcity of clinical outcome studies. METHODS: Over a course of 25 years, data on 23 patients treated for BF at our institutions (mean age 44 years) were collected prospectively. Of those, 16 patients had a Weber type B fracture with displacement of the proximal fibular fragment and 7 patients Weber type C fractures with displacement of the distal fibular fragment behind PM. All but 1 patient, who refused operative treatment, were treated with open reduction and internal fixation. A total of 21 patients were followed up for an average of 66 (range, 18-204) months. RESULTS: The PM was fractured in 96% and the Tillaux-Chaput tubercle in 13% of cases. In 80% of patients with preoperative CT scans, the fibular fragment was entrapped between the posterior aspect of the distal tibia and the displaced PM fragment. An initial attempt at closed reduction was successful in 4 of 7 Weber type C fractures and in none of 16 Weber type B fractures. The overall complication rate was 22%. Eighty-one percent of patients rated their results as good or excellent. The American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score at the final follow-up averaged 84.1 (range, 45-100). Risk factors for postoperative osteoarthritis and poor functional results included unsuccessful closed reduction, inadequate open reduction, and avascular necrosis of the talus. Clinical and radiographic results were correlated. CONCLUSION: Unsuccessful initial reduction and failure to achieve anatomic open reduction were associated with posttraumatic arthritis whereas open anatomic reduction and internal fixation resulted in favorable functional and radiographic results in the medium to long term.

• MeSH
• dospělí MeSH
• fibula * zranění   diagnostické zobrazování   chirurgie   MeSH
• fraktury kostí chirurgie   diagnostické zobrazování   MeSH
• fraktury kotníku chirurgie   diagnostické zobrazování   MeSH
• lidé středního věku MeSH
• lidé MeSH
• mladý dospělý MeSH
• otevřená repozice fraktury metody   MeSH
• počítačová rentgenová tomografie * MeSH
• pooperační komplikace MeSH
• prospektivní studie MeSH
• senioři MeSH
• vnitřní fixace fraktury * metody   MeSH
• Check Tag
• dospělí MeSH
• lidé středního věku MeSH
• lidé MeSH
• mladý dospělý MeSH
• mužské pohlaví MeSH
• senioři MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH

PURPOSE: The aim of this study was to describe the incidence and a complex pathoanatomy of posterior malleolus fractures in a Maisonneuve fracture. METHODS: The study included 100 prospectively collected patients with a complete clinical and radiological documentation of an ankle fracture or fracture-dislocation including a fracture of the proximal quarter of the fibula. RESULTS: A posterior malleolus fracture was identified in 74 patients, and in 27% of these cases it carried more than one quarter of the fibular notch. Displacement of the posterior fragment by more than 2 mm was shown by scans in 72% of cases. Small intercalary fragments were identified in 43% of cases. Fractures of the Tillaux-Chaput tubercle were identified in 20 patients. CONCLUSION: Our study has proved a high rate of posterior malleolus fractures associated with a Maisonneuve fracture, and documented their considerable variability in terms of involvement of the fibular notch, tibiotalar contact area, direction of displacement and frequency of intercalary fragments. Of no less importance is a combination of Tillaux-Chaput fractures with a Maisonneuve fracture.

• MeSH
• dislokovaná fraktura diagnostické zobrazování   MeSH
• dospělí MeSH
• fibula zranění   diagnostické zobrazování   MeSH
• fraktury kotníku * diagnostické zobrazování   chirurgie   MeSH
• incidence MeSH
• lidé středního věku MeSH
• lidé MeSH
• mladiství MeSH
• mladý dospělý MeSH
• počítačová rentgenová tomografie MeSH
• prospektivní studie MeSH
• senioři nad 80 let MeSH
• senioři MeSH
• Check Tag
• dospělí MeSH
• lidé středního věku MeSH
• lidé MeSH
• mladiství MeSH
• mladý dospělý MeSH
• mužské pohlaví MeSH
• senioři nad 80 let MeSH
• senioři MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH

Úvod: Přístup ke zlomeninám zadního kotníku doznal v posledních letech velkého pokroku, především na podkladě Bartoníček-Rammeltovy klasifikace, vycházející z CT vyšetření. Cílem této studie je dokumentovat rozvoj těchto trendů na našem pracovišti. Metody: Retrospektivně bylo analyzováno 66 pacientů se zlomeninou zadního kotníku, řešených na našem pracovišti operačně v letech 2020 a 2021. Tito pacienti byli klasifikováni podle Lauge-Hansenovy klasifikace a v případě provedení CT dle Bartoníček-Rammeltovy klasifikace. Výsledky: CT vyšetření proběhlo u 30 pacientů (45,45 %), které jsme rozřadili podle Bartoníček-Rammeltovy klasifikace (typ I přítomen ve 2 případech, typ II v 7 případech, typ III ve 12 případech a typ IV v 9 případech). Nejhorší výsledky léčby jsme zaznamenali u pacientů bez specifické fixace zadního kotníku typu III dle Bartoníček-Rammelta. Závěr: Z našich výsledků vyplývá postupná tendence k navyšování CT vyšetření mezi lety 2020 a 2021, která byla v těchto letech stále nedostatečná, a proto jsme zvýšili naši snahu o indikování CT vyšetření. Dále se ukazuje problematičnost neadekvátního ošetření zlomeniny typu III dle Bartoníček-Rammeltovy klasifikace, která byla v našem vzorku překvapivě vysoká a byla provázena vysokou mírou komplikací. Důvodem neadekvátního ošetření těchto na CT diagnostikovaných zlomenin je zdráhavé přebírání moderních terapeutických postupů operatéry. To ukazuje na nutnost dlouhodobé a intenzivní osvěty na všech typech pracovišť včetně těch s primární specializací na chirurgii hlezna a nohy.

Introduction: The management of posterior malleolus fractures has experienced notable advancements in recent years, predominantly driven by the CT-based Bartoníček-Rammelt classification. This study aims to systematically document the evolving trends in the approach to these fractures within the context of our institution. Methods: A comprehensive retrospective analysis was undertaken involving 66 patients who underwent surgical intervention for posterior malleolus fractures at our institution during the years 2020 and 2021. Patient classification was conducted based on the Lauge-Hansen classification, with additional categorization according to the Bartoníček-Rammelt classification in instances where CT scans were performed. Results: CT examinations were performed in 30 patients (45.45%); according to the Bartoníček-Rammelt classification they revealed type I in 2 cases, type II in 7 cases, type III in 12 cases, and type IV in 9 cases. Patients lacking specific fixation for type III posterior malleolus fractures, as per the Bartoníček-Rammelt classification, exhibited the most unfavorable treatment outcomes. Conclusion: Our findings elucidate a progressive trend in the utilization of CT examinations between 2020 and 2021, although this escalation remained insufficient during this period. Consequently, we have intensified efforts to advocate for increased use of CT scans. The issues with not optimally treated type III fractures, as classified by Bartoníček-Rammelt, are quite clear from our study. We were surprised by how often these cases occurred, and they often led to more complications. These fractures diagnosed by CT scans were not treated optimally, as surgeons tend to be reluctant in adopting modern treatment procedures. This emphasizes the importance of ongoing and thorough education in all kinds of healthcare settings, including those that specialize in ankle and foot surgery.

• Klíčová slova
• Bartoníček-Rammeltova klasifikace,
• MeSH
• dospělí MeSH
• fraktury kotníku * chirurgie   diagnostické zobrazování   klasifikace   MeSH
• hlezenní kloub diagnostické zobrazování   MeSH
• lidé středního věku MeSH
• lidé MeSH
• mladiství MeSH
• počítačová rentgenová tomografie MeSH
• retrospektivní studie MeSH
• senioři nad 80 let MeSH
• senioři MeSH
• vnitřní fixace fraktury MeSH
• Check Tag
• dospělí MeSH
• lidé středního věku MeSH
• lidé MeSH
• mladiství MeSH
• mužské pohlaví MeSH
• senioři nad 80 let MeSH
• senioři MeSH
• ženské pohlaví MeSH

INTRODUCTION: Complex ankle fractures frequently include the posterior malleolus (PM). Despite advances in diagnostic and treatment strategies, PM fracture involvement still predisposes to worse outcomes. While not incorporated into the most common PM fracture classifications, the presence of an intercalary fragment (ICF) complicates treatment. This study aims to describe the incidence, morphology, and location of ICFs in PM fractures. MATERIALS AND METHODS: A total of 135 patients with a mean age of 54.4 (SD ± 18.9) years and PM fractures were analyzed for the presence of an ICF. Patients with an ICF were compared to those without in terms of age, gender, and treatment received. Characteristics of the ICFs in terms of location and size were assessed. Furthermore, the presence of an ICF in relation to the PM fracture classification according to Haraguchi et al., Bartoníček/Rammelt et al., and Mason et al. was investigated. RESULTS: ICFs presented in 55 (41%) of the 135 patients. Patients with an ICF were younger, and the PM was more often operatively treated when compared to patients without an ICF. A posterolateral approach was used significantly more often in patients with an ICF. Almost all ICFs were found in the posterolateral (58%) and posterocentral (35%) regions. The majority of fragments were found in Bartoníček/Rammelt type 2 fractures, the most common fracture type. Bartoníček/Rammelt type 3 fractures had the highest relative frequency of ICFs. CONCLUSION: ICFs are frequently found in PM fractures; however, they are not incorporated into any of the common classifications. They are generally found in younger patients and associated with more complex PM fractures. As they can complicate reduction of the main fragment and may require direct exposure to restore joint congruency, ICFs should be considered in PM fracture classifications. Due to their location, the majority of ICFs are able to be accessed using a posterolateral approach.

• MeSH
• fraktury kotníku * diagnostické zobrazování   chirurgie   MeSH
• incidence MeSH
• lidé středního věku MeSH
• lidé MeSH
• počítačová rentgenová tomografie MeSH
• retrospektivní studie MeSH
• tibie MeSH
• vnitřní fixace fraktury MeSH
• výsledek terapie MeSH
• Check Tag
• lidé středního věku MeSH
• lidé MeSH
• Publikační typ
• časopisecké články MeSH

Maisonneuveova zlomenina (MZ) je definována jako luxační zlomenina hlezna, kde došlo vždy ke zlomenině proximální čtvrtiny fibuly a roztržení lig. tibiofibulare anterius a lig. tibiofibulare interosseum. Další poranění jsou variabilní. Recentní CT studie ukázaly, že MZ je mnohem komplexnější poranění, než se předpokládalo. Proto je třeba zásadním způsobem změnit pohled na tuto problematiku. MZ je spojena přibližně v 80 % případů se zlomeninou malleolus posterior a dále s malpozicí distální fibuly v incisura fibularis tibiae (IFT). Přesné zhodnocení těchto poranění vyžaduje úrazové CT, které by mělo být u MZ v dnešní době standardem. Hlavním cílem ošetření je anatomická repozice distální fibuly do IFT. To vyžaduje v případě odlomení většího fragmentu malleolus posterior provést nejdříve jeho repozici a fixaci z posterolaterálního přístupu. Tím dojde k obnovení integrity IFT. Zavřená repozice distální fibuly je spojena s malpozicí až v 50 % případů. Proto se dává přednost otevřené repozici z krátkého anterolaterálního přístupu. Přesnost repozice je nutné vždy ověřit pooperačním CT.

Maisonneuve fracture (MF) is defined as an ankle fracture-dislocation associated always with a fracture of the proximal quarter of the fibula and rupture of the anterior and interosseous tibiofibular ligaments. Other injuries are variable. Recent CT studies have demonstrated that MF is a far more complex injury than initially supposed. Therefore it is necessary to change substantially the current concepts related to this issue. MF is combined in about 80% of cases with a fracture of the posterior malleolus and also with malposition of the distal fibula in the fibular notch. An exact assessment of these injuries requires post-injury CT examination which should be used as a standard in MFs. The main goal of treatment is anatomical reduction of the distal fibula into the fibular notch. In case of avulsion of a larger fragment of the posterior malleolus, it is necessary to perform as the first step its reduction and fixation from the posterolateral approach and thus restore integrity of the notch. Closed reduction of the distal fibula is associated with malposition in up to 50% of cases and therefore open reduction from a short anterolateral approach is preferred. Accuracy of reduction should be always checked by postoperative CT scan.

• Klíčová slova
• Maisonneuveova zlomenina,
• MeSH
• dislokace kloubu chirurgie   MeSH
• fibula * chirurgie   diagnostické zobrazování   zranění   MeSH
• fraktury fibuly * chirurgie   diagnostické zobrazování   MeSH
• fraktury kotníku * chirurgie   diagnostické zobrazování   MeSH
• lidé MeSH
• vnitřní fixace fraktury MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• přehledy MeSH

Bosworthova zlomenina (BZ) je vzácné, ale závažné poranění hlezna, charakterizované dislokací fragmentu zlomené fibuly (většinou typ Weber B) z incisura fibularis tibiae na zadní plochu distální tibie. V 70 % případů je doprovázeno zlomeninou malleolus posterior. Toto poranění není příliš známé, v literatuře bylo dosud popsáno 175 případů. BZ vyžaduje CT vyšetření včetně 3D rekonstrukcí. Zavřená repozice je téměř vždy neúspěšná a opakované pokusy zvyšují riziko kompartment syndromu. Proto je vždy indikována operační léčba. Výsledek operace je třeba zkontrolovat na pooperačním CT.

Bosworth fracture (BF) is a rare, but a severe injury to the ankle, characterized by displacement of a fragment of the fractured fibula (mostly of Weber B type) from the tibiofibular incisure to the posterior surface of the distal tibia. In 70% of cases, it is associated with a fracture of the posterior malleolus. This injury is not quite well known, with only 175 cases described in the literature to date. BF requires CT examination, including 3D reconstructions. Closed reduction almost always fails as there is an increased risk of compartment syndrome, mainly after repeated attempts at closed reduction. Therefore, operative treatment is indicated as a standard. The outcome of the operation should be always checked by postoperative CT examination.

• Klíčová slova
• Bosworthova zlomenina,
• MeSH
• fraktury kotníku * chirurgie   diagnostické zobrazování   komplikace   MeSH
• klinická studie jako téma MeSH
• kompartment syndrom etiologie   MeSH
• lidé MeSH
• ortopedické výkony metody   škodlivé účinky   MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• práce podpořená grantem MeSH
• přehledy MeSH

PURPOSE: During study of anatomy of a fractured posterior malleolus of the ankle on CT scans, the authors noticed a prominent crest on the lateral malleolus, which they termed the lateral malleolar crest (LMC). As, in their view, LMC is a clinically important structure which was only briefly mentioned by a few authors without an official term, they focused on the anatomy of this structure. MATERIALS AND METHODS: A total of 352 dry fibulae were analyzed and the following parameters recorded: (F) length of the fibula, (LMC) total length of LMC, (A) length of the part of the examined crest from the superior border of the articular facet of the lateral malleolus (AFLM) to its most proximal intersection with the midline of the fibula, (B) height of the medial triangular rough surface, and (A/F) A/F ratio. RESULTS: The crest was observed in all specimens. (F) was 346.5 ± 26 mm (95% confidence interval [CI] 344-349), (LMC) was 85.4 ± 11.6 mm (95% CI 84.2-86.6), (A/F) was 25% ± 3% (95% CI 24.7-25.3) in the whole group. (A) was 25.9 ± 6.5 mm (95% CI 24.8-26.8) in the whole group, (B) was 34.9 ± 4.7 mm (95% CI 34.3-35.5) in the whole group, 36 ± 6.1 mm (95% CI 35.1-36.9). CONCLUSION: LMC is an important structure on the lateral malleolus. The knowledge of its anatomy is essential for placement of syndesmotic screws or/and the fibular plate.

• MeSH
• fibula * diagnostické zobrazování   anatomie a histologie   MeSH
• fraktury kotníku * diagnostické zobrazování   chirurgie   MeSH
• hlezenní kloub diagnostické zobrazování   chirurgie   anatomie a histologie   MeSH
• klinická relevance MeSH
• kotník MeSH
• lidé MeSH
• tibie anatomie a histologie   MeSH
• vnitřní fixace fraktury MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH

PURPOSE: The aim of this study was to describe pathoanatomy and to raise awareness of a fracture of the lateral malleolus combined with a high subcapital fracture of the fibula caused by a dislocation mechanism. METHODS: The study comprised 11 patients, 5 men and 6 women, with the mean age of 57 years (range, 21-87), with a "Double Maisonneuve fracture". Individual lesions of ankle structures were described on the basis of radiographs, CT, and intraoperative findings. RESULTS: The distal fibular fracture was classified as Weber type B in 1 case and Weber type C in 10 cases. The proximal fibular fracture was described as a subcapital oblique spiral fracture with metadiaphyseal involvement in nine cases and a high short oblique fracture with fibular head involvement in two cases. Injury to the deltoid ligament was revealed in six cases; a bicollicular fracture of the medial malleolus was found in five patients. Posterior malleolar fractures were classified as type 1 in eight cases and type 2 in three cases. Avulsion of the Chaput tubercle was detected in four cases. Injury to the interosseous tibiofibular ligament was assessed in nine patients. CONCLUSION: Double Maisonneuve fracture is a rare but probably underreported injury that must be taken into consideration during examination, as it may be easily overlooked. The essential part of diagnosis is a careful clinical examination and radiological assessment of the lower leg with additional CT examination of the ankle.

• MeSH
• fibula diagnostické zobrazování   MeSH
• fraktury kotníku * diagnostické zobrazování   chirurgie   MeSH
• hlezenní kloub patologie   MeSH
• lidé středního věku MeSH
• lidé MeSH
• mnohočetné fraktury * MeSH
• poranění kotníku * diagnostické zobrazování   chirurgie   MeSH
• tibie zranění   MeSH
• vnitřní fixace fraktury MeSH
• Check Tag
• lidé středního věku MeSH
• lidé MeSH
• mužské pohlaví MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH

»: Maisonneuve fractures (MFs), originally described as subcapital (high) fibular fractures with additional injury to the anterior and interosseous tibiofibular ligaments, display a variable injury pattern, ranging from stable to highly unstable fractures. »: The high incidence of associated fractures of the posterior malleolus, the medial malleolus, and the anterolateral distal tibia (the "anterior malleolus") as well as the variable position of the fibula in the fibular notch (FN) warrant preoperative examination via computed tomography (CT). »: The main goal of treatment is anatomic reduction of the distal fibula into the FN, which requires prior reduction of displaced posterior malleolar fractures, if present, to restore the integrity of the FN. »: Open reduction of the distal fibula into the FN and fixation with 2 transsyndesmotic screws or fixation with a screw(s) and suture-button implant, under direct vision, on the lateral aspect of the ankle joint and anterior tibiofibular alignment are preferred over closed reduction to avoid sagittal or rotational malpositioning, which is associated with an inferior outcome. »: Intra- or postoperative 3D CT visualization is essential for assessment of the accuracy of the reduction of the distal fibula into the FN.

• MeSH
• fibula diagnostické zobrazování   chirurgie   MeSH
• fraktury kotníku * diagnostické zobrazování   chirurgie   MeSH
• hlezenní kloub diagnostické zobrazování   chirurgie   MeSH
• kotník MeSH
• lidé MeSH
• poranění kotníku * diagnostické zobrazování   chirurgie   MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• přehledy MeSH

BACKGROUND: The anterior distal tibial tubercle provides attachment to the anterior tibiofibular syndesmosis. It may be considered a fourth, or anterior, malleolus (AM). Fractures of the AM may extend into the tibial incisura and tibial plafond. The purpose of this study was to analyze the pathoanatomy of AM fractures and associated ankle injuries. METHODS: One hundred and forty patients (median age, 61.0 years) with a total of 140 acute malleolar fractures (OTA/AO 44) involving the anterolateral distal tibial rim were analyzed with computed tomography (CT) imaging. All components of the malleolar fractures were analyzed and classified. Fracture patterns were compared with those of all patients with malleolar fractures treated during the same 9-year period. Patients with fractures of the tibial pilon (OTA/AO 43) and patients <18 years of age were excluded. RESULTS: Of the 140 AM fractures, 52.9% were classified as type 1 (extra-articular avulsion); 35.7%, type 2 (incisura and plafond involvement); and 11.4%, type 3 (impaction of the anterolateral plafond). The fibula was fractured in 87.1%; the medial malleolus, in 66.4%; and the posterior malleolus, in 68.6%. An isolated AM fracture was seen in 4.3%. The size of the AM fractures correlated negatively with that of the posterior malleolar fractures. The proportion of pronation-abduction fractures increased and the proportion of supination-external rotation fractures decreased as the type of AM fracture increased. A fracture involving the AM occurred in 12.6% of all ankle fractures and occurred significantly more frequently in pronation-type injuries and elderly patients. No supination-adduction fractures with AM involvement were seen. The intraclass correlation coefficient for the proposed classification of the AM fractures was 0.961 (95% confidence interval [CI] = 0.933 to 0.980) for interobserver agreement and 0.941 (95% CI = 0.867 to 0.974) for intraobserver agreement. CONCLUSIONS: Knowledge of the 3D pathoanatomy of AM fractures and associated malleolar fractures may help with surgical decision-making and planning. CT imaging should be employed generously in the diagnosis of complex ankle fractures, in particular with pronation-type injuries. CLINICAL RELEVANCE: Depending on the individual 3D fracture pattern, fixation of displaced anterolateral distal tibial fragments potentially contributes to the restoration of joint congruity, tibiofibular alignment, and syndesmotic stability in complex malleolar fractures.

• MeSH
• dospělí MeSH
• fraktury kotníku diagnostické zobrazování   chirurgie   MeSH
• hlezenní kloub diagnostické zobrazování   chirurgie   MeSH
• lidé středního věku MeSH
• lidé MeSH
• počítačová rentgenová tomografie MeSH
• předoperační péče MeSH
• senioři nad 80 let MeSH
• senioři MeSH
• tibie diagnostické zobrazování   chirurgie   MeSH
• vnitřní fixace fraktury metody   MeSH
• Check Tag
• dospělí MeSH
• lidé středního věku MeSH
• lidé MeSH
• mužské pohlaví MeSH
• senioři nad 80 let MeSH
• senioři MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH