1. Mid to long term functional outcomes of reduced and malreduced ankle fractures in two university teaching hospitals
V Roberts1, L Mason2, E Harrison2, A Molloy2, J Mangwani1
1Leicester Royal Infirmary
2Aintree University Hospital

2. Aims
Analyse adequacy of reduction and internal fixation of ankle fractures
Assess the midterm functional outcome of these patients

3. Methods Retrospective outcome study
Cohort 1: Nov 2006 – Nov 2007, Leicester Royal Infirmary
Cohort 2: January – December 2009, Aintree University Hospital
Adequacy of reduction assessed using Pettrone’s criteria
(JBJS Am 1983;65:667-77) :
Medial Malleolus
Fracture separation <1mm
Lateral Malleolus
Fracture separation <2mm
Deltoid
Medial clear space ≤3mm
Syndesmosis
AP: Tibia-fibula clear space ≤5mm
AP: Tibia-fibula overlap ≥10mm
Mortise: Tibia-fibula overlap ≥1mm

4. Methods Postal questionnaire Olerud–Molander Ankle Score
9 topics: pain, stiffness, swelling, stairs, running, jumping, squatting, supports, daily life
Score out of 100 (best)
Second posting / telephone contact
Minimum of 6 years post ORIF

5. Results Total number of patients included in study - 261
Sex: F – 141, M – 120
Age: (mean 48)

6. Malreduced Percentage Malreduced = Pettrone of 1 or greater
Results
Fracture Type
Number B1 67 B2 87 B3 40 C 68
Total
261
Malreduced Percentage % % % %
More complex injuries have higher percentage of malreduction %
Malreduced = Pettrone of 1 or greater

7. Results Died: 26 Lost to follow-up: 17 Survivors: 209
Responders: 107 (52%)

8. Malreduced = Pettrone of 1 or greater
Results
Malreduced Cohort
Reduced Cohort
Number 88
173
Gender M:F
1: 1.7
1: 1
Number of respondents 36 71
Lower mean OMAS score even with only 1 Pettrone score loss but only small.As Nilssons paper showed, a difference of 4.4 points in OMAS should be interpreted as the smallest change that indicates a real change of clinical interes, so this is clinically significant
Mean OMAS score
Malreduced = Pettrone of 1 or greater

9. Results by Fracture Type
Reduced Number
OMAS (mean score)
Malreduced Number B1 17 77 14 58 B2 23 64 11 62 B3 59 3 C 22 79 6 68
Trimalleolar fractures (B3) in low fibular fractures have lower scores in both the reduced and malreduced injuries. This maybe caused by the unrecognised poserior syndesmotic injuries in the reduced cohort. In the malreduced fractures, this is in keeping with the general poor results in posterior malleolar injuries in general in the literature.
Malreduced = Pettrone of 1 or greater

10. Malreduction Results Pettrone’s Value Number of Patients
Mean OMAS Score
Standard Deviation 73 71
29.8 1 21 68
31.5 2 9 47
35.3 3 36
32.1 4 20
Greater than 2 scores for malreduction on Pettrones score significantly affects functional outcomes. This is likely the result of the talus malposition that occurs with Pettrones score >2

11. Using a Pettrone score of 2 or greater as definition of malreduced
Results
Using a Pettrone score of 2 or greater as definition of malreduced
Malreduced Cohort
Reduced Cohort
Number 13 94
Mean OMAS Score 43 71
When comparing the overall OMAS score using a Pettron score of 2 as a cut off, there is a significant difference both clinically and
Significant difference on Mann Whitney test (p= 0.006)

12. Further Surgery Further Surgery Malreduced Cohort Reduced Cohort
Revision 6 1
Removal of metal 3 7
Arthrodesis 2

13. Limitations Retrospective study Two centres – potential disparity
Response rate

14. Conclusion More complex fractures more likely to be malreduced
Lower functional score related to more criteria malreduced
Significantly worse outcomes in posterior malleolar fractures

15. Conclusion Address patient expectation
Educate to improve the rate of malreduction in our hospitals
Potentially define who should operate on particular fractures
Special care to be taken with posterior malleolar fracture

16. Thank you