The Radiographic and Functional Outcome of Bimalleolar Fractures Treated by Open Reduction and Internal Fixation with Screws/Tbw and Plates: A Prospective Study

Background: Bimalleolar fractures are one of the most common fractures in orthopedic traumatology. As with all intra articular fracture, malleolar fracture necessitate accurate reduction and stable internal fixation. When malleolar fractures are not reduced accurately they may lead to post traumatic painful restriction of motion or osteoarthritis or both. To study the functional and radiological outcome and result of surgical treatment of bimalleolar fractures and to know the complication of open reduction internal fixation in bimalleolar fractures. Materials A Prospective review was conducted for 60 patients between January 2018 to December 2019 with closed bimalleolar fracture. Open reduction and internal fixation was done with specific modalities. Patients were evaluated with Subjective and objective assessments of the patients’ ankles were done using a modification of the scoring system proposed by Olerud and Molander and radiologically by Kristenson criteria. The functional and radiographic outcome of ORIF and advantages of the procedures were recorded. Functional and radiographic evaluations were performed at immediate post op, 6 weeks, 3 months and 6 months, 1 year after surgery. At each follow up, patients were assessed for syndesmotic reduction, loss of fixation, and implant failure and any arthritis changes. The reduction in quality was evaluated on immediate postoperative radiography. Results: In the present study of 60 patients with bimalleolar fractures treated by open reduction and internal fixation. Excellent results were achieved in 49 (81.7%) patients, good in 9 (15%), and poor in 2 (3.3%) patient. The patient with poor result had mild pain with activities of daily living, diminution in the abilities to run and to do work, reduced motion of ankle and narrowing of joint space. Conclusions: Understanding the mechanism of injury is essential for good reduction and internal fixation. The fibular length has to be maintained for lateral stability of the ankle. Anatomical reduction is essential in all intra articular fractures more so if a weight bearing joint like ankle joint is involved. Our series encourage operative intervention within 48 hours in the management of bimalleolar fractures of the ankle as the key for high percentage of good result.


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The firstCase of surgery in the talo-crural joint was reported by von Volkmann in 1875 [6]. Initially however, surgical techniques of fracture treatment did combine the disadvantages of non-surgical and operative treatment: the osteosynthesis was unstable and the fracture site had been exposed with a high risk of infection and disturbed bone healing [5].
The ankle joint (talocrural joint) consists of three bones; tibia, fibula and talus. There are three articular surfaces: the upper joint surface, which are the dome of the talus and the tibial plafond and the main articulation of the joint; the medial joint surface, between the talus and the inner aspect of the medial malleolus; the lateral joint surface, between the talus and the inner surface of the lateral malleolus of the fibula [6]. Malleolor fracture has varied presentation understanding of the biomechanics of the joint and mechanism of injury is essential for adequate reduction and of all fractures [7]. Ankle injuries have great importance as body weight is transmitted through it and locomotion depends on the stability of the joint. Intra articular fractures like bimalleolar fractures need thorough understanding of mechanism of injury, proper anatomical alignment, accurate and stable reduction and fixation with appropriate implants in order to reduce painful restriction of movements and osteoarthritis [8].

Materials And Methods
From January 2018 to December 2019, 60 Bimalleolar fractures fixation were performed using specific modalities implant. The study was conducted at Amandeep Hospital, Amritsar, and Punjab after obtaining the ethical clearance from institutional ethical committee.
Initial management was done in the orthopedic emergency area, which included getting standard AP and lateral radiographs of the ankle joint ( Figure 1). Distal neurovascular status and clinical signs to exclude compartment syndrome were assessed and documented.
Patients with gross ankle dislocation were attempted to be reduced in the emergency itself under sedation after prior consent from the patient and relatives. A below-knee plaster slab was applied to immobilize the joint and analgesics were instituted. The limb was kept elevated to prevent excessive swelling. After routine blood investigations and pre-anesthesia clearance, patients were posted for surgery. An ankle CT scan was conducted in all cases as part of the preoperative planning. Intravenous 1 g cefazolin was administered 30 min prior to skin incision in the operating room after prior antibiotic sensitivity testing. Patient's age between 18 to 85 years with close bimalleolar fractures were included in this study. Patients with open fractures, active infection at site of injury or other associated fractures in the body elsewhere were excluded.
Patients with severe preexisting arthritis in the affected ankle joint, limp, or assisted walk due to some previous or ongoing pathology in the hip or knee joint either in ipsilateral or in contralateral limb were excluded from the study.

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X-rays at 12 months of follow-up were documented in all cases [9,10]. Post-operative antibiotics were continued for a period ranging from 3 to 5 days depending on the presence of other injuries and therapy was prolonged if there were signs of infection. Once painfree, patient was trained in non-weight bearing crutch walking and advised dorsiflexion and plantar flexion exercises. Postoperative, assessment was done immediately then 6 weeks, 3 months, 6 months and 1 year according to Olerud, et al. [9] functional scoring.
Fractures were classified according to Dannis-Weber Classificaton system and operated within 24hrs of presentation. Subjective and objective assessments of the patient's ankles were done using a modification of the scoring system proposed by Olerud, et al. [9].

Results
In our series, most of the patient affected by the fracture belongs to age group of 18-50 years, which were 42(70%). The commonest mode of injury is road traffic accident (63.3%) and fall (36.7%). 31 were male patients (51.7%) and 29 were female patients (48.3%).

cases involved the right ankle and 26 cases involved the left ankle.
The most common injury pattern seen was Dennis Weber Type B in 34 patients (56.7%). In the present study group, 41 cases (68.3%) had a stay of more than 5 days while 19 cases (31.7%) had a stay of less than or equal to 5 days. The mean duration of stay was 5 days.

Surgical technique used was open reduction and internal fixation
of the lateral malleolus with semi tubular plate or recon plate; medial malleolus with cancellous screws or tension band wiring.
In the present study out of 60 patients, 4 patients presented with persistent swelling, 9 patients presented with residual pain while   (Table 1). Bargon criteria [10] for grading post-traumatic arthritis of the ankle joint at the end of 12 months with the help of weight-bearing ankle X-rays were assessed. Only two patients had grade 2 arthritis, eight patients had grade 1, while the rest had grade 0 arthritis. No complications related to soft tissue healing, pain, or hardware impingement or breakages were encountered.

Discussion
Understanding the mechanism of injury is important for good