The positioning of the fracture fragment of a posterior malleolus fracture is critical to healing and a successful outcome as malunion of a posterior malleolar fracture, a condition seen in clinical practice, can affect the dynamics of the ankle joint, cause posterolateral rotational subluxation of the talus and ultimately lead to destruction of the joint. Current consensus is to employ anatomic reduction with internal fixation when the fragment size is larger than 25 to 33% of the tibial plafond.
A 3-dimensional finite element (FE) model of ankle was developed in order to investigate the effect of fragment size (6–15 mm) and offset (1–4 mm) of a malunited posterior malleolus on tibiotalar joint contact area, pressure, motion of joint and ligament forces. Three positions of the joint were simulated; neutral position, 20° dorsiflexion and 30° plantarflexion.
Compared to the intact joint our model predicted that contact area was greater in all malunion scenarios considered. In general, the joint contact area was affected more by section length than section offset. In addition fibula contact area played a role in all the malunion cases.
We found no evidence to support the current consensus of fixing posterior malleolus fractures of greater than 25% of the tibial plafond. Our model predicted joint instability only with the highest level of fracture in a loaded limb at an extreme position of dorsiflexion. No increase of peak contact pressure as a result of malunion was predicted but contact pattern was modified. The results of our study support the view that in cases of posterior malleolar fracture, posttraumatic osteoarthritis occurs as a result of load on areas of cartilage not used to loading rather than an increase in contact pressure. Ankle repositioning resulted in increased force in two ankle ligaments. Our finding could explain commonly reported clinical observations.
Aiyenuro O, Goldberg AJ. Fractures of the foot and ankle. Surgery. 2013;31:474–81.
Nordin M, Frankel VH. Basic Biomechanics of the Musculoskeletal System, 4th ed. Philadelphia: Lippincott Williams & Wilkins, a Wolters Kluwer business; 2012.
Moore KL, Dalley AF, Agur AMR. Moore Clinically Oriented Anatomy, 7th ed. Philadelphia: Lippincott Williams & Wilkins, a Wolters Kluwer business; 2014
Yufit P, Seligson D. Malleolar ankle fractures. A guide to evaluation and treatment. Orthopoaedics Trauma. 2010;24:286–97. CrossRef
Paulo B, Felix B, Kodi K. AO Surgery Reference. 2006. https://www2.aofoundation.org/wps/portal/surgery?showPage=diagnosis&bone=Tibia&segment=Malleoli. Accessed 11 Sept 2016.
Ekman A, Brauer L. Malleolar Fractures. AOTrauma ORP. 2013. https://aotrauma.aofoundation.org/Structure/education/educational-programs/operating-roompersonnel/Documents/Malleolar%20fractures_Handout.pdf. Accessed 11 Sept 2016.
Deland JT, Morris GD, Sung IH. Biomechanics of the ankle joint. A perspective on total ankle replacement. Foot Ankle Clin. 2000;5:747–59. PubMed
Lindsjö U. Operative treatment of ankle fracture dislocations. A follow-up study of 306/321 consecutive cases. Clin Orthop Relat Res. 1985;199:28–38.
McDaniel WJ, Wilson FC. Trimalleolar fractures of the ankle. An end result study. Clin Orthop Relat Res. 1977;122:37–45.
Broos PLO, Bisschop APG. Operative treatment of ankle fractures in adults: correlation between types of fracture and final results. Injury. 1991;22:403–6. http://dx.doi.org/10.1016/0020-1383(91)90106-O. CrossRefPubMed
Hartford JM, Gorczyca JT, McNamara JL, Mayor MB. Tibiotalar contact area. Contribution of posterior malleolus and deltoid ligament. Clin Orthop Relat Res. 1995;320:182–7.
Macko VW, Matthews LS, Zwirkoski P, Goldstein SA. The joint-contact area of the ankle. The contribution of the posterior malleolus. The Journal of Bone &. Joint Surg. 1991;73:347–51.
Corazza F, Stagni R, Parenti Castelli V, Leardini A. Articular contact at the tibiotalar joint in passive flexion. J Biomech. 2005;38:1205–12. http://dx.doi.org/10.1016/j.jbiomech.2004.06.019. CrossRefPubMed
Vrahas M, Fu F, Veenis B. Intraarticular contact stresses with simulated ankle malunions. J Orthop Trauma. 1994;8:8. CrossRef
Trivedi S. Finite element analysis: A boon to dentistry. J Oral Biol Craniofacial Res. 2014;4(3):200–3. CrossRef
Kluess D, Wieding J, Souffrant R, Mittelmeier W, and Bader R. Finite element analysis in orthopaedic biomechanics, in Finite Element Analysis (Ed David Moratal). (2010). pp 151-170. Sciyo, ISBN 978-953-307-123-7, http://www.intechopen.com/books/finite-element-analysis/finite-element-analysis-in-orthopaedic-biomechanics, retrieved 04-02-2017. Accessed 4 Feb 2017.
Zheng M, Zou Z, Bartolo P J, Peach C, Ren L. Finite element models of the human shoulder complex: a review of their clinical implications and modelling techniques. Int J Numer Method Biomed Eng. 2017;33(2):e02777. http://dx.doi.org/10.1002/cnm.2777.
Fagan MJ, Julian S, Mohsen AM. Finite element analysis in spine research. Proc Inst Mech Eng Part H. 2002;216(5):281–98. CrossRef
Rahemi H, Mostafavi SK, Esfandiarpour F, Parnianpour M, Shirazi-Adl A. Review of finite element model studies in knee joint biomechanics. J Mod Rehabilitation. 2011;5(3):1–12.
Henninger HB, Reese SP, Anderson AE, Weiss JA. Validation of computational models in biomechanics. Proc Inst Mech Eng Part H. 2010;224(7):801–12. CrossRef
Miguel-Andres I, Alonso-Rasgado T, Walmsley A, Watts AC. Effect of anconeus muscle blocking on elbow kinematics: electromyographic, inertial sensors and finite element study. Ann Biomed Eng. 2016; 1–14. doi: 10.1007/s10439-016-1715-2
Goh J, Mech A, Lee E, et al. Biomechanical study on the load-bearing characteristics of the fibula and the effects of fibular resection. Clin Orthop Relat Res. 1992;279:223–8.
Takebe K, Nakagawa A, Minami H, et al. Role of the fibula in weight-bearing. Clin Orthopaedics Related Res. 1984;184:289–92.
Wang Q, Whittle M, Cunningham J, Kenwright J. Fibula and its ligaments in load transmission and ankle joint stability. Clin Orthopaedics Related Res. 1996;330:261–70.
Dassault Systèmes. Abaqus 6.12 online documentation. Notes. 2012;92:815–21. doi: 10.1097/TP.0b013e31822ca79b.
Kim S, and Carl Miller M. Validation of a finite element humeroradial joint model of contact pressure using Fuji pressure sensitive film. J Biomech Eng. 2016;138(1):014501–4. http://dx.doi.org/10.1115/1.4031976.
- 3-D computer modelling of malunited posterior malleolar fractures: effect of fragment size and offset on ankle stability, contact pressure and pattern
- BioMed Central
Neu im Fachgebiet Orthopädie und Unfallchirurgie
Mail Icon II