Anatomical reconstruction of the anterior inferior tibiofibular ligament in elite athletes using InternalBrace suture tape

AIMS

The ideal management of acute syndesmotic injuries in elite athletes is controversial. Among several treatment methods used to stabilize the syndesmosis and facilitate healing of the ligaments, the use of suture tape (InternalBrace) has previously been described. The purpose of this study was to analyze the functional outcome, including American Orthopaedic Foot & Ankle Society (AOFAS) scores, knee-to-wall measurements, and the time to return to play in days, of unstable syndesmotic injuries treated with the use of the InternalBrace in elite athletes.

METHODS

Data on a consecutive group of elite athletes who underwent isolated reconstruction of the anterior inferior tibiofibular ligament using the InternalBrace were collected prospectively. Our patient group consisted of 19 elite male athletes with a mean age of 24.5 years (17 to 52). Isolated injuries were seen in 12 patients while associated injuries were found in seven patients (fibular fracture, medial malleolus fracture, anterior talofibular ligament rupture, and posterior malleolus fracture). All patients had a minimum follow-up period of 17 months (mean 27 months (17 to 35)).

RESULTS

All patients returned to their pre-injury level of sports activities. One patient developed a delayed union of the medial malleolus. The mean return to play was 62 days (49 to 84) for isolated injuries, while the patients with concomitant injuries returned to play in a mean of 104 days (56 to 196). The AOFAS score returned to 100 postoperatively in all patients. Knee-to-wall measurements were the same as the contralateral side in 18 patients, while one patient lacked 2 cm compared to the contralateral side.

CONCLUSION

This study suggests the use of the InternalBrace in the management of unstable syndesmotic injuries offers an alternative method of stabilization, with good short-term results, including early return to sports in elite athletes. Cite this article: Bone Joint J 2022;104-B(1):68-75.

Can treatment of posterior malleolus fractures with tibio-fibular instability be usefully addressed by Bartonicek classification?

INTRODUCTION

Ankle fractures account for 4% of all fractures and treatment of those involving the Posterior Malleolus remains controversial. Clinical and radiological outcomes in a cohort of patients with Posterior Malleolus fractures conservatively treated were retrospectively evaluated; furthermore, a treatment algorithm was suggested.

METHODS

Patients were divided according to Bartoníček classification. The clinical evaluation was made with OMAS/AOFAS scores; the radiological evaluation with Van Dijk classification for post-traumatic arthritis.

RESULTS

Clinical outcome worsened with the severity of Bartoníček classification, but early degenerative changes were not correlated neither to the clinical outcome nor to the injury pattern. Clinical and radiological outcomes depended on the damage of the syndesmosis as articular step-offs and tibio-fibular notch involvement.

DISCUSSION

We recommend conservative treatment for Bartoníček type I, type II and type III fractures, the latter when undisplaced and without tibial plafond depression. We suggest surgical treatment for type IV and displaced type III fractures.

Ankle fracture management using smartphone multimedia messaging service (MMS) imaging - How reliable and to what point?

BACKGROUND

The use of smartphones and multimedia messaging service (MMS) continues to increase in day to day orthopaedic clinical practice. However, there is limited evidence to support the safe utilisation of MMS.

OBJECTIVES

The aim of this study was to correlate the performance of MMS imaging to picture archiving and communication systems (PACS) imaging within the setting of diagnosis and management of ankle fractures.

METHODS

The ankle fracture radiograph series of 82 consecutive patients were evaluated by five orthopaedic consultant specialists. A questionnaire regarding diagnosis and preferred management was completed separately for each patient using smartphone and PACS images. Statistical analysis was performed using Intraclass Correlation Coefficient (ICC).

RESULTS

Ankle fracture diagnosis showed strong to excellent correlation both inter- and intraobserver MMS vs PACS when using the Weber (0.815, 0.988), Anatomical (0.858, 0.988), and AO classification systems (0.855, 0.985). MMS was less reliable than PACS in determining many management options.

CONCLUSION

The reliability of ankle fracture classification using MMS image viewing was not significantly different to interpretation on PACS workstations. Smartphone use in ankle fracture classification is supported by this study. Smartphone use was less accurate than PACS in devising management plans and future use should be limited to making only initial plans that must be corroberated with PACS and intraoperative findings prior to definitive fixation.

Morphological analysis of posterior malleolar fractures with intra-articular impacted fragment in computed tomography scans

Background

Intraarticular impacted fragment (IAIF) of posterior malleolar fractures has been reported by a few studies. However its location, morphology, and the correlation of posterior malleolar fractures have not been described in detail. The aim of this study was to describe the morphology of IAIF in posterior malleolar fractures, to analyze the related factors between IAIF and posterior malleolar fragments, and explore the treatment of IAIF.

Materials and methods

Between January 2013 and December 2018, 108 consecutive patients with unilateral posterior malleolar fractures were managed in our hospital. Basic demographic and computed tomography (CT) data were collected and classified by Lauge–Hansen, OTA/AO, Haraguchi, and Mason classification. Additional radiographic data, including the length and area of posterior malleolar fragment, IAIF, and stable tibial plafond were measured. The location of IAIF was described, and involvement of the fibular notch and medial malleolus was also observed. Statistics were analyzed based on univariate analysis (Chi-square test, t-test, Mann–Whitney U test, Fisher’s test) and Spearman’s correlation test.

Results

Among the 108 cases of posterior malleolar fractures, 75 (69.4%) were with IAIF and 33 (30.6%) cases were without. There were 74 (68.5%) females and 34 (31.5%) males, and the average age of the patients was 49 years (18–89 years). The average L_IFN/(L_IFN + L_SFN) [length of involving fibular notch/(length of involving fibular + length of stable notch fibular notch)] was 32.9% (11.6–64.9%). The A_PMF/(A_PMF + A_STP + A_IAIF) [area of posterior malleolar fragment/(area of posterior malleolar fragment + area of IAIF + area of stable tibial plafond)] and A_IAIF/A_PMF (area of IAIF/area of posterior malleolar fragment) were 13.1% (0.8–39.7%) and 52.6% (1.2–235.4%), respectively. Involvement of medial malleolus (fracture line extended to medial malleolus, P = 0.022), involvement of fibular notch (P = 0.021), L_IFN/(L_IFN + L_SFN) (P = 0.037), L_MPMF (P = 0.004), and A_PMF were significantly related to the occurrence of IAIF.

Conclusion

Our research indicates a high incidence of IAIF in posterior malleolar fractures. All IAIFs were found in posterior malleolar, and the most common location was within the lateral area A. Posterior malleolar fracture lines that extend to medial malleolus or fibular notch herald the incidence of IAIF. L_IFN/(L_IFN + L_SFN), L_MPMF and A_PMF are also associated with the incidence of IAIF. CT scans are useful for posterior malleolar fractures to determine the occurrence of IAIF and make operational plans. Operation approach selection should be based on the morphology of posterior malleolar fragments and the location of IAIF.

Level of evidence

Level III, retrospective case analysis.

Minimally invasive treatment of AO B ankle fractures: Surgical technique and long-term outcomes

BACKGROUND

Ankle fractures are the most common traumatic bone injuries of the lower limb. Over 50% of ankle fractures occur at the syndesmosis level (type AO B). The goal of treatment is to achieve an anatomical reduction and appropriate stabilization. The present study aimed to evaluate the clinical-functional and radiological results, and complications of minimally invasive reduction and fixation technique for ankle fractures type AO B. The surgical technique also is detailed.

MATERIAL AND METHODS

A prospective analysis of 451 patients undergoing surgery for type AO B displaced ankle fracture was performed. All patients were treated with minimally invasive surgery. The following times were recorded: time between trauma and osteosynthesis, hospitalization length, surgical time, and exposure time to fluoroscopy. Age and gender, mechanism of injury, and characteristics of fractures were recorded. For functional outcome, AOFAS score, VAS, and Weber score were used. Radiographic analysis was performed. The average follow-up was 112 months.

RESULTS

Mean age was 48.2 years old. Average length of stay in hospital was 5.72 h. Mean duration of the surgery was 32.8 min. Average fluoroscopic exposure time during surgery was 9.25 s. Mean bone union time was 38.2 days. Weber's score was on average 1.5/24 points and the long-term follow-up AOFAS score was on average 97.5/100. Postoperative complications incidence was 2.7%.

CONCLUSIONS

Distal fibula fixation with the MIPO technique presented good functional outcomes and could be helpful in the avoidance of the complications associated with conventional open reduction and internal fixation. However, it needs more exposition to intraoperative fluoroscopy.

LEVEL OF EVIDENCE

II.

Deltoid ligament arthroscopic repair in ankle fractures: Case series

INTRODUCTION

Diagnosis and treatment of ankle medial ligament lesions in malleolar fractures has always been a matter of controversy. Even when deltoid involvement is clear, the direct repair of this structure is not a consensus. Recently, deltoid repair through an arthroscopic technique was described aiming to potentialize better clinical results and minimize complications.

OBJECTIVE

Demonstrate safety and functional results on patients with ankle fractures submitted to open reduction and internal fixation and arthroscopic deltoid repair.

METHODS

This is a retrospective study in patients diagnosed with ankle fractures associated with acute deltoid injuries submitted to open malleolar fixation and deltoid arthroscopic repair between June 2016 and January 2020. All patients were evaluated for pain and functionality according to the Visual Analogue Scale (VAS) and the American Orthopedic Foot and Ankle Society Score (AOFAS) at a minimum of 6 months follow-up.

RESULTS

From January 2016 to January 2020, 20 ankles with fractures or dislocations were operated and the deltoid ligament rupture was repaired arthroscopically. A mean follow-up of 14.45 months (6-48) was observed, and patients presented an average AOFAS of 93.5 (SD 7.25) and a VAS of 0.75 (SD 1.05). Three minor complications were noticed and no signs of medial chronic instability, loss of reduction or osteoarthritis were observed.

DISCUSSION

The repair of the deltoid complex and the low morbidity of the arthroscopic technique used may improve the clinical outcomes of these patients. Additional studies, with a prospective and comparative methodology are required to sustain this proposal.

DESIGN

Level IV. Retrospective case series.

Diabetic ankle fracture complications: a meta-analysis

INTRODUCTION

This meta-analysis aimed to review complication rates following the treatment of an ankle fracture in diabetic patients and to early detect the subgroup of patients at potential risk in order to minimise this complication rate.

METHODS

A search of 3 databases was performed for studies published till March 2018. Twelve studies met the eligibility criteria for further statistical analysis. An odds ratio (OR) with a 95% confidence interval (95% CI) for each complication was calculated between the diabetic and non-diabetic groups.

RESULTS

The overall complication risk after ankle fracture was twice as high in diabetes mellitus (DM) than non-diabetes mellitus (non-DM) patients (OR 1.9, 95%CI: 1.7-2.03). This risk was considerably higher with surgery versus non-surgical treatment (OD 3.7, 95%CI: 2.3-6.2). The risk of infection was 3 times higher in DM than in non-DM patients (OR 3.4, 95%CI: 2.9-9.8). The complication rate was even higher in patients with advanced DM (OR 8.4, 95%CI: 2.9-24.5).

CONCLUSION

This meta-analysis provides evidence that diabetic patients are at a greater risk of complication after an ankle fracture.

"Double Maisonneuve fracture": an unknown fracture pattern

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.

Psychological dysfunction associated with calcaneal fractures

INTRODUCTION

The calcaneus is the most commonly fractured hindfoot bone, accounting for over 60% of all tarsal fractures. The aim of this study was to compare the mechanism of injury and psychological health status in patients presenting with calcaneal fractures to an age- and sex-matched control group with ankle fractures.

PATIENTS AND METHODS

This retrospective study was undertaken within an orthopaedic unit at a tertiary hospital. An electronic medical record chart review was performed to identify eligible patients. Descriptive statistics were used to summarise the demographic and clinical characteristics of the patients. Between-group differences were analysed with the Mann-Whitney U test and Fisher's exact test for continuous and categorical variables, respectively. Multivariable binary logistic regression was used to determine the relationship between fracture type and underlying psychopathology, adjusting for mechanism of injury.

RESULTS

Two-hundred and fifteen patients met the eligibility criteria for calcaneal fractures and these patients were subsequently matched to 215 ankle fracture patients. Men accounted for 154 (71.6%) of the patients in each group. Over half (51.2%) of all calcaneal fractures were due to an uncontrolled fall above one-metre, as opposed to 26.0% of ankle fractures, p < 0.001. Falling from a standing height was more common in the ankle fracture group, 37 (17.2%) versus 10 (4.7%), p < 0.001. Patients with calcaneal fractures were more likely to have a diagnosed psychological health complaint, 63 (29.3%) versus 32 (14.9%), p < 0.001. Suicidal ideation was significantly more common in the calcaneal fracture group 14 (6.5%) versus 3 (1.4%), p = 0.011. The presence of premorbid psychopathology was associated with calcaneal fracture, after adjusting for mechanism of injury (odds ratio 2.20, 95% confidence interval 1.32 to 3.65, p = 0.003).

CONCLUSION

Calcaneal and ankle fractures display differences in both the mechanism of injury and the history of psychological health conditions. However, after adjusting for the mechanism of injury, diagnosed premorbid psychopathology remains twice as likely in someone with a calcaneal fracture as opposed to an ankle fracture. It may be prudent for orthopaedic surgeons to consider further investigations of psychological health when managing patients with a calcaneal fracture.

Management of posterior malleolus fractures: A multicentre cohort study in the United Kingdom

BACKGROUND

There is a need to assess clinical practice in light of increasing literature recommending fixation of posterior malleolus (PM) fractures. This multicentre study examines treatment approaches, within both Major Trauma Centres and District General Hospitals and role of radiographs and CT scanning.

METHODS

Trauma lists and databases were used to identify patients and data collected from electronic and paper medical records and imaging systems between August 2017-18. Analysis of treatment and outcomes was then conducted.

RESULTS

One-hundred-and-sixty ankle fractures were included in the study, only 68 ankle fractures underwent CT scanning following initial radiographs and of these, 65 were managed operatively, with 32 undergoing PM fixation. Syndesmotic stabilisation was performed in 9.6% where the PM was fixed.

CONCLUSION

CT is still under-utilised, PM fractures that appear to be anything other than small avulsion-type injuries should undergo CT scanning. Syndesmotic stabilisation is statistically less likely to be performed with fixation of the PM.

Provisional reduction plating in the treatment of ankle fractures: a technical trick

Reduction plating is a concept used to provisionally maintain reduction in the treatment of various fractures throughout the body. It is often used in challenging fracture patterns where the use of reduction clamps hinders placement of the definitive fixation construct. In this article, we present a technique for fixation of ankle fractures, in which a mini-fragment plate is used to keep provision reduction of the fracture, while the definitive plate is applied. This technique is particularly useful when using a posterolateral one-third tubular plate as your definitive construct. This study provides Level V evidence.

The level of bifurcation of peroneal artery and its implications for posterolateral approach to the ankle: a CT angiography study

PURPOSE

This study aims to provide data, with the use of computed tomography angiography, regarding the level of bifurcation of the peroneal artery to the anterior perforating branch and the lateral calcaneal branch, in relation to the osseous anatomic structures of the tibial plafond, the medial malleolus and the lateral malleolus.

METHODS

The study included patients who underwent diagnostic computed tomography angiography of the lower extremities. Measurements were performed in two-dimensional reconstructions and included the perpendicular distance from peroneal artery bifurcation into anterior perforating branch and lateral calcaneal branch to the lowest level of tibial plafond (D1), medial malleolus (D2) and lateral malleolus (D3). The distances were also normalized to the length of the tibia.

RESULTS

Sixty patients and a total of 115 limbs were enrolled in this study. The mean distance ± standard deviation from peroneal artery bifurcation to tibial plafond (D1) was 4.33 ± 1.12 cm (normalized 0.12 ± 0.03) (range 2.54-8.26 cm), to medial malleolus (D2) was 5.53 ± 1.18 cm (normalized 0.16 ± 0.03) (range 3.27-9.5 cm) and to lateral malleolus (D3) was 6.53 ± 1.17 cm (normalized 0.18 ± 0.03) (range 4.71-10.2 cm), respectively. There was no significant difference between right and left limb measurements (p > 0.05). Females presented lower, but not statistically significant (p > 0.05), D1, D2 and D3 measurements compared to males.

CONCLUSION

The bifurcation of the peroneal artery takes place at lower level compared to previously published studies and consequently extreme caution should be exercised when performing the posterolateral approach to the ankle. This study adds to the understanding of the relevant vascular anatomy of the region and assists in performing the posterolateral approach to the ankle with safety.

The CT morphological characteristics and the clinical management strategy of posterior malleolar fractures with talar subluxation

BACKGROUND

The optimal clinical treatment and the computed tomography (CT) morphological characteristics of posterior malleolar fractures (PMF) with talar subluxation remain inconclusive. Clinically, both plate screws and lag screws are widely used to fix posterior malleolar fragments using a direct or indirect approach. We sought to summarize the morphological characteristics and modified classification on the basis of CT and the intraoperative strategy for posterior talar subluxation in PMF.

METHODS

Retrospectively, 46 adult PMF patients with subluxations of the talus were recruited as the study cohort. According to its morphological features, PMF with subluxation of the talus can be divided mainly into two types using this modified classification: a complete fracture (the single-fragment type) and PMF with two-angled fracture fragments (the double-fragment type). The cohort's demographic information, classifications, fracture morphology, fixation methods, pain levels, and functional scores were recorded for both fracture types.

RESULTS

The average values of the depths and heights of the posterior malleolar fragments were (29.1±7.3) mm for the single-fragment type and (17.9±4.2) mm for the double-fragment type. There was a significant difference in the mean values between the two types (P < 0.05). Posterior plate fixation was suitable for the single-fragment type, while antero-posterior and postero-anterior (AP-PA) lag screws fixations were made available for the double-fragment type. Both methods achieved good results. No significant differences were found in terms of sex, age, body mass index (BMI), side, Haraguchi classification, Bartoníček and Rammelt classification, Visual Analog Scale (VAS) scores, or American Orthopedic Foot & Ankle Society scores (AOFAS) when comparing the single-/double-fragment type groups after the mid-term follow-up (P > 0.05).

CONCLUSION

According to the injury mechanism and the morphological characteristics of the fractures, the proposed improved classification system for PMF with subluxation of the talus based on the injury mechanism and the fracture morphology can provide guidance for surgical management strategies and achieve optimal outcomes.

Seasonality of adult fragility fractures and association with weather: 12-year experience of a UK Fracture Liaison Service

PURPOSE

To investigate the monthly and seasonal variation in adult osteoporotic fragility fractures and the association with weather.

METHODS

12-year observational study of a UK Fracture Liaison Service (outpatient secondary care setting). Database analyses of the records of adult outpatients aged 50 years and older with fragility fractures. Weather data were obtained from the UK's national Meteorological Office. In the seasonality analyses, we tested for the association between months and seasons (determinants), respectively, and outpatient attendances, by analysis of variance (ANOVA) and Tukey's test. In the meteorological analyses, the determinants were mean temperature, mean daily maximum and minimum temperature, number of days of rain, total rainfall and number of days of frost, per month, respectively. We explored the association of each meteorological variable with outpatient attendances, by regression models.

RESULTS

The Fracture Liaison Service recorded 25,454 fragility fractures. We found significant monthly and seasonal variation in attendances for fractures of the: radius or ulna; humerus; ankle, foot, tibia or fibula (ANOVA, all p-values <0.05). Fractures of the radius or ulna and humerus peaked in December and winter. Fractures of the ankle, foot, tibia or fibula peaked in July, August and summer. U-shaped associations were showed between each temperature parameter and fractures. Days of frost were directly associated with fractures of the radius or ulna (p-value <0.001) and humerus (p-value 0.002).

CONCLUSION

Different types of fragility fractures present different seasonal patterns. Weather may modulate their seasonality and consequent healthcare utilisation.

Vascular impulse technology versus elevation for the reduction of swelling of lower extremity joint fractures: results of a prospective randomized controlled study

AIMS

Complex joint fractures of the lower extremity are often accompanied by soft-tissue swelling and are associated with prolonged hospitalization and soft-tissue complications. The aim of the study was to evaluate the effect of vascular impulse technology (VIT) on soft-tissue conditioning in comparison with conventional elevation.

METHODS

A total of 100 patients were included in this prospective, randomized, controlled monocentre study allocated to the three subgroups of dislocated ankle fracture (n = 40), pilon fracture (n = 20), and intra-articular calcaneal fracture (n = 40). Patients were randomized to the two study groups in a 1:1 ratio. The effectiveness of VIT (intervention) compared with elevation (control) was analyzed separately for the whole study population and for the three subgroups. The primary endpoint was the time from admission until operability (in days).

RESULTS

The mean length of time until operability was 8.2 days (SD 3.0) in the intervention group and 10.2 days (SD 3.7) in the control group across all three fractures groups combined (p = 0.004). An analysis of the subgroups revealed that a significant reduction in the time to operability was achieved in two of the three: with 8.6 days (SD 2.2) versus 10.6 days (SD 3.6) in ankle fractures (p = 0.043), 9.8 days (SD 4.1) versus 12.5 days (SD 5.1) in pilon fractures (p = 0.205), and 7.0 days (SD 2.6) versus 8.4 days (SD 1.5) in calcaneal fractures (p = 0.043). A lower length of stay (p = 0.007), a reduction in pain (p_preop = 0.05; p_discharge < 0.001) and need for narcotics (p_preop = 0.064; p_postop = 0.072), an increased reduction in swelling (p < 0.001), and a lower revision rate (p = 0.044) could also be seen, and a trend towards fewer complications (p = 0.216) became apparent.

CONCLUSION

Compared with elevation, VIT results in a significant reduction in the time to achieve operability in complex joint fractures of the lower limb. Cite this article: Bone Joint J 2021;103-B(4):746-754.

Trans-calcaneal retrograde nailing for secondary-displaced traumatic ankle fractures in diabetics with insensate feet: a less-invasive salvage-arthrodesis technique

PURPOSE

Secondary displacement of traumatic ankle fractures with subsequent soft-tissue breakdown is a troublesome issue after inappropriate conservative treatment among non-compliant diabetic patients with severe peripheral neuropathy. This study was conducted to evaluate the results of a less-invasive arthrodesis procedure as an alternative to osteosynthesis in these complex scenarios.

METHODS

A total of 46 diabetics, who underwent fluoroscopy-assisted trans-calcaneal retrograde nailing-based ankle arthrodesis between 2012 and 2018 for salvaging secondary-displaced diabetic ankle fractures in their insensate feet, were evaluated in this retrospective study. All fractures were associated with uninfected mechanical ulcers overlying malleoli, without Charcot changes, after failed conservative cast immobilization. The patients (mean age: 52.52 ± 3.70 years; 18 males; 46 feet) were evaluated radiologically for union and clinically for limb salvage, modified American Orthopedic Ankle and Foot Scale (AOAFS), and the overall subjective patients' satisfaction.

RESULTS

The mean follow-up was 29.5 ± 3.1 months. All ulcers have healed with local care only with 100% limb salvage. Four patients experienced minor wound healing problems at posterior heel, and another one developed acute Charcot changes that was successfully managed by offloading and repeat surgery. Forty patients (86.96%) had fully consolidated fusions with a mean time to fusion 15.78 ± 2.58 weeks, while the other six cases had stable fibrous-union. At the final follow-up, the mean modified-AOFAS was 76.85 ± 6.0 from 86 total points. All, but four patients (91.30%) were completely satisfied while the other four patients were partially satisfied.

CONCLUSIONS

The presented less-invasive arthrodesis technique is reproducible and effective alternative for salvaging unstable diabetic ankle fractures in the insensate feet when standard surgical procedures would be more risky.

LEVEL OF EVIDENCE

IV, retrospective case series.

A fibular notch approach for the treatment of ankle fractures involving the distal tibial plafond

Background

Although efficacy is related to many factors, the surgical approach is one of the most important intervention factors for complex ankle fractures. Ankle fractures involving the distal tibial plafond frequently present a surgical challenge in choosing which incisions will be best for surgical treatment. Here, we present an innovative fibular notch approach for the treatment of some specific ankle fractures and present a series of patients with either functional or radiographic outcomes.

Methods

Twenty-two patients with distal tibial plafond fractures with concomitant fibular and distal tibiofibular syndesmosis injuries were treated through a fibular notch approach in this retrospective study. The details of the surgical technique were reviewed from the operative notes. Relevant data were reviewed from the medical records. The quality of fractures and syndesmosis reduction was examined using CT scans, and lateral stability of the ankle was assessed by physical examination and stress radiographs. The American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS) score was implemented for clinical functional assessment.

Results

All surgeries were successfully performed via the fibular notch approach as the primary approach with excellent intraoperative visualization. Postoperative radiography revealed satisfying restoration of all fractures and syndesmosis. All fractures healed with an average time of 17.3 ± 3.6 weeks. Mild posttraumatic osteoarthritis (PTOA) was present in 4 patients. The average AOFAS score was 88.8 at the last follow-up.

Conclusions

The fibular notch approach is a safe and reliable approach for the treatment of specific ankle fractures involving the distal tibial plafond. This approach provides excellent direct visualization of the fragments and articular surface without significantly increasing iatrogenic injuries. Satisfactory radiographic and clinical results were observed, and further clinical and anatomical studies are recommended to ascertain the feasibility of this approach in the treatment of complex distal tibial fractures.

Effectiveness of ankle arthroscopic debridement in acute, subacute ankle- bimalleolar, and trimalleolar fractures

BACKGROUND

The purpose of this retrospective study was to evaluate the usefulness of ankle arthroscopy at the time of ORIF or after six months in patients with residual symptoms. The hypothesis was that in patients treated arthroscopically at the time of ORIF, there were faster and better clinical results than those treated after or untreated with arthroscopy.

METHODS

In this retrospective study, we compared three homogeneous groups of selected patients with specific inclusion criteria (144 in total, mean age 38.2 years). They have been surgically treated for an ankle fracture (bimalleolar or trimalleolar without frank syndesmotic injuries) with open technique (ORIF) or arthroscopic ORIF (AORIF), between 2013 and 2017. The AO classification system was used for each patient. The clinical assessment was based on the Foot and Ankle Outcome Score (FAOS).

RESULTS

At the final follow-up (mean 38 months), both patients treated with ankle arthroscopic debridement at the time of ORIF and patients treated with arthroscopic debridement after ORIF showed a significant improvement of the FAOS, which reported 84 and 85 respectively at final follow-up.

CONCLUSION

Through minimally invasive visualization of intra-articular structures, ankle arthroscopy can offer an essential option for selected patients both in acute and in sequelae after an ankle fracture. More studies are needed to understand the real effectiveness of the procedure, especially in acute at the same time of osteosynthesis.

Unstable malleolar ankle fractures: evaluation of prognostic factors and sports return

INTRODUCTION

Ankle malleolar fractures are one of the most common surgical fractures. The literature about ankle fracture sport related is reduced. Severe fractures, fractures-dislocations, syndesmosis lesions, associated osteochondral lesions, postoperative complications, as well as age are associated in several studies with worse functional results and may, therefore, also be associated with a lower rate of sports return. This study aims to retrospectively assess the return to physical activity at the level prior to injury in individuals undergoing surgical treatment of unstable malleolar ankle injuries and to identify risk factors associated with a non-return.

MATERIALS AND METHODS

We retrospectively evaluated between January 2008 and December 2017, patients with an unstable malleolar fracture of the ankle surgically treated, recreational or competitive sportsman with a minimum follow-up of one year. Demographic data, fracture classification according to AO classification, presence/absence of osteochondral lesion, presence/absence of unstable syndesmosis lesion, associated dislocation, type of surgery, postoperative complications, functional outcome evaluation with the AOFAS score and sports return.

RESULTS

92 patients met the inclusion criteria. The mean AOFAS score observed was 90.93 (67-100). 69.7% of patients returned without limitations in performing physical activity. 21.75% returned with limitations and 8.7% did not return to physical activity. No association was observed between age, sex, syndesmosis lesion and greater risk of not returning to physical activity. Patients with bimalleolar or trimalleolar fractures, osteochondral injury, or associated dislocation presented an increased risk of inferior functional score and non-return sporting activity.

CONCLUSIONS

Bimalleolar and trimalleolar fractures, associated presence of dislocation and osteochondral lesions are associated with worse clinical outcome and lower return onset.

Improving the efficiency of ankle fracture care through home care and day-surgery units: Delivering safe surgery on a value-based healthcare model

OBJECTIVES

Preoperative home care for suitable patients with ankle fractures is becoming an increasingly common practice. It allows adequate time for reduction of ankle swelling following a decision to undertake operative fixation has been made. We aim to assess the safety, efficiency, cost-effectiveness and differences in clinical & patient outcomes of day surgery unit (DSU) care for ankle fracture treatment in selected patients. Our study combined home therapy treatment with DSU care for suitable ankle fractures.

DESIGN

Prospective cohort study.

SETTING

Trauma Centre.

PATIENTS

Fifty-three patients requiring operative fixation for an ankle fracture were divided into 2 groups. Patients in group 1 entered the home care combined with DSU treatment pathway whilst in group 2 were treated as in patient in the main trauma theatre in our standard pathway.

INTERVENTION

Comparison of Home Care & Day Case Surgery vs. in patient admission for patients requiring operative ankle fractures fixation.

MAIN OUTCOME MEASURES

Prospective data collection was undertaken over a 2-year period, on fracture type, logistical outcomes including time to surgery and total length of stay in the hospital and clinical outcomes including the rate of post-operative complications, incidence of unplanned surgical revisions and objective patient satisfaction. Economic analysis was performed to compare the marginal cost saving per case for group 1 vs. group 2.

RESULTS

There were 21 patients in group 1. They waited for on average 5.8 days at home for their operation and none were admitted pre or post operatively. There were no associated complications and the majority of patients were discharged from follow-up at 6 weeks post-surgery. In-group 2, there were 32 patients. They waited on average 2.4 days for their operation in the hospital and had an average length of stay of 4.9 days. One patient in group 2 suffered from a deep vein thrombosis. The benefit from our chargeable tariff for group 1 patients was £2295 per case while the margin for group 2 patients was £277 per case. The financial benefit to the health care provider was £2018 in favour of home care and DSU treatment, with high service satisfaction and low complication rates.

DISCUSSION

This study provides focused evidence supporting the use of home care for the management of ankle fractures. The DSU pathway improves the value in healthcare delivery with high patient satisfaction scores when compared to the traditional pathway. Our model demonstrates predictably good clinical outcomes with a financial cost benefit over in-patient admission care model for selected patients.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Clinical and radiological mid- to long-term results after direct fixation of posterior malleolar fractures through a posterolateral approach

BACKGROUND

Direct fixation of posterior malleolar fractures has been shown to lead to higher accuracy of fracture reduction compared to an indirect anterior to posterior fixation but lacks long-term clinical results. This study shows the mid- to long-term clinical and radiological outcome after direct fixation of the posterior malleolus through a posterolateral approach.

MATERIALS AND METHODS

Thirty-six patients with an ankle fracture including a posterior malleolar fragment (23 × AO-44C, 12 × AO-44B, 1 × unclassifiable) treated with direct fixation of the fragment through a posterolateral approach were retrospectively evaluated. There were 24 females (67%) with a mean age of 63 (range 34-80) years and a BMI of 28 (range 19-41) kg/m² at the time of surgery. An initial fracture-dislocation was seen in 67%. The clinical outcome was assessed with the Visual Analog Scale (VAS, 0-10 points) and the American Foot and Ankle Society (AOFAS, 0-100 points) score. Posttraumatic osteoarthritis was recorded with the Van Dijk Classification (grade 0-III). Subgroup analyses of patient- and fracture-associated risk factors (age, BMI, smoking, fracture-dislocation, postoperative articular step-off) were assessed to reveal possible negative prognostic predictors.

RESULTS

After a mean follow-up of 7.9 (range 3-12) years, the median VAS was 1 (IQR 0-2) point, and the median AOFAS score was 96 (IQR 88-100) points. Ankle range of motion measurements showed a significant, but clinically irrelevant, difference in plantar- and dorsiflexion between the affected and unaffected ankle. 92% of the patients were very satisfied or satisfied with the postoperative course. 89% had no preoperative signs of ankle osteoarthritis. Osteoarthritis progression was seen in 72%, with 50% showing grade II or III osteoarthritis at the final follow-up. No significant negative prognostic factors for a worse clinical outcome could be detected.

CONCLUSION

Direct fixation of posterior malleolar fractures through a posterolateral approach showed good clinical mid- to long-term results with a high satisfaction rate but substantial development of posttraumatic ankle osteoarthritis. Further studies should include CT analysis of the preoperative fracture morphology and even, perhaps, the postoperative reduction accuracy to evaluate the benefit of posterior malleolar fracture reduction in preventing ankle osteoarthritis in the long term.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for authors for a complete description of levels of evidence.

Reduction of routine use of radiography in patients with ankle fractures leads to lower costs and has no impact on clinical outcome: an economic evaluation

BACKGROUND

To evaluate the cost-effectiveness of a reduction in the number of routine radiographs in the follow-up of patients with ankle fractures.

METHODS

We performed an economic evaluation alongside the multicentre, randomised WARRIOR trial. Participants were randomised to a reduced imaging follow-up protocol (i.e. radiographs at week 6 and 12 follow-up obtained on clinical indication) or usual care (i.e. routine radiography at weeks 6 and 12). The Olerud & Molander Ankle Score (OMAS) was used to assess ankle function and the EQ-5D-3L was used to estimate Quality-Adjusted Life Years (QALYs). Costs and resource use were assessed using self-reported questionnaires and medical records, and analysed from a societal perspective. Multiple imputation was used for missing data, and data were analysed using seemingly unrelated regression analysis and bootstrapping.

RESULTS

In total, 246 patients had data available for analysis (reduced imaging = 118; usual care = 128). Fewer radiographs were obtained in the reduced imaging group (median = 4) compared with the usual-care group (median = 5). Functional outcome was comparable in both groups. The difference in QALYs was - 0.008 (95% CI:-0.06 to 0.04) and the difference in OMAS was 0.73 (95% CI:-5.29 to 6.76). Imaging costs were lower in the reduced imaging group (-€48; 95% CI:- €72 to -€25). All other cost categories did not statistically differ between the groups. The probability of the reduced imaging protocol being cost-effectiveness was 0.45 at a wiliness-to-pay of €20,000 per QALY.

CONCLUSIONS

Reducing the number of routine follow-up radiographs has a low probability of being cost-effective compared with usual care. Functional outcome, health-related quality of life and societal costs were comparable in both groups, whereas imaging costs were marginally lower in the reduced imaging group. Given this, adherence to a reduced imaging follow-up protocol for those with routine ankle fractures can be followed without sacrificing quality of care, and may result in reduced costs.

TRIAL REGISTRATION

The trial was registered on 26-05-2014 in the Netherlands Trial Registry, with reference number NL4477 ( www.trialregister.nl/trial/4477 ).

Reconstruction of tibiofibular syndesmosis using autologous semitendinosus graft and lengthening derotational osteotomy of the distal fibula

Distal tibiofibular syndesmosis is a complex anatomical structure that is essential for the stability and function of the ankle. Ankle fractures are a common source of chronic syndesmosis instability with associated functional impairments and early development of osteoarthritis. Case presentation: we described a case of a 28-year-old patient who presented with symptomatic ankle subluxation and chronic syndesmosis instability. Eight months earlier, the patient sustained a minimally displaced ankle fracture that had been treated conservatively elsewhere. The surgical approach included the anatomical realignment of the distal fibula with a lengthening derotational osteotomy and tibiofibular syndesmosis reconstruction using an autologous semitendinosus tendon graft. One year after surgery, the ankle function was restored, and the patient was asymptomatic. Conclusion: The instability of ankle fractures should be carefully evaluated during the treatment decision-making. Surgical treatment of syndesmosis instability should be performed even in chronic cases to restore function. The reconstruction of syndesmosis with semitendinous tendon graft associated with fibular length and realignment improves the ankle stability and function.

A lean bioabsorbable magnesium-zinc-calcium alloy ZX00 used for operative treatment of medial malleolus fractures: early clinical results of a prospective non-randomized first in man study

Aims

This study is a prospective, non-randomized trial for the treatment of fractures of the medial malleolus using lean, bioabsorbable, rare-earth element (REE)-free, magnesium (Mg)-based biodegradable screws in the adult skeleton.

Methods

A total of 20 patients with isolated, bimalleolar, or trimalleolar ankle fractures were recruited between July 2018 and October 2019. Fracture reduction was achieved through bioabsorbable Mg-based screws composed of pure Mg alloyed with zinc (Zn) and calcium (Ca) ( Mg-Zn0.45-Ca0.45, in wt.%; ZX00). Visual analogue scale (VAS) and the presence of complications (adverse events) during follow-up (12 weeks) were used to evaluate the clinical outcomes. The functional outcomes were analyzed through the range of motion (ROM) of the ankle joint and the American Orthopaedic Foot and Ankle Society (AOFAS) score. Fracture reduction and gas formation were assessed using several plane radiographs.

Results

The follow-up was performed after at least 12 weeks. The mean difference in ROM of the talocrural joint between the treated and the non-treated sites decreased from 39° (SD 12°) after two weeks to 8° (SD 11°) after 12 weeks (p ≤ 0.05). After 12 weeks, the mean AOFAS score was 92.5 points (SD 4.1). Blood analysis revealed that Mg and Ca were within a physiologically normal range. All ankle fractures were reduced and stabilized sufficiently by two Mg screws. A complete consolidation of all fractures was achieved. No loosening or breakage of screws was observed.

Conclusion

This first prospective clinical investigation of fracture reduction and fixation using lean, bioabsorbable, REE-free ZX00 screws showed excellent clinical and functional outcomes.

Cite this article: Bone Joint Res 2020;9(8):477–483.

Incidence of deep venous thrombosis (DVT) of the lower extremity in patients undergoing surgeries for ankle fractures

Objective

To investigate the incidence of postoperative deep venous thrombosis (DVP) in patients undergoing surgeries for ankle fractures and identify the associated risk factors.

Methods

This was a retrospective study. A total of 1451 patients undergoing surgery of ankle fractures from January 2016 to June 2019 were included. The inpatient medical record system was inquired for data collection, including demographics, comorbidities, injury, and surgery-related data, and laboratory biomarkers. DVT of the lower extremity was diagnosed by routine Doppler examination. Univariate analyses and multivariate logistic regression analyses were used to identify the independent risk factors.

Results

Among the 1451 patients, DVT was confirmed in 38 cases, indicating an incidence of 2.6%. DVT involved both the operated and non-operated limbs in 8 patients (21.1%). DVT involved superficial femoral vein in 4 cases (6.6%), deep femoral vein in 2 (3.3%), popliteal vein in 5 (8.2%), posterior tibial vein in 11 (18.0%), and peroneal vein in 39 (63.9%). The median interval between operation and diagnosis of DVT was 7 days. Six risk factors were identified to be independently associated with DVT, including age (10-year increase) (OR, 1.44), preoperative stay (delay of each day) (OR, 1.11), anesthesia (general vs regional) (OR, 3.51), lower hemoglobin level (OR, 2.02), total cholesterol > 5.2 mmol/L (OR, 3.20), and reduced lymphocyte count (OR, 3.16).

Conclusion

These identified factors, although not easily modifiable, do help counsel patients about the risk of DVT and help individualized assessment of the risk factors and accordingly the risk stratification.