Health related quality of life in patients with supination-external rotation stage IV ankle fractures

BACKGROUND

While open reduction of displaced ankle fractures generally is accepted as the standard of care, relatively little is known about the health related quality of life after treatment. It is generally accepted that clinical results of treatment for supination-external rotation stage IV ankle fractures are favorable. The goal of this investigation was to determine the relationship between clinical results and health-related quality of life outcome measures in a consecutive series of patients treated for closed supination-external rotation stage IV ankle fractures.

METHODS

Twenty-six of 156 patients who had operative treatment for closed, displaced supination-external rotation stage IV ankle fractures during a 9-year period, completed the Short Musculoskeletal Function Assessment (SMFA) outcome questionnaire. Radiographs and clinical records were reviewed to determine quality of operative repair, postoperative morbidity, and the development of post-traumatic arthritis.

RESULTS

There were no postoperative complications. Of the 26 patients who returned the SMFA questionnaires, 19 had "good," and seven had "fair" reduction of their fractures. Six showed radiographic evidence of arthritis at followup. Study participants reported scores that were similar to the general population in five of the six domains of the SMFA. Their scores in the mobility index were statistically less favorable (23.72 vs. 13.61, p = 0.016) when compared to the general population. Participants with "good" operative reductions and no evidence of arthritis at followup showed no significant difference to the general population. Participants with either a "fair" operative reduction or evidence of postoperative arthritis at followup had less favorable scores in the daily activities (mean 13.45 vs. 11.82, p = 0.004), mobility (43.43 vs. 13.61, p = 0.001), dysfunction (32.89 vs. 12.70, p = 0.014), and bother (35.80 vs. 13.77, p = 0.020) domains, when compared to the general population.

CONCLUSIONS

The results of this investigation suggest that patients with excellent radiographic operative reductions and no arthritis as early as 6 months after surgery sustain no lasting unfavorable effect on health related quality of life. Patients with "fair" radiographic reduction, or presence of arthritis or both at followup, are likely to have a negative effect on their quality of life.

Chronic pain after ankle fracture: an arthroscopic assessment case series

BACKGROUND

The purpose of this study was to document findings of ankle arthroscopy in patients with residual complaints after an appropriately treated ankle fracture.

METHODS

Patients who had ankle arthroscopy at the Alpine Orthosports Clinic between 1998 and 2000 were identified by a retrospective review of the ankle arthroscopy database. Fifty patients were identified who had arthroscopy for complaints after ankle fracture. The mean duration from injury to arthroscopy was 20.5 +/- 33.5 months, with a range of 2 to 184.6 months.

RESULTS

There were 37 isolated fractures and 13 combination fractures. The Danis-Weber classification was used for lateral malleolar fractures. There were five type A, 14 type B, and 11 type C lateral malleolar fractures.

RESULTS

Synovitis was present in 46 ankles and was located anterolaterally in 36. Synovitis was noted in 26 of the 30 ankles that had a lateral malleolar fracture. Arthrofibrosis was found in 20 ankles, with anterolateral joint involvement in 16. There was chondral damage noted in 45 ankles, 30 located on the talus and 15 on the tibia. Spurs were found in 15 ankles, and nine had loose bodies or debris. There were two postoperative complications: one patient had bleeding from a portal and the other had an area of paresthesia at the anterolateral portal site.

CONCLUSION

Synovitis and chondral damage were more frequent than arthrofibrosis and spurs. Synovitis and arthrofibrosis were found most frequently in the anterolateral aspect of the joint. Also, the higher the lateral malleolar fracture was in relation to the syndesmosis, the higher was the occurrence of talar chondral damage.

Outcome of physeal and epiphyseal injuries of the distal tibia with intra-articular involvement

The authors reviewed 83 physeal and epiphyseal injuries of the distal tibia with intra-articular involvement. The children, aged 11 to 14 years, were treated in the authors' department during 1987 to 1999. Treatment was nonoperative for 72.25% (60/83) and surgical for 27.75% (23/83) according to specific indications. This gives the basis for a classification of these injuries. The main purpose of the study was to investigate the long-term results of these injuries according to a radiologic classification. The parameters considered were the patient's age, the mechanism of injury, and the possibility of growth deformities or functional disorders. They were studied relative to the long-term results, with a follow-up of 2 to 13 years. Regardless of treatment, varus deformity, ranging from 10 to 15 degrees in relation to the normal opposite leg, occurred in four cases. In only one case was there painful limitation of ankle joint movement; in two other children an overgrowth of the medial malleolus was detected, with no functional impairment.

Interobserver reliability of a CT-based fracture classification system

OBJECTIVES

This study was designed to determine whether the interobserver reliability of a fracture classification scheme applied based on a single, carefully defined, computed tomography (CT) cut is greater than those previously reported for systems designed for use with plain radiographs.

DESIGN

Observer review of selected cases.

SETTING

Four, level one, trauma centers.

PATIENTS

Pretreatment CT scans of patients with calcaneus fractures were screened by the authors. Thirty cases were selected that had an appropriate semicoronal CT image. Ten orthopaedic traumatologists who were members of the Orthopaedic Trauma Association and had a minimum of 5 years postresidency experience were selected as reviewers.

INTERVENTION

The reviewers were provided with a digital CT image for each case as well as written and diagrammatic representations of the Sanders classification system. The observers then classified each fracture according to the Sanders classification.

RESULTS

: The mean kappa value for interobserver reliability for fracture types I-IV was 0.41 +/- 0.02 (mean +/- standard error of the mean; range, 0.07-0.64). Observers disagreed by more than 1 fracture type (ie, I vs. III or II vs. IV) in 10% of the cases. Observers agreed on the location of the fracture lines (A, B, C) in 90% of type II fractures and 52% of type III fractures.

CONCLUSIONS

The results indicate that in a carefully controlled paradigm, the interobserver reliability with a classification system based on interpretation of a single, carefully defined CT image was no better than the results reported for the same classification system used with full CT data or for other classification systems used for various fractures in the skeleton. Agreement in identifying the location of the fracture lines was very good for simple fractures but much worse for complex injuries. Additional study may determine whether the use of a full complement of CT images can improve reliability in classification of complex injuries.

Five years of ankle fractures grouped by stability

Categories of displaced and undisplaced stable ankle fracture are well recognised. We report on a further group of ankle fractures which are undisplaced at presentation, but do not fulfil criteria for stable injuries, and therefore, may be at risk of displacement. The Blackburn Foot and Ankle Service operates evidence-based guidelines for ankle fractures, introduced in 1998. These were prospectively applied to 306 skeletally mature patients (308 fractures) following classification of the ankle fracture based upon clinical examination and radiography (mortise and lateral views). One hundred and forty-eight (48.4%) of fractures were stable, including 63 male and 85 women, median age 53 years (14-92). Eighty-eight (28.8%) of fractures were undisplaced but potentially unstable based on criteria, including 53 men and 35 women, median age 42 years (14-93). Seventy (22.9%) of fractures were displaced, including 41 men and 29 women, median age 44 years (16-94). Undisplaced, unstable fractures were treated mostly in below-knee casts with immediate weight-bearing and follow-up radiography. Two fractures in this group subsequently displaced requiring fixation according to AO principles. The risk of displacement in potentially unstable fractures is 2.3%. The unstable fracture groups, whether displaced or not, were similar in age/sex profile.

Operative treatment of displaced lateral malleolar fractures: the Knowles pin technique

OBJECTIVES

To assess the use of Knowles pin fixation for isolated displaced lateral malleolar fractures and to present our surgical experience using this method.

DESIGN

Retrospective evaluation.

SETTING

The study was carried out at a municipal teaching hospital. The senior surgeons were all orthopedic trauma subspecialists.

PATIENTS

A total of 168 patients meeting our inclusion criteria, an isolated displaced lateral malleolar fracture surgically treated by a Knowles pin between 1995 and 2000, were studied. All the patients had a stable syndesmosis, less than 50% comminution, and had no other operations in the same extremity. Patients were assigned into 4 groups according to the Orthopedic Trauma Association classification of ankle fractures.

INTERVENTION

Open reduction and internal fixation with a Knowles pin fixation of the lateral malleolus.

MAIN OUTCOME MEASUREMENTS

Functional results were evaluated using the Baird and Jackson ankle scoring system.

RESULTS

There was a 100% union rate. The average satisfactory outcome of the 4 groups was 88.1%. No instrumentation problems were encountered. Three complications occurred, but resolved with nonoperative therapy.

CONCLUSIONS

Knowles pin fixation for displaced lateral malleolar fractures is a useful and effective method. This implant offers several advantages, including easy application, less soft tissue dissection, less palpable instrumentation, stable fixation, and a short operating time.

[Treatment strategy for talus fractures]

Fractures of the talus are uncommon, but they present difficult treatment challenges. The classifications of fractures are based on conventional X-rays, but the CT scan is necessary for treatment decisions. Open fractures, displaced fracture dislocations, or extrusion of the talus must be reduced and stabilized as an emergency procedure. In all cases of displaced fractures, ORIF is indicated. The use of standardized approaches depends on the type of fracture and the soft tissue lesion. Precise anatomic reduction of all facets and reconstruction of the shape of the talus and stabilization with interfragmentary lag screws is the method of choice in almost all fractures. This procedure allows early mobilization postoperatively. The outcome is related to the degree of fracture displacement and the soft tissue lesion but may be poor due to inadequate treatment. Talus malunion, nonunion, and secondary deformity should be corrected early with preservation of the joints whenever possible. Arthrodeses should be restricted to the affected joints.

The incisural fracture

A case report is presented on two adolescent patients with fracture of the distal tibial articular surface that is different than the Tillaux, Wagstaffe-Le Fort, and Chaput fractures.

The nomenclature for intra-articular vertical impact fractures of the tibial plafond: pilon versus pylon

Although most of the controversy surrounding the treatment of intra-articular, vertical impact fractures of the lower tibia is due to the difficult clinical problems they pose, there is a minor, ongoing dispute regarding nomenclature. In the last several decades, these fractures have been called either pilon or pylon fractures. This study traces the etymology of both terms and relates them to their usage in the orthopaedic literature. Based on the origins of each word, and how they were introduced into the orthopaedic literature, it is concluded that the correct term for an intra-articular, vertical impact fracture of the lower tibia is pilon fracture.

Pilon-tibiale-Frakturen

In the AO classification, the distal tibia is 43 and A type injuries are extra-articular, B type partial articular and C type involve the whole of the articular surface with complete separation of the joint from the diaphysis. The term pilon fracture should be confined to B(3) and C type fractures. The injury mechanism of pilon fractures will vary from a simple fall to a high energy road traffic accident, leading to increasing fracture comminution and greater soft tissue injury with more open fractures. Plain radiographs and CT-scans are diagnostic prerequisites. A spanning external fixator, with or without fixing the fibula, is the initial method of choice. The goal is to span the zone of injury with the fixator, to align the limb, to reduce the articular surface through very limited approaches, and to minimize complications related to treatment to maintain length and provisionally align the fracture. When soft tissue swelling has subsided definitive stabilization is performed. Bone grafting of defects is rarely necessary.

Retrospective analysis of malleolar fractures in an impact environment

To protect against malleolar fractures in frontal crashes it is important to understand the mechanisms of injury. We have investigated the accuracy of Orthopaedic Specialists in deducing the injury mechanisms of experimentally generated malleolar fractures from radiographs; and the applicability of classic descriptors of injury mechanisms, such as the Lauge-Hansen classification system, in analysing impact induced trauma. Orthopaedic Specialists did not consistently deduce the mechanism of ankle injuries suggesting there may not be a unique fracture pattern for every injury mechanism and that the Lauge-Hansen classification system does not reliably describe ankle fractures created in the impact environment.

[Kirschner wire transfixation of syndesmosis rupture--an alternative treatment of type B and C malleolar fractures]

After completing ORIF of the lateral malleolus, the standard technique for fixation of the syndesmosis involves placement of a 3.5 mm locking screw across the fibula to the tibia. Alternative there is a possibility to make the transfixation with two 1.6 mm Kirschner wires introduced obliquely across the distal tibiofibular syndesmosis. No early removing of the implant is necessary. This retrospective study was conducted on a total of 50 cases of Weber type B or C malleolar fractures with syndesmotic rupture between 1988 and 1996. In 45 patients (90%) there is no complication seen for the transfixation, but in five patients a Kirschner wire dislocation was observed. We were able to review 36 of these patients after a median follow-up of 8.3 years (range 5-12 years). The results were evaluated using objective, subjective and roentgenographic criteria. Subjective rating had 29 patients (81%) with very good or good results. Good radiological results were found in 29 patients (81%). Concluding of this results the Kirschner wires transfixation is a technical simple method with good or very good results.

Mechanisms of foot and ankle injuries in soccer

BACKGROUND

Although player-to-player contact is a risk factor in the majority of soccer injuries, the mechanisms leading to these injuries have not been analyzed.

PURPOSE

To assess the relationships between foot/ankle injuries and foul play and tackle type, and to identify the position of the foot and ankle at the time of injury.

STUDY DESIGN

Prospective cohort study.

METHODS

Team physicians prospectively recorded each injury in four world soccer competitions, and the videotaped incident leading to the injury was retrospectively analyzed.

RESULTS

Of 76 foot and ankle injuries (52 contusions, 20 sprains, 4 fractures), direct contact occurred between players in 72. Significantly more injuries involved a tackle from the side and a lateral or medial tackle force. The injured limb was weightbearing in 41 and nonweightbearing in 35 of the incidents. Significantly more injuries resulted in time lost from soccer when the limb was weightbearing. The most common foot and ankle positions at the time of injury were pronated/neutral in the sagittal plane for weightbearing limbs, and plantar flexed/neutral in the coronal plane for nonweightbearing limbs. The most common foot and ankle rotations at the time of injury were external (23) and eversion (28).

CONCLUSIONS

The majority of injuries were caused by tackles involving lateral or medial forces that created a corresponding eversion or inversion rotation of the foot or ankle. The weightbearing status of the injured limb was a significant risk factor.

[Simultaneous reimplantation of both lower legs--5-year follow-up (case report)]

We are reporting the case of a 29 year old male in whom we performed successful reimplantaton of both lower legs following trauma inflicted by a railroad boxcar. Five years after this accident, the patient's walk is almost normal and both deep sensitivity and two point discrimination on the soles of his feet are sufficient. The patient can walk, run and stand very well on one leg, both on even and on uneven ground.He returned to his job with the railroad 8 months after his accident. Originally the patient was employed as a railroad workman, and is now an office employee. His private life is normal and he enjoys hiking and dancing. In our opinion, sufficient function of the tibial nerve in the reconstructed extremity is important for clinically satisfactory long-term results. Both the Mangled Extremity Severity Score (MESS) and the NISSSA are helpful in making the decision on whether to primarily amputate or reconstruct Gustillo IIIC cases. Good long-term results as well as general cost reduction are achievable following reconstruction of extremities. Amputation of an extremity can be predicted with 100% certainty when MESS is 9 or more. Primary shortening and secondary lengthening of an extremity is a good method of treating Gustillo III C fractures.

Treatment of complete rupture of the lateral ligaments of the ankle: a randomized clinical trial comparing cast immobilization with functional treatment

This study compared the therapeutic efficacy between cast immobilization and functional treatment of grade III ruptures of the lateral ankle ligaments. Subjects ( n=121) had closed physeal cartilage, age under 35 years, grade III rupture without previous or associated injuries, and practiced regular sports. Patients were randomized into an immobilization group (21 days plaster cast) or a functional one (15 days strapping plus early controlled mobilization). Symptoms (pain, swelling, stiffness, subjective instability), joint laxity, return to preinjury activity (time and level) and rate of reinjury were assessed 3, 6, and 12 months after sprain. Objective joint laxity was related to constitutional laxity, creating a new variable [talar tilt at injury - talar tilt at control]/contralateral talar tilt. The functional group showed significantly earlier and better return to physical activity, fewer symptoms at 3 and 6 months but no intergroup difference at 12 months. Functional treatment also showed better decrease in joint laxity. No intergroup differences were found in the reinjury rate. We conclude that functional treatment is safe, associated with a more rapid recovery, and particularly suitable in athletic populations.

Adolescent osteochondral lesion of the talus. Ankle arthroscopy in pediatric patients

Osteochondral lesions of the talus can be difficult to diagnose and can result in a significant functional limitation in young, active patients. New imaging modalities have improved the diagnosis and staging of these lesions. In general, nonoperative treatment results in poorer outcomes compared with operative treatment, and arthroscopic treatment has results similar to open treatment. Although the literature is limited, the treatment of adolescents results in outcomes similar to the adult population.

Fractures of the ankle

This article is aimed at accident and emergency and orthopaedic senior house officers. While this review is not exhaustive, it attempts to emphasize some key points as an aid to the safe initial management of ankle fractures as they are such common injuries, whose management can be more clearly understood by the application of basic principles.

Determining foot and ankle impairments by the AMA fifth edition guides

The fifth edition of the Guides has been criticized for its failure to provide a comprehensive, valid, reliable, unbiased, and evidenced-based system for rating impairments and the way in which workers' compensation systems use the ratings, resulting in inappropriate compensation [8]. The lower extremity chapter utilizes numerous functional and anatomic methods of assessment, as well as diagnosis-based estimates. Though this process of using multiple approaches to measure impairment increases the chances that an underlying physical impairment may be detected, it is time-consuming and may increase rating variability [9]. McCarthy et al studied the correlation between measures of impairment for patients with fractures of the lower extremity. They found that the anatomic approach of evaluation was better correlated than functional and diagnostic methods with measures of task performance based on direct observations as well as the patient's own assessment of activity limitation and disability. Also, muscle strength assessment as described in the Guides was a more sensitive measure of impairment than range of motion [9]. The most elusive part of the foot and ankle evaluation is the inability to capture the added impairment burden caused by pain. The assessment of pain is the most problematic part of any evaluation. Pain is considered and incorporated into the impairment ratings found in the foot and ankle section, as well as the other individual chapters. Chronic pain is often not adequately accounted for, however, and the examiner must evaluate permanent impairment from chronic pain separately. The examiner has the ability to increase the percentage of organ system impairment from 1% to 3% if there is pain-related impairment that increases the burden of illness slightly. If there is significant pain-related impairment, a formal pain assessment is performed. Chapter 18 provides guidance in making these determinations. Impairments for Complex Regional Pain syndrome (CRPS), type 1 (reflex sympathetic dystrophy), and CRPS, type 2 (causalgia) should incorporate the use of a formal pain assessment in addition to the standard methods of assessment. The formal pain evaluation relies mostly on self-reports from the individual and is most heavily weighted for ADL deficits. The physician must make assessments of the individual's pain behavior and credibility for this evaluation. The formal pain assessment classifies the pain-related impairment into categories of mild, moderate, moderately severe, or severe and determines whether this impairment is ratable or not. These categories do not have impairment percentages associated with them. The individual's symptoms or presentation should match known conditions or syndromes in order to be ratable. If not ratable, the examiner should report that the individual has apparent impairment that is not ratable on the basis of current medical knowledge. In the end, pain evaluations are used administratively and, depending on the situation, may be given equal weight with the standard evaluation or may be totally disregarded.

Nerve injuries to the foot and ankle in the industrial setting

Nerve injuries of the foot and ankle are among the most difficult to diagnose and treat. With the added influences of potential secondary gain and poor motivation of the work injured patient, these injuries can be taxing and frustrating to manage in the acute or chronic setting. This article reviews the neuroanatomy, mechanisms of injury, diagnosis and management of these injuries with specific reference to the patient injured in the industrial setting.