Posterior Tibiotalar Impingement After Pediatric Ankle Fracture Surgical Fixation: A Case Report

CASE

A 13-year-old healthy, nearly skeletally mature, female patient presented to an outpatient clinic after sustaining a bimalleolar ankle fracture-dislocation, which was subsequently treated with open reduction and internal fixation and casting. Postoperatively, the patient had significant limitations to ankle range of motion. Imaging revealed posterior tibiotalar impingement. The patient underwent arthroscopic debridement and osteoplasty, and she was able to return to previous levels of activity.

CONCLUSIONS

Complications from pediatric ankle fractures are rare, so further diagnostic workup is warranted for patients with persistent pain and limitations.

The treatment of a malunited posterior pilon fracture with talar dislocation: A staged surgical treatment protocol

BACKGROUND

Malunited posterior pilon fractures with talus dislocation (mPPFtd) are rare and there are no appropriate treatment strategies. The purpose of this study was to introduce a stepped strategy featuring preliminary soft tissue management according to the Ilizarov principle and delayed open reduction and internal fixation (ORIF) through a modified posteromedial approach to overcome rigid soft tissue contracture.

METHOD

From February 2015 to August 2021, 12 selected patients with mPPFtd who were treated with the staged protocol (Group A) were retrospectively analysed. The clinical and radiographic outcomes were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, the visual analogue scale (VAS) score, and the Burwell-Charnley score. Moreover, this case series was compared with some cases of fresh fracture (Group B) in patients that had the same baseline data from our previous study.

RESULTS

In Group A, the average length of time between the date of injury and the date of surgery was 4.8 ± 3.3 months. The average time to external fixator distraction, as the first-stage treatment, was 13.4 ± 1.0 days. In the second stage of ORIF, the posterosuperior dislocation of the talus was corrected with osteotomy and leverage manoeuvres. According to the Burwell-Charnley score system, the reduction quality was excellent in 9 cases and good in 3 cases. After a mean follow-up of 3.8 ± 2.1 years, there were no infections, wound healing problems, or nerve injuries in our cohort, and union was observed in all fractures without a loss of reduction. The baseline data of the two groups were not significantly different (p>0.05). The mean AOFAS score in Group A was 85.0 ± 10.5 and that in Group B was 95.4 ± 6.1 (p<0.05). The mean VAS score in Group A was 1.7 ± 1.4 and that in Group B was 0.7 ± 0.9 (p<0.05).

CONCLUSION

A staged surgical treatment strategy characterized by soft tissue management will improve the treatment of mPPFtd and produce satisfactory clinical outcomes.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Reducing Complications in Pilon Fracture Surgery: Surgical Time Matters

OBJECTIVE

To correlate patient-specific and surgeon-specific factors with outcomes after operative management of distal intra-articular tibia fractures.

DESIGN

Retrospective cohort study.

SETTING

3 Level 1 tertiary academic trauma centers.

PATIENTS/PARTICIPANTS

The study included a consecutive series of 175 patients with OTA/AO 43-C pilon fractures.

MAIN OUTCOME MEASUREMENTS

Primary outcomes included superficial and deep infection. Secondary outcomes included nonunion, loss of articular reduction, and implant removal.

RESULTS

The following patient-specific factors correlated with poor surgical outcomes: increased age with superficial infection rate ( P < 0.05), smoking with rate of nonunion ( P < 0.05), and Charlson Comorbidity Index with loss of articular reduction ( P < 0.05). Each additional 10 minutes of operative time over 120 minutes was associated with increased odds of requiring I&D and any treatment for infection. The same linear effect was seen with the addition of each fibular plate. The number of approaches, type of approach, use of bone graft, and staging were not associated with infection outcomes. Each additional 10 minutes of operative time over 120 minutes was associated with an increased rate of implant removal, as did fibular plating.

CONCLUSIONS

While many of the patient-specific factors that negatively affect surgical outcomes for pilon fractures may not be modifiable, surgeon-specific factors need to be carefully examined because these may be addressed. Pilon fracture fixation has evolved to increasingly use fragment-specific approaches applied with a staged approach. Although the number and type of approaches did not affect outcomes, longer operative time was associated with increased odds of infection, while additional fibular plate fixation was associated with higher odds of both infection and implant removal. Potential benefits of additional fixation should be weighed against operative time and associated risk of complications.

LEVEL OF EVIDENCE

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

Technical note: Intraoperative ultrasound measurement for evaluating the stability of the inferior tibiofibular joint in patients with ankle fractures

OBJECTIVES

Injury to the tibiofibular syndesmosis is a common complication of ankle fractures. Currently, it is challenging to determine the stability of the tibiofibular joint caused by ankle fractures during surgery. This study aims to establish a standardized method for dynamically evaluating the stability of the inferior tibiofibular joint under intraoperative ultrasound and assess its utility in surgery, thereby assisting in determining the necessity for fixation of the inferior tibiofibular joint after fracture reduction and fixation.

METHODS

The stability of the inferior tibiofibular joint was assessed using an intraoperative ultrasonic external rotation stress test, with a torque set at 7.2 N·m. The measured parameters included the width of the inferior tibiofibular space in neutral (N) and external rotation (E) positions, stretch ratio (E/N), and injured/healthy side stretch ratio (I/H). Patients with Weber B or C type ankle fractures were selected as participants.

RESULTS

For the case with Weber C fracture, the N measurement was 4.22 mm after fracture fixation, while E measured 5.77 mm and E/N ratio was 1.37, which were larger than those on the healthy side (N: 4.17, E: 4.50, E/N:1.08), with an I/H ratio of 1.27. Intraoperative X-ray revealed instability of the inferior tibiofibular joint. After inserting a tibiofibular screw, the N measurement was 4.20 mm, while the E measurement recorded 4.32 mm, resulting in an E/N ratio of 1.03 and an I/H ratio of 0.95, indicating improved joint stability. For the Weber B fracture case, the N measurement was 3.55 mm after fracture fixation, while E measured 3.98 mm and the E/N ratio was 1.12, slightly lower than those on the healthy side (N: 3.94, E: 4.47, E/N: 1.13), with an I/H ratio of 0.99. The intraoperative X-ray revealed stability of the inferior tibiofibular joint. Therefore, no further fixation was performed on it.

CONCLUSION

Standardized intraoperative ultrasound stress test allows for real-time, dynamic assessment of the stability of the inferior tibiofibular joint after ankle fracture reduction and fixation, which can help guide the fixation of the inferior tibiofibular joint, thereby reducing the risk of postoperative traumatic arthritis.

Two-staged management of ankle fracture-dislocations with a posterior fragment: computer-tomography-based classification, treatment and its outcome

INTRODUCTION

Trimalleolar fractures are difficult to treat and malreduction can lead to functional impairment. Involvement of the posterior malleolus has a poor predictive value. Current computed-tomography (CT)-based fracture classifications led to an increase in fixation of the posterior malleolus. The aim of this study was to describe the functional outcome after a two-stage stabilisation with direct fixation of the posterior fragment in trimalleolar dislocation fractures.

MATERIALS AND METHODS

In a retrospective study, all patients presenting with a trimalleolar dislocation fracture, an available CT scan, and a two-stage operative stabilisation including the posterior malleolus by a posterior approach were included. All fractures were treated with initial external fixator and delayed definitive stabilisation including fixation of the posterior malleolus. Next to clinical and radiological follow-up, outcome measures (Foot and Ankle Outcome Score (FAOS), Numeric Rating Scale (NRS), Activity of Daily Living (ADL), Hulsmans implant removal score) and complications were analysed.

RESULTS

Between 2008 and 2019, of 320 trimalleolar dislocation fractures, 39 patients were included. Mean follow-up was 49 months (standard deviation (SD) 29.7, range 16-148). Mean age was 60 years (SD 15.3, 17-84) with 69% female patients. The mean FAOS was 93/100 (SD 9.7, 57-100), NRS 2 (interquartile range (IQR) 0-3) and ADL 2 (IQR 1-2). Four patients showed a postoperative infection, three re-operations had to be performed and implants were removed in 24 individuals.

CONCLUSION

A two-stage procedure of trimalleolar dislocation fractures with in-direct reduction and fixation of the posterior tibial fragment through a posterior approach leads to good functional outcome scores with a low rate of complications.

Morphological analysis and classification of posterior malleolar fractures based on CT scans

OBJECTIVES

The aim of the study was to propose a classification system of posterior malleolar fractures by fracture lines with the use of CT scans, including 3D CT reconstruction, which can better understand morphological characteristics, analyze the mechanism and guide the surgeon to choose the optimal approach and fixation.

METHODS

Patients with OTA/AO type 44 fractures involving the posterior malleolus and preoperative CT scans were included. We retrospectively analyzed 128 consecutive patients with posterior malleolar fractures from January 2013 to December 2019 at our institution. CT data were loaded into Mimics software (V20.0, Materialize), in which 3D CT reconstruction, morphological analysis and data measurements were made.

RESULTS

Based on the number of fracture lines in 128 consecutive patients, posterior malleolar fractures were classified into three types: type 1 with a single fracture line, type 2 with double fracture lines and type 3 with multiple fracture lines. According to the distribution of the fracture line, type 1 was divided into types 1A, 1B and 1C, and type 2 was divided into types 2A, 2B and 2C. The fracture line from the fibular notch to the posterior rim of the distal tibia was defined as type 1A, and the fracture line to the medial malleolus was defined as type 1B. Type 1C was a small fragment in the posterior rim of the distal tibia. Type 2A was regarded as type 1A with type 1C. It was considered type 2B because another fracture line started from the fracture line of type 1A and extended to the medial malleolus. In type 2C, we could see that the double fracture lines were all from the fibular notch to the posterior rim of the distal tibia and did not cross. Type 3 fractures were comminuted fractures with multiple fracture lines.

CONCLUSION

The morphology of posterior malleolar fractures, involvement of the fibular notch, or the medial malleolus can be obviously assessed by our classification system. We found the relation of the injury mechanism between type 1 and type 2 by comparing the area of the fragment. We have indicated that each type of fracture corresponds to its associated injury mechanism and which surgical approach and fixation can be chosen.

Risk factors for fracture-related infection after ankle fracture surgery

INTRODUCTION

Ankle fracture surgery comes with a risk of fracture-related infection (FRI). Identifying risk factors are important in preoperative planning, in management of patients, and for information to the individual patient about their risk of complications. In addition, modifiable factors can be addressed prior to surgery. The aim of the current paper was to identify risk factors for FRI in patients operated for ankle fractures.

METHODS

A cohort of 1004 patients surgically treated for ankle fractures at Haukeland University Hospital in the period of 2015-2019 was studied retrospectively. Patient charts and radiographs were assessed for the diagnosis of FRI. Binary logistic regression was used in analyses of risk factors. Regression coefficients were used to calculate the probability for FRI based on the patients' age and presence of one or more risk factors.

RESULTS

FRI was confirmed in 87 (9%) of 1004 patients. Higher age at operation (p < .001), congestive heart failure (CHF), p = 0.006), peripheral artery disease (PAD, p = 0.001), and current smoking (p = .006) were identified as risk factors for FRI. PAD and CHF were the risk factors displaying the strongest association with FRI with an adjusted odds ratio of 4.2 (95% CI 1.8-10.1) and 4.7 (95% CI 1.6-14.1) respectively.

CONCLUSION

The prevalence of FRI was 9% after surgical treatment of ankle fractures. The combination of risk factors found in this study demonstrate the need for a thorough, multidisciplinary, and careful approach when faced with an elderly or frail patient with an ankle fracture. The results of this study help the treating surgeons to inform their patients of the risk of FRI prior to ankle fracture surgery.

LEVEL OF EVIDENCE

Level III retrospective case-control study.

Pediatric Maisonneuve and Tillaux Fractures with Lateral Ankle Dislocation: A Pediatric "Logsplitter" Injury: A Case Report

CASE

A 12-year-old adolescent boy presented with a proximal fibula fracture and lateral ankle dislocation consistent with a Maisonneuve fracture (MF) associated with a transsyndesmotic ankle dislocation. The dislocation was reduced under conscious sedation in the emergency department. Postreduction imaging studies demonstrated a Tillaux fracture. The patient underwent surgical stabilization of the Tillaux fragment and of the distal tibiofibular syndesmosis. At the 26-month follow-up, the patient remained active without restrictions.

CONCLUSION

Operative treatment of a concurrent MF, Tillaux fracture with lateral ankle dislocation, or a pediatric "logsplitter" injury resulted in satisfactory alignment and function of the ankle joint.

A More Conservative Approach in the Surgical Management of Pediatric Physeal Ankle Fractures Should be Preferred: Mid to Long-term Functional Outcomes of Three Different Surgical Techniques for Salter-Harris Type II and Triplane Distal Tibial Fractures

BACKGROUND

Pediatric physeal ankle fractures carry a high risk of complications. This study aimed to (1) investigate the effect of anatomic reduction of the physis on mid to long-term functional outcomes in Salter-Harris type II and triplane distal tibial physeal fractures (DTPFs) and (2) compare the outcomes of 3 different surgical techniques applied in these fractures.

METHODS

The database of a single level-I trauma center was retrospectively reviewed for DTPFs between 2012 and 2022. A total of 39 eligible patients with operative Salter-Harris type II and triplane fractures between 2012 and 2022 were included. Surgical treatment methods were closed reduction-percutaneous fixation (CR-PF), open reduction-screw fixation, or open reduction-plate fixation. Patients were further divided into subgroups for fractures reduced anatomically (<1 mm) or nonanatomically (1 to 3 mm). The primary outcome measures were the American Orthopaedic Foot and Ankle Society Score, ankle range of motion, presence of premature physeal closure and angular deformities, and Takakura ankle osteoarthritis grade.

RESULTS

A total of 39 patients were included, with an average age of 12.9 ± 2.2 years. The mean follow-up time was 68.9±38.0 months. The CR-PF group had higher postoperative fracture displacement ( P = 0.011). American Orthopaedic Foot and Ankle Society scores were excellent in all groups, statistically similar between surgical techniques, and similar between anatomic and nonanatomic reduction groups. The CR-PF group ( P =0.030) and nonanatomic reduction ( P = 0.030) provided a significantly lower ankle osteoarthritis rate. All 4 patients with premature physeal closure were observed in patients treated with open techniques.

CONCLUSIONS

CR-PF for the treatment of DTPFs should be preferred in suitable cases as it is less invasive and provides satisfactory mid to long-term functional outcomes without increasing complications compared with anatomic reduction and open techniques.

LEVEL OF EVIDENCE

Level III.

Weight-Bearing CT with Maximum Ankle Dorsiflexion to Identify Impingement and Tibial Plafond Stress Fracture: A Case Report

CASE

A 25-year-old male pole vaulter presented with several months of right ankle pain. Radiographs showed an anterior tibial osteophyte with a small intra-articular body suggesting impingement. Weight-bearing computed tomography (CT) revealed an associated tibial plafond stress fracture. Subsequent arthroscopy with osteophyte resection and loose body removal significantly improved symptoms, and he gradually resumed training.

CONCLUSION

Stress fractures should always be considered in athletes with ankle pain. A unique aspect of this case was the use of weight-bearing CT in diagnosis and surgical planning. To our knowledge, this is the first described case in which weight-bearing CT was used in this fashion.

The safe zone of distal fibula was determined based on the classification of lateral malleolus fossa

BACKGROUND

Lateral malleolus fractures are very common, and the distal fibular geometry is complex. This study aimed to classify the lateral malleolus fossa (MF) into different types by characterizing the lateral MF imaging morphology and exploring the relationship between the lateral MF and internal fixation position after distal fibula fractures.

METHODS

Anteroposterior CT reconstruction was performed on 248 subjects. After reconstruction, the deepest point of the lateral MF was located, and then, the cross-sectional shape of the lateral MF was observed and classified.

RESULTS

According to the morphology of the CT cross section, the lateral MF was divided into three types: type C (43.1%), type V (32.2%), and type Flat (24.7%). Type V (3.98 ± 0.82) was significantly longer than type C(2.83 ± 0.54) and type Flat (1.84 ± 0.42) in cd. Similarly, in ∠α, Type Flat(136.31 ± 9.63) was the largest, followed by type C (116.51 ± 8.79), and type V (89.31 ± 9.07) was the smallest. Other measurements were not found any significant differences between the above.

CONCLUSION

According to the morphology of the CT cross section, the lateral MF was divided into three types: type C, type V and type Flat. Type V is most likely to be invaded when fixing the distal fibula. Screws less than 9 mm should be selected when fixing, and screws no more than 10 mm should be selected when there are type C and type Flat of MF.

Concomitant Unstable and Stable Gravity Stress Tests on Weight-Bearing Stable Weber B Ankle Fractures Treated Nonoperatively: A 2-Year Outcome Study

BACKGROUND

Replacing gravity stress tests with weight-bearing radiographs to evaluate the stability of Weber B (also called Lauge-Hansen supination-external rotation [SER]) ankle fractures results in a lower surgery rate, thus avoiding associated risks and complications. Still, nonoperative treatment of weight-bearing stable fractures is controversial because of the scarcity of strong evidence. We investigated the influence of a concomitant unstable gravity stress test compared with a stable gravity stress test on outcomes after nonoperative treatment of weight-bearing stable fractures.

METHODS

We performed a prospective, noninferiority study on 149 patients with Weber B ankle fractures and stable weight-bearing radiographs. Gravity stress radiographs classified fractures as stable (SER2 [n = 88]) or partially unstable (SER4a [n = 61]). All were treated with a functional orthosis and weight-bearing was allowed; patients were followed for 2 years. The primary outcome was the Manchester-Oxford Foot and Ankle Questionnaire (MOXFQ), with a range from 0 to 100, in which lower scores indicate fewer symptoms. A noninferiority margin was prospectively defined as 7.5 points. The secondary outcomes included the Olerud-Molander Ankle Score, assessment of ankle congruence, and treatment-related adverse events.

RESULTS

The primary outcome data were available for 144 (96.6%) of 149 participants at 2 years. The between-group difference in the MOXFQ score was 1.0 point (95% confidence interval, -1.4 to 3.4 points; p = 0.397) in favor of the SER2 group, consistent with noninferiority. We found no appreciable between-group differences for any other outcome.

CONCLUSIONS

In Weber B/SER ankle fractures that are stable on weight-bearing radiographs, are treated with removable orthoses, and are allowed to bear weight, a concomitant unstable gravity stress test (SER4a) was not associated with worse patient-reported or radiographic outcomes compared with a stable gravity stress test (SER2) at the 2-year follow-up. Thus, the identification of stress instability seems redundant, which questions the applicability of stress instability for surgical decision-making.

LEVEL OF EVIDENCE

Diagnostic Level II . See Instructions for Authors for a complete description of levels of evidence.

A Novel Flexible Fixation Method for Syndesmotic Injury

BACKGROUND

This study aims to evaluate the results and the safety of a novel fixation method we developed for syndesmosis injuries that we call the "embrace" technique.

METHODS

Between March 2018 and October 2020, a total of 67 patients with ankle fractures and syndesmotic injuries underwent syndesmosis fixation with the embrace technique at our institute. Plain radiographs and computed tomographic (CT) scans were obtained preoperatively. Postoperative radiographic assessment included anteroposterior (AP) and lateral radiographs and CT scans of both ankles. Additionally, the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Score, Olerud-Molander Ankle Score, and visual analog scale (VAS) score were used for postoperative assessment.

RESULTS

The mean age was 27.6 ± 10.9 (range, 14-56) years. The mean follow-up time was 30.3 ± 6.2 (range, 24-48) months. There were no malreductions indicated by any CT parameter except fibular rotation in a postoperative comparison between 2 sides. We found significant preoperative-postoperative changes in anterior difference, posterior difference, and fibular rotation but no significant preoperative-postoperative difference in fibular translation. There was no significant postoperative difference between the affected-side and normal-side measurements of any parameter. Complications included delayed wound healing, lateral pain because of wire knot irritation (11.9%), and medial fiber wire irritation (7.5%). The mean AOFAS, Olerud-Molander, and VAS scores at the last follow-up were 94.4 ± 6.8 (range, 84-100), 95.4 ± 6.1 (range, 80-100), and 0.68 ± 1.0 (range, 0-3) points, respectively.

CONCLUSION

In our cohort, this novel technique proved to be an effective method for syndesmosis fixation in patients with ankle fractures associated with very good radiologic and patient-reported outcomes.

LEVEL OF EVIDENCE

Level IV, case series.

The Use of Hindfoot Nails for Elderly Complex Distal Tibial and Ankle Fractures

Elderly patients who sustain complex ankle or distal tibial fractures are often frail and comorbid and need surgery to contain the talus underneath the tibia in order to protect the soft tissue envelope and allow early unrestricted weightbearing. We performed a retrospective observational review of patients >65 years old who underwent a hindfoot nail fixation of an ankle or distal tibial fracture in our institution. Data collected included: injury sustained, open or closed injury, ASA grade, age at time of surgery, length of stay, postoperative mortality, complications, and further treatment. The primary outcome was reoperation. Secondary outcomes were infection and 1 year mortality. Seventy hind foot nailing procedures were undertaken. Sixty-three out of 70 patients were female. The average age of those who died within 1 year of surgery was 84 years. Forty-five out of 70 were open injuries. Eleven out of 70 patients died with 1 year of surgery (range 1-358 days postsurgery). Five out of 70 (7%) patients developed an infection. Four out of 5 of these injuries were open. Three out of 5 underwent removal of the nail due to infection. Two out of 5 had the infection suppressed with antibiotics. Ten out of 70 (14%) patients underwent locking bolt removal due to it backing out or being prominent and causing wound healing issues. Two out of 70 (3%) patients went on to have below knee amputations. Both were due to ongoing wound problems following open fractures. The hindfoot nail is an important implant when treating complex ankle and distal tibial fractures in an elderly population. It facilitates early mobilization to avoid deconditioning and other medical complications.

Evaluation of Contact Area and Pressure After Malreduction in Isolated Medial Malleolar Fractures With 2 mm of Displacement: A Cadaveric Study

This study was performed to evaluate the changes in contact area and pressure in the tibiotalar joint, with a 2 mm displacement after IMMF (isolated medial malleolar fracture). Ten cadavers with pairs were used to establish a situation in which IMMF occurred during ankle injury. We performed IMMF corresponding to types C and D of the Herscovici classification, and it was displaced by 2 mm. The normal group was defined as a normal tibiotalar joint, the TF (transverse fracture) group as a 2 mm transverse displacement corresponding to the Herscovici classification type C, and the OF (oblique fracture) group as a 2 mm oblique displacement corresponding to the Herscovici classification type D. We measured the contact area and pressure at the tibiotalar joint. The film was scanned and analyzed using the digital imaging software, Scion Image (Scion Crop. Frederick, MD). In normal group, the average contact area of the tibiotalar joint was 317 mm2 (IQR; interquartile range, 256; 347) and 308 mm2 (IQR, 262; 364), average pressure was 2.19 N/mm2 (IQR, 1.94; 2.27) and 2.15 N/mm2 (IQR, 2.06; 2.53). In the TF and OF groups, the average contact area of the tibiotalar joint decreased by 9% and 12%, respectively, and the average pressure increased by 8% and 14%, respectively. There was no statistical difference in peak pressure between the normal, TF, and OF groups. In the case of transverse and oblique fractures, a 2 mm displacement showed significant changes in contact area and contact pressure compared to the normal tibiotalar joint, but there were no significant changes pertaining to type, between the 2 fractures.

Study on the effect of self-made fracture positioning compression guide device for posterior malleolus fracture surgery: Medical prevention

To evaluate the effectiveness of a self-designed pressure-guided fracture positioning device, a prospective study was conducted in patients with posterior ankle fractures undergoing surgery using the device. Twenty-seven cases of ankle joint fracture with posterior malleolus fracture were treated by surgery. In the process of fixing posterior malleolus fracture, a self-designed fracture positioning compression guide device was used to fix posterior malleolus bone by anterior and posterior approaches. Postoperative CT images were used to assess the fixation position as well as length of the screw and the compression of the fracture. All patients had healed ankle fractures, and the anterior-posterior screws were fixed in the central area of the posterior malleolus. Posterior malleolus fragment displacement was <2 mm. The screw effectively secured the cortex beyond the length of the posterior malleolus cortex by no more than two threads. The good rate of ankle joint function was 85.16%. Compared to traditional surgical techniques, minimally invasive fixation using the self-designed positioning compression guide device has several advantages, including smaller trauma, faster postoperative recovery, and improved patient satisfaction. The device also provides the surgeon with greater control and precision during the surgical procedure, which can contribute to better surgical outcomes.

Tension band wiring versus screw fixation for the treatment of medial malleolar fractures: A systematic review and meta-analysis

INTRODUCTION

Tension band wiring (TBW) and screw fixation (SF) are common surgical treatments for medial malleolar fractures (MMFs); however, no systematic review has identified which fixation method is superior. This study aimed to determine the most optimal MMF fixation method by comparing the clinical and radiological outcomes of TBW and SF through a systematic review and meta-analysis of the literature.

HYPOTHESIS

We hypothesized that there may be differences in outcomes between TBW and SF for treating MMFs.

METHODS

MEDLINE, Embase, and the Cochrane Library were systematically searched for studies that compared TBW and SF for MMF treatment published through June 8, 2021. Fracture union, outcome scores, and postoperative complications were analyzed.

RESULTS

We included 10 studies with 512 MMF cases; 218 and 294 patients were treated with TBW and SF, respectively. Pooled analysis revealed no significant differences between them for all outcome variables, including the time to fracture union (mean difference=-0.59 weeks; 95% confidence interval [CI], -1.82 to 0.64; p=0.35; I2=70%), number of excellent or good outcomes based on the final Olerud and Molander Ankle score (odds ratio [OR], 1.46; 95% CI, 0.53-5.02; p=0.47; I2=0%), delayed union rate (OR, 0.94; 95% CI, 0.34-2.59; p=0.91; I2=17%), superficial infection rate (OR, 1.19; 95% CI, 0.33-4.26; p=0.79; I2=0%), and number of fixation failures (OR, 0.53; 95% CI, 0.16-1.74; p=0.29; I2=13%).

CONCLUSIONS

Both TBW and SF are excellent clinical and radiological methods for MMF fixation. However, an appropriate fixation method should be chosen according to the fracture type and size and bone quality considering the advantages and disadvantages of each method.

LEVEL OF EVIDENCE

III, meta-analysis.

Direct fixation of posterior malleolus fractures-posterolateral or posteromedial approach?

Ankle fractures involving the posterior malleolus (PM) generally have worse prognosis. There is a trend towards it's direct fixation, yet the exact indications are a subject of debate. The purpose of our study was to present our treatment protocol and to discuss the advantages and limitations of the direct posterolateral and posteromedial approaches. We present a prospective series of 35 ankle fractures involving the PM, operated for a period of 4 years (2018-2022). Direct posterolateral approach was used in 20 ankles, 15 were operated via a posteromedial approach. Clinical and functional assessment was performed according to the criteria of AOFAS. 14 patients received an excellent score, 16 had good and the rest had an average score. The overall score was 85,4 (54-100). The average range of motion was 50° (15°-55°).Eight patients had superficial skin necrosis along the surgical incision. Thirteen patients need their fibular plates removed due to local irritation. Five patients, operated through a posterolateral approach, had lateral heel numbness suggestive of a sural nerve disfunction. PM is important for normal ankle kinematics. When it's direct fixation is considered appropriate, the safest and shortest route is optimal. It is determined by the preoperative CT. The posterolateral approach is more versatile, but lead to more complications in our study.

Influence of quality of reduction using radiological criteria on kinematics and kinetics in ankle fractures with unstable syndesmotic injury

BACKGROUND

In ankle fractures with syndesmotic injury, the anatomic reduction of the ankle mortise is crucial for preventing osteoarthritis. Yet, no studies have analysed the effect of surgical reduction after unstable ankle fractures on patients' active functional outcome.

METHODS

The Intraoperative 3D imaging data of patients surgically treated between 2012 and 2019 for ankle fracture with concomitant syndesmotic injury were reviewed. 58 patients were allocated to two groups depending on whether the criteria for radiologically optimal reduction were met (39 patients) or not (19 patients). Criteria for optimal reduction were composed of objectively measured and subjectively rated data. After undertaking the Olerud/Molander ankle score, a gait analysis and several active function tests using 3D motion capture were performed in order to evaluate kinetic and kinematic differences between both groups.

FINDINGS

Patients showed deficits of range of motion and balance parameters on the injured ankle, however, there were no significant differences between both groups.

INTERPRETATION

Although, the data did not show that radiological reduction criteria have a statistically significant effect on active functional outcome after a mean follow up time of 5.7 years, tendencies for a better outcome of patients that met the criteria could be seen. It also must be taken into consideration that results are limited by case number and allocation ratio, which made a sub-analysis of the separate reduction criteria unfeasible.

Posteromedial Surgical Approach for Fixation of Haraguchi Type 2B Posterior Malleolar Fracture

SUMMARY

A case of a 26-year-old man with a displaced medial malleolus fracture with extension into the posteromedial aspect of the posterior malleolus is presented. A CT scan of the ankle is obtained demonstrating a Haraguchi type 2B posterior malleolus fracture with a posteromedial and posterolateral fragment. The posteromedial fragment extends into the posterior colliculus of the medial malleolus and has a subchondral impaction fracture. There is also a 1 × 1 cm piece of the articular surface of the posterior malleolus that has flipped 90 degrees and lodged itself between the posterolateral fracture fragment. This video overview and case presentation demonstrates a posteromedial approach with fixation strategy for the posterior malleolus.

Preoperative CT parameters to predict tibiofibular syndesmosis injury associated with ankle fracture: a propensity score-matched analysis

BACKGROUND

Untreated ankle fractures with concomitant tibiofibular syndesmosis injury often lead to postoperative pain and early traumatic arthritis. CT has advantages in the preoperative diagnosis of combined ankle injuries. However, a few studies have investigated the best preoperative CT parameters to predict tibiofibular syndesmosis injuries associated with ankle fractures. This study aimed to identify and evaluate the optimal preoperative CT parameters for predicting tibiofibular syndesmosis injuries associated with ankle fractures.

METHODS

We retrospectively analyzed 129 patients who underwent preoperative CT of an ankle fracture treated between January 2016 and April 2022 at a tertiary A hospital. All patients underwent open reduction and internal fixation and intraoperative stability testing. Based on the Cotton test, the patients were divided into the stable group (n = 83, 64.3%) and unstable group (n = 46, 35.7%). After 1:1 propensity score matching, the general conditions, anterior tibiofibular distance (TFD), posterior TFD, maximum TFD, tibiofibular syndesmosis area, sagittal fracture angle, Angle-A, and Angle-B were compared between the stable and unstable groups.

RESULTS

The propensity score-matched cohort comprised 82 patients. There were no significant differences between the stable and unstable groups in sex, age, affected side, operation interval, injury mechanism, Lauge-Hansen classification, sagittal fracture angle, and Angle-A (all P > 0.05). Compared with the stable group, the unstable group had a significantly greater aTFD, pTFD, maxTFD, and area (all P < 0.05). PTFD, maxTFD, and area were positively correlated with joint instability. Angle-B was smaller in the unstable group (57.13°) than the stable group (65.56°). ROC analysis showed that Area (AUC 0.711) and maxTFD (AUC 0.707) had the highest diagnostic efficacy.

CONCLUSION

MaxTFD and Area were the best predictive parameters; a larger Area was associated with a higher likelihood of instability of the tibiofibular syndesmosis after ankle fracture fixation.

Management of High-Energy Tibial Pilon Fractures

➤ Pilon fractures in the younger patient population are frequently high-energy, intra-articular injuries and are associated with devastating, long-term impacts on patient-reported outcomes and health-related quality of life, as well as high rates of persistent disability.➤ Judicious management of associated soft-tissue injury, including open fractures, is essential to minimizing complications. Optimizing medical comorbidities and negative social behaviors (e.g., smoking) should be addressed perioperatively.➤ Delayed internal fixation with interval temporizing external fixation represents the preferred technique for managing most high-energy pilon fractures presenting with characteristically substantial soft-tissue trauma. In some cases, surgeons elect to utilize circular fixation for these scenarios.➤ Although there have been treatment advances, the results have been generally poor, with high rates of posttraumatic arthritis, despite expert care.➤ Primary arthrodesis may be indicated in cases with severe articular cartilage injury that, in the opinion of the treating surgeon, is likely unsalvageable at the time of the index management.➤ The addition of intrawound vancomycin powder at the time of definitive fixation represents a low-cost prophylactic measure that appears to be effective in reducing gram-positive deep surgical site infections.

Intraobserver and Interobserver Reliability of the Computed Tomography-Based Classifications Used in Posterior Malleolar Fractures: The Haraguchi and Bartoníček-Rammelt Classifications

BACKGROUND

Three main computed tomography (CT)-based classification systems have been defined and used for posterior malleolar fractures. The intraobserver and interobserver reliability of two of these systems has never been investigated. The aim of this study was to investigate the intraobserver and interobserver reliability of the Haraguchi (HC) and Bartoníček-Rammelt (BRC) classifications.

METHODS

Axial and sagittal CT sections and three-dimensional reconstruction images of 60 fractures were evaluated twice by six observers at a 6-week interval. Cohen κ values for intraobserver reliability and Fleiss κ values for interobserver reliability were calculated.

RESULTS

The interobserver reliability of the HC was fair in both assessments (Fleiss κ: 0.263 and 0.249 for the first and second evaluations, respectively). The interobserver reliability of the BRC was moderate in both evaluations (Fleiss κ: 0.535 and 0.447, respectively). The intraobserver reliability values (Cohen κ) of the HC were determined to be between 0.532 and 0.927 for the six observers. These values indicated moderate agreement for one observer, substantial for four, and very good for one. Intraobserver reliability values for the BRC were determined to be between Cohen κ of 0.626 and 0.884. Based on these values, the BRC's intraobserver reliability indicated substantial agreement for two observers and very good for four observers.

CONCLUSIONS

Intraobserver and interobserver reliability values of the BRC were higher than those of the HC.

The Impact of Surgical Timing After Ankle Fracture on Clinical and Long-Term Patient Reported Outcomes

The goal of this study is to evaluate the effect of time-to-surgery following closed ankle fractures on long-term patient reported outcomes, fracture healing, and wound complications. To date, little research has been done focusing on the impact "time to definitive fixation" has on patient reported outcomes. We performed a retrospective analysis of 215 patient records who underwent open reduction and internal fixation (ORIF) for an ankle fracture from July 2011 to July 2018. A total of 86 patients completed the patient reported outcome measurement information systems (PROMIS) survey at long-term follow-up. Primary outcomes were the rate of delayed union, postoperative wound complications, patient reported outcome measurement information system (PROMIS) pain interference (PI), and physical function (PF) scores. No differences were found when comparing time to surgery on a continuous scale with rates of delayed union, nonunion, or wound complications (p = .84, .47, and .63, respectively). PROMIS scores were collected at a median of 4.5 years (2.0 interquartile range (IQR), range 2.5-12.3) postoperatively. The time from ankle fracture to surgery was independently associated with worse PROMIS PI scores (unstandardized β 0.38, 95% CI 0.07-0.68) but not PROMIS PF scores. Severe Lauge-Hansen injuries were independently associated with decreased PROMIS PF scores (unstandardized β -7.02, 95% CI -12.0 to -2.04). Increased time to surgical intervention and severe Lauge-Hansen injuries were independently associated with worse long-term patient reported outcomes. Surgical timing did not impact union rates or wound complications. Surgeons should be aware that delaying ankle fracture repair beyond 12 days after injury may negatively affect long-term patient reported pain scores.