Thirty-year follow-up of ankle fractures

Conservative treatment of isolated fractures of the medial malleolus

Between 1992 and 2000, 57 patients with 57 isolated fractures of the medial malleolus were treated conservatively by immobilisation in a cast. The results were assessed by examination, radiography and completion of the short form-36 questionnaire and American Orthopaedic Foot and Ankle Society ankle-hindfoot score.

Of the 57 fractures 55 healed without further treatment. The mean combined dorsi- and plantar flexion was 52.3° (25° to 82°) and the mean short form-36 and American Orthopaedic Foot and Ankle Society scores 48.1 (28 to 60) and 89.8 (69 to 100), respectively. At review there was no evidence of medial instability, dermatological complications, malalignment of the mortise or of post-traumatic arthritis.

Isolated fractures of the medial malleolus can obtain high rates of union and good functional results with conservative treatment. Operation should be reserved for bi- or trimalleolar fractures, open fractures, injuries which compromise the skin or those involving the plafond or for patients who develop painful nonunion.

Malreduction of the tibiofibular syndesmosis in ankle fractures

BACKGROUND

Diagnosis and reduction of syndesmosis injuries in ankle fractures can be challenging. Previous studies have demonstrated that standard radiographic measurements used to evaluate the integrity of the syndesmosis are inaccurate. The purpose of this study was to determine the adequacy of standard postoperative radiographic measurements in assessing syndesmotic reduction compared to CT and to determine the prevalence of postoperative syndesmotic malreduction in a patient cohort.

METHODS

Twenty-five patients with ankle fractures and syndesmotic instability who had open reduction and syndesmotic fixation were evaluated. All patients had a standard radiographic series postoperatively followed by a CT scan. Radiographic measurements were made by three observers to determine the tibiofibular relationship. Axial CT scan images were judged for quality of reduction of the syndesmosis by measuring the distance between the fibula and the anterior and posterior facets of the incisura. Differences between the anterior and posterior measurements of more than 2 mm were considered incongruous.

RESULTS

Six patients (24%) had evidence of postoperative diastasis using the radiographic criteria, four of whom had evidence of malreduction on postoperative CT scan. Conversely, 13 patients (52%) had incongruity of the fibula within the incisura on CT scan (average 3.6 mm, range 2.0 to 8.0 mm), only four of whom had one or more abnormal radiographic measurements. In 10 (77%) of the 13 malreductions seen on CT scan, the posterior measurement was greater, indicating that internal rotation or anterior translation of the fibula may have occurred. Sensitivity of radiographs was 31% and the specificity was 83% compared to CT.

CONCLUSIONS

Many syndesmoses were malreduced on CT scan but went undetected by plain radiographs. Radiographic measurements did not accurately reflect the status of the distal tibiofibular joint in this series of ankle fractures. Furthermore, postreduction radiographic measurements were inaccurate for assessing the quality of the reduction. Although we did not seek to correlate functional outcomes, the known morbidity of postoperative syndesmotic malreduction should lead to heightened vigilance for assessing accurate syndesmosis reduction intraoperatively.

Stress radiographs after ankle fracture: the effect of ankle position and deltoid ligament status on medial clear space measurements

OBJECTIVE

This study was designed to determine 1) how ankle position affects the medial clear space by using stress radiographs, 2) which medial clear space measurement, overall width or increase in width, better predicts deep deltoid ligament disruption after Weber type-B distal fibular fracture, and 3) what value of medial clear space is most predictive of deep deltoid ligament disruption after Weber type-B distal fibular fracture.

DESIGN

Cadaveric fracture model.

SETTING

Biomechanics laboratory.

INTERVENTION

Fluoroscopic mortise views were taken of 6 fresh cadaveric ankles mounted in a fixture permitting both positioning in neutral flexion, dorsiflexion, and plantarflexion, and the application of internal and external rotational forces. After destabilizing the ankles according to the supination-external rotation mechanism of Lauge-Hansen, repeat radiographs were taken with the same combination of flexion and applied rotational stress.

MAIN OUTCOME MEASURE

Radiographic measurements of medial clear space width and changes in medial clear space were made.

RESULTS

A medial clear space of > or =5 mm on radiographs taken in dorsiflexion with an external rotational stress was most predictive of deep deltoid ligament transection after distal fibular fracture. In dorsiflexion-external rotation, medial clear spaces of > or =4 mm yielded lower specificity and positive predictive value, whereas > or =6 mm yielded lower sensitivity and negative predictive value. All other stress conditions and increases in medial clear space of 2 or 3 mm were less predictive.

CONCLUSIONS

Ankle stress radiographs taken in dorsiflexion-external rotation were most predictive of deep deltoid ligament disruption after distal fibular fracture. Under this stress condition, a medial clear space of > or =5 mm was the most reliable predictor of deep deltoid ligament status.

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.

Combination of hook plate and tibial pro-fibular screw fixation of osteoporotic fractures: a clinical evaluation of operative strategy

BACKGROUND

Internal fixation of osteoporotic ankle fractures is technically difficult and may fail because of unreliable purchase. This study was undertaken to determine if a combination of a hook plate and tibial pro-fibular screws can provide secure fixation until fracture union.

METHODS

Thirty-one patients between the ages of 55 and 90 years had open reduction and internal fixation of ankle fractures between April, 2001, and April, 2003. Sixteen patients with an average age of 71.4 years had ankle fracture fixation with a combination of hook plate and tibial pro-fibular screws for the distal fibular fracture, and 15 patients with an average age of 71.9 years had fixation of their ankle fractures with standard fixation technique using AO/ASIF principles but no tibial pro-fibular screws. All patients were followed with clinical and radiologic assessment at 2 weeks, 6 weeks, and 12 weeks postoperatively. At an average of 15.8 months after injury, patients also completed a mailed questionnaire with the Olerud-Molander ankle score and the AOFAS ankle-hindfoot score for preoperative and postoperative status.

RESULTS

All patients who had tibial pro-fibular screw fixation had fracture union without hardware failure or complications. In the standard fixation group two patients had wound breakdown and one had a valgus malunion with screw pull out. The AOFAS and Olerud-Molander scores for the standard open reduction and internal fixation were 57.3 and 82.8 before injury and 37 and 43.8 postoperatively, respectively. The AOFAS and Olerud-Molander scores for the hook plate and tibial pro-fibular fixation group were 55.9 and 81.3 before injury and 42.4 and 50.3 postoperatively, respectively.

CONCLUSIONS

The combination of hook plate and tibial pro-fibular screws in osteoporotic ankle fractures in a series of patients has not been reported before. This novel technique provides stable fixation for osteoporotic ankle fractures in elderly patients until union is achieved with good clinical scores.

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.

Stress examination of supination external rotation-type fibular fractures

BACKGROUND

Deltoid incompetence in association with an isolated fibular fracture is assumed to be present if there is medial tenderness, ecchymosis, or substantial swelling. We sought to determine whether these soft-tissue indicators predict deltoid incompetence by comparing such findings with the findings on stress radiographs.

METHODS

Over a thirty-two-month period, 138 patients who presented acutely with a Weber type-B supination-external rotation (SE) fibular fracture were evaluated for tenderness (in nine locations), ecchymosis, and swelling. Patients who presented with an apparently isolated fibular fracture and an intact ankle mortise (with a medial clear space of < or =4 mm and no talar subluxation) were evaluated with a stress radiograph to determine deltoid competence. Four groups of patients were identified: those who had an SE2 fracture (defined as those who had a stable ankle on the stress radiograph), those who had a stress (+) SE4 fracture (defined as those who had an unstable ankle on the stress radiograph), those who had an SE4 fracture (defined as those who presented with a wide medial clear space), and those who had a bimalleolar fracture. These four groups were compared with regard to tenderness, swelling, and ecchymosis at the time of initial presentation. Patients with SE2 injuries were allowed immediate weight-bearing.

RESULTS

Of the ninety-seven patients who presented with an isolated fibular fracture and an intact mortise, sixty-one had a stable SE2 injury and thirty-six had an unstable stress (+) SE4 injury. All stable SE2 injuries healed with an intact mortise. Medial tenderness, ecchymosis, and swelling were not predictive of deltoid incompetence (instability).

CONCLUSIONS

Stress radiographs allow for the accurate diagnosis of deltoid incompetence in patients with Weber type-B SE fibular fractures and no other osseous injury. Soft-tissue indicators are not accurate predictors of instability. If medial tenderness, ecchymosis, and swelling are used as operative indications, in some cases surgery may be performed on stable ankles.

Improvement in the treatment of stable ankle fractures: an audit based approach

Stable ankle fracture patients form a distinct, clinically benign group in which functional treatment can be used. An initial retrospective audit of the fracture clinic records of our institution for 1 calendar year demonstrated that recognition and functional treatment of stable ankle fractures was rarely followed. After the introduction of formal departmental evidence-based guidelines, subsequent audits have showed progressive improvements with significant reductions of time spent immobilised in plaster, time spent non-weight bearing and number of routine check radiographs, without compromising patient safety. This study illustrates the value of evidence-based guidelines in maintaining high standards of care over time.

Deltoid ligament integrity in lateral malleolar fractures: a comparative analysis of arthroscopic and radiographic assessments

Foot and ankle surgeons often rely on the medial clear space to evaluate competency of the deep deltoid ligament when evaluating ankle fractures. This investigation assesses the integrity of the deep deltoid ligament after lateral malleolar fracture by using direct arthroscopic visualization and medial clear-space separation on plain film radiographs. The objectives of this study were to test the reliability of medial clear-space separation and the Lauge-Hansen classification scheme in predicting deep deltoid rupture in displaced lateral malleolar fractures. The medial clear space was measured on injury radiographs of 40 patients with an isolated displaced lateral malleolar fracture who underwent open reduction and internal fixation. Injury radiographs were classified according to the Lauge-Hansen scheme. Direct arthroscopic visualization was used to evaluate the deep deltoid ligament under manual stress before fracture reduction. The mean preoperative medial clear space in patients with a deep deltoid rupture (n = 13) was 6.6 +/- 2.4 mm (range, 4 to 12 mm), and in patients without a deep deltoid rupture (n = 26), it was 4.0 +/- 1.0 mm (range, 2.5 to 6 mm) (P =.002, 2-sample t test). At an injury medial clear space > or =3 mm, the false positive rate for deltoid rupture was 88.5% (P =.54, Fisher's exact test). At > or =4 mm, the false positive rate was 53.6% (P =.007). All fractures were rotational injuries according to the Lauge-Hansen system. Three fractures were not classifiable; another 3 fractures showed deltoid ligament integrity opposite the expected finding. The results indicate that, in isolated displaced fractures of the lateral malleolus, radiographic widening of the medial clear space is not a reliable indicator for deep deltoid rupture. Some fractures considered stable by the Lauge-Hansen classification may require careful scrutiny to rule out deep deltoid injury.

Ankle fractures resulting from rotational injuries

Ankle fractures are among the most common skeletal injuries; selection of an optimal management method depends on ankle stability. Stable fractures (eg, isolated lateral malleolar) generally are managed nonsurgically; unstable fractures (eg, bimalleolar, bimalleolar equivalent) usually are managed with open reduction and internal fixation. Stress radiographs may aid in the management of incomplete deltoid injury in which there is medial swelling and tenderness without radiographic talar shift. A posterior malleolar fracture should be reduced and stabilized if it comprises >30% of the articular surface and remains displaced after fibular stabilization. Ankle fractures with syndesmotic injury have additional tibiofibular instability that can be controlled by screw fixation. However, the choice between metal and bioabsorbable screws, screw size, number of cortices fixed, and indications for screw removal remain controversial. Conditions such as diabetes or advanced age are no longer contraindications to usual management recommendations.

Kinematic behavior of the ankle following malleolar fracture repair in a high-fidelity cadaver model

BACKGROUND

Previous studies involving axially loaded ankle cadaver specimens undergoing a passive range of motion after fracture have demonstrated rotatory instability patterns consisting of excessive external rotation during plantar flexion. The present study was designed to expand these studies by using a model in which ankle motion is controlled by physiologically accurate motor forces generated through phasic force-couples attached to the muscle-tendon units.

METHODS

Eight right unembalmed cadaver feet were tested in a dynamic gait simulator that reproduces the sagittal kinematics of the tibia while applying physiological muscle forces to the tendons of the major extrinsic muscles of the foot. Six-degrees-of-freedom kinematics of the tibia and talus were measured with use of a VICON motion-analysis system. The experimental conditions included all combinations of lateral and medial injury to reproduce the clinical classifications of ankle fracture. Statistical analysis was performed with repeated-measures analyses of variance.

RESULTS

The talus of the intact ankles demonstrated coupled external rotation and inversion relative to the tibia as the ankle plantar flexed. Osteotomy of the fibula, simulating a lateral ankle fracture, slightly but significantly increased external rotation and inversion of the talus (p < 0.001), whereas disruption of either the superficial or the deep deltoid ligament increased talar eversion (p < 0.003) and disruption of the deep deltoid ligament increased internal rotation (p < 0.0001). The aberrant motions were corrected by repair of the injured structure.

CONCLUSIONS

The predominant coupled rotation of the talus is external rotation associated with plantar flexion. Following progressive ankle destabilization, talar external rotation and inversion increased.

CLINICAL RELEVANCE

The clinical decision-making process regarding the treatment of ankle fractures centers on determination of whether the injury is expected to result in abnormal motion, which is thought to predispose to the development of arthritis. The present study demonstrated a remarkable degree of ankle stability during stance phase even when there was severe disruption of medial and lateral structures. This finding suggests that a main determinant of clinical outcome after ankle fracture may be ankle motion during swing phase, when ankle stability is not augmented by the combination of axial loading and active motor control of motion. If swing-phase motion is abnormal, then the ankle may be in a vulnerable position at the point of heel-strike.

Ankle fractures: functional and lifestyle outcomes at 2 years

BACKGROUND

Ankle fractures form a high proportion of the total number of fractures treated in New Zealand. International studies show that there are mixed functional outcomes with differing fracture types and subsequently differing lifestyle outcomes.

METHODS

Fracture clinic records and orthopaedic admissions books for Wellington Public Hospital, Capital Coast Health, -Wellington, were retrospectively reviewed to gain a population of patients who sustained ankle fractures for the period January--December 1998. These patients were asked to fill in postal questionnaires detailing their current ankle function and lifestyle, two years after fracturing their ankle. The patients' radiographs were reviewed to classify the types of ankle fractures sustained.

RESULTS

Of 141 patients that sustained ankle fractures, 74 were followed up 2 years after their ankle fracture. All fracture types averaged Olerud-Molander ankle scores of 71.1. Weber A fractures averaged ankle function scores of 90, Weber B fractures 80, and Weber C fractures 78. Four patients (5%) achieved 'poor' results, 12 (16%) patients achieved a 'fair' result, 30 (41%) patients gained a 'good' result, 27 (36%) patients attained 'excellent' results. Lifestyle outcomes were reflected in the patient's ankle function outcomes (P < 0.05).

CONCLUSION

Patients who sustain ankle fractures can be expected to be still experiencing functional difficulties two years post-treatment.

Treatment of osteoporotic ankle fractures in the elderly: surgical strategies

The goal of displaced ankle fracture treatment is to restore congruity and stability to the ankle mortise. However, adequate fixation in patients with osteoporosis is difficult due to poorly mineralized bone. This article presents alternative fixation strategies that can helpachieve ankle stability in this patient population.

The influence of perioperative soft tissue complications on the clinical outcome in surgically treated ankle fractures

The influence of perioperative soft tissue complications on the functional outcome after open reduction and internal fixation of closed ankle fractures was investigated. Eighty-eight consecutive patients were followed 3.7 years (SD +/- 0.6) after the injury. Two major and 21 minor soft tissue complications were registered. Average dorsal extension was 29.9 degrees (range four to 54, SD +/- 9.5) of the fractured ankles and 37.2 degrees (range eight to 60, SD +/- 9.1) of the non-fractured ankles. The average subjective functional score was 84.6 (range 40 to 100, SD +/- 14.9). A significant difference was found with respect to the subjective functional score (p = 0.048, Kruskal-Wallis test) but not with respect to dorsal extension (0.358, Kruskal-Wallis test) when comparing groups of minor, major and no soft tissue complications. This study suggests that major soft tissue complications have a negative effect on the long-term functional outcome after surgical repair of an ankle fracture. Minor soft tissue complications, primary skin problems, the timing of primary surgery and fracture types according to AO/ASIF have no or minor influence on the long-term functional result. This study confirms previous reports that the presence of osteoarthritis is frequently associated with a reduced functional outcome.

Diagnosing deltoid injury in ankle fractures: the gravity stress view

In the lateral malleolar ankle fracture without talar shift there is much uncertainty regarding the diagnosis of deltoid ligament injury severe enough to require surgical treatment. The current study evaluated the mechanical integrity of the ankle using a novel gravity-stress mortise radiographic view, which is practical for clinical use. Eight cadaveric lower extremities were tested under the following conditions: (1) intact ankle, (2) distal fibular oblique osteotomy, (3) plated fibula after osteotomy, (4) transection of the superficial deltoid with fibula osteotomized or plated, and (5) all possible combinations of deep deltoid transection with superficial deltoid transected or repaired and fibula osteotomized or plated. For each condition, a mortise radiograph was taken of the specimen while it was mounted horizontally, lateral side down. Fibular osteotomy with or without transection of the superficial deltoid did not alter the mortise radiograph appearance of the ankles. With combined deep and superficial deltoid transection and fibular osteotomy, the talus always (eight of eight specimens) showed a lateral shift of 2 mm or greater and a valgus tilt of 15 degrees or more. The gravity stress view of the ankle was found to reproducibly document destabilizing deltoid ligament damage.

Incidence of lateral talar dome lesions in SER IV ankle fractures

Osteochondral lesions of the talar dome are commonly the result of ankle trauma. While the technique of surgical repair of ankle fractures has been well reported, there are no studies that correlate the presence or absence of talar dome lesions. A possible explanation for this may be lack of intraoperative inspection of the talar articular surface. This retrospective study evaluates the incidence of lateral talar dome lesions in 50 supination-external rotation stage IV ankle fractures. Specifically, operative reports were reviewed for the presence of lateral talar dome lesions documented through intraoperative inspection. Overall, 19 of 50 fractures, or 38%, were found to have a lateral talar dome lesion. While the bimalleolar and deltoid ligament tear type fractures exhibited more talar dome lesions, there was no significant difference between these two fracture types (p = .1111). There was no statistically significant difference among the three types (unimalleolar, bimalleolar, and trimalleolar) of supination-external rotation ankle fractures (p = .0804). The authors conclude that intraoperative inspection of the lateral talar dome should be a routine part of ankle fracture repair.

The ANK device: a new approach in the treatment of the fractures of the lateral malleolus associated with the rupture of the syndesmosis

The ANK device was developed for the treatment of fractures of the lateral malleolus occurring with rupture of the syndesmosis. While it provides the anatomic reduction of the fracture and the syndesmosis, it allows the physiologic movements of the fibula. It is not used for comminuted fractures of the lateral malleolus and in cases where fibular medullary canal is narrow. We included forty-nine patients who had the ANK device applied and at least 2 years follow-up. The mean follow-up was 41 months (range 24-124). The fractures were evaluated according to the Lauge-Hansen classification; 25 cases were evaluated as supination-external rotation, 11 cases were pronation-abduction, and 13 cases were pronation-external rotation type fractures. There were also 46 fractures of the medial malleolus and three ruptures of the deltoid ligament. Twenty-nine (59,2%) patients were evaluated as excellent, 12 (24,5%) as good, 5 (10.2%) as fair and 3 (6.1%) as poor. Arthrosis was observed in 3 (6.1%) of the patients.

Nonoperatively treated displaced bimalleolar and trimalleolar fractures: a 20-year follow-up

This study evaluates the long-term results of displaced bi- and trimalleolar fractures treated closed. Few reports exist in the literature regarding the long-term outcomes of ankle fractures, and none of these specifically addresses displaced bi- and trimalleolar fractures treated nonoperatively. This study analyzed the results of bi- and trimalleolar fractures treated by a single surgeon from 1973 to 1981. As was the standard of care at that time, these fractures were treated nonoperatively if a stable reduction was achieved and maintained. Serial radiographs confirmed the maintenance of reduction in a non-weightbearing long leg cast for 6 weeks and then a short leg walking cast for 6 weeks. Of the 34 patients in this series, 19 were available for review, 10 were deceased, and five were lost to follow-up. The average age at the time of injury was 39 years (range, 17-79 years), and the average length of follow-up was 20 years (range, 16-24 years). At the time of review, only two patients with trimalleolar fractures were minimally symptomatic or had radiographic evidence of mild degenerative changes. The average American Orthopaedic Foot and Ankle Score was 98 of 100 points (range, 87-100 points). This long-term follow-up shows that bi- and trimalleolar fractures can be treated nonoperatively if an anatomic reduction is maintained and closely followed. With reports indicating as much as a 5% deep infection rate and a 10% incidence of loss of reduction after internal fixation, universally recommending an operation for these injuries should be reconsidered, especially in high surgical risk patients.

Functional outcome and quality of life in patients with Type B ankle fractures: a two-year follow-up study

OBJECTIVES

To compare a specific score designed for ankle fractures with a general quality-of-life instrument as an outcome measure, and to describe the two-year results for patients with Type B ankle fractures.

DESIGN

Follow-up study.

SETTING

Large teaching hospital, Sweden.

PATIENTS

Fifty-three patients, aged nineteen to sixty-three years, treated operatively for Type B ankle fractures. Forty-one patients completed the follow-up.

MAIN OUTCOME MEASUREMENTS

Olerud Molander Ankle Score (OMA score), Short Form-36 Health Survey (SF-36), and a visual analogue scale (VAS).

RESULTS

A significant correlation was found between the OMA score and SF-36 subscores for physical functioning, physical and emotional role function, social functioning, and bodily pain (p < 0.05). VAS for physical symptoms correlated with the OMA score and with all SF-36 subscores (p < 0.001). The mean OMA score was 84 (standard deviation = 22.5); 64 percent of patients scored 90 or more. Patients with an OMA score <90 more often had a B3-type fracture (p < 0.05) and more often considered themselves as not recovered compared with patients with an OMA score > or =90 (p < 0.001). Only thirteen patients (36 percent) reported a complete recovery. Sixteen patients (44 percent) had work-related problems and twenty-two (61 percent) had some problems with sport activities. The SF-36 subscores for physical functioning, physical and emotional role function, vitality, and mental health were lower compared with an average Swedish population (p < 0.05).

CONCLUSIONS

Our results suggest that the SF-36 Health Survey may be useful in measuring outcome after an ankle fracture, that disability, i.e., self-perceived limitations in everyday life, is common after B-type ankle fractures.

The effect of fibular malreduction on contact pressures in an ankle fracture malunion model

Nine fresh-frozen cadaveric specimens were disarticulated through the knee, and the soft tissues, except for the interosseous ligaments and interosseous membrane, were removed to the level of the ankle. The subtalar joint was secured with screws in neutral position (approximately 5 degrees of valgus). Contact pressures in the tibiotalar joint were measured with use of low-grade pressure-sensitive film, which was placed through an anterior capsulotomy. For each measurement, 700 newtons of load was applied to the specimen for one minute. The film imprints were scanned, and the contact pressures were quantitated in nine equal quadrants over the talar dome. A fracture-displacement device was secured to the distal end of the fibula; the device allowed for individual or combined displacements consisting of shortening, lateral shift, and external rotation of the fibula. The ankle was maintained in neutral flexion. The ligamentous injury associated with a pronation-lateral rotation fracture of the ankle was simulated by dividing the deep fibers of the deltoid ligament, the anterior-inferior tibiofibular ligament, and the interosseous membrane to a point that was an average of fifty-three millimeters proximal to the ankle joint. Baseline contact area and contact pressure in the joint were determined, followed by measurements after two, four, and six millimeters of shortening of the fibula; after two, four, and six millimeters of lateral shift of the fibula; and after 5, 10, and 15 degrees of external rotation of the fibula. The three types of displacement were tested individually as well as in combination. The simulated deformities were found to cause a shift of the contact pressure to the mid-lateral and posterolateral quadrants of the talar dome, with pressures as high as 4.1 megapascals. A corresponding decrease in the contact pressures was noted in the medial quadrants of the talar dome. The highest pressures were recorded for maximum shortening of the fibula, the combination of maximum shortening and lateral shift, the combination of maximum shortening and external rotation, and the combination of maximum shortening, lateral shift, and external rotation. In general, increases in each displacement variable corresponded to increasing contact pressures.

Ankle fractures involving the fibula proximal to the distal tibiofibular syndesmosis

Thirty-two cases of ankle fractures associated with fibular fractures above the distal tibiofibular syndesmosis were studied. All were treated with open reduction and internal fixation. The average follow-up was 25 months. The results of the postoperative evaluation were rated, based on subjective clinical criteria, as good, fair, and poor. According to the Lauge-Hansen classification, there were 17 (53%) cases of supination-external rotation injury (2 stage 2 and 15 stage 4), 9 (28%) cases of stage 3 pronation-abduction injury, and 6 (19%) cases of pronation-external rotation injury (3 stage 3 and 3 stage 4). All cases could be classified as Weber type C or as suprasyndesmotic, fibular diaphyseal fracture (44-C) according to the Orthopaedic Trauma Association classification. In 18 (56%) cases, the fracture was associated with ankle dislocation. There were seven (22%) open fractures, (two grade I, four grade II, and one grade IIIA). Syndesmotic screws were used in 23 (72%) cases (12 supination-external rotation injury, 6 pronation-external rotation injury, and 5 pronation-abduction injury). The syndesmotic screw was removed after an average of 9 weeks. Four (13%) nonunions and two (6%) delayed unions of the fibula were treated with bone grafting and/or hardware revision and eventually healed. Three of the nonunions had poor clinical results because of degenerative ankle joint arthritis in two (one of them ended in arthrodesis) and deep infection, which was eventually cured, in the third. The fourth nonunion had a fair result. One of the delayed unions had a fair result (an obese patient) and the other had a good result. Two patients developed deep infections; one ended in gangrene and amputation in a diabetic patient, and the other was a patient with fibular nonunion that eventually healed. Three patients had superficial infections that were treated successfully. Of the 32 cases, 23 (72%) showed good results, 4 (13%) showed fair results, and 5 (16%) showed poor results. The cases with poor results included three fibular nonunions, one deep infection, and one recurrent superficial infection and wound dehiscence after hardware removal. A syndesmotic screw is usually needed in cases of fracture-dislocations. Two patients with occult fibular nonunions developed diastasis of the syndesmosis after removal of the syndesmotic screw. It was found that reduction and temporary pinning of the distal tibiofibular joint helps achieve fibular length, which is crucial to restoring the biomechanics of the ankle joint. It seems advisable not to remove the syndesmotic screw until there are signs of healing of fibular fracture to avoid diastasis of the distal tibiofibular joint. Bone grafting should be considered in high energy fractures with comminution. These complex injuries are associated with higher rates of complications. Poor results can be attributed to fracture factors, e.g., open fractures, infections; patient factors, e.g., obesity, lowered immunity as in diabetes, and noncompliance; and iatrogenic factors, e.g., early removal of syndesmotic screws.

Observer reliability in ankle radiographic measurements

We analyzed 50 sets of ankle radiographs to determine the interobserver and intraobserver reliability when obtaining common linear and angular measurements. The radiographs were divided into two groups: one group included 25 normal ankles, and the second group included 25 fractured ankles. Each set of radiographs was evaluated independently by four different observers on two separate occasions under controlled conditions. Six radiographic parameters were measured on all 50 sets of films: syndesmosis A, syndesmosis B, syndesmosis C, the medial clear space, and the talocrural and bimalleolar angles. On the 25 sets of fracture films, four additional measurements of fracture displacement were included: displacement of the medial malleolus (mortise), displacement of the lateral malleolus (AP and lateral), and displacement of the posterior malleolus. Reliability was evaluated with an analysis of variance intraclass correlation coefficient. Among the examiners, 9 of the 10 parameters could be measured reliably. Intraobserver reliability was found to increase with the experience of the examiner.

Stable lateral malleolar fractures treated with aircast ankle brace and DonJoy R.O.M.-Walker brace: a prospective randomized study

Stable lateral malleolar fractures can be treated with dynamic braces and early mobilization. In a randomized clinical trial, 66 patients with supination-eversion stage II fractures were treated with Aircast Air-Stirrup ankle braces or DonJoy R.O.M.-Walker braces. Average bracing time was 5 weeks, and average time until return to work was 6 weeks. At 4 weeks, 70% to 80% of patients were able to walk without pain. Subjective satisfaction with comfort and ease of use was significantly higher with Aircast, although it was high in both groups. Pain relief and an inflammatory score were significantly better in the R.O.M.-Walker group after 4 weeks. Three months after injury, no differences were observed in grade of ambulation, pain, swelling, range of motion, or inflammatory score. Both braces can be recommended.

An axially loaded model of the ankle after pronation external rotation injury

Using a testing apparatus that allows axial loading and displacement in the sagittal, axial, and coronal planes, 6 ankles were tested under experimental conditions intended to model the Lauge-Hansen pronation external rotation injury. All specimens were rotated through a continuous range of sagittal motion with the ankle under 300 N of axial load as the coupled motion of the ankle in the coronal and axial axes was recorded. Combinations of fibular osteotomy, disruption of the syndesmosis up to 6 cm above the plafond, and deltoid transection were tested to mimic Stages I to III of the pronation external rotation ankle fracture. The effects of stabilization of the fibula and syndesmosis also were examined. Neither fracture of the fibula 4 cm above the plafond nor disruption of the syndesmosis to 6.0 cm resulted in a significant change in coupled motion of the talus. When the superficial deltoid was sectioned, the ankle had increased external rotation in plantar flexion. When the deep deltoid was sectioned, the ankle dislocated in plantar flexion unless the fibula was stabilized. This prevented dislocation but failed to restore normal talar kinematics. This study found no biomechanical support for placement of a syndesmotic screw unless the medial side cannot be stabilized anatomically.

Motion of the ankle in a simulated supination-external rotation fracture model

An experimental study was undertaken with use of axially loaded, unconstrained cadaver ankles to determine the motion patterns seen with progressive stages of the supination-external rotation type of fracture. As described by Lauge-Hansen, these fractures were modeled by transection of the anterior aspect of the capsule and the anterior tibiofibular ligament (stage I), followed by oblique fibular osteotomy ending at the level of the ankle joint (stage II), transection of the posterior aspect of the capsule (stage III), and sequential sectioning of the superficial and deep fibers of the deltoid ligament (stage IV). Thirteen specimens were tested on an apparatus that allowed for controlled loading while the ankle was passed through a physiological range of dorsiflexion and plantar flexion. The ankles were unconstrained about the axial (internal and external rotation) and coronal (varus and valgus angulation) axes. Measurements were made throughout the range of motion in these axes in order to define the kinematic behavior. In the intact specimens, maximum plantar flexion was associated with a mean (and standard deviation) of 1.9 +/- 4.12 degrees of internal rotation of the talus and maximum dorsiflexion, with a mean of 7.2 +/- 3.88 degrees of external rotation. Varus angulation increased slightly with plantar flexion compared with the value in dorsiflexion (2.4 +/- 2.40 compared with 0.3 +/- 1.96 degrees). Internal and external rotation was not affected by fibular osteotomy or by transection of the superficial fibers of the deltoid ligament. Transection of the deep fibers of the deltoid ligament caused a significant (p < 0.02) increase in external rotation of the talus at maximum plantar flexion; this was corrected incompletely by insertion of an anatomical fibular plate. With the numbers available for study, we could not show that varus or valgus angulation was significantly affected by any combination of sectioning of the deltoid ligament and fibular osteotomy. These experiments were repeated with the addition of fixation of the subtalar joint with a talocalcaneal screw. With the number of specimens available, we could detect no significant difference, with respect to axial rotation, due to fixation of the subtalar joint. However, along the coronal axis, increased valgus angulation (p < 0.02) was seen during plantar flexion when either the deep or the superficial fibers of the deltoid ligament had been cut.

CLINICAL SIGNIFICANCE

These results indicate that stability of the loaded ankle is primarily due to the deltoid ligament, which exerts a restraining influence on external rotation of the talus. Complete fibular osteotomy did not cause abnormal motion of the ankle in the absence of a medial injury. In the presence of a complete injury, lateral reconstruction only partially restored the mechanical integrity of the ankle. The results provide justification for the non-operative treatment of isolated fractures of the lateral malleolus. The data also suggest that a lateral fracture associated with a major injury of the deltoid ligament should be treated with anatomical lateral fixation followed by immobilization without early motion, to allow adequate healing of the deltoid ligament at its resting length.

Contribution of the deltoid ligament to ankle joint contact characteristics: a cadaver study

Changes in ankle biomechanics lead to altered load transmission through the ankle joint, possibly predisposing it to osteoarthritis. Contributions of the different bands of the deltoid ligament to the contact characteristics in the ankle were examined. Fifteen normal cadaveric lower extremities were axially loaded to 445 N after intra-articular Fuji film placement. Ankles were tested in neutral, 10 degrees dorsiflexion, and 10 degrees plantarflexion. Repeated testing was done following sequential sectioning of the deltoid ligament, and the contact characteristics were analyzed. The greatest significant tibiotalar changes (P < 0.0001) occurred after sectioning of the tibiocalcaneal fibers of the superficial deltoid ligament complex. Contact areas decreased up to 43%, peak pressures increased up to 30%, and centroids moved 4 mm laterally, on average. In contrast, sectioning of the other bands led to insignificant changes in joint contact characteristics. The data indicate that significant changes in contact characteristics occur before radiographic evidence of deltoid ligament damage is evident, and may indicate that greater attention to the medial side of the ankle is indicated to restore normal biomechanics to this joint.

Tibiotalar contact area and pressure distribution: the effect of mortise widening and syndesmosis fixation

An unconstrained cadaver ankle model was designed to reevaluate the effect of ankle mortise widening and syndesmotic fixation on the load-bearing characteristics of the tibiotalar joint. Tibiotalar contact area, centroid shift, and mean contact pressure were quantified using a pressure-sensitive film technique. Six fresh-frozen below-knee amputation specimens were axially loaded with 500 N in three positions: neutral, 10 degrees of dorsiflexion, and 20 degrees of plantarflexion. The tibiotalar contact area and centroid position for each specimen in its intact state were first determined and then compared with values obtained after syndesmotic fixation, mortise widening of 2 and 4 mm, and deep deltoid ligament transection. Syndesmotic fixation significantly decreased joint contact area but did not consistently affect centroid position. However, unlike earlier studies, which used more constrained ankle fracture models, mortise widening with or without deltoid rupture was not found to significantly affect contact area, centroid position, or joint contact pressure. When statically loaded, the talus moved to its position of maximal congruence in the mortise, rather than displacing laterally along with the lateral malleolus.

Internal fixation of distal fibula fractures: a case presentation demonstrating a unique technique for a severely comminuted fibula

The laterally comminuted fracture-dislocation of the ankle can be associated with devastating consequences. Previously described surgical as well as nonsurgical-treatment results have been disappointing. Accurate anatomical reduction and rigid fracture stabilization of a comminuted fibula can be extremely difficult. This manuscript presents some of the more common methods of comminuted fibular fracture fixation described in the literature. A case report demonstrates successful anatomical stabilization of a comminuted fibula, utilizing a method for internal fibular fixation which has been previously employed, but has not been advocated, in the literature. Clinical and radiographic results at 12 and 20 months post-injury are promising.

Changes in gait and maximum ankle torque in patients with ankle arthritis

Findings from quantitative gait analysis and maximum ankle torque were used to assess the walking pattern of patients with ankle arthritis and to correlate the changes of gait parameters and muscle strength with severity of arthritis. Gait analysis and the isokinetic maximum ankle torque test were performed in 20 patients with first to fourth degree traumatic ankle arthritis. Six patients without evidence of traumatic arthritis were used as controls. Isokinetic maximum ankle plantarflexion and dorsiflexion torques were determined with Cybex instrumentation. Force plate and foot switch data were gathered during level walking. Maximum ankle plantarflexion and dorsiflexion torques were diminished in the injured ankles. Velocity, stride length, and cadence were decreased in arthritic patients compared with controls. The arthritic limbs had shorter single limb stance and longer double stance during free and fast walking speeds compared with the controls' affected ankles. The patterns of ground reaction forces were similar in the injured and uninvolved limbs as well as the control subjects, except the magnitude of vertical forces during push-off were reduced in arthritic ankles. The gait parameters and muscle strength deteriorated as the arthritis became severe, but they showed significant changes only when the patients had third or fourth degree arthritis.

Isolated fracture of the lateral malleolus requires no treatment. 49 prospective cases of supination-eversion type II ankle fractures

54 patients with isolated SE II fractures through the lateral malleolus, with 2 mm maximum dislocation, were treated with an elastic bandage and immediate weight bearing. 2 patients suffered dislocation but both should not, on reassessment, have been included in the study. 49 of the remaining patients were assessed after an average of 1.5 years. All but 4 patients had very minor, if any, symptoms. The average sick leave was 6.3 weeks and the patients were back to normal activity in about 4 months. This virtual nontreatment was safe and beneficial to both the patients and the health service.

Tibiotalar contact and fibular malunion in ankle fractures. A cadaver study

Six cadaveric ankles were dissected, preserving medial and lateral ligaments; an axial load of 455N was applied to the tibia supported by the foot and ankle. The unconstrained tibia was moved through 20 degrees of flexion and extension to simulate walking. The tibiotalar contact area was defined using carbon black suspension, recorded photographically, and measured using computerized area analysis. Osteotomy of the distal fibula was performed and fixed with a specially modified plate; a selection of plates provided fixation with 0 degrees or 30 degrees of external rotation in combination with 0 or 2 mm of shortening. The contact area was measured for each of the plates and after division of the deltoid ligament. There were greater than 30 percent decreases in tibiotalar contact with both fibular shortening and external rotation, doubled with a divided deltoid ligament. Anatomic restoration of both fibular length and rotation is essential for normal ankle mechanics. The deltoid ligament has crucial effects on the stability of the ankle mortise.

The posterior antiglide plate for fixation of fractures of the lateral malleolus

Anatomical reduction and internal fixation of displaced lateral malleolar fractures are the cornerstone of the operative treatment of ankle fractures. The classical method of fixation is the application of one-third tubular plates laterally to the distal fibula, a technique, however, that has several disadvantages. In exceptional cases and under special circumstances we prefer a dorsal approach with the use of an antiglide plate. Indications, technique and experiences are discussed.

Tibio-talar stability in bimalleolar ankle fractures: a dynamic in vitro contact area study

A dynamic weight-bearing model has been developed in a cadaveric ankle model to assess the contact areas of the talus in varying degrees of bimalleolar ankle fractures. A surgically created transverse fibula osteotomy with up to 6 mm of displacement did not cause a significant change in the contact area. Sectioning of the deltoid ligament, regardless of fibular displacement, created a 15% to 20% decrease in the contact area (P less than .001). This model represents a clinically relevant situation, as it examines motion of an unconstrained, axillary loaded ankle. Additional medial side disruption increases ankle instability by allowing anterior and lateral translation of the talus out of the mortise. Isolated lateral malleolar displacement does not appear to cause ankle instability.

The effect of loading on tibiotalar alignment in cadaver ankles

The tibiotalar movements which occur with axial loading, without applied moment forces were studied in cadaver ankles using a minimally constrained testing apparatus. Lateral translation of the talus measured up to 2 mm, which was associated with increased tibiotalar valgus angulation. Neither displacing the distal fibula laterally, nor sectioning the deltoid ligament, significantly influenced the talar shift. The tibiotalar motion which was observed after simple axial loading in a stable configuration (e.g., fibula and deltoid ligament intact) is of the same magnitude that is usually regarded as signifying an unstable ankle fracture. Consequently, this study suggests that the criteria for an unstable ankle fracture may need closer scrutiny.

Ankle fractures treated with a stabilizing shoe

Twenty-four patients with a Lauge-Hansen Stage II supination-eversion fracture of the lateral malleolus were treated with a stabilizing shoe, which prevents supination and eversion of the foot, but allows a tibiotalar motion. In 23 patients the result was excellent, without secondary dislocation during healing. We therefore conclude that this fracture type can be treated functionally.

No arthrosis of the ankle 20 years after malaligned tibial-shaft fracture

We interviewed 92 patients with nonoperatively treated tibial-shaft fractures with minimum of soft-tissue injury 20-39 years after the injury. Seventeen fractures had healed with an angular deformity exceeding 10 degrees. Seven patients with and 15 without symptoms, but with angular deformity exceeding 10 degrees, were examined clinically and radiographically. None of these 22 patients had arthrosis of the ankle. We concluded that angular deformity within 15 degrees will not lead to restricted motion, pain, or arthrosis of the ankle.

Surgical treatment of scaphoid nonunion. Review of the literature and recommendations for treatment

The management of scaphoid pseudarthrosis is still controversial. The numerous methods that have been proposed can be roughly classified according to their aim - relief of pain or healing of bone. Following a review of the literature, and guided by personal experience with the Matti-Russe technique and McLaughlin internal fixation, the authors present recommendations for treatment according to clinical presentation of the condition.

Supination-eversion fractures of the ankle joint: changes in incidence over 30 years

The sex- and age-specific incidence has been calculated for ankle fractures from the first part of the 1950s and compared with the 1980s, a 30-year interval. The fractures were also classified according to Lauge-Hansen. Altogether 1784 fractures were found. During that time interval ankle fractures had become more common, particularly those with extensive skeletal involvement, such as the stage IV supination-eversion fractures, which today have an incidence pattern more typical of a fragility fracture in elderly women.

Ankle fractures

The results of three separate studies on ankle fractures are presented. Clinical information is provided concerning the epidemiology and a comparison of closed versus open treatment, and a discussion is presented concerning what results can be expected 30 years after closed treatment for an ankle fracture.