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Zambelli R, Fagundes AO, Arêas TS, Baumfeld D, Brandão JMM, Castilho RS, Leal PMC, Baumfeld T. Ankle arthroscopy does not elevate complication rates in ankle fractures. Foot Ankle Surg 2024; 30:309-312. [PMID: 38302327 DOI: 10.1016/j.fas.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 12/13/2023] [Accepted: 01/05/2024] [Indexed: 02/03/2024]
Abstract
INTRODUCTION Ankle fractures rank as the second most common lower limb fractures, and surgical intervention is essential for unstable ankle fractures. The use of ankle arthroscopy in such cases offers several advantages. This study aim is to assess whether arthroscopy influenced on complication rates in 171 ankle fractures treated with arthroscopic assistance. METHODS This retrospective epidemiological analysis encompassed adult ankle fractures between December 2018 and December 2021. Initially, 173 patients were considered, but two were excluded, leaving a final sample of 171 patients. Postoperative complications were categorized as major or minor. RESULTS The study included 171 patients with surgically treated ankle fractures assisted by arthroscopy, comprising 76 females and 95 males, with an average age of 41.9 years. Syndesmosis injuries were treated in all diagnosed cases (55.0%), and deltoid ligament injuries received attention when identified (33.7%). Arthroscopic techniques were preferred over open techniques (47.4%). Ten patients experienced complications, consisting of 2 major and 8 minor complications (5.8%). DISCUSSION Our study's epidemiological findings align with prior literature, demonstrating that intra-articular injuries accompany 63% to 79% of ankle fractures. Arthroscopy allows for both diagnosis and treatment within the same procedure, including joint lavage to reduce inflammation. We diagnosed 57 deltoid injuries and identified a statistical relationship between chondral, syndesmotic, and deltoid ligament injuries. Infection is a common complication in ankle fracture surgery, with rates ranging from 1.44% to 16%. Our study yielded a 5.8% complication rate, comprising 1.2% major and 4.6% minor complications. Patients undergoing ORIF with arthroscopic assistance had a lower prevalence of infection. CONCLUSION The use of arthroscopic assistance in the surgical treatment of ankle fractures does not increase the overall complication rate. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Roberto Zambelli
- Faculdade de Ciências Médicas de Minas Gerais, Rua Vereda, 50 - Torre 2 / Ap 2001, Nova Lima, MG 34006-077, Brazil
| | | | - Thiago Szvarça Arêas
- Hospital Mater Dei, Rua Vereda, 50 - Torre 2 / Ap 2001, Nova Lima, MG 34006-077, Brazil
| | - Daniel Baumfeld
- Universidade Federal de Minas Gerais (UFMG), Rua Vereda, 50 - Torre 2 / Ap 2001, Nova Lima, MG 34006-077, Brazil
| | - João Murilo Magalhães Brandão
- Hospital Mater Dei, Rua Vereda, 50 - Torre 2 / Ap 2001, Nova Lima, MG 34006-077, Brazil; Hospital Unimed, Belo Horizonte, Rua Vereda, 50 - Torre 2 / Ap 2001, Nova Lima, MG 34006-077, Brazil
| | | | - Paulo Magno Crusoé Leal
- Hospital São Vicente de Paulo, Santa Casa Rua Vereda, 50 - Torre 2 / Ap 2001, Nova Lima, MG 34006-077, Brazil; Vitória da Conquista Rua Vereda, 50 - Torre 2 / Ap 2001, Nova Lima, MG 34006-077, Brazil
| | - Tiago Baumfeld
- Hospital Felício Rocho, MG Rua Vereda, 50 - Torre 2/Ap 2001, Nova Lima, MG 34006-077, Brazil.
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Terstegen J, Weel H, Frosch KH, Rolvien T, Schlickewei C, Mueller E. Classifications of posterior malleolar fractures: a systematic literature review. Arch Orthop Trauma Surg 2023; 143:4181-4220. [PMID: 36469121 PMCID: PMC10293398 DOI: 10.1007/s00402-022-04643-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 09/30/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Complex ankle fractures frequently involve the posterior malleolus. Many classifications describing posterior malleolar fractures (PMF) exist. The aim of this study was to provide a systematic literature review to outline existing PMF classifications and estimate their accuracy. METHODS The databases PubMed and Scopus were searched without time limits. Only specific PMF classifications were included; general ankle and/or pilon fracture classifications were excluded. Selection and data extraction was performed by three independent observers. The systematic literature search was performed according to the current criteria of Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). The methodological quality of the included studies was quantified using the modified Coleman score. RESULTS A total of 110 studies with a total of 12.614 patients were included. Four main classifications were identified: Those describing the size of the posterior malleolar fracture (n = 66), Haraguchi (n = 44), Bartoníček/Rammelt (n = 21) and Mason (n = 12). The quality of the studies was moderate to good with a median Coleman-score of 43.5 (14-79) and a weighted median Coleman-score of 42.5 points. All classifications achieved a substantial to perfect score regarding the inter- and intraobserver reliability, with Mason scoring the lowest in comparison. CONCLUSIONS None of the reviewed PMF classifications has been able to establish itself decisively in the literature. Most of the classifications are insufficient in terms of a derivable treatment algorithm or a prognosis with regard to outcome. However, as the Bartoníček/Rammelt classification has the greatest potential due to its treatment algorithm, its reliability in combination with consistent predictive values, its usage in clinical practice and research appears advisable.
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Affiliation(s)
- Julia Terstegen
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Hanneke Weel
- Department of Orthopedics, Bergman Clinics, Arnhem, The Netherlands
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
- Department of Trauma Surgery, Orthopaedics, and Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany
| | - Tim Rolvien
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Carsten Schlickewei
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Elena Mueller
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
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Reproducibility of Bartoníček and Haraguchi classifications of the posterior malleolus fractures. Arch Orthop Trauma Surg 2023:10.1007/s00402-023-04823-z. [PMID: 36905426 DOI: 10.1007/s00402-023-04823-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 02/25/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND Two of the most commonly used classifications for the posterior malleolus fracture are Haraguchi and Bartoníček. Both classifications are based on the morphology of the fracture. This study makes an inter- and intra-observer agreement analysis of the mentioned classifications. METHODS 39 patients with ankle fractures who met inclusion criteria were selected. All the fractures were analyzed and classified twice by each of the 20 observers using Bartoníček and Haraguchi's classifications, with a window period of at least 30 days between the two rounds. RESULTS Analysis was made by Kappa coefficient (ƙ). The global intraobserver value was ƙ = 0.627 in the Bartoníček classification and ƙ = 0.644 in the Haraguchi one. The first round global interobserver ƙ = 0.589 (0.574-0.604) on the Bartoníček classification and ƙ = 0.534 (0.517-0.551) on the Haraguchi one. Second round coefficients were ƙ = 0.601 (0.585-0.616) and ƙ = 0.536 (0.519-0.554), respectively. The best agreement was when there was involvement of the posteromedial malleolar zone with ƙ = 0.686 and ƙ = 0.687 in Haraguchi II and ƙ = 0.641 and ƙ = 0.719 in Bartoníček III. No differences were observed in Kappa values when an experience-based analysis was made. CONCLUSION Bartoníček and Haraguchi classifications of the posterior malleolus fracture have both substantial intraobserver agreement but moderate to substantial agreement in interobserver analysis. LEVEL OF EVIDENCE IV.
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Rajan L, Eble S, Kim J, Kukadia S, Kumar P, Day J, Cho D, Drakos M, Ellis S. Risk Factors Associated With Worse Clinical Outcomes of Ankle Fractures Involving the Posterior Malleolus. FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231154217. [PMID: 36860801 PMCID: PMC9969454 DOI: 10.1177/24730114231154217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023] Open
Abstract
Background Ankle fractures involving the posterior malleolus (PM) tend to result in inferior clinical outcomes compared to other ankle fractures. However, it is unclear which specific risk factors and fracture characteristics are associated with negative outcomes in these fractures. The aim of this study was to identify risk factors for poor postoperative patient-reported outcomes in patients with fractures involving the PM. Methods This retrospective cohort study included patients who sustained ankle fractures involving the PM between March 2016 and July 2020 and had preoperative computed tomography (CT) scans. In total, 122 patients were included for analysis. One patient (0.8%) had an isolated PM fracture, 19 (15.6%) had bimalleolar ankle fractures involving the PM, and 102 (83.6%) had trimalleolar fractures. Fracture characteristics including the Lauge-Hansen (LH) and Haraguchi classifications and posterior malleolar fragment size were collected from preoperative CT scans. Patient Reported Outcome Measurement Information System (PROMIS) scores were collected preoperatively and at a minimum of 1 year postoperatively. The association between various demographic and fracture characteristics with postoperative PROMIS scores was assessed. Results Involvement of more malleoli was associated with worse PROMIS Physical Function (P = .04), Global Physical Health (P = .04), and Global Mental Health (P < .001), and Depression scores (P = .001). Elevated BMI was also associated with worse PROMIS Physical Function (P = .0025), Pain Interference (P = .0013), and Global Physical Health (P = .012) scores. Time to surgery, fragment size, Haraguchi classification, and LH classification were not associated with PROMIS scores. Conclusion In this cohort, we found that trimalleolar ankle fractures were associated with inferior PROMIS outcomes compared with bimalleolar ankle fractures involving the PM in multiple domains. Level of Evidence Level III, retrospective cohort study.
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Affiliation(s)
- Lavan Rajan
- Hospital for Special Surgery, New York,
NY, USA,Lavan Rajan, BA, Research Assistant,
Hospital for Special Surgery, 523 East 72nd St, 5th Floor, New York, NY 10021,
USA.
| | | | | | | | | | | | - David Cho
- Hospital for Special Surgery, New York,
NY, USA
| | - Mark Drakos
- Hospital for Special Surgery, New York,
NY, USA
| | - Scott Ellis
- Hospital for Special Surgery, New York,
NY, USA
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Rashid MS, Islam R, Marsden S, Trompeter A, Teoh KH. Validation of three classification systems for posterior malleolus fractures of the ankle. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-023-03476-3. [PMID: 36723774 DOI: 10.1007/s00590-023-03476-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 01/18/2023] [Indexed: 02/02/2023]
Abstract
PURPOSE A number of classification systems exist for posterior malleolar ankle fractures. The user reliability of these classification systems remains unclear. The primary aim of this study was to evaluate the reliability of three commonly utilised classification systems for fractures of the posterior malleolus. METHODS Imaging of 60 patients across 2 hospitals with ankle fractures including a posterior malleolar fragment was identified. All patients had undergone plain radiographs and computed tomography of their injured ankle as part of their normal standard of care. 9 surgeons including pre-resident/registrar level, resident/registrar level, and attending/consultant level applied the Haraguchi, Bartoníček, and Mason classifications to these fractures, at two timepoints, at least 4 weeks apart. The order was randomised between assessments. Inter-rater reliability was assessed using Fleiss' κ and standard error (SE). Intra-rater reliability was assessed using Cohen's κ and standard error (SE). RESULTS Inter-rater reliability (Fleiss' κ) was calculated for the Haraguchi classification as 0.588 (SE 0.023), for the Bartoníček classification as 0.626 (SE 0.019), and the Mason classification as 0.541 (SE 0.098). Intra-rater reliability (Cohen's κ) was 0.761 (SE 0.098) for the Haraguchi classification, 0.761 (SE 0.091) for the Bartoníček, classification, and 0.724 (SE 0.096) for the Mason classification. CONCLUSIONS This study reports the inter-rater and intra-rater reliability for three classification systems for posterior malleolus fractures. Based on definitions by Landis and Koch (Biometrics 33:159-174, 1977), inter-rater reliability was rated as 'moderate' for the Haraguchi and Mason classifications and 'substantial' for the Bartoníček classification. Similarly, the intra-rater reliability was rated as 'substantial' for all three classifications.
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Affiliation(s)
- Mustafa S Rashid
- St George's University Hospital, St. George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, England, UK.
| | - Raisa Islam
- The Princess Alexandra Hospital NHS Trust, Harlow, UK
| | - Samuel Marsden
- St George's University Hospital, St. George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, England, UK
| | - Alexander Trompeter
- St George's University Hospital, St. George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, England, UK
| | - Kar Hao Teoh
- The Princess Alexandra Hospital NHS Trust, Harlow, UK
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Plinsinga M, Manzanero S, Johnston V, Andrews N, Barlas P, McCreanor V. Characteristics and Effectiveness of Postoperative Rehabilitation Strategies in Ankle Fractures: A Systematic Review. J Orthop Trauma 2022; 36:e449-e457. [PMID: 36399682 DOI: 10.1097/bot.0000000000002436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To explore the characteristics and to report on the effectiveness of postoperative rehabilitation strategies for people with an ankle fracture. DATA SOURCES PubMed, Cochrane Library, EMBASE, Web of Science, and CINAHL were searched to identify studies published from January 2010 to November 2021. STUDY SELECTION Studies that described or evaluated postoperative rehabilitation strategies for surgically repaired ankle fractures were included. DATA EXTRACTION Data on postoperative rehabilitation were extracted in accordance with the Template for Intervention Description and Replication guide. Quality was assessed using the National Heart, Lung, and Blood Institute's Study Quality Assessment Tools. DATA SYNTHESIS Meta-analysis was planned to look at the effectiveness of postoperative rehabilitation strategies. Forty studies described postoperative rehabilitation strategies without evaluating effectiveness, whereas 15 studies focused on evaluating effectiveness. Because of the large variety in postoperative strategies and outcomes, narrative synthesis was deemed most suitable to answer our aims. Characteristics of postoperative rehabilitation strategies varied widely and were poorly described in a way that could not be replicated. Most of the studies (48%) used a late weight-bearing approach, although definitions and details around weight-bearing were unclear. CONCLUSIONS Late weight-bearing has been the most common postoperative approach reported in the past 10 years. The variety of definitions around weight-bearing and the lack of details of rehabilitation regimens limit replication and affect current clinical practice. The authors propose to adopt consistent definitions and terminology around postoperative practices such as weight-bearing to improve evidence for effectiveness and ultimately patient outcomes. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Melanie Plinsinga
- Jamieson Trauma Institute, Metro North Health, Herston, Australia
- RECOVER Injury Research Centre, the University of Queensland, Herston, Australia
- Menzies Health Institute Queensland, Griffith University, Nathan, Australia
| | - Silvia Manzanero
- Jamieson Trauma Institute, Metro North Health, Herston, Australia
- School of Clinical Sciences, Queensland University of Technology, Kelvin Grove, Australia
| | - Venerina Johnston
- RECOVER Injury Research Centre, the University of Queensland, Herston, Australia
- The University of Queensland, School of Health and Rehabilitation Sciences, St Lucia, Australia
| | - Nicole Andrews
- RECOVER Injury Research Centre, the University of Queensland, Herston, Australia
- Tess Cramond Pain and Research Centre, Metro North Hospital and Health Service, Herston, Australia
- Occupational Therapy Department, the Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Herston, Australia; and
| | - Panos Barlas
- Jamieson Trauma Institute, Metro North Health, Herston, Australia
| | - Victoria McCreanor
- Jamieson Trauma Institute, Metro North Health, Herston, Australia
- AusHSI, Centre for Healthcare Transformation, Queensland University of Technology, Kelvin Grove, Australia
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Pflüger P, Harder F, Müller K, Biberthaler P, Crönlein M. Evaluation of ankle fracture classification systems in 193 trimalleolar ankle fractures. Eur J Trauma Emerg Surg 2022; 48:4181-4188. [PMID: 35348840 PMCID: PMC9532295 DOI: 10.1007/s00068-022-01959-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 03/13/2022] [Indexed: 11/07/2022]
Abstract
Purpose Different classification systems have been developed for ankle fractures. In recent years, the posterior malleolus has gained in importance and led to computed tomography (CT)-based classification systems. The aim of the study was to analyse their reliability, fracture patterns and influence on treatment strategy. Methods Patients with a trimalleolar ankle fracture treated between 2011 and 2020 with preoperative radiographs and CT images were included. The blinded images were independently classified by three reviewers according to the AO/OTA, Herscovici, Bartoníček, Mason and Haraguchi classifications. The interobserver reliability was calculated by Fleiss' kappa (κ). CT images were analysed to determine the dimensions of the posterior malleolus fragments. Patient registries were reviewed regarding the treatment data. Results A total of 193 patients were included. The AO/OTA classification showed almost perfect inter- and intraobserver reliability (Fleiss’ κ = 0.86, 95% CI 0.82–0.90). Regarding the posterior malleolus, the Bartoníček classification demonstrated the highest reliability (Fleiss’ κ = 0.78, 95% CI 0.73–0.83). The Herscovici classification only reached moderate reliability for medial malleolus fractures (Fleiss' κ = 0.59, 95% CI 0.54–0.65). There was a trend towards direct fixation of the posterior malleolus in the last 3 years of the observation period (OR: 2.49, 95% CI 1.03–5.99). Conclusion In trimalleolar ankle fractures, the AO/OTA classification is a reliable system to characterize the type of fracture, but it fails to provide solid information about the posterior malleolus. Nowadays, treatment recommendations for trimalleolar ankle fractures focus on the configuration of the posterior malleolus; therefore, the results of this study advocate the use of the Bartoníček classification as a reliable tool to guide treatment.
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