Serial Radiographs Do Not Change the Clinical Course of Nonoperative Stable OTA/AO 44-B1 Ankle Fractures

The Use of the Lateral Tibial Line to Assess Ankle Alignment: A Preliminary Investigation

BACKGROUND

Although the medial clear space (MCS) is commonly used to assess talar alignment and ankle stability, its measurement is variable with multiple reported normal values. We have observed that the lateral tibial shaft is a reliable landmark to assess talar alignment. The objective of the current investigation was to determine the normal relationship of the lateral tibia to the superolateral talus using a tangent drawn inferiorly from the lateral tibial shaft, which we refer to as the "lateral tibial line" (LTL).

METHODS

The relationship of the LTL to the superolateral talus was assessed by three reviewers on 99 standing ankle mortise radiographs in uninjured patients. This relationship was quantified by measuring the distance (in millimeters) between the LTL and the superolateral talus. In addition, the interobserver reliability of the LTL measurement was recorded and compared with that of the MCS.

RESULTS

The median value for the distance between the superolateral talus and LTL was -0.50 mm with an interquartile range of -1.4 to 0.0 mm. The LTL was within 1 mm of the lateral talus in 176 of 297 reviewer measurements (59.3%). Moreover, it was either lateral to or at most 1 mm medial to the lateral talus in 90.9% of cases. The LTL measurement also demonstrated good interobserver reliability (0.764, 95% confidence interval, 0.670 to 0.834), similar to the measurement of MCS (0.742, 95% confidence interval, 0.539 to 0.846).

CONCLUSIONS

The relationship between the LTL and superolateral talus is easily measured with good reliability for assessing the anatomic relationship of the tibia and talus. The LTL uncommonly fell more than 1 mm medial to the superolateral talus, as might be seen with displaced ankle fractures. These findings will hopefully serve as a basis for future studies evaluating its role in assessing lateral displacement and stability of isolated fibula fractures.

LEVEL OF EVIDENCE

Level III, retrospective review.

Post Post-Mobilization Films for LC1 Pelvic Ring Injuries: Follow up Stress Imaging Demonstrates Minimal Utility

OBJECTIVE

To assess the utility of outpatient postmobilization radiographs in the nonoperative treatment of lateral compression type I (LC1) (OTA/AO 61-B1) pelvic ring injuries.

DESIGN

Retrospective series.

SETTING

Academic, Level 1 trauma center, 2008-2018.

PATIENTS/PARTICIPANTS

A series of 173 patients with nonoperatively treated LC1 pelvic ring injuries was identified. Of these, 139 received a complete set of outpatient pelvic radiographs with which to assess displacement.

INTERVENTION

Outpatient pelvic radiographs to assess additional fracture displacement and potential need for surgical intervention.

MAIN OUTCOME MEASUREMENTS

Rate of conversion to late operative intervention based on radiographic displacement.

RESULTS

No patient in this cohort received late operative intervention. A majority of the patients sustained incomplete sacral fractures (82.6%) and unilateral rami fractures (75.1%), and 92.8% demonstrated less than 10 mm of displacement on their final radiographs.

CONCLUSIONS

There is a low utility of repeat outpatient radiographs of stable, nonoperative LC1 pelvic ring injuries as they do not undergo late displacement.

LEVEL OF EVIDENCE

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

Utility of Post-Splinting Conventional Radiographs in Adult Patients With Ankle Fractures Presenting to the Emergency Department

BACKGROUND

Post-splinting radiographs are often performed in patients with ankle fractures to identify displacement that potentially occurs during splinting. The objective of this study was to investigate the significance of post-splinting conventional radiographs, with an emphasis on stable ankle fractures, not requiring reduction.

METHODS

A retrospective study in which all adult patients presenting with ankle fractures to the emergency department of a level 1 trauma center were included. The primary outcome was frequency of displacement at post-splinting radiographs. Secondary outcome was the rate of successful reduction attempts.

RESULTS

A total of 225 patients were included and the majority had a Supination-External Rotation (SER) type 2 or Weber B ankle fracture. One hundred fifty patients (mainly SER 2 fractures [68%] or Weber B [89%] fractures), were treated with a splint without fracture reduction. Post-splinting radiographs in these patients, as well as in all patients with a Supination-Adduction (SA) type 1 and 2 fractures, did not show loss of alignment.

CONCLUSION

Post-splinting radiographs are probably not necessary in any SA and SER type 2 or Weber A/B ankle fractures without medical clear space widening or need for reduction as no loss of alignment occurred when applying a splint.

LEVEL OF EVIDENCE

IV-Case Series.

True antiglide fixation of Danis-Weber B fibula fractures has lower rates of removal of hardware

INTRODUCTION

Plating of unstable OTA/AO 44-B2 equivalent lateral malleolus (Danis-Weber B) fractures has been associated with pain, peroneal irritation, and the need for subsequent hardware removal (ROH). The purpose of this study is to retrospectively compare the rates of ROH in unstable Weber B fractures fixed with a posterior, true antiglide plate with no screws in the distal segment versus those that were fixed with a similarly placed posterior, neutralization construct that included screws in the distal fragment. Thus, evaluating the role of the distal screws in rates of ROH.

METHODS

Skeletally mature patients that were treated for an unstable, isolated Weber B fracture at a single level-1 trauma center over a ten-year period were reviewed. Fractures treated with a single posterior plate with at least six months of follow-up were included and those fixed with a direct lateral plate were excluded. The primary outcome of this study was hardware removal defined as entire plate removal; isolated syndesmotic screw removal was not included.

RESULTS

Ninety-six patients were included in the study with average age of 46 years (range 17-83) and mean length of follow-up of 24.5 months (range 6.1-140.3). There were 33 patients in the antiglide group (mean follow-up 25.5 months) and 63 in the neutralization plate group (mean follow-up 24 months, p=0.81). Fractures fixed with or without distal screws had equivalent excellent results related to bony union and alignment. However, there was a statistically significant decrease in ROH rates in the antiglide group (antiglide ROH rate 15.2%; neutralization ROH rate 38.1%; p=0.02). Relative risk of ROH with antiglide plate was 0.4 (95% CI 0.17 - 0.95; p=0.04).

CONCLUSIONS

Antiglide plating shows a significant risk reduction in the rate of ROH when compared to posterior based neutralization plating. A true antiglide plating construct should be considered as a safe and effective way of managing Weber B fractures with a lower relative risk of a second operation for hardware removal.

LEVEL OF EVIDENCE

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

Utility and Associated Charge of Anteroposterior Radiographs in Rotational Ankle Fractures During Postoperative Follow-Up: The Results of an Orthopaedic Trauma Association Survey

OBJECTIVES

To evaluate the perceived utility and associated charges of the anteroposterior (AP) radiograph during rotational ankle fracture postoperative follow-up.

DESIGN

Survey study with charge analysis using published data at 50 orthopaedic hospitals in the United States.

SETTING

Not Applicable.

PARTICIPANTS

Orthopaedic Trauma Association Members with an active email address who were invited and interested in answering a survey.

RESULTS

Ninety-four percent of respondents stated that they did routinely obtain an AP radiograph during rotational ankle fracture follow-up. However, 57% thought that the AP view should be eliminated from standard follow-up and only 51% found this view useful after initial treatment.

CHARGE ANALYSIS

The mean difference between a 2-view and 3-view ankle radiograph series was $102.00. Using this value and the assumption that each patient with a rotational ankle fracture gets 3 follow-up radiographs, there is the potential for a charge reduction of $306 per patient. Assuming over 134,000 rotational ankle fractures, a charge reduction of 41 million US dollars (USD) per year is possible if the AP image is routinely removed. Actual savings are likely to be less based on agreed on payer rates. Although less easy to quantify, there is also a potential reduction of radiation exposure, radiologists' interpretation time, and data storage.

CONCLUSIONS

Routine AP radiographs should potentially be eliminated from routine postoperative ankle x-ray protocols based on this survey of experienced orthopaedic surgeons. If this specific radiograph is ordered on a case-by-case basis, then significant savings may occur.

Lack of Displacement of the Fibula Is Not a Confirmation of Ankle Stability in Supination External Pattern Ankle Fractures

OBJECTIVES

To evaluate and compare radiographic findings in supination external (SE)2 injuries versus stress (+) SE4 injuries.

DESIGN

Retrospective.

SETTING

Academic Level 1 trauma center.

PATIENTS

The study included 350 skeletally mature patients at a single Level 1 trauma center who presented with an isolated, Lauge-Hansen type supination-external rotation pattern, Weber B lateral malleolar fracture, OTA/AO 44-B.

RESULTS

We reviewed 350 patients (185 men and 165 women), 18-95 years of age (avg 45), with isolated SE pattern lateral malleolar fractures. One hundred nine had SE4 injuries [medial clear space (MCS) = 8.3 mm]. Two hundred forty-one ankles were stressed; 164 were unstable and 77 were stable (SE2). Avg MCS at presentation and on stress radiographs was 3.59 mm for the SE2 (no widening) and 3.86 mm and 5.94 mm for the stress (+) SE4 group, respectively. The fibular displacement for the SE2, stress (+) SE4, and SE4 groups was 1.5 (0-4.5), 3.5 (0-6.6), and 4.1 (0-30.5), respectively. Sixteen of the 77 (20%) SE2 and 24 of the 164 (15%) stress (+) SE4 fractures had no displacement of the fibula on the lateral view. Similarly, 53 of the 77 (68%) SE2 and 91 of the 164 (55%) stress (+) SE4 had ≤2 mm of fibular displacement Fibular displacement of ≤2 mm on the lateral radiograph corresponded with 0.69 sensitivity and only 0.37 positive predictive value for stable ankle mortise on stress examination.

CONCLUSIONS

Previous work indicated that patients with an isolated SE pattern fibula fracture, a normal MCS, and ≤2 mm of fibular displacement on the lateral radiograph have a high rate of ankle stability, with a positive predictive value of approximately 97%. We were unable to confirm this finding because 15% of unstable ankles had 0 mm and 55% had ≤2 mm of fibular displacement. We conclude that stability may not be inferred from a lack of fibular displacement on the lateral view in this population of patients. If stability is to be determined, it must be tested irrespective of fibular displacement on the lateral radiograph.

LEVEL OF EVIDENCE

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

Stability-Based Classification of Ankle Fractures-The Long-Term Outcome After 11-13 Years of Follow-up

OBJECTIVES

To assess the long-term functional and radiological outcome, as well as complications and reoperations of ankle fracture patients treated based on stability classification.

DESIGN

Retrospective.

SETTING

Main Trauma Center, University Hospital.

PATIENTS AND INTERVENTIONS

One hundred sixty patients were treated based on stability classification. After a mean follow-up of 12 years, 102 patients were assessed; 67 visited the outpatient clinic, and standard standing ankle radiographs were taken; osteoarthritis (OA) was graded according to Kellgren-Lawrence classification. The remaining patients (n = 35) were followed up via mail or telephone. The complications and reoperations of all 160 patients were collected from electronic patient records.

MAIN OUTCOME MEASURES

Olerud-Molander ankle score, foot and ankle outcome score, visual analog scale, RAND-36 item health survey, range-of-motion measurements, and Kellgren-Lawrence OA classification.

RESULTS

Very good to excellent ankle functional outcome was reported by 96% of the stable fracture group [mean Olerud-Molander ankle score (OMAS), 92; range, 20-100] and 82% of the unstable group (mean OMAS, 86; range, 30-100). For patients with an unstable fracture, OMAS and VAS pain scores significantly improved from 2 to 12 years, even though higher grades of radiologic OA were found. No patients with fractures deemed stable needed operative intervention even in the long-term follow-up. Instead, 30% of the operatively treated patients underwent reoperation during the long follow-up.

CONCLUSIONS

The treatment of ankle fractures based on stability-based classification led to predictable, functionally good outcomes even during long-term follow-up. Ankle fractures can reliably be deemed stable based on this classification and treated without failures in the long term.

LEVEL OF EVIDENCE

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

Ankle fractures in patients over age 55 years: Predictors of functional outcome

OBJECTIVES

To identify predictors of functional outcomes following treatment of ankle fracture in patients 55 years or older.

SETTING

Level 1 Trauma Center.

PATIENTS/PARTICIPANTS

Four hundred twenty-nine patients with torsional ankle fractures (44A-C): 233 patients (54%) were ages 55 to 64, 25% were between the ages 65 and 74; 21% were 75 years or older.

INTERVENTION

Operative or nonoperative management of ankle fracture.

MAIN OUTCOME MEASURE

Early complications were assessed for all patients after minimum of 6 months, and functional outcome scores as assessed by the Foot Function Index (FFI; n = 166, 39%) and Short Musculoskeletal Function Assessment (SMFA; n = 168, 39%) after median 57 months follow-up.

RESULTS

Surgical management was elected in 67% of patients. Nonoperative management became more common with advancing age and was associated with fewer unplanned operations (12% vs 3%, P < .01) and complications (21% vs 13%, P = .07). African American race was associated with worse pain on the FFI (P = .002) and BMI was associated with worse (higher) scores on all categories of the FFI and SMFA (all P < .05). Diabetes, neuropathy, and mental illness were also predictive of worse scores on various categories of both surveys. Assistive device use or nonambulatory status at the time of injury was associated with worse disability/dysfunction, activity, and mobility scores on both the FFI and SMFA (all P > 15, P < .05). Sex, Hispanic ethnicity, tobacco use, open fracture, dislocation, fracture pattern, and operative management were not independent predictors in this regression model.

CONCLUSIONS

Baseline health and ambulatory capacity at injury were more predictive of outcomes following ankle fracture than were fracture characteristics or type of treatment.

Is serial radiological evaluation of one-part proximal humeral fractures necessary?

AIMS

In order to determine whether and for whom serial radiological evaluation is necessary in one-part proximal humerus fractures, we set out to describe the clinical history and predictors of secondary displacement in patients sustaining these injuries.

PATIENTS AND METHODS

Between January 2014 and April 2016, all patients with an isolated, nonoperatively treated one-part proximal humerus fracture were prospectively followed up. Clinical and radiological evaluation took place at less than two, six, 12, and 52 weeks. Fracture configuration, bone quality, and comminution were determined on the initial radiographs. Fracture healing, secondary displacement, and treatment changes were recorded during follow-up.

RESULTS

In 100 patients (59 female, 41 male; mean age 57 years), 91 of the fractures (91%) remained stable. In five of nine patients (55%) with secondary displacement, surgery was recommended. Comminution, present in 23 patients (23%), was identified as a predictor of secondary displacement (p < 0.001). Patients' age, sex, fracture configuration, and bone quality were not associated with secondary displacement (p ≥ 0.438). Nonoperative treatment resulted in a mean absolute Constant score (CS) of 80 (49 to 98), relative CS of 101% (63% to 138%), median subjective shoulder value of 95% (interquartile range (IQR) 90% to 100%), and median EuroQol five-dimensional questionnaire score of 0.89 (IQR 0.80 to 1.00) with bone union in all cases at one-year follow-up.

CONCLUSION

Radiological re-evaluation was only necessary in patients presenting with comminution and may be redundant for 77% of patients with one-part proximal humerus fractures. Nonoperative treatment of one-part proximal humerus fractures remains the mainstay of treatment with a low rate of secondary surgery, a high union rate, and good clinical results. Cite this article: Bone Joint J 2019;101-B:1307-1312.

Orthopedic Surgeons Have Inadequate Knowledge of the Cost of Trauma-Related Imaging Studies

Radiographic imaging is integral to the diagnosis and treatment of orthopedic injuries. Previous studies have shown that orthopedists consistently underestimate the price of implants, but their knowledge of imaging charges is unknown. This study evaluated whether orthopedic residents and faculty could accurately estimate charges of imaging modalities at their respective institutions. A survey with 10 common imaging studies was sent to 8 academic level I trauma centers. Participants estimated the total charge of each imaging modality. This was compared with the actual charge at their institution. Seven centers produced 162 responders: 74 faculty and 88 residents. The differences between the estimated cost and the billing charge were calculated and broken down by training level and imaging modality. Overall, imaging charges were underestimated by 31% (P<.001), with 19.4% of estimates being within 20% of actual charges (95% confidence interval, 19.1-19.9). There was no difference between training levels (P=.69). There was greater than 1000% variation in charges between institutions. Orthopedists across training levels underestimate hospital charges associated with common imaging studies, and there is a large variation in charges between centers. Awareness of charges is important because charges affect clinical decision making and are relevant to practicing both cost-conscious and clinically sound medicine. [Orthopedics. 2019; 42(5):e454-e459.].