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Tansey PJ, Chen J, Panchbhavi VK. Current concepts in ankle fractures. J Clin Orthop Trauma 2023; 45:102260. [PMID: 37872976 PMCID: PMC10589378 DOI: 10.1016/j.jcot.2023.102260] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/09/2023] [Indexed: 10/25/2023] Open
Abstract
Ankle fractures are among the most common orthopaedic injuries. Operative management is performed in unstable ankle fracture patterns to restore the stability and native kinematics of the ankle mortise and minimize the risk of post-traumatic degenerative changes. In this study, we review current concepts in ankle fracture management, including posterior malleolus fixation, syndesmosis fixation, deltoid ligament repair, fibular nailing, and early weightbearing, from both a biomechanical and clinical perspective.
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Affiliation(s)
- Patrick J. Tansey
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, 301 University Blvd, Route 0165, Galveston, TX, 77555-0165, USA
| | - Jie Chen
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, 301 University Blvd, Route 0165, Galveston, TX, 77555-0165, USA
| | - Vinod K. Panchbhavi
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, 301 University Blvd, Route 0165, Galveston, TX, 77555-0165, USA
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Bragg JT, Masood RM, Spence SS, Citron JE, Moon AS, Salzler MJ, Ryan SP. Predictors of Hardware Removal in Orthopaedic Trauma Patients Undergoing Syndesmotic Ankle Fixation With Screws. FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231198841. [PMID: 37724307 PMCID: PMC10505342 DOI: 10.1177/24730114231198841] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023] Open
Abstract
Background Indications for removal of syndesmotic screws are not fully elucidated. This study aimed to determine factors related to elective syndesmotic screw removal. Methods Patients who underwent fixation of ankle syndesmotic injuries were included. Screw removal was offered after a minimum of 12 weeks after surgery for pain, stiffness or patient desire to remove painful or broken hardware. Patient demographics, surgical data, distance of the syndesmotic screw from the joint, location of the screw at the physeal scar, and number of syndesmotic screws placed were collected for all patients. Bivariate and multivariate analyses were performed to determine the relationship between patient characteristics and screw removal and independent predictors of hardware removal. Results Of 160 patients, 60 patients (38%) with an average age of 36.1 (range: 18-84) years underwent elective syndesmotic screw removal at a mean of 7 (range, 3-47) months after initial fixation. The most common reason for screw removal (50/60 patients) was ankle stiffness and pain (83%). Patients who underwent screw removal were more likely to be younger (36.1 years ± 13.0 vs 46.6 years ± 18.2, P < .001) and have a lower ASA score (2 ± 0.8 vs 2.1 ± 0.7, P = .003) by bivariate analysis. Of patients who underwent screw removal, 21.7% (13/60) had a broken screw at the time of removal. Whether the screw was placed at the physeal scar was not significantly associated with patient decision for hardware removal (P = .80). Conclusion Younger and healthier patients were more likely to undergo elective removal of syndesmotic hardware. Screw distance from joint and screw placement at the physeal scar were not significantly associated with hardware removal. Level of Evidence Level III, retrospective cohort study.
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Affiliation(s)
- Jack T. Bragg
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA, USA
| | | | | | | | - Andrew S. Moon
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA, USA
| | - Matthew J. Salzler
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA, USA
| | - Scott P. Ryan
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA, USA
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Houwen T, de Munter L, Lansink KWW, de Jongh MAC. There are more things in physical function and pain: a systematic review on physical, mental and social health within the orthopedic fracture population using PROMIS. J Patient Rep Outcomes 2022; 6:34. [PMID: 35384568 PMCID: PMC8986932 DOI: 10.1186/s41687-022-00440-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 03/21/2022] [Indexed: 11/16/2022] Open
Abstract
Background The Patient-Reported Outcomes Information System (PROMIS®) is more and more extensively being used in medical literature in patients with an orthopedic fracture. Yet, many articles studied heterogeneous groups with chronic orthopedic disorders in which fracture patients were included as well. At this moment, there is no systematic overview of the exact use of PROMIS measures in the orthopedic fracture population. Therefore this review aimed to provide an overview of the PROMIS health domains physical health, mental health and social health in patients suffering an orthopedic fracture.
Methods This systematic review was documented according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. We searched Embase, Medline, Web of Science Core Collection, and Cochrane Central Register of controlled Trials, CINAHL and Google Scholar in December 2020 using a combination of MeSH terms and specific index terms related to orthopedic fractures and PROMIS questionnaires. Inclusion criteria were available full text articles that were describing the use of any PROMIS questionnaires in both the adult and pediatric extremity fracture population. Results We included 51 relevant articles of which most were observational studies (n = 47, 92.2%). A single fracture population was included in 47 studies of which 9 involved ankle fractures (9/51; 17.6%), followed by humeral fractures (8/51; 15.7%), tibia fractures (6/51; 11.8%) and radial -or ulnar fractures (5/51; 9.8%). PROMIS Physical Function (n = 32, 32/51 = 62.7%) and PROMIS Pain Interference (n = 21, 21/51 = 41.2%) were most frequently used questionnaires. PROMIS measures concerning social (n = 5/51 = 9.8%) and mental health (10/51 = 19.6%) were much less often used as outcome measures in the fracture population. A gradually increasing use of PROMIS questionnaires in the orthopedic fracture population was seen since 2017. Conclusion Many different PROMIS measures on multiple domains are available and used in previous articles with orthopedic fracture patients. With physical function and pain interference as most popular PROMIS measures, it is important to emphasize that other health-domains such as mental and social health can also be essential to fracture patients. Supplementary Information The online version contains supplementary material available at 10.1186/s41687-022-00440-3.
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Affiliation(s)
- Thymen Houwen
- Network Emergency Care Brabant, ETZ Hospital (Elisabeth-TweeSteden Ziekenhuis), Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands. .,Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Leonie de Munter
- Department of Traumatology, ETZ Hospital (Elisabeth-TweeSteden Ziekenhuis), Hilvarenbeekseweg 60, 5022 GC, Tilburg, the Netherlands
| | - Koen W W Lansink
- Department of Surgery, ETZ Hospital (Elisabeth-TweeSteden Ziekenhuis), Hilvarenbeekseweg 60, 5022 GC, Tilburg, the Netherlands
| | - Mariska A C de Jongh
- Network Emergency Care Brabant, ETZ Hospital (Elisabeth-TweeSteden Ziekenhuis), Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands
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Khurana A, Kumar A, Katekar S, Kapoor D, Vishwakarma G, Shah A, Singh MS. Is routine removal of syndesmotic screw justified? A meta-analysis. Foot (Edinb) 2021; 49:101776. [PMID: 33992455 DOI: 10.1016/j.foot.2021.101776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 01/10/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Syndesmosis injuries are common with rotational ankle injuries, and placement of a positional syndesmotic screw to maintain its reduction is used as the ligaments heal. There is no clear consensus on routine removal or retention of syndesmotic screw. This study aimed to appraise the current evidence both on removal and retention of syndesmotic screw and to conduct a meta-analysis comparing outcomes and rate of complications of syndesmotic screw removal and retention. METHODS Following PROSPERO registration, a systematic search using was performed using keywords ('Syndesmosis' OR 'Syndesmotic' OR 'Transsyndesmotic' OR 'distal tibiofibular') AND ('Screw') AND ('Removal' OR 'Retention') AND 'Outcome' in various databases. No language restrictions were applied and the meta-analysis incorporated the PRISMA statement. VAS (Visual analogue scale for pain), AOFAS (American Orthopaedic Foot And Ankle Society) scores expressed as mean ± SD, and both groups' complication rates were compared. Comparisons with a random-effects model were performed, and heterogeneity between the studies was calculated using the I2 statistic. T-test for two independent sample means was used to compare pooled mean and Z-test for two proportions to assess the difference in the proportion of complications. RESULTS A total of 7 studies with 522 patients were included in this review for analysis. Pooled analysis showed non-significant difference in AOFAS score (MD = -1.84; 95% CI: -4.33 to 0.66; p = 0.150) as well as for VAS score (MD = -0.48; 95% CI: -1.56 to 0.60; p = 0.390) between the two groups. The value of z and p-value for complication rates was 0.6021 and 0.5485, respectively, which was not significant. CONCLUSION There doesn't appear to be a difference in functional outcome, pain scores, and complication rates between patients who had their syndesmotic screws removed and those where screw was retained. The fear of inferior outcomes with retained screws is thus unfounded, and routine removal adds to morbidity and financial burden. In conclusion, present data does not support the routine removal of the intact syndesmosis screw, and a change in practice is needed to abandon routine syndesmotic screw removal.
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Affiliation(s)
- Ankit Khurana
- Department of Orthopaedics, ESI Hospital, Rohini, Delhi, India
| | - Arun Kumar
- Department of Orthopaedics, Indian Spinal Injury Centre, Delhi, India
| | - Shyam Katekar
- Department of Orthopaedics, Indian Spinal Injury Centre, Delhi, India
| | - Darshan Kapoor
- Department of Orthopaedics, Indian Spinal Injury Centre, Delhi, India
| | | | - Ashish Shah
- Department of Orthopaedics, UAB, Birmingham, Alabama, USA
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Kaiser PB, Bejarano-Pineda L, Kwon JY, DiGiovanni CW, Guss D. The Syndesmosis, Part II: Surgical Treatment Strategies. Orthop Clin North Am 2021; 52:417-432. [PMID: 34538352 DOI: 10.1016/j.ocl.2021.05.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Syndesmotic injuries in the setting of ankle fracture are critically important to diagnosis and treat to restore an anatomic tibiotalar relationship. Physical examination and clinical suspicion remain critically important for diagnosis. Ultrasound examination and weight-bearing computed tomography scans are evolving to help diagnosis more subtle injuries. Although flexible syndesmotic fixation may decrease malreduction rates, the benefits over rigid fixation is the subject of ongoing study. Anatomic reduction remains critical regardless of fixation choice. Routine removal of rigid syndesmotic hardware does not seem to offer substantial clinical improvement in pain or range of motion; however, broken hardware may cause irritation.
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Affiliation(s)
- Philip B Kaiser
- Department of Orthopaedic Surgery, Foot and Ankle Service, Harvard Medical School, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA; Foot & Ankle Research and Innovation Laboratory - Harvard Medical School, Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital - Newton-Wellesley Hospital, Boston, MA, USA.
| | - Lorena Bejarano-Pineda
- Department of Orthopaedic Surgery, Foot and Ankle Service, Harvard Medical School, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA; Foot & Ankle Research and Innovation Laboratory - Harvard Medical School, Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital - Newton-Wellesley Hospital, Boston, MA, USA
| | - John Y Kwon
- Department of Orthopaedic Surgery, Foot and Ankle Service, Harvard Medical School, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA; Foot & Ankle Research and Innovation Laboratory - Harvard Medical School, Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital - Newton-Wellesley Hospital, Boston, MA, USA
| | - Christopher W DiGiovanni
- Department of Orthopaedic Surgery, Foot and Ankle Service, Harvard Medical School, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA; Foot & Ankle Research and Innovation Laboratory - Harvard Medical School, Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital - Newton-Wellesley Hospital, Boston, MA, USA
| | - Daniel Guss
- Department of Orthopaedic Surgery, Foot and Ankle Service, Harvard Medical School, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA; Foot & Ankle Research and Innovation Laboratory - Harvard Medical School, Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital - Newton-Wellesley Hospital, Boston, MA, USA
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Sperring CP, Danford NC, Saltzman BM, Constant M, Dantzker NJ, Trofa DP. Patient-Reported Outcome Measurement Information System (PROMIS) in Orthopaedic Trauma Research. SICOT J 2021; 7:39. [PMID: 34269677 PMCID: PMC8284342 DOI: 10.1051/sicotj/2021035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 05/15/2021] [Indexed: 12/15/2022] Open
Abstract
This review describes the development, advantages and disadvantages, and applications of the Patient-Reported Outcome Measurement Information System (PROMIS) in orthopaedic trauma. PROMIS is a useful tool for quantifying outcomes in orthopedic trauma. It allows measurement of outcomes across multiple domains while minimizing administration time. PROMIS also reliably identifies clinical, social, and psychological risk factors for poor outcomes across a variety of orthopaedic injuries and disease states. However, PROMIS lacks specificity for certain anatomic regions and validation for mental health outcomes. It also is limited by ceiling effects in certain active patient populations. Orthopaedic traumatologists should be familiar with PROMIS, as its use is increasing and it is a valuable tool that can aid in clinical decision making.
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Affiliation(s)
- Colin P Sperring
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center/NY-Presbyterian Hospital, 622 West 168th Street, PH 11-1130, New York, 10032 NY, USA
| | - Nicholas C Danford
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center/NY-Presbyterian Hospital, 622 West 168th Street, PH 11-1130, New York, 10032 NY, USA
| | - Bryan M Saltzman
- Department of Orthopaedic Surgery, OrthoCarolina, 1915 Randolph Road, Charlotte, 28207 NC, USA
| | - Michael Constant
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center/NY-Presbyterian Hospital, 622 West 168th Street, PH 11-1130, New York, 10032 NY, USA
| | - Nicholas J Dantzker
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center/NY-Presbyterian Hospital, 622 West 168th Street, PH 11-1130, New York, 10032 NY, USA
| | - David P Trofa
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center/NY-Presbyterian Hospital, 622 West 168th Street, PH 11-1130, New York, 10032 NY, USA
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