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Comadoll SM, Paull TZ, Boike S, Swenson R, Wojahn RD, Nguyen MP. Preoperative CT Scans Prior to Distal Tibial Intramedullary Nailing Do not Change Treatment Decisions or Surgical Outcomes. J Am Acad Orthop Surg 2024:00124635-990000000-01114. [PMID: 39378430 DOI: 10.5435/jaaos-d-24-00600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 08/17/2024] [Indexed: 10/10/2024] Open
Abstract
INTRODUCTION Distal tibia shaft fractures have a high association with posterior malleolar fractures (PMFs); hence, a preoperative ankle CT scan is commonly obtained. The purpose of this study was to determine whether a CT scan for distal third tibia shaft fractures is associated with differences in recognition of a posterior malleolus fracture (PMF), treatment of an identified PMF, outcomes, and postoperative complications. METHODS We retrospectively reviewed cases of adult patients with distal third tibia shaft fractures treated with an intramedullary nail between 2018 and 2020. Patients were divided into 2 groups based on whether they received a preoperative ankle CT scan. Outcomes included surgical time, the rate of missed PMFs or postoperative PMF displacement, the treatment of the PMFs, postoperative weight-bearing restrictions, Patient-Reported Outcomes Measurement Information System Global-10 (PROMIS Global-10) scores, and unplanned revision surgeries. RESULTS 124 patients (age 45 ± 18 years; 39.5% female) with distal third tibia shaft fractures treated with intramedullary nailing and with minimum 6 months of follow-up were reviewed. 26 patients received preoperative CT scans, and 98 patients did not have CT scans. The rate of detected PMF was 69.2% (N = 18) in patients with CT and 55.1% (N = 54) in patients without CT (P = 0.19). No significant differences were observed in all outcomes between the 2 groups (P > 0.05). 3 PMFs not visible on radiographs were identified on CT, and they did not require fixation and did not displace. PMFs that were greater than one-third of the joint surface were more likely to have a preoperative CT (P < 0.01). DISCUSSION Preoperative CT scans for distal third tibia shaft fractures may be useful in characterizing large PMFs; however, this knowledge does not translate into shorter surgical time, increased fixation rates, decreased unplanned revision surgery, or improved patient-reported outcomes. Discovery of PMFs did not always lead to fixation, and PMFs without fixation did not become further displaced.
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Affiliation(s)
- Shea M Comadoll
- From the Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN (Comadoll, Paull, Boike, Swenson, Wojahn, and Nguyen), and the Department of Orthopaedic Surgery, Regions Hospital, Saint Paul, MN (Paull, Swenson, Wojahn, and Nguyen)
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Nedder VJ, Moon TJ, Swetz AM, Ochenjele G, Wetzel RJ, Sontich JK, Napora JK. Utility of CT Scans for Detecting Operative Malleolar Fractures Associated With Tibial Shaft Fractures. J Orthop Trauma 2024; 38:e318-e324. [PMID: 39150304 DOI: 10.1097/bot.0000000000002862] [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: 06/06/2024] [Indexed: 08/17/2024]
Abstract
OBJECTIVES The purpose of this study was to define the utility of CT scans for detecting articular extension in tibial shaft fractures and determine whether radiographic parameters can predict the presence of operative distal tibial articular fractures (DTAFs). METHODS DESIGN Retrospective cohort study. SETTING Single level I trauma center. PATIENT SELECTION CRITERIA Patients age 18 years and older who were treated operatively for tibial shaft fractures occurring at or below the tibial isthmus were included. Patients were excluded for extension of the main tibial shaft fracture into the tibial plafond (AO/OTA 43 B/C), ballistic injuries, and absence of a preoperative CT scan. OUTCOME MEASURES AND COMPARISONS The primary outcome was CT utility, defined as the presence of a DTAF or DTAF displacement on CT that was not recognized on plain radiographs on secondary analysis at the time of the study by a senior-level resident. Secondary outcome was the association between radiographic parameters and operative DTAFs. Variables with P ≤ 0.2 on univariate testing were included in a multiple binary logistic regression model to determine independent predictors of operative DTAFs. RESULTS One hundred forty-four patients were included, with a mean age of 52 years. Seventy-six patients (53%) were men. CT utility was 41% for the identification of unrecognized DTAFs. CT utility was 79% for isolated pDTAF, 57% for medial DTAF, 83% for isolated anterolateral DTAF, and 100% for multiple DTAFs. Operative DTAFs were independently associated with spiral tibial shaft fracture type (P < 0.001) and low fibular fracture (P = 0.04). In patients who had both spiral tibial shaft fracture type and low fibula fracture, the rate of operative DTAF was 46% (22/48). CONCLUSIONS CT scans identified DTAFs that were unrecognized on plain radiographs in 41% of cases. CT scans were most useful in identifying nonposterior DTAFs. CT scans may be considered for all distal third tibial fractures, but especially those with spiral tibial shaft patterns and low fibular fractures, to avoid missing operative articular injury. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Victoria J Nedder
- Case Western Reserve University School of Medicine, Cleveland, OH; and
| | - Tyler J Moon
- Department of Orthopaedic Trauma Surgery, University Hospitals, Cleveland, OH
| | - Anna M Swetz
- Case Western Reserve University School of Medicine, Cleveland, OH; and
| | - George Ochenjele
- Department of Orthopaedic Trauma Surgery, University Hospitals, Cleveland, OH
| | - Robert J Wetzel
- Department of Orthopaedic Trauma Surgery, University Hospitals, Cleveland, OH
| | - John K Sontich
- Department of Orthopaedic Trauma Surgery, University Hospitals, Cleveland, OH
| | - Joshua K Napora
- Department of Orthopaedic Trauma Surgery, University Hospitals, Cleveland, OH
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Kalantar SH, Bagheri N, Milan N, Mehni SM, Oskouie IM, Alinia T, Rahimdoost N. Evaluation of treatment planning discrepancies: CT versus plain radiographic findings in patients with foot and ankle trauma. BMC Res Notes 2024; 17:238. [PMID: 39215333 PMCID: PMC11365251 DOI: 10.1186/s13104-024-06902-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 08/19/2024] [Indexed: 09/04/2024] Open
Abstract
This study aimed to compare the findings of plain radiography and computed tomography (CT) of foot and ankle in patients submitted to the emergency department with high-energy foot and ankle trauma, to demonstrate if missing fractures on plain radiographs will significantly alter the treatment plan considered for each patient based on the findings of each imaging modality. We retrospectively observed standard radiological foot and ankle x-rays and CT scans in patients who presented to our center from April 2019 to June 2020 with a history of foot and ankle trauma with either loss of consciousness, a history of high-energy trauma, or clinical presentation disproportionate to plain radiographic findings. We investigated the number of fractures of each bone detected on plain radiographs and CT scans and the treatments based on each modality's findings in patients admitted to our center. Sixty-five out of 163 (39.87%) included in our study had at least one missed fracture on plain radiography that was detected on CT. Thirty-one (19%) patients had normal radiography despite actually having fractures. In 38 (23.31%) patients CT changed the treatment plan decided by our surgeons (P < 0.001). The two imaging modalities had a moderate agreement for detecting foot and ankle fractures overall (κ = 0.432). The failure to detect fractures in patients with high-energy trauma can significantly impact treatment effectiveness. Integrating CT scans into the diagnostic process can lead to changes in treatment planning and ultimately improve patient outcomes. LEVEL OF CLINICAL EVIDENCE: IV.
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Affiliation(s)
- Seyed Hadi Kalantar
- Department of Orthopedic and Trauma Surgery, Joint Reconstruction Research Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Nima Bagheri
- Department of Orthopedic and Trauma Surgery, Joint Reconstruction Research Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Nesa Milan
- Department of Orthopedic and Trauma Surgery, Joint Reconstruction Research Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Sare Moslemi Mehni
- Department of Radiology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Tina Alinia
- Department of Orthopedic and Trauma Surgery, Joint Reconstruction Research Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Nazanin Rahimdoost
- Center for Orthopedic Trans-Disciplinary Applied Research, Tehran University of Medical Sciences, Tehran, Iran.
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Gougoulias N, Christidis P, Christidis G, Markopoulos P, Biniaris G. Posterior Malleolus Fracture Fixation In Lateral Decubitus Position: Surgical Technique and Results in 60 Patients. J Foot Ankle Surg 2024:S1067-2516(24)00172-8. [PMID: 39098651 DOI: 10.1053/j.jfas.2024.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 07/14/2024] [Accepted: 07/27/2024] [Indexed: 08/06/2024]
Abstract
The present study shows how posterior malleolus fractures (PMFs) and distal fibular fractures were fixed using the posterolateral approach with the patient in lateral decubitus position, not previously described in the literature. This technique has been used in 60 consecutive patients (42 women and 18 men; mean age 54.7; range 21-92 years), 33 of which presented as fracture dislocations from March, 2021 to December, 2023. After PMFs fixation in lateral decubitus position, release of the sacral support allowed patients to be placed supine (without de-sterilizing the operative field), in order to proceed with medial malleolus or posteromedial fragment fixation. Fractures were classified according to the Lauge Hansen classification as SER4 (n = 50), PER4 (n = 7), SAD (n = 1), and PAB (n = 2). Fractures were classified according to Rammelt & Bartonicek, as type B (n = 40), C (n = 13), and D (n = 7). During the same period of time 14 fractures involving the PM, classified as type A, were treated with indirect fixation, whilst 6 geriatric and/or poor mobility patients with fracture dislocations were treated with retrograde hindfoot nail fixation. Follow-up period ranged from 4-36 months (mean = 14.4; SD = 8.8). Complications occurred in 5 patients (8.3%; 3 had delayed (medial) wound healing, one developed CRPS and one required implants removal and arthroscopy because of metal irritation and stiffness). No deep infections, thromboembolic events, fracture malreductions or malunions were recorded and all patients returned to the preinjury mobilization status. In conclusion, PM fracture fixation was feasible and safely performed with patients in lateral decubitus position.
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Affiliation(s)
- Nikolaos Gougoulias
- Department of Orthopaedic Surgery, General Hospital of Katerini, Katerini, Greece.
| | | | - Georgios Christidis
- Department of Orthopaedic Surgery, General Hospital of Katerini, Katerini, Greece
| | | | - Georgios Biniaris
- Department of Orthopaedic Surgery, General Hospital of Katerini, Katerini, Greece
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Lassiter EM, Brown KJ, Patel D, Sparks A, Liu J, Elattar O. A systematic review of posterior pilon variant fractures. J Orthop 2024; 53:73-81. [PMID: 38476677 PMCID: PMC10926286 DOI: 10.1016/j.jor.2024.02.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 02/19/2024] [Indexed: 03/14/2024] Open
Abstract
Posterior pilon variant ankle fractures (PPVF) are a unique subtype of posterior malleolar fractures which have been a source of controversy and confusion in recent years. There has not been a thorough literature review previously written on the topic. Database searches of PubMed and Embase were conducted from inception until June 2023. The key words included "pilon variant," "posterior pilon variant," and "posterior pilon" fractures. Outcomes were evaluated by union time, rates of delayed union, nonunion, malunion, and complication. A total of 15 articles relevant to surgical repair of pilon variant fractures were included in the literature review. The unique mechanism of injury has been reported to involve both rotational and axial forces, leading to involvement of the posterior and medial aspects of the distal tibia. Pilon variant fractures can be suspected by several characteristics on radiographs and have a high confirmation rate via CT images. Multiple systems have been proposed to classify this fracture pattern, but there is no consensus on the ideal classification system. Surgically, direct fixation has shown better short-term clinical outcomes versus indirect fixation or no fixation. PPVF have a distinct fracture pattern involving the posterior and medial columns of the distal tibial plafond, and results from a mechanism intermediate to rotational and axial forces. These fractures are more severe than tri-malleolar fractures due to increased rates of articular impaction and incongruity. Future classification systems should focus on joint surface area and the tibial pilon column involved to avoid confusion with less severe posterior malleolar fractures.
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Affiliation(s)
- Eric M. Lassiter
- Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, OH, 43614, United States
| | - Kevin J. Brown
- Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, OH, 43614, United States
| | - Devon Patel
- Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, OH, 43614, United States
| | - Addison Sparks
- Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, OH, 43614, United States
| | - Jiayong Liu
- Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, OH, 43614, United States
| | - Osama Elattar
- Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, OH, 43614, United States
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Hunt AA, Maschhoff C, Van Rysselberghe N, Gonzalez CA, Goodnough H, Gardner M, Bishop JA. Historic indications for fixation of posterior malleolus fractures- where did they come from and where are we now? Injury 2024; 55:111537. [PMID: 38657283 DOI: 10.1016/j.injury.2024.111537] [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: 10/28/2023] [Revised: 03/14/2024] [Accepted: 04/01/2024] [Indexed: 04/26/2024]
Abstract
INTRODUCTION The indications for reduction and fixation of the posterior malleolus component of rotational ankle fractures have been controversial for nearly a century. This study aims to identify the historical basis for surgical intervention and trace trends in management strategies over time. METHODS In March 2023, a systematic review of full-text, English-language articles providing indications for surgical fixation of the posterior malleolus component of rotational ankle fractures was performed. Articles underwent title and abstract screening before undergoing full-text review. RESULTS Historical indications for surgical fixation were size-dependent, with fractures comprising 25 % to 33 % of the plafond recommended for internal fixation. Modern studies suggest that nonoperative management of posterior malleolus fractures below this threshold results in residual malreduction of the articular surface, syndesmotic instability, and an increased need for independent fixation of the syndesmosis. CONCLUSIONS Size-based indications for posterior malleolus fracture fixation are based on Level V evidence from small retrospective case series published nearly one century ago and should be retired. While the size of the posterior malleolus component cannot be ignored, additional factors like fracture morphology and location within the plafond should guide modern surgical indications. Contemporary studies indicate that reduction and fixation of small posterior malleolus fractures (comprising less than 25 % of the articular surface) are associated with improved articular reductions, tibiotalar contact pressures, syndesmotic stability with decreased need for independent fixation of the syndesmosis, and superior postoperative outcomes.
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Affiliation(s)
- Anastasia A Hunt
- Stanford University, Department of Orthopedic Surgery, 300 Pasteur Drive, Edwards Bldg, R144, Stanford, CA USA.
| | - Clayton Maschhoff
- University of Illinois at Chicago School of Medicine, Chicago, IL USA
| | - Noelle Van Rysselberghe
- Stanford University, Department of Orthopedic Surgery, 300 Pasteur Drive, Edwards Bldg, R144, Stanford, CA USA
| | | | - Henry Goodnough
- Stanford University, Department of Orthopedic Surgery, 300 Pasteur Drive, Edwards Bldg, R144, Stanford, CA USA
| | - Michael Gardner
- Stanford University, Department of Orthopedic Surgery, 300 Pasteur Drive, Edwards Bldg, R144, Stanford, CA USA
| | - Julius A Bishop
- Stanford University, Department of Orthopedic Surgery, 300 Pasteur Drive, Edwards Bldg, R144, Stanford, CA USA
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Mansur NSB, Neves CMSCC, Celestino FS, Gonçalves JPP, Pereira VF, Silva PDV, Matsunaga FT, Nery CAS, Astur DC. Computed tomography changes diagnosis, management and surgical planning of ankle fractures. Musculoskelet Surg 2024; 108:183-194. [PMID: 38462596 DOI: 10.1007/s12306-024-00814-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 02/16/2024] [Indexed: 03/12/2024]
Abstract
PURPOSE To demonstrate how the use of adjunctive Computed Tomography (CT) can modify diagnosis, treatment options, and operative planning of ankle fractures in comparison with conventional radiographs (CR) in isolation. MATERIALS AND METHODS A total of 53 patients diagnosed with an ankle fracture between 2011 and 2016, were assessed with CT and CR. Evaluations of the fractures using CR in isolation and CR combined with CT were compared using different readers. Fractures were assessed in terms of type, displacement, size, associated injuries, treatment, patient position and surgical planning. RESULTS The medial malleolus fractures characteristics (posteromedial fragment and anterior colliculus), the presence of posterior malleolus fracture and its characteristics (displacement, size, posteromedial or posterolateral segment) (ps < 0.042), syndesmosis injury (p < 0.001), and the absence of deltoid ligament lesion (p < 0.001), were more evident with the combination of CT and radiographs. There was an increase in operative indication (p = 0.007), prone positioning (p = 0.002), posterior malleolus surgical treatment (p < 0.001), posterolateral approach for the lateral malleolus (p = 0.003), and syndesmosis fixation (p = 0.020) with the association of CT and CR, among all groups of expertise, with a high interobserver reliability (> 0.75). CONCLUSIONS The CR may fail to demonstrate subtle lesions, such as posterior malleolus fractures and syndesmotic injuries. The CT evaluation increases the diagnostic precision and improves the quality of information the surgeon receives, what might positively affect patient care. LEVEL OF EVIDENCE III Retrospective Comparative Study.
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Affiliation(s)
- N S B Mansur
- Department of Orthopedics and Traumatology, Escola Paulista de Medicina, Universidade Federal de São Paulo, 740 Botucatu St, 1st Floor, São Paulo, SP, 04023-062, Brazil.
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA.
| | - C M S C C Neves
- Department of Orthopedics and Traumatology, Escola Paulista de Medicina, Universidade Federal de São Paulo, 740 Botucatu St, 1st Floor, São Paulo, SP, 04023-062, Brazil
| | - F S Celestino
- Department of Orthopedics and Traumatology, Escola Paulista de Medicina, Universidade Federal de São Paulo, 740 Botucatu St, 1st Floor, São Paulo, SP, 04023-062, Brazil
| | - J P P Gonçalves
- Department of Orthopedics and Traumatology, Escola Paulista de Medicina, Universidade Federal de São Paulo, 740 Botucatu St, 1st Floor, São Paulo, SP, 04023-062, Brazil
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - V F Pereira
- Department of Orthopedics and Traumatology, Escola Paulista de Medicina, Universidade Federal de São Paulo, 740 Botucatu St, 1st Floor, São Paulo, SP, 04023-062, Brazil
| | - P D V Silva
- Department of Orthopedics and Traumatology, Escola Paulista de Medicina, Universidade Federal de São Paulo, 740 Botucatu St, 1st Floor, São Paulo, SP, 04023-062, Brazil
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - F T Matsunaga
- Department of Orthopedics and Traumatology, Escola Paulista de Medicina, Universidade Federal de São Paulo, 740 Botucatu St, 1st Floor, São Paulo, SP, 04023-062, Brazil
| | - C A S Nery
- Department of Orthopedics and Traumatology, Escola Paulista de Medicina, Universidade Federal de São Paulo, 740 Botucatu St, 1st Floor, São Paulo, SP, 04023-062, Brazil
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - D C Astur
- Department of Orthopedics and Traumatology, Escola Paulista de Medicina, Universidade Federal de São Paulo, 740 Botucatu St, 1st Floor, São Paulo, SP, 04023-062, Brazil
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Massri-Pugin J, Morales S, Serrano J, Mery P, Filippi J, Villa A. Percutaneous Fixation of Posterior Malleolar Fractures: A Contemporary Review. FOOT & ANKLE ORTHOPAEDICS 2024; 9:24730114241256371. [PMID: 38840784 PMCID: PMC11151760 DOI: 10.1177/24730114241256371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Affiliation(s)
- Jafet Massri-Pugin
- Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Sergio Morales
- Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Javier Serrano
- Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Pablo Mery
- Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jorge Filippi
- Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Andrés Villa
- Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
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Kocan J, Joseph E, Mercado P, Haider MN, Pavlesen S, Rohrbacher B. Computed Tomography Scans and Fixation Rates for Trimalleolar Ankle Fractures Over 10 Years at a Level 1 Trauma Center. FOOT & ANKLE ORTHOPAEDICS 2024; 9:24730114231216984. [PMID: 38223655 PMCID: PMC10785731 DOI: 10.1177/24730114231216984] [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: 01/16/2024] Open
Abstract
Background The posterior malleolus component of the trimalleolar ankle fracture has posed a controversial topic for diagnostic imaging and surgical management. Preoperative computed tomography (CT) scans are used to better appreciate fracture morphology and may affect management techniques. No prior study has investigated the trend in preoperative CT scan use and the rates of posterior and syndesmotic fixation for trimalleolar injuries. Methods This retrospective cohort study evaluated the use of preoperative CT scans and the rates of posterior and syndesmotic fixation for trimalleolar ankle fractures over a 10-year period at an adult level 1 trauma center. Patients surgically managed for ankle fractures with OTA/AO classifications of 44B3, 44C3.3, 44C1.3, 44C2.3, and 44A3 were identified and included using Current Procedural Terminology codes and a prospectively collected fracture registry. Demographic information, comorbidities, fixation methods, and use of preoperative CT scan were recorded. Comparative analyses were performed to assess for yearly differences in demographic characteristics along with changes in trends of preoperative CT scans and posterior and syndesmotic fixation. Results A total of 1191 patients were included in the analyses. OTA/AO 44B3.2 fractures were the most common injuries (yearly range of 59.4%-80.1%). The rate of posterior fixation did not significantly increase during the study interval (1.4% growth per year [95% CI -0.27, 3.07]). However, the rate of preoperative CT scan use significantly increased by 2.76% (95% CI 1.99, 3.52) per year and the rate of syndesmotic fixation increased by 2.58% (95% CI 1.17, 3.99) per year. Fixation methods for both the syndesmosis and posterior malleolus changed during the study timeline. Conclusion Despite a relatively stable rate of posterior fixation, the frequency of preoperative CT scans and use of syndesmotic fixation increased significantly over a 10-year study period. Level of Evidence Level IV, descriptive pilot study.
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Affiliation(s)
- Joseph Kocan
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
| | - Elias Joseph
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
| | - Paul Mercado
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
| | - Mohammad N. Haider
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
| | - Sonja Pavlesen
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
| | - Bernard Rohrbacher
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
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Fűzy EJ, Ferreira N, Brown C, Hugo D, Joubert E, Burger M. The reliability of posterior malleolar ankle fracture assessment: a unique perspective. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:539-548. [PMID: 37644335 PMCID: PMC10771354 DOI: 10.1007/s00590-023-03702-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 08/17/2023] [Indexed: 08/31/2023]
Abstract
AIM This study aims to elucidate the pathology of PMFs in the South African population, establish correlations between fracture patterns and international classification guidelines and evaluate the interobserver reliability of current classifications. METHODS A retrospective review was conducted in a multicentre analysis over a one-year period from January 2019 to December 2019 at our institution. Computer tomography scans for foot and ankle injuries were reviewed, and posterior malleolus fractures were included. Pathoanatomical data was collected and analysed according to known classification systems and subsequent treatment modalities evaluated. A panel of observers individually reviewed radiographic data to determine interobserver reliability. RESULTS A total of 71 patients were included with a mean age of 41 ± 13.4 years (range 18-78) and a female predominant population (69%). A greater proportion of injuries were high energy (23.9%), with significant fragment comminution (53.5%), and half (52.1%) of all injuries were subluxated/dislocated at presentation. A total of 93% of injuries were managed operatively, despite theatre access limitations resulting in significant delays to fixation (19.1 days). Despite good pathoanatomical agreement with most international classifications, interobserver reliability was poor (Krippendorff α-coefficient < 0.667). Inconsistent treatment patterns in operative and non-operative strategies are reported. CONCLUSION A unique patient population of younger, female individuals incurred posterior malleolar fractures due to higher energy mechanisms of injury. Whilst injury patterns were mostly comparable, significant interobserver variability was noted. Resource limitations, diagnostic challenges, poorly defined and inconsistent treatment strategies, inevitably impact outcomes within the South African population. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Edward Joseph Fűzy
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, 7505, South Africa
| | - Nando Ferreira
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, 7505, South Africa.
| | - Craig Brown
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, 7505, South Africa
| | - Daniel Hugo
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, 7505, South Africa
| | - Etienne Joubert
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, 7505, South Africa
| | - Marilize Burger
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, 7505, South Africa
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De Marchi Neto N, Nesello PFT, Bergamasco JM, Costa MT, Christian RW, Severino NR. Importance of computed tomography in posterior malleolar fractures: Added information to preoperative X-ray studies. World J Orthop 2023; 14:868-877. [PMID: 38173804 PMCID: PMC10758590 DOI: 10.5312/wjo.v14.i12.868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/18/2023] [Accepted: 10/16/2023] [Indexed: 12/15/2023] Open
Abstract
BACKGROUND Ankle fractures are common lesions of the lower limbs. Approximately 40% of ankle fractures affect the posterior malleolus (PM). Historically, PM osteosynthesis was recommended when PM size in X-ray images was greater than 25% of the joint. Currently, computed tomography (CT) has been gaining traction in the preoperative evaluation of ankle fractures. AIM To elucidate the similarity in dimensions and to correlate PM size in X-ray images with the articular surface of the affected tibial plafond in the axial view on CT (AXCT) of a PM fracture. METHODS Eighty-one patients (mean age: 39.4 ± 13.5 years) were evaluated (54.3% were male). Two independent examiners measured PM size in profile X-ray images (PMXR) and sagittal CT (SAGCT) slices. The correlation of the measurements between the examiners and the difference in the PM fragment sizes between the two images were compared. Next, the PM size in PMXR was compared with the surface of the tibial plafond involved in the fracture in AXCT according to the Haraguchi classification. RESULTS The correlation rates between the examiners were 0.93 and 0.94 for PMXR and SAGCT, respectively (P < 0.001). Fragments were 2.12% larger in SAGCT than in PMXR (P = 0.018). In PMXR, there were 56 cases < 25% and 25 cases ≥ 25%. When PMXR was < 25%, AXCT corresponded to 10.13% of the tibial plafond. When PMXR was ≥ 25%, AXCT was 24.52% (P < 0.001). According to the Haraguchi classification, fracture types I and II had similar PMXR measurements that were greater than those of type III. When analyzing AXCT, a significant difference was found between the three types, with II > I > III (P < 0.001). CONCLUSION PM fractures show different sizes using X-ray or CT images. CT showed a larger PM in the sagittal plane and allowed the visualization of the real dimensions of the tibial plafond surface.
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Affiliation(s)
- Noé De Marchi Neto
- Department of Orthopedics and Traumatology of the São Paulo Mercy Hospital (Santa Casa de São Paulo)-Fernandinho Simonsen Pavillion, Faculdade de Ciências Médicas da Santa Casa de São Paulo-Brazil, São Paulo 01221-020, Brazil
| | - Pietro Felice Tomazini Nesello
- Department of Orthopedics and Traumatology of the São Paulo Mercy Hospital (Santa Casa de São Paulo)-Fernandinho Simonsen Pavillion, Faculdade de Ciências Médicas da Santa Casa de São Paulo-Brazil, São Paulo 01221-020, Brazil
| | - Jordanna Maria Bergamasco
- Department of Orthopedics and Traumatology of the São Paulo Mercy Hospital (Santa Casa de São Paulo)-Fernandinho Simonsen Pavillion, Faculdade de Ciências Médicas da Santa Casa de São Paulo-Brazil, São Paulo 01221-020, Brazil
| | - Marco Tulio Costa
- Department of Orthopedics and Traumatology of the São Paulo Mercy Hospital (Santa Casa de São Paulo)-Fernandinho Simonsen Pavillion, Faculdade de Ciências Médicas da Santa Casa de São Paulo-Brazil, São Paulo 01221-020, Brazil
| | - Ralph Walter Christian
- Department of Orthopedics and Traumatology of the São Paulo Mercy Hospital (Santa Casa de São Paulo)-Fernandinho Simonsen Pavillion, Faculdade de Ciências Médicas da Santa Casa de São Paulo-Brazil, São Paulo 01221-020, Brazil
| | - Nilson Roberto Severino
- Department of Orthopedics and Traumatology of the São Paulo Mercy Hospital (Santa Casa de São Paulo)-Fernandinho Simonsen Pavillion, Faculdade de Ciências Médicas da Santa Casa de São Paulo-Brazil, São Paulo 01221-020, Brazil
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Lawson KA, Ayala AE, Morin ML, Latt LD, Wild JR. Republication of "Ankle Fracture-Dislocations: A Review". FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231195058. [PMID: 37582190 PMCID: PMC10423454 DOI: 10.1177/24730114231195058] [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: 08/17/2023] Open
Abstract
Ankle fractures are common musculoskeletal injuries that may result in tibiotalar joint dislocations. Ankle fracture-dislocations occur via similar mechanisms as ankle fractures, although the persistence or magnitude of the deforming force is sufficient to disrupt any remaining bony or soft-tissue stability. Ankle fracture-dislocations likely represent distinct clinical entities, as the pathology, management, and patient outcomes following these injuries differ from those seen in more common ankle fractures without dislocation. Ankle fracture-dislocations have higher rates of concomitant injury including open fractures, chondral lesions, and intra-articular loose bodies. Long-term outcomes in ankle fracture-dislocations are worse than ankle fractures without dislocation. Higher rates of posttraumatic osteoarthritis and chronic pain have also been reported. In this review, we discuss the current literature regarding the history, management, and outcomes of ankle-fracture dislocations and highlight the need for future study.
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Affiliation(s)
- Kevin A Lawson
- Department of Orthopaedic Surgery, The University of Arizona College of Medicine, Tucson, AZ, USA
| | - Alfonso E Ayala
- The University of Arizona College of Medicine, Tucson, AZ, USA
| | - Matthew L Morin
- Department of Orthopaedic Surgery, The University of Arizona College of Medicine, Tucson, AZ, USA
| | - L Daniel Latt
- Department of Orthopaedic Surgery, The University of Arizona College of Medicine, Tucson, AZ, USA
| | - Jason R Wild
- Department of Orthopaedic Surgery, The University of Arizona College of Medicine, Tucson, AZ, USA
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Haws BE, Karnyski S, DiStefano DA, Soin SP, Flemister AS, Ketz JP. Reduction of Posterior Malleolus Fractures With Open Fixation Compared to Percutaneous Treatment. FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231200485. [PMID: 37786607 PMCID: PMC10541751 DOI: 10.1177/24730114231200485] [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: 10/04/2023] Open
Abstract
Background Operative decision making between approaches to posterior malleolus reduction remains a challenge. The purpose of this study is to compare the quality of reduction between percutaneous and open reduction of posterior malleolus fractures and to identify factors associated with malreduction. Methods Operatively managed ankle fractures that included posterior malleolus fixation were reviewed. Fracture characteristics were determined on preoperative CT scans. Initial postoperative radiographs were used to measure reduction of the posterior malleolus articular surface and graded as satisfactory (<2 mm step-off) or malreduced (≥2 mm step-off). Final postoperative PROMIS scores and 1-year complications were compared between percutaneous and open cohorts. A multivariate stepwise regression model was used to evaluate predictors for malreduction. Results A total of 120 patients were included. Open reduction was performed in 91 (75.8%) compared with 29 (24.2%) who underwent percutaneous reduction. Malreduction (≥2-mm articular step-off) occurred in 11.7% of patients. Malreduction rates were significantly higher with percutaneous fixation than open fixation (24.1% vs 7.7%, P = .02). Multiple fragments and those with ≥5 mm of displacement demonstrated higher malreduction rates with percutaneous fixation (P < .05 for both), whereas single fragments and those with <5 mm of displacement experienced similar malreduction rates with percutaneous or open fixation. Initial displacement ≥5 mm (relative risk [RR] = 3.8, 95% CI = 1.2-11.5, P = .02) and percutaneous treatment (RR = 4.1, 95% CI = 1.6-10.5, P < .01) were identified as independent risk factors for malreduction. There were no significant differences in 1-year complication rates or final PROMIS scores between groups. Conclusion Open reduction of the posterior malleolus may lead to improved fracture reduction compared to percutaneous reduction without significant increase in complications. Open fixation improves reduction among fractures with multiple fragments or ≥5 mm of displacement, whereas fractures with a single fragment or <5 mm of displacement achieve similar reductions regardless of approach. Initial displacement ≥5 mm and percutaneous reduction are independent risk factors for malreduction. Level of evidence Level III, therapeutic.
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Affiliation(s)
- Brittany E. Haws
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
| | - Steven Karnyski
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
| | - David A. DiStefano
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
| | - Sandeep P. Soin
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
| | - Adolph S. Flemister
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
| | - John P. Ketz
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
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14
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Abstract
The distal tibiofibular syndesmosis (DTFS) is more frequently injured than previously thought. Early diagnosis and appropriate treatment is essential to avoid long term complications like chronic instability, early osteoarthritis and residual pain. Management of these injuries require a complete understanding of the anatomy of DTFS, and the role played by the ligaments stabilizing the DTFS and ankle. High index of suspicion, appreciating the areas of focal tenderness and utilizing the provocative maneuvers help in early diagnosis. In pure ligamentous injuries radiographs with stress of weight bearing help to detect subtle instability. If these images are inconclusive, then further imaging with MRI, CT scan, stress examination under anesthesia, and arthroscopic examination facilitate diagnosis. An injury to syndesmosis frequently accompanies rotational fractures and all ankle fractures need to be stressed intra-operatively under fluoroscopy after fixation of the osseous components to detect syndesmotic instability. Non-operative treatment is appropriate for stable injuries. Unstable injuries should be treated operatively. Anatomic reduction of the syndesmosis is critical, and currently both trans-syndesmotic screws and suture button fixation are commonly used for syndesmotic stabilization. Chronic syndesmotic instability (CSI) requires debridement of syndesmosis, restoration of ankle mortise with or without syndesmotic stabilization. Arthrodesis of ankle is used a last resort in the presence of significant ankle arthritis. This article reviews anatomy and biomechanics of the syndesmosis, the mechanism of pure ligamentous injury and injury associated with ankle fractures, clinical, radiological and arthroscopic diagnosis and surgical treatment.
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Affiliation(s)
- Rajeev Vohra
- Department of Foot & Ankle Surgery, Amandeep Hospital, Amritsar, India
| | - Avtar Singh
- Department of Foot & Ankle Surgery, Amandeep Hospital, Amritsar, India
| | - Babaji Thorat
- Department of Foot & Ankle Surgery, Amandeep Hospital, Amritsar, India
| | - Dharmesh Patel
- Department of Foot & Ankle Surgery, Amandeep Hospital, Amritsar, India
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15
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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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16
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Togher CJ, Ferrise T, Sahli H, Sebag JA, Butterfield J, Shane AM, Reeves C. Identifying the Potential Role of Regional Bone Mineral Density on the Degree of Malleolar Involvement in Acute Ankle Fractures. J Foot Ankle Surg 2023; 62:333-337. [PMID: 36210259 DOI: 10.1053/j.jfas.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 08/22/2022] [Accepted: 08/25/2022] [Indexed: 02/03/2023]
Abstract
Ankle fractures are a common traumatic lower extremity injury and are generally classified and characterized by the rotational mechanism of injury. At each malleolus (i.e., posterior, medial, and lateral) a fracture can occur or a ligamentous injury may be sustained. The purpose of this retrospective study was to determine if bone mineral density is a contributing factor on the number of fractured malleoli versus soft tissue injury in adult ankle fractures. Data was obtained from a registry of ankle fractures that were operatively treated by the foot and ankle team throughout our institutional facilities, from July 2017 to August 2019, and in which a preoperative computerized tomography scan was performed. Regional bone mineral density (BMD) was measured by calculating the average Hounsfield Unit (HU) on axial computerized tomography images of the distal fibula and tibia. The average HU was then compared to the number of fractured malleoli. One hundred eight patients met the study criteria. We identified statistically significant relationships between decreased BMD with increasing age (p < .01) and the male gender (p < .01). After adjusting for the covariates age and gender, no statistically significant relationship was identified between BMD and the number of malleoli involved in a given ankle fracture (p = .11). These findings suggest that while more investigation is required for ankle fracture patterns and BMD evaluation, increased age and biologic female gender is significantly related to decreased BMD as identified via HU.
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Affiliation(s)
| | - Thomas Ferrise
- Advent Health East Orlando Podiatric Surgery Residency, Orlando, FL
| | | | - Joshua A Sebag
- Coastal Orthopedic & Sports Medicine Center, Port Saint Lucie, FL
| | | | - Amber M Shane
- Orlando Foot and Ankle Clinic-Upperline Health, Orlando, FL
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17
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Fernández-Rojas E, Herrera-Pérez M, Vilá-Rico J. [Translated article] Posterior malleolar fractures: Indications and surgical approaches. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:T160-T169. [PMID: 36574833 DOI: 10.1016/j.recot.2022.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 10/27/2022] [Indexed: 12/25/2022] Open
Abstract
Posterior malleolus fractures are frequent injuries, present in 7-44% of all ankle fractures. The objective of this study is to review the evidence to indicate the fixation of this fracture and to choose the appropriate surgical approach. The classic indications for fixation were fragment size greater than 25-30% of the articular surface and displacement greater than 2mm. However, current evidence suggests that, rather than size, factors such as syndesmotic instability, intra-articular step-off greater than 1-2mm, plafond impaction and the presence of intercalary fragments should be considered. When comparing the different surgical approaches, the literature supports the use of posterior approaches and reserves the recommendation of the traditional approach for exceptional cases. For the treatment of this injury it is essential to know the anatomy of the ankle and to consider all the factors described above, in addition to the presence of concomitant injuries.
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Affiliation(s)
- E Fernández-Rojas
- Equipo de Tobillo y Pie, Servicio de Traumatología y Ortopedia, Hospital Las Higueras, Talcahuano, Chile; Universidad Católica de la Santísima Concepción, Concepción, Chile.
| | - M Herrera-Pérez
- Unidad de Pie y Tobillo, Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Islas Canarias, Spain; Escuela de Medicina, Universidad de La Laguna, Santa Cruz de Tenerife, Islas Canarias, Spain
| | - J Vilá-Rico
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, Spain; Departamento de Cirugía, Universidad Complutense de Madrid, Madrid, Spain
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18
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Fernández-Rojas E, Herrera-Pérez M, Vilá-Rico J. Posterior malleolar fractures: Indications and surgical approaches. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:160-169. [PMID: 36371071 DOI: 10.1016/j.recot.2022.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/10/2022] [Accepted: 10/27/2022] [Indexed: 11/11/2022] Open
Abstract
Posterior malleolus fractures are frequent injuries, present in 7-44% of all ankle fractures. The objective of this study is to review the evidence to indicate the fixation of this fracture and to choose the appropriate surgical approach. The classic indications for fixation were fragment size greater than 25-30% of the articular surface and displacement greater than 2 mm. However, current evidence suggests that, rather than size, factors such as syndesmotic instability, intra-articular step-off greater than 1-2 mm, plafond impaction and the presence of intercalary fragments should be considered. When comparing the different surgical approaches, the literature supports the use of posterior approaches and reserves the recommendation of the traditional approach for exceptional cases. For the treatment of this injury it is essential to know the anatomy of the ankle and to consider all the factors described above, in addition to the presence of concomitant injuries.
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Affiliation(s)
- E Fernández-Rojas
- Equipo de Tobillo y Pie, Servicio de Traumatología y Ortopedia, Hospital Las Higueras, Talcahuano, Chile; Universidad Católica de la Santísima Concepción, Concepción, Chile.
| | - M Herrera-Pérez
- Unidad de Pie y Tobillo, Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Islas Canarias, España; Escuela de Medicina, Universidad de La Laguna, Santa Cruz de Tenerife, Islas Canarias, España
| | - J Vilá-Rico
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, España; Departamento de Cirugía, Universidad Complutense de Madrid, Madrid, España
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19
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Posterior Malleolar Fracture Assessment: An Independent Interobserver and Intraobserver Validation of Three Computed Tomography-Based Classifications. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202301000-00004. [PMID: 36622849 PMCID: PMC9831157 DOI: 10.5435/jaaosglobal-d-22-00258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/06/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Posterior malleolus fractures occur in up to 50% of all ankle fractures. Several classification systems exist for their characterization, especially under CT. However, those classifications do not report the level of agreement or do it incompletely. This study aims to independently assess three posterior malleolus fracture classifications (Haraguchi, Bartoníček/Rammelt, and Mason). METHODS This study was designed according to the Guidelines for Reporting Reliability and Agreement Studies. Ninety-four CT scans of patients with ankle fractures that had posterior malleolus fractures were included. Posterior malleolus fractures were assessed by six evaluators (three attending foot and ankle surgeons and three orthopaedic surgery residents) according to Haraguchi, Bartoníček/Rammelt, and Mason classifications. All images were reassessed by the same evaluators in a random sequence 3 weeks later. The kappa (k) coefficient was used to determine the interobserver and intraobserver agreement. Statistical significance was established using P < 0.05 with a 95% confidence interval (CI). RESULTS The interobserver agreement was moderate for Haraguchi, Bartoníček/Rammelt, and Mason classifications with a global k value of 0.52 (95% CI, 0.43 to 0.60), 0.53 (95% CI, 0.46 to 0.61), and 0.54 (95% CI, 0.47 to 0.62), respectively. The intraobserver agreement was substantial for Haraguchi, Bartoníček/Rammelt, and Mason classifications, with an overall k value of 0.70 (95% CI, 0.64 to 0.74), 0.73 (95% CI, 0.68 to 0.78), and 0.73 (95% CI, 0.69 to 0.78), respectively. Interobserver and intraobserver agreement among orthopaedic surgeons and residents had no significant difference. CONCLUSION The current classifications for posterior malleolus fractures showed a substantial intraobserver agreement. Nevertheless, the interobserver agreement obtained was just moderate for all classifications, independent of the level of expertise of the evaluators.
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20
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Thomas A, Fredette R, Han G, Curtin P, Swart E. Can Lateral X-Rays Reliably Determine Which Posterior Malleolus Ankle Fractures Need a CT? Foot Ankle Spec 2022:19386400221128159. [PMID: 36217982 DOI: 10.1177/19386400221128159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND For rotational ankle fractures with a posterior malleolus fracture (PMF), the decision to further evaluate the ankle injury with computed tomography (CT) is challenging. The objective of this study is to determine how well PMF fracture size on x-rays correlates with size on CT, and how well x-rays can predict which patients receive PMF fixation after CT review. METHODS This is a retrospective study of adult ankle fractures with PMFs that had preoperative radiographs and CT imaging over a 5-year period. PMF x-ray and CT measurements were recorded, and relationships between x-ray measurements and final PMF fixation plan after CT review were evaluated. RESULTS A total of 98 patients were identified with both x-rays and preoperative CT imaging. Pearson's rank correlation demonstrated a strong relation between PMF width percentage measured on x-ray and CT (r = 0.724). Of the 45 patients with a PMF size under 20% on x-ray, only one patient (with an apparent incarcerated fragment) underwent PMF fixation after review of the CT. CONCLUSIONS PMF width on lateral x-ray correlates well with CT size and is sensitive for predicting the need for dedicated posterior malleolus based on one institutional practice pattern. Below 20% fracture width on lateral x-ray, a dedicated CT rarely leads to a decision to perform PMF fixation. Limiting pre-operative CT to those with PMF width >20% could reduce CT utilization by as much as 45% without negatively affecting patient care. LEVELS OF EVIDENCE Level III: Diagnostic.
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Affiliation(s)
- Ayush Thomas
- Department of Orthopaedic Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Ryan Fredette
- Department of Orthopaedic Surgery, University of Massachusetts, Worcester, Massachusetts
| | - George Han
- Department of Orthopaedic Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Patrick Curtin
- Department of Orthopaedic Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Eric Swart
- Department of Orthopaedic Surgery, Lahey Hospital & Medical Center, Burlington, Massachusetts
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21
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Nicolai C, Bierry G, Faruch-Bilfeld M, Sans N, Willaume T. The concept of ring of injuries: evaluation in ankle trauma. Skeletal Radiol 2022; 51:2027-2037. [PMID: 35501494 DOI: 10.1007/s00256-022-04062-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 04/20/2022] [Accepted: 04/20/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Radiographs are first-line imaging in ankle trauma but lack sensitivity to detect ligamentous injuries and undisplaced fractures. Our hypothesis was that ankle injuries occur in predefined sequences along two osteoligamentous rings, so that occult injuries non-visible on initial radiographs can be predicted. We, therefore, aimed to validate a ring model of progressive damages in the interpretation of ankle trauma radiographs. METHODS This study retrospectively enrolled 277 adult patients that presented an acute fibular fracture on ankle radiographs between May and November 2019. Four different types of fibula fracture were differentiated, each being considered to correspond to a different mechanism of injury. Patients were classified into four groups, upon the appearance of their fibular fracture. Then, injuries to the distal tibiofibular syndesmosis, medial malleolus, and deltoid ligament (medial clear space) were assessed in each patient radiographs. Traumatic injuries were independently evaluated by a resident and an experienced MSK radiologist. For each patient, observed features were compared to those predicted by the ring concept. Inter- and intraobserver agreements were calculated. RESULTS Injuries were observed according to the predictable sequence in 266 of the 277 patients (96%). In the 11 remaining patients, discordances were presumably due to undisplaced injuries to the syndesmosis or deltoid ligament. Agreements were considered very good for each evaluated item. CONCLUSION The Lauge-Hansen ring concept was found to be highly accurate and reproducible for radiographic assessment of ankle injuries. Discordances to the predicted sequence might reflect occult injuries, especially of the syndesmosis or deltoid ligament.
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Affiliation(s)
- Caroline Nicolai
- Department of Radiology, Strasbourg University Hospital, 1 Avenue Moliere, 67098, Strasbourg, France
| | - Guillaume Bierry
- Department of Radiology, Strasbourg University Hospital, 1 Avenue Moliere, 67098, Strasbourg, France.,Icube Laboratory, Strasbourg University, 300 bd Sébastien Brant CS 10413, 67412, Illkirch Cedex, France
| | - Marie Faruch-Bilfeld
- Department of Radiology, Toulouse University Hospital, 1 Place Dr Baylac, 31059, Toulouse, France
| | - Nicolas Sans
- Department of Radiology, Toulouse University Hospital, 1 Place Dr Baylac, 31059, Toulouse, France
| | - Thibault Willaume
- Department of Radiology, Strasbourg University Hospital, 1 Avenue Moliere, 67098, Strasbourg, France.
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22
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Myers DM, Kelley JA, Taylor BC, Umbel B, Buchan J, Melaragno A. The Intercalary Fragment in Posterior Malleolus Fractures: Characterization and Significance. J Foot Ankle Surg 2022; 61:1060-1064. [PMID: 35197223 DOI: 10.1053/j.jfas.2022.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 07/06/2021] [Accepted: 01/11/2022] [Indexed: 02/03/2023]
Abstract
Methods of fixation in ankle fractures involving the posterior malleolus have become increasingly scrutinized. With the increase in computed tomography (CT), an intercalary fracture fragment (ICF) adjacent to the posterior malleolus has been oft described. Treatment of the ICF remains controversial and the purpose of this study was to evaluate radiographic and clinical outcomes in patients who had direct reduction and fixation of this fragment compared to those where the ICF was not fixed. This retrospective study included 249 trimalleolar and posterior pilon ankle fractures grouped into those who had the ICF reduced and fixed (n = 74) and those where the ICF was not directly addressed (n = 175). CT scans were evaluated for size and location of the ICF. Demographic, radiographic and intraoperative variables were collected and analyzed. The group which had the ICF reduced and fixed had decreased Kellgren-Lawrence scores (p = .001). There was also a higher rate of repeat surgery in the group who had the ICF fixed, although not meeting statistical significance. There were no differences in size or location of the ICF fragment between groups. We did identify similarities with other studies in regard to size and posterolateral location of the ICF between groups. However, based on worsening radiographic outcomes of the group where the ICF was reduced and fixed, we do not necessarily recommend universal treatment of this fragment. The surgeon's goal should always be a concentric articular reduction and treatment of the ICF should be considered on a case-by-case basis.
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Affiliation(s)
- Devon M Myers
- Department of Orthopaedic Surgery, OhioHealth Grant Medical Center, Columbus, OH; Ohio University Heritage College of Osteopathic Medicine, Athens, OH.
| | - Justin A Kelley
- Department of Orthopaedic Surgery, OhioHealth Grant Medical Center, Columbus, OH; Ohio University Heritage College of Osteopathic Medicine, Athens, OH
| | - Benjamin C Taylor
- Department of Orthopaedic Surgery, OhioHealth Grant Medical Center, Columbus, OH; Ohio University Heritage College of Osteopathic Medicine, Athens, OH
| | - Benjamin Umbel
- Department of Orthopaedic Surgery, OhioHealth Grant Medical Center, Columbus, OH; Ohio University Heritage College of Osteopathic Medicine, Athens, OH
| | - John Buchan
- Department of Orthopaedic Surgery, OhioHealth Grant Medical Center, Columbus, OH; Ohio University Heritage College of Osteopathic Medicine, Athens, OH
| | - Anthony Melaragno
- Department of Orthopaedic Surgery, OhioHealth Grant Medical Center, Columbus, OH; Ohio University Heritage College of Osteopathic Medicine, Athens, OH
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Voss EE, Goode RD, Cook JL, Crist BD. Survey of Orthopaedic Trauma Providers: Is MRI Superior to CT Scan for Evaluating and Preoperative Planning for Tibial Plateau Fractures? MISSOURI MEDICINE 2022; 119:261-265. [PMID: 36035573 PMCID: PMC9324694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
A computerized tomography (CT) scan is the current advanced imaging standard of care for evaluation and preoperative planning for tibial plateau fractures, but magnetic resonance imaging (MRI) is emerging as a better method to identify soft tissue injuries. This study compares MRI and CT for fracture classification, associated soft tissue injuries, and preoperative planning for tibial plateau fractures. MRI offers lack of radiation and enhanced soft tissue evaluation, and as a result improved preoperative planning. MRI was favored among survey respondents for preoperative planning, Schatzker classification, and surgical approach planning.
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Affiliation(s)
- Elliott E Voss
- Medical student at the University of Missouri School of Medicine, Columbia, Missouri
| | | | - James L Cook
- Department of Orthopeadic Surgery, University of Missouri School of Medicine, Columbia, Missouri
| | - Brett D Crist
- Department of Orthopeadic Surgery, University of Missouri School of Medicine, Columbia, Missouri
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Comparison of routine computed tomography and plain X-ray imaging for malleolar fractures-How much do we miss? Foot Ankle Surg 2022; 28:263-268. [PMID: 33832814 DOI: 10.1016/j.fas.2021.03.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 03/27/2021] [Accepted: 03/30/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Most patients with ankle arthrosis have a history of ankle fracture. Evaluation of malleolar fractures solely on X-ray may be insufficient to identify many pathologies that potentially contribute to ankle arthrosis, with a consequent poor prognosis. We investigated the pathologies that may be overlooked in malleolar fractures evaluated solely on plain X-ray. METHODS During 2012-2019, 65,479 patients attended our Emergency Department, of which 6508 complained of an ankle joint problem. X-rays indicated a fracture in 454 of these patients. Patients with isolated, simple fracture of the lateral or medial malleolus, or talus, or a history of surgery to this area were excluded; finally, 67 patients were enrolled (31 males, 36 females; mean age: 51,2 years (range: 9-83 years). Patients underwent X-ray imaging of both ankles in anterio-posterior, lateral, and Mortise views, as well as CT scans. Three independent observers with varied experience in diagnostic imaging (orthopaedic resident, experienced orthopaedic surgeon, and musculoskeletal radiologist) evaluated X-ray images blinded to CT scans. Their diagnoses were subsequently compared with CT findings. RESULTS Modeling results indicated that about 40% [95% CI: 32%, 50%] of pathologies may be overlooked based on X-ray evaluation, regardless of evaluator experience. The most frequently overlooked injuries were: Tillaux fracture, Pillon fracture, loose bodies and syndesmosis injury. All of that missed pathologies required dedicated treatment and could be easily missed with standard surgical approach. CONCLUSION Evaluation of malleolar fractures by X-ray only inevitably results in overlooking of many pathologies, despite the clinician's experience. Routine CT scan can help to improve the accuracy of diagnosis, and thereby reduce the risk of ankle osteoarthrosis.
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Neumann AP, Rammelt S. Ankle fractures involving the posterior malleolus: patient characteristics and 7-year results in 100 cases. Arch Orthop Trauma Surg 2022; 142:1823-1834. [PMID: 33835195 PMCID: PMC9296426 DOI: 10.1007/s00402-021-03875-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 03/23/2021] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The presence of a posterior malleolar (PM) fragment has a negative prognostic impact in ankle fractures. The best treatment is still subject to debate. The aim of this study was to assess the medium-to-long-term clinical and functional outcome of ankle fractures with a PM fragment in a larger patient population. MATERIALS AND METHODS One hundred patients (69 women, 31 men, average age 60 years) with ankle fractures including the PM were evaluated clinically and radiographically. Patients with Bartoníček-Rammelt type 3 and 4 fracture displayed a significant female preponderance. Fixation of the PM was performed in 63% and tailored to the individual fracture pattern. RESULTS Internal fixation of the PM fragment was negatively correlated with the need for syndesmotic screw placement at the time of surgery (p = 0.010). At an average follow-up of 7.0 years, the mean Foot Function Index (FFI) was 16.5 (SD: 21.5), the Olerud Molander Ankle Score (OMAS) averaged 80.2 (SD: 24) and the American Orthopedic Foot & Ankle Society (AOFAS) ankle/hindfoot score averaged 87.5 (SD: 19.1). The maximum score of 100 was achieved by 44% of patients. The physical (PCS) and mental health component summary (MCS) scores of the SF-36 averaged 47.7 (SD: 12.51) and 50.5 (SD: 9.36), respectively. Range of motion was within 3.4 (SD: 6.63) degrees of the uninjured side. The size of the PM fragment had no prognostic value. There was a trend to lower outcome scores with slight anterior or posterior shift of the distal fibula within the tibial incisura. Patients who underwent primary internal fixation had significantly superior SF-36 MCS than patients who underwent staged internal fixation (p = 0.031). CONCLUSIONS With an individualized treatment protocol, tailored to the CT-based assessment of PM fractures, favorable medium and long-term results can be expected.
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Affiliation(s)
- Annika Pauline Neumann
- University Center of Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Stefan Rammelt
- University Center of Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
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Rasi A, Sayyadi S, Omidian M, Pourmojarab A, Khodayi A, Baroutkoub M, Salimi S. Intraoperative chertsey test, is it a reliable alternative to computed tomography scan for diagnosing syndesmotic injuries of the ankle? Adv Biomed Res 2022; 11:20. [PMID: 35386542 PMCID: PMC8977619 DOI: 10.4103/abr.abr_258_21] [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: 08/16/2021] [Revised: 11/08/2021] [Accepted: 11/09/2021] [Indexed: 11/05/2022] Open
Abstract
Background: The present study aims to evaluate the diagnostic exactitude of the intraoperative Chertsey test in tibiofibular syndesmotic injuries in patients with malleolar fractures, in comparison with a computed tomography (CT) scan. Materials and Methods: In this study, patients with malleolar fractures operated between 2018 and 2020 were examined. Thirty-nine patients were enrolled in the study. A three-dimensional preoperative CT scan was obtained. The opposite unfractured ankle was also scanned and considered as the control group. The Chertsey test was performed during the operation to assess the syndesmosis injury. Then, patients were partitioned into two distinct groups, considering the condition of their ankle, namely the Chertsey positive (unstable syndesmosis) group and the Chertsey negative (stable syndesmosis) group. Results: The outcomes of the present survey illustrated that the Chertsey test was positive in 16 patients (41.03%) and negative in 23 patients (59.07%). The median of all CT scan parameters (anterior tibiofibular distances (TFD), middle TFD, posterior TFD, and maximal TFD and volume) before surgery in the group of patients with a positive Chertsey test was significantly higher, measured against the unfractured control group (P < 0.001 for all parameters). Furthermore, a comparison of CT scan parameters and syndesmosis space volume before surgery between the two groups of patients with positive and negative Chertsey test results showed that the measurement of parameters in Chertsey-positive patients was significantly higher than the Chertsey-negative patients (P < 0.001). Conclusion: Chertsey test could be used to diagnose syndesmosis injuries in patients with malleolar fractures due to its high importance in the outcome of patients.
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Abstract
In patients with ankle fractures, the presence of a posterior malleolar fracture has a negative impact on the prognosis. Computed tomography (CT) scanning is essential for fracture classification and treatment planning, as the indication for surgery depends on the 3-dimensional fragment outline and displacement, incisura involvement, and the presence of joint impaction. Anatomic reduction of a posterior malleolar fragment restores the incisura, facilitating reduction of the distal part of the fibula, and it also restores the integrity of the posterior portion of the syndesmosis, reducing the need for additional syndesmotic stabilization. Direct open reduction and fixation of posterior malleolar fragments from a posterior orientation is biomechanically more stable and provides a more accurate reduction than does indirect reduction and anterior-to-posterior screw fixation. Intra-articular step-off of >=2 mm is an independent risk factor for an inferior outcome and the development of posttraumatic arthritis, irrespective of the fragment size.
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Affiliation(s)
- Stefan Rammelt
- University Center of Orthopaedics and Traumatology, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Jan Bartoníček
- Department of Orthopaedics, First Faculty of Medicine, Charles University and Central Military Hospital Prague, Prague, Czech Republic.,Department of Anatomy, First Faculty of Medicine, Charles University Prague, Prague, Czech Republic
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Management of posterior malleolus fractures: A multicentre cohort study in the United Kingdom. Foot Ankle Surg 2021; 27:629-635. [PMID: 32878722 DOI: 10.1016/j.fas.2020.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 07/13/2020] [Accepted: 08/05/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND There is a need to assess clinical practice in light of increasing literature recommending fixation of posterior malleolus (PM) fractures. This multicentre study examines treatment approaches, within both Major Trauma Centres and District General Hospitals and role of radiographs and CT scanning. METHODS Trauma lists and databases were used to identify patients and data collected from electronic and paper medical records and imaging systems between August 2017-18. Analysis of treatment and outcomes was then conducted. RESULTS One-hundred-and-sixty ankle fractures were included in the study, only 68 ankle fractures underwent CT scanning following initial radiographs and of these, 65 were managed operatively, with 32 undergoing PM fixation. Syndesmotic stabilisation was performed in 9.6% where the PM was fixed. CONCLUSION CT is still under-utilised, PM fractures that appear to be anything other than small avulsion-type injuries should undergo CT scanning. Syndesmotic stabilisation is statistically less likely to be performed with fixation of the PM.
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Tarallo L, Micheloni GM, Mazzi M, Rebeccato A, Novi M, Catani F. Advantages of preoperative planning using computed tomography scan for treatment of malleolar ankle fractures. World J Orthop 2021; 12:129-139. [PMID: 33816140 PMCID: PMC7995337 DOI: 10.5312/wjo.v12.i3.129] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/07/2021] [Accepted: 01/28/2021] [Indexed: 02/06/2023] Open
Abstract
Malleolar ankle fractures have been classified using plain radiographs, and there is no consensus regarding the role of computed tomography (CT) scans in preoperative planning. We analyzed critical aspects, such as limits of standard radiographs, types of injury, classification methods and cost/benefit evaluations. CT scans allow a 3D analysis of the fracture to be obtained and consequently assess the indication for surgical procedure, surgical access and the type of fixation devices required. This exam is useful for detecting lesions that may go unnoticed on radiographs and will help surgeons to clarify the pathoanatomy of ankle fractures. According to Arbeitsgemeinschaft fur Osteosynthesefragen/ Orthopaedic Trauma Association (AO/OTA) classification, CT scan is recommended in medial malleolar fractures with vertical rim, type 44B fractures with posterior malleolar involvement and all type 44C fractures (according to AO/OTA). Also Tillaux-Chaput fractures (43-B1 according to AO/OTA), malleolar fractures in the presence of distal tibial fractures (43 according to AO/OTA) and distal tibia fractures in adolescents should be studied with CT scans.
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Affiliation(s)
- Luigi Tarallo
- Dipartimento di Scienze Mediche e Chirurgiche Materno-Infantili e dell’Adulto, University of Modena and Reggio Emilia, Modena 41121, Italy
| | - Gian Mario Micheloni
- Dipartimento di Scienze Mediche e Chirurgiche Materno-Infantili e dell’Adulto, University of Modena and Reggio Emilia, Modena 41121, Italy
| | - Michele Mazzi
- Dipartimento di Chirurgia, AULSS8 Berica-Ospedale San Bortolo-Vicenza, Vicenza 36100, Italy
| | - Arturo Rebeccato
- Dipartimento di Chirurgia, AULSS8 Berica-Ospedale San Bortolo-Vicenza, Vicenza 36100, Italy
| | - Michele Novi
- Dipartimento di Scienze Mediche e Chirurgiche Materno-Infantili e dell’Adulto, University of Modena and Reggio Emilia, Modena 41121, Italy
| | - Fabio Catani
- Dipartimento di Scienze Mediche e Chirurgiche Materno-Infantili e dell’Adulto, University of Modena and Reggio Emilia, Modena 41121, Italy
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Abstract
Anatomic reduction of the posterior malleolus is mandatory for a good functional outcome. Preoperative planning with a computed tomography scan's axial view helps to decide which approach and surgical position we should choose. Based on posterior malleolus fracture anatomy, a guideline is suggested to facilitate decision making on which approach seems to give the best exposure with minimum complications.
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Affiliation(s)
- Guillermo Martin Arrondo
- Foot and Ankle Division "CEPP", Instituto Dupuytren, Av. Belgrano 3402, Ciudad Autónoma de Buenos Aires CP 1078, Argentina
| | - German Joannas
- Foot and Ankle Division "CEPP", Instituto Dupuytren, Av. Belgrano 3402, Ciudad Autónoma de Buenos Aires CP 1078, Argentina; Foot and Ankle Division, Orthopaedics Department, Centro Artroscópico Jorge Batista SA, Pueyrredón 2446 1 Er Piso, Ciudad Autónoma de Buenos Aires (CABA) CP 1119, Argentina; Instituto Barrancas, Hipolito Yrigoyen 902, QUILMES, CP 1878, Buenos Aires, Argentina.
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31
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Sheikh HQ, Mills EJ, McGregor-Riley JC, Chadwick C, Davies MB. The effect of computerised tomography on operative planning in posterior malleolus ankle fractures. Foot Ankle Surg 2020; 26:676-680. [PMID: 31515200 DOI: 10.1016/j.fas.2019.08.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 08/07/2019] [Accepted: 08/19/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim of this project was to analyse whether a CT influences surgical planning in ankle fracture involving the posterior malleolus. METHODS Twenty consecutive patients with fractures involving the posterior malleolus were retrospectively selected and had their plain radiographs and CT scan anonymised. Initially, radiographs alone were presented to nine trauma surgeons to formulate a surgical plan individually. After a minimum of 6 weeks, the same process was repeated with CT scans available. RESULTS The surgical approach for ankle fracture fixation changed in 32.7% of cases following CT scan review. A CT scan altered the decision to stabilise the posterior malleolus in 25.6% and the decision of whether to stabilise the syndesmosis in 16.6% of cases. CONCLUSIONS This study demonstrates that a pre-operative CT scan changes the surgical approach in 32.7% of cases and therefore we recommend use of CT scanning in this subset of ankle injuries.
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Affiliation(s)
- Hassaan Q Sheikh
- Trauma and Orthopaedic Unit, Sheffield Teaching Hospitals, Herries Road, Sheffield, S5 7AU, United Kingdom.
| | - Edward J Mills
- Trauma and Orthopaedic Unit, Sheffield Teaching Hospitals, Herries Road, Sheffield, S5 7AU, United Kingdom.
| | - Jonathan C McGregor-Riley
- Trauma and Orthopaedic Unit, Sheffield Teaching Hospitals, Herries Road, Sheffield, S5 7AU, United Kingdom.
| | - Carolyn Chadwick
- Trauma and Orthopaedic Unit, Sheffield Teaching Hospitals, Herries Road, Sheffield, S5 7AU, United Kingdom.
| | - Mark B Davies
- Trauma and Orthopaedic Unit, Sheffield Teaching Hospitals, Herries Road, Sheffield, S5 7AU, United Kingdom.
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32
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How to address the posterior malleolus in ankle fractures? A decision-making model based on the computerised tomography findings. INTERNATIONAL ORTHOPAEDICS 2020; 44:1177-1185. [DOI: 10.1007/s00264-020-04481-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 01/15/2020] [Indexed: 10/25/2022]
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Tuček M, Rammelt S, Kostlivý K, Bartoníček J. CT controlled results of direct reduction and fixation of posterior malleolus in ankle fractures. Eur J Trauma Emerg Surg 2020; 47:913-920. [PMID: 32008051 DOI: 10.1007/s00068-020-01309-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 01/20/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE The aim of this study was to present outcomes of operative treatment of the posterior malleolus fractures of type four of the Bartoníček/Rammelt classification. METHODS In 19 patients, direct reduction and fixation of the posterior malleolus was performed from the posterolateral or posteromedial approaches. The accuracy of reduction was assessed with the use of postoperative CT scans. RESULTS The mean size of the avulsed articular surface carried by posterior malleolus amounted to 36%. Reduction of the posterior malleolus fracture was assessed as anatomical in 14 cases and as satisfactory in five cases. Position of the distal fibula was assessed as anatomical in 15 cases. The mean AOFAS score was 89.4 points. All nine patients with anatomical reduction of all lesions achieved the mean AOFAS score of 93.1 points, five patients with malposition of posterior malleolus 89.1 points and five patients with malposition of the fibula in the fibular notch 87.8 points. A total of six patients developed osteoarthritic changes of grades one and two according to the Kellgren and Lawrence classification. CONCLUSIONS Outcomes of the study demonstrated good mid-term results in type four fractures of the posterior malleolus treated by direct reduction from posterior approaches. Postoperative CT examination allowed evaluation of the accuracy of reduction of all fractures and reduction of the distal fibula into the fibular notch. Based on postoperative CT examination, it will be possible to assess the effect of reduction of individual lesions on the functional results.
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Affiliation(s)
- Michal Tuček
- Department of Orthopaedics, First Faculty of Medicine, Charles University and Military University Hospital Prague, U Vojenské Nemocnice 1200, 169 02, Prague 6, Czech Republic.
| | - Stefan Rammelt
- University Center of Orthopedics and Traumatology, University Hospital Carl Gustav Carus Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Karel Kostlivý
- Surgical Department, Thomayer's Hospital, First Faculty of Medicine, Charles University, Vídeňská 800, 140 59, Prague 4, Czech Republic
| | - Jan Bartoníček
- Department of Orthopaedics, First Faculty of Medicine, Charles University and Military University Hospital Prague, U Vojenské Nemocnice 1200, 169 02, Prague 6, Czech Republic
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Chaparro F, Ahumada X, Urbina C, Lagos L, Vargas F, Pellegrini M, Barahona M, Bastias C. Posterior pilon fracture: Epidemiology and surgical technique. Injury 2019; 50:2312-2317. [PMID: 31630782 DOI: 10.1016/j.injury.2019.10.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 07/12/2019] [Accepted: 10/03/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To review a case series of patients with posterior pilon variant fracture using a novel approach, focusing on demographic data, injury pattern, surgical results based on computed tomography (CT) scan, and short-term complications. DESIGN Consecutive case series. SETTING Level I trauma center. PATIENTS/PARTICIPANTS Twenty-five patients with posterior pilon fracture. INTERVENTION Posterior pilon fracture open reduction and internal fixation. MAIN OUTCOME MEASUREMENTS Parameters measured included age, sex, type of fracture, surgical technique, anatomical reduction, and complications. RESULTS Twenty-five patients sustained a posterior pilon fracture, accounting for 13.4% of all operatively treated ankle fractures with median follow-up of 21.7 months. The average age of patients was 42 years (22-62); 19/25 (76%) were female, and 6/25 (24%) were male. A modified posteromedial approach was used in 18/25 (72%) patients. Persistent syndesmotic instability was present in 11/25 (44%) patients after posterior malleolar stabilization. Quality of reduction was assessed under CT scan in 19 patients, with 15/19 (78.9%) having anatomic reduction. We report 2/25 (8%) patients with early wound problems and 7/25 (20%) with short-term complications during follow-up. CONCLUSION Posterior pilon variant fracture appears to be less common than previously reported. Most fractures can be satisfactorily treated through a modified posteromedial approach. Albeit obtaining posterior malleolar fracture rigid fixation, syndesmotic instability was more prevalent than expected. The short-term complication rate was low. LEVEL OF EVIDENCE Therapeutic level IV.
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Affiliation(s)
- Felipe Chaparro
- Department of Orthopaedic Surgery, Clinica Universidad de Los Andes, Av. La Plaza 2501, Las Condes, Santiago 7620157, Chile; Department of Orthopaedic Surgery, Hospital Clínico Mutual de Seguridad, Alameda 4848, Estación Central, Santiago 9190015, Chile.
| | - Ximena Ahumada
- Department of Orthopaedic Surgery, Hospital Clínico Mutual de Seguridad, Alameda 4848, Estación Central, Santiago 9190015, Chile
| | - Christian Urbina
- Department of Orthopaedic Surgery, Hospital Clínico Mutual de Seguridad, Alameda 4848, Estación Central, Santiago 9190015, Chile
| | - Leonardo Lagos
- Department of Orthopaedic Surgery, Hospital Clínico Mutual de Seguridad, Alameda 4848, Estación Central, Santiago 9190015, Chile
| | - Fernando Vargas
- Department of Orthopaedic Surgery, Hospital Clínico Mutual de Seguridad, Alameda 4848, Estación Central, Santiago 9190015, Chile
| | - Manuel Pellegrini
- Department of Orthopaedic Surgery, Clinica Universidad de Los Andes, Av. La Plaza 2501, Las Condes, Santiago 7620157, Chile; Department of Orthopaedic Surgery, Hospital Clínico Universidad de Chile, Santos Dumont 999, Independencia, Santiago 7640275, Chile
| | - Maximiliano Barahona
- Department of Orthopaedic Surgery, Hospital Clínico Universidad de Chile, Santos Dumont 999, Independencia, Santiago 7640275, Chile
| | - Christian Bastias
- Department of Orthopaedic Surgery, Hospital Clínico Mutual de Seguridad, Alameda 4848, Estación Central, Santiago 9190015, Chile
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Rammelt S, Boszczyk A. Computed Tomography in the Diagnosis and Treatment of Ankle Fractures: A Critical Analysis Review. JBJS Rev 2019; 6:e7. [PMID: 30562210 DOI: 10.2106/jbjs.rvw.17.00209] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Stefan Rammelt
- University Center for Orthopaedics & Traumatology, University Hospital Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Andrzej Boszczyk
- Department of Traumatology and Orthopaedics, Centre of Postgraduate Medical Education, Prof. Adam Gruca Clinical Hospital, Otwock, Poland
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Jeyaseelan L, Malagelada F, Parker L, Panagopoulos A, Heidari N, Vris A. Intra-Operative 3-Dimensional Imaging (O-arm) in Foot and Ankle Trauma Surgery: Report of 2 Cases and Review of the Literature. Open Orthop J 2019. [DOI: 10.2174/1874325001913010189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
Background:
Intraoperative two-dimensional (2D) fluoroscopy is the standard imaging modality available to orthopaedic surgeons worldwide. It is well-accepted, however, multiplanar 3 dimensional (3D) CT scanning is superior to 2D imaging for visualising joint surfaces and is now a fundamental feature of the pre-operative planning of intra-articular fractures.
Objective:
We present two cases in which the use of 3D intraoperative imaging and the O-arm® (Medtronic, Minneapolis, USA) led to immediate intraoperative revision to optimise fixation and articular congruity. A review of the current literature is also provided.
Methods:
During the trial period of the O-arm at our major trauma centre, intra-operative imaging was used in the lower limb trauma setting. The O-arm was used intra-operatively in a comminuted pilon fracture and a displaced talus fracture. We recorded all the intra-operative events, including quality of reduction, implant positioning and operation time. Each patient was followed-up for 12 months post-operation and was finally assessed with x-rays and the AOFAS score.
Results:
In both the cases, either fracture reduction or the implant position/usage that was observed with 2D fluoroscopy was revised following a 3D intra-operative scan. No postoperative complications were noted and the healing process was uneventful. X-rays at the final follow-up were excellent and acceptable for the talus and pilon fracture, respectively, with corresponding clinical results and AOFAS score.
Conclusion:
Although frequently used in spinal surgery, to the best of our knowledge, the use of intra-operative 3D techniques in lower limb trauma is sparse and sporadically reported. We present our cases in which the most current innovative imaging techniques influenced intra-operative outcomes without compromising patient safety. We feel that this is a real example of how innovation can positively influence patient care.
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Ankle Fractures: An Expert Survey of Orthopaedic Trauma Association Members and Evidence-Based Treatment Recommendations. J Orthop Trauma 2019; 33:e318-e324. [PMID: 31335507 DOI: 10.1097/bot.0000000000001503] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To describe current practice patterns of orthopaedic trauma experts regarding the management of ankle fractures, to review the current literature, and to provide recommendations for care based on a standardized grading system. DESIGN Web-based survey. PARTICIPANTS Orthopaedic Trauma Association (OTA) members. METHODS A 27-item web-based questionnaire was advertised to members of the OTA. Using a cross-sectional survey study design, we evaluated the preferences in diagnosis and treatment of ankle fractures. RESULTS One hundred sixty-six of 1967 OTA members (8.4%) completed the survey (16% of active members). There is considerable variability in the preferred method of diagnosis and treatment of ankle fractures among the members surveyed. Most responses are in keeping with best evidence available. CONCLUSIONS Current controversy remains in the management of ankle fractures. This is reflected in the treatment preferences of the OTA members who responded to this survey. LEVEL OF EVIDENCE Therapeutic Level V. See Instructions for authors for a complete description of levels of evidence.
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Lawson KA, Ayala AE, Morin ML, Latt LD, Wild JR. Ankle Fracture-Dislocations. FOOT & ANKLE ORTHOPAEDICS 2018. [DOI: 10.1177/2473011418765122] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Ankle fractures are common musculoskeletal injuries that may result in tibiotalar joint dislocations. Ankle fracture-dislocations occur via similar mechanisms as ankle fractures, although the persistence or magnitude of the deforming force is sufficient to disrupt any remaining bony or soft-tissue stability. Ankle fracture-dislocations likely represent distinct clinical entities, as the pathology, management, and patient outcomes following these injuries differ from those seen in more common ankle fractures without dislocation. Ankle fracture-dislocations have higher rates of concomitant injury including open fractures, chondral lesions, and intra-articular loose bodies. Long-term outcomes in ankle fracture-dislocations are worse than ankle fractures without dislocation. Higher rates of posttraumatic osteoarthritis and chronic pain have also been reported. In this review, we discuss the current literature regarding the history, management, and outcomes of ankle-fracture dislocations and highlight the need for future study.
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Affiliation(s)
- Kevin A. Lawson
- Department of Orthopaedic Surgery, The University of Arizona College of Medicine, Tucson, AZ, USA
| | | | - Matthew L. Morin
- Department of Orthopaedic Surgery, The University of Arizona College of Medicine, Tucson, AZ, USA
| | - L. Daniel Latt
- Department of Orthopaedic Surgery, The University of Arizona College of Medicine, Tucson, AZ, USA
| | - Jason R. Wild
- Department of Orthopaedic Surgery, The University of Arizona College of Medicine, Tucson, AZ, USA
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