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Hu SY, Cao MM, Zhang YW, Shi L, Dai GC, Zhao YK, Xie T, Chen H, Rui YF. Dislocations deteriorate postoperative functional outcomes in supination-external rotation ankle fractures. Chin J Traumatol 2024:S1008-1275(24)00069-5. [PMID: 38937167 DOI: 10.1016/j.cjtee.2024.06.001] [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: 10/09/2023] [Revised: 05/26/2024] [Accepted: 06/02/2024] [Indexed: 06/29/2024] Open
Abstract
PURPOSE To assess the relationship between dislocation and functional outcomes in supination-external rotation (SER) ankle fractures. METHODS A retrospective case series study was performed on patients with ankle fractures treated surgically at a large trauma center from January 2015 to December 2021. The inclusion criteria were young and middle-aged patients of 18-65 years with SER ankle fractures that can be classified by Lauge-Hansen classification and underwent surgery at our trauma center. Exclusion criteria were serious life-threatening diseases, open fractures, fractures delayed for more than 3 weeks, fracture sites ≥2, etc. Then patients were divided into dislocation and no-dislocation groups. Patient demographics, injury characteristics, surgery-related outcomes, and postoperative functional outcomes were collected and analyzed. The functional outcomes of SER ankle fractures were assessed postoperatively at 1-year face-to-face follow-up using the foot and ankle outcome score (FAOS) and American orthopedic foot and ankle society score and by 2 experienced orthopedic physicians. Relevant data were analyzed using SPSS version 22.0 by Chi-square or t-test. RESULTS During the study period, there were 371 ankle fractures. Among them, 190 (51.2%) were SER patterns with 69 (36.3%) combined with dislocations. Compared with the no-dislocation group, the dislocation group showed no statistically significant differences in gender, age composition, fracture type, preoperative complications with diabetes, smoking history, preoperative waiting time, operation time, and length of hospital stay (all p > 0.05), but a significantly higher Lauge-Hansen injury grade (p < 0.001) and syndesmotic screw fixation rate (p = 0.033). Moreover, the functional recovery was poorer, revealing a significantly lower FAOS in the sport/rec scale (p < 0.001). Subgroup analysis showed that among SER IV ankle fracture patients, FAOS was much lower in pain (p = 0.042) and sport/rec scales (p < 0.001) for those with dislocations. American orthopedic foot and ankle society score revealed no significant difference between dislocation and no-dislocation patients. CONCLUSION Dislocation in SER ankle fractures suggests more severe injury and negatively affects functional recovery, mainly manifested as more pain and poorer motor function, especially in SER IV ankle cases.
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Affiliation(s)
- Sheng-Ye Hu
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Mu-Min Cao
- School of Medicine, Southeast University, Nanjing, 210009, China
| | - Yuan-Wei Zhang
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China; School of Medicine, Southeast University, Nanjing, 210009, China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, 210009, China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Liu Shi
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China; School of Medicine, Southeast University, Nanjing, 210009, China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, 210009, China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Guang-Chun Dai
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China; School of Medicine, Southeast University, Nanjing, 210009, China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, 210009, China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Ya-Kuan Zhao
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China; School of Medicine, Southeast University, Nanjing, 210009, China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, 210009, China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Tian Xie
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China; School of Medicine, Southeast University, Nanjing, 210009, China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, 210009, China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Hui Chen
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China; School of Medicine, Southeast University, Nanjing, 210009, China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, 210009, China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Yun-Feng Rui
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China; School of Medicine, Southeast University, Nanjing, 210009, China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, 210009, China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China.
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Zimmermann J, Zingg L, Frey WO, Schläppi M, Babians A, Zingg U. Clinical, functional and radiological outcome after osteosynthesis of ankle fractures using a specific provocation test. J Orthop Surg Res 2024; 19:327. [PMID: 38825673 PMCID: PMC11145828 DOI: 10.1186/s13018-024-04820-x] [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: 03/18/2024] [Accepted: 05/29/2024] [Indexed: 06/04/2024] Open
Abstract
BACKGROUND Ankle fractures are frequent, and despite numerous publications on their treatment and outcome, there is a lack of precise data on the functional results in young, healthy and physically active patients. We hypothesized that patients who underwent open reduction and internal fixation (ORIF) for simple ankle fractures would have similar function compared to a healthy control group, whereas patients with complex fractures will have significant functional deficits. Furthermore, we postulate that there is a discrepancy between the radiological and the functional outcomes. METHODS A set of specific provocation tests was developed to evaluate the postoperative possibility of weight bearing, stop-and-go activities and range of motion. In combination with three questionnaires and a radiographic evaluation, the true functional outcome and the possibility of participating in sporting activities were investigated and compared with those of an age- and sex-matched control group. RESULTS A significant impairment was found in unilateral and simple ankle fractures. This impairment increased in tests including stop-and-go activities in combination with load bearing and with the complexity of the fractures. Concerning the subjective outcome, there was a significant adverse effect for daily activities without any difference in preoperative or postoperative sporting activity between the groups. No difference was found in the radiological assessment. CONCLUSIONS Both simple and complex ankle fractures treated with ORIF have a significant and long-lasting impact on functional outcome in young and active patients. The radiological result is not associated with a good functional outcome. TRIAL REGISTRATION BASEC-Nr. 2018 - 01124.
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Affiliation(s)
- Julian Zimmermann
- Department of Orthopaedics and Traumatology, Limmattal Hospital, Urdorferstrasse 100, Zurich-Schlieren, 8952, Switzerland.
| | - Liv Zingg
- Department of Orthopaedics and Traumatology, Limmattal Hospital, Urdorferstrasse 100, Zurich-Schlieren, 8952, Switzerland
| | - Walter O Frey
- Movemed, Department of Sport Medicine, University Hospital Balgrist, Zurich, 8008, Switzerland
- Klinik Hirslanden Zurich, Witellikerstrasse 40, Zürich, 8032, Switzerland
| | - Michel Schläppi
- Department of Orthopaedics and Traumatology, Hospital of Winterthur, Brauerstrasse 15, Postfach, Winterthur, 8401, Switzerland
| | - Arby Babians
- Department of Orthopaedics and Traumatology, Limmattal Hospital, Urdorferstrasse 100, Zurich-Schlieren, 8952, Switzerland
| | - Urs Zingg
- Department of Orthopaedics and Traumatology, Limmattal Hospital, Urdorferstrasse 100, Zurich-Schlieren, 8952, Switzerland
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González-Morgado D, Bargalló-Granero J, Pujol O, Altayó-Carulla M, Castellanos-Alonso S, Reverté-Vinaixa MM, Nomdedéu J, Tomás-Hernández J, Joshi-Jubert N, Teixidor-Serra J, Minguell-Monyart J, Andrés-Peiró JV. Temporary immobilization methods for closed low-energy ankle fracture-dislocations: comparative analysis of a retrospective cohort. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024:10.1007/s00590-024-03966-y. [PMID: 38796813 DOI: 10.1007/s00590-024-03966-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 04/16/2024] [Indexed: 05/29/2024]
Abstract
PURPOSE Ankle fracture-dislocations (AFD) often necessitate staged management involving temporary external fixation (EF) due to mechanical instability or blistering. However, limited literature exists on the optimal temporary immobilization method for low-energy closed AFD. This study compared baseline patient and fracture characteristics, along with clinical and radiological outcomes between AFD initially immobilized with EF versus splinting. METHODS A retrospective cohort study was conducted involving patients with AFD temporarily immobilized using EF or splinting, followed by definitive open reduction and internal fixation. Quality of reduction (QOR) was assessed for each patient post-initial immobilization and after the definitive surgery. RESULTS The study encompassed 194 patients: 138 treated with a splint (71.1%) and 56 (28.9%) with EF. Secondary loss of reduction had occurred in three patients who were splinted (2.2%). The mean ages in the EF and splint groups were 63.2 and 56.1 years, respectively (p = 0.01). Posterior malleolus fracture (PMF) and blisters were more prevalent in EF patients (69.6% vs. 43.5% for PMF and 76.8% vs. 20.3% for blisters, respectively; p = 0.05 and p < 0.01). Postoperative complication rates were 8.9% for EF versus 10.9% for splinting (p = 0.69). Satisfactory final QOR was attained in 79.8% of patients treated with a splint versus 64.3% with EF (p = 0.02). CONCLUSION Patients immobilized by EF presented with poorer baseline characteristics and had more unstable injuries. Nevertheless, postoperative complication rates were comparable. Thus, EF appears to be a valuable tool for standardizing outcomes in AFD patients with a less favorable prognosis.
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Affiliation(s)
- Diego González-Morgado
- Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
| | - Júlia Bargalló-Granero
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
| | - Oriol Pujol
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
- Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Marta Altayó-Carulla
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
| | - Sara Castellanos-Alonso
- Department of Orthopaedic Surgery and Traumatology, Hospital Municipal de Badalona, Badalona, Spain
| | - María Mercedes Reverté-Vinaixa
- Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
- Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Josep Nomdedéu
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
| | - Jordi Tomás-Hernández
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
- Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Nayana Joshi-Jubert
- Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
- Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Jordi Teixidor-Serra
- Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
- Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Joan Minguell-Monyart
- Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
- Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - José Vicente Andrés-Peiró
- Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain.
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain.
- Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain.
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Mandelka E, Wikanardi BA, Beisemann N, Gruetzner PA, Franke J, Vetter SY. Temporary Cast Application in Dislocated Ankle Fractures Leads to High Rates of Secondary Loss of Reduction: Does the Lauge-Hansen Injury Type Matter? Foot Ankle Int 2024; 45:446-455. [PMID: 38501715 DOI: 10.1177/10711007241231563] [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] [Indexed: 03/20/2024]
Abstract
BACKGROUND For the temporary treatment of ankle fracture dislocations (AFDs), previous studies indicate higher rates of secondary loss of reduction (LOR) with splint immobilization, prompting consideration for expanding indications for external fixation (ExFix). However, these studies did not investigate the influence of fracture morphology to further improve patient selection. The aim of this study was to investigate the influence of Lauge-Hansen injury type on the LOR rate in bimalleolar or trimalleolar AFDs for temporary cast vs ExFix immobilization. METHODS In this retrospective cohort study, patients with isolated AFD cases treated at our institution from 2011 to 2020 were reviewed. Inclusion criteria required radiographs depicting initial dislocation and appropriate reduction after Cast or ExFix immobilization. Exclusion criteria encompassed concomitant injuries, open fractures, conservative management as well as surgery performed within 48 hours or at a different facility. Patients were grouped by temporary treatment (Cast or ExFix). The primary endpoint was LOR prior to definitive surgery across various Lauge-Hansen types. RESULTS The LOR rate was significantly higher in the cast group (40/152, 26.3%) compared to the ExFix group (5/191, 2.6%; P < .0001). In the cast group, LOR was associated with an increase in time to definitive surgery by a mean of 3 days (P < .002). During cast treatment, LOR was significantly more likely for pronation abduction (P = .001) and supination external rotation injuries (P < .0001), whereas no significant differences were observed for pronation external rotation (P = .006), supination adduction (P > .99), and fractures not classifiable (P > .99). CONCLUSION In cases of AFDs resulting from supination external rotation or pronation abduction trauma according to the Lauge-Hansen classification, especially in the setting of an additional posterior malleolar fracture, primary application of external fixation should be considered to reduce the risk for secondary loss of reduction. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Eric Mandelka
- BG Trauma Center Ludwigshafen, Department of Trauma and Orthopedic Surgery, Ludwigshafen, Germany
| | - Bernhard Arya Wikanardi
- BG Trauma Center Ludwigshafen, Department of Trauma and Orthopedic Surgery, Ludwigshafen, Germany
- University of Heidelberg, Medical Faculty Heidelberg, Heidelberg, Germany
| | - Nils Beisemann
- BG Trauma Center Ludwigshafen, Department of Trauma and Orthopedic Surgery, Ludwigshafen, Germany
| | - Paul Alfred Gruetzner
- BG Trauma Center Ludwigshafen, Department of Trauma and Orthopedic Surgery, Ludwigshafen, Germany
| | - Jochen Franke
- BG Trauma Center Ludwigshafen, Department of Trauma and Orthopedic Surgery, Ludwigshafen, Germany
| | - Sven Yves Vetter
- BG Trauma Center Ludwigshafen, Department of Trauma and Orthopedic Surgery, Ludwigshafen, Germany
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Welzel L, Omar M, Müller CW. Complications following surgical treatment of ankle fractures in the elderly: can they be avoided? Orthop Rev (Pavia) 2024; 16:116370. [PMID: 38666190 PMCID: PMC11043027 DOI: 10.52965/001c.116370] [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: 02/26/2024] [Accepted: 03/24/2024] [Indexed: 04/28/2024] Open
Abstract
Background Following surgical treatment of ankle fractures, geriatric patients face high complication rates (CR) in literature. Commonly used diagnostic and treatment algorithms fail to consider requirements of ageing patients which increases the risk of postoperative complications. Objective Present study critically evaluated surgical management of ankle fractures in patients over 65 years old, with focus on identifying modifiable risk factors and effective comorbidity management strategies. Methods We conducted a retrospective single-center study on patients who underwent surgical treatment of an ankle fracture. Based on their age, participants were divided into non-geriatric patients (NGP<65y) and geriatric patients (GP≥65y). We analyzed overall CR and number of minor and major complications in relation to timing of surgery, biological sex, injury pattern, osteosynthesis, pre-existing medical conditions, and postoperative care. Results 402 patients were included. GP encountered significantly higher overall (p<0.001), minor (p<0.001) and major (p=0.003) complications. They presented more complex, displaced and open fractures. Predominant factor contributing to higher CR in NGP and markedly in GP was concomitant diseases, presenting a strong OR of 19,290 (p<0.001) and 17,022 (p<0.001). Delaying surgery and managing comorbidities preoperatively had a favorable impact. Conclusion We revealed a high significant correlation between pre-existing medical conditions and postoperative results. To ascertain viability of delayed surgery in facilitating additional diagnostics and treatment of comorbidities, further comparative trials with a larger cohort are imperative.
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Affiliation(s)
- Lukas Welzel
- Department of Orthopedics and Traumatology Asklepios Klinik Wandsbek
- Department of Traumatology Hannover Medical School
- Department of Orthopedics and Traumatology Schön Klinik Neustadt
| | - Mohamed Omar
- Department of Traumatology Hannover Medical School
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Jiang F, Guo H, Zeng Q, Long P, Zeng C, Yan H. Preoperative temporary fixation for fractures around the ankle using a simple extensible external fixator significantly improves patient comfort. Foot Ankle Surg 2024; 30:239-244. [PMID: 38123374 DOI: 10.1016/j.fas.2023.12.001] [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: 10/03/2023] [Revised: 11/13/2023] [Accepted: 12/10/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND The authors developed a simple extensible external fixator, which has the advantages of easy application and inexpensiveness. The present study aimed to make a comparison between this external fixator and calcaneal traction in preoperative temporary fixation for malaligned ankle fractures and pilon fractures. METHODS From May 2020 to February 2022, patients with malaligned ankle fractures or Rüedi-Allgöwer type 2 or 3 pilon fractures with obvious soft tissue swelling were retrospectively reviewed and divided into the calcaneal traction group and the external fixation group. The two groups of patients were matched 1:1 before making comparisons. RESULTS A total of 38 patients were included. Higher General Comfort Questionnaire score and lower visual analog scale score were noticed in the external fixation group during hospitalization (p < 0.05), while the operation latency time, total cost, patient satisfaction, and functional outcomes one year after surgery were not significantly different between the two groups. No wound complications were observed. CONCLUSION Preoperative temporary fixation for fractures around the ankle using this simple extensible external fixator significantly improves patient comfort when compared to calcaneal traction. LEVEL OF EVIDENCE III, retrospective comparative study.
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Affiliation(s)
- Feijuan Jiang
- Department of Foot and Ankle Surgery, Center for Orthopedic Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou, PR China
| | - Hao Guo
- Department of Foot and Ankle Surgery, Center for Orthopedic Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou, PR China
| | - Qing Zeng
- Department of Foot and Ankle Surgery, Center for Orthopedic Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou, PR China
| | - Peibo Long
- Department of Foot and Ankle Surgery, Center for Orthopedic Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou, PR China
| | - Canjun Zeng
- Department of Foot and Ankle Surgery, Center for Orthopedic Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou, PR China.
| | - Han Yan
- Department of Foot and Ankle Surgery, Center for Orthopedic Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou, PR China.
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Xie W, Li H, Zhang C, Cui X, Zhang S, Rui Y, Chen H. Comparison of temporary external and percutaneous k-wire fixations for treatment of ankle fracture-dislocations. BMC Musculoskelet Disord 2023; 24:880. [PMID: 37951888 PMCID: PMC10638746 DOI: 10.1186/s12891-023-07020-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 11/03/2023] [Indexed: 11/14/2023] Open
Abstract
PURPOSE Ankle fracture-dislocations are among the most severe injuries, and the use of an external fixator as a recommended fixation method has some disadvantages. The aim of this study was to compare the clinical outcomes and complication rates of external and K-wire fixations in the treatment of ankle fracture dislocations. METHODS A total of 67 patients with ankle fracture-dislocations requiring temporary external or percutaneous K-wire fixation were included. The exclusion criteria were pilon fractures, open fractures, and those who required acute open reduction internal fixation (ORIF). The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, a 10-point visual analog scale (VAS) score (range 0-10), and complications before and after the definitive surgery were recorded. RESULTS A significant difference between the two groups was not observed for age, sex, affected side, fracture type, smoking status, or diabetes. The average AOFAS scores were 83.2 and 83.3, the median VAS scores were 3 and 3, and the complication rates were 32.4% and 6.7% in the external and K-wire fixation groups, respectively (p = 0.010). However, skin necrosis, re-dislocation of the ankle, surgical wound infection, and posttraumatic ankle osteoarthritis frequency were not significantly different between the groups, except for pin-sites infection (p = 0.036). CONCLUSION Ankle fracture-dislocations using percutaneous k-wire fixation showed a low rate of complications and favorable clinical outcomes. This method could be a good alternative treatment option for ankle fracture-dislocations.
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Affiliation(s)
- Wenjun Xie
- Department of OrthopaedicsZhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Trauma Center, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Orthopaedic Trauma Institute (OTI), Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
| | - He Li
- Department of OrthopaedicsZhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Trauma Center, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Orthopaedic Trauma Institute (OTI), Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
| | - Cheng Zhang
- Department of OrthopaedicsZhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Trauma Center, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Orthopaedic Trauma Institute (OTI), Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
| | - Xueliang Cui
- Department of OrthopaedicsZhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Trauma Center, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Orthopaedic Trauma Institute (OTI), Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
| | - Sheng Zhang
- Department of OrthopaedicsZhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Trauma Center, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Orthopaedic Trauma Institute (OTI), Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
| | - Yunfeng Rui
- Department of OrthopaedicsZhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Trauma Center, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Orthopaedic Trauma Institute (OTI), Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
| | - Hui Chen
- Department of OrthopaedicsZhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China.
- Trauma Center, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China.
- Orthopaedic Trauma Institute (OTI), Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China.
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Percutaneous Reduction and Provisional Pinning of the Distal Fibula: A Novel Way to Maintain Fibular Length in Temporary Stabilization. J Orthop Trauma 2023; 37:e95-e98. [PMID: 35613325 DOI: 10.1097/bot.0000000000002421] [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] [Accepted: 05/23/2022] [Indexed: 02/02/2023]
Abstract
Ankle fractures are commonly observed by orthopaedic trauma surgeons, foot and ankle surgeons, and general orthopaedists with more than 135,000 fractures surgically treated every year in the United States. 1 The soft tissue envelope surrounding the osseous anatomy of the ankle is limited and many injuries, including those that result from higher injury mechanisms and/or those occurring in hosts with vascular and metabolic comorbidities may benefit from a delay in definitive fixation; this may minimize risks of wound healing issues and fracture-related infection. 2,3 Open fractures may benefit from temporizing fixation after debridement and irrigation for the same reasons. 4-6 The benefits of temporizing external fixation in pilon fractures has been recognized for decades. 7 The use of ankle-spanning external fixation for ankle fractures and dislocations has become more frequently used to maintain coronal and sagittal alignment of the ankle mortise as a bridge to definitive fixation. 8-10 However, standard ankle-spanning external fixation techniques do not always directly restore fibular length and rotation, especially in fracture patterns with syndesmotic disruption and/or segmental fibular comminution. Some authors have advocated for limited internal fixation of fibula fractures at time of external fixation application to address this problem, 7 but this still necessitates a surgical approach through a traumatized soft tissue envelope and potentially compromises posterolateral and anterolateral approaches that could be used to address associated Volkman or Chaput fragments. Delayed distal fibular open reduction and internal fixation of shortened fractures has frustrated orthopaedic surgeons for decades and techniques such as "push-pull" screws 11 and extensive soft tissue dissection 12 are often necessary to restore anatomic fibular reduction of length and rotation. Given these challenges, the senior author began to use a technique of percutaneous reduction and buried provisional pinning of the distal fibula to the talus for fibula fractures with persistent shortening after ankle-spanning external fixation of injuries not deemed appropriate for immediate open reduction and internal fixation. We aim to report early results and describe this novel, low-cost surgical technique.
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Mandelka E, Wikanardi BA, Beisemann N, Gruetzner PA, Franke J, Vetter SY, Privalov M. Comparing Temporary Immobilization Using Cast and External Fixator in Unimalleolar Ankle Fracture Dislocations: A Retrospective Case Series. J Clin Med 2023; 12:jcm12030748. [PMID: 36769397 PMCID: PMC9917604 DOI: 10.3390/jcm12030748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 12/28/2022] [Accepted: 01/14/2023] [Indexed: 01/20/2023] Open
Abstract
Studies have reported a high percentage of ankle fracture dislocations with secondary loss of reduction during primary treatment with a splint or cast. This study aimed to assess the rate of secondary loss of reduction in unimalleolar ankle fracture dislocations treated primarily with a cast or external fixator, identify the potential influence of fracture morphology, and investigate the potential implications. Unimalleolar ankle fracture dislocations with and without posterior malleolar fracture between 2011 and 2020 were included. Patients were categorized into two groups, depending on the method of temporary treatment. Fracture morphology, time to definitive surgery, and soft-tissue complications were compared. Of 102 patients, loss of reduction tended to occur more often in the cast group (17.3%) than in the external fixator group (6.0%). The presence of a posterior malleolar fracture did not have a significant influence on loss of reduction in cast immobilization; however, the fragment proved to be significantly bigger in cases with loss of reduction. No statistically significant differences in soft tissue complications or time to definitive surgery were found. Surgeons should consider the application of interval external fixation in the primary treatment of unimalleolar ankle fracture dislocations with additional posterior malleolar fractures.
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Affiliation(s)
- Eric Mandelka
- Research Group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), BG Klinik Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071 Ludwigshafen, Germany
| | - Bernhard A. Wikanardi
- Research Group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), BG Klinik Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071 Ludwigshafen, Germany
- Medical Faculty of Heidelberg, Ruprecht-Karls-Universität Heidelberg, Im Neuenheimer Feld 672, 69120 Heidelberg, Germany
| | - Nils Beisemann
- Research Group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), BG Klinik Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071 Ludwigshafen, Germany
| | - Paul A. Gruetzner
- Research Group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), BG Klinik Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071 Ludwigshafen, Germany
| | - Jochen Franke
- Research Group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), BG Klinik Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071 Ludwigshafen, Germany
| | - Sven Y. Vetter
- Research Group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), BG Klinik Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071 Ludwigshafen, Germany
| | - Maxim Privalov
- Research Group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), BG Klinik Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071 Ludwigshafen, Germany
- Correspondence:
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10
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Saad BN, Rampertaap Y, Menken LG, Whitlock KG, Crook BS, Baker RL, Keller DM, Liporace FA, Gage MJ, Yoon RS. Direct versus indirect posterior malleolar fixation in the treatment of trimalleolar ankle fractures: Is there a difference in outcomes? OTA Int 2022; 5:e219. [PMID: 36569113 PMCID: PMC9782365 DOI: 10.1097/oi9.0000000000000219] [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] [Received: 10/07/2021] [Accepted: 07/07/2022] [Indexed: 06/17/2023]
Abstract
PURPOSE The purpose of this study was to examine the differences in functional outcomes between direct and indirect surgical fixation methods of the posterior malleolus in the setting of trimalleolar fractures and identify any variables affecting patient outcomes. METHODS Primary outcomes were evaluated by PROMIS scores for short-term outcomes regarding total pain (TP) and total function (TF) comparing 40 patients with direct fixation with 77 with indirect fixation. Continuous variables were analyzed using t tests for parametric variables and the Mann-Whitney U test for nonparametric variables. Categorical variables were analyzed using a χ2 test. Univariate and multivariate linear regression models were performed to analyze factors that affect outcomes of TP and TF. RESULTS There was no difference in TP or TF between groups (P = 0.65 vs. P = 0.19). On univariate linear regression for TP, BMI, incidence of complication, tobacco use, and open injury showed significance in increasing pain levels with open injuries providing the greatest effect (coef = 11.8). On multivariate analysis, BMI, incidence of complication, open injury, and tourniquet time all significantly increased pain. For TF, univariate analysis showed age, BMI, incidence of complication, and diabetes to decrease function, and use of external fixator and tourniquet time increased function. In the multivariate model, increased BMI, open injuries, and increasing tourniquet time all decreased TF while use of an external fixator increased TF. CONCLUSION This study showed no difference in TP and TF using the PROMIS outcome scores when comparing direct fixation versus indirect fixation under univariate and multivariate models. LEVEL OF EVIDENCE Therapeutic III.
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Affiliation(s)
- Bishoy N. Saad
- Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center—RWJBarnabas Health, Jersey City, NJ and
| | - Yajesh Rampertaap
- Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center—RWJBarnabas Health, Jersey City, NJ and
| | - Luke G. Menken
- Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center—RWJBarnabas Health, Jersey City, NJ and
| | - Keith G. Whitlock
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Bryan S. Crook
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Rafael L. Baker
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - David M. Keller
- Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center—RWJBarnabas Health, Jersey City, NJ and
| | - Frank A. Liporace
- Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center—RWJBarnabas Health, Jersey City, NJ and
| | - Mark J. Gage
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Richard S. Yoon
- Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center—RWJBarnabas Health, Jersey City, NJ and
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Gerlach R, Toepfer A, Jacxsens M, Zdravkovic V, Potocnik P. Temporizing cast immobilization is a safe alternative to external fixation in ankle fracture-dislocation while posterior malleolar fragment size predicts loss of reduction: a case control study. BMC Musculoskelet Disord 2022; 23:698. [PMID: 35869482 PMCID: PMC9306170 DOI: 10.1186/s12891-022-05646-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 07/08/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
To determine if temporizing cast immobilization is a safe alternative to external fixator (ex-fix) in ankle fracture-dislocations with delayed surgery or moderate soft-tissue injury, we analysed the early complications and re-dislocation rates of cast immobilization in relation to ex-fix in patients sustaining these injuries.
Methods
All skeletally mature patients with a closed ankle fracture-dislocation and a minimum 6-months follow-up treated between 2007 and 2017 were included. Baseline demographics, comorbidities, injury description, treatment history and complications were assessed.
Results
In 160 patients (94 female; mean age 50 years) with 162 ankle fracture-dislocations, 35 underwent primary ex-fix and 127 temporizing cast immobilizations. Loss of reduction (LOR) was observed in 25 cases (19.7%) and 19 (15.0%) were converted to ex-fix. The rate of surgical site infections (ex-fix: 11.1% vs cast: 4.6%) and skin necrosis (ex-fix: 7.4% vs cast: 6.5%) did not differ significantly between groups (p = 0.122 and p = 0.825). Temporizing cast immobilization led to an on average 2.7 days earlier definite surgery and 5.0 days shorter hospitalization when compared to ex-fix (p < 0.001). Posterior malleolus fragment (PMF) size predicted LOR with ≥ 22.5% being the threshold for critical PMF-size (p < 0.001).
Conclusion
Temporizing cast immobilization was a safe option for those ankle fracture-dislocations in which immediate definite treatment was not possible. Those temporized in a cast underwent definite fixation earlier than those with a fix-ex and had a complication rate no worse than the ex-fix patients. PMF-size was an important predictor for LOR. Primary ex-fix seems appropriate for those with ≥ 22.5% PMF-size.
Trial registration
The study does not meet the criteria of a prospective, clinical trial. There was no registration.
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12
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Harrison WD, Fortuin F, Durand-Hill M, Joubert E, Ferreira N. Temporary circular external fixation for spanning the traumatised ankle joint: A cohort comparison study. Injury 2022; 53:3525-3529. [PMID: 35995609 DOI: 10.1016/j.injury.2022.07.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 06/05/2022] [Accepted: 07/18/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Temporary spanning fixation aims to provide bony stability whilst allowing access and resuscitation of the traumatised soft-tissue envelope. Conventional monolateral fixators are prone to half-pin morbidity in feet, variation in construct stability and limited weight-bearing potential. This study compares traditional delta-frame monolateral external fixators to ankle spanning circular fixators. METHODS Two cohorts were matched for demographics and fracture patterns. The quality of initial reduction and the maintenance of reduction until definitive surgery was assessed by two authors and categorised into four domains. Secondary measures included fixator costs, time to definitive surgery and complications. RESULTS Fifty-five delta-frames and 51 circular fixators were statistically matched for demographics and fracture pattern. "Excellent" and "Good" initial reduction was achieved in 50 (91%) delta-frames and 51 (100%) circular fixators (p = 0.027). Deterioration of initial reduction quality was seen in 12 (22%) delta-frames and two (4%) circular fixators (p < 0.001). Post-fixator dislocation occurred in five (9%) delta-frames and one (2%) circular fixator (p = 0.147). Median duration in spanned fixation was 11 days in both groups (p = 0.114). Three (5%) delta-frames and 13 (25%) circular fixators were used as definitive fixation. The mean implant cost was 4,307 USD for delta-frames and 3747 USD for circular fixators. CONCLUSION Temporary spanning circular fixation offers superior intra-operative reduction and maintenance of reduction and provides more opportunity to be used as definitive fixation. Circular fixation implants also proved to be less expensive and protected against further scheduled or unscheduled returns to theatre. LEVEL OF EVIDENCE IV, retrospective cohort study.
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Affiliation(s)
- William D Harrison
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa
| | - Franklin Fortuin
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa
| | - Matthieu Durand-Hill
- 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
| | - Nando Ferreira
- 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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Cao MM, Zhang YW, Hu SY, Rui YF. A systematic review of ankle fracture-dislocations: Recent update and future prospects. Front Surg 2022; 9:965814. [PMID: 36017521 PMCID: PMC9398172 DOI: 10.3389/fsurg.2022.965814] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundAnkle fracture-dislocations are one of the most severe types of ankle injuries. Compared to the simple ankle fractures, ankle fracture-dislocations are usually more severely traumatized and can cause worse functional outcomes. The purpose of this study was to review the previous literatures to understand the anatomy, mechanisms, treatment, and functional outcomes associated with ankle fracture-dislocations.MethodsThe available literatures from January 1985 to December 2021 in three main medical databases were searched and analyzed. The detailed information was extracted for each article, such as researchers, age, gender, groups, type of study, type of center research, level of evidence, significant findings, study aim, cause of injury, time from injury to surgery, type of fracture, direction of dislocation, follow-up, postoperative complications and functional evaluation scores.ResultsA total of 15 studies (1,089 patients) met the inclusion criteria. Only one study was a prospective randomized trial. The top-ranked cause of injury was high-energy injury (21.3%). Moreover, the most frequent type of fracture in ankle dislocations was supination-external rotation (SER) ankle fracture (43.8%), while the most common directions of dislocation were lateral (50%) and posterior (38.9%).ConclusionsCollectively, most ankle fracture-dislocations are caused by high-energy injuries and usually have poor functional outcomes. The mechanism of injury can be dissected by the ankle anatomy and Lauge-Hansen's classification. The treatment of ankle fracture-dislocations still requires more detailed and rational solutions due to the urgency of occurrence, the severity of injury, and the postoperative complications.
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Affiliation(s)
- Mu-Min Cao
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Yuan-Wei Zhang
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Sheng-Ye Hu
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Yun-Feng Rui
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Correspondence: Yun-Feng Rui
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14
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Establishing a low-risk zone for a temporary extra-articular calcaneo-tibial pin fixation in an unstable ankle or subtalar joint. Sci Rep 2022; 12:13313. [PMID: 35922456 PMCID: PMC9349277 DOI: 10.1038/s41598-022-17490-8] [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: 07/09/2021] [Accepted: 07/26/2022] [Indexed: 11/12/2022] Open
Abstract
This study aimed to establish a low-risk zone to avoid neurovascular injury during a temporary extra-articular calcaneo-tibial pin fixation in an unstable ankle or subtalar joint. A line from the calcaneal tuberosity center to the lateral end of the posterior malleolus at the ankle joint level defines the lateral border of this zone. Another line from the calcaneal tuberosity center to the midpoint of the anterior distal tibial articular surface at the joint level defines its medial border. This region was assumed to have a low neurovascular injury risk upon pin insertion. Fifty ankles from 50 patients who had undergone magnetic resonance imaging (MRI) for ankle disorders were assessed. T1-weighted oblique axial MRI slices were oriented to the pin trajectory. The mean distances between the sural nerve and the lateral border of the low-risk zone and between the posterior tibial neurovascular structures and the medial border of the low-risk zone were 15.0 ± 2.5 (range 9.1 to 21.1) and 12.8 ± 2.6 (6.3 to 20.8) mm, respectively. No neurovascular structures were identified within the low-risk zone. These findings demonstrated that an unstable ankle or subtalar joint can be temporarily fixated with an extra-articular calcaneo-tibial pin at a defined zone with a low neurovascular injury risk.
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15
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Pilskog K, Gote TB, Odland HEJ, Fjeldsgaard KA, Dale H, Inderhaug E, Fevang JM. Association of Delayed Surgery for Ankle Fractures and Patient-Reported Outcomes. Foot Ankle Int 2022; 43:762-771. [PMID: 35184581 PMCID: PMC9168892 DOI: 10.1177/10711007211070540] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Several studies probe the association between prolonged time to surgery and postoperative complications in ankle fractures, but little is known about how a longer wait time affects clinical outcomes. The present study aims to assess the association between time from injury to surgery and patient-reported outcomes after operative treatment of severe ankle fractures. METHOD Patients treated operatively for low-energy ankle fractures that also involve the posterior malleolus from 2014 to 2016 were included. Patient charts were reviewed for patient demographics, type of trauma, fracture characteristics, treatment given, and complications. Ankle function was evaluated on a follow-up visit by clinical examination, radiographs, and patient-reported outcome measures (Self-Reported Foot and Ankle Score [SEFAS], RAND-36, visual analog scale [VAS] of Pain, VAS of Satisfaction). We compared patients treated within 1 week to those treated later than a week from injury for analyses. RESULTS Follow-up visits of 130 patients were performed at mean 26 (SD 9) months after surgery. Patient demographics and fracture characteristics were similar between groups. Mean SEFAS was 34 (SD 10) in patients treated later than a week from injury vs 38 (SD 9) in those treated earlier (P = .012). Patients operated on later than 7 days from injury reported more pain (P = .008) and lower satisfaction than those treated earlier (P = .016). CONCLUSION In this retrospective patient series of low-energy ankle fractures with posterior malleolar fragments, we found that waiting >7 days for definitive surgery was associated with poorer clinical outcomes and more pain compared with those who had surgery earlier. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Kristian Pilskog
- Orthopedic department, Haukeland University Hospital, Norway,Clinical Institute 1, The University of Bergen,Kristian Pilskog, MD, Orthopedic Department, Haukeland University Hospital, Pb. 1400, Bergen, 5021, Norway.
| | | | | | | | - Håvard Dale
- Orthopedic department, Haukeland University Hospital, Norway,Clinical Institute 1, The University of Bergen
| | - Eivind Inderhaug
- Orthopedic department, Haukeland University Hospital, Norway,Clinical Institute 1, The University of Bergen
| | - Jonas Meling Fevang
- Orthopedic department, Haukeland University Hospital, Norway,Clinical Institute 1, The University of Bergen
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16
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De Luna V, Caterini A, Casci C, Marsiolo M, Efremov K, De Maio F, Farsetti P. Clinical and Radiological Results after Fracture-Dislocations of the Ankle: A Medium- to Long-Term Followup Study. J Funct Morphol Kinesiol 2022; 7:jfmk7020030. [PMID: 35466265 PMCID: PMC9036221 DOI: 10.3390/jfmk7020030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/17/2022] [Accepted: 03/22/2022] [Indexed: 12/03/2022] Open
Abstract
The authors report the long-term outcome in a series of 26 patients surgically treated for a fracture-dislocation of the ankle by open reduction and internal fixation (ORIF), reviewed after an average followup of 5.2 years. The average age of the patients was 46.8 years; 17 were female and 9 male; the right side was involved in 22 patients and the left side in 4; 10 patients had a unimalleolar fracture, 11 a bimalleolar fracture, and 5 a trimalleolar fracture. The quality of reduction was excellent in 14 cases and good in 12. The functional results were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) score, while radiographic results followed the Van Dijk classification. At followup, the AOFAS score ranged from 75 to 98 points with an average of 87.9, while the radiographic results were evaluated as grade 0 in 16 ankles and grade I in 10. Fracture-dislocations of the ankle occurred more frequently after high-energy traumas in younger patients on the right side, but they were also observed in older females after low-energy trauma. Excellent reduction was correlated with better radiographic results at long term followup. However, these injuries may lead to a poor functional outcome, despite an anatomical reduction and good radiographic results; in fact, in nine of our cases (34.6 percent), the AOFAS score was less than 90 points.
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17
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Buyukkuscu MO, Basilgan S, Mollaomeroglu A, Misir A, Basar H. Splinting vs temporary external fixation in the initial treatment of ankle fracture-dislocations. Foot Ankle Surg 2022; 28:235-239. [PMID: 33814287 DOI: 10.1016/j.fas.2021.03.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/15/2021] [Accepted: 03/22/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND To compare the efficacy, functional outcome, and complication frequency of splinting and external fixation in the initial treatment of ankle fracture-dislocations. METHOD Ankles with poor soft tissue conditions who underwent temporary stabilization due to using a splint or external fixator due to an ankle fracture-dislocation between 2012 and 2019 were retrospectively evaluated. Ankles were divided into two groups as the splint (n=69) and external fixator (n=48). The time between the injury to definitive surgery, reduction loss, operation time, functional outcome, pain, and soft-tissue complication frequency before and after definitive surgery were compared. RESULTS The frequency of reduction loss (25% vs. 4%, p=0.019) and skin necrosis (22% vs. 6%, p=0.028) were significantly higher in the splint group. Posterior malleolar fracture fragment ratio was calculated by dividing the fracture fragment axial length by the total axial length of the articular surface on computed tomography. Posterior malleolar fracture fragment ratio was found to be significantly higher in ankles with reduction loss in both the splint (25% vs 75%, p=0.032) and fixator groups (4% vs 96%, p=0.021). The mean time period between injury and definitive surgery was significantly shorter in the external fixator group (11±5 vs 7±4 days, p=0.033). Before definitive treatment, pin tract infection was observed in two ankles in the fixator group. CONCLUSION Splint immobilization of ankle fracture-dislocations may predispose to reduction loss, soft tissue complications, and a longer time period between injury and definitive fixation. The risk of these potential complications can be reduced with the use of an external fixator.
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Affiliation(s)
- Mehmet Ozbey Buyukkuscu
- Department of Orthopaedics and Traumatology, Health Science University Gaziosmanpasa Training and Research Hospital, Istanbul, 34433, Turkey.
| | - Seckin Basilgan
- Department of Orthopaedics and Traumatology, Health Science University Gaziosmanpasa Training and Research Hospital, Istanbul, 34433, Turkey
| | - Ali Mollaomeroglu
- Department of Orthopaedics and Traumatology, Health Science University Gaziosmanpasa Training and Research Hospital, Istanbul, 34433, Turkey
| | - Abdulhamit Misir
- Department of Orthopaedics and Traumatology, Health Science University Gaziosmanpasa Training and Research Hospital, Istanbul, 34433, Turkey
| | - Hakan Basar
- Department of Orthopaedics and Traumatology, Health Science University Gaziosmanpasa Training and Research Hospital, Istanbul, 34433, Turkey
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18
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Tarkin IS, Murawski CD, Mittwede PN. Temporizing Care of Acute Traumatic Foot and Ankle Injuries. Orthop Clin North Am 2022; 53:95-103. [PMID: 34799027 DOI: 10.1016/j.ocl.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Temporizing care has become a critical part of the treatment armamentarium for select foot and ankle injuries. Indications for performing temporizing care are based on the specific injury pattern, the host, associated injuries, as well as surgeon resources. Foot and ankle injuries are often associated with severe adjacent injury to the soft tissue sleeve. An acute procedure performed through a traumatized soft tissue envelope will often lead to the failure of wound healing and/or infectious complications. Thus, delayed reconstruction of acute foot and ankle injuries is often advisable in these cases.
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Affiliation(s)
- Ivan S Tarkin
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Suite 1010, Pittsburgh, PA 15213, USA.
| | | | - Peter N Mittwede
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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19
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Kamin K, Rammelt S, Kleber C, Marx C, Schaser KD. [External fixator: temporary fixation and soft tissue management of the ankle]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2020; 32:421-432. [PMID: 32945938 DOI: 10.1007/s00064-020-00677-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 06/11/2020] [Accepted: 06/16/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE OF SURGERY Joint-spanning transfixation of the ankle joint aims at mostly temporary retention of the reduction, i.e. restoring length and axial alignment and stabilization of the ankle mortise in highly unstable fractures around the ankle and under critical soft tissue conditions. In selected cases, external fixation serves as an additional stabilization also following completed internal fixation or the fracture can be treated in the external fixator. The goal of surgery is to allow quick soft tissue recovery, prevention of redislocation and stabilization of the ankle and adjacent structures. INDICATIONS a) Fractures of the tibial pilon; b) very distal, extra-articular lower leg fractures (without the option for pin positioning in the distal fragment); c) highly unstable malleolar fractures with tendency to subluxation and dislocation fractures; d) critical soft tissue conditions around the ankle; e) dislocation fractures of the talus, Chopart and Lisfranc joints (if necessary with additional transarticular transfixation). CONTRAINDICATIONS Missing consent to surgery by the conscious patient, life-threatening general condition by other prioritized injuries. SURGICAL TECHNIQUE Percutaneous pin placement of the appropriate caliber into so-called safe zones of the tibia, metatarsus and calcaneus, as needed. Additional transfixation of the Chopart and Lisfranc joints with K‑wires as needed. Fixation of the struts with the foot in a neutral position. Besides consideration of biomechanical principles, pin placement must be done in anticipation of the definitive stabilization and future approaches respecting the anatomical structures while achieving maximum stability and soft tissue protection. POSTOPERATIVE MANAGEMENT Following initial transfixation, elevation of the injured leg for soft tissue protection, local cooling and bed rest are indicated. In cases of compartment syndrome and open fractures with temporary soft tissue coverage, second look surgery after 24-72 h is mandatory. For exact fracture analysis and optimal planning of the definitive surgical strategy, the indications for CT imaging should be generously considered. The timing of definitive care depends on the local soft tissue status and the overall condition of the patient. RESULTS The presence of a dislocation at the time of the accident represents a negative prognostic factor for ankle fractures. Higher rates of posttraumatic arthrosis are also found in pilon fractures and trimalleolar fractures, direct cartilage damage and rupture of the syndesmosis. In cases of anatomic reconstruction of the mortice and ankle joint congruence, good to excellent results can be achieved in 75-89%.
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Affiliation(s)
- Konrad Kamin
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Deutschland.
| | - Stefan Rammelt
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - Christian Kleber
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - Christine Marx
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - Klaus-Dieter Schaser
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Deutschland
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