A systematic review of ankle fracture-dislocations: Recent update and future prospects

The influence of imaging protocols on complex ankle fracture manipulation in the ED: A before and after study

INTRODUCTION

Ankle injuries that present to the ED with instability of the joint due to multiple fractures/disruption of the mortise need to be re-aligned promptly to minimise complications. A protocol change was introduced whereby mobile radiographs would be performed in the ED resuscitation room during manipulation of a complex ankle injury. The aim of this study was to determine if the overall time to definitive reduction had reduced for these patients, improving patient flow.

METHOD

Data was collected from patients attending the ED with a complex or unstable ankle injury in a UK single-centre over 6-months periods, pre pathway introduction (2019), immediately post change (2021) and 2 years post implementation (2023).

RESULTS

In excess of 3000 patients had ankle radiographs performed in each cohort of data collection with an average of 2.9 % of injuries categorised as complex or unstable and requiring manipulation, consistent across the cohorts (p = 0.246). Increasing compliance with the new pathway was evident over time with a significant time reduction demonstrated from initial ED presentation to final post manipulation imaging if mobile radiographs were obtained with the mean time 113 min quicker than those performed in the radiology department in 2023 (p = 0.00).

CONCLUSION

Although it takes time to embed new pathways and changes in practice, this study demonstrated that a simple change in imaging provision had a positive impact for patients with a complex ankle injury.

IMPLICATIONS FOR PRACTICE

Providing post manipulation radiographs in the ED resuscitation room allowed earlier confirmation of restored anatomical alignment for patients with a complex ankle injury and enabled clinicians to perform multiple manipulation attempts, if necessary, under the same sedation episode.

Functional outcomes after ankle fracture-dislocation: a systematic review

INTRODUCTION

Ankle fractures represent a significant portion of orthopedic injuries, with fracture dislocations tending to have worse outcomes. Logsplitter fractures represent a subset of fracture dislocations in which the talus is axially wedged in the tibiofibular joint. We aim to comprehensively investigate and report on the complications and functional outcomes associated with ankle fracture-dislocations.

MATERIALS AND METHODS

Following PRISMA guidelines, a medical librarian conducted a literature search in Embase, Ovid Medline, Scopus, Cochrane Central Register of Controlled Trials, and The Cochrane Database of Systematic Reviews. Studies examining ankle fracture-dislocations and reporting on functional or employment outcomes were included. Excluded were non-English studies, abstracts, conference proceedings, letters, perspective pieces, reviews, editorials, and case reports or series with fewer than five patients. Data on functional outcomes were extracted and reported using descriptive statistics. A comparative analysis of AOFAS scores between Logsplitter and ankle fracture-dislocations was conducted using pooled means and independent t-tests.

RESULTS

A total of 21 studies involving 810 cases of ankle fracture-dislocations were included. The pooled mean AOFAS score across 13 studies was 81.5, indicating "good" outcomes, while Logsplitter injuries had a significantly lower mean score of 75.8 compared to 82.9 for other ankle fracture-dislocations (p = 0.016). Complications included wound infection (7.3%), posttraumatic osteoarthritis (29.2%), nonunion/malunion (12.6%), and malunion. No studies reported on employment outcomes.

CONCLUSIONS

Ankle fracture-dislocations are high-energy injuries that affect a younger population compared to non-dislocated ankle fractures. Their functional outcomes resemble those of pilon fractures more than common ankle fractures. Logsplitter injuries are a subset of fracture dislocations that occur in even younger patients, with worse functional outcomes. This information can guide perioperative discussion and expectations for functional recovery. Additional studies are needed to evaluate the impact of these injuries on return to employment.

A case report on the successful treatment of a specific type of open ankle fracture-dislocation called logsplitter injury

This case report presents the successful management of a rare and complex open ankle fracture-dislocation known as a 'Logsplitter Injury', resulting from a high-energy traumatic event. The patient, a Chinese male in his early 20 s, sustained a severe left lower limb injury in a traffic accident. Initial clinical assessments revealed significant swelling, pain and an open fracture with extensive soft tissue damage. The patient underwent an emergency surgical intervention, involving meticulous wound debridement, internal fixation and reconstruction of the lower tibiofibular union, was performed. The use of vancomycin-loaded polymethylmethacrylate bone cement and negative pressure wound therapy contributed to the favourable outcome. Post-operative care encompassed comprehensive analgesia and infection prevention measures, resulting in substantial ankle function recovery. Follow-up assessments revealed healed fractures and excellent joint alignment, with the patient attaining an AOFAS score of 85, indicative of good functional recovery. This case underscores the effectiveness of individualised treatment plans and multidisciplinary teamwork in managing such challenging injuries, offering valuable clinical insights and highlighting the potential for successful outcomes with timely and precise surgical interventions.

Robot-Assisted Reduction of the Ankle Joint via Multi-Body 3D-2D Image Registration

Purpose

Robot-assisted orthopaedic joint reduction offers enhanced precision and control across multiple axes of motion, enabling precise realignment according to predefined plans. However, the high levels of forces encountered may induce unintended anatomical motion and flex mechanical components. To address this, this work presents an approach that uses 2D fluoroscopic imaging to verify and readjust the 3D reduction path by tracking deviations from the planned trajectory.

Methods

The proposed method involves a 3D-2D registration algorithm using a pair of fluoroscopic images, along with prior models of each body in the radiographic scene. This objective is formulated to couple and constrain multiple object poses (fibula, tibia, talus, and robot end effector), and incorporate novel methods for automatic view and hyperparameter selection to improve robustness. The algorithms were refined through cadaver studies and evaluated in a preclinical trial, employing a robotic system to manipulate a dislocated fibula.

Results

Studies with cadaveric specimens highlighted the joint-specific formulation's high registration accuracy (Δ x = 0.3 ± 1.5 mm ), further improved with the use of automatic view and hyperparameter selection (Δ x = 0.2 ± 0.8 mm ). Preclinical studies demonstrated a high deviation between the intended and the actual path of the robotic system, which was accurately captured (Δ x < 1 mm ) using the proposed techniques.

Conclusions

The solution offers to close the loop on image-based guidance of robot-assisted joint reduction by tracking the robot and bones to dynamically correct the course. The approach uses standard clinical images and is expected to lower radiation exposure by providing 3D information and allowing the staff to stay clear of the x-ray beam.

Predictive factors to return to sport after surgical management of ankle fractures

Achieving Return to Sport (RTS) is crucial in managing ankle fractures for athletes. This study aimed to identify RTS factors post-surgical fixation of ankle fractures. A retrospective analysis was conducted on 93 active patients with surgically treated displaced or unstable ankle fractures from January 2020 to January 2021. The median follow-up was 2.12 years. Clinical, functional, and radiographic aspects were evaluated. Among the athletes, 82.8 % resumed sports post-surgery, with 26.9 % returning within 3 months and 75.3 % at 1 year. At 1 year, 40.9 % regained their pre-injury activity level. There was a significant association between RTS and AO/OTA fracture subtype (p = 0.038). Unimalleolar fractures had the best outcomes, with 100 % achieving RTS in a median of 4 months. Bimalleolar fractures had 80.77 % RTS in 6 months, and trimalleolar fractures had 65.22 % RTS in 8 months. AO/OTA subtypes B and C predicted lower RTS to pre-injury levels, with delayed recovery for bimalleolar and trimalleolar fractures. These findings underscore the impact of fracture severity on RTS, with more complex fractures leading to poorer and delayed recovery outcomes.

Ankle syndesmotic ligaments avulsion fractures: incidence in adult population

BACKGROUND

Distal tibiofibular syndesmosis injury is often associated with ankle fractures in adults. Injuries to the anterior/posterior inferior tibiofibular ligament (AITFL/PITFL) may present as a mid-substance tear or as an avulsion at insertion. Tibial and fibular avulsion of the AITFL is known as Tillaux fracture and Wagstaffe fracture, respectively. Tibial avulsion of the PITFL is referred to as a Volkmann fracture, and fibular avulsion of the PITFL is still undefined and has not been reported yet. The aim of this study is to summarize the incidence of these four avulsions, that is, tibial and fibular avulsions of the AITFL and PITFL.

METHOD

Radiography and computed tomography (CT) imaging data of all adult patients with ankle fractures treated at our hospital between November 2010 and March 2023 were retrospectively analyzed. All ankle fractures were classified according to the Weber-AO and Lauge-Hansen classification systems by two experienced radiologists and two surgeons. The incidence of the four avulsions of the AITFL/PITFL was determined.

RESULTS

In total, 1,770 ankle fractures in 1,758 patients were included in this study. The total incidence of avulsions at the four insertions of the AITFL/PITFL (occurring at one, two, or three insertions) was found to be 26.3% (465/1,770). Volkmann fracture had the highest incidence (19.9%, 353/1,770), and it was followed by Tillaux fracture (5.3%, 93/1,770), Wagstaffe fracture (3.3%, 59/1,770), and fibular avulsion of the PITFL (0.5%, 8/1,770). It is noteworthy that fibular avulsion of the PITFL has been reported here for the first time. The incidence of avulsion at one insertion was 23.6% (418/1770) and 2.7% (47/1770) at multiple insertions.

CONCLUSION

In adult ankle fractures, avulsion occurs at the four insertions of the AITFL/PITFL in more than 25% of patients. The tibial insertion of the PITFL had the highest incidence of avulsion among the four insertions, while the fibular insertion of the PITFL had the lowest. The four types of avulsions can be isolated or in association with other avulsions. Future research studies on these four types of avulsion fractures would help in accurate diagnosis, decision-making and treatment of ankle Syndesmosis injuries.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Trans-syndesmotic fixation in supination external rotation type 4 injuries: Are intraoperative tests reliable?

BACKGROUND

Ankle fractures occur due to a rotational mechanism. According to the Lauge-Hansen classification, supination-external rotation (SER) injuries are the most common type. Following osseous fixation, the evaluation and treatment of syndesmotic injuries in these injuries are controversial. This study aimed to evaluate the clinical, functional, and radiological results of trans-syndesmotic fixation using intraoperative tests in SER type 4 ankle injuries.

METHODS

Ankle syndesmosis was intraoperatively evaluated using cotton/hook and manual external rotation stress tests in 64 patients with SER type 4 fracture dislocation injuries. These patients were divided into two groups: those treated with and without trans-syndesmotic fixation in addition to open reduction and internal fixation of the fractures. Ankle range of motion (ROM), American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score, and Olerud-Molander Ankle Score (OMAS), tibiofibular overlap, tibiofibular clear space, and joint arthritis based on the Kellgren-Lawrence (K-L) scale were evaluated.

RESULTS

Median values of OMAS (Z=-3.92, p<0.001), AOFAS (Z=-4.31, p<0.001), and ROM (Z=-2.95, p=0.003) were higher in Group 1. There were no differences between the groups regarding tibiofibular overlap median values (Z=-0.59, p=0.0554), tibiofibular clear space (Z=-1.13, p=0.258), and Kellgren-Lawrence arthritis scale. Lack of posterior malleolus fixation was found to increase the risk of arthritis by 18.197 times, despite having trans-syndesmotic fixation, which was statistically significant (Confidence Interval, CI: 2.482-133.417, p=0.004) (Table 4).

CONCLUSION

Median values of OMAS, AOFAS, and ROM in patients without trans-syndesmotic fixation were lower. These results indicate that intraoperative tests may not provide entirely accurate results in SER type 4 injuries. Failure to detect a syndesmotic injury timely can result in instability. Therefore, we think that routine trans-syndesmotic fixation, as well as posterior malleolus fixation in SER type 4 ankle injuries, may improve outcomes.

Dislocations deteriorate postoperative functional outcomes in supination-external rotation ankle fractures

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.

Temporary Cast Application in Dislocated Ankle Fractures Leads to High Rates of Secondary Loss of Reduction: Does the Lauge-Hansen Injury Type Matter?

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.

Impact of Syndesmotic Screw Removal on Quality of Life, Mobility, and Daily Living Activities in Patients Post Distal Tibiofibular Diastasis Repair

Background and Objectives: While numerous studies have been conducted on syndesmotic screw management following distal tibiofibular diastasis repair, a clear consensus remains unclear. This research aims to evaluate whether the postoperative removal of syndesmotic screws leads to improved patient outcomes, specifically in quality of life, mobility, and daily living activities, and whether it offers a cost-effective solution. Materials and Methods: Patients with a history of unimalleolar or bimalleolar ankle fractures, classified according to the Danis-Weber and Lauge-Hansen systems, were included. Comprehensive evaluations were made via standardized questionnaires like the SF-36 Health Survey, HADS, and WHOQOL-BREF, distributed approximately 2 months post surgery. A total of 93 patients underwent syndesmotic screw removal while 51 retained the screws (conservative approach). Results: Patients who underwent screw removal reported superior satisfaction in mobility, with a score of 7.8, compared to 6.7 in the conservative approach (p = 0.018). Similarly, their ability to perform daily activities scored 8.1, higher than the 6.5 from the conservative cohort (p < 0.001). Pain levels were also more favorable in the screw removal group, with a score of 5.3 against 6.8 in the conservative group (p = 0.003). On the SF-36 physical domain, the screw removal group achieved a mean score of 55.9 versus 53.3 for the conservative group (p = 0.027). Notably, the HADS anxiety subscale highlighted reduced anxiety levels in the screw removal cohort with a mean score of 5.8 against 7.3 in the conservative group (p = 0.006). However, overall quality of life and recommendations to others showed no significant difference between the groups. Conclusions: Syndesmotic screw removal postoperatively leads to marked improvements in patients' mobility, daily activity abilities, and reduced postoperative pain and anxiety levels. However, overall quality of life was similar between the two approaches. The findings offer valuable insights for orthopedic decision making and patient-centered care concerning the management of syndesmotic screws after distal tibiofibular diastasis repair.

Comparing Temporary Immobilization Using Cast and External Fixator in Unimalleolar Ankle Fracture Dislocations: A Retrospective Case Series

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.