Surgical versus nonsurgical treatment of the SE4-equivalent ankle fracture: a retrospective functional outcome study

The association between person and fracture characteristics with patient reported outcome after ankle fractures in adults: A systematic review

BACKGROUND

The incidence of ankle fractures is increasing and the clinical outcome is highly variable.

QUESTION

What person and fracture characteristics are associated with patient reported outcomes after surgically or conservatively managed ankle fractures in adults?

DATA SOURCES

Medline, EMBASE, and Allied and Complimentary Health Medical Database (AMED) databases were searched from the earliest available date until 16th July 2020.

STUDY SELECTION

Prognostic factors studies recruiting adults of age 18 years or older with a radiologically confirmed ankle fracture, and evaluating function, symptoms and quality of life by patient reported outcome measures, were included.

STUDY APPRAISAL/SYNTHESIS METHODS

Risk of bias of individual studies was assessed by the Quality in Prognostic Factors Studies tool. Correlation coefficients were calculated and data were analysed using narrative synthesis.

RESULTS

Fifty-one phase 1 explanatory studies with 6177 participants met the inclusion criteria. Thirty-one studies were rated as high risk of bias using the Quality in Prognostic Factors Studies tool. There was low quality evidence that age, body mass index, American Society of Anesthesiologists classification and pre-injury mobility were associated with function, and low to moderate quality evidence that age, smoking and American Society of Anesthesiologists classification were associated with quality of life. No person characteristics were associated with symptoms and no fracture characteristics were associated with any outcomes.

CONCLUSION

There was low to moderate quality evidence that person characteristics may be associated with patient reported function and quality of life following ankle fracture.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42020184830.

Comparison of Open Anterior Syndesmotic Repair Augmented With Suture-Tape and Trans-syndesmotic Screw Fixation: A Biomechanical Study

The treatment of syndesmotic injuries with ankle fractures is controversial. The purpose of this study was to compare the biomechanical properties of open anterior syndesmotic repair with those of screw fixation. Ten matched pairs of human cadaver specimens were subjected to open syndesmotic repair or screw fixation. Each specimen underwent initial intact physiologic loading, consisting of 10 cycles of external torsional loading with a peak torque of 7.5 Nm at 0.05 Hz. Injuries of the anterior inferior tibiofibular ligament, tibiofibular interosseous membrane, and deltoid ligament were applied to each specimen. Postfixation cyclic loading consisted of 50 cycles of combined axial and external rotation loading with peak torques of 750 N and 7.5 Nm at a rate of 0.05 Hz. After postfixation loading, each specimen underwent failure loading by external rotation at 0.25 degrees/second. Failure torque and failure angle were measured. The paired t test and Wilcoxon signed-rank test were used to analyze the data. Mean failure torques were 95.63 Nm in the open anterior syndesmotic repair augmented with suture-tape group and 108.61 Nm in the screw group. Mean failure angles were 34.93 degrees in the open anterior syndesmotic repair augmented with suture-tape group and 43.55 degrees in the screw group. These data were not statistically significantly different between the groups (p= .7682 and .4133, respectively). Open anterior syndesmotic repair augmented with suture tape for ankle syndesmotic injury provides similar torsional strength to that of screw fixation. Therefore, this technique can be considered as an alternative treatment option for syndesmosis injury.

Functional Outcomes of Unstable Ankle Fractures in Adolescents

BACKGROUND

The purpose of this study was to describe the functional outcomes and complications of unstable supination external rotation (SER) and pronation external rotation (PER) ankle fractures in adolescents. A secondary outcome was to compare functional outcomes of SER stage IV injuries that were treated definitively with closed reduction and cast application to a similar group of minimally displaced fractures treated with open reduction and internal fixation (ORIF).

METHODS

A retrospective review of adolescents aged 10 to 18 years with unstable ankle fractures treated at a single institution between 2009 and 2017 was conducted. All patients had functional outcomes data from the Foot and Ankle Ability Measure obtained at a minimum of 1-year follow-up.

RESULTS

In total, 67 adolescents (41 SER, 26 PER) were included (mean follow-up: 52.3±24.8 mo). A total of 56 were treated with ORIF and 11 were closed reduced and casted. No patients treated nonsurgically had a loss of reduction and none required subsequent surgical intervention. Preoperative radiographic predictors of syndesmotic injury (>6 mm of tibiofibular clear space or <2 mm of tibiofibular overlap) were not sensitive and only moderately specific predictors of intraoperative syndesmotic injury. There was no difference in functional outcome between the 11 SER stage IV fractures treated nonoperatively and a group of minimally displaced SER injuries treated with ORIF. Patients with open or partially open physes had better functional outcomes. Patients with syndesmotic injuries, medial malleolus fractures, or fracture-dislocations were not associated with lower functional outcome scores in our adolescent cohort.

CONCLUSIONS

Unstable SER and PER injuries in adolescents have favorable functional outcomes at intermediate-term follow-up, though a minority continue to have impaired ankle function. Minimally displaced SER stage IV injuries with near anatomic alignment after closed reduction can be successfully treated with continued closed management, and have no difference in functional outcomes compared with similar injuries treated with ORIF.

LEVEL OF EVIDENCE

Level III.

Machine Learning Accurately Predicts Short-Term Outcomes Following Open Reduction and Internal Fixation of Ankle Fractures

Ankle fractures are common orthopedic injuries with favorable outcomes when managed with open reduction and internal fixation (ORIF). Several patient-related risk factors may contribute to poor short-term outcomes, and machine learning may be a valuable tool for predicting outcomes. The objective of this study was to evaluate machine-learning algorithms for accurately predicting short-term outcomes after ORIF for ankle fractures. The Nationwide Inpatient Sample and Nationwide Readmissions Database were queried for adult patients ≥18 years old who underwent ORIF of an ankle fracture during 2013 or 2014. Morbidity and mortality, length of stay >3 days, and 30-day all-cause readmission were the outcomes of interest. Two machine-learning models were created to identify patient and hospital characteristics associated with the 3 outcomes. The machine learning models were evaluated using confusion matrices and receiver operating characteristic area under the curve values. A total of 16,501 cases were drawn from the Nationwide Inpatient Sample and used to assess morbidity and mortality and length of stay >3 days, and 33,504 cases were drawn from the Nationwide Readmissions Database to assess 30-day readmission. Older age, Medicaid, Medicare, deficiency anemia, congestive heart failure, chronic lung disease, diabetes, hypertension, and renal failure were the variables associated with a statistically significant increased risk of developing all 3 adverse events. Logistic regression and gradient boosting had similar area under the curve values for each outcome, but gradient boosting was more accurate and more specific for predicting each outcome. Our results suggest that several comorbidities may be associated with adverse short-term outcomes after ORIF of ankle fractures, and that machine learning can accurately predict these outcomes.

Percutaneous screw fixation of unstable ankle fractures in patients with poor soft tissues and significant co-morbidities

INTRODUCTION

We describe a minimally invasive technique to stabilise unstable ankle fractures by inserting a 100mm screw up the fibula medullary canal along with percutaneous screw fixation of the medial malleolus if required. This technique is utilised in patients with poor soft tissues and significant co-morbidities where the fracture cannot be adequately controlled by a cast alone.

PATIENTS AND METHODS

Retrospective review of 23 patients the average age being 70 years (29-89) and 74% had significant co-morbidities. Postoperative radiographs were examined for adequacy of reduction using the method described by Mclenna and Ungersma. Patient based functional and health questionnaires were performed, reviewed and scored.

RESULTS

Six patients were lost during the follow-up period due to death caused by issues unrelated to the ankle fracture. There were no reported intraoperative complications, no postoperative wound infections and no non-unions. There was two complications one loss of fixation, and another required removal of the screw due to irritation. Radiographic reduction was good in 52%, fair in 44% and poor in 4%. Patient questionnaire results were 70 (20-100) for the Abbreviated Olerud and Molander score and the SF-12 physical component score was 42 and mental component was 44.

CONCLUSIONS

With appropriate patient selection percutaneous screw fixation is an excellent technique supplementing cast immobilisation of unstable ankle fractures with poor soft tissues.

Anatomic Ligament Repair Restores Ankle and Syndesmotic Rotational Stability as Much as Syndesmotic Screw Fixation

OBJECTIVES

To compare the external rotation stability of 3 different syndesmotic stabilization techniques in a cadaveric ankle fracture model.

METHODS

Nondestructive external rotation stresses of 4 N·m were applied to 8 cadaveric limbs using a hydraulic loading frame. Four conditions were tested using a repeated-measures design: intact and 3 repair conditions after a destabilizing ligamentous ankle injury with syndesmotic disruption. The 3 repair conditions were tricortical trans-syndesmotic screw fixation, posterior inferior tibiofibular ligament (PITFL) repair, and combined PITFL and deltoid ligament repair. External rotation of the ankle joint and syndesmosis was measured using a motion capture system and compared for each test condition. Repeated-measures 1-way analyses of variance statistical tests were performed to compare the ankle and syndesmotic rotation findings between the 3 repair conditions and intact condition.

RESULTS

Rotational ankle stability was not fully restored by any of the 3 repair constructs. The intact ankle joint externally rotated approximately half as many degrees as the 3 repair conditions (intact: 10.9; trans-syndesmotic screw: 17.0; PITFL: 21.4; and PITFL/deltoid: 15.6). The intact condition also demonstrated significantly fewer degrees of syndesmotic rotation than the repair constructs (intact 2.4; trans-syndesmotic screw 5.2; PITFL 8.5; and PITFL/deltoid 6.9). Each of the repair conditions resulted in an externally rotated fibula when no loads were applied. The ligamentous repairs externally rotated the fibula twice as much as the trans-syndesmotic screw (P < 0.016).

CONCLUSIONS

We found that combined repair of the PITFL and deltoid ligament restores an equivalent amount of ankle and syndesmotic rotational stability when compared to trans-syndesmotic screw fixation. Based on our findings, ligamentous repair can potentially be a viable treatment alternative in unstable ankle fracture patients with syndesmotic disruption.

LEVEL OF EVIDENCE

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

Comparison of clinical outcome of pronation external rotation versus supination external rotation ankle fractures

BACKGROUND

A pronation external rotation (PER) ankle fracture is a relatively uncommon injury. The purpose of this study was to examine the immediate and short-term clinical outcomes of operatively treated PER IV ankle fractures and compare them with a similarly treated cohort of supination external rotation IV (SER IV) fractures.

METHODS

22 PER IV and 108 SER IV fractures were identified from a single surgeon's prospectively collected database from 2004 to 2010. All patients were treated with fracture fragment and ligament specific fixation during the same time period by the same surgeon. Postoperative radiographs and bilateral ankle computed tomography (CT) scans were reviewed for articular incongruity, syndesmotic malreduction, and loss of reduction. Clinical outcome measures, including the Foot and Ankle Outcome Score (FAOS) and ankle range of motion (ROM), were collected at latest follow-up visit.

RESULTS

There was no difference in the rate of wound complications, fracture nonunion, or loss of reduction between the PER IV and SER IV groups. There was no significant difference in the incidence of postoperative articular incongruity (19% vs 8%, P = .23); however, the PER IV cohort was found to have a significantly higher rate of syndesmotic malreduction (40% vs 18%, P = .04). No clinically or statistically significant differences were detected between the 2 groups in regard to all FAOS domains.

CONCLUSION

In a cohort of operatively treated PER IV fractures, fracture fragment and ligament specific fixation resulted in good short-term outcomes that were comparable to those seen in similarly treated patients with an SER IV fracture pattern. However, a notably greater number of syndesmotic malreductions were noted in the PER IV cohort, and therefore heightened scrutiny is recommended in treating this particular injury pattern.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Treatment of the stress positive ligamentous SE4 ankle fracture: incidence of syndesmotic injury and clinical decision making

OBJECTIVES

The objective of the study was to review our experience with the treatment of stress positive (+) supination and external pattern injuries using shared decision making with the patients.

DESIGN

Retrospective case review.

SETTING

Level 1 trauma center.

PATIENTS

Over a 9-year period, we treated 114 patients (aged 19-76 years, average 43 years) with stress (+) supination and external rotation type fibula fractures, who were included in the present study.

INTERVENTION

X-rays were reviewed, and the medial clear space (MCS) measured on the presentation, stress, and final united radiographs. The decision for surgical or nonsurgical management was made by the patient and surgeon after a discussion of risks/benefits of both. Syndesmotic instability for the operative cases was diagnosed by medial widening and talar subluxation on abduction/external rotation stress after fibular fixation.

MAIN OUTCOME MEASURE

MCS measurement at union.

RESULTS

Of the 114 cases, 54 were definitively treated in a cast, and 60 were treated operatively. Twenty-seven (45%) of the operative cases demonstrated syndesmotic instability on radiographic examination. The MCS on stress examination was statistically different, with greater widening seen for operatively treated patients (4.8 ± 0.5 vs. 6.9 ± 0.86) (P < 0.001). No patient healed with any subluxation on weight bearing x-rays.

CONCLUSIONS

Stress (+) SE pattern fibular fractures with minimal MCS widening on stress examination may be treated in a cast to union with predictable healing. In those patients treated operatively, the treating surgeon should be aware of the high rate of syndesmotic injury.

LEVEL OF EVIDENCE

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