Ankle fractures resulting from rotational injuries

Comparison of operatively and nonoperatively treated isolated Weber B ankle fractures: a systematic review and meta-analysis

BACKGROUND

Despite fractures of Isolated Weber B being prevalent, there is a lack of clarity regarding the relative effectiveness of surgical versus conservative treatment. This systematic review and meta-analysis aimed to investigate the clinical effects and complications of surgical versus conservative treatment of the Isolated Weber B ankle fractures.

METHODS

This study involved thorough searches across multiple electronic databases, including PubMed, Cochrane, Embase, and Web of Science, to identify all relevant publications on Isolated Weber B ankle fractures repaired through surgical versus conservative treatment. Through a comprehensive meta-analysis, several outcomes were evaluated, including post-operative function, complications and reoperation rate.

RESULT

Six articles involving 818 patients who met the inclusion criteria. Among these participants, 350 were male and 636 were female. 651 patients received conservative treatment, while 396 underwent surgical intervention. The findings indicate no significant differences in OMAS, FAOQ, PCS, MCS scores, and return to work between surgical and non-surgical treatments for isolated Weber B ankle fractures. However, compared with surgical treatment, non-surgical treatment has a higher AOFAS score(MD = -5.31, 95% CI = [-9.06, -1.55], P = 0.20, I2 = 39%), lower VAS score(MD = 0.72, 95% CI = [0.33, 1.10], P = 0.69, I2 = 0%), lower complication rate (RR = 3.06, 95% CI = [1.58, 6.01], P = 0.05, I2 = 54%), and lower reoperation rate(RR = 8.40, 95% CI = [1.57, 45.06], P = 0.05, I2 = 67%).

CONCLUSION

Can Anatomical Differences Contribute to the Etiology of Danis-Weber Type B Lateral Malleolus Fractures?

Introduction Lateral malleolus fractures are among the most common ankle fractures, but the anatomical factors that may predispose individuals to this specific type of fracture are not fully understood. This study aims to explore whether distinct anatomical characteristics of the ankle joint contribute to an increased susceptibility to lateral malleolar fractures. Methods A retrospective analysis was conducted on 73 patients diagnosed with isolated lateral malleolar fractures between 2020 and 2023. An array of radiologic parameters, including distal tibial articular surface (DTAS) angle, bimalleolar tilt (BMT), medial malleolar length (MML), lateral malleolar length (LML), medial malleolar relative length (MMRL), lateral malleolar relative length (LMRL), medial malleolar slip angle (MMSA), talocrural angle (TCA), anterior inclination of the tibia (AI), and fibular position (FP), were meticulously measured on anteroposterior and lateral ankle radiographs for each study participant. We also measured the same parameters in 126 individuals who had not experienced an ankle fracture for comparison. Results Statistically significant differences were observed between the fracture group and the control group for DTAS angle, BMT, MML, MMRL, LMRL, TCA, AI, and FP (p<.05). Conversely, LML and MMSA displayed no significant variations between the two groups (p=0.745 and p=0.623). Effect sizes were notably large for DTAS and TCA, medium for MMRL, BMT, and AI, and small for LMRL, MML, and FP. Conclusion Our findings indicate an increased risk of lateral malleolus fractures in individuals with a relatively longer medial malleolus, a valgus-oriented ankle, reduced anterior inclination of the tibia, and an anteriorly positioned fibula. Taking protective measures during risky activities in individuals with these differences may help to prevent fractures.

Return to Play Rates Following Operative Ankle Fractures Differ Between High- and Low-Performing National Football League Athletes

This study investigated predictive factors for return to play among National Football League athletes after operative treatment of ankle fractures and the impacts of these injuries on career longevity and player performance. Athletes who underwent surgery to repair ankle fractures from the 2013 to 2017 seasons were identified from injury reserve lists and press releases. Demographics and season metrics were collected before and after the injury. Statistical analysis assessed for differences in recorded variables between injured and uninjured players. Thirty-one players met study inclusion criteria. Twenty-two (71%) athletes successfully returned to play. Players who did not return showed no significant differences (P>.05) in position, age, body mass index, number of games or seasons played preinjury, or snaps per game the season prior to injury and had a significantly lower (42.6%, P=.013) preinjury season approximate value (SAV) compared with returning players. Returning athletes showed no significant differences (P>.05) in SAV or snaps per game compared with their preinjury season or with uninjured controls. A high preinjury SAV is associated with successful return to play. No difference in game time or performance metrics was detectable between returning players and uninjured controls, or between preinjury and postinjury seasons. [Orthopedics. 2024;47(1):22-27.].

Anterior Displacement of a Posterior Malleolar Fragment Through the Syndesmosis: A Case Report

Ankles are the most common site of injury in lower limb fractures. Despite this, the classification of the Maisonneuve fracture is still highly controversial, perhaps due to its low incidence. Typically described as a proximal fibular fracture with associated injury to the syndesmosis and medial structures secondary to an external rotation mechanism, the injury often necessitates surgical intervention to restore joint stability for good functional outcomes. A 32-year-old lady sustained a pronation external rotation injury resulting in a proximal fibula fracture with disruption of the distal tibiofibular syndesmosis as well as an associated posterior malleolar fracture with displacement of the fragment anteriorly through the syndesmosis to the ventral aspect of the ankle joint. The patient underwent surgical fixation of the posterior malleolar fracture as well as repair of the syndesmosis with a screw. This report aims to highlight the details of a Maisonneuve fracture with the rarer associated posterior malleolar fracture, and its anterior displacement through the syndesmosis, as well as provide a narrative review of the current literature.

Difference in Joint Stability Between Small Posterior Malleolar Fragments With Fixation and Those Without Fixation: A Biomechanical Cadaver Study

The indication for the surgical treatment of ankle fractures that involve a posterior malleolar fragment remains controversial. This cadaver study assessed the biomechanical results of rotation stiffness of Haraguchi type 1 posterior malleolar fragments with or without cannulated screw fixation. Twelve anatomic lower-extremity specimens from 6 cadavers were tested. Six right legs were subjected to posterior malleolus osteotomy (Haraguchi type I) followed with (group A; n = 3) or without (group B; n = 3) fixation using a cannulated screw. Ankle joint stability was measured under both external rotation force and axial loading, and the passive resistive torque was measured in both groups. The mean torque value in group A was 0.1093 Nm/º, while that in group B was 0.0537 Nm/º. There was a significant intergroup difference (p = .004). In group B, the torque value was further increased in the latter rotation period (about 40-60 degrees). Group A proved more stable under experimental conditions than group B. Fixation in type I posterior malleolar fragments produced improved stability in ankle rotation, even for posterior malleolar fragments involving <25% of the articular surface, and has been considered an effective aid in treatment.

Effect of Postoperative Immobilization Time on PROMIS Scores and Clinical outcomes in Ankle Fracture Patients

Background

Ankle fractures are among the most common injuries treated by orthopaedic surgeons, yet little guidance exists in postoperative protocols for ankle fractures concerning time of immobilization. Here, we aim to investigate the association between early mobilization and patient-reported outcomes. Our null hypothesis was that no difference in Patient-Reported Outcomes Measurement Information System (PROMIS) scores would be identified in patients when comparing the effect of time of immobilization.

Methods

A retrospective review identified ankle fractures that underwent surgical fixation between 2015 and 2020 at a level 1 trauma center and its associated facilities. One hundred nineteen patients from 9 providers met inclusion criteria for our final analysis. Forty-seven patients were immobilized for <6 weeks (early) and 68 patients were immobilized for ≥6 weeks (late). Our primary outcome measures included the PROMIS questionnaire, time of immobilization, and time to full weightbearing. Our secondary outcome measures included time to return to work, wound complications (infection, delayed healing), and complications associated with fracture fixation (loss of reduction, delayed union, reoperation, hardware failure). Repeated measures analysis of variance as well as linear mixed outcome regression were used to predict each of the PROMIS outcomes of anxiety, depression, physical function, and pain interference. Each model included the predictors of age, sex, race, body mass index (BMI), diabetes, rheumatoid arthritis, smoking status, payor, provider, time to radiographic union, time to return to work, time to full weightbearing, and early vs late immobilized groups.

Results

We found no differences in PROMIS scores between mobilization groups even when controlling for possible confounders such as age, BMI, rheumatoid arthritis, smoking status, and diabetes mellitus (P > .05). Furthermore, we found no differences in complications associated with fracture fixation (P > .05). Across our cohort, lower physical function scores were associated with higher BMI, increasing age, and longer time to return to work/play (P < .05). Our analysis further showed that depression, anxiety, pain interference, and physical function levels improve as a function of time (P < .05). Higher BMI was also noted to have a significant impact on PROMIS depression and anxiety when controlling for other variables. African Americans had greater pain interference scores (P < .05).

Conclusion

Our study suggests that early mobilization in a walker boot after operative treatment of ankle fractures is a safe alternative to casting in non-neuropathic patients. When considering operative treatment of ankle fractures, factors such as increasing age and BMI are likely to negatively affect postoperative anxiety, physical function, and depression PROMIS scores regardless of immobilization time.

Level of Evidence

Level III, retrospective cohort study.

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

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.

Detection of ankle fractures using deep learning algorithms

BACKGROUND

Early and accurate detection of ankle fractures are crucial for optimizing treatment and thus reducing future complications. Radiographs are the most abundant imaging techniques for assessing fractures. Deep learning (DL) methods, through adequately trained deep convolutional neural networks (DCNNs), have been previously shown to faster and accurately analyze radiographic images without human intervention. Herein, we aimed to assess the performance of two different DCNNs in detecting ankle fractures using radiographs compared to the ground truth.

METHODS

In this retrospective case-control study, our DCNNs were trained using radiographs obtained from 1050 patients with ankle fracture and the same number of individuals with otherwise healthy ankles. Inception V3 and Renet-50 pretrained models were used in our algorithms. Danis-Weber classification method was used. Out of 1050, 72 individuals were labeled as occult fractures as they were not detected in the primary radiographic assessment. Single-view (anteroposterior) radiographs was compared with 3-views (anteroposterior, mortise, lateral) for training the DCNNs.

RESULTS

Our DCNNs showed a better performance using 3-views images versus single-view based on greater values for accuracy, F-score, and area under the curve (AUC). The highest sensitivity was 98.7 % and specificity was 98.6 % in detection of ankle fractures using 3-views using inception V3. This model missed only one fracture on radiographs.

CONCLUSION

The performance of our DCNNs showed that it can be used for developing the currently used image interpretation programs or as a separate assistant solution for the clinicians to detect ankle fractures faster and more precisely.

LEVEL OF EVIDENCE

III.

Effect of Fibular Malrotation on Tibiotalar Joint Contact Mechanics in a Weber B Ankle Fracture Model

BACKGROUND

In minimally displaced Weber B ankle fractures, the distal fibular fracture fragment can be externally rotated. This malrotation is difficult to detect on radiographs and, when left malreduced through nonoperative treatment, may contribute to altered joint mechanics, predisposing to posttraumatic osteoarthritis. This study evaluates the effects of fibular malrotation on tibiotalar joint contact mechanics.

METHODS

Six cadaveric ankles were tested using a materials testing system (MTS) machine. A tibiotalar joint sensor recorded contact area and pressure. Samples were tested in the intact, neutrally rotated, and malrotated state. Each trial applied a 686N axial load and a 147N Achilles tendon load in neutral position, 15° dorsiflexion, and 15° plantarflexion.

RESULTS

In the comparison of malrotated to intact ankles, peak contact pressure was found to be significantly greater at neutral flexion (intact 5.56 MPa ± 1.39, malrotated 7.21 MPa ± 1.07, P = .03), not significantly different in dorsiflexion, and significantly decreased in plantarflexion (intact 11.2 MPa ± 3.04, malrotated 9.01 MPa ± 1.84, P = .01). Significant differences in contact area were not found between conditions.

CONCLUSION

The findings suggest that fibular malrotation contributes to significant alterations in tibiotalar joint contact pressures, which may contribute to the development of posttraumatic osteoarthritis. When malrotation of the fibula is suspected on plain radiographs, a computer tomography (CT) scan should be obtained to evaluate its extent and further consideration should be given to surgical treatment.

LEVELS OF EVIDENCE

Level V: Bench testing.

The concept of ring of injuries: evaluation in ankle trauma

OBJECTIVE

Radiographs are first-line imaging in ankle trauma but lack sensitivity to detect ligamentous injuries and undisplaced fractures. Our hypothesis was that ankle injuries occur in predefined sequences along two osteoligamentous rings, so that occult injuries non-visible on initial radiographs can be predicted. We, therefore, aimed to validate a ring model of progressive damages in the interpretation of ankle trauma radiographs.

METHODS

This study retrospectively enrolled 277 adult patients that presented an acute fibular fracture on ankle radiographs between May and November 2019. Four different types of fibula fracture were differentiated, each being considered to correspond to a different mechanism of injury. Patients were classified into four groups, upon the appearance of their fibular fracture. Then, injuries to the distal tibiofibular syndesmosis, medial malleolus, and deltoid ligament (medial clear space) were assessed in each patient radiographs. Traumatic injuries were independently evaluated by a resident and an experienced MSK radiologist. For each patient, observed features were compared to those predicted by the ring concept. Inter- and intraobserver agreements were calculated.

RESULTS

Injuries were observed according to the predictable sequence in 266 of the 277 patients (96%). In the 11 remaining patients, discordances were presumably due to undisplaced injuries to the syndesmosis or deltoid ligament. Agreements were considered very good for each evaluated item.

CONCLUSION

The Lauge-Hansen ring concept was found to be highly accurate and reproducible for radiographic assessment of ankle injuries. Discordances to the predicted sequence might reflect occult injuries, especially of the syndesmosis or deltoid ligament.

Doctor, I fractured my ankle. When can I return to play? An updated systematic review

INTRODUCTION

Ankle fractures in sport are common. Their optimal management is unclear, as is when patients can return to their sports activities. This systematic review provides a contemporary assessment of the literature on return to sports following acute traumatic ankle fractures managed both operatively and non-operatively.

SOURCES OF DATA

We systematically searched Pubmed, Google Scholar, the Cochrane Library, EMBASE and CINAHL using the terms 'ankle fractures', 'ankle injuries', 'athletes', 'sports', 'return to sport', 'return to activity', 'operative management', 'non-operative management'.

AREAS OF AGREEMENT

Thirteen retrospective studies fulfilled the inclusion criteria. The methodological quality of the studies was generally poor. The proportion of patients returning to sporting activity was high. In some studies, a quicker return to sporting activity was demonstrated in patients managed non-operatively.

AREAS OF CONTROVERSY

The time to return to sporting activity and level of performance post-treatment are not universally recorded, and the optimal time to return to sport remains to be confirmed.

GROWING POINTS

Conservative management for stable or undisplaced fracture may result in a higher proportion of patients returning to sport more quickly.

AREAS TIMELY FOR DEVELOPING RESEARCH

Randomized controlled trials should compare conservative to surgical treatment for appropriately chosen fracture patterns. Future studies should routinely report the timing of return to sport, the level of performance reached, and the time to achieve this.

Surgical treatment of displaced isolated lateral malleolar fractures: incidence of adverse events requiring revision: a retrospective cohort study

Background

Recent systematic reviews support that non-operative management should be the standard treatment for all stable isolated lateral malleolar fractures (ILMFs), regardless of fibular fracture displacement. Surgical fixation of ILMFs carries a risk of adverse events (AEs), and many patients will later require implant removal. We wanted to estimate the incidence of AEs requiring revision after surgical fixation of “potentially stable” displaced ILMFs before non-operative treatment became standard care in our department.

Materials and methods

To identify patients with “potentially stable” ILMFs who had been treated surgically in a historical cohort, we retrospectively applied the stability-based classification system, introduced by Michelson et al., to a cohort of 1006 patients with ankle fractures treated surgically from 2011 to 2016. The primary outcome of this retrospective cohort study was the incidence of AEs that had functionally significant adverse effects on outcome and required revision in the first 12 months after surgery. AEs were graded and categorized using the Orthopedic Surgical Adverse Events Severity (OrthoSAVES) System.

Results

The study population comprised 108 patients with “potentially stable” displaced ILMFs; 4 patients (3.7% [95% CI (0.1–7.3%]) experienced AEs requiring revision in the first twelve months after surgery. There were 5 additional patients (4.6%) with functionally significant AEs where revision surgery was not indicated within the first twelve months after surgical fixation. A further 5 patients (4.6%) had AEs managed in the outpatient clinic (grade II); 36 patients (33.3%) required secondary implant removal due to implant-related discomfort.

Conclusions

Surgical fixation of ILMFs carries a risk of severe AEs, and many patients will subsequently need implant-removal procedures. Further prospective studies are required to ascertain whether non-operative treatment can lower the risk of AEs and the need for additional surgical procedures.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03135-z.

A novel technique of isolated gastrocnemius recession: A cadaveric comparison with Strayer procedure

BACKGROUND

Strayer's gastrocnemius recession is a common technique in treating ankle equinus of gastrocnemius origin. Nevertheless, this technique is associated with a few flaws. We aim to introduce a novel technique of isolated gastrocnemius recession and perform a cadaveric study to evaluate its safety and at the same time compare this novel technique with the existing Strayer procedure biomechanically.

METHODS

Eight fresh cadaveric models of gastrocnemius tightness were established by isolated traction of the gastrocnemius muscles. Gastrocnemius recession was performed on all eight models with Strayer method and the novel method randomized equally. The safety of both the techniques was evaluated by identifying any iatrogenic injury to the surrounding structures. The lengthening and improvement of the ankle dorsiflexion was measured and compared between the two techniques.

RESULTS

There was no iatrogenic sural nerve or saphenous vein injury in all eight models. There was no significant difference between the two techniques in terms of lengthening (24.25 mm vs 21.00 mm; p = 0.838) and improvement of ankle dorsiflexion (26.5° vs 26°; p = .829).

CONCLUSIONS

Both Strayer technique and the novel technique of gastrocnemius recession lengthened the gastrocnemius and improved the ankle dorsiflexion in this cadaver trial. Both procedures were safe with proper techniques, and there was no significant difference in efficacy between them.

LEVEL OF EVIDENCE

Level II, randomized controlled trial.

Risk Factors for Aseptic Revision of Operatively Treated Ankle Fractures

BACKGROUND

Early revision rates within 12 months after ankle fracture open reduction internal fixation (AF-ORIF) are fairly low; however, they remain relevant given the volume of ankle fractures occurring annually. Understanding these rates is complex because reoperation due to technical or mechanical complications is typically reported alongside soft tissue-related problems such as symptomatic hardware, wound dehiscence, or infection. There are limited data identifying risk factors specifically for revision of ankle fracture fixation in the absence of soft tissue complications. Understanding variables that predispose to aseptic technical and mechanical failure without this confounder may provide insight and improve patient care.

METHODS

A retrospective cohort study was performed at 2 large academic medical centers. Research Patient Data Registry (RPDR) data available from 2002 to 2019 were used to identify patients who underwent aseptic revision of AF-ORIF within 12 months (n = 33). A control group (n = 100) was selected by identifying sequential patients who underwent AF-ORIF not requiring revision within 12 months. Multiple factors were recorded for all patients in both cohorts. Each fracture was also evaluated according to the Ankle Reduction Classification System (ARCS) of Chien et al,⁸ which categorizes biplanar talar displacement in relation to a central tibial plumb line into 1 of 3 grades: A (0-2 mm), B (3-10 mm), and C (>10 mm). Adapted from its original purpose of grading reduction quality, we applied ARCS to pre-reduction radiographs to assess initial fracture displacement. All variables collected were compared in univariate analysis. Variables that achieved significance in univariate comparisons were included as candidates for multivariable analysis.

RESULTS

Final multivariable logistic regression modeling demonstrated the following factors to independently predict the need for aseptic revision surgery: documented falls in the early postoperative period (aOR, 298; 95% CI, 15.4, 5759; P < .001), movement-altering disorders (aOR, 81.7; 95% CI, 4.12, 1620; P = .004), a nonanatomic mortise (medial clear space [MCS] > superior clear space [SCS]) on immediate postoperative imaging (aOR, 38.4; 95% CI, 5.53, 267; P < .001), initial coronal plane tibiotalar displacement >10 mm and sagittal plane tibiotalar dislocation (ARCS-C) (aOR vs ARCS-A, 25.8; 95% CI, 2.81, 237; P = .004), substance abuse (aOR, 15.7; 95% CI, 2.66, 92.8; P = .002), and polytrauma (aOR, 12.3; 95% CI, 2.02, 74.8; P = .006).

CONCLUSION

In this investigation we found a notable increase in risk for revision surgery after AF-ORIF for patients who had one of the following: (1) falls in the early postoperative period, (2) movement-altering disorders, (3) a nonanatomic mortise (MCS > SCS) on immediate postoperative imaging, (4) more severe initial fracture displacement, (5) substance abuse, or (6) polytrauma. Identifying these factors may allow surgeons to better understand risk and counsel patients, and may serve as future targets for intervention aimed at improving patient safety and outcomes after ankle fracture ORIF.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Syndesmotic Stabilization: Syndesmotic Screw Versus Flexible Fixation: A Systematic Review

Syndesmotic injuries are common injuries that occur in isolation or associated with ankle fractures. The suture button device fixation (SBDF) has become increasingly attractive to orthopedic surgeons as an alternative to metallic screw fixation (MSF) for syndesmotic fixation. This review involved the highest-quality clinical biomechanical and cost analysis studies to provide a comprehensive review. A literature search in the electronic databases was conducted to identify clinical, biomechanical as well as cost analysis studies in which the MSF was compared to SBDF from 1990 to 2018. Only comparative clinical studies with a level of evidence I or II were included besides any comparative biomechanical or cost analysis study. The (PRISMA) guidelines were followed. Eight clinical, 11 biomechanical, and 3 cost analysis studies were included. The clinical studies consisted of 5 randomized controlled trials (RCTs) and 3 cohort studies. The average American Orthopaedic Foot and Ankle Society score for the SBDF group was (92.4) compared to (86.6) for the MSF group at 1 year follow-up. SBDF group showed a lower rate of malreduction, implant removal, implant failure, and complications. The biomechanical studies showed better reduction accuracy in the SBDF group. The reduction maintenance was comparable in the coronal plane but not in the sagittal plane. The cost-effectiveness of the SBDF was highly dependent on the difference in implant removal rate. In conclusion, the SBDF showed comparable to better outcomes compared to the MSF. It may be a better option for syndesmotic fixation.

A novel classification for medial malleolar fracture based on the 3-D reconstruction CT

Background

Fracture of the medial malleolus is one of the most frequent injuries treated surgically; however, the classification of the fracture has not attracted much attention and a good classification system is still lacking.

Methods

Consecutive cases of medial malleolus fractures were prospectively enrolled. Based on the 3-D reconstruction CT morphology and centered on the posterior colliculus of the medial malleolus, we classified the fractures into 4 types: type 1 with no involvement of the posterior colliculus, type 2 with partial involvement of posterior colliculus, type 3 with the entire involvement of posterior colliculus, and type 4 with the fracture line 4 vertically extended from the intercollicular groove to the comminuted fracture of the posterior malleolus. Statistical analyses were performed to evaluate the clinical significance of the classification.

Results

There were 273 cases prospectively enrolled. The distribution of the cases was type 1 of 12.1%, type 2 of 41.0%, type 3 of 30.0%, and type 4 of 16.8%. Statistics showed that the new classification had significant associations but did not totally depend on the classical ankle fracture classifications. Results showed that the new classification had implications in the severity of ankle fractures. From type 1 to type 4, the ankle joint was more and more unstable. Furthermore, comminuted medial malleolar fractures could be subdivided, and the new classification could provide useful information for surgical decision-making.

Conclusions

The novel classification was a useful system to describe the 3-D geometry of the fractured medial malleolus.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02688-9.

Supination Adduction Ankle Fractures Are Associated With Arthritis and Poor Outcomes

OBJECTIVE

To compare complications and functional outcomes between supination adduction type II (SAD) injuries and torsional ankle injuries (TAI).

DESIGN

Retrospective cohort.

SETTING

Level 1 trauma center.

PATIENTS AND METHODS

Patients (n = 1531) treated for ankle fractures (OTA/AO 43B or 44) over 16 years were identified. The most recent 200 consecutive adult patients treated for TAI (OTA/AO 44, not SAD) served as controls.

MAIN OUTCOME MEASURES

Complications, unplanned secondary procedures, and patient-reported functional outcome scores, as measured by the Foot Function Index and Short Musculoskeletal Function Assessment.

RESULTS

Sixty-five patients with SAD injuries (4.2%) were included. They were younger (43.2 vs. 47.7 years, P = 0.08) and more commonly involved in a motorized collision, (58.5% vs. 29.0%) and more often multiply injured: other orthopaedic injuries (66.2% vs. 31.0%) and other nonorthopaedic injuries (40.0% vs. 7.5%, all P < 0.001 vs. TAI). Overall complication and unplanned secondary procedure rates were not different between groups. Those with a SAD injury had more posttraumatic arthrosis (80.0% vs. 40.9%, P = 0.004), but no differences were noted in infection, wound healing, malunion, or nonunion. The mean functional outcome scores were worse for SAD patients over 6 years after injury among all the Foot Function Index and Short Musculoskeletal Function Assessment categories; however, these differences were not significant.

CONCLUSIONS

SAD injuries represented 4.2% of all ankle fractures, occurring in younger patients through higher-energy mechanisms and more often associated with polytrauma. Despite 80% of SAD patients developing posttraumatic arthrosis, secondary procedures were not more common, and functional outcomes after a SAD injury were not different from TAI.

LEVEL OF EVIDENCE

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

Therapeutic approach to combined deltoid ligament disruption with lateral malleolus fracture: Current evidence and literature review

Ankle fractures are among the most common injuries treated by orthopaedic traumatologists. These fractures range from stable, simple injuries to complex, multi-planar unstable ones. Osseo-ligamentous structures play a paramount role in maintaining the stability of the ankle joint. The deltoid ligament is among the most important ankle static stabilizers. Rupture of this ligament along with a lateral malleolar fracture is considered by many as an unstable type of injury and usually requires surgical treatment (bi-malleolar equivalent). Left untreated, it may lead to chronic pain, loss of function and secondary arthritis. Due to lack of high-quality evidence, there are no welldefined, well-accepted criteria for the diagnosis and treatment for treating this type of injury.

Complications after fibula intramedullary nail fixation of pilon versus ankle fractures

BACKGROUND

Intramedullary nail (IMN) fixation of the fibula in malleolar ankle fractures has been shown to result in less wound complications then plate fixation. Therefore, IMN fibula fixation may also be associated with lower rates of wound complications when used for higher-risk pilon fractures. The purpose of this study was to compare complications of fibula IMN fixation in pilon versus malleolar ankle fractures.

METHODS

A retrospective cohort comparison was performed at an urban level one trauma center involving fibula fractures in 47 patients with AO/Orthopaedic Trauma Association (OTA) type 43 fractures and 48 patients with AO/OTA type 44 fractures being treated with fibula IMN fixation. Complications, fibula-specific complications, revision surgeries, and implant removals were reviewed.

RESULTS

There was no detectable difference in complications (27% vs. 23%, 95% confidence interval of the odds ratio (CIOR) 0.5 to 3.2), fibular-specific complications (6% vs. 10%, CIOR 0.1 to 3.5), revision surgeries (4% vs. 4%, CIOR 0.1 to 7.5), or symptomatic fibula implant removals (13% vs. 21%, CIOR 0.1 to 1.6) between pilon and ankle fracture groups, respectively. There was one (2%) fibular nonunion and one wound complication (2%) in each of the fracture groups.

CONCLUSION

Fibula IMN fixation of pilon versus ankle fractures resulted in a similar number of complications. Comparative studies of fibula IMN and plate fixation are necessary to determine if the benefits of fibula IMN in ankle fractures extends to pilon fractures.

LEVEL OF EVIDENCE

Level III, retrospective cohort.

Value of Ultrasound for Stability Assessment of Isolated Lateral Malleolar Fractures Compared to Stress Radiography and Arthroscopy

Background

This study was performed to evaluate the value of using ultrasound for stability assessment of isolated lateral malleolar fractures compared to simple X-ray, stress radiography, and arthroscopy.

Methods

This is a prospective cohort study with 25 consecutive patients who underwent an arthroscopic examination and subsequent surgery for isolated lateral malleolar ankle fractures. Before operation, simple and external rotation stress radiographs were obtained. Ultrasound was performed to assess the medial deltoid ligament prior to operation. Arthroscopic findings were used as reference standards. Sensitivity, specificity, and positive and negative predictability were calculated and compared using receiver operating characteristic (ROC) curve analysis for simple radiography, stress radiography, and ultrasound examination.

Results

The sensitivity and specificity of ultrasound for tears of the deep deltoid ligament were 94.74% and 66.67%, respectively. But, they were both 100% for complete tears of the ligament. ROC curve analysis showed that the ultrasound examination was significantly more accurate than simple and stress radiography.

Conclusions

Ultrasound could be used to assess the instability of isolated lateral malleolar fractures. Commonly used stress radiography appears to overrate the need for operative treatment.

Functional Outcome Estimation of Bimalleolar Ankle Fractures Treated by Open Reduction and Internal Fixation at a Tertiary Care Center: A Descriptive Cross-sectional Study

Introduction:

Ankle fractures account for about 9% of all fractures in adults. Open reduction and internal fixation is the preferred treatment for such injuries. However, surgery is not free of complications, and outcomes following surgery are not always satisfactory. Therefore, this study aimed to estimate the functional outcomes of bimalleolar ankle fractures treated by open reduction and internal fixation.

Methods:

This descriptive, cross-sectional study was carried out at a tertiary care center in the western region of Nepal among the patients with bimalleolar ankle fractures from March 2017 to August 2020 after approval from the Institutional review committee. Convenience sampling was done to reach the sample size. Twenty-nine cases were included in the study. Data were recorded in proforma and data analysis was done in the statistical package for social sciences (SPSS 16.0). The American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was used to assess the final outcome.

Results:

At the final evaluation mean AOFAS ankle-hindfoot score was 89.86 (±7.95). According to the AOFAS ankle-hindfoot score, there were 19 excellent (65.51%), six good (20.68%), and four fair (13.79%) results. Complications in the form of superficial infection were seen in four (13.79%) cases.

Conclusions:

Functional outcomes following surgical treatment of bimalleolar ankle fractures are mostly excellent to good and complications following surgery are few, therefore, surgery is a better option of treatment in bimalleolar ankle fractures.

An Exceptional Avulsion Fracture Above the Medial Malleolus: A Retrospective Case Series

The Lauge-Hansen classification does not cover all types of ankle injuries. The present report details three cases of exceptional fragment of the medial tibia that differed from the traditional Lauge-Hansen supination-external rotation and pronation-external rotation fracture patterns. The information obtained from this study will be helpful for conducting basic research of this condition and determining appropriate surgical approaches.

Intramedullary nailing as an alternative to plate fixation in patients with distal fibular fracture

BACKGROUND

We examined whether the intramedullary nailing (IMN) can be used as an alternative modality to the plate fixation (PF) in patients with distal fibular fracture with displaced fragments.

PATIENTS AND METHODS

The eligible patients of two treatment arms (IMN group: n=30 and the group: n=31) were evaluated at 3, 6, 9 and 12 months postoperatively, for which functional outcome measures include differences in the American Orthopaedic Foot and Ankle Society Scores (AOFAS) and the Olerud Molander Ankle Scores (OMAS) between the two groups. In addition, radiological outcome measures include differences in radiological outcome scores at 12 months between the two groups. Differences in the percentage of frequency of postoperative complications between the two groups served as safety outcome measures.

RESULTS

At 3 months, the AOFAS and OMAS were significantly higher in the IMN group as compared with the PF group (p<0.0001 and p=0.0177, respectively). At 6 months, the AOFAS were significantly higher in the IMN group as compared with the PF group (p=0.0255). But there were no significant differences in the OMAS between the two groups (p=0.1077). At 9 and 12 months, there were no significant differences in the AOFAS and OMAS between the two groups (p=0.4334 and 0.3227, respectively at 9 months and p=0.8731 and 0.7610, respectively, at 12 months). These results indicate that the IMN group achieved a faster recovery as compared with the PF group. At 12 months, the radiological outcome scores were 3.67±0.60 in the IMN group and 3.71±0.52 in the PF group (p=0.7816). All the patients of each group achieved a bony union at 12 months. At 12 months, the percentage of frequency of postoperative complications was significantly lower in the IMN group as compared with the PF group (p=0.0227).

CONCLUSIONS

The IMN might be considered as an alternative surgical modality to the PF in patients with distal fibular fracture with displaced fragments. But further large-scale, multi-center studies are warranted to establish our results.

Effect of Early Weightbearing Following Open Reduction and Internal Fixation of Unstable Ankle Fractures on Wound Complications or Failures of Fixation

BACKGROUND

There is a growing trend toward early weightbearing as tolerated (WBAT) after open reduction and internal fixation (ORIF) of ankle fractures. To date, studies have excluded fractures with associated syndesmotic injuries from their cohorts.

METHODS

In this retrospective cohort study, a chart review was performed at a single level 1 trauma center, identifying all unstable ankle fractures that underwent operative fixation between July 2016 and July 2017. After exclusion criteria, 63 patients were identified and 31 were included in the final analysis, with 14 undergoing syndesmotic fixation. WBAT was initiated after suture removal, between 2 and 4 weeks postoperatively. Outcomes included fracture union, radiographic maintenance of alignment, hardware failures, wound complications, and the need for repeat surgery.

RESULTS

Weightbearing was initiated at an average of 17.8 days. All 31 patients progressed toward fracture union, with no hardware failures. Three patients developed superficial wound breakdown, which was treated with protected weightbearing in all cases and oral antibiotics in 1 case. All 3 went on to heal from their incisions. One patient had delayed wound breakdown and required a split-thickness skin graft that subsequently healed without complication. One patient underwent hardware removal 6 months postoperatively. There were no revision ORIF procedures.

CONCLUSION

There is literature supporting early WBAT after ORIF of unstable ankle fractures in patients without major comorbidities. This article supports this trend, demonstrating that a group of ankle fractures requiring syndesmotic fixation were included in the early weightbearing cohort without a higher rate of catastrophic failure or increased wound problems.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

Screw Fixation of the Posterior Malleolus Fragment in Ankle Fracture

BACKGROUND

This study aimed to evaluate the outcomes of ankle fractures with posterior malleolus fragments (PMFs) involving <25% of the articular surface treated with or without screw fixation.

METHODS

Among patients with ankle fractures and PMFs who underwent surgery between March 2014 and February 2017, 62 with type 1 PMFs involving <25% of the articular surface were included. Of these 62 patients, 32 underwent screw fixation for PMFs and lateral and/or medial malleolar fracture fixation (group A) and 30 underwent internal fixation for malleolar fractures without screw fixation for PMFs (group B). Ankle joint alignment and fracture healing were measured using plain radiography and computed tomography (CT). Clinical outcomes were determined using the American Academy of Orthopaedic Surgeons Foot and Ankle Questionnaire, Short Form-36, and American Orthopaedic Foot & Ankle Society Scale.

RESULTS

Nonunion was not noted in either group. However, we detected union with a step-off of 2 mm or more in 2 cases from group B. With regard to ankle joint alignment, 1 case in group A and 3 cases in group B showed mild asymmetry of the medial and lateral clear spaces on CT at 12 months. Clinical outcomes at 6 and 12 months after surgery were better in group A than in group B.

CONCLUSION

Screw fixation of PMFs was effective for fracture healing and maintaining ankle alignment. Additionally, it improved short-term clinical outcomes, which we believe was due to stabilization of ankle fractures with PMFs involving <25% of the articular surface.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Transarticular external fixation versus deltoid ligament repair in treating SER IV ankle fractures: a comparative study

BACKGROUND

The topic that whether the injured deltoid ligament should be repaired when associated with ankle joint fractures is still discussed. The objective of this study was to compare the clinical effect of open reduction and internal fixation (ORIF) with deltoid ligament repair (DLR) or transarticular external fixation (TEF) in treating supination-external rotation type IV (SER IV) ankle fractures.

METHODS

Between January 2012 and December 2015, 43 patients were diagnosed as SER IV ankle fractures, 20 underwent ORIF and transarticular external fixation (TEF) without DLR (group 1), 23 were treated with ORIF and DLR (group 2). The pre- and post-operative radiographic examination were performed, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, the visual analog scale (VAS), the Medical Outcomes Short Form 36-item questionnaire score (SF-36), and the ankle range of motion (ROM) were used for functional evaluation.

RESULTS

In both groups, the three scores improved significantly after surgery, but there was no significant difference between the two groups. At 6 weeks after surgery, patients in group 2 had better ankle ROM than group 1 (29.35 ± 2.033 vs. 40.35 ± 3.550, P <  0.001), but there was no difference at 12 months postoperatively. No cases of bone nonunion or post-traumatic arthritic changes were seen during the follow-up. Patients in group 1 required a shorter time to achieve fracture union than patients in group 2.

CONCLUSIONS

ORIF with TIF is an optional strategy to manage SER IV ankle fractures as it achieves comparable functional results to ORIF with DLR. It also allows patients to start relatively earlier weight-bearing and may promote fracture union.

Validated Risk-Stratification System for Prediction of Early Adverse Events Following Open Reduction and Internal Fixation of Closed Ankle Fractures

BACKGROUND

As orthopaedic surgery moves toward bundled payments, there is growing interest in identifying patients at high risk of early postoperative adverse events. The purpose of this study was to develop and validate a risk-stratification system for the occurrence of early adverse events among patients treated with open reduction and internal fixation (ORIF) for a closed fracture of the ankle.

METHODS

Patients undergoing ORIF for a closed ankle fracture during the period of 2006 to 2017, as documented by the American College of Surgeons National Surgical Quality Improvement Program, were identified. For the 60% of patients randomly selected as the development cohort, multivariate Cox proportional hazards modeling was used to identify factors that were independently associated with the occurrence of adverse events (including events such as reoperation, surgical site infection, and pulmonary embolism). On the basis of these results, a nomogram analysis was used to generate a point-based risk-stratification system. To evaluate the validity of the point-based system, the system was applied to the remaining 40% of patients constituting the validation cohort and tested for its ability to predict adverse events.

RESULTS

Of the 7,582 patients in the development cohort, 455 developed an adverse event (estimated adverse event risk of 6%). On the basis of Cox proportional-hazards regression, patients were assigned points for each of the following significant risk factors: +1 point for age of 40 to 59 years, +3 points for age of 60 to 79 years, +5 points for age of ≥80 years, +1 point for female sex, +2 points for chronic obstructive pulmonary disease (COPD), +2 points for insulin-dependent diabetes, +3 points for anemia, and +4 points for end-stage renal disease. The validation cohort included 5,263 patients. Among this second cohort, the risk-stratification system predicted the risk of early adverse events (p < 0.001; Harrell C = 0.697).

CONCLUSIONS

The occurrence of early adverse events following ORIF for closed ankle fractures was associated with greater age, female sex, COPD, insulin-dependent diabetes, anemia, and end-stage renal disease. We present and validate a simple point-based risk-stratification system to predict the risk of early adverse events.

LEVEL OF EVIDENCE

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

Physiologic widening of the medial clear space: What's normal?

BACKGROUND

Literature has validated the use of stress radiographs for evaluation of ankle stability. However, to our knowledge no study has reported the amount of physiological widening that occurs with manual external rotation stress test in uninjured ankles. The purpose of this study was to assess the amount of medial clear space widening that occurs with a manual external rotation stress test in uninjured ankles.

METHODS

A cohort of adult patients undergoing operative fixation of unstable ankle fractures were prospectively enrolled to have their contralateral ankle undergo manual external rotation stress examination. Fluoroscopic images of the unaffected ankle were performed in the OR. A non-stressed mortise view and manual external rotation stress view were obtained with a standardized marker to correct for magnification differences. The images were de-identified, presented in a randomized order and reviewers who were blinded. Each reviewer measured the medial clear space.

RESULTS

Thirty fluoroscopic images on fifteen patients were obtained. The mean medial clear space on the non-stressed mortise view was 3.1 mm (SD-0.69; Range 1.9 to 4.2, 95% CI [2.75, 3.45]) versus a mean of 3.2 mm (SD-0.71; Range 2.0 to 4.7, 95% CI [2.94, 3.66]) in the stressed mortise view group. Inter-rater reliability was excellent between all observers for medial clear space (ICC-0.88; CI [0.78, 0.94]).

CONCLUSIONS

Our results support the previous literature and allow us to advocate for ankle fractures with >5 mm medial clear space after external rotational stress to be considered unstable. Additionally, ankles with a medial clear space between 4 and 5 mm, instability should be considered only if lateral shift is > 2 mm on stress examination. Our data shows that no physiologically healthy ankles widened beyond these established cut-offs before or after the manual external rotation stress.

Ankle Fracture Stability-Based Classification: A Study of Reproducibility and Clinical Prognostic Ability

OBJECTIVE

To compare the reproducibility and prognostic capacity of 2 commonly used ankle fracture classifications to the stability-based classification.

METHODS

One hundred ninety-three consecutive rotational-type ankle fractures treated during a year at our institution in patients older than 18 years were retrospectively analyzed. Pilon and pathologic fractures were excluded. The fractures were treated by attending physicians who were unaware of the stability-based classification system. Three observers classified injury radiographs using the Lauge-Hansen, Weber/AO, and stability-based classifications systems. Reproducibility (interobserver variation) of each classification system was calculated using kappa statistics. Prognostic values were evaluated by calculating the area under the curve for the receiver-operating characteristic curves (using surgery as the positive outcome).

RESULTS

The stability-based and Weber/AO classifications showed better reproducibility [kappa 0.938 (95% confidence interval 0.921-0.952), kappa 0.97 (0.961-0.976)], respectively, than the Lauge-Hansen [kappa 0.74 (0.664-0.795); P < 0.05]. The stability-based classification was more accurate (P < 0.001) in predicting surgical treatment [area under the curve 0.883 (95% confidence interval 0.852-0.914)] compared with the other 2 classifications [0.626 (0.576-0.675) and 0.698 (0.641-0.755)], respectively.

CONCLUSIONS

The stability-based classification was both highly reproducible (kappa 0.938) and had superior prognostic capacity to identify patients who needed surgical intervention compared with both the Lauge-Hansen and AO/Weber classification systems. Importantly, there were no patients who were classified as stable who failed nonoperative treatment. This extends earlier studies by directly demonstrating its prognostic advantage to other classification systems.

The Diagnostic Accuracy of Radiographs and Magnetic Resonance Imaging in Predicting Deltoid Ligament Ruptures in Ankle Fractures

BACKGROUND

Operative indications for supination-external rotation (SER) ankle fractures depend on the integrity of the medial structures. Despite the importance of assessing deep deltoid ligament injuries, the accuracy of common diagnostic tests has not been established.

QUESTIONS/PURPOSES

The objective of this study was to compare the ability of injury (non-stress) and stress radiographs and magnetic resonance imaging (MRI) to diagnose deep deltoid ligament ruptures in operative SER ankle fractures.

METHODS

Patients were included who underwent surgical fixation of SER ankle fractures and had appropriate injury and manual stress test radiographs, pre-operative ankle MRI, and intra-operative assessment of deep deltoid integrity by direct visualization. The medial clear space (MCS) was considered positive for all values over 5 mm on the injury or stress mortise radiographs. MRI analysis of the deep deltoid ligament injury was performed by blinded fellowship-trained musculoskeletal radiologists. Intra-operative direct visualization and assessment of the deltoid was performed using a direct medial ankle approach at the time of operative fracture fixation.

RESULTS

Using intra-operative visualization as the gold standard, MCS measurements and MRI had differing abilities to diagnose a deep deltoid rupture. In cases where the MCS was less than 5 mm on injury radiographs and stress tests were performed, MCS measurements were much less accurate than MRI in predicting deltoid ruptures (46% versus 79%, respectively) with a high false positive rate (80%). In contrast, an MCS measurement of greater than 5 mm on injury radiographs was a strong predictor of deep deltoid rupture (accuracy of 95%).

CONCLUSION

Compared with direct visualization of the deltoid ligament intra-operatively, these data support proceeding with surgery when the MCS on injury radiographs is greater than 5 mm without any additional stress tests or advanced imaging. When the MCS is less than 5 mm, we recommend MRI analysis because of its increased accuracy and decreased false positive rate. Improving our ability to diagnose deltoid ruptures will contribute to more effective management of patients with SER ankle fractures.

Surgical Reconstruction of an Open Medial Malleolus Fracture Using a Novel Technique: A Case Report

CASE

A 17-year-old male sustained an open fracture of the right medial malleolus (MM) with significant bone and soft tissue loss following a motor-vehicle accident. Following serial wound debridement, his ankle was effectively reconstructed with MM antiglide plate stabilization, iliac autogenous bone graft, and a free radial forearm soft tissue flap.

CONCLUSIONS

Open MM fracture with bone and soft tissue loss is rare. It is feasible to treat this injury with a novel surgical reconstruction technique involving autogenous bicortical iliac bone graft and radial forearm free flap.

Comparison of different locking plate fixation methods in lateral malleolus fractures

BACKGROUND

Several fixation methods may be used for displaced lateral malleolar fractures. We aimed to compare clinical and radiologic outcomes associated with use of locking one third tubular plate vs. anatomical distal fibula locking plate in lateral malleolar fractures.

METHODS

A total of 62 orthopedic patients operated for lateral malleolus fracture were included in this retrospective study. Patients were divided into two groups regarding the plate used for fixation as locking one third tubular plate (group I; n=37) and locking anatomical distal fibula plate (group II; n=25). Data on Danis-Weber ankle fracture classification (Type A, Type B), duration of follow up, clinical outcome [ankle range of motion (ROM), American Orthopaedic Foot & Ankle Society (AOFAS) score], radiological outcomes (adequacy of reduction, loss of alignment), time to fracture healing and complications were recorded in study groups.

RESULTS

No significant difference was noted between groups in terms of AOFAS score [87.0 (73-100) vs. 85.0 (71-100), respectively (p=0.339)] and no patients had severe restriction in sagittal and hindfoot motion in both groups. The two groups showed similar healing time [9.0 (7-13) weeks vs. 10.0 (8-13) weeks, respectively (p=0.355)] and complication rate [0.0% vs. 4.0%, respectively (p=0.403)].

CONCLUSIONS

This study revealed no significant difference between use of locking one third tubular plate and locking anatomical distal fibula plate in lateral malleolar fixation, in terms of clinical and radiological outcomes, complication rates and fracture healing time.

Supination External Rotational Ankle Fracture Injury Pattern Correlation With Regional Bone Density

BACKGROUND:

Rotational ankle fractures can present with an array of possible osseous and ligamentous injury combinations in reliable anatomic locations. What accounts for these different injury patterns and whether specific patient and injury factors underlie the different injury patterns is unclear. The purpose of this study was to determine whether causative factors exist that could account for the various injury patterns seen with rotational ankle fractures.

METHODS:

A registry of operatively treated supination external rotation stage IV (SER IV) ankle fractures was used to identify patients. Computed tomography imaging was used to calculate regional bone density by using average Hounsfield unit measurements on axial images from the distal tibia and fibula. Patients were grouped into those with no posterior or medial malleolar fracture (equivalent group), those with either a posterior or medial malleolus fracture (bimalleolar group), and those with both posterior and medial malleolar fractures (trimalleolar group). Sixty-seven patients met inclusion criteria.

RESULTS:

Regional bone density at the ankle, as measured with Hounsfield units, was significantly higher in the equivalent group (371) than in the bimalleolar group (271, P < .0001) and trimalleolar group (228, P < .0001). Logistic regression analyses identified regional bone density as a significant predictor of a medial malleolus fracture ( P = .002) and of a posterior malleolus fracture ( P = .005).

CONCLUSION:

In our cohort of SER IV ankle fractures, regional bone density at the ankle significantly correlated with the presence and number of malleolar fractures compared with ligamentous ruptures. Treating surgeons can use this information to anticipate bone quality during operative fixation based on ankle fracture injury pattern. In addition, the presence of a trimalleolar ankle fracture was a significant indicator of poor bone quality and may represent the first clinical sign of abnormal bone metabolism in many patients.

LEVEL OF EVIDENCE:

Level III, prognostic retrospective cohort study.

Compatibility of Lauge-Hansen Classification Between Plain Radiographs and Magnetic Resonance Imaging in Ankle Fractures

We evaluated the accuracy of the predictive injury sequences of the Lauge-Hansen (L-H) classification using magnetic resonance imaging (MRI) in patients with ankle fractures and determined the possible causes of mismatch. Sixty-five patients with ankle fractures who had a complete series of anteroposterior, lateral, and oblique radiographs and ankle MRI studies available were included. The fracture pattern was assigned by 2 senior orthopedic surgeons according to the L-H classification system. The syndesmotic ligaments, lateral collateral ligaments, and medial deltoid complex ligaments were evaluated on the preoperative MRI scans. Comparisons were performed between the predicted ankle ligamentous injury based on the radiographic L-H classification and preoperative MRI analysis. Of the 65 feet in 65 patients, 50 feet (76.9%) were classified as having a supination-external rotation (SER) fracture, 6 feet (9.2%) as having a pronation-external rotation fracture, 4 feet (6.2%) as having a supination adduction fracture, and 2 feet (3.1%) as having a pronation abduction fracture. The overall compatibility of the radiologic classification with the MRI classification was 66.1%. In the evaluation of 50 feet with the MRI SER designation, maximum compatibility was found for stage 4 (77.3%). The main cause for the discrepancy in the SER designation was missing the presence of deltoid ligament disruption on the plain radiographs, especially in the stage 2 and 3 SER fracture pattern. In the evaluation of deltoid complex injuries, all injuries were localized to the anterior part of the medial deltoid complex. The validity of the L-H classification system was low. A new classification system is needed to address the medial malleolus fracture or deltoid complex injuries without posterior injury. Also, stress radiographs could be added to standard radiographs for the classification to address deltoid complex injuries.

Early and mid-term results of transarticular external fixation in the treatment of supination-external rotation type IV equivalent ankle fractures

PURPOSE

To investigate the early and mid-term results of open reduction and internal fixation (ORIF) with transarticular external fixation (TEF) but no deltoid ligament repair (DLR) in the treatment of supination-external rotation type IV equivalent (SER IV E) ankle fractures (AO/OTA classification 44-B 3.1) and provide evidence for clinical practice.

METHODS

This study cohort consisted of 22 patients with SER IV E ankle fractures that underwent ORIF with TEF but no DLR between December 2011 and December 2014. There were 13 males and 9 females, mean age 38.9 years (range, 17-73 years). Eight cases involved the left side and 14 the right side. The causes of fractures included road traffic accidents (11 cases), falling from height (6 cases) and sports injuries (5 cases). The mean period of hospitalization was 9.8 days (range, 6-14 days). For all the patients, MRI and three-dimensional CT were done before surgery and X-rays done preoperatively and during follow-ups. The external frame was kept for 8-10 weeks. The preoperative American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was 56.86 ± 4.400, the Medical Outcomes Short Form 36-item (SF-36) questionnaire score was 57.41 ± 4.102 and the visual analog score (VAS) was 5.50 ± 1.058. Patients' main complaints about inconvenience of daily life were also recorded.

RESULTS

All the 22 patients were followed up for 24-63 months (mean, 33.6 months). None of them developed nonunion during the follow-up; pin site infection was observed in one patient and posttraumatic osteoarthritis in another. At the final follow-up, the average AOFAS score, SF-36 score and VAS score were respectively 90.59 ± 5.096, 79.59 ± 5.394 and 1.82 ± 1.181, which were significantly improved compared with the preoperative data (t = 26.221, p < 0.001; t = 11.910, p < 0.001; t = 11.571, p < 0.001). The therapeutic effect was excellent in 13 cases, good in 7 cases and fair in 2 cases, with a good-excellent rate of 90.9%. Patients' main complaints were inconvenience of clothing (17 cases) and extremity cleaning (5 cases).

CONCLUSION

In the treatment of SER IV E ankle fractures, ORIF with TEF but no DLR can achieve satisfactory outcome, but long-term effect should be confirmed by large sample randomized controlled trials.

An Incidental Finding of a Talonavicular and Talocalcaneal Joint Coalition After a Tibial Pilon Fracture: A Case Report

It has been proposed that patients with talocalcaneal and talonavicular coalitions have decreased ankle joint range of motion. It has also been reported that rotational forces regularly absorbed by the talocalcaneal joint are transferred to the ankle joint in patients with coalitions, increasing the stress on the ankle joint after trauma. To the best of our knowledge, only 1 reported study has detailed the increased stress placed on the ankle joint secondary to a coalition. We present a case study of a 53-year-old female who experienced a traumatic fall and subsequent right ankle fracture. Advanced imaging studies revealed a comminuted tibial pilon fracture and talocalcaneal and talonavicular joint coalitions. She underwent open reduction and internal fixation for treatment of the fracture, and the coalitions were not treated because they were asymptomatic. She was kept non-weightbearing for 6 weeks postoperatively and was returned to a regular sneaker at 10 weeks postoperatively. The postoperative films revealed stable intact fixation and pain-free gait with no increased restriction in her ankle joint range of motion. The hardware was removed at 13 months postoperatively. She had not experienced increased pain or arthritic changes at 15 months postoperatively.

Economic Burden of Inpatient Admission of Ankle Fractures

BACKGROUND

Ankle fractures are among the most prevalent traumatic orthopaedic injuries. A large proportion of patients sustaining operative ankle fractures are admitted directly from the emergency department prior to operative management. In the authors' experience, however, many closed ankle injuries may be safely and effectively managed on an outpatient basis. The aim of this study was to characterize the economic impact of routine inpatient admission of ankle fractures.

METHODS

A retrospective review of all outpatient ankle fracture surgery performed by a single foot and ankle fellowship-trained surgeon at a tertiary level academic center in 2012 was conducted to identify any patients requiring postoperative inpatient admission. The National Inpatient Sample was queried for operative management of lateral malleolus, bimalleolar, and trimalleolar ankle fractures in 2012 with regard to national estimates of total volume and length of stay by age. The maximum allowable Medicare inpatient facility reimbursements for diagnosis related group 494 and Medicare outpatient facility reimbursements for Current Procedural Terminology codes 27792, 27814, and 27822 were obtained from the Medicare Acute Inpatient Prospective Pricer and the Medicare Outpatient Pricer Code, respectively. Private facility reimbursement rates were estimated at 139% of inpatient Medicare reimbursement and 280% of outpatient reimbursement, as described in the literature. Surgeon and anesthesiologist fees were considered similar between both inpatient and outpatient groups. A unique stochastic decision-tree model was derived from probabilities and associated costs and evaluated using modified Monte Carlo simulation.

RESULTS

Of 76 lateral malleolar, bimalleolar, and trimalleolar ankle fracture open reduction internal fixation cases performed in 2012 by the senior author, 9 patients required admission for polytrauma, medical comorbidities, or age. All 67 outpatients were discharged home the day of surgery. In the 2012 national cohort analyzed, 48,044 estimated inpatient admissions occurred postoperatively for closed ankle fractures. The median length of stay was 3 days for each admission and was associated with an estimated facility reimbursement ranging from $12,920 for Medicare reimbursement of lateral malleolus fractures to $18,613 for private reimbursement of trimalleolar fractures. Outpatient facility reimbursements per case were estimated at $4,125 for Medicare patients and $11,459 for private insurance patients. Nationally, annual inpatient admissions accounted for $796,033,050 in reimbursements, while outpatient surgery would have been associated with $419,327,612 for treatment of these same ankle fractures.

CONCLUSION

In the authors' experience, closed lateral malleolus, bimalleolar, and trimalleolar fractures were safely and effectively treated on an outpatient basis. Routine perioperative admission of patients sustaining ankle fractures likely results in more than $367 million of excess facility reimbursements annually in the United States. Even if a 25% necessary admission rate were assumed, routine inpatient admission of ankle fractures would result in a $282 million excess economic burden annually in the United States. Although in certain cases, inpatient admission may be necessary, with value-based decision making becoming increasingly the responsibility of the orthopaedic surgeon, understanding the implications of inpatient stays for ankle fracture surgery can ultimately result in cost savings to the US health care system and patients individually.

LEVEL OF EVIDENCE

Level III, comparative series.

Repair of Bimalleolar Ankle Fracture

PURPOSE

The incidence of ankle fractures is rapidly increasing in geriatric populations. Of the 4 fracture patterns described by the Lauge-Hansen classification system, supination-external rotation (SER) accounts for most ankle fractures. This video demonstrates surgical repair of a SER type 4 ankle fracture in a geriatric patient.

METHODS

SER type 4 ankle fractures are considered unstable and are generally treated with surgical fixation. After placement of plate and screws, intraoperative stress tests can be used to assess for syndesmotic widening. If necessary, the syndesmosis can be reduced open, with screw fixation placed parallel to the joint. Patients are kept non-weight-bearing for 6 weeks after surgery.

RESULTS

This video, shot on an iPhone 6S, shows the case of a 66-year-old female status after a fall with twisting mechanism resulting in an unstable SER type 4 fracture requiring operative repair. Intraoperative stress test revealed medial clear space widening requiring syndesmotic reduction.

CONCLUSIONS

SER type 4 ankle fractures are a common injury that must be properly managed to return patients to baseline functional status. The surgical technique described in this video provides for good stabilization and allows for early range of motion with advancement to weight-bearing as tolerated at 6 weeks postoperatively.

Patient selection for total ankle arthroplasty

Total ankle arthroplasty is a treatment option for end-stage osteoarthritis of the ankle, as is ankle arthrodesis. Many variables, including patient characteristics, are thought to influence clinical outcome and survival. As with any surgery, but especially with total ankle replacement (TAR), patient selection is considered critical for good (long-term) outcome. In this review, we summarize the available scientific evidence regarding patient characteristics and its influence on the results of TAR.

Type B ankle fractures: a retrospective study of longer-term outcomes

OBJECTIVES

Ankle fractures are common and can be treated with or without surgery. The aim of the present study was to compare patient reported outcomes between patients who sustained an Orthopaedic Trauma Association type 44-B1 ankle fracture who had either surgical or non-surgical fixation.

RESULTS

Forty-six people were recruited; 38 were treated non-surgically and 8 were treated surgically. Mean follow-up time was 24 and 25 months for surgical and non-surgical groups respectively. Baseline characteristics were similar between the two groups. On unadjusted analysis, there was no significant difference between the two groups with respect to any outcome. After adjusting for age and gender, the surgical group had a significantly lower outcome score with respect to the FAOQ. Surgical management was associated with a significantly lower patient-reported ankle function compared to non-surgical management for the treatment of patients with type 44-B1 ankle fracture after adjusting for age and gender. However, there was no significant difference between the two groups with respect to the general health outcomes or adverse events. Higher-level evidence is required to inform optimal practice for this common fracture.

Serial Radiographs Do Not Change the Clinical Course of Nonoperative Stable OTA/AO 44-B1 Ankle Fractures

OBJECTIVE

To assess radiographic markers of ankle stability in stable OTA/AO 44-B1 ankle fractures.

DESIGN

Retrospective review.

SETTING

Academic Level-I trauma hospital.

PATIENTS

One hundred thirty-four patients with stable OTA/AO 44-B1 (Danis-Weber B, Supination-External Rotation-II) ankle fractures.

INTERVENTION

Analysis of mortise view radiographs at the time of initial evaluation and final follow-up.

VARIABLES MEASURED

(1) medial clear space; (2) Mueller-Nose Distance.

MAIN OUTCOME MEASURE

Change in radiographic measurements resulting in conversion to operative intervention.

RESULTS

Patients followed up an average of 2.6 visits in our clinics (SD 1.06). Patients received an average of 11.2 individual radiographic images to evaluate their injury (SD 3.9, maximum 29). No patients progressed to surgery in this cohort. Mean medial clear space at the time of injury was 3.4 mm (SD 0.8) and was 3.3 mm (SD 0.7) at the time of final follow-up (P = 0.1). Mean Mueller-Nose measurement at the time of injury was 3.5 mm (SD 1.0) and was 3.5 mm (SD 0.8) at the time of final follow-up (P = 0.47).

CONCLUSIONS

No patients with stable OTA/AO 44-B1 fractures proceeded to surgery for loss of tibiotalar reduction or any other cause. Radiographic relationships were conserved during the follow-up, and serial radiographs may not be needed when managing these patients.

LEVEL OF EVIDENCE

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

Gravity Stress Radiographs and the Effect of Ankle Position on Deltoid Ligament Integrity and Medial Clear Space Measurements

INTRODUCTION

External rotation and gravity stress radiographs have been described to distinguish stable supination-external rotation-II (SER-II) ankle fractures from unstable SER-IV fractures. It has been previously shown that both external rotation and gravity stress views are equivalent in their ability to diagnose deltoid ligament injury. It has also been shown that the position of the ankle influences the external rotation stress radiograph. However, no data of ankle position exist for gravity stress radiographs.

METHODS

Eight fresh-frozen cadaveric ankles were dissected and destabilized sequentially according to the SER mechanism of ankle fractures, starting with the anterior inferior tibiofibular ligament, distal fibula osteotomy at the level of the syndesmosis, posterior inferior tibiofibular ligament, superficial deltoid ligament, and finally the deep deltoid ligament. Fluoroscopic radiographs were taken with gravity stress views in both neutral and plantarflexion. Measurements of both dorsal and the medial clear space were taken for each stage. The difference between the dorsal and medial clear space was measured.

RESULTS

Positive predictive value (PPV) with a medial clear space cutoff of 5 mm was 80% in plantarflexion and 72.72% in neutral with a negative predictive value (NPV) of 100% in both positions. Using a 6-mm cutoff, the PPV improved to 100% and NPV remained 100% for both neutral and plantarflexion. When the difference measurement is used, a 1.0-mm difference yielded a PPV of 72% and an NPV of 100% in both neutral and plantarflexion. With a 1.5-mm cutoff, the PPV and NPV were 100% for both positions.

CONCLUSIONS

The position of the ankle during gravity stress radiographs does not influence the clinical effectiveness of the images. Using larger references for stability, the PPV can be improved.

Medial Malleolar Fractures and Associated Deltoid Ligament Disruptions: Current Management Controversies

Operative fixation of medial malleolar fractures, whether isolated or in the setting of bi- or trimalleolar fractures, remains controversial. Increasingly, anatomic reduction and internal fixation is used to treat medial malleolar fractures to avoid long-term sequelae of symptomatic nonunion and posttraumatic osteoarthritis. However, outcomes have not been significantly different between operative and nonoperative cohorts. Repair of associated deltoid ligament disruption is not common because of reportedly poor outcomes. This review provides an overview of the literature on medial malleolar fracture fixation and current treatment options. [Orthopedics. 2017; 40(2):e216-e222.].

Preoperative radiography versus computed tomography for surgical planning for ankle fractures

PURPOSE

To review preoperative radiography and computed tomography (CT) of the ankle in 69 patients who underwent surgery for ankle fractures to determine the value of CT in diagnosis and surgical planning.

METHODS

Preoperative radiography and CT of the ankle of 46 women and 23 men aged 17 to 90 (mean, 48.8) years were reviewed. CT was deemed necessary when radiographs showed the following features: (1) comminuted fracture of the medial malleolus involving the tibial plafond, (2) comminuted fracture of the posterior malleolus, (3) presence of loose bodies, and/or (4) suspected Chaput or Volkman fracture fragment. Two orthopaedic surgeons independently reviewed the radiographs to look for any of the above features for which CT was indicated. In patients whose radiographs did not show any of the above features, each surgeon formulated a surgical plan based on radiographs alone and decided if any modification was needed after reviewing the CT scan.

RESULTS

Based on radiographs of the 69 patients, 19 (28%) patients had features of posterior malleolar comminution (n=7), medial malleolar comminution (n=7), suspected Chaput fracture fragment (n=1), suspected Volkman fracture fragment (n=1), and combination of 2 lesions (n=3), and were deemed to require CT. In 10 (20%) of the remaining 50 patients, the surgical plan was modified after review of the CT scan. The intra- and inter-observer agreement was good to excellent.

CONCLUSION

Radiography alone is not adequate for surgical planning for ankle fractures. More accurate imaging tools such as CT are needed to enable a more accurate diagnosis and surgical planning.

Correlation Between the Lauge-Hansen Classification and Ligament Injuries in Ankle Fractures

OBJECTIVE

To evaluate the ability of the Lauge-Hansen classification to predict ligament injuries in ankle fractures using magnetic resonance imaging (MRI) and intraoperative findings.

DESIGN

Prospective evaluation in consecutive patients.

SETTING

Academic level 1 trauma center.

PATIENTS

Three-hundred patients with an operatively treated ankle fracture who met the inclusion and exclusion criteria.

INTERVENTION

Injury ankle radiographs were assigned to a Lauge-Hansen classification. MRI scans were obtained to evaluate the syndesmotic and deltoid ligaments. A Lauge-Hansen classification for each patient was recorded based on intraoperative findings.

MAIN OUTCOME MEASUREMENTS

Comparisons were made between the predicted ankle ligamentous injuries based on radiographic Lauge-Hansen classifications, preoperative MRI analyses, and intraoperative findings.

RESULTS

On the basis of the Lauge-Hansen system and injury radiographs, 77% (231/300) were classified as supination external rotation, 13% (40/300) were pronation external rotation, 4% (11/300) were supination adduction, <1% (1/300) was pronation abduction, and 6% (17/300) were not classifiable. Of the 283 fractures that were classified into Lauge-Hansen classes, 266 (94%) had MRI readings of ligamentous injuries consistent with the Lauge-Hansen predictions. Intraoperative findings also highly correlated with the Lauge-Hansen class of ankle fractures, with nearly complete agreement. Comparing MRI and intraoperative findings revealed discrepancies in 6% (16/283) of ankle fracture classifications.

CONCLUSIONS

In our large cohort of patients, comparisons between injury radiographs, preoperative MRI, and intraoperative findings suggest that the Lauge-Hansen system is an accurate predictor of ligamentous injuries. The predictions based on the Lauge-Hansen system can be useful for fracture reduction maneuvers and operative planning.

LEVEL OF EVIDENCE

Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

High Ankle Sprains and Syndesmotic Injuries in Athletes

Treatment of athletes with ligamentous injuries of the tibiofibular syndesmosis can be problematic. The paucity of historic data on this topic has resulted in a lack of clear guidelines to aid in imaging and diagnosing the injury, assessing injury severity, and making management decisions. In recent years, research on this topic has included an abundance of epidemiologic, clinical, and basic science investigations of syndesmotic injuries that are purely ligamentous or associated with ankle fracture. Several classification systems can be used to classify ligamentous injury to the syndesmosis. These systems integrate clinical and radiographic findings but do not address the location of the injury or its severity. Injury to the syndesmosis can be purely ligamentous; however, many unstable syndesmotic injuries are associated with fractures. Nonsurgical management can be used for stable ligamentous injuries without frank diastasis, but surgical management, including screw or suture-button fixation, is indicated for fractures with unstable syndesmotic injuries.

Quality and Utility of Immediate Formal Postoperative Radiographs in Ankle Fractures

BACKGROUND

Patients who undergo internal fixation of ankle fractures commonly have postoperative imaging performed immediately after surgery. As these patients typically are typically immobilized, radiographs provide limited visualization. The purpose of this study was to evaluate the utility and quality of formal radiographs performed immediately following ankle fracture surgery.

METHODS

Ankle fractures undergoing open reduction and internal fixation at a single institution from January 1, 2011, to January 1, 2013, were reviewed. Intraoperative and formal postoperative radiographs were evaluated using defined parameters. The postoperative images were compared with the intraoperative fluoroscopic images in terms of quality. Postoperative complications were evaluated in terms of fracture displacement, hardware malpositioning, and need for return to the operating room. A total of 411 patients with 413 ankle fractures underwent surgical fixation, with 271 patients undergoing formal postoperative radiographs.

RESULTS

Twenty-eight patients (10.3%) had 3 good quality postoperative views of the ankle, with the lateral (35.2%) and mortise (41.3%) views least commonly performed with good technique. None of the patients without radiographs had a complication that could have been detected earlier using postoperative radiographs. No patients required return to the operating room based on immediate postoperative radiographs. Postoperative radiographs cost $191 per patient.

CONCLUSION

The routine use of formal postoperative radiographs prior to discharge from the hospital did not provide additional value to the patient or orthopedic surgeon. The quality of these images was generally inferior to the quality of those obtained and saved intraoperatively due to malrotation and overlying cast material. To reduce cost and radiation exposure, formal postoperative radiographs should be obtained only in specific circumstances, such as increasing postoperative pain, marginal fixation, or instability.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Guesstimation of posterior malleolar fractures on lateral plain radiographs

BACKGROUND

Accurate assessment of articular involvement of the posterior malleolar fracture fragments in ankle fractures is essential, as this is the leading argument for internal fixation. The purpose of this study is to assess diagnostic accuracy of measurements on plain lateral radiographs.

METHODS

Quantification of three-dimensional computed tomography (Q-3D-CT) was used as a reference standard for true articular involvement (mm(2)) of posterior malleolar fractures. One-hundred Orthopaedic Trauma surgeons were willing to review 31 trimalleolar ankle fractures to estimate size of posterior malleolus and answer: (1) what is the involved articular surface of the posterior malleolar fracture as a percentage of the tibial plafond? and (2) would you fix the posterior malleolus?

RESULTS

The average posterior malleolar fragment involved 13.5% (SD 10.8) of the tibial plafond articular surface, as quantified using Q-3D-CT. The average involvement of articular surface of the posterior malleolar fragment, as estimated by 100 observers on plain radiographs was 24.4% (SD 10.0). The factor 1.8 overestimation of articular involvement was statistically significant (p<0.001). Diagnostic accuracy of measurements on plain lateral radiographs was 22%. Interobserver agreement (ICC) was 0.61. Agreement on operative fixation, showed an ICC of 0.54 (Haraguchi type I=0.76, Haraguchi type II=0.40, Haraguchi type III=0.25).

CONCLUSIONS

Diagnostic accuracy of measurements on plain lateral radiographs to assess articular involvement of posterior malleolar fractures is poor. There is a tendency to misjudge posteromedial involvement (Haraguchi type II).