A Smaller Tibiotalar Sector Is a Risk Factor for Recurrent Anterolateral Ankle Instability after a Modified Broström-Gould Procedure

BACKGROUND

Several demographic and clinical risk factors for recurrent ankle instability have been described. The main objective of this study was to investigate the potential influence of morphologic characteristics of the ankle joint on the occurrence of recurrent instability and the functional outcomes following a modified Broström-Gould procedure for chronic lateral ankle instability.

METHODS

Fifty-eight ankles from 58 patients (28 males and 30 females) undergoing a modified Broström-Gould procedure for chronic lateral ankle instability between January 2014 and July 2021 were available for clinical and radiological evaluation. Based on the preoperative radiographs, the following radiographic parameters were measured: talar width (TW), tibial anterior surface (TAS) angle, talar height (TH), talar radius (TR), tibiotalar sector (TTS), and tibial lateral surface (TLS) angle. The history of recurrent ankle instability and the functional outcome using the Karlsson Score were assessed after a minimum follow-up of 2 years.

RESULTS

Recurrent ankle instability was reported in 14 patients (24%). The TTS was significantly lower in patients with recurrent ankle instability (69.8 degrees vs 79.3 degrees) (P < .00001). The multivariate logistic regression model confirmed the TTS as an independent risk factor for recurrent ankle instability (OR = 1.64) (P = .003). The receiver operating characteristic curve analysis revealed that patients with a TTS lower than 72 degrees (=low-TTS group) had an 82-fold increased risk for recurrent ankle instability (P = .001). The low-TTS group showed a significantly higher rate of recurrent instability (58% vs 8%; P = .0001) and a significantly lower Karlsson score (65 points vs 85 points; P < .00001).

CONCLUSION

A smaller TTS was found to be an independent risk factor for recurrent ankle instability and led to poorer functional outcomes after a modified Broström-Gould procedure.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

[Impact of the COVID-19 pandemic on the care of major trauma patients: analysis from the TraumaRegister DGU®]

BACKGROUND

The treatment of major trauma patients requires intensive care capacity, which is a critical resource particularly during the coronavirus disease 2019 (COVID-19) pandemic. Therefore, the aim of this study was to analyze the impact on major trauma care considering the intensive care treatment of COVID-19 positive patients.

METHODS

Demographic, prehospital, and intensive care treatment data from the TraumaRegister DGU® of the German Trauma Society (DGU) in 2019 and 2020 were analyzed. Only major trauma patients from the state of Bavaria were included. Inpatient treatment data of COVID-19 patients in Bavaria in 2020 were obtained using IVENA eHealth.

RESULTS

In total, 8307 major trauma patients were treated in the state of Bavaria in the time period investigated. The number of patients in 2020 (n = 4032) compared to 2019 (n = 4275) was not significantly decreased (p = 0.4). Regarding COVID-19 case numbers, maximum values were reached in the months of April and December with more than 800 intensive care unit (ICU) patients per day. In the critical period (> 100 patients with COVID-19 on ICU), a prolonged rescue time was evident (64.8 ± 32.5 vs. 67.4 ± 30.6 min; p = 0.003). The length of stay and ICU treatment of major trauma patients were not negatively affected by the COVID-19 pandemic.

CONCLUSION

The intensive medical care of major trauma patients could be ensured during the high-incidence phases of the COVID-19 pandemic. The prolonged prehospital rescue times show possible optimization potential of the horizontal integration of prehospital and hospital.

The coronal alignment differs between two-dimensional weight-bearing and three-dimensional nonweight bearing planning in total knee arthroplasty

Purpose

The goal of this study is (1) to assess differences between two-dimensional (2D) weight-bearing (WB) and three-dimensional (3D) nonweight-bearing (NWB) planning in total knee arthroplasty (TKA) and (2) to identify factors that influence intermodal differences.

Methods

Retrospective single-centre analysis of patients planned for a TKA with patient-specific instruments (PSI). Preoperative WB long-leg radiographs and NWB computed tomography were analysed and following radiographic parameters included: hip-knee-ankle angle (HKA) (+varus/-valgus), joint line convergence angle (JLCA), femorotibial subluxation and bony defect classified according to Anderson. Preoperative range of motion was also considered as possible covariate. Demographic factors included age, sex, and body mass index.

Results

A total of 352 knees of 323 patients (66% females) with a mean age of 66 ± 9.7 years were analysed. The HKA differed significantly between 2D and 3D planning modalities; varus knees (n = 231): 9.9° ± 5.1° vs. 6.7° ± 4°, p < 0.001; valgus knees (n = 121): -8.2° ± 6° vs. -5.5° ± 4.4°, p < 0.001. In varus knees, HKA (β = 0.38; p < 0.0001) and JLCA (β = 0.14; p = 0.03) were associated with increasing difference between 2D/3D HKA. For valgus knees, HKA (β = -0.6; p < 0.0001), JLCA (β = -0.3; p = 0.0001) and lateral distal femoral angle (β = -0.28; p = 0.03) showed a significant influence on the mean absolute difference.

Conclusion

The coronal alignment in preoperative 3D model for PSI-TKA significantly differed from 2D WB state and the difference between modalities correlated with the extent of varus/valgus deformity. In the vast majority of cases, the 3D NWB approach significantly underestimated the preoperative deformity, which needs to be considered to achieve the planned correction when using PSI in TKA.

Level of Evidence

Level III.

[Surgical treatment of intra-articular calcaneus fractures with plate osteosynthesis via the sinus tarsi approach]

OBJECTIVE

Surgical treatment of intra-articular calcaneus fractures via a minimally invasive approach.

INDICATIONS

Intra-articular dislocated calcaneus fractures.

CONTRAINDICATIONS

Fracture older than 14 days; poor soft tissue quality in the surgical area.

SURGICAL TECHNIQUE

Patient in lateral position. Identifying the anatomic landmarks. Incision (3-5 cm) from the tip of the fibula to metatarsal IV. Preparation through the subcutis. Retraction of the peroneal tendons. Preparation of the lateral calcaneal wall and later plate position via raspatory. Placement of a Schanz screw in the calcaneal tuberosity from lateral or posterior as a reduction aid for restoring of the calcaneal length and reduction of the hindfoot varus. Reduction of the sustentaculum fragment with the help of fluoroscopy from lateral. Elevation of the subtalar articular surface. Positioning of the calcaneal plate and fixation of the sustentaculum fragment by placing a cannulated screw through the long hole. Afterwards, definite internal fixation of the reduction with locking screws. Completion of the operation with final X‑rays and, if available, an intraoperative computed tomography. Wound closure with closing of the peroneal sheath.

POSTOPERATIVE MANAGEMENT

Lower leg-foot orthoses. Mobilization with partial weight-bearing of the injured foot with 15 kg for 6-8 weeks; subsequently increased load bearing.

RESULTS

Due to the smaller incision and the associated lower soft tissue trauma, the risk of wound healing complications can be reduced. Radiographic and functional outcomes are comparable to the outcomes of calcaneal fractures treated via the extended lateral approach.

Treatment strategies for complex ankle fractures-current developments summarized in a narrative review

Background and Objective

Ankle fractures occur frequently in patients throughout all ages. Due to the many pitfalls associated with their treatment, complex ankle and especially tibial pilon fractures remain a challenge for surgeons. As there is still need for improvement in treating complex ankle fractures and treatment options are steadily increasing this review aims to summarize current practice and aims to highlight current developments by reviewing the literature.

Methods

We conducted a thorough search of PubMed database in December 2022 to identify relevant articles on complex ankle and tibial pilon fractures. Articles in English and German were included in this study.

Key Contents and Findings

Complication rates, especially wound infection are still high, emphasizing the need for careful preoperative planning. Soft tissue management is crucial to reduce complication rates and will often dictate the treatment plan utilized. Open reduction and internal fixation (ORIF) remains the treatment of choice. Nevertheless, in select cases alternative methods such as external fixation, tibiotalocalcaneal nailing or conservative treatment need to be considered as well. Furthermore, additional treatment options such as arthroscopically assisted surgery might help to improve functional outcome after complex ankle fractures. The incidence of complex ankle fractures in geriatric patients keeps rising with our aging population. This group of patients demands particular care and further high-quality studies are needed to warrant best results.

Conclusions

However, more randomized controlled trials are need in order to enhance evidence of newly developed treatment options.

Sprain of the Medial Ankle Ligament Complex

Injuries of the medial ankle ligament complex (MALC; deltoid and spring ligament) are more common following ankle sprains than expected, especially in eversion-external rotation mechanisms. Often these injuries are associated with concomitant osteochondral lesions, syndesmotic lesions, or fractures of the ankle joint. The clinical assessment of the medial ankle instability together with a conventional radiological and MR imaging is the basis for the definition of the diagnosis and therefore the optimal treatment. This review aims to provide an overview as well as a basis to successfully manage MALC sprains.

Use of Distal Tibial Cortical Bone Thickness and FRAX Score for Further Treatment Planning in Patients with Trimalleolar Ankle Fractures

Trimalleolar ankle fractures show a bimodal age distribution, affecting younger men and older women. Postmenopausal women often exhibit low bone mineral density, which contributes to a higher prevalence of osteoporotic-related fractures. The primary goal of this study was to analyse the association of patient characteristics with the cortical bone thickness of the distal tibia (CBTT) in trimalleolar ankle fractures.

METHODS

A total of 193 patients with a trimalleolar ankle fracture treated between 2011 and 2020 were included. Patient registries were reviewed regarding demographics, mechanism, and type of injury. The CBTT was assessed in radiographs and CT images. The FRAX score was calculated to estimate the probability for an osteoporotic fracture. A multivariable regression model was calculated to identify independent variables affecting the cortical bone thickness of the distal tibia.

RESULTS

Patients older than 55 years were 4.22 (95% CI: 2.12; 8.38) times more likely to be female. In the multivariable regression analysis, female sex (β -0.508, 95% CI: -0.739; -0.278, p < 0.001) and a higher age (β -0.009, 95% CI: -0.149; -0.003, p = 0.002) were independent variables associated with a lower CBTT. Patients with a CBTT < 3.5 mm had a higher 10-year probability for a major osteoporotic fracture (12% vs. 7.75%; p = 0.001).

CONCLUSIONS

The assessment of the peripheral bone quality in routine computed tomography demonstrated that higher age and female sex are significantly associated with reduced cortical bone thickness of the distal tibia. Patients with a lower CBTT showed a higher probability for a subsequent osteoporotic fracture. In female patients with reduced distal tibial bone quality and associated risk factors, an osteoporosis assessment should be evaluated.

[Postprimary early elective total arthroplasty in severe ankle fractures]

Treatment of the ankle joint with total ankle arthroplasty (TAA) is an established and safe surgical treatment for osteoarthritis of the ankle. Modern implants have low revision rates and are superior to ankle arthrodesis in terms of patient-reported outcomes. The importance of primary TAA treatment of ankle fractures is unclear. There are currently no studies in the literature on this topic. In view of the increasing number of cases of unstable ankle fractures, especially in older patients and with increasing functional demands also in old age, it is important to consider TAA in the management of these fractures in the future. Clinical studies are necessary to evaluate the treatment of ankle fractures using TAA.

Clinical and Radiological Outcome of Vancouver B2 Fracture Treated With Open Reduction and Internal Fixation. A Multicenter Cohort Analysis

OBJECTIVES

To determine whether open reduction and internal fixation (ORIF) of periprosthetic Vancouver B2 fractures can lead to successful fracture healing in selected patients, when attention is given to the surgical exposure and the creation of a balanced extramedullary construct.

DESIGN

Retrospective.

SETTING

Two Level-1 trauma centers in Germany and United Kingdom.

METHODS

Patients with a B2 fracture receiving solely ORIF using a polyaxial locking plate were included for analysis. Patients with other fracture types, or treated with other methods, or with follow-up less than 12 months were excluded. Clinical characteristics, including the Charlson index, the American Society for Anesthesiologists score, and their preinjury functional levels, were recorded. Main outcome measures were 1-year mortality, revision rate, and radiological healing according to the Beals-Tower criteria.

RESULTS

A total of 32 patients (mean age ,79 ± 12 years) were enrolled. Six patients died within the first year (1-year mortality: 19%), and 5 were unavailable for follow-up studies. The remaining 21 patients had a mean follow-up of 30 months. Of 21, 20 had an excellent/good result using the criteria of Beals-Tower. One patient required revision surgery due to loosening and secondary subsidence of the stem.

CONCLUSION

ORIF can be offered to selected patients suffering from B2 fractures, especially if their functional demand is limited, and perioperative risk high for revision arthroplasty. In this challenging cohort of patients, ORIF was a safe and effective therapeutic option.

LEVEL OF EVIDENCE

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

[Decline in work and commuting injuries during the first lockdown in the SARS-CoV-2 pandemic : Comparison to the time period 2015-2019]

BACKGROUND

Measures such as restrictions on personal contact and going out were taken to reduce SARS-CoV‑2 infection numbers, ultimately resulting in the first lockdown. This was intended to create capacity in the healthcare system to manage the pandemic.

AIM OF THE WORK

To analyze whether the number of work and commuting injuries decreased during the lockdown compared to the years 2015-2019.

MATERIAL AND METHODS

All work and commuting accidents treated at the Klinikum rechts der Isar and the Berufsgenossenschaftliche Unfallklinik Murnau during the observational period 16 March-4 May 2020 were retrospectively compared with the figures from the same observation period in the years 2015-2019. The data on case numbers according to the transit physician procedure (DAV) were further broken down into cases of the injury type procedure (VAV) and severe injury type procedure (SAV) according to the injury type index of the German Social Accident Insurance (DGUV). In addition, the collected data were compared with data from the Federal Statistical Office on the numbers of traffic accidents and traffic fatalities.

RESULTS

A total of 4313 cases were considered. In 2020, the number of work and commuting accidents decreased by 31% compared to the observation period 2015-2019. VAV cases were decreased by 26% in 2020. SAV cases decreased by 5% in 2020. Road traffic accidents decreased by 17% in thre first four months in 2020 compared to the first four months in 2019. Traffic fatalities decreased by 11%.

DISCUSSION

There was a 31% decrease in work and commuting accidents. This contributed to resource reallocation in the context of the pandemic. Nevertheless, almost constant numbers of severely injured patients and accidental deaths occurred, which shows the relevance of trauma surgery structures especially in times of crisis and makes it indispensable to include them in the calculation of intensive care resources.

Evaluation of ankle fracture classification systems in 193 trimalleolar ankle fractures

Purpose

Different classification systems have been developed for ankle fractures. In recent years, the posterior malleolus has gained in importance and led to computed tomography (CT)-based classification systems. The aim of the study was to analyse their reliability, fracture patterns and influence on treatment strategy.

Methods

Patients with a trimalleolar ankle fracture treated between 2011 and 2020 with preoperative radiographs and CT images were included. The blinded images were independently classified by three reviewers according to the AO/OTA, Herscovici, Bartoníček, Mason and Haraguchi classifications. The interobserver reliability was calculated by Fleiss' kappa (κ). CT images were analysed to determine the dimensions of the posterior malleolus fragments. Patient registries were reviewed regarding the treatment data.

Results

A total of 193 patients were included. The AO/OTA classification showed almost perfect inter- and intraobserver reliability (Fleiss’ κ = 0.86, 95% CI 0.82–0.90). Regarding the posterior malleolus, the Bartoníček classification demonstrated the highest reliability (Fleiss’ κ = 0.78, 95% CI 0.73–0.83). The Herscovici classification only reached moderate reliability for medial malleolus fractures (Fleiss' κ = 0.59, 95% CI 0.54–0.65). There was a trend towards direct fixation of the posterior malleolus in the last 3 years of the observation period (OR: 2.49, 95% CI 1.03–5.99).

Conclusion

In trimalleolar ankle fractures, the AO/OTA classification is a reliable system to characterize the type of fracture, but it fails to provide solid information about the posterior malleolus. Nowadays, treatment recommendations for trimalleolar ankle fractures focus on the configuration of the posterior malleolus; therefore, the results of this study advocate the use of the Bartoníček classification as a reliable tool to guide treatment.

Management of Pilon Fractures-Current Concepts

Tibial pilon fractures were first described by Étienne Destot in 1911. He used the French word “pilon” (i.e., pestle), to describe the mechanical function of the distal tibia in the ankle joint. This term has further been used to portray the mechanism involved in tibial pilon fractures in which the distal tibia acts as a pestle with heavy axial forces over the talus basically causing the tibia to burst. Many different classification systems exist so far, with the AO Classification being the most commonly used classification in the clinical setting. Especially Type C fractures are extremely difficult to manage as the high energy involved in developing this type of injury frequently damages the soft tissue surrounding the fracture zone severely. Therefore, long -term outcome is often poor and correct initial management crucial. In the early years of this century treatment has evolved to a two–staged protocol, which nowadays is the gold standard of care. Additional methods of treating the soft tissue envelope are currently being investigated and have shown promising results for the future. The aim of this review is therefore to summarize protocols in managing these difficult fractures, review the literature on recent developments and therefore give surgeons a better understanding and ability to handle tibial pilon fractures.

Functional outcome of 103 fractures of the proximal fifth metatarsal bone

Background

Metatarsal fractures are common skeletal injuries of the lower extremity in adults. The majority involves the proximal fifth metatarsal bone. In the current literature, there still exists controversy regarding treatment recommendations for the different fracture entities.

Methods

All patients suffering from single fractures to the proximal fifth metatarsal bone between 2003 and 2015 were enrolled in this retrospective analysis. Only patients with a minimum follow-up of 12 months were included. The fractures were classified according to Lawrence and Botte (L&B). Data were collected via patient registry, radiographs and a standardized questionnaire (Foot and Ankle Outcome Score = FOAS). For outcome analysis, the nonparametric Mann–Whitney U test was performed and Spearman’s rank correlation coefficient calculated.

Results

In total, the functional outcomes of 103 patients suffering from fractures to the proximal fifth metatarsal bone were analyzed. L&B type I fractures (n = 13) had a FAOS score of 91 ± 23, L&B type II (n = 67) presented a score of 91 ± 15 and L&B type III (n = 23) a score of 93 ± 11. Surgically treated patients with an L&B type II fracture had no statistically significant better functional outcome in comparison to conservative management (p = 0.89). Operatively treated L&B type III fractures tended to have a better functional score (p = 0.16). The follow-up time was 58 (min: 15; max: 164) months.

Conclusions

Overall, the functional outcome following fractures to the proximal fifth metatarsal bone is satisfactory. Conservatively treated L&B type II fractures showed an equivalent functional outcome compared to surgical management. Patients with an L&B type III fracture mainly were treated surgically, but difference in FAOS score did not reach level of significance.

Revision rate is higher in patients with periprosthetic femur fractures following revision arthroplasty in comparison with ORIF following our algorithm: a two-center 1 analysis of 129 patients

Purpose

Effective therapy of periprosthetic femur fractures of the hip (PPF) are challenging due to patients’ frailty and complexity of fracture patterns. The aim of this cohort study was to analyze the radiological and functional outcome following PPF.

Methods

A retrospective, multicenter study in the period 2009–2019 of patients with PPF at two level I trauma centers in Germany was performed. PPF were classified according to the Vancouver classification system. Demographic data, American Society of Anesthesiologists (ASA) classification, type of surgery, complications, and reoperation rate were obtained from patient records. The functional outcome was assessed by the modified Harris-Hip Score (mHHS), general health using the EQ-5D, and radiological outcome by Beals & Tower (B&T) criteria.

Results

A total of 129 patients with a mean age of 79 years (range 43–102) were included. 70% of all patients were female and 68% of the patients had an ASA score ≥ 3. 20 patients suffered from a Vancouver A, 90 from a Vancouver B and 19 from a Vancouver C fracture. 14% of the patients died within the first 2 years after surgery. The reoperation rate after open reduction and internal fixation (ORIF) (n = 60) was 8% and after revision arthroplasty (RA) (n = 47) 30% (OR 3.4, 95% CI [1.21–10.2]). Mean mHHS (n = 32) was 53 ± 19.4 and EQ-VAS was 50 ± 24.6. According to B&T criteria, 82% of patients treated with ORIF (n = 17) and 62% after RA (n = 13) showed an excellent outcome.

Conclusion

Patients with a PPF of the hip are elderly and at increased operative risk. In cases with a stable prosthesis, ORIF provides good radiological outcome with low reoperation rates. In case of RA, the risk for revision surgery is higher.

Excellent clinical and radiological outcome following locking compression plate fixation of displaced medial clavicle fractures

BACKGROUND

Treatment of medial clavicle fractures is still controversially discussed in the community of upper extremity surgeons. An increasing number of symptomatic non-unions following conservative treatment of displaced fractures led to the development of various surgical approaches. Aim of this study was to evaluate the clinical and radiological outcome following operative treatment of displaced medial end clavicle fractures.

METHODS

Patients who presented with a displaced fracture of the medial clavicle between September 2012 and December 2019 were retrospectively enrolled in this study. All patients were operatively treated with open reduction and internal fixation (ORIF) using an anatomically precontoured locking compression plate (LCP) originally designed for the lateral clavicle (Synthes®, Umkirch, Germany). Functional outcome was recorded using the American Shoulder and Elbow Surgeons (ASES) Score, the Munich Shoulder Questionnaire (MSQ), Shoulder Pain and Disability Index (SPADI) and Constant Score.

RESULTS

Overall 18 patients with a mean age of 54.5 ± 23.5 years suffering from a displaced fracture of the medial clavicle were identified. The mean follow-up was 40.9 ± 26.2 months. The mean ASES accounted for 88.3 ± 20.8 points, the mean MSQ was 83.1 ± 21.7 points, the mean SPADI was 85.6 ± 22.5 and a mean normative age- and sex-specific Constant Score of 77.5 ± 19.1 points resulted. No minor or major complications were observed. Radiologic fracture consolidation was achieved in all patients after a mean of 6.4 months.

CONCLUSION

Surgical treatment of displaced medial clavicle fractures using an anatomically precontoured locking plate originally designed for the lateral clavicle led to very good to excellent clinical and functional results.

TRIAL REGISTRATION

No: DRKS00024813 , retrospectively registered 19.03.2021 ( www.drks.de ).

[Operation preparation in trauma surgery]

The success of a surgical procedure is significantly influenced by several critical factors. The safety of the patient is the primary goal. To this end, the term surgical preparation covers a number of procedures aiming to ensure the safety for the patient and a successful surgical intervention: verifying the indications, planning the intervention, identification of potential harmful factors, risks and countermeasures, patient education and documentation. Trauma surgery poses a particular challenge to preoperative preparation, especially due to urgent surgical interventions. Here, a standardized and evidence-based preoperative evaluation ensures a successful treatment of the patient.

[Analysis of 6851 foot and ankle injuries from 2010-2017 in an emergency department]

Hintergrund

Sprunggelenk- und Fußverletzungen gehören zu den häufigsten Krankheitsbildern in der Traumatologie. Ziel dieser Studie war es, die demografischen Veränderungen von Patienten mit Fuß- und Sprunggelenkverletzungen, das zeitliche Auftreten und die Entwicklung über die Jahre in einer Notaufnahme zu untersuchen.

Material und Methoden

Retrospektive Datenauswertung von Patienten, welche aufgrund einer Fuß- und Sprunggelenkverletzung in der Notaufnahme im Zeitraum von 2010 bis 2017 behandelt wurden. Die Patienten wurden mittels ICD-Codes identifiziert und die demografischen Veränderungen, das zeitliche Auftreten und die Entwicklung über die Jahre analysiert. Mittels Quantil-Quantil-Diagramm wurden kontinuierliche Variablen auf Normalverteilung getestet und, falls zutreffend, mittels t‑Test oder nichtparametrischem Mann-Whitney-U-Test auf Signifikanz überprüft.

Ergebnisse

Insgesamt wurden 6581 Fuß- und Sprunggelenkverletzungen in die Analyse eingeschlossen. Das mittlere Alter von Patienten mit einer Fußfraktur war 39 ± 17,4 Jahre und mit einer Sprunggelenkfraktur 47 ± 19,2 Jahre (p < 0,001). Ligamentäre Verletzungen des Sprunggelenks traten insbesondere bei jüngeren Patienten in den Sommermonaten auf. Die Altersverteilung bei Sprunggelenkfrakturen zeigte für Männer einen Häufigkeitsgipfel zwischen dem 30. und 39. Lebensjahr und bei Frauen ein vermehrtes Auftreten ab dem 50. Lebensjahr. In der Altersgruppe zwischen 65 und 75 Jahren stellten Trimalleolarfrakturen die zweithäufigste Sprunggelenkfraktur dar. Frakturen des Fußes betrafen am häufigsten Patienten im Alter von 20 bis 29 Jahren, wobei bei Frauen ein 2. Häufigkeitsgipfel zwischen dem 50. und 59. Lebensjahr zu beobachten war.

Schlussfolgerung

Ligamentäre Verletzungen des Sprunggelenks sind häufige Krankheitsbilder in der Notaufnahme und betreffen v. a. jüngere Patienten. Sprunggelenkfrakturen zeigten für Frauen eine bimodale Altersverteilung, und insbesondere Bi- und Trimalleolarfrakturen waren vermehrt bei Frauen ab dem 65. Lebensjahr zu beobachten. Aufgrund der erhöhten Prävalenz von Fuß- und Sprunggelenkfrakturen bei älteren Frauen sollte in diesem Patientenkollektiv eine weitere Osteoporoseabklärung veranlasst werden.

Current management of trimalleolar ankle fractures

A trimalleolar ankle fracture is considered unstable and treatment is generally performed operatively. Computed tomography is important for the operative planning by providing an elaborated view of the posterior malleolus.

Trimalleolar ankle fractures have a rising incidence in the last decade with up to 40 per 100,000 people per year. With a growing number of elderly patients, trimalleolar ankle injuries will become more relevant in the form of fragility fractures, posing a particular challenge for trauma surgeons.

In patients with osteoporotic trimalleolar ankle fractures and relevant concomitant conditions, further evidence is awaited to specify indications for open reduction and internal fixation or primary transfixation of the ankle joint.

In younger, more demanding patients, arthroscopic-assisted surgery might improve the outcome, but future research is required to identify patients who will benefit from assisted surgical care.

This review considers current scientific findings regarding all three malleoli to understand the complexity of trimalleolar ankle injuries and provide the reader with an overview of treatment strategies and research, as well as future perspectives.

Cite this article: EFORT Open Rev 2021;6:692-703. DOI: 10.1302/2058-5241.6.200138

Patient reported outcome of 33 operatively treated talar fractures

BACKGROUND

Management of talar fractures remains to be one of the most challenging aspects in trauma surgery. Unfortunately, the evidence regarding the correct treatment of these fractures is mainly based on retrospective case series, while studies assessing the patient-reported outcome are rare. Therefore, the aim of this trial was to analyze the patient reported outcome in context of trauma mechanism and concomitant injuries following operative treatment of talar fractures.

METHODS

A retrospective outcome study of patients with operatively treated talar fractures between 2003 and 2015 was conducted. The fractures were classified according to AO-/Hawkins classification system and to the Marti-Weber classification. Data was collected via patient registry, radiographs and a validated patient-reported outcome measure (PROM) for foot and ankle pathologies (Foot and Ankle Outcome Score = FOAS). An analysis regarding the functional outcome, concomitant injury and timing of surgery using the nonparametric Mann-Whitney U test and Spearman`s rank correlation was performed.

RESULTS

In total the functional outcome of 32 patients suffering from fractures to the talus were analyzed. The median age of the study cohort was 35±12.2 years, including 9 female (28 %) and 23 male (72 %) patients. The median FAOS score was 72±22.7 (range 13-94). Patients with an isolated talar fracture had an FAOS of 87±20 and with concomitant injury a score of 60±23.4 (p = 0.016). Patients with a closed talar fracture without emergency operation due to dislocation or polytrauma, showed no correlation between timing of surgery and FAOS (r= -0.17, p = 0.43). 10 % of the patients developed an avascular necrosis and 25 % showed signs of a posttraumatic arthritis. The follow-up time was 41 months (range: 16-145).

CONCLUSIONS

Talar fractures were typically caused by high-energy trauma often associated with additional injuries of the lower extremity. The majority of the patients showed a fair to poor functional long-term outcome. Concomitant injuries of the lower extremity led to a lower FAOS. In closed talar fractures without the necessity of an emergency surgical intervention, time to surgery did not influence the patient reported outcome. Relating to the presented data, delayed surgery after soft tissue consolidation was not associated with a higher risk of developing an avascular necrosis.

Patient-Reported Outcome Following Operative and Conservative Treatment of Calcaneal Fractures: A Retrospective Analysis of 79 Patients at Short- to Midterm Follow-Up

Background: Fractures of the calcaneus are severe injuries of the hindfoot, mostly resulting from high-energy axial loads, which still present enormous challenges to modern trauma surgery. Possible variables influencing the outcome are the type of fracture, age, and quality of fracture reduction. These might also be factors affecting the self-reported patient outcome, but large studies are still lacking. Therefore, the aim of this study was to analyze the patient-reported outcome of calcaneal fractures following operative and conservative treatment.

Methods: All patients suffering from calcaneal fractures between 2002 and 2015 were enrolled in this retrospective analysis. The calcaneal fractures were classified according to Sanders and the AO classification system. For further analysis, two groups were formed: group I involved complex intra-articular fractures defined by the involvement of the posterior calcaneal facet, while group II consisted of extra-articular and process calcaneal fractures. Data were collected via the patient registry, radiographs, and a standardized questionnaire (Foot and Ankle Outcome Score, FAOS). For outcome analysis, non-parametric Mann–Whitney U-test was performed, and Spearman's rank correlation coefficient was calculated.

Results: In total, the functional outcome of 79 patients with calcaneal fractures was analyzed. In group 1 (n = 43), the mean FAOS score was 65.5 ± 18.9. The surgically treated patients with a Sanders type II calcaneal fracture had a mean FAOS score of 72.9 ± 17.2, type III fractures had 65.6 ± 20.8, and type IV had 61.1 ± 19 (p = 0.15). The reoperation rate was 22%, most frequently caused by wound complications (10%). The mean follow-up time was 64.5 ± 44 months. The mean FAOS score of group 2 (n = 36) was 75.2 ± 18.4, and 83% of the patients (=30) were managed conservatively. Only one out of six operatively managed patients had a reoperation due to regular implant removal. The mean follow-up time was 31 ± 25.9 months.

Conclusion: Intra-articular calcaneal fractures are severe injuries of the hindfoot leading to a fair to poor functional outcome in the majority of the patients. Complications regarding wound healing are the most common causes for revisional surgery. Extra-articular calcaneal fractures are a heterogenous entity commonly managed non-operatively. Overall, they show a better functional outcome in comparison to intra-articular calcaneal fractures.

[Functional outcome of 111 metatarsal fractures following conservative in comparison to operative treatment]

Hintergrund

Mittelfußfrakturen gehören zu einer der häufigsten Verletzungen des Fußes und treten v. a. bei Patienten zwischen dem 40. und 50. Lebensjahr auf. Insbesondere die Verletzung mehrerer Mittelfußknochen kann zu bleibenden Einschränkungen führen, und daher war das Ziel dieser Studie, das funktionelle Outcome von Mittelfußfrakturen mittels eines validierten selbstberichteten patientenbasierten Ergebnisfragebogens zu untersuchen.

Material und Methoden

Im Zeitraum von 2003 bis 2015 wurden alle Patienten mit einer Mittelfußfraktur mit konservativer sowie operativer Behandlung in diese retrospektive Kohortenstudie eingeschlossen. Es wurden demografische Daten, Art der Fraktur (AO-Klassifikation), Behandlung, Reoperationsrate sowie das funktionelle Ergebnis mittels Foot and Ankle Outcome Score (FAOS) erfasst. Der Mann-Whitney-U-Test und Exakte Fisher-Test wurden bei der statistischen Analyse eingesetzt.

Ergebnisse

Insgesamt wurden in diese Studie 111 Patienten mit 81 isolierten und 30 multiplen Mittelfußfrakturen eingeschlossen. Das Durchschnittsalter der Patienten war 45 ± 15,2 Jahre mit insgesamt 48 Männern (43 %) und 63 Frauen (57 %). Patienten mit isolierter Mittelfußfraktur hatten einen FAOS von 88 ± 17,1. Die Patienten mit multiplen Mittelfußfrakturen erzielten einen FAOS von 78 ± 17,7 (p = 0,046). In der Gruppe der isolierten Mittelfußfrakturen wurden 43 Patienten (53 %) operativ behandelt. Hiervon zeigten 36 Patienten eine C‑Fraktur (84 %). In der Gruppe der multiplen Mittelfußfrakturen wurden 16 Patienten (53 %) operativ behandelt.

Diskussion

Das funktionelle Outcome nach isolierten Mittelfußfrakturen ist sowohl nach operativer als auch konservativer Therapie gut bis sehr gut. Einfache Frakturen lassen sich erfolgreich konservativ und komplexe, mehrfragmentäre Frakturen operativ behandeln. Bei Frakturen von mehr als einem Mittelfußknochen ist das Ergebnis signifikant schlechter, und es bleiben vom Patienten berichtete Einschränkungen zurück.

[Prognostic implications of stone heart syndrome in cardiac arrest]

Der Begriff Stone heart ist definiert als systolische Kontraktur des Herzens und wird auch als kontraktiler Herzstillstand bezeichnet. Er wurde erstmals 1972 durch den US-amerikanischen Herzchirurgen Denton Cooley bei Patienten mit Bypass-Operation beschrieben. Das Stone heart ist meist Folge eines prolongierten Herz-Kreislauf-Stillstands, welcher zu einer Anoxie bzw. Hypoxie des Myokards führt. Es wird über 3 Traumapatienten berichtet, welche nach kardiopulmonaler Reanimation in der postmortalen Computertomographie (CT) ein Stone-heart-Phänomen zeigten.

Is early full weight bearing safe following locking plate ORIF of distal fibula fractures?

Background

In the modern western world appraisal of economical points such as treatment and disability after trauma present a financial burden. In this context open reduction internal fixation techniques allowing for early full weight bearing might not only improve the clinical outcome but also shorten the period of disability in working life. The aim of the study was to analyze whether ORIF of ankle fractures using either a standard semitubular plate or a new polyaxial locking plate system result in a better clinical outcome.

Methods

In this prospective study, all patients with distal fibula fractures (AO 44 B1.1, B1.2, B1.3), with indication for surgery were included. Patients were randomized to either the DePuy Synthes® one-third semitubular plate (Group I) or NEWCLIP TECHNICS, Active Ankle® polyaxial locking plate (Group II). Primary outcome parameter was function of the ankle joint, assessed by the Olerud and Molander ankle score, Foot and Ankle outcome score and Karlsson and Peterson Scoring System for Ankle function. Secondary outcome parameter were postoperative complications. Superficial wound infection, delayed wound healing, mechanically prominent implant, skin irritations were considered as minor and deep wound infection, material loosening, loss of reduction were regarded as major complications requiring revision surgery. Clinical and radiological follow-up were performed 6 and 12 weeks, 6 months and 1 year postoperatively.

Results

Fifty-two patients (31 W/21 M) with a mean age of 43 yrs. (range 22–64 yrs.) were enrolled. Seven patients (13.5%) were excluded, so that 45 patients were available for follow up. Twenty-five patients were treated with DePuy Synthes® one-third semitubular plate (55.6%; group I) while 20 patients received an anatomically preformed polyaxial locking plate (44.4%, group II). Four minor complications occurred in Group I (16%) compared to two minor complications in group II (10%). Significant better clinical results regarding OMAS (p < 0.02, < 0.04), KPSS (p < 0.04) and FAOS (p < 0.02, < 0.03) were observed 6 and 12 weeks after surgery in group II.

Conclusions

The results of the presented study demonstrate a significant better clinical functional outcome in the early postoperative follow-up in patients treated with a polyaxial locking plate. Furthermore, our data show that ORIF using polyaxial locking plates in combination with an early postoperative weight bearing presents a safe, stable treatment option for ankle fractures so that patients benefit especially in the early stages of recovery.

Trial registration

Registered 20 April 2020, retrospectively on ClinicalTrails.gov (NCT04370561).

Forced Centralized Allocation of Patients to Temporarily 'Closed' Emergency Departments

BACKGROUND

Because insufficient data are available, the overall number of patients treated in German emergency departments can only be estimated. It is evident, however, that case numbers have been rising steadily in recent years, and that a lack of capacity is now leading with increasing freuqency to forced centralized allocation of patients by the emergency medical services (EMS) to emergency departments that are, officially, temporarily "closed".

METHODS

Trends in patient allocation of this type in greater Munich, Germany, over the years 2013-2019 were analyzed for the first time on the basis of data from 904 997 cases treated by the emergency rescue services.

RESULTS

From 2014 to 2019, the number of forced centralized patient allocations rose approximately by a factor of nine, from 70 to 634 per 100 000 persons per year. In the same period, the overall number of cases treated by the emergency rescue services rose by 14.5%. Peak values for forced centralized allocations were reached in the first quarter of each calendar year (2015: 1579, 2017: 2435, 2018: 3161, 2019: 3990). Of all medical specialties, internal medicine was the most heavily affected (more than 59% of the total). Especially in the years 2017-2019, the free availability of internal medicine declined in hospitals participating in the common greater Munich reporting system.

CONCLUSION

The reasons for the sharp rise in forced centralized allocations are unclear. This observed trend seems likely to persist over the coming years, in view of the current staff shortage, the aging population, and diminishing hospital capacities. The relevant decision-makers must collaborate to create emergency plans that will prevent care bottlenecks so that patients will not be endangered.

Chronically Implanted Microelectrodes Cause c-fos Expression Along Their Trajectory

When designing electrodes and probes for brain–machine interfaces, one of the challenges faced involves minimizing the brain-tissue response, which would otherwise create an environment that is detrimental for the accurate functioning of such probes. Following the implantation process, the brain reacts with a sterile inflammation response and resulting astrocytic glial scar formation, potentially resulting in neuronal cell loss around the implantation site. Such alterations in the naïve brain tissue can hinder both the quality of neuronal recordings, and the efficacy of deep-brain stimulation. In this study, we chronically implanted a glass-supported polyimide microelectrode in the dorsolateral striatum of Sprague–Dawley rats. The effect of high-frequency stimulation (HFS) was investigated using c-fos immunoreactivity techniques. GFAP and ED1 immunohistochemistry were used to analyze the brain-tissue response. No changes in c-fos expression were found for either the acute or chronic stimulus groups; although a c-fos expression was found along the length of the implantation trajectory, following chronic implantation of our stiffened polyimide microelectrode. Furthermore, we also observed the formation of a glial scar around the microelectrode, with an accompanying low number of inflammation cells. Histological and statistical analysis of NeuN-positive cells did not demonstrate a pronounced “kill zone” with accompanying neuronal cell death around the implantation site, neither on the polymer side, nor on the glass side of the PI-glass probe.

Emergency room as primary point of access in the German healthcare system : Objective evaluation and interview of motivation for ER entrance of 235 ER patients in a German hospital

BACKGROUND

The importance of emergency rooms (ERs) as everyday healthcare suppliers is growing. Due to increasing patient flows, hospitals are forced to raise physicians' and caregivers' headcount continuously to meet the new demand of patients seeing the ER as primary point of contact in non-emergency situations. Patients from various cultural and educational backgrounds approach the ER for different reasons. Detailed understanding of these reasons and their roots is key to be able to offer guidance for patients as well as planning and staffing of hospitals in the future.

AIM

This study examines motivation for the entrance to the medical system via the ER in Germany via an anonymized patient survey. Evaluation in regard to socioeconomic and medical reasons is taken into account.

MATERIALS AND METHODS

Over the course of 210 h in the ER, a total of 235 patients were interviewed in the surgical emergency room of Klinikum rechts der Isar in the year 2016. Focus was set on standard cases to allow for facilitated comparability. Heavily injured patients were excluded from the study.

RESULTS

The main reasons for patients entering the ER were immediate help (45.9%) and treatment by a specialist (35.4%). Furthermore, the location/good accessibility (47.9%) and prior positive experience with the emergency room (20.7%) were decisive reasons for choosing the hospital over the outpatient sector. Analysis of demands of patients in relation to their migration background and their religious confession showed no significant difference between groups.

CONCLUSION

Younger patients tend to more often access the ER instead of an outpatient clinic or doctor in private practice. As a survey suits the less urgent patients, our research describes this population in detail. The need for better information of patients regarding treatment options becomes apparent. The study's outcomes aim to teach physicians as well as operators how to influence resource management in the healthcare system by meaningful information of patients. Further research may evaluate long-term results of information measures.