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Abstract
Successful outcomes in the surgical treatment of the fractured ankle require methods that respect the soft tissue envelope and establish a stable mortise for functional rehabilitation. Ankle fractures in patients with osteopenia and in diabetic patients with deranged bone remodeling constitute high-risk injuries that may result in catastrophic complications. These patients present unique care challenges and should not be approached in the same manner as their healthy counterparts. We present the principles of treatment in high-risk ankle fractures, operative treatment philosophy illustrating techniques frequently used at our institution, and a review of current literature.
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Affiliation(s)
- Craig E Krcal
- The CORE Institute, 18444 N 25th Avenue Suite 320, Phoenix, AZ 85023, USA; Kaiser San Francisco Bay Area Foot & Ankle Residency Program Alumni Class of 2023
| | - David R Collman
- Kaiser San Francisco Bay Area Foot & Ankle Residency Program; Department of Orthopedics, Podiatry, Injury, Sports Medicine; Kaiser Permanente San Francisco Medical Center, 450 6th Avenue, French Campus, 5th Floor, San Francisco, CA 94118, USA.
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2
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Graef F, Rühling M, Niemann M, Stöckle U, Gehlen T, Tsitsilonis S. Retrospective analysis of treatment strategies and clinical outcome of isolated talar dislocations. J Clin Orthop Trauma 2021; 23:101648. [PMID: 34745877 PMCID: PMC8548980 DOI: 10.1016/j.jcot.2021.101648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/26/2021] [Accepted: 10/12/2021] [Indexed: 12/16/2022] Open
Abstract
Talar dislocations are rare injuries of the foot and ankle and require quick and decisive diagnostic and therapeutic decisions. Evidence concerning the treatment and outcome of these injuries is sparse. The aim of this study was to analyze all talar dislocations of the last ten years treated in a large German level I trauma center in an effort to add to the experience on these injuries. METHODS All patients with a talar dislocation injury were retrospectively included. Medical reports, x-ray and computertomography scans were analyzed for the sex, age, trauma mechanism, and injury classifications as well as for the clinical outcome as measured by the Foot Function Index (FFI). RESULTS A total of 18 patients were included in this study: Luxatio pedis cum talo (n = 1), Luxatio tali totalis (n = 3), Luxatio pedis sub talo (n = 14). Analysis of the therapeutic algorithms revealed that only one patient was treated conservatively, the other 17 patients underwent operation. In most cases, stabilization was achieved using an external fixator and if necessary, the subtalar and talonavicular joints were temporarily stabilized using K-wires. The mean follow-up time was 4.25 years (2.05 SD) and the mean FFI-sum score 45.00 (42.26 SD). Two patients required subtalar fusion two years after the injury. CONCLUSION Isolated talar dislocations can have a good outcome and be effectively treated in the emergency setting by basic techniqes if neurovasular structures are not injured. Often, these injuries are associated with fractures of adjacent bones which then need complex reconstruction.
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Affiliation(s)
- Frank Graef
- Charité — Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany
| | - Marlene Rühling
- Charité — Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany
| | - Marcel Niemann
- Charité — Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany
| | - Ulrich Stöckle
- Charité — Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany
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3
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Weber CD, Hildebrand F, Lichte P. [Arthroscopically assisted transmalleolar internal fixation of a lateral osteochondral lesion of the talus]. Unfallchirurg 2021; 124:333-337. [PMID: 33599791 DOI: 10.1007/s00113-021-00958-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2021] [Indexed: 11/30/2022]
Abstract
Osteochondral lesions (OCL) of the talus can be caused by isolated or recurrent traumatic events. The established surgical treatment techniques are predominantly based on defect coverage by stimulation of fibrous cartilage or transplantation of osteochondral tissue or chondrocytes. An alternative is the preservation of an intact autochthonous hyaline cartilage surface with reconstruction of the subchondral lamella and the natural joint congruence. This anatomical technique can be used for selected acute and chronic OCL and can frequently be carried out arthroscopically. This article presents the indications, contraindications, advantages and targets as well as the planning and execution of arthroscopically assisted transmalleolar internal fixation of a lateral OCL of the talus.
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Affiliation(s)
- Christian David Weber
- Klinik für Unfall- und Wiederherstellungschirurgie, Universitätsklinikum der RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland.
| | - Frank Hildebrand
- Klinik für Unfall- und Wiederherstellungschirurgie, Universitätsklinikum der RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
| | - Philipp Lichte
- Klinik für Unfall- und Wiederherstellungschirurgie, Universitätsklinikum der RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
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Smith SE, Chang EY, Ha AS, Bartolotta RJ, Bucknor M, Chandra T, Chen KC, Gorbachova T, Khurana B, Klitzke AK, Lee KS, Mooar PA, Ross AB, Shih RD, Singer AD, Taljanovic MS, Thomas JM, Tynus KM, Kransdorf MJ. ACR Appropriateness Criteria® Acute Trauma to the Ankle. J Am Coll Radiol 2020; 17:S355-S366. [PMID: 33153549 DOI: 10.1016/j.jacr.2020.09.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 09/01/2020] [Indexed: 02/07/2023]
Abstract
Acute injuries to the ankle are frequently encountered in the setting of the emergency room, sport, and general practice. This ACR Appropriateness Criteria defines best practices for imaging evaluation for several variants of patients presenting with acute ankle trauma. The variants include scenarios when Ottawa Rules can be evaluated, when there are exclusionary criteria, when Ottawa Rules cannot be evaluated, as well as specific injuries. Clinical scenarios are followed by the imaging choices and their appropriateness with an accompanying narrative explanation to help physicians to order the most appropriate imaging test. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Stacy E Smith
- Brigham & Women's Hospital & Harvard Medical School, Boston, Massachusetts.
| | - Eric Y Chang
- Panel Chair, VA San Diego Healthcare System, San Diego, California
| | - Alice S Ha
- Panel Vice-Chair, University of Washington, Seattle, Washington
| | | | - Matthew Bucknor
- University of California San Francisco, San Francisco, California
| | | | - Karen C Chen
- VA San Diego Healthcare System, San Diego, California
| | | | | | - Alan K Klitzke
- Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Kenneth S Lee
- University of Wisconsin Hospital & Clinics, Madison, Wisconsin
| | - Pekka A Mooar
- Temple University Hospital, Philadelphia, Pennsylvania; American Academy of Orthopaedic Surgeons
| | - Andrew B Ross
- University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin
| | - Richard D Shih
- Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, American College of Emergency Physicians
| | - Adam D Singer
- Emory University School of Medicine, Atlanta, Georgia
| | | | - Jonelle M Thomas
- Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Katherine M Tynus
- Northwestern Memorial Hospital, Chicago, Illinois; American College of Physicians
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Szaro P, Geijer M, Solidakis N. Traumatic and non-traumatic bone marrow edema in ankle MRI: a pictorial essay. Insights Imaging 2020; 11:97. [PMID: 32804284 PMCID: PMC7431516 DOI: 10.1186/s13244-020-00900-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 07/21/2020] [Indexed: 01/16/2023] Open
Abstract
Bone marrow edema (BME) is one of the most common findings on magnetic resonance imaging (MRI) after an ankle injury but can be present even without a history of trauma. This article will provide a systematic overview of the most common disorders in the ankle and foot associated with BME. The presence of BME is an unspecific but sensitive sign of primary pathology and may act as a guide to correct and systematic interpretation of the MR examination. The distribution of BME allows for a determination of the trauma mechanism and a correct assessment of soft tissue injury. The BME pattern following an inversion injury involves the lateral malleolus, the medial part of the talar body, and the medial part of the distal tibia. In other cases, a consideration of the distribution of BME may indicate the mechanism of injury or impingement. Bone in direct contact with a tendon may lead to alterations in the bone marrow signal where BME may indicate tendinopathy or dynamic tendon dysfunction. Changed mechanical forces between bones in coalition may lead to BME. Degenerative changes or minor cartilage damage may lead to subchondral BME. Early avascular necrosis, inflammation, or stress fracture may lead to more diffuse BME; therefore, a detailed medical history is crucial for correct diagnosis. A systematic analysis of BME on MRI can help to determine the trauma mechanism and thus assess soft tissue injuries and help to differentiate between different etiologies of nontraumatic BME.
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Affiliation(s)
- Pawel Szaro
- Department of Musculoskeletal Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden. .,Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Mats Geijer
- Department of Musculoskeletal Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Nektarios Solidakis
- Department of Musculoskeletal Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden
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Ohliger E, Ohliger Iii J, Sultan A, Miniaci-Coxhead SL. Effectiveness of the saline load test in diagnosis of simulated traumatic ankle arthrotomies. Injury 2020; 51:1114-1117. [PMID: 32107007 DOI: 10.1016/j.injury.2020.02.087] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 02/16/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Limited studies have been conducted to determine the minimum amount and sensitivity of the saline load test of the ankle. Prior studies, only performed in arthroscopic models, have suggested a wide range of volumes necessary to confirm arthrotomy. The purpose of this study was to investigate the amount of fluid required and the sensitivity of the saline load test to identify an intra-articular arthrotomy of the ankle. Using cadavers without prior ankle trauma or surgeries we aim to assess volume needed to detect ankle arthrotomies at varying arthrotomy locations. We hypothesized that the volume needed would vary based on site of arthrotomy. METHODS Twenty thawed, fresh-frozen below knee cadavers were divided into four groups based on arthrotomy location. An ankle arthrotomy was made using a 4 mm trochar at the four standard ankle portal sites; anteromedial, anterolateral, posteromedial, and posterolateral. To confirm intra-articular location, a arthroscope was inserted for direct visualization of the ankle joint. An 18-gauge needle was then inserted into the ankle joint, and saline mixed with methylene blue was injected. During the injection, the known arthrotomy site was viewed for extravasation. Amount of saline required to diagnose arthrotomy was recorded. All injections were confirmed as intra-articular by demonstrating methylene blue staining of the anterior joint. RESULTS The saline volume required to achieve extravasation ranged from 3 mL to 11 mL. The mean saline volume required to achieve extravasation was 5.3 mL. A total of 8 mL was required to achieve 90% sensitivity, 10 mL for 95% sensitivity and 11 mL for 99% sensitivity. For the anterolateral, anteromedial, posteromedial, and posterolateral arthrotomy sites the mean saline volume needed to detect a traumatic arthrotomy was 5.2 mL, 6.2 mL, 5 mL, and 4.8 mL respectively. There was no statistically significant difference in volume needed to detect arthrotomies across all four locations (p = 0.69). CONCLUSION In this cadaveric model, an injection of 10 mL identified 95% of arthrotomies approximately 4 mm in size. No difference in volume needed to detect extravasation was found across all four arthrotomy locations. Prior studies performed in arthroscopic models with patients undergoing ankle arthroscopy may overestimate volume needed to detect arthrotomies. LEVEL OF EVIDENCE V.
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Affiliation(s)
- Erin Ohliger
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, United States.
| | - James Ohliger Iii
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, United States
| | - Assem Sultan
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, United States
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Abstract
Combined fractures of the talar body and the adjacent bones are rare. We present a case of a 35-year-old male with a complex foot and ankle trauma resulting in an unusual combined ipsilateral fracture of the anterolateral tibial plafond, talar body, and sustentaculum tali of the calcaneus. To the best of our knowledge, this particular combination of fractures has not yet been reported in the literature. The combination of talar body fracture with fractures of the adjacent bones was treated by a bilateral open reduction with anatomic reconstruction of the joint surfaces resulting in an excellent clinical outcome at 4-year followup.
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Affiliation(s)
- Henriette Bretschneider
- University Center for Orthopaedics and Traumatology, University Hospital Carl Gustav Carus at TU Dresden, Dresden, Germany
| | - Stefan Rammelt
- University Center for Orthopaedics and Traumatology, University Hospital Carl Gustav Carus at TU Dresden, Dresden, Germany,Address for correspondence: Prof. Stefan Rammelt, University Center for Orthopaedics and Traumatology, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstrasse 74, 01307 Dresden, Germany. E-mail:
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Ellenbogen AL, Rice AL, Vyas P. Retrospective comparison of the Low Risk Ankle Rules and the Ottawa Ankle Rules in a pediatric population. Am J Emerg Med 2017; 35:1262-1265. [PMID: 28363615 DOI: 10.1016/j.ajem.2017.03.058] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 03/18/2017] [Accepted: 03/19/2017] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND A recent multicenter prospective Canadian study presented prospective evidence supporting the Low Risk Ankle Rules (LRAR) as a means of reducing the number of ankle radiographs ordered for children presenting with an ankle injury while maintaining nearly 100% sensitivity. This is in contrast to a previous prospective study which showed that this rule yielded only 87% sensitivity. OBJECTIVE It is important to further investigate the LRAR and compare them with the already validated Ottawa Ankle Rules (OAR) to potentially curb healthcare costs and decrease unnecessary radiation exposure without compromising diagnostic accuracy. METHODS We conducted a retrospective chart review of 980 qualifying patients ages 12months to 18years presenting with ankle injury to a commonly staffed 310 bed children's hospital and auxiliary site pediatric emergency department. RESULTS There were 28 high-risk fractures identified. The Ottawa Ankle Rules had a sensitivity of 100% (95% CI 87.7-100), specificity of 33.1% (95% CI 30.1-36.2), and would have reduced the number of ankle radiographs ordered by 32.1%. The Low Risk Ankle Rules had a sensitivity of 85.7% (95% CI 85.7-96), specificity of 64.9% (95% CI 61.8-68), and would have reduced the number of ankle radiographs ordered by 63.1%. The latter rule missed 4 high-risk fractures. CONCLUSION The Low Risk Ankle Rules may not be sensitive enough for use in Pediatric Emergency Departments, while the Ottawa Ankle Rules again demonstrated 100% sensitivity. Further research on ways to implement the Ottawa Ankle Rules and maximize its ability to decrease wait times, healthcare costs, and improve patient satisfaction are needed.
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Affiliation(s)
- Amy L Ellenbogen
- Department of Radiology, George Washington University Hospital, Washington, DC 20037, United States.
| | - Amy L Rice
- Independent Consultant (Biostatistics), Chevy Chase, MD 20815, United States
| | - Pranav Vyas
- Department of Radiology, Children's National Medical Center, Washington, DC 20010, United States
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Leduc S, Nault ML, Rouleau DM, Hebert-Davies J. My Experience as a Foot and Ankle Trauma Surgeon in Montreal, Canada: What's Not in the Books. Foot Ankle Clin 2016; 21:297-334. [PMID: 27261808 DOI: 10.1016/j.fcl.2016.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Foot and ankle fractures are sometimes seen as routine and easy to treat. However, many fractures vary from typical patterns and require more complex management. Obtaining good outcomes in these situations can be challenging. Often, the difference between average and good results has to do with preoperative planning and good surgical technique. This article outlines numerous techniques and tricks that are not always mentioned in classic textbooks. It focuses on ankle, talus, calcaneus, and midfoot fractures, and discusses numerous techniques and aids to avoid potential problems that may be encountered intraoperatively.
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10
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Veltman ES, Halma JJ, de Gast A. Longterm outcome of 886 posterior malleolar fractures: A systematic review of the literature. Foot Ankle Surg 2016; 22:73-7. [PMID: 27301724 DOI: 10.1016/j.fas.2015.05.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Revised: 01/31/2015] [Accepted: 05/02/2015] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The objective of the present study was to review the current data on the long-term outcomes of posterior malleolar fractures, with special emphasis on the role of the type of treatment, surgical approach, and reduction and internal fixation. METHODS The search was limited to skeletally mature patients. Major databases were searched from 1978 to 2014 to identify studies relating to functional outcome, subjective outcome, and radiographic evaluation at least 2 years after either surgical or conservative treatment of posterior malleolar fractures. RESULTS Of 68 initially relevant studies, 19 met our inclusion criteria. A total of 886 fractures were identified in 885 patients. The mean sample size-weighted follow-up period was 3.7 years. Comparable results are achieved when comparing open reduction and internal fixation to conservative treatment for posterior malleolar fractures. DISCUSSION Current consensus suggests posterior malleolar fragments comprising of >25% of the distal tibial plafond as seen on a true lateral radiograph and fragments with more than 2mm dislocation require open reduction and internal fixation of the fragment. The current consensus on treatment of posterior malleolar fractures is neither supported nor disapproved by the available evidence.
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Affiliation(s)
- Ewout S Veltman
- Clinical Orthopedic Research Center Midden Nederland, Utrecht, The Netherlands.
| | - Jelle J Halma
- Department of Orthopedic Surgery, Diakonessenhuis Utrecht, The Netherlands
| | - Arthur de Gast
- Clinical Orthopedic Research Center Midden Nederland, Utrecht, The Netherlands; Department of Orthopedic Surgery, Diakonessenhuis Utrecht, The Netherlands
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Claessen FMAP, Meijer DT, van den Bekerom MPJ, Gevers Deynoot BDJ, Mallee WH, Doornberg JN, van Dijk CN. Reliability of classification for post-traumatic ankle osteoarthritis. Knee Surg Sports Traumatol Arthrosc 2016; 24:1332-7. [PMID: 26611896 PMCID: PMC4823329 DOI: 10.1007/s00167-015-3871-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 11/10/2015] [Indexed: 01/03/2023]
Abstract
PURPOSE The purpose of this study was to identify the most reliable classification system for clinical outcome studies to categorize post-traumatic-fracture-osteoarthritis. METHODS A total of 118 orthopaedic surgeons and residents-gathered in the Ankle Platform Study Collaborative Science of Variation Group-evaluated 128 anteroposterior and lateral radiographs of patients after a bi- or trimalleolar ankle fracture on a Web-based platform in order to rate post-traumatic osteoarthritis according to the classification systems coined by (1) van Dijk, (2) Kellgren, and (3) Takakura. Reliability was evaluated with the use of the Siegel and Castellan's multirater kappa measure. Differences between classification systems were compared using the two-sample Z-test. RESULTS Interobserver agreement of surgeons who participated in the survey was fair for the van Dijk osteoarthritis scale (k = 0.24), and poor for the Takakura (k = 0.19) and the Kellgren systems (k = 0.18) according to the categorical rating of Landis and Koch. This difference in one categorical rating was found to be significant (p < 0.001, CI 0.046-0.053) with the high numbers of observers and cases available. CONCLUSIONS This study documents fair interobserver agreement for the van Dijk osteoarthritis scale, and poor interobserver agreement for the Takakura and Kellgren osteoarthritis classification systems. Because of the low interobserver agreement for the van Dijk, Kellgren, and Takakura classification systems, those systems cannot be used for clinical decision-making. LEVEL OF EVIDENCE Development of diagnostic criteria on basis of consecutive patients, Level II.
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Affiliation(s)
- Femke M. A. P. Claessen
- Orthopaedic Hand and Upper Extremity Service, Yawkey Centre, Massachusetts General Hospital, Harvard Medical School and University of Amsterdam Medical School, 55 Fruit Street, Boston, MA 02114 USA
| | - Diederik T. Meijer
- Orthotrauma Research Centre Amsterdam, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | | | | | - Wouter H. Mallee
- Orthotrauma Research Centre Amsterdam, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Job N. Doornberg
- Orthotrauma Research Centre Amsterdam, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - C. Niek van Dijk
- Department of Orthopaedic Surgery, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
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12
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Abstract
Current clinical concepts are reviewed regarding the epidemiology, anatomy, evaluation, and treatment of pediatric ankle fractures. Correct diagnosis and management relies on appropriate examination, imaging, and knowledge of fracture patterns specific to children. Treatment is guided by patient history, physical examination, plain film radiographs and, in some instances, computed tomography. Treatment goals are to restore acceptable limb alignment, physeal anatomy, and joint congruency. For high-risk physeal fractures, patients should be monitored for growth disturbance as needed until skeletal maturity.
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Affiliation(s)
- Alvin W Su
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA; School of Medicine, National Yang-Ming University, No. 155, Section 2, Linong Street, Beitou, Taipei, Taiwan
| | - A Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA.
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13
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Tucker A, Street J, Kealey D, McDonald S, Stevenson M. Functional outcomes following syndesmotic fixation: A comparison of screws retained in situ versus routine removal - Is it really necessary? Injury 2013; 44:1880-4. [PMID: 24021584 DOI: 10.1016/j.injury.2013.08.011] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 07/16/2013] [Accepted: 08/10/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Syndesmotic disruption can occur in up to 20% of ankle fractures and is more common in Weber Type C injuries. Syndesmotic repair aims to restore ankle stability. Routine removal of syndesmosis screws is advocated to avoid implant breakage and adverse functional outcome such as pain and stiffness, but conflicting evidence exists to support this. The aim of the current study is to determine whether functional outcome differs in patients who had syndesmosis screws routinely removed, compared to those who did not, and whether a cost benefit exists if removal of screws is not routinely necessary. PATIENTS AND METHODS A retrospective review of consecutive syndesmosis repairs was performed from 1 January 2008 to 31 December 2010 in a single regional trauma centre. We identified 91 patients who had undergone open reduction internal fixation of an ankle fracture with placement of a syndesmosis screw at index procedure. As many as 69 patients were eligible for the study as defined by the inclusion criteria and they completed a validated functional outcome questionnaire. The functional outcomes of patients with 'retained screws' and 'removed screws' were analysed and compared using the Olerud Molander Ankle Score (OMAS). RESULTS A total of 63 patients responded with a mean follow-up period of 31 months (range 10-43 months). Of those patients, 43 underwent routine screw removal whilst 20 had screws left in situ. The groups were comparable considering age, gender and follow-up time. The 'retained' group scored higher mean OMAS scores, 81.5±19.3 compared to 75±12.9 in the 'removed' group (p=0.107). The retained group achieved higher functional scores in each of the OMAS domains as well as experiencing less pain. When adjusted for gender, the findings were found to be statistically significant (p=0.046). CONCLUSION Our study has shown that retained-screw fixation does not significantly impair functional capacity, with additional cost-effectiveness. We therefore advocate that syndesmosis screws be left in situ and should only be removed in case of symptomatic implants beyond 6 months postoperatively.
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Affiliation(s)
- Adam Tucker
- Orthopaedic Department, C/O Fracture Clinic, Level 2, Royal Victoria Hospital, Grosvenor Road, Belfast BT12 6BA, Northern Ireland, UK.
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