The Influence of Talar Displacement on Articular Contact Mechanics: A 3D Finite Element Analysis Study Using Weightbearing Computed Tomography

BACKGROUND

Talar displacement is considered the main predictive factor for poor outcomes and the development of post-traumatic osteoarthritis after ankle fractures. Isolated lateral talar translation, as previously studied by Ramsey and Hamilton using carbon powder imprinting, does not fully replicate the multidirectional joint subluxations seen in ankle fractures. The purpose of this study was to analyze the influence of multiple uniplanar talar displacements on tibiotalar contact mechanics utilizing weightbearing computed tomography (WBCT) and finite element analysis (FEA).

METHODS

Nineteen subjects (mean age = 37.6 years) with no history of ankle surgery or injury having undergone WBCT arthrogram (n = 1) and WBCT without arthrogram (n = 18) were included. Segmentation of the WBCT images into 3D simulated models of bone and cartilage was performed. Three-dimensional (3D) multiple uniplanar talar displacements were simulated to investigate the respective influence of various uniaxial displacements (including lateral translation, anteroposterior translation, varus-valgus angulation, and external rotation) on the tibiotalar contact mechanics using FEA. Tibiotalar peak contact stress and contact area were modeled for each displacement and its gradations.

RESULTS

Our modeling demonstrated that peak contact stress of the talus and tibia increased, whereas contact area decreased, with incremental displacement in all tested directions. Contact stress maps of the talus and tibia were computed for each displacement demonstrating unique patterns of pressure derangement. One millimeter of lateral translation resulted in 14% increase of peak talar contact pressure and a 3% decrease in contact area.

CONCLUSION

Our model predicted that with lateral talar translation, there is less noticeable change in tibiotalar contact area compared with prior studies whereas external rotation greater than 12 degrees had the largest effect on peak contact stress predictions.

LEVEL OF EVIDENCE

Level V, computational simulation study.

Insights into optimal surgical fixation for posterior malleolar fractures

Aims

The optimal management of posterior malleolar ankle fractures, a prevalent type of ankle trauma, is essential for improved prognosis. However, there remains a debate over the most effective surgical approach, particularly between screw and plate fixation methods. This study aims to investigate the differences in outcomes associated with these fixation techniques.

Methods

We conducted a comprehensive review of clinical trials comparing anteroposterior (A-P) screws, posteroanterior (P-A) screws, and plate fixation. Two investigators validated the data sourced from multiple databases (MEDLINE, EMBASE, and Web of Science). Following PRISMA guidelines, we carried out a network meta-analysis (NMA) using visual analogue scale and American Orthopaedic Foot and Ankle Score (AOFAS) as primary outcomes. Secondary outcomes included range of motion limitations, radiological outcomes, and complication rates.

Results

The NMA encompassed 13 studies, consisting of four randomized trials and eight retrospective ones. According to the surface under the cumulative ranking curve-based ranking, the A-P screw was ranked highest for improvements in AOFAS and exhibited lowest in infection and peroneal nerve injury incidence. The P-A screws, on the other hand, excelled in terms of VAS score improvements. Conversely, posterior buttress plate fixation showed the least incidence of osteoarthritis grade progression, postoperative articular step-off ≥ 2 mm, nonunions, and loss of ankle dorsiflexion ≥ 5°, though it underperformed in most other clinical outcomes.

Conclusion

The NMA suggests that open plating is more likely to provide better radiological outcomes, while screw fixation may have a greater potential for superior functional and pain results. Nevertheless, clinicians should still consider the fragment size and fracture pattern, weighing the advantages of rigid biomechanical fixation against the possibility of soft-tissue damage, to optimize treatment results.

Enhancing Consistency in Posterior Malleolus Fracture Classification: A Comprehensive Interobserver Reliability Study With 20 Raters Using the Mason & Molloy Classification

INTRODUCTION

Over the past decade, there has been a growing interest in the identification and treatment of posterior malleolus fragments, driven by a better understanding of their significance. The Mason & Molloy (M&M) classification system has emerged as a valuable tool for systematically categorizing these fractures and assisting clinicians in formulating treatment. We aim to assess the interobserver reliability of the M&M classification for posterior malleolus fracture by using 20 raters.

METHODOLOGY

The study was conducted at a major foot and ankle referral center in Wythenshawe, Manchester, UK. Thirty-eight Computed Tomography (CT) scans were evaluated by 20 independent raters: 15 general orthopedic and trauma surgeons plus five foot and ankle surgeons. Each rater classified the posterior malleolus fracture according to M&M classification into type 1, 2A, 2B, 3, or not classifiable. Statistical analysis was done with the R software package and SPSS (v26; IBM Corp., Armonk, NY). Fleiss kappa (κ) coefficient with a 95% confidence interval (CI) was applied.

RESULTS

The interobserver agreement was moderate with a global κ value of 0.531 (95% CI: 0.518, 0.544). There were good agreements for identifying type 3 M&M (κ=0.785) and those that are not applicable for M&M classification (κ=0.785). There was a strong correlation between all raters in using M&M classification (Tb=0.53-0.59) except for Rater 12.

CONCLUSION

M&M classification remains a valuable tool to guide the management of patients with these subsets of ankle fractures.

An Examination of Personalized Approaches in the Management of Ankle Fractures: A Thorough Evaluation of Soft Tissue Factors, Treatment Methods, and Patient Adherence

This study offers a thorough analysis of tibial pilon fractures, accounting for patient compliance, diverse treatment options, and soft tissue implications. The article discusses varied treatment pathways, ranging from single-stage interventions to two-stage methods for open fractures by presenting seven clinical cases. The emphasis is on the intricate interplay of trauma intensity, bone damage, and adjacent soft tissue in dictating treatment plans and patient outcomes. The challenges posed by non-compliant patients rejecting advised treatments are underscored, illuminating the inherent risks. Drawing from varied patient demographics, comorbidities, and fracture types, a comprehensive guide for clinicians emerges. The findings underscore the importance of a tailored, patient-centric approach, considering the multifaceted nature of ankle fractures, local soft tissue health, patient's overall well-being, and their adherence to the proposed treatment regimen.

Predictors of Hardware Removal in Orthopaedic Trauma Patients Undergoing Syndesmotic Ankle Fixation With Screws

Background

Indications for removal of syndesmotic screws are not fully elucidated. This study aimed to determine factors related to elective syndesmotic screw removal.

Methods

Patients who underwent fixation of ankle syndesmotic injuries were included. Screw removal was offered after a minimum of 12 weeks after surgery for pain, stiffness or patient desire to remove painful or broken hardware. Patient demographics, surgical data, distance of the syndesmotic screw from the joint, location of the screw at the physeal scar, and number of syndesmotic screws placed were collected for all patients. Bivariate and multivariate analyses were performed to determine the relationship between patient characteristics and screw removal and independent predictors of hardware removal.

Results

Of 160 patients, 60 patients (38%) with an average age of 36.1 (range: 18-84) years underwent elective syndesmotic screw removal at a mean of 7 (range, 3-47) months after initial fixation. The most common reason for screw removal (50/60 patients) was ankle stiffness and pain (83%). Patients who underwent screw removal were more likely to be younger (36.1 years ± 13.0 vs 46.6 years ± 18.2, P < .001) and have a lower ASA score (2 ± 0.8 vs 2.1 ± 0.7, P = .003) by bivariate analysis. Of patients who underwent screw removal, 21.7% (13/60) had a broken screw at the time of removal. Whether the screw was placed at the physeal scar was not significantly associated with patient decision for hardware removal (P = .80).

Conclusion

Younger and healthier patients were more likely to undergo elective removal of syndesmotic hardware. Screw distance from joint and screw placement at the physeal scar were not significantly associated with hardware removal.

Level of Evidence

Level III, retrospective cohort study.

Treatment of Open Traumatic Medial Malleolus Bone Loss With Osteochondral Allograft: A Case Report

Osteochondral damage to the ankle joint can be a difficult problem to manage in a young active patient. There are several described surgical treatments ranging from cartilage repair techniques to arthrodesis and ankle replacement. In this case, we present a 28-year-old male who sustained a right type IIIA open medial malleolus fracture following an all-terrain vehicle crash. After sharp debridement, the clinical decision was made to treat the patient with an osteochondral allograft. At one- and two-year post-allograft reconstruction, radiographs demonstrated good incorporation of the graft. The patient was ambulating with no pain or assistive devices. Our case report specifically describes the successful treatment of a traumatic medial malleolus ankle fracture with bone loss using an osteochondral allograft in a young active patient.

Are Electronic Notifications in Imaging Order Communication Systems an Effective Means of Changing Clinicians' Behaviour?

Introduction Order Communication Systems (Ordercomms) are computer applications used to enter diagnostic and therapeutic patient care orders and view test results. These electronic systems allow the integration of Clinical Decision Support Systems (CDSS). CDSS are computer applications designed to aid clinicians in making diagnostic and therapeutic decisions in patient care (e.g. can notify clinicians of best practice guidelines when requesting investigations or prescribing medications). The aims of this study were to determine whether electronic notifications (via Ordercomms) are effective in improving clinician compliance with the Ottawa Rules in plain radiographs requesting for ankle trauma, and the efficacy of electronic notifications in reducing inappropriate imaging requests. Methods The Ottawa Rules are a globally validated clinical decision tool with a sensitivity of 99%-100% for ankle fractures. When used, they can reduce the number of unnecessary radiographs by 30%-40%. Importantly, the Royal College of Radiologists stipulates that a patient must fulfill the Ottawa Rules in order to proceed with a plain radiograph of the ankle in trauma. A retrospective analysis of 366 plain ankle radiographs was performed to exclude bony injury in the emergency department between February and March 2018. Information gathered included patient demographics, the request form completed by the emergency department clinician, and radiology report. A pop-up reminder was then implemented on the electronic requesting system to prompt clinicians to apply the Ottawa Ankle Rules and document their plain radiograph request accordingly. Following the intervention, a further 473 plain radiographs were analysed in the same way over a three-month period (April-June 2018). Results In the two months prior to the intervention, 366 plain radiographs were performed for ankle trauma. Of these, 45.1% fulfilled the Ottawa Rules. In the three months following our intervention, 473 plain radiographs were carried out. There was no significant increase in the percentage of requests fulfilling the Ottawa Rules (45.7%). Unnecessary radiographs (those which did not fulfill the Ottawa Rules and consequently showed no fracture) also showed no change. The data demonstrates that the electronic reminder asking individuals to apply and document the Ottawa Rules appropriately had no impact on the imaging requesting behaviour, and subsequently on the number of unnecessary plain radiographs. Conclusion Electronic notifications in Order Communication Systems did not change clinicians' behaviour in this specific circumstance. This study has implications for electronic notifications in prescribing systems and pathology requesting systems. Further research is needed to determine if the findings are replicated with other imaging types.

Results From an All Wales Trainee Led Collaborative Prospective Audit on Management of Ankle Fractures

Aim The purpose of this all Wales national audit was to compare compliance against British Orthopedic Association Standards for Trauma (BOAST) guidelines on the management of ankle fractures. Methods A multi-center prospective audit of the management of adult ankle fractures was conducted between February 2, 2020, and February 17, 2020, via the Welsh Orthopedic Research Collaborative (WORC). Regional leads were recruited in nine NHS hospitals across six university health boards, and recruited collaborators in their respective hospitals. Questionnaires for the data collection on both surgical and conservative management were made available via a password-protected website (walesortho.co.uk). We defined early weight-bearing (EWB) as unrestricted weight-bearing on the affected leg within three weeks of injury or surgery and delayed weight-bearing (DWB) as unrestricted weight-bearing after three weeks of injury or surgery. Results A total of 28 collaborators contributed data for 238 ankle fractures. Poor documentation at the time of injury was noted. Less than 50% of patients with posterior malleolus fracture had a CT scan for further evaluation. Eighty-four percent of the non-operatively treated patients did not have a weight-bearing X-ray (WBXR). Patients who had a WBXR were more likely to be allowed EWB but this was not statistically significant. EWB was allowed in 59.43% and 10% of the non-operatively and operatively treated patients, respectively. DWB was higher in patients who had fixation of the posterior malleolus or syndesmosis. Conclusion There is poor compliance with BOAST guidelines on the management of ankle fractures across Wales. We need to improve documentation and also consider performing a CT scan when the posterior malleolus is fractured. A weight-bearing X-ray should be performed more often to ascertain the stability of an ankle fracture, and those that are deemed stable should be treated with early weight-bearing. The guidelines need to be clearer regarding weight-bearing after fixation especially when posterior malleolus and/or syndesmosis are fixed.

Routine Follow-Up Radiographs for Ankle Fractures Seldom Add Value to Clinical Decision-Making: A Retrospective, Observational Study

Currently, the routine use of radiographs for uncomplicated ankle fractures represents good clinical practice. However, radiographs are associated with waiting time, radiation exposure, and costs. Studies have suggested that radiographs seldom alter the treatment strategy if no clinical indication for the imaging study was present. The objective of the present study was to evaluate the effect of routine radiographs on the treatment strategy during the follow-up period of ankle fractures. All patients aged ≥18 years, who had visited 1 of the participating clinics with an eligible ankle fracture in 2012 and with complete follow-up data were included. The data were retrospectively analyzed. The sociodemographic and clinical characteristics and the number of, and indications for, the radiographs taken were collected from the medical records of the participating clinics. We assessed the changes in treatment strategy according to the radiographic findings. In 528 patients with an ankle fracture, 1174 radiographs were performed during the follow-up period. Of these radiographs, 936 (79.7%) were considered routine. Of the routine radiographs taken during the follow-up period, only 11 (1.2 %) resulted in changes to the treatment strategy. Although it is common practice to take radiographs routinely during the follow-up period for ankle fractures, the results from the present study suggest that routine radiographs seldom alter the treatment strategy. This limited clinical relevance should be weighed against the health care costs and radiation exposure associated with the use of routine radiographs. For a definitive recommendation, however, the results of our study should be confirmed by a prospective trial, which we are currently conducting.

Incarceration of the Posterior Tibial Tendon in an Isolated Comminuted Medial Malleolus Fracture

Isolated medial malleolar fractures are a less common presentation of an ankle fracture. Treatment is not universally accepted, although many have agreed that any displacement warrants anatomic reduction and fixation. We present a case of an isolated, comminuted medial malleolar fracture that was displaced secondary to entrapment of the posterior tibial tendon between the fracture fragments requiring surgical intervention. The patient was treated with prompt open reduction and internal fixation and had an excellent functional outcome at 1 year. When open reduction and internal fixation of the medial malleolus is indicated, a thorough exploration of the zone of injury is required to identify and adequately address any surrounding pathologic features beyond just the disrupted bony anatomy. To the best of our knowledge, this specific injury has never been previously reported and emphasizes the importance of understanding the local anatomy and how restoration of the distorted anatomy is vital to optimize patient function.

Imaging of Chopart (Midtarsal) Joint Complex: Normal Anatomy and Posttraumatic Findings

OBJECTIVE

The objective of this article is to review the normal anatomy and posttraumatic findings of the Chopart joint complex. Key imaging features of the normal ligaments and patterns of ligamentous and osseous injuries are discussed.

CONCLUSION

Traumatic midtarsal injuries, particularly midtarsal sprain, are often overlooked clinically and on imaging but are relatively common and typically are associated with inversion ankle injuries. Radiologists should be familiar with Chopart joint anatomy and the imaging features of midtarsal injuries because early diagnosis may help optimize clinical management.

The use of arthroscopy in acute foot and ankle trauma: a review

The use of arthroscopy in the management of acute traumatic conditions of the foot and ankle has increased in recent years, primarily because of an appreciation of fracture morphology and the utility of reducing the surgical footprint. This article presents an overview of the use of this modality in foot and ankle trauma and presents an anatomical survey of the various fractures where arthroscopic assistance can be of benefit. In addition, a discussion of the seminal articles on this subject is included.

LEVEL OF EVIDENCE

Therapeutic Level IV: Review.

Bone marrow-derived cells and biophysical stimulation for talar osteochondral lesions: a randomized controlled study

BACKGROUND

Osteochondral lesions of the talus (OLT) frequently occur after ankle sprains in young patients participating in sports activities. These injuries may lead to chronic pain, joint swelling, and finally osteoarthritis, therefore, surgical repair is frequently needed. A collagen scaffold seeded with bone marrow-derived cells (BMDCs) harvested from patient's iliac crest and implanted into the OLT through a single arthroscopic procedure has been recently proposed as an effective treatment option. Nevertheless, BMDCs, embedded in an inflammatory environment, tend to differentiate toward a fibroblast phenotype with a consequential loss of mechanical characteristics. Biophysical stimulation with pulsed electromagnetic fields (PEMFs) has been shown to promote anabolic chondrocyte activity, stimulate proteoglycan synthesis, and reduce the release of the most relevant pro-inflammatory cytokines. The aim of this randomized controlled trial was to evaluate the effects of PEMFs on clinical outcome in patients who underwent BMDCs transplantation for OLT.

METHODS

Thirty patients affected by grade III and IV Outerbridge OLT underwent BMDCs transplantation. After surgery, patients were randomly assigned to either experimental group (PEMFs 4 hours per day for 60 days starting within 3 days after operation) or control group. Clinical outcome was evaluated with (American Orthopaedic Foot and Ankle Society) AOFAS score, Visual Analog Scale (VAS), and Short Form-36 (SF-36).

RESULTS

Significantly higher AOFAS score was recorded in the experimental group both at 6 or 12 months follow-up. At 60 days and 6 and 12 months follow-up, significant lower pain was observed in the experimental group. No significant difference was found in SF-36 between groups.

CONCLUSION

A superior clinical outcome was found in the experimental group with more than 10 points higher AOFAS score at final follow-up. Biophysical stimulation started soon after surgery aided patient recovery leading to pain control and a better clinical outcome with these improvements lasting more than 1 year after surgery.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Bone marrow-derived cells and biophysical stimulation for talar osteochondral lesions: a randomized controlled study

BACKGROUND

Osteochondral lesions of the talus (OLT) frequently occur after ankle sprains in young patients participating in sports activities. These injuries may lead to chronic pain, joint swelling, and finally osteoarthritis, therefore, surgical repair is frequently needed. A collagen scaffold seeded with bone marrow-derived cells (BMDCs) harvested from patient's iliac crest and implanted into the OLT through a single arthroscopic procedure has been recently proposed as an effective treatment option. Nevertheless, BMDCs, embedded in an inflammatory environment, tend to differentiate toward a fibroblast phenotype with a consequential loss of mechanical characteristics. Biophysical stimulation with pulsed electromagnetic fields (PEMFs) has been shown to promote anabolic chondrocyte activity, stimulate proteoglycan synthesis, and reduce the release of the most relevant pro-inflammatory cytokines. The aim of this randomized controlled trial was to evaluate the effects of PEMFs on clinical outcome in patients who underwent BMDCs transplantation for OLT.

METHODS

Thirty patients affected by grade III and IV Outerbridge OLT underwent BMDCs transplantation. After surgery, patients were randomly assigned to either experimental group (PEMFs 4 hours per day for 60 days starting within 3 days after operation) or control group. Clinical outcome was evaluated with (American Orthopaedic Foot and Ankle Society) AOFAS score, Visual Analog Scale (VAS), and Short Form-36 (SF-36).

RESULTS

Significantly higher AOFAS score was recorded in the experimental group both at 6 or 12 months follow-up. At 60 days and 6 and 12 months follow-up, significant lower pain was observed in the experimental group. No significant difference was found in SF-36 between groups.

CONCLUSION

A superior clinical outcome was found in the experimental group with more than 10 points higher AOFAS score at final follow-up. Biophysical stimulation started soon after surgery aided patient recovery leading to pain control and a better clinical outcome with these improvements lasting more than 1 year after surgery.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Use of tensioned olive wires through a neutralization plate for syndesmotic reduction

Ankle fractures are a common osteologic outcome from trauma. These fracture patterns include a variety of concomitant soft tissue disruptions, including diastasis. Surgical treatment of a syndesmotic injury can be performed in conjunction with open reduction with internal fixation. The present technique guide demonstrates the use of pre-existing hardware, after open reduction with internal fixation from a previous ankle fracture, with an Ilizarov fixation construct to percutaneously reduce a bimalleolar equivalent fracture and diastasis to the syndesmosis.