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Zambelli R, Fagundes AO, Arêas TS, Baumfeld D, Brandão JMM, Castilho RS, Leal PMC, Baumfeld T. Ankle arthroscopy does not elevate complication rates in ankle fractures. Foot Ankle Surg 2024; 30:309-312. [PMID: 38302327 DOI: 10.1016/j.fas.2024.01.004] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 12/13/2023] [Accepted: 01/05/2024] [Indexed: 02/03/2024]
Abstract
INTRODUCTION Ankle fractures rank as the second most common lower limb fractures, and surgical intervention is essential for unstable ankle fractures. The use of ankle arthroscopy in such cases offers several advantages. This study aim is to assess whether arthroscopy influenced on complication rates in 171 ankle fractures treated with arthroscopic assistance. METHODS This retrospective epidemiological analysis encompassed adult ankle fractures between December 2018 and December 2021. Initially, 173 patients were considered, but two were excluded, leaving a final sample of 171 patients. Postoperative complications were categorized as major or minor. RESULTS The study included 171 patients with surgically treated ankle fractures assisted by arthroscopy, comprising 76 females and 95 males, with an average age of 41.9 years. Syndesmosis injuries were treated in all diagnosed cases (55.0%), and deltoid ligament injuries received attention when identified (33.7%). Arthroscopic techniques were preferred over open techniques (47.4%). Ten patients experienced complications, consisting of 2 major and 8 minor complications (5.8%). DISCUSSION Our study's epidemiological findings align with prior literature, demonstrating that intra-articular injuries accompany 63% to 79% of ankle fractures. Arthroscopy allows for both diagnosis and treatment within the same procedure, including joint lavage to reduce inflammation. We diagnosed 57 deltoid injuries and identified a statistical relationship between chondral, syndesmotic, and deltoid ligament injuries. Infection is a common complication in ankle fracture surgery, with rates ranging from 1.44% to 16%. Our study yielded a 5.8% complication rate, comprising 1.2% major and 4.6% minor complications. Patients undergoing ORIF with arthroscopic assistance had a lower prevalence of infection. CONCLUSION The use of arthroscopic assistance in the surgical treatment of ankle fractures does not increase the overall complication rate. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Roberto Zambelli
- Faculdade de Ciências Médicas de Minas Gerais, Rua Vereda, 50 - Torre 2 / Ap 2001, Nova Lima, MG 34006-077, Brazil
| | | | - Thiago Szvarça Arêas
- Hospital Mater Dei, Rua Vereda, 50 - Torre 2 / Ap 2001, Nova Lima, MG 34006-077, Brazil
| | - Daniel Baumfeld
- Universidade Federal de Minas Gerais (UFMG), Rua Vereda, 50 - Torre 2 / Ap 2001, Nova Lima, MG 34006-077, Brazil
| | - João Murilo Magalhães Brandão
- Hospital Mater Dei, Rua Vereda, 50 - Torre 2 / Ap 2001, Nova Lima, MG 34006-077, Brazil; Hospital Unimed, Belo Horizonte, Rua Vereda, 50 - Torre 2 / Ap 2001, Nova Lima, MG 34006-077, Brazil
| | | | - Paulo Magno Crusoé Leal
- Hospital São Vicente de Paulo, Santa Casa Rua Vereda, 50 - Torre 2 / Ap 2001, Nova Lima, MG 34006-077, Brazil; Vitória da Conquista Rua Vereda, 50 - Torre 2 / Ap 2001, Nova Lima, MG 34006-077, Brazil
| | - Tiago Baumfeld
- Hospital Felício Rocho, MG Rua Vereda, 50 - Torre 2/Ap 2001, Nova Lima, MG 34006-077, Brazil.
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Tenenbaum SA, Shenkar Y, Fogel I, Maoz O, Balziano S, Barzilai Y, Prat D. Ankle fracture surgery performed by orthopaedic residents without supervision has comparable outcomes to surgery performed by fellowship trained orthopaedic surgeons. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05259-9. [PMID: 38703214 DOI: 10.1007/s00402-024-05259-9] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 02/18/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND Unstable fractures often necessitate open reduction and internal fixation (ORIF), which generally yield favourable outcomes. However, the impact of surgical trainee autonomy on healthcare quality in these procedures remains uncertain. We hypothesized that surgery performed solely by residents, without supervision or participation of an attending surgeon, can provide similar outcomes to surgery performed by trauma or foot and ankle fellowship-trained orthopaedic surgeons. METHODS A single-center cohort of an academic level-1 trauma center was retrospectively reviewed for all ankle ORIF between 2015 and 2019. Data were compared between surgery performed solely by post-graduate-year 4 to 6 residents, and surgery performed by trauma or foot and ankle fellowship-trained surgeons. Demographics, surgical parameters, preoperative and postoperative radiographs, and primary (mortality, complications, and revision surgery) and secondary outcome variables were collected and analyzed. Univariate analysis was performed to evaluate outcomes. RESULTS A total of 460 ankle fractures were included in the study. Nonoperative cases and cases operated by senior orthopaedic surgeons who are not trauma or foot and ankle fellowship-trained orthopaedic surgeons were excluded. The average follow-up time was 58.4 months (SD ± 12.5). Univariate analysis of outcomes demonstrated no significant difference between residents and attendings in complications and reoperations rate (p = 0.690, p = 0.388). Sub-analysis by fracture pattern (Lauge-Hansen classification) and the number of malleoli involved and fixated demonstrated similar outcomes. surgery time was significantly longer in the resident group (p < 0.001). CONCLUSION The current study demonstrates that ankle fracture surgery can be performed by trained orthopaedic surgery residents, with similar results and complication rates as surgery performed by fellowship-trained attendings. These findings provide valuable insights into surgical autonomy in residency and its role in modern clinical training and surgical education. LEVEL OF EVIDENCE Level III - retrospective cohort study.
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Affiliation(s)
- Shay A Tenenbaum
- Department of orthopedic surgery, Chaim Sheba medical center at Tel Hashomer, Tel Aviv University Faculty of medicine, Ramat Gan, 5262100, Tel Aviv, Israel.
| | - Yorye Shenkar
- Department of orthopedic surgery, Chaim Sheba medical center at Tel Hashomer, Tel Aviv University Faculty of medicine, Ramat Gan, 5262100, Tel Aviv, Israel
| | - Itay Fogel
- Department of orthopedic surgery, Chaim Sheba medical center at Tel Hashomer, Tel Aviv University Faculty of medicine, Ramat Gan, 5262100, Tel Aviv, Israel
| | - Or Maoz
- Department of orthopedic surgery, Chaim Sheba medical center at Tel Hashomer, Tel Aviv University Faculty of medicine, Ramat Gan, 5262100, Tel Aviv, Israel
| | - Snir Balziano
- Department of orthopedic surgery, Chaim Sheba medical center at Tel Hashomer, Tel Aviv University Faculty of medicine, Ramat Gan, 5262100, Tel Aviv, Israel
| | - Yuval Barzilai
- Department of orthopedic surgery, Chaim Sheba medical center at Tel Hashomer, Tel Aviv University Faculty of medicine, Ramat Gan, 5262100, Tel Aviv, Israel
| | - Dan Prat
- Department of orthopedic surgery, Chaim Sheba medical center at Tel Hashomer, Tel Aviv University Faculty of medicine, Ramat Gan, 5262100, Tel Aviv, Israel
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Nair V, Mirle V, Hynes K, Strelzow J. Efficacy of post-operative X-rays after operatively treated ankle fractures: What is their role? Injury 2024; 55:111595. [PMID: 38703573 DOI: 10.1016/j.injury.2024.111595] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 03/30/2024] [Accepted: 04/28/2024] [Indexed: 05/06/2024]
Abstract
OBJECTIVE The utility of routine post-operative imaging in clinically asymptomatic patients is unclear. We sought to determine how frequently X-rays following operatively treated ankle fractures result in a change in management. DESIGN Retrospective cohort study conducted with hospital electronic health record SETTING: Single level 1 trauma center in major urban city. PATIENTS/PARTICIPANTS 193 patients with operatively treated ankle fractures at our institution between January 2020 and December 2021. MAIN OUTCOME MEASURES Patient radiographs were categorized as surveillance X-rays and clinically indicated X-rays. Changes in management were defined as alteration in follow-up, deviation from standard post-operative protocols, or revision surgery. A logistic regression was performed looking at factors predicting whether an X-ray changes management. A cost analysis was also performed looking at the financial implications of asymptomatic surveillance of ankle fractures. RESULTS 438 post-operative X-rays were found and included in analysis. Of these, 391 were considered surveillance X-rays and 47 clinically indicated. 23 X-rays were determined to have resulted in changes in management (18 clinically indicated, 5 taken in asymptomatic patients). The number of management changing X-rays was significantly higher in the clinically indicated group (p < 0.0001). The only factor associated with whether an X-ray changed management was whether the patient was symptomatic at the visit (p < 0.0001). Asymptomatic surveillance X-rays cost our institution 21,825.62 USD per year. CONCLUSIONS Radiographs in clinically asymptomatic patients with operatively managed ankle fractures have a low likelihood of changing management. Such imaging represents costs to the healthcare system, increased time for patients during clinic visits, and radiation exposure. The use of screening radiographic studies remains commonplace because the risk of delayed diagnosis is great, and the goal of any surgeon should be the swift identification of complications in order to minimize patient morbidity. Future surveillance protocols should consider the findings of this and other studies on the use of screening radiographs and strike a careful balance between minimizing unnecessary imaging, maximizing early complication detection, and ensuring a personalized approach towards patient-level factors to optimize care and efficiency for both patient and health system. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Vivek Nair
- Beaumont Hospital Royal Oak Department of Orthopaedic Surgery, USA; UChicago Medicine Department of Orthopaedic Surgery and Rehabilitation Medicine, USA
| | - Vikranth Mirle
- UChicago Medicine Department of Orthopaedic Surgery and Rehabilitation Medicine, USA
| | - Kelly Hynes
- UChicago Medicine Department of Orthopaedic Surgery and Rehabilitation Medicine, USA
| | - Jason Strelzow
- UChicago Medicine Department of Orthopaedic Surgery and Rehabilitation Medicine, USA.
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Wang H, Ying J, Liu J, Yu T, Huang D. Harnessing ResNet50 and SENet for enhanced ankle fracture identification. BMC Musculoskelet Disord 2024; 25:250. [PMID: 38561697 PMCID: PMC10983628 DOI: 10.1186/s12891-024-07355-8] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 03/13/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Ankle fractures are prevalent injuries that necessitate precise diagnostic tools. Traditional diagnostic methods have limitations that can be addressed using machine learning techniques, with the potential to improve accuracy and expedite diagnoses. METHODS We trained various deep learning architectures, notably the Adapted ResNet50 with SENet capabilities, to identify ankle fractures using a curated dataset of radiographic images. Model performance was evaluated using common metrics like accuracy, precision, and recall. Additionally, Grad-CAM visualizations were employed to interpret model decisions. RESULTS The Adapted ResNet50 with SENet capabilities consistently outperformed other models, achieving an accuracy of 93%, AUC of 95%, and recall of 92%. Grad-CAM visualizations provided insights into areas of the radiographs that the model deemed significant in its decisions. CONCLUSIONS The Adapted ResNet50 model enhanced with SENet capabilities demonstrated superior performance in detecting ankle fractures, offering a promising tool to complement traditional diagnostic methods. However, continuous refinement and expert validation are essential to ensure optimal application in clinical settings.
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Grants
- 2020AS0031 Science and Technology Projects in the Field of Agriculture and Social Development in Yinzhou District, Ningbo City, Zhejiang Province, China
- 2020AS0031 Science and Technology Projects in the Field of Agriculture and Social Development in Yinzhou District, Ningbo City, Zhejiang Province, China
- 2020AS0031 Science and Technology Projects in the Field of Agriculture and Social Development in Yinzhou District, Ningbo City, Zhejiang Province, China
- 2020AS0031 Science and Technology Projects in the Field of Agriculture and Social Development in Yinzhou District, Ningbo City, Zhejiang Province, China
- 2020AS0031 Science and Technology Projects in the Field of Agriculture and Social Development in Yinzhou District, Ningbo City, Zhejiang Province, China
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Affiliation(s)
- Hua Wang
- Department of Medical Imaging, Ningbo No. 6 Hospital, Ningbo, China
| | - Jichong Ying
- Department of Orthopedics, Ningbo No. 6 Hospital, Ningbo, China
| | - Jianlei Liu
- Department of Orthopedics, Ningbo No. 6 Hospital, Ningbo, China
| | - Tianming Yu
- Department of Orthopedics, Ningbo No. 6 Hospital, Ningbo, China
| | - Dichao Huang
- Department of Orthopedics, Ningbo No. 6 Hospital, Ningbo, China.
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Patel P, Little Z, Beak P, Williams R, Trompeter A. The Effect of Prone and Supine Limb Positioning on the Radiographic Evaluation of Posterolateral Plate Fixation of the Posterior Malleolus. Indian J Orthop 2024; 58:250-256. [PMID: 38425831 PMCID: PMC10899138 DOI: 10.1007/s43465-023-01066-3] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 11/15/2023] [Indexed: 03/02/2024]
Abstract
Aim To facilitate the posterolateral approach to the posterior malleolus patients are often positioned prone initially, then turned supine to complete fixation at the medial malleolus. We sought to define observed differences in the radiographic appearance of implants relative to the joint line, in prone and supine positions. Methods A 3.5 mm tubular plate and a 3.5 mm posterior distal tibial periarticular plate were applied sequentially to 3 individual cadaveric legs, via a posterolateral approach. The tubular plate was positioned to simulate buttress fixation and the posterolateral plate placed more distally. Each limb was secured on a custom jig and radiographs were taken on a mobile c-arm fluoroscopy machine with a calibration ball. A series of prone AP, supine PA and mortise radiographs were taken. Prone radiographs were also taken in different degrees of caudal tilt to simulate knee flexion which occurs in practice, during intraoperative positioning. Plate tip-joint line distances were measured and Mann-Whitney U tests performed. Results There was no statistically significant difference in plate tip-joint line distance when comparing equivalent prone and supine views (PA/AP or mortise). However, significant differences in apparent implant position were noted with alterations in caudal tilt. When taking a prone image, when the knee is flexed to 20 degrees, the plate tip will appear 6.5-8.5 mm more proximal than in the equivalent supine image where the knee is extended and the fluoroscopy beam is orthogonal to the anatomic axis of the tibia. Conclusion Observed differences in radiographic appearance of metalwork in the prone and supine position are most likely due to knee flexion and the resulting variation in the angle of the fluoroscopy beam, rather than projectional differences between supine and prone views. Surgeons should be alert to this when analysing intraoperative images.
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Affiliation(s)
- Preemal Patel
- Department of Trauma and Orthopaedics, St George’s University Hospital NHS Foundation Trust, St George’s University, London, UK
| | - Zoe Little
- Department of Trauma and Orthopaedics, St George’s University Hospital NHS Foundation Trust, St George’s University, London, UK
| | - Phillip Beak
- Trauma and Orthopaedics, Kingston Hospital, London, UK
| | - Rachel Williams
- Department of Radiology, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Alex Trompeter
- Department of Trauma and Orthopaedics, St George’s University Hospital NHS Foundation Trust, St George’s University, London, UK
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Pradana AS, Mustamsir E, Phatama KY, Putra DP, Oktafandi IGNAA. Arthroscopic assisted percutaneous fixation in ankle pilon fracture: A case report. Int J Surg Case Rep 2024; 115:109300. [PMID: 38281380 PMCID: PMC10839263 DOI: 10.1016/j.ijscr.2024.109300] [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] [Received: 07/19/2023] [Revised: 01/18/2024] [Accepted: 01/19/2024] [Indexed: 01/30/2024] Open
Abstract
INTRODUCTION Results of operative fixation for ankle fractures had been suboptimal, with cases of posttraumatic osteoarthritis occurring following the surgeries. Intra-articular injuries have been suggested as the cause of this problem. This case report aims to present an ankle pilon fracture Ruedi Allgower type II case treated with percutaneous fixation and arthroscopy evaluation. PRESENTATION OF CASE Female, 17 years old, complained of pain and swelling at the right ankle. The physical examination revealed swelling, deformity, tenderness, and limited range of motion at the right ankle. The radiological examination showed a Ruedi Allgower type II pilon fracture with right ankle dislocation. The patient underwent closed reduction, arthroscopy to evaluate her right ankle and percutaneous internal fixation. The post-surgery evaluation showed a stable ankle. DISCUSSION Patients undergoing ankle fracture surgery may benefit from ankle arthroscopy because it may increase visualization of articular reductions, assess and repair cartilage and ligament damage, remove loose bodies, decrease soft tissue exposure, preservative vascularity, and evaluate syndesmosis. Moreover, rapid arthroscopic evaluation has a low complication rate. The ability of arthroscopy to improve syndesmotic instability diagnosis suggests that arthroscopy may play a significant role in managing ankle fractures. CONCLUSION Arthroscopy-assisted internal fixation provides more benefits and information as a single case report, and more studies are warranted; regarding patients' intra-articular injuries, preventing future complications, such as posttraumatic osteoarthritis.
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Affiliation(s)
- Ananto Satya Pradana
- Orthopaedics and Traumatology Department, Faculty of Medicine, Universitas Brawijaya - Saiful Anwar General Hospital, Malang, East Java, Indonesia.
| | - Edi Mustamsir
- Orthopaedics and Traumatology Department, Faculty of Medicine, Universitas Brawijaya - Saiful Anwar General Hospital, Malang, East Java, Indonesia
| | - Krisna Yuarno Phatama
- Orthopaedics and Traumatology Department, Faculty of Medicine, Universitas Brawijaya - Saiful Anwar General Hospital, Malang, East Java, Indonesia
| | - Domy Pradana Putra
- Orthopaedics and Traumatology Department, Faculty of Medicine, Universitas Brawijaya - Saiful Anwar General Hospital, Malang, East Java, Indonesia
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de Sa R, Shah N, Rudge B, Ieong E. Safety of early weightbearing after ankle fracture fixation. Eur J Orthop Surg Traumatol 2024; 34:1003-1007. [PMID: 37843568 DOI: 10.1007/s00590-023-03758-w] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/02/2023] [Indexed: 10/17/2023]
Abstract
PURPOSE Patients with surgically treated ankle fractures are traditionally kept non-weightbearing for at least six weeks post-operatively; however, recent literature suggests numerous benefits of early weightbearing (EWB) before six weeks without significantly impacting long-term outcomes. This study aims to review the safety of early vs late weightbearing following ankle fracture fixation by assessing the complication rate. METHODS This was a single-centre retrospective study. Between 2020 and 2023, all ankle fixations that commenced weightbearing at two weeks were added to the EWB group. An equal number of similar patients with six-week non-weightbearing were added to the late weightbearing (LWB) group. Baseline characteristics, risk factors, types of fractures and any complications in the six-month post-operative period were evaluated from these cohorts. RESULTS In total, 459 ankle fixations were identified of which 87 patients met the criteria for the EWB group, with a further 87 added to the LWB group. There was no significant difference in age between the two groups (51.7 ± 20.1 vs 51.0 ± 15.5, respectively; p = 0.81), but more female patients and diabetics in the EWB group. Fracture types were similar between both cohorts (p = 0.51). Complication rate in the EWB group was not significantly different to the LWB group (5 vs 9, p > 0.05). CONCLUSION No increase in complication rate was identified by commencing weightbearing early at two weeks after ankle fixation compared to six weeks. We therefore suggest EWB if appropriate, given its associated benefits including restoration of patient independence and improved quality of life. LEVEL OF EVIDENCE Therapeutic, Level IV.
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Affiliation(s)
- Russell de Sa
- Department of Trauma & Orthopaedics, West Hertfordshire Teaching Hospital NHS Trust, Hertfordshire, UK.
| | - Nikki Shah
- Department of Trauma & Orthopaedics, West Hertfordshire Teaching Hospital NHS Trust, Hertfordshire, UK
| | - Benjamin Rudge
- Department of Trauma & Orthopaedics, West Hertfordshire Teaching Hospital NHS Trust, Hertfordshire, UK
| | - Edmund Ieong
- Department of Trauma & Orthopaedics, West Hertfordshire Teaching Hospital NHS Trust, Hertfordshire, UK
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Patel R, McCarthy K, Christensen J, Jacobs B, Karsch J, Sephien A, Matson C, Sanders RW, Mir HR. Cost analysis and clinical outcomes of anatomic pre-contoured locking versus conventional plates for distal fibula ankle fractures. Eur J Orthop Surg Traumatol 2024; 34:959-965. [PMID: 37779131 DOI: 10.1007/s00590-023-03728-2] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 09/04/2023] [Indexed: 10/03/2023]
Abstract
PURPOSE To analyze differences in union, complication rates and cost from surgical fixation of distal fibula fractures with fibular plating implants. METHODS In total, 380 adult patients from 2012 to 2015 treated with 12 fibular plates from 4 different manufacturers utilized by 9 surgeons were retrospectively reviewed. They were stratified into a conventional one-third tubular fibular plate group, pre-contoured anatomic locking plate group, or a heterogeneous group including 3.5-mm reconstruction, one-third tubular locking, composite, and limited compression plates. The outcomes included failure of fixation, deep infection requiring debridement, time to union, anatomic reduction, superficial infection, hardware removal, and post-traumatic arthritis. Plate and screw costs were calculated from hospital billing records. RESULTS Pre-contoured locking plates were used in older, female patients with a greater number of comorbidities. Open injuries and OTA 44B fractures were more likely to be an indication for pre-contoured plates. There was no difference noted in time to union between the different plating groups. Risk factors for deep infection requiring debridement included a history of tobacco use, open fractures, and pre-contoured locking plates relative to the conventional plating group. The pre-contoured plating group was on average $586 more expensive compared to the conventional group. CONCLUSION Pre-contoured locking plates achieved similar radiographic outcomes compared to conventional plates with an increased risk of complications and higher cost. Surgeons should consider their choice of implant based on the patient's fracture pattern, underlying comorbidities, and risk for infection.
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Affiliation(s)
- Raahil Patel
- Department of Orthopaedic Surgery, University of South Florida, 5 Tampa General Circle, HMT 710, Tampa, FL, 33606, USA.
| | - Kevin McCarthy
- Department of Orthopaedic Surgery, University of South Florida, 5 Tampa General Circle, HMT 710, Tampa, FL, 33606, USA
| | - Joseph Christensen
- Department of Orthopaedic Surgery, University of South Florida, 5 Tampa General Circle, HMT 710, Tampa, FL, 33606, USA
| | - Bonamico Jacobs
- Department of Orthopaedic Surgery, University of South Florida, 5 Tampa General Circle, HMT 710, Tampa, FL, 33606, USA
| | - Jordan Karsch
- Department of Orthopaedic Surgery, University of South Florida, 5 Tampa General Circle, HMT 710, Tampa, FL, 33606, USA
| | - Andrew Sephien
- Department of Orthopaedic Surgery, University of South Florida, 5 Tampa General Circle, HMT 710, Tampa, FL, 33606, USA
| | - Christopher Matson
- Department of Orthopaedic Surgery, University of South Florida, 5 Tampa General Circle, HMT 710, Tampa, FL, 33606, USA
| | - Roy W Sanders
- Department of Orthopaedic Surgery, University of South Florida, 5 Tampa General Circle, HMT 710, Tampa, FL, 33606, USA
- Florida Orthopaedic Institute, 13020 N Telecom Parkway, Tampa, FL, 33637, USA
| | - Hassan Riaz Mir
- Department of Orthopaedic Surgery, University of South Florida, 5 Tampa General Circle, HMT 710, Tampa, FL, 33606, USA
- Florida Orthopaedic Institute, 13020 N Telecom Parkway, Tampa, FL, 33637, USA
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Bouaicha W, Jlidi M, Sbaihi S, Gharbi MH, Mallek K, Jaziri S, Daas S. A Modified Dynamic Fixation Technique for Acute Syndesmotic Injuries. Foot Ankle Orthop 2024; 9:24730114241232979. [PMID: 38426008 PMCID: PMC10903226 DOI: 10.1177/24730114241232979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Affiliation(s)
- Walid Bouaicha
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, Nabeul, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Mohamed Jlidi
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, Nabeul, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Siwar Sbaihi
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Radiology Department, Mohamed Taher Maamouri Hospital, Nabeul, Tunisia
| | - Mohamed Hedi Gharbi
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, Nabeul, Tunisia
| | - Karim Mallek
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, Nabeul, Tunisia
| | - Salma Jaziri
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Department of Anaesthesia and Intensive Care, Mohamed Bourguiba Hospital, Kef, Tunisia
| | - Selim Daas
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, Nabeul, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
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Becerra E, Castro M, Ruiz-Riquelme P. Results of prophylactic simple fasciocutaneous advancement in the initial management of acute ankle fractures with high risk of operative wound complication. Foot Ankle Surg 2024; 30:37-43. [PMID: 37730458 DOI: 10.1016/j.fas.2023.09.002] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 08/24/2023] [Accepted: 09/04/2023] [Indexed: 09/22/2023]
Abstract
Ankle fracture is the third most prevalent fracture in older adults. Wound dehiscence is the most frequent complication. Our objective is to determine the operative wound complication rate in patients with unstable ankle fracture in whom a prophylactic simple fasciocutaneous advancement was used. METHODS Prospective registry of patients with unstable ankle fracture, in whom a prophylactic fasciocutaneous advancement was performed between August 2020 and July 2021. Demographic variables, time spent in performing the flap, cost of osteosynthesis, minor and major complications of the surgical wound, readmission or reoperation were registered. RESULTS 42 older adults with ankle fracture were included. Median age 69 (60-94). 31% diabetics and 21.5% active smokers. A 40% trimalleolar fracture pattern. There were 7% of superficial complications of the surgical wound. No major complications, no reoperations. CONCLUSIONS Prophylactic fasciocutaneous advancement at the beginning of traumatological surgery is technically simple, reproducible, cheap and with low complications. LEVEL OF EVIDENCE Level IV, cross-sectional study.
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Affiliation(s)
- Eduardo Becerra
- Foot and Ankle Surgery Unit, Department of Orthopedic and Traumatology, Hospital Clínico La Florida, Santiago, Chile; Foot and Ankle Surgery Unit, Department of Orthopedic and Traumatology, Hospital Carabineros de Chile, Santiago, Chile
| | - Magdalena Castro
- School of Medicine, Finis Terrae University, Santiago, Chile; Clinical Epidemiology and Research Unit, School of Medicine, Finis Terrae University, Santiago, Chile
| | - Pablo Ruiz-Riquelme
- Foot and Ankle Surgery Unit, Department of Orthopedic and Traumatology, Hospital Clínico La Florida, Santiago, Chile; School of Medicine, Finis Terrae University, Santiago, Chile; Foot and Ankle Surgery Unit, Department of Orthopedics and Traumatology, Clinic Las Condes, Santiago, Chile.
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Bartoníček J, Rammelt S, Naňka O. Early history of posterior malleolus fractures in ankle fractures. Int Orthop 2023:10.1007/s00264-023-06080-6. [PMID: 38157040 DOI: 10.1007/s00264-023-06080-6] [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] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 12/20/2023] [Indexed: 01/03/2024]
Abstract
INTRODUCTION No comprehensive treatise on the early history of fractures of posterior malleolus (PM) has yet been published, and many substantial discoveries have fallen into oblivion-particularly if not having been published in English originally. MATERIALS AND METHODS Literature search was performed in original publications and historical sources. RESULTS Early history of PM fractures from their first description up to the beginnings of their operative treatment may be divided into three basic periods, covering the era between 1828 and 1940. In the pre-radiological period (1828-1895), description of PM injuries was based merely on the autopsy findings in deceased patients. The first mentions of this injury were published by the British authors. In the radiologic period (1899-1916), the x-ray examination started a revolution also in diagnostics of ankle fractures, with the first radiographs performed as early as in 1899. Radiographic examination had subsequently become an integral part of the diagnostics of these injuries and initiated a number of significant studies of PM fractures. The first detailed mention of a PM injury may be found in the French and German literature. The period of early operative treatment (1918-1940), i.e., open reduction and internal fixation of PM, was started by the younger post-WWI generation, primarily the French surgeons, represented by Gaston Picot. His operative technique and the first six cases treated operatively between 1918 and 1921 were described in 1921 by Edouard Huc. Picot himself published his technique in great detail in 1923. CONCLUSION The early history of diagnostics and treatment of PM fractures witnesses the remarkable body of knowledge gathered about that topic by numerous visionary surgeons predominantly French and German surgeons immediately before and after World War I. They substantially contributed to the radiological examination and operative treatment of this injury.
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Affiliation(s)
- Jan Bartoníček
- Department of Orthopaedics, First Faculty of Medicine, Charles University and the Central Military Hospital, U Vojenské nemocnice 1200, Prague 6, Czech Republic
- Institute of Anatomy, First Faculty of Medicine, Charles University, U Nemocnice 3, 128 00, Prague 2, Czech Republic
| | - Stefan Rammelt
- University Center of Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstraße 74, DE-01307, Dresden, Germany
| | - Ondřej Naňka
- Institute of Anatomy, First Faculty of Medicine, Charles University, U Nemocnice 3, 128 00, Prague 2, Czech Republic.
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12
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Nguyen MQ, Broström A, Iversen MM, Harboe K, Paulsen A. Assessing the content validity of the Manchester-Oxford Foot Questionnaire in surgically treated ankle fracture patients: a qualitative study. J Orthop Surg Res 2023; 18:941. [PMID: 38066592 PMCID: PMC10704649 DOI: 10.1186/s13018-023-04418-9] [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] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 11/28/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Roughly 10% of fractures in adults are ankle fractures. These injuries are found in both sexes and present with different fracture characteristics. The treatment varies with the patients' biology and fracture type, and the goals are to restore stability, prevent pain and maintain ankle function. Clinicians generally use outcomes like assessment of radiography, pain level, or function. The use of patient-reported outcome measures is increasing, and the Manchester-Oxford Foot Questionnaire (MOXFQ) has been shown to have good measurement properties when validated in patients with foot and ankle disorders. However, the instrument has not been validated for ankle fracture patients. This study aims to assess the content validity of the items in MOXFQ in surgically treated ankle fracture patients. METHODS A qualitative deductive design was used to investigate patients' response process of the MOXFQ. Individual interviews were conducted using cognitive interviewing based on the theoretical framework of the 4-step model by Tourangeau. Adult patients that were surgically treated for an ankle fracture between four weeks and 18 months were purposively sampled, and interviews followed a semi-structured interview guide. The predetermined categories were comprehension, retrieval, judgement, and response. RESULTS Seventeen respondents (65% females) were interviewed. Respondents' age ranged from 27 to 76 years. Some of the respondents in the early recovery phase were limited by post-operative restrictions and did not find the items in the walking/standing domain relevant. Respondents that were allowed weight-bearing as tolerated (WBAT) were able to recall relevant information for most items. Respondents with time since surgery more than 12 months had less pain and remembered fewer relevant episodes in the recall period. Items in the social interaction domain contained ambiguous questions and were generally considered less important by respondents. The summary index score lacked important concepts in measuring overall quality of life. CONCLUSIONS Pain was a central concept in the post-operative recovery of ankle fracture patients. The MOXFQ-subscales for pain and walking/standing had acceptable content validity in patients that were allowed WBAT. The social interaction-subscale and the summary index score had insufficient content validity for this patient population.
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Affiliation(s)
- Michael Q Nguyen
- Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.
- Department of Orthopedic Surgery, Stavanger University Hospital, Helse Stavanger HF, Stavanger, Norway.
- Department of Orthopedic Surgery, The Fracture Registry of Western Norway, Stavanger University Hospital, Helse Vest RHF, Stavanger, Norway.
| | - Anders Broström
- School of Health and Welfare, Jönköping University, Jönköping, Sweden
- Department of Clinical Neurophysiology, Linköping University Hospital, Linköping, Sweden
- Department of Health and Caring Sciences, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Marjolein M Iversen
- Department of Health and Caring Sciences, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
- Centre on Patient-Reported Outcomes, Department of Research and Development, Haukeland University Hospital, Helse Bergen HF, Bergen, Norway
| | - Knut Harboe
- Department of Orthopedic Surgery, Stavanger University Hospital, Helse Stavanger HF, Stavanger, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
- Department of Anesthesia, Stavanger University Hospital, Helse Stavanger HF, Stavanger, Norway
| | - Aksel Paulsen
- Department of Orthopedic Surgery, Stavanger University Hospital, Helse Stavanger HF, Stavanger, Norway
- Department of Orthopedic Surgery, The Fracture Registry of Western Norway, Stavanger University Hospital, Helse Vest RHF, Stavanger, Norway
- Department of Public Health, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
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13
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Lisitano L, Röttinger T, Wiedl A, Rau K, Helling S, Cifuentes J, Jehs B, Härting M, Feitelson LM, Gleich J, Kiesl S, Pfeufer D, Neuerburg C, Mayr E, Förch S. Plain X-ray is insufficient for correct diagnosis of tibial shaft spiral fractures: a prospective trial. Eur J Trauma Emerg Surg 2023; 49:2339-2345. [PMID: 37269304 PMCID: PMC10728229 DOI: 10.1007/s00068-023-02285-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/20/2023] [Indexed: 06/05/2023]
Abstract
PURPOSE Tibial shaft spiral fractures and fractures of the distal third of the tibia (AO:42A/B/C and 43A) frequently occur with non-displaced posterior malleolus fractures (PM). This study investigated the hypothesis that plain X-ray is not sufficient for a reliable diagnosis of associated non-displaced PM fractures in tibial shaft spiral fractures. METHODS 50 X-rays showing 42A/B/C and 43A fractures were evaluated by two groups of physicians, each group was comprised of a resident and a fellowship-trained traumatologist or radiologist. Each group was tasked to make a diagnosis and/or suggest if further imaging was needed. One group was primed with the incidence of PM fractures and asked to explicitly assess the PM. RESULTS Overall, 9.13/25 (SD ± 5.77) PM fractures were diagnosed on X-ray. If the posterior malleolus fracture was named or a CT was requested, the fracture was considered "detected". With this in mind, 14.8 ± 5.95 posterior malleolus fractures were detected. Significantly more fractures were diagnosed/detected (14 vs. 4.25/25; p < 0.001/14.8 vs. 10.5/25; p < 0.001) in the group with awareness. However, there were significantly more false positives in the awareness group (2.5 vs. 0.5; p = 0.024). Senior physicians recognized slightly more fractures than residents (residents: 13.0 ± 7.79; senior physicians: 16.5 ± 3.70; p = 0.040). No significant differences were demonstrated between radiologists and trauma surgeons. The inner-rater reliability was high with 91.2% agreement. Inter-rater reliability showed fair agreement (Fleiss-Kappa 0.274, p < 0.001) across all examiners and moderate agreement (Fleiss-Kappa 0.561, p < 0.001) in group 2. CONCLUSION Only 17% of PM fractures were identified on plain X-ray and awareness of PM only improved diagnosis by 39%. While experiencing improved accuracy, CT imaging should be included in a comprehensive examination of tibial shaft spiral fractures. LEVEL OF EVIDENCE II. Diagnostic prospective cohort study. TRAIL REGISTRATION NUMBER DRKS00030075.
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Affiliation(s)
- Leonard Lisitano
- Department for Trauma, Orthopedics, Hand and Plastic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany.
| | - Timon Röttinger
- Department for Trauma, Orthopedics, Hand and Plastic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Andreas Wiedl
- Department for Trauma, Orthopedics, Hand and Plastic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Kim Rau
- Department for Trauma, Orthopedics, Hand and Plastic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Sönke Helling
- Department for Trauma, Orthopedics, Hand and Plastic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Jairo Cifuentes
- Department for Trauma, Orthopedics, Hand and Plastic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Bertram Jehs
- Department for Diagnostic and Interventional Radiology, University Hospital Augsburg, Augsburg, Germany
| | - Mark Härting
- Department for Diagnostic and Interventional Radiology, University Hospital Augsburg, Augsburg, Germany
| | - Laura-Marie Feitelson
- Department for Diagnostic and Interventional Radiology, University Hospital Augsburg, Augsburg, Germany
| | - Johannes Gleich
- Department for Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital LMU Munich, Munich, Germany
| | - Sophia Kiesl
- Department of Radiology, University Hospital LMU Munich, Munich, Germany
| | - Daniel Pfeufer
- Department for Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital LMU Munich, Munich, Germany
| | - Carl Neuerburg
- Department for Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital LMU Munich, Munich, Germany
| | - Edgar Mayr
- Department for Trauma, Orthopedics, Hand and Plastic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Stefan Förch
- Department for Trauma, Orthopedics, Hand and Plastic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
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14
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Fisher ND, Nwakoby E, Hernandez H, McLaurin TM. Electric scooter injuries: Incidence and injury patterns at a level I trauma center. Chin J Traumatol 2023; 26:334-338. [PMID: 36922264 PMCID: PMC10755772 DOI: 10.1016/j.cjtee.2023.02.003] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 01/31/2023] [Accepted: 02/20/2023] [Indexed: 03/18/2023] Open
Abstract
PURPOSE Electric scooters (e-scooters) have become an increasingly popular mode of public transportation in recent years. As the incidence of related injuries rises, it is important to understand specific fracture patterns unique to e-scooters and electric bikes (e-bikes) to help guide management. The purpose of this study was to review the prevalence and describe specific fracture patterns of e-scooter and e-bike related injuries at the busiest level 1 trauma center in the borough of Manhattan. METHODS Chart review to determine mechanism of injury was performed on all patients for whom an orthopedic consult was requested from 1/1/2021 to 12/31/2021. All patients whose injuries were sustained due to an e-scooter or e-bike were further reviewed for demographics, injury characteristics including fracture pattern, and definitive injury management. Any patients who had an orthopedic consult placed for a reason other than an acute injury were excluded. Descriptive statistics are reported as frequency (percentage) for categorical variables and means for continuous variables. RESULTS Of the 1815 orthopedic consults requested, 1357 (74.8%) were for acute injury management. Of those with acute injuries, 119 (8.8%) sustained 136 e-scooter or e-bike related injuries. There were 92 (77.3%) males at an average age of (33.8 ± 15.7) years. Approximately one-fifth of all patients presented in June 2021 (26, 21.8%). There was a 9.2% rate of open fractures. The 136 injuries were evenly split between the upper and lower extremities, with 57 (47.9%) upper extremity, 57 (47.9%) lower extremity injuries, and 5 (4.2%) concomitant upper and lower extremity injuries. The most common fracture patterns were ankle fractures (16, 11.7%), followed by tibial shaft (14, 10.2%), tibial plateau (13, 9.5%), and radial head fractures (11, 8.0%). There was a 33.3% incidence of associated posterior malleolar fractures in the spiral tibial shaft fractures, 31.0% of posterior malleolar involvement and 18.8% of isolated vertical medial malleolar fractures in the ankle fractures, and 61.5% of posterior comminution in the tibial plateau fractures. CONCLUSION E-scooter and e-bike related injuries have a high incidence of tibial shaft fractures, ankle fractures, tibial plateau fractures, and radial head fractures. There should be a high index of suspicion for posterior and medial involvement in lower extremity fractures sustained due to e-scooter or e-bikes. Identifying specific fracture patterns seen in e-scooter and e-bike related mechanisms will help guide management of these injuries.
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Affiliation(s)
- Nina D Fisher
- Department of Orthopedic Surgery, Langone Orthopedic Hospital, New York University, New York, United States.
| | - Ekenedilichukwu Nwakoby
- Department of Orthopedic Surgery, Langone Orthopedic Hospital, New York University, New York, United States
| | - Hunter Hernandez
- Department of Orthopedic Surgery, Langone Orthopedic Hospital, New York University, New York, United States
| | - Toni M McLaurin
- Department of Orthopedic Surgery, Langone Orthopedic Hospital, New York University, New York, United States; Department of Orthopedic Surgery, Health+Hospitals/Bellevue New York City, New York, United States
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15
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Baumfeld T, Burgos V, Souza V, Pires RE, Campos T, Baumfeld D. Ankle fractures malreduction rate and its causes in two Brazilian tertiary training hospitals. Injury 2023; 54 Suppl 6:110811. [PMID: 38143130 DOI: 10.1016/j.injury.2023.05.042] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/07/2023] [Accepted: 05/11/2023] [Indexed: 12/26/2023]
Abstract
INTRODUCTION Ankle fractures are one of the most frequent injuries managed by any trauma surgeon. Literature has shown that adequate reduction is of utmost importance to achieve satisfactory functional outcomes. However, malreduction rates remain high worldwide. The objective of the present study is to evaluate the quality of ankle fracture reduction in two major trauma centers in a large Brazilian city and to analyze the factors associated with malreduction METHODS: Epidemiologic data of 382 patients (189 men; 193 women) aged between 7 and 87 years who underwent osteosynthesis of the ankle in two trauma centers in a large Brazilian city. Electronic clinical records, preoperative and immediate postoperative radiographs in anteroposterior (AP), lateral and mortise views were evaluated. Pettrone's criteria were used to evaluate the quality of ankle fractures reduction. All radiographs were independently evaluated by two foot and ankle senior surgeons RESULTS: Overall, malreduction rate was 22.2%. Forty-seven (55.2%) fractures classified as malreduced had medial malleolar displacement The results showed three factors that significantly affected the quality of reduction (p<0.05), patients over 60 years, open fractures and fracture-dislocations. Patients aged over 60 years were twice more likely to have poor reduction of ankle fractures than younger ones. The risk of poor fracture reduction among those individuals with open fractures is 2.15 times greater than among patients with closed injuries. Fracture-dislocation imposed a 2.7 higher risk for malreduction DISCUSSION: We found a malreduction rate below most series previously published. Further results agree with the literature. Elderly people aged over 60 years, fracture dislocations and open fractures are associated with worse results, influencing the quality of the reduction, clinical outcomes, and the development of post-traumatic arthrosis CONCLUSION: Ankle fractures malreduction are associated with higher age, open fractures, and fracture-dislocations.
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Affiliation(s)
| | | | | | | | - Túlio Campos
- Universidade Federal de Minas Gerais (UFMG) - Brazil
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16
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Llano L, Theaux JI, Forti N, Barbaglia V, Taype D, Sancineto C, Carabelli G, Barla J. Very early prescription of range of motion exercises in ankle fractures treated with ORIF does not increase the rate of complications and reoperations: A survival risk analysis. Injury 2023; 54 Suppl 6:111019. [PMID: 38143111 DOI: 10.1016/j.injury.2023.111019] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 08/10/2023] [Accepted: 09/05/2023] [Indexed: 12/26/2023]
Abstract
BACKGROUND Ankle fractures are commonly treated with non-surgical or surgical (preferably ORIF) approaches based on fracture characteristics. The postoperative care regimens vary widely, and the impact of very early mobilization on complications and reoperation rates in ankle fractures treated with ORIF remains unclear. METHODS A retrospective analysis was conducted on ankle fractures treated between January 2014 and November 2020. Demographic and fracture characteristic data were collected. Very early prescription of range of motion exercises was defined as initiation within the first week after surgery, typically between the second and seventh postoperative day. Complications, reoperations, and time to these events were analyzed. Kaplan Meier survival analysis was performed to assess the risk of complications with very early mobilization. RESULTS A total of 299 patients met the inclusion criteria. The cohort included 83 unimalleolar, 77 bimalleolar, and 138 trimalleolar fractures. Of the patients, 116 (38.8%) underwent very early range of motion. Complications occurred in 45 events among 39 patients (13%), with 16 events (41%) in the very early range of motion group. Reoperations were required for 23 patients (3.67% of the cohort). No statistically significant differences were found in the analysis of complications, with a hazard ratio (HR) of 1.17, and in the adjusted analysis with an HR of 1.12. Similarly, the reoperation analysis showed no significant differences, with an HR of 0.85 and 0.68 in the adjusted analysis. CONCLUSION Very early prescription of range of motion exercises in ankle fractures treated with ORIF is a safe approach, as it does not increase the rates of complications or reoperations compared to early or late mobilization. This study supports the use of very early mobilization as a rehabilitation method for ankle fractures.
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Affiliation(s)
- Lionel Llano
- Trauma Section, Instituto de Ortopedia y Traumatología "Carlos E. Ottolenghi" Hospital Italiano de, Buenos Aires, Argentina.
| | - Juan Ignacio Theaux
- Trauma Section, Instituto de Ortopedia y Traumatología "Carlos E. Ottolenghi" Hospital Italiano de, Buenos Aires, Argentina
| | - Nehuen Forti
- Trauma Section, Instituto de Ortopedia y Traumatología "Carlos E. Ottolenghi" Hospital Italiano de, Buenos Aires, Argentina
| | - Victoria Barbaglia
- Trauma Section, Instituto de Ortopedia y Traumatología "Carlos E. Ottolenghi" Hospital Italiano de, Buenos Aires, Argentina
| | - Danilo Taype
- Trauma Section, Instituto de Ortopedia y Traumatología "Carlos E. Ottolenghi" Hospital Italiano de, Buenos Aires, Argentina
| | - Carlos Sancineto
- Trauma Section, Instituto de Ortopedia y Traumatología "Carlos E. Ottolenghi" Hospital Italiano de, Buenos Aires, Argentina
| | - Guido Carabelli
- Trauma Section, Instituto de Ortopedia y Traumatología "Carlos E. Ottolenghi" Hospital Italiano de, Buenos Aires, Argentina
| | - Jorge Barla
- Trauma Section, Instituto de Ortopedia y Traumatología "Carlos E. Ottolenghi" Hospital Italiano de, Buenos Aires, Argentina
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17
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Tu DP, Cai LJ, Zhao HY, Huang LG, Nie J. Complicated Bosworth fracture-dislocation: A case report and review of the literature. Chin J Traumatol 2023; 26:344-350. [PMID: 37925272 PMCID: PMC10755783 DOI: 10.1016/j.cjtee.2023.07.003] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 04/30/2023] [Accepted: 06/02/2023] [Indexed: 11/06/2023] Open
Abstract
Bosworth fracture and dislocation is relatively rare, accounting for about 1% of ankle fractures. It is characterized by the proximal fibula fracture embedded in the posterolateral distal tibia. Due to an insufficient understanding of this fracture, it is easy to cause missed diagnosis and misdiagnosis in clinical practice. Due to the insertion of the fracture, it is challenging to perform closed reduction, and improper treatment is easy to cause complications. Surgical treatment is recommended for this type of fracture. In order to improve the understanding of orthopedic surgeons about Bosworth fracture and dislocation, this paper reports the diagnosis and treatment of 2 cases of Bosworth fracture and dislocation, and reviews the literature on Bosworth fracture's mechanism, diagnosis, classification, complications, and treatment options in recent years.
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Affiliation(s)
- Dong-Peng Tu
- Department of Orthopaedics, Hangzhou Xiaoshan Orthopaedic Hospital of Traditional Chinese Medicine, Hangzhou, 311261, China.
| | - Li-Jun Cai
- Department of Orthopaedics, Hangzhou Xiaoshan Orthopaedic Hospital of Traditional Chinese Medicine, Hangzhou, 311261, China
| | - Hong-Yong Zhao
- Department of Orthopaedics, Hangzhou Xiaoshan Orthopaedic Hospital of Traditional Chinese Medicine, Hangzhou, 311261, China
| | - Li-Gang Huang
- Department of Orthopaedics, Hangzhou Xiaoshan Orthopaedic Hospital of Traditional Chinese Medicine, Hangzhou, 311261, China
| | - Jing Nie
- Department of Orthopaedics, Hangzhou Xiaoshan Orthopaedic Hospital of Traditional Chinese Medicine, Hangzhou, 311261, China
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Kibble KM, Cunningham BP, Rivard RL, Vang S, Nguyen MP. Ankle fractures: High implant cost is not associated with better patient reported outcomes. Injury 2023; 54:110963. [PMID: 37542790 DOI: 10.1016/j.injury.2023.110963] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 07/12/2023] [Accepted: 07/25/2023] [Indexed: 08/07/2023]
Abstract
INTRODUCTION Ankle fractures comprise 9% of all fractures and are among the most common fractures requiring operative management. Open reduction and internal fixation (ORIF) with plates and screws is the gold standard for the treatment of unstable, displaced ankle fractures. While performing ORIF, orthopaedic surgeons may choose from several fixation methods including locking versus nonlocking plating and whether to use screws or suture buttons for syndesmotic injuries. Nearly all orthopaedic surgeons treat ankle fractures but most are unfamiliar with implant costs. No study to date has correlated the cost of ankle fracture fixation with health status as perceived by patients through patient reported outcomes (PROs). The purpose of this study was to determine whether there is a relationship between increasing implant cost and PROs after a rotational ankle fracture. METHODS All ankle fractures treated with open reduction internal fixation (ORIF) at a level I academic trauma center from January 2018 to December 2022 were identified. Inclusion criteria included all rotational ankle fractures with a minimum 6-month follow-up and completed 6-month PRO. Patients were excluded for age <18, polytrauma and open fracture. Variables assessed included demographics, fracture classifications, Foot and Ankle Ability Measure-Activities of Daily Living (FAAM-ADL) score, implant type, and implant cost. RESULTS There was a statistically significant difference in cost between fracture types (p < 0.0001) with trimalleolar fractures being the most expensive. The mean FAAM-ADL score was lowest for trimalleolar fractures at 78.9, 95% CI [75.5, 82.3]. A diagnosis of osteoporosis/osteopenia was associated with a decrease in cost of $233.3, 95% CI [-411.8, -54.8]. There was no relationship between syndesmotic fixation and implant cost, $102.6, 95% CI [-74.9, 280.0]. There was no correlation between implant cost and FAAM-ADL score at 6 months (p = 0.48). CONCLUSIONS The utilization of higher cost ankle fixation does not correlate with better FAAM-ADL scores. Orthopaedic surgeons may choose less expensive implants to improve the value of ankle fixation without impacting patient reported outcomes.
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Affiliation(s)
- Kendra M Kibble
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN, United States of America; Department of Orthopaedic Surgery, Regions Hospital, Saint Paul, MN, United States of America
| | - Brian P Cunningham
- Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park, MN, United States of America; Department of Orthopaedic Surgery, TRIA Orthopaedic Institute, Bloomington, MN, United States of America
| | - Rachael L Rivard
- Department of Orthopaedic Surgery, Regions Hospital, Saint Paul, MN, United States of America
| | - Sandy Vang
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN, United States of America; Department of Orthopaedic Surgery, Regions Hospital, Saint Paul, MN, United States of America
| | - Mai P Nguyen
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN, United States of America; Department of Orthopaedic Surgery, Regions Hospital, Saint Paul, MN, United States of America.
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19
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Xie W, Lu H, Liu Y, Quan Y, Xu H, Fu Z, Zhang D, Jiang B. Morphological analysis and classification of posterior malleolar fractures based on CT scans. Injury 2023; 54:111006. [PMID: 37643538 DOI: 10.1016/j.injury.2023.111006] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 08/03/2023] [Accepted: 08/19/2023] [Indexed: 08/31/2023]
Abstract
OBJECTIVES The aim of the study was to propose a classification system of posterior malleolar fractures by fracture lines with the use of CT scans, including 3D CT reconstruction, which can better understand morphological characteristics, analyze the mechanism and guide the surgeon to choose the optimal approach and fixation. METHODS Patients with OTA/AO type 44 fractures involving the posterior malleolus and preoperative CT scans were included. We retrospectively analyzed 128 consecutive patients with posterior malleolar fractures from January 2013 to December 2019 at our institution. CT data were loaded into Mimics software (V20.0, Materialize), in which 3D CT reconstruction, morphological analysis and data measurements were made. RESULTS Based on the number of fracture lines in 128 consecutive patients, posterior malleolar fractures were classified into three types: type 1 with a single fracture line, type 2 with double fracture lines and type 3 with multiple fracture lines. According to the distribution of the fracture line, type 1 was divided into types 1A, 1B and 1C, and type 2 was divided into types 2A, 2B and 2C. The fracture line from the fibular notch to the posterior rim of the distal tibia was defined as type 1A, and the fracture line to the medial malleolus was defined as type 1B. Type 1C was a small fragment in the posterior rim of the distal tibia. Type 2A was regarded as type 1A with type 1C. It was considered type 2B because another fracture line started from the fracture line of type 1A and extended to the medial malleolus. In type 2C, we could see that the double fracture lines were all from the fibular notch to the posterior rim of the distal tibia and did not cross. Type 3 fractures were comminuted fractures with multiple fracture lines. CONCLUSION The morphology of posterior malleolar fractures, involvement of the fibular notch, or the medial malleolus can be obviously assessed by our classification system. We found the relation of the injury mechanism between type 1 and type 2 by comparing the area of the fragment. We have indicated that each type of fracture corresponds to its associated injury mechanism and which surgical approach and fixation can be chosen.
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Affiliation(s)
- Wenyong Xie
- Department of Orthopedics and Trauma, Peking University People's Hospital, 100044, Beijing, China; Beijing Jishuitan Hospital, 100035, Beijing, China
| | - Hao Lu
- Department of Orthopedics and Trauma, Peking University People's Hospital, 100044, Beijing, China
| | - Yijun Liu
- Department of Foot and Ankle Surgery, Center for Orthopaedic Surgery, the Third Affiliated Hospital of Southern Medical University, Guangzhou, China; Orthopaedic Hospital of Guangdong Province, Guangzhou, China
| | - Yuan Quan
- Department of Orthopedics and Trauma, Peking University People's Hospital, 100044, Beijing, China
| | - Hailin Xu
- Department of Orthopedics and Trauma, Peking University People's Hospital, 100044, Beijing, China.
| | - Zhongguo Fu
- Department of Orthopedics and Trauma, Peking University People's Hospital, 100044, Beijing, China
| | - Dianying Zhang
- Department of Orthopedics and Trauma, Peking University People's Hospital, 100044, Beijing, China
| | - Baoguo Jiang
- Department of Orthopedics and Trauma, Peking University People's Hospital, 100044, Beijing, China; Trauma Center, National Center for Trauma Medicine, 100044, Beijing, China; Key Laboratory of Trauma and Neural Regeneration, Peking University People's Hospital Beijing, 100044, China
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Abstract
Ankle fractures are among the most common orthopaedic injuries. Operative management is performed in unstable ankle fracture patterns to restore the stability and native kinematics of the ankle mortise and minimize the risk of post-traumatic degenerative changes. In this study, we review current concepts in ankle fracture management, including posterior malleolus fixation, syndesmosis fixation, deltoid ligament repair, fibular nailing, and early weightbearing, from both a biomechanical and clinical perspective.
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Affiliation(s)
- Patrick J. Tansey
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, 301 University Blvd, Route 0165, Galveston, TX, 77555-0165, USA
| | - Jie Chen
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, 301 University Blvd, Route 0165, Galveston, TX, 77555-0165, USA
| | - Vinod K. Panchbhavi
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, 301 University Blvd, Route 0165, Galveston, TX, 77555-0165, USA
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Wang L, Li D, Ni X, Sun G. The "Hand as Foot" teaching method in the Lauge-Hansen classification of ankle fractures. Asian J Surg 2023; 46:3881-3882. [PMID: 37062600 DOI: 10.1016/j.asjsur.2023.03.152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 03/28/2023] [Indexed: 04/18/2023] Open
Affiliation(s)
- Lihang Wang
- Graduate School of Baotou Medical College, Inner Mongolia University of Science&Technology, Inner Mongolia, Baotou, 014040, China
| | - Deer Li
- Graduate School of Baotou Medical College, Inner Mongolia University of Science&Technology, Inner Mongolia, Baotou, 014040, China
| | - Xiyu Ni
- Graduate School of Baotou Medical College, Inner Mongolia University of Science&Technology, Inner Mongolia, Baotou, 014040, China
| | - Guanwen Sun
- Department of Orthopedics, People's Hospital of Inner Mongolia, Inner Mongolia, Hohhot, 010020, China.
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Morcos Z, Yousaf A, Duggleby L, Koç T. A Stability-Based Management Protocol for Isolated Lateral Malleolar Ankle Fractures at the Level of the Syndesmosis Reduces the Need for Surgical Intervention. Indian J Orthop 2023; 57:1296-1301. [PMID: 37525731 PMCID: PMC10386987 DOI: 10.1007/s43465-023-00926-2] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 06/05/2023] [Indexed: 08/02/2023]
Abstract
Purpose The study aimed to establish and subsequently improve the rate of stability assessments of fractures with uncertain stability and the impact on the avoidance of potentially unnecessary surgery. Methods Two independent audit cycles were conducted from October 2019 to May 2020. All patients had closed isolated lateral malleolar fractures at the level of the tibiotalar syndesmosis involving skeletally mature bone. A stability-based management protocol was introduced, incorporating an education programme and management guideline. Results 75 ankles fractures were included. In the initial audit cycle, 13 patients did not undergo stability X-rays within 2 weeks of injury. Interestingly, only one stability assessment was performed for five operated ankles in the first audit, versus a 100% compliance rate in the second cycle. We observed more accurate documentation following education and awareness of clinical importance. Conclusion By implementing a stability-based management guideline, there was an improvement in compliance with guidance towards stability assessments of ankle fractures. This potentially led to the avoidance of unnecessary surgery on fractures where stability assessments supported non-operative management.
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Affiliation(s)
- Zeid Morcos
- Department of Trauma and Orthopaedics, Queen Alexandra Hospital, Portsmouth, PO6 3LY UK
| | - Ali Yousaf
- Department of Trauma and Orthopaedics, Queen Alexandra Hospital, Portsmouth, PO6 3LY UK
| | - Luke Duggleby
- Department of Trauma and Orthopaedics, Queen Alexandra Hospital, Portsmouth, PO6 3LY UK
| | - Togay Koç
- Department of Trauma and Orthopaedics, Queen Alexandra Hospital, Portsmouth, PO6 3LY UK
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Kelemework AD, Haile AW, Bayable SD. Assessing the functional outcomes of ankle fracture and its predictive factors following surgical treatment at Addis Ababa burn, emergency, and trauma (AaBET) hospital, Addis Ababa, Ethiopia, 2021: A 5-year retrospective cross-sectional study. Eur J Orthop Surg Traumatol 2023; 33:661-667. [PMID: 35666308 DOI: 10.1007/s00590-022-03283-2] [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] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 05/01/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Ankle fracture is a common injury that is treated at Addis Ababa Burn, Emergency, and Trauma Hospital. Previous studies show that there are mixed functional outcomes after surgically treated ankle fractures. METHODS After Ethical clearance was obtained from the ethical review committee of St. Paul Millennium Medical College, a retrospective cross-sectional study was conducted on 122 patients from September to October 2021. Patients fulfilling the inclusion criteria were called through phone and verbal consent was obtained, and the patients' responses were recorded with Olerud and Molander ankle outcome score (OMAS). For those study subjects who were unanswered to phone calls or non-functioning cell phones were repeated at least two times per week during the data collection period. The collected data were coded, entered, checked for its completeness, cleaned, and analyzed using SPSS Version 22. Descriptive statistics were presented with frequency, percentage, text, and graphs. Finally, the strength of association between functional outcome of ankle fracture and independent variables were evaluated using the Chi-square test, and a P-value < 0.05 was declared to be statistically significant. RESULTS Out of the total 122 patients, 72.1% of study subjects were males, and the mean OMAS for males and females was 76.79, and 75.65, respectively. Among all ankle fractures, nearly two-thirds (63.1%) of them were closed fractures, which are initially stabilized with splinting, open reduction, and internal fixation (ORIF), and external fixation were 77%, 13.9%, and 9%, respectively, whereas 83.3% definitive management of operatively treated ankle fracture was open reduction and internal fixation. In this study, the score of Olerud and Molander was 82.9% patients 'good' or 'excellent,' whereas 10.5% and 4.5% were fair and poor, respectively. In the present study patients with 40 years and younger (p-value, 0.022) and early surgical treatment (p-value 0.02) were strongly associated with the positive functional outcome of ankle surgery. CONCLUSION Even though the surgical treatment of ankle fracture results in good postoperative functional outcomes, restores ankle function, and allows good mobility of the ankle joint, still some patients experience few restrictions in functional activities of 2-5-year post-surgical treatment.
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Affiliation(s)
- Anteneh Damena Kelemework
- Department of Orthopedics and Traumatology, Addis Ababa Burn, Emergency and Trauma (AaBET) Hospital, St. Paul Millennium Medical College, Addis Ababa, Ethiopia
| | - Abiy Worku Haile
- Department of Orthopedics and Traumatology, Addis Ababa Burn, Emergency and Trauma (AaBET) Hospital, St. Paul Millennium Medical College, Addis Ababa, Ethiopia
| | - Samuel Debas Bayable
- Department of Anaesthesia, College of Medicine and Health Science, Debre Markos University, Debre Markos, Ethiopia.
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Fernández-Rojas E, Herrera-Pérez M, Vilá-Rico J. [Translated article] Posterior malleolar fractures: Indications and surgical approaches. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:T160-T169. [PMID: 36574833 DOI: 10.1016/j.recot.2022.12.017] [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] [Received: 09/20/2022] [Accepted: 10/27/2022] [Indexed: 12/25/2022] Open
Abstract
Posterior malleolus fractures are frequent injuries, present in 7-44% of all ankle fractures. The objective of this study is to review the evidence to indicate the fixation of this fracture and to choose the appropriate surgical approach. The classic indications for fixation were fragment size greater than 25-30% of the articular surface and displacement greater than 2mm. However, current evidence suggests that, rather than size, factors such as syndesmotic instability, intra-articular step-off greater than 1-2mm, plafond impaction and the presence of intercalary fragments should be considered. When comparing the different surgical approaches, the literature supports the use of posterior approaches and reserves the recommendation of the traditional approach for exceptional cases. For the treatment of this injury it is essential to know the anatomy of the ankle and to consider all the factors described above, in addition to the presence of concomitant injuries.
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Affiliation(s)
- E Fernández-Rojas
- Equipo de Tobillo y Pie, Servicio de Traumatología y Ortopedia, Hospital Las Higueras, Talcahuano, Chile; Universidad Católica de la Santísima Concepción, Concepción, Chile.
| | - M Herrera-Pérez
- Unidad de Pie y Tobillo, Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Islas Canarias, Spain; Escuela de Medicina, Universidad de La Laguna, Santa Cruz de Tenerife, Islas Canarias, Spain
| | - J Vilá-Rico
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, Spain; Departamento de Cirugía, Universidad Complutense de Madrid, Madrid, Spain
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25
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Fernández-Rojas E, Herrera-Pérez M, Vilá-Rico J. Posterior malleolar fractures: Indications and surgical approaches. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:160-169. [PMID: 36371071 DOI: 10.1016/j.recot.2022.10.019] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/10/2022] [Accepted: 10/27/2022] [Indexed: 11/11/2022] Open
Abstract
Posterior malleolus fractures are frequent injuries, present in 7-44% of all ankle fractures. The objective of this study is to review the evidence to indicate the fixation of this fracture and to choose the appropriate surgical approach. The classic indications for fixation were fragment size greater than 25-30% of the articular surface and displacement greater than 2 mm. However, current evidence suggests that, rather than size, factors such as syndesmotic instability, intra-articular step-off greater than 1-2 mm, plafond impaction and the presence of intercalary fragments should be considered. When comparing the different surgical approaches, the literature supports the use of posterior approaches and reserves the recommendation of the traditional approach for exceptional cases. For the treatment of this injury it is essential to know the anatomy of the ankle and to consider all the factors described above, in addition to the presence of concomitant injuries.
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Affiliation(s)
- E Fernández-Rojas
- Equipo de Tobillo y Pie, Servicio de Traumatología y Ortopedia, Hospital Las Higueras, Talcahuano, Chile; Universidad Católica de la Santísima Concepción, Concepción, Chile.
| | - M Herrera-Pérez
- Unidad de Pie y Tobillo, Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Islas Canarias, España; Escuela de Medicina, Universidad de La Laguna, Santa Cruz de Tenerife, Islas Canarias, España
| | - J Vilá-Rico
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, España; Departamento de Cirugía, Universidad Complutense de Madrid, Madrid, España
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Verhage SM, Hoogendoorn JM, Krijnen P, Schipper IB. Variation in posterior fragment fixation in the Netherlands: a nationwide study. Eur J Trauma Emerg Surg 2023; 49:317-26. [PMID: 36018372 DOI: 10.1007/s00068-022-02066-y] [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] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 07/16/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE The treatment of the posterior fragment in trimalleolar fractures differs from hospital to hospital in the Netherlands. A nationwide survey was performed to evaluate the fixation criteria and practice variation. METHODS An online cross-sectional survey amongst (orthopaedic) trauma surgeons was performed in the Netherlands. It consisted of three sections: a general section, a section showing preoperative images of six cases and a section with postoperative images of nine cases. RESULTS A total of 151 surgeons completed the online survey. 45% of the respondents indicated that they fixated the posterior fragment if smaller than 25% of the intra-articular surface. 48% preferred an open posterior approach to fixate the posterior fragment. There was good consensus in treatment for the two cases with Bartonicek type 4 fractures (operative treatment in 73 and 72% respectively). Little consensus was found for Bartonicek type 2 and 3 fractures (88% opted for operative treatment in one case, but 89% for conservative treatment in the second case). Reoperation was mostly considered in cases with a step-off of more than 1 mm (by 33-38% of the respondents). There was great variation in the choice of treatment if only the size of the posterior fragment was considered. Other fixation criteria such as postoperative step-off or instability after fixation of the lateral and medial malleoli are taken into account. In cases where fixation was needed, a percutaneous approach and an open posterolateral approach were equally preferred. CONCLUSIONS There is much variation in treatment of the posterior malleolar fracture amongst orthopaedic and trauma surgeons in the Netherlands. The percutaneous approach and open posterolateral approach to fixate the posterior malleolar fracture seem to be equally used in the Netherlands. Still, there is no uniformity in treatment of posterior malleolar fracture, especially for Bartonicek 2 and Bartonicek 3 fractures. Reoperation is considered by less than half of the surgeons in case of postoperative persistent step-off of more than 1 mm.
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Xie W, Lu H, Zhan S, Liu Y, Xu H, Fu Z, Zhang D, Jiang B. Outcomes of posterior malleolar fractures with intra-articular impacted fragment. Arch Orthop Trauma Surg 2023; 143:141-147. [PMID: 34196772 DOI: 10.1007/s00402-021-04002-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [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: 04/18/2021] [Accepted: 06/14/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION An intra-articular impacted fragment (IAIF) could lead to articular incongruity and malreduction in ankle fractures with posterior malleolar fractures (PMFs). No studies have been conducted to determine whether the presence of IAIF affects the outcome of ankle fractures with PMF. The aim of our retrospective study was to evaluate the effect of IAIF on postoperative outcomes in PMF and analyze the relationship between area of IAIF and outcomes. MATERIALS AND METHODS We conducted a retrospective study of patients with a posterior malleolar fractures between June 2012 and January 2019 with a minimum follow-up of 2 years. Results of the Olerud-Molander ankle score (OMAS), EuroQol-5D (EQ-5D) index, EQ-5D visual analog scale (VAS), AOFAS (American orthopedic foot and ankle society ankle-hindfoot scale), visual analog scale (VAS) pain score and overall patient satisfaction scale were recorded. Outcomes of the PMF with IAIF group and PMF without IAIF group were compared. Sub-group analysis was given emphasis on the AIAIF > 40 mm2 group and AIAIF < 40 mm2 group in PMF with IAIF. RESULTS A total of 128 patients were included in the study, consisting of 86 patients with IAIF and 42 patients without IAIF. Regarding the osteoarthritis grade (> 1, ≤ 1), the differences werestatistically significant between the two groups (P = 0.044). The risk of articular malreduction was higher in the PMF with IAIF group than in the PMF without IAIF group (P = 0.035). Osteoarthritis grade (> 1, ≤ 1) was closely related to articular malreduction (P < 0.001). There were 51 patients in the AIAIF > 40 mm2 group and 35 patients in the AIAIF < 40 mm2 group of 86 patients in PMF with IAIF. There were statistically significant differences in trimalleolar fracture (P = 0.004), malreduction (P = 0.022), osteoarthritis grade (> 1, ≤ 1; P = 0.027), EQ-5D VAS score (P = 0.031), and AOFAS score (P = 0.047) between the subgroups. CONCLUSION The incidence of IAIF is associated with the area of the posterior malleolar fragment. Articular malreduction can lead to post-traumatic osteoarthritis, while IAIF is an important element for the quality of reduction, which is more likely to lead to articular malreduction. IAIF should be reduced if AIAIF is over 40 mm2. Otherwise, the patient will suffer a poor prognosis and post-traumatic osteoarthritis. Therefore, ankle fractures with PMF should undergo a CT scan preoperatively in order for providers to optimal treatment protocols. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Wenyong Xie
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Hao Lu
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Sizheng Zhan
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Yijun Liu
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Hailin Xu
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China.
| | - Zhongguo Fu
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Dianying Zhang
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Baoguo Jiang
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
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Lu V, Tennyson M, Zhang J, Thahir A, Zhou A, Krkovic M. Ankle fusion with tibiotalocalcaneal retrograde nail for fragility ankle fractures: outcomes at a major trauma centre. Eur J Orthop Surg Traumatol 2023; 33:125-133. [PMID: 34820741 PMCID: PMC8612118 DOI: 10.1007/s00590-021-03171-1] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/15/2021] [Indexed: 01/07/2023]
Abstract
PURPOSE Fragility ankles fractures in the geriatric population are challenging to manage, due to fracture instability, soft tissue compromise, and patient co-morbidities. Traditional management options include open reduction internal fixation, or conservative treatment, both of which are fraught with high complication rates. We aimed to present functional outcomes of elderly patients with fragility ankle fractures treated with retrograde ankle fusion nails. METHODS A retrospective observational study was performed on patients who underwent intramedullary nailing with a tibiotalocalcaneal nail. Twenty patients met the inclusion criteria of being over sixty and having multiple co-morbidities. Patient demographics, AO/OTA fracture classification, intra-operative and post-operative complications, time to mobilisation and union, AOFAS and Olerud-Molander scores, and patient mobility were recorded. RESULTS There were seven males and thirteen females, with a mean age of 77.82 years old, five of whom are type 2 diabetics. Thirteen patients returned to their pre-operative mobility state, and the average Charlson Co-morbidity Index (CCI) was 5.05. Patients with a low CCI are more likely to return to pre-operative mobility status (p = 0.16; OR = 4.00). All patients achieved radiographical union, taking on average between 92.5 days and 144.6 days. The mean post-operative AOFAS and Olerud-Molander scores were 53.0 and 50.9, respectively. There were four cases of superficial infection, four cases of broken or loose distal locking screws. There were no deep infections, periprosthetic fractures, nail breakages, or non-unions. CONCLUSION Tibiotalocalcaneal nailing is an effective and safe option for managing unstable ankle fractures in the elderly. This technique leads to lower complication rates and earlier mobilisation than traditional fixation methods.
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Affiliation(s)
- Victor Lu
- School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0SP UK ,Christ’s College, St. Andrew’s Street, Cambridge, CB2 3BU UK
| | - Maria Tennyson
- Department of Trauma and Orthopaedics, Addenbrooke’s Hospital, Cambridge, CB2 0QQ UK
| | - James Zhang
- School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0SP UK
| | - Azeem Thahir
- Department of Trauma and Orthopaedics, Addenbrooke’s Hospital, Cambridge, CB2 0QQ UK
| | - Andrew Zhou
- School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0SP UK
| | - Matija Krkovic
- Department of Trauma and Orthopaedics, Addenbrooke’s Hospital, Cambridge, CB2 0QQ UK
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Nguyen MQ, Dalen I, Iversen MM, Harboe K, Paulsen A. Ankle fractures: a systematic review of patient-reported outcome measures and their measurement properties. Qual Life Res 2023; 32:27-45. [PMID: 35716224 PMCID: PMC9829578 DOI: 10.1007/s11136-022-03166-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2022] [Indexed: 01/13/2023]
Abstract
PURPOSE Ankle fractures are commonly occurring fractures, especially in the aging population, where they often present as fragility fractures. The disease burden and economic costs to the patient and society are considerable. Choosing accurate outcome measures for the evaluation of the management of ankle fractures in clinical trials facilitates better decision-making. This systematic review assesses the evidence for the measurement properties of patient-reported outcome measures (PROMs) used in the evaluation of adult patients with ankle fractures. METHODS Searches were performed in CINAHL, EMBASE, Medline and Google Scholar from the date of inception to July 2021. Studies that assessed the measurement properties of a PROM in an adult ankle fracture population were included. The included studies were assessed according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology for systematic reviews of PROMs. RESULTS In total, 13 different PROMs were identified in the 23 included articles. Only the Ankle Fracture Outcome of Rehabilitation Measure (A-FORM) presented some evidence on content validity. The Olerud-Molander Ankle Score (OMAS) and Self-reported Foot and Ankle Score (SEFAS) displayed good evidence of construct validity and internal consistency. The measurement properties of the OMAS, LEFS and SEFAS were most studied. CONCLUSION The absence of validation studies covering all measurement properties of PROMs used in the adult ankle fracture population precludes the recommendation of a specific PROM to be used in the evaluation of this population. Further research should focus on validation of the content validity of the instruments used in patients with ankle fractures.
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Affiliation(s)
- Michael Quan Nguyen
- Department of Orthopedic Surgery, Stavanger University Hospital, Helse Stavanger HF, Stavanger, Norway.
- Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.
| | - Ingvild Dalen
- Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- Department of Research, Stavanger University Hospital, Helse Stavanger HF, Stavanger, Norway
| | - Marjolein Memelink Iversen
- Centre on Patient-Reported Outcomes, Department of Research and Development, Haukeland University Hospital, Helse Bergen HF, Bergen, Norway
- Department of Health and Caring Sciences, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Knut Harboe
- Department of Orthopedic Surgery, Stavanger University Hospital, Helse Stavanger HF, Stavanger, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Aksel Paulsen
- Department of Orthopedic Surgery, Stavanger University Hospital, Helse Stavanger HF, Stavanger, Norway
- Department of Public Health, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
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Vanderkarr MF, Ruppenkamp JW, Vanderkarr M, Parikh A, Holy CE, Putnam M. Incidence, costs and post-operative complications following ankle fracture - A US claims database analysis. BMC Musculoskelet Disord 2022; 23:1129. [PMID: 36567314 PMCID: PMC9791722 DOI: 10.1186/s12891-022-06095-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 12/15/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The epidemiology and payer costs for ankle fractures are not well documented. This study evaluated: (1) the incidence of ankle fracture and ankle surgery following fracture in the US population; and (2) the clinical presentation of patients presenting with ankle fractures requiring surgery, their complication rates, and payer costs. METHODS Patients in the IBM® MarketScan® Commercial and Medicare Supplemental databases with an inpatient/outpatient diagnosis of ankle fracture from 2016 to 2019 were stratified by age group and gender, and rates of fracture per 10,000 enrollees were estimated. Surgically-treated patients between January 2016 - October 2021 were further analyzed. One-year post-surgical outcomes evaluated complication rates (e.g., infection, residual pain), reoperations, and 1-year payments. Standard descriptive statistics were calculated for all variables and outcomes. Generalized linear models were designed to estimate payments for surgical care and incremental payments associated with postoperative complications. RESULTS Fracture cases affected 0.14% of the population; 23.4% of fractures required surgery. Pediatric and elderly patients were at increased risk. From 3 weeks to 12 months following index ankle surgery, 5.5% (5.3% - 5.7%) of commercially insured and 5.9% (5.1% - 6.8%) of Medicare patients required a new surgery. Infection was observed in 4.4% (4.2% - 4.6%) commercially insured and 9.8% (8.8% - 10.9%) Medicare patients, and residual pain 3 months post-surgery was observed in 29.5% (28.7% - 30.3%) commercially-insured and 39.3% (36.0% - 42.6%) Medicare patients. Commercial payments for index surgery ranged from $9,821 (95% CI: $9,697 - $9,945) in the ambulatory surgical center to $28,169 (95% CI: $27,780 - $28,559) in the hospital inpatient setting, and from $16,775 (95% CI: $16,668 - $16,882) in patients with closed fractures, to $41,206 (95% CI: $38,795 - $43,617) in patients with Gustilo III fractures. Incremental commercial payments for pain and infection averaged $5,200 (95% CI: $4,261 - $6,139) and $27,510 (95% CI: $21,759 - $33,261), respectively. CONCLUSION Ankle fracture has a high incidence and complication rate. Residual pain affects more than one-third of all patients. Ankle fracture thus presents a significant societal impact in terms of patient outcomes and payer burden.
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Affiliation(s)
- Mari F. Vanderkarr
- grid.417429.dEpidemiology & Real-World Data Sciences, Johnson & Johnson MedTech, New Brunswick, NJ USA
| | - Jill W. Ruppenkamp
- grid.417429.dEpidemiology & Real-World Data Sciences, Johnson & Johnson MedTech, New Brunswick, NJ USA
| | | | | | - Chantal E. Holy
- grid.417429.dEpidemiology & Real-World Data Sciences, Johnson & Johnson MedTech, New Brunswick, NJ USA
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Patel S, Baburaj V, Sharma S, Mason LW, Dhillon MS. Influence of posterior malleolar fragment morphology on the outcomes of trimalleolar fractures: A systematic review and meta-analysis. Foot Ankle Surg 2022; 28:1337-44. [PMID: 35810125 DOI: 10.1016/j.fas.2022.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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] [Received: 04/12/2022] [Revised: 06/08/2022] [Accepted: 06/21/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Trimalleolar fractures are generally considered to have inferior outcomes among ankle injuries. Historically, emphasis was placed on the size of the posterior malleolar fracture (PMF) to guide surgical decision-making and predict outcomes. Recent studies have suggested that the morphology of the PMF fragment is more important than its size. The aim of this systematic review was to determine if the outcomes of trimalleolar fractures depend on the morphology of the PMF as per the Haraguchi classification system after surgical fixation. METHODS A systematic literature search was conducted in the electronic databases of PubMed, Embase, Scopus, and Ovid. Title and abstracts were screened, and data from eligible studies were extracted. Meta-regression and pooled analysis was performed using appropriate computer software. RESULTS 11 studies with 597 patients were included in the final analysis. Pooled mean AOFAS score was 87.43 (95% CI 84.24-90.62) after a mean follow-up of 31.6 months. Univariate and multivariate meta-regression analysis demonstrated that as the percentage of Haraguchi type 1 patients increased, there was a statistically significant improvement in outcome scores. A similar trend was noted for Haraguchi type 3 fractures, and a reverse trend was observed for Haraguchi type 2 injuries, although neither were statistically significant. CONCLUSION Our review suggests that the outcomes of trimalleolar fractures after surgical fixation may depend on the morphology of the PMF, with Haraguchi type 1 fractures having overall superior functional outcomes than Haraguchi type 2 and 3 injuries. Future studies need to done to conclusively prove or refute these findings.
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Li J, Yu Y, Wu Y, Wang J, Zeng X, Zhao J. Does the Level of Syndesmotic Screw Insertion Affect Clinical Outcome after Ankle Fractures with Syndesmotic Instability? Orthop Surg 2022; 15:247-255. [PMID: 36444957 PMCID: PMC9837214 DOI: 10.1111/os.13569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 09/14/2022] [Accepted: 09/26/2022] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Ankle fractures are often combined with syndesmotic instability, requiring reduction and stabilization. However, the optimal level for syndesmotic screw positioning remains unclear. This study aims to evaluate the effect of different syndesmotic screw insertion levels on postoperative clinical outcomes and determine whether an optimal level exists. METHODS This retrospective study included data from 43 adult patients with acute closed ankle fractures combined with intraoperative evidence of unstable syndesmotic injuries who underwent open reduction internal fixation from January 1, 2017 to March 1, 2018 according to the inclusion and exclusion criteria. All 43 patients were divided into three groups based on the syndesmotic screw placement level: trans-syndesmotic group: screw level of 2-3 cm; inferior-syndesmotic group: screw level <2 cm; and supra-syndesmotic group: screw level >3 cm. Clinical outcomes were measured at the final follow-up, including the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Olerud-Molander Ankle Score (OMAS), short-form 36-item questionnaire (SF-36), visual analogue scale (VAS) score and restrictions in ankle range of motion (ROM). The relationships between screw placement level and clinical outcomes were analyzed with the Kruskal-Wallis H-test and Spearman correlation analysis. RESULTS The median follow-up duration was 15 months (range, 10-22 months). No patients developed fracture nonunion or malunion or experienced hardware failure. The outcome scoring systems showed an overall score for the entire group of 94.91 points for the AOFAS ankle-hindfoot score, 83.14 for the OMAS, 96.65 for the SF-36, 1.77 for the VAS, 9.14° for the restrictions in dorsiflexion, and 1.30° for the restrictions in plantarflexion. There were no significant differences among three groups in clinical outcomes (P > 0.05). Neither the AOFAS score nor OMAS had significant correlations with screw insertion level (P = 0.825 and P = 0.585, respectively). No postoperative arthritis or widening of the tibiofibular space was observed at the final follow-up. CONCLUSION Different syndesmotic screw placement levels appear not to affect the clinical outcomes of ankle fractures with syndesmotic instability. No optimal level was observed in this study. Our findings suggest other clinically acceptable options apart from syndesmotic screw placement 2-3 cm above the ankle.
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Affiliation(s)
- Jin‐Kun Li
- Graduate SchoolTianjin University of Traditional Chinese MedicineTianjinChina
| | - Yi Yu
- Zhanjiang First Hospital of Traditional Chinese MedicineZhanjiangChina
| | - Ying‐Hua Wu
- Department of Orthopaedic SurgeryTianjin HospitalTianjinChina
| | - Jia Wang
- Department of Orthopaedic SurgeryTianjin HospitalTianjinChina
| | - Xian‐Tie Zeng
- Department of Orthopaedic SurgeryTianjin HospitalTianjinChina
| | - Jia‐Guo Zhao
- Department of Orthopaedic SurgeryTianjin HospitalTianjinChina
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Park YH, Cho HW, Choi JW, Kim HJ. Comparison between headless compression screws and tension band wires for the fixation of medial malleolar fractures: a prospective randomized trial. Arch Orthop Trauma Surg 2022; 142:2627-33. [PMID: 34160673 DOI: 10.1007/s00402-021-04003-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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] [Received: 05/13/2021] [Accepted: 06/14/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION To date, there has been no prospective randomized trial supporting the rationale of the use of headless compression screw (HCS) compared to conventional fixation methods for medial malleolar fractures. This study aimed to prospectively compare the outcomes of the HCS and tension band wire (TBW) for the fixation of medial malleolar fractures. MATERIAL AND METHODS Sixty patients were randomized to receive either an HCS or a TBW for the fixation of a medial malleolar fracture. Clinical outcomes were assessed using the Olerud-Molander ankle score (OMAS), EuroQoL five-dimensional instrument (EQ-5D) score, visual analog scale (VAS) score, patient satisfaction with implant-related symptoms, operative time, and incision length. Radiographic outcomes were assessed using the presence of nonunion, delayed union, and articular incongruity. Clinical and radiographic assessments were performed at 2 and 6 weeks and 3, 6, and 12 months postoperatively. RESULTS The OMAS, EQ-5D score, VAS score, and operative time did not differ between the HCS and TBW groups; however, the HCS group had greater satisfaction with implant-related symptoms and smaller incision than the TBW group. There was no difference in the presence of nonunion, delayed union, and articular incongruity. CONCLUSION HCS fixation for medial malleolar fractures is not inferior to TBW fixation, while reducing implant-related symptoms. These findings suggest that HCS is a viable alternative for the fixation of medial malleolar fractures.
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Blondin E, Stourbe O, Plancq MC, Deroussen F, Gouron R, Klein C. Outcomes of pediatric distal tibial physeal fractures. Orthop Traumatol Surg Res 2022; 108:103199. [PMID: 35031515 DOI: 10.1016/j.otsr.2022.103199] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 05/10/2021] [Accepted: 05/20/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Fractures of the distal tibia involving the physis are relatively common in children. The data reported on long-term complication rates vary between studies. HYPOTHESIS Pediatric distal tibial fractures cause medium- and long-term growth disturbances. MATERIALS AND METHODS This was a retrospective single-center study. We included physeal distal tibial fractures that were treated in the operating room with a minimum 12-month follow-up. The analysis included age, gender, weight status, circumstances and energy of the injury, fracture type, subsequent treatment, complications, duration of follow-up, radiologic findings and functional outcomes using the AOFAS. RESULTS A total of 46 patients were included with a mean age of 12.8 years (2.4-15.9 years) and a mean follow-up of 35.8 months (12-119). At the longest follow-up, 7 patients (15.2%) had growth disturbances. The mean AOFAS score was 95/100 and a decreased ankle range of motion was observed in 18 patients, but it was always less than 10°. High-energy injuries (20 patients) resulted in worse clinical outcomes and a significantly higher rate of growth disturbances (p=.03). DISCUSSION This study confirmed the presence of growth disturbances following pediatric distal tibial fractures, especially in cases of high-energy trauma. Therefore, these fractures should be monitored until the end of the growth period. LEVEL OF EVIDENCE IV; retrospective study.
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Affiliation(s)
- Emile Blondin
- Service d'Orthopédie et Traumatologie pédiatrique, CHU Amiens-Picardie, Groupe Hospitalier Sud, 80054 Amiens Cedex 1, France
| | - Olivier Stourbe
- Service d'Orthopédie et Traumatologie pédiatrique, CHU Amiens-Picardie, Groupe Hospitalier Sud, 80054 Amiens Cedex 1, France
| | - Marie-Christine Plancq
- Service d'Orthopédie et Traumatologie pédiatrique, CHU Amiens-Picardie, Groupe Hospitalier Sud, 80054 Amiens Cedex 1, France
| | - François Deroussen
- Service d'Orthopédie et Traumatologie pédiatrique, CHU Amiens-Picardie, Groupe Hospitalier Sud, 80054 Amiens Cedex 1, France
| | - Richard Gouron
- Service d'Orthopédie et Traumatologie pédiatrique, CHU Amiens-Picardie, Groupe Hospitalier Sud, 80054 Amiens Cedex 1, France
| | - Céline Klein
- Service d'Orthopédie et Traumatologie pédiatrique, CHU Amiens-Picardie, Groupe Hospitalier Sud, 80054 Amiens Cedex 1, France.
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Kohler FC, Schenk P, Koehler P, Hofmann GO, Biedermann U, Wildemann B, Graul I, Hallbauer J. The role of the posterior malleolus in the treatment of unstable upper ankle joint injuries - A biomechanical study. Foot Ankle Surg 2022; 28:979-985. [PMID: 35177329 DOI: 10.1016/j.fas.2022.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 09/26/2021] [Revised: 01/28/2022] [Accepted: 02/09/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND This biomechanical study aimed to test if the fixation of the posterior malleolus (PM) only with screws inserted from posterior to anterior (PA) restores stability comparable with the natural condition. The extent of stability was also compared with that of anterior to posterior (AP) screw osteosynthesis (OS) with an additional syndesmotic screw (SS). METHODS First, the stability of the upper ankle joint in seven pairs of intact lower legs were examined. Subsequently, half of the lower legs were treated with PA screw fixation of a PM fracture without SS and the other half with AP screw fixation with additional tricortical SS. RESULTS PA OS without SS showed significantly more diastasis (p = 0.027). The AP OS with an SS revealed a diastasis that was comparable with the intact condition (p = 0.797). The use of SS led to significantly higher stability compared to OS without SS (p = 0.019). CONCLUSIONS The Fixation of the PM alone without an additional syndesmotic screw cannot achieve intact upper ankle stability. Fixation of a PM fracture with an SS helps in nearly achieving the natural condition.
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Affiliation(s)
- F C Kohler
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747 Jena, Germany.
| | - P Schenk
- Reseaserch Executive Department, BG Klinikum Bergmannstrost, 06112 Halle, Germany
| | - P Koehler
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747 Jena, Germany
| | - G O Hofmann
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747 Jena, Germany; Department of Trauma and Reconstructive Surgery, BG Klinikum Bergmannstrost, 06112 Halle, Germany
| | - U Biedermann
- Institute of Anatomy I, Jena University Hospital, Friedrich Schiller University Jena, 07743 Jena, Germany
| | - B Wildemann
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747 Jena, Germany
| | - I Graul
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747 Jena, Germany
| | - J Hallbauer
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747 Jena, Germany
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Sharma T, Farrugia P. Early versus late weight bearing & ankle mobilization in the postoperative management of ankle fractures: A systematic review and meta-analysis of randomized controlled trials. Foot Ankle Surg 2022; 28:827-835. [PMID: 35337752 DOI: 10.1016/j.fas.2022.03.003] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 02/11/2022] [Accepted: 03/01/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND While open reduction and internal fixation is currently considered the optimum treatment option for displaced ankle fractures, the most optimal post-operative rehabilitation strategy in this setting remains unclear. The objective of this investigation was to compare the effect of early vs. late weight bearing and ankle mobilization in the post-operative management of ankle fractures. METHODS Medline, Embase, CENTRAL, Scopus, CINHAL, and Web of Science were searched to identify randomized controlled trials (RCTs) and quasi-RCTs. Two review authors screened articles, abstracted data, and evaluated risk of bias in duplicate. Outcomes of interest included post-operative ankle function and overall time to return to work. Studies on weight bearing and ankle mobilization were analysed separately and all data were pooled using random-effects models. RESULTS Eighteen trials were included in the review of which 14 were included in the meta-analysis of at least one outcome of interest. Majority of the studies presented a high overall risk of bias. Early weight bearing demonstrated significantly better short-term postoperative functional scores at 6-9 weeks postoperatively (SMD: 0.39, 95% CI: 0.19, 0.58; p < 0.0001; I2 = 0%). However, the functional effect of early weight bearing compared to late weight bearing gradually became equivalent by the 6 month postoperative time-period. Early weight bearing also demonstrated a significant reduction in the time to return to work/daily activities (MD: -12.29, 95% CI: -17.39, -7.19; p < 0.0001; I2 = 0%). In comparison, no significant differences were found between early ankle mobilization/exercises and immobilization. CONCLUSION Our findings suggest a potential role of EWB in improving post-operative ankle-function in the short-term and reducing the overall time to return to work/daily activities, but no clinical benefit associated with early ankle mobilization post-surgery.
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Affiliation(s)
- Tanmay Sharma
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Patricia Farrugia
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
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Gomes YE, Chau M, Banwell HA, Causby RS. Diagnostic accuracy of the Ottawa ankle rule to exclude fractures in acute ankle injuries in adults: a systematic review and meta-analysis. BMC Musculoskelet Disord 2022; 23:885. [PMID: 36151550 PMCID: PMC9502997 DOI: 10.1186/s12891-022-05831-7] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 09/14/2022] [Indexed: 11/29/2022] Open
Abstract
Background Ankle traumas are common presenting injuries to emergency departments in Australia and worldwide. The Ottawa Ankle Rules (OAR) are a clinical decision tool to exclude ankle fractures, thereby precluding the need for radiographic imaging in patients with acute ankle injury. Previous studies support the OAR as an accurate means of excluding ankle and midfoot fractures, but have included a paediatric population, report both the ankle and mid-foot, or are greater than 5 years old. This systematic review and meta-analysis aimed to update and assess the existing evidence of the diagnostic accuracy of the Ottawa Ankle Rule (OAR) acute ankle injuries in adults. Methods A systematic search and screen of was performed for relevant articles dated 1992 to 2020. Prospective and retrospective studies documenting OAR outcomes by physicians to assess ankle injuries were included. Critical appraisal of included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Outcomes related to psychometric data were pooled using random effects or fixed effects modelling to calculate diagnostic performance of the OAR. Between-study heterogeneity was assessed using the Higgins I2 test, with Spearman’s correlation test for threshold effect. Results From 254 unique studies identified in the screening process, 15 were included, involving 8560 patients from 13 countries. Sensitivity, specificity, negative likelihood ratio, positive likelihood ratio and diagnostic odds ratio were 0.91 (95% CI, 0.89 to 0.92), 0.25 (95% CI, 0.24 to 0.26), 1.47 (95% CI, 1.11 to 1.93), 0.15 (95% CI, 0.72 to 0.29) and 10.95 (95% CI, 5.14 to 23.35) respectively, with high between-study heterogeneity observed (sensitivity: I2 = 94.3%, p < 0.01; specificity: I2 = 99.2%, p < 0.01). Most studies presented with low risk of bias and concern regarding applicability following assessment against QUADAS-2 criteria. Conclusions Application of the OAR is highly sensitive and can correctly predict the likelihood of ankle fractures when present, however, lower specificity rates increase the likelihood of false positives. Overall, the use of the OAR tool is supported as a cost-effective method of reducing unnecessary radiographic referral, that should improve efficiency, lower medical costs and reduce waiting times. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05831-7.
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Affiliation(s)
- Yolanda E Gomes
- Allied Health and Human Performance Unit, University of South Australia, Adelaide, South Australia, Australia.,South Australia Medical Imaging, Flinders Medical Centre, South Australia, Australia
| | - Minh Chau
- Allied Health and Human Performance Unit, University of South Australia, Adelaide, South Australia, Australia.,South Australia Medical Imaging, Flinders Medical Centre, South Australia, Australia.,Faculty of Health, University of Canberra, Australian Capital Territory, Australia
| | - Helen A Banwell
- Allied Health and Human Performance Unit, University of South Australia, Adelaide, South Australia, Australia
| | - Ryan S Causby
- Allied Health and Human Performance Unit, University of South Australia, Adelaide, South Australia, Australia.
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Abarca M, Besa P, Mora E, Palma J, Lira MJ, Filippi J. The use of intraoperative comparative fluoroscopy allows for assessing sagittal reduction and predicting syndesmosis reduction in ankle fractures. Foot Ankle Surg 2022; 28:750-755. [PMID: 34686414 DOI: 10.1016/j.fas.2021.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 05/16/2021] [Revised: 08/24/2021] [Accepted: 10/04/2021] [Indexed: 02/04/2023]
Abstract
UNLABELLED Intraoperative fluoroscopic parameters have shown to be poor predictors for ankle syndesmosis reduction, with up to 52% of syndesmotic malreduction (SMR) reported in the literature. Anteroposterior Tibio-Fibular index (APTF) was previously described to evaluate sagittal tibiofibular alignment in lateral ankle radiographs with a high correlation between both ankles in uninjured subjects. Reproducible intraoperative measurements for sagittal syndesmotic reduction are lacking. We propose the use of the "cAPTF," calculated as the absolute difference between the APTF of the non-injured and the operated ankle, to evaluate sagittal syndesmotic reduction. OBJECTIVE Determine the predictive capability of cAPTF for SMR. METHOD Prospective observational study. INCLUSION CRITERIA patients with unstable ankle fractures requiring syndesmotic fixation, with a healthy contralateral ankle. Intraoperatively APTF was measured in both ankles after syndesmotic fixation. Postoperatively cAPTF was calculated. Only direct syndesmosis visualization through the lateral approach and AP and mortise views were used by surgeons to assess syndesmotic reduction. Quality of syndesmotic reduction was evaluated with bilateral postoperative CT. To estimate cAPTF discriminatory power for SMR, a receiver operative characteristic (ROC) curve was obtained and the area under the ROC curve was calculated. Youden index was used to determine the ideal cAPTF cut-off value for predicting SMR. For this determined cut-off value, sensitivity, specificity, and likelihood ratio were calculated. RESULTS Fifty-two patients were included. Sixteen (30%) had SMR. Patients with SMR had a statistically significant higher cAPTF value than the well reduced (median 0.26 vs 0.09; P < 0.01). The cAPTF cut-off value to predict SMR was 0.161. A cAPTF greater than 0.161 had 100% sensitivity and 97,2% specificity for SMR. The area under the ROC curve was 0.99. CONCLUSION Intraoperative cAPTF has excellent discriminatory power for predicting syndesmotic malreduction. We propose the routine use of intraoperative bilateral comparative fluoroscopy to assess sagittal syndesmotic reduction.
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Affiliation(s)
- Mario Abarca
- Complejo Asistencial Doctor Sótero del Río, C.A.S.R., Chile; Foot and Ankle Unit, Department of Orthopedic Surgery, Hospital del Trabajador, Santiago, Chile
| | - Pablo Besa
- Department of Orthopedic Surgery, Pontificia Universidad Católica de Chile, Chile
| | - Eduardo Mora
- Complejo Asistencial Doctor Sótero del Río, C.A.S.R., Chile
| | - Joaquin Palma
- Complejo Asistencial Doctor Sótero del Río, C.A.S.R., Chile; Department of Orthopedic Surgery, Pontificia Universidad Católica de Chile, Chile
| | - Maria Jesus Lira
- Department of Orthopedic Surgery, Pontificia Universidad Católica de Chile, Chile
| | - Jorge Filippi
- Foot and Ankle Unit, Department of Orthopedic Surgery, Hospital del Trabajador, Santiago, Chile; Foot and Ankle Unit, Department of Orthopedic Surgery, Clinica Las Condes, Chile.
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Abstract
INTRODUCTION Ankle fractures are amongst the most common open fracture injuries presenting to major trauma centres (MTC) and their management remains a topic of debate. Incidence is increasing particularly in the elderly population however the optimal surgical approach and risk factors for unplanned reoperation remain scarce. We therefore conducted a retrospective case study to analyse our institution's outcomes as well as identify risk factors for early unplanned reoperation. MATERIALS AND METHODS Sixty-five consecutive open ankle fractures were identified using our institutional database between July 2016 and July 2020. Medical records and operation notes were reviewed to identify patient age at injury, Sex, co-morbidities and other co-morbidities, fracture configuration, extent of soft tissue injury, fixation type and post-operative complications. The data was categorised into four groups for analysis, 1) age, 2) AO-OTA classification 3) Sex 4) Gustilo-Anderson grade. Statistical analysis was undertaken to identify predictors of unplanned reoperation. RESULTS The mean age of patients at the time of injury was 60.8. Unplanned reoperation rate was 17.5%. Age and Gustilo-Anderson classification grade were both statistically significant predictors of unplanned reoperation. AO-OTA classification, Sex and Diabetes were not statistically significant factors associated with unplanned reoperation. CONCLUSION Age and quality of soft tissue envelope are significant risk factors for unplanned reoperation. Patients with these risk factors may benefit from an alternative surgical approach.
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Affiliation(s)
- Monketh Jaibaji
- Health Education England North East, Newcastle Upon Tyne, United Kingdom.
| | - Mark Sohatee
- Health Education England North East, Newcastle Upon Tyne, United Kingdom
| | - Christopher Watkins
- Department of Trauma and Orthopaedics, Royal Victoria Infirmary, Newcastle Upon Tyne, United Kingdom
| | - Sultan Qasim
- Department of Trauma and Orthopaedics, Royal Victoria Infirmary, Newcastle Upon Tyne, United Kingdom
| | - Paul Fearon
- Department of Trauma and Orthopaedics, Royal Victoria Infirmary, Newcastle Upon Tyne, United Kingdom
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Salas-Gómez D, Fernández-Gorgojo M, Sanchez-Juan P, Bercero EL, Isabel Perez-Núñez M, Barbado D. Quantifying balance deficit in people with ankle fracture six months after surgical intervention through the Y-Balance test. Gait Posture 2022; 95:249-55. [PMID: 33243522 DOI: 10.1016/j.gaitpost.2020.10.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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] [Received: 11/27/2019] [Revised: 10/28/2020] [Accepted: 10/30/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Ankle fractures are among the most common traumatic fractures and have a great socio-economic impact. Consequences of an ankle fracture requiring surgical treatment (e.g. pain, reduced ankle range of motion (ROM), muscle weakness, etc.) lead to balance deterioration, which has a profound impact on activities of daily living. However, to the best of the authors' knowledge, no reliable clinical tests are available to monitor balance in patients after ankle surgery. OBJECTIVES To quantify single-leg dynamic balance in patients with bimalleolar ankle fracture through the Y-Balance test (YBT). The second objective was to analyze the impact of ankle dorsiflexion ROM and hip strength on balance to optimize balance rehabilitation programs. DESIGN Cross-sectional study. METHODS 22 participants, who had undergone surgery after bimalleolar ankle fractures, were assessed for ankle ROM, hip strength, and dynamic balance six-months after the surgical intervention. The within-session reliability of YBT was calculated through the intraclass correlation coefficient (ICC) and the standard error of measurement (SEM). Student's t-tests were used to assess leg differences. A multiple regression analysis was performed to evaluate the role of ankle dorsiflexion ROM and hip abductor and adductor strength in predicting balance performance. RESULTS YBT showed high-to-excellent within-session relative reliability (Healthy leg: 0.85 ≤ ICC≤0.96; Operated leg: 0.84 ≤ ICC≤0.96). SEM values were below 3.3 %. The operated leg showed significant lower YBT scores for anterior reach direction (-9.0 %; g=-0.70) and composite score (-4.5 %; g=-0.34). Multiple regression analysis showed that both, ankle dorsiflexion and hip abductor and adductor strength explained 66 % of the variance in the YBT anterior direction of the operated leg. CONCLUSIONS The YBT is a reliable tool that allows the quantification of single-leg dynamic balance impairments from 6-months after surgery in patients with bimalleolar ankle fracture. Between-leg YBT differences in the anterior direction can be used as reference scores (3.3 %) for balance restoration. Balance rehabilitation programs should focus on improving ankle functionality and reducing hip muscle weakness with specific hip strength exercises and balance exercises with similar demands to the reaching tasks of the YBT to promote a faster recovery.
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Zawam SH, Mabrouk MG, El-Desouky MA. Lateral malleolar fractures Weber Type A and B: does percutaneous intramedullary screw confer a solid alternative to the traditional neutralization plate? Int Orthop 2022; 46:2127-2134. [PMID: 35575804 PMCID: PMC9372115 DOI: 10.1007/s00264-022-05425-x] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 04/30/2022] [Indexed: 11/05/2022]
Abstract
Purpose To compare the clinical results, complication rates, and radiographic outcome between both methods of fixation of lateral malleolar fractures: lateral neutralization plates and intramedullary fully threaded screws. Patients and methods This prospective case series study involved 73 patients with fractured lateral malleolus of type A, B according to Weber classification, to whom internal fixation was performed by either lateral plate and screws construct (Group A) or intramedullary screw (Group B). All patients were followed up for 12 months at least, with an average follow-up time of 12.7 months. Results There was no significant difference in the functional outcome score between both groups. The intramedullary screw group had a significantly shorter operative time and time to full union (P<0.001 and =0.006 respectively). There was a relatively higher accuracy of reduction with the plate fixation group, but it was statistically insignificant. There was a relatively fewer complication rate with the use of intramedullary screw fixation compared to plate fixation. Conclusion The use of intramedullary fixation is a good alternative for plate fixation in low fibular fractures (Weber A and B). Although plate fixation provides an optimal anatomic reconstruction of the fractures, intramedullary fixation may have a lower risk of complications.
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Affiliation(s)
- Sherif Hamdy Zawam
- Department of Trauma and Orthopedics, Faculty of Medicine, Cairo University, Giza, Egypt.
| | - Mohamed Goda Mabrouk
- Department of Trauma and Orthopedics, Faculty of Medicine, Cairo University, Giza, Egypt
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Frederiksen JO, Malmberg C, Karimi D, Tengberg PT, Troelsen A, Terndrup M. Surgical treatment of displaced isolated lateral malleolar fractures: incidence of adverse events requiring revision: a retrospective cohort study. J Orthop Surg Res 2022; 17:252. [PMID: 35505429 DOI: 10.1186/s13018-022-03135-z] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 04/19/2022] [Indexed: 11/12/2022] Open
Abstract
Background Recent systematic reviews support that non-operative management should be the standard treatment for all stable isolated lateral malleolar fractures (ILMFs), regardless of fibular fracture displacement. Surgical fixation of ILMFs carries a risk of adverse events (AEs), and many patients will later require implant removal. We wanted to estimate the incidence of AEs requiring revision after surgical fixation of “potentially stable” displaced ILMFs before non-operative treatment became standard care in our department. Materials and methods To identify patients with “potentially stable” ILMFs who had been treated surgically in a historical cohort, we retrospectively applied the stability-based classification system, introduced by Michelson et al., to a cohort of 1006 patients with ankle fractures treated surgically from 2011 to 2016. The primary outcome of this retrospective cohort study was the incidence of AEs that had functionally significant adverse effects on outcome and required revision in the first 12 months after surgery. AEs were graded and categorized using the Orthopedic Surgical Adverse Events Severity (OrthoSAVES) System. Results The study population comprised 108 patients with “potentially stable” displaced ILMFs; 4 patients (3.7% [95% CI (0.1–7.3%]) experienced AEs requiring revision in the first twelve months after surgery. There were 5 additional patients (4.6%) with functionally significant AEs where revision surgery was not indicated within the first twelve months after surgical fixation. A further 5 patients (4.6%) had AEs managed in the outpatient clinic (grade II); 36 patients (33.3%) required secondary implant removal due to implant-related discomfort. Conclusions Surgical fixation of ILMFs carries a risk of severe AEs, and many patients will subsequently need implant-removal procedures. Further prospective studies are required to ascertain whether non-operative treatment can lower the risk of AEs and the need for additional surgical procedures. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-022-03135-z.
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Black JDJ, Dhillon G, Tadros BJ, Malik-Tabassum K, Southgate C, Dhinsa B. Ultrasonography for the diagnosis of deltoid injury in supination external rotation ankle fractures - A scoping review. Foot (Edinb) 2022; 51:101897. [PMID: 35255405 DOI: 10.1016/j.foot.2021.101897] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 10/19/2021] [Accepted: 12/21/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Lauge-Hansen supination external rotation (SER)-type ankle fractures are very common and account for up to 75% of all ankle fractures. Assessing deltoid integrity is key for surgical decision making. Ultrasound has been used recently to assess the integrity of the deltoid ligament and differentiate between SER II and SER IV fractures. The aim of this article is to review the literature for studies assessing the diagnostic accuracy of ultrasound in this group of patients. METHODS After registering the protocol with PROSPERO, Embase, Ovid MEDLINE, Web of Science Core Collection, and Google Scholar were systematically searched. Studies that satisfied the following inclusion criteria were assessed: (1) Adult patients (>16 years), (2) Acute SER-type ankle fractures assessed within 2 weeks of the injury, (3) Diagnostic accuracy studies. Risk of bias assessment was conducted and a narrative synthesis of the results presented. RESULTS A total of five studies satisfied our inclusion criteria and were included for review. These had a total of 175 patients studied. All studies showed a sensitivity of 100% and specificity of 90-100% for detecting a complete tear of the deltoid. All papers had a significant risk of bias inherent to the design. Only patients undergoing surgery were exposed to the gold standard of operative intervention. CONCLUSION Ultrasound scan has shown excellent diagnostic accuracy for detecting complete deltoid ruptures in SER ankle fractures. These results however should be interpreted with caution. Perhaps a different approach is needed to assess the efficacy of ultrasound scans in patient with SER type fractures.
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Affiliation(s)
| | - Govind Dhillon
- Lister Hospital, East and North Hertfordshire NHS Trust, Coreys Mill Lane, Stevenage, Hertfordshire, SG1 4AB, UK.
| | - Baha John Tadros
- William Harvey Hospital, East Kent Hospitals NHS Trust, Kennington Rd, Willesborough, Ashford, TN24 0LZ, UK.
| | - Khalid Malik-Tabassum
- Royal Surrey County Hospital, Royal Surrey NHS Foundation Trust, Egerton Road, Guildford, Surrey, GU2 7XX, UK.
| | - Crispin Southgate
- William Harvey Hospital, East Kent Hospitals NHS Trust, Kennington Rd, Willesborough, Ashford, TN24 0LZ, UK.
| | - Baljinder Dhinsa
- William Harvey Hospital, East Kent Hospitals NHS Trust, Kennington Rd, Willesborough, Ashford, TN24 0LZ, UK.
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Verhage SM, Leijdesdorff A, Schipper IB, Hoogendoorn JM. Open reduction and internal fixation of the posterior malleolus fragment via the posterolateral approach is radiologically superior to 'A to P' screw fixation. Foot (Edinb) 2022; 51:101894. [PMID: 35255401 DOI: 10.1016/j.foot.2021.101894] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 11/18/2021] [Accepted: 12/21/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Functional outcome in trimalleolar fractures is largely correlated to the reduction of the posterior fragment. Until recently, fixation was mainly performed for large fragments, by percutaneous anterior to posterior ('A to P') screw placement after closed reduction. Nowadays, ORIF via a posterolateral approach seems to gain in popularity. The aim of this study was to compare the postoperative photographs of operated trimalleolar fractures after either fracture treatment method, for fracture diastasis and step-off. MATERIAL AND METHODS All consecutive patients with trimalleolar fractures, including posterior fragments of >5% of the articular surface and operated between 2007-2013 were analysed on size of posterior fragment, post-operative gap and step-off by three observers. The patients were divided into three groups; A to P screw fixation, ORIF via the posterolateral approach and no posterior fragment fixation at all. RESULTS 180 patients with trimalleolar ankle fractures were included for analyses. Twenty five posterior fragments were fixated percutaneously from anterior to posterior (group 1) and 51 underwent open reduction and internal fixation through a posterolateral approach (group 2). 104 patients underwent no posterior malleolus fixation (group 3). The average size of posterior fragment was 34% in group 1, 27% in group 2 and 16% in group 3. A postoperative step-off >1 mm was found in 40% (group 1), 9% (group 2) or 34% respectively (group 3). CONCLUSIONS Fixation of the posterior malleolus through an open posterolateral approach leads to better radiological results as compared to percutaneous 'A to P' screw fixation or no fixation at all.
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Affiliation(s)
- Samuel Marinus Verhage
- Haaglanden Medical Center, Department of Surgery, The Hague, The Netherlands; Leiden University Medical Center, Department of Trauma Surgery, Leiden, The Netherlands.
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Burnett-Jones L, Srinivasan A, Mead A, Malik A. Intervention to Improve Compliance With National Guidelines on Venous Thromboembolism Chemoprophylaxis for Patients With Operatively Managed Ankle Fractures. Ochsner J 2022; 22:319-23. [PMID: 36561096 DOI: 10.31486/toj.22.0038] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: Trauma and subsequent immobilization of the lower limb increase the risk of venous thromboembolism (VTE). Our aim was to evaluate compliance with national guidance on operatively managed ankle fractures and VTE chemoprophylaxis before and after implementation of a change in practice. Methods: We conducted an initial single-center audit of patients undergoing ankle fracture fixation. The primary outcome was quality of operation note documentation, and the secondary outcome was whether VTE chemoprophylaxis was prescribed on discharge. All stakeholders were educated on audit findings, new guidelines were synthesized, and the practice was re-audited. Results: A total of 137 patients were included in the initial audit, and 49 patients were included in the loop closure. The first audit highlighted that chemoprophylaxis prescription on discharge was significantly higher when both the agent and treatment duration were clearly stipulated in the operation note compared to when either treatment duration or both agent and treatment duration were omitted (97.2% vs 51.8% and 32.4%, respectively, P<0.001). Following our intervention, operation note documentation of agent and treatment duration improved from 29% to 90% (P<0.001). VTE chemoprophylaxis on discharge significantly improved from 57% to 98% (P<0.001). Conclusion: Our closed-loop audit identified suboptimal operation note documentation as the root cause of VTE noncompliance. The operation note is an important clinical interface between the operating theater and ward staff. We addressed these deficiencies with a basic intervention.
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Abstract
AIMS The ideal management of acute syndesmotic injuries in elite athletes is controversial. Among several treatment methods used to stabilize the syndesmosis and facilitate healing of the ligaments, the use of suture tape (InternalBrace) has previously been described. The purpose of this study was to analyze the functional outcome, including American Orthopaedic Foot & Ankle Society (AOFAS) scores, knee-to-wall measurements, and the time to return to play in days, of unstable syndesmotic injuries treated with the use of the InternalBrace in elite athletes. METHODS Data on a consecutive group of elite athletes who underwent isolated reconstruction of the anterior inferior tibiofibular ligament using the InternalBrace were collected prospectively. Our patient group consisted of 19 elite male athletes with a mean age of 24.5 years (17 to 52). Isolated injuries were seen in 12 patients while associated injuries were found in seven patients (fibular fracture, medial malleolus fracture, anterior talofibular ligament rupture, and posterior malleolus fracture). All patients had a minimum follow-up period of 17 months (mean 27 months (17 to 35)). RESULTS All patients returned to their pre-injury level of sports activities. One patient developed a delayed union of the medial malleolus. The mean return to play was 62 days (49 to 84) for isolated injuries, while the patients with concomitant injuries returned to play in a mean of 104 days (56 to 196). The AOFAS score returned to 100 postoperatively in all patients. Knee-to-wall measurements were the same as the contralateral side in 18 patients, while one patient lacked 2 cm compared to the contralateral side. CONCLUSION This study suggests the use of the InternalBrace in the management of unstable syndesmotic injuries offers an alternative method of stabilization, with good short-term results, including early return to sports in elite athletes. Cite this article: Bone Joint J 2022;104-B(1):68-75.
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Affiliation(s)
- Nick J Harris
- Spire Leeds Hospital, Leeds, UK.,Carnegie School of Sport, Leeds Becket University, Leeds, UK
| | | | - Ippokratis Pountos
- Academic Department of Trauma and Orthopaedics, University of Leeds, Leeds, UK.,Chapel Allerton Hospital, Leeds Teaching Hospitals, Leeds, UK
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Maluta T, Samaila EM, Amarossi A, Dorigotti A, Ricci M, Vecchini E, Magnan B. Can treatment of posterior malleolus fractures with tibio-fibular instability be usefully addressed by Bartonicek classification? Foot Ankle Surg 2022; 28:126-133. [PMID: 33685829 DOI: 10.1016/j.fas.2021.02.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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: 01/04/2021] [Revised: 02/12/2021] [Accepted: 02/19/2021] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Ankle fractures account for 4% of all fractures and treatment of those involving the Posterior Malleolus remains controversial. Clinical and radiological outcomes in a cohort of patients with Posterior Malleolus fractures conservatively treated were retrospectively evaluated; furthermore, a treatment algorithm was suggested. METHODS Patients were divided according to Bartoníček classification. The clinical evaluation was made with OMAS/AOFAS scores; the radiological evaluation with Van Dijk classification for post-traumatic arthritis. RESULTS Clinical outcome worsened with the severity of Bartoníček classification, but early degenerative changes were not correlated neither to the clinical outcome nor to the injury pattern. Clinical and radiological outcomes depended on the damage of the syndesmosis as articular step-offs and tibio-fibular notch involvement. DISCUSSION We recommend conservative treatment for Bartoníček type I, type II and type III fractures, the latter when undisplaced and without tibial plafond depression. We suggest surgical treatment for type IV and displaced type III fractures.
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Affiliation(s)
- T Maluta
- Department of Orthopedics and Trauma Surgery, University of Verona, Italy
| | - E M Samaila
- Department of Orthopedics and Trauma Surgery, University of Verona, Italy
| | - A Amarossi
- Department of Orthopedics and Trauma Surgery, University of Verona, Italy
| | - A Dorigotti
- Department of Orthopedics and Trauma Surgery, University of Verona, Italy
| | - M Ricci
- Department of Orthopedics and Trauma Surgery, University of Verona, Italy
| | - E Vecchini
- Department of Orthopedics and Trauma Surgery, University of Verona, Italy
| | - B Magnan
- Department of Orthopedics and Trauma Surgery, University of Verona, Italy.
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O'Callaghan WB, Nielsen DEA, Hope MJ, Whitehouse SL, Tan SLE. Ankle fracture management using smartphone multimedia messaging service (MMS) imaging - How reliable and to what point? Foot Ankle Surg 2022; 28:20-24. [PMID: 33500217 DOI: 10.1016/j.fas.2021.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 11/11/2020] [Revised: 12/27/2020] [Accepted: 01/07/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND The use of smartphones and multimedia messaging service (MMS) continues to increase in day to day orthopaedic clinical practice. However, there is limited evidence to support the safe utilisation of MMS. OBJECTIVES The aim of this study was to correlate the performance of MMS imaging to picture archiving and communication systems (PACS) imaging within the setting of diagnosis and management of ankle fractures. METHODS The ankle fracture radiograph series of 82 consecutive patients were evaluated by five orthopaedic consultant specialists. A questionnaire regarding diagnosis and preferred management was completed separately for each patient using smartphone and PACS images. Statistical analysis was performed using Intraclass Correlation Coefficient (ICC). RESULTS Ankle fracture diagnosis showed strong to excellent correlation both inter- and intraobserver MMS vs PACS when using the Weber (0.815, 0.988), Anatomical (0.858, 0.988), and AO classification systems (0.855, 0.985). MMS was less reliable than PACS in determining many management options. CONCLUSION The reliability of ankle fracture classification using MMS image viewing was not significantly different to interpretation on PACS workstations. Smartphone use in ankle fracture classification is supported by this study. Smartphone use was less accurate than PACS in devising management plans and future use should be limited to making only initial plans that must be corroberated with PACS and intraoperative findings prior to definitive fixation.
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Affiliation(s)
| | - David E A Nielsen
- Department of Orthopaedics, Pindara Private Hospital, Gold Coast, Queensland, Australia
| | - Matthew J Hope
- Department of Orthopaedics, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Sarah L Whitehouse
- Orthopaedic Research Unit, Queensland University of Technology, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - S L Ezekiel Tan
- Department of Orthopaedics, Gold Coast University Hospital, Gold Coast, Queensland, Australia
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Xie W, Lu H, Xu H, Quan Y, Liu Y, Fu Z, Zhang D, Jiang B. Morphological analysis of posterior malleolar fractures with intra-articular impacted fragment in computed tomography scans. J Orthop Traumatol 2021; 22:52. [PMID: 34890022 PMCID: PMC8664919 DOI: 10.1186/s10195-021-00615-6] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 11/17/2021] [Indexed: 11/22/2022] Open
Abstract
Background Intraarticular impacted fragment (IAIF) of posterior malleolar fractures has been reported by a few studies. However its location, morphology, and the correlation of posterior malleolar fractures have not been described in detail. The aim of this study was to describe the morphology of IAIF in posterior malleolar fractures, to analyze the related factors between IAIF and posterior malleolar fragments, and explore the treatment of IAIF. Materials and methods Between January 2013 and December 2018, 108 consecutive patients with unilateral posterior malleolar fractures were managed in our hospital. Basic demographic and computed tomography (CT) data were collected and classified by Lauge–Hansen, OTA/AO, Haraguchi, and Mason classification. Additional radiographic data, including the length and area of posterior malleolar fragment, IAIF, and stable tibial plafond were measured. The location of IAIF was described, and involvement of the fibular notch and medial malleolus was also observed. Statistics were analyzed based on univariate analysis (Chi-square test, t-test, Mann–Whitney U test, Fisher’s test) and Spearman’s correlation test. Results Among the 108 cases of posterior malleolar fractures, 75 (69.4%) were with IAIF and 33 (30.6%) cases were without. There were 74 (68.5%) females and 34 (31.5%) males, and the average age of the patients was 49 years (18–89 years). The average LIFN/(LIFN + LSFN) [length of involving fibular notch/(length of involving fibular + length of stable notch fibular notch)] was 32.9% (11.6–64.9%). The APMF/(APMF + ASTP + AIAIF) [area of posterior malleolar fragment/(area of posterior malleolar fragment + area of IAIF + area of stable tibial plafond)] and AIAIF/APMF (area of IAIF/area of posterior malleolar fragment) were 13.1% (0.8–39.7%) and 52.6% (1.2–235.4%), respectively. Involvement of medial malleolus (fracture line extended to medial malleolus, P = 0.022), involvement of fibular notch (P = 0.021), LIFN/(LIFN + LSFN) (P = 0.037), LMPMF (P = 0.004), and APMF were significantly related to the occurrence of IAIF. Conclusion Our research indicates a high incidence of IAIF in posterior malleolar fractures. All IAIFs were found in posterior malleolar, and the most common location was within the lateral area A. Posterior malleolar fracture lines that extend to medial malleolus or fibular notch herald the incidence of IAIF. LIFN/(LIFN + LSFN), LMPMF and APMF are also associated with the incidence of IAIF. CT scans are useful for posterior malleolar fractures to determine the occurrence of IAIF and make operational plans. Operation approach selection should be based on the morphology of posterior malleolar fragments and the location of IAIF. Level of evidence Level III, retrospective case analysis.
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Affiliation(s)
- Wenyong Xie
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Hao Lu
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Hailin Xu
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Yuan Quan
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Yijun Liu
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Zhongguo Fu
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Dianying Zhang
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Baoguo Jiang
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China. .,Trauma Center, National Center for Trauma Medicine, Beijing, 100044, China. .,Key Laboratory of Trauma and Neural Regeneration, Peking University People's Hospital, Beijing, 100044, China.
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Yañez Arauz JM. Minimally invasive treatment of AO B ankle fractures: Surgical technique and long-term outcomes. Foot Ankle Surg 2021; 27:742-749. [PMID: 33097404 DOI: 10.1016/j.fas.2020.09.010] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/22/2020] [Accepted: 09/21/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Ankle fractures are the most common traumatic bone injuries of the lower limb. Over 50% of ankle fractures occur at the syndesmosis level (type AO B). The goal of treatment is to achieve an anatomical reduction and appropriate stabilization. The present study aimed to evaluate the clinical-functional and radiological results, and complications of minimally invasive reduction and fixation technique for ankle fractures type AO B. The surgical technique also is detailed. MATERIAL AND METHODS A prospective analysis of 451 patients undergoing surgery for type AO B displaced ankle fracture was performed. All patients were treated with minimally invasive surgery. The following times were recorded: time between trauma and osteosynthesis, hospitalization length, surgical time, and exposure time to fluoroscopy. Age and gender, mechanism of injury, and characteristics of fractures were recorded. For functional outcome, AOFAS score, VAS, and Weber score were used. Radiographic analysis was performed. The average follow-up was 112 months. RESULTS Mean age was 48.2 years old. Average length of stay in hospital was 5.72 h. Mean duration of the surgery was 32.8 min. Average fluoroscopic exposure time during surgery was 9.25 s. Mean bone union time was 38.2 days. Weber's score was on average 1.5/24 points and the long-term follow-up AOFAS score was on average 97.5/100. Postoperative complications incidence was 2.7%. CONCLUSIONS Distal fibula fixation with the MIPO technique presented good functional outcomes and could be helpful in the avoidance of the complications associated with conventional open reduction and internal fixation. However, it needs more exposition to intraoperative fluoroscopy. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Juan Manuel Yañez Arauz
- Austral University Hospital, Buenos Aires, Argentina; Universidad de Buenos Aires (UBA), Argentina; Austral University, Buenos Aires, Argentina.
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