1
|
Patel S, Dionisopoulos SB. Current Concepts in Ankle Fracture Management. Clin Podiatr Med Surg 2024; 41:519-534. [PMID: 38789168 DOI: 10.1016/j.cpm.2024.01.008] [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] [Indexed: 05/26/2024]
Abstract
Ankle fractures are one of the more common musculoskeletal injuries that are treated by foot and ankle specialists. A thorough understanding of managing these injuries requires the ability to differentiate between stable and unstable fractures. The current literature supports the nonoperative management of stable Weber B ankle fractures, whereas unstable fractures have much better outcomes with surgical intervention. Specifically, we review the fixation strategies for the lateral, medial, and posterior malleolar fractures respectively. Finally, we discuss the current trends in postoperative management of some of the more common fracture patterns, and the safety in early weight-bearing protocols.
Collapse
Affiliation(s)
- Sandeep Patel
- The Permanente Medical Group Diablo Service Area, Department of Orthopedics and Podiatry, San Francisco Bay Area Foot and Ankle Residency, 1425 S. Main Street, Walnut Creek, CA 94596, USA.
| | - Shontal Behan Dionisopoulos
- The Permanente Medical Group Diablo Service Area, Department of Orthopedics and Podiatry, San Francisco Bay Area Foot and Ankle Residency, 1425 S. Main Street, Walnut Creek, CA 94596, USA
| |
Collapse
|
2
|
Aamir J, Caldwell R, Long S, Sreenivasan S, Mavrotas J, Panesa A, Jeevaresan S, Lampridis V, Mason L. A morphological review of medial malleolar fractures - A large single centre series. Foot Ankle Surg 2024:S1268-7731(24)00038-9. [PMID: 38429178 DOI: 10.1016/j.fas.2024.02.012] [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: 06/04/2023] [Revised: 01/23/2024] [Accepted: 02/23/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND Many approaches to management of medial malleolar fractures are described in the literature however, their morphology is under investigated. The aim of this study was to analyse the morphology of medial malleolar fractures to identify any association with medial malleolar fracture non-union or malunion. METHODS Patients who had undergone surgical fixation of their MMF were identified from 2012 to 2022, using electronic patient records. Retrospective analysis of their preoperative, intraoperative, and postoperative radiographs was performed to determine their morphology and prevalence of non-union and malunion. Lauge-Hansen classification was used to characterise ankle fracture morphology and Herscovici classification to characterise MMF morphology. RESULTS A total of 650 patients were identified across a 10-year period which could be included in the study. The overall non-union rate for our cohort was 18.77% (122/650). The overall malunion rate was 6.92% (45/650). Herscovici type A fractures were significantly more frequently mal-reduced at time of surgery as compared to other fracture types (p = .003). Medial wall blowout combined with Hercovici type B fractures showed a significant increase in malunion rate. There is a higher rate of bone union in patients who had been anatomically reduced. CONCLUSION The morphology of medial malleolar fractures does have an impact of the radiological outcome following surgical management. Medial wall blowout fractures were most prevalent in adduction-type injuries; however, it should not be ruled out in rotational injuries with medial wall blowouts combined with and Herscovici type B fractures showing a significant increase in malunions. Herscovici type A fractures had significantly higher malreductions. LEVEL OF EVIDENCE Level 3 - Retrospective Cohort Study.
Collapse
Affiliation(s)
- Junaid Aamir
- Liverpool Orthopaedic Trauma Service, Liverpool University Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Robyn Caldwell
- Liverpool Orthopaedic Trauma Service, Liverpool University Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Sarah Long
- Liverpool Orthopaedic Trauma Service, Liverpool University Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Sachith Sreenivasan
- Liverpool Orthopaedic Trauma Service, Liverpool University Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Jason Mavrotas
- Liverpool Orthopaedic Trauma Service, Liverpool University Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Ayn Panesa
- University of Liverpool, Liverpool, United Kingdom
| | | | - Vasileios Lampridis
- Liverpool Orthopaedic Trauma Service, Liverpool University Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Lyndon Mason
- Liverpool Orthopaedic Trauma Service, Liverpool University Hospital NHS Foundation Trust, Liverpool, United Kingdom; University of Liverpool, Liverpool, United Kingdom.
| |
Collapse
|
3
|
Tsuyuguchi Y, Nakasa T, Ikuta Y, Sumii J, Nekomoto A, Kawabata S, Adachi N. The role of the oblique medial osteotomy angle during osteochondral fragment fixation in patients with a posteromedial osteochondral lesion of the talus. J Orthop Sci 2023; 28:1093-1098. [PMID: 35864028 DOI: 10.1016/j.jos.2022.06.016] [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: 03/10/2022] [Revised: 05/26/2022] [Accepted: 06/27/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Medial malleolar osteotomy has been widely performed for posteromedial osteochondral lesions of the talus (OLT) to expose the lesion. In osteochondral fragment fixation, bioabsorbable pins should be inserted as perpendicular as possible to obtain the rigid fixation. However, the exposure of the lesion may depend on the osteotomy angle, which affects the pin insertion angles. This study aimed to analyze the relationship between pin insertion and osteotomy angles in the medial malleolar osteotomy. METHODS Twenty-four ankles of 23 patients were included. The malleolar bisector angle which was calculated from radiographs and actual osteotomy angles were measured on radiographs, and the pin insertion and osteotomy angles were measured using MRI. The intersection angle was defined by the tangential line of the tibial plafond and medial malleolar articular facet, and the bisector of this angle was defined as the malleolar bisector angle. The relationship between pin insertion and osteotomy angles was analyzed. RESULTS There was no significant difference between the actual osteotomy (55.7° ± 6.6°) and malleolar bisector angles (57.4° ± 4.3°) on the radiograph. There was a significant correlation between pin insertion and osteotomy angles (rs = 0.601). The pin insertion angle (54.3° ± 5.9°) in the lower actual osteotomy angle than the malleolar bisector angle was smaller than those in the higher actual osteotomy angle (63.4° ± 8.2°). CONCLUSIONS This study showed the osteotomy angle affected pin insertion angle. The osteotomy angle should not be smaller than the malleolar bisector angle at medial malleolar osteotomy to insert pins as perpendicular as possible for fixation of posteromedial OLTs.
Collapse
Affiliation(s)
- Yusuke Tsuyuguchi
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minamiku, Hiroshima City, Hiroshima, 734-8551, Japan
| | - Tomoyuki Nakasa
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minamiku, Hiroshima City, Hiroshima, 734-8551, Japan; Medical Center for Translational and Clinical Research, Hiroshima University Hospital, 1-2-3 Kasumi, Minamiku, Hiroshima City, Hiroshima, 734-8551, Japan.
| | - Yasunari Ikuta
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minamiku, Hiroshima City, Hiroshima, 734-8551, Japan
| | - Junichi Sumii
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minamiku, Hiroshima City, Hiroshima, 734-8551, Japan
| | - Akinori Nekomoto
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minamiku, Hiroshima City, Hiroshima, 734-8551, Japan
| | - Shingo Kawabata
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minamiku, Hiroshima City, Hiroshima, 734-8551, Japan
| | - Nobuo Adachi
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minamiku, Hiroshima City, Hiroshima, 734-8551, Japan
| |
Collapse
|
4
|
Bektas YE, Özmanevra R, Cici H, Ciklacandir S, Demirkiran ND, Isler Y, Basci O, Erduran M. A Novel Plate for Vertical Shear Fractures of Medial Malleolus: A Biomechanical Study. J Am Podiatr Med Assoc 2023:1-20. [PMID: 37494299 DOI: 10.7547/22-100] [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] [Indexed: 07/28/2023]
Abstract
BACKGROUND This study aims to evaluate and compare stiffness and the load to failure values of our novel medial malleolus compression plate (MP) and 3,5mm 1/3 tubular plate (TP) in the treatment of vertical shear fractures of medial malleolar fractures. METHODS Fourteen identical synthetic third generation composite polyurethane bone models of right distal tibia were randomly separated into two groups. Fracture models were created with a custom-made osteotomy guide to provide the same fracture characteristics in every sample (AO OTA type 44A2). Fractures were reduced and novel medial malleolus compression plate was applied to bone models in MP group and tubular plate was applied to TP group. All samples were evaluated biomechanically, force/displacement and the load to failure values were recorded. RESULTS The force required to create displacement in MP group was twice of that of the TP group. There was a significant difference between two groups in all amounts of displacement (p = .006, p = .005, p = .007 and .015 for 0.5, 1.0, 1.5, and 2.0 mm, respectively). CONCLUSIONS In the treatment of vertical shear fractures of the medial malleolus, the strength of fixation with the novel medial malleolar compression plate is biomechanically higher than the one-third semi-tubular plate.
Collapse
Affiliation(s)
- Yunus Emre Bektas
- *Gaziemir State Hospital, Orthopedics and Traumatology, Gaziemir, İzmir, Turkey
| | | | - Hakan Cici
- ‡İzmir Atatürk Training and Research Hospital, Orthopedics and Traumatology, Karabaglar, İzmir, Turkey
| | - Samet Ciklacandir
- §İzmir Katip Çelebi University, Biomedical Engineering, İzmir, Turkey
| | | | - Yalcin Isler
- ǁKütahya Health Sciences University, Orthopedics and Traumatology, Kütahya, Turkey
| | - Onur Basci
- ¶Dokuz Eylül University, Orthopedics and Traumatology, İzmir, Turkey
| | - Mehmet Erduran
- ¶Dokuz Eylül University, Orthopedics and Traumatology, İzmir, Turkey
| |
Collapse
|
5
|
Lu H, Liu Y, Xie W, Liang H, Guo H, Quan Y, Zhang B, Zeng C, Xu H. The Reliability and Accuracy of the Medial Malleolar Fracture Classification Based on 3D CT Reconstruction. Orthop Surg 2023. [PMID: 37259971 DOI: 10.1111/os.13754] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 04/14/2023] [Accepted: 04/14/2023] [Indexed: 06/02/2023] Open
Abstract
OBJECTIVE There is a new medial malleolar fracture classification based on 3D CT reconstruction. However, there is no study assessing the reliability and accuracy of the new classification system and comparison between the new and the classic classification. This study aimed to compare the reliability and accuracy of the medial malleolar fracture classification based on 3D CT reconstruction and the Herscovici classification system. METHODS We retrospectively analyzed the consecutive ankle fractures in our hospital from January 2013 to September 2020. Five inexperienced and five experienced orthopedic surgeons were included as observers to assess 68 cases with medial malleolar fractures. Ten evaluators classified the cases according to the two classification systems. The reference results of each case were made by the consensus of three senior trauma surgeons. The interobserver reliability, intraobserver reliability, and accuracy were evaluated at an interval of 6 weeks using Fleiss's kappa (κ) statistics. RESULTS We found substantial interobserver and intraobserver reliability and 81.4% accuracy for the new classification, which was statistically superior to the Herscovici classification (P < 0.05). The reliability and accuracy of both classifications were similar in inexperienced and experienced groups, except for type III in the new classification. The interobserver reliability of type II was the best (P < 0.05), and the intraobserver reliability of IVc ranked the worst (P < 0.05) in the new classification. CONCLUSION The reliability and accuracy of the new classification are superior to the Herscovici classification. Clinical experiences will not affect the assessment of both classification systems in most instances.
Collapse
Affiliation(s)
- Hao Lu
- Department of Orthopaedics and Trauma, Peking University People's Hospital, Beijing, China
| | - Yijun Liu
- Department of Foot and Ankle Surgery, Center for Orthopaedic Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
- Department of Foot and Ankle Surgery, Center for Orthopaedic Surgery, Orthopaedic Hospital of Guangdong Province, Guangzhou, China
| | - Wenyong Xie
- Department of Orthopaedics and Trauma, Peking University People's Hospital, Beijing, China
| | - Hui Liang
- Department of Foot and Ankle Surgery, Center for Orthopaedic Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
- Department of Foot and Ankle Surgery, Center for Orthopaedic Surgery, Orthopaedic Hospital of Guangdong Province, Guangzhou, China
| | - Hao Guo
- Department of Foot and Ankle Surgery, Center for Orthopaedic Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
- Department of Foot and Ankle Surgery, Center for Orthopaedic Surgery, Orthopaedic Hospital of Guangdong Province, Guangzhou, China
| | - Yuan Quan
- Department of Orthopaedics and Trauma, Peking University People's Hospital, Beijing, China
| | - Boyu Zhang
- Department of Orthopaedics and Trauma, Peking University People's Hospital, Beijing, China
| | - Canjun Zeng
- Department of Foot and Ankle Surgery, Center for Orthopaedic Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
- Department of Foot and Ankle Surgery, Center for Orthopaedic Surgery, Orthopaedic Hospital of Guangdong Province, Guangzhou, China
| | - Hailin Xu
- Department of Orthopaedics and Trauma, Peking University People's Hospital, Beijing, China
| |
Collapse
|
6
|
Cho BK, Kim JB, Choi SM. Efficacy of hook-type locking plate and partially threaded cancellous lag screw in the treatment of displaced medial malleolar fractures in elderly patients. Arch Orthop Trauma Surg 2022; 142:2585-2596. [PMID: 34089372 DOI: 10.1007/s00402-021-03945-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 03/04/2021] [Accepted: 05/03/2021] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Traditionally, partially threaded cancellous lag screws (PTCS) are used for most medial malleolar fractures but are often challenging to execute in elderly patients because of the high risk of postoperative complications. Limited literature explores whether hook-type locking compression plates (LCPs) reliably offer better outcomes than PTCS in elderly patients. We aimed to compare the midterm radiologic and clinical outcomes between hook-type LCP and PTCS for medial malleolar fractures in an elderly population. METHODS We included 258 patients, aged 65 years and above, treated with either a hook-type locking plate (hook LCP group: 121 patients) or PTCS (screw group: 137 patients), and with follow-ups of at least 36 months in this retrospective study. Radiographic assessments included the union rate and interval to fracture union. Clinical assessment included the postoperative complications and revision procedures. RESULTS Although a significantly higher rate of comminuted fractures was observed in the hook LCP group than in the screw group (p < .001), no significant difference in the union rate was observed between the two groups (hook LCP group: 93.4% vs. screw group: 89.8%, p = .151), and a significantly shorter interval to union was observed in the hook LCP group (10.2 ± 7.0 vs. 12.3 ± 6.7 weeks, p = .015). There was a trend toward a lower rate of complications, including revision procedures, in the hook LCP group than in the screw group (19.9% vs. 28.5%, p = .107 and 6.6% vs. 13.8%, p = .074). CONCLUSION Hook-type LCP may be an alternative option for treating medial malleolar fractures with comminution in elderly patients.
Collapse
Affiliation(s)
- Byung-Ki Cho
- Department of Orthopaedic Surgery, School of Medicine, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Jun-Beom Kim
- Wellbone Orthopedic Clinic, Daejeon, Republic of Korea
| | - Seung-Myung Choi
- Department of Orthopedic Surgery, Eulji University School of Medicine, Uijeongbu Hospital, 712, Dongil-ro, Uijeongbu-si, Gyeonggi-do, 11759, Republic of Korea.
| |
Collapse
|
7
|
Mazzucchelli RA, Lamdark T, Meier C, Brøns EA. [Anterior intraosseous dislocation of the tibialis posterior muscle tendon : A case report]. Unfallchirurg 2022; 125:999-1002. [PMID: 35179612 DOI: 10.1007/s00113-022-01152-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2022] [Indexed: 11/24/2022]
Abstract
We report the case of a 69-year-old female patient who sustained a traumatic anterior dislocation of the tibialis posterior muscle tendon. A computed tomography (CT) scan demonstrated an osseous avulsion of the flexor retinaculum with the tendon dislocated underneath it. The patient underwent surgical exploration with reduction of the tendon to its anatomical position and screw fixation of the avulsed fragment. The postoperative course showed pain-free mobility and no signs of tibial posterior muscle tendon insufficiency.
Collapse
Affiliation(s)
- Ruben A Mazzucchelli
- Klinik für Orthopädie und Traumatologie, Kantonsspital Winterthur, Brauerstraße 15, 8400, Winterthur, Schweiz.
| | - Tenzin Lamdark
- Klinik für Orthopädie und Traumatologie, Kantonsspital Winterthur, Brauerstraße 15, 8400, Winterthur, Schweiz
| | - Christoph Meier
- Klinik für Orthopädie und Traumatologie, Kantonsspital Winterthur, Brauerstraße 15, 8400, Winterthur, Schweiz
| | - Egil A Brøns
- Klinik für Orthopädie und Traumatologie, Kantonsspital Winterthur, Brauerstraße 15, 8400, Winterthur, Schweiz
| |
Collapse
|
8
|
Choi BS, Lee SH, Kim MB, Lee YH. Mini-Screws-Only Fixation Method for Small Fragments of Medial Malleolus Fractures. Clin Orthop Surg 2021; 13:307-314. [PMID: 34484622 PMCID: PMC8380529 DOI: 10.4055/cios20293] [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: 12/01/2020] [Revised: 01/05/2021] [Accepted: 01/05/2021] [Indexed: 12/03/2022] Open
Abstract
Backgroud Open reduction and internal fixation is the standard treatment for a displaced medial malleolus fracture (MMFx), achieving ankle stability and bony union to prevent post-traumatic arthritis. Previous fixation techniques including tension band wiring and unicortical screw fixation are not optimal for fixation of small fragments in MMFx due to their small size and poor manipulability. Here, we describe a novel surgical method using mini-screws only for fixation of small fragments in MMFx. Methods We conducted a retrospective consecutive study of patients who underwent surgery using mini-screws for small fragment MMFx between April 2013 and March 2018. We reviewed the patients' clinical characteristics and assessed the fracture features radiographically. Clinical outcomes were assessed by measuring the range of motion of both ankle joints and investigating symptomatic implants. We reviewed the radiographic outcomes of the medial malleolus and the functional outcomes using the Foot and Ankle Outcome Score (FAOS) at the last follow-up. Results Nine patients were included in the study. The minimal follow-up period was 27 months. There was no incidental bone breakage during the procedure. All MMFx healed without reduction loss, nonunion, or implant failure at the last follow-up. Two patients had mild osteoarthritic changes of the ankle joint. The mean FAOS score of the patients was 80.99 (range, 65.44–98.42). No patients required removal of the hardware. Conclusions Fixation of comminuted fractures of the medial malleolus using mini-screws for young adult patients is a straightforward and simple technique. Safe fixation of the anterior and posterior colliculi reduces the risk of implant irritation symptoms that necessitate implant removal.
Collapse
Affiliation(s)
- Byung Sun Choi
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Hoo Lee
- Department of Orthopaedic Surgery, Regional Rheumatoid and Degenerative Arthritis Center, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Min Bom Kim
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Young Ho Lee
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
9
|
Hu F, Bu G, Liang J, Huang H, He J. A novel classification for medial malleolar fracture based on the 3-D reconstruction CT. J Orthop Surg Res 2021; 16:538. [PMID: 34454566 PMCID: PMC8400757 DOI: 10.1186/s13018-021-02688-9] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/21/2021] [Indexed: 11/12/2022] Open
Abstract
Background Fracture of the medial malleolus is one of the most frequent injuries treated surgically; however, the classification of the fracture has not attracted much attention and a good classification system is still lacking. Methods Consecutive cases of medial malleolus fractures were prospectively enrolled. Based on the 3-D reconstruction CT morphology and centered on the posterior colliculus of the medial malleolus, we classified the fractures into 4 types: type 1 with no involvement of the posterior colliculus, type 2 with partial involvement of posterior colliculus, type 3 with the entire involvement of posterior colliculus, and type 4 with the fracture line 4 vertically extended from the intercollicular groove to the comminuted fracture of the posterior malleolus. Statistical analyses were performed to evaluate the clinical significance of the classification. Results There were 273 cases prospectively enrolled. The distribution of the cases was type 1 of 12.1%, type 2 of 41.0%, type 3 of 30.0%, and type 4 of 16.8%. Statistics showed that the new classification had significant associations but did not totally depend on the classical ankle fracture classifications. Results showed that the new classification had implications in the severity of ankle fractures. From type 1 to type 4, the ankle joint was more and more unstable. Furthermore, comminuted medial malleolar fractures could be subdivided, and the new classification could provide useful information for surgical decision-making. Conclusions The novel classification was a useful system to describe the 3-D geometry of the fractured medial malleolus. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-021-02688-9.
Collapse
Affiliation(s)
- Fangke Hu
- Orthopedic Department, Tianjin Hospital, Tianjin, 300211, China
| | - Guoyun Bu
- Orthopedic Department, Tianjin Hospital, Tianjin, 300211, China
| | - Jun Liang
- Orthopedic Trauma Department of Foot and Ankle Surgery I, Tianjin Hospital, Tianjin, 300211, China
| | - Haijing Huang
- Orthopedic Trauma Department of Foot and Ankle Surgery I, Tianjin Hospital, Tianjin, 300211, China
| | - Jinquan He
- Orthopedic Trauma Department of Foot and Ankle Surgery I, Tianjin Hospital, Tianjin, 300211, China.
| |
Collapse
|
10
|
Abstract
AIMS The morphology of medial malleolar fracture is highly variable and difficult to characterize without 3D reconstruction. There is also no universally accepeted classification system. Thus, we aimed to characterize fracture patterns of the medial malleolus and propose a classification scheme based on 3D CT reconstruction. METHODS We retrospectively reviewed 537 consecutive cases of ankle fractures involving the medial malleolus treated in our institution. 3D fracture maps were produced by superimposing all the fracture lines onto a standard template. We sliced fracture fragments and the standard template based on selected sagittal and coronal planes to create 2D fracture maps, where angles α and β were measured. Angles α and β were defined as the acute angles formed by the fracture line and the horizontal line on the selected planes. RESULTS A total of 121 ankle fractures were included. We revealed several important fracture features, such as a high correlation between posterior collicular fractures and posteromedial fragments. Moreover, we generalized the fracture geometry into three recurrent patterns on the coronal view of 3D maps (transverse, vertical, and irregular) and five recurrent patterns on the lateral view (transverse, oblique, vertical, Y-shaped, and irregular). According to the fracture geometry on the coronal and lateral view of 3D maps, we subsequently categorized medial malleolar fractures into six types based on the recurrent patterns: anterior collicular fracture (27 type I, 22.3%), posterior collicular fracture (12 type II, 9.9%), concurrent fracture of anterior and posterior colliculus (16 type III, 13.2%), and supra-intercollicular groove fracture (66 type IV, 54.5%). Therewere three variants of type IV fractures: transverse (type IVa), vertical (type IVb), and comminuted fracture (type IVc). The angles α and β varied accordingly. CONCLUSION Our findings yield insight into the characteristics and recurrent patterns of medial malleolar fractures. The proposed classification system is helpful in understanding injury mechanisms and guiding diagnosis, as well as surgical strategies. Cite this article: Bone Joint J 2021;103-B(5):931-938.
Collapse
Affiliation(s)
- Yijun Liu
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, China
| | - Hao Lu
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, China
| | - Hailin Xu
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, China
| | - Wenyong Xie
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, China
| | - Xiaokun Chen
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, China
| | - Zhongguo Fu
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, China
| | - Dianying Zhang
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, China
| | - Baoguo Jiang
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, China
| |
Collapse
|
11
|
Ochman S, Raschke MJ. [Operative treatment of bimalleolar fractures]. Oper Orthop Traumatol 2021; 33:91-103. [PMID: 33760932 DOI: 10.1007/s00064-021-00704-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 04/22/2020] [Revised: 10/03/2020] [Accepted: 11/07/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Anatomical restoration of the function and anatomy of the talocrural joint, anatomical reduction of fractures of the lateral and medial malleoli and to address ligamentous instability when achieving exercise stability. INDICATIONS Dislocated and intra-articular fractures of the lateral and medial malleoli. CONTRAINDICATIONS Infections, peripheral arterial occlusive disease, critical soft tissue conditions. SURGICAL TECHNIQUE Placement in a supine position, lateral and medial access, reduction of the fractures by manipulation of the fragments with Kirschner wires or use of reduction clamps, control of the joint reduction, definitive fixation with traction screws and plate osteosynthesis of the distal fibula, screw, tension-band or plate osteosynthesis of the medial malleolus, in cases of syndesmosis instability exact restoration of the talocrural joint by implantation of adjusting screws, alternatively dynamic fixation with a suture-button system. POSTOPERATIVE MANAGEMENT Movement exercises of the talocrural joint after postoperative day 1, mobilization with partial weight-bearing of the affected leg with 20kg postoperatively for 6-8 weeks, with implantation of adjusting screws removal after 8 weeks and staged increase of weight-bearing, if necessary postoperative insertion of an orthesis. RESULTS The anatomical reconstruction is decisive. Surgically treated bimalleolar fractures show good to excellent long-term results, the increasing number of affected malleoli correlates with a poorer outcome.
Collapse
Affiliation(s)
- Sabine Ochman
- Universitätsklinikum Münster, Albert Schweitzer Campus 1, Gebäude W1, 48149, Münster, Deutschland.
| | - Michael J Raschke
- Universitätsklinikum Münster, Albert Schweitzer Campus 1, Gebäude W1, 48149, Münster, Deutschland
| |
Collapse
|
12
|
Yoshimoto K, Noguchi M, Maruki H, Ishibashi M, Okazaki K. Nonunion of a medial malleolar stress fracture in an adolescent athlete secondary to lateral ankle instability: A case report. Int J Surg Case Rep 2020; 78:235-240. [PMID: 33360975 PMCID: PMC7772367 DOI: 10.1016/j.ijscr.2020.12.043] [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] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 12/15/2020] [Indexed: 11/25/2022] Open
Abstract
A 13-year-old male football player presented with chronic medial left ankle pain. Radiographic examination showed nonunion of the medial malleolar stress fracture and chronic lateral ankle instability. Internal fixation with the arthroscopic modified Broström procedure was performed. The Self-Administered Foot Evaluation Questionnaire improved in all parameters. The method is useful for medial malleolar stress fractures due to chronic lateral ankle instability.
Introduction Medial malleolar stress fractures are relatively uncommon. This report describes the successful treatment of nonunion of a medial malleolar stress fracture due to chronic lateral ankle instability. Presentation of case A 13-year-old middle school student who belonged to a football club presented to our clinic with chronic medial left ankle pain lasting over a year. He had sprained his left ankle several times 6 years earlier. A plain anteroposterior ankle radiograph showed a vertical fracture line in the medial malleolus involving the epiphyseal plate, and computed tomography demonstrated the vertical fracture seen on the plain radiographs and bone sclerosis at the fracture site. We performed internal fixation for nonunion of the medial malleolar stress fracture with arthroscopic modified Broström for lateral ankle instability. Two years after surgery, the Self-Administered Foot Evaluation Questionnaire improved in all parameters, and both the anterior drawer and varus stress tests were negative. Discussion Early diagnosis of medial malleolar stress fracture is important for a rapid return to sports. Magnetic resonance imaging is helpful for early diagnosis. Because lateral ankle instability can cause medial malleolar stress fracture, arthroscopic modified Broström procedure is meaningful for medial malleolar stress fracture with lateral ankle instability. Conclusion Internal fixation and the arthroscopic modified Broström procedure could achieve good clinical outcomes for medial malleolar stress fractures with lateral ankle instability.
Collapse
Affiliation(s)
- Kensei Yoshimoto
- Department of Orthopedic Surgery, Tokyo Women's Medical University, 8-1 Kawadacho, Shinjuku-ku, Tokyo 162-0054, Japan; Orthopaedic Foot and Ankle Center, Shiseikai Daini Hospital, 5-19-1 Kamisoshigaya, Setagaya-ku, Tokyo, 157-8550, Japan
| | - Masahiko Noguchi
- Department of Orthopedic Surgery, Tokyo Women's Medical University, 8-1 Kawadacho, Shinjuku-ku, Tokyo 162-0054, Japan; Orthopaedic Foot and Ankle Center, Shiseikai Daini Hospital, 5-19-1 Kamisoshigaya, Setagaya-ku, Tokyo, 157-8550, Japan; Orthopedic Foot and Ankle Center, Daisan, Kitashinagawa Hospital, 3-3-7 Kitashinagawa, Shinagawa-ku, Tokyo 140-0001, Japan.
| | - Hideyuki Maruki
- Orthopaedic Foot and Ankle Center, Shiseikai Daini Hospital, 5-19-1 Kamisoshigaya, Setagaya-ku, Tokyo, 157-8550, Japan
| | - Mina Ishibashi
- Orthopaedic Foot and Ankle Center, Shiseikai Daini Hospital, 5-19-1 Kamisoshigaya, Setagaya-ku, Tokyo, 157-8550, Japan
| | - Ken Okazaki
- Department of Orthopedic Surgery, Tokyo Women's Medical University, 8-1 Kawadacho, Shinjuku-ku, Tokyo 162-0054, Japan
| |
Collapse
|
13
|
Sayyed-Hosseinian SH, Bagheri F, Ebrahimzadeh MH, Moradi A, Golshan S. Comparison of Partially Threaded and Fully Threaded 4mm Cancellous Screws in Fixation of Medial Malleolar Fractures. Arch Bone Jt Surg 2020; 8:710-715. [PMID: 33313352 DOI: 10.22038/abjs.2020.46112.2263] [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] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Several devices have been described for fixation of displaced medial malleolar fractures. Fully threaded cancellous screws engaging the bone may provide advantages compared to partially threaded screws. This study was designed to compare the clinical results of fully and partially threaded 4 millimeter cancellous screws in fixation of medial malleolar fractures. Methods In a randomized clinical trial study 44 patients with displaced closed medial malleolar fractures were randomly divided into two groups. Two fully threaded four millimeter cancellous screws were used for fracture stabilization (FT group) in the first group, while, the second group was operated by use of two partially threaded four millimeter cancellous screws (PT group). The clinical outcomes and complications were compared in two groups at one year follow up. Results Nineteen patients in FT group and 21 in PT group were present at final follow up. Nonunion was not developed in either group but two cases (9%) of delayed union occurred in PT group. The rate of postoperative infection and symptomatic hardware were not statistically different. Functional assessment using AOFAS, MOXFQ and VAS scores showed no significant difference between the two groups. Conclusion Both fully and partially threaded 4 mm cancellous screws can be considered as acceptable devices for the fixation of medial malleolar fractures with good and comparable clinical results.
Collapse
Affiliation(s)
| | - Farshid Bagheri
- Orthopedic Research Center, Shahid Kamyab Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Ali Moradi
- Orthopedic Research Center Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sogol Golshan
- Orthopedic Research Center, Shahid Kamyab Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| |
Collapse
|
14
|
He JQ, Ma XL, Xin JY, Cao HB, Li N, Sun ZH, Wang GX, Fu X, Zhao B, Hu FK. Pathoanatomy and Injury Mechanism of Typical Maisonneuve Fracture. Orthop Surg 2020; 12:1644-1651. [PMID: 32896104 PMCID: PMC7767678 DOI: 10.1111/os.12733] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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: 03/10/2020] [Revised: 04/22/2020] [Accepted: 06/01/2020] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE Maisonneuve fracture is a special type of injury which are rare in clinic. The manifestation of such fractures is variable. The aim of this study is to describe the pathoanatomical features of typical Maisonneuve fracture on the basis of radiographs, computed tomography (CT) scans, magnetic resonance imaging (MRI), and intraoperative exploration findings, and to investigate the injury mechanism of this variety. METHODS The data of 41 patients with Maisonneuve fracture from April 2014 to September 2019 were retrospectively analyzed. There were 32 males and nine females, the average age was 37.9 years (range, 18 to 61 years), the fractures occurred on the left side in 20 patients and on the right side in 21 patients. The cause of injuries were traffic accident in five patients, sprain injury in 20 patients, and falling injury from height in 16 patients. All patients underwent posteroanterior and lateral X-ray examinations of the ankle and calf. CT scan of the ankle was performed in 38 patients, including three-dimensional reconstruction in 33 patients. MRI examination of the ankle and calf was performed in 28 and five patients, respectively. Forty patients were treated with open reduction and internal fixation. The features of proximal fibular fracture, injuries of the medial and posterior structures of the ankle, injuries of the anterior inferior tibiofibular ligament and the interosseous membrane were recorded and analyzed. RESULTS Forty-one patients had proximal one-third fractures of the fibula including six patients with fracture involving the fibular neck, 30 with proximal one-third fractures of the fibular shaft, and five with proximal-medial one-third junction fracture of the fibular shaft. Thirty-five patients (35/41, 85.37%) with injury of posterior structures, 34 patients had posterior malleolar fracture (34/41, 82.93%), and one patient had posterior inferior tibiofibular ligament rupture (1/41, 2.44%). There were 20 patients with type I fracture, four patients with type II fracture, and 10 patients with type III fracture according to the Haraguchi classification of posterior malleolus fracture. The fracture of the medial malleolus was in 30 patients (30/41, 73.17%), rupture of the deltoid ligament was in 10 patients (10/41, 24.39%), and medial structures intact were in one patient (1/41, 2.44%). All 41 patients had injury of the anterior inferior tibiofibular ligament. CONCLUSIONS Maisonneuve fracture is characterized by fractures of the proximal fibula and the complete rupture of the anterior inferior tibiofibular ligament. Pronation-external rotation is the main injury mechanism. The manifestations of typical Maisonneuve fracture including that the fibular fracture located in proximal one-third diaphysis and the fracture line was from anterosuperior to posteroinferior.
Collapse
Affiliation(s)
- Jin-Quan He
- The First Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, China
| | - Xin-Long Ma
- The First Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, China
| | - Jing-Yi Xin
- The First Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, China
| | - Hong-Bin Cao
- The First Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, China
| | - Nan Li
- The First Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, China
| | - Zhen-Hui Sun
- The First Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, China
| | - Gui-Xin Wang
- The First Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, China
| | - Xin Fu
- The First Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, China
| | - Bin Zhao
- The First Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, China
| | - Fang-Ke Hu
- The First Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, China
| |
Collapse
|
15
|
Oesman I, Nugroho A. A rare combination of closed fracture of right talar body Sneppen 2 with associated medial malleolus: A case report. Int J Surg Case Rep 2019; 65:20-6. [PMID: 31678695 DOI: 10.1016/j.ijscr.2019.10.010] [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] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 10/03/2019] [Accepted: 10/07/2019] [Indexed: 12/02/2022] Open
Abstract
Talar fractures are uncommon. Anatomic and stable reduction of talar fractures is of paramount importance. ORIF plate screw and ORIF TBW can be used to treat talar fracture. Good prognosis can be achieved by ORIF plate screw and ORIF TBW.
Introduction Ankle fractures are common, with the incidence of up to 174 cases per 100,000 adults per year. The talus, the second largest tarsal bone, has distinctive imaging characteristics and injury patterns. The combination of talar body fracture in sagittal plane along with medial malleolus fracture is an unusual pattern of injury and rarely reported in the literature. Presentation of case We presented a case of nineteen-year old male with pain on the right ankle as a result from motorcycle accident twelve hours before admitted to Cipto Mangunkusumo Hospital. After the patient underwent close reduction and immobilization using back slab, patient then underwent open reduction surgery of the right ankle then fixated using plate and screw combined by tension band wiring (TBW) at the right medial malleolus. Discussion Talar and Medial malleolus fracture was initially evaluated by physical examination and radiographic imaging and classified by Sneppen classification. After the diagnosis was established the patient underwent ORIF plate, screw and tension band wiring. In post-operative x-ray examination, there was a significant improvement in talocrural angle and medial clear space but same result in tibiofibular overlap and tibiofibular. Conclusion Open reduction and internal fixation (ORIF) plate and screw combined by tension band wiring (TBW) is the right surgical treatment for patient with closed fracture of right talar body Sneppen 2 with associated medial malleolus fracture. The outcome of the treatment is excellent because the patient presented was able to fully recover to normal activity.
Collapse
|
16
|
Carter TH, Oliver WM, Graham C, Duckworth AD, White TO. Medial malleolus: Operative Or Non-operative (MOON) trial protocol - a prospective randomised controlled trial of operative versus non-operative management of associated medial malleolus fractures in unstable fractures of the ankle. Trials 2019; 20:565. [PMID: 31514744 PMCID: PMC6739910 DOI: 10.1186/s13063-019-3642-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 08/09/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND There are limited data reporting the outcome of patients with non-operatively managed medial malleolus fractures compared to those treated surgically in the presence of fibular stabilisation for unstable fractures of the ankle. Conservative management could result in fewer complications, reduced surgical time and lower cost. The purpose of this study is to determine if any difference exists in patient reported and surgical outcomes 1 year after surgery between operative and non-operative treatment of medial malleolar fractures in combination with stabilisation of the lateral malleolus. METHODS/DESIGN This is a single-centre, prospective, randomised controlled trial that aims to randomise 154 participants with an unstable ankle fracture to 'non-fixation' (n = 77) or 'fixation' (n = 77) of an associated well-reduced medial malleolus fracture following fibular stabilisation. The study will include patients ≥ 16 years of age with a closed bimalleolar or trimalleolar ankle fracture who are able to consent, complete questionnaires in the English language, and complete follow-up over a 1-year period. Randomisation will occur intra-operatively when the medial malleolus fracture is deemed 'well-reduced', with 2 mm or less of fluoroscopic displacement. The technique for fixation of both the medial and lateral malleoli is at the discretion of the operating surgeon. Patient-reported, observer-rated, and radiographic assessments will be collected at baseline and then at the following post-operative assessment points: 2 weeks, 6 weeks and 1 year. Postal questionnaire outcome data will be collected at 3 and 6 months. The primary outcome measure will be the Olerud Molander Ankle Score (OMAS) at 1 year following surgery. Secondary outcome measures will include the Manchester-Oxford Foot Questionnaire (MOXFQ), EuroQol-5D (EQ-5D), pain, treatment satisfaction, time to return to activity, operative tourniquet time, and complications. DISCUSSION There is only one previous randomised trial comparing non-fixation with fixation of associated medial malleolus fractures but that was limited by the lack of baseline patient-reported outcome data and an inferior sample size. This current prospective trial aims to provide high-quality evidence regarding the requirement for medial malleolar fixation in unstable ankle fractures. TRIAL REGISTRATION ClinicalTrials.gov, NCT03362229 . Registered retrospectively on 5 December 2017.
Collapse
Affiliation(s)
- Thomas H Carter
- Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, UK.
| | - William M Oliver
- Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Catriona Graham
- Wellcome Trust Clinical Research Facility, Western General Hospital, Edinburgh, EH4 2XU, UK
| | - Andrew D Duckworth
- Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Timothy O White
- Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, UK
| |
Collapse
|
17
|
Nguyen A, Beasley I, Calder J. Stress fractures of the medial malleolus in the professional soccer player demonstrate excellent outcomes when treated with open reduction internal fixation and arthroscopic spur debridement. Knee Surg Sports Traumatol Arthrosc 2019; 27:2884-9. [PMID: 30915513 DOI: 10.1007/s00167-019-05483-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 09/10/2018] [Accepted: 03/08/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE Despite a debilitating effect on athletic performance and an incidence of up to 4% of all stress fractures, there have been only 31 documented cases of medial malleolus stress fractures (MMSF) to our knowledge in the literature. The largest series to date is presented in this study, of 16 professional soccer players undergoing uniform operative treatment. The authors attempt to justify their preferred treatment of MMSFs in the professional soccer player, with an emphasis on patient satisfaction, clinical and radiographic union, and return to high level sport. The authors aim to prove an association between lower limb varus alignment and the development of MMSFs. METHOD Sixteen professional soccer players of mean age 23.6 years were analysed. A biomechanic assessment was performed. Preoperative CT+-MRI scan were performed to assess fracture lines and the presence of anteromedial tibial and/or talar spurs; which are the likely pathognomic lesion in the development of MMSFs. All patients underwent open reduction and internal fixation with three screws, as well as arthroscopic debridement of impringement spurs, and concentrated bone marrow aspirate into the fracture site. Patients completed the Ogilvie-Harris score, and all patients had CT scans at 3 months and until union. RESULTS All the patients in this cohort had causative bony spurs that were debrided at surgery. All of the cohort achieved clinical union. All patients were able to return to professional football; at the same level as prior to the injury. There was complete cohort follow up; and 81% of patients were graded as excellent and 19% as good by the Ogilvie-Harris score. We noted 50% of our cohort demonstrated varus malalignment, either genu varum or hindfoot varus. CONCLUSIONS The authors conclude that open reduction and internal fixation of MMSFs with screws combined with arthroscopic spur debridement results in excellent clinical outcomes. It can be concluded that varus lower limb malalignment is a risk factor for MMSFs. Given the treatment controversy for these injuries, the results herein demonstrate that aggressive multimodal operative treatment produces excellent outcomes in high demand professional footballers. This study is the first to report a biomechanic association, which can alert the clinician to preventative measures; such as hindfoot orthoses. LEVEL OF EVIDENCE IV.
Collapse
|
18
|
Kolitsch D, Einicke F, Hofmann GO, Mendel T. [Surgical treatment strategy for traumatic luxation of the posterior tibial tendon : Case report and literature review]. Unfallchirurg 2019; 122:901-904. [PMID: 31407025 DOI: 10.1007/s00113-019-0695-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Based on a case study, the injury pattern and surgical procedure for traumatic dislocation of the posterior tibial tendon is presented. A 32-year-old ice hockey player suffered a direct impact from a puck at the dorsomedial aspect of the inner ankle. In the course of the injury a ganglion developed due to recurrent dislocation of the posterior tibial tendon. Intraoperatively, a distracted retinaculum and a flattened retromalleolar sulcus were present. An open wedge osteotomy and suture anchor refixation of the retinaculum were performed. This procedure is described in the context of a review of the literature.
Collapse
Affiliation(s)
- D Kolitsch
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost Halle gGmbH, Merseburger Straße 165, 06112, Halle (Saale), Deutschland.
| | - F Einicke
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost Halle gGmbH, Merseburger Straße 165, 06112, Halle (Saale), Deutschland
| | - G O Hofmann
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost Halle gGmbH, Merseburger Straße 165, 06112, Halle (Saale), Deutschland.,Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Jena, Erlanger Allee, 07747, Jena, Deutschland
| | - T Mendel
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost Halle gGmbH, Merseburger Straße 165, 06112, Halle (Saale), Deutschland.,Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Jena, Erlanger Allee, 07747, Jena, Deutschland
| |
Collapse
|
19
|
Abstract
The medial malleolus, once believed to be the primary stabilizer of the ankle, has been the topic of conflicting clinical and biomechanical data for many decades. Despite the relevant surgical anatomy being understood for almost 40 years, the optimal treatment of medial malleolar fractures remains unclear, whether the injury occurs in isolation or as part of an unstable bi- or trimalleolar fracture configuration. Traditional teaching recommends open reduction and fixation of medial malleolar fractures that are part of an unstable injury. However, there is recent evidence to suggest that nonoperative management of well-reduced fractures may result in equivalent outcomes, but without the morbidity associated with surgery. This review gives an update on the relevant anatomy and classification systems for medial malleolar fractures and an overview of the current literature regarding their management, including surgical approaches and the choice of implants. Cite this article: Bone Joint J 2019;101-B:512-521.
Collapse
Affiliation(s)
- T H Carter
- Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - T O White
- Royal Infirmary of Edinburgh, Edinburgh, UK
| |
Collapse
|
20
|
Carter TH, Mackenzie SP, Bell KR, Hollyer MA, Gill EC, MacDonald DJ, Duckworth AD, White TO. Selective fixation of the medial malleolus in unstable ankle fractures. Injury 2019; 50:983-989. [PMID: 30879641 DOI: 10.1016/j.injury.2019.03.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 09/10/2018] [Revised: 02/23/2019] [Accepted: 03/09/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Whilst the lateral malleolus appears to be crucial in controlling anatomical reduction of the talus, the role of the medial malleolus is less clear. Medial sided complications including infection, damage to local structures and symptomatic hardware are not without morbidity. This study compares the outcomes of patients with bimalleolar or trimalleolar ankle fractures who underwent fibular nail stabilisation with or without medial malleolar fixation. METHODS From a prospective single-centre trauma database, we identified 342 patients over a nine-year period who underwent fibular nail insertion to stabilise a bimalleolar or trimalleolar ankle fracture. Isolated lateral malleolar fractures were excluded. Demographic data, clinical outcomes, radiographic evaluation, return to work and sport, and patient reported outcomes, including Olerud-Molander Ankle Score (OMAS), EuroQol-5D (EQ-5D) and Manchester-Oxford Foot Questionnaire (MOXFQ) were collected. RESULTS This study included 247 patients with a mean age of 66.7 years (range, 25-96 years), of whom 200 were female (81%). Medial malleolar fixation was not performed in 54 cases (22%). There was no significant difference between groups with respect to failure of fixation (p = 0.634) or loss of talar reduction (p = 0.157). No patient required surgery for a symptomatic medial malleolar non-union. Medial sided complications occurred in 32 (16%) of the fixation group, of whom 20 (10%) required further surgery. At a mean mid-term follow-up of 4.8 years (range, 8 months - 9 years) there was no significant difference between the non-fixation and fixation groups with respect to the median OMAS (85 vs 80; p = 0.885) or median EQ-5D (0.80 vs 0.81; p = 0.846). Patient satisfaction was not significantly different between the two groups (85/100 vs 87/100; p = 0.410). CONCLUSION Non-operative management of the medial malleolar component of an unstable ankle fracture treated with a fibular nail may reduce the rate of post-operative complications without compromising the patient reported outcome.
Collapse
Affiliation(s)
- Thomas H Carter
- Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, United Kingdom.
| | - Samuel P Mackenzie
- Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, United Kingdom
| | - Katrina R Bell
- Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, United Kingdom
| | - Marcus A Hollyer
- Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, United Kingdom
| | - Emma C Gill
- Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, United Kingdom
| | - Deborah J MacDonald
- Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, United Kingdom
| | - Andrew D Duckworth
- Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, United Kingdom
| | - Timothy O White
- Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, United Kingdom
| |
Collapse
|
21
|
Abstract
As the geriatric population and associated ankle fractures continues to increase, fracture surgeons should be prepared to surgically manage osteoporotic ankle fractures. There are abundant challenges in management, soft tissue care, and fixation of ankle fractures with poor bone quality especially in elderly patients who have difficulty limiting weight bearing. This article summarizes several different surgical techniques that can be used to optimize outcomes of these fractures.
Collapse
Affiliation(s)
- Raymond Y Hsu
- Department of Orthopedic Surgery, The Warren Alpert Medical School at Brown University, 1 Kettle Point Avenue, East Providence, RI 02915, USA.
| | - Jose M Ramirez
- Department of Orthopedic Surgery, The Warren Alpert Medical School at Brown University, 593 Eddy Street, Providence, RI 02903, USA
| | - Brad D Blankenhorn
- Department of Orthopedic Surgery, The Warren Alpert Medical School at Brown University, 1 Kettle Point Avenue, East Providence, RI 02915, USA
| |
Collapse
|
22
|
Corey RM, Cannada LK, Bledsoe G, Israel H. Biomechanical evaluation of medial malleolus fractures treated with headless compression screws. J Clin Orthop Trauma 2019; 10:310-314. [PMID: 30828200 PMCID: PMC6383165 DOI: 10.1016/j.jcot.2018.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 04/15/2018] [Accepted: 04/19/2018] [Indexed: 10/17/2022] Open
Abstract
PURPOSE The gold standard for fixation of medial malleolus fractures has yet to be determined. Most agree the best results of displaced unstable ankle fractures are with open reduction and internal fixation. Hardware irritation necessitating screw removal is a known complication. An alternative fixation method of medial malleolar fractures has been described using headless compression screws. There are currently no biomechanical studies that assess the stability of this method. The purpose of the study is to complete a biomechanical evaluation of partially threaded cancellous screws (PT) and headless compression screws (HC) in an external rotation ankle fracture model. METHODS Composite polyurethane sawbone models of tibia were obtained. A custom jig was created to ensure identical osteotomies. The models were fixed with either two partially threaded cancellous screws or two headless compression screws. The models were fitted into the Material Test System (MTS) machine and the force transducer was programed to apply axial offset. The two constructs were loaded until 5 mm of displacement occurred, our defined point of failure. The amount of force (Newtons) necessary to create fracture line displacement was recorded for each model. RESULTS The axial rotational force to create facture displacement between 1 mm and 3 mm, between 1 mm and 5 mm, and between 3 mm and 5 mm were statistically significant (p < 0.05) for both models. The mean axial rotational force measured in Newtons at 1 mm, 3 mm, and 5 mm of displacement for the PT was 149.32, 244.19 and 477.76 respectively. The mean axial rotational force measured in Newtons at 1 mm, 3 mm, and 5 mm of displacement for the HC was 152.05, 224.07, and 498.31 respectively. CONCLUSION No statistically significant difference was found between the biomechanical properties of partially threaded cancellous screws and headless compression screws used in the fixation of medial malleolus fractures. These results support HC screws as a viable alternative in a biomechanical model of medial malleolus fractures.
Collapse
Affiliation(s)
- Robert M. Corey
- Department of Orthopaedics, Saint Louis University, United States
| | - Lisa K. Cannada
- Department of Orthopaedics, Saint Louis University, United States,Corresponding author at: Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 3635 Vista Avenue, 7th Floor Desloge Towers, St. Louis, MO, 63110, United States.
| | - Gary Bledsoe
- Parks College of Engineering, Saint Louis University, United States
| | - Heidi Israel
- Department of Orthopaedics, Saint Louis University, United States
| |
Collapse
|
23
|
Cheng RZ, Wegner AM, Behn AW, Amanatullah DF. Headless compression screw for horizontal medial malleolus fractures. Clin Biomech (Bristol, Avon) 2018; 55:1-6. [PMID: 29604557 DOI: 10.1016/j.clinbiomech.2018.03.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [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: 06/22/2017] [Revised: 03/21/2018] [Accepted: 03/26/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Horizontal medial malleolus fractures are caused by the application of rotational force through the ankle joint in several orientations. Multiple techniques are available for the fixation of medial malleolar fractures. METHODS Horizontal medial malleolus osteotomies were performed in eighteen synthetic distal tibiae and randomized into two fixation groups: 1) two parallel unicortical cancellous screws or 2) two Acutrak 2 headless compression screws. Specimens were subjected to offset axial tension loading. Frontal plane interfragmentary motion was monitored. FINDINGS The headless compression group (1699 (SD 947) N/mm) had significantly greater proximal-distal stiffness than the unicortical group (668 (SD 298) N/mm), (P = 0.012). Similarly, the headless compression group (604 (SD 148) N/mm) had significantly greater medial-lateral stiffness than the unicortical group (281 (SD 152) N/mm), (P < 0.001). The force at 2 mm of lateral displacement was significantly greater in the headless compression group (955 (SD 79) N) compared to the unicortical group (679 (SD 198) N), (P = 0.003). At 2 mm of distal displacement, the mean force was higher in the headless compression group (1037 (SD 122) N) compared to the unicortical group (729 (SD 229) N), but the difference was not significant (P = 0.131). INTERPRETATION A headless compression screw construct was significantly stiffer in both the proximal-distal and medial-lateral directions, indicating greater resistance to both axial and shear loading. Additionally, they had significantly greater load at clinical failure based on lateral displacement. The low-profile design of the headless compression screw minimizes soft tissue irritation and reduces need for implant removal.
Collapse
Affiliation(s)
- Robin Z Cheng
- Stanford University School of Medicine, Stanford, CA, USA
| | - Adam M Wegner
- University of California Davis Medical Center, Sacramento, CA, USA
| | - Anthony W Behn
- Stanford University School of Medicine, Stanford, CA, USA
| | | |
Collapse
|
24
|
Aitken SA, Johnston I, Jennings AC, Chua ITH, Buckley RE. An evaluation of the Herscovici classification for fractures of the medial malleolus. Foot Ankle Surg 2017; 23:317-20. [PMID: 29202995 DOI: 10.1016/j.fas.2016.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [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: 06/16/2016] [Revised: 10/03/2016] [Accepted: 10/24/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Despite its use in the literature, the application of the Herscovici classification system for medial malleolus fractures has not been evaluated. METHODS We aimed to determine the reliability and accuracy of the Herscovici classification. The blinded radiographs of 130 patients were independently classified by four orthopaedic trauma surgeons. We held a consensus meeting where observers agreed on a final classification and this served as our reference standard. We used weighted kappa (κ) coefficients of agreement. RESULTS Twenty-four fractures (18%) were deemed unclassifiable. The classification system demonstrated moderate inter-observer reliability (κ=0.54, 95% CI 0.40-0.68) but substantial reproducibility (κ=0.64, 95% CI 0.51-0.79). Accuracy, when compared with the reference standard, was κ=0.54 (95% CI 0.40-0.66). CONCLUSIONS The obliquity of the fracture line, and fracture extension, created difficulty in classification in 26% of cases. 18% of our cases could not be classified by majority decision. Our results emphasise the challenges faced in classifying these fractures. Future work should focus on refining the Herscovici classification.
Collapse
|
25
|
Hanhisuanto S, Kortekangas T, Pakarinen H, Flinkkilä T, Leskelä HV. The functional outcome and quality of life after treatment of isolated medial malleolar fractures. Foot Ankle Surg 2017; 23:225-229. [PMID: 29202979 DOI: 10.1016/j.fas.2016.06.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [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: 04/01/2016] [Revised: 06/05/2016] [Accepted: 06/05/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND The optimal treatment of isolated medial malleolar fractures is widely debated. The aim of this study is to analyse the different treatment methods. METHODS The study included 137 patients with an isolated medial malleolar fracture treated at our hospital between 2000 and 2010. Functional outcome was assessed using Olerud-Molander score and health-related quality-of-life (HRQoL) was measured with RAND36 item health survey. Patients were sent follow-up questionnaires after an average of 9.5 years (4.3-15.2) from the date of treatment. RESULTS The overall improvement in function was equivalent in both operative and non-operative treatment groups. However, the outcome scores declined in both groups as the primary displacement increased, regardless of the treatment method. HRQoL was similar in both groups. CONCLUSIONS If maximal fracture displacement is ≤2mm, isolated medial malleolar fractures can be treated non-operatively with good outcome, but the operative treatment may also be performed without serious complications. The degree of fracture displacement is an independent risk factor for inferior functional result, regardless of the treatment method. LEVEL OF EVIDENCE Therapeutic level of evidence: IV, retrospective cohort study.
Collapse
Affiliation(s)
- Sini Hanhisuanto
- Oulu University Hospital, Department of Surgery, Division of Orthopedic and Trauma Surgery, Oulu, Finland.
| | - Tero Kortekangas
- Oulu University Hospital, Department of Surgery, Division of Orthopedic and Trauma Surgery, Oulu, Finland
| | - Harri Pakarinen
- Oulu University Hospital, Department of Surgery, Division of Orthopedic and Trauma Surgery, Oulu, Finland
| | - Tapio Flinkkilä
- Oulu University Hospital, Department of Surgery, Division of Orthopedic and Trauma Surgery, Oulu, Finland
| | - Hannu-Ville Leskelä
- Oulu University Hospital, Department of Surgery, Division of Orthopedic and Trauma Surgery, Oulu, Finland
| |
Collapse
|
26
|
Turati M, Glard Y, Griffet J, Afonso D, Courvoisier A, Bigoni M. Osteochondrosis of the medial malleolar epiphysis: A case report and review of the literature. Int J Surg Case Rep 2017; 39:176-180. [PMID: 28846950 PMCID: PMC5573787 DOI: 10.1016/j.ijscr.2017.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 08/05/2017] [Accepted: 08/08/2017] [Indexed: 11/26/2022] Open
Abstract
Presentation and management of medial malleolar osteochondrosis based on our experience and a complete literature review. All ossification centres are predisposed to develop osteochondrosis: we report a rare case of this painful condition. The first review of all described cases of medial malleolar osteochondrosis. In a pediatric ankle pain medial malleolar osteochondrosis should be considered in the differential diagnosis. A complete clinical and radiological description of a rare case of medial malleolar osteochondrosis.
Introduction Osteochondrosis is characterized by a disturbance of enchondral ossification in skeletally immature patients and should be investigated in children having a history of persistent foot and ankle pain. Involvement of the medial malleolar epiphysis is rarely reported. Presentation of case We describe the case of a sporty 12-year-old male with osteochondrosis of the left medial malleolar epiphysis treated with a conservative management. Discussion Calcanear, navicular and metatarsal apophysis are the most common locations for osteochondrosis in ankle and foot. Anyway other osteochondrosis should be excluded. Medial malleolar osteochondrosis is occasionally described. We performed a review of the relevant literature and we summarized clinical aspects, radiological characteristics and reported management of this painful and probably underestimated condition. Conclusion Medial malleolar osteochondrosis is a rare but well recognized condition. Only seven cases are described in literature.
Collapse
Affiliation(s)
- Marco Turati
- Department of Paediatric Orthopedic Surgery, University Hospital Grenoble-Alpes, University Grenoble-Alpes, France; Orthopedic Department, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy.
| | - Yann Glard
- Department of Paediatric Orthopaedics, Saint Joseph Hospital, Marseille, France
| | - Jacques Griffet
- Department of Paediatric Orthopedic Surgery, University Hospital Grenoble-Alpes, University Grenoble-Alpes, France
| | - David Afonso
- Department of Paediatric Orthopaedics, Saint Joseph Hospital, Marseille, France
| | - Aurélien Courvoisier
- Department of Paediatric Orthopedic Surgery, University Hospital Grenoble-Alpes, University Grenoble-Alpes, France
| | - Marco Bigoni
- Orthopedic Department, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, 20900 Monza, Italy
| |
Collapse
|
27
|
Turan A, Kose O, Acar B, Unal M. Posterior tibial tendon impingement due to os subtibiale: a case report and up-to-date review. Skeletal Radiol 2017; 46:705-714. [PMID: 28255943 DOI: 10.1007/s00256-017-2601-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 11/08/2016] [Revised: 02/06/2017] [Accepted: 02/08/2017] [Indexed: 02/02/2023]
Abstract
Os subtibiale is a rare accessory ossicle located at the tip of the medial malleolus. Although this small ossicle usually has no clinical significance, in some cases it may be a source of ankle pain. Symptomatic os subtibiale is an extremely rare diagnosis, and few cases have been reported to date. The case presented is of a 35-year-old female patient with symptomatic os subtibiale, with a discussion of the diagnosis, clinical findings, and treatment options.
Collapse
Affiliation(s)
- Adil Turan
- Orthopedics and Traumatology Department, Antalya Training and Research Hospital, Antalya, Turkey
| | - Ozkan Kose
- Orthopedics and Traumatology Department, Antalya Training and Research Hospital, Antalya, Turkey.
- Kazım Karabekir cd. Antalya Eğitim ve Araştırma Hastanesi, 07100, Soğuksu Muratpaşa, Antalya, Turkey.
| | - Baver Acar
- Orthopedics and Traumatology Department, Antalya Training and Research Hospital, Antalya, Turkey
| | - Melih Unal
- Orthopedics and Traumatology Department, Antalya Training and Research Hospital, Antalya, Turkey
| |
Collapse
|
28
|
Xu G, Su R, Lv J, Hu B, Gu H, Li X, Gu J, Yu X. Anterior wrist and medial malleolus as the novel sites of tissue selection: a retrospective study on electric shock death through the hand-to-foot circuit pathway. Int J Legal Med 2017; 131:677-683. [PMID: 28058573 DOI: 10.1007/s00414-016-1527-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 09/27/2016] [Accepted: 12/28/2016] [Indexed: 02/05/2023]
Abstract
Our previous work demonstrated that characteristic changes could occur in the anterior wrist and medial malleolus in electric deaths through the hand-to-foot electric circuit pathway in an electric shock rat model. However, whether the same phenomenon occurs in humans is unknown. The aim of the present retrospective study was to ascertain whether the anterior wrist and medial malleolus could also be selected as the promising and significant sites in electric death through the hand-to-foot circuit pathway. Nineteen human cases from the autopsy and one clinical survivor who sustained a severe electric shock through the hand-to-foot circuit pathway were analyzed. Additional ten autopsy patients who died from traffic accidents and sudden cardiac attacks were used as the control group. Histopathological changes in the soft tissues of the anterior wrist and medial malleolus in all autopsy patients, as well as the electric current pathway of the survivor, were observed. The results showed that the nuclear polarizations in the anterior wrist and medial malleolus soft tissues of the electric death were extremely noticeable as compared with the controls. The most severe electrical injury in the survivor occurred in the anterior wrist. These findings suggest that the soft tissues of the anterior wrist and/or the medial malleolus as the narrowest parts of the limbs could be used as the complementary sites for tissue selection and considered as necessary locations for examinations to assess the electric death in medicolegal identification.
Collapse
Affiliation(s)
- Guangtao Xu
- Department of Forensic Pathology, National Key Disciplines, Collaborative and Creative Center, Shantou University Medical College, Shantou, Guangdong Province, People's Republic of China
- Department of Forensic Pathology, Provincial Key Disciplines, Jiaxing University Medical College, Jiaxing, Zhejiang Province, People's Republic of China
| | - Ruibing Su
- Department of Forensic Pathology, National Key Disciplines, Collaborative and Creative Center, Shantou University Medical College, Shantou, Guangdong Province, People's Republic of China
| | - Junyao Lv
- Department of Forensic Pathology, National Key Disciplines, Collaborative and Creative Center, Shantou University Medical College, Shantou, Guangdong Province, People's Republic of China
| | - Bo Hu
- Department of Pathology, Jiaxing Hospital of Traditional Chinese Medicine, Jiaxing, Zhejiang Province, People's Republic of China
| | - Huan Gu
- Department of Forensic Pathology, National Key Disciplines, Collaborative and Creative Center, Shantou University Medical College, Shantou, Guangdong Province, People's Republic of China
- Department of Physics, University of Maryland, College Park, MD, USA
| | - Xianxian Li
- Department of Forensic Pathology, National Key Disciplines, Collaborative and Creative Center, Shantou University Medical College, Shantou, Guangdong Province, People's Republic of China
| | - Jiang Gu
- Department of Forensic Pathology, National Key Disciplines, Collaborative and Creative Center, Shantou University Medical College, Shantou, Guangdong Province, People's Republic of China
| | - Xiaojun Yu
- Department of Forensic Pathology, National Key Disciplines, Collaborative and Creative Center, Shantou University Medical College, Shantou, Guangdong Province, People's Republic of China.
| |
Collapse
|
29
|
Wang X, Zhang C, Yin JW, Wang C, Huang JZ, Ma X, Wang CW, Wang X. Treatment of Medial Malleolus or Pure Deltoid Ligament Injury in Patients with Supination-External Rotation Type IV Ankle Fractures. Orthop Surg 2017; 9:42-48. [PMID: 28296225 DOI: 10.1111/os.12318] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [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: 09/01/2016] [Accepted: 11/23/2016] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To investigate the effect of internal fixation on postoperative ankle function in patients with supination-external rotation type IV ankle fractures, including medial malleolus fractures and deltoid ligament injury. METHODS Between January 2012 and June 2014, patients with medial structure injuries were enrolled in this study and assigned to the medial malleolus fracture group or the deltoid ligament group. The surgical procedures for the two groups were documented. The follow-up endpoint was the time point when the steel plate or screw was removed from the lateral ankle. The Olerud-Molander ankle scoring system was used to assess ankle function. RESULTS A total of 84 patients with supination-external rotation type IV ankle fractures had complete medical records and were included in this study. The average age of the patients was 44.16 years (range, 15-75). The patient sample included 39 males and 45 females. Overall, 49 patients (19 males and 30 females) suffered a medial malleolus fracture. The average age of these patients was 40.20 years (range, 15-75). Patients with a posterior malleolar fracture fragment >25% of the articular surface accounted for 81.6% (40 patients) of these patients. Overall, 35 patients (20 males and 15 females) experienced a deltoid ligament injury. The average age of these patients was 44.21 years (range, 17-73). Patients with a posterior malleolar fracture fragment >25% of the articular surface accounted for 11.5% (four patients) of these patients. Open reduction was performed in patients with medial malleolus fractures, and two 4.0-mm cannulated screws were used to fixate the posterior malleolus and the medial malleolus. The suture-anchor technique was used to repair the ligaments in patients with deltoid ligament injuries. The follow-up endpoint was the time point when the steel plate and screws were removed from the lateral ankle in patients. The average follow-up period was 13.4 months (range, 11-17). The Olerud-Molander ankle scoring system was used to assess postoperative ankle function. The average score for the patients in the medial malleolus fracture group was 90.3 points (range, 85-95). The average score for the patients in the deltoid ligament injury group was 87.7 points (range, 80-95). No significant differences were found in the scores between the two groups. CONCLUSION Medial malleolus fracture and deltoid ligament injury are two different presentations of supination-external rotation type IV ankle fractures. Anatomic reduction of the articular surface concurrent with restoration of ankle stability can achieve favorable results for these two injuries.
Collapse
Affiliation(s)
- Xu Wang
- Department of Orthopaedic Surgery, Huashan Hospital of Fudan University, Shanghai, China
| | - Chao Zhang
- Department of Orthopaedic Surgery, Huashan Hospital of Fudan University, Shanghai, China
| | - Jian-Wen Yin
- Department of Orthopaedic Surgery, Huashan Hospital of Fudan University, Shanghai, China
| | - Chen Wang
- Department of Orthopaedic Surgery, Huashan Hospital of Fudan University, Shanghai, China
| | - Jia-Zhang Huang
- Department of Orthopaedic Surgery, Huashan Hospital of Fudan University, Shanghai, China
| | - Xin Ma
- Department of Orthopaedic Surgery, Huashan Hospital of Fudan University, Shanghai, China
| | - Cheng-Wei Wang
- Department of Orthopaedic Surgery, The Sixth Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Xue Wang
- Department of Orthopaedic Surgery, The Sixth Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| |
Collapse
|
30
|
Xu G, Su R, Lv J, Lai X, Li X, Wu J, Hu B, Xu L, Shen R, Gu J, Yu X. Anterior wrist and medial malleolus: the optimal sites for tissue selection in electric death through hand-to-foot circuit pathway. Int J Legal Med 2017; 131:433-439. [PMID: 27752779 DOI: 10.1007/s00414-016-1474-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 05/27/2016] [Accepted: 10/11/2016] [Indexed: 02/05/2023]
Abstract
Specific morphological changes may be absent in some cases of electrocution shocked by the voltage of 220 V or lower. In this study, we attempted to demonstrate that the anterior wrist and medial malleolus were the optimal sites with promising and significant changes in electric death through the hand-to-foot circuit pathway. We established an electric shock rat model and observed histopathologic changes in the anterior wrist and medial malleolus. The results showed that the current intensities in the left anterior wrist and right medial malleolus were remarkably higher than those in the other sites, and the nuclei long/short (L/S) axis ratios of the arterial endotheliocyte and the skeletal muscle cell in these two areas were significantly higher than those in other parts of the body. These findings suggested that the anterior wrist and/or medial malleolus soft tissues as the narrowest parts of the limbs could be used as promising and useful sites for the assessment of electrical shock death, especially in forensic pathologic evaluation.
Collapse
Affiliation(s)
- Guangtao Xu
- National Key Disciplines, Department of Forensic Pathology, Shantou University Medical College, Shantou, Guangdong Province, People's Republic of China
- Department of Forensic Pathology, Jiaxing University Medical College, Jiaxing, Zhejiang Province, People's Republic of China
| | - Ruibing Su
- National Key Disciplines, Department of Forensic Pathology, Shantou University Medical College, Shantou, Guangdong Province, People's Republic of China
| | - Junyao Lv
- National Key Disciplines, Department of Forensic Pathology, Shantou University Medical College, Shantou, Guangdong Province, People's Republic of China
| | - Xiaoping Lai
- Department of Forensic Science, Guangdong Medical University, Dongguan, Guangdong Province, People's Republic of China
| | - Xianxian Li
- National Key Disciplines, Department of Forensic Pathology, Shantou University Medical College, Shantou, Guangdong Province, People's Republic of China
| | - Jiayan Wu
- National Key Disciplines, Department of Forensic Pathology, Shantou University Medical College, Shantou, Guangdong Province, People's Republic of China
| | - Bo Hu
- Department of Pathology, Jiaxing Hospital of Traditional Chinese Medicine, Jiaxing, Zhejiang Province, People's Republic of China
| | - Long Xu
- National Key Disciplines, Department of Forensic Pathology, Shantou University Medical College, Shantou, Guangdong Province, People's Republic of China
| | - Ruilin Shen
- Department of Pathology, Jiaxing Hospital of Traditional Chinese Medicine, Jiaxing, Zhejiang Province, People's Republic of China
| | - Jiang Gu
- National Key Disciplines, Department of Forensic Pathology, Shantou University Medical College, Shantou, Guangdong Province, People's Republic of China
| | - Xiaojun Yu
- National Key Disciplines, Department of Forensic Pathology, Shantou University Medical College, Shantou, Guangdong Province, People's Republic of China.
| |
Collapse
|
31
|
Wegner AM, Wolinsky PR, Cheng RZ, Robbins MA, Garcia TC, Amanatullah DF. Sled fixation for horizontal medial malleolus fractures. Clin Biomech (Bristol, Avon) 2017; 42:92-96. [PMID: 28119205 DOI: 10.1016/j.clinbiomech.2017.01.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 01/12/2017] [Accepted: 01/15/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Horizontal fractures of the medial malleolus occur through exertion of various rotational forces on the ankle, including supination--external rotation, pronation--external rotation, and pronation-abduction. Many methods of fixation are employed for these fractures, but the optimal fixation construct remains unclear. METHODS Horizontal medial malleolus osteotomies were performed in synthetic distal tibiae and randomized into two fixation groups: 1) two parallel unicortical cancellous screws or 2) medial malleolar sled fixation. Specimens were subjected to offset axial tension loading and tracked using high-resolution video. Clinical failure was defined as 2mm of articular displacement. FINDINGS There were statistically significant increases in mean stiffness (127% higher, P=0.0007) and mean force to clinical failure (52% higher, P=0.0002) with the medial malleolar sled. The mean stiffness in offset tension loading was 232 (SD 83) N/mm for medial malleolar sled and 102 (SD 20) N/mm for parallel unicortical cancellous screws. The mean force to clinical failure was 595 (SD 112) N for medial malleolar sled and 392 (SD 34) N for unicortical screws. In addition, the medial malleolar sled demonstrated elastic recoil to pre-testing alignment while the unicortical screws did not. INTERPRETATION Medial malleolar sled fixation was significantly stiffer and required more force to clinical failure than parallel unicortical cancellous screws. A medial malleolar sled requires more dissection to apply surgically, but provides significantly more initial fixation strength. Additionally, a medial malleolar sled acts like a tension band in its ability to capture comminuted fragments while being low profile enough to minimize soft tissue irritation.
Collapse
Affiliation(s)
- Adam M Wegner
- University of California Davis Medical Center, Sacramento, CA, USA
| | | | - Robin Z Cheng
- Stanford University School of Medicine, Stanford, CA, USA
| | | | | | | |
Collapse
|
32
|
Arkesh M, Gaba S, Das S, Palanisamy JV, Trikha V. A rare combination of sagittal plane fracture of talar body with medial malleolus fracture: Case report and review of literature. J Clin Orthop Trauma 2016; 7:30-34. [PMID: 28018067 PMCID: PMC5167511 DOI: 10.1016/j.jcot.2016.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Accepted: 10/09/2016] [Indexed: 10/20/2022] Open
Abstract
Fractures of talus are relatively uncommon injuries with majority of them involving the neck region. Talar body fracture in sagittal plane in combination with medial malleolus fracture is very rare with few cases being reported in the literature earlier. We report such an unusual combination in an adolescent, which was treated with open reduction and internal fixation with screws for both talus and medial malleolus. This was followed by physiotherapy and non-weight bearing till the fracture united.
Collapse
|
33
|
Wegner AM, Wolinsky PR, Robbins MA, Garcia TC, Maitra S, Amanatullah DF. Antiglide plating of vertical medial malleolus fractures provides stiffer initial fixation than bicortical or unicortical screw fixation. Clin Biomech (Bristol, Avon) 2016; 31:29-32. [PMID: 26482240 DOI: 10.1016/j.clinbiomech.2015.10.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [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: 06/28/2015] [Revised: 10/05/2015] [Accepted: 10/06/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Vertical shear fractures of the medial malleolus (44-A2 ankle fractures) occur through a supination-adduction mechanism. There are numerous methods of internal fixation for this fracture pattern. METHODS Vertical medial malleolus osteotomies were created in synthetic distal tibiae. The models were divided into four fixation groups: two parallel unicortical cancellous screws, two divergent unicortical cancellous screws, two parallel bicortical cortical screws, or an antiglide plate construct. Specimens were subjected to offset axial loading and tracked using high-resolution video. FINDINGS The antiglide plate construct was stiffer (P<0.05) than each of the other three constructs, and the bicortical screw construct was stiffer (P<0.05) than both unicortical screw constructs. The mean stiffness (standard deviation) was 111 (SD 35) N/mm for the parallel unicortical screw construct, 173 (SD 57) N/mm for the divergent unicortical screw construct, 279 (SD 30) N/mm for the bicortical screw construct, and 463 (SD 91) N/mm for the antiglide plate construct. The antiglide plate construct resisted displacement better (P<0.05) than each of the other three constructs. The mean force for 2mm of articular displacement was 284 (SD 51) N for the parallel unicortical screw construct, 339 (SD 46) N for the divergent unicortical screw construct, 429 (SD 112) N for the bicortical construct, and 922 (SD 297) N for the antiglide plate construct. INTERPRETATION An antiglide plate construct provides the stiffest initial fixation while withstanding higher load to failure for vertical medial malleolus fractures when compared to unicortical and bicortical screw fixation.
Collapse
Affiliation(s)
- Adam M Wegner
- University of California Davis Medical Center, Sacramento, CA 95817, USA.
| | - Philip R Wolinsky
- University of California Davis Medical Center, Sacramento, CA 95817, USA.
| | - Michael A Robbins
- University of California Davis Medical Center, Sacramento, CA 95817, USA.
| | | | - Sukanta Maitra
- University of California Davis Medical Center, Sacramento, CA 95817, USA.
| | | |
Collapse
|
34
|
Abstract
Cartilage damage or mechanical blocking from screw penetration into intra-articular cartilage can reduce the chances of successful outcomes during medial malleolus fixation. There have been diverging opinions among surgeons concerning the reliability of radiographic assessment of fracture fixation and malleolus screw positioning. Therefore, this radiographic study examines the location of medial malleolus lag screws relative to the ankle mortise articular surface. In three Sawbones models, Kirschner wires were overdrilled with a 4.0-mm cannulated cortical screw simulating screws that would be intra- and extra-articular when performing open reduction and internal fixation of a medial malleolar fracture. Under fluoroscopy, images were evaluated to determine whether known intra-articular screws appeared extra-articular in any radiographic view. No image from models with known intra-articular penetration appeared extra-articular in any view or under "live" fluoroscopy. At 20° internal rotation, a screw with a known extra-articular position appeared to be within the cartilage. Intra-operative fluoroscopy is necessary to ensure proper extra-articular placement of screws. If a screw is pictured extra-articular in any radiograph, then it can be assumed that the screw is indeed out of the joint.
Collapse
|
35
|
Soni A, Vollans S, Haendlmayer K, Ng A. Bilateral medial malleolus stress fractures due to osteoarthritis of knee: A case report and review of literature. Int J Surg Case Rep 2014; 6C:266-8. [PMID: 25553531 PMCID: PMC4334956 DOI: 10.1016/j.ijscr.2014.10.078] [Citation(s) in RCA: 3] [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] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 10/20/2014] [Accepted: 10/21/2014] [Indexed: 11/29/2022] Open
Abstract
We present first ever reported association of medial malleoli stress fracture to medial compartment tibiofemoral osteoarthritis. Etiology, pathomechanics and management challenges are discussed here. Identification and treatment of predisposing factors for stress fractures are of paramount importance.
Introduction Medial malleolar stress fracture is a relatively uncommon injury but it can occur in athletes participating in running and jumping activities. Stress fractures of pelvis, proximal tibia and metatarsals are well documented in the elderly population but medial malleolus involvement in this subgroup has never been reported. Presentation of case We report a case of bilateral medial malleolus stress fractures secondary to bilateral knee osteoarthritis. Discussion Osteoporosis and mechanical malalignment have been postulated as the possible risk factors for stress fractures in the elderly population. The pathomechanics and management of the case are discussed here. Conclusion A high index of suspicion is required to identify such fractures. Identification and treatment of the predisposing factors are a very important part of treatment.
Collapse
Affiliation(s)
- Ashish Soni
- Department of Trauma & Orthopaedics, Pinderfield General Hospital, Wakefield, West Yorkshire, UK.
| | - Samuel Vollans
- Department of Trauma & Orthopaedics, Pinderfield General Hospital, Wakefield, West Yorkshire, UK
| | - Kurt Haendlmayer
- Department of Trauma & Orthopaedics, Pinderfield General Hospital, Wakefield, West Yorkshire, UK
| | - Aaron Ng
- Department of Trauma & Orthopaedics, Pinderfield General Hospital, Wakefield, West Yorkshire, UK
| |
Collapse
|
36
|
Saini P, Aggrawal A, Meena S, Trikha V, Mittal S. Miniarthrotomy assisted percutaneous screw fixation for displaced medial malleolus fractures - A novel technique. J Clin Orthop Trauma 2014; 5:252-6. [PMID: 25983507 PMCID: PMC4264056 DOI: 10.1016/j.jcot.2014.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [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: 05/21/2014] [Accepted: 07/14/2014] [Indexed: 11/15/2022] Open
Abstract
AIM To describe here a technique of miniarthrotomy assisted percutaneous screw insertion for displaced Herscovici type B and C medial malleolar fractures. METHOD Incision was made centred over the superomedial angle of the ankle mortise, about half a cm medial to tibialis anterior. Arthrotomy was done and reduction obtained. Percuntaneously, two 4 mm cancellous cannulated screws were inserted through medial malleolus. RESULTS AND CONCLUSION This approach allows direct visualization of reduction, removal of entrapped soft tissue and preservation of saphenous vein and nerve.
Collapse
Affiliation(s)
- Pramod Saini
- Registrar, Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Abhinav Aggrawal
- Registrar, Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Sanjay Meena
- Registrar, Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Vivek Trikha
- Additional Professor, Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Samarth Mittal
- Registrar, Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi 110029, India
| |
Collapse
|
37
|
Abstract
BACKGROUND Medial malleolus fractures have traditionally been managed using partially threaded screws and/or Kirschner wire fixation. Using these conventional techniques, a non-union rate of as high as 20% has been reported. In addition too many patients complaining of prominent hardware as a source of pain post-fixation. This study was designed to assess the outcomes of medial malleolar fixation using a headless compression screw in terms of union rate, the need for hardware removal, and pain over the hardware site. SETTING Saint Louis University and Mercy Medical Center, Level 1 Trauma Centers, St. Louis, MO. METHODS After IRB approval, we used billing records to identify all patients with ankle fractures involving the medial malleolus. Medical records and radiographs were reviewed to identify patients with medial malleolar fractures treated with headless compression screw fixation. Our inclusion criteria included follow-up until full weight bearing and a healed fracture. Follow-up clinical records and radiographs were reviewed to determine union, complication rate and perception of pain over the site of medial malleolus fixation. Sixty-four ankles were fixed via headless compression screws and 44 had adequate follow-up for additional evaluation. RESULTS Seven patients had isolated medial malleolar fractures, 23 patients had bimalleolar fractures, and 14 patients had trimalleolar fractures. One patient (2%) required hardware removal due to cellulitis. One patient (2%) had a delayed union, which healed without additional intervention. Ten patients (23%) reported mild discomfort to palpation over the medial malleolus. The median follow-up was 35 weeks (range: 12-208 weeks). There were no screw removals for painful hardware and no cases of non-union. CONCLUSIONS Headless compression screws provide effective compression of medial malleolus fractures and result in good clinical outcomes. The headless compression screw is a beneficial alternative to the conventional methods of medial malleolus fixation.
Collapse
Affiliation(s)
- Hayley Barnes
- Department of Orthopaedic Surgery, Saint Louis University Medical Center, St. Louis, MO, USA
| | - Lisa K Cannada
- Department of Orthopaedic Surgery, Saint Louis University Medical Center, St. Louis, MO, USA.
| | - J Tracy Watson
- Department of Orthopaedic Surgery, Saint Louis University Medical Center, St. Louis, MO, USA
| |
Collapse
|
38
|
Prasad KSRK, Vali H, Hussain A. Hawkins Group I fracture of neck of talus and Salter Harris Type III tibial epiphyseal injury of medial malleolus. Foot (Edinb) 2014; 23:96-9. [PMID: 23639364 DOI: 10.1016/j.foot.2013.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Revised: 03/02/2013] [Accepted: 03/11/2013] [Indexed: 02/04/2023]
Abstract
We are reporting an unusual combination of Hawkins Group I fracture of the neck of left talus in association with Salter Harris Type III distal tibial epiphyseal injury of medial malleolus in a child with cerebral palsy and hemiplegia of contralateral limbs and discussed the possible mechanism as well as management. Fractures of medial malleolus usually occur in Hawkins Group III fracture-dislocations in adults. Forced dorsiflexion of talus against the anterior edge of tibia appears to be the accepted common mechanism, despite limited experimental and clinical evidence incriminating axial compression. Fracture of medial malleolus implicates supination. We managed this unusual pattern of injury conservatively. At 15 months, the child was asymptomatic with no radiological evidence of avascular necrosis of body of talus or growth disturbance of distal tibial epiphysis.
Collapse
|
39
|
Mechchat A, Bensaad S, Shimi M, Elibrahimi A, Elmrini A. Unusual ankle fracture: A case report and literature review. J Clin Orthop Trauma 2014; 5:103-6. [PMID: 25983480 DOI: 10.1016/j.jcot.2014.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [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: 04/01/2014] [Accepted: 05/09/2014] [Indexed: 11/21/2022] Open
Abstract
Fractures of the talus are uncommon, and talar body fractures in the sagittal plane are still rarer. The aim of its treatment is urgent anatomic reduction to restore congruency of the ankle and to reduce the risk of avascular necrosis by preserving any remaining blood supply. We report the case of a body talar fracture in sagittal plane associated with fracture of the medial malleolus in a young adult; the mechanism of the fracture was plantar hyperflexion, internal rotation and axial compression. We perform an open reduction and stabilization with two screws for the talus and screw the medial malleolus. At 14 months following the injury patient had good range of movement with little pain. The mechanism is discussed along with a literature review.
Collapse
|
40
|
Zhang K, Chen Y, Qiang M, Hao Y, Li H, Dai H. The morphology of medial malleolus and its clinical relevance. Pak J Med Sci 2014; 30:348-51. [PMID: 24772141 PMCID: PMC3999008 DOI: 10.12669/pjms.302.4268] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 12/12/2013] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To provide morphological data of medial malleolus to decrease the possibility of posterior tibial tendon injury and inadvertent ankle penetration. METHODS Computed tomography scans of the ankle in 215 patients were reviewed. Then parameters in the 3-D reconstruction images were measured by three independent, qualified observers on two separate occasions. RESULTS The average angle between tibia plafond and the articular facet of the medial malleolus was 55.88±4.11°. The distance from the most anterior point of the anterior colliculus to the center of the intercollicular groove was 11.68±1.13 mm. And the average angle between the bimalleolar axis and the articular facet of the medial malleolus was 76.61±2.04°. Significant differences were observed in the distance from the most anterior point of the anterior colliculus to the center of the intercollicular groove between males and females. (P<0.05) All of the parameters exhibited moderate to excellent intra-class correlation coefficient (ICC). CONCLUSIONS According to this study, the insertion angle is much smaller than previously believed, and adequate space only exists for two 4.0-mm screws in some large cases. The second screw will probably be near the posterior tibial tendon, especially in some small cases.
Collapse
Affiliation(s)
- Kun Zhang
- Kun Zhang, MS, Department of Orthopaedic Trauma, East Hospital, Tongji University School of Medicine, 150 Jimo Rd, 200120 Shanghai, China
| | - Yanxi Chen
- Yanxi Chen, MD, PhD, Department of Orthopaedic Trauma, East Hospital, Tongji University School of Medicine, 150 Jimo Rd, 200120 Shanghai, China
| | - Minfei Qiang
- Minfei Qiang, MS, Department of Orthopaedic Trauma, East Hospital, Tongji University School of Medicine, 150 Jimo Rd, 200120 Shanghai, China
| | - Yini Hao
- Yini Hao, MS, Department of Orthopaedic Trauma, East Hospital, Tongji University School of Medicine, 150 Jimo Rd, 200120 Shanghai, China
| | - Haobo Li
- Haobo Li, MS, Department of Orthopaedic Trauma, East Hospital, Tongji University School of Medicine, 150 Jimo Rd, 200120 Shanghai, China
| | - Hao Dai
- Hao Dai, MS, Department of Orthopaedic Trauma, East Hospital, Tongji University School of Medicine, 150 Jimo Rd, 200120 Shanghai, China
| |
Collapse
|
41
|
Takahara M, Fujiwara Y, Sakamoto F, Katakami N, Matsuoka T, Kaneto H, Shimomura I. Assessment of vibratory sensation with a tuning fork at different sites in Japanese patients with diabetes mellitus. J Diabetes Investig 2014; 5:90-3. [PMID: 24843743 PMCID: PMC4025230 DOI: 10.1111/jdi.12126] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [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: 05/13/2013] [Revised: 06/14/2013] [Accepted: 06/25/2013] [Indexed: 11/28/2022] Open
Abstract
The current study compared the vibratory sensations at different sites, using a retrospective database of 547 Japanese diabetic patients. The vibratory sensation was assessed with a 128-Hz tuning fork at the medial malleolus, the great toe and the fifth toe. The vibratory sensations at different sites were significantly associated with one another (all P < 0.01). The vibratory sensation at one site corresponding to 10 s at another site was calculated to be 9-11 s. Although the vibratory sensations at the three sites had different associations with the pressure sensation and the ankle reflex, they showed similar C-statistics for the impaired pressure sensation and the disappeared ankle reflex. In conclusion, the vibratory sensations at different sites were strongly associated with one another. They would be clinically acceptable alternatives to one another in the assessment of diabetic peripheral neuropathy.
Collapse
Affiliation(s)
- Mitsuyoshi Takahara
- Department of Metabolic MedicineGraduate School of MedicineOsaka UniversityOsakaJapan
| | - Yuko Fujiwara
- Division of NursingDiabetic & Foot Care CenterOsaka University HospitalOsakaJapan
| | - Fumie Sakamoto
- Department of Metabolic MedicineGraduate School of MedicineOsaka UniversityOsakaJapan
| | - Naoto Katakami
- Department of Metabolic MedicineGraduate School of MedicineOsaka UniversityOsakaJapan
| | - Taka‐aki Matsuoka
- Department of Metabolic MedicineGraduate School of MedicineOsaka UniversityOsakaJapan
| | - Hideaki Kaneto
- Department of Metabolic MedicineGraduate School of MedicineOsaka UniversityOsakaJapan
| | - Iichiro Shimomura
- Department of Metabolic MedicineGraduate School of MedicineOsaka UniversityOsakaJapan
| |
Collapse
|
42
|
Kim GD, Chae SU, Cha MS. Medial malleolar insufficiency fracture of the ankle in an elderly patient with osteoporosis. J Bone Metab 2013; 20:119-22. [PMID: 24524069 PMCID: PMC3910308 DOI: 10.11005/jbm.2013.20.2.119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 07/18/2013] [Revised: 08/06/2013] [Accepted: 08/06/2013] [Indexed: 01/13/2023] Open
Abstract
Insufficiency fracture is a type of stress fracture, which is the result of normal stresses on abnormal bone. Postmenopausal osteoporosis is the most common cause of insufficiency fractures. An early diagnosis is best made with a bone scan or magnetic resonance imaging, as radiographs may initially appear normal. Insufficiency fractures of the lower leg and ankle are less common. Furthermore, reports of medial malleolar insufficiency fracture without any history of trauma in elderly patients are extremely rare. Thus, we report a case with a medial malleolar insufficiency fracture of the ankle in an elderly patient with osteoporosis. This case shows that we should be aware of the possibility of encountering an uncommon medial malleolar insufficiency fracture as a cause of pain in the ankle region of an elderly patient with osteoporosis.
Collapse
Affiliation(s)
- Gang Deuk Kim
- Department of Radiology, School of Medicine, Wonkwang University Hospital, Iksan, Korea
| | - Soo Uk Chae
- Department of Orthopedic Surgery, School of Medicine, Wonkwang University Hospital, Iksan, Korea
| | - Myoung Soo Cha
- Department of Orthopedic Surgery, School of Medicine, Wonkwang University Hospital, Iksan, Korea
| |
Collapse
|