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Li X, Wang XK, Han LR, Li H, Tian HC, Yan J, Liu HJ. Evaluation of the horizontal approach to the medial malleolar facet in sagittal talar fractures through dorsiflexion and plantarflexion positions. PLoS One 2024; 19:e0295350. [PMID: 38748674 PMCID: PMC11095721 DOI: 10.1371/journal.pone.0295350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 03/10/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Talar fractures often require osteotomy during surgery to achieve reduction and screw fixation of the fractured fragments due to limited visualization and operating space of the talar articular surface. The objective of this study was to evaluate the horizontal approach to the medial malleolus facet by maximizing exposure through dorsiflexion and plantarflexion positions. METHODS In dorsiflexion, plantarflexion, and functional foot positions, we respectively obtained the anterior and posterior edge lines of the projection of the medial malleolus on the medial malleolar facet. The talar model from Mimics was imported into Geomagic software for image refinement. Then Solidworks software was used to segment the medial surface of the talus and extend the edge lines from the three positions to project them onto the "semicircular" base for 2D projection. The exposed area in different positions, the percentage of total area it represents, and the anatomic location of the insertion point at the groove between the anteroposternal protrusions of the medial malleolus were calculated. RESULTS The mean total area of the "semicircular" region on the medial malleolus surface of the talus was 542.10 ± 80.05 mm2. In the functional position, the exposed mean area of the medial malleolar facet around the medial malleolus both anteriorly and posteriorly was 141.22 ± 24.34 mm2, 167.58 ± 22.36mm2, respectively. In dorsiflexion, the mean area of the posterior aspect of the medial malleolar facet was 366.28 ± 48.12 mm2. In plantarflexion, the mean of the anterior aspect of the medial malleolar facet was 222.70 ± 35.32 mm2. The mean overlap area of unexposed area in both dorsiflexion and plantarflexion was 23.32 ± 5.94 mm2. The mean percentage of the increased exposure area in dorsiflexion and plantarflexion were 36.71 ± 3.25% and 15.13 ± 2.83%. The mean distance from the insertion point to the top of the talar dome was 10.69 ± 1.24 mm, to the medial malleolus facet border of the talar trochlea was 5.61 ± 0.96 mm, and to the tuberosity of the posterior tibiotalar portion of the deltoid ligament complex was 4.53 ± 0.64 mm. CONCLUSIONS Within the 3D model, we measured the exposed area of the medial malleolus facet in different positions and the anatomic location of the insertion point at the medial malleolus groove. When the foot is in plantarflexion or dorsiflexion, a sufficiently large area and operating space can be exposed during surgery. The data regarding the exposed visualization area and virtual screws need to be combined with clinical experience for safer reduction and fixation of fracture fragments. Further validation of its intraoperative feasibility will require additional clinical research.
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Affiliation(s)
- Xian Li
- Department of Orthopaedic Surgery, Liaocheng People’s Hospital, Liaocheng, China
- Beijing Jishuitan Hospital Liaocheng Hospital, Liaocheng, China
- School of Clinical Medicine, Shandong Second Medical University, Weifang, China
| | - Xiao-ke Wang
- School of Clinical Medicine, Shandong Second Medical University, Weifang, China
| | - Li-ren Han
- Department of Orthopaedic Surgery, Liaocheng People’s Hospital, Liaocheng, China
| | - Hao Li
- Department of Orthopaedic Surgery, Liaocheng People’s Hospital, Liaocheng, China
| | - Hui-chao Tian
- Department of Orthopaedic Surgery, Liaocheng People’s Hospital, Liaocheng, China
| | - Jun Yan
- Department of Orthopaedic Surgery, Liaocheng People’s Hospital, Liaocheng, China
- Beijing Jishuitan Hospital Liaocheng Hospital, Liaocheng, China
| | - Hai-juan Liu
- Department of Endocrinology, Liaocheng People’s Hospital, Clinical Hospital of Shandong First Medical University, Liaocheng, China
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Wang C, Dong S, Li X, Ma J, Wang W, Ling Z. Maisonneuve fracture treated with short leg cast: A case report with 41-month follow-up. Medicine (Baltimore) 2024; 103:e38105. [PMID: 38728515 PMCID: PMC11081625 DOI: 10.1097/md.0000000000038105] [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: 01/08/2024] [Accepted: 04/12/2024] [Indexed: 05/12/2024] Open
Abstract
RATIONALE Maisonneuve fracture is a specific type of severe ankle injury. To our current knowledge, once a Maisonneuve fracture is diagnosed, the surgery is always recommended for fear of sequelae from inaccurate joint reconstruction. However, in this case, we treated a Maisonneuve fracture with a short leg cast, and the 41-month follow-up showed a favorable outcome with no post-traumatic osteoarthritis, chronic pain, and instability. Therefore, this case provides evidence for the feasibility of conservative treatment of Maisonneuve fracture. PATIENT CONCERNS A female patient in her early twenties sprained her left ankle while running, suffering regional pain, swelling, and limited mobility. DIAGNOSES We diagnosed a Maisonneuve fracture with superior fibular fracture and Volkmann tuberosity fracture, a slight separation of inferior tibiofibular syndesmosis (ITS). INTERVENTIONS The patient rejected our surgical recommendations in favor of nonsurgical treatment, in addition to refusing immobilization of the knee. Consequently, we had to treat her with a short leg cast for 8 weeks and asked her to return for regular follow-up visits. OUTCOMES At the final follow-up, the radiography showed complete healing of proximal fibula fracture. The patient reported no discernible subjective differences between her bilateral ankles. The range of motion of the left ankle was measured at 22° of dorsiflexion and 40° of plantarflexion. Functional assessments using Olerud-Molander ankle scale and American Orthopedic Foot and Ankle Society Ankle-Hindfoot scale both scored 100 points. Additionally, the radiographic assessment classified arthritis as stage 0 according to Morrey-Wiedeman classification. LESSONS To avoid missing and misdiagnosing, the physical examination should always extend to 2 neighboring joints. Secondly, if a Maisonneuve fracture is suspected, further computed tomography scans, radiography, and magnetic resonance imaging can help to determine the stability of the ITS and the integrity of the lateral collateral ligaments before making therapeutic decisions. Finally, considering the lateral collateral ligaments may remain intact, we recommend stabilizing ITS by repairing the medial ligaments, which can be conducted arthroscopically and be more minimally invasive, providing an elastic fixation that aligns better with the biomechanics of the ITS which is characterized as a micro-mobile rather than fully fixed joint.
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Affiliation(s)
- Chaoqun Wang
- Traumatic Orthopedic Department, The Affiliated Hospital of Wuhan Sports University, Hongshan District, Wuhan City, Hubei Province, China
- Center of Musculoskeletal Surgery, Charité Medical University Hospital Berlin, Berlin, Germany
| | - Shengnan Dong
- Traumatic Orthopedic Department, The Affiliated Hospital of Wuhan Sports University, Hongshan District, Wuhan City, Hubei Province, China
| | - Xugui Li
- Traumatic Orthopedic Department, The Affiliated Hospital of Wuhan Sports University, Hongshan District, Wuhan City, Hubei Province, China
| | - Jiakai Ma
- Traumatic Orthopedic Department, The Affiliated Hospital of Wuhan Sports University, Hongshan District, Wuhan City, Hubei Province, China
| | - Wangcai Wang
- Traumatic Orthopedic Department, The Affiliated Hospital of Wuhan Sports University, Hongshan District, Wuhan City, Hubei Province, China
| | - Zexi Ling
- Traumatic Orthopedic Department, The Affiliated Hospital of Wuhan Sports University, Hongshan District, Wuhan City, Hubei Province, China
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Wang R, You G, Yin S, Jiang S, Wang H, Shi H, Zhang L. Three-dimensional Mapping Analysis of Talus Fractures and Demonstration of Different Surgical Approaches for Talus Fractures. Orthop Surg 2024; 16:1196-1206. [PMID: 38485459 PMCID: PMC11062851 DOI: 10.1111/os.14033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 02/20/2024] [Accepted: 02/25/2024] [Indexed: 05/03/2024] Open
Abstract
OBJECTIVE The talus is an important component in the ankle, and its treatment after injury is crucial. However, complications and adverse events due to incomplete traditional classifications may still occur, and these classifications fail to analyze the patterns and distribution of fractures from a three-dimensional perspective. Therefore, in this study, we aimed to analyze the location and distribution of fracture lines in different types of talus fractures using three-dimensional (3D) and heat mapping techniques. Additionally, we aimed to determine the surface area of the talus that can be utilized for different approaches of internal fixation, aiding in the planning of surgical procedures. METHODS We retrospectively analyzed data from CT scans from 126 patients diagnosed with talus fractures at our two hospitals. We extracted the CT data of a healthy adult and created a standard talus model. We performed 3D reconstruction using patients' CT images and superimposed the fracture model onto the standard model for drawing fracture lines. Subsequently, we converted the fracture lines into a heat map for visualization. Additionally, we measured 20 specimens to determine the boundary for various ligaments attached to the talus. We determined the surface area of the talus available for different surgical approaches by integrating the boundary data with previously reported data on area of exposure. RESULTS Without considering the displacement distance of the fracture, fracture types were classified as follows, by combining Hawkins and Sneppen classifications: talar neck, 41.3%; posterior talar tubercle, 22.2%; body for the talus and comminuted, 17.5%; lateral talar tubercle, 11.9%; and talar head, 7.1%. We established fracture line and heat maps using this classification. Additionally, we demonstrated the available area for anteromedial, anterolateral, posteromedial, posterolateral, and medial malleolus osteotomy and Chaput osteotomy approaches. CONCLUSION Fracture line and heat map analyses can aid surgeons in planning a single or combined surgical approach for the reduction and internal fixation of talus fractures. Demonstrating the different surgical approaches can help surgeons choose the most effective technique for individual cases.
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Affiliation(s)
- Ruihan Wang
- School of Physical Education, Southwest Medical UniversityLuzhouChina
- Department of RehabilitationYibin Integrated Traditional Chinese and Western Medicine HospitalYibinChina
| | - Guixuan You
- School of Physical Education, Southwest Medical UniversityLuzhouChina
| | - Shiqin Yin
- School of Physical Education, Southwest Medical UniversityLuzhouChina
| | - Songtao Jiang
- School of Clinical Medicine, Southwest Medical UniversityLuzhouChina
| | - Hai Wang
- Department of Medical ImagingYibin Integrated Traditional Chinese and Western Medicine HospitalYibinChina
| | - Houyin Shi
- Department of OrthopaedicsThe Affiliated Traditional Chinese Medicine Hospital, Southwest Medical UniversityLuzhouChina
- Center for Orthopaedic Diseases ResearchThe Affiliated Traditional Chinese Medicine Hospital, Southwest Medical UniversityLuzhouChina
- Luzhou Key Laboratory of Orthopedic DisordersLuzhouChina
| | - Lei Zhang
- Department of OrthopaedicsThe Affiliated Traditional Chinese Medicine Hospital, Southwest Medical UniversityLuzhouChina
- Center for Orthopaedic Diseases ResearchThe Affiliated Traditional Chinese Medicine Hospital, Southwest Medical UniversityLuzhouChina
- Luzhou Key Laboratory of Orthopedic DisordersLuzhouChina
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Kerut CK, Mudiganty S, Kerut DG, Horswell RL, Williams R, Valencia M, Gonzales J. Probability of Occult Ankle Fracture Based on Radiograph-Measured Swelling. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202405000-00012. [PMID: 38743847 PMCID: PMC11095954 DOI: 10.5435/jaaosglobal-d-23-00271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/26/2024] [Accepted: 03/15/2024] [Indexed: 05/16/2024]
Abstract
INTRODUCTION Pediatric ankle injuries are a common presentation in the emergency department (ED). A quarter of pediatric ankle fractures show no radiographic evidence of a fracture. Physicians often correlate non-weight bearing and tenderness with an occult fracture. We present this study to predict the probability of an occult fracture using radiographic soft-tissue swelling on initial ED radiographs. METHODS This is a retrospective study at a Level 1 pediatric trauma center from 2021 to 22. Soft-tissue swelling between the lateral malleolus and skin was measured on radiographs, and weight-bearing status was documented. Statistical analysis was conducted using Stata software. DISCUSSION The study period involved 32 patients with an occult fracture, with 8 (25%) diagnosed with a fracture on follow-up radiographs. The probability of an occult fracture was calculated as a function of the ankle swelling in millimeters (mm) using a computer-generated predictive model. False-negative and false-positive rates were plotted as a function of the degree of ankle swelling. CONCLUSION Magnitude of ankle soft-tissue swelling as measured on initial ED radiographs is predictive of an occult fracture. Although weight-bearing status was not a sign of occult fracture, it improves the predictive accuracy of soft-tissue swelling.
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Affiliation(s)
- Christian Kenneth Kerut
- From the Louisiana State University, School of Medicine, New Orleans, Louisiana (Mr. CK Kerut); Department of Orthopedics, Louisiana State University, School of Medicine, Children's Hospital, New Orleans, LA (Dr. Mudiganty, Dr. Gonzales); Department of Pediatrics, Louisiana State University, School of Medicine, New Orleans, Louisiana (Dr. DG Kerut); Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, Louisiana (Dr. Horswell); Mercer University, School of Medicine, Savannah, Georgia (Mr. Williams and Ms. Valencia)
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Baker HP, Gerak S, Muir S, Rizzieri TJ, Straszewski A, Erdman MK, Dillman DB. All-suture fixation of syndesmotic injuries: a case series. Eur J Orthop Surg Traumatol 2024; 34:1279-1286. [PMID: 38070017 DOI: 10.1007/s00590-023-03797-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 11/19/2023] [Indexed: 04/02/2024]
Abstract
BACKGROUND To retrospectively evaluate the clinical outcomes of patients treated for syndesmotic injuries with an all-suture construct technique and compare their patient reported outcome scores with historically published outcomes of syndesmotic injuries fixed with suspensory suture buttons. METHODS This was a retrospective case series of patients treated at a Level 1 Trauma Center from May 1, 2018, to June 30, 2022. Ten patients aged 18 and older with unstable syndesmotic injuries treated with all-suture repair. Patients were excluded if they were treated with trans-osseous screws, had previous failed syndesmotic fixation, or suspensory suture button fixation. Patient-reported outcomes including Visual Analog Scale (VAS) pain scores, American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scores, and complications were recorded. RESULTS In the patients with 6 weeks or more of radiographic follow-up (N = 9), there was no evidence of nonunion, loss of fixation, hardware complication, or whitling of the fibula by the suture. At final follow-up average VAS pain scores were 1.5 out of 10 (range 0-4; SD 1.2), AOFAS ankle and hindfoot scores averaged 89.6 out of 100 (range 86-100; SD 6.1). The pain subscale of the AOFAS score averaged 37.5 out of 40 (range 35-40; SD 2.5). The functional subscale of the AOFAS score averaged 46 out of 50 (range 44-50; SD 3.0). Stiffness was reported in one patient at their follow-up visits, which resolved with continued physical therapy. There were no superficial or deep infections. CONCLUSIONS In conclusion, this case series presents the first clinical outcomes of an all-suture fixation technique for treatment of unstable syndesmotic ankle injuries. Our results suggest that the all-suture fixation technique results in similar patient reported outcomes when compared with historically reported patient reported outcomes of suspensory suture button fixation, and low rates of complication or hardware failure. LEVEL OF EVIDENCE 4
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Affiliation(s)
- Hayden P Baker
- Department of Orthopaedic Surgery, The University of Chicago, 5758 S. Maryland Avenue, Dept. 4B, Chicago, IL, 60637, USA.
| | - Samuel Gerak
- The University of Cincinnati College of Medicine, Cincinnati, OH, 45267, USA
| | - Sean Muir
- Edward Via College of Osteopathic Medicine, Spartanburg, SC, 29303, USA
| | | | - Andrew Straszewski
- Department of Orthopaedic Surgery, The University of Chicago, 5758 S. Maryland Avenue, Dept. 4B, Chicago, IL, 60637, USA
| | - Mary-Kate Erdman
- Department of Orthopaedic Surgery, The University of Chicago, 5758 S. Maryland Avenue, Dept. 4B, Chicago, IL, 60637, USA
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Liu Z, Gao W, Zhang X, Wang W, Tan M, Qiu E, Cai A. The distance between the anterior and posterior edges of the fibula at a lateral internal rotation of 15° is associated with postoperative malreduction in patients with an ankle joint fracture combined with a lower tibiofibular syndesmosis injury. ADV CLIN EXP MED 2024; 33:343-350. [PMID: 37589226 DOI: 10.17219/acem/169190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 06/18/2023] [Accepted: 07/03/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Malreduction remains a problem in patients with an ankle joint fracture combined with a lower tibiofibular syndesmosis injury. Current methods of malreduction evaluation have many limitations, and novel techniques are required. OBJECTIVES The aim of the study was to investigate the association between the distance between the anterior and posterior edges of the fibula at a 15° lateral internal rotation and postoperative malreduction in patients with an ankle joint fracture combined with a lower tibiofibular syndesmosis injury. MATERIAL AND METHODS This prospective observational cohort study enrolled 187 patients diagnosed with an ankle joint fracture combined with a lower tibiofibular syndesmosis injury between January 2020 and January 2022. The patients were divided into 2 groups according to their postoperative malreduction condition: the malreduction group and the non-malreduction group. After tibiofibular syndesmosis reduction, a computed tomography (CT) scan was used to measure the distance between the anterior and posterior edges of the fibula at a standard lateral position and a position with a lateral internal rotation of 15°. Demographic data and basic clinical characteristics were recorded for all patients. RESULTS The mean distance between the anterior and posterior edges of the fibula was longer in malreduction patients than non-malreduction patients at the standard lateral and 15° lateral internal rotation positions. At a lateral internal rotation of 15°, the distance between the anterior and posterior edges correlated negatively with the postoperative Mazur and American Orthopaedic Foot and Ankle Society (AOFAS) scores, and correlated positively with the length of hospitalization and fracture healing time. Receiver operating characteristic (ROC) curves revealed the potential postoperative malreduction diagnostic value of fibular anterior-posterior edge distance using an internal rotation of 15°. Postoperative AOFAS score, length of hospitalization, fracture healing time, and the distance between the anterior and posterior edges of the fibula at a lateral internal rotation of 15° were independent risk factors of malreduction. CONCLUSIONS The fibular anterior-posterior edge distance at an internal rotation of 15° is associated with postoperative ankle joint function and the occurrence of malreduction.
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Affiliation(s)
- Zhiqin Liu
- Department of Orthopedic Surgery, Zhuzhou Central Hospital, Zhuzhou Hospital Affiliated to Xiangya School of Medicine, Central South University, Changsha, China
| | - Wentao Gao
- Department of Orthopedic Surgery, Zhuzhou Central Hospital, Zhuzhou Hospital Affiliated to Xiangya School of Medicine, Central South University, Changsha, China
| | - Xiping Zhang
- Department of Orthopedic Surgery, Zhuzhou Central Hospital, Zhuzhou Hospital Affiliated to Xiangya School of Medicine, Central South University, Changsha, China
| | - Weifeng Wang
- Department of Orthopedic Surgery, Zhuzhou Central Hospital, Zhuzhou Hospital Affiliated to Xiangya School of Medicine, Central South University, Changsha, China
| | - Miduo Tan
- Department of Orthopedic Surgery, Zhuzhou Central Hospital, Zhuzhou Hospital Affiliated to Xiangya School of Medicine, Central South University, Changsha, China
| | - Eryue Qiu
- Department of Orthopedic Surgery, Zhuzhou Central Hospital, Zhuzhou Hospital Affiliated to Xiangya School of Medicine, Central South University, Changsha, China
| | - Anlie Cai
- Department of Orthopedic Surgery, Zhuzhou Central Hospital, Zhuzhou Hospital Affiliated to Xiangya School of Medicine, Central South University, Changsha, China
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Penning D, Molendijk J, Halm JA, Schepers T. Measuring External Rotation of the Fibula and Fibular Length in Bilateral Computed Tomography Scans: How Reliable Is This Method? J Orthop Trauma 2024; 38:205-209. [PMID: 38306014 PMCID: PMC10942176 DOI: 10.1097/bot.0000000000002774] [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: 10/24/2023] [Accepted: 01/11/2024] [Indexed: 02/03/2024]
Abstract
OBJECTIVES During ankle fracture surgery, goals include accurate reduction and fixation of the fibula regarding rotation and fibular length. Bilateral postoperative computed tomography (CT) can be performed to assess fibular rotation using the talar dome angle, and fibular length. The aim of this study was to compare side-to-side differences of the fibular rotation and fibular length using bilateral CT scans of uninjured ankles. METHODS DESIGN Retrospective. SETTING Single center, Level I Academic Trauma Center. PATIENT SELECTION CRITERIA Patients with bilateral CT scans of uninjured ankles. OUTCOME MEASURES AND COMPARISONS External rotation using the Nault talar dome method and fibular length using the coronal method of Prior et al. The average, difference, and ratio (injured side/healthy side) and interobserver variability were calculated. RESULTS There were 83 patients included (166 ankles, mean age 47 years, 77.1% male). A random set of 66 ankles (33 CT scans) were used to measure interobserver variability. The mean degrees of external rotation ranged from 6.6 to 7.7, mean difference ranged from 1.4 to 3.4 degrees, mean ratio ranged from 1.1 to 1.5, and interobserver variability ranged from 0.27 to 0.65. For fibular length, the mean ranged from 24.6 to 25.8 mm, mean difference in fibular length ranged from 0.5 to 2.1 mm, mean ratio ranged from 1.0 to 1.1 mm, and interobserver variability ranged from 0.45 to 0.73. CONCLUSIONS Using bilateral ankle CT scans, mean differences in fibular rotation using the Nault talar dome method were 1.4-3.4 degrees. The distal fibular length had a mean difference between both sides of 0.5-2.1 mm. Although the intraclass correlation's were low, the interleg differences between patients were small, making them useful for clinical practice. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Diederick Penning
- Trauma Unit, Department of Surgery, Amsterdam UMC location Meibergdreef, Amsterdam, the Netherlands
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Laco N, Poynter T, Wireman G, Parkulo T, Gainer J, Schmidt G, Sisto J, Ankem H, Seligson D. Reconstruction of the Medial Malleolus With Iliac Crest Autograft After Traumatic Loss: A Case Report. JBJS Case Connect 2024; 14:01709767-202406000-00022. [PMID: 38704855 DOI: 10.2106/jbjs.cc.22.00559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
CASE A 19-year-old woman sustained an open ankle fracture with complete destruction of the left medial malleolus and significant soft-tissue loss. After temporizing external fixation and coverage with a rotational posterior tibial artery perforator flap, the medial malleolus was reconstructed with an autologous iliac crest bone graft and direct repair of the deltoid ligament. The patient achieved excellent improvement in functional outcomes at 21 months with adequate restoration of ankle motion. CONCLUSION This case shows reconstruction of the medial malleolus with autologous iliac crest bone graft after traumatic loss can be a viable treatment option for young patients.
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Affiliation(s)
- Nicholas Laco
- Department of Orthopaedics, University of Louisville, Louisville, Kentucky
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Gao Y, Peng X, Wang C, Jiang C, Yu X. Early posterior column internal fixation: A staged treatment of type C3 tibial pilon fracture. Injury 2024; 55:111385. [PMID: 38359710 DOI: 10.1016/j.injury.2024.111385] [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: 08/15/2023] [Revised: 12/23/2023] [Accepted: 01/23/2024] [Indexed: 02/17/2024]
Abstract
Pilon fractures represent a challenging subset of tibial fractures. The management of AO/OTA Type C3 fractures remains complex due to associated complications and lack of clear guidelines for surgical timing and methods. A prospective cohort study was conducted to evaluate two staged treatment strategies for AO/OTA Type C3 tibial pilon fractures. The study focused on assessing surgical difficulty, complications, and patient prognosis. One group of patients received early internal fixation of the fibula and tibial posterior column combined with external fixation, while the other group received external fixation alone in the first stage. Patients who received early internal fixation of the fibula and tibial posterior column combined with external fixation had better outcomes, including lower rate of allogeneic bone grafting (67.74 % versus 94.64 %), reduced incidence of wound delay and skin necrosis (3.23 % versus 21.43 %), shorter surgical time (133.06 ± 23.99 min versus 163.04 ± 26.83 min), shorter hospital stay (13.77 ± 2.53 days versus 18.25 ± 3.67 days), and higher AOFAS (83.05 ± 8.68 versus 79.36 ± 8.92). Additionally, avoiding fibular shortening was shown to be crucial in preventing prolonged surgery and improving patient function. The study demonstrated that the staged treatment approach with early internal fixation led to shorter operative times, improved ankle function, and reduced complications, including a lower risk of infection. The findings support the use of this treatment to optimize outcomes in AO/OTA Type C3 pilon fractures.
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Affiliation(s)
- Yanchun Gao
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai 200233, China
| | - Xiaoyuan Peng
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai 200233, China
| | - Chengchen Wang
- Shanghai Institute of Technology, Shanghai 201418, China
| | - Chengyi Jiang
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai 200233, China.
| | - Xingang Yu
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai 200233, China.
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Hegde A, Shetty C, Joseph N, Mane P. Comparison of Posterior and Lateral Surface Plating for Type B Weber Lateral Malleoli Fractures. Foot Ankle Spec 2024; 17:155-161. [PMID: 35193432 DOI: 10.1177/19386400221079197] [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] [Indexed: 11/15/2022]
Abstract
PURPOSE The purpose of this study is to compare the functional outcomes, radiological outcomes, complication rates, and hardware removal between lateral and posterior surface plating in isolated type B Weber lateral malleolus fractures. METHODS It was a retrospective study that compared the outcomes of type B Weber lateral malleoli fractures treated by either lateral surface or posterior surface plating. Radiological and functional outcomes were assessed at regular intervals. The follow-up details and the complications and need for implant removal were collected from the hospital records. RESULTS Our study included 60 patients (male-35 and female-25). The mean age was 41.7 ± 10.5 years. In all, 28 (46.7%) patients received lateral surface plating and 32 (53.3%) patients received posterior surface plating. The mean time gap between the injury and the surgery was significantly more among patients who underwent lateral plate insertion (P < .001). The mean operative time required for both the procedures was comparable, hence nonsignificant (P = .576). The mean American Orthopaedic Foot and Ankle Society score (AOFAS) after 2 years of operation was significantly higher for posterior plate insertion (P = .014). The complication rates as well as the implant removal rates were higher in patients with lateral plating (P < .05). CONCLUSION Posterior surface plating can be considered as the procedure of choice for isolated type B Weber lateral malleolus fractures with respect to better functional outcome, lesser complications rates, and need for implant removal. LEVEL OF EVIDENCE Level III: Economic/decision.
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Affiliation(s)
- Atmananda Hegde
- Department of Orthopaedics, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education (MAHE), Manipal, India
| | - Chethan Shetty
- Department of Orthopaedics, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education (MAHE), Manipal, India
| | - Nitin Joseph
- Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education (MAHE), Manipal, India
| | - Prajwal Mane
- Department of Orthopaedics, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education (MAHE), Manipal, India
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11
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Wang H, Ying J, Liu J, Yu T, Huang D. Harnessing ResNet50 and SENet for enhanced ankle fracture identification. BMC Musculoskelet Disord 2024; 25:250. [PMID: 38561697 PMCID: PMC10983628 DOI: 10.1186/s12891-024-07355-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 03/13/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Ankle fractures are prevalent injuries that necessitate precise diagnostic tools. Traditional diagnostic methods have limitations that can be addressed using machine learning techniques, with the potential to improve accuracy and expedite diagnoses. METHODS We trained various deep learning architectures, notably the Adapted ResNet50 with SENet capabilities, to identify ankle fractures using a curated dataset of radiographic images. Model performance was evaluated using common metrics like accuracy, precision, and recall. Additionally, Grad-CAM visualizations were employed to interpret model decisions. RESULTS The Adapted ResNet50 with SENet capabilities consistently outperformed other models, achieving an accuracy of 93%, AUC of 95%, and recall of 92%. Grad-CAM visualizations provided insights into areas of the radiographs that the model deemed significant in its decisions. CONCLUSIONS The Adapted ResNet50 model enhanced with SENet capabilities demonstrated superior performance in detecting ankle fractures, offering a promising tool to complement traditional diagnostic methods. However, continuous refinement and expert validation are essential to ensure optimal application in clinical settings.
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Grants
- 2020AS0031 Science and Technology Projects in the Field of Agriculture and Social Development in Yinzhou District, Ningbo City, Zhejiang Province, China
- 2020AS0031 Science and Technology Projects in the Field of Agriculture and Social Development in Yinzhou District, Ningbo City, Zhejiang Province, China
- 2020AS0031 Science and Technology Projects in the Field of Agriculture and Social Development in Yinzhou District, Ningbo City, Zhejiang Province, China
- 2020AS0031 Science and Technology Projects in the Field of Agriculture and Social Development in Yinzhou District, Ningbo City, Zhejiang Province, China
- 2020AS0031 Science and Technology Projects in the Field of Agriculture and Social Development in Yinzhou District, Ningbo City, Zhejiang Province, China
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Affiliation(s)
- Hua Wang
- Department of Medical Imaging, Ningbo No. 6 Hospital, Ningbo, China
| | - Jichong Ying
- Department of Orthopedics, Ningbo No. 6 Hospital, Ningbo, China
| | - Jianlei Liu
- Department of Orthopedics, Ningbo No. 6 Hospital, Ningbo, China
| | - Tianming Yu
- Department of Orthopedics, Ningbo No. 6 Hospital, Ningbo, China
| | - Dichao Huang
- Department of Orthopedics, Ningbo No. 6 Hospital, Ningbo, China.
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12
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Osanami H, Akuzawa H, Sakamoto K, Yokota H, Hirabayashi R, Sekine C, Ishigaki T, Edama M. Validation of anterior ankle soft tissue dynamics and shear modulus for anterior ankle impingement syndrome after ankle fracture surgery. Sci Rep 2024; 14:5863. [PMID: 38467787 PMCID: PMC10928075 DOI: 10.1038/s41598-024-56671-5] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 03/08/2024] [Indexed: 03/13/2024] Open
Abstract
Anterior ankle impingement syndrome (AAIS) has been reported to account for a high percentage of complications following ankle fracture surgery. The soft tissue etiology of AAIS is thought to be thickening and inflammation of the anterior ankle soft tissues intervening anteriorly at the tibiotalar joint, causing pain and functional limitation during dorsiflexion. However, the effects of anterior ankle soft tissue dynamics and stiffness on AAIS have yet to be clarified. This study aimed to determine the relationship between AAIS and the anterior ankle soft tissue thickness change ratio and shear modulus using ultrasonography (US). The participants were 20 patients with ankle joint fractures (AO classification A, B) who had undergone open reduction and internal fixation and 20 healthy adults. The evaluation periods were 3 months and 6 months postoperatively. US was used to delineate the tibialis anterior tendon, extensor hallucis longus tendon, and the extensor digitorum longus tendon over the talus and tibia on a long-axis image. Anterior ankle soft tissue thickness was measured as the shortest distance from the most convex part of the talus to the tendon directly above it. The Anterior ankle soft tissue thickness change ratio was determined by dividing the value at 0° dorsiflexion by the value at 10° plantarflexion. The same images as for the anterior soft tissue thickness measurement were drawn for the shear modulus measurement, and the average shear modulus (kPa) was calculated using shear-wave elastography. There was no significant difference in the thickness change ratio between the postoperative and healthy groups. Compared with the healthy group, the shear modulus was significantly higher at 3 and 6 months in the postoperative group (p < 0.01). The shear elastic modulus at 6-month postoperative group was significantly lower than at 3-month postoperative group (p < 0.01). Anterior ankle joint soft tissue stiffness may increase after surgery for an ankle fracture.
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Affiliation(s)
- Haruki Osanami
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Shimami-cho, 1398, Kita-ku, Niigata City, Niigata, 950-3198, Japan
- Department of Rehabilitation, Keiyu Orthopaedic Hospital, 2267 Akoda, Tatebayashi, Gunma, 374-0013, Japan
| | - Hiroshi Akuzawa
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Shimami-cho, 1398, Kita-ku, Niigata City, Niigata, 950-3198, Japan
| | - Kodai Sakamoto
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Shimami-cho, 1398, Kita-ku, Niigata City, Niigata, 950-3198, Japan
| | - Hirotake Yokota
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Shimami-cho, 1398, Kita-ku, Niigata City, Niigata, 950-3198, Japan
| | - Ryo Hirabayashi
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Shimami-cho, 1398, Kita-ku, Niigata City, Niigata, 950-3198, Japan
| | - Chie Sekine
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Shimami-cho, 1398, Kita-ku, Niigata City, Niigata, 950-3198, Japan
| | - Tomonobu Ishigaki
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Shimami-cho, 1398, Kita-ku, Niigata City, Niigata, 950-3198, Japan
| | - Mutsuaki Edama
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Shimami-cho, 1398, Kita-ku, Niigata City, Niigata, 950-3198, Japan.
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13
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Kadiyala ML, Merrell LA, Ganta A, Konda SR, Rivero SM, Leucht P, Tejwani NC, Egol KA. Does Flipping From Prone to Supine for Medial Malleolar Fixation of Trimalleolar Ankle Fractures Improve Results? J Foot Ankle Surg 2024; 63:291-294. [PMID: 38103721 DOI: 10.1053/j.jfas.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 12/04/2023] [Accepted: 12/10/2023] [Indexed: 12/19/2023]
Abstract
There has been a paradigm shift towards fixing the posterior malleolus in trimalleolar ankle fractures. This study evaluated whether a surgeon's preference to intraoperatively flip or not flip patients from prone to supine for medial malleolar fixation following repair of fibular and posterior malleoli impacted surgical outcomes. A retrospective patient cohort treated at a large urban academic center and level 1 trauma center was reviewed to identify all operative trimalleolar ankle fractures initially positioned prone. One hundred and forty-seven patients with mean 12-month follow-up were included and divided based on positioning for medial malleolar fixation, prone or supine (following closure, flip and re-prep, and drape). Data was collected on patient demographics, injury mechanism, perioperative variables, and complication rates. Postoperative reduction films were reviewed by orthopedic traumatologists to grade the accuracy of anatomic fracture reduction. Overall, 74 (50.3%) had the medial malleolus fixed prone, while 73 (49.7%) were flipped and fixed supine. No differences in demographics, injury details, and fracture type existed between the groups. The supine group had a higher rate of initial external fixation (p = .047), longer operative time in minutes (p < .001), and a higher use of plate and screw constructs for medial malleolar fixation (p = .019). There were no differences in clinical and radiographic outcomes and complication rates. This study demonstrated that intraoperative change in positioning for improved medial malleolar visualization in trimalleolar ankle fractures results in longer operative times but similar radiographic and clinical results. The decision of operative position should be based on surgeon comfort.
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Affiliation(s)
- Manasa L Kadiyala
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - Lauren A Merrell
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - Abhishek Ganta
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY; Department of Orthopedic Surgery, Jamaica Hospital Medical Center, Queens, NY
| | - Sanjit R Konda
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY; Department of Orthopedic Surgery, Jamaica Hospital Medical Center, Queens, NY
| | - Steven M Rivero
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - Philipp Leucht
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - Nirmal C Tejwani
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - Kenneth A Egol
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY.
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14
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Wang J, Jia HB, Li HM, Jiang HQ, Zhao JG. Intramedullary Nailing Versus Open Reduction and Plate Fixation for Lateral Malleolar Fractures: A Meta-Analysis. J Foot Ankle Surg 2024; 63:275-280. [PMID: 38052379 DOI: 10.1053/j.jfas.2023.11.016] [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: 07/26/2023] [Revised: 11/24/2023] [Accepted: 11/28/2023] [Indexed: 12/07/2023]
Abstract
The fixation for lateral malleolar fracture in ankle fractures is still controversial. The purpose of this meta-analysis is to compare clinical and radiological outcomes between intramedullary nail (IMN) and plate for lateral malleolar fractures in ankle fractures. The PubMed, EMBASE, and Cochrane Library were searched for randomized controlled trials (RCTs) from databases inception to June 2023. Data on outcomes were extracted and the methodological quality of the included studies were assessed. A meta-analysis was performed using RevMan 5.3 software when the data extracted from included studies could be synthesized. Seven RCTs were included. The methodological quality of the included studies was moderate to high. The meta-analysis results showed that the infection rate of the IMN group was significantly lower than that of the plate group (RR = 0.38; 95%CI 0.18-0.82; p = .01). There were no significant differences between the 2 groups in Olerud and Molander Ankle Score (OMAS), union rate, radiological outcomes, nerve injury rate, reoperation rate, loss of reduction, and total complication rate. Our present meta-analysis demonstrated that the IMN might be a better method for the fixation of lateral malleolar fracture in ankle fracture, as the infection rate was significantly lower than a plate.
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Affiliation(s)
- Jie Wang
- Department of Orthopaedics, Tianjin Hospital, Tianjin, China
| | - Hao-Bo Jia
- Department of Orthopaedics, Tianjin Hospital, Tianjin, China
| | - Hao-Min Li
- Department of Orthopaedics, Tianjin Hospital, Tianjin, China
| | | | - Jia-Guo Zhao
- Department of Foot and Ankle Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China.
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15
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Romsom J, Hoogendoorn JM. The additional value of weight-bearing radiographs in assessing stability of isolated type B fibular fractures. Injury 2024; 55:111348. [PMID: 38290382 DOI: 10.1016/j.injury.2024.111348] [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: 10/07/2023] [Revised: 12/11/2023] [Accepted: 01/13/2024] [Indexed: 02/01/2024]
Abstract
INTRODUCTION In isolated type B fibular fractures, the decision whether to operate or treat conservatively is principally based on congruency and stability of the ankle joint. The purpose of the current study is to examine the additional diagnostic value of the weight-bearing radiograph (WBR) in assessing stability of potentially unstable type B fibular fractures. MATERIALS AND METHODS In this retrospective cohort study, patients were selected based on who presented an isolated type B fracture of the fibula. Unstable fractures were directly planned for surgery. Other patients underwent additional weight-bearing imaging 4-7 days after initial trauma, on which definitive treatment was based. The medial clear space (MCS) was compared between the WBR and the conventional radiograph. RESULTS A total of 70 patients were included in the period January 2018-December 2021. The average MCS on conventional mortise radiograph was 3.56 mm compared to 3.02 mm on the WBR(p<0.05). The superior clear space (SCS) was equal between both groups (respectively 3.12 mm and 3.08 mm, p = 0.44). All 70 patients were initially treated conservatively with immediate weight-bearing in a brace or soft cast. One patient had the need for open repair and internal fixation due to non-union. DISCUSSION Different techniques for the assessment of deep deltoid ligament integrity exist, such as the MRI, the ultrasonography and different kinds of stress test radiographs. As fractured ankles don't need direct fixation and operative treatment can be postponed, a stepped approach for the assessment of deep deltoid ligament (DDL) integrity can be of assistance in assessing ankle stability. In isolated type B fibular fractures a stepped approach, using the weight-bearing radiograph can be of additional value in assessing the stability. It is a low cost, prevents unnecessary surgery and contributes to a quick weight-bearing non-operative treatment.
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Affiliation(s)
- Jesse Romsom
- Haaglanden Medical Centre, Lijnbaan 32, The Hague, VA 2512 Netherlands.
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Gwak HC, Kim JH, Park DH, Kim JY, Seo WS, Lee HY, Kim DY. Patterns of Anterior Inferior Tibiofibular Ligament Avulsion Fracture Accompanied by Ankle Fracture. J Foot Ankle Surg 2024; 63:127-131. [PMID: 37898330 DOI: 10.1053/j.jfas.2023.06.006] [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: 10/25/2021] [Revised: 04/22/2023] [Accepted: 06/23/2023] [Indexed: 10/30/2023]
Abstract
The anterior inferior tibiofibular ligament (AITFL) avulsion fracture accompanying an ankle fracture can compromise ankle stability, necessitating accurate evaluation and a clear understanding of its pathophysiology.. The aim of this study was to investigate the association between AITFL avulsion fracture and Lauge-Hansen, Wagstaffe classification. A retro-prospective study was conducted at a university-affiliated tertiary care medical center. We selected 128 patients who underwent surgery at our institution between January 2013 and July 2017 and analyzed the association between AITFL avulsion fracture and the foot position. According to the modified Wagstaffe classification system, there were 39 cases of type II, followed by 9 cases of type III and 8 cases of type IV. Of the7 pronation-abduction fractures, 3 were AITFL avulsion fracture (43%), while of the 21 pronation-external rotation fractures, 9 were AITFL avulsion fracture (43%). Of the 95 supination-external rotation fractures, there were 56 cases (59%) of AITFL avulsion fractures. Of the pronation fractures, 0% were fibular avulsion fractures and 43% were tibial avulsion fractures. Of the supination fractures, 44% were fibular avulsion fractures and 16% were tibial avulsion fracture. The difference in the ratio of fibular to tibial avulsion fractures between pronation and supination fractures was significant (p < .001). These results suggest that tibial avulsion fractures of type IV in the modified Wagstaffe classification and pronation fractures occur due to collision with the anterolateral corners of the distal bone when the talus externally rotates. Moreover, in cases of pronation fractures, a new type of AITFL avulsion fracture has been observed.
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Affiliation(s)
| | - Jung-Han Kim
- Department of Orthopedic Surgery, Busan Paik Hospital, College of Medicine, Inje University, Busan, Korea
| | - Dae-Hyun Park
- Department of Orthopedic Surgery, Busan Paik Hospital, College of Medicine, Inje University, Busan, Korea
| | - Ji-Youn Kim
- Department of Orthopedic Surgery, Kosin University Gospel Hospital, Busan, Korea
| | - Won-Seok Seo
- Department of Orthopedic Surgery, Busan Paik Hospital, College of Medicine, Inje University, Busan, Korea
| | - Hyo-Young Lee
- Department of Orthopedic Surgery, Busan Paik Hospital, College of Medicine, Inje University, Busan, Korea
| | - Dae-Yoo Kim
- Department of Orthopedic Surgery, Busan Paik Hospital, College of Medicine, Inje University, Busan, Korea.
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17
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Li Q, Wang X, Wang Y, Liu F, Fu B. A unilateral external fixator combined with bone transport and tibio-talar fusion for the treatment of severe postoperative infection of peri-ankle fractures: retrospective analysis of 32 cases. J Orthop Surg Res 2024; 19:110. [PMID: 38308313 PMCID: PMC10837972 DOI: 10.1186/s13018-024-04586-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 01/26/2024] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND To investigate the clinical effects of a unilateral external fixator combined with bone transport and tibio-talar fusion in the treatment of severe postoperative infection of peri-ankle fractures. METHODS The clinical data of 32 patients (22 men and 10 women) with severe postoperative infection of peri-ankle fractures were retrospectively analyzed. Patients' age ranged from 26 to 62 (mean, 42 ± 9.5) years old. The types of fractures were distal tibia fracture (25 cases), distal tibia and fibula fracture (5 cases), and talus fracture (2 cases). All patients underwent treatment with unilateral external fixation combined with bone transport and tibio-talar fusion. 6 patients with severe infection received two-stage treatment involving focal debridement and external fixation, osteotomy, and bone transport. The remaining 26 patients underwent debridement, external fixation, and osteotomy simultaneously. The length of bone transport, total fixation time of the external fixator, and postoperative complications were recorded for all patients. The efficacy of the treatment was assessed using the American Association of Foot and Ankle Society (AOFAS) ankle-hindfoot score. RESULTS Patients were followed up for 16-36 months, with an average follow-up time of 24 months. The length of tibia bone transport ranged from 5 to 15 cm, with a mean length of 8.5 cm. The external fixator was applied for 12-24 months, with an average duration of 16 months. One patient suffered from refracture at tibio-talar fusion site, and one patient had external fixation pin-tract infection. No complications, such as recurrent infections (especially the MRSA infection), poor mineralization, refracture, iatrogenic nerve damage or fusion failure, were found in the remaining patients. The preoperative AOFAS ankle-hindfoot function score was 40.0 ± 3.8 (range, 30-52) points, and it increased to 75.0 ± 3.0 (range, 67-78) points at the last follow-up. CONCLUSION A unilateral external fixator combined with bone transport and tibio-talar fusion is an effective method for treating severe postoperative infection of peri-ankle fractures. This approach is capable of reconstructing large bone defects that remain after clearing the infected lesion. Additionally, it provides stability to the ankle, enhances ankle-hindfoot function, and improves the patient's quality of life.
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Affiliation(s)
- Qinghu Li
- Department of Orthopedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No.324, Road Jing Wu Wei Qi, Jinan, 250021, Shandong, China
| | - Xin Wang
- Department of Anesthesiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No.324, Road Jing Wu Wei Qi, Jinan, 250021, Shandong, China
| | - Yonghui Wang
- Department of Orthopedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No.324, Road Jing Wu Wei Qi, Jinan, 250021, Shandong, China
| | - Fanxiao Liu
- Department of Orthopedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No.324, Road Jing Wu Wei Qi, Jinan, 250021, Shandong, China
| | - Baisheng Fu
- Department of Orthopedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No.324, Road Jing Wu Wei Qi, Jinan, 250021, Shandong, China.
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Greenhill DA, Mundluru SN, Gomez RW, Romero J, Riccio AI. Metaphyseal Fracture Displacement is Predictive of Intra-articular Diastasis in Adolescent Triplane Ankle Fractures. J Pediatr Orthop 2024; 44:94-98. [PMID: 37779308 DOI: 10.1097/bpo.0000000000002530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
BACKGROUND Triplane fractures are rare enough that large homogeneous series to support management decisions are lacking. During initial evaluation, the addition of computed tomography (CT) to conventional X-rays (XR) does not always alter the patient's clinical course. Therefore, routine use of CT is controversial. This study aims to: (1) clarify quantitative relationships between articular displacement measured on XR versus CT and (2) identify whether metaphyseal displacement on the lateral XR predicts clinically relevant articular displacement on a CT scan. METHODS A 10-year retrospective review of consecutive triplane fractures was performed at a level 1 pediatric trauma center. Maximum articular and metaphyseal displacement were recorded from XR and CT. Quantitative relationships between XR and CT measurements were compared among imaging modalities and radiographically operative versus nonoperative fractures. RESULTS Eighty-seven patients met the inclusion criteria. XR underestimated articular displacement by 229% in the sagittal plane (1 mm on XR vs 3.3 mm on CT; P < 0.05) and 17% in the coronal plane (2.3 mm on XR vs 2.7 mm on CT; P < 0.05). XR underestimated articular step-off by 184% in the coronal plane and 177% in the sagittal plane ( P < 0.05). CT measurements more often differentiated patients who did or did not undergo surgery at our institution. Metaphyseal displacement was significantly higher in patients with traditionally operative articular displacement (≥2.5 mm on CT) versus those with articular displacement below traditionally operative thresholds (2.4 vs 0.9 mm, P = 0.001). Sixty patients had metaphyseal displacement >1 mm on the lateral XR, of whom 56 had surgical-magnitude articular displacement (≥2.5 mm) on CT (positive predictive value = 94%). CONCLUSIONS Conventional radiographs underestimate the true articular displacement of triplane fractures. Surgical-magnitude articular step-off is rare, and the largest articular gap is usually visualized on the axial CT image. Metaphyseal displacement >1 mm, which is easily measured on a lateral XR, is strongly predictive of clinically relevant articular displacement on CT. This radiographic finding should prompt advanced imaging before proceeding with nonoperative management. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Dustin A Greenhill
- Department of Orthopaedic Surgery, St. Luke's University Health Network, Bethlehem, PA
| | - Surya N Mundluru
- Department of Orthopedic Surgery, University of Texas Houston McGovern School of Medicine, Houston
| | - Robert W Gomez
- Department of Orthopaedic Surgery, St. Luke's University Health Network, Bethlehem, PA
| | - Joseph Romero
- Department of Orthopedic Surgery, University of Texas Southwestern
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19
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Hasan YO, Bourget-Murray J, Page P, Penn-Barwell JG, Handley R. Tibiotalar nailing using an antegrade intramedullary tibial nail: a salvage procedure for unstable distal tibia and ankle fractures in the frail elderly patient. Eur J Orthop Surg Traumatol 2024; 34:847-852. [PMID: 37742301 DOI: 10.1007/s00590-023-03735-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 09/10/2023] [Indexed: 09/26/2023]
Abstract
AIM This article describes the technique of tibiotalar nailing performed using an antegrade tibial nail for salvage of distal tibia and ankle fractures in elderly patients. MATERIALS AND METHODS We report indications, surgical technique, and the clinical outcomes and complication rate in our series to date. A retrospective review was performed at our level 1 major trauma centre. Patient demographics, comorbidities, and 12-month post-operative course were collected. Fractures were classified using the OTA/AO and modified Gustilo-Anderson classification. Fifteen patients underwent the procedure. We present data with a minimum 12-month follow-up. The median age of the patients in this cohort was 83 years (range, 51-102). Five patients were diabetic. Six patients (6/15; 40%) presented with an open fracture. RESULTS At final follow-up, fourteen patients reported painless walking and had returned to baseline activity. CONCLUSION This technique may serve as a salvage procedure, with indications similar to those for tibio-talar-calcaneal arthrodesis. Indications would include non-constructible pilon fractures, comminuted intra-articular fractures in low-demand patients, or patients at high risk of wound complications. LEVEL OF CLINICAL EVIDENCE 3.
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Affiliation(s)
- Yusuf Omran Hasan
- Oxford Trauma Unit, John Radcliffe Hospital, Oxford University Hospitals, Oxford, United Kingdom.
- Orthopaedic Department, Salmaniya Medical Complex, Manama, Kingdom of Bahrain.
| | - Jonathan Bourget-Murray
- Oxford Trauma Unit, John Radcliffe Hospital, Oxford University Hospitals, Oxford, United Kingdom
- Division of Orthopaedic Surgery, Royal Inland Hospital, Kamloops, Canada
| | - Piers Page
- Oxford Trauma Unit, John Radcliffe Hospital, Oxford University Hospitals, Oxford, United Kingdom
| | - Jowan G Penn-Barwell
- Oxford Trauma Unit, John Radcliffe Hospital, Oxford University Hospitals, Oxford, United Kingdom
| | - Robert Handley
- Oxford Trauma Unit, John Radcliffe Hospital, Oxford University Hospitals, Oxford, United Kingdom
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Giordano V, Rodrigues A, Voelcker L, Alves G, Pires RE, Freitas A, Mariolani JR, Belangero WD. Is just one screw really enough? Single- versus double-screw in the medial malleolus in supination-external rotation ankle fractures: A comparative biomechanical study using partially threaded cancellous screws. Injury 2024; 55:111175. [PMID: 37926664 DOI: 10.1016/j.injury.2023.111175] [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: 10/06/2023] [Revised: 10/24/2023] [Accepted: 10/29/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE The aim of this study is to investigate stiffness and the maximum load to failure values of single- and double-screw fixation of oblique medial malleolus fractures using partially threaded cancellous screws. Our hypothesis is that single-screw fixation of medial malleolus fractures after SER injuries provides similar stiffness when compared with double-screw fixation. DESIGN Biomechanical study. METHODS Twelve composite polyurethane synthetic right distal tibiae were used in the experiment. Oblique fractures of the medial malleolus were created with a band saw using a custom-made osteotomy guide to standardize the cuts in all models. Bone models were randomly separated into two groups and fixed with one (n = 6) or two (n = 6) 4.0 mm partially threaded cancellous screws placed perpendicular to the fracture line. These were tested by applying an offset axial tension at 10 mm/minute up to maximum load displacement, defined as subsidence of the medial malleolus fragment. Maximum load to failure was determined for the groups at the point where the curve ceased to be linear and suffered an inflection. Force versus displacement curves were obtained and recorded. The student's t-test for independent samples was used to compare stiffness (N / mm) and maximum load (N) between experimental groups, with a p value of < 0.05. RESULTS There were no significant differences in stiffness (p = 0.290) and maximum load (p = 0.191) among the two fixation constructs. Mean stiffness was 62.26 (±SD 21.11) N/mm for double-screw fixation group and 48.24 (±SD 22.40) N/mm for single-screw fixation group. Mean maximum load was 387.83 (±SD 115.78) N for double-screw fixation group and 306.64 (±SD 81.97) N for single-screw fixation group. CONCLUSION Fixation with one 4.0 mm partially threaded cancellous screw was not shown to be biomechanically inferior to fixation with two 4.0 mm partially threaded cancellous screws in an oblique fracture of the medial malleolus, supporting previous clinical studies that have shown that one screw is sufficient for fractures of the medial malleolus.
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Affiliation(s)
- Vincenzo Giordano
- Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro, Hospital Municipal Miguel Couto, Rio de Janeiro, Brazil; Clínica São Vicente, Rede D'or São Luiz, Rio de Janeiro, Brazil.
| | - Aliny Rodrigues
- Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro, Hospital Municipal Miguel Couto, Rio de Janeiro, Brazil
| | - Luiza Voelcker
- Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro, Hospital Municipal Miguel Couto, Rio de Janeiro, Brazil
| | - Gabriel Alves
- Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro, Hospital Municipal Miguel Couto, Rio de Janeiro, Brazil
| | - Robinson Esteves Pires
- Departamento do Aparelho Locomotor, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil
| | | | - José Ricardo Mariolani
- Laboratório de Biomateriais em Ortopedia (LABIMO), Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), Campinas, Brazil
| | - William Dias Belangero
- Laboratório de Biomateriais em Ortopedia (LABIMO), Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), Campinas, Brazil; Departamento de Ortopedia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), Campinas, Brazil
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21
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Laurence G, Perdue AM, Hake ME, Talusan PG, Holmes JR, Walton DM. Comparison of Outcomes at Midterm Follow-up of Operatively and Nonoperatively Treated Isolated Weber B Ankle Fractures. J Orthop Trauma 2024; 38:115-120. [PMID: 38031297 DOI: 10.1097/bot.0000000000002735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 11/17/2023] [Indexed: 12/01/2023]
Abstract
OBJECTIVES A novel protocol was previously presented for nonoperative management of Weber B (OTA/AO 44B) ankle fractures with criteria of medial clear space <7 mm on gravity stress (GS) radiographs and ipsilateral superior clear space and contralateral GS medial clear space within 2 mm. This study recruited an operative cohort for comparison of outcomes. METHODS DESIGN Retrospective cohort study. SETTING Level 1 academic center. PATIENT SELECTION CRITERIA The recruited operative cohort consisted of patients who may have been considered for the nonoperative protocol, but underwent surgery instead. OUTCOME MEASURES AND COMPARISONS Kellgren-Lawrence scale for evaluation of arthritis, American Orthopedic Foot and Ankle Society Hindfoot, Olerud Molander Ankle, Lower Extremity Functional Scale (LEFS), and PROMIS (physical function, depression, pain interference) scores for the current operative cohort were compared with that of the original nonoperative cohort. RESULTS There were 20 patients in the operative cohort and 29 in the original nonoperative cohort. Mean follow-up was 6.9 and 6.7 years, respectively. The following outcome scores were better for the nonoperative cohort compared with the operative, respectively: LEFS, 75.2 and 68.1 ( P = 0.009); Olerud Molander Ankle, 94.1 and 89.0 ( P = 0.05); American Orthopedic Foot and Ankle Society, 98.5 and 91.7 ( P = 0.0003); PROMIS Physical Function, 58.2 and 50.4 ( P = 0.01); PROMIS Pain Interference, 42.2 and 49.7 ( P = 0.004). The PROMIS Depression, 42.8 and 45.4 ( P = 0.29), was not different between groups. All patients achieved union of their fracture. Surgical complications included implant removal (15%), SPN neurapraxia (5%), and delayed wound healing (5%). CONCLUSIONS In carefully selected patients with isolated Weber B fractures, nonoperative management may be considered because it can lead to equivalent or superior outcomes with none of the risks typically associated with surgical intervention. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ge Laurence
- Department of Orthopedic Surgery, University of Michigan Health System, Ann Arbor, MI
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Aamir J, Syziu A, Andritsos L, Caldwell R, Mason L. Tibialis posterior tendon entrapment in posterior malleolar and pilon injuries of the ankle: a retrospective analysis. Eur J Orthop Surg Traumatol 2024; 34:781-787. [PMID: 37698673 PMCID: PMC10858079 DOI: 10.1007/s00590-023-03714-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 08/22/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND The Tibialis Posterior tendon (TPT) is the only tendon to encounter the distal tibia and is therefore at greatest risk of injury in fractures of the distal tibia. Although TPT injury has been reported rarely with injuries around the ankle, they often have been missed and present late. AIM Our aim was to analyse the rate to TPT entrapment in fractures involving the posterior tibia, i.e. Pilon (PLM) and posterior malleolar fractures (PMF). METHODS A retrospective analysis of PMF and Pilon fractures over an 8-year period was undertaken. Patients who had undergone surgical fixation of their PMF or PLM were identified from 2014 to 2022, using our prospectively collected database. Any fracture which had undergone a preoperative CT was included. Analysis of their pre-operative CT imaging was utilised to identify TPT entrapment, where if < 50% of the tendon cross section was present in the fracture site, this was denoted as a minor entrapment and if ≥ 50% of the tendon was present in the fracture site was denoted as major. RESULTS A total of 363 patients were identified for further analysis, 220 who had a PMF and 143 with PLM injury. The incidence of TPT entrapment was 22% (n = 79) with 64 minor and 15 major entrapments. If the fracture line entered the TPT sheath, there was a 45% rate (72/172) of entrapment as compared to 3.7% (7/190) in fractures not entering the sheath (p < .001). There was no significant difference in TPT entrapment in PMF as compared to PML (p = 0.353). CONCLUSION In our assessment, we found significant prevalence of 22% of TPT entrapment in fractures involving the posterior tibia. PMF and PLF had no statistically significant difference in the rate of TPT entrapment. Additionally, we found that there was a significant risk of TPT entrapment when the CT images display the fracture line entering the tendon sheath. We recommend that surgeons consider taking care assessing pre-operative imaging to seek to identify the TPT and to assess intraoperatively where entrapment does occur.
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Affiliation(s)
- Junaid Aamir
- Liverpool Orthopaedic Trauma Service, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
| | - Anxhela Syziu
- School and Medicine, University of Liverpool, Liverpool, UK
| | - Loukas Andritsos
- Liverpool Orthopaedic Trauma Service, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
| | - Robyn Caldwell
- Liverpool Orthopaedic Trauma Service, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
| | - Lyndon Mason
- Liverpool Orthopaedic Trauma Service, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK.
- School and Medicine, University of Liverpool, Liverpool, UK.
- Department of Trauma and Orthopaedics, Aintree University Hospital, Liverpool, UK.
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Wood L, Ahmed Z. Does using 3D printed models for pre-operative planning improve surgical outcomes of foot and ankle fracture fixation? A systematic review and meta-analysis. Eur J Trauma Emerg Surg 2024; 50:21-35. [PMID: 36418394 PMCID: PMC10924018 DOI: 10.1007/s00068-022-02176-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 11/11/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE The systematic review aims to establish the value of using 3D printing-assisted pre-operative planning, compared to conventional planning, for the operative management of foot and ankle fractures. METHODS The systematic review was performed according to PRISMA guidelines. Two authors performed searches on three electronic databases. Studies were included if they conformed to pre-established eligibility criteria. Primary outcome measures included intraoperative blood loss, operation duration, and fluoroscopy time. The American orthopaedic foot and ankle score (AOFAS) was used as a secondary outcome. Quality assessment was completed using the Cochrane RoB2 form and a meta-analysis was performed to assess heterogeneity. RESULTS Five studies met the inclusion and exclusion criteria and were eventually included in the review. A meta-analysis established that using 3D printed models for pre-operative planning resulted in a significant reduction in operation duration (mean difference [MD] = - 23.52 min, 95% CI [- 39.31, - 7.74], p = 0.003), intraoperative blood loss (MD = - 30.59 mL, 95% CI [- 46.31, - 14.87], p = 0.0001), and number of times fluoroscopy was used (MD = - 3.20 times, 95% CI [- 4.69, - 1.72], p < 0.0001). Using 3D printed models also significantly increased AOFAS score results (MD = 2.24, 95% CI [0.69, 3.78], p = 0.005), demonstrating improved ankle health. CONCLUSION The systematic review provides promising evidence that 3D printing-assisted surgery significantly improves treatment for foot and ankle fractures in terms of operation duration, intraoperative blood loss, number of times fluoroscopy was used intraoperatively, and improved overall ankle health as measured by the AOFAS score.
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Affiliation(s)
- Lea Wood
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Zubair Ahmed
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
- Neuroscience and Ophthalmology, Institute of Inflammation and Ageing, College of Medical and Dental Science, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
- Centre for Trauma Sciences Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
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Rooke G, Sharplin P, Buckley R. Healed ORIF in a fibula fracture - Hardware removal or hardware retention for the fibula in a patient with minor symptoms? Injury 2024; 55:111190. [PMID: 37984011 DOI: 10.1016/j.injury.2023.111190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
HISTORY - A 31yo female is involved in a fall while climbing on some wet rocks. She was brought into the emergency department and was found to have suffered a closed fracture of the right fibula with a deltoid ligament injury. Distal neurovascular exam was normal. She is otherwise unhurt. She had ORIF of her ankle injury and it has gone onto heal with good results. She comes back at 6 months and complains of vague pain over her lateral ankle and hardware with a normal physical exam. She wonders about hardware removal, (Figs. 1 and 2). PAST MEDICAL HISTORY: - previous history of breast reduction surgery and she has delivered one child vaginally. No chronic diseases and she takes no pills except the birth control pill. SOCIAL HISTORY: - married with one child and works as an administrative assistant for a manufacturing company; she is a social drinker and nonsmoker. Has a history of using some recreational drugs but none for 10 years. She is moderately active.
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Affiliation(s)
- Gareth Rooke
- Department of Orthopedic Surgery, Wellington Regional Hospital, Riddiford Street, Wellington, New Zealand
| | - Paul Sharplin
- Christchurch Hospital, Department of Orthopedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch, New Zealand
| | - Richard Buckley
- University of Calgary, 0490 McCaig Tower, Foothills Hospital, 3134 Hospital Drive NW Calgary, Alberta T2N 5A1, Canada.
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Li M, Liu Z, Dong G. Could medial malleolus fracture be combined with deltoid ligament injury?: A rare case report. Medicine (Baltimore) 2024; 103:e37011. [PMID: 38277575 PMCID: PMC10817007 DOI: 10.1097/md.0000000000037011] [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: 10/23/2023] [Accepted: 12/29/2023] [Indexed: 01/28/2024] Open
Abstract
RATIONALE Medial malleolus injuries mainly comprise of fractures and deltoid ligament ruptures. Medial malleolus fractures, as a kind of common ankle fractures, could occur separately or be accompanied by lateral and posterior malleolus fractures. It is generally agreed that medial malleolus fracture and deltoid ligament rupture could not occur simultaneously. PATIENT CONCERNS In our study, we report a case of 36 year-old man diagnosed with trimalleolar fracture accompanying ankle dislocation initially. The patient was admitted to our hospital due to traffic accident. DIAGNOSIS The patient was diagnosed with trimalleolar fracture accompanying ankle dislocation initially. We missed the diagnosis of accompanied deltoid ligament due to the arthralgia of medial ankle and the widened medial articular space in X-ray after operation. INTERVENTION As we missed the diagnosis of accompanied deltoid ligament, we only selected open reduction and internal fixation for trimalleolar fracture at first. After we realized the existence of deltoid ligament rupture, the patient refuse further diagnosis and treatment in our hospital. OUTCOMES During the rehabilitation exercise, the patient had medial arthralgia in his right ankle. He complained it and refuse further diagnosis and treatment in our hospital. LESSONS The newfound injury pattern, medial malleolus fracture accompanying deltoid ligament rupture, has not been reported in previous studies. The injury pattern needs further researches to explore the mechanism and it should be taken seriously in clinical practice.
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Affiliation(s)
- Mingyan Li
- Department of Orthopaedic Trauma, Harrison International Peace Hospital, Hengshui, Hebei, China
| | - Zihao Liu
- Department of Orthopaedic Trauma, Harrison International Peace Hospital, Hengshui, Hebei, China
| | - Guixian Dong
- Department of Orthopaedic Trauma, Harrison International Peace Hospital, Hengshui, Hebei, China
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Saatvedt O, Riiser M, Frihagen F, Figved W, Madsen JE, Molund M, Furunes H. Non-operative versus operative treatment of suprasyndesmotic ankle fractures: protocol for a prospective, multicentre, randomised controlled trial. BMJ Open 2024; 14:e075122. [PMID: 38191245 PMCID: PMC10806705 DOI: 10.1136/bmjopen-2023-075122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 12/20/2023] [Indexed: 01/10/2024] Open
Abstract
INTRODUCTION Surgery is widely recognised as the treatment of choice for suprasyndesmotic ankle fractures, because of the assumption that these injuries yield instability of the ankle joint. Stability assessment of ankle fractures using weightbearing radiographs is now used regularly to guide the treatment of transsyndesmotic and infrasyndesmotic ankle fractures. Patients with a congruent ankle joint on weightbearing radiographs can be treated non-operatively with excellent results. Weightbearing radiographs are, however, rarely performed on suprasyndesmotic fractures due to the assumed unstable nature of these fractures. If weightbearing radiographs can be used to identify suprasyndesmotic fractures suitable for non-operative treatment, we may save patients from the potential burdens of surgery.Our aim is to compare the efficacy of operative and non-operative treatment of patients with suprasyndesmotic ankle fractures that reduce on weightbearing radiographs. METHODS AND ANALYSIS A non-inferiority randomised controlled trial involving 120 patients will be conducted. A total of 120 patients with suprasyndesmotic ankle fractures with an initial radiographic medial clear space of <7 mm will be subjected to weightbearing radiographs. If the tibio-talar joint is completely reduced, we will randomise in a 1:1 ratio to either operative treatment including reduction and fixation of the syndesmosis or non-operative treatment with an orthosis. The primary study outcome is patient-reported ankle function and symptoms as measured by the Olerud-Molander Ankle Score at 2-year follow-up. Secondary outcomes include the Manchester-Oxford Foot Questionnaire, range of motion, radiographic results and rates of adverse events. ETHICS AND DISSEMINATION The Regional Committee for Medical and Health Research South East, group A (permission number: 169307), has granted ethics approval. The results of this study will provide valuable insights for developing future diagnostic and treatment strategies for a common fracture type. The findings will be shared through publication in peer-reviewed journals and presentations at conferences. TRIAL REGISTRATION NUMBER NCT04615650.
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Affiliation(s)
- Ola Saatvedt
- Department of Orthopedic Surgery, Innlandet Hospital Trust Gjøvik Hospital, Gjovik, Norway
- University of Oslo Faculty of Medicine, Oslo, Norway
| | - Martin Riiser
- University of Oslo Faculty of Medicine, Oslo, Norway
- Department of Orthopedic Surgery, Oslo Universitetssykehus, Oslo, Norway
| | - Frede Frihagen
- Department of Orthopedic Surgery, Østfold Hospital Trust, Sarpsborg, Norway
| | - Wender Figved
- Department of Orthopaedic Surgery, Bærum Hospital, Vestre Viken Hospital Trust, Bærum, Norway
| | - Jan Erik Madsen
- University of Oslo Faculty of Medicine, Oslo, Norway
- Department of Orthopedic Surgery, Oslo Universitetssykehus, Oslo, Norway
| | - Marius Molund
- Department of Orthopedic Surgery, Østfold Hospital Trust, Sarpsborg, Norway
| | - Håvard Furunes
- Department of Orthopedic Surgery, Innlandet Hospital Trust Gjøvik Hospital, Gjovik, Norway
- University of Oslo Faculty of Medicine, Oslo, Norway
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Daas S, Jlidi M, Baghdadi N, Bouaicha W, Mallek K, Lamouchi M, Khorbi A. Risk factors for malunion of distal tibia fractures treated by intramedullary nailing. J Orthop Surg Res 2024; 19:5. [PMID: 38169392 PMCID: PMC10762967 DOI: 10.1186/s13018-023-04472-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/14/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND The treatment of distal tibia fractures (DTF) has historically been a difficult challenge for orthopedic surgeons because of the particular characteristics of this anatomical region. Intra medullary nailing (IMN) remains the best treatment option. However, achieving and maintaining perfect reduction and stable fixation with IMN can be technically challenging due to the large medullary cavity within a short distal fragment. The aim of our study is to determine the risk factors for malunion in DTF treated with IMN. METHODS It is a retrospective study including DTF treated surgically by IMN in the Orthopedics and Trauma Department at a tertiary hospital over a period of 7 years. The quality of reduction was evaluated by radiological assessment of the antero-posterior (AP) and lateral views of the tibia and ankle at the last follow-up. RESULTS Our series included 90 patients with an average age of 44.8 years. Sex-ratio was 2.6. Tobacco use was reported in 35.6% of the patients. Diabetes was present in 11.1% of the patients, and 12.2% of them had open fractures. According to the OTA/AO classification, the majority of injuries were classified as type A1 (76.7%). Fibula fractures were present in 86.7% of cases. The mean follow-up was 48 months. Malunion occurred in 13 cases. Based on the univariate analysis, smoking and dynamic fixation were significantly associated with malunion. In the multiple logistic regression analysis, dynamic fixation was found to be a significant factor that increased the risk of malunion by 7.5 times. CONCLUSION Neither patient demographics nor fracture characteristics were risk factors for malunion. Nevertheless, it should be noted that dynamic nailing must be avoided as it is associated with a higher risk of malunion. Furthermore, one to two medial to lateral distal locking screws provide sufficient stability without the need for additional fibular fixation. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Selim Daas
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Mohamed Jlidi
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia.
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia.
| | - Nahla Baghdadi
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia
| | - Walid Bouaicha
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Karim Mallek
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia
| | - Mouldi Lamouchi
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia
| | - Adel Khorbi
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
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Bashir A, Satalich JR, Hampton H, Cinats DJ. Circular External Fixation of Ankle and Pilon Fractures Using Novel Polyaxial Locking Struts. J Long Term Eff Med Implants 2024; 34:65-69. [PMID: 37938207 DOI: 10.1615/jlongtermeffmedimplants.2023047155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Ankle fractures and pilon fractures are common injuries and can range in severity from low-energy rotational injuries to high-energy fractures of the articular surface. External fixation can be used in a staged treatment strategy to allow for a closed reduction and soft tissue rest before definitive internal fixation or as a definitive treatment method. We describe a technique that involves the use of novel polyaxial locking struts in conjunction with circular external fixation that can be used as a temporary form of external fixation or as definitive treatment of high-energy ankle and pilon fractures.
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Affiliation(s)
- Azhar Bashir
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, Richmond VA, 23219
| | - James R Satalich
- Department of Orthopaedics Surgery, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Hailey Hampton
- Virginia Commonwealth University Medical School, Richmond VA, 23219
| | - David J Cinats
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, Richmond VA, 23219
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Yüce A, Erkurt N, Yerli M, Saygılı MS, Özkan CB. Morphology of Fibular Incisura is a Deciding Factor Between Posterior Malleolus Avulsion Fracture or Syndesmotic Ligament Injury in Ankle Fractures. J Foot Ankle Surg 2024; 63:18-21. [PMID: 37572828 DOI: 10.1053/j.jfas.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 07/18/2023] [Accepted: 08/03/2023] [Indexed: 08/14/2023]
Abstract
The bone anatomy of tibiofibular syndesmosis has been a topic of interest. Fibular incisura morphology has been analyzed on cadaver specimens, plain radiographs, or CT images. The aim of this study is to examine the effects of fibula incisura features and fibula morphology in ankle injuries, especially involving posterior malleolus and posteroinferior tibiofibular ligament injuries. From 2017 through 2022, A total of 59 patients with isolated lateral malleolar fracture, Mason-Malloy type 1 posterior malleolar fracture, syndesmosis injury in those without posterior malleolar fracture, supination external rotation type 3 injuries according to Lauge-Hansen classification, and preoperative bilateral ankle computed tomography images were included in the study. Fibula morphologies and syndesmosis measurements were made from preoperative computed tomography images using axial CT images from 1 cm proximal to the tibial plafond. The diagnosis of posterior malleolar fractures was made using the CT classification system of Mason and Malloy, and the diagnosis of syndesmosis injury was made with a cotton test during surgery. Age, gender, fractured side, incisura type, incisor depth, width, anterior and posterior facet lengths, incisor version (antevert-retrovert), the angle between the anterior and posterior facets, and fibula type were recorded. There was a statistically significant difference between the groups in posterior facet length and incisura width. Morphological features of fibular incisura may be the determinant of PITFL injury or PMA injury in fibular fractures caused by an external rotation mechanism.
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Affiliation(s)
- Ali Yüce
- Department of Orthopedic and Traumatology, Prof. Dr. Cemil Taşcıoğlu City Hospital, Istanbul, Turkey.
| | - Nazım Erkurt
- Department of Orthopedic and Traumatology, Prof. Dr. Cemil Taşcıoğlu City Hospital, Istanbul, Turkey
| | - Mustafa Yerli
- Department of Orthopedic and Traumatology, Prof. Dr. Cemil Taşcıoğlu City Hospital, Istanbul, Turkey
| | - Mehmet Selçuk Saygılı
- Department of Orthopedic and Traumatology, Prof. Dr. Cemil Taşcıoğlu City Hospital, Istanbul, Turkey
| | - Can Burak Özkan
- Department of Orthopedic and Traumatology, Prof. Dr. Cemil Taşcıoğlu City Hospital, Istanbul, Turkey
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Abstract
Successful outcomes in the surgical treatment of the fractured ankle require methods that respect the soft tissue envelope and establish a stable mortise for functional rehabilitation. Ankle fractures in patients with osteopenia and in diabetic patients with deranged bone remodeling constitute high-risk injuries that may result in catastrophic complications. These patients present unique care challenges and should not be approached in the same manner as their healthy counterparts. We present the principles of treatment in high-risk ankle fractures, operative treatment philosophy illustrating techniques frequently used at our institution, and a review of current literature.
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Affiliation(s)
- Craig E Krcal
- The CORE Institute, 18444 N 25th Avenue Suite 320, Phoenix, AZ 85023, USA; Kaiser San Francisco Bay Area Foot & Ankle Residency Program Alumni Class of 2023
| | - David R Collman
- Kaiser San Francisco Bay Area Foot & Ankle Residency Program; Department of Orthopedics, Podiatry, Injury, Sports Medicine; Kaiser Permanente San Francisco Medical Center, 450 6th Avenue, French Campus, 5th Floor, San Francisco, CA 94118, USA.
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Abbot MD, Siebert MJ, Wimberly RL, Wilson PL, Riccio AI. Physeal Bar Formation After Pediatric Medial Malleolus Fractures. Orthopedics 2024; 47:e33-e37. [PMID: 37341563 DOI: 10.3928/01477447-20230616-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
Pediatric medial malleolus fractures are commonly Salter-Harris (SH) type III or IV fractures of the distal tibia and are associated with a risk of physeal bar formation and subsequent growth disturbance. The purpose of this study was to determine the incidence of physeal bar formation following pediatric medial malleolus fracture and evaluate for patient and fracture characteristics predictive of physeal bar formation. Seventy-eight consecutive pediatric patients during a 6-year period who had either an isolated medial malleolar or a bimalleolar ankle fracture were retrospectively reviewed. Forty-one of 78 patients had greater than 3 months of radiographic follow-up and comprised the study population. Medical records were reviewed for demographic information, mechanism of injury, treatment, and need for further surgery. Radiographs were reviewed to assess for initial fracture displacement, adequacy of fracture reduction, SH type, percentage of the physeal disruption from the fracture, and physeal bar formation. Twenty-two of 41 patients (53.7%) developed a physeal bar. The mean time to diagnosis of physeal bar was 4.9 months (range, 1.6-11.8 months). Twenty-seven percent (6 of 22) of bars were diagnosed at greater than 6 months from injury. Adequacy of reduction was predictive of physeal bar formation, although all patients were reduced to within 2 mm. The mean residual displacement of patients with a bar was 1.2 mm compared with 0.8 mm for those without a bar (P=.03). Because the bar formation rate is greater than 50% on radiographs, routine radiographic assessment of all pediatric medial malleolar fractures should continue for at least 12 months after injury. [Orthopedics. 2024;47(1):e33-e37.].
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Korrapati A, Ta CN, Mitchell BC, Wall PV, Gurusamy P, Dwight K, Girard PJ, Schwartz AK, Kent WT. Fracture blisters: predictors for time to definitive fixation in pilon fractures. Eur J Orthop Surg Traumatol 2024; 34:161-166. [PMID: 37386191 PMCID: PMC10771370 DOI: 10.1007/s00590-023-03623-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 06/17/2023] [Indexed: 07/01/2023]
Abstract
PURPOSE Fracture blisters, a common soft-tissue complication of pilon fractures, are associated with post-operative wound infections, delays in definitive fixation, and alterations in surgical plan. The purpose of this study was to (1) identify the delay in surgery attributable to the presence fracture blisters and (2) investigate the relationship of fracture blisters to comorbidities and fracture severity. METHODS Patients with pilon fractures at an urban level 1 Trauma center from 2010 to 2021 were identified. The presence or absence of fracture blisters was noted, along with location. Demographic information, time from injury to external fixator placement, and time to definitive open reduction internal fixation (ORIF) were collected. Pilon fractures were classified according to AO/OTA guidelines using CT imaging and plain radiographs. RESULTS 314 patients with pilon fractures were available for analysis, eighty (25%) of whom were found to have fracture blisters. Patients with fracture blisters had longer time to surgery compared to those without fracture blisters (14.2 days vs 7.9 days, p < 0.001). A greater proportion of patients with fracture blisters had AO/OTA 43C fracture patterns, compared with those without fracture blisters (71.3% vs 53.8%, p = 0.03). Fractures blisters were less likely to be localized over the posterior ankle (12%, p = 0.007). CONCLUSION The presence of fracture blisters in pilon fractures are associated with significant delays in time to definitive fixation and higher energy fracture patterns. Fracture blisters are less commonly located over the posterior ankle which may support the implementation of a staged posterolateral approach when managing these injures.
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Affiliation(s)
- Avinaash Korrapati
- Department of Orthopaedic Surgery, University of California San Diego, 200 W Arbor Drive, MC 8894, San Diego, CA, 92103, USA
| | - Canhnghi N Ta
- Department of Orthopaedic Surgery, University of California San Diego, 200 W Arbor Drive, MC 8894, San Diego, CA, 92103, USA
| | - Brendon C Mitchell
- Department of Orthopaedic Surgery, University of California San Diego, 200 W Arbor Drive, MC 8894, San Diego, CA, 92103, USA
| | - Pelle V Wall
- Department of Orthopaedic Surgery, University of California San Diego, 200 W Arbor Drive, MC 8894, San Diego, CA, 92103, USA
| | - Pradyumna Gurusamy
- Department of Orthopaedic Surgery, University of California San Diego, 200 W Arbor Drive, MC 8894, San Diego, CA, 92103, USA
| | - Kathryn Dwight
- Department of Orthopaedic Surgery, University of California San Diego, 200 W Arbor Drive, MC 8894, San Diego, CA, 92103, USA
| | - Paul J Girard
- Department of Orthopaedic Surgery, University of California San Diego, 200 W Arbor Drive, MC 8894, San Diego, CA, 92103, USA
| | - Alexandra K Schwartz
- Department of Orthopaedic Surgery, University of California San Diego, 200 W Arbor Drive, MC 8894, San Diego, CA, 92103, USA
| | - William T Kent
- Department of Orthopaedic Surgery, University of California San Diego, 200 W Arbor Drive, MC 8894, San Diego, CA, 92103, USA.
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Herscovici D, Scaduto JM, Early JS, Pinzur MS, Sammarco VJ. Management of Acute Ankle Fractures
in Patients With Diabetes. Instr Course Lect 2024; 73:197-207. [PMID: 38090898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Ankle fractures in patients with diabetes can be difficult to manage, especially when patients present with hyperglycemia. Treatment often requires a combination of both medical and surgical care, especially in patients with poorly controlled diabetes. The goal of any treatment is to obtain a well-aligned ankle fracture that heals without any further displacement and to avoid the development of a Charcot joint. Nonsurgical treatment is usually reserved for nondisplaced fractures. Displaced fractures often require surgical treatment, and there are different options available, including standard fixation, fixation with multiple syndesmotic screw placement, external (thin wire) fixation alone, hybrid or combined internal and external fixation techniques, and primary arthrodesis. It is important to discuss the approach to the evaluation and treatment of these patients.
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Stockwell E, Thomas P, Grossman L, Lyden E, Mormino M, Siebler J, Putnam S. Successful Outcomes With Nonoperative Treatment and Immediate Weightbearing Despite Stress-Positive Radiographs in Isolated Distal Fibula (OTA/AO 44B) Fractures. J Orthop Trauma 2024; 38:e20-e27. [PMID: 37853554 DOI: 10.1097/bot.0000000000002719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/12/2023] [Indexed: 10/20/2023]
Abstract
OBJECTIVES To determine whether a nonoperative management protocol results in equivalent outcomes in isolated OTA/AO 44B (Weber B) fractures without initial medial clear space (MCS) widening regardless of stress radiography findings. METHODS DESIGN Prospective cohort. SETTING Level 1 academic trauma center. PATIENT SELECTION CRITERIA Nonoperatively managed patients with isolated OTA/AO 44B fractures and MCS ≤4 mm on initial non-weightbearing injury radiographs between from January 2018 and January 2022 were included. All patients underwent emergency department gravity stress radiographs and those with widening were considered the widening cohort and those without the non-widening cohort. OUTCOME MEASURE AND COMPARISONS MCS measurements on weightbearing radiographs were obtained at first follow-up, 6 weeks, 12 weeks, and 6 months postinjury, were considered indicative of instability if >4 mm and were compared between cohorts.; American Orthopaedic Foot and Ankle Society ankle-hindfoot scores were also compared between cohorts. RESULTS Sixty-nine patients were studied. None of the 38 patients (55%) with widening on gravity stress radiographs demonstrated widening with weightbearing radiographs at any time point. Mean MCS measurement differences between the 2 cohorts were statistically significant for all time points ( P = 0.012); however, with a model adjusted mean MCS value of 2.7 mm for the nonwidening cohort and 2.9 mm for the widening cohort, these are not clinically significant. There was no statistically significant difference in overall final American Orthopaedic Foot and Ankle Society scores between the 2 groups ( P = 0.451). In addition, statistical equivalence using Schuirmann 2 one-sided tests was achieved between the 2 groups. Both cohorts had mean American Orthopaedic Foot and Ankle Society scores representing excellent outcomes at the final follow-up. CONCLUSIONS Patients with isolated OTA/AO 44B fractures without MCS widening on initial injury radiographs did not demonstrate instability on subsequent weightbearing radiographs and had equivalent outcomes regardless of gravity stress radiography findings when treated nonoperatively. Weightbearing radiographs at the initial follow-up appear to be a reliable assessment of ankle stability in these injuries and are an appropriate alternative to painful and time-consuming stress radiography. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Erin Stockwell
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha, NE
| | | | | | - Elizabeth Lyden
- University of Nebraska Medical Center College of Public Health, Omaha, NE
| | - Matthew Mormino
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha, NE
| | - Justin Siebler
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha, NE
| | - Sara Putnam
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha, NE
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Pollard JD, Krcal CE. Considerations with Fractures of the Posterior Malleolus in Ankle Fractures. Clin Podiatr Med Surg 2024; 41:103-117. [PMID: 37951669 DOI: 10.1016/j.cpm.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Foot and ankle surgeons are commonly confronted with the surgical dilemma on when and how to best surgically address trimalleolar ankle fractures with a posterior malleolar component. This may involve either direct fixation of the posterior malleolus or indirect stabilization with the fixation of the medial and lateral malleoli and trans-syndesmotic fixation. Recently there has been a paradigm shift in the management of these injuries with a more thorough understanding of anatomy, stability, and long-term sequela of these injuries. This article aims to evaluate the current literature on posterior malleolar ankle fractures, approaches to fixing the posterior malleolus, and outcomes and complications of these procedures.
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Affiliation(s)
- Jason D Pollard
- Department of Podiatric Surgery, Kaiser Permanente, 3600 Broadway, Suite 17, Oakland, CA 94611, USA.
| | - Craig E Krcal
- The CORE Institute, 18444 North 25th Avenue Suite 320, Phoenix, AZ 85023, USA; Graduate Kaiser San Francisco Bay Area Foot & Ankle Residency, 2023
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Stassen RC, Franssen S, Meesters B, Boonen B, de Loos ER, van Vugt R. Prospective randomized controlled trial: early weight bearing after conservative treatment of Weber B ankle fractures (pancake trial). Eur J Orthop Surg Traumatol 2024; 34:591-598. [PMID: 37658912 PMCID: PMC10771350 DOI: 10.1007/s00590-023-03651-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 07/15/2023] [Indexed: 09/05/2023]
Abstract
PURPOSE Different studies have shown that weightbearing is safe in stable transsyndesmotic, isolated lateral simple ankle fractures. Despite this evidence, AO guidelines still recommend immobilization with above-the-knee cast for 4-6 weeks for these fractures. The objective of this study was to compare the outcomes of mobilization and weightbearing to those of immobilization and non-weightbearing in patients with stable transsyndesmotic, lateral isolated simple ankle fractures. METHODS Fifty patients were randomly assigned to permissive weightbearing in a walking boot or non-weightbearing immobilization using a below-the-knee cast. Primary outcome was ankle functionality as scored by the Olerud-Molander Ankle Score (OMAS). Secondary outcomes were radiological displacement of fracture, range of motion (ROM), calf circumference, and RAND 36-item health survey. Patients were in follow-up for 24 months. RESULTS Ankle functionality after six and twelve weeks was significantly higher for the intervention group, with respectively 30 points (p = 0.001) and 10 points (p = 0.015) of difference. ROM improved significantly in the intervention group after six weeks. All fractures showed radiological progression of fracture healing. RAND 36-item showed differences in both physical (60.3 vs. 46.3, p = 0.017) and mental (78.5 vs. 58.2, p = 0.034) components in favor of the intervention group. In 16% of patients who initially showed stable fractures on radiographic imaging, joint dislocation was identified on weightbearing radiographs prior to randomization, leading to exclusion. CONCLUSION Weightbearing and mobilization using a walking boot may be a safe treatment for patients with stable Weber B fractures.
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Affiliation(s)
- R C Stassen
- Department of Traumatology, Zuyderland Medical Centre, Henri Dunantstraat 5, 6419 PC, Heerlen, The Netherlands
| | - S Franssen
- Department of Traumatology, Zuyderland Medical Centre, Henri Dunantstraat 5, 6419 PC, Heerlen, The Netherlands
| | - B Meesters
- Department of Traumatology, Zuyderland Medical Centre, Henri Dunantstraat 5, 6419 PC, Heerlen, The Netherlands
| | - B Boonen
- Department of Orthopaedic Surgery, Zuyderland Medical Centre, Henri Dunantstraat 5, 6419 PC, Heerlen, The Netherlands
| | - E R de Loos
- Department of Traumatology, Zuyderland Medical Centre, Henri Dunantstraat 5, 6419 PC, Heerlen, The Netherlands
| | - R van Vugt
- Department of Traumatology, Zuyderland Medical Centre, Henri Dunantstraat 5, 6419 PC, Heerlen, The Netherlands.
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Fűzy EJ, Ferreira N, Brown C, Hugo D, Joubert E, Burger M. The reliability of posterior malleolar ankle fracture assessment: a unique perspective. Eur J Orthop Surg Traumatol 2024; 34:539-548. [PMID: 37644335 PMCID: PMC10771354 DOI: 10.1007/s00590-023-03702-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 08/17/2023] [Indexed: 08/31/2023]
Abstract
AIM This study aims to elucidate the pathology of PMFs in the South African population, establish correlations between fracture patterns and international classification guidelines and evaluate the interobserver reliability of current classifications. METHODS A retrospective review was conducted in a multicentre analysis over a one-year period from January 2019 to December 2019 at our institution. Computer tomography scans for foot and ankle injuries were reviewed, and posterior malleolus fractures were included. Pathoanatomical data was collected and analysed according to known classification systems and subsequent treatment modalities evaluated. A panel of observers individually reviewed radiographic data to determine interobserver reliability. RESULTS A total of 71 patients were included with a mean age of 41 ± 13.4 years (range 18-78) and a female predominant population (69%). A greater proportion of injuries were high energy (23.9%), with significant fragment comminution (53.5%), and half (52.1%) of all injuries were subluxated/dislocated at presentation. A total of 93% of injuries were managed operatively, despite theatre access limitations resulting in significant delays to fixation (19.1 days). Despite good pathoanatomical agreement with most international classifications, interobserver reliability was poor (Krippendorff α-coefficient < 0.667). Inconsistent treatment patterns in operative and non-operative strategies are reported. CONCLUSION A unique patient population of younger, female individuals incurred posterior malleolar fractures due to higher energy mechanisms of injury. Whilst injury patterns were mostly comparable, significant interobserver variability was noted. Resource limitations, diagnostic challenges, poorly defined and inconsistent treatment strategies, inevitably impact outcomes within the South African population. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Edward Joseph Fűzy
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, 7505, South Africa
| | - Nando Ferreira
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, 7505, South Africa.
| | - Craig Brown
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, 7505, South Africa
| | - Daniel Hugo
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, 7505, South Africa
| | - Etienne Joubert
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, 7505, South Africa
| | - Marilize Burger
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, 7505, South Africa
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Thomas S, Huang BK, Korrapati A, O'Leary B, Gurusamy P, O'Leary R, Kent WT. The effect of spanning external fixation on entrapped structures in tibial pilon fractures. Eur J Orthop Surg Traumatol 2024; 34:237-242. [PMID: 37433971 PMCID: PMC10771588 DOI: 10.1007/s00590-023-03641-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 06/29/2023] [Indexed: 07/13/2023]
Abstract
PURPOSE Pilon fractures are often complex injuries involving severe soft tissue injury. Studies have shown pilon fractures may entrap soft tissue structures between fracture fragments. Staged fixation of pilon fractures with spanning external fixation (SEF) is important for soft tissue rest and plays an important role in the management of these injuries. While SEF has been shown to promote soft tissue rest prior to definitive fixation, no studies have shown the effect SEF has on entrapped structures (ES). The purpose of this study was to evaluate how SEF effects ES in pilon fractures. METHODS A retrospective review of 212 pilon fractures treated at our institution between 2010 and 2022 was performed. Patients with a CT scan pre-SEF and post-SEF met inclusion criteria. CTs were reviewed to characterize ES in pre- and post-SEF imaging. RESULTS Of the 19 patients with ES identified on CT pre-SEF, seven (36.8%) had full release of ES post-SEF and 12 (63.2%) had no release of ES. The posterior tibial tendon was the most commonly ES and remained entrapped in 62.5% of cases. Only 25% of 43-C3 fractures had release of ES post-SEF, while 100% of 43-C1 and 43-C2 fractures demonstrated complete release of ES post-SEF. CONCLUSION Entrapped structures in pilon fractures are likely to remain entrapped post-SEF, with only one-third of our cohort demonstrating release. In 43-C3 patterns, if ES are identified on CT pre-SEF, surgeons should consider addressing these either through mini open versus open approaches at the time of SEF as they are likely to remain entrapped post-SEF.
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Affiliation(s)
- Sean Thomas
- University of California San Diego School of Medicine, 200 West Arbor Drive MC 8894, San Diego, CA, 92103, USA
| | - Brady K Huang
- Division of Musculoskeletal Imaging, Department of Radiology, University of California San Diego, San Diego, CA, USA
| | - Avinaash Korrapati
- Department of Orthopaedic Surgery, University of California San Diego, 200 West Arbor Drive MC 8894, San Diego, CA, 92103, USA
| | - Brendan O'Leary
- Department of Orthopaedic Surgery, University of California San Diego, 200 West Arbor Drive MC 8894, San Diego, CA, 92103, USA
| | - Pradyumna Gurusamy
- Department of Orthopaedic Surgery, University of California San Diego, 200 West Arbor Drive MC 8894, San Diego, CA, 92103, USA
| | - Ryan O'Leary
- Department of Orthopaedic Surgery, University of California San Diego, 200 West Arbor Drive MC 8894, San Diego, CA, 92103, USA
| | - William T Kent
- Department of Orthopaedic Surgery, University of California San Diego, 200 West Arbor Drive MC 8894, San Diego, CA, 92103, USA.
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Huang S, Zhu J, Xing H, Yang R, Ye J, Ye F, Wu Q, Lan S. Finite element analysis and a pilot study of different fixation constructs for Danis-Weber A and B lateral malleolus fractures. BMC Musculoskelet Disord 2023; 24:981. [PMID: 38114924 PMCID: PMC10729578 DOI: 10.1186/s12891-023-07115-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 12/13/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Displaced lateral malleolus fractures are typically stabilised through open reduction and internal fixation. The biomechanically and clinically efficacy of locking plates and lag screws, particularly in Weber A and B distal fibular fractures remains a subject of contention. This study examines two locking plate designs for lateral malleolus fractures, evaluating their performance with and without interfragmentary screws using finite element models. METHODS Utilising CT images of a healthy adult male volunteer, a three-dimensional finite element model was constructed. The Fibula-specific Flank Multiaxial Locking Anatomic Plate (FMLP) and the Conventional Locking Plate (CLP) were subjected to stabilisation, both with and without an interfragmentary screw, mimicking the Danis-Weber A and B lateral malleolus oblique fracture fixation. Loads of 140 N and 70 N, equivalent to 20% of the body weight, were applied to simulate the single-leg and two-leg standing conditions in the axial direction. The von Mises stress (VMS) distributions and element displacements were subsequently analyzed. RESULTS In the Danis-Weber A fracture model group, the FMLP with an interfragmentary screw fixation exhibited the lowest peak VMS values: 51.9 MPa in the fibula, 89.0 MPa in the plate, and 61.3 MPa in the screws for simulating single-leg conditions. Under two-leg standing conditions, these peak VMS values decreased to 25.9 MPa in the fibula, 44.5 MPa in the plate, and 30.6 MPa in the screws, respectively. Furthermore, the overall structural peak displacements during single-leg standing for both Weber-A and B fractures with different implants ranged from 1.61 to 2.54 mm. While standing on two feet, the ranged was from 0.80 to 1.27 mm. An interfragmentary screw at the oblique fracture site resulted in reduced the peak value of VMS in the fibula, plate, screws, consequently decreased the overall structural displacement for FMLP and CLP fixation in lateral malleolus fractures. CONCLUSIONS The current finite element analysis (FEA) demonstrates that FMLP exhibits superior mechanical characteristics in Danis-Weber A and B lateral malleolus fractures compared to CLP. The inclusion of an interfragmentary screw, combined with locking plate design, enhances stability for simple oblique distal fibular fractures. The FMLP presents itself as potential as an alternative for lateral malleolus fractures from a biomechanical perspective. Nevertheless, further verification of these results is imperative through subsequent clinical studies.
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Affiliation(s)
- Shuming Huang
- Department of Orthopedic Surgery, Lishui Hospital, Zhejiang University School of Medicine, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Municipal Central Hospital, Lishui, Zhejiang, 323000, People's Republic of China
| | - Junkun Zhu
- Department of Orthopedic Rehabilitation, Lishui Hospital, Zhejiang University School of Medicine, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Municipal Central Hospital, Zhejiang323000, Lishui, People's Republic of China
| | - Hailin Xing
- Department of Orthopedic Surgery, Lishui Hospital, Zhejiang University School of Medicine, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Municipal Central Hospital, Lishui, Zhejiang, 323000, People's Republic of China
| | - Ruifeng Yang
- Department of Orthopedic Surgery, Lishui Hospital, Zhejiang University School of Medicine, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Municipal Central Hospital, Lishui, Zhejiang, 323000, People's Republic of China
| | - Jifei Ye
- Department of Orthopedic Surgery, Lishui Hospital, Zhejiang University School of Medicine, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Municipal Central Hospital, Lishui, Zhejiang, 323000, People's Republic of China
| | - Fang Ye
- Department of Orthopedic Surgery, Lishui Hospital, Zhejiang University School of Medicine, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Municipal Central Hospital, Lishui, Zhejiang, 323000, People's Republic of China
| | - Quanzhou Wu
- Department of Orthopedic Surgery, Lishui Hospital, Zhejiang University School of Medicine, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Municipal Central Hospital, Lishui, Zhejiang, 323000, People's Republic of China
| | - Shuhua Lan
- Department of Orthopedic Surgery, Lishui Hospital, Zhejiang University School of Medicine, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Municipal Central Hospital, Lishui, Zhejiang, 323000, People's Republic of China.
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Liang H, Zhang H, Chen B, Yang L, Xu R, Duan S, Cai Z. 3D printing technology combined with personalized plates for complex distal intra-articular fractures of the trimalleolar ankle. Sci Rep 2023; 13:22667. [PMID: 38114629 PMCID: PMC10730506 DOI: 10.1038/s41598-023-49515-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 12/08/2023] [Indexed: 12/21/2023] Open
Abstract
This study investigated the effectiveness of 3D printing technology in combination with personalized custom-made steel plates in the treatment of complex distal intra-articular trimalleolar fractures, with the aim of providing a new approach to improve ankle joint function in patients. The 48 patients with complex distal intra-articular trimalleolar fractures included in the study were randomly divided into two groups: the personalized custom-made steel plate group (n = 24) and the conventional steel plate group (n = 24). A comparison was made between the two groups in terms of preoperative preparation time, hospitalization duration, surgical time, fracture reduction and internal fixation time, intraoperative fluoroscopy instances, surgical incision length, fracture healing time, follow-up duration, degree of fracture reduction, ankle joint functional recovery, and the occurrence of complications. The personalized steel plate group exhibited longer preoperative preparation time and hospitalization duration compared to the conventional steel plate group (p < 0.001). However, the personalized steel plate group demonstrated significantly shorter surgical duration, time for fracture reduction and internal fixation, reduced intraoperative fluoroscopy frequency, and a shorter overall surgical incision length (p < 0.001). Both groups displayed similar fracture healing times and follow-up durations (p > 0.05). The personalized steel plate group showed a higher rate of successful fracture reduction (87.5% vs. 79.2%, p > 0.05) and a lower incidence of complications (8.3% vs. 20.8%, p = 0.22), although these differences did not reach statistical significance. Furthermore, the personalized steel plate group exhibited superior ankle joint function scores during follow-up compared to the conventional steel plate group (p < 0.05). By utilizing 3D printing technology in conjunction with personalized custom-made steel plates, personalized treatment plans are provided for patients with complex comminuted tri-malleolar ankle fractures, enabling safer, more efficient, and satisfactory orthopedic surgeries.
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Affiliation(s)
- Hairui Liang
- Department of Orthopedics Surgery, Central Hospital Afliated to Shenyang Medical College, 5 Nanqi West Road, Shenyang, 110075, Liaoning, China
| | - He Zhang
- Department of Orthopedics Surgery, Central Hospital Afliated to Shenyang Medical College, 5 Nanqi West Road, Shenyang, 110075, Liaoning, China
| | - Beibei Chen
- Department of Orthopedics Surgery, Central Hospital Afliated to Shenyang Medical College, 5 Nanqi West Road, Shenyang, 110075, Liaoning, China
| | - Lei Yang
- School of Pharmacy, Inner Mongolia Medical University, 5 Xinhua Street, Hohhot, 010107, Inner Mongolia Autonomous Region, China
| | - Rongda Xu
- Department of Orthopedics Surgery, Central Hospital Afliated to Shenyang Medical College, 5 Nanqi West Road, Shenyang, 110075, Liaoning, China
| | - Siyu Duan
- Department of Orthopedics Surgery, Central Hospital Afliated to Shenyang Medical College, 5 Nanqi West Road, Shenyang, 110075, Liaoning, China
| | - Zhencun Cai
- Department of Orthopedics Surgery, Central Hospital Afliated to Shenyang Medical College, 5 Nanqi West Road, Shenyang, 110075, Liaoning, China.
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Little M, Beer A, Deierl K. Emergency definitive management of a subtalar dislocation with an associated lateral malleolus fracture. BMJ Case Rep 2023; 16:e257744. [PMID: 38103901 PMCID: PMC10728935 DOI: 10.1136/bcr-2023-257744] [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: 12/19/2023] Open
Abstract
Lateral subtalar dislocations are rare injuries with the potential for misdiagnosis and for poor patient outcomes if missed. Prompt reduction and surgical intervention is the consensus and is key to improved patient outcomes.We present a case of a male patient in his 70s who was brought in by ambulance to the emergency department late one afternoon with a lateral subtalar dislocation associated with calcaneal and lateral malleolar fractures. He was operated on that evening, involving cannulated screw fixation of the calcaneus and buttress plating of the lateral malleolus. Non-weight-bearing mobilisation was permitted at 2 weeks and weight-bearing was commenced at 6 weeks postoperatively.The authors could not find any precedent in the literature for same-day definitive fixation and early mobilisation of this rare but significant injury, the combination of which resulted in excellent functional outcomes for the patient.
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Affiliation(s)
- Max Little
- Trauma and Orthopaedics, West Hertfordshire Hospitals NHS Trust, Watford, UK
| | - Alexander Beer
- Trauma and Orthopaedics, West Hertfordshire Hospitals NHS Trust, Watford, UK
| | - Krisztian Deierl
- Trauma and Orthopaedics, West Hertfordshire Hospitals NHS Trust, Watford, UK
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Ying J, Liu J, Wang H, Zhuang Y, Yu T, Wang S, Huang D. Biomechanical insights into ankle instability: a finite element analysis of posterior malleolus fractures. J Orthop Surg Res 2023; 18:957. [PMID: 38087344 PMCID: PMC10714561 DOI: 10.1186/s13018-023-04432-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 11/29/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Posterior malleolus fractures are known to be associated with ankle instability. The complexities involved in obtaining precise laboratory-based spatial pressure measurements of the ankle highlight the significance of exploring the biomechanical implications of these fractures. METHODS Finite element analysis was utilized to examine the stress distribution across the contact surface of the ankle joint, both in its natural state and under varied sagittal fracture line angles. The study aimed to identify stress concentration zones and understand the influence of sagittal angles on stress distribution. RESULTS Three distinct stress concentration zones were identified on the ankle's contact surface: the anterolateral tibia, the anteromedial tibia, and the fracture line. The most significant stress was observed at the fracture line when a fracture occurs. Stress at the fracture line notably spikes as the sagittal angle decreases, which can potentially compromise ankle stability. Larger sagittal angles exhibited only minor stress variations at the contact surface's three vertices. It was inferred that sagittal angles below 60° might pose risks to ankle stability. CONCLUSIONS The research underscores the potential implications of fractures on the stress profile of the ankle joint, emphasizing the role of the contact surface in ensuring stability. The identification of three zones of stress concentration and the influence of sagittal angles on stress distribution offers a valuable reference for therapeutic decision-making. Further, the study reinforces the importance of evaluating sagittal fracture angles, suggesting that angles below 60° may compromise ankle stability.
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Affiliation(s)
- Jichong Ying
- Department of Orthopaedic Trauma, Ningbo No.6 Hospital, Ningbo, China
| | - Jianlei Liu
- Department of Orthopaedic Trauma, Ningbo No.6 Hospital, Ningbo, China
| | - Hua Wang
- Department of Medical Imaging, Ningbo No.6 Hospital, Ningbo, China
| | - Yunqiang Zhuang
- Department of Orthopaedic Trauma, Ningbo No.6 Hospital, Ningbo, China
| | - Tianming Yu
- Department of Orthopaedic Trauma, Ningbo No.6 Hospital, Ningbo, China
| | - Shuaiyi Wang
- Department of Orthopaedic Trauma, Ningbo No.6 Hospital, Ningbo, China
| | - Dichao Huang
- Department of Orthopaedic Trauma, Ningbo No.6 Hospital, Ningbo, China.
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Batar S, Şişman A. Comparison of anteroposterior and posteroanterior screw fixation techniques for posterior malleolar fractures: a retrospective and clinical study. ULUS TRAVMA ACIL CER 2023; 29:1376-1381. [PMID: 38073458 PMCID: PMC10767291 DOI: 10.14744/tjtes.2023.66204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 10/23/2023] [Accepted: 11/23/2023] [Indexed: 12/18/2023]
Abstract
BACKGROUND The posterior malleolus is an important component of the distal tibiofibular complex and plays a crucial role in maintaining ankle joint stability. This study aimed to compare the clinical and radiological outcomes of fixation with anteroposterior (AP) and posteroanterior (PA) compression screws in patients with Haraguchi Type 1 PMFs. METHODS Data from 306 patients who underwent surgery for trimalleolar fractures between January 2018 and March 2022 were retrospectively reviewed, and 60 patients meeting the criteria were included in the study. Thirty-one patients with AP screw fixation and 29 patients with PA screw fixation were compared clinically and radiologically. Radiological parameters such as fracture healing time, step-off amount, displacement amount, and development of arthritis were evaluated. Clinical outcomes including ankle joint range of motion at final follow-up, American Orthopedic Foot and Ankle Society (AOFAS) score, Visual Analog Scale (VAS), and Olerud-Molander Score were compared. RESULTS There were no statistically significant differences between the groups in terms of average age, gender distribution, smoking history, fracture etiology, time from injury to surgery, operation time, fracture healing time, and follow-up duration. Step-off and displacement amounts were lower in the PA screw group (P<0.001, P=0.004, respectively). When comparing the development of arthritis, according to the Kellgren-Lawrence Classification, no signs of arthritis were observed in 62.1% of the PA screw group, while this rate was 22.6% in the AP screw group. Ankle dorsiflexion, plantar flexion range of motion, AOFAS score, Olerud-Molander Score, and VAS results were statistically better in the PA screw group (P=0.002, P=0.001, P=0.002, P=0.001, P=0.002, respectively). There were no significant differences between the groups regarding complications. CONCLUSION Two different screw fixation techniques used in the treatment of trimalleolar fracture patients with Haraguchi Type 1 PMF were compared. In conclusion; percutaneous PA screw fixation is more advantageous than the AP screw fixation method because it provides less step-off in the fracture line, less arthrosis in the ankle, and better functional scores.
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Affiliation(s)
- Suat Batar
- Department of Orthopedics and Traumatology, Ümraniye Training and Research Hospital, Istanbul-Türkiye
| | - Ali Şişman
- Department of Orthopedics and Traumatology, Adnan Menderes University Faculty of Medicine, Aydın-Türkiye
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Balziano S, Baran I, Prat D. Hindfoot nailing without joint preparation for ankle fractures in extremely elderly patients: Comparison of clinical and patient-reported outcomes with standard ORIF. Foot Ankle Surg 2023; 29:588-592. [PMID: 37468359 DOI: 10.1016/j.fas.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/25/2023] [Accepted: 07/02/2023] [Indexed: 07/21/2023]
Abstract
INTRODUCTION Tibiotalocalcaneal (TTC) nailing without joint preparation has been indicated as an alternative to open reduction and internal fixation (ORIF) in the treatment of unstable fragility ankle fractures. We hypothesized that primary hindfoot nailing without joint preparation, and immediate weight bearing can provide a safe and effective treatment for unstable fragility fractures of the ankle compared to ORIF. METHODS A retrospectively single-center cohort was reviewed for all surgically treated ankle fractures in patients aged 75 years and older between 2016 and 2021. The cases were grouped by the surgical technique: ORIF or TTC nailing. Diagnosis and treatment were validated by a review of the radiographs and the patients' charts. Primary outcomes included complication rates and revision rates. The PROMs questionnaires included the Foot and Ankle-Ability Measure (FAAM-ADL) and the Olerud-Molander Ankle Score (OMAS). RESULTS Forty-six cases met the inclusion criteria during the study period. Eighteen in the TTC group and 28 in the ORIF group. The average follow-up was 46.4 months (Median 49.5, SD ± 25.3). The mean age of the TTC group was significantly higher (88.6 versus 81.8, p < 0.001). The mean surgery duration and length of stay were similar. The complication rates were 50.0 % in the ORIF group (28.6 % major) versus 22.2 % in the TTC group (5.6 % major), (p = 0.060). The revision rates were 28.6 % and 11.1 % in the ORIF and TTC groups respectively (p = 0.161). The FAAM-ADL was higher in the ORIF group (62.6 % versus 32.4 %, p = 0.020), as well as the OMAS (60.0 versus 32.8, p = 0.029). CONCLUSION TTC nailing without joint preparation for unstable fragility fractures of the ankle in the extremely elderly provided a better complication profile compared to traditional ORIF. However, PROMs were inferior.
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Affiliation(s)
- Snir Balziano
- Department of Orthopaedic Surgery, Chaim Sheba Medical Center, Tel-Aviv University, Tel-Hashomer, Israel, Affiliated with the Faculty of Medicine of Tel-Aviv University, Ramat-Aviv, Tel-Aviv, Israel
| | - Isaac Baran
- Department of Orthopaedic Surgery, Chaim Sheba Medical Center, Tel-Aviv University, Tel-Hashomer, Israel, Affiliated with the Faculty of Medicine of Tel-Aviv University, Ramat-Aviv, Tel-Aviv, Israel
| | - Dan Prat
- Department of Orthopaedic Surgery, Chaim Sheba Medical Center, Tel-Aviv University, Tel-Hashomer, Israel, Affiliated with the Faculty of Medicine of Tel-Aviv University, Ramat-Aviv, Tel-Aviv, Israel.
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Lisitano L, Röttinger T, Wiedl A, Rau K, Helling S, Cifuentes J, Jehs B, Härting M, Feitelson LM, Gleich J, Kiesl S, Pfeufer D, Neuerburg C, Mayr E, Förch S. Plain X-ray is insufficient for correct diagnosis of tibial shaft spiral fractures: a prospective trial. Eur J Trauma Emerg Surg 2023; 49:2339-2345. [PMID: 37269304 PMCID: PMC10728229 DOI: 10.1007/s00068-023-02285-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/20/2023] [Indexed: 06/05/2023]
Abstract
PURPOSE Tibial shaft spiral fractures and fractures of the distal third of the tibia (AO:42A/B/C and 43A) frequently occur with non-displaced posterior malleolus fractures (PM). This study investigated the hypothesis that plain X-ray is not sufficient for a reliable diagnosis of associated non-displaced PM fractures in tibial shaft spiral fractures. METHODS 50 X-rays showing 42A/B/C and 43A fractures were evaluated by two groups of physicians, each group was comprised of a resident and a fellowship-trained traumatologist or radiologist. Each group was tasked to make a diagnosis and/or suggest if further imaging was needed. One group was primed with the incidence of PM fractures and asked to explicitly assess the PM. RESULTS Overall, 9.13/25 (SD ± 5.77) PM fractures were diagnosed on X-ray. If the posterior malleolus fracture was named or a CT was requested, the fracture was considered "detected". With this in mind, 14.8 ± 5.95 posterior malleolus fractures were detected. Significantly more fractures were diagnosed/detected (14 vs. 4.25/25; p < 0.001/14.8 vs. 10.5/25; p < 0.001) in the group with awareness. However, there were significantly more false positives in the awareness group (2.5 vs. 0.5; p = 0.024). Senior physicians recognized slightly more fractures than residents (residents: 13.0 ± 7.79; senior physicians: 16.5 ± 3.70; p = 0.040). No significant differences were demonstrated between radiologists and trauma surgeons. The inner-rater reliability was high with 91.2% agreement. Inter-rater reliability showed fair agreement (Fleiss-Kappa 0.274, p < 0.001) across all examiners and moderate agreement (Fleiss-Kappa 0.561, p < 0.001) in group 2. CONCLUSION Only 17% of PM fractures were identified on plain X-ray and awareness of PM only improved diagnosis by 39%. While experiencing improved accuracy, CT imaging should be included in a comprehensive examination of tibial shaft spiral fractures. LEVEL OF EVIDENCE II. Diagnostic prospective cohort study. TRAIL REGISTRATION NUMBER DRKS00030075.
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Affiliation(s)
- Leonard Lisitano
- Department for Trauma, Orthopedics, Hand and Plastic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany.
| | - Timon Röttinger
- Department for Trauma, Orthopedics, Hand and Plastic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Andreas Wiedl
- Department for Trauma, Orthopedics, Hand and Plastic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Kim Rau
- Department for Trauma, Orthopedics, Hand and Plastic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Sönke Helling
- Department for Trauma, Orthopedics, Hand and Plastic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Jairo Cifuentes
- Department for Trauma, Orthopedics, Hand and Plastic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Bertram Jehs
- Department for Diagnostic and Interventional Radiology, University Hospital Augsburg, Augsburg, Germany
| | - Mark Härting
- Department for Diagnostic and Interventional Radiology, University Hospital Augsburg, Augsburg, Germany
| | - Laura-Marie Feitelson
- Department for Diagnostic and Interventional Radiology, University Hospital Augsburg, Augsburg, Germany
| | - Johannes Gleich
- Department for Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital LMU Munich, Munich, Germany
| | - Sophia Kiesl
- Department of Radiology, University Hospital LMU Munich, Munich, Germany
| | - Daniel Pfeufer
- Department for Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital LMU Munich, Munich, Germany
| | - Carl Neuerburg
- Department for Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital LMU Munich, Munich, Germany
| | - Edgar Mayr
- Department for Trauma, Orthopedics, Hand and Plastic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Stefan Förch
- Department for Trauma, Orthopedics, Hand and Plastic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
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Bakan ÖM, Vahabi A, Özkayın N. Management of complex pilon fractures: Is it necessary to fix all the columns in AO/OTA type 43-C fractures? Injury 2023; 54:111153. [PMID: 37944452 DOI: 10.1016/j.injury.2023.111153] [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: 06/14/2023] [Revised: 10/04/2023] [Accepted: 10/22/2023] [Indexed: 11/12/2023]
Abstract
INTRODUCTION Surgical treatment of AO/OTA 43-C pilon fractures has not yet taken a standard form. We aimed to evaluate whether patients that appeared to be labelled as unsupported columns according to the four-column theory would affect long-term clinical and radiological outcomes. MATERIALS AND METHODS Patients with AO/OTA 43-C type who were treated surgically between January 2010 and December 2019 were included in the study. 53 fractures in 52 patients who received osteosynthesis were categorized based on the fixed columns. These groups were formed as fully supported columns (FSC- Group A), partly supported columns (PSC-Group B), Ankle range of motions (ROM), Burwell Charnley's reduction evaluation criteria, Kellgren-Lawrence ankle osteoarthritis staging system, and American Orthopedic Foot and Ankle Society (AOFAS) Scoring System, Olerud-Molander Ankle Score, Visual Analog Scale were used for evaluating radiological and functional outcomes. RESULTS The mean follow-up period was 72.6 (12-131) months. Mean age was 42.6 (18-76). Two groups were homogenously distributed in terms of age (p = 0.785), sex (p = 0.376), laterality (p = 0.732), smoking status (p = 0.488) and reduction quality. There was no difference in AOFAS score (p = 0.452), Olerud-Molander score (p = 0.354) and VAS scores (p = 0.589). TAS, TLS and TT angle measurements suggested no difference between groups (p = 0.493, p = 0.834, p = 0.577). There was no difference between groups in terms of infection (p = 0.734), malunion (p = 0.688) and arthritis (p = 0.483) CONCLUSION: We presented findings that contradicted the hypothesis positing the existence of four distinct columns in pilon fractures, as well as the notion that each fractured column requires support from distinct implants. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Özgür Mert Bakan
- Çiğli State Hospital, Department of Orthopedics and Traumatology, Turkey
| | - Arman Vahabi
- Ege University School of Medicine, Department of Orthopedics and Traumatology, Turkey.
| | - Nadir Özkayın
- Ege University School of Medicine, Department of Orthopedics and Traumatology, Turkey.
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Ding W, Xu J, Zhu Y, Nian S, Lu Y, Zheng M, Zhu X, Wang Z, Ji F, Tang H. Comparative study on the clinical efficacy of small plate assisted anatomic plate and traditional double plate in the treatment of Rüedi and Allgöwer II - III pilon fracture. BMC Surg 2023; 23:352. [PMID: 37980470 PMCID: PMC10657612 DOI: 10.1186/s12893-023-02251-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 10/27/2023] [Indexed: 11/20/2023] Open
Abstract
OBJECTIVE The aim of this study was to investigate the clinical efficacy of small plate assisted anatomical plate and traditional double plate in the treatment of Rüedi and Allgöwer II - III pilon fracture. METHODS AND MATERIALS The data of 68 patients with pilon fracture admitted to Hospital from June 2017 to June 2020 were retrospectively analyzed. Study group and control group were divided according to different operation methods, with 34 cases in each group. There were 28 cases of Rüedi and Allgöwer II type and 40 cases of Rüedi and Allgöwer III type. Perioperative period data, Ankle joint function score, visual analog scale (VAS) scores and the incidence of incision complications were analyzed between these two groups. RESULTS There were no significant differences in full load time, fracture healing time between these two groups (P > 0.05). The operation time, intraoperative blood loss, length of hospital stay, Ankle joint function score and postoperative incision complication rate in observation group were lower than those in control group (P < 0.05). CONCLUSION Small plate assisted anatomic plate is comparable to traditional double plate in the treatment of pilon fracture in terms of complete loading time, fracture healing time, but the former can shorten the operation time, reduce intraoperative blood loss and effectively reduce the incidence of postoperative complications.
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Affiliation(s)
- Wenbin Ding
- Department of Orthopedics, Changhai Hospital, Naval Military Medical University, 168 Changhai Road, Shanghai, China
| | - Jianing Xu
- Department of Orthopedics, Changhai Hospital, Naval Military Medical University, 168 Changhai Road, Shanghai, China
| | - Ya Zhu
- Department of Orthopedics, The Second People's Hospital of Huai'an, The Affiliated Huai'an Hospital of Xuzhou Medical University, Huai'an, 223003, Jiangsu Province, China
| | - Shensheng Nian
- Department of Orthopedics, Changhai Hospital, Naval Military Medical University, 168 Changhai Road, Shanghai, China
| | - Yifeng Lu
- Department of Orthopedics, Changhai Hospital, Naval Military Medical University, 168 Changhai Road, Shanghai, China
| | - Miaomiao Zheng
- Department of Orthopedics, Changhai Hospital, Naval Military Medical University, 168 Changhai Road, Shanghai, China
| | - Xiang Zhu
- Department of Orthopedics, Changhai Hospital, Naval Military Medical University, 168 Changhai Road, Shanghai, China
| | - Zimin Wang
- Department of Orthopedics, Changhai Hospital, Naval Military Medical University, 168 Changhai Road, Shanghai, China.
- Department of Orthopedics, The Ninth People's Hospital, Shanghai Jiaotong University, Shanghai, China.
| | - Fang Ji
- Department of Orthopedics, The Ninth People's Hospital, Shanghai Jiaotong University, Shanghai, China.
| | - Hao Tang
- Department of Orthopedics, Changhai Hospital, Naval Military Medical University, 168 Changhai Road, Shanghai, China.
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Xie W, Li H, Zhang C, Cui X, Zhang S, Rui Y, Chen H. Comparison of temporary external and percutaneous k-wire fixations for treatment of ankle fracture-dislocations. BMC Musculoskelet Disord 2023; 24:880. [PMID: 37951888 PMCID: PMC10638746 DOI: 10.1186/s12891-023-07020-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 11/03/2023] [Indexed: 11/14/2023] Open
Abstract
PURPOSE Ankle fracture-dislocations are among the most severe injuries, and the use of an external fixator as a recommended fixation method has some disadvantages. The aim of this study was to compare the clinical outcomes and complication rates of external and K-wire fixations in the treatment of ankle fracture dislocations. METHODS A total of 67 patients with ankle fracture-dislocations requiring temporary external or percutaneous K-wire fixation were included. The exclusion criteria were pilon fractures, open fractures, and those who required acute open reduction internal fixation (ORIF). The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, a 10-point visual analog scale (VAS) score (range 0-10), and complications before and after the definitive surgery were recorded. RESULTS A significant difference between the two groups was not observed for age, sex, affected side, fracture type, smoking status, or diabetes. The average AOFAS scores were 83.2 and 83.3, the median VAS scores were 3 and 3, and the complication rates were 32.4% and 6.7% in the external and K-wire fixation groups, respectively (p = 0.010). However, skin necrosis, re-dislocation of the ankle, surgical wound infection, and posttraumatic ankle osteoarthritis frequency were not significantly different between the groups, except for pin-sites infection (p = 0.036). CONCLUSION Ankle fracture-dislocations using percutaneous k-wire fixation showed a low rate of complications and favorable clinical outcomes. This method could be a good alternative treatment option for ankle fracture-dislocations.
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Affiliation(s)
- Wenjun Xie
- Department of OrthopaedicsZhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Trauma Center, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Orthopaedic Trauma Institute (OTI), Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
| | - He Li
- Department of OrthopaedicsZhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Trauma Center, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Orthopaedic Trauma Institute (OTI), Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
| | - Cheng Zhang
- Department of OrthopaedicsZhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Trauma Center, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Orthopaedic Trauma Institute (OTI), Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
| | - Xueliang Cui
- Department of OrthopaedicsZhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Trauma Center, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Orthopaedic Trauma Institute (OTI), Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
| | - Sheng Zhang
- Department of OrthopaedicsZhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Trauma Center, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Orthopaedic Trauma Institute (OTI), Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
| | - Yunfeng Rui
- Department of OrthopaedicsZhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Trauma Center, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Orthopaedic Trauma Institute (OTI), Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
| | - Hui Chen
- Department of OrthopaedicsZhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China.
- Trauma Center, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China.
- Orthopaedic Trauma Institute (OTI), Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China.
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Prijs J, Rawat J, Ten Duis K, IJpma FFA, Doornberg JN, Jadav B, Jaarsma RL. Triplane ankle fracture patterns in paediatric patients. Bone Joint J 2023; 105-B:1226-1232. [PMID: 37909160 DOI: 10.1302/0301-620x.105b11.bjj-2023-0204.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Aims Triplane ankle fractures are complex injuries typically occurring in children aged between 12 and 15 years. Classic teaching that closure of the physis dictates the overall fracture pattern, based on studies in the 1960s, has not been challenged. The aim of this paper is to analyze whether these injuries correlate with the advancing closure of the physis with age. Methods A fracture mapping study was performed in 83 paediatric patients with a triplane ankle fracture treated in three trauma centres between January 2010 and June 2020. Patients aged younger than 18 years who had CT scans available were included. An independent Paediatric Orthopaedic Trauma Surgeon assessed all CT scans and classified the injuries as n-part triplane fractures. Qualitative analysis of the fracture pattern was performed using the modified Cole fracture mapping technique. The maps were assessed for both patterns and correlation with the closing of the physis until consensus was reached by a panel of six surgeons. Results Fracture map grouped by age demonstrates that, regardless of age (even at the extremes of the spectrum), the fracture lines consolidate in a characteristic Y-pattern, and no shift with closure of the physis was observed. A second fracture map with two years added to female age also did not show a shift. The fracture map, grouped by both age and sex, shows a Y-pattern in all different groups. The fracture lines appear to occur between the anterior and posterior inferior tibiofibular ligaments, and the medially fused physis or deltoid ligament. Conclusion This fracture mapping study reveals that triplane ankle fractures have a characteristic Y-pattern, and acknowledges the weakness created by the physis, however it also challenges classic teaching that the specific fracture pattern at the level of the joint of these injuries relies on advancing closure of the physis with age. Instead, this study observes the importance of ligament attachment in the fracture patterns of these injuries.
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Affiliation(s)
- Jasper Prijs
- Department of Orthopaedic Surgery, Groningen University Medical Centre, Groningen, The Netherlands
- Department of Surgery, Groningen University Medical Centre, Groningen, The Netherlands
- Department of Orthopaedic & Trauma Surgery, Flinders University, Flinders Medical Centre, Adelaide, Australia
| | - Jaideep Rawat
- Department of Orthopaedic & Trauma Surgery, Flinders University, Flinders Medical Centre, Adelaide, Australia
- Department of Orthopaedics, Women's and Children's Hospital, Adelaide, Australia
| | - Kaj Ten Duis
- Department of Surgery, Groningen University Medical Centre, Groningen, The Netherlands
| | - Frank F A IJpma
- Department of Surgery, Groningen University Medical Centre, Groningen, The Netherlands
| | - Job N Doornberg
- Department of Orthopaedic Surgery, Groningen University Medical Centre, Groningen, The Netherlands
- Department of Surgery, Groningen University Medical Centre, Groningen, The Netherlands
- Department of Orthopaedic & Trauma Surgery, Flinders University, Flinders Medical Centre, Adelaide, Australia
| | - Bhavin Jadav
- Department of Orthopaedic & Trauma Surgery, Flinders University, Flinders Medical Centre, Adelaide, Australia
| | - Ruurd L Jaarsma
- Department of Orthopaedic & Trauma Surgery, Flinders University, Flinders Medical Centre, Adelaide, Australia
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Junior MDSL, Ciardullo MB, Neto OC, Herrera YEG, Ochoa PGG, Silva JDS, Kojima KE. Protected immediate weight-bearing is safe after fixation of ankle fractures with syndesmosis injury fixed with position screw. A retrospective case-series study. Injury 2023; 54 Suppl 6:110745. [PMID: 38143122 DOI: 10.1016/j.injury.2023.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/15/2023] [Accepted: 04/14/2023] [Indexed: 12/26/2023]
Abstract
BACKGROUND About 10% of ankle fractures are located above the syndesmosis, which causes injury to the ligament structure of the syndesmosis. There is no consensus regarding when to allow weight-bearing on the operated limb of patients who suffered ankle fractures requiring intraoperative fixation. OBJECTIVE The aim of this study is the evaluation of radiographic parameters of syndesmosis reduction and fixation in patients with ankle fracture who underwent immediate protected weight-bearing (use of walking-boot and crutches). PATIENT AND METHODS Retrospective case series from January 2015 to December 2020. Evaluation of the tibiofibular clear space, tibiofibular overlap, and medial clear space in the preoperative x-ray, immediate postoperative, 3-, 6- and 12-month after syndesmosis fixation and rehabilitation with protected immediate weight-bearing with crutches and walking-boot. RESULTS Out of 137 ankle fractures 39 were included. There was no significant difference in the tibiofibular clear space between the immediate x-ray and after 12 months (4.5 mm ± 1.1 vs. 4.6 mm ± 1.8; p > 0.999). Tibiofibular overlap hasn't shown significant difference between immediate and 12-month x-ray (6.2 mm ± 2.6 vs. 6.6 mm ± 2.6; p > 0.999). Medial clear space also has shown no worsening from immediate to 12-month x-ray (3.1 mm ± 0.9 vs. 2.8 mm ± 0.9; p > 0.999). There were no fixation failure nor postoperative infection. CONCLUSION Immediate weight-bearing for patients with ankle fractures with syndesmosis injury and treated with intraoperative fixation with positioning screw proved to be safe with good maintenance of the reduction, no failures of the synthesis material observed and no reports of postoperative infection in the period. LEVEL 3 EVIDENCE: therapeutic retrospective case-series.
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Affiliation(s)
- Milton da Silva Linhares Junior
- Trauma Service, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil.
| | - Marcos Broggi Ciardullo
- Trauma Service, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil.
| | - Orlando Colavolpe Neto
- Trauma Service, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil.
| | - Yasmín Estefanía González Herrera
- Trauma Service, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil.
| | - Pablo Gabriel Garcia Ochoa
- Trauma Service, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil.
| | - Jorge Dos Santos Silva
- Trauma Service, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil.
| | - Kodi Edson Kojima
- Trauma Service, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil.
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