Medial insufficiency in postoperative weight-bearing radiographs in supination-external rotation type 4 bimalleolar ankle fractures: is the Lauge-Hansen classification insufficient in predicting medial soft tissue damage?

Background: Ankle fracture ranks second among lower limb fractures, accounting for about 10% of all fractures. It occurs in about 137 per 1 lakh people each year. Bimalleolar fractures are the most common fracture in outpatient as well as in emergency department which accounts for 1/4th of all ankle fractures. Treatment of this fracture is complicated and challenging as the outcome will influence the locomotive power. Improper and inadequate fixation will cause long term disability as the body weight is transmitted through the ankle joint. This study was conducted to evaluate the functional outcome of bimalleolar ankle fractures treated with various surgical modalities. We also try to delineate the types of fractures occurred and its outcome after surgical fixation and also to understand the advantages and disadvantages of various implants used along with its complications. Aims and Objectives: To determine the functional outcome of surgical management of bimalleolar ankle fractures and to know the risks and complications associated with surgical fixation of bimalleolar ankle fractures. Subjects and Methods: A prospective study is conducted among 40 patients who came to the Emergency Department and to Orthopaedics Outpatient Department in Sree Mookambika Institute of Medical Sciences between April 2021 and September 2022 were analyzed. We have included bimalleolar ankle fractures with Lauge–Hansen classification (SER4, SAD 2, PER 3, PAB 3), Danis–Weber Type (A2, B2, C2, C3) in this study and we have excluded patients with Lauge–Hansen classification (SER1,2,3, SAD1, PER1,2,4, PAB1,2), Danis-Weber Type (A1, A3, B1, B3, C1), Systemic infections, open injury, fracture with dislocation, skin diseases over the incision site Trimalleolar ankle fracture, previous arthrodesis at target level. Based on the fracture pattern, the patients were planned for surgical fixation with appropriate implants. Results: In our present study of 40 patients, we assessed the functional outcome based on Baird and Jackson’s scoring system. Based on which 21 patients (52.5%) had excellent outcome, 14 patients (35%) had good outcome, 3 patients (7.5%) had fair outcome, and 2 patients (5%) had poor outcome. Out of total population, 35 patients (87.5%) had no complications followed by 3 patients (7.5%) had superficial infection and 2 patient (5%) who had ankle stiffness. Conclusion: Medial malleolus fracture can be effectively treated by various modalities such as Screw fixation, tension band wiring (TBW) and K-wire fixation, giving excellent to good results. Among which TBW and Screw fixation are relatively better than K-wire fixation for medial malleolus fracture. Similarly, lateral malleolus fracture can be treated with plate fixation, screw fixation and K-wire fixation which gives excellent to good results. Among which plate fixation (locking compression plate) is better than K-wire and screw fixation for lateral malleolus fracture. Superficial skin infection is the most common complication we encountered in our study.

The association between medial malleolar fracture geometry, injury mechanism, and syndesmotic disruption.

Résultats radiologiques des fractures bimalléolaires : importance du délai de la chirurgie et du type de reconstruction

Radiological outcomes of bimalleolar fractures: Are timing of surgery and type of reconstruction important?

Open reduction and internal fixation of high fibular fractures in ankle injuries: Is it necessary? – A review of the literature

Predictors of Adverse Events for Ankle Fractures: An Analysis of 6800 Patients

Objective To investigate the value of X-ray and MRI in judging degree of the deltoid ligament injury after lateral malleolus fracture.Methods The data of X-ray and MRI of 41 patients with acute lateral malleolus fracture,excluding patients combined with medial malleolus fracture,were retrospectively analyzed.The medial clear space (MCS) was measured according to the mortise X-rays.The degree of injury of the superficial deltoid ligament and deep deltoid ligament was graded according to MRIs obtained from PACS (picture archiving and communication system) system.Moreover,the correlation between the width of the MCS and the degree of the deltoid ligament injury were statistically analyzed.The classification results of all patients according to the Lauge-Hansen classification based on X-rays and MRIs were recorded,respectively.Results A positive correlation was found between the width of the MCS and the degree of the deltoid ligament injury,and the optimal critical value of MCS was 7.85 mm for diagnosing complete rupture of the total deltoid ligament or the single rupture of the deep deltoid ligament,while 6.48mm for the complete rupture of the superficial deltoid ligament.Based on the MRIs,the accuracy of the results of Lauge-Hansen classification was 58.5％,and the accuracy for predicting the rupture of the deltoid ligament was 82.9％,however the degree of the deltoid ligament injury cannot be distinguished very well.Conclusion The deltoid ligament injury is common in acute lateral malleolus fracture,even though there is no medial malleolus fracture.The X-ray is still the prefenred choice for the evaluation of the ankle fracture; however the MRI is helpful in judging the degree of the deltoid ligament injury. Key words: Ankle injuries; Fractures, bone; Ligaments, articular; Magnetic resonance imaging

Supination-adduction (SAD) type injuries are pylon variant injuries and lie between partial intra-articular pylon fractures and rotational ankle fractures. We aimed to evaluate functional outcomes of SAD type 2 bimalleolar fractures in comparison to supination-external rotation (SER) type 4 fractures. We retrospectively reviewed data of 42 cases with SER type 4 and 20 cases with SAD type 2 injuries. Patients with a history of rheumatic disease, open fractures, pathologic fractures, nonbimalleolar fractures, neuropathic disease, and talus osteochondral lesion, and those operated on after greater than 72 hours because of skin lesion or managed with a two-stage surgical protocol after external fixation, were not included in the study. We compared these two groups in terms of the mean age, follow-up time, visual analog scale pain and American Orthopedic Foot and Ankle Society scores, Kellgren-Lawrence arthrosis classification, union time, and complications. The groups did not differ in terms of mean age (P = .115) and sex (P = .573). There was no significant difference in terms of union time between the groups (P = .686). American Orthopedic Foot and Ankle Society score was significantly higher in the SER group (91.2 ± 9.9) than in the SAD group (86.1 ± 13.2; P = .034). Visual analog scale pain scores were similar in the SAD (0.3 ± 0.92) and the SER (0.26 ± 0.7) groups (P = .897). Supination-adduction bimalleolar fractures may have worse functional outcomes in the intermediate term than do SER bimalleolar fractures, implying pylon variant fractures as a mechanism of injury. Supination-adduction bimalleolar fractures might be associated with a high rate of intra-articular cartilage impaction, resulting in varus deformity after surgery.

The authors describe an alternative method for assessment of the integrity of the distal tibiofibular syndesmosis. In their description of the technique, they highlight the importance of fixation of the fibular fracture prior to performing the test. However, they neglect to mention the importance of fixation of any associated medial malleolar fracture prior to testing syndesmotic stability. Indeed, the images accompanying the note show their test being performed on a bimalleolar fracture with the medial malleolar fracture untouched, but the final image shows medial malleolar fracture fixation and syndesmosis screws present. This is in contrast to conventional teaching. In the majority of bimalleolar fractures, rigid fixation of both medial malleolar and fibular fractures should stabilise the syndesmosis and abolish the need for a syndesmosis screw.1,2 The exception to this is if there is co-existing ligamentous disruption medially or laterally, in which case syndesmotic widening would be observed on testing the syndesmosis after fixation of both medial malleolar and fibular fractures.

Category: Ankle Introduction/Purpose: To evaluate the effect of repairing deltoid ligament in patients with supination-external rotation type? ankle fractures. Methods: Between January 2013 and June 2016, 35 patients of supination-external rotation type? ankle fractures associated with deltoid ligament injury had complete medical records and were included in this study. Among all, 30 cases involved pure deltoid ligament injuries while others also included medial malleolus fractures. All fractures were treated by open reduction and internal fixation. Patients were assigned to the repaired group (21 patients) or the non-repaired group (14 patients) according to whether deltoid ligament injuries were treated during the surgery. No significant difference was found in gender, age, injury pattern, time from injury to operation(P>0.05), which was comparable. Medial clear space, visual analogue scale(VAS) score, and American Orthopaedic Foot and Ankle Society(AOFAS) ankle-hindfoot score(6 months, one year, two years after surgery), Baird-Jackson scoring system and complications were recorded. Results: Thirty-five patients were followed up 21-28months.The mean duration of operation in the repaired group was significantly longer than that of the non-repaired group.Baird-Jackson scoring system: the excellent rate of the repaired group was 90.5% while the non-repaired group was 85.7% . The VAS scores and the medial clear space of preoperative and final follow-up were significantly improved. At the last follow-up,2.85 percent of the patients presented with ankle instability while 8.5 percent of them occured traumatic arthritis. The AOFAS scores at 6, 12, and 24 months after operation were (82.1 ± 6.6; 86.2 ± 5.9; 91.5 ± 5.8) and (78.1 ± 6.5; 83.9 ± 5.6; 90.3 ± 5.6). However, none of them showed significant difference between the two groups (P>0.05). Conclusion: It’s unnecessary to repair the deltoid ligament in patients with supination-external rotation type? ankle fractures when ankle mortise restores after the fractures are fixed.

Category:Ankle; Basic Sciences/Biologics; TraumaIntroduction/Purpose:In isolated lateral malleolar fractures of the supination-external rotation (SER) type and competent medial stabilizers (type II and III), non-operative treatment has yielded excellent outcome. With complete rupture of the deltoid ligament (SER type IV) fracture instability increases substantially. The rationale for operative treatment of SER type IV fractures is based upon good clinical results and previous biomechanical studies. A significant reduction of the ankle contact area that however is caused by an artificially forced lateralization of the talus in the ankle mortise has been demonstrated. Presumed resultant elevated joint contact stresses are thought to lead to ankle arthritis in the longterm.Methods:In 12 lower leg specimen SER type injuries were simulated by gradual bony and ligamentous destabilization of the ankle from lateral to medial according to the mechanism of injury as described by Lauge and Hansen. High-resolution pressure sensors placed in the ankle joint recorded tibio-talar pressure changes at physiologic weightbearing (700N) in three positions (plantigrade, 10° dorsiflexion and 20° plantarflexion).Results:With increasing instability changes of the ankle kinematics were seen in SER II and III fractures with the same trend also in SER IV lesions. In the plantigrade position, the medial clear space (MCS) increased significantly from an average of 2.5+-0.4mm (no fracture) to 3.9+-1.1mm (SER type IV fracture). However, the corresponding peak pressure increased only slightly from 2.6+-0.5 mPa to 3.0+-1.4 mPa on average, and the contact area decreased slightly from 810+-42 mm2 to 735+-27mm2 on average representing a non-significant reduction of only 9% of the contact area (p=0.08) after the deep deltoid ligament was completely dissected.The comparison of the results in plantigrade and plantarflexed position revealed substantial differences for MCS, contact area and center of force.Conclusion: Under physiologic load SER type IV isolated lateral malleolar fracture with completely disrupted deep deltoid ligament led to a significant increase of the MCS, but neither to a significant decrease of the of the joint contact area nor significant increase of peak pressure. Clinical Relevance: The findings of this biomechanical study support the recently reported good clinical results of non-operative treatment of SER type II to IV fractures.

Category: Ankle; Trauma Introduction/Purpose: The term ‘quadrimalleolar fracture’ (QMF) describes a trimalleolar (TM) ankle fracture with an associated Chaput or Wagstaffe fracture. Optimal fixation of these injuries not only allows for bone-to-bone healing but also facilitates syndesmotic reduction. However, this is a relatively new concept, and the literature on QMFs is limited to a few case series. Hence, we conducted this study to determine the epidemiology, patterns, and clinicoradiologic correlations of QMFs. The primary objective of this study was to describe the prevalence and patterns of QMFs. The secondary objective was to determine if certain clinical or radiological parameters were associated with different types and patterns of QMFs. Methods: A retrospective analysis of ankle fractures presenting to three tertiary referral hospitals was undertaken. Adult patients (≥18 years) presenting with an acute, traumatic TM ankle fracture over 3 years (July 2018 to July 2021) were included. Isolated medial and lateral malleolar fractures, bimalleolar ankle fractures, pediatric patients, pilon fractures, pathological fractures, and those with delayed presentation or (≥3 weeks of injury) were excluded. Clinical demographic variables were obtained from the patients’ medical records. AP, lateral, and mortise ankle radiographs, and CT scans, (axial, coronal, and sagittal sections along with 3D volume reconstructed models) whenever available, were evaluated in detail. Demographics and radiological parameters were compared between TM and QMF, as well as between different types of QMFs. Odds ratios with 95% confidence intervals were determined to test the strength of association. Results: A total of 876 adult patients with ankle fractures were included after the screening, of which 323 had a TM ankle fracture for which a CT scan had been performed. A total of 159 AITFL avulsions were identified, yielding a prevalence of 18.2% amongst all ankle fractures and 26.1% in ankle fractures where a CT scan had been performed. TMFs had the significantly highest proportion of CT-confirmed AITFL avulsions (44.4%) in comparison to unimalleolar (4.4%) and bimalleolar fractures (6.4%) (P < 0.0001). Age and osteoporosis were significant associations of QMFs. Avulsion of the medial malleolus, Weber B fibular fracture, and supination external rotation mechanism were significantly associated with Wagstaffe fractures. Size of the Chaput fracture was inversely related to that of the posterior malleolar fracture. Conclusion: Quadrimalleolar ankle fractures account for a significant proportion of ankle fractures. The strengths of this study include a large sample size, which was derived from three different hospitals, consecutive inclusion (or exclusion) of cases, strict adherence to the STROBE guidelines, and the fact that only CT-confirmed cases were used to determine clinic-radiological associations. Wagstaffe and Chaput fractures have distinct clinical and radiological correlations. However, further research is needed to determine the optimal fixation protocols for these injuries.

Category: Ankle Arthritis; Ankle Introduction/Purpose: There is limited evidence regarding risk factors for medial malleolar fractures after total ankle arthroplasty (TAA). A previous study showed that patients with medial pain following TAA had significantly thinner (<11mm) medial malleolar width, which has been used as a threshold for placing a prophylactic screw. However, this study included only six patients with pain over the medial malleolus. Other previously reported risk factors include coronal malalignment and poor bone quality. Therefore, this study examined the risk factors of postoperative medial malleolar stress fractures. In addition, we sought to assess the effect of the prophylactic screw placement. We hypothesized that a medial malleolar width <11mm and varus malalignment would be associated with increased fracture risk and that the prophylactic screw placement would be protective. Methods: A case-control study was conducted on 838 patients undergoing primary TAA between 2015 and. TAA revisions, arthrodesis takedowns, and intraoperative medial malleolar fractures were excluded. Demographic and surgical data were obtained. A total of 21 patients with postoperative medial malleolar stress fractures > 4 weeks postoperatively (cases) were identified through radiologic assessment (radiograph, CT, or MRI) and matched to a control group of 129 patients. Radiographic evaluation included pre- and post-TAA tibial coronal alignment, postoperative medial malleolar width at the tibial component, and prophylactic screw fixation. Demographics and radiographic variables were compared between cohorts using the Mann-Whitney U test for continuous variables and Pearson Chi-square for categorical variables. Logistic regression was used to investigate the association of medial malleolar stress fractures with gender, coronal tibial implant size, postoperative coronal alignment, prophylactic screw fixation, and medial malleolar width using odds ratios (OR), and standard error (SE). Results: Of 838 TAAs, 2.51% sustained a postoperative medial malleolar fracture (n = 21). Of these, 13/21 (61.9%) required reoperation: internal fixation (12) and TAA revision (1). Mean (SD) medial malleolar width was significantly smaller in the fracture cohort (8.62 mm [1.63]) than in controls (11.78mm [1.75]), P<0.001). Mean (SD) postoperative tibial component coronal alignment was 92.2º (2.82) for patients with medial malleolar fracture and 90.23º (1.68) for the control cohort (P = 0.003). Postoperative varus tibial component alignment (OR = 1.61 [95%CI 1.16 02 − 2.22], P = 0.004) and smaller medial malleolar width (OR = 0.11 [95% CI 0.04 02 − 0.3], P < 0.001) were associated with increased probability of a post-TAA medial malleolar fracture. Prophylactic screw fixation resulted in a 90% reduction in the odds of a fracture (OR = 0.10 [95%CI 0.02 02 − 0.64], P = 0.015). A medial malleolar width of 10.31 mm was identified as a threshold for predicting a medial malleolar stress fracture. Conclusion: In this study, the prevalence of postoperative periprosthetic fractures after TAA was similar to prior studies. Decreased medial malleolar thickness and postoperative varus malalignment were associated with an increased risk of a postoperative medial malleolar stress fracture. A malleolar width of 10.31 mm was identified as a potential threshold. Prophylactic medial malleolar screw fixation was protective and associated with a 90% reduction in fracture probability. Surgeons should consider prophylactic screw fixation patients with a medial malleolar width < 10.31 mm or at risk of postoperative varus deformity.

Objective To evaluate the treatment of posterior malleolar two-part fractures complicated with medial and lateral malleolar fractures via a combination of posterolateral and posteromedial approaches. Methods From January 2014 to January 2017, 26 patients were operatively treated at Department of Or-thopaedics, Tongji Hospital for posterior malleolar two-part fractures complicated with medial and lateral malleolar fractures via a combination of posterolateral and posteromedial approaches.They were 10 men and 16 women, aged from 53 to 67 years (average, 61.5 years).The surgery was conducted in prone position via the posterolateral and posteromedial approaches to expose simultaneously the fractures ends at medial, lateral and posterior malleoli for open reduction.The lateral malleolar fractures were fixated with plate, the medial malleolar fractures with screws and posterior malleolar fractures with plate or cannulated screws depending on the size of the fracture blocks.The outcomes were assessed using the ankle-hindfoot scores of American Or-thopaedic Foot and Ankle Society (AOFAS) and the visual analogue scale (VAS). Results Of this co-hort, 22 were followed up for 30 months on average (range, from 18 to 48 months).All the cases healed by the first intension without any infection.Their postoperative X-ray showed bone union after an average of 12.5 weeks (range, from 10 to 15 weeks).No nonunion, loosening or breakage of implants was found.The mean time for walking with full weight-bearing was 13 weeks (range, from 11 to 16 weeks).Their AOFAS ankle-hindfoot scores at the final follow-ups were 85.4 (range, from 80 to 92), yielding 13 excellent and 9 good cases with a good to excellent rate of 100%.Their mean VAS scores were decreased significantly from preoperative 8.6±0.6 to postoperative 1.7±0.3 (t=153.000, P=0.000). Conclusion In treatment of posterior malleolar two-part fractures complicated with medial and lateral malleolar fractures, a combination of pos-terolateral and posteromedial approaches in prone position can expose and reduce simultaneously the fractures ends at medial, lateral and posterior malleoli, leading to satisfactory clinical outcomes. Key words: Ankle joint; Posterior malleolus; Fracture; Surgical treatment

ABSTRACTObjective: To evaluate the frequency of deltoid ligament injury in bimalleolar supination-external rotation type fractures and whether there is a correlation between the size of the fractured medial malleolus and deltoid ligament injury.Methods: Twenty six consecutive patients underwent magnetic resonance exams after clinical and radiographic diagnosis of bimalleolar supination-external rotation type ankle fractures.Results: Thirteen patients (50%) presented deltoid ligament injury associated to bimalleolar ankle fracture. Partial injury was present in seven (26.9%) patients and total injury in six (23.1%). Regarding medial fragment size, the average was 2.88 cm in the absence of deltoid ligament injury. Partial injuries presented 1.93 cm and total 2.1 cm on average.Conclusion: Deltoid ligament injury was present in 50% of bimalleolar ankle fractures. Smaller medial malleolus fragments, especially concerning the anterior colliculus, presented greater association with partial deltoid ligament injuries. Level of Evidence IV, Cross Sectional Study.