Reduction Of Ankle Fractures Research Articles

The Single-Person Lateral Decubitus Ankle Sling Fracture Reduction Technique

Ankle fractures are common pathologies encountered in the emergency department. Reduction of ankle fractures can be a challenging task to perform alone and can place medical personnel in mechanically disadvantageous positions. In addition, body weight and awkward lifting are leading preventable causes of musculoskeletal injuries among medical staff. The single-person lateral decubitus ankle sling fracture reduction method described is a simple and reproducible technique that utilizes the classic principles described by Dr Quigley in 1959. This technique optimizes patient positioning, utilizes gravity, and incorporates a stable ankle sling. This also incorporates a relaxed patient position to promote a successful ankle fracture reduction. Level of Evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Ankle fractures malreduction rate and its causes in two Brazilian tertiary training hospitals

IntroductionAnkle fractures are one of the most frequent injuries managed by any trauma surgeon. Literature has shown that adequate reduction is of utmost importance to achieve satisfactory functional outcomes. However, malreduction rates remain high worldwide. The objective of the present study is to evaluate the quality of ankle fracture reduction in two major trauma centers in a large Brazilian city and to analyze the factors associated with malreduction MethodsEpidemiologic data of 382 patients (189 men; 193 women) aged between 7 and 87 years who underwent osteosynthesis of the ankle in two trauma centers in a large Brazilian city. Electronic clinical records, preoperative and immediate postoperative radiographs in anteroposterior (AP), lateral and mortise views were evaluated. Pettrone's criteria were used to evaluate the quality of ankle fractures reduction. All radiographs were independently evaluated by two foot and ankle senior surgeons ResultsOverall, malreduction rate was 22.2%. Forty-seven (55.2%) fractures classified as malreduced had medial malleolar displacement The results showed three factors that significantly affected the quality of reduction (p<0.05), patients over 60 years, open fractures and fracture-dislocations. Patients aged over 60 years were twice more likely to have poor reduction of ankle fractures than younger ones. The risk of poor fracture reduction among those individuals with open fractures is 2.15 times greater than among patients with closed injuries. Fracture-dislocation imposed a 2.7 higher risk for malreduction DiscussionWe found a malreduction rate below most series previously published. Further results agree with the literature. Elderly people aged over 60 years, fracture dislocations and open fractures are associated with worse results, influencing the quality of the reduction, clinical outcomes, and the development of post-traumatic arthrosis ConclusionAnkle fractures malreduction are associated with higher age, open fractures, and fracture-dislocations.

Technical note: Intraoperative ultrasound measurement for evaluating the stability of the inferior tibiofibular joint in patients with ankle fractures

ObjectivesInjury to the tibiofibular syndesmosis is a common complication of ankle fractures. Currently, it is challenging to determine the stability of the tibiofibular joint caused by ankle fractures during surgery. This study aims to establish a standardized method for dynamically evaluating the stability of the inferior tibiofibular joint under intraoperative ultrasound and assess its utility in surgery, thereby assisting in determining the necessity for fixation of the inferior tibiofibular joint after fracture reduction and fixation. MethodsThe stability of the inferior tibiofibular joint was assessed using an intraoperative ultrasonic external rotation stress test, with a torque set at 7.2 N·m. The measured parameters included the width of the inferior tibiofibular space in neutral (N) and external rotation (E) positions, stretch ratio (E/N), and injured/healthy side stretch ratio (I/H). Patients with Weber B or C type ankle fractures were selected as participants. ResultsFor the case with Weber C fracture, the N measurement was 4.22 mm after fracture fixation, while E measured 5.77 mm and E/N ratio was 1.37, which were larger than those on the healthy side (N: 4.17, E: 4.50, E/N:1.08), with an I/H ratio of 1.27. Intraoperative X-ray revealed instability of the inferior tibiofibular joint. After inserting a tibiofibular screw, the N measurement was 4.20 mm, while the E measurement recorded 4.32 mm, resulting in an E/N ratio of 1.03 and an I/H ratio of 0.95, indicating improved joint stability. For the Weber B fracture case, the N measurement was 3.55 mm after fracture fixation, while E measured 3.98 mm and the E/N ratio was 1.12, slightly lower than those on the healthy side (N: 3.94, E: 4.47, E/N: 1.13), with an I/H ratio of 0.99. The intraoperative X-ray revealed stability of the inferior tibiofibular joint. Therefore, no further fixation was performed on it. ConclusionStandardized intraoperative ultrasound stress test allows for real-time, dynamic assessment of the stability of the inferior tibiofibular joint after ankle fracture reduction and fixation, which can help guide the fixation of the inferior tibiofibular joint, thereby reducing the risk of postoperative traumatic arthritis.

Intraoperative 3D-Fluoroscopy Increases Accuracy of Syndesmotic Reduction in Ankle Fractures with Syndesmotic Instability

Abstract Background Direct visual control and 2D-fluoroscopy is widely used to achieve an anatomic syndesmotic reduction in ankle fractures with syndesmotic instability. However, significant malreduction rates are reported. Aims It was the aim of this study to evaluate the accuracy of conventional syndesmotic reduction and to assess the impact of intraoperative 3D-imaging to improve the quality of syndesmotic reduction. Methods Single institution consecutive case series (02/2021–12/2022) including all patients undergoing operative treatment for ankle fractures with syndesmotic instability. Syndesmotic reduction was performed following open reduction and internal fixation of the malleolar fractures. Provisional tibiofibular alignment was obtained under visual control and 2D-fluoroscopy. With the ankle held in a neutral position, temporary fibulotibial transfixation was performed with 2 K-wires. 3D-imaging was obtained (Cios Spin, Siemens Healthineers, Forchheim-Germany). Non-anatomical positions of the fibula were devided into anterior, posterior, or rotational malreductions. If reduction was not satisfactory, the reduction was improved and 3D-imaging repeated. Once adequate reduction was obtained, definitive syndesmotic fixation was performed and the K-wires were removed. Results A total of 50 patients (mean age 44±16 years, m/f 27/23) were operated for ankle fractures with syndesmotic instability. Intraoperative 3D-imaging confirmed anatomic syndesmotic reduction in 31 patients (62%). In 15 patients (30%) reduction was repeated once, in 4 patients (8%) two additional reduction manoeuvers were necessary to obtain an anatomic result. Thus, a total of 23 malreductions were recorded in a total of 73 reduction manoeuvers (32%). Of these, we observed 16 anterior (70%), 2 posterior (9%) and 5 rotational malreductions (22%). Conclusions Syndesmotic reduction under visual control and 2D-fluoroscopy proved to be unreliable with a syndesmotic malreduction in almost one-third of all reduction manoeuvers. With the help of intraoperative 3D-imaging incorrect tibiofibular alignment before definite fixation was identified, reduction corrected and thereby the rate of malreductions reduced.

Review article: Ankle intra-articular haematoma block for reduction of unstable ankle fractures in the emergency department: An integrative review.

A review was conducted to assess the efficacy and safety of the intra-articular haematoma block (IAHB) for manipulation of ankle fractures in ED. Any study investigating the success of IAHB for ankle fracture reduction published in English was sought. Seven databases were searched. The Cochrane Risk of Bias tool was used to quality assess the included studies. Three studies met the inclusion criteria (n=436 patients). Just one study was a randomised controlled trial (n=42). The two non-randomised studies that included the majority of patients were assessed as at high overall risk of bias. The studies reported no significant difference in the overall rate of successful reduction or patient-reported pain scores between IAHB and procedural sedation groups. A subgroup analysis in one study suggested timelier reduction by 51.4min (P=0.01) for fractures involving subluxation when using IAHB, but that more patients with dislocation were reduced on first attempt when using procedural sedation compared to IAHB (74.0% vs 54.8%, P < 0.01). No adverse events were reported from using IAHB, although no study measured events such as joint sepsis or chondrolysis. Findings suggest that IAHB might be safe and effective but the evidence is very limited. High-quality research is required before IAHB can be considered a routine alternative. However, IAHB could be considered in situations where the risk of procedural sedation outweighs the likely very low risk of chondrolysis.

Gravity assisted reduction of ankle (GARA) fractures: Results of a novel technique for relocating displaced ankle fractures in the emergency setting in comparison to traditional manipulation and reduction (TMR) technique

BackgroundAnkle fracture displacements cause significant discomfort to the patient and can compromise soft tissues including the neurovascular structures. Prompt reduction and plaster splint application are vital in the early management of these potentially limb-threatening conditions. The process can be distressing for the patient often requiring additional personnel or equipment. We have used a novel technique of Gravity Assisted Reduction of Ankle (GARA) fractures and compared the results with the Traditional Manipulation and Reduction (TMR) technique. Material and methodsWith adequate analgesia, the patient turns to lay either in lateral or prone position depending on fracture pattern, thus permitting gravity to gradually aid in reduction and hold the fracture in place while Plaster Of Paris (POP) is applied. We performed a retrospective comparative study of GARA vs TMR using validated radiological parameters to assess the quality of reduction with both techniques. Results21 patients had GARA technique, in comparison with 19 patients in TMR group. All measured radiological parameters showed similar improvement in both the groups, despite the fact that the pronation-external rotation injury pattern was more often seen in the GARA group. Intravenous sedation and monitoring were needed in 10 patients of TMR group, none in GARA group. On an average 4 personnel needed for TMR, but only 2 personnel needed for GARA technique. ConclusionGravity assisted ankle fracture reduction is a simple, effective and reproducible alternative technique to TMR, with no need of intravenous sedation along with fewer people needed to perform the procedure. Level of evidence3b

Three-Dimensional Fluoroscopy Influence in Intraoperative Decision-Making Concerning Syndesmotic Reduction

Category:Ankle; TraumaIntroduction/Purpose:The use of intraoperative three-dimensional fluoroscopy to evaluate syndesmotic and articular reduction in ankle fractures is a relatively new tool demonstrating usefulness in the literature. It has been described that it can detect up to 32.7% of intraoperative malreduction. The objective of this prospective study is to observe if surgeons, when performing operative treatment in ankle fractures with three- dimensional fluoroscopy assistance, modify the syndesmotic reduction and/or fixation. The definitive syndesmotic reduction was assessed with bilateral ankle CT-scan postoperatively.Methods:Sixteen patients with ankle fracture and syndesmotic instability were analyzed. After malleolar and syndesmotic fixation, intraoperative three-dimensional fluoroscopy was performed. The surgeon then analyzed cross-sectional images to evaluate the reduction of the fracture and syndesmosis. In this scenario, the surgeon decided whether to make any changes in the reduction of the syndesmosis or in the configuration of the fixation strategy. Postoperative bilateral computed tomography was carried out to corroborate in detail if there was any syndesmotic malreduction.Results:Sixteen patients were included in this study (10 men) with a mean age of 40 years (range 25-60 years). 62% were supination-external rotation fractures according to Lauge-Hansen classification. Of all the patients evaluated, only 4 underwent any modification after performing intraoperative three-dimensional fluoroscopy. From the previous group, in 3 patients (19% of the total) there was a change in syndesmal reduction and in only one there was a change of any element of osteosynthesis. When evaluating syndesmal reduction with postoperative bilateral CT, there were 6 patients in the total group who presented syndesmal malreduction. In patients in whom a modification to syndesmal reduction was made, it persisted in 2 of the 3 cases.Conclusion:In our series, the use of intraoperative three-dimensional fluoroscopy did not motivate most surgeons to make changes in syndesmotic reduction, unlike other previously published studies. Even despite making changes in syndesmotic reduction, the percentage of patients who persists with poor reduction is considerable. In this study, the percentage of poor syndesmotic reductions was 32.7%. Despite being a figure that is within what is expected according to the literature, we consider that it is high even using intraoperative fluoroscopy as support.

The use of intraoperative comparative fluoroscopy allows for assessing sagittal reduction and predicting syndesmosis reduction in ankle fractures

Intraoperative fluoroscopic parameters have shown to be poor predictors for ankle syndesmosis reduction, with up to 52% of syndesmotic malreduction (SMR) reported in the literature. Anteroposterior Tibio-Fibular index (APTF) was previously described to evaluate sagittal tibiofibular alignment in lateral ankle radiographs with a high correlation between both ankles in uninjured subjects. Reproducible intraoperative measurements for sagittal syndesmotic reduction are lacking. We propose the use of the “cAPTF,” calculated as the absolute difference between the APTF of the non-injured and the operated ankle, to evaluate sagittal syndesmotic reduction. ObjectiveDetermine the predictive capability of cAPTF for SMR. MethodProspective observational study. Inclusion criteria: patients with unstable ankle fractures requiring syndesmotic fixation, with a healthy contralateral ankle. Intraoperatively APTF was measured in both ankles after syndesmotic fixation. Postoperatively cAPTF was calculated. Only direct syndesmosis visualization through the lateral approach and AP and mortise views were used by surgeons to assess syndesmotic reduction. Quality of syndesmotic reduction was evaluated with bilateral postoperative CT. To estimate cAPTF discriminatory power for SMR, a receiver operative characteristic (ROC) curve was obtained and the area under the ROC curve was calculated. Youden index was used to determine the ideal cAPTF cut-off value for predicting SMR. For this determined cut-off value, sensitivity, specificity, and likelihood ratio were calculated. ResultsFifty-two patients were included. Sixteen (30%) had SMR. Patients with SMR had a statistically significant higher cAPTF value than the well reduced (median 0.26 vs 0.09; P < 0.01). The cAPTF cut-off value to predict SMR was 0.161. A cAPTF greater than 0.161 had 100% sensitivity and 97,2% specificity for SMR. The area under the ROC curve was 0.99. ConclusionIntraoperative cAPTF has excellent discriminatory power for predicting syndesmotic malreduction. We propose the routine use of intraoperative bilateral comparative fluoroscopy to assess sagittal syndesmotic reduction.

317 Audit of The Management of Ankle Fractures in The Emergency Department of Leighton Hospital

Abstract Background Ankle fractures are common presentations in the emergency department. The aim of treatment is to provide stability and restore alignment of the joint to as close as possible to the pre – injury state. The British Orthopaedic Association Audits Standards for Trauma (BOAST) guidelines provide clear recommendations for effective management of ankle fractures. Specific aspects of this guidelines that could be objectively assessed were selected for this audit to check if practices in the emergency department were meeting the national recommendations. Method Data was collected retrospectively. All patients with closed ankle fractures seen in the emergency department between 01/08/2020 and 31/08/2020 were included. Patients’ emergency department notes as well as electronic radiographic records were reviewed and analysed. Results There was 100% compliance rate for 3 of the domains assessed which include: clear documentations of mechanism of injury and clinical findings; documentation of co-morbidities of patients that can influence treatment and urgent performance of radiographs in clinically deformed ankles before manipulation.There was 75% compliance in performing and documentation of radiographs before transfer from the emergency. The worst domain was the re-assessment and documentation of neurovascular status post manipulation with only one reviewer out of five assessed documenting clearly after the process was completed. Conclusions Posters circulated in the department highlighting the findings of the audit. Furthermore, the LocSSIPs for reduction of ankle fractures was edited to include re-assessment of neurovascular status post manipulation.

Second-look arthroscopic findings and clinical outcomes after management of intra-articular lesions in acute ankle fractures with arthroscopy

BackgroundAnatomically surgical reduction of ankle fractures does not always result in a clinically favorable outcome. Arthroscopic examination combined with treatment of intra-articular lesion may related to clinical outcomes ObjectivesThe purpose of the present study was to review initial and second look arthroscopic finding of acute ankle fracture and to evaluate clinical outcomes. ResultsLauge-Hansen classification system of ankle fractures included supination-external rotation type (n = 24), supination-adduction type (n = 3), pronation-external rotation type (n = 7), and pronation-abduction type (n = 6), total 40 ankles. Osteochondral lesions were found in 25 ankles (62%) with an initial arthroscopic finding of acute ankle fracture. Newly discovered chondral lesions in secondary arthroscopy were found in 17 cases. According to the Ferkel and Cheng staging at secondary arthroscopy, 4 of 25 ankles with osteochondral lesions of the talus were deteriorating (more than stage D). In terms of ICRS overall repair grades, 5 ankles (20%) were abnormal (grade III). Diffuse synovitis and arthrofibrosis were found in 12 and 7 ankles, respectively, in secondary arthroscopy, and correlations were found between AOFAS scores, VAS and intra-articular lesions. ConclusionSecond-look arthroscopic examination combined with treatment of intra-articular lesion such as arthrofibrosis and osteochondral lesion arising from ankle fracture surgery may consider to improve clinical outcomes.

Reliability of Postoperative Radiographies in Ankle Fractures.

The accuracy of reduction of ankle fractures using postoperative plain radiographies (x-ray) remains widely controversial. Some authors have demonstrated that postoperative computed tomography (CT) scan can be useful for these patients. In current study, the efficacy of x-rays after fixation of ankle fractures was investigated based on the CT scan findings. A total of 73 patients with ankle fractures who were subjected to open reduction internal fixation (ORIF) were enrolled. After surgery, if the reduction was acceptable based on the x-rays according to standard measurements, the patient was referred for CT scanning. Forty four patients were included in the study. Undesirable CT scan findings including malreduction of fragments or articular surfaces, device malpositioning, missed fractures, and undetected intra-articular fragments were documented. Undesirable CT findings were seen in 25 patients (56.8%). CT scan showed acceptable reduction without device malpositioning in 19 patients. The most prevalent findings in CT images were malreduction and device malpositioning in 17 and 16 patients, respectively. There was no abnormal finding in CT imaging of lateral malleolar fractures. In two thirds of the injured syndesmosis, device malpositioning, and malreduction were detected in CT scan. Despite acceptable postoperative x-rays, a considerable number of patients with ankle fractures had inappropriate reduction or undesirable findings in their postoperative CT scan. It seems necessary to use CT scan after ORIF of ankle fractures in order to examine the accuracy of reduction. Further validation of postoperative CT scan in ankle fracture surgery should be investigated.

Ankle fracture: The operative outcome of 30 patients

Background & Objectives: Ankle fractures are the most common injuries treated by orthopaedic surgeons. However very few investigators have examined the functional recovery following operative treatment of ankle fractures. Anatomic restoration with open reduction and internal fixation is the goal of management in ankle fractures. The purpose of this study is to analyse the functional outcome following operative treatment of ankle fractures using subjective as well as objective criteria. Methods: 30 patients with ankle fractures who fulfilled the inclusion criteria were included in the study. All patients underwent surgical fixation of the fractures. The follow-up assessment which consisted of subjective (Pain, Walking, activity, Radiographs, Ankle and Subtalar Joint function) and objective (Ankle-Hindfoot Scoring System) evaluations, were performed at 6 weeks, 3 months and 9 months postoperatively. Results: Out of 30 patients, the commonest injury pattern seen was supination external rotation followed by pronation external rotation. The most common modality of fixation for the lateral malleolus was 1/3rd tubular plate and for the medial malleolus was 4 mm cannulated cancellous screws with washer, K-wire and tension band wiring and for the posterior malleolus fixation with lag screws and Syndesmotic screws for syndesmotic injuries. At 6 weeks follow-up of 60% (n=19) had complications of persistent swelling and residual pain, Which improved significantly in function from 3rd month to 9 month postoperatively. However subjective radiographic assessment shows statistically significant improvement. The mean Ankle-Hindfoot Scoring System was statistically significant 50.5±18.7 at 3rd month post-op and, 85.1±14.2 at 9th month post-op. Age was a significant predictor of final outcome, with younger patients having a better functional outcome. Conclusions: Anatomical reduction of ankle fracture results in good functional outcome postoperatively. Early treatment without delay, anatomic reduction and fracture fixation, stringent postoperative mobilization and rehabilitation should help improve outcome in an operated ankle fracture.

Second-Look Arthroscopic Findings and Clinical Outcomes After Management of Intra-Articular Lesions in Acute Ankle Fractures with Arthroscopy

Category: Ankle, Arthroscopy, Trauma Introduction/Purpose: Anatomically successful surgical reduction of ankle fractures does not always result in a clinically favorable outcome. The purpose of the present study was to compare initial and second look arthroscopic finding of acute ankle fracture and to evaluate clinical outcomes. Methods: A total of 39 patients (40 ankles, 20 male, 20 female) who underwent surgery for ankle fracture between March 2009 and August 2016 were retrospectively reviewed. All patients gave consent to the exploratory arthroscopic surgery for the removal of internal fixation devices placed in the initial surgery. Intra-articular lesions (osteochondral lesion, loose body, injury of ligaments and fibrosis) were evaluated via ankle arthroscopy. Arthroscopic finding of osteochondral lesion were classified using the Ferkel and Cheng staging system, and cartilage repair was assessed using the international Cartilage Repar System (ICRS). Clinicial outcomes were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale and Visual Analogue Scale (VAS) Results: Chondral lesions were found in 26 ankles (65%) with initial arthroscopic finding of acute ankle fracture. Newly discovered chondral lesions in second-look arthroscopy was 15 cases. Accoding to the Ferkel and Cheng staging at second-look arthroscopy, 4 of 23 ankles with chondral lesions of talus was getting worse (more than stage D). In terms of ICRS overall repair grades, 4 ankle (15%) were abnormal (grade III). Diffuse synovitis and arthrofibrosis were found in 12 and 7 ankles respectively in second-look arthroscopy. Correlation were found between AOFAS scores, VAS and intra-articular lesions with second-look arthroscopy. Conclusion: Second-look arthroscopic examination combined with treatment of intra-articular lesion arising from ankle fracture surgery may consider to improve clinical outcomes.

Fibula hook plate as an excellent implant of choice for lateral malleolar fracture

Fractures involving the ankle are one of the most common injuries treated by orthopedic surgeons. The anatomy of the joint makes it very unstable in cases of fractures or ligamentous injuries of the ankle. As fractures of the ankle have been treated with various modes of internal fixation devices, the best possible implant is determined according to the anatomy of the fracture. Various internal fixation devices like interfragmentary screw, reconstruction plate, tubular plate have been used for lateral malleolus fracture. We studied the use of fibula hook plate for lateral malleolus fracture. Total 40 patients were studied and were followed up post-operatively after 3 months, 6 months and 12 months. The fractures were classified according to the Lauge-Hansen classification system. Ankle score for symptom evaluation of ankle fracture by C. Olerud and H. Molander was calculated. Radiological evaluation was done by Kristenson’s criteria. Out of 40 patients, 10 patients had excellent outcome and 19 patients had good outcome. Eight patients showed fair results whereas three patients had poor results. No intra-operative complication was observed. Post-operatively six patients developed skin infection. Anatomical reduction of ankle fractures is very important for normal weight bearing stress. The length of fibula must be maintained for this purpose. Hook plate helps to achieve this by holding the reduction of lateral malleolar fragment.

Relationships Between Radiographic Pre- and Postoperative Alignment and Patient Perceived Outcomes Following Weber B and C Ankle Fractures

Anatomic reduction of ankle fractures may influence outcomes but the relationships between these 2 variables are still unknown and require further investigation. The purpose of this study was to investigate the relationships between radiologic alignment of surgically treated ankle fractures and functional outcomes. This retrospective study included patients who were surgically treated for Weber B and C ankle fractures. The outcome measures consisted of the Olerud and Molander Ankle Score (OMAS) and the foot and ankle disability measure. Standard radiographs included anteroposterior, lateral, and mortise views of the ankle, both on pre- and postoperatively. Between June 2011 and December 2013, a total of 152 patients were treated for ankle fractures and 76 patients with a mean age of 41.3 ± 17.1 years and a mean follow-up of 39.6 ± 8.9 months were included. There were 45 Weber type B fractures (mean age 43.4 ± 17.8, 28 females, 17 males) and 31 Weber type C fractures (mean age 40.7 ± 17.3, 12 females, 19 males). Linear regression did not reveal any significant relationships with the exception of age. There was a moderate correlation between the OMAS outcome score and age ( r2 = 0.46, P = .01). We found that younger age was a moderate predictor of functional outcome following surgical treatment of ankle fractures. Radiographic alignment using standard non-weight-bearing radiographs and fracture severity did not predict functional outcomes at 24 months postoperatively. Level III, prognostic, retrospective cohort study.

Assessment Inter- and Intraobserver Agreement in Two Radiological Indexes in True Lateral X-Rays View for Syndesmotic Reduction in Ankle Fractures

Category: Trauma Introduction/Purpose: Malreduction of distal tibio-fibular syndesmosis in ankle fractures has been reported from 20% to 52% in surgically treated patients. Current intraoperative methods, fluoroscopy and intraoperative CT, have not improved consistently this results. Recently, new indexes to determine the normal anatomy of the syndesmosis have been published using a true lateral view of the ankle to evaluate the relation of the fibula with the tibia in the sagittal plane. These studies have been made in non- injured ankles. If these measurements could be performed intra operatively, they may improve the evaluation of syndesmotic reduction. To our knowledge this indexes have been not tested in injured ankles. The purpose of this study is to assess intra- observer and inter-observer agreement in two radiological indexes by evaluating true lateral x-ray view in surgically treated patients for ankle fractures with syndesmotic injury. Methods: Retrospective study of case series. Forty-three consecutive patients who underwent open reduction and internal fixation for ankle fractures with syndesmotic screw were evaluated. The inclusion criteria were syndesmotic injury fixed with one or two screws, and having a true lateral postoperative ankle x-ray view. Two measurements were performed: Anteroposterior Tibiofibular Ratio (APTF) and Anterior Tibiofibular Ratio (ATFR). Three independent evaluators performed the measurements. The intra-class correlation was used to determine inter- and intra-observer agreement, through statistical package SPSS 20. Results: The intra-observer and inter-observer agreement in the APTF was good to very good, with intra-class correlation values between 0.77 and 0.81; The reproducibility of the ATFR was also good to very good, but with lower intra-class correlation values between 0.62 and 0.79. Conclusion: Intra- and inter-observer concordance in APTF and ATFR in operated ankle fractures with syndesmotic injury was similar to that reported in healthy ankles. This study validates, in terms of intra and inter-observer agreement, the use of these indexes in surgically treated ankle fractures with syndesmotic repair. The next step is to compare these measurements made intra-operatively with a CT scan.

Value of Early Postoperative Computed Tomography Assessment in Ankle Fractures Defining Joint Congruity and Criticizing the Need for Early Revision Surgery

Previous investigators have questioned the reliability of plain radiographs in assessing the accuracy of ankle fracture reduction when these were compared with the computed tomography (CT) evaluation in the preoperative setting, in particular, in fractures with syndesmosis injuries or trimalleolar fragments. The role of CT assessment, however, has not been investigated in the early postoperative setting. In the early postoperative setting, reduction still relies most commonly on fluoroscopy and plain radiographs alone. In the present study, we hypothesized that early postoperative CT assessment of ankle fractures with syndesmosic injuries and posterior malleolar fragments can add valuable information about the joint congruity compared with plain radiographs alone and that this information could affect the decisions regarding the need for early revision surgery. A total of 352 consecutive operated ankle fractures were reviewed. Of these, 68 (19%) underwent early postoperative CT assessment and were studied further to identify the causes that prompted revision surgery. Of the 68 cases, despite acceptable reduction found on the plain radiographs, 20 (29%) underwent early (within 1 week) revision surgery after studying the CT scans, which revealed malreduction of the syndesmosis, malreduction of the posterior lip fragment, and intra-articular fragments. We concluded that in ankle fractures involving disruptions of the syndesmosis or posterior malleolar fragments, early postoperative CT assessment could be justified, because it will reveal malreduction and prompt early revision intervention for a substantial proportion of these patients.

Single provider reduction and splinting of displaced ankle fractures: a modification of Quigley's classic technique.

Ankle fractures are commonly treated by orthopaedic surgeons and often require manipulative reduction. This can be painful for the patient and frequently uses 2 or more providers. Intra-articular injection of local anesthetic into the ankle joint precludes the need for conscious sedation (intravenous narcotics and benzodiazepines, propofol, or ketamine). By combining an ankle block with a modification of the classic ankle fracture reduction technique described by Quigley 1959, a single provider can effectively perform a manipulative reduction and splinting of an ankle fracture without conscious sedation.

The TROJAN Project: Creating a Customized International Orthopedic Training Program for Junior Doctors.

Musculoskeletal problems account for a vast proportion of presentations encountered by doctors globally, with figures ranging from 15-36%. However, the time medical schools allocate to learning orthopedics is by no means proportional to this. This study aims to bridge this gap by developing an international orthopedic teaching program tailored to the specific knowledge and skills required by junior doctors in different countries. This prospective study asked fifty junior doctors, who had recently completed an orthopedics job, what three orthopedic teaching topics taught retrospectively would have benefitted their clinical practice. The most requested topics were used to design educational workshops for junior doctors and these consequently comprised the TROJAN (Teaching Requested by Orthopaedic Juniors And Novices) training program. Data was collected from twenty-five junior doctors in KwaZulu-Natale State, South Africa, and twenty-five in London, UK. It is therefore in these two countries that the TROJAN program was subsequently made available. Participants who selected topics were within two years of graduating medical school and had worked an orthopedic or Accident and Emergency job within the last year. 49% of topics chosen by SA doctors were practical skills such as wrist and ankle fracture reduction techniques, and management of open fractures. The most requested topic by UK doctors (11 out of 25) was management of neck of femur fractures. This is rationalized by the fact South African doctors require more hands-on responsibility in their daily practice whereas in the UK greater emphasis is placed on optimizing patients for theatre and making sound management plans. TROJAN currently develops orthopedic skills and knowledge in junior doctors in South Africa and United Kingdom with teaching customized based upon location. Feedback has been exceptionally positive with every candidate thus far rating the usefulness of TROJAN as the highest option, very useful.

Failed anatomical reduction of ankle fractures

Failed anatomical reduction of ankle fractures