Lauge-Hansen Classification Research Articles

Correlation factors for distal syndesmosis ossification following internal fixation of ankle fracture

This clinical retrospective study explored factors associated with distal tibiofibular syndesmosis ossification (TFSO) after ankle fracture fixation. Between August 2012 and January 2015, 172 patients with ankle fractures (121 men) with an average age of 46.6 years (range, 22–71 years) were treated surgically with an average follow-up period of 26 months (range, 16–34 months). According to the Danis-Weber AO classification rubric, 54 fractures were type A, 78 were type B, and 40 were type C. According to the Lauge-Hansen classification, there were 17 supination-adduction (SA) fractures, 98 supination-external rotation (SE) fractures, 31 pronation-external rotation (PE) fractures, and 26 pronation-abduction (PA) fractures. The average injury to operation interval was 4.3 days (6 hours-7 days). Multiple factor analysis was conducted to examine risk factors for TFSO. It was observed in 36 (20.9%) cases (11 complete ossification cases; 25 partial ossification cases). Multivariate logistic regression revealed the following independent risk factors for TFSO were: AO classification, distal tibiofibular syndesmosis separation, and fibular fracture morphology. In conclusion, AO type C fracture, syndesmosis separation, and high fibular fracture were associated with distal TFSO following ankle fracture fixation.

Factors Associated With Wound- and Implant-Related Complications After Surgical Treatment of Ankle Fractures

We have described the epidemiology of complications after surgical treatment of ankle fractures and assessed which factors are associated with the most frequent complications. We conducted a retrospective cohort study at 2 level 2 and 1 level 1 trauma center in a single trauma region in the Netherlands. The study variables were collected from the electronic medical patient records; all ankle fractures were classified using the Lauge-Hansen classification, and the complications were recorded. A total of 989 patients were included from 3 hospitals, with 173 complications in 156 patients (15.8%). The most frequent complication was wound related, occurring in 101 patients (10.2%). Implant-related complications occurred in 44 patients (4.4%). Other complications, such as cast pressure spots, posttraumatic dystrophy, nonunion, impingement, and pneumonia occurred in 28 patients (2.8%). The 2 most important complications were further analyzed for risk factors. Multivariate analysis showed the risk factors for wound-related complications were advanced age, increased American Society of Anesthesiologists classification, smoking, right side symptomatic, open fracture, and initial external fixation. Most implant-related complications were caused by malreduction (n = 22) or untreated syndesmotic injury (n = 19). Malreduction was associated with supination eversion fractures (p = .059), and untreated syndesmotic injury occurred more often with pronation external rotation fractures (p < .001). The most frequent complications after ankle fracture surgery were wound- and implant-related complications. Postoperative wound-related complications were multifactorial and dependent on a combination of trauma-, patient-, and treatment-related factors. In contrast, implant-related complications resulted from the interaction between the fracture type and subsequent surgical treatment.

Ankle fracture – correlation of Lauge-Hansen classification and patient reported fracture mechanism

Category: Trauma Introduction/Purpose: The genetic Lauge-Hansen classification is considered to provide a link between mechanism of ankle injury and resulting fracture morphology. In this study, we addressed the question of agreement between the mechanism of the fracture as postulated by the Lauge-Hansen classification and mechanism reported by the patient in rotational ankle fractures. Understanding of the actual mechanisms of ankle fracture may guide treatment decisions. Methods: Of 110 screened patients with acute malleolar fractures, 78 were able to provide information on their fracture mechanism and were included in the study. The study group consisted of 43 women and 35 men with a mean age of 47.8 (range 19.5-88.4) years. Patients were asked to describe the direction of deformation with primary question being pronation and supination as demonstrated by the examiner. As hyperplantarflexion and hyperdorsiflexion has been spontaneously reported by the patients, these directions were added to the analysis. Radiographs were analyzed according to Lauge-Hansen classification and compared with fracture mechanisms reported by the patients. Results: The majority (35/78 = 44.8%) of patients reported pronation as their fracture mechanism, 27 (34.6%) patients reported supination, 15 (19.2%) patients reported hyperplantarflexion (3 pure, one combined with pronation and 11 combined with supination), and 1 patient reported hyperdorsiflexion combined with pronation. Radiographs revealed 61 supination-external rotation (79%), 1 supination-adduction (1.3%), 14 pronation-external rotation (18%), 1 pronation-abduction (1.3%) fractures. One x-ray was unclassifiable with the Lauge-Hansen classification. The patient reported mechanisms were in concordance with the mechanism deducted from the x-rays in 49% of cases. Only 17% of patients who recalled a pronation trauma actually had radiographs classified as pronation fractures while 76% of patients who recalled a supination trauma were also radiographically classified as having sustained supination type fractures. Conclusion: The Lauge-Hansen classification should be used with caution for determining the actual mechanism of injury as it was able to predict the patient reported fracture mechanism in less than 50% of cases. A substantial percentage of fractures appearing radiographically as supination type injuries may have been actually produced by a pronation fracture mechanism.

Morphological Analysis of Tibiofibular Disruption Using CT images in Ankle Fractures with Unstable Syndesmotic Injury

Category: Trauma Introduction/Purpose: We aimed to investigate the diagnostic value of CT scan and the morphologic pattern of distal tibiofibular disruption associated with fracture-type or concomitant avulsion fractures in cases of ankle fracture with unstable syndesmosis requiring surgical fixation. Methods: 104 cases images(preoperative plane radiographs and CT axial images) of ankle fractures needed syndesmotic fixation due to unstable syndesmosis on intraoperative stress test were retrospectively reviewed. We classified ankle fractures by Lauge-Hansen classification and AO-OTA classification. Also, associated tibiofibular avulsion fractures including anterior distal tibiofibular avulsion fractures and posterior malleolar fractures were identified. Classification of posterior malleolar fractures based on Bartonícek-Rammelt classification was conducted. We grouped morphologic patterns of distal tibiofibular disruption which is 10 mm proximal to the plafond on CT axial images. We divided them into no diastasis, symmetric diastasis, anterior open, and posterior open according to the diastasis pattern, and no translation, anterior translation, and posterior translation depending on sagittal translation. Chi-square test/Fisher’s exact test and adjusted residual analysis were used for statistical analysis. Results: On LH classification, SER in 78(75%), PER in 18(17.3%), and PA in 8(7.7%). AITFL avulsions were in 37(35.6%) and PM fractures in 58(55.8%). Diastasis patterns were recorded in 30(28.8%) of no diastasis, 41(39.4%) of symmetric diastasis, 3(2.9%) of anterior open, and 30(28.8%) of posterior open. Depending on sagittal translation, 53(51.0%) of no translation, 44(42.3%) of anterior translation, and 7(6.7%) of posterior translation. Neither diastasis nor sagittal translation was revealed by CT in 17.3% of all. Syndesmotic morphologic pattern was various in SER [no diastasis (35.9%, AR=2.7), posterior open (35.9%, AR=2.7), and anterior translation (48.7%, AR=2.3)] whereas PER had relatively consistent pattern (symmetric diastasis in 88.9%, AR=4.7). Tibiofibular avulsion fractures such as Charput and PM fracture did not create distinct feature of widening. Conclusion: In terms of syndesmotic disruption pattern by CT images, PER fractures tend to show simple symmetric diastasis pattern, but SER fractures have a variety of patterns including normal appearance. Even if associated avulsion fracture do not make certain diastasis feature on static CT images, we still have to be careful not to overlook the syndesmotic instability. Diagnostic value of static imaging such as CT may not be higher than expected if not accompanied with intraoperative dynamic stress test.

Reproducibility assessment of the Lauge-Hansen classification for ankle fractures

Objective: To evaluate the reproducibility, among orthopaedists, of the Lauge-Hansen classification performed at two different times, with an understanding of the trauma mechanism in each type of fracture. Methods: Thirty radiographs of ankle fractures were selected for assessment by five orthopaedists from our service, two of whom were already trained and three of whom were undergoing orthopaedic residency training. Results: The results were tabulated and plotted, and in a second assessment after 1 week, 66% correct answers and 34% errors were found. In the first assessment, the percentage of correct answers was 61.33%. Conclusion: Management of the classification makes the orthopaedists habituated to using it routinely, facilitating the understanding by other professionals in the field and reducing disagreement among observers. Level of Evidence III; Retrospective Comparative Study.

Compatibility of Lauge-Hansen Classification Between Plain Radiographs and Magnetic Resonance Imaging in Ankle Fractures

We evaluated the accuracy of the predictive injury sequences of the Lauge-Hansen (L-H) classification using magnetic resonance imaging (MRI) in patients with ankle fractures and determined the possible causes of mismatch. Sixty-five patients with ankle fractures who had a complete series of anteroposterior, lateral, and oblique radiographs and ankle MRI studies available were included. The fracture pattern was assigned by 2 senior orthopedic surgeons according to the L-H classification system. The syndesmotic ligaments, lateral collateral ligaments, and medial deltoid complex ligaments were evaluated on the preoperative MRI scans. Comparisons were performed between the predicted ankle ligamentous injury based on the radiographic L-H classification and preoperative MRI analysis. Of the 65 feet in 65 patients, 50 feet (76.9%) were classified as having a supination-external rotation (SER) fracture, 6 feet (9.2%) as having a pronation-external rotation fracture, 4 feet (6.2%) as having a supination adduction fracture, and 2 feet (3.1%) as having a pronation abduction fracture. The overall compatibility of the radiologic classification with the MRI classification was 66.1%. In the evaluation of 50 feet with the MRI SER designation, maximum compatibility was found for stage 4 (77.3%). The main cause for the discrepancy in the SER designation was missing the presence of deltoid ligament disruption on the plain radiographs, especially in the stage 2 and 3 SER fracture pattern. In the evaluation of deltoid complex injuries, all injuries were localized to the anterior part of the medial deltoid complex. The validity of the L-H classification system was low. A new classification system is needed to address the medial malleolus fracture or deltoid complex injuries without posterior injury. Also, stress radiographs could be added to standard radiographs for the classification to address deltoid complex injuries.

Morphological characteristics of the posterior malleolar fragment according to ankle fracture patterns: a computed tomography-based study

BackgroundThe posterior malleolar fragment (PMF) of an ankle fracture can have various shapes depending on the injury mechanism. The purpose of this study was to evaluate the morphological characteristics of the PMF according to the ankle fracture pattern described in the Lauge-Hansen classification by using computed tomography (CT) images.MethodsWe retrospectively analyzed CT data of 107 patients (107 ankles) who underwent surgery for trimalleolar fracture from January 2012 to December 2014. The patients were divided into two groups: 76 ankles in the supination-external rotation (SER) stage IV group and 31 ankles in the pronation-external rotation (PER) stage IV group. The PMF type of the two groups was assessed using the Haraguchi and Jan Bartonicek classification. The cross angle (α), fragment length ratio (FLR), fragment area ratio (FAR), sagittal angle (θ), and fragment height (FH) were measured to assess the morphological characteristics of the PMF.ResultsThe PMF in the SER group mainly had a posterolateral shape, whereas that in the PER group mainly had a posteromedial two-part shape or a large posterolateral triangular shape (P = 0.02). The average cross angle was not significantly different between the two groups (SER group = 19.4°, PER group = 17.6°). The mean FLR and FH were significantly larger in the PER group than in the SER group (P = 0.024, P = 0.006). The mean fragment sagittal angle in the PER group was significantly smaller than that in the SER group (P = 0.017).ConclusionsWith regard to the articular involvement, volume, and vertical nature, the SER-type fracture tends to have a smaller fragment due to the rotational force, whereas the PER-type fracture tends to have a larger fragment due to the combination of rotational and axial forces.

Targeted suture anchor repair technique for deltoid ligament rupture

Objective To summarize the characteristics of deltoid ligament rupture and explore the feasibility and short-term clinical outcomes of targeted suture anchor repair technique according to the rupture site. Methods From May 2011 to October 2014, 19 cases of complete deltoid ligament rupture (17 males and 2 females) were recruited in this study, with an average age of 34.15±1.23 years (ranged from 15 to 60 years). According to Lauge-Hansen classification, there were 7 cases of pronation external rotation grade IV injury, including 3 cases of Maisonnuve fracture; 1 case of pronation abduction type III degree injury, 1 case of pronation abduction grade IV injury; and 10 cases of supination external rotation grade IV injury. According to AO/OTA classification, there were 9 cases of 43B type injury and 10 cases of 43C type injury. According to the rupture site of deltoid ligament, the targeted suture anchor repair surgery was operated respectively. Early mobilization with the help of hinged ankle brace was encouraged. The evaluation at last follow-up was based on the American Orthopedic and Ankle Association (AOFAS) criteria of ankle and hindfoot, and the visual analogue scale (VAS) scoring system. Results Nineteen patients were all followed up for 24 to 48 months, with an average of 30.42±5.11 months. Fourteen cases (73.7%, 14/19) with talus end avulsion were treated by double suture anchor in the talus, with continuous locking suture of the avulsed end. Four cases (21.1%, 4/19) with middle part rupture were treated by double suture anchor in the talus, with the sutures crossing three bone tunnels at the medial malleolus. One case (5.3%, 1/19) with medial malleolus end avulsion was treated by single suture anchor at the medial malleolus, with continuous locking suture of the avulsed end. At the last follow-up, the AOFAS score was ranged from 70 points to 96 points, with an average of 90.53 points, and excellent in 16 cases, good in 2 cases, fair in 1 case, excellent and good rate was 94.7%. The VAS score was ranged from 0 to 2 points, with an average of 0.42 point. No wide medical clear space was detected. But traumatic arthritis was happened in 2 patients. Conclusion The targeted suture anchor repair technique according to the rupture site was a save technique in treating deltoid ligament rupture, which is conducive to early postoperative functional exercise, with excellent short-term clinical outcomes and few complications. Key words: Ligaments; Ankle joint; Wounds and injuries; Suture anchors

The Risk Factors Associated with Nonunion after Surgical Treatment for Distal Fibular Fractures

Purpose The purpose of this study was to evaluate the radiologic outcomes of distal fibular fractures and to analyze the risk factors associated with nonunion. Materials and Methods Between January 2009 and March 2016, 13 patients who had final nonunion with ankle fracture were included. In the control group, 370 patients who had undergone bony union and removed metal implants were included. All patients underwent the same surgical procedure and had the same treatment method, ultimately achieving satisfactory open reduction results with less than 2 mm fracture gap. Surgical treatment of fracture was considered to have the same effect on nonunion, and factors that might be associated with nonunion were evaluated. SPSS ver. 13.0 (SPSS Inc., USA) was used for all statistical analyses. Pearson's chi-square test and multi-variate regression analysis were performed to determine the factors affecting nonunion of distal fibular fracture. A p-value less than 0.05 was considered statistically significant, and relative risk was assessed. Results The mean age of 13 patients was 46.9 years (range, 16∼57 years); there were 8 men and 5 women. Among the 13 patients with nonunion, atrophic was the most common (12 cases). The association between the injury mechanism and the Lauge-Hansen classification and diabetes mellitus was not statistically significant. Distal fibular fractures with tibia shaft fracture (p=0.015) and Danis-Weber type C fracture (p=0.023), open fracture (p=0.011), and smoking (p=0.023) were significantly associated with nonunion. Conclusion In this study, the combined injury of the ipsilateral tibia shaft fracture, open fracture, and Danis-Weber type C fracture may increase the possibility of nonunion. Therefore, caution is advised to prevent nonunion.

Discussion Concerning Deltoid Ligament and Antero-Medial Capsule Repair in the Surgical Management of Supination External Rotation Ankle Fractures

Ankle fracture is one of the most common injuries. In order to determine the severity of ankle fractures, the Lauge-Hansen classification is frequently utilized. In the classification, Supination-External Rotation (SER) injuries are the most common occurrences. In a clinical setting, SER stage IV (SER IV) can be seen as a fracture of the lateral malleolus (Weber B fibular fractures) on radiographs, when there is no medial malleolus fracture.

Reproducibility of the Lauge-Hansen, Danis-Weber, and AO classifications for ankle fractures

ObjectiveThis study evaluated the reproducibility of the three main classifications of ankle fractures most commonly used in emergency clinical practice: Lauge-Hansen, Danis-Weber, and AO-OTA. The secondary objective was to assess whether the level of professional experience influenced the interobserver agreement for the classification of this pathology. MethodsThe study included 83 digitized preoperative radiographic images of ankle fractures, in anteroposterior and lateral views, of different adults that had occurred between January and December 2013. For sample calculation, the estimated accuracy was approximately 15%, with a sampling error of 5% and a sampling power of 80%. The images were analyzed and classified by six different observers: two foot and ankle surgeons, two general orthopedic surgeons, and two-second-year residents in orthopedics and traumatology. The Kappa statistical method of multiple variances was used to assess the variations. ResultsThe Danis-Weber classification indicated that 40% of the agreements among all observers were good or excellent, whereas only 20% of good and excellent agreements were obtained using the AO and Lauge Hansen classifications. The Kappa index was 0.49 for the Danis-Weber classification, 0.32 for Lauge Hansen, and 0.38 for AO. ConclusionThe Hansen-Lauge classification presented the poorest interobserver agreement among the three systems. The AO classification demonstrated a moderate agreement and the Danis-Weber classification presented an excellent interobserver agreement index, regardless of professional experience.

Ankle fracture — Correlation of Lauge-Hansen classification and patient reported fracture mechanism

IntroductionThe genetic Lauge-Hansen classification is used for reconstruction of the mechanism of ankle injury. In this study, we addressed the question of agreement between the mechanism of the fracture as postulated by the Lauge-Hansen classification and mechanism reported by the patient in rotational ankle fractures. Material and methodsRadiographs of 78 patients with acute malleolar fractures were analyzed and compared with fracture mechanisms reported by these patients. ResultsThe patient reported mechanisms were in concordance with the mechanism deducted from the X-rays in 49% of cases. Only 17% of patients who recalled a pronation trauma actually had radiographs classified as pronation fractures while 76% of patients who recalled a supination trauma were also radiographically classified as having sustained supination type fractures. ConclusionThe Lauge-Hansen classification should be used with caution for determining the actual mechanism of injury as it was able to predict the patient reported fracture mechanism in less than 50% of cases. A substantial percentage of fractures appearing radiographically as supination type injuries may have been actually produced by a pronation fracture mechanism.

Ankle Arthroscopy for Diagnosis and Treatment of Full Thickness Cartilage Lesions in the Setting of Ankle Fracture

Category: Ankle, Arthroscopy, Sports Introduction/Purpose: Ankle fractures treated with anatomic open reduction and internal fixation (ORIF) can still be associated with poor clinical outcomes. The presence of radiographically occult intra-articular chondral injury is a known entity, however the clinical relevance in the setting of ankle fractures is not well established. The purpose of this study aims to evaluate the prevalence of chondral lesions, in particular full thickness talar dome lesions, with concurrent arthroscopy in acute ankle fracture ORIF and determine if there is a correlation with patient and fracture characteristics. In addition, we aimed to evaluate the treatment effect on clinical outcomes to establish the role of concurrent arthroscopy in ankle fracture management. Methods: A retrospective chart review was conducted from prospectively collected registry data at the investigators’ institution from 2011 to 2016. All patients that underwent an acute ankle fracture ORIF with concurrent arthroscopy were identified. Patients with concomitant injuries were excluded. Baseline patient and fracture characteristics were recorded. Fracture type by the Lauge-Hansen classification as well as by anatomic location were determined. Charts were reviewed to determine the prevalence and grade of chondral lesions. The treatment performed for each chondral lesion was determined. Clinical outcomes with a minimum of one year follow up were assessed using the Foot and Ankle Outcome Score (FAOS). Results: One hundred and sixteen consecutive patients undergoing acute ankle fracture ORIF with concurrent arthroscopy were included. A chondral lesion was identified in 78% (90/116). Of those, a Grade IV full thickness talar dome chondral lesion was identified in 43% (39/90). Patient age was a significant predictor, with patients less than thirty being less likely to have a chondral injury compared to those greater than thirty (59% vs 85%, p=0.0077). Of the patients that sustained a dislocation at the time of injury, 100% had a chondral lesion which was statistically significant (p=0.039). Patients with complete syndesmosis disruption and instability were also more likely to have a chondral lesion (96% vs 73%, p=0.013). Patients with chondral lesions had statistically significant worse clinical outcomes than those without (Table). Conclusion: Arthroscopy performed concomitantly with ankle ORIF is useful in diagnosing chondral injuries. In particular, full thickness talar dome chondral lesions are quite common. Increased fracture severity, as indicated by the presence of a dislocation at presentation, and a syndesmotic injury may be more likely to present with a chondral lesion and thus should raise suspicion and prompt evaluation. The presence of a concurrent talar chondral injury has a negative impact on clinical outcomes. Concurrent arthroscopy allows for simultaneous diagnosis and acute treatment of full thickness talar lesions.

Repair of Bimalleolar Ankle Fracture

The incidence of ankle fractures is rapidly increasing in geriatric populations. Of the 4 fracture patterns described by the Lauge-Hansen classification system, supination-external rotation (SER) accounts for most ankle fractures. This video demonstrates surgical repair of a SER type 4 ankle fracture in a geriatric patient. SER type 4 ankle fractures are considered unstable and are generally treated with surgical fixation. After placement of plate and screws, intraoperative stress tests can be used to assess for syndesmotic widening. If necessary, the syndesmosis can be reduced open, with screw fixation placed parallel to the joint. Patients are kept non-weight-bearing for 6 weeks after surgery. This video, shot on an iPhone 6S, shows the case of a 66-year-old female status after a fall with twisting mechanism resulting in an unstable SER type 4 fracture requiring operative repair. Intraoperative stress test revealed medial clear space widening requiring syndesmotic reduction. SER type 4 ankle fractures are a common injury that must be properly managed to return patients to baseline functional status. The surgical technique described in this video provides for good stabilization and allows for early range of motion with advancement to weight-bearing as tolerated at 6 weeks postoperatively.

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.

Differences in Classification Between Mono- and Polytrauma and Low- and High-Energy Trauma Patients With an Ankle Fracture: A Retrospective Cohort Study

Although fracture type and treatment options for ankle fractures are well defined, the differences between mono- and polytrauma patients and low- and high-energy trauma have not been addressed. The aim of the present study was to compare the fracture type and trauma mechanism between mono- and polytrauma and low- and high-energy trauma patients with an ankle fracture. We performed a single-center retrospective cohort study. Fractures were classified according to the Lauge-Hansen classification and a descriptive classification. High-energy trauma (HET) was defined using triage criteria. All other patients were classified as having experienced low-energy trauma (LET). The patients were divided into 2 groups according to the injury severity score (ISS). Monotrauma patients were defined as patients with an ISS of 4 to 11 with an isolated ankle fracture or an ankle fracture with a minor contusion or laceration. Polytrauma patients were defined as patients with an ISS of ≥16 with ≥2 body regions involved. Patients with an ISS from 12 to 15 were excluded. A total of 96 patients were eligible for analysis. Of the 96 patients, 62 had experienced monotrauma and 34 had experienced polytrauma. A significant difference was found between the mono- and polytrauma patients in the Lauge-Hansen classification (p < .001). Monotrauma patients had a high incidence of an isolated supination external rotation injury. Supination adduction and pronation abduction injuries were more often observed in polytrauma patients. The same pattern was observed for ankle fractures after HET compared with LET (p < .001), because all pronation abduction and supination adduction injuries were observed after a HET mechanism. The results of the present study indicate that polytrauma patients sustain different types of ankle fractures than patients with an isolated ankle fracture. This difference likely results from the high-energy transfer associated with polytrauma, because pronation abduction and supination adduction injuries were only observed after HET.

Temporal Variation in Ankle Fractures and Orthopedic Resident Program Planning in an Urban Level 1 Trauma Center

Previous studies have described the mechanism of ankle fractures, their seasonal variation, and fracture patterns but never in conjunction. In addition, the cohorts previously studied were either not from trauma centers or were often dominated by low-energy mechanisms. The present study aimed to describe the epidemiology of ankle fractures presenting to an urban level 1 trauma center. The records from an urban level 1 trauma center located in the Midwestern United States were retrospectively reviewed, and the injury mechanism and energy, time of injury, day of week, month, and patient characteristics (age, gender, comorbidities, smoking status) were collected. The fractures were classified using the AO (Arbeitsgemeinschaft für Osteosynthesefragen), Lauge-Hansen, and Danis-Weber systems. Of these systems, the Lauge-Hansen classification system resulted in the greatest number of “unclassifiable” cases. Most ankle fractures were due to high-energy mechanisms, with motor vehicle collisions the most common high-energy mechanism. The review found that most ankle fractures were malleolar fractures, regardless of the mechanism of injury. The ankle fracture patients had greater rates of obesity, diabetes, and smoking than present in the region where the hospital is located. The fractures were most likely to occur in the afternoon, with more fractures presenting on the weekend than earlier in the week and more fractures in the fall and winter than in the spring and summer. The temporal variation of these fractures should be considered for health services planning, in particular, in regard to resident physician staffing at urban level 1 trauma centers.

Antiglide versus lateral plate fixation for Danis-Weber type B malleolar fractures caused by supination-external rotation injury

The purpose of this study was to evaluate functional results and the frequency of complications in the distal fibula Danis-Weber type B fractures caused by supination-external rotation injury in a group of lateral and antiglide plate fixation. This prospective study evaluated 44 patients with a minimum of one-year follow-up. Patients were divided into two groups: one lateral plate group (24 patients) and group with an antiglide plate (20 patients). The patients of both groups were always positioned supine, and lateral approach was used. In the lateral plate group, the fracture was anatomically reduced, an optional anteroposterior lag screw was placed perpendicular to fracture line, and then the one-third tubular plate was applied on the lateral fibular site. In the antiglide group, the palate was implemented on the posterolateral surface of the fibula and the fracture was anatomically reduced. An optional lag-screw was used. Distal screw fixation was applied deliberately. Functional assessment according to the American Orthopaedic Foot and Ankle Society hind foot-ankle score (AOFAS) were performed at one year after surgery. The complications were recorded. According to Lauge-Hansen classification of supination-external rotation injury, a total of 27 (61.4%) patients was classified as stage 2, 2 (4.5%) patients as stage 3 and 15 (34.1%) patients with stage 4. In the lateral plate group, there were 13 (54.2%) male and 11 (45.8%) female patients. In the antiglide plate group, men comprised 12 (60%) and women 8 (40%) of patients. The AOFAS in the lateral and antiglide group performed one year after surgery was, on average, 93.7±6.1 (range 85-100) and 94.5±6.0 (range 85-100) points respectively. There were no statistically significant differences in both groups (p=0.37). Complications were observed in 7 (29.3%) patients of lateral plate and 3 (15%) patients of an antiglide plate (p=0.31). There was no case of tendinopathy. Revision surgery was performed in one patient with superficial infection. In the present study, the outcome of the surgically treated Weber type B fractures caused by supination external rotation injury was comparable in both groups. The antiglide plate fixation showed no signs of peroneal tendinopathy, low rate of complications. We believe this technique is safe and a good method of fixation as well as traditional lateral plating.

Análise da reprodutibilidade das classificações de Lauge‐Hansen, Danis‐Weber e AO para as fraturas de tornozelo

ObjectiveThis study evaluated the reproducibility of the three main classifications of ankle fractures most commonly used in emergency clinical practice: Lauge‐Hansen, Danis‐Weber, and AO‐OTA. The secondary objective was to assess whether the level of professional experience influenced the interobserver agreement for the classification of this pathology. MethodsThe study included 83 digitized preoperative radiographic images of ankle fractures, in anteroposterior and lateral views, of different adults that had occurred between January and December 2013. For sample calculation, the estimated accuracy was approximately 15%, with a sampling error of 5% and a sampling power of 80%. The images were analyzed and classified by six different observers: two foot and ankle surgeons, two general orthopedic surgeons, and two second year residents in orthopedics and traumatology. The Kappa statistical method of multiple variances was used to assess the variations. ResultsThe Dannis‐Weber classification indicated that 40% of the agreements among all observers were good or excellent, whereas only 20% of good and excellent agreements were obtained using the AO and Lauge Hansen classifications. The Kappa index was 0.49 for the Dannis‐Weber classification, 0.32 for Lauge Hansen, and 0.38 for AO. ConclusionThe Hansen‐Lauge classification presented the poorest interobserver agreement among the three systems. The AO classification demonstrated a moderate agreement and the Dannis‐Weber classification presented an excellent interobserver agreement index, regardless of professional experience.

The diagnostic accuracy of smartphones in the radiographic analysis of ankle fractures

Background: Orthopaedic surgeons rely on radiographs to assist in the evaluation and treatment of patients. The technological advances of smartphones have allowed data to be transferred quickly and viewed from remote locations. The diagnostic accuracy of viewing radiographs on smartphones remains unproven. As such, this study aimed to evaluate the ability of smartphones to allow surgeons to correctly diagnose and interpret radiographs of ankle fractures on one of the most popular smartphones, an Apple iPhone 4S (Apple Inc, Cupertino, CA, USA). Methods: Using the smartphone, individual pictures were taken of anteroposterior, mortise, and lateral radiographs of 20 ankle fractures. These images were then evaluated through 10 questions that included acceptable quality, presence and displacement of fibula, medial malleolus, and posterior malleolar fractures, ankle subluxation, syndesmotic disruption, Lauge-Hansen classification, and the need for open reduction and internal fixation. Results were compared to the same radiographs viewed on a picture archiving and communication system (PACS) workstation. Results: Ten orthopaedic surgery residents and five orthopaedic surgery attendings evaluated the radiographs and answered a total of 6000 questions. When comparing the responses between those images viewed on the smartphone versus those viewed on the PACS workstation, 826 differences were found. After analysis of both interobserver and intraobserver reliability, a significant difference was found between viewing modalities, with the smartphone found to be not as reliable as the PACS workstation. However, when looking at the single question of whether or not the fracture would require operative fixation, no significant difference was found between the use of a smartphone or PACS workstation. Conclusions: The smartphone images demonstrated a reliable prediction of the proper treatment for the 20 ankle fractures despite noted differences between the two viewing modalities.