Lauge-Hansen Classification Research Articles

Preoperative CT parameters to predict tibiofibular syndesmosis injury associated with ankle fracture: a propensity score-matched analysis

Untreated ankle fractures with concomitant tibiofibular syndesmosis injury often lead to postoperative pain and early traumatic arthritis. CT has advantages in the preoperative diagnosis of combined ankle injuries. However, a few studies have investigated the best preoperative CT parameters to predict tibiofibular syndesmosis injuries associated with ankle fractures. This study aimed to identify and evaluate the optimal preoperative CT parameters for predicting tibiofibular syndesmosis injuries associated with ankle fractures. We retrospectively analyzed 129 patients who underwent preoperative CT of an ankle fracture treated between January 2016 and April 2022 at a tertiary A hospital. All patients underwent open reduction and internal fixation and intraoperative stability testing. Based on the Cotton test, the patients were divided into the stable group (n = 83, 64.3%) and unstable group (n = 46, 35.7%). After 1:1 propensity score matching, the general conditions, anterior tibiofibular distance (TFD), posterior TFD, maximum TFD, tibiofibular syndesmosis area, sagittal fracture angle, Angle-A, and Angle-B were compared between the stable and unstable groups. The propensity score-matched cohort comprised 82 patients. There were no significant differences between the stable and unstable groups in sex, age, affected side, operation interval, injury mechanism, Lauge-Hansen classification, sagittal fracture angle, and Angle-A (all P > 0.05). Compared with the stable group, the unstable group had a significantly greater aTFD, pTFD, maxTFD, and area (all P < 0.05). PTFD, maxTFD, and area were positively correlated with joint instability. Angle-B was smaller in the unstable group (57.13°) than the stable group (65.56°). ROC analysis showed that Area (AUC 0.711) and maxTFD (AUC 0.707) had the highest diagnostic efficacy. MaxTFD and Area were the best predictive parameters; a larger Area was associated with a higher likelihood of instability of the tibiofibular syndesmosis after ankle fracture fixation.

Weber Ankle Fracture Classification System Yields Greatest Interobserver and Intraobserver Reliability Over AO/OTA and Lauge-Hansen Classification Systems Under Time Constraints in an Asian Population

No previous studies have evaluated the intra- and interobserver reliability between the Weber, Lauge-Hansen and AO Foundation/Orthopaedic Trauma Association (AO/OTA) classification systems under time constraints. This study compares the interobserver and intraobserver reliability of the aforementioned classification systems under simulated time constraints. Anteroposterior and lateral radiographs of ankle malleolar fractures from 80 consecutive patients from 2015 to 2016 were classified by 2 independent observers according to Weber, Lauge-Hansen and AO/OTA. Classifications were conducted over 4 successive weeks under timed (25-seconds) and untimed conditions, with 1-week gaps between each classification. Cohen's kappa and percentage agreement were calculated. Cohen's kappa for interobserver agreement ranged 0.67 to 0.67 and 0.59 to 0.73 for untimed and timed classifications for Weber; 0.38 to 0.47 and 0.44 to 0.50 for Lauge-Hansen; 0.28 to 0.49 and 0.13 to 0.37 for AO/OTA. Intraobserver agreement ranged from 0.83 to 0.85 and 0.78 to 0.79 for untimed and timed classifications for Weber; 0.46 to 0.65 and 0.59 to 0.73 for Lauge-Hansen; 0.42 to 0.63 and 0.40 to 0.51 for AO/OTA. Based on the Landis and Koch's benchmark scale, there was substantial agreement in the inter- and intraobserver variables for Weber; moderate agreement in inter- and intraobserver variables for Lauge-Hansen; fair and moderate agreement in inter- and intraobserver variables respectively for AO/OTA. Interobserver and intraobserver reliability was the most substantial for Weber, followed by Lauge-Hansen and AO/OTA. Time constraint did not have a statistically significant effect on the reliability of classifications. We recommend concurrent usage of the Weber and Lauge-Hansen system, since they demonstrate the greatest reliability and reproducibility, and confer better understanding of the fracture type, respectively.

Prospective study of outcome of trimalleolar ankle fractures

&lt;p class="abstract"&gt;Trimalleolar fracture are complex and challenging to treat. We conducted a study on 15 patients with trimalleolar fracture. Fractures were classified based on Lauge Hansen classification. They were treated with open reduction and internal fixation (ORIF) with plate and screws for posterior malleolus and lateral malleolus, tension band wire (TBW)/cannulated cancellous (CC) screw for medial malleolus functional and radiological outcomes were assessed by Olerud and Molender score and Kristenson’s criteria respectively. Functional outcome was satisfactory in 93% of cases and radiological outcome in 86%. Early treatment without delay, anatomical reduction of fracture with stable fixation of every fracture component, stringent post operative mobilization should help to improve outcome in operated trimalleolar fracture patients.&lt;/p&gt;

Cerrahi Tedavi uygulanmış Ayak Bileği Kırıklarının Klinik, Radyolojik ve Fonksiyonel Sonuçlarının Değerlendirilmesi

Objective: The ankle is an important joint in the walking function of the body.&#x0D; Surgical treatment is required in cases where displaced and unstable fractures and&#x0D; joint compatibility cannot be achieved by conservative methods. The main goal of&#x0D; surgical treatment is to restore the anatomical position of the talus within the ankle&#x0D; for a normal tibiotalar joint relationship.&#x0D; Methods: 73 patients who were admitted to our outpatient clinics between January&#x0D; 2006 and October 2015, who were diagnosed with ankle fracture and underwent&#x0D; surgical treatment, were retrospectively evaluated and compared with the intact&#x0D; ankle.&#x0D; Results: Of the patients who had surgery; Bimalleol fracture in 34 (46.58%),&#x0D; trimalleol fracture in 8 (10.96%), lateral malleolar fracture in 14 (19.18%), medial&#x0D; malleolar fracture in 13 (17.81%), with posterior malleolar fracture in 1 ankle&#x0D; dislocation (1.37%) and 1 had posterior malleolar fracture with medial malleolus&#x0D; fracture (1.37%). According to the Lauge Hansen classification, the most common&#x0D; type of SER (Supination External Rotation) fracture (14 cases) (19.18%), followed&#x0D; by the second most common PER (Pronation External Rotation) fracture type (14&#x0D; cases) (19.18%). According to the Danis - Weber classification, Type C (21 cases)&#x0D; (52.50%) was the most common and Type B (14 cases) (35.00%) was the second&#x0D; most common. When the union time was analyzed according to the fracture type, no&#x0D; statistically significant difference was observed (p=0.064).&#x0D; Conclusions: If surgical treatment is applied in ankle fractures the length of the&#x0D; fibula should be ensured, rigid internal fixation should be made with the aim of&#x0D; anatomical reduction of the joint surface, and ankle movements should be started&#x0D; early.

Malleolar Fractures - Indication for Nonoperative and Operative Treatment

Malleolar Fractures - Indication for Nonoperative and Operative Treatment Abstract. In order to understand the trauma mechanism and the expected pattern of injury, malleolar fractures can be classified according to Lauge-Hansen [1]. For isolated lateral malleolar fractures, the Weber classification is also frequently used [2]. For most Weber A fractures and 80% of Weber B fractures conservative treatment is indicated. In all isolated Weber B fractures a supination-external rotation (SER) injury has to be distinguished from a pronation-abduction (PA) injury according to the Lauge-Hansen classification. In SER fractures, stability should be assessed by a gravity stress and a weightbearing radiograph. If the fracture is stable, it can be treated nonoperatively. We recommend surgical treatment for unstable Weber B SER injuries, Weber B PA injuries, and Weber C fractures.

A systematic review of ankle fracture-dislocations: Recent update and future prospects.

BackgroundAnkle fracture-dislocations are one of the most severe types of ankle injuries. Compared to the simple ankle fractures, ankle fracture-dislocations are usually more severely traumatized and can cause worse functional outcomes. The purpose of this study was to review the previous literatures to understand the anatomy, mechanisms, treatment, and functional outcomes associated with ankle fracture-dislocations.MethodsThe available literatures from January 1985 to December 2021 in three main medical databases were searched and analyzed. The detailed information was extracted for each article, such as researchers, age, gender, groups, type of study, type of center research, level of evidence, significant findings, study aim, cause of injury, time from injury to surgery, type of fracture, direction of dislocation, follow-up, postoperative complications and functional evaluation scores.ResultsA total of 15 studies (1,089 patients) met the inclusion criteria. Only one study was a prospective randomized trial. The top-ranked cause of injury was high-energy injury (21.3%). Moreover, the most frequent type of fracture in ankle dislocations was supination-external rotation (SER) ankle fracture (43.8%), while the most common directions of dislocation were lateral (50%) and posterior (38.9%).ConclusionsCollectively, most ankle fracture-dislocations are caused by high-energy injuries and usually have poor functional outcomes. The mechanism of injury can be dissected by the ankle anatomy and Lauge-Hansen's classification. The treatment of ankle fracture-dislocations still requires more detailed and rational solutions due to the urgency of occurrence, the severity of injury, and the postoperative complications.

Treatment of Posterior Malleolar Fractures in Elderly Individuals with Kirschner Wire Tension Band Fixation.

Generally, posterior malleolar fragments are fixed either with percutaneous anteroposterior screws or through a posterolateral approach using screws and/or a buttress plate. Both surgical methods have some shortcomings, and the use of anteroposterior screws to fix osteoporotic posterior malleolar fractures carries a risk of failure. Nine elderly patients (average age, 67 years) with posterior malleolar fractures were treated with transfibular Kirschner wire tension band fixation. According to the Lauge-Hansen classification, all fractures were of the supination-external rotation type. The operative duration, intraoperative blood loss, and wound healing outcome were recorded. During the follow-up period, clinical outcomes were measured using the American Orthopaedic Foot and Ankle Society ankle-hindfoot score, and the occurrence of complications was observed. The patients were followed up for 12 to 18 months (mean, 15 months). The operative duration ranged from approximately 30 to 95 minutes, with an average of 70 minutes. Anatomical reduction was achieved in nine cases, and there were no complications, such as skin necrosis, wound infection, or skin sensory disturbance. There was one case of delayed wound healing caused by fat liquefaction, which was cured by a dressing change. The functional scores were excellent in four cases, good in four cases, fair in one case, and poor in zero cases. The rate of excellent and good results was 88.89% (eight of nine), with an average of 78.78 points. Kirschner wire tension band fixation through a transfibular approach for the treatment of posterior malleolar fractures does not require a change in patient posture. It facilitates the reduction and internal fixation of the posterior malleolar fragment; furthermore, it is easier to remove internal fixation after fracture healing, which provides a new surgical method for elderly patients with posterior malleolus fracture. Thus, this has potential as a new surgical method for elderly patients with posterior malleolar fractures.

New Therapy Option: Maisonneuve Fracture without Trans-syndesmotic Fixation

Ankle fracture is one of the common injuries in orthopedic department, the Maisonneuve fracture is a specific type of ankle injury. This fracture is usually caused by rotational force. According to the Lauge-Hansen classification, it is a pronation and external rotation type injury, often resulting in inferior tibiofibular injury. Because it is extremely unstable, it is usually treated surgically. Operative treatment includes medial malleolus fixtion, reduction of the inferior tibiofibular joint and screw fixation. When the fibula fractured is without shortening or dislocation, it is still controversial if inferior tibiofibular joint needs fixation. The aim of this study is to introduce a new method-Maisonneuve without trans-syndesmotic fixation and analysis the follow-up result.

Evaluation of Ankle Fractures in 228 Patients From a Single Center Using Three-Dimensional Computed Tomography Mapping.

Purpose: The ankle joint has a complex anatomy structure with many causative factors and various injury mechanisms, and the clinical presentation of ankle fractures is diverse. This study aimed to analyze the characteristics of ankle fractures by applicating three-dimensional fracture line mapping technique. Methods: A retrospective study was conducted on 228 patients with ankle fractures. Three-dimensional reconstruction was performed by CT images and the fracture reconstruction model was superimposed onto a standard model of the tibiofibula for fracture line drawing. Then the fracture lines were converted into a three-dimensional coordinate point data set. And the fracture line maps as well as the fracture line heat maps were generated in 3-Matic software and Unigraphics NX software, respectively. Results: The dense area of the fibular fracture lines was located above the tibiofibular joint ligament and wrapped obliquely around the distal fibula from the anterior edge of the fibular neck. The fibular fracture line could be divided into three categories according to the degree of denseness. The dense area of the tibial fracture line is located within the anterior tibial fornix, the anterolateral corner, and the fibular notch. The tibial fracture lines can be classified into four categories according to the density of the fracture lines. The combined medial malleolus + posterior malleolar fracture line situation was found to be not encompassed by the existing AO and Lauge-Hansen (LH) classification systems according to this classification. Conclusion: The 3D fracture line mapping technique can better reflect the distribution of ankle fracture lines and could help to establish a new ankle fracture typing system in the future.

Does the Lauge-Hansen Injury Mechanism Predict Posterior Malleolar Fracture Morphology?

The Lauge-Hansen ankle fracture classification system is widely accepted and is utilized to describe and predict ankle fracture patterns based on the mechanism of injury. Multiple studies have shown inconsistencies in the Lauge-Hansen's ability to predict fracture patterns based on the mechanism of injury. We set out to determine if the posterior malleolar fracture pattern is associated with the fracture types described by Lauge-Hansen. In this retrospective cohort study, we reviewed 153 patients with trimalleolar ankle fractures as diagnosed using computed tomography scans. Timing of injury was from February 2013 to August 2017. Patient ages ranged between 18 and 89 years old. Each patient had a complete clinical and radiographic workup including a preoperative computed tomographic scan following initial fracture reduction in the emergency room. We classified each ankle fracture based on plain film radiographs using the Lauge-Hansen classification scheme. Each individual posterior malleolar fracture was evaluated on computed tomography imaging and described using both the Haraguchi and Bartonicek-Rammelt classification systems. Of the 153 patients identified with trimalleolar ankle fractures, 70% were female (±20%), the mean age was 51 y (±8 y), and the mean body mass index was 30 kg/m2 (±3 kg/m2). We did not observe a significant association between the Lauge-Hansen injury mechanism and either the Bartonicek-Rammelt or the Haraguchi trimalleolar ankle fracture classification systems (chi-square correlation tests p > .05).

Early Unprotected Weight Bearing and Pre-Scheduled Supervised Rehabilitation Program after Surgical Treatment of Ankle Fractures.

Ankle fractures represent one of the most common orthopedic injuries in the lower extremity. Weight-bearing and rehabilitation protocols after surgical treatment of ankle fracture have recently evolved from traditional methods to full weight-bearing protocols. However, more evidence is needed on unprotected immediate weight-bearing along with a standardized rehabilitation program. The purpose of this study was to evaluate effects of unprotected immediate weight-bearing as tolerated and an eight-week prescheduled supervised rehabilitation program on the mid-term clinical and functional outcomes of surgically treated ankle fractures, and to compare functional results with the unaffected side. Eighty patients (24F and 56M) who underwent rigid fixation of bimalleolar ankle fractures were included (mean age 41.57±13.22 years). Preoperative radiographs and computed tomography scans were used to evaluate and classify the fractures. The fractures were classified using Lauge-Hansen classification system. Ankle ROMs, Pain Disability Index (PDI), American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scores, and Short Form-36 scores were evaluated. Patients were allowed unprotected weight-bearing on the immediate postoperative period and a standardized supervised prescheduled rehabilitation program was undertaken following surgery. The mean follow-up period was 30.32±6.91 months. Based on Lauge-Hansen classification, supination-external rotation injuries were found in 32(40%) patients, supination adduction injuries in 14(17.4%) patients, pronation-external rotation injuries in 28(35%) patients, and pronation-abduction fractures in 6(7.6%) patients. The solid union was achieved in all patients at the final follow-up. The mean PDI score was 12.78±14.78, and the AOFAS score was 80.93±17.24. Although patients' health-related quality of life was at a good level, the injured-side ankle ROM was lower than the healthy side (p ≤ 0.05). Satisfactory clinical and functional outcome can be achieved at mid-term with unprotected weight-bearing as tolerated and pre-scheduled supervised eight-week rehabilitation program following rigid internal fixation of ankle fractures. However, this protocol is not studied in patients with associated comorbidities.

3D Mapping of the Lateral Malleolus Fractures for Predicting Syndesmotic Injuries in Supination External Rotation Type Ankle Fractures

Supination external rotation (SER) type ankle fracture is the most common ankle fracture in the Lauge-Hansen classification and is often accompanied with syndesmotic injury. However, the mechanism of this injury is indistinct and a suggestive role can be given by preoperative imaging. This study was to preoperatively predict whether SER type ankle fractures are accompanied with syndesmotic injuries by the means of lateral malleolus fracture mapping. One hundred and forty-eight patients diagnosed with SER type ankle fractures were retrospectively enrolled in this study. The baseline data were collected and computed tomography data were reconstructed in 3-dimensional (3D) model. Patients were divided into stable and unstable groups according to intraoperative Cotton test and whether the inferior tibiofibular screw was placed. All fracture lines were superimposed on the ankle template to create a fracture map, and the data on the fracture map were further measured. Logistic regression was conducted to identify relevant factors and the cutoff values were given using receiver operating characteristic curves. Forty-one patients were enrolled in the unstable group and 107 patients were enrolled in the stable group. The lateral malleolus fracture lines of the unstable group were higher and steeper than that in the stable group on lateral and posterior views. The fracture height of the posterior cortex and peak height were the significant contributing factors, and the cut-off values of posterior cortex, peak height and inclination angle were 40.35 mm (sensitivity: 78%, specificity: 82%), 55.34 mm (sensitivity: 85%, specificity: 70%) and 55.6° (sensitivity: 66%, specificity: 86%), respectively. In general, when the fracture lines of the lateral malleolus were high and steep, it was usually indicative of a syndesmotic injury and can be predicted by the preoperative 3D reconstruction of fracture height of posterior cortex, peak height and inclination angle. If the cut-off values of these indicators are exceeded, the syndesmotic injuries may be presented and need to be verified in the intraoperative Cotton test to decide whether to insert an inferior tibiofibular screw.

Talus Visualization in Ankle Fractures: How Much Are We Really Seeing?

Background:Despite appropriate care, a subset of patients with ankle fractures has persistent pain. This condition may be associated with intra-articular pathology, which is present up to 65% of the time.Purpose:To quantify how much of the talus is visible through an open approach to a standard supination external rotation bimalleolar ankle fracture as a percentage of the entire weightbearing surface of the talus.Study Design:Descriptive laboratory study.Methods:Standard ankle approaches to lateral and medial malleolar fractures were performed in 4 cadaveric ankles from 2 cadavers. Osteotomies were made to simulate a supination external rotation bimalleolar ankle fracture based on the Lauge-Hansen classification. The visible segments of talar cartilage were removed. The tali were then exhumed, and the entire weightbearing superior portion of the talus was assessed and compared with the amount of cartilage removed by an open approach. The mean of the data points as well as the 95% confidence interval were calculated.Results:Four ankle specimens from 2 cadavers were used for these measurements. The mean surface area of the talus was 14.0 cm2 (95% CI, 13.3-14.7 cm2), while the mean area visible via an open approach was 2.1 cm2 (95% CI, 0.5-3.6 cm2). The mean proportion of the talus visualized via an open approach was 14.8% (95% CI, 3.6-26.1%).Conclusion:These findings indicate that the true area of weightbearing talar surface visible during an open exposure may be less than what many surgeons postulate.Clinical Relevance:Only a small fracture of the talus is visible via an open approach to the talus during fracture fixation. This could warrant arthroscopic evaluation of these injuries to evaluate and treat osteocondral lesions resulting from ankle fractures.

Does Time to Intervention Affect Patient Reported Outcomes after Ankle Fracture?

Category:AnkleIntroduction/Purpose:Advances in surgical technique and technology have allowed orthopedic surgeons to attempt early operative fixation of closed ankle fractures. Little is known about the modifiable factors impacting the recovery of these patients and how early operative intervention affects patient reported outcomes. This study aims to determine if early surgical treatment can be performed safely without increasing a patient’s risk for postoperative wound complications and how time to surgery affects both clinical and patient reported outcomes.Methods:A review of 311 patients records who underwent open reduction and internal fixation (ORIF) for an ankle fracture between July 1st, 2011 and July 1st, 2018 at a single academic center was conducted. Medical records were reviewed. Patients were contacted for collection of PROMIS Physical function, PROMIS Pain Interference, and the Foot Function Index. Patients with open fractures, high energy fractures with ipsilateral lower extremity injuries, pilon fractures, revision cases, non-respondents to the patient reported outcomes survey, and those lost to follow-up prior to radiographic evidence of union or non-union were excluded. After exclusions, 86 patients were then stratified by time to surgery after injury and injury classification. A linear regression model was constructed for each outcome instrument with the covariates of age, BMI, diabetes, smoking status, union, wound complication, time from surgery, and severe injuries by the Lauge-Hansen classification.Results:The delayed union, nonunion, and wound complication rate was similar regardless of timing of operative intervention (p=.470, p=.149, & p=.578, respectively). At a median of 4.5 (2.0 IQR) years postoperatively, outcomes scores were as follows (median (IQR)): PROMIS Physical Function 47.9 (11.2), PROMIS Pain Interference 50.1 (17.4), FFI Pain 26.0 (52.0), FFI Disability 17.0 (49), FFI Activity Limitation 3.0 (22.0), and FFI Total 20.0 (41.5). Time to intervention was not found to have an independent effect on any outcome score. Severe injuries by the Lauge-Hasen classification were found to be independent predictors of PROMIS physical function -6.3 (Unstandardized beta, 95% CI -11.5 to -1.1). Diabetes had a significant independent effect on PROMIS pain interference 52.4 (Unstandardized beta, 95% CI 24.3 to 80.5).Conclusion:Early surgical intervention did not significantly delayed union rate, nonunion rate, wound complications, or patient reported outcomes instruments. Severity of injury classification has a significant independent effect on patient’s physical function. Notably, this effect is above the minimal clinically important difference for PROMIS physical function. Overall, the intermediate term outcomes of ankle fracture fixation indicate patients are within one standard deviation of the population mean in terms of pain and physical function. Surgeons should be aware timing of intervention did not have an effect on outcomes scores at intermediate term follow-up.

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.

Surgical management of malleolar fracture with their functional outcome at tertiary care centre

Background: With the advent of A.O principles of management, the results of bimalleolar ankle fractures are better with emphasis on anatomical reduction of fracture, stable internal fixation, regaining full length of fibula and early active pain free mobilization. This study was done to analyse the results of surgical management of bimalleolar ankle fractures in a tertiary care hospital. Materials and Methods: A prospective study was done in a tertiary care hospital in the year 2020 for 6 months. Cases with bimalleolar ankle fractures in the age group of 20-60 years were included in the study. Cases with systemic infection, open injury with dislocation, skin diseases and previous arthrodesis at target level. The Lauge-Hansen classification and AO classification were used to evaluate the fractures radiologically. The patients who were presented in the casualty and out-patient department were examined clinically and radiologically. Outcome was assessed subjectively and objectively with scoring system and graded accordingly. Post-op complications were also noted. Results: In our study, 30 cases of bimalleolar ankle fractures were analysed. Classification used was Lauge-Hansen and A.O. classification. Road traffic accident was major mode of injury. Average injury surgery interval was 6 days. Malleolar screw for medial malleolus and plate and screws for fibula was common mode of fixation. Results were analysed using Olerud and Molendar subjective and objective scoring. The subjective scoring was excellent and good in 80% of cases and objective scoring was good in 22 cases. Conclusion: Accurate anatomical reduction and fixation results in good functional outcome.

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?

Objectives: According to the Lauge-Hansen classification, supination external-rotation (SER) type 4 fractures should be accompanied by medial malleolar fracture or deltoid ligament injury. The aim of the study was to investigate medial insufficiency rates in postoperative weight-bearing radiographs in SER type 4 bimalleolar fractures. Methods: The files of the patients who were operated with the diagnosis of SER type 4 bimalleolar ankle fracture between 2017-2020 were evaluated retrospectively. Thirty-seven cases (15 males and 22 females) were included in the study. The data based on the evaluation of the weight-bearing radiographs of the patients taken in the postoperative 1st year were examined statistically. Results: The injury mechanism was sports injury in 17 (45.9%) cases, traffic accidents in 8 (21.6%) cases, falling in 9 (24.3%) cases, and falling from height in 3 (8.2%) cases. The preoperative tibiofibular distance was 6.05 ± 1.86 mm, and the postoperative tibiofibular distance was 4.19 ± 0.40 mm (p = 0.001). The preoperative tibiofibular overlap was 5.03 ± 2.93 mm, and the postoperative tibiofibular overlap was 8.62 ± 1.04 mm (p = 0.001). The postoperative medial clear space was 4.11 ± 0.57 mm. Postoperative medial clear space of 5 mm and higher was determined in 7 (18.9%) cases. Conclusions: In SER type 4 bimalleolar fractures with a large medial malleolar fragment fracture, weight-bearing radiographs may show an increase in medial clear space. This means that a medial malleolar fracture in bimalleolar fractures may be also accompanied by deltoid ligament injury. The Lauge-Hansen classification system may be insufficient to identify a medial ligament injury.

English

BACKGROUND Ankle fractures are among the most common injuries encountered by orthopaedic surgeons. An ankle is considered unstable when the loss of normal constraints around the ankle permits the talus to move in a non-physiologic pattern. Under such circumstances, the dynamic joint surface contact area within the ankle is diminished, which predisposes to articular cartilage damage and premature degeneration. In today’s time, many modalities are available for surgical fixation of bimalleolar fractures. Such interventions restore anatomy and biomechanics of the ankle joint. Even though there are plethora of foreign studies on similar matter, deficiency of such analysis has been depicted in literature from developing countries, particularly from South-East Asian region. In this study, we wanted to assess various methods of internal fixation in ankle fracture &amp; evaluate their clinical and radiological outcome post-operatively. METHODS 26 ankle fracture patients in the age group of 18 - 60 years were included in this study. Fractures were classified pre-operatively based on Lauge-Hansen classification. Patients were followed up at regular intervals of 1st, 2nd, 3rd, 6th &amp; 12 month after surgery and assessed by Baird and Jackson scoring system based on subjective, objective and radiographic criteria. Complications like infection, arthritis, stiffness &amp; implant failure were assessed on regular follow-up. RESULTS Variety of methods (including k-wires, plates &amp; screws) were used for surgical fixation. Majority of fractures resulted from road traffic accident (RTA). Patients were evaluated using Baird &amp; Jackson scoring system during follow-up at 1st, 2nd , 3 rd, 6th &amp; 12 month. All patients had poor scores for initial 3 months. Patients showed good to excellent result on final follow-up at 9 to 12 months after surgery. Complications were observed in 19 % cases with arthritis being most common. CONCLUSIONS Open reduction and internal fixation restores the articular congruity of the ankle joint. The operative result was satisfactory with good clinical outcome. KEYWORDS Ankle, Fracture, Anatomy, Modalities

P109 Sherlock Holmes in Clinical Practice: The Deduction of the Pattern and Mechanism of Injury in Ankle Fractures Using Lauge-Hansen System

IntroductionAnkle fractures are among the commonest fractures in adults and as population ages, the incidence is also increasing. It is crucial to ascertain the mechanism of injury of an ankle fracture as it determines the management plan. The diagnosis and management of ankle fractures are usually relatively straightforward but they are not always the case. Most patients are unable to recall the exact mechanism of injury due to the instantaneous nature of incident. We herein describe a case report of a patient who sustained an ankle fracture following a fall but was unable to recall the exact mechanisms of injury. This case report addresses the importance of recognising Maisonneuve fractures and how Lauge-Hansen Classification system might be useful in diagnosing and making management plans for ankle fractures.Case ReportA 30-year-old male self-presented to the Emergency Department in a wheelchair following a fall. He tripped down the last four steps of stairs the night before, sustaining a right ankle injury as a result. He has been unable to weight-bear since. Elevation and application of ice packs have showed limited effect. Patient was unable to recall the exact mechanism of injury. On examination, the right ankle was swollen and there were bruises around the medial malleolus. Upon palpation, he complained of bony tenderness around lateral and medial malleoli. No other injury was found and patient was neurovascularly intact. A referral was made to the Orthopaedics team and further orthopaedic examinations revealed tenderness and crepitus upon palpation over the proximal fibula. Full lower leg X-rays was ordered to look for possible proximal fibula fracture. A diagnosis of closed, Maisonneuve (Weber C)/trimalleolar fracture of the right ankle was made.A CT-scan of the right ankle was requested to determine the involvement of joint surface to aid surgical planning. Both CT-scan and ankle X-rays showed disrupted syndesmosis. Disrupted syndesmosis is most commonly associated with Weber C fractures as shown in this case. Since the fibular fracture is greater than 4.5cm away from the tibial plafond, syndesmosis fixation is required. In Maisonneuve fractures, syndesmotic screws can be used to achieve anatomical reduction and ankle stability. This patient was scheduled for an ORIF surgery.DiscussionsBased on the findings of medial and posterior malleoli fractures from the ankle X-rays, we can deduce that the patient has most likely sustained a complete Pronation-External Rotation (PER) injury. A Maisonneuve fracture was almost missed initially due to distracting injuries and not obtaining full lower leg X-rays. However, based on Lauge-Hansen Classification, we know that it is highly unlikely to have a posterior malleolus fracture (Stage 4) without any fibular fracture (Stage 3). Hence, a full-fibula X-ray was ordered to look for proximal fibula fracture and the X-rays revealed a spiral fracture at the proximal fibula (Maisonneuve fracture). The injury force was transmitted along the interosseous membrane and exited at the shaft of proximal fibula, causing a proximal fibular fracture. PER or injury sustained from an internally rotated leg on a planted foot may cause external rotation injury, resulting in a disruption of the ligaments. The syndesmosis, which provides primary support to the ankle, if disrupted, will disrupt the ankle mortise, displacing the fibula laterally, as demonstrated in this case.ConclusionAs demonstrated in this case, some fractures, like the Maisonneuve fracture, can easily be missed. Due to distracting injuries, the chief complain in most cases of Maisonneuve fracture is severe ankle pain instead of the fracture site at proximal fibula. These fractures, if not identified early, can lead to poor prognosis. It is important to consider Maisonneuve fracture in all ankle injuries. A delayed diagnosis can lead to post-traumatic arthritis and pain, leading to loss of function. This case report addresses the importance of recognising easily missed fractures and how Lauge- Hansen Classification system is useful in aiding the diagnosis and management of ankle fracture

Application of X-ray image measurement in the early diagnosis of sports injury of ankle ligament.

Objectives:To study the value of X-ray analysis method of ankle fracture based on injury mechanism to improve the imaging diagnosis level of ankle fracture.Methods:This study was conducted from January 2016 to December 2019. It included 105 cases of fractures caused by sprained ankle joints. Their age was between 21-81 years with an average of 49.5 years, The traditional X-ray analysis method (Group-A) and the injury mechanism-based ankle fracture X-ray analysis method (Group-B) were used to analyze X-ray image data. Group-B also performed Weber classification and Lauge-Hansen classification on cases. Installment.Results:Of the 105 patients with ankle fractures, 97 patients in Group-B were able to make Lauge-Hansen classification. Of these 97 ankle fractures, 137 were found in Group-A, and 158 were found in Group-B. The wrong diagnosis of fracture in Group-A was 18%, and the wrong diagnosis of fracture in Group-B was 0.5%. There was a statistically significant difference between the two groups (P <0.05).Conclusion:The X-ray analysis method of ankle fractures based on injury mechanism can effectively improve the detection rate of hidden ankle fractures and high fibular fractures, and reduce the missed diagnosis, which is superior to the traditional X-ray analysis methods. At the same time, Weber classification, Lauge-Hansen classification and staging can be made for most cases, which is conducive to guiding clinical treatment.