Lauge-Hansen Supination-external Rotation Research Articles

Ligamentous Injuries in Stable Ankle Fractures

Category: Ankle; Trauma Introduction/Purpose: When considering ankle fractures requiring fixation, it has been shown that stability is the key determinant. Lauge-Hansen supination external rotation (SER) 2 injuries are by definition stable and has been shown to be successfully managed non-operatively. SER 3 and SER 4 ankle fractures are unstable with complete syndesmosis disruption and the majority are managed operatively. We hypothesise that a percentage of radiologically stable injuries involve more structures than previously thought. The primary aim is to determine the prevalence of SER3 and SER4 ankle injuries amongst radiographically SER 2 injuries. Methods: This cross-sectional study uses baseline data from a longitudinal study at Gold Coast University Hospital and Health Service (GCHHS). Patients attending the GCHHS fracture clinic were invited to participate provided they had a radiographically stable SER 2 fracture. Those meeting the eligibility criteria were referred for ankle magnetic resonance imaging (MRI) to assess the integrity of the syndesmotic and ankle ligaments. Results: To date, this study has recruited 33 participants. Following MRI, 23 were determined to have true SER 2 injuries. Nine participants were however reclassified as SER 3 and one participant was reclassified as having an SER 4 injury. Of the SER 3 injuries six included a non-displaced posterior malleolus fracture, while the remaining three were purely ligamentous. Conclusion: This study demonstrates that a portion of radiographically stable ankle injuries involve more structures than previously thought. When radiographic SER 2 injuries were further evaluated with MRI, nearly half were reclassified as SER 3 and 4 injuries. This may suggest that some SER 3 and 4 injuries are functionally stable and can be managed successfully non-operatively.

Concomitant Unstable and Stable Gravity Stress Tests on Weight-Bearing Stable Weber B Ankle Fractures Treated Nonoperatively: A 2-Year Outcome Study.

Replacing gravity stress tests with weight-bearing radiographs to evaluate the stability of Weber B (also called Lauge-Hansen supination-external rotation [SER]) ankle fractures results in a lower surgery rate, thus avoiding associated risks and complications. Still, nonoperative treatment of weight-bearing stable fractures is controversial because of the scarcity of strong evidence. We investigated the influence of a concomitant unstable gravity stress test compared with a stable gravity stress test on outcomes after nonoperative treatment of weight-bearing stable fractures. We performed a prospective, noninferiority study on 149 patients with Weber B ankle fractures and stable weight-bearing radiographs. Gravity stress radiographs classified fractures as stable (SER2 [n = 88]) or partially unstable (SER4a [n = 61]). All were treated with a functional orthosis and weight-bearing was allowed; patients were followed for 2 years. The primary outcome was the Manchester-Oxford Foot and Ankle Questionnaire (MOXFQ), with a range from 0 to 100, in which lower scores indicate fewer symptoms. A noninferiority margin was prospectively defined as 7.5 points. The secondary outcomes included the Olerud-Molander Ankle Score, assessment of ankle congruence, and treatment-related adverse events. The primary outcome data were available for 144 (96.6%) of 149 participants at 2 years. The between-group difference in the MOXFQ score was 1.0 point (95% confidence interval, -1.4 to 3.4 points; p = 0.397) in favor of the SER2 group, consistent with noninferiority. We found no appreciable between-group differences for any other outcome. In Weber B/SER ankle fractures that are stable on weight-bearing radiographs, are treated with removable orthoses, and are allowed to bear weight, a concomitant unstable gravity stress test (SER4a) was not associated with worse patient-reported or radiographic outcomes compared with a stable gravity stress test (SER2) at the 2-year follow-up. Thus, the identification of stress instability seems redundant, which questions the applicability of stress instability for surgical decision-making. Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Comparison of Two Surgical Approaches to Supination-External Rotation-Type Ankle Fractures.

Objective To compare the clinical outcome and postoperative complications of the treatment of supination-external rotation-type ankle fractures using the posterolateral approach in the prone position and the lateral approach in the supine position. Methods A retrospective cohort study was conducted in our hospital, including a total of 66 patients ranging from January 2013 to February 2016, regardless of age or sex. All the patients were classified as Lauge-Hansen supination-external rotation (SER)-type ankle fractures and were assigned to receive an open reduction and internal fixation (ORIF) through a posterolateral approach performed in the prone position (the “posterolateral approach group,” 32 patients), or a lateral approach performed in the supine position (the “Lateral Approach Group,” 34 patients). In the posterolateral approach group, 5 patients had Grade II fractures, 8 had Grade III fractures, and 19 had Grade IV fractures; among whom, 12 underwent fixation of the posterior malleolus with hollow screws and 6 with plates, and none of them had fixation of the distal tibiofibular syndesmosis; in the lateral approach group, 4 patients had Grade II fractures, 12 had Grade III fractures, and 18 had Grade IV fractures; among whom, 21 received fixation of the posterior malleolus, and 5 received fixation of the distal tibiofibular syndesmosis. The postoperative complications and ankle scores were recorded. Results After 1 year of follow-up, in the posterolateral approach group, the incision healed by primary intention and sutures were removed 2 weeks after the operation in all patients; 1 patient had pain in the region posterior to the fibula, presumably peroneal tendon irritation induced by internal fixation, which disappeared after fracture union and fixation device removal; no loosening or breakage of the internal fixation device was reported; the rate of good to excellent results was 96.8% at 12 months. In the lateral approach group: 1 case of wound infection, 1 case of necrosis of lateral skin flap, and 3 cases of lateral skin irritation were reported; the rate of good to excellent results was 94.6% at 12 months. Conclusion Compared with the traditional lateral approach, the posterolateral approach for the reduction and internal fixation of supination-external rotation-type ankle fractures performed in the prone position has more satisfactory clinical outcomes, with better reduction, more secure fixation, and smaller wound.

Postoperative Complications of Minimally Invasive Intramedullary Nail Fixation Versus Plate Fixation for Distal Fibular Fractures in Elderly Patients: A Retrospective Double Cohort Study in a Geriatric Trauma Unit in the Netherlands

Intramedullary fixation using a fibular nail is a minimally invasive alternative to conventional plate fixation that provides superior biomechanical strength and allows immediate full weightbearing postoperatively. The study aim was to compare the postoperative complications of minimally invasive intramedullary fibular nail fixation to plate fixation for Lauge-Hansen supination external rotation type 4 (Weber B) fractures in patients aged 65 years or older treated in a single geriatric trauma unit in the Netherlands. A retrospective cohort study was performed including patients aged 65 years or older with a Lauge-Hansen supination external rotation type 4 (Weber B) fracture treated with either intramedullary fibular fixation or plate fixation between January 2017 and January 2019. A total number of 58 patients were included with a mean age of 73.9 years (range 65-95). The intramedullary fixation-cohort (n=13) had a significantly higher mean age (82.5 vs 71.4 years, p=.002) and Charlson Co-morbidity Index (4.7 vs 3.6, p=.005) compared to the plate fixation-cohort (n=45). The total number of postoperative complications was lower after intramedullary fixation (n=2, 15%) compared to plate fixation (n=15, 33%), although this relative difference was not significant (p=.307). All 2 complications observed after intramedullary fixation were wound infections demanding no debridement or implant removal. No implant related complications, hospital-acquired complications or mortality were observed after intramedullary fixation. Despite the higher mean age and co-morbidity status of patients treated with minimally invasive intramedullary fibular nailing, the total number of postoperative complications was lower after intramedullary fixation compared to plate fixation. This technique might be a promising alternative in selected patients.

Factors Affecting Hospital Length of Stay in Geriatric Patients With a Surgically Treated Fragility Ankle Fracture

Fragility ankle fractures in elderly have a rising incidence and hospitalization may be prolonged due to pre-existing comorbidities, compromised soft tissue and postoperative difficulties in the rehabilitation process. The aim of this retrospective cohort study was to investigate risk factors for longer total hospitalization duration in elderly patients with surgically treated fragility (Lauge Hansen supination external rotation type 4) fractures. We included all patients ≥ 70 years with a fragility fracture, who were treated surgically between 2011 and 2019 (n = 97) in a level 1 and 2 trauma center. Data on patient demographics, fracture characteristics, surgical treatment strategies and postoperative complications were retrieved from medical records. Multivariate regression analysis was performed to identify independent risk factors for longer hospitalization duration. The mean age of the included patients was 78.27 (± 6.56) years; 71 patients (73.20%) were female. Ten fractures (10.30%) were classified as open and 49 (50.50%) as a luxation type fracture. Fifty-nine patients (60.80%) were hospitalized after admission to the emergency department. External fixation was performed in 34 patients (35.10%) and served as bridge to definitive fixation in 29 patients (85.30%). The mean total hospital length of stay of all patients was 7.04 (± 6.58) days. Multivariate regression analysis demonstrated that the use of external fixation (p < .001) and the postoperative discharge destination (p < .001) were independently associated with a prolonged hospital stay. External fixation and discharge destination were independent risk factors for a prolonged hospital stay in elderly patients with a fragility fracture.

An Exceptional Avulsion Fracture Above the Medial Malleolus: A Retrospective Case Series.

The Lauge-Hansen classification does not cover all types of ankle injuries. The present report details three cases of exceptional fragment of the medial tibia that differed from the traditional Lauge-Hansen supination-external rotation and pronation-external rotation fracture patterns. The information obtained from this study will be helpful for conducting basic research of this condition and determining appropriate surgical approaches.

Management and Clinical Outcome of Trimalleolar Fracture of Ankle: a case report

Objectives:Ankle fractures are one of the most common lower limb fractures, where account for 9% of all fractures. Most ankle fractures are isolated malleolar fractures, while trimalleolar fractures occur in the remaining 7-11% cases. The trimalleolar fracture involves fracture of the medial malleolus, fibula and posterior lip of articular surface of the tibia, associated with subluxation or dislocation of tibiotalar joint and rupture of one or more ligaments. These fractures are commonly caused by a twisting mechanism. The management of the trimalleolar fracture is by open reduction and internal fixation due to its unstable position. The postoperative outcome is evaluated by using the American Orthopedics Foot and Ankle Society (AOFAS) scoring system.Case presentation:A 38-year-old woman was admitted to the ER with chief complain a painful left ankle after a motor vehicle accident. She was previously riding a motorcycle, then stopped at the traffic light with left leg stepping on the road. Her left leg was hit from behind by a moving car. On the physical examination at the left ankle region, there was laceration with size 5x1x1 cm at the anteromedial side. There was also swelling around the left ankle with no deformity. From the palpation, there was tenderness around the left ankle and a. dorsalis paedis was still palpable with capillary refill time < 2 seconds. We performed the ankle X-Ray which considered as a fracture of distal os. tibia and os. fibula. We diagnosed this patient as a closed fracture of the left ankle with a classification of Lauge-Hansen supination external rotation (SER) injury. We did an ORIF, and the patient has been doing rehabilitation for 12weeks. We evaluated the outcome by the AOFAS scoring system, resulting in 85out of 100.ResultsThe incidence of ankle fractures is approximately 187 fractures per 100,000 people each year, where the percentage of trimalleolar fracture occurs in 7 to 11% cases. Many of stable fractures are reduced by conservative treatment and the other unstable displaced and open fractures require open reduction internal fixation. From anamnesis, physical examination and radiographic imaging, we diagnosed this patient as closed fracture of left ankle Lauge-Hansen supination external rotation (SER). SER injury is the most common occurring among Lauge-Hansen’s categories, where firstly in the first stage the anterior inferior tibiofibular ligament (AITFL) was injured. Then in the second stage, an oblique/spiral fracture of the distal fibula occurred. With more force, the posterior inferior tibiofibular ligament (PITFL) was injured or the posterior malleolus was fractured in third stage. Finally, in fourth stage, the medial malleolus was fractured or the deltoid ligament was injured. We considered the fracture as unstable trimalleolar fracture, therefore we performed ORIF by using plate for lateral malleolus, wires for medial malleolus and screw for posterior malleolus. The patient was kept non-weight-bearing for a total of nine weeks postoperatively. We did a 3-months follow-up by clinical outcome and ankle X-Ray. The clinical outcome was measured by AOFAS scoring system and showed a good result which is 85/100. This result is in accordance with the previous study in 2014 which showed a quick recover of adults in activity limitation in the first 3 months following the fracture.ConclusionTrimalleolar fracture is a rare case which needs a challenging management to achieve the goal of reduced and stable fixation. Understanding the trauma mechanism is essential for good reduction and internal fixation. The concern of treatment and clinical outcome evaluation are needed to prevent complications, e.g. non-union, joint stiffness and secondary osteoarthritis.

Weight-bearing or non-weight-bearing after surgical treatment of ankle fractures: a multicenter randomized controlled trial

PurposeThe goal of this study was to assess if unprotected weight-bearing as tolerated is superior to protected weight-bearing and unprotected non-weight-bearing in terms of functional outcome and complications after surgical fixation of Lauge-Hansen supination external rotation stage 2–4 ankle fractures.MethodsA multicentered randomized controlled trial was conducted in patients ranging from 18 to 65 years of age without severe comorbidities. Patients were randomized to unprotected non-weight-bearing, protected weight-bearing, and unprotected weight-bearing as tolerated. The primary endpoint of the study was the Olerud Molander Ankle Score (OMAS) 12 weeks after randomization. The secondary endpoints were health-related quality of life using the SF-36v2, time to return to work, time to return to sports, and the number of complications.ResultsThe trial was terminated early as advised by the Data and Safety Monitoring Board after interim analysis. A total of 115 patients were randomized. The O’Brien–Fleming threshold for statistical significance for this interim analysis was 0.008 at 12 weeks. The OMAS was higher in the unprotected weight-bearing group after 6 weeks c(61.2 ± 19.0) compared to the protected weight-bearing (51.8 ± 20.4) and unprotected non-weight-bearing groups (45.8 ± 22.4) (p = 0.011). All other follow-up time points did not show significant differences between the groups. Unprotected weight-bearing showed a significant earlier return to work (p = 0.028) and earlier return to sports (p = 0.005). There were no differences in the quality of life scores or number of complications.ConclusionsUnprotected weight-bearing and mobilization as tolerated as postoperative care regimen improved short-term functional outcomes and led to earlier return to work and sports, yet did not result in an increase of complications.

The Predictive Value of MRI for Syndesmotic Instability of Ankle Fracture

Category: Ankle, Trauma Introduction/Purpose: Although many ankle fractures are combined with syndesmosis injury, preoperative imaging studies rarely reveal instability of the syndesmosis. This study assessed the use of magnetic resonance imaging (MRI) for syndesmotic instability in patients who have an unstable ankle fracture. Methods: A total of 74 patients who were treated for Lauge-Hansen supination external rotation, Weber B type fracture or pronation external rotation, Weber C type fracture and who underwent MRI before surgery to evaluate syndesmosis injury were enrolled. The MRI findings of the syndesmotic ligament and the results of an intraoperative stress test were assessed. Results: Twenty-six patients had a positive result on the intraoperative stress test. Regarding the MRI findings of the syndesmotic ligaments, complete tear of the posterior inferior tibiofibular ligament (PITFL) was the most reliable predictor of syndesmotic instability (sensitivity, 0.62; specificity, 0.94; positive predictive value, 0.84). Interobserver agreements for the intraoperative stress test and MRI assessment were excellent, except for the MRI findings of the interosseous ligament (62% agreement; kappa, 0.3). Conclusion: On the basis of the study results, complete tear of the PITFL on MRI has additional diagnostic value for syndesmotic instability in ankle fracture.

Minimally invasive percutaneous plate osteosynthesis for ankle fractures: a prospective observational cohort study

The gold standard for the surgical management of ankle fractures is through open reduction and internal fixation. The rate of wound problems has been reported to be as high as 18%, especially in patients with poor vascular supply or in diabetics. Minimally invasive percutaneous plate osteosynthesis (MIPPO) has been described as a potential solution for these patients. This is a prospective observational cohort study. From October 2009 to February 2010, and following ethical approval of our research, adult patients admitted at our level I trauma center with a closed lateral malleolar displaced unstable fracture (Lauge-Hansen supination-external rotation) with or without a medial-sided injury and patients with an undisplaced fracture associated with medial clear space opening on external rotation stress radiographs were recruited and managed using MIPPO technique. All patients were followed up for a minimum of 12 months post-surgery (12-20 with a mean of 16.5 months). Trauma mechanism, comorbidities, classifications, trauma-surgery interval, image intensifier duration, surgery duration, complications, and function American Orthopaedic Foot and Ankle Society (AOFAS) were analyzed. Thirty-two patients were recruited of which 20 fulfilled the inclusion criteria (16 females, 4 males) and were available for follow-up. Ten fractures (50%) were classified as 44-B1, 7 fractures (35%) as 44-B2, and 3 fractures (15%) as 44-B3 according to the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association classification (100% were supination-external rotation injuries). At 8 weeks post-surgery, all fractures had healed. The duration of surgery ranged between 15 and 73 min (average 32.8) from skin incision to closure. There were 2 complications (1 malunion and 1 skin necrosis requiring implant removal). At 12-month follow-up, AOFAS average was 88.3 (72-100 standard deviation of 6.8 points). MIPPO technique proved to be a viable option for lateral malleolar fracture treatment with a low complication rate and high functional outcome at 1 year. It is particularly useful in patients with a high risk of wound complication.

Unstable Ankle Fractures in Older Patients: A Consecutive Series with Modern Internal Fixation Techniques

ABSTRACT Background Ankle fractures are among the most common injuries sustained by older patients. Management of these fractures remains both controversial and challenging. Clinical outcomes from a series of older patients treated surgically for unstable ankle fractures were reviewed to determine the effects of patient, injury and fixation factors on postoperative outcomes. Materials and methods A retrospective series of 58 consecutive patients age 60 years and older with 63 unstable ankle fractures treated surgically by a single surgeon over a 5- year period was reviewed. Forty-seven females (81.0%) and 11 males (19.0%) with a mean age of 72.6 (range, 60 to 88.4) years made up the sample. Results The most common injuries were OTA type 44-B2 (66.7%) or Lauge-Hansen supination-external rotation type-4 (76.2%) fractures. Forty-seven (74.6%) fractures were due to a low energy mechanism. Nineteen (30.6%) injuries were fracturedislocations and seven (11.1%) fractures were open. Augmented techniques were used in 31 (49.2%) cases overall. Ten (17.2%) patients experienced postoperative complications. Males, patients with fracture dislocations, high energy fractures, and open fractures experienced significantly worse outcomes (p &lt; 0.05). Age, fracture type and the use of augmented technique were not predictive of clinical outcomes. Conclusion Overall in this series, older patients treated surgically for ankle fractures experienced good clinical outcomes. Further investigations are required in order to find patient and injury factors that can assist preoperative planning and predict outcomes. Viens NA, Sutter EG, Mangiapani DS, Adams SB, Zura RD. Unstable Ankle Fractures in Older Patients: A Consecutive Series with Modern Internal Fixation Techniques. The Duke Orthop J 2013;3(1):25-31.

Syndesmotic Fixation in Supination-External Rotation Ankle Fractures: A Prospective Randomized Study

This study was designed to assess whether transfixion of an unstable syndesmosis is necessary in supination-external rotation (Lauge-Hansen SE/Weber B)-type ankle fractures. A prospective study of 140 patients with unilateral Lauge-Hansen supination-external rotation type 4 ankle fractures was done. After bony fixation, the 7.5-Nm standardized external rotation (ER) stress test for both ankles was performed under fluoroscopy. A positive stress examination was defined as a difference of more than 2 mm side-to-side in the tibiotalar or tibiofibular clear spaces on mortise radiographs. If the stress test was positive, the patient was randomized to either syndesmotic transfixion with 3.5-mm tricortical screws or no syndesmotic fixation. Clinical outcome was assessed using the Olerud-Molander scoring system, RAND 36-Item Health Survey, and Visual Analogue Scale (VAS) to measure pain and function after a minimum 1-year of followup. Twenty four (17%) of 140 patients had positive standardized 7.5-Nm ER stress tests after malleolar fixation. The stress view was positive three times on tibiotalar clear space, seven on tibiofibular clear space, and 14 times on both tibiotalar and tibiofibular clear spaces. There was no significant difference between the two randomization groups with regards to Olerud-Molander functional score, VAS scale measuring pain and function, or RAND 36-Item Health Survey pain or physical function at 1 year. Relevant syndesmotic injuries are rare in supination-external rotation ankle fractures, and syndesmotic transfixion with a screw did not influence the functional outcome or pain after the 1-year followup compared with no fixation.

Ultrasonographic Examination of the Deltoid Ligament in Bimalleolar Equivalent Fractures

Lauge-Hansen supination-external rotation Stage IV ankle injuries may simulate a Stage II or Stage III injury radiographically if the medial disruption occurred through the deltoid ligament instead of the medial malleolus, making it difficult to determine whether an operation is indicated. Seventeen patients presented with radiographically isolated lateral malleolar fractures at the syndesmotic level. They were examined with ultrasonography for evaluation of the integrity of the deltoid ligament. Patients in whom ultrasonography showed complete rupture of the deltoid ligament received operative fixation of the ankle fracture, with exploration and repair of the deltoid ligament at the same time. Patients without complete rupture of the deltoid ligament were treated conservatively with a short leg cast for 6 weeks followed by an ankle brace for another 6 weeks. Nine male and six female patients completed the final clinical and radiographic evaluations. Ultrasonography showed complete rupture of the deltoid ligament in six patients. Exploration of the deltoid ligaments confirmed the sonographic findings in all these patients. In the remaining nine patients, the deltoid ligaments were not completely ruptured on ultrasound. These fractures were treated conservatively, and all healed uneventfully. All the 15 patients had good or fair results on the final evaluation. Ultrasonography is a convenient and accurate diagnostic tool to differentiate unstable bimalleolar-equivalent ankle fractures from an isolated lateral malleolar fracture. Thus, it can be helpful in the decision process for the treatment of choice for different fracture patterns.

Examination of the Pathologic Anatomy of Ankle Fractures

A prospective study of the translational and rotational displacement of the lateral malleolus in ankle fractures was carried out utilizing roentgenographic techniques. Twenty-six ankle fractures in 25 patients were studied using both routine plain films and CT scanning with two- and three-dimensional multiplanar reconstruction. Eighty-one percent were Lauge-Hansen supination-external rotation type injuries. Overall, 21 fractures did not involve the medial malleolus. Initial talar shift was less than or equal to 2 mm in 15 fractures. Although all patients exhibited external rotation deformities of the lateral malleolus on plain films, only one fracture was found to possess any degree of external rotation relative to the talus. The proximal fibula was seen on CT scans to have increased internal rotation with respect to the tibia in 19 cases. One patient had a slightly externally rotated proximal fibula; the remainder appeared normally aligned. The displacements measured by the CT scans at the talofibular articulation were compared with the standard plain film measurements. The displacements at the distal lateral malleolus were consistently overestimated by the plain roentgenograms, presumably because the capsular and ligamentous attachments to the distal fibula limit malleolar displacement. The talocrural angle, determined on both plain films and CT scans, was also not found to be a sensitive measure of fibular shortening nor of the severity of the fracture. The results of this study suggest that, in an isolated lateral malleolar ankle fracture, the apparent external rotation of the fracture fragment is relative only to the proximal fibula and is not associated with derangement of the talofibular articulation. Based on these mechanical considerations, surgical intervention for such fractures may not be necessary. This hypothesis is consistent with previous long-term clinical studies.