Malleolar Fractures Research Articles

Association Between Pronation External Rotation IV Fracture Pattern and Regional Bone Density.

Throughout the musculoskeletal system, fracture patterns and subsequent healing rely partly on bone density. In the foot and ankle, bone density has been shown to play a role in supination and external rotation fracture patterns. Adding to previous research, this investigation examines the association between bone density and trimalleolar versus trimalleolar equivalent fracture patterns following pronation and external rotation injuries using computed tomography (CT)-derived Hounsfield units (HU). A retrospective chart review was conducted among patients without a history of fracture or osteoporosis who sustained a PER IV fracture. Demographic data were collected. Fractures were separated between PER IV equivalent and fracture groups. CT-derived HU was assessed at the distal tibia and fibula. Density was compared between PER IV equivalent and fracture groups and among posterior malleolar fracture patterns. Seventy-five patients met the selection criteria, with 17 comprising the equivalent group and 58 in the fracture group. There were 38 type 1, 9 type 2, and 11 type 3 posterior malleolus fractures. The ankle bone density of the PER fracture equivalent group (331.98 ± 65.71HU) was greater than the PER fracture group (281.61 ± 76.99HU; P = .008). A statistically significant difference in tibial bone densities among equivalent and all PER fracture types (P = .01) with the equivalent group (331.98 ± 65.71HU) maintaining a greater tibial bone density than the type 2 posterior malleolus fracture group (252.35 ± 57.33HU; P = .009). Higher bone density was associated with PER IV equivalent fractures; however, there was no density difference among posterior malleolus fracture types. When presented with PER IV fractures, consider fixation that addresses a lower bone density. III.

Locking versus nonlocking plates for the treatment of posterior malleolar ankle fractures: A retrospective cohort study and cost analysis

BackgroundWe hypothesized that, as posterior malleolar ankle fractures usually present one or two main fragments, the buttress plating principle can be successfully achieved either with conventional nonlocking or anatomic locking posterior tibia plates, and no clinical differences should be found. The aim of this study was to evaluate the outcomes of posterior malleolar ankle (PM) fractures treated with conventional nonlocking (CNP) or anatomic locking plates (ALP), and also to compare both constructs in terms of crude costs. MethodsA retrospective cohort study was designed. CNP was used in 22 patients and ALP was used in 11 patients. American Orthopedic Foot and Ankle Society (AOFAS) score was registered at four weeks, 3–6 months, 12 and 24 months to assess all patients’ functional status. The primary outcome was ankle and hindfoot AOFAS score at 12 months follow-up visit. All complications, radiographic evaluation and implant construct costs were also registered and compared. The average follow-up was 25.4 (range, 12–42) months. ResultsNo significant difference was observed between both cohorts, in terms of AOFAS score and complication rate (P > .05). We found that ALP construct is 17 times more expensive than CNP construct in our institution (P < .001). ConclusionAnatomic locking posterior tibial plates may be an interesting device when poor bone quality is present or when a true multifragmentary pilon fracture is faced. Anatomic locking posterior tibia plate should not become a regular implant for any PM fracture since equivalent clinical and radiological results were obtained in our study using CNP with a significant reduced cost.

Three-dimensional morphological study of type B lateral malleolar fractures with special reference to the end-tip location of proximal apexes.

Objective: We aimed to describe the morphological characteristics of Danis-Weber type B lateral malleolar fractures, with special attention given to the end-tip locations of fracture apexes, and to construct a 3D (three-dimensional) fracture line map. Methods: A total of 114 surgically treated cases of type B lateral malleolar fractures were retrospectively reviewed. The baseline data were collected, and computed tomography data were reconstructed in a 3D model. We measured the morphological characteristics and the end-tip location of the fracture apex on the 3D model. All the fracture lines were superimposed on a template fibula to generate a 3D fracture line map. Results: Among these 114 cases, 21 were isolated lateral malleolar fractures, 29 were bimalleolar fractures, and 64 were trimalleolar fractures. All the type B lateral malleolar fractures demonstrated a spiral or oblique fracture line. As measured from the distal tibial articular line, the fracture started at -6.22 ± 4.62mm anteriorly and terminated at 27.23 ± 12.32mm posteriorly, and the average fracture height was 33.45 ± 11.89mm. The fracture line inclination angle was 56.85° ± 9.58°, and the total fracture spiral angle was 269.81° ± 37.09°, with fracture spikes of 156.20° ± 24.04°. The proximal end-tip location of the fracture apex was classified into four zones in the circumferential cortex: zone I (lateral ridge) in seven cases (6.1%), zone II (posterolateral surface) in 65 cases (57%), zone III (posterior ridge) in 39 cases (34.2%), and zone IV (medial surface) in three cases (2.6%). Altogether, 43% (49 cases) of fracture apexes were not distributed on the posterolateral surface of the fibula, as 34.2% (39 cases) were located on the posterior ridge (zone III). The aforementioned morphological parameters in fractures with zone III, sharp spikes, and further broken spikes were greater than those in zone II, blunt spikes, and fractures without further broken spikes. The 3D fracture map suggested that the fracture lines with the zone-III apex were steeper and longer than those with the zone-II apex. Conclusion: Nearly half of type B lateral malleolar fractures had their proximal end-tip of apexes not on the posterolateral surface, which may impair the mechanical application of antiglide plates. A steeper fracture line and longer fracture spike indicate a more posteromedial distribution of the fracture end-tip apex.

Indications and Interpretation of Stress Radiographs in Supination External Rotation Ankle Fractures.

Introduction In supination external rotation (SER) ankle fractures with an intact medial malleolus, stability hinges upon the competence of the deltoid ligament. The purpose of this study is to define the indications and establish criteria for a positive stress radiograph. Methods This is a prospective study of 27 isolated SER lateral malleolar fractures with a reduced ankle mortise. Pain and swelling were noted about the medial ankle, followed by an ultrasound to evaluate the integrity of the deltoid ligament. Static and stress radiographs were performed on both the fractured and contralateral ankles. Results Fourteen patients were normal on ultrasound examination, eight had partial tears, and five had full-thickness tears. The difference in the level of pain to palpation postero-medially between the complete tear (7 +/- 1) and the partial tear (1.3 +/- 2.4) group was significant (p < .001). The negative predictive values for medial swelling and tenderness were 93% and 100%, respectively. Sensitivity and specificity for medial clear space on stress radiograph (fracture (fx)) > 5.0 mm were both 100% while a 2.5 mm or greater change to the contralateral side yielded a sensitivity of 100% and specificity of 95%. Conclusion The lack of significant medial pain, as well as swelling, implies the absence of a complete ligament tear and eliminates the need for stress examination. Conversely, the presence of medial signs of injury is suggestive, but not pathognomonic for a complete deltoid tear. Medial clear space (MCS) variability prompts to recommend a minimum of 2.5 mm on stress radiographs compared to the contralateral side as indirect evidence for a complete tear of the deltoid ligament.

Total Ankle Arthroplasty for Posttraumatic Fracture Versus Primary Osteoarthritis: An Analysis of Complications, Revisions, and Prosthesis Survival.

Most outcome studies of total ankle arthroplasty (TAA) do not discriminate by arthritis etiology. The primary purpose of this study was to compare the complications of TAA between posttraumatic fracture osteoarthritis (fracture PTOA) and primary osteoarthritis (POA). Ninety-nine patients who underwent TAA were retrospectively evaluated with a mean follow-up of 3.2 years (range 2 to 7.6 years). 44 patients (44%) had a diagnosis of POA while 55 patients (56%) had a diagnosis of fracture PTOA (40 malleolar fractures [73%], 14 pilon fractures[26%], and 1 talar fracture [1%]). Patient demographics, preoperative coronal plane alignment, postoperative complications, and revision surgery data were collected. Categorical variables were compared with chi square and Fisher exact tests and means with the Student t-test. Survival was assessed with Kaplan-Meier and log-rank analyses. A higher overall complication rate was associated with fracture PTOA (53%) compared with POA (30%) (P = 0.04). No difference was observed in rates of any specific complication by etiology. Survival, defined as revision surgery with TAA prosthesis retention, was comparable between POA (91%) and fracture PTOA (87%) (P = 0.54). When defined as failure requiring prosthesis explant, POA demonstrated significantly greater survival (100%) as compared with fracture PTOA (89%) (P = 0.03). A higher rate of talar implant subsidence and loosening was noted in TAA with prior pilon (29%) as compared to malleolar fractures (8%) that was not statistically significant (P = 0.07). Fracture PTOA was associated with preoperative valgus deformity (P = 0.04). Compared with varus and normal alignment, preoperative valgus deformity was associated with the need for any revision surgery (P = 0.01) and prosthesis explant (P = 0.02). Compared with POA, fracture PTOA was associated with a markedly higher complication rate after TAA and was at higher risk of failure requiring prosthesis explant. Fracture PTOA was markedly associated with preoperative valgus malalignment, an identified risk factor in this series for revision surgery and prosthesis explant. Pilon fractures may represent a group at risk of complications related to talar implant subsidence and loosening compared with malleolar fractures and thus warrants additional investigation. III.

Postoperative Outcomes in Malleolar Fractures Fixed With a 3.5-mm Locking Compression Plate Hook Plate.

Ankle fractures are among the most common types of fractures seen in the United States. Few studies have analyzed the use of a locking compression plate (LCP) hook plate in the fixation of malleolar fractures. The goal of this study was to analyze postoperative outcomes in malleolar fractures fixed with a 3.5-mm LCP hook plate. A cohort of 74 patients with ankle fractures treated operatively with hook plates between 2011 and 2021 by a single orthopedic surgeon was retrospectively reviewed. Time to union, duration of non-weight bearing, final range of motion, postoperative complications, demographics, and comorbidities were recorded. A total of 66 patients fulfilled our inclusion criteria. There were 5 isolated medial malleolar, 34 bimalleolar, and 27 trimalleolar fractures. There were 46 women and 20 men with a mean age of 60.9±18.9 years. Fourteen patients had diabetes, 27 had osteoporosis, and 4 were current or former tobacco users. All patients achieved union, with a mean time to union of 10.9±5.3 weeks. The mean time to weight bearing was 50.2±18.4 days. The mean length of follow-up was 8.1±5.6 months. At final follow-up, mean dorsiflexion was 9.9°±4.3° and mean plantarflexion was 14.1°±5.1°. Six patients experienced postoperative complications such as surgical site infections and posttraumatic osteoarthritis. This study demonstrates that the use of a 3.5-mm LCP hook plate in the operative fixation of malleolar fractures has a high rate of union while maintaining low rates of postoperative complications. [Orthopedics. 2023;46(6):340-344.].

Allogeneic tendons in the treatment of malunited lateral malleolar avulsion fractures with chronic lateral ankle instability

BackgroundThe aim of this study is to report our institution’s experience regarding the application of allogeneic tendons for the reconstruction of malunited lateral malleolar avulsion fractures with chronic lateral ankle instability.MethodsThis retrospective study included 34 (34 ankles) patients surgically treated for malunited lateral malleolar avulsion fractures with chronic lateral ankle instability from January 2016 to December 2019. All patients underwent allogeneic tendon reconstruction. The pre- and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores、Karlsson Ankle Functional Scores (KAFS) and visual analogue scale (VAS) scores were used to evaluate the functional recovery of the ankle joint. The final follow-up, based on radiographic assessment, including talar tilt and anterior talar translation, was performed to evaluate the stability of the postoperative ankle joints.ResultsThirty-two patients (32 ankles) returned for final clinical and radiologic follow-up at an average of 29 (range 24–35) months and 2 patients (2 ankles) were lost to follow-up. The preoperative talus inclination angle (13.6 ± 1.9°) and anterior displacement (9.6 ± 2.8 mm) were re-examined under X-ray and found to be reduced to 3.4 ± 1.2° and 3.8 ± 1.1 mm, respectively (p＜0.01). The AOFAS scores increased from 58.5 ± 4.0 to 90.9 ± 3.8 and the Karlsson scores improved from 52.2 ± 3.6 to 89.8 ± 4.5, which was obviously better and the difference was statistically significant (P < 0.01). The VAS scores were significantly reduced from a preoperative mean of 6.8 ± 1.0 to 2.8 ± 0.9 postoperatively (p＜0.01).ConclusionIn this population and with this follow-up, the application of allogeneic tendons to treat malunited lateral malleolar avulsion fractures combined with chronic lateral ankle instability appeared safe and effective.

Evaluation of Contact Area and Pressure After Malreduction in Isolated Medial Malleolar Fractures With 2 mm of Displacement: A Cadaveric Study

This study was performed to evaluate the changes in contact area and pressure in the tibiotalar joint, with a 2 mm displacement after IMMF(isolated medial malleolar fracture). Ten cadavers with pairs were used to establish a situation in which IMMF occurred during ankle injury. We performed IMMF corresponding to types C and D of the Herscovici classification, and it was displaced by 2 mm. The normal group was defined as a normal tibiotalar joint, the TF(transverse fracture) group as a 2 mm transverse displacement corresponding to the Herscovici classification type C, and the OF(oblique fracture) group as a 2 mm oblique displacement corresponding to the Herscovici classification type D. We measured the contact area and pressure at the tiobiotalar joint. The film was scanned and analyzed using the digital imaging software, Scion Image (Scion Crop. Frederick, MD). In normal group, the average contact area of the tibiotalar joint was 317 mm2 (IQR; interquartile range,256; 347) and 308 mm2 (IQR, 262; 364), average pressure was 2.19 N/mm2 (IQR, 1.94; 2.27) and 2.15 N/mm2 (IQR, 2.06; 2.53). In the TF and OF groups, the average contact area of the tibiotalar joint decreased by 9% and 12%, respectively, and the average pressure increased by 8% and 14%, respectively. There was no statistical difference in peak pressure between the normal, TF, and OF groups. In the case of transverse and oblique fractures, a 2 mm displacement showed significant changes in contact area and contact pressure compared to the normal tibiotalar joint, but there were no significant changes pertaining to type, between the two fractures. Level of Clinical Evidence: 5.

One quick and simple fixation method: posterior malleolus fractures in spiral tibial fractures

ObjectiveSpiral fracture of tibia combined with posterior malleolar fracture (PMF) is a special and regular injury. There is no uniform fixation method for PMF in this kind of injury. Intramedullary nail is the first choice for the treatment of tibial spiral fracture. We proposed a minimally invasive percutaneous screw combined with intramedullary nail technology to fix the PMF in the tibial spiral fracture. This study aims to explore the effectiveness and advantages of this technology.Materials and methodsFrom January 2017 to February 2020, 116 cases of spiral fracture of tibia combined with PMF who were operated in our hospital were divided into Fixation Group (FG) and No Fixation Group (NG) according to whether PMF was fixed. After minimally invasive percutaneous screw fixation of ankle fracture in FG patients, the tibial intramedullary nail was inserted to fix the fracture. Collected the operation and postoperative recovery of the two groups of patients, including the operation time, intraoperative blood loss, AOFAS score, VAS score and dorsiflexion restriction of ankle joint at the last follow-up, and compared whether there is any difference between the two groups of patients.ResultsThe fracture of both groups healed.2 patients in NG had secondary displacement of PMF during operation, and the fracture finally healed after fixation. There were statistical differences between the two groups in terms of operation time, AOFAS score and weight bearing time. The operation time of FG was 67.9±11.2 min, and that of NG was 60.8±9.4 min; The weight bearing time of FG was 57.35±34.72 days, and that of NG was 69.17±21.43 days; The AOFAS score of FG was 92.50±3.46, and that of NG was 91.00±4.16. There were no significant difference in blood loss, VAS and dorsiflexion restriction of ankle joint between the two groups. The blood loss of FG was 66.8±12.3 ml, the blood loss of NG was 65.6±11.7 ml, the VAS score of FG was 1.37±0.47, the VAS score of NG was 1.43±0.51, the dorsiflexion restriction of FG was 5.8±4.1; the NG was 6.1±5.7.ConclusionFor the injury of tibial spiral fracture combined with PMF, our fixation technology can achieve minimally invasive fixation of PMF with percutaneous screws on the basis of intramedullary nail fixation of tibial fracture, promoting early functional exercise of ankle joint and early weight bearing of patients. This fixation technology is also characterized by simple and fast operation.

A Comparison of Femoropopliteal Block versus Spinal Anesthesia for Malleolar Surgeries

Background and Aim Surgery for malleolar fractures is associated with severe pain. Ultrasonography-guided nerve blocks have quality, precision, and drug dose reduction but are not preferred over spinal anesthesia. We have conducted a study to compare the effectiveness of femoropopliteal block with spinal anesthesia. Objective The aim of this study was to compare onset, duration, and hemodynamic variability and total analgesic requirement of femoropopliteal block with spinal anesthesia. Methods Preoperatively patients were divided into two groups (30 in each): Group 1—patients receiving spinal anesthesia with 0.5% hyperbaric bupivacaine; Group 2—patients receiving 15 mL in popliteal block and 5 mL in femoral block of 20 mL 0.5% bupivacaine with 8 mg dexamethasone. Onset, duration, hemodynamic changes, and postoperative analgesia requirements were monitored. Results Mean onset of sensory blockade in group 1 and 2 was 3.83 ± 0.92 and 12.68 ± 3.03 minutes (p-value &lt;0.001.) and motor blockade in group 1 and 2 was 5.36 ± 1.7 and 12.68 ± 3.03 minutes (p-value &lt;0.01), respectively. Mean duration of analgesia in group 1 and 2 was 3 ± 1.31 and 20.2 ± 4.7 hours, respectively. None of the patients in group 2 and 3% in group 1 had hypotension and bradycardia (p-value &gt; 0.05). The mean dose of morphine required in group 1 and 2 was 20.3 ± 2.1 and 3.56 ± 0.02 mg in 24 hours (p-value &lt; 0.001), respectively. Conclusion Femoropopliteal block was slower in onset but produced longer postoperative analgesia with markedly reduced opioid consumption.

MEDIAL MALLEOLUS: OPERATIVE OR NONOPERATIVE (MOON): A PROSPECTIVE RANDOMIZED CONTROLLED TRIAL OF OPERATIVE VERSUS NONOPERATIVE MANAGEMENT OF ASSOCIATED MEDIAL MALLEOLUS FRACTURES IN UNSTABLE ANKLE FRACTURES

This prospective randomised trial aimed to assess the superiority of internal fixation of well-reduced medial malleolar fractures (displacement □2mm) compared with non-fixation, following fibular stabilisation in patients undergoing surgical management of a closed unstable ankle fracture.A total of 154 adult patients with a bi- or trimalleolar fracture were recruited from a single centre. Open injuries and vertically unstable medial malleolar fractures were excluded. Following fibular stabilisation, patients were randomised intra-operatively on a 1:1 basis to fixation or non-fixation after satisfactory fluoroscopic fracture reduction was confirmed. The primary outcome was the Olerud Molander Ankle Score (OMAS) at 12 months post-randomisation. Complications were documented over the follow-up period.The baseline group demographics and injury characteristics were comparable. There were 144 patients reviewed at the primary outcome point (94%). The median OMAS was 80 (IQR, 60-90) in the fixation group vs. 72.5 (IQR, 55-90) in the non-fixation group (p=0.165). Complication rates were comparable, although significantly more patients (n=13, 20%) in the non-fixation group developed a radiographic non-union (p&lt;0.001). The majority (n=8/13) were asymptomatic, with one patient requiring surgical reintervention. In the non-fixation group, a superior outcome was associated with an anatomical medial malleolar fracture reduction.Internal fixation is not superior to non-fixation of well-reduced medial malleolar fractures when managing unstable ankle fractures. However, one in five patients following non-fixation developed a radiographic non-union and whilst the re-intervention rate to manage this was low, the longer-term consequences of this are unknown. The results of this trial may support selective non-fixation of anatomically reduced fractures.

Racial disparities in early adverse events and unplanned readmission after open fixation of fractures distal to the knee

Abstract Objectives: To determine whether (1) early postoperative complications and (2) time to surgery for operative fixation of fractures distal to the knee differ for Black versus White patients and to assess whether disparities exist within fracture subtypes. Design: Retrospective database review. Setting: Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program database. Patients/Participants: Patients (18 years or older) undergoing open fixation of fractures distal to the knee between 2010 and 2019 (n = 9172 patients). Intervention: Open reduction and internal fixation of fractures distal to the knee. Main Outcome Measurements: Thirty-day postoperative complications and time to surgery by race, as compared by multivariable regression with nearest-neighbor propensity score matching. Results: Of the 9172 patients in our cohort, 1120 (12%) were Black. After matching, we identified 1120 White patients with equal propensity scores as our Black patients. Black patients had 1.5 times higher odds (95% confidence interval [CI]: 1.0–2.0) of experiencing any early adverse event when compared with matched White counterparts. Black patients also had 1.9 times higher odds (95% CI: 1.2–3.0) of requiring unplanned readmission within 30 days of operative fixation. There were no significant differences by race in time to surgery. Fracture subtype (tibia/fibula shaft, isolated malleolar, bi/trimalleolar, and pilon fractures) was not associated with postoperative complications or time to surgery in the multivariable analysis. Conclusion: Racial disparities in the early postoperative course after open fixation of fractures distal to the knee exist, with significantly higher rates of early adverse events and unplanned readmission persist for Black versus White patients after propensity matching. Level of Evidence: Prognostic level III.

Bone Morphology as a Determinative Risk Factor for Type of Ankle Fracture.

We investigated the relationship between ankle radiographic bone morphology and observed fracture type. We retrospectively reviewed patients who had visited the emergency department with ankle injuries between June 1, 2012, and July 31, 2018. Patients were treated with open reduction and internal fixation. Patients were grouped by fracture pattern. Group 1 consisted of isolated lateral malleolar fractures, and group 2 comprised bimalleolar fractures. Group 1 was further divided into subgroups A and B based on classification as Weber type B and C fractures, respectively. Four radiographic parameters were measured postoperatively on a standing whole-leg anteroposterior view of the ankle: talocrural angle (TCA), medial malleolar relative length (MMRL), lateral malleolar relative length (LMRL), and distance between the talar dome and distal fibula. One hundred seventeen patients were included in group 1-A, 89 in group 1-B, and 168 in group 2. The TCA and MMRL were significantly larger in group 2 than in group 1. Lateral to medial malleolar length ratio was also significantly different between the groups. However, there were no significant differences between the groups in terms of LMRL and the distance between the distal fibula tip and talar process. Between subgroups 1-A and 1-B, LMRL (P = .402) and MMRL (P = .592) values were not significantly different. However, there was a significant difference between groups in TCA and the distance between the distal fibula tip and talar process. The TCA, MMRL, and lateral malleolar length to medial malleolar length ratio were significantly higher in patients with bimalleolar fracture than in patients with isolated lateral malleolar fractures.

Electric scooter injuries: Incidence and injury patterns at a level I trauma center

PurposeElectric scooters (e-scooters) have become an increasingly popular mode of public transportation in recent years. As the incidence of related injuries rises, it is important to understand specific fracture patterns unique to e-scooters and electric bikes (e-bikes) to help guide management. The purpose of this study was to review the prevalence and describe specific fracture patterns of e-scooter and e-bike related injuries at the busiest level 1 trauma center in the borough of Manhattan. MethodsChart review to determine mechanism of injury was performed on all patients for whom an orthopedic consult was requested from 1/1/2021 to 12/31/2021. All patients whose injuries were sustained due to an e-scooter or e-bike were further reviewed for demographics, injury characteristics including fracture pattern, and definitive injury management. Any patients who had an orthopedic consult placed for a reason other than an acute injury were excluded. Descriptive statistics are reported as frequency (percentage) for categorical variables and means for continuous variables. ResultsOf the 1815 orthopedic consults requested, 1357 (74.8%) were for acute injury management. Of those with acute injuries, 119 (8.8%) sustained 136 e-scooter or e-bike related injuries. There were 92 (77.3%) males at an average age of (33.8 ± 15.7) years. Approximately one-fifth of all patients presented in June 2021 (26, 21.8%). There was a 9.2% rate of open fractures. The 136 injuries were evenly split between the upper and lower extremities, with 57 (47.9%) upper extremity, 57 (47.9%) lower extremity injuries, and 5 (4.2%) concomitant upper and lower extremity injuries. The most common fracture patterns were ankle fractures (16, 11.7%), followed by tibial shaft (14, 10.2%), tibial plateau (13, 9.5%), and radial head fractures (11, 8.0%). There was a 33.3% incidence of associated posterior malleolar fractures in the spiral tibial shaft fractures, 31.0% of posterior malleolar involvement and 18.8% of isolated vertical medial malleolar fractures in the ankle fractures, and 61.5% of posterior comminution in the tibial plateau fractures. ConclusionE-scooter and e-bike related injuries have a high incidence of tibial shaft fractures, ankle fractures, tibial plateau fractures, and radial head fractures. There should be a high index of suspicion for posterior and medial involvement in lower extremity fractures sustained due to e-scooter or e-bikes. Identifying specific fracture patterns seen in e-scooter and e-bike related mechanisms will help guide management of these injuries.

Does the type of anesthesia (regional vs. general) represent an independent predictor for in-hospital complications in operatively treated malleolar fractures? A retrospective analysis of 5262 patients

PurposeThe impact of the type of anesthesia (regional vs. general anesthesia) on in-hospital complications in ankle fractures has not been thoroughly studied yet. Identifying factors that place patients at risk for complications following ankle fractures may help reduce their occurrence. The primary goal of this study was (1) to describe the cohort of patients and (2) to evaluate independent risk factors for complications during hospitalization.MethodsWe analyzed patients from 2005 to 2019 with an operatively treated isolated fracture of the medial or lateral malleolus using a prospective national quality measurement database. Patients were selected based on international classifications (ICD) and national procedural codes (CHOP). Uni- and multivariate analysis were applied.ResultsIn total, we analyzed 5262 patients who suffered a fracture of the malleolus; 3003 patients (57%) had regional and 2259 (43%) general anesthesia. Patients with regional anesthesia were significantly older (51 vs. 46 years), but healthier (23 vs. 28% comorbidities) than patients who received general anesthesia. The in-hospital complication rate was not significantly lower in regional anesthesia (2.2% vs 3.0%). The type of anesthesia was not an independent predictor for complications while controlling for confounders.ConclusionType of anesthesia was not an independent predictor of complications; however, higher ASA class, age over 70 years, fracture of the medial versus lateral malleolus, longer preoperative stay, and duration of surgery were significant predictors of complications. Patient and procedure characteristics, as well as changes in medical care and epidemiological changes along with patient requests, influenced the choice of the type of anesthesia.

Effect of Posterior Malleolar Fixation on Syndesmotic Stability

Background: Transsyndesmotic fixation with suture buttons (SBs), posterior malleolar fixation with screws, and anterior inferior tibiofibular ligament (AITFL) augmentation using suture tape (ST) have all been suggested as potential treatments in the setting of a posterior malleolar fracture (PMF). However, there is no consensus on the optimal treatment for PMFs. Purpose: To determine which combination of (1) transsyndesmotic SBs, (2) posterior malleolar screws, and (3) AITFL augmentation using ST best restored native tibiofibular and ankle joint kinematics after 25% and 50% PMF. Study Design: Controlled laboratory study. Methods: Twenty cadaveric lower-leg specimens were divided into 2 groups (25% or 50% PMF) and underwent biomechanical testing using a 6 degrees of freedom robotic arm in 7 states: intact, syndesmosis injury with PMF, transsyndesmotic SBs, transsyndesmotic SBs + AITFL augmentation, transsyndesmotic SBs + AITFL augmentation + posterior malleolar screws, posterior malleolar screws + AITFL augmentation, and posterior malleolar screws. Four biomechanical tests were performed at neutral and 30° of plantarflexion: external rotation, internal rotation, posterior drawer, and lateral drawer. The position of the tibia, fibula, and talus were recorded using a 5-camera motion capture system. Results: With external rotation, posterior malleolar screws with AITFL augmentation resulted in best stability of the fibula and ankle joint. With internal rotation, all repairs that included posterior malleolar screws stabilized the fibula and ankle joint. Posterior and lateral drawer resulted in only small differences between the intact and injured states. No differences were found in the efficacy of treatments between 25% and 50% PMFs. Conclusion: Posterior malleolar screws resulted in higher syndesmotic stability when compared with transsyndesmotic SBs. AITFL augmentation provided additional external rotational stability when combined with posterior malleolar screws. Transsyndesmotic SBs did not provide any additional stability and tended to translate the fibula medially. Clinical Relevance: Posterior malleolar fixation with AITFL augmentation using ST may be the preferred surgical method when treating patients with acute ankle injury involving an unstable syndesmosis and a PMF ≥25%.

Validation of three classification systems for posterior malleolus fractures of the ankle.

A number of classification systems exist for posterior malleolar ankle fractures. The user reliability of these classification systems remains unclear. The primary aim of this study was to evaluate the reliability of three commonly utilised classification systems for fractures of the posterior malleolus. Imaging of 60 patients across 2 hospitals with ankle fractures including a posterior malleolar fragment was identified. All patients had undergone plain radiographs and computed tomography of their injured ankle as part of their normal standard of care. 9 surgeons including pre-resident/registrar level, resident/registrar level, and attending/consultant level applied the Haraguchi, Bartoníček, and Mason classifications to these fractures, at two timepoints, at least 4weeks apart. The order was randomised between assessments. Inter-rater reliability was assessed using Fleiss' κ and standard error (SE). Intra-rater reliability was assessed using Cohen's κ and standard error (SE). Inter-rater reliability (Fleiss' κ) was calculated for the Haraguchi classification as 0.588 (SE 0.023), for the Bartoníček classification as 0.626 (SE 0.019), and the Mason classification as 0.541 (SE 0.098). Intra-rater reliability (Cohen's κ) was 0.761 (SE 0.098) for the Haraguchi classification, 0.761 (SE 0.091) for the Bartoníček, classification, and 0.724 (SE 0.096) for the Mason classification. This study reports the inter-rater and intra-rater reliability for three classification systems for posterior malleolus fractures. Based on definitions by Landis and Koch (Biometrics 33:159-174, 1977), inter-rater reliability was rated as 'moderate' for the Haraguchi and Mason classifications and 'substantial' for the Bartoníček classification. Similarly, the intra-rater reliability was rated as 'substantial' for all three classifications.

PREOPERATIVE ANKLE SWELLING DOES NOT AFFECT POSTOPERATIVE WOUND COMPLICATIONS FOLLOWING ANKLE FRACTURE SURGERY

Swelling following an ankle fracture is commonly believed to preclude surgical fixation, delaying operative treatment to allow the swelling to subside. This is in an attempt to achieve better soft tissue outcomes. We aim to identify whether pre-operative ankle swelling influences postoperative wound complications following ankle fracture surgery.This is a prospective cohort study of 80 patients presenting to a tertiary referral centre with operatively managed malleolar ankle fractures.Ankle swelling was measured visually and then quantitatively using the validated ‘Figure-of-eight’ technique. Follow-up was standardised at 2, 6, and 12 weeks post-operatively. Wound complications, patient co-morbidities, operative time, surgeon experience, and hospital stay duration were recorded.The complication rate was 8.75% (n=7), with 1 deep infection requiring operative intervention and all others resolving with oral antibiotics and wound cares. There was no significant difference in wound complication rates associated with quantitative ankle swelling (p=0.755), visual assessment of ankle swelling (p=0.647), or time to operative intervention (p=0.270).Increasing age (p=0.006) and female gender (p=0.049) had a significantly greater probability of wound complications. However, BMI, smoking status, level of the operating surgeon, and tourniquet time were not significantly different.Visual assessment of ankle swelling had a poor to moderate correlation to ‘Figure-of-eight’ ankle swelling measurements ICC=0.507 (0.325- 0.653).Neither ankle swelling nor time to surgery correlates with an increased risk of postoperative wound complication in surgically treated malleolar ankle fractures. Increasing patient age and female gender had a significantly greater probability of wound infection, irrespective of swelling. Visual assessment of ankle swelling is unreliable for quantifying true ankle swelling.Operative intervention at any time after an ankle fracture, irrespective of swelling, is safe and showed no better or worse soft tissue outcomes than those delayed for swelling.

Single lateral approach for open reduction and internal fixation of posterior malleolar fragment in Weber B rotational ankle fracture.

Ankle fractures involving the posterior malleolus are a relatively common injuries, but various surgical approaches are still being introduced, and the selection of an appropriate surgical method is still controversial. The aim of this study was to introduce the surgical method using a single lateral approach for open reduction and internal fixation for posterior malleolar (PM) fractures associated with Weber B type ankle fractures. In this retrospective study, the single lateral approach was used for osteosynthesis of the PM fracture with Weber B lateral malleolar fractures. A total of 40 patients were followed up at for least 12 months (mean, 23.3; range, 12-88). Clinical assessment was based on the Olerud and Molander score, Foot and Ankle Outcome Score, visual analog scale, and subjective patient satisfaction 1 year after surgery. The accuracy of reduction was evaluated as <1 mm of displacement on the lateral view of the postoperative radiographs. The mean Olerud and Molander ankle score was 85.6 ± 12.7 and the mean Foot and Ankle Outcome Score was 82.7 ± 15.9 at 1-year postoperatively. Acceptable reduction was achieved in 38 of 40 (95%) cases. During the follow-up period, arthritic change was observed in 1 case and limited range of motion was confirmed in 2 cases. There was 1 case of postoperative wound problem and no case of sural nerve injury. The single lateral approach is a relatively simple and convenient method that enables accurate reduction and minimizing complication for fixation of the PM fractures with Weber B lateral malleolar fractures.

Comparing Temporary Immobilization Using Cast and External Fixator in Unimalleolar Ankle Fracture Dislocations: A Retrospective Case Series.

Studies have reported a high percentage of ankle fracture dislocations with secondary loss of reduction during primary treatment with a splint or cast. This study aimed to assess the rate of secondary loss of reduction in unimalleolar ankle fracture dislocations treated primarily with a cast or external fixator, identify the potential influence of fracture morphology, and investigate the potential implications. Unimalleolar ankle fracture dislocations with and without posterior malleolar fracture between 2011 and 2020 were included. Patients were categorized into two groups, depending on the method of temporary treatment. Fracture morphology, time to definitive surgery, and soft-tissue complications were compared. Of 102 patients, loss of reduction tended to occur more often in the cast group (17.3%) than in the external fixator group (6.0%). The presence of a posterior malleolar fracture did not have a significant influence on loss of reduction in cast immobilization; however, the fragment proved to be significantly bigger in cases with loss of reduction. No statistically significant differences in soft tissue complications or time to definitive surgery were found. Surgeons should consider the application of interval external fixation in the primary treatment of unimalleolar ankle fracture dislocations with additional posterior malleolar fractures.