Pronation External Rotation Ankle Research Articles

Should Diastatic Syndesmosis be Stabilized in Advanced Pronation-External Rotation Ankle Injuries? A Retrospective Cohort Comparison.

ObjectiveWith or without screw stabilization for diastatic syndesmosis in advanced pronation‐external rotation (PE) ankle injuries has not yet been well‐determined. Both techniques were retrospectively compared to investigate the superiority of either of the two.MethodsA retrospective cohort study was carried out. From January 1, 2008, to December 31, 2017, 81 consecutive adult patients (average, 42 years; range, 18–78 years; 44 men and 37 women) with advanced PE ankle injuries (stage 3 or 4 PE type) were treated. After malleolar fractures were internally stabilized with screws and plates, the syndesmotic stability was rechecked by external rotation and hook tests. The necessity of cortical screw insertion to stabilize diastatic syndesmosis was decided by the individual orthopaedic surgeon. Postoperatively, a short leg splint was used for 6 weeks. The syndesmotic screw was removed based on the surgeon's policy. The removal of internal fixation for malleolar fractures was required after 1 year. The outcomes of both approaches were compared clinically, and ankle function was compared using the American Orthopaedic Foot and Ankle Society (AOFAS) score. For statistical comparison, the chi‐square test was used for categorical data and the Mann–Whitney U test was used for numerical data.ResultsSeventy‐one patients (average, 40 years; range, 18–78 years; 40 men and 31 women) were followed for at least 1 year (87.7%; average, 2 years; range, 1–11 years). Group 1 (with syndesmotic stabilization) had 22 patients and Group 2 (without syndesmotic stabilization), 49 patients. The union rate in Group 1 patients was 100% (22/22), and in Group 2 patients, 91.8% (45/49; p = 0.17). One deep wound infection occurred in Group 1 patients and two in Group 2 patients. Syndesmosis re‐diastasis occurred in 13.6% (3/22) of Group 1 patients and 30.6% (15/49) of Group 2 patients (p = 0.13). One syndesmotic screw broke at 6 months. Satisfactory ankle function according to the AOFAS score was noted in 86.4% (19/22) of Group 1 patients and 65.3% (32/49) of Group 2 patients (p = 0.07).ConclusionInsertion of syndesmotic screws to promote ligament healing after internal fixation of malleolar fractures in advanced PE ankle injuries may be reasonable.

Suture button versus syndesmosis screw fixation in pronation-external rotation ankle fractures: A minimum 6-year follow-up of a randomised controlled trial

ObjectiveRandomised controlled trials (RCT) with short-term follow-ups have shown that, in treatment of syndesmosis injuries, a suture button device (SB) resulted in better radiographic and functional outcome compared to syndesmosis screw fixation (SS). However, only one RCT has reported long-term results; thus, the syndesmosis malreduction rates for both implants might increase during longer follow-up. The primary objective of this RCT was to evaluate the maintenance of syndesmosis reduction with the SS compared to the SB fixation in patients during a minimum follow-up of 6-years. The secondary objectives were to assess the post-traumatic osteoarthritis (OA) grade and the functional outcome. Patients and MethodsAt Oulu University Hospital, between January 2010 and December 2011, we enrolled 43 patients with Lauge-Hansen pronation-external rotation type 4/Weber C, ankle fractures with unstable syndesmosis. Patients were randomised to treatment with either a single 3.5-mm tricortical SS (22 patients) or an SB (21 patients). The mean follow-up was 7.1 years (range, 6.2—7.9). Syndesmosis reduction and OA grade was assessed with standing cone-beam computed tomography (CBCT) of both ankles. Malreduction was defined as >2 mm side-to-side difference in the mean width of the syndesmosis. OA was graded according to the Morrey & Wiedeman classification. The Olerud-Molander Ankle Outcome Score (OMAS) and a quality of life questionnaire (RAND 36-Item Health Survey) were used to evaluate functional outcome. ResultsTwo syndesmoses in the SS group and one in the SB group were malreduced (P = 0.58). Moderate OA after a mean of 7 years post-injury was common. In the SS and SB groups, 9 of 16 and 11 of 13 patients, respectively, had one or more grades serious OA in the injured ankle than in the uninjured ankle (P = 0.11). The mean OMAS was 88 in the SS group and 78 in the SB group (difference between means 7.1, 95% CI: −7.0–21.1, P = 0.32). The RAND-36 results did not differ between groups. ConclusionThe SS and SB maintained syndesmosis reduction equally well during follow-up. Our study findings also suggest that both methods result in moderate OA rates and the functional outcome is comparable between these two syndesmosis fixation methods.

To evaluate the clinical effect of repairing former inferior tibiofibular ligament in the treatment of gradeIII pronation-external rotation ankle fractures

To evaluate the clinical effect of repairing former inferior tibiofibular ligament in the treatment of gradeIII pronation-external rotation ankle fractures

Analysis of clinical effect of operative treatment for grade IV pronation-external rotation ankle injury

Objective To explore the clinical effect of operative treatment for grade Ⅳ pronation-external rotation ankle injury. Methods 60 patients with pronation extorsion type Ⅳ degree of ankle injury were selected as the research subjects.According to the digital table, they were divided into two groups, 30 cases in each group.The group A adopted ordinary steel plate, the group B adopted locking plate fixation.The clinical curative effect, postoperative recovery index, AOFAS score and complications were observed. Results The total effective rate of group A was 93.3%, which of group B was 90.0%, the difference was not statistically significant(χ2=0.218, P>0.05). The swelling subsided time[(24.2±5.0)d vs.(22.9±4.1)d], fracture healing time[(42.4±9.5)d vs.(41.3±9.4)d], postoperative recovery time of walking[(46.6±9.2)d vs.(45.7±9.0)d], AOFAS score[(87.3±2.6) vs.(88.4±2.2)] between the two groups had no statistically significant differences(t=1.101, 0.451, 0.383, 1.769, all P>0.05). The group A had 1 case in infection, the incidence rate of complications was 3.3%.The group B had no complication.The difference was not statistically significant in the incidence of complications between the two groups(χ2=1.017, P>0.05). Conclusion In the operative treatment for patients with grade Ⅳ pronation-external rotation ankle injury, whether choose ordinary steel plate fixation, or choose the locking plate fixation, the clinical effects of the two methods are both good, and the postoperative healing is fast. Key words: Ankle injuries; Pronation screw type; Surgical treatment; Clinical curative effect

Surgical treatment of grade III pronation-external rotation fractures of ankle

To summarize the short-term effectiveness of the surgical treatment for grade III pronation-external rotation ankle fractures. Between October 2011 and May 2015, 36 patients with pronation-external rotation ankle fractures (grade III) were treated with internal fixation and repair of the anterior lower tibiofibular ligament, including 21 males and 15 females with an average age of 45.2 years (range, 21-72 years). Injury was caused by sprain in 19 cases, by traffic accident in 6 cases, and by falling from height in 11 cases. All patients had closed fractures, with no blood vessel and nerve injury. The locations were the left ankle in 13 cases and the right ankle in 23 cases. The time from injury to operation was 3 to 10 days (mean, 6.5 days). At last follow-up, ankle function was evaluated by American Orthopaedic Foot and Ankle Society (AOFAS) ankle-foot score, and the improvement of pain was evaluated by visual analogue scale (VAS). Primary healing of incision was obtained in all patients, no incision infection and skin necrosis occurred. Twenty-eight patients were followed up 12-36 months (mean, 17.5 months). X-ray films showed bone union was achieved within 2.6-5 months (mean, 3.2 months). No fracture of internal fixation and disruption of tibiofibular diastasis occurred. At last follow-up, according to AOFAS score for ankle function evaluation, the pain score was 36.3±2.9, the function score was 44.3±3.2, the ligament condition score was 9.2±0.5, and the total score was 89.8±6.6; the results were excellent in 11 cases, good in 15 cases, and fair in 2 cases. VAS score was 1.6±0.5. The range of motion of the ankle was (13±5)° in dorsiflexion and (38±9)° in planteroflexion. Repair of anterior tibial ligament is an effective method to treat tibiofibular diastasis injury in the surgical treatment of grade III pronation-external rotation ankle fractures, with convenient operation, and satisfactory short-term effectiveness.

TREATMENT OF PRONATION EXTERNAL ROTATION ANKLE FRACTURE COMBINED WITH SEPARATION OF DISTAL TIBIOFIBULAR SYNDESMOSIS

To evaluate the difference between using and not using syndesmotic screw to treat pronation external rotation (PER) ankle fracture combined with separation of distal tibiofibular syndesmosis. Between April 2011 and October 2014, 46 cases of PER ankle fracture combined with separation of distal tibiofibular syndesmosis were treated, and syndesmotic screw was used in 24 cases (fixation group) and syndesmotic screw was not used in 22 cases (non-fixation group). There was no significant difference in gender, age, weight, cause of injury, side, injury to operation time, and fracture type between 2 groups (P>0.05). The time for full weight-bearing, fracture healing time, and complications were recorded after operation. Anteroposterior and lateral X-ray films were taken to measure the tibiofibular overlap (TBOL) and tibiofibular clear space (TBCS). Baird-Jackson score was used to evaluate functional recovery of the ankle. All incision healed by first intention without complications. The cases were followed up 13-18 months (mean, 15.2 months) in 2 groups. The time for full weight-bearing was 8-12 weeks (median, 11 weeks) in fixation group, which was significantly later than that in non-fixation group (range, 6-10 weeks; median, 8 weeks) (Z=-5.049, P=0.000). X-ray examination showed reduction of separation of distal tibiofibular syndesmosis. All fractures healed. The fracture healing time was (13.83±1.37) weeks in fixation group, and was (13.91±1.31) weeks in non-fixation group, showing no significant difference (t=-0.191, P=0.945). No separation of distal tibiofibular syndesmosis, delayed union, nonunion, loosening, or breakage of fixation devices was observed in 2 groups. There was no significant difference in TBOL, TBCS, Baird-Jackson score and the excellent and good rate between 2 groups (P>0.05). If the medial, lateral, and posterior structures of the ankle could be repaired according to injury, no significant influence on functional outcome of ankle or radiologic findings could be detected whether syndesmotic fixation is given or not in treating PER ankle fracture (exclude Maisonneuve fracture) combined with separation of distal tibiofibular syndesmosis.

Clinical outcomes of endobutton versus traditional screw fixation for distal tibiofibular syndesmosis in ankle fractures

Objective To compare the clinical outcomes for endobutton versus traditional screw fixation of distal tibiofibular syndesmosis in ankle fractures. Methods Sixty-nine cases of ankle fractures accompanied with distal tibiofibular syndesmosis injury hospitalized between November 2012 and November 2014 were reviewed retrospectively. Thirty-two cases (19 males and 13 females) aged (38.1±15.3) years (range, 22-62 years) underwent syndesmosis stabilization with endobutton system (endobutton group), and mechanism of injury was sprain injury in 20 cases, traffic injury in 7 and high fall injury in 5. Another 37 cases (20 males and 17 females) aged(33.9±11.1)years (range, 22-65 years) were managed with traditional screw fixation (tradition group), and mechanism of injury was sprain injury in 22 cases, traffic injury in 8 and high fall injury in 7. According to the Lauge-Hansen classification, all had pronation external rotation ankle fractures. Operation time, manipulation angle, tibiofibular clear space (TBCS), tibiofibular overlap distance (TBOL), complications and final follow-up evaluation of American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score were recorded. Results Comparison of endobutton group to tradition group showed no significant differences in operation time [10 min(5-17 min) ∶9 min(4-15 min)], TBOL [(9.1±1.8)mm ∶(8.2±2.3)mm], TBCS [(3.7±0.6)mm ∶(3.6±0.9)mm], total complication rate [6.3% ∶13.5%] and AOFAS score [(89.1±18.5)points ∶(86.6±12.4) points] (P>0.05), but endobutton technique was associated with a larger manipulation angle [(45.8±16.7)° ∶(28.5±5.6)°] and earlier full weight bearing [(6.8±1.6)weeks ∶(10.9±2.7)weeks] than traditional screw fixation (P<0.05). Conclusion Endobutton technique has comparative effect with traditional screw fixation and has advantages such as low demand in fixation angle, early weight bearing and no need for removal of implant. Key words: Ankle injuries; Fracture fixation, internal; Distal tibiofibular syndesmosis

Long-Term Outcome of Pronation-External Rotation Ankle Fractures Treated with Syndesmotic Screws Only

There is sparse information in the literature on the outcome of Maisonneuve-type pronation-external rotation ankle fractures treated with syndesmotic screws. The primary aim of this study was to determine the long-term results of such treatment of these fractures as indicated by standardized patient-based and physician-based outcome measures. The secondary aim was to identify predictors of the outcome with use of bivariate and multivariate statistical analysis. Fifty patients with pronation-external rotation (predominantly Maisonneuve) fractures were treated with open reduction and internal fixation of the syndesmosis utilizing only one or two screws. The results were evaluated at a mean of twenty-one years after the fracture utilizing three standardized outcomes instruments: (1) the Foot and Ankle Ability Measure (FAAM), (2) the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale, and (3) the Center for Epidemiologic Studies-Depression (CES-D) Scale. Osteoarthritis was graded according to the van Dijk and revised Takakura radiographic scoring systems. Bivariate and multivariate analyses were performed to identify predictors of long-term outcome. Forty-four (92%) of forty-eighty patients had good or excellent AOFAS scores, and forty-four (90%) of forty-nine had good or excellent FAAM scores. Arthrodesis for severe osteoarthritis was performed in two patients. Radiographic evidence of osteoarthritis was observed in twenty-four (49%) of forty-nine patients. Multivariate analysis identified pain as the most important independent predictor of long-term ankle function as indicated by the AOFAS and FAAM scores, explaining 91% and 53% of the variation in scores, respectively. Analysis of pain as the dependent variable in bivariate analyses revealed that depression, ankle range of motion, and a subsequent surgery were significantly correlated with higher pain scores. No firm conclusions could be drawn after multivariate analysis of predictors of pain. Long-term functional outcomes at a mean of twenty-one years after pronation-external rotation ankle fractures treated with one or two syndesmotic screws were good to excellent in the great majority of patients despite substantial radiographic evidence of osteoarthritis in one-half of the patients. The most important predictor of long-term functional outcome was patient-reported pain rather than physician-reported function or posttraumatic osteoarthritis. There was no significant association between radiographic signs of posttraumatic osteoarthritis and perceived pain in the present series.

Twenty-Two-Year Follow-up of Pronation External Rotation Type III–IV (OTA Type C) Ankle Fractures

Long-term evaluation protocolled treatment of pronation external rotation (PER) type III-IV (OTA type C) ankle fractures. Level III retrospective cohort study. Level I trauma center. A consecutive series of 98 patients with PER III-IV ankle fractures between 1985 and 1990. Stable fractures with tibiotalar congruity were treated conservatively, whereas osteosynthesis was performed in unstable and displaced fractures to restore tibiotalar congruity. Outcome parameters were (1) functional outcome questionnaire (Olerud score), (2) physical evaluation (loaded dorsal range of motion), (3) functional impairment (AMA Guides, 5th ed.), and (4) radiographic evaluation (Cedell score, medial clear space widening, and osteoarthritis). After a median of 22 years, follow-up was achieved in 95% (n = 60) of living patients. Four patients had a true PER III injury, 5 patients had an unclear injury (between PER III and IV), and 51 patients (85%) sustained a PER IV injury. Excellent or good results were found in 90% of patients (Olerud score). Functional impairment, expressed as percentage of Whole Person Impairment, varied between 0% and 3%. Patients treated operatively and conservatively had statistically equivalent scores. The long-term result of surgical treatment of PER ankle fractures is "good" or "excellent" in the majority of patients. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Osteonecrosis of the Distal Tibia after a Pronation External Rotation Ankle Fracture: Literature Review and Management

Posttraumatic osteonecrosis of the distal tibia is a rare but recognized complication of Weber C ankle fractures. To our knowledge, we report the first documented case managed with early percutaneous drilling of the defect. The patient noticed an improvement in symptoms, and magnetic resonance imaging confirmed resolution of the avascular area. The previously reported complication of secondary periarticular collapse and subsequent osteoarthritis was avoided. We advocate that a high index of suspicion, early detection, and drilling can encourage neovascularisation and prevent secondary joint destruction.

Percutaneous drilling for osteonecrosis of the distal tibia following a pronation external rotation ankle fracture—a case report and literature review

Posttraumatic osteonecrosis of the distal tibia is a rare but recognised complication of Weber C ankle fractures, frequently resulting in peri-articular collapse and subsequent joint destruction. To our knowledge, we report the only documented case of early percutaneous drilling of the defect. Symptoms improved, MRI confirmed the resolution of the avascular area, and a peri-articular collapse was avoided. We advocate that a high index of suspicion, early detection and drilling can encourage neovascularisation and prevent secondary joint destruction.

Syndesmotic Stabilization in Pronation External Rotation Ankle Fractures

Boden et al. suggested syndesmosis fixation was not necessary in distal pronation external rotation (PER) ankle fractures if rigid bimalleolar fracture fixation is achieved and was not necessary with deltoid ligament injury if the fibular fracture is no higher than 4.5 cm of the tibiotalar joint. We asked whether height of the fibular fracture with or without medial stability predicted syndesmotic instability as compared with intraoperative hook testing in these fractures. We reviewed 62 patients (35 male, 27 female) with a mean age of 45.6 years (range, 19–80 years). Using a bone hook applied to the distal fibula with lateral force to the distal fibula in the coronal plane, we fluoroscopically assessed the degree of syndesmosis diastasis in all patients. The mean height of the fibular fracture in patients with a positive hook test was higher than in patients with a negative hook test (54.2 mm; standard deviation [SD], 29.3 versus 34.8 mm; SD, 21.4, respectively). The height of the fibular fracture showed a positive predictive value of 0.93 and a negative predictive value of 0.53 in predicting syndesmotic instability; specificity of the criteria of Boden et al. was high (0.96). However, sensitivity was low (0.39) using the hook test as the gold standard. The criteria of Boden et al. may be helpful in planning, but may have some limitations as a predictor of syndesmotic instability in distal PER ankle fractures. Level of Evidence: Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

An axially loaded model of the ankle after pronation external rotation injury.

Using a testing apparatus that allows axial loading and displacement in the sagittal, axial, and coronal planes, 6 ankles were tested under experimental conditions intended to model the Lauge-Hansen pronation external rotation injury. All specimens were rotated through a continuous range of sagittal motion with the ankle under 300 N of axial load as the coupled motion of the ankle in the coronal and axial axes was recorded. Combinations of fibular osteotomy, disruption of the syndesmosis up to 6 cm above the plafond, and deltoid transection were tested to mimic Stages I to III of the pronation external rotation ankle fracture. The effects of stabilization of the fibula and syndesmosis also were examined. Neither fracture of the fibula 4 cm above the plafond nor disruption of the syndesmosis to 6.0 cm resulted in a significant change in coupled motion of the talus. When the superficial deltoid was sectioned, the ankle had increased external rotation in plantar flexion. When the deep deltoid was sectioned, the ankle dislocated in plantar flexion unless the fibula was stabilized. This prevented dislocation but failed to restore normal talar kinematics. This study found no biomechanical support for placement of a syndesmotic screw unless the medial side cannot be stabilized anatomically.

Tibiotalar joint dynamics: indications for the syndesmotic screw--a cadaver study.

Pronation-external rotation ankle injuries involve varying degrees of disruption of the syndesmotic ligaments. The loss of ligament support and alteration in the stability of the mortise have been postulated to lead to an increase in joint reactive forces and traumatic arthritis. The purpose of this study was to determine the changes in tibiotalar joint dynamics associated with syndesmotic diastasis as a result of the sequential sectioning of the syndesmotic ligaments to simulate a pronation-external rotation injury. Dissections were conducted on 10 fresh-frozen, knee-disarticulated cadaveric specimens which were then axially loaded in an unconstrained manner. Tibiotalar joint forces were measured at each level of sequential sectioning of the syndesmotic ligaments, the interosseous membrane, and finally the deltoid ligament. Complete disruption of the syndesmosis with the medical structures of the ankle intact resulted in an average syndesmotic widening of 0.24 mm and no significant change in the tibiotalar contact area or the peak pressure. However, deltoid ligament strain increases with sectioning of the syndesmosis. With the addition of deltoid ligament sectioning, there was an average syndesmotic diastasis of 0.73 mm, a 39% reduction in the tibiotalar contact area, and a 42% increase in the peak pressure. In a simulated unconstrained cadaveric model of a pronation-external rotation ankle injury that results in complete disruption of the syndesmosis, if rigid anatomic medial and lateral joint fixation is obtained and the deltoid ligament complex is intact, syndesmotic screw fixation is not required to maintain the integrity of the tibiotalar joint.

Long-Term Results of Pronation-External Rotation Ankle Fracture-Dislocations Treated with Anatomical Open Reduction, Internal Fixation

Long-Term Results of Pronation-External Rotation Ankle Fracture-Dislocations Treated with Anatomical Open Reduction, Internal Fixation

A prospective, randomized study of the management of severe ankle fractures.

One hundred and thirty-eight patients with a closed grade-4 supination-external rotation or pronation-external rotation ankle fracture (Lauge-Hansen classification) who were seen in the emergency room of the University of Chicago Hospitals were entered into a randomized study of the results of various methods of treatment. Ninety-six patients with satisfactory initial closed reduction were randomized between continued closed treatment in a plaster cast and open reduction with rigid internal fixation according to the techniques of the Association for the Study of Internal Fixation (ASIF). Forty-two patients with unsatisfactory closed reduction were randomized between open reduction with internal fixation of only the medial malleolus and open reduction with rigid internal fixation according to the ASIF techniques. Of the 138 patients who were admitted to the study, only seventy-one (51 per cent) could be followed for an average of 3.5 years (a typical return rate of urban trauma centers). The outcomes were evaluated by a scoring system that included clinical, anatomical, and arthritis scores. Statistical analysis of the data showed that, of the patients with initial satisfactory closed reduction, the ones treated by open reduction and rigid internal fixation had significantly higher total scores, particularly the patients who were more than fifty years old and those with a medial malleolar fracture. The small number of patients with unsatisfactory closed reduction who were treated by one of the two types of open reduction and internal fixation and were available for follow-up precluded drawing any conclusions about the superiority of one method of internal fixation over the other in that group. The difference in the talocrural angle between the injured and normal sides was the only statistically significant radiographic indicator of a good prognosis.