Supination-external Rotation Fractures Research Articles

Assessment of the Biomechanical Effects of Hindfoot Alignment in Supination External Rotation Malleolar Fractures in a Cadaveric Model

Category: Trauma; Hindfoot Introduction/Purpose: Pressure distribution in the ankle joint is known to be dependent on various factors, including hindfoot alignment. We seek to evaluate how hindfoot alignment affects contact pressures in the ankle joint in the setting of supination external rotation (SER) type ankle fractures. Methods: SER fractures were created in 10 human cadaver lower extremity specimens, simulating progressive stages of injury: without fracture (step 0), SER fracture and intact deltoid ligament (step1), superficial deltoid ligament disruption (step2) and deep deltoid ligament disruption (step3). At each step, varus and valgus alignment was simulated by displacing the calcaneal tuberosity 7mm medial or lateral. Each limb was axially loaded following each osteotomy at a static load of 350N. The center of force (COF), contact area (CA), and peak contact pressure (PP) under load were measured, and x-rays of the ankle mortise were taken to analyze the medial clear space (MCS) and talar tilt (TT). Results: The COF (5.3mm, p=0.030) and the CA (-188.4 mm2, p=0.015) changed in step 3 in the valgus hindfoot alignment compared to baseline parameters, indicating the importance of deep deltoid ligament integrity in maintaining normal ankle joint contact stress in the valgus hindfoot. These changes were not seen in the setting of varus alignment (COF: 2,3mm, p=0.059; CA -121mm2, p=0.133). PP were found to not change significantly in either varus or valgus (varus:-4.9N, p=0.132;valgus:-4N, p =0.464). The MCS demonstrated widening in step 3 compared to step 2 (0.7mm, p=0.020) in both varus and valgus hindfoot. The TT increased significantly in step 3 in the valgus hindfoot (2.8°, p=0.020) compared to step 0. Conclusion: SERIV fractures with valgus hindfoot alignment showed significant changes in pressure distribution and radiographic parameters when compared to SER IV fractures with varus hindfoot alignment. Based on this cadaver modelling study, patients with SERIV fracture with varus hindfoot alignment and complete deltoid ligament lesion may not need fracture fixation, whereas those with valgus hindfoot alignment likely need fracture fixation. Results of the measurements of COF (center of force), CA (contact area), PP (peak contact pressure) MCS (medical clear space) in mm, TT (talar tilt) in degree in varus and valgus hindfoot alignment in the different steps. It shows the mean and (standard deviation)

Comparison of Prevalence of Arthroscopically Detected Intra-Articular Pathologies Between Supination and Pronation Type Ankle Fractures

Category: Arthroscopy; Ankle Introduction/Purpose: Ankle fractures are among the most common fractures of the lower extremity. Most unstable ankle fractures have good outcomes following operative fixation; however, residual pain and swelling are not uncommon despite anatomical bone reduction. Untreated associated injuries, including syndesmotic injury, deltoid ligament injury, and osteochondral injury, are potential causes for suboptimal outcomes. These pathologies are often underappreciated. The Lauge-Hansen classification is used to categorize fractures based on the mechanism of injury and thus has the potential to predict intra-articular pathology. To date, there is limited literature reporting the comprehensive prevalence of arthroscopically diagnosed intra-articular pathologies in acute ankle fractures based on the mechanism of injury. This study aims to report the prevalence of each intra-articular pathology between different fracture patterns. Methods: A retrospective database review was conducted on 203 patients with rotational ankle fractures who underwent arthroscopic-assisted open reduction and internal fixation for unstable acute ankle fractures between 2016 and 2023. Patients with open fractures, pilon fractures, delayed treatment, and children with open physes were excluded from the study. The patients were categorized into groups according to the Lauge-Hansen classification: Supination-Adduction (SA), Supination-External Rotation (SER), Pronation-External Rotation (PER), and Pronation-Abduction (PA). Syndesmotic injuries were determined by the arthroscopic drive-through sign with a 3mm shaver, while deltoid ligament injuries and osteochondral injuries were identified using arthroscopic visualization. Results: There were 3 patients (1.48%) with SA fractures, 143 patients (70.44%) with SER fractures, 6 patients (2.96%) with PA fractures, and 51 patients (25.12%) with PER fractures. The prevalence of arthroscopically diagnosed syndesmotic instability following malleoli fixation was extremely high in most fracture patterns except the SA mechanism (PER: 98.04%, PA: 100%, SER: 89.51%, SA: 33.33%). The prevalence of osteochondral injury was higher in pronation-type injuries than supination-type injuries (73.78% vs 53.9%, p=0.03). Deltoid ligament injury was found in 56.74% of SER fractures and 68.42% of PA/PER fractures. Conclusion: The prevalence of intra-articular pathologies in ankle fracture was higher in pronation-type injuries. However, the prevalence of these pathologies, especially syndesmotic instability, in SER fracture patterns was also alarming. The authors advocate for routine ankle arthroscopy simultaneously with ankle fixation to provide adequate treatment and predict prognosis.

Multivariate analysis of influencing functional recovery after ankle fracture of typeⅡand above supination-external rotation

To explore influencing factors of functional recovery after ankle fracture of typeⅡdegree and above supination-external rotation. Clinical data of 120 patients with ankle fractures of typeⅡdegree and above supination-external rotation admitted from February 2019 to April 2021 were retrospectively analyzed. According to American Orthopaedic Foot and Ankle Society (AOFAS), patients were divided into excellent group with 73 patients (90 to 100 points), good group with 35 patients (75 to 89 points), and fair group with 12 patients(<50 points). The differences of ankle active range of motion (ROM) and AOFAS score were compared among three groups at the latest follow-up. Multivariate Logistic regression analysis was performed to analyze the factors related to functional recovery after ankle fracture of supination-external rotation. There were significant differences in postoperative ROM (dorsoextension, plantar flexion, varus and valgus) and complications between excellent group and good and acceptable group (P<0.05). Univariate analysis showed there were differences in age above 50 years old, Ⅳ degree of supination-external rotation fracture, lower tibiofibular ligament injury, posterior ankle fracture, no drainage tube placed, infection, antibiotic use time above 7 days (P<0.05). Multivariate Logistic regression analysis showed age above 50 years old[OR=2.829, 95%CI(1.049, 7.628), P=0.040], Ⅳ degree fracture of supination-external rotation[OR=6.13, 95%CI(1.153, 32.593), P=0.033], lower tibiofibular ligament injury[OR=10.785, 95%CI(3.338, 34.894), P=0.000], and posterior ankle fracture[OR=6.349, 95%CI(1.869, 21.560), P=0.003] were independent risk factors for functional recovery after ankle fracture of supination-external rotation (P<0.05). The postoperative excellent outcome of ankle fracture was good, and the recovery of joint motion was better. The older age of patient, Ⅳ degree of supination-external rotation fracture, the lower tibiofibular ligament injury, and posterior ankle fracture are all adverse factors affecting functional recovery after supination-external rotation ankle fracture. In clinical, effective measures should be taken to deal with these influencing factors, and strive to improve the functional recovery after the operation of this type of fracture and reduce the occurrence of related complications.

Morphology of the proximal tibiofibular joint does not affect the type of lateral malleolus fracture and syndesmotic ligament injuries: A computed tomography-based study

IntroductionThe Proximal Tibiofibular Joint (PTFJ) is a synovial joint with anatomical variations located between the anteromedial surface of the fibula and the posterolateral facet of the tibia. These anatomical variations are believed to contribute to different biomechanical behaviors in both the knee and ankle joint and play a role in both physiological and pathological movements. Therefore, the morphology of the proximal tibiofibular joint may play a decisive role in the characteristics of ankle fractures and syndesmotic ligament injuries. Materials and methodsIn this retrospective comparative our CT database was searched between January 2015 and December 2022. Following inclusion criteria were used: Availability of knee CT scans for the fractured ankle, external rotation-type injuries (pronation external rotation and supination external rotation fractures). After applying the exclusion criteria (Plafond fractures, supination adduction and pronation abduction type fractures, pathological fractures, patients with previous fractures or surgeries around the knee, patients with previous fractures or surgeries around the knee, proximal tibiofibular arthrosis), 44 CT scans (mean age = 42.8 ± 14.1) confirmed eligible for further analysis. On each scan following measurements were performed: Coronal and sagittal PTFJ inclination angle, Joint obliquity, fibula head-tibia joint distance and tibia plateau-fibular axis angle. ResultsThe study consisted of 24 (54.5 %) male and 20 (45.5 %) female patients. According to the proximal fibular inclination, 29 cases (65.9 %) were of the oblique type, and 15 cases (34.1 %) were of the horizontal type. The distribution of PTFJ variations was as follows: 17 (38.6 %) concave, 4 (9.1 %) convex, 7 (15.9 %) atypical, and 16 (36.4 %) flat type. Regarding the PTFJ joint contour, the distribution was 13 (29.5 %) type a, 11 (25 %) type b, and 20 (45.5 %) type c. There was no relationship between measurements of PITFJ morphology and the type of ankle fracture and/or syndesmosis injury (p > 0.05). ConclusionPTFJ morphological features are not associated with rotational ankle fractures and syndesmotic ligament injuries.

Biomechanical Effects of Hindfoot Alignment in Supination External Rotation Malleolar Fractures: A Human Cadaveric Model.

Pressure distribution in the ankle joint is known to be dependent on various factors, including hindfoot alignment. We seek to evaluate how hindfoot alignment affects contact pressures in the ankle joint in the setting of supination external rotation (SER) type ankle fractures. SER fractures were created in 10 human cadaver lower extremity specimens, simulating progressive stages of injury: without fracture (step 0), SER fracture and intact deltoid ligament (step 1), superficial deltoid ligament disruption (step 2), and deep deltoid ligament disruption (step 3). At each step, varus and valgus alignment was simulated by displacing the calcaneal tuberosity 7 mm medial or lateral. Each limb was axially loaded following each osteotomy at a static load of 350 N. The center of force (COF), contact area (CA), and peak contact pressure (PP) under load were measured, and radiographs of the ankle mortise were taken to analyze the medial clear space (MCS) and talar tilt (TT). The COF (5.3 mm, P = .030) and the CA (-188.4 mm2, P = .015) changed in step 3 in the valgus hindfoot alignment compared to baseline parameters, indicating the importance of deep deltoid ligament integrity in maintaining normal ankle joint contact stress in the valgus hindfoot. These changes were not seen in the setting of varus alignment (COF: 2.3 mm, P = .059; CA -121 mm2, P = .133). PP were found to not change significantly in either varus or valgus (varus: -4.9 N, P = .132; valgus: -4 N, P = .464).The MCS demonstrated widening in step 3 compared to step 2 (0.7 mm, P = .020) in both varus and valgus hindfoot. The TT increased significantly in step 3 in the valgus hindfoot (2.8 degrees, P = .020) compared to step 0. SER-IV fractures with valgus hindfoot alignment showed significant changes in pressure distribution and radiographic parameters when compared to SER-IV fractures with varus hindfoot alignment. Based on this cadaver modeling study, patients with SERIV fracture with varus hindfoot alignment and complete deltoid ligament lesion may not need fracture fixation, whereas those with valgus hindfoot alignment likely need fracture fixation.

Patterns of Anterior Inferior Tibiofibular Ligament Avulsion Fracture Accompanied by Ankle Fracture

The anterior inferior tibiofibular ligament (AITFL) avulsion fracture accompanying an ankle fracture can compromise ankle stability, necessitating accurate evaluation and a clear understanding of its pathophysiology.. The aim of this study was to investigate the association between AITFL avulsion fracture and Lauge–Hansen, Wagstaffe classification. A retro-prospective study was conducted at a university-affiliated tertiary care medical center. We selected 128 patients who underwent surgery at our institution between January 2013 and July 2017 and analyzed the association between AITFL avulsion fracture and the foot position. According to the modified Wagstaffe classification system, there were 39 cases of type II, followed by 9 cases of type III and 8 cases of type IV. Of the7 pronation-abduction fractures, 3 were AITFL avulsion fracture (43%), while of the 21 pronation-external rotation fractures, 9 were AITFL avulsion fracture (43%). Of the 95 supination-external rotation fractures, there were 56 cases (59%) of AITFL avulsion fractures. Of the pronation fractures, 0% were fibular avulsion fractures and 43% were tibial avulsion fractures. Of the supination fractures, 44% were fibular avulsion fractures and 16% were tibial avulsion fracture. The difference in the ratio of fibular to tibial avulsion fractures between pronation and supination fractures was significant (p < .001). These results suggest that tibial avulsion fractures of type IV in the modified Wagstaffe classification and pronation fractures occur due to collision with the anterolateral corners of the distal bone when the talus externally rotates. Moreover, in cases of pronation fractures, a new type of AITFL avulsion fracture has been observed.

Patterns of Anterior Inferior Tibiofibular Ligament Avulsion Fracture Accompanied by Ankle Fracture

Category: Ankle; Trauma Introduction/Purpose: The anterior inferior tibiofibular ligament (AITFL) avulsion fracture accompanying an ankle fracture cause compromising ankle stability, and requires accurate evaluation and clarifies pathophysiology. The aim of this study was to investigate the correlation between AITFL avulsion fracture and Lauge–Hansen, Wagstaffe classification. Methods: 128 patients (70 males and 58 females) operated at the present institution between January 2013 and July 2017 were included. AITFL avulsion fractures occurred in 68 patients. Fracture was diagnosed based on the preoperative simple radiographs obtained of the ankle joint in the anteroposterior, lateral and mortise views. In cases wherein diagnosis was difficult using radiographs alone, CT was additionally used. AITFL avulsion fractures were classified based on the fracture site according to the Wagstaffe classification system. The anteroposterior and horizontal lengths as well as the height of the avulsed bone fragment were measured using CT scans in the coronal, sagittal and axial views. Thereafter, the relationship between the Lauge-Hansen classification of ankle fractures and the characteristics of AITFL fracture was statistically analysed using the Fisher exact test. Results: Type II of the modified Wagstaffe classification system was 39 examples, followed by type III (9 examples) and type IV (8 examples). Out of 7 pronation-abduction fractures, 3 were those of AITFL avulsion fracture, while out of the 21 pronation- external rotation fracture examples, 9 were those of AITFL avulsion fracture. Out of the 95 examples of supination-external rotation fracture, there were 56 examples (59%) of AITFL avulsion fracture. Of the pronation fractures, 0% was a fibular avulsion fracture and 43% were a tibial avulsion fracture. Of the supination fractures, 44% were a fibular avulsion fracture and 16% were a tibial avulsion fracture. The difference in the ratio of fibular and tibial avulsion fractures between the pronation and supination fractures was significant. (p &lt; 0.0001) Conclusion: Some of the AITFL avulsion fractures examined in this study may have been caused by collisions with the talus rather than the traction of the AITFL. Although Wagstaffe fractures accompanied by a supination–external rotation-type fracture results from the traction of the AITFL, a tibial avulsion fracture in a patient with a modified Wagstaffe type 4 fracture and a supination fracture appears to result from a continuous external rotation and repeated collisions of the talus with the anterolateral corner of the distal tibia.

Role of the posterior deep deltoid ligament in ankle fracture stability: A biomechanical cadaver study

The deltoid ligament is a key component of ankle fracture stability. Clinical tests to assess deltoid ligament injury have low specificity. In supination external-rotation (SER) type-IV ankle fractures, there is either a medial malleolus fracture or deltoid ligament injury. These injuries are often considered unstable, requiring surgical stabilisation. We look to identify the anatomical basis for this instability. This study investigates the anatomical basis for such instability by re-creating SER type ankle fractures in a standardised cadaveric study model, investigating the anatomical basis for such instability. To investigate the anatomical basis for fracture instability in SER type ankle fractures. Four matched pairs of cadaveric limbs were tested for stability both when axially loaded and under external rotation stress. Four matched pairs of cadaveric limbs (8 specimens) were tested for stability when axially loaded to 750 N with a custom rig. Specimens were tested through increasing stages of SER injury in a stepwise fashion before restoring the lateral side with open reduction and internal fixation (ORIF). Clinical photographs and radiographs were recorded at each step. We defined instability in accordance with well accepted radiological parameters: > 4 mm medial clear space opening on a mortise-view radiograph or > 7 degrees of talar tilt. All specimens with an intact posterior deep deltoid ligament were stable. Once the posterior deep deltoid ligament was sectioned there was instability in all specimens. Stabilisation of the lateral side prevented talar shift, but not talar tilt. If the posterior deep deltoid ligament is intact then SER fractures can be managed without surgery. If the posterior deep deltoid is incompetent, ORIF and cautious rehabilitation is recommended because the talus can still tilt in the mortise.

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

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

Anterior Malleolar Fractures: Pathoanatomy, Classification and Treatment Options

Category: Trauma; Ankle Introduction/Purpose: The anterior distal tibial tubercle (Tillaux-Chaput tubercle) frequently fractures in the wake of malleolar fractures. It provides attachment to the anterior tibiofibular syndesmosis and may be considered a fourth or anterior malleolus (AM). In analogy to posterior malleolar fractures, AM fractures may extend into the tibial incisura and tibial plafond. We analyzed the pathoanatomy of AM fractures and associated injuries in ankle fractures in adults. Methods: Over a course of 9 years, 140 patients (average age 58.3 years) with 140 acute malleolar fractures (OTA/AO 44) involving the anterolateral distal tibial rim were analyzed with CT imaging. All components of the malleolar fractures were analyzed and classified. Fracture patterns were compared with those of all 1,379 patients treated for malleolar fractures at our institution during the same 9-year period. Patients with fractures of the tibial pilon (OTA/AO 43) and patients aged less than 18 years were excluded as the frequent anterolateral distal tibial fractures along the physeal growth plate in adolescents are beyond the scope of this analysis. Fractures were classified according to the most frequent patterns and possible treatment options. Results: Of the 140 AM fractures, 52.9% were classified type 1 (extra-articular avulsion), 35.7% type 2 (incisura and plafond involvement), and 11.4% type 3 (impaction of the anterolateral plafond). The fibula was fractured in 87.1%, the medial malleolus in 67.1%, and the posterior malleolus in 69.3%. Isolated AM fractures were seen in only 6 cases (4.3%). The severity of AM fractures correlated negatively with that of posterior malleolar fractures (p&lt;0.001). The proportion of pronation-abduction fractures increased and the proportion of supination external rotation fractures decreased with increasing severity of AM fractures (p=0.055). Fractures involving the AM had a prevalence of 12.6% of all ankle fractures and occurred significantly more frequently in pronation-type injuries (p&lt;0.001). No supination-abduction fractures were seen with AM involvement. The interclass correlation coefficient for the proposed classification of AM fractures was 0.961 (95% CI 0.933-0.980) for interobserver agreement and 0.941 (95% CI 0.867-0.974) for intraobserver agreement. Conclusion: Knowledge of the 3D pathoanatomy of AM fractures and associated injuries may help with surgical planning. CT imaging should be employed generously in the assessment of complex ankle fractures, particularly with pronation injuries. In analogy to posterior malleolar fractures, fixation of displaced AM fractures potentially restores syndesmotic stability, congruity of the tibial incisura thus facilitating fibular reduction and joint congruity at the anterolateral tibial plafond. Proposed treatment options include transosseous suture for syndesmotic avulsions (type 1), screw fixation for fractures involving the incisura and plafond (type 2), and elevation of the impacted plafond with buttress plating for type 3 fractures.

Malleolar Fractures - Indication for Nonoperative and Operative Treatment

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

Three-Dimensional Fluoroscopy Influence in Intraoperative Decision-Making Concerning Syndesmotic Reduction

Category:Ankle; TraumaIntroduction/Purpose:The use of intraoperative three-dimensional fluoroscopy to evaluate syndesmotic and articular reduction in ankle fractures is a relatively new tool demonstrating usefulness in the literature. It has been described that it can detect up to 32.7% of intraoperative malreduction. The objective of this prospective study is to observe if surgeons, when performing operative treatment in ankle fractures with three- dimensional fluoroscopy assistance, modify the syndesmotic reduction and/or fixation. The definitive syndesmotic reduction was assessed with bilateral ankle CT-scan postoperatively.Methods:Sixteen patients with ankle fracture and syndesmotic instability were analyzed. After malleolar and syndesmotic fixation, intraoperative three-dimensional fluoroscopy was performed. The surgeon then analyzed cross-sectional images to evaluate the reduction of the fracture and syndesmosis. In this scenario, the surgeon decided whether to make any changes in the reduction of the syndesmosis or in the configuration of the fixation strategy. Postoperative bilateral computed tomography was carried out to corroborate in detail if there was any syndesmotic malreduction.Results:Sixteen patients were included in this study (10 men) with a mean age of 40 years (range 25-60 years). 62% were supination-external rotation fractures according to Lauge-Hansen classification. Of all the patients evaluated, only 4 underwent any modification after performing intraoperative three-dimensional fluoroscopy. From the previous group, in 3 patients (19% of the total) there was a change in syndesmal reduction and in only one there was a change of any element of osteosynthesis. When evaluating syndesmal reduction with postoperative bilateral CT, there were 6 patients in the total group who presented syndesmal malreduction. In patients in whom a modification to syndesmal reduction was made, it persisted in 2 of the 3 cases.Conclusion:In our series, the use of intraoperative three-dimensional fluoroscopy did not motivate most surgeons to make changes in syndesmotic reduction, unlike other previously published studies. Even despite making changes in syndesmotic reduction, the percentage of patients who persists with poor reduction is considerable. In this study, the percentage of poor syndesmotic reductions was 32.7%. Despite being a figure that is within what is expected according to the literature, we consider that it is high even using intraoperative fluoroscopy as support.

Pathoanatomy of the Anterolateral Tibial Fragment in Ankle Fractures.

The anterior distal tibial tubercle provides attachment to the anterior tibiofibular syndesmosis. It may be considered a fourth, or anterior, malleolus (AM). Fractures of the AM may extend into the tibial incisura and tibial plafond. The purpose of this study was to analyze the pathoanatomy of AM fractures and associated ankle injuries. One hundred and forty patients (median age, 61.0 years) with a total of 140 acute malleolar fractures (OTA/AO 44) involving the anterolateral distal tibial rim were analyzed with computed tomography (CT) imaging. All components of the malleolar fractures were analyzed and classified. Fracture patterns were compared with those of all patients with malleolar fractures treated during the same 9-year period. Patients with fractures of the tibial pilon (OTA/AO 43) and patients <18 years of age were excluded. Of the 140 AM fractures, 52.9% were classified as type 1 (extra-articular avulsion); 35.7%, type 2 (incisura and plafond involvement); and 11.4%, type 3 (impaction of the anterolateral plafond). The fibula was fractured in 87.1%; the medial malleolus, in 66.4%; and the posterior malleolus, in 68.6%. An isolated AM fracture was seen in 4.3%. The size of the AM fractures correlated negatively with that of the posterior malleolar fractures. The proportion of pronation-abduction fractures increased and the proportion of supination-external rotation fractures decreased as the type of AM fracture increased. A fracture involving the AM occurred in 12.6% of all ankle fractures and occurred significantly more frequently in pronation-type injuries and elderly patients. No supination-adduction fractures with AM involvement were seen. The intraclass correlation coefficient for the proposed classification of the AM fractures was 0.961 (95% confidence interval [CI] = 0.933 to 0.980) for interobserver agreement and 0.941 (95% CI = 0.867 to 0.974) for intraobserver agreement. Knowledge of the 3D pathoanatomy of AM fractures and associated malleolar fractures may help with surgical decision-making and planning. CT imaging should be employed generously in the diagnosis of complex ankle fractures, in particular with pronation-type injuries. Depending on the individual 3D fracture pattern, fixation of displaced anterolateral distal tibial fragments potentially contributes to the restoration of joint congruity, tibiofibular alignment, and syndesmotic stability in complex malleolar fractures.

Closed Reduction for the Treatment of Grade IV Supination-External Rotation Fracture of the Ankle Joint: A Retrospective Analysis.

ObjectiveTo investigate the curative effect of closed reduction and external fixation in the treatment of grade IV supination‐external rotation fractures of the ankle joint.MethodsFifty‐six patients treated with closed reduction and external fixation from February 2016 to March 2020 were included in this retrospective study, all with sprains. After receiving nerve block anesthesia, the patient underwent closed reduction under C‐arm fluoroscopy, and the ankle joint was fixed in a dorsiflexion‐inversion position with casting and splints after the end of the fracture met the reduction standard by fluoroscopy. One week and four weeks after the reduction treatment, oblique axial and coronal MR scans of the ankle joint were performed to determine the degree of injury and healing of the inferior tibiofibular syndesmosis; anteroposterior and lateral X‐rays of the ankle joint (including the ankle acupoints) were regularly reviewed to observe the fracture alignment and healing. Combined with the images and physical examination, the patients were instructed to undergo ankle weight‐bearing rehabilitation training when they met the clinical healing standard, and at the last follow‐up, the Mazur ankle evaluation and grading system were used for evaluation. After the reduction, the images were evaluated according to the Leeds standard. The image healing of fracture was evaluated by callus growth criteria.ResultsThe follow‐up period of patients ranged from 11 to 58 months, with an average of 26.8 months. The clinical healing time was (8.51 ± 2.12) weeks. The excellent and good rating after reduction was 82.1%, and the excellent and good rating during clinical fracture healing was 73.2%, according to the Leeds imaging evaluation. According to the Mazur ankle evaluation and grading system, the excellent and good rating was 75.0%. Pairwise comparison of callus images at 4, 6 and 12 weeks showed statistically significant differences (P < 0.05), suggesting callus growth at different time periods. A total of 56 patients had anterior inferior tibial fibular ligament (AITFL) injuries (grade II‐III), among which 11 patients had AITFL injuries combined with grade II injuries of the interosseous ligament (IOL) and 4 patients had AITFL injuries combined with grade III injuries of the IOL.ConclusionsMost of the patients with grade IV supination‐external rotation fracture of the ankle joint had good prognosis after closed reduction and plaster combined with splint fixation. For patients with IOL injury who had poor prognosis, open reduction and internal fixation therapy is appropriate.

Lag Screw Trajectory in Supination-External Rotation Fractures: Does the Direction of the Fibula Lag Screw Have an Effect?

BackgroundThe fracture obliquity of supination-external rotation injury of the fibula is often amenable to lag screw insertion. The purpose of the study was to determine whether biomechanical differences exist between lag screws inserted from an anterior to posterior direction and from a posterior to anterior direction and the thickness of the anterior and posterior fibular cortices were correlated with biomechanical testing.MethodsTen cadaver fibulae were harvested and submitted to material testing following 3.5-mm cortical screw insertion from either an anterior to posterior direction or a posterior to anterior direction. Screw torsional insertion strength and axial pullout strength were measured. Computed tomography images of 40 consecutive patients undergoing preoperative planning for fractures excluding the fibula were examined to define fibular cortical thickness and correlate anatomic findings with the biomechanical testing.ResultsThe axial pullout strength of lag screws inserted from posterior to anterior was significantly greater than that of lag screws inserted from anterior to posterior (p < 0.05). Screw insertion torque measurements demonstrated a similar trend although the data did not reach statistical significance (p = 0.056). The anterior cortex of the distal fibula exhibited a radiographically greater thickness than that of the posterior cortex at the same level (p < 0.001).ConclusionsFor oblique fractures of the distal fibula, posterior to anterior lag screw insertion exhibited improved biomechanical properties when compared with a similar screw inserted from anterior to posterior. These results correlated with the thicker cortical bone present along the anterior fibula.

The Role of Deep Deltoid Ligament in Ankle Fracture Stability: A Biomechanical Cadaveric Study

Category:Ankle; Basic Sciences/Biologics; TraumaIntroduction/Purpose:Supination-external rotation (SER) injuries make up 80% of all ankle fractures. SER stage 2 injuries (AITFL and Weber B) are considered stable. SER stage 3 injury includes disruption of the posterior malleolus (or PITFL). In SER stage 4 there is either medial malleolus fracture or deltoid injury. SER 4 injuries have been considered unstable, requiring surgery. The deltoid ligament is a key component of ankle stability, but clinical tests to assess deltoid injury have low specificity. This biomechanical cadaveric study specifically investigates the role of the components of the deep deltoid ligament in the stabillity of SER ankle fractures.Methods:In the first phase of the study, three specimens were utilised to standardise dissection of the deltoid ligament and creation and fixation of SER ankle fracture. In phase two, four matched pairs (8 specimens) were tested using this standardised protocol (Figure1). Specimens were sequentially tested for stability when axially loaded with a custom rig with up to 750N. Specimens were tested with: ankle intact; lateral injury (AITFL and Weber B); additional posterior injury (PITFL); additional anterior deep deltoid; additional posterior deep deltoid; lateral side ORIF. Clinical photographs and radiographs were recorded at each stage. In addition, dynamic stress radiographs were performed after sectioning the deep deltoid and following fracture fixation to assess talar tilt in eversion.Results:All specimens behaved in an identical manner when subjected to this standardised protocol. When the posterior deep deltoid ligament was intact, the ankle remained stable when loaded and showed no talar tilt on dynamic stress test. Once the posterior deep deltoid ligament was sectioned, there was demonstrable instability in all specimens. Surgical stabilisation of the lateral side using standard technique with a plate prevented talar shift but not talar tilt. In adequately stabilised ankle specimens, there was no loss of fixation on axial loading.Conclusion:This biomechanical cadaveric experiment demonstrates that under the standardised test conditions, all SER fracture ankle specimens with an intact posterior deep deltoid ligament behaved as stable injuries. The posterior portion of the deep deltoid ligament is a crucial structure in conferring stability to SER stage 4 injuries. The clinical implication of this is that when the posterior deep deltoid ligament is intact, SER fractures may be managed without surgical intervention in a plantigrade cast. We also conclude that without immobilisation, the talus may tilt in the mortise risking long-term deltoid incompetence.

Systematic Review of Stress Radiographic Modalities Stability Assessment in Supination External Rotation Ankle Fractures.

Background:Isolated distal fibular fractures resulting from supination external rotation (SER) injuries without evidence of obvious talar shift on standard radiographs present a diagnostic dilemma for clinicians. The status of the deep deltoid ligament, the main stabilizer of the ankle joint, is assessed by an increase in medial clear space (MCS) on radiographs. Therefore, these injuries can be either stable or unstable. In recent years, considerable clinical and research efforts have been made to determine ankle stability following SER fracture. The purpose of this systematic review was to evaluate and compare the role of different stress radiograph modalities in assessing stability of the ankle with SER fractures with no obvious talar subluxation on standard radiographs.Methods:The electronic databases MEDLINE, EMBASE, Ovid, Cochrane Central, CINAHL, and Google Scholar were searched from January 2000 to January 2018 to identify literature relating to radiologic assessment of stability of SER ankle fractures.Results:Our literature search revealed 10 peer-reviewed articles that fulfilled inclusion criteria. This yielded a total of 698 patients. The systematic review found 3 broad categories of radiographic investigations in the assessment of ankle joint stability: external rotation (ER) stress radiographs, gravity stress views (GSV), and weightbearing (WB) radiographs. Proponents of WB radiographs have demonstrated how axial load can normalize ankle joint alignment in cases of proven instability. There was a consistently high grade of evidence for using a medial clear space (MCS) value of more than 4 to 5 mm to indicate an unstable ankle following SER fracture.Conclusion:In conclusion, the results of this systematic review support an MCS value of less than 4 to 5 mm as a good indicator of stability, regardless of choice of stress imaging modality. These patients can be allowed early weightbearing with expected good functional outcomes. Recent published literature favors WB stress radiographs as a reliable and safe technique for assessing stability in SER ankle fractures. However, it should be kept in mind that this is based on studies with relatively low grades of evidence.Level of Evidence:Level II, systematic review of variable quality studies.

Arthroscopic Reduction and Minimally Invasive Surgery in Supination–External Rotation Ankle Fractures: A Comparative Study With Open Reduction

To describe an algorithm for arthroscopic reduction and minimally invasive surgery (ARMIS) and compare the surgical outcomes with standard open reduction-internal fixation (ORIF) for the treatment of supination-external rotation (SER) ankle fractures. The inclusion criteria for this study were patients aged 16years or older, the presence of a unilateral SER fracture, and injuries less than 2weeks old. We retrospectively identified patients with SER fractures who underwent ORIF from January 2008 to December 2011 or ARMIS from January 2012 to December 2015. Data collected in December 2013 for the ORIF group and in December 2017 for the ARMIS group were compared. The algorithm for ARMIS was minimally invasive plating for lateral malleolar fractures first, followed by ankle arthroscopy for detection of syndesmotic injuries and then arthroscopic reduction of medial malleolar fractures or mini-open repair of the deltoid ligament. The talocrural angle, fibular length, tibiomedial malleolar angle, medial clear space, and tibiofibular clear space were measured radiographically. Functional evaluations included the visual analog scale pain score, American Orthopaedic Foot & Ankle Society ankle-hindfoot scales, and range of motion of bilateral ankles. Complications and reoperations were recorded for comparison. A total of 105 patients with SER fractures, 65 in the ARMIS group and 40 in the ORIF group, were included. Significantly lower incidences of complications (7.7% vs 27.5%, P= .006) and reoperations (1.5% vs 12.5%, P= .029) were found in the ARMIS group than in the ORIF group. More syndesmotic injuries were detected in the ARMIS group than in the ORIS group (80% vs 57.5%, P= .021). The visual analog scale pain score was significantly lower on day 3 postoperatively in the ARMIS group than in the ORIS group (1.96 ± 1.18 vs 2.83 ± 1.07, P= .027). The postoperative stay was shorter in the ARMIS group than in the ORIF group (3.66 ± 1.39days vs 4.46 ± 2.23days, P= .024). The operative time was longer in the ARMIS group than in the ORIS group (105.22 ± 27.13minutes vs 93.59 ± 22.79minutes, P= .038). A longer fluoroscopic time (0.43 ± 0.25minutes vs 0.17 ± 0.07minutes, P < .001) and a higher dose of irradiation (1,216.46 ± 603.99μGy vs 389.38 ± 217.89μGy, P < .001) were observed in the ARMIS group. No significant differences in radiographic measurements were found between the operative and nonoperative ankles in both groups. Our algorithm and the ARMIS techniques may be a safe, reliable, and effective option in the treatment of SER fractures. ARMIS achieves promising surgical outcomes with less early postoperative pain, a shorter postoperative stay, and lower incidences of complications and reoperations compared with ORIF. However, the operative time is longer and the irradiation dose is higher with the ARMIS techniques. Level III, retrospective comparative study.

Do weight bearing radiographs estimate the stability of an isolated distal fibula fracture?

Category: Trauma Introduction/Purpose: Differentiating stable isolated fibula fractures consistent with supination external rotation (SER) II ankle fractures from unstable SER IV fractures is essential in determining the need for surgical stabilisation. Stress radiographs are usually required to assess stability including gravity stress views (GSV) and external rotation views (ER). There is no clear consensus as to which modality is most useful to determine stability in a fracture clinic or emergency setting. In last, few years clinical uncertainty about the reliability has led researcher to focus on weight bearing radiographs (WB) .We aim to review recent literature regarding reliability of WB radiographs to estimate the stability of supination external rotation ankle fractures. Methods: A systematic review of the literature relating to radiological assessment of stability of supination external rotation ankle fractures was conducted according to PRISMA guidelines. The systematic review was prospectively registered with PROSPERO. It involved the following steps: Researching the question-Do weight bearing radiographs estimate the stability of an isolated distal fibula fracture? Setting inclusion and exclusion criteria-All English language articles published in the including any Randomised controlled trials (RCT’s) and cohort studies. Data collection)– A literature search of Medline (PubMed), the Cochrane Bone, Joint, and Muscle Trauma Group trial register, the Cochrane central register of controlled trials, Embase and CINAHL was undertaken. The grey literature was searched. Key terms ‘supination external rotation fracture’, ‘stability’. Other variations to the key words were ‘weight bearing’, “axial load”, ‘stress x-rays’, ‘systematic reviews’ and ‘meta-analysis’. Results: A total of six studies met the inclusion criteria including 601 patients. No previous systematic review on stress radiographs including weight bearing was published. All studies concluded weight bearing radiographs is an easy, pain-free, safe and reliable method to estimate stability of isolated distal fibula fractures. No serious concerns or complications were reported. Conclusion: The evidence base contained many methodological limitations and most of the evidence was either level III or IV, and so any conclusion drawn from the research must be done so with caution. The studies suggest that GSV overestimates the instability which should be assessed with studies should focus on randomized controlled trials with narrow range of clinically useful outcome measures.

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

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