Supination-external Rotation Type Research Articles

Trauma

The June 2024 Trauma Roundup360 looks at: Skin antisepsis before surgical fixation of limb fractures; Comparative analysis of intramedullary nail versus plate fixation for fibula fracture in supination external rotation type IV ankle injury; Early weightbearing versus late weightbearing after intramedullary nailing for distal femoral fracture (AO/OTA 33) in elderly patients: a multicentre propensity-matched study; Long-term outcomes with spinal versus general anaesthesia for hip fracture surgery; Operative versus nonoperative management of unstable medial malleolus fractures: a randomized clinical trial; Impact of smoking status on fracture-related infection characteristics and outcomes; Reassessing empirical antimicrobial choices in fracture-related infections; Development and validation of the Nottingham Trauma Frailty Index (NTFI) for older trauma patients.

The Outcomes of Mini-Plate Fixation for Unstable Wagstaffe Tubercle Fracture, an Indirect Syndesmosis Injury in Rotational Ankle Fracture.

Background: Wagstaffe fracture constitutes an indirect injury to the AITFL and can precipitate syndesmotic instability. The prevailing fixation methods often involve the use of mini-screws or K-wires, with absorbable suture repair reserved for cases with small or comminuted fragments exhibiting instability. In this study, we devised a mini-plate fixation method capable of securing the fracture fragment irrespective of its size or condition. Methods: A retrospective chart review was conducted on patients who underwent surgery for ankle fractures between May 2022 and October 2023. The surgical technique involved direct fixation of the Wagstaffe fracture using mini-plate fixation. Radiologic evaluation was performed using postoperative CT images, and clinical outcomes were assessed using the OMAS and VAS. Results: Fourteen patients with an average age of 62.5 years were included. Most fractures were associated with the supination-external rotation type. The average preoperative OMAS significantly improved from 5.95 to 83.57 postoperatively. The average VAS score decreased from 7.95 preoperatively to 0.19 postoperatively. Conclusions: The mini-plate technique for Wagstaffe fractures exhibited dependable fixation strength, effective fracture reduction, a minimal complication rate, and judicious surgical procedure duration.

Open Reduction and Internal Fixation for Supination-External Rotation Type IV Ankle Fractures by Means of Anterolateral and Posterolateral Approaches.

The present study aimed to analyze and compare the efficacy of the anterolateral and posterolateral approaches for surgical treatment of supination-external rotation type IV ankle fractures. This retrospective study enrolled 60 patients (60 feet) with supination-external rotation type IV ankle fractures, including 30 patients (30 feet) treated by means of the anterolateral approach and 30 patients (30 feet) treated by means of the posterolateral approach. Postoperative clinical efficacy was compared between the groups based on operation time, intraoperative blood loss, postoperative complications, fracture healing time, visual analog scale scores, Short Form-36 Health Survey scores, and American Orthopedic Foot and Ankle Society scores. Comparisons between the two groups were performed using independent-samples t tests and analyses of variance. Intragroup differences were compared using paired t tests, and the χ2 test was used to compare categorical variables. All 60 included patients completed follow-up ranging from 12 to 18 months (mean duration, 14.8 ± 3.5 months). Although baseline characteristics were similar in the two groups, there were significant differences in operation time (86.73 ± 17.44 min versus 111.23 ± 10.05 min; P < .001) and intraoperative blood loss (112.60 ± 25.05 mL versus 149.47 ± 44.30 mL; P < .001). Although fracture healing time (10.90 ± 0.66 weeks versus 11.27 ± 0.94 weeks; P = .087) was shorter in the anterolateral group than in the posterolateral group, the difference was not significant. Postoperative complications occurred in one and three patients in the anterolateral and posterolateral approach groups, respectively. Visual analog scale scores were significantly lower in the anterolateral group than in the posterolateral group (1.43 ± 0.50 versus 1.83 ± 0.75; P = .019), although there was no significant difference in Short Form-36 Health Survey scores between the groups (73.63 ± 4.07 versus 72.70 ± 4.04; P = .377). However, American Orthopedic Foot and Ankle Society scores were higher in the anterolateral group than in the posterolateral group (80.43 ± 4.32 versus 75.43 ± 11.32; P = .030). Both the anterolateral and posterolateral approaches can achieve good results in the treatment of supination-external rotation type IV ankle fractures. Compared with the posterolateral approach, the anterolateral approach is advantageous for the treatment of supination-external rotation type IV ankle fractures given its safety and ability to reduce trauma, clear field of view revealed, and allow for exploration and repair of the inferior tibiofibular anterior syndesmosis within the same incision.

Comparison of Supination-Adduction Type 2 and Supination-External Rotation Type 4 in Bimalleolar Ankle Fractures: Does Partial Pylon Variant of Supination-Adduction Type Fracture Affect Functional Outcomes?

Supination-adduction (SAD) type injuries are pylon variant injuries and lie between partial intra-articular pylon fractures and rotational ankle fractures. We aimed to evaluate functional outcomes of SAD type 2 bimalleolar fractures in comparison to supination-external rotation (SER) type 4 fractures. We retrospectively reviewed data of 42 cases with SER type 4 and 20 cases with SAD type 2 injuries. Patients with a history of rheumatic disease, open fractures, pathologic fractures, nonbimalleolar fractures, neuropathic disease, and talus osteochondral lesion, and those operated on after greater than 72 hours because of skin lesion or managed with a two-stage surgical protocol after external fixation, were not included in the study. We compared these two groups in terms of the mean age, follow-up time, visual analog scale pain and American Orthopedic Foot and Ankle Society scores, Kellgren-Lawrence arthrosis classification, union time, and complications. The groups did not differ in terms of mean age (P = .115) and sex (P = .573). There was no significant difference in terms of union time between the groups (P = .686). American Orthopedic Foot and Ankle Society score was significantly higher in the SER group (91.2 ± 9.9) than in the SAD group (86.1 ± 13.2; P = .034). Visual analog scale pain scores were similar in the SAD (0.3 ± 0.92) and the SER (0.26 ± 0.7) groups (P = .897). Supination-adduction bimalleolar fractures may have worse functional outcomes in the intermediate term than do SER bimalleolar fractures, implying pylon variant fractures as a mechanism of injury. Supination-adduction bimalleolar fractures might be associated with a high rate of intra-articular cartilage impaction, resulting in varus deformity after surgery.

Conservative treatment of supination and external rotation for type Ⅲ and Ⅳankle fracture by bone setting

To explore curative effect of conservative treatment of supination-lateral rotation (SER) with type Ⅲ and Ⅳ ankle fracture by bone setting technique. From January 2017 to December 2019, 64 patients diagnosed with SER with type Ⅲ and Ⅳ ankle fracture were treated with manipulative reduction and conservative treatment (manipulation group) and surgical treatment with open reduction and internal fixation (operation group), 32 patients in each group. In manipulation group, there were 17 males and 15 females, aged from 15 to 79 years old with an average of (51.42±13.68) years old;according to Lauge-Hansen classification, there were 8 patients with supination external rotation type Ⅲ and 24 patients with type Ⅳ. In operation group, there were 13 males and 19 females, aged from 18 to 76 years old with an average of (47.36±15.02) years old;7 patients with type Ⅲ and 25 patients with type Ⅳ. Displacement of ankle fracture was measured by Digimizer software, and compared before treatment, 3 and 12 months after treatment between two groups. Lateral medial malleolus displacement, lateral medial malleolus displacement, lateral malleolus displacement, lateral malleolus displacement, lateral malleolus contraction displacement and posterior malleolus displacement were measured and compared between two groups. Mazur score was used to evaluate ankle joint function. All patients were followed up from 12 to 36 months with an average of (17.16±9.36) months. There were statistical differences in lateral medial malleolus displacement, lateral medial malleolus displacement, lateral malleolus displacement, lateral malleolus displacement, lateral malleolus contraction displacement and posterior malleolus displacement in manipulation group before and after reduction(P<0.05). Compared with operation group, there were no statistically significant differences in lateral malleolus shift, lateral malleolus shift, lateral malleolus contraction shift(P>0.05), while there were statistically significant differences in lateral malleolus shift, posterior malleolus shift up and down (P<0.05). Mazur scores of ankle joint at 3 months after treatment in manipulation group and operation group were 68.84±13.08 and 82.53±7.31, respectively, and had statistical differences(P<0.05), while there was no difference in evaluation of clnical effect(P>0.05). There were no differences in Mazur score and evaluation of clnical effect between two groups at 12 months after treatment (P>0.05). Bone setting technique could effectively correct lateral displacement of medial malleolus, lateral displacement of medial malleolus, lateral displacement of lateral malleolus and lateral contraction displacement of lateral malleolus in supination lateral rotation type Ⅲ and Ⅳ ankle fracture, and has good long-term clinical effect, which could avoid operation for some patients and restore ankle function after fracture.

Morphology of Fibular Incisura is a Deciding Factor Between Posterior Malleolus Avulsion Fracture or Syndesmotic Ligament Injury in Ankle Fractures

The bone anatomy of tibiofibular syndesmosis has been a topic of interest. Fibular incisura morphology has been analyzed on cadaver specimens, plain radiographs, or CT images. The aim of this study is to examine the effects of fibula incisura features and fibula morphology in ankle injuries, especially involving posterior malleolus and posteroinferior tibiofibular ligament injuries. From 2017 through 2022, A total of 59 patients with isolated lateral malleolar fracture, Mason-Malloy type 1 posterior malleolar fracture, syndesmosis injury in those without posterior malleolar fracture, supination external rotation type 3 injuries according to Lauge-Hansen classification, and preoperative bilateral ankle computed tomography images were included in the study. Fibula morphologies and syndesmosis measurements were made from preoperative computed tomography images using axial CT images from 1 cm proximal to the tibial plafond. The diagnosis of posterior malleolar fractures was made using the CT classification system of Mason and Malloy, and the diagnosis of syndesmosis injury was made with a cotton test during surgery. Age, gender, fractured side, incisura type, incisor depth, width, anterior and posterior facet lengths, incisor version (antevert-retrovert), the angle between the anterior and posterior facets, and fibula type were recorded. There was a statistically significant difference between the groups in posterior facet length and incisura width. Morphological features of fibular incisura may be the determinant of PITFL injury or PMA injury in fibular fractures caused by an external rotation mechanism.

Lateral talar subluxation (LTS) in SER ankle fractures is more responsive than medial clear space widening: A cadaveric biomechanical study

Category: Ankle; Trauma Introduction/ Purpose: Supination-external rotation (SER) ankle fractures are characterized by posterolateral translation and external rotation. In isolated fibula fracture SER variants, medial soft tissue structure incompetence can be identified with medial clear space (MCS) widening or with lateral talar subluxation (LTS), frequently obtained on stress view imaging. This assessment is a key determination of which patients may require surgical management to restore ankle joint stability. Current radiographic studies demonstrated increased sensitivity and specificity of LTS versus MCS which may be due to increased rotational movement occurring in the direction of the talar displacement. Biomechanical data has not yet been established. The purpose of this study was to investigate MCS and LTS displacements in a cadaveric biomechanical study to confirm this rotational movement principle in a controlled setting. Methods: An open approach was utilized to surgically create an SER isolated fibula fracture in five below-knee cadaveric specimens. Open anteromedial and lateral ankle approaches were created for visualization of the medial and lateral structures, also allowing direct measurement of the MCS and LTS with a ruler. There was no ankle instability prior to injury, MCS and LTS were zero in each specimen prior to experimental model creation. An SER-pattern fibular osteotomy was made with an oscillating saw. The superficial and deep deltoid were then released from the medial malleolus, and the foot was displaced maximally creating an SER-4b variant ankle fracture. The MCS and LTS were then measured. Differences were analyzed using a paired Student’s t-test. Effect size (Cohen’s d) was measured to characterize statistical significance and determine relative importance in the degree of change. Results: There was no underlying ankle stability, deformity, or arthritis in any of the 5 cadaveric ankle specimens. In our simulated SER-4b ankle fractures, the mean MCS widening using medial landmarks was 7.2 mm (+/- 1.3mm). The mean lateral displacement utilizing the LTS landmarks was 11.2mm (+/- 1.3mm). The difference between medial and lateral displacement was found to be statistically significant (p = 0.0067, 95% CI [1.85, 6.15]). Cohen’s d was equal to 3.1 (95% CI [1.24, 4.90]), demonstrating a large effect size, showing the mean to be different by 3 standard deviations. The increase in mean lateral displacement was 43% greater when compared to the mean medial displacement. Conclusion: In this cadaveric study, LTS displacement was significantly greater than MCS widening following simulation of SER type IV ankle fracture injuries. The effect size of 3.1 confirms statistical significance. This data supports that talus external rotation is a significant factor in SER pattern displacement. The rotational moment arm is largest laterally with external rotation, and posterolateral displacement. Our study supports the idea of measuring the LTS radiographically as a marker to assist in surgical decision-making. Further characterization of the displacement pattern of SER injuries will be helpful to assist surgical decision- making in these common ankle injuries.

Biomechanical investigation of the effects of various treatment options on the talus in supination external rotation type 4 ankle injuries with ruptured deltoid ligament: Finite element analysis

Purpose: The purpose of this study is the biomechanical investigation of the rotation, stress and deformation caused in the talus, under a specific load, by various fixation methods in ankle which has supination external rotation (SER) injury and deltoid rupture.&#x0D; Method: Ankle of a healthy individual was analyzed with the help of a package program which was based on finite elements method (FEM). Then, SER injury model was created. Lateral malleolar plate was fixed with a screw and created different repair models for ankle fit. In the analysis section, forces obtained from the literature were applied to the healthy and repaired models. As the result of the analyses, mechanical values which occured in the talus were obtained.&#x0D; Results: As a result of this study, mechanical changes in talus, which were caused by, (in order) deltoid ligament repair, suture button syndesmosis fixation, syndesmosis fixation with transfixation screw, suture button fixation + deltoid ligament repair and transfixation screw + deltoid ligament repair in the SER type 4 injury model with deltoid ligament rupture, were evaluated.&#x0D; Conlusion: This study showed that the application of syndesmosis screw together with deltoid ligament repair in the treatment of SER type 4 ankle injuries with rupture of deltoid ligament made regression, displacement and talus rotations on the talus almost normal. In addition, syndesmosis fixation screw applications give better results than syndesmosis fixation suture button applications.

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.

Utility of Post-Splinting Conventional Radiographs in Adult Patients With Ankle Fractures Presenting to the Emergency Department.

Post-splinting radiographs are often performed in patients with ankle fractures to identify displacement that potentially occurs during splinting. The objective of this study was to investigate the significance of post-splinting conventional radiographs, with an emphasis on stable ankle fractures, not requiring reduction. A retrospective study in which all adult patients presenting with ankle fractures to the emergency department of a level 1 trauma center were included. The primary outcome was frequency of displacement at post-splinting radiographs. Secondary outcome was the rate of successful reduction attempts. A total of 225 patients were included and the majority had a Supination-External Rotation (SER) type 2 or Weber B ankle fracture. One hundred fifty patients (mainly SER 2 fractures [68%] or Weber B [89%] fractures), were treated with a splint without fracture reduction. Post-splinting radiographs in these patients, as well as in all patients with a Supination-Adduction (SA) type 1 and 2 fractures, did not show loss of alignment. Post-splinting radiographs are probably not necessary in any SA and SER type 2 or Weber A/B ankle fractures without medical clear space widening or need for reduction as no loss of alignment occurred when applying a splint. IV-Case Series.

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

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

Predicting factors for better outcomes of stable supination external rotation type 2 ankle fractures

PurposeStable Weber B ankle fractures are treated by a walking boot for 6 weeks and bearing full weight through the boot as tolerated. The aim of the present study was to assess the outcome parameters of this treatment protocol, evaluate the efficacy of using the walking boot, and investigate any possible predicting factors that could affect the outcomes. MethodsAll the patients with stable Weber B ankle fractures, treated in our hospital between January 2018 and December 2018, were prospectively included to the study. The patients were evaluated clinically, and the patient-reported outcome measures data were collected at the 2 and 6 weeks post-injury. Chi square, Spearman's rho test, independent samples and paired sample t-tests were used for the monovariant analysis. ResultsA total of 128 consecutive patients (aged 52.2 ± 19.1 years) with supination external rotation type 2 fracture were finally included to the study. At the 2 weeks follow-up, the reported outcome measures scores were in moderate levels, but improved significantly at the 6 weeks follow-up (p < 0.0001). Multivariant analysis revealed that the ability to bear full weight without the boot at the 2 weeks after diagnosis was the only variable, which made statistically unique contribution to the foot and ankle disability index score at the 6 weeks (p = 0.005). ConclusionConservative treatment using a walking boot with advice to bear full weight of stable ankle Weber B fractures can bring to good functional outcomes. The ability to bear full weight without the aid of the walking boot at 2 weeks after diagnosis was the only significant predicting factor for better outcomes at 6 weeks after diagnosis.

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

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

Effectiveness of Standalone Weight-bearing Radiographs in Guiding the Management of Supination External Rotation Type Isolated Lateral Malleolar Fractures in Indian Population: A Prospective Clinical Study

Effectiveness of Standalone Weight-bearing Radiographs in Guiding the Management of Supination External Rotation Type Isolated Lateral Malleolar Fractures in Indian Population: A Prospective Clinical Study

Diagnosing Medial Ankle Instability with Gravity Stress, Weight-Bearing, and External Rotation Stress Ultrasonography: A Cadaveric Study

Category:Ankle; TraumaIntroduction/Purpose:Destabilizing injuries to the deltoid ligament have historically relied on radiographic stress examination for diagnosis, with a focus on medial clear space (MCS) widening. Increasingly, Portable ultrasound (P-US) has increasingly been used in the clinical setting, allowing dynamic and non-invasive evaluation at the point of care. This study aims to determine whether the P-US assisted MCS evaluation during the gravity stress (GST), weight-bearing, and external rotation stress test can detect medial side instability in supination-external rotation (SER) type ankle injuries with sequential disruption of the anterior inferior tibiofibular ligament (AITFL) (stage I), the fibula (Weber B fracture) (stage II), the posterior inferior tibiofibular ligament (PITFL) (stage III), the superficial deltoid ligament (stage IVa) and the deep deltoid ligament (stage IVb).Methods:Ten fresh-frozen cadaveric specimens were used. Medial ankle instability was assessed by the P-US. The assessment was performed with all structures intact and later with sequential transection of the AITFL, Weber-B fibular fracture, the PITFL, the superficial and deep deltoid ligament. In all scenarios, three loading conditions were considered, including the GST, the external rotation stress test (45N), and the simulated weight-bearing (750N). The P-US measurement of the MCS was assessed at the anteromedial aspect and inferomedial aspect of the ankle joint. Three different MCS distances were measured, as demonstrated in Figure 1. To investigate the correlation between the P-US measurements and the staging of SER ankle injuries, a Spearman rank correlation was used. To detect a difference in MCS distances between each injured stage and the intact stage for each stress test, a Wilcoxon signed-rank test was used. P-values were adjusted for multiple comparisons using the Holm- Bonferroni method.Results:MCS values measured with the P-US increased as the SER ankle injury stage progressed. The Spearman's rank correlation coefficient ranged from 0.43 to 0.90 (p-values <0.001), which represent moderate to strong positive correlations between the ultrasonographic MCS measurements, and the sequentially created supination-external rotation ankle injury model. All MCS values measured with the P-US during; 1) the GST in neutral ankle position, 2) the GST in plantarflexed ankle position, 3) weight-bearing, and 4) the external rotation stress test, were significantly different between intact stage vs. stage IVb (p ranged from 0.02-0.03). When compared between SER ankle injury stage IVa vs. IVb, the P-US MCS values measured in SER stage IVb were significantly larger (p ranged from 0.005-0.03). Inter-rater (0.97; 95% confidence interval: 0.96-0.98) and intra-rater reliability (0.95; 95% confidence interval: 0.94-0.96) for the P-US MCS measurements were all substantial.Conclusion:Portable ultrasonography is a feasible tool for diagnosing medial ankle instability in SER ankle injury. The MCS measurements assessed with P-US during the GST, weight-bearing, and the external rotation stress test well correlated with the SER ankle injury staging. Besides, the P-US method is capable of differentiating the SER ankle injury stage IVb from the intact stage, as well as differentiating the stable SER ankle injury stage from the unstable stage. Therefore, the P-US can be a valuable diagnostic tool at the point of care due to its ability to dynamically evaluate suspect medial ankle instability in SER type injury.

A Comparison of Portable Ultrasonography and the Fluoroscopy for Evaluating Medial Ankle Instability: A Cadaveric Study

Category:Ankle; TraumaIntroduction/Purpose:Diagnosis of destabilizing deltoid ligament injuries remains challenging and is best identified with dynamic imaging techniques. This study aims to assess and compare medial clear space (MCS) distances in various stages of sequentially created supination external rotation (SER) ankle injury model using portable ultrasound (P-US) and fluoroscopy. We hypothesize that there is a strong correlation between the P-US and fluoroscopic measurements for the assessment of medial ankle instability in SER type ankle injury during the gravity stress test (GST), weight-bearing, or external rotation stress test.Methods:Ten cadaveric specimens were used for assessing medial ankle instability. The assessment was performed with all structures intact, and later with sequential transection of the anterior inferior tibiofibular ligament (Stage I), fibular (Weber-B fracture) (Stage II), posterior inferior tibiofibular ligament (Stage III), superficial deltoid ligament (Stage IVa), and deep deltoid ligament (Stage IVb). In all scenarios, the GST, external rotation stress test(45N), and Simulated weight-bearing condition(750N) were performed. The P-US measurement of the MCS was assessed at the anteromedial and inferomedial aspect of the ankle joint. Three different MCS distances were measured, as demonstrated in Figure 1. The fluoroscopic MCS measurements were assessed on a true mortise ankle view achieved during each loading condition. Spearman rank correlation was used to investigate the relationship between the P-US and fluoroscopic measurements. The inter- and intra-observer agreement was assessed using the intraclass correlation coefficient (ICC) through a two-way mixed-effects model with absolute agreement.Results:The P-US and fluoroscopic assessed medial ankle instability values during the GST, weight-bearing, and the external rotation stress test increased as the SER ankle injury stage progressed. The P-US values measured during all stress tests demonstrated a moderate to strong positive correlation with those measured with the fluoroscopy (Spearman's rank correlation ranged from 0.61-0.93, p-values <0.001). Inter-rater (P-US: 0.97, 95%CI: 0.96-0.98) and intra-rater reliability (P-US, 0.95, 95%CI: 0.94-0.96) for the P-US measurements were all substantial.Conclusion:The use of dynamic P-US to measure the MCS appears to be a reliable and repeatable technique. The P-US MCS measurement values measured in the SER ankle injury model during the GST, weight-bearing and the external rotation stress test are well correlated with those values measured with fluoroscopy. Therefore, the dynamic P-US with stress examination of the ankle has the potential to quantify medial ankle instability in a radiation-free, non-invasive, low cost, and point of care setting.

THE ASSOCIATION BETWEEN INJURY TO THE DELTOID LIGAMENT AND THE SIZE OF THE FRACTURED MEDIAL MALLEOLUS FRAGMENT

Aim: To determine if there is a relationship between the size of the fractured medial malleolus and deltoid ligament injury, as well as the occurrence of a deltoid ligament injury in bimalleolar supination-external rotation-type fractures. Methodology: Following a medical and radiographic identification of ankle fractures of the bimalleolar supination-external rotation type, 20 consecutive patients underwent magnetic resonance tests. Results: 11 (51%) of those with bimalleolar ankle fractures also had deltoid ligament injuries. Six patients (26.8%) had partial injuries, and three patients (23%) had complete injuries. In the absence of deltoid ligament damage, the average length of the medial fragment was 2.87 cm. On average, partial injuries measured 1.92 cm and complete injuries 2.0 cm. Conclusion: In 51% of ankle fractures caused by bimalleolar, the deltoid ligament was injured. The anterior colliculus and smaller medial malleolus fragments showed a stronger correlation with incomplete deltoid ligament damage.

Effectiveness of Gravity and Manual Stress Radiographs and the Use of Lateral Talar Displacement in Determining Ankle Stability of Supination-External Rotation Type Ankle Fractures.

(1) To evaluate adequacy and reproducibility of the gravity and manual stress imaging in the diagnosis of unstable ankle fractures and (2) to evaluate the diagnostic utility of lateral talar displacement ratio (LTDR) derived in relation to the talar body width on ankle stress imaging. Retrospective cohort study. Level 1 Trauma Center. One hundred seventy consecutive patients who presented with supination-external rotation 2 ankle fractures (OTA/AO 44-B2.1) requiring dynamic stress testing. Dynamic stress imaging to determine ankle stability. Ankle instability and subsequent need for surgical fixation as determined by dynamic stress imaging. No statistical significant difference was found between the adequacy of gravity stress radiographs and manual stress images in regards to surgical decision-making (P = 0.595). Using manual and gravity stress images, receiver operating characteristic curves were generated for medial clear space (MCS) (area under the curve = 0.793, 0.901) and LTDR (0.849, 0.850), corresponding to thresholds of 10.5% and 10.2% for manual and gravity, respectively. Seventy-three of 105 patients (69.5%) with MCS > 5 mm and 62 of 75 patients (82.7%) with LTDR > 10% were offered surgical intervention. Sixty-two of the 77 patients (80.5%) offered surgery had both MCS > 5 mm and LTDR > 10%. This study shows that manual stress radiographs are just as effective as gravity stress radiographs in making an assessment of ankle fracture stability as there was no difference in diagnostic value between gravity and manual stress imaging in regards to surgical decision-making. Use of additional radiographic measurements such as the LTDR can provide additional information in determining stability when MCS is within a clinical gray area. Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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

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

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

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