Supination-external Rotation Research Articles

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

Measuring Deltoid Insufficiency after Supination-External Rotation Ankle Fracture with Lateral Talar Subluxation on Gravity Stress View

Category: Trauma; Ankle Introduction/Purpose: Supination-external rotation (SER) variant ankle fracture is common, and identifying the unstable SER variants requiring surgery has been controversial. Stress view radiographs are frequently obtained to assist in decision-making. Measurement of the medial clear space (MCS) is used to determine medial structure integrity. SER variant ankle injuries are characterized by talus external rotation, and posterolateral translation causing a posterior displaced distal fibula fracture, with possible medial and posterior injury at further subluxation events. We propose that the MCS measurement is flawed by measuring from the point of rotational pivoting. Measurement of lateral displacement of the lateral talus versus the tibial plafond will be a more sensitive measurement tool for an injury mechanism characterized by external rotation and posterolateral subluxation. Methods: IRB-approved, retrospective review of ankle injury radiographs for acute SER-variant isolated lateral malleolar fractures during a 3-year consecutive period. Patients were included if they had a gravity-stress view (GSV) evaluation. Patients were excluded for different fracture morphology, pediatric fractures, no GSV films, or prior history of ankle or foot arthritis or trauma. A priori power analysis was performed demonstrating 32 patients would be required to detect a change in 2mm. 102 patients underwent analysis. GSV were analyzed with measurements taken of the medial clear space (MCS), superior clear space (SCS), and we propose two novel measurements of lateral talus subluxation (LTS) by comparison to the anterior ankle syndesmosis marked by a vertical line at the tibial plafond. Standardized measurements were acquired by foot-and-ankle fellowship-trained orthopaedic surgeons and musculoskeletal radiologists. ICC data was obtained. Surgeons separately provided blinded decisions- for-surgery which patients appeared to have ankle instability requiring surgical stabilization. Results: Measurements were performed for 102 patients, there were no significant differences in baseline demographics. There was a statistically significant increase in mean MCS, SCS, and LTS within the operative group (MCS 7.3 vs 5, p=0.005, SCS 4.6 vs 3.9, p=0.02, LTS 6.1 vs 2.9, p <0.001) with the LTS having the highest statistical significance. Pearson correlation analysis demonstrated positive and significant correlations between MCS and SCS (0.43, 0.37, P<0.001), MCS and LTS (0.51, p<0.001). MCS >=5mm had a sensitivity of 95% and specificity of 60% in our cohort, LTS >4mm demonstrating the same sensitivity (95%) with improved specificity to 75%. Receiver-operator-characteristic analysis for MCS vs LTS demonstrates an area under the curve (AUC) 0.786 for MCS >4 versus LTS (AUC) 0.918. Conclusion: The LTS measurement is superior to MCS measurement as a surrogate for medial ankle structure stability. We propose that ankle joint subluxation can be more accurately identified by measuring nearer to the point of maximal talar displacement in an external rotation and posterolaterally displacing injury pattern. The LTS measurement elevation >4mm was found to be superior to the MCS measurement >4mm in all categories, with high sensitivity and specificity, and superior performance in ROC analysis. We propose this will be a useful tool for clinicians when evaluating SER variant ankle fractures.

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<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<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.

MRI Findings in Patients with Discordant Results Between Gravity Test and Weight-Bearing Stress Views in Isolated Supination-External Rotation Fibular Fracture

Category: Trauma Introduction/Purpose: Medial and syndesmotic stability evaluation of isolated supination-external rotation fibula fractures (ISER) is critical to determine surgical conduct. However, there is no agreement on the best method to diagnose instability preoperatively. This problem is especially relevant in those with less than 2mm displacement in non-weightbearing radiographs. Different radiographic stress methods have been proposed: external rotation, weightbearing x-rays (WBx), and gravity stress radiographs (GSx). Likewise, the literature describes the use of ultrasound and magnetic resonance imaging (MRI) as complementary studies. To our knowledge, no studies have described the MRI findings in patients with discordant results between GSx and WBx views. Purpose: To analyze the imaging findings in WBx, GSx, and MRI in a consecutive group of patients with ISER with discordant results on stress views. Methods: For two years and prospectively, consecutive patients treated in a Level 1 trauma center were enrolled, performing the following imaging study protocol:- All patients with ISER fractures with a congruent tibiotalar joint on non-weightbearing radiographs underwent a bilateral WBx and GSx.- When there was a discordant result between WBx and GSx, MRI was taken. A retrospective analysis of the patients who had a complete study was carried out, considering the radiological findings and measurements. Measurements on radiographs were performed by six physicians (2 general practitioners, two trauma residents, and two ankle and foot subspecialists). One musculoskeletal radiologist analyzed the MRIs. The following parameters were measured, medial clear space (MCS), superior clear space (SCS), and tibiofibular clear space (TFCS). Inter-observer agreement in radiographs was analyzed using the intra-class correlation coefficient. Differences between groups were evaluated by t-student for independent samples, considering α <=5% significant. Results: Thirty-four patients were recruited. Interobserver agreement was good to excellent on all radiographic measurements. For all the measurements in the WBx, there were no significant differences between the injured and the healthy side. Average of MCS 2.51, SCS 3.07 and TFCS 3.74 mm for the uninjured side; and MCS 2.51, SCS 3.12, and TFCS 3.67 mm for the injured side. In the GSx, significant differences were observed for all measurements between the fractured and the healthy side. Average of MCS 3.55, SCS 3.85, and TFCS 3.89 for the healthy side; and MCS 5.87, SCS 4.25, and TFCS 4.44 for the injured side.100% of GSx and 0% of WBx met instability criteria (more than 2 mm compared to the healthy side). None of the MRIs showed a complete lesion of the deep deltoid ligament nor syndesmal complex. Conclusion: MRI did not demonstrate a complete deltoid nor syndesmal lesion in any patient with ISER fracture with normal WBx and altered GSx. A positive GSx does not correlate with MRI findings in patients with a non-displaced WBx study.

Measuring Deltoid Insufficiency After Supination-External Rotation Ankle Fracture With Lateral Talar Subluxation on Gravity Stress View.

Stress-view radiographs are frequently obtained to evaluate supination-external rotation (SER) variant ankle fractures. Measurement of the ankle medial clear space (MCS) is a surrogate of medial structure integrity as part of overall ankle stability. Measurement of the lateral talus displacement with respect to the incisura may be a sensitive and specific method to assess joint subluxation. Retrospective review of acute SER-variant isolated lateral malleolar fractures with gravity stress views (GSVs) were performed for 103 patients. GSV analysis was performed with standardized measurements of the MCS, superior clear space (SCS), and 2 new novel measurements of lateral talus subluxation (LTS). Decision for surgery was obtained by surgeons who reviewed masked injury radiographs for predictive performance analysis of the LTS vs MCS. MCS, SCS, and LTS measurements were performed on 103 patients. Mean MCS, SCS, and LTS within the operative group was increased. MCS ≥5 mm and LTS >4 mm had equal sensitivity (95%), with higher specificity for LTS (75% vs 60%). Receiver operating characteristic analysis demonstrates an area under the curve of 0.786 for MCS ≥5 mm vs 0.918 for LTS >4 mm. We found LTS to be superior to MCS for medial ankle structure stability on gravity stress views of SER-variant ankle fractures. We propose this as a useful tool for clinicians to consider when evaluating SER-variant ankle fractures. Level II, prospective comparative study of radiographs.

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.

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.

A systematic review of ankle fracture-dislocations: Recent update and future prospects.

BackgroundAnkle fracture-dislocations are one of the most severe types of ankle injuries. Compared to the simple ankle fractures, ankle fracture-dislocations are usually more severely traumatized and can cause worse functional outcomes. The purpose of this study was to review the previous literatures to understand the anatomy, mechanisms, treatment, and functional outcomes associated with ankle fracture-dislocations.MethodsThe available literatures from January 1985 to December 2021 in three main medical databases were searched and analyzed. The detailed information was extracted for each article, such as researchers, age, gender, groups, type of study, type of center research, level of evidence, significant findings, study aim, cause of injury, time from injury to surgery, type of fracture, direction of dislocation, follow-up, postoperative complications and functional evaluation scores.ResultsA total of 15 studies (1,089 patients) met the inclusion criteria. Only one study was a prospective randomized trial. The top-ranked cause of injury was high-energy injury (21.3%). Moreover, the most frequent type of fracture in ankle dislocations was supination-external rotation (SER) ankle fracture (43.8%), while the most common directions of dislocation were lateral (50%) and posterior (38.9%).ConclusionsCollectively, most ankle fracture-dislocations are caused by high-energy injuries and usually have poor functional outcomes. The mechanism of injury can be dissected by the ankle anatomy and Lauge-Hansen's classification. The treatment of ankle fracture-dislocations still requires more detailed and rational solutions due to the urgency of occurrence, the severity of injury, and the postoperative complications.

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.

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

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

The Anatomy and Function of the Individual Bands of the Deltoid Ligament-and Implications for Stability Assessment of SER Ankle Fractures.

Background:Deltoid ligament injury occurs often with supination-external rotation (SER) ankle trauma. SER fibula fractures with concomitant deltoid ligament injury are considered unstable—requiring operative fixation. Recent studies have questioned this general practice with emphasis on better defining the medial side ankle ligamentous injury. The function of the individual bands of the deltoid ligament, and the interplay between them, are not fully understood. We undertook this study to develop a better understanding of these complex ligamentous structures and ultimately aid assessment and treatment choice of SER ankle fractures with concomitant deltoid ligament injuries.Methods:Ten fresh-frozen cadaveric foot and ankle specimens were studied. We identified the various ligament bands and did a functional analysis by assessment of ligament length and tension at predefined angles of ankle dorsi-plantarflexion combined with valgus/varus and rotation. The results were determined by manual evaluation with calipers and goniometers, manual stress, and direct visualization.Results:We recorded primarily 5 different bands of the deltoid ligament: the tibionavicular (TNL; 10/10) tibiospring (TSL; 9/10), tibiocalcaneal (TCL; 10/10), deep anterior tibiotalar (dATTL; 9/10), and deep posterior tibiotalar (dPTTL; 10/10) ligaments. The tibiospring ligament was tense in plantarflexion, while the tibiocalcaneal and deep posterior tibiotalar ligaments were tense in dorsiflexion. The superficial layer ligaments and the deep anterior tibiotalar ligament length and tension were largely affected by changes in varus/valgus and rotation. The deep posterior tibiotalar ligament length and tension was altered predominantly by changes in dorsi-plantarflexion; varus/valgus positioning had a minor effect on this band.Conclusions:We confirmed the finding of previous studies that dorsi-plantarflexion affects the tensile engagement of the separate ligament bands differently. Likewise, combined movements with varus/valgus and rotation seem to affect the separate ligament bands differently. Our results suggest that the TNL, TSL, and dATTL are at risk of injury, whereas the TCL and particularly the dPTTL are protected in the event of an SER-type ankle fracture mechanism of injury.Level of EvidenceLevel V, cadaveric study.

Early Unprotected Weight Bearing and Pre-Scheduled Supervised Rehabilitation Program after Surgical Treatment of Ankle Fractures.

Ankle fractures represent one of the most common orthopedic injuries in the lower extremity. Weight-bearing and rehabilitation protocols after surgical treatment of ankle fracture have recently evolved from traditional methods to full weight-bearing protocols. However, more evidence is needed on unprotected immediate weight-bearing along with a standardized rehabilitation program. The purpose of this study was to evaluate effects of unprotected immediate weight-bearing as tolerated and an eight-week prescheduled supervised rehabilitation program on the mid-term clinical and functional outcomes of surgically treated ankle fractures, and to compare functional results with the unaffected side. Eighty patients (24F and 56M) who underwent rigid fixation of bimalleolar ankle fractures were included (mean age 41.57±13.22 years). Preoperative radiographs and computed tomography scans were used to evaluate and classify the fractures. The fractures were classified using Lauge-Hansen classification system. Ankle ROMs, Pain Disability Index (PDI), American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scores, and Short Form-36 scores were evaluated. Patients were allowed unprotected weight-bearing on the immediate postoperative period and a standardized supervised prescheduled rehabilitation program was undertaken following surgery. The mean follow-up period was 30.32±6.91 months. Based on Lauge-Hansen classification, supination-external rotation injuries were found in 32(40%) patients, supination adduction injuries in 14(17.4%) patients, pronation-external rotation injuries in 28(35%) patients, and pronation-abduction fractures in 6(7.6%) patients. The solid union was achieved in all patients at the final follow-up. The mean PDI score was 12.78±14.78, and the AOFAS score was 80.93±17.24. Although patients' health-related quality of life was at a good level, the injured-side ankle ROM was lower than the healthy side (p ≤ 0.05). Satisfactory clinical and functional outcome can be achieved at mid-term with unprotected weight-bearing as tolerated and pre-scheduled supervised eight-week rehabilitation program following rigid internal fixation of ankle fractures. However, this protocol is not studied in patients with associated comorbidities.

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

Combining Salter-Harris and Dias-Tachdjian could be better at determining the prognosis of distal tibial physeal fractures

ObjectivesThe aim of this study is determining the factors that affect prognosis of distal tibial physeal fractures (DTPF) and analyzing whether Salter-Harris (SH) or Dias-Tachdjian (DT) classification is more predictive for outcomes. MethodsPatients treated for DTPF were retrospectively analyzed. Fracture patterns were classified according to SH and DT. Treatment methods and fracture characteristics were noted. Distal tibial angles and joint irregularities were analyzed on patient's final ankle radiographs followed by American Orthopedic Foot and Ankle Score questionnaire. Results75 patients followed-up between 6 and 96 months meeting the inclusion criteria were evaluated. Joint irregularity was observed in 41.3% and partial premature physeal closure (PPC) in 34.7% of the patients. Lateral distal tibial angle (LDTA) and talocrural angle related deformity were detected in 20% and 14.7% of the patients, respectively. Partial PPC and joint irregularities that have been developed in pronation-eversion-external rotation and supination-inversion injuries (SH type 3, 4) were 62% and 50%, and 42% and 75%, respectively. On follow-ups of supination-external rotation injuries (SH type 2) joint irregularity has never been observed. Following supination-external rotation and supination-plantar flexion injuries, a low rate of partial PPC have been developed; LDTA related deformity was revealed at a high rate of 39.1% after supination-inversion injuries. There weren't any differences observed between the initial displacement, residual displacement or surgical technique and PPC, joint irregularity and angular deformities. Patients treated by ORIF technique had lower AOFAS scores than patients treated by other surgical techniques. ConclusionsIn this study it was revealed that SH classification system is not sufficient alone to determine the prognosis of DTPF, the injury mechanisms causing SH types might be also significant in prediction of the prognosis of DTPF.

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.

Dynamic Portable Ultrasound Cutoff Values for Diagnosing Medial Ankle Instability in Supination External Rotation Ankle Injury: A Cadaveric Study

Category:Ankle; TraumaIntroduction/Purpose:In the setting of an isolated lateral malleolar fracture, stability is predicated by whether the deep deltoid ligament is intact. Portable ultrasound (P-US) has also been used in the clinical setting, allowing dynamic and non-invasive evaluation at the point of care. This study aimed to determine the cutoff values, as well as its sensitivity and specificity for diagnosing supination external rotation (SER) ankle injury stage IVb (with complete deltoid ligament rupture) using the P-US.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. The P-US measurement of the MCS was assessed by placing the ultrasound probe perpendicularly to the medial gutter at the anteromedial aspect and inferomedial aspect of the ankle joint. Three different MCS distances were measured, as demonstrated in Figure 1. To determine the sensitivity and specificity of the diagnosis of SER injury type IV using the P-US, a receiver operating characteristic (ROC) curve analysis was performed.Results:The MCS optimal cutoff point to distinguish SER ankle injury stage IVb from other injury stages ranged from 10.4 to 13.8 during the GST, 4.2 to 7.9mm during the weight-bearing stress, and 10.6-17.9mm during the external rotation stress test (Table 1). All P-US cutoff values provided acceptable sensitivity (60-100%), specificity (84-100%), and the area under ROC curve (0.8-1.0) for diagnosing SER ankle injury stage IVb.Conclusion:MCS cutoff points assessed with the P-US under the GST, weight-bearing, and the external rotation stress test demonstrate high sensitivity and specificity for detecting SER ankle injury stage IVb. The cutoff values vary depending on which loading condition is being used. Additional clinical studies are necessary in the in vivo setting to better understand the implications of these test conditions.

Functional assessment of surgically managed ankle fractures

Background: Civilization has made man more prone to injuries. Ankle fractures are one of the most common injuries treated by orthopedic surgeons. Aims and Objectives: The aim of the study is to assess the functional outcome in surgically managed ankle fractures. Materials and Methods: Sixty patients were included in this study with ankle fractures that were surgically treated at NIMS Hospital, Hyderabad. Observations: The study had a male preponderance of 66.6%, with road traffic accidents being the major cause of injury. Supination-external rotation was the most common mechanism of injury and Weber's type B fractures were the most common type of fracture. The associated fractures and injuries noted and the comorbidities seen in these patients have been enumerated. Open reduction and internal fixation under image intensifier control was done in all patients. Postoperatively, patients were immobilized with a plaster splint for a period of 3–6 weeks and were followed up with full weight-bearing walking and active range of movement of ankle exercises. The final outcome as per the Weber's radiological criteria was 66.6% good, 26.6% fair, and 6.8% poor result which showed a good correlation between the immediate postoperative radiological score and the final radiological outcome. The factors that affected the final poor outcome were late presentation, patients with fracture subluxation, post massaging, the presence of long-standing and uncontrolled diabetes, and old age. Conclusion: The present study suggests that anatomical reduction of the ankle fracture and restoration of the joint congruity at the earliest will give a good functional outcome. The postoperative immobilization in a plaster slab up to 3–6 weeks (depending on associated injuries, fracture severity, bone quality, quality of fixation, and patient compliance) does not affect the final outcome with respect to achieving the ankle and subtalar range of movements as most of the patients had achieved full range of motion at the end of 12 weeks.