Supination-external Rotation Research Articles

Talus Visualization in Ankle Fractures: How Much Are We Really Seeing?

Background:Despite appropriate care, a subset of patients with ankle fractures has persistent pain. This condition may be associated with intra-articular pathology, which is present up to 65% of the time.Purpose:To quantify how much of the talus is visible through an open approach to a standard supination external rotation bimalleolar ankle fracture as a percentage of the entire weightbearing surface of the talus.Study Design:Descriptive laboratory study.Methods:Standard ankle approaches to lateral and medial malleolar fractures were performed in 4 cadaveric ankles from 2 cadavers. Osteotomies were made to simulate a supination external rotation bimalleolar ankle fracture based on the Lauge-Hansen classification. The visible segments of talar cartilage were removed. The tali were then exhumed, and the entire weightbearing superior portion of the talus was assessed and compared with the amount of cartilage removed by an open approach. The mean of the data points as well as the 95% confidence interval were calculated.Results:Four ankle specimens from 2 cadavers were used for these measurements. The mean surface area of the talus was 14.0 cm2 (95% CI, 13.3-14.7 cm2), while the mean area visible via an open approach was 2.1 cm2 (95% CI, 0.5-3.6 cm2). The mean proportion of the talus visualized via an open approach was 14.8% (95% CI, 3.6-26.1%).Conclusion:These findings indicate that the true area of weightbearing talar surface visible during an open exposure may be less than what many surgeons postulate.Clinical Relevance:Only a small fracture of the talus is visible via an open approach to the talus during fracture fixation. This could warrant arthroscopic evaluation of these injuries to evaluate and treat osteocondral lesions resulting from ankle fractures.

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.

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.

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.

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.

Morphological study of CT image of posterior pilon variant fracture and its possible clinical significance.

The incidence of posterior pilon variant fractures has been underestimated. The purpose was to study the characteristics of posteromedial (PM) and posterolateral (PL) fragments in CT imaging of posterior pilon variant fractures, and to provide help for clinical diagnosis and treatment. CT imaging data of 109 cases of posterior pilon variant fractures in our hospital from January 2013 to December 2020 were retrospectively analyzed. According to Mason and Molloy classification, PM fragments were further divided into pilon subtypes and avulsed subtypes. The largest actual area of fragments in axial and sagittal were selected as the study plane, and the maximum axial lengths of X, Y and Z, α angle, β angle, fragment area (S1-7) and fragment area ratio (FAR1-4), interfragmentary (IF) angle, and back of tibia (BT) angle were measured. A total of 109 cases were included in this study, 61 of whom were pilon subtypes [90.16% were supination-external rotation (SER) injuries]. 48 cases were avulsed subtypes [81.25% were pronation-external rotation (PER) injuries]. Pilon subtypes were larger than avulsed subtypes in X, Y, Z, α2 Angle, β2 Angle, fragment area and ratio, and IF and BT angle (P < 0.05). There was no difference between α1 and β1 angle (P > 0.05). The morphology of pilon subtype was larger than that of avulsion subtype. According to fragment size, morphology, and injury mechanism, two fragments of pilon subtype should be anatomic reduction and fixation. However, the PL fragment of avulsion subtype should to be fixed, while PM fragment may only need conservative treatment.

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.

A prospective study of functional and radiological outcome of open reduction and internal fixation of malleolar fracture and associated complications

Background: Malleolar fractures are a kind of regularly seen fractures in orthopedic department. As with all intra articular fractures, malleolar fractures necessitate anatomical reduction and stable internal fixation.Objective: To study functional and radiological outcome of open reduction and internal fixation of malleolar fracture and associated complications and to study role of early mobilization and graded weight bearing.Materials and Method: This study prospectively evaluated clinical, radiological and functional outcome of 39 patients of malleolar fracture treated with open reduction and internal fixation at Madras institute of orthopaedics and traumatology, Chennai from May 2016 to May 2017. After open reduction, patients were followed clinically and radio logically at 6 weeks, 3 months and 6 months. After operative procedure, functional and radiological outcome was assessed using Baird and Jackson score system.Results: Majority were Supination-External Rotation injuries 19 cases. Most common implant used for medial malleolus fracture was 3.5mm cortical screw (84.6%) cases and for lateral malleolus semi tubular plate (64.1%). According to Baird and Jackson scoring system our results were excellent in 6 cases (15.4%), good in 22 cases (56.4%), fair in 8 cases (20.5%), poor in 3 cases (7.7%). Good results were observed in maximum patients, one patient developed infection and two patients developed ankle stiffness.Conclusion: Open reduction and internal fixation of malleolar fracture is necessary to achieve anatomical reduction of the fracture fragments, ankle mortise congruity, restoration of the length of the fibula and restoration of syndesmotic integrity. We recommend to apply POP cast to prevent equines deformity and to start early range of motion of ankle as early as possible in cast after making dorsal window cut for 1 month.

Diagnostic tools to evaluate ankle instability caused by a deltoid ligament rupture in patients with supination-external rotation ankle fractures: A systematic review and meta-analysis

AimSupination-external rotation (SER) ankle fractures account for the majority of ankle fractures and can be divided into stable or unstable fractures, based on the state of the deltoid ligament. The objective of this review was to appraise the available literature concerning diagnostic tools to evaluate deltoid ligament integrity in patients with SER-type ankle fractures. MethodsA comprehensive literature search of Pubmed and Embase was performed up to December 2020. The outcome measures were sensitivity, specificity and positive and negative predictive value of the diagnostic tools. A meta-analysis was performed to obtain an overview of sensitivity, specificity and area under the curve (AUC). The methodological quality of the articles was evaluated using Quality Assessment of Diagnostic Accuracy Studies. ResultsA total of 12 studies investigating tools for deltoid ligament rupture in patients with SER-type ankle fractures were included. The present study found sensitivity (and specificity) ranges of 0.20-0.90 (and 0.38-0.97) for clinical features, Magnetic Resonance Imaging (MRI) 0.57-0.85 (and 0.81-1.00), ultrasonography 1.00 (and 0.89-1.00), Malleolar Medial Fleck Sign (MMFS) 0.25 (and 0.99), conventional ankle mortise radiography 0.33-0.57 (and 0.60-0.94), gravity stress radiography 0.71-1.00 (and 0.72-0.88) and manual stress ankle radiography 0.65-1.00 (and 0.00-0.77). The largest AUC was found for ultrasonography, followed by MMFS, gravity stress radiography and MRI. ConclusionUltrasonography and gravity stress radiography seem the most accurate diagnostic tools to evaluate deltoid ligament integrity. To strengthen this conclusion, future research should use an identical reference test to ensure comparability of results. Nevertheless, present study is of high value to close the knowledge gap about which presently available diagnostic tool is to be preferred to evaluate deltoid ligament integrity in patients with SER-type ankle fractures.

The Effect of Syndesmotic Screw Level on Postoperative Syndesmosis Malreduction

Tibiofibular injury repair of ankle fractures may result in over-compression when performed via a partially threaded screw depending on its placed level. We aimed to examine the relationship between the screw level relative to the tibiotalar joint and syndesmosis malreduction in postoperative radiographs of ankle fractures treated with partially threaded screws. We retrospectively analyzed 129 patients who underwent surgery due to lateral malleolar fractures between 2011 and 2019. We measured the distance between the screw and the tibiotalar joint and stratified the patients per their screw level as either trans-syndesmotic or suprasyndesmotic. According to Lauge-Hansen, 83 cases were supination-external rotation type (64.3%), and the remaining were pronation-external rotation type (35.7%) injuries. We found postoperative syndesmosis malreduction in 20 cases (15.5%). Eight (6.2%) cases had medial clear space mismatch. As the distance of the screw to the joint increased, postoperative medial clear space values increased (rho: 0.190, p = .031). The relationship between postoperative syndesmosis mismatch and the level of the syndesmotic screw was statistically significant (p = .044). In syndesmosis repair with a partially threaded screw, as the distance of the screw from the joint increases, the over-compression caused by the screw may cause an increase in postoperative syndesmotic malreduction rates.

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.

Medial insufficiency in postoperative weight-bearing radiographs in supination-external rotation type 4 bimalleolar ankle fractures: is the Lauge-Hansen classification insufficient in predicting medial soft tissue damage?

Objectives: According to the Lauge-Hansen classification, supination external-rotation (SER) type 4 fractures should be accompanied by medial malleolar fracture or deltoid ligament injury. The aim of the study was to investigate medial insufficiency rates in postoperative weight-bearing radiographs in SER type 4 bimalleolar fractures. Methods: The files of the patients who were operated with the diagnosis of SER type 4 bimalleolar ankle fracture between 2017-2020 were evaluated retrospectively. Thirty-seven cases (15 males and 22 females) were included in the study. The data based on the evaluation of the weight-bearing radiographs of the patients taken in the postoperative 1st year were examined statistically. Results: The injury mechanism was sports injury in 17 (45.9%) cases, traffic accidents in 8 (21.6%) cases, falling in 9 (24.3%) cases, and falling from height in 3 (8.2%) cases. The preoperative tibiofibular distance was 6.05 ± 1.86 mm, and the postoperative tibiofibular distance was 4.19 ± 0.40 mm (p = 0.001). The preoperative tibiofibular overlap was 5.03 ± 2.93 mm, and the postoperative tibiofibular overlap was 8.62 ± 1.04 mm (p = 0.001). The postoperative medial clear space was 4.11 ± 0.57 mm. Postoperative medial clear space of 5 mm and higher was determined in 7 (18.9%) cases. Conclusions: In SER type 4 bimalleolar fractures with a large medial malleolar fragment fracture, weight-bearing radiographs may show an increase in medial clear space. This means that a medial malleolar fracture in bimalleolar fractures may be also accompanied by deltoid ligament injury. The Lauge-Hansen classification system may be insufficient to identify a medial ligament injury.

Répartition des traits de fracture malléolaire postérieure dans les fractures en supination et rotation externe

IntroductionSupination-external rotation ankle fracture is one of the most common fractures. Studies on the fracture line distribution of this fracture type are limited. The purpose of this study is to explore the distribution characteristics of intra-articular posterior malleolus fracture lines in supination-external rotation. HypothesisMost of the fracture lines are concentrated in a particular area. Material and methodsComputed tomography scans of a consecutive series of 70 ankle fractures of supination-external rotation were used for this study. The DICOM files were loaded into Mimics 16.0 for 3D reconstruction of the distal tibial articular surface. The intra-articular posterior malleolus fracture lines were identified after virtual fracture reduction. All the fracture lines were drawn on one picture of the distal tibial articular surface after standardization before a heat map was created based on the frequency of fracture lines. ResultsAlthough the distribution of posterior malleolus intra-articular fracture lines varied, most of them were concentrated in an arcuate zone. The ratios of the area of posterior fracture fragment to the total area of articular surface averaged 14.96 % (range, from 2.23 % to 38.45 %). They were most likely to enter the articular surface at 20.4 % of the tangent of the posterior edge in a standardized image and exit at 58.7 % of the tangent of the lateral edge. ConclusionsIn ankle fractures of supination-external rotation, most intra-articular posterior malleolus fracture lines may be distributed regularly in an arcuate zone of the articular surface. Level of proofV; descriptive research.

Fibula pro-tibia vs standard locking plate fixation in an ankle fracture saw bone model.

BACKGROUNDLocking plate fixation in osteoporotic ankle fractures may fail due to cut-out or metalwork failure. Fibula pro-tibia fixation was a technique prior to the advent of locking plates that was used to enhance stability in ankle fractures by achieving tri or tetra-cortical fixation. With locking plates, the strength of this fixation construct can be further enhanced. There is lack of evidence currently on the merits of tibia-pro-fibula augmented locking plate fixation of unstable ankle fractures.AIMTo assess if there is increased strength to failure, in an ankle fracture saw bone model, with a fibula pro-tibia construct when compared with standard locking plate fixation.METHODSTen osteoporotic saw bones with simulated supination external rotation injuries were used. Five saw bones were fixed with standard locking plates whilst the other 5 saw bones were fixed with locking plates in a fibula pro-tibia construct. The fibula pro-tibia construct involved fixation with 3 consecutive locking screws applied across 3 cortices proximally from the level of the syndesmosis. All fixations were tested in axial external rotation to failure on an electromagnetic test frame (MTS 858 Mini-Bionix test machine, MTS Corp, Eden Praire, MN, United States). Torque at 30 degrees external rotation, failure torque, and external rotation angle at failure were compared between both groups and statistically analyzed.RESULTSThe fibula pro-tibia construct demonstrated a statistically higher torque at 30 degrees external rotation (4.421 ± 0.796 N/m vs 1.451 ± 0.467 N/m; t-test P = 0.000), as well as maximum torque at failure (5.079 ± 0.694N/m vs 2.299 ± 0.931 N/m; t-test P = 0.001) compared to the standard locking plate construct. The fibula pro-tibia construct also had a lower external rotation angle at failure (54.7 ± 14.5 vs 67.7 ± 22.9).CONCLUSIONThe fibula pro-tibia locking plate construct demonstrates biomechanical superiority to standard locking plates in fixation of unstable ankle fractures in this saw bone model. There is merit in the use of this construct in patients with unstable osteoporotic ankle fractures as it may aid improved clinical outcomes.

Analysis of functional outcome following open reduction and internal fixation of closed bimalleolar fracture in adults

Aim: To analyse the functional outcome following operative treatment of bimalleolar fractures using Olerud and Molander Ankle Score. Material and Methods: 30 patients aged between 18-60 years with bimalleolar fractures who fulfilled the inclusion criteria were included in the study. All patients underwent surgical fixation of the fractures. Subjective assesment of persistent pain and swelling was done at 6 weeks post op. The follow-up assessment which consisted of objective (Olerud and Molander Ankle Score) evaluations, were performed at 3 months and 6 months postoperatively. Results: Out of 30 patients, the commonest injury pattern seen was supination external rotation followed by pronation external rotation. Statistically significant improvement in the mean olerud and molander ankle score from 3month post to 6 month post op at follow up. The mean Olerud and Molander Ankle Score was statistically significant 56.667±16.365 at 3rd month post-op and 78.5±17.722 at 6th month post-op. Conclusion: Operative treatment for ankle fractures results in good functional outcome postoperatively. Anatomical reduction of the fracture is associated with better functional outcome.

Antiglide plating for distal fibula fractures caused by supination-external rotation injury

Supination-external rotation type of fracture is the most common pattern of ankle fractures. Anatomical reduction of ankle is always desired and poor reduction usually leads to shortening of fibula, or alter the biomechanics of ankle leading to chronic pain as a result of failure of fixation always. Both lateral and antiglide plating of fibula achieve in accurate anatomical reduction of these fractures. But, maintaining the reduction until bony union is also required to avoid failure of hardware or non union. Antiglide construct enhances biomechanics strength of the fixation device due to its anti gliding effect of the applied plate upon weight bearing and thereby is more favourable. This study evaluated clinical outcomes and complications seen in fixations done by antiglide technique done during 2018-2021 among patients admitted with SER pattern injuries at our institute. A total of 24 patients were included in the study. Mean operative time in the study group was 57.5 ± 27.4 (range 20–120) minutes. The most commonly used plates were five-hole plates in 10 (42%) patients, six holed plates in 10 (42%) patients and seven holed in 4 (16%) patients. The median number of screws distal to the fracture line in the antiglide plate was 0.5 (range 0–2); 10 (50%) fibulas with no fixation, 8 (40%) with one and 2 (10%) with two screws. The AOFAS in the antiglide group performed at one year after surgery was 94.5 ± 6.0 (range 85–100).We conclude that the use of the antiglide plate in a posterolateral position, without using unreasonable distal screws, is an appropriate method of fixation in every short oblique lateral malleolus fractures occurring as a part of SER pattern injury of ankle.

Distribution of posterior malleolus fracture lines in ankle fracture of supination-external rotation

IntroductionSupination-external rotation ankle fracture is one of the most common fractures. Studies on the fracture line distribution of this fracture type are limited. The purpose of this study is to explore the distribution characteristics of intra-articular posterior malleolus fracture lines in supination-external rotation. HypothesisMost of the fracture lines are concentrated in a particular area. Material and methodsComputed tomography scans of a consecutive series of 70 ankle fractures of supination-external rotation were used for this study. The DICOM files were loaded into Mimics 16.0 for 3D reconstruction of the distal tibial articular surface. The intra-articular posterior malleolus fracture lines were identified after virtual fracture reduction. All the fracture lines were drawn on one picture of the distal tibial articular surface after standardization before a heat map was created based on the frequency of fracture lines. ResultsAlthough the distribution of posterior malleolus intra-articular fracture lines varied, most of them were concentrated in an arcuate zone. The ratios of the area of posterior fracture fragment to the total area of articular surface averaged 14.96% (range, from 2.23% to 38.45%). They were most likely to enter the articular surface at 20.4% of the tangent of the posterior edge in a standardized image and exit at 58.7% of the tangent of the lateral edge. ConclusionsIn ankle fractures of supination-external rotation, most intra-articular posterior malleolus fracture lines may be distributed regularly in an arcuate zone of the articular surface. Level of proofV; Descriptive research.

Study on functional outcome of bimalleolar ankle fractures treated by open reduction and internal fixation

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Ankle injury is the most common weight bearing orthopaedic musculoskeletal trauma encountered in emergency medicine and practice. Ankle joint is highly congruous and any disturbance of normal articular relationship may result in some progressive arthrosis of biomechanical dysfunction. As with all intra-articular fractures it necessitates accurate reduction and stable internal fixation. The objectives were to study the functional outcome of surgical treatment of bimalleolar ankle fractures and to know the complications of open reduction internal fixation of bimalleolar fractures.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; 45 patients with malleolar fractures were included in this prospective longitudinal interventional study. Patients who underwent operative treatment were followed up regularly for 6 months with OPD visits and X-ray imaging at each stage. Patient parameters were recorded at immediate post op period, 6 weeks, 12 weeks and 24 weeks. Baird and Jackson scoring system for ankle were used for the functional outcome measurement.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Most common type of injury pattern was supination-external rotation with 21 cases (47% of cases). The results are excellent to good in 65% of patients, 27% of patients had fair and 8% had poor result. Syndesmotic screw fixation was done with 4.5 mm cortical screw in 7 cases. Most common complication was surgical site infection in 3 cases (6.67%). 2 patients underwent implant removal due to unresolved infection at 3 months.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; The results of operative fixation were satisfactory in 90% of patients. Most of the complications were minor and resolved within three weeks.&lt;/p&gt;&lt;p class="abstract"&gt; &lt;/p&gt;

Case report of a Tillaux Chaput fracture in an adult having Becker muscular dystrophy with fracture of medial and posterior malleloli

Tillaux fractures are the avulsion of the distal tibial physis caused by the stress placed on the anterior tibio-fibular ligament, which are very rare in case of an adult. Due to severe swelling and overlapping of bones they are often missed in an innocuous looking X ray. Our case includes a 40 year old presented with severe pain and swelling of the ankle joint following trauma on a background history of Becker’s muscular dystrophy .While, the patient had proximal muscle weakness in lower limbs due to the comorbidity, Investigations also revealed the tillaux fracture with fractures of posterior and medial malleolus, which roughly outlines the injury mechanism to be of Supination-external rotation type. The objective of this publication is to highlight this unusual injury, to avoid incorrect diagnosis and its management which focuses on different challenges in achieving absolute reduction with early rehabilitation of the patient keeping in view of the existing co-morbidity. Keywords: Ankle injury, Adult Tillaux fracture, Chaput fracture syndesmotic injury, Tibiofibular ligament, Becker muscular dystrophy.