Types Of Ankle Fractures Research Articles

A Retrospective Cohort Analysis Comparing the Costs of Ankle Fracture Fixation in Orthopaedics and Podiatry in a U.S. Medicare Limited Data Set.

Increasing overlap exists between surgeries performed by podiatrists and orthopaedic surgeons. Large-scale cost comparisons between the two are lacking despite the current climate of cost containment in health care. Using national Medicare data, we aimed to compare per-case Medicare payments between podiatrists and orthopaedic surgeons for ankle fracture fixation. This retrospective cohort study included patients in an outpatient setting undergoing either unimalleolar, bimalleolar, or trimalleolar ankle fracture repair from the national Medicare Limited Data Set (2013-2019). Type of surgeon (podiatrist or orthopaedic surgeon) was determined using publicly available information. The primary outcome was total Medicare payments specific to the procedure, as a surrogate for cost. A subset analysis was also done to directly compare costs of orthopaedic surgeons to podiatric surgeons while excluding other fees (eg, hospital facility fees and surgery-related imaging payments). Additionally, patient demographics and hospital characteristics were compared to determine if any factors associated with costs may influence group differences. Univariable tests assessed significance of group differences. Overall, 16 927 unimalleolar, 17 244 bimalleolar, and 11 717 trimalleolar fracture repairs were included; 86.7% and 13.3%, 92.4% and 7.6%, and 92.2% and 7.8% were performed by an orthopaedic surgeon or podiatrist, respectively. Median age (70-71 years) and median Charlson-Deyo Comorbidity Index (0) did not significantly differ between patients treated by either surgeon type. Median procedure-specific Medicare payments for all 3 categories of ankle fracture repairs (uni-, bi-, trimalleolar) were significantly lower for orthopaedic surgeons compared to podiatrists: $4156 vs $4300, $4205 vs $4379, and $4396 vs $4525, respectively (all P < .001). Our investigation using a national Medicare data set (2013-2019) found that the 3 types of ankle fractures (unimalleolar, bimalleolar, and trimalleolar) performed by orthopaedic surgeons in an outpatient setting were less expensive and that cost differences do not appear to be driven by patient characteristics. These results and further research into the causes of the cost differences may help improve the cost-effectiveness of ankle fracture surgery.

Outcomes of surgical management of ankle fractures in patients with diabetes

ObjectiveAnkle fracture surgeries among diabetic are common and can have fatal consequences and serious adverse outcomes. A target hemoglobin A1c (HbA1c) level <8% in all elective surgeries for patients with diabetes is suggested to minimize poor outcomes. We investigated the postoperative outcomes and complications among patients who underwent ankle fracture surgery using HbA1c level as a predictor value. MethodsThis retrospective cohort study was conducted at King Abdulaziz Medical City between January 2016 and December 2022 on all patients with diabetes who underwent open reduction and internal fixation and who had a documented HbA1c level. Radiological outcomes and complications were noted along with the levels of HbA1c and analyzed statistically. ResultsA total of 44 patients were included in the study: 29 women (65.9%) and 15 (34.1%) men. The most frequent ankle fracture type was bimalleolar (54.5%). HbA1c was elevated (54.5%) in patients. A significantly higher proportion of patients who had <8% HbA1c level had radiological union compared to patients who had ≥8% HbA1c level (p = 0.036). Patients who had elevated HbA1c level had more complications although it did not reach statistical significance (p > 0.05). Multivariate regression analysis showed that age and HbA1c level were the significant factors for an uncomplicated and successful ankle surgery. ConclusionPoor postoperative outcomes and complications are more common among patients with elevated HbA1c. This suggests that an elevated HbA1c level is associated with a poor treatment outcome. Determination of HbA1c levels may predict potential problems post ankle fracture surgery and improve management outcomes.

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

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

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

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

Patterns of Ankle Fractures Based on Radiographs and CT Images of 1000 Consecutive Patients.

The knowledge of different types of ankle fractures based on plain radiographs and computed tomography (CT) images can help improve patients' management. This cross-sectional study assessed the plain radiographs and CT images of 1,000 consecutive patients observed in an emergency department between March 2015 and March 2020. Fractures were labeled as uni-, bi-, or trimalleolar. Malleolar fractures were classified into medial, lateral, and posterior ones based on Herscovici, Danis-Weber, and Mason and Molloy classifications, respectively. Bi- and trimalleolar fractures, on the other hand, were categorized according to the Lauge-Hansen classification. This study included 1,000 patients with 1,003 ankle fractures. Of them, 901 were adults (mean±SD age: 41.6±16.7, male: 567 [62.9%]) with 904 fractures. In total, 53% of adult patients were 18 to 39 years old. Considering unilateral ankle fractures, the medial malleolar fracture was the most common unimalleolar fracture (62.6%), with Herscovici C being the most frequent subtype (65.3%). On the other hand, the most common type of lateral malleolar fracture was Danis-Weber type B (65.5%). There were also 209 (23.3%) bimalleolar and 114 (12.7%) trimalleolar fractures, 5.8% (16 fractures) of which could not be classified based on the Lauge-Hansen classification. Unimalleolar fractures were also observed in 87 (87.9%) children, with the medial malleolar fracture being the most common type (89.7%). Medial malleolar fractures were the most frequent malleoli in patients observed in the emergency department under study. Among bi- and trimalleolar ankle fractures, supination-external rotation and pronation-external rotation injuries were the most common patterns. The Lauge-Hansen classification was not applicable in 5.8% of bi- and trimalleolar fractures.

Radiographic Evaluation of Syndesmosis Stabilisation Using the TightRope System Versus Syndesmotic Screw Fixation for the Management of Ankle Fractures With a Syndesmotic Injury.

Background Ankle syndesmotic injuries represent complex orthopaedic injuries, commonly requiring open reduction and fixation. Several techniques have been described for fixation, with syndesmotic screwfixation being traditionally considered as the 'gold standard'. Among the relatively new techniques developed, the TightRope system stabilisation provides 'dynamic' stabilisation with promising results. We aimed to evaluate the radiographic performance of these two different surgical techniques in the management ofankle fractures with an underlying syndesmotic injury. Methods A total of 85 cases were included in the studyand were divided into two groups: syndesmotic screw fixation (48 cases) and TightRope system (37 cases). Patient demographics, type of ankle fracture and type of implant used were recorded for all the cases, andevaluation of the postoperative radiographs was performed for all. For all patients, the radiographic parameters assessed included the medial clear joint space (MCS), tibiofibular overlap (TFO), and anterior and posterior tibiofibular interval in order to calculate the anterior tibiofibular ratio (ATFR). Results Statistical analysis revealed no statistically significant differences in the radiographic parameters of the postoperative radiographs between the twogroups. However, in the syndesmotic screw group, a higher incidence of radiographic malreduction was seen, as indicated by the MCS and ATFR parameters, in comparison to the TightRope fixation group. An equal distribution of radiographic abnormal parameters was noted among the different types of ankle fractures included in the study (trimalleolar, bimalleolar and isolated fibula fractures with syndesmotic injury) with no obvious positive correlation noted (Pearson correlation test). Conclusion Both surgical techniques seem to provide adequate reduction of the syndesmosis, with no statistical significant differences detected from the radiographic evaluation of both groups. In our study though, the syndesmotic screw group was associated with a higher incidence of radiographic malreduction as indicated by the MCS and ATFR parameters. The TightRope system seems to have a lower rate of radiographic malreduction and provides an equally effective way of syndesmosis fixation based on a dynamic mode of stabilisation.

Disparity in sex in ankle fracture treatment

BackgroundLiterature has shown implicit bias in the treatment between non-operative and surgical treatment in patients with certain types of ankle fractures, which comprise 7.6% of all adult fractures. An understanding of any bias across all ankle fracture management may prove to be critical for the understanding of potential correlations between treatment methods and outcomes of patients with ankle fractures. Therefore, this study aimed to determine whether there is a sex-based bias in the operative and non-operative treatment of all ankle fractures. MethodsA retrospective study of 1175 adult patients with ankle fractures was conducted. Data extracted included sex, race, age, type of treatment (non-operative/operative), fracture type (displaced/non-displaced), fracture class, BMI, and length of hospital stay. Odds ratio (OR), Chi-squared, t-test, and Pearson’s correlation tests were used with p < 0.05 considered significant. ResultsThe study population consisted of 750 females (63.8%) and 425 males (36.2%). The study demonstrated a sex-based disparity in operative and non-operative treatment revealing that women are less likely than men to receive operative treatment for displaced ankle fractures (OR = 0.7, 95% CI: 0.5–0.9, p = 0.01). Of the 750 females, 417 (55.6%) underwent non-operative treatment, while 333 (44.4%) females had an operation. Of the 425 males, 204 (48%) had non-operative treatment, while 221 (52%) underwent operative treatment. The distribution of ankle fracture classes between both sexes was similar, suggesting fracture class did not influence the observed disparity. ConclusionOur results suggest sex correlates with the treatment type for ankle fractures, with women more likely to receive non-operative treatment for displaced fractures. As post-treatment outcomes often reflect the chosen form of treatment, it is imperative to determine if a disparity in sex explicates differences in clinical outcomes.

Technical note: Intraoperative ultrasound measurement for evaluating the stability of the inferior tibiofibular joint in patients with ankle fractures

ObjectivesInjury to the tibiofibular syndesmosis is a common complication of ankle fractures. Currently, it is challenging to determine the stability of the tibiofibular joint caused by ankle fractures during surgery. This study aims to establish a standardized method for dynamically evaluating the stability of the inferior tibiofibular joint under intraoperative ultrasound and assess its utility in surgery, thereby assisting in determining the necessity for fixation of the inferior tibiofibular joint after fracture reduction and fixation. MethodsThe stability of the inferior tibiofibular joint was assessed using an intraoperative ultrasonic external rotation stress test, with a torque set at 7.2 N·m. The measured parameters included the width of the inferior tibiofibular space in neutral (N) and external rotation (E) positions, stretch ratio (E/N), and injured/healthy side stretch ratio (I/H). Patients with Weber B or C type ankle fractures were selected as participants. ResultsFor the case with Weber C fracture, the N measurement was 4.22 mm after fracture fixation, while E measured 5.77 mm and E/N ratio was 1.37, which were larger than those on the healthy side (N: 4.17, E: 4.50, E/N:1.08), with an I/H ratio of 1.27. Intraoperative X-ray revealed instability of the inferior tibiofibular joint. After inserting a tibiofibular screw, the N measurement was 4.20 mm, while the E measurement recorded 4.32 mm, resulting in an E/N ratio of 1.03 and an I/H ratio of 0.95, indicating improved joint stability. For the Weber B fracture case, the N measurement was 3.55 mm after fracture fixation, while E measured 3.98 mm and the E/N ratio was 1.12, slightly lower than those on the healthy side (N: 3.94, E: 4.47, E/N: 1.13), with an I/H ratio of 0.99. The intraoperative X-ray revealed stability of the inferior tibiofibular joint. Therefore, no further fixation was performed on it. ConclusionStandardized intraoperative ultrasound stress test allows for real-time, dynamic assessment of the stability of the inferior tibiofibular joint after ankle fracture reduction and fixation, which can help guide the fixation of the inferior tibiofibular joint, thereby reducing the risk of postoperative traumatic arthritis.

Bilateral simultaneous rotational ankle fractures: case series and literature review

Bilateral Simultaneous rotational ankle injuries are rare entities with little number of cases reported in literature. Unlike axial type ankle fractures, they tend to happen as a result of pivoting trauma on the supportive limb. We conducted a case series and literature review of patients who presented with simultaneous bilateral ankle injuries and discussed their presentation and imaging. A total of Four cases in our institute and 6 separate cases reported in literature were found who sustained bilateral simultaneous rotational ankle fractures. There were 10 cases, nine of which were simultaneous and symmetrical ankle injuries. Injuries found were; Maisonneuve fracture, Tillaux fracture, Syndesmotic injury, Lauge-Hansen’s supination external rotation (SER), pronation external rotation (PER), supination adduction (SAD), and pronation abduction (PA). Four cases were presented in our institute over the last 10 years. A single case was asymmetrical in nature given the presence of an associated distal tibial metaphyseal fracture. Bilateral rotational ankle injuries are rare entity presenting simultaneously unlike axial type ankle fractures. When they present, they are likely caused by higher mechanism of injury than typical unilateral rotational ankle fractures. SER injuries are the most commonly found mechanism in both unilateral and bilateral ankle injuries.

Bone Morphology as a Determinative Risk Factor for Type of Ankle Fracture.

We investigated the relationship between ankle radiographic bone morphology and observed fracture type. We retrospectively reviewed patients who had visited the emergency department with ankle injuries between June 1, 2012, and July 31, 2018. Patients were treated with open reduction and internal fixation. Patients were grouped by fracture pattern. Group 1 consisted of isolated lateral malleolar fractures, and group 2 comprised bimalleolar fractures. Group 1 was further divided into subgroups A and B based on classification as Weber type B and C fractures, respectively. Four radiographic parameters were measured postoperatively on a standing whole-leg anteroposterior view of the ankle: talocrural angle (TCA), medial malleolar relative length (MMRL), lateral malleolar relative length (LMRL), and distance between the talar dome and distal fibula. One hundred seventeen patients were included in group 1-A, 89 in group 1-B, and 168 in group 2. The TCA and MMRL were significantly larger in group 2 than in group 1. Lateral to medial malleolar length ratio was also significantly different between the groups. However, there were no significant differences between the groups in terms of LMRL and the distance between the distal fibula tip and talar process. Between subgroups 1-A and 1-B, LMRL (P = .402) and MMRL (P = .592) values were not significantly different. However, there was a significant difference between groups in TCA and the distance between the distal fibula tip and talar process. The TCA, MMRL, and lateral malleolar length to medial malleolar length ratio were significantly higher in patients with bimalleolar fracture than in patients with isolated lateral malleolar fractures.

Анализ среднесрочных результатов оперативного лечения пациентов с нестабильными переломами лодыжек аппаратом Илизарова

Introduction The aim of the study was to analyze the functional results of surgical treatment in patients with unstable ankle fractures with the Ilizarov method (controlled retrospective cohort monocenter non-randomized study; Level of evidence II). Materials and methods Fifty-three patients, 15 males and 38 females, in the mean age of 48 years, with ankle fractures met the inclusion criteria. The patients were divided into three groups according to the principle of dominant lesion location and according to the number of damaged bone structures. The patients underwent surgical interventions comprising closed reduction and external fixation with the Ilizarov apparatus bridging the ankle and subtalar joints. The study period was 34.6 months after surgery. Functional outcomes were evaluated based on the data of the AOFAS questionnaire. Results The average AOFAS score for Weber type A fractures was 95.25 ± 6.84 (SD), 93.77 ± 6.85 (SD) for type B, and 93.57 ± 4.03 (SD) for type C. In the patients with isolated fractures of the lateral malleolus it was 93.44 ± 8.38 (SD), in bimalleolar fractures – 94.09 ± 6.41 (SD), and in trimalleolar fractures – 93.71 ± 6.39 (SD). There were no significant differences between the groups of patients with different (Weber) types of ankle fractures. There was tendency to worse outcomes in patients whose surgical treatment was carried out 7 days or more after the injury. Conclusion Ankle osteosynthesis with the Ilizarov apparatus in unstable ankle fractures demonstrates excellent mid-term (range, 2 to 4 years) functional outcomes. The number of damaged bone structures of the ankle joint and the location of the dominant injury are not predictors of an unfavorable outcome in unstable ankle fractures in case of definitive fixation with the Ilizarov apparatus. There is a tendency to worse functional outcomes in delayed surgical treatment if the time from injury to surgery is more than seven days.

Epidemiology of more than 50,000 ankle fractures in the Swedish Fracture Register during a period of 10 years

BackgroundDespite being one of the most common types of fracture, there is a lack of epidemiological studies involving ankle fractures of all kinds. Since 2012, the Swedish Fracture Register (SFR) has prospectively collected data on surgically and non-surgically treated ankle fractures. The aim of this study is to describe the epidemiology of ankle fractures between 2012 and 2022.MethodsAll ankle fractures registered in the SFR between 1 April 2012 and 31 March 2022 in patients aged 16 years or older were included. Information on age, sex, mechanism of injury, fracture classification according to AO/OTA and high- or low-energy trauma was retrieved from the SFR.ResultsDuring the study period, 56,439 patients sustained 57,443 ankle fractures. Women (61%) were more commonly affected than men (39%). The mean age at the time of injury was 55 years. Men were found to be younger at the time of injury compared with women. Women were found to sustain open fractures more frequently, whereas the men more frequently sustained high-energy trauma. The most common mechanism of injury for all ankle fractures and for each AO/OTA44 fracture group separately was a simple fall. A seasonal variation in ankle fractures was found, where the number of ankle fractures peaked during the between November and March.ConclusionsThis study presents the epidemiology of all AO/OTA types of ankle fractures. We have demonstrated that most ankle fractures are caused by a simple fall and occur during wintertime. Women are more commonly affected than men and are older at the time of injury. These findings indicate that age-related skeletal fragility, as well as an increasing risk of simple falls in the elderly, may be risk factors for ankle fractures. This study will contribute to the planning of primary prevention for ankle fractures.

Single lateral approach for open reduction and internal fixation of posterior malleolar fragment in Weber B rotational ankle fracture.

Ankle fractures involving the posterior malleolus are a relatively common injuries, but various surgical approaches are still being introduced, and the selection of an appropriate surgical method is still controversial. The aim of this study was to introduce the surgical method using a single lateral approach for open reduction and internal fixation for posterior malleolar (PM) fractures associated with Weber B type ankle fractures. In this retrospective study, the single lateral approach was used for osteosynthesis of the PM fracture with Weber B lateral malleolar fractures. A total of 40 patients were followed up at for least 12 months (mean, 23.3; range, 12-88). Clinical assessment was based on the Olerud and Molander score, Foot and Ankle Outcome Score, visual analog scale, and subjective patient satisfaction 1 year after surgery. The accuracy of reduction was evaluated as <1 mm of displacement on the lateral view of the postoperative radiographs. The mean Olerud and Molander ankle score was 85.6 ± 12.7 and the mean Foot and Ankle Outcome Score was 82.7 ± 15.9 at 1-year postoperatively. Acceptable reduction was achieved in 38 of 40 (95%) cases. During the follow-up period, arthritic change was observed in 1 case and limited range of motion was confirmed in 2 cases. There was 1 case of postoperative wound problem and no case of sural nerve injury. The single lateral approach is a relatively simple and convenient method that enables accurate reduction and minimizing complication for fixation of the PM fractures with Weber B lateral malleolar fractures.

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.

Minimum 5-Year Follow-up Results: CROSSBAT (Combined Randomised and Observational Study of Surgery vs No Surgery for Type B Ankle Fracture Treatment).

Isolated Weber B, AO (Association for the Study of Internal Fixation) type 44B ankle fractures with no fracture to the medial side are the most common type of ankle fracture and may be treated with internal fixation or without surgery.This study aimed to determine if surgery is superior to nonsurgical management for the treatment of these fractures after a minimum 5-year follow-up. Design: A pragmatic, multicenter, single-masked, randomized controlled trial with minimum 5-year follow-up. Setting/participants/interventions: Participants between 18 and 65 years with AO type 44B ankle fracture and minimal talar shift were recruited from 22 hospitals in Australia and New Zealand. Participants willing to be randomized were randomly allocated to undergo surgical fixation followed by mobilization in a walking boot for 6 weeks. Those treated nonsurgically were managed in a walking boot for 6 weeks. Outcome assessors were masked for the treatment allocation. Primary outcomes: Patient-reported ankle function using the American Academy of Orthopaedic Surgeons Foot and Ankle Outcomes Questionnaire (FAOQ) and the physical component summary (PCS) of the SF-12v2 General Health Survey at 12 months postinjury and at minimum 5 years post injury. Primary analysis was intention-to-treat. Of the 160 (80 surgical, 80 nonoperative) randomized patients included in the CROSSBAT analysis, 77 (40 surgical, 37 nonoperative) were followed up for repeat analysis at minimum 5-year follow-up (mean 7.3 years, range 5.1-8.9). This cohort demonstrated that surgery was not associated with clinically or statistically significant differences compared to nonoperative management for the FAOQ (51.7 vs 49.6; mean difference 2.1, 95% CI -2.1 to 6.2, P = .95), or the PCS (51.5 vs 49.1; mean difference 2.3, 95% CI -2.0 to 6.7, P = .54). The surgical cohort had a higher rate of any adverse events (odds ratio 3.7, 95% CI 1.2-11.6, P = .04). The results of this study suggest that surgical management is not superior to nonsurgical management in type B ankle (fibula) fractures with minimal talar shift over a 5-year period and is associated with increased adverse events. Level II, randomized clinical trial.

Arthroscopic-Assisted Minimal Invasive Surgery for Weber C Ankle Fractures: Comparation to Open Reduction Internal Fixation

Category: Trauma; Arthroscopy Introduction/Purpose: After acceptable reduction and internal fixation for ankle fractures, some patients regularly suffer from residual symptoms, presumably due to occult intra-articular injuries. Recently, arthroscopic-assisted technique for ankle fractures was introduced. However, there was no previous study that investigate the outcomes of arthroscopic-assisted minimal invasive surgery (MIS) for pronation type ankle fractures. The aim of this study was to compare the clinical outcomes after arthroscopic- assisted MIS surgery to conventional open reduction internal fixation (ORIF) for Weber C ankle fractures. Methods: Between 2016 and 2019, 86 patients with Weber C type ankle fractures with minimum 2 years follow up were included. Patients were sorted to 2 groups according to operation technique (MIS group (n=34): arthroscopic-assisted MIS, ORIF group (n=52): conventional ORIF). In MIS group, fibula fractures were fixed using fibula nail. Medial and posterior malleolus fractures were fixed using cannulated screw arthroscopically assisted with pin point wound. Syndesmosis injury was treated with arthroscopic reduction and screw fixation. Intraarticular lesions such as loose body or osteochondral lesion of talus were removed or debrided arthroscopically. Clinical outcomes were compared using a visual analog scale (VAS), Foot and Ankle Outcome Score (FAOS). In addition, postoperative complications including posttraumatic arthritis were evaluated. Results: There were no significant differences between 2 groups in VAS, FAOS. There were 2 cases of postoperative infections and 4 cases of wound problems in ORIF group, but there was no complication in MIS group. There were 1 cases of obvious advanced posttraumatic arthritis in MIS group and 3 cases in ORIF group. Conclusion: Arthroscopic-assisted minimal invasive surgery was effective treatment option with low rate of wound problem in for Weber C ankle fractures.

Does the posterior approach offer advantages in short-term in trimalleolar ankle fractures?

Objective: The aim of this study was to compare the early (nine months after surgery) synthesis of the posterior malleolus by direct posterior (P) approach versus the percutaneous anteroposterior (AP) screw in trimalleolar ankle fractures to analyze the early clinical status of the patient (eight months) by studying the American Orthopedic Foot And Ankle Society (AOFAS) scale to compare postsurgical clinical recovery between both approaches, the rate of hospital days in both groups, the quality of joint reduction by computed tomography (CT) study and the rate of most frequent complications (fibular tendinopathy and surgical wound). Methods: A retrospective comparative study was performed between 2016-2020, including 94 patients with trimalleolar ankle fracture type 44-A/B/C (27 percutaneous AP surgical treatment and 67 P approach). Both groups were compared by analyzing demographic variables, clinical-functional status, radiological variables, and complications. Statistical analysis was performed using SPSS-20, with a p-value of 0.05 as significance. Results: Demographically, both groups were comparable, not finding significant differences between them. An increase in the days of admission before surgery was observed in the P approach with a mean of 4 (p=0.001). No significant clinical differences were found in the AOFAS scale, with a mean of 85 in both groups. Regarding the radiological result, a better reduction was observed with P approach (good=57, fair=9, poor=0) compared to the AP approach (good=10, fair=7, poor=9) (p=0.001). As for the complications, no significant differences were observed for the surgical wound. However, a higher need for fibular plate removal could be observed with P approach (n=17) (p=0.046). Conclusions: Clinically, both groups observed no significant differences through the AOFAS scale. The posterolateral approach has a higher rate of hospital days before surgery. Radiologically, a better joint reduction is achieved by a direct approach to the posterior fragment. Level of Evidence III; Retrospective Comparative Study.

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.

Quantitative initial safety range of early passive rehabilitation after ankle fracture surgery

BackgroundEarly rehabilitation training after ankle fracture surgery is critical to healing and avoiding complications. Inappropriate or excessive motion may impede healing or even lead to secondary injury. Currently, there is a lack of scientific quantitative postoperative rehabilitation methods after ankle fracture. Our purpose was to develop a universal method of quantifying early passive rehabilitation training after surgery by finite element (FE) analysis. MethodsA three-dimensional (3D) FE model of normal ankle was reconstructed from a computed tomography scan of a healthy male adult. Six types of ankle fractures were considered based on AO classification. We exerted joint motion load to explore the effect of movement on ankle joint mechanics after surgery. The corresponding relationship between the Inter-bone displacement and range of motion was measured to quantifying the ankle range of motion. The 44A3.3 fracture was used as an example to describe the implementation process in detail. ResultsDuring ankle movement, most of the stress was sustained by the internal fixation devices, and the ratio of stress borne by the implants ranged from 67.9 to 94.9%. Flexion/extension exercise did not cause extra stress on the ankle contact surfaces. Ligament traction was the reason for ankle load during flexion/extension motion. The range of early passive postoperative rehabilitation training for six types of ankle fractures (AO classification) were provided. ConclusionA quantitative method of early passive rehabilitation training after ankle fracture surgery was developed using FE analysis. This modeling method has universality for any fracture that can be reconstructed.

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.