Types Of Ankle Fractures Research Articles

Are SER-II Ankle Fractures Actually Anatomic? Bilateral CT Demonstrates Subtle Non-Anatomic Mortise & Syndesmotic Alignment in the Setting of Apparent Normal Radiographs

Category:Ankle; TraumaIntroduction/Purpose:Current treatment of ankle fractures is predicated on 1-2 mm of talar shift leading to abnormal contact pressures. Determination of anatomic alignment has conventionally been based on plain radiographs. The ability of x-ray to detect subtle mortise displacement however is unknown. The purpose of this investigation is to determine if CT scan can detect malalignment undetectable utilizing plain radiography when assessing injuries assumed to have anatomic mortise alignment. The findings have implications for utilizing higher resolution diagnostic imaging to assess malalignment and challenging the validity of previous literature in which conclusions of anatomic mortise alignment were determined based on plain radiography.Methods:24 patients with stress-negative, stable SER-II type ankle fractures were included. Contralateral ankle mortise radiographs were obtained in addition to static and gravity stress radiographs of the injured side. Bilateral CT scans were performed once patients were deemed to have achieved clinical/radiographic healing. Measurements of the medial clear space (MCS) and syndesmosis were performed by two blinded orthopedic surgeons at two different time points. Intraclass correlation coefficients (ICC) were calculated to evaluate the intra- and inter-rater reliability and consistency of measurements. Statistical analyses were performed to determine any differences between x-ray and CT scan measurements to detect discrepancies between the injured and normal ankle measurements. Statistical significance was defined as a two-sided alpha error of less than 0.05 (p < 0.05).Results:Despite plain radiographs demonstrating no statistical side-to-side differences and achieving apparent final anatomic alignment in the majority of the cohort, CT MCS on coronal, axial planes and syndesmosis measurements were significantly different when comparing the injured to the normal contralateral ankle by on average of about 0.5mm. There was also excellent intra and interobserver agreement achieved for the measurements.Conclusion:CT is superior to plain radiography in detecting subtle mortise/syndesmotic displacement and side-to-side differences undetectable by x-ray. These findings challenge conventional assumption of anatomic alignment for SER II injuries and reliance on x-rays to assess anatomic alignment. While injured ankles uniformly demonstrated non-anatomic alignment as compared to the uninjured side, the clinical implications of subtle malalignment are unknown. However, broad reaching implications of this preliminary study include challenging the validity of x-ray to detect possibly clinically-relevant mortise malalignment in patients presenting with isolated lateral malleolus fractures.

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.

A comparative study of the clinical efficacy of supination-adduction type II ankle fracture surgery based on the medial pilon fracture concept versus the ankle fracture concept

BackgroundA supination-adduction (SAD) ankle fracture is a special type of ankle fracture that results in collapse of the distal tibial articular surface; as such, orthopaedic surgeons require greater awareness of this type of fracture. The severity of this injury lies between that of an ordinary ankle fracture and a pilon fracture, and the treatment of such fractures based on the ankle fracture concept leads to extremely high rates of postoperative complications and a poor prognosis. In this retrospective study, we aimed to explore the treatment of SAD fractures based on the pilon fracture concept.MethodsWe retrospectively analysed the clinical data of 67 patients with Lauge-Hansen supination-adduction type II (SAD-II) ankle fractures, most of whom had a 44-A AO classification. Patients underwent surgical treatment at the Second Affiliated Hospital of Anhui Medical University from January 2009 to June 2019. The patients were divided into two groups based on the surgical concept employed: 43 patients were included in the ankle fracture surgical concept group, and 24 patients were included in the medial pilon fracture surgical concept group. The therapeutic effect was evaluated based on the Burwell-Charnley radiological reduction standard, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and postoperative visual analogue scale (VAS) pain score 1 year after surgery using regression with adjustment for confounding factors.ResultsAll 67 patients were followed up. Twenty-four patients were treated according to the medial pilon fracture concept, and forty-three patients were treated according to the ankle fracture concept. The AOFAS score 1 year after surgery in the medial pilon group (89.83 ± 2.77) was higher than that in the ankle fracture group (83.63 ± 7.97) (p < 0.05). The VAS score 1 year after surgery in the medial pilon fracture group (1.17 ± 0.96) was significantly better than that in the ankle fracture group (2.28 ± 0.96) (p < 0.05).ConclusionPatients with Lauge-Hansen SAD-II ankle fractures treated based on the medial pilon fracture surgical concept had better postoperative outcomes than those treated based on the ankle fracture surgical concept.Level of evidenceLevel III, retrospective cohort study.

Quality of life and complications in elderly patients after pronation rotation type III ankle fractures treated with a cast and early weight-bearing

BackgroundEarly weight-bearing is becoming increasingly common because it can positively affect the quality of life of patients. Therefore, the efficacy and safety of this conservative treatment should be assessed for different types of ankle fractures. The goal of this study was to compare early weight-bearing and non-weight-bearing in terms of effectiveness and safety in patients with pronation rotation type III ankle fractures treated nonsurgically.MethodsA prospective multicenter cohort study was conducted over two years. Elderly patients with a nondisplaced pronation rotation type III ankle fracture were included. The main variables were the Barthel Index and SF-12 scores. The patients completed the questionnaires at six weeks, one year and two years. We also compared the complications associated with the two interventions.Results30 patients were included in the weight-bearing group, while 32 patients were included in the non-weight-bearing (WB) group. The mean ages were 82.6 ± 2.6 years and 83.1 ± 2.6 years, respectively. Quality of life, measured with the SF-12 scale, increased significantly in both the short and long term in the WB group (53.5 ± 5.8 points vs 65.2 ± 4.4 points at 6 weeks and 70.1 ± 4.2 points vs. 80.9 ± 3.7 points at 2 years; p<0.001). The WB group also showed a higher quality of life, as measured by the Barthel Index (54.5 ± 5.2 points vs. 64.3 ± 4.0 points at 6 weeks and 71.0 ± 4.3 points vs. 80.7 ± 3.4 points at 2 years; p<0.001).ConclusionsElderly patients with pronation rotation type III fractures could benefit from an early weight-bearing protocol in terms of quality of life and functionality.

Lack of Surgeon Standardization on Implant Selection in Ankle Fracture Fixation May Increase Costs and Decrease Contribution Margin.

Surgical standardization has been shown to decrease costs without impacting quality; however, there is limited literature on this subject regarding ankle fracture fixation. Methods. Between October 5, 2015 and September 27, 2017, a total of 168 patients with isolated ankle fractures who underwent open reduction, internal fixation (ORIF) were analyzed. Financial data were analyzed across ankle fracture classification type, implant characteristics, and surgeons. Bivariate analyses were conducted. One-way analysis of variance was used to compare hardware costs across all 5 surgeons. Linear regression analysis was used to determine if hardware cost differed by surgeon when accounting for fracture type. The mean contribution margin was $4853 (SD $6446). There was a significant difference in implant costs by surgeon (range, lowest-cost surgeon: $471 [SD $283] to $1609 [SD $819]; P < .001). There was no difference in the use of a suture button or locking plate by fracture type (P = .13); however, the cost of the implant was significantly higher if a suture button or locking plate was used ($1014 [SD $666] vs $338 [SD $176]; P < .001). There was an association between surgeon 3 (β = 200.32 [95% CI 6.18-394.47]; P = .043) and surgeon 4 (β = 1131.07 [95% CI 906.84-1355.30]; P < .001) and higher hardware costs. Even for the same ankle fracture type, a wide variation in implant costs exists. The lack of standardization among surgeons accounted for a nearly 3.5-fold difference, on average, between the lowest- and highest-cost surgeons, negatively affecting contribution margin. Level IV.

Incidence of Talar Osteochondral Lesions After Acute Ankle Fracture: A Retrospective Analysis

Recent literature suggests the majority of osteochondral lesions occur in the ankle joint. Previous studies have suggested that varying incidences of talar osteochondral lesions (OCLT) are associated with ankle fractures. The primary aim of our study was to investigate the incidence of osteochondral lesions associated with acute ankle fractures as observed on computed tomographic (CT) imaging. We also compared the rates of talar osteochondral lesions in patients who had ankle fractures with dislocation and closed manual reduction (CMR) prior to open reduction with internal fixation, to those who did not suffer from ankle joint dislocation. Additionally, a correlation between the location of talar dome lesions with type of ankle fracture as classified by Lauge-Hansen was investigated. Preoperative CT imaging was retrospectively reviewed in 108 patients with acute ankle fractures. A CT-modified version of Berndt Hardy's classification of osteochondral lesions, as previously described by Loomer et al, was used for diagnosis of lesions in our study. The incidence of lesions was calculated across all subjects, and retrospective comparison was performed in those who did and did not undergo closed manual reduction. Supplementary data on location of lesion and its association with ankle fracture type was also recorded. We found an overall incidence of 50.9% OCLT in patients with acute ankle fractures. This number did not significantly differ from those who underwent closed manual reduction (49%). Although a majority of lesions did occur posteriorly, we saw no statistically significant information was seen between either type of fractures or OCLT locations. Careful consideration and thorough evaluation of preoperative CT imaging should be assessed by the performing surgeon, as this could guide both diagnostic and therapeutic treatments for patients with possible osteochondral lesions of the talus undergoing surgical repair of a fractured ankle.

Operatively treated ankle fractures in Switzerland, 2002\u20132012: epidemiology and associations between baseline characteristics and fracture types

BackgroundAnkle fractures are common, and their incidence has been increasing. Previous epidemiological studies have been conducted in the US, Scandinavia, and Scotland. Our objectives were to provide a current epidemiological overview of operatively treated ankle fractures and to evaluate the influence of age, sex, lifestyle factors, and comorbidities on fracture types.MethodsWe performed a population-based epidemiological study of all ankle fractures treated operatively in a 10- year period from 2002 to 2012.ResultsTwo thousand forty-five ankle fractures were operated upon. Men and women differed significantly in age (median 41 vs. 57 years old), obesity (16% vs. 23%), diabetes (5% vs. 10%), smoking (45% vs. 24%), and accident type (daily activities 48% vs. 79%, transportation 24% vs. 9%, sports 21% vs. 8%) respectively. Overall, there were 2% Weber A, 77% Weber B, and 21% Weber C fractures; 54% were uni-, 25% bi-, and 21% trimalleolar; 7.5% of all fractures were open. Weber C fractures were much more frequent among men and with higher BMI (lowest vs. highest category: 14% vs. 32%), but slightly less frequent with older age and among current smokers. Trimalleolar fractures were twice as frequent in women and increased with age.ConclusionMen and women differed substantially in age, lifestyle factors, comorbidities, accident type, and type of ankle fracture. Male sex and higher BMI were more frequently associated with Weber C fractures, whereas female sex and older age were associated with trimalleolar fracture. The risk for severe fracture increased linearly with the degree of obesity.

Ankle Fractures: Minimally Invasive Surgery

Many patients with ankle fractures present different comorbidities, like diabetes, peripheral vascular disease, tobacco use, fractures blisters, etc., and have a high risk of wound healing complications. The potential for wound dehiscence and infection with open reduction and internal fixation is higher in these patients. The minimally invasive technique allows for proper stabilization with a minimal approach and less soft tissue trauma. These percutaneous methods, allow to reduce the damage of the soft tissues, protect vascularization and, consequently, improve the outcomes with faster rehabilitation and faster return to the patient’s activity. According to the anatomic joint reduction and stable fracture fixation criteria, the author developed a minimally invasive technique for the most frequent type of ankle fracture, with good and excellent outcomes in long-term follow-up. The author mentions that this technique involves higher exposition to fluoroscopy. Level of Evidence: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Comparison of Syndesmotic Malreduction Rate following Trans-Syndesmotic Screw Fixation in SER versus PER Type Ankle Fracture: A Prospective Analytic Study

Category:Ankle; TraumaIntroduction/Purpose:Syndesmotic injury frequently presents in severe rotational ankle fracture and a trans-syndesmotic screws fixation is commonly used technique. Bases on previous literatures, syndesmotic malreduction rate can occur between 20- 70 percent following traditional trans-syndesmotic screw fixation in all type of ankle fracture. However, there is a little evidence regarding the malreduction rate in each type of ankle fractures. The purpose of this study is to demonstrate malreduction rate of syndesmosis using simultaneously bilateral post-operative CT measurement after trans-syndesmotic screw fixation between supination external rotation and pronation external rotation type ankle fracture.Methods:A prospective comparative study of patients who had acute ankle fracture with syndesmotic injury between January 2015 and December 2017 were enrolled. Lague-Hansen classification was used to classify all patient into 2 groups: SER and PER based on mechanism of injury. Syndesmotic injury was confirmed by ankle arthroscopic examination in all patients and they were treated with ORIF distal fibula using either 1/3 tubular plate or anatomical locking plate under direct visualization of syndesmosis. Syndesmosis was fixed by one or two of 3.5-mm cortical screw with three or four cortices. The accuracy of syndesmotic reduction was evaluated by simultaneously bilateral post-operative CT scan. Syndesmotic reduction was measured using anterior to posterior distance (AP) and medial to lateral distance (ML). A widening of distance between anterior tibia and fibula at 1-cm above the ankle joint more than 2 mm compared to uninjured sides considered a malreduction of syndesmosis.Results:There were 67 patients were enrolled in this study (SER=48 and PER=15). The syndesmotic injury was present 60% (48/70) in SER and 100% (15/15) in PER group respectively. The malreduction was significant higher in PER than SER (2.1% in SER vs 20% in PER). Operative time was 58.2 and 79.2 minutes in SER and PER. The tibiofibular clear space was 4.0mm versus 4.8mm in SER and PER. The AP distance was -0.33mm and -0.51mm and ML distance was 1.91 mm and 1.59mm for SER compared to normal side and 0.19 mm and -0.21 and ML distance was 2.59mm and 1.63mm for PER compared to normal side. There were significant improvements of functional outcomes (FAAM, SF-36, and VAS) but no significant different between the two groups.Conclusion:The incidence of concomitant syndesmotic injury and syndesmotic malreduction rate following trans-syndesmotic screw fixation was significantly higher in PER type compared SER type ankle fracture. The malposition of distal fibula was displaced anteriorly and laterally (undercompression) compared to uninjured side.

Syndesmosis Injuries in Ankle Fractures: Correlation of Fracture Type and Syndesmotic Instability

Category:Ankle; TraumaIntroduction/Purpose:Ankle fractures are among the most common injuries treated by orthopedic surgeons. Syndesmotic disruption in ankle fractures can be identified preoperatively, however the decision to fix the syndesmosis is made after this intraoperative assessment. The AO classification groups ankle or malleolar fractures into A (infrasyndesmotic fibula fracture), B (transsyndesmotic fibula fracture), and C (suprasyndesmotic fibula fracture) with succeeding digits that further classify each fracture group in more detail. This study aimed to retrospectively review databases of ankle fractures across two major academic centers to determine the rate of syndesmotic injury and to assess the association between ankle fracture type (utilizing the AO classification) and presence of syndesmotic injury.Methods:Patients 18 years or older who were treated surgically for an ankle fracture at two major academic institutions between 2010 and 2016 were selected for review. Exclusion criteria were open fractures, pilon fractures, tibial shaft fractures, or patients who underwent open reduction and internal fixation of an ankle fracture involving the posterior malleolus. The preoperative injury films of each ankle fracture was reviewed and classified according to the AO classification. The postoperative films were then reviewed for each case to classify the fractures into stable or unstable syndesmosis based on whether syndesmotic fixation was performed. Stability of the syndesmosis was tested intraoperatively after internal fixation of the fracture fragments using the Cotton test and external rotation stress views. Fixation of the syndesmosis was performed with either a syndesmotic screw or suture button fixation per surgeon preference. Chi-square analysis was used to assess the association between fracture types and syndesmotic injury.Results:733 patients met inclusion criteria. Average patient age was 54.22 with 52.8% being female. 273 patients had sustained a syndesmotic injury (Figure 1). Association between fracture type (AO classification) and syndesmotic injury was assessed with chi- square analysis showing significant association (X28=193.842, p<0.001). Type B fractures in this study were further classified with AO classification (9 subcategories) to assess for an association with syndesmotic injury within a subcategory of these fractures (Figure 1). Chi-square analysis of type B fracture subgroups revealed significant association between fracture subgroup and syndesmotic disruption (X28=76.379, p<0.001). There was a statistically significant association between single digit AO classification and syndesmotic injury (X28=193.842, p<0.001) as well as the two-digit AO classification for type B fractures and syndesmotic injury (X28=76.379, p<0.001).Conclusion:This study aimed to identify ankle fracture patterns that are prone to syndesmotic injury. Identifying fractures preoperatively that are likely to have syndesmotic injury is beneficial to surgeon and patient as it aids in operative planning, intraoperative equipment needs, managing patient expectations, and counselling patients preoperatively about changes in rehabilitation protocols with injuries that involve the syndesmosis. Most of the type C fractures (88.50%) had syndesmotic injury, 7.14% of type A fractures involved the syndesmosis, and type B fractures had variable syndesmotic involvement (31.15%). Chi- square analysis revealed that significant association exists between type B2 and syndesmotic injury (X28=76.379, p<0.001).

Incidence of Chondral and Osteochondral Lesions in Ankle Fracture Patients Identified with Ankle Arthroscopy Following Rotational Ankle Fracture

Category:Ankle; TraumaIntroduction/Purpose:It is controversial whether routine arthroscopy is beneficial at the time of ankle fracture fixation. This may be, in part, due to sparse information regarding the incidence of chondral injury in the setting of ankle fractures.The purpose of this study is to systematically review the incidence of chondral injures in patients with ankle fractures and to further characterize intra-articular chondral injuries of the talus, tibial plafond, medial malleolus, and lateral malleolus in patients who undergo ankle arthroscopy following an ankle fracture.Methods:The literature search was performed based on the PRISMA guidelines. Studies evaluating the incidence of chondral lesions at the time of arthroscopy for ankle fractures were included. The incidence of intraarticular chondral lesions was recorded, as well as location within the ankle, ankle fracture type, time of arthroscopy, characterization of chondral injury, complications, and outcome if available. All statistical analyses were carried out with statistical software package SPSS 24.0 (SPSS, Chicago, IL, USA). Multiple comparisons were used to compare incidence rates of chondral injury based on Weber classification, malleolar fracture type, and Lauge-Hansen classification, using Pearson chi-square test. For all analyses, p < 0.05 was considered statistically significant.Results:Fifteen studies with 1,355 ankle fractures were included. Of those ankles, 738 demonstrated evidence of chondral or osteochondral lesion (54.5%). Overall, 648 ankles had chondral lesions on the talus (47.8%), 207 ankles had lesions on the tibial plafond (15.3%), 165 has lesions of the lateral malleolus (12.2%), and 133 had lesions of the medial malleolus (9.8%). Weber C group had significantly higher incidence than Weber A group (p=0.015). Trimalleolar and isolated lateral malleolar fracture groups had significantly higher incidence of chondral injury than bimalleolar and isolated medial malleolar fracture groups (p<0.001). A significant difference was found in occurrence rate of chondral injury among Lauge-Hansen classification, with supination-adduction having the lowest incidence (p=0.001).Conclusion:Our study found a high incidence of intra-articular chondral lesion in the setting of ankle fractures as demonstrated by arthroscopy, with more than half of all patients having a chondral lesion. Talar lesions were most common. This study may help direct greater attention to the Talus as a source of chondral injury particularly in higher grade fracture patterns.

A Multicenter Retrospective Study Examining Complication Rates Following Syndesmotic Screw Removal

Category:Ankle; TraumaIntroduction/Purpose:20% of ankle fractures in the US involve a concomitant injury to the syndesmosis. What syndesmotic fixation is most appropriate is a subject of some debate. When syndesmotic screws are used, many of the variables surrounding treatment are unclear. One recent study quoted an alarmingly high rate of complications after syndesmotic screw removal (reference). The authors of the current study have routinely removed syndesmotic screws with little in the way of complications. This multicenter study was conducted in order to compare complication rates following syndesmotic screw removal in two institutions that regularly remove syndesmotic screws.Methods:Patient selection was based on the ankle fracture databases of the orthopedic department in two major academic institutions. At both institutions, databases includes all patients treated surgically for any type of ankle fracture between 01/2010 and 12/2016 in patients older than 18 years. Patients meeting the following inclusion criteria were selected: patients suffering any type of an acute, closed ankle fracture, syndesmotic disruption treated using a syndesmotic screw, removal of the syndesmotic screw in the same institution, and patient chart available for review. Exclusion criteria: pilon fractures, and tibial shaft fractures, as well as any postoperative infection following the original osteosynthesis. Data from the chart included age, sex, height, weight, BMI, days until screw removal, smoking status, alcohol use, diabetes status, and any wound complications or complication related to the screw removal. A logistic regression analysis was conducted to assess for predictors of wound complications after syndesmotic screw removal.Results:In our cohort of 152 patients, 1.3% of patients had wound complications. When looking at the cohorts separately, there was a reported wound complication in 3.2% (1 out of 31) of patients in institution 1, whereas there was a 0.83% (1 out of 121) wound complication rate in the cohort at institution 2 (p=0.296). There were no significant predictors of wound complications when looking at age (p=0.992), height (p=0.511), weight (p=0.735), BMI (p=0.755), days until screw removal (p=0.80), sex (p=0.404), smoking status (p=0.999), alcohol use (p=0.102), or diabetes status (p=0.269). Chi-square analysis revealed that there was not a significant association between wound complication and smoking (p=0.177), alcohol use (p=0.461) and diabetes status (p=0.602) in each cohort.Conclusion:A recent study reported a high rate of complications as a result of syndesmotic screw removal. Our multicenter study found minimal complications after syndesmotic screw removal. Further, out of two patients that did have reported complications, neither required secondary intervention as a form of treatment. These complications were considered minor and were treated with oral antibiotics.

Recurrence of Syndesmotic Diastasis Following Syndesmotic Screw Removal: Does the Time Point of Screw Removal Matter?

Category:AnkleIntroduction/Purpose:Ankle fractures involving disruption to the syndesmotic complex are regularly treated with reduction and syndesmotic screw fixation. When syndesmotic screw fixation is used, it is a common to remove the screw after enough time has passed to allow for sufficient healing of the ligamentous tibiofibular syndesmosis complex. Delayed removal increases the risk of screw loosening or breakage, and more importantly prolongs the time to full weight bearing. Currently, there is little evidence supporting a definitive time point for screw removal. This multicenter study compared two different post-operative protocols following syndesmotic screw insertion. The goal was to determine an optimal time point for screw removal by assessing syndesmotic diastasis between these two institutions, each of which removed the screw at different time points.Methods:Patients from two institutions treated surgically for any type of ankle fracture between 01/2010 and 12/2016 that met the following inclusion criteria were selected: patients suffering any type of an acute, closed ankle fracture, syndesmotic disruption treated using a syndesmotic screw, removal of the syndesmotic screw in the same institution, at least one x-ray (mortise view) prior to screw removal and one following screw removal available for review. Exclusion criteria were open / pilon / tibial shaft fractures. The syndesmotic screw was removed approximately 12 weeks after insertion in the first institution, and 6 weeks after insertion in the second. Four radiographic measurements were performed and averaged by three researchers: medical clear space (oblique), tibio-fibular clear space, and tibio-fibular overlap. An independent samples t-test was conducted to analyze differences in radiographic parameters between the two cohorts. Measurements after syndesmotic screw insertion and at final follow-up after removal were compared.Results:The average time to removal of syndesmotic screw was 79.71 days in institution one (n=31) and 50.92 days in institution two (n=121) (p<0.001). For institution 1 the paired samples t-test revealed no significant differences when comparing measurements prior to syndesmotic screw removal with after screw removal for the tibio-fibular overlap (p=0.088) and tibio- fibular clear space (p=0.312) measurements. A significant difference was observed only regarding the medial clear space (p=0.008). For institution 2, significant differences were observed for all of these measurements (p<0.001). When comparing the measurements after syndesmotic screw removal between the two institutions, the independent samples t-test revealed significant differences in regard to the tibio-fibular overlap (p=0.001) and tibio-fibular clear space (p=0.004) measurements, but not in the medial clear space measurement (p=0.959).Conclusion:Removal of the syndesmotic screw after seven weeks led to a significant loss of reduction of the syndesmosis. In contrast, screw removal after 11 weeks did not lead to a significant loss of reduction. Our results suggest that it is not advisable to remove syndesmotic screws after 7 weeks. It is common to have the patient partial or non-weight bearing until screw removal to avoid screw breakage. To recommend non-weight bearing for 11 weeks will delay return to work and daily activity, and can lead to significant atrophy, however, it does allow for better maintenance of reduction.

Assessing the prevalence of various modes of injury and type of malleolar fractures based on Lauge-Hansen classification presenting at a tertiary care center

&lt;p class="abstract"&gt;&lt;strong&gt;&lt;span lang="EN-US"&gt;Background: &lt;/span&gt;&lt;/strong&gt;&lt;span lang="EN-US"&gt;Ankle fractures represent approximately 9% of all fractures and are a common occurrence with an incidence of 138-169 per 100,000 per year. The mechanism of injury differs in terms of mode of injury in various age groups. The Lague-Hansen classification is a pathologic-anatomic classification and emphasizes different stages of ligamentous injury, in addition to the fracture pattern, and provides options for fracture treatment.&lt;/span&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;&lt;span lang="EN-US"&gt;Methods: &lt;/span&gt;&lt;/strong&gt;&lt;span lang="EN-US"&gt;A retrospective observational study, where the prevalence of various types of ankle fractures were classified according to the Lauge-Hansen Classification, in the period of 2018 onwards till date. The mode of injury and age group of the patient was also noted.&lt;/span&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;&lt;span lang="EN-US"&gt;Results: &lt;/span&gt;&lt;/strong&gt;&lt;span lang="EN-US"&gt;A total of 84 patients were analyzed, supination-external rotation (48.7%) were the most frequently observed fractures in our study population, with no significant correlation between mode of injury and fracture pattern noted. &lt;/span&gt;There was a statistically significant association (p&amp;lt;0.05) between the velocity of injury and the age groups suffering ankle trauma.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;&lt;span lang="EN-US"&gt;Conclusion: &lt;/span&gt;&lt;/strong&gt;&lt;span lang="EN-US"&gt;The Lauge-Hansen Classification continues to be an important tool in assessing the biomechanics of ankle fractures and the management options available, especially in a country like India where more expensive imaging modalities may not be available or affordable at times. Our study also highlights that high velocity fractures continue to be a major cause of morbidity in the younger age group, especially in developing countries such as India. Stringent traffic rules and public awareness need to be put into practice to reduce the toll of this problem.&lt;/span&gt;&lt;/p&gt;

Bosworth type of ankle fracture treated with open reduction of fibula fracture following temporary Ilizarov external fixation: a case report

Bosworth type of ankle fracture treated with open reduction of fibula fracture following temporary Ilizarov external fixation: a case report

Ankle arthroscopy–assisted closed reduction in Bosworth fracture dislocation

The Bosworth fracture dislocation is a rare type of ankle fracture and is usually unrecognized on initial radiographs, therefore early open reduction is recommended. This study reports a 51-year-old female with uncommon imaging and clinical features. Preoperative X-ray, computed tomography, and magnetic resonance imaging of the ankle showed posterior detached dislocation of the intact distal fibula, the loose osteochondral fragments located in the tibiotalar joint, and the rupture of the deltoid ligament. Due to the initial infected wound on the severely swollen ankle, delayed arthroscopy-assisted closed reduction and internal fixation, removal of loose bodies, and repair of the deltoid ligament were performed, 19 days after injury. Postoperative imaging, including the X-ray, computed tomography, and magnetic resonance imaging, demonstrated the anatomic reduction of the ankle joint. After 6 months of follow-up, the patient gained a pain-free motion of the ankle with a range of passive 10° dorsiflexion and 40° plantar flexion, and resumed her normal gait and activity. This report indicates that the detached posterior dislocation of the intact distal fibula is a rare variant of the Bosworth fracture dislocation, and suggests that arthroscopy-assisted closed reduction and removal of loose osteochondral fragments in joint space are useful technique for this special type of the Bosworth lesions.

Association Between Syndesmotic Stability and Fracture Patterns of Lateral Malleolus After Supination-External Rotation-Type Ankle Fractures

Category:Ankle, TraumaIntroduction/Purpose:Syndesmotic injury with supination-external rotation (SER)-type ankle fractures are well known for the serious damages to the osseous and soft tissue envelope. However, the Lauge-Hansen classification system does not provide sufficient information related to syndesmotic injury. In this study, we aimed to investigate factors for preoperative detection of syndesmotic injury according to fracture patterns in SER III and IV ankle fractures by using radiography and computed tomography (CT).Methods:All operative SER III and IV ankle fractures treated by a single surgeon from 2009 to 2015 were enrolled in a retrospective database. Based on computed tomographic evidence and intra-operative cotton test, two groups of the ankle factures were divided(stable and unstable). And .2%). Medial space widening and fragment angle of the fibular posterior cortex were measured (Figure1).Results:A total of 52 patients with SER III, 75 patients with SER IV, and 27 patients with SER IV equivalent ankle fractures were identified, with 106 in the unstable syndesmosis group (68.8%) and 48 patients in the stable syndesmosis group (31.2%). Medial space widening and fragment angle of the fibular posterior cortex were significant predictors(p<0.01, p<0.01, respectively). The cutoff values of these factors were 4.4 mm and 32.8 degrees, respectively (Figure2).Conclusion:In predicting syndesmotic injury at the preoperative period in SER-type III and IV, medial clear space widening and fragment angle of the fibular posterior cortex showed significant correlations. In particular, sharper fragment angle of the posterior cortex indicated higher probability of instability that remained after fracture fixation.

In Isolated Stable Weber-B Type Ankle Fractures, Immobilization for 3 Weeks with a Cast or Orthosis Was Noninferior to Cast Immobilization for 6 Weeks for Outcomes at 1 Year.

In Isolated Stable Weber-B Type Ankle Fractures, Immobilization for 3 Weeks with a Cast or Orthosis Was Noninferior to Cast Immobilization for 6 Weeks for Outcomes at 1 Year.

Quantification of Postoperative Posterior Malleolar Fragment Reduction Using 3-Dimensional Computed Tomography (Q3DCT) Determines Outcome in a Prospective Pilot Study of Patients With Rotational Type Ankle Fractures.

To correlate Q3DCT measurements of residual step-off, gap, and 3D multidirectional displacement of postoperative posterior malleolar fracture fragment reduction in patients with rotational type ankle fractures, with patients' clinical outcome using standardized patient- and physician-based outcome measures. Prospective cohort study. Level-I Trauma Center. Thirty-one patients with ankle fractures including a posterior malleolar fracture (OTA/AO type 44) were included. All patients underwent open reduction internal fixation of their ankle fracture, of which 18 patients (58%) had direct fixation of the posterior malleolar fragment. Decision of (direct) fixation of the posterior malleolar fragment was not standardized and guided by surgeons' preference. Quality of postoperative reduction was quantified using Q3DCT: posterior fragment size (% of joint surface), residual step-off (mm), postoperative gaps (mm), and overall multidirectional displacement were quantified. Foot and Ankle Outcome Score pain and symptoms subscales and quality of life (Short Form-36) at 1 year postoperatively were included as the main outcome measures. Step-off (mean 0.6 mm, range 0.0-2.7, SD 0.8) showed a significant correlation with worse Foot and Ankle Outcome Score pain and symptoms subscales. Residual fracture gap (mean 12.6 mm, range 0.0-68.8, SD 19.5) and 3D multidirectional displacement (mean 0.96 mm, range 0.0-2.8, SD 0.8) showed no correlation. In patients with rotational type ankle fractures involving a posterior malleolar fracture, contemporary Q3DCT measurements of posterior fragment size and residual intra-articular step-off-but not gap-show significant correlation with patient-reported pain and symptoms. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Posterior malleolar fracture morphology determines outcome in rotational type ankle fractures

IntroductionRotational type ankle fractures with a concomitant fracture of the posterior malleolus are associated with a poorer clinical outcome as compared to ankle fractures without. However, clinical implications of posterior malleolar (PM) fracture morphology and pattern have yet to be established. Many studies on this subject report on fragment size, rather than fracture morphology based on computed tomography (CT). The overall purpose of the current study was to elucidate the correlation of PM fracture morphology and functional outcome, assessed with CT imaging and not with –unreliable- plain radiographs. MethodsBetween January 2010 and May 2014, 194 patients with an operatively (ORIF) treated ankle fracture, were prospectively included in the randomized clinical EF3X-trial at our Level-I trauma center. The current study retrospectively included 73 patients with rotational type ankle fractures and concomitant fractures of the posterior malleolus. According to the CT-based Haraguchi fracture morphology, all patients were divided into three groups: 20 Type I (large posterolateral-oblique), 21 Type II (transverse medial-extension) and 32 Type III (small-shell fragment). At 12 weeks, 1 year and 2 years postoperatively the Foot and Ankle Outcome Scores (FAOS) and SF-36 scores were obtained, with the FAOS domain scores at two years postoperative as primary study outcome. Statistical analysis included a multivariate regression and secondary a mixed model analysis. ResultsHaraguchi Type II PM ankle fractures demonstrated significantly poorer outcome scores at two years follow-up compared to Haraguchi Types I and III. Mean FAOS domain scores at two years follow-up showed to be significantly worse in Haraguchi Type II as compared to Type III, respectively: Symptoms 48.2 versus 61.7 (p = 0.03), Pain 58.5 versus 84.4 (p < 0.01), Activities of Daily Living (ADL) 64.1 versus 90.5 (p < 0.01). ConclusionPosterior malleolar ankle fractures with medial extension of the fracture line (i.e. Haraguchi Type II) are associated with significantly poorer functional outcomes. The current dogma to fix PM fractures that involve at least 25–33% of the tibial plafond may be challenged, as posterior malleolar fracture pattern and morphology - rather than fragment size - seem to determine outcome.