Tourniquet Use During Open Reduction and Internal Fixation of Ankle Fractures – A Systematic Review and Meta-Analysis

The intra-operative use of tourniquet in open reduction and internal fixation (ORIF) of ankle fractures remains a topic of debate. The purpose of this study was to perform a systematic review and meta-analysis of randomized control trials (RCTs) comparing clinical outcomes of patients undergoing ankle ORIF with tourniquet use versus a control group where no tourniquet was used. A systematic review was performed with reference to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines of the Pubmed, Scopus, Embase, and Cochrane Library databases. Studies were included if they were an RCT comparing tourniquet and no-tourniquet in ankle ORIF. Meta-analysis was performed using RevMan, and p-value <.05 was considered to be statistically significant. On completion of the literature search, a total of 4 RCTs including 350 ankles (52.6% males), with a mean age of 47.1 ± 5.7 years were included. There were 173 patients in the tourniquet group (T), versus 177 patients in the no tourniquet control group (NT), with nonsignificant differences between the groups for age, gender and body mass index demographics (all p > .05). There were significantly shorter duration of surgery, with significantly higher patient-reported rates of pain levels at day 2 postoperatively (both p < .001) in the T group. Additionally, there were significantly greater ranges of ankle motion at 6 weeks postoperatively (p = .03), with nonsignificant differences reported incidence of wound infections and deep vein thrombosis (p = .056 and p = .130 respectively) between the groups. In conclusion, current evidence suggests that although intraoperative tourniquet usage in cases of ankle ORIF results in significant reductions in duration of surgery, this may be at the expense of higher patient-reported pain scores and reduced range of motion postoperatively.     

Effectiveness of Arthroscopically Assisted Surgery for Ankle Arthrodesis

Regarding the treatment of ankle arthritis, the choice of arthroscopic ankle arthrodesis (AAA) or open ankle arthrodesis (OAA) remains controversial. To guide clinical decision-making, we conducted a meta-analysis on the optimal treatment of ankle arthrodesis. We identified eligible studies published from June 1, 1969 to June 1, 2020 using the Cochrane Library, PubMed, OVID, Embase, and Medline searched the references of relevant studies. Randomized and non-randomized studies that compared outcomes of AAA and OAA were included. After the methodologic assessment, available data were extracted and statistically reviewed. The primary outcomes were overall complications rate, tourniquet time, length of the hospital stay, non-union rate, and rate to fusion. The secondary outcomes were delayed union and postoperative infection rate. We included 9 studies comparing arthroscopic and open in patients with ankle arthrodesis, comprising 467 participants. AAA had the advantage of demonstrating a lower overall complication rate (odds ratio [OR], 0.44 [95% confidence interval [CI], 0.26-0.73]; p = .002), shorter intraoperative tourniquet time (mean difference [MD], -16.49 [95% CI, -23.51 to -9.46]; p < .001), shorter length of the hospital stay (MD -1.75, 95% CI -1.94 to -1.2, p < .001),lower non-union rate (OR, -0.07 [95% CI, -0.13 to -0.02]; p <.01) and higher rate to fusion (OR, 4.2 [95% CI, 1.96-8.99]; p < .001) in comparison with OAA. Yet, no significant differences were found in delayed union (OR, 0.46 [95% CI, 0.10-2.04]; p = .30) and postoperative infection rate (OR, 0.45 [95% CI, 0.17-1.15]; p = .09) between the groups. Our results suggest that arthroscopic ankle arthrodesis is superior to open ankle arthrodesis alone in the treatment of ankle arthritis based on the overall complication rate, intraoperative tourniquet time, length of the hospital stay, non-union rate and rate to fusion. However, further high-quality randomized controlled trials with appropriate blinding methods are needed to confirm the findings.     

Peripheral Nerve Blocks Associated With Shorter Length of Stay Without Increasing Readmission Rate for Ankle Open Reduction Internal Fixation in the Outpatient Setting: A Propensity-Matched Analysis

Peripheral nerve blocks (PNB) have become an important modality for pain management in ankle fracture surgery. Previous studies have reported their efficacy, but concerns with rebound pain and readmissions have been cited as possible deterrents. The purpose of this study was to evaluate the effects of PNB on hospital length of stay (LOS), narcotic intake, visual analog scale (VAS) for pain, and associated complications in patients undergoing outpatient ankle open reduction internal fixation (ORIF). Adult patients undergoing ankle ORIF were matched 2:1 (no block:block) using propensity-score matching. Preoperative patient characteristics and postoperative outcomes were compared between cohorts. VAS and total narcotic intake were evaluated for each of the first 3 postoperative 8-hour shifts. Narcotic medication was converted to morphine milligram equivalents (MME). Thirty-two patients who received PNB were matched to 64 patients who did not. The PNB group had lower VAS and MME during each of the 8-hour shifts after surgery: 0 to 8 hours (VAS 1.8 vs 6.3; MME 10.6 vs 77.9; p < .001), 8 to 16 hours (VAS 1.2 vs 5.9; MME 9.2 vs 28.2; p < .001), 16 to 24 hours (VAS 3.7 vs 6.2; MME 13.2 vs 24.2; p = .006 and 0.019). PNB had a shorter LOS (average 16.7 hours vs 26.8 hours; p < .001). There were no differences in rates of ED presentations after discharge, hospital readmissions, or complications between cohorts. Peripheral nerve blocks after ankle ORIF are associated with shorter hospital LOS, lower VAS, and reduced narcotic intake without increasing rates of ED visits, hospital readmissions, or complications.     

A Systematic Review and Meta-Analysis on Treatment of Ankle Fractures With Syndesmotic Rupture: Suture-Button Fixation Versus Cortical Screw Fixation

Ankle fractures accompanied by syndesmotic rupture are a complex challenge for orthopedic surgeons. Sufficient reduction and stabilization of the syndesmosis are important to prevent early degeneration of the ankle joint and to optimize clinical outcomes. The purpose of the study was to systematically review the literature comparing the suture-button fixation method with the cortical screw fixation method when treating syndesmotic rupture. For this, a systematic review of the literature was performed that included Cochrane, PubMed, and Embase. The following search terms were used: ankle fractures, syndesmosis rupture, tibiofibular syndesmosis injury, ankle joint, tightrope, and suture button. Inclusion criteria were comparison studies, acute ankle fractures with syndesmotic rupture, adult patients, and Coleman score >60. Cadaveric studies, chronic instability, open fractures, polytrauma, and arthropathies were exclusion criteria. Two investigators independently reviewed titles and relevant abstracts. Reoperation and malreduction rates were compared in a meta-analysis. Six studies with 275 patients were included: 2 randomized controlled trials and 2 prospective and 2 retrospective cohort studies. All studies used similar surgical techniques. Functional outcomes (American Orthopedic Foot and Ankle Society scale and the Olerud-Molander score) were not quantitatively comparable. No significantly less number of malreduction events were detected in the suture-button group (risk ratio = 0.19, 95% confidence interval 0.03 to 1.04, p = .06). Significantly lower reoperation rate was detected in the suture-button group (risk ratio = 0.21, 95% confidence interval 0.06 to 0.69, p = .01). We conclude that the suture-button technique showed a significantly lower reoperation rate and tendency toward less malreduction and better American Orthopedic Foot and Ankle Society scale scores. This finding is clinically relevant; however, this conclusion is primarily based on 2 studies, and therefore the interest for further research increases.     

Rest easy? Is bed rest really necessary after surgical repair of an ankle fracture?

IntroductionBed rest with elevation of the affected limb is commonly prescribed postoperatively following ankle fracture fixation although there is no evidence that this is necessary.AimThe aim of this prospective, randomised study was to investigate the effects of early mobilisation following surgical fixation of an ankle fracture on wound healing and length of stay (LOS).MethodA total of 104 patients underwent primary internal fixation of an ankle fracture at The Alfred hospital, Melbourne between July 2008 and January 2010.InterventionThe strategy included either early mobilisation group (first day post surgery) or control group (bed rest with elevation until day 2 post surgery).Outcome measuresData collected included demographic, injury type and surgical procedure. Outcome data included inpatient LOS, wound condition at 10–14 days, opioid use and re-admission rate.ResultsGroups were comparable at baseline. Wound breakdown rate was 2.9% (3 patients in the control group). Median LOS of the early mobilisation group was 55 h compared with 71 h in the control group (p < 0.0001). Opioid use for the control group was an average of 90 mg morphine equivalent in the first 24 h post surgery compared with 67 mg morphine equivalent for the early mobilisation group (p = 0.32).ConclusionThis study indicates that early mobilisation following surgical fixation of an ankle fracture results in a shorter hospital stay without evidence of an increased risk of re-admission or wound complication.     

Use of the HemaClear™ elastic tourniquet reduces blood loss in operative treatment of humeral shaft fractures

BackgroundTo determine if the use of a narrower elastic tourniquet compared to a standard pneumatic tourniquet reduces operative blood loss in the operative fixation of humeral shaft fractures.MethodsThis retrospective cohort study was performed at a level I trauma center and included 134 patients, aged 18 to 90 years, with a humeral shaft fracture treated with open reduction internal fixation (ORIF) from January 2007 through June 2018. The primary variable of interest was the application of a HemaClear? elastic tourniquet versus a standard pneumatic tourniquet during the fixation of a humeral shaft fracture. The primary outcome was estimated blood loss (EBL) during the humerus ORIF surgery as recorded in the operative record. The secondary outcomes were total tourniquet time and operative time. The primary purpose of the study was to compare the above outcomes between the two tourniquet types.ResultsEstimated blood loss was 42% lower (95% CI: 11% to 73%, p < 0.01) in the elastic tourniquet group when compared to the standard pneumatic tourniquet group. The use of the elastic tourniquet was also associated with a 67% increase (95% CI: 35% to 100%, p < 0.01) in tourniquet time compared to the standard pneumatic tourniquet. No difference in the total operative time between the two groups (difference, -3%; 95% CI: -21 to 14, p = 0.72) was observed.ConclusionElastic tourniquet use was associated with 42% less blood loss in the fixation of humeral shaft fractures compared to use of a traditional pneumatic tourniquet, although this may be of unclear clinical importance given the relatively low estimated blood loss in this cohort. The potential benefit of reduced blood loss associated with the narrower elastic tourniquet is likely caused by the increased tourniquet time, without a change in overall operative time.     

Postoperative Reoperations and Complications in 32,307 Ankle Fractures With and Without Concurrent Ankle Arthroscopic Procedures in a 5-Year Period Based on a Large U.S. Healthcare Database

Residual symptoms often persist even after successful operative reduction and internal fixation (ORIF) of ankle fractures. Concurrent ankle arthroscopic procedures (CAAPs) have been proposed to improve clinical outcomes; however, a dearth of evidence is available supporting this practice. The purpose of the present study was to investigate the reoperation and complication rates after ORIF of ankle fractures with and without CAAPs. Reoperations and complications after ORIF of ankle fractures were identified using the PearlDiver database from January 2007 to December 2011. The CAAPs included bone marrow stimulation, debridement, synovectomy, and unspecified cartilage procedures. Reoperation procedures consisted of ankle fracture repeat fixation, arthroscopic procedures, osteochondral autograft transfers, and ankle arthrodesis. Of the 32,307 patients who underwent ankle fracture fixation, 248 received CAAP and 32,059 did not. No significant difference was found in the reoperation rate between the 2 groups (7.7% versus 8.6%; odds ratio 0.89; 95% confidence interval 0.55 to 1.42; p?=?.61). Of the 248 patients in the CAAP group, 19 (7.7%) underwent reoperation, of which 13 (68.4%) were arthroscopic debridement and 6 were either ankle refixation or osteochondral autograft transfer. For the non-CAAP group, 3021 reoperation procedures were performed, consisting of ankle refixation in 83.2%, arthroscopic procedures in 14.3%, and ankle arthrodesis in 2.5%. The complication rate in the non-CAAP group included wound dehiscence in 2.4%, wound surgery in 0.4%, deep vein thrombosis in 0.8%, and pulmonary embolism in 0.4%. No complications were detected in the CAAP group. Ankle fracture fixation with CAAPs did not increase the postoperative reoperation rate compared with ankle fracture fixation without CAAPs.     

Spinal Anesthesia Associated With Increased Length of Stay Compared to General Anesthesia for Ankle Open Reduction Internal Fixation: A Propensity-Matched Analysis

General and spinal anesthesia are both utilized for patients undergoing open reduction internal fixation of the ankle, but there are little data comparing early complication rates. The purpose of this study was to compare duration of surgery, length of stay, and rates of postoperative adverse events within 30 days in patients undergoing open reduction internal fixation of ankle fracture using spinal versus general anesthesia. Adult patients who underwent open reduction internal fixation of a closed ankle fracture from 2012 to 2016 were retrospectively identified from American College of Surgeons National Surgical Quality Improvement Program. Duration of surgery, length of stay, 30-day adverse events, and unplanned readmissions were compared between patients who received general anesthesia and spinal anesthesia. Propensity adjustment with respect to known risk factors for complications and adjunctive regional block was used to match patients. Of the 10,795 patients included after applying the inclusion and exclusion criteria, 9862 (91.36%) received general anesthesia and 933 (8.64%) received spinal anesthesia. Using propensity-scored matching, 841 patients in the spinal cohort were matched to 3364 patients in the general cohort. Spinal anesthesia was associated with increased length of stay (+0.5 days, 95% confidence interval 0.23-0.77, p < .001). There were no differences in the rates of major/minor complications, mortality, transfusions, unplanned readmissions, or duration of surgery. General anesthesia is predominantly used for fixation of ankle fractures. While spinal anesthesia is associated with lower complication rates in hip and knee surgery, we found that it is associated with increased length of stay in patients undergoing open reduction internal fixation of the ankle within 30 days of surgery.     

Steroids for surgery during cardiopulmonary bypass in adults: a meta-analysis

Study ObjectiveTo evaluate the effect of steroid administration on myocardial infarction (MI), stroke, renal insufficiency, death, intensive care (ICU) length of stay (LOS) and hospital LOS of patients undergoing cardiopulmonary bypass (CPB).DesignMeta-analysis of parallel randomized controlled trials.SettingUniversity hospital.MeaurementsA search was conducted in PubMed, EMBASE, MEDLINE(R) and the Cochrane Central Register of Controlled Trials of studies on adults undergoing surgery with CPB who received steroid administration. Effect size (risk ratio or mean difference) for MI, stroke, renal insufficiency, death, ICU LOS, and hospital LOS were evaluated.Main Results48 RCTs published between 1977 and 2012 were retained for analysis. Steroids had no effect on the MI risk ratio (RR) 0.91 (95% confidence interval [CI] 0.63, 1.32); death at 30 days RR 0.84 (0.59, 1.20); stroke RR 0.92 (0.60, 1.42) or renal insufficiency RR 0.83 (0.52, 1.32). Administration of steroids reduced ICU LOS (P = 0.00001; I² 87.5%) and hospital LOS (P = 0.03; I² 81.1%). Metaregressions showed that duration of steroid administration was correlated with the reduction in ICU LOS (P = 0.0004) and hospital LOS (P < 0.00001).ConclusionsIncreasing the duration of steroid administration may reduce ICU and hospital LOS greater than increasing the dose.     

Anterior Ankle Incision Healing Complications With and Without Tourniquet Use: A Retrospective Comparative Cohort Study

Anterior ankle incisions and tourniquet use in foot and ankle surgery have both been associated with increased incidence of incisional healing complications. Although a tourniquet is commonly used for procedures such as total ankle replacement and ankle arthrodesis that utilize an anterior ankle incision, it is possible to avoid tourniquet use while preserving adequate visualization with atraumatic layered dissection and closure, appropriate use of electrocautery, and ligation of vessels as needed. The primary aim of this study is to report rates of anterior ankle incisional healing complications both with and without tourniquet use. A retrospective chart review was performed on consecutive patients undergoing total ankle replacement or ankle arthrodesis through a multi-provider foot and ankle surgery practice between 2013 and 2018. A total of 121 patients, 58 (47.9%) in the tourniquet group and 63 (52.1%) in the no-tourniquet group, were included in this study with a median follow-up period of 36 (range 2-96) months. There was a higher rate of incisional healing complications for the tourniquet group (5.2%) compared to the no-tourniquet group (3.2%), however this did not reach statistical significance (p = .670). There was no significant difference in operative time between the tourniquet and no-tourniquet group (p = .405). The overall incisional healing complication rate was 4.1%. Although avoiding tourniquet use alone does not appear to significantly reduce anterior ankle incisional healing complications, the described technique has yielded an overall lower rate of incisional complications compared to those commonly reported in the literature.     

Lisfranc Fixation Techniques and Postoperative Functional Outcomes: A Systematic Review

The optimal method of fixation of acute Lisfranc injuries is yet to be established. We aim to systematically review the literature to identify the impact of fixation method on postoperative functional outcomes. A systematic review was undertaken using the PRISMA framework to identify all studies reporting postoperative functional outcomes in patients who underwent open-reduction internal fixation of acute Lisfranc injuries. Studies reporting outcomes of numerous fixation methods were divided into fixation subcohorts. Studies comparing bridge plate with transarticular screw fixation were included for meta-analysis, conducted using a random-effects model. Seventeen studies (20 subcohorts) with 462 patients were included. Mean patient age was 29.6 (rang, 15-81) years. Mean follow-up was 38.7 (range 11 to 287) months. American Academy of Orthopaedic Surgeons midfoot score (AOFAS-MF) was the most frequently reported functional outcome (16/20 subcohorts). Overall weighted mean AOFAS-MF was 76.3 ± 9.4 for all cases, with 74.2 ± 9.4 for transarticular screws and 79.2 ± 8.3 for bridge plates. The mean difference between screw and plate was not statistically significant (mean difference = 5.0, 95% confidence interval, -4.8 – 14.8, p = .3). A single study reported AOFAS-MF mean of 92 using suture button fixation. Meta-analysis of the 2 available comparative studies revealed higher postoperative AOFAS-MF with bridge plate fixation (pooled standardized mean difference, 0.51; 95% confidence interval, 0.15-0.87, p = .006). There is scarcity of literature examining the impact of fixation method on postoperative functional outcomes in acute Lisfranc injuries. A small number of studies have reported superior functional outcomes with use of bridge plate fixation. Further evidence is needed to ascertain which injuries are best managed with each fixation method or whether 1 fixation construct is universally superior.     

Operative Ankle Fractures in Complicated Diabetes: Outcomes of Prolonged Non-Weightbearing

Diabetes increases the risk of developing postoperative complications such as superficial and deep infection, wound dehiscence, and revisional surgery. Prolonged non-weightbearing and/or augmented fixation may reduce postoperative complications in complicated diabetic ankle fractures. This study's purpose was to compare the development of postoperative infection, wound dehiscence, and revisional surgery in complicated diabetic ankle fractures with respect to weightbearing status. We hypothesized that fewer complications would occur in patients with prolonged non-weightbearing. Medical records of 90 surgically treated complicated diabetic ankle fractures were retrospectively reviewed for postoperative radiographs, weightbearing status, and complications. Complicated diabetes was defined as HbA1c ≥ 8% within 1 year of surgery. Twenty-four out of 90 patients had prolonged non-weightbearing status, which was defined as ≥ 8 weeks of non-weightbearing postoperatively. Twelve out of 90 patients had augmented fixation, which was defined as standard open reduction and internal fixation plus ≥ 2 tetra-cortical or > 2 tri-cortical syndesmotic screws with medial plate, external fixation, or other combination. Thirty-three out of 90 patients (36.7%) patients developed complications postoperatively. Patients with prolonged non-weightbearing had less complications (29.2% vs 39.4%, p = .37) and larger HbA1c values compared with early weightbearing patients (10.0 vs 9.3, p = .04). A one-unit increase in creatinine value (mg/dL) revealed a 3.15-fold increase in development of complications (95% confidence interval 1.29-7.65, p = .01). Although not statistically significant, complicated diabetic ankle fractures treated with prolonged non-weightbearing had less complications postoperatively except for ankle Charcot. Creatinine can be utilized as an independent risk factor for postoperative complications in this population.     

Total Ankle Arthroplasty Survivorship: A Meta-analysis

The gold standard for management of end-stage ankle arthritis was previously ankle arthrodesis; however, improvements in total ankle replacements are making this a more viable treatment option. The primary aim of this meta-analysis was to evaluate the survivorship of total ankle replacement implants currently in use. An extensive search strategy initially captured 20,842 citations that were evaluated for relevance. Abstract screening produced 97 articles to be read in entirety, of which 10 articles studying 1963 implants met all prospective inclusion criteria for analysis. Overall survivorship of all implants was 93.0% (95% confidence interval, 85.2-96.9) using a random effect model. There was significant heterogeneity between the studies (Q = 131.504). Meta-regression identified an inverse relationship between survivorship and study follow-up duration (p < .0001). Furthermore, age (p = .36) and implant type (fixed-bearing [95.6%, 95% confidence interval, 85.9-98.7] versus mobile-bearing ]89.4%, 95% confidence interval, 79.6%-94.8%]) did not have a statistically significant impact on survivorship, p = .213. However, patients with higher preoperative functional scores had improved survivorship (p = .001). Complications were inconsistently reported with varied definitions. In order of reported frequency, complications were classified into technical error (28.15%), subsidence (16.89%), implant failure (13.28%), aseptic loosening (6.3%), intraoperative fracture (5.67%), wound problems (4.3%), deep infection (1%), and postoperative fracture (0.0001%). Overall study quality was low, with only 10% being prospective and 90% from nonregistry data. The results from this meta-analysis revealed a promising overall survivorship of current implants in use for total ankle replacement; however higher quality studies with standardized outcomes measures are needed.     

Early radiographic outcomes following deltoid ligament repair in bimalleolar equivalent ankle fractures

BackgroundIndications for deltoid ligament repair in bimalleolar equivalent ankle fractures are unclear. This study compared radiographic outcomes in bimalleolar equivalent ankle fractures undergoing open reduction internal fixation (ORIF) +/? deltoid ligament repair.MethodsA retrospective review of 1024 ankle fractures was performed. Bimalleolar equivalent injuries treated with ORIF +/? deltoid ligament repair were included. Radiographic assessment was performed preoperatively, and at three months postoperatively.ResultsOne hundred and forty-seven ankle fractures met inclusion criteria with 46 undergoing deltoid ligament repairs. There was a significant decrease in medial clear space (1.93 ± 0.65 mm vs. 2.26 ± 0.64 mm, p = 0.01), and tibiofibular clear space (3.89 ± 1.20 mm vs. 4.87 ± 1.37 mm, p = 0.0001) at 3 months postoperative in the deltoid repair group compared to the no repair group. When syndesmotic fixation was performed, there were no differences between groups.ConclusionDeltoid ligament repair in bimalleolar equivalent ankle fractures resulted in reduced medial clear space, and tibiofibular clear space in the early postoperative period. These differences were small and remained within established normal limits.Level of clinical evidenceLevel III, retrospective cohort study.     

Intraoperative intravenous lidocaine reduces hospital length of stay following open gastrectomy for stomach cancer in men

Study ObjectiveTo evaluate whether intraoperative low-dose lidocaine infusion decreases postoperative analgesic consumption, ileus, and duration of hospital stay.DesignProspective, randomized, double-blinded trial.SettingOperating room in a university hospital.Patients48 ASA physical status 1 and 2 men scheduled for subtotal gastrectomy.InterventionsPatients were randomly allocated to two groups to receive either intravenous (IV) lidocaine 1.5 mg/kg 20 minutes before incision followed by a continuous lidocaine infusion of 1.5 mg/kg/hr until the end of surgery (lidocaine group) or saline in a similar manner (control group).MeasurementsOutcomes such as pain intensity, postoperative analgesic consumption, duration of ileus, and hospital length of stay (LOS) were recorded.Main ResultsThere were no differences in total consumption of IV patient-controlled analgesia (IVPCA) or pain scores at 24, 48, or 72 hours postoperatively. However, lidocaine group patients had significantly decreased average supplemental pethidine requirement per patient for pain control until 72 hours postoperatively [150 (75-200) mg vs 50 (50-150) mg, P = 0.039] and hospital LOS (9.5 ± 3 d vs 8.7 ± 1 d, P = 0.006, 95% CI: - 0.3 - 1.9 d) than control group patients. However, no differences were noted between the groups in pain intensity or duration of ileus.ConclusionsIntraoperative IV low-dose lidocaine infusion decreased opioid consumption and hospital LOS after gastrectomy.     

Intramedullary Fixation Versus Plate Fixation of Distal Fibular Fractures: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Observational Studies

Intramedullary fixation (IMF) has been described as a minimally invasive alternative to open reduction and internal fixation for operative treatment of distal fibular fractures in case of compromised soft tissue or severe comorbidities. The objective was to compare postoperative complications and functional outcomes of intramedullary versus plate fixation (PF) in distal fibular fractures. A systematic review and meta-analysis was performed. The PubMed/MEDLINE, Embase, Cochrane, and CINAHL databases were searched for both randomized controlled trials and observational studies. A total of 26 studies was included, reporting on 1710 patients with a mean age of 51.6 years. Meta-analysis was performed on 8 comparative studies, including subgroup and sensitivity analyses on all outcomes. IMF was associated with significantly fewer wound related complications (odds ratio [OR], 0.11; 95% confidence interval [CI], 0.04 to 0.25; p < .01), implant removals (OR, 0.54; 95% CI, 0.31 to 0.93; p?=?.03), and nonunions (OR, 0.31; 95% CI, 0.15 to 0.62; p < .01). No differences were found regarding malunion (OR, 0.45; 95% CI, 0.17 to 1.21; p?=?.11) and the Olerud Molander Ankle Score for long-term functional outcome (mean difference, 9.56; 95% CI, 1.24 to 20.37; p?=?.08). Results of this study apply to a select group of patients, in which the advantages of minimal soft tissue damage by IMF are preferable to optimal fracture reduction by PF. IMF of distal fibular fractures resulted in fewer wound-related complications, implant removals, and nonunions compared with PF. Especially in elderly patients, patients with chronic comorbidity, and patients with compromised soft tissue, IMF may be preferred over PF.     

Foot Pressure Changes Before and After Ankle Fusion: A Pedobarograph Study

We performed a case-control study with the purpose of establishing the pressure patterns in the soles of the feet of patients with ankle osteoarthritis, determining whether the pattern changed after treating the arthritis with ankle joint fusion (arthrodesis), and whether the change is significant. We also studied the benefits of ankle fusion with respect to the Short-Form 36-item Health Survey and the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale. The study included 18 participants (9 in the study group and 9 in the control group) to reach statistical significance with a 95% confidence interval (CI). A demonstrable increase was found in both forefoot and hind-foot pressures in the study group preoperatively compared with the control group. Also, a demonstrable increase was found in the pressure in both the forefoot (mean difference 50.56 ± 267.39 kPa) and the hindfoot (mean difference 57.44 ± 160.27 kPa) from preoperatively to postoperatively. This difference was not statistically significant (p = .59 [t(8) = 0.57]; 95% CI 256.10 to ?154.98) for the forefoot pressures and for the hindfoot pressures (p = .31 [t(8) = 1.08]; 95% CI 180.64 to ?65.76). The Short-Form 36-item scores significantly improved from preoperatively to postoperatively (p = .000054 for the physical component and p = .018 for the mental component). The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale score also improved significantly (p = .0000005). The foot pressures, as measured by using the insole sensors, showed an increase in forefoot and hindfoot pressures that was not statistically significant.     

Ankle Structures of Professional Soccer (Football) Players With Proximal Diaphyseal Stress Fractures of the Fifth Metatarsal

Despite a high incidence of proximal diaphyseal stress fractures of the fifth metatarsal (zone 3) in soccer (football) players, studies that examine risk factors of the fractures in professional soccer players are scarce; in particular, ankle structures have not yet been investigated. This study was designed to investigate ankle structures of professional soccer players with proximal diaphyseal stress fractures of the fifth metatarsal. We reviewed the ankle radiographs of 100 professional soccer players (stress fractures n = 15; controls n = 85) and measured the medial malleolar slip angle (MMSA), the ratio of the medial malleolar length to the width of the talar dome (MML:TD ratio), the ratio of the lateral malleolar length to the width of the TD (LML:TD ratio), and the ratio of the MML to the LML (MML:LML ratio). The MMSA (p < .01: 28.7° ± 5.8° versus 23.0° ± 4.9°) in the stress fractures was significantly wider and the MML:TD ratio (p = .08: 0.49 ± 0.08 versus 0.52 ± 0.07) had a trend to be smaller compared with the values of the controls. Logistic regression analysis revealed that a wider malleolar slip angle became a factor associated with stress fractures in professional soccer players (p < .01: odds ratio 1.27, 95% confidence interval 1.110 to 1.463). Receiver operating characteristic curve with MMSA for the stress fractures was depicted with an area under the curve of 0.778, and the suitable cut-off point was set at MMSA >27° with a positive likelihood ratio of 3.67 (95% confidence interval 2.173 to 6.188). Our study results show that a wide MMSA was associated with proximal diaphyseal stress fractures of the fifth metatarsal in professional soccer players.     

The Influence of Obesity on Hospital Admission After Outpatient Foot and Ankle Surgery

We examined the association of body mass index (BMI) with sociodemographic data, medical comorbidities and hospital admission following ambulatory foot and ankle surgery. We conducted an analysis utilizing data from the American College of Surgeons National Surgical Quality Improvement Program database from 2007 to 2016. Adult patients who underwent ankle surgery defined as ankle arthrodesis, ankle open reduction and internal fixation, and Achilles tendon repair in the outpatient setting. We examined 6 BMI ranges: <20 kg/m² underweight, ≥20 to <25 kg/m² normal weight, ≥25 to <30 kg/m² overweight, ≥30 to <40 kg/m² obese, ≥40 kg/m²to <50 kg/m² severely obese, and ≥50 kg/m² extremely obese. The primary outcome was hospital admission. We performed multivariable logistic regression and reported odds ratios (OR) and their associated 95% confidence interval (CI) and considered a p value of <.05 as statistically significant. Data extraction yielded 13,454 adult patients who underwent ambulatory ankle surgery. We then performed listwise deletion to exclude cases with missing observations. After excluding 5.4% of the data, the final study population included 12,729 patients. The overall rate of hospital admission was in the population was 18.6% (2,377/12,729). The overall rate of postoperative complications was 0.03% (4/12,729). We found no significant association of BMI with hospital admission following multivariable logistic regression. We recommend that BMI alone should not be solely used to exclude patients from having ankle surgery performed in an outpatient setting, especially since this patient group makes up a significant proportion of orthopedic surgery.