Short-Term Outcomes and Influencing Factors After Ankle Fracture Surgery

The present study investigated the factors influencing the early clinical outcomes after ankle fracture surgery. We included 88 patients, who had undergone implant removal surgery at 1 year after ankle fracture surgery, with ankle computed tomographic (CT) scans obtained before ankle fracture surgery and at implant removal available. We collected demographic information, including age, sex, the presence of diabetes mellitus, level of trauma energy, and fracture classification from the medical records. We also recorded the fracture height using the radiographs and CT images. The medial joint space and articular incongruity were assessed on the follow-up radiographs and CT scans. Bone attenuation was measured by placing a circular region of interest around the ankle joint on the preoperative CT image. The postimplant removal outcomes were assessed using 2 functional questionnaires, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale and Foot and Ankle Outcome Score (FAOS). Significant factors related to the AOFAS ankle-hindfoot scale scores and FAOS were identified through univariate analysis using age, sex, radiographic measurements, and CT findings as explanatory variables, followed by multiple regression analysis. On multiple regression analysis, the total FAOS was independently related to the AO classification (p?=?.003) and Lauge-Hansen classification (p?=?.003). The total AOFAS ankle-hindfoot scale score was related to articular incongruity (p?=?.044). The early clinical outcomes after ankle fracture surgery were affected by involvement of the ankle joint fracture rather than the lateral malleolus fracture height. Female sex and the presence of postoperative articular incongruity correlated with inferior early clinical outcomes.     

Surgical Outcomes of Articular Surface Crush Injury of Hawkins Ⅲ Talus Neck and Medial Malleolus Fracture

The present study was performed to evaluate the effects of the medial and anterolateral approach combined with internal fixation by double head compression screws and countersunk K-wires for Hawkins Ⅲ talus neck and medial malleolus fracture. Eleven patients with articular surface crush injury resulting in Hawkins Ⅲ talus neck fractures accompanied by medial malleolus fractures were reviewed. All patients underwent emergency operations. The fractures were fixed using double head compression screws and countersunk K-wires through combined medial and anterolateral approaches. FAOS, AOFAS ankle-hindfoot scale, and VAS questionnaire scores were recorded. In addition, ROM of the ankle and postoperative complications were assessed. All patients were followed up for a median of 52.45 ± 5.15 months. The multiple scales data of FAOS on the affected side were: pain score 89.14 ± 7.08; activities of daily living score 89.57 ± 8.88; quality-of-life score 89.20 ± 7.44; sports score 75.00 ± 15.49; and other symptoms score 84.74 ± 7.51. The mean overall AOFAS ankle-hindfoot score was 88.36 ± 6.39. The VAS score was 0.72 ± 0.65. Ankle motion included dorsiflexion (13.18° ± 9.02°) and plantar flexion (32.27° ± 12.34°). Subtalar joint motion included eversion (10.91° ± 7.01°) and inversion (11.36° ± 7.45°). All scores of the healthy side were higher than those of the affected side (p < .05). In addition to ROM of the ankle and subtalar joint and sports score, various indicators of recovery rate had scores > 80%. One patient developed skin necrosis, which healed after debridement and wound dressing. Late complications included subtalar and/or ankle traumatic arthritis in six patients, four of whom showed no obvious clinical symptoms. In conclusion, the method of emergency surgery and medial and anterolateral approach combined with countersunk K-wires to fix small bone fragments to restore the integrity of the articular surface is acceptable for Hawkins Ⅲ talus neck with medial malleolus fracture.     

Mid-term functional outcomes following reoperation after total ankle arthroplasty: A retrospective cohort study

BackgroundDespite a significant reported rate of non-revision reoperation after total ankle arthroplasty (TAA), it is uncertain if these subsequent procedures have an impact on the longer term outcomes. This study aimed to compare minimum five-year functional outcomes of patients who had undergone reoperation after TAA to those who did not require reoperation.MethodsSeventy-six ankles (74 patients) who underwent TAA with the Salto Talaris fixed bearing system between 2007 and 2014 were allocated into two groups based on presence (n = 16) or absence of reoperation (n = 60). Reoperations included all secondary procedures after index TAA, excluding revision surgeries requiring removal or exchange of the original prosthesis. The foot and ankle outcome score (FAOS) at preoperative and minimum five-year follow-up was compared between the groups. Additionally, improvements in FAOS subscales were compared. Preoperative deformity, postoperative implant alignment, number of periprosthetic cysts, and subsidence between groups were compared using standard weightbearing radiographs.ResultsThe most common cause of reoperation was gutter impingement (n = 11), followed by stress fracture of the medial malleolus (n = 2), tarsal tunnel syndrome (n = 1), periprosthetic cyst (n = 1), and infection (n = 1). In comparison to the non-reoperation group, all FAOS subscales except for the Sports and Recreational Activities subscale were significantly lower in the reoperation group at final follow-up. The reoperation group exhibited significantly less improvement in the Pain, Symptoms, and Quality of Life subscales at final follow-up (p < 0.05). There were no statistical differences in the radiographic parameters between both groups.ConclusionsPatients who underwent reoperation after TAA demonstrated inferior functional outcomes at mid-term follow-up. An emphasis should be placed on preventing possible causes of reoperations to achieve favorable patient outcomes. Additionally, if a reoperation is deemed necessary, a thorough evaluation and surgical correction of underlying causes should be achieved.     

内踝解剖型钩钢板治疗粉碎性内踝骨折的疗效分析

目的 评价内踝解剖型钩钢板治疗粉碎性内踝骨折的临床疗效。方法 对2015年3月至2017年6月采用内踝解剖型钩钢板治疗粉碎性内踝骨折的30例病人进行回顾性分析,其中男18例,女12例;年龄为21~50岁,平均34.5岁。受伤原因：扭伤10例,直接暴力骨折20例。左踝12例,右踝18例。30例病人均行切开复位内固定手术,内踝应用解剖型钩钢板固定,合并外踝及后踝骨折的病人,外踝应用解剖钢板固定,后踝应用空心螺钉或钢板固定。采用美国足踝外科医师协会（American Orthopedic Foot and Ankle Society, AOFAS）踝与后足功能评分系统、踝关节活动度和疼痛视觉模拟评分量表（visual analogue scale, VAS）评价术前及末次随访时病人的踝关节功能。结果 所有30例病人的随访时间为6~18个月,平均13.1个月。术后切口均一期甲级愈合,无感染、皮瓣坏死、骨折移位、内固定松动、骨不愈合等并发症出现。手术前后的AOFAS踝-后足评分分别为（12.0±10.0）分、（90.0±3.1）分,VAS评分分别为（5.4±1.0）分、（1.3±0.3）分,差异均有统计学意义（P均＜0.05）。末次随访时平均踝关节活动度为60.2°±6.2°。结论 采用内踝解剖型钩钢板治疗粉碎性内踝骨折,固定牢固,操作方便,病人术后功能恢复好,是治疗粉碎性内踝骨折有效的固定方法。     

Functional outcomes of unstable ankle fractures with and without syndesmotic fixation in the adolescent population

PurposeThe purpose of this study was to compare functional outcomes of adolescents with and without ankle syndesmotic injuries and identify predictors of functional outcome after operative ankle fractures.MethodsA retrospective review was conducted on operative adolescent ankle fractures treated between 2009 and 2019 with a minimum of one-year follow-up (mean 4.35 years). Patients who underwent syndesmotic fixation (SF) (n = 48) were compared with operative ankle fractures without syndesmotic injury (n = 63). Functional outcomes were assessed using standardized questionnaires, specifically the Foot and Ankle Ability Measure (FAAM) and Single Assessment Numerical Evaluation.ResultsThere were no differences in patient-reported outcomes, rates of return to sport or complications between groups with and without SF. The SF group had a longer tourniquet time (p = 0.04), duration of non-weight-bearing (p = 0.01), more Weber C fibula fractures (p < 0.001), fewer medial malleolus fractures (p = 0.03) and more frequently underwent implant removal (p < 0.0001). Male sex, lower body mass index (BMI) and longer duration of follow-up were significant predictors of a higher FAAM sports score using multivariable linear regression. SF was not a predictor of functional outcome.ConclusionThis study demonstrated that patients that undergo surgical fixation of syndesmotic injuries have equivalent functional outcomes compared to operative ankle fractures without intraoperative evidence of syndesmotic injury. We also identified that male sex, lower BMI and longer duration of follow-up are predictors of a good functional outcome.Level of EvidenceIII     

A clinical evaluation of alternative fixation techniques for medial malleolus fractures

Background

Medial malleolus fractures have traditionally been managed using partially threaded screws and/or Kirschner wire fixation. Using these conventional techniques, a non-union rate of as high as 20% has been reported. In addition too many patients complaining of prominent hardware as a source of pain post-fixation. This study was designed to assess the outcomes of medial malleolar fixation using a headless compression screw in terms of union rate, the need for hardware removal, and pain over the hardware site.

Setting

Saint Louis University and Mercy Medical Center, Level 1 Trauma Centers, St. Louis, MO.

Methods

After IRB approval, we used billing records to identify all patients with ankle fractures involving the medial malleolus. Medical records and radiographs were reviewed to identify patients with medial malleolar fractures treated with headless compression screw fixation. Our inclusion criteria included follow-up until full weight bearing and a healed fracture. Follow-up clinical records and radiographs were reviewed to determine union, complication rate and perception of pain over the site of medial malleolus fixation. Sixty-four ankles were fixed via headless compression screws and 44 had adequate follow-up for additional evaluation.

Results

Seven patients had isolated medial malleolar fractures, 23 patients had bimalleolar fractures, and 14 patients had trimalleolar fractures. One patient (2%) required hardware removal due to cellulitis. One patient (2%) had a delayed union, which healed without additional intervention. Ten patients (23%) reported mild discomfort to palpation over the medial malleolus. The median follow-up was 35 weeks (range: 12–208 weeks). There were no screw removals for painful hardware and no cases of non-union.

Conclusions

Headless compression screws provide effective compression of medial malleolus fractures and result in good clinical outcomes. The headless compression screw is a beneficial alternative to the conventional methods of medial malleolus fixation.     

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.     

Outcomes of posterior malleolar fixation in ankle fractures in a major trauma centre

AimsOngoing controversy exists over the indications and benefits of posterior malleolar fixation in ankle fractures. The aim of this pragmatic study was to evaluate the outcomes of posterior malleolar fracture fixation in ankle fractures in the setting of a major trauma centre. Our hypothesis is that posterior malleolus fixation leads to improved clinical outcomes.MethodsA total of 320 patients were identified with operatively treated ankle fractures involving a posterior malleolus component, at our institution between January 2012 and January 2018, ensuring a minimum 2 year follow-up. Of these patients, 160 had the posterior malleolus fixed as part of their surgery and 160 did not. Patient demographics, surgical details and complications were assessed. The Manchester-Oxford Foot Questionnaire (MOXFQ) was the primary patient outcome measure.ResultsFixation of the posterior malleolus was associated with a statistically significant improvement in patient outcomes. Mean MOXFQ score in the unfixed posterior malleolus group was 24.03 (0 - 62), compared to 20.10 (0 - 67) in the fixed posterior malleolus group (p = 0.04). Outcomes were worse with increasing size of posterior malleolar fragment. Metalwork-related issues were higher in the posterior malleolus fixed group (24/160 (15%) versus 10/160 (6.2%)) and re-operation rate was double.ConclusionThis study demonstrates that in the practical setting of a major trauma unit, fixation of the posterior malleolar fracture leads to improved patient outcomes but with increased metalwork risks and reoperation rates.     

三角韧带深层损伤是否影响旋前外旋型踝关节骨折的中期临床疗效

目的了解三角韧带深层损伤对PER型踝关节骨折中期临床疗效的影响。方法回顾性研究2013年1月至2014年12月北京积水潭医院创伤骨科手术治疗的50例PERⅢ度或Ⅳ度骨折患者。其中男37例,女13例;年龄16~68岁,平均30.2岁。根据踝关节内侧损伤类型分为两组:未修复组为内踝三角韧带深层损伤且无内踝骨折患者,未行三角韧带修复手术,共28例;对照组为内踝丘上骨折且三角韧带深层完整患者,行内踝丘上骨折切开复位内固定,共22例。两组患者均行腓骨骨折切开复位内固定和下胫腓螺钉固定。比较两组患者术后6个月以上影像学检查的内踝间隙和下胫腓间隙,以及中期随访的美国足踝外科协会的(AOFAS)的踝-后足评分和疼痛视觉模拟评分(VAS)。结果两组患者的性别、年龄、出现踝关节半脱位或脱位时的表现方式差异有统计学意义(P<0.05)。两组患者在损伤暴力程度、腓骨骨折线高度、是否完全脱位、后踝骨折率、后踝固定率、内固定物取出率、手术时间等差异均无统计学意义(P>0.05)。38例完成术后6个月影像学检查,21例未修复组的内踝间隙为3.7 mm,下胫腓间隙为4.5 mm;17例对照组的内踝间隙为3.4 mm;下胫腓间隙为4.4 mm。术后约3年时随访,未修复组和对照组的平均AOFAS评分分别为98.3分和94.6分,平均VAS评分分别为0.4分和1.5分。术后约5年时随访,未修复组和对照组的平均AOFAS评分分别为97.1分和93.6分,平均VAS评分分别为0.5分和1.2分。对于年龄<45岁的患者,术后约3、5年时随访的AOFAS评分、VAS评分与三角韧带完整与否均无相关性(P>0.05)。年龄与术后5年随访时AOFAS评分(P=0.021)相关。结论对于PER型Ⅲ、Ⅳ度踝关节骨折,在腓骨骨折及下胫腓螺钉固定后,残留三角韧带深层损伤不会影响45岁以内患者的中期疗效。     

Symptomatic ossicle lesion at the anterior tip of the medial malleolus in soccer players

BackgroundUnfused accessory ossification centers in the medial ankle are sometimes misdiagnosed and should be distinguished from other bone lesions such as fracture, stress fracture, os subtibiale, or pseudoarthrosis of the medial malleolus. The purpose of this study was to report our experience in treating soccer players with bony elements in the subtibial region.MethodsWe surgically treated seven soccer players who experienced medial ankle pain with bony fragments at the tip of the medial malleolus. Their ages were between 13 and 27 years. The mean duration from symptom onset to hospital visit was 4.7 years (range: 2 months to 14 years). The bony lesion located at the anterior tip of the medial malleolus in all patients and we diagnosed the lesion as an unfused accessory ossification center.ResultsThree types of surgical treatments were performed in patients according to age, ossicle size, status of the epiphyseal plate, and degenerative changes around the lesion. Bony fusion was achieved in patients who underwent open reduction and fusion with bone graft. Patients who underwent focal drilling or removal of the bony fragment experienced improvement in symptoms, and all patients were allowed to resume their sports or full preinjury activities.ConclusionWe believe that surgery is the first-line treatment for the patients with unfused accessory ossification centers with their prolonged symptom and favorable outcomes can be expected. Bony fusion should be attempted in the patients with the large ossicle especially in their growth period.     

Selective fixation of the medial malleolus in unstable ankle fractures

BackgroundWhilst the lateral malleolus appears to be crucial in controlling anatomical reduction of the talus, the role of the medial malleolus is less clear. Medial sided complications including infection, damage to local structures and symptomatic hardware are not without morbidity. This study compares the outcomes of patients with bimalleolar or trimalleolar ankle fractures who underwent fibular nail stabilisation with or without medial malleolar fixation.MethodsFrom a prospective single-centre trauma database, we identified 342 patients over a nine-year period who underwent fibular nail insertion to stabilise a bimalleolar or trimalleolar ankle fracture. Isolated lateral malleolar fractures were excluded. Demographic data, clinical outcomes, radiographic evaluation, return to work and sport, and patient reported outcomes, including Olerud-Molander Ankle Score (OMAS), EuroQol-5D (EQ-5D) and Manchester-Oxford Foot Questionnaire (MOXFQ) were collected.ResultsThis study included 247 patients with a mean age of 66.7 years (range, 25–96 years), of whom 200 were female (81%). Medial malleolar fixation was not performed in 54 cases (22%). There was no significant difference between groups with respect to failure of fixation (p = 0.634) or loss of talar reduction (p = 0.157). No patient required surgery for a symptomatic medial malleolar non-union. Medial sided complications occurred in 32 (16%) of the fixation group, of whom 20 (10%) required further surgery. At a mean mid-term follow-up of 4.8 years (range, 8 months – 9 years) there was no significant difference between the non-fixation and fixation groups with respect to the median OMAS (85 vs 80; p = 0.885) or median EQ-5D (0.80 vs 0.81; p = 0.846). Patient satisfaction was not significantly different between the two groups (85/100 vs 87/100; p = 0.410).ConclusionNon-operative management of the medial malleolar component of an unstable ankle fracture treated with a fibular nail may reduce the rate of post-operative complications without compromising the patient reported outcome.     

Nonunion of a medial malleolar stress fracture in an adolescent athlete secondary to lateral ankle instability: A case report

IntroductionMedial malleolar stress fractures are relatively uncommon. This report describes the successful treatment of nonunion of a medial malleolar stress fracture due to chronic lateral ankle instability.Presentation of caseA 13-year-old middle school student who belonged to a football club presented to our clinic with chronic medial left ankle pain lasting over a year. He had sprained his left ankle several times 6 years earlier. A plain anteroposterior ankle radiograph showed a vertical fracture line in the medial malleolus involving the epiphyseal plate, and computed tomography demonstrated the vertical fracture seen on the plain radiographs and bone sclerosis at the fracture site. We performed internal fixation for nonunion of the medial malleolar stress fracture with arthroscopic modified Broström for lateral ankle instability. Two years after surgery, the Self-Administered Foot Evaluation Questionnaire improved in all parameters, and both the anterior drawer and varus stress tests were negative.DiscussionEarly diagnosis of medial malleolar stress fracture is important for a rapid return to sports. Magnetic resonance imaging is helpful for early diagnosis. Because lateral ankle instability can cause medial malleolar stress fracture, arthroscopic modified Broström procedure is meaningful for medial malleolar stress fracture with lateral ankle instability.ConclusionInternal fixation and the arthroscopic modified Broström procedure could achieve good clinical outcomes for medial malleolar stress fractures with lateral ankle instability.     

Tension band fixation of medial malleolus fractures.

A prospective study on tension band fixation of medial malleolus fractures was performed on 30 consecutive patients with 31 fractures from October 1987 until December 1990. All patients had at least a displaced medial malleolus fracture unreduced by closed methods. The fractures were classified into small, medium and large using a modified Lauge-Hansen classification. There were no nonunions or movements of wires postoperatively and only two patients had subjective complaints with reference to the wires that required hardware removal. There was one 2-mm malreduction and one patient with a wound slough and subsequent osteomyelitis. One fragment had 2 mm of displacement after fixation but went on to union. A biomechanical study was undertaken to compare fixation of the medial malleolus with K wires alone, K wires plus a tension band, and two cancellous screws. The tension band fixation provided the greatest resistance to pronation forces: for times stiffer than the two screws and 62% of the intact specimen. Tension band fixation of the medial malleolus is a biomechanically strong and clinically acceptable method of treatment for displaced medial malleolus fractures. This method of fixation may be especially useful for small fragments and in osteoporotic bone.     

Middle-sized posterior malleolus fractures: Fixed versus non-fixed – A prospective randomized study

PurposeThis study aimed to assess the impact of fixation on functional and radiological outcomes of ankle fractures involving the posterior malleolus. We hypothesized that fixation of the posterior malleolus would be associated with improved radiological and functional outcome.MethodsA prospective randomized controlled study was planned and 40 consecutive ankle fractures involving middle-sized (10–25%) posterior fragment were included. Posterior fragments in Group 1 were not fixated while Group 2 underwent posterior malleolus fixation. The patients were evaluated both functionally and radiologically at minimum 2-years.ResultsDemographics and fracture type distributions were similar between the groups. Despite the slightly better functional outcome in Group 2, no significant functional or radiological outcome difference could be detected. Articular step-off> 1 mm was more common in Group 1 (p = 0.04) and the patients with articular step-off showed significantly worse functional outcome in all functional parameters (p < 0.05). Radiological and functional outcome parameters were positively correlated when all patients were evaluated together. Lateral radiographs caused an overestimation in the size of posterior fragment compared to CT (p < 0.001).ConclusionAlthough there was a slightly better clinical outcome in patients with fixed posterior fragments, it was not significant at short to mid-term follow-up. However, posterior fragment fixation contributed to functional outcomes by decreasing the incidence of articular step-off> 1 mm, which was found to be a negative prognostic factor.Level of evidenceLevel I; prospective randomized controlled study.     

胫骨干骨折伴同侧后踝骨折的诊断与治疗

目的 探讨胫骨干骨折伴同侧无移位的后踝骨折的损伤机制与防治. 方法 2001年5月至2004年11月,共收治34例胫骨干骨折伴后踝骨折,2例为开放性骨折.手术前摄胫腓骨全长和踝关节x线片,发现或怀疑有后踝骨折者,均予CT检查,术中先予后踝骨折块经皮螺钉固定,再行胫骨髓内钉手术治疗. 结果所有患者平均随访时间11个月.33例患者骨折愈合良好,踝关节功能优良.1例患者术前漏诊,随访时发现后踝骨折,踝关节疼痛功能差. 结论胫骨干合并后踝骨折在临床常见,后踝骨折漏诊是后期踝关节功能障碍的主要原因,术前踝关节CT检查及术中后踝精确固定是防治的关键.     

Untreated small posterior fragment of ankle fracture with early removal of syndesmotic screw is associated with recurrent syndesmotic instability

IntroductionThis retrospective study aimed to report outcomes of fixation of bi-malleolar or tri-malleolar fractures combined with syndesmotic injury with or without posterior malleolar fracture (PMF), and to ascertain whether syndesmotic screw removal at 6 to 8 weeks or 3 months postoperatively is more beneficial.MethodsWe retrospectively reviewed patients who received open reduction and internal fixation for bi-malleolar (without PMF) or tri-malleolar ankle fracture (with PMF) with syndesmotic injury between January 2013 and December 2017 with at least 24 months of postoperative follow-up. All patients suffered syndesmotic instabilities and were treated using a syndesmotic screw without PMF fixation. Patients with bi-malleolar fracture with syndesmotic screw removal at 6 to 8 weeks postoperatively were included in Group I, tri-malleolar fracture with syndesmotic screw removal at 6 to 8 weeks in Group II, and tri-malleolar fracture with syndesmotic screw removal at 3 months in Group III. Demographic data, clinical and radiographic outcomes were analyzed.ResultsA total of 113 patients were included (Group I, n=47; Group II, n=43; Group III, n=23). Average size of PMF was 14% in patients with tri-malleolar fractures (Groups II and III). No significant difference in ankle functional outcome among groups was observed. The recurrence rate of syndesmotic instability was 10.6% in Group I, 20.9% in Group II, and 8.7% in Group III. Although the difference in recurrence rates of syndesmotic instability among three groups was not statistically significant (P=0.264), Group II showed more interval change in tibiofibular clear space between initial postoperative radiographs and last follow-up radiographs (P=0.028) compared to the other two groups. Fracture union was achieved in all patients without screw breakage.ConclusionWe suggest that the better timing for syndesmotic screw removal is 3 months, instead of 6 to 8 weeks postoperatively, to reduce the risk of recurrence of syndesmotic instability for tri-malleolar fracture without posterior fragment fixation.Level of EvidenceLevel III- Case-control study.     

撬拨复位内固定治疗儿童内踝骨折伴骨骺损伤的疗效评价

目的 探讨克氏针撬拨闭合复位空心螺钉内固定治疗儿童内踝骨折伴骨骺损伤的临床疗效。方法 回顾性分析2014年6月至2019年6月我院采用克氏针撬拨闭合复位空心螺钉内固定治疗的35例内踝骨折伴骨骺损伤的患儿病例资料。男25例,女10例,年龄5-15岁,平均(8.3±2.8)岁。左踝16例,右踝19例。按Salter-Harris骨骺损伤分型：Ⅲ型22例(包括2例Tillaux骨折),Ⅳ型 13例。手术在C型臂X线机透视下进行,取细克氏针采用撬拨闭合复位空心螺钉内固定,记录双侧小腿的长度、手术时长、手术过程中的出血量、随访的时间以及手术前和手术后的踝关节AOFAS踝-后足功能评分、ASAMI评分、围手术期并发症发生情况等。结果 所有患儿均顺利完成手术,手术时间30-55min,平均(40.2±3.8)min,术中出血5-20ml,平均(12.1±2.7)ml。所有患儿均获得随访,随访18～48个月,平均(32.2±4.9)个月。健侧小腿的与患侧小腿长度差异无统计学意义(P>0.05)。随访的35例患儿AOFAS踝-后足功能评分较术前有显著的统计学差异(P<0.05),患侧足踝ASAMI评分显示：优34例,良1例,优良率100%。X线及CT检查提示所有病例在末次随访时均骨性愈合。并发症方面所有患儿均未出现术中及术后并发症,末次随访时所有患儿踝关节活动均不受限,均能参加日常活动及功能锻炼。 结论 克氏针撬拨闭合复位空心螺钉内固定术治疗儿童内踝骨折伴骨骺损伤的疗效确切,手术时间短、手术过程中出血量少、对内踝骨折块固定牢靠,值得在临床工作中进一步推广应用。     

Screw-only fibular construct for Weber B ankle fractures: A retrospective clinical and cost comparison to assess feasibility for resource-limited settings

IntroductionAnkle fractures are one of the most common injuries sustained worldwide, with the majority being isolated lateral malleolus fractures. The majority of the world's population live in Low and Middle Income Countries (LMIC), where implant cost may limit surgical treatment of ankle fractures. We investigate if Weber B ankle fractures could be effectively treated with a lower-cost technique using two screws between the fibula and the tibia to neutralize an interfragmentary lag screw.MethodsAfter IRB approval, consecutive patients from January 1, 2020 to December 31, 2020 with Weber-B ankle fractures were treated using AO technique (AOT) with plate osteosynthesis neutralizing an interfragmentary screw. Syndesmotic injuries, as well as injuries to the medial malleolus or foot were treated according to the surgeon's preferences. From January 1, 2021 to December 31, 2021 these injuries were treated with a screw-only technique (SOT) with two fibula pro tibia screws to neutralize an interfragmentary screw. Patient demographics including age, sex, BMI, smoking status, associated rheumatoid arthritis, and associated diabetes mellitus were recorded. The primary outcome variable was a stable radiographic mortise at six weeks post-surgery, secondary outcome variables included clinical union, infection, hardware removal, and implant cost for lateral malleolar fixation charged to the hospital.ResultsSeventeen AOT and 10 SOT constructs were included. Demographic characteristics were similar between groups. All fractures maintained a stable mortise with clinical union at 6 weeks without infection. There was a statistically significant difference in hardware removal (17.6% AOT, 50% SOT, p = 0.012). The average implant cost to the hospital of the lateral malleolar fixation was significantly less in the SOT group ($592 (SD $229)), compared to the AOT group ($1,949.97 (SD $562)), (p < 0.0001).ConclusionWe introduce proof of concept of a novel lower-cost fixation strategy for Weber B ankle fractures that maintained a stable mortise with clinical union at six weeks post-surgery. However, there was a significantly higher rate of hardware removal following fixation with a screw-only construct.     

闭合复位经皮微创内固定治疗内踝骨折

目的：探讨一种采用微创、有效、经济的手术方式治疗内踝骨折的临床疗效。方法：2008年3月至2010年8月,治疗内踝骨折19例,男12例,女7例;年龄17～42岁,平均31.7岁。内踝骨折经闭合复位后,分别采用1枚空心加压螺钉经骨折面中央并与其垂直置入,1枚克氏针过骨折面与内踝轴线一致斜行打入并过对侧骨皮质。术后通过Kaikkonen踝关节损伤功能评分与影像学检查进行疗效评定。结果：术后所有患者切口Ⅰ期愈合,均获随访,时间为6～30个月,平均18.7个月。均达骨性愈合,临床愈合时间2.6～3.8个月,平均3.2个月。按Kaikkonen功能评分,优5例,良10例,可3例,差1例。结论：闭合复位、空心加压螺钉和克氏针联合内固定治疗内踝骨折微创、恢复快及费用少。     

The Cedell method (cerclage wire and staple) leads to less reoperations than the AO method

Background and purpose — Fractures of the lateral malleolus often require open reduction and internal fixation (ORIF). Despite uneventful fracture healing, many patients will suffer from long-term detriments after ORIF, such as local tenderness that requires hardware removal. In Sweden, there are 2 major fixation methods, either the AO method (plate and screws) or the Cedell method (cerclage wire and staple). The purpose of this study was to establish whether there is a difference in extraction frequency between the 2 methods.

Patients and methods — We performed a retrospective comparative study of all isolated fractures through the lateral malleolus that were operated at Skåne University Hospital, Sweden, during the period January 2007 to December 2010. 347 patients fulfilled the inclusion criteria (dislocated Weber B isolated fractures of the lateral malleolus) and were categorized according to fixation method. The numbers of reoperations, with preceding indication, were established from the charts. The median follow-up time was 59 (38–86) months after the primary surgery.

Results — 22% of the 110 patients treated with the AO method underwent a reoperation, as compared to 8% of the 237 patients treated with the Cedell method (p < 0.001). The median time to extraction was 16 (4–55) months.

Interpretation — Less implant removal is needed with the Cedell method than with the conventional AO method. This favors the use of the Cedell method in uncomplicated Weber B lateral ankle fractures, provided that other clinical parameters are comparable.