Does intra-articular load distribution change after lateral malleolar fractures? An in vivo study comparing operative and non-operative treatment

PurposeThe impact of isolated malleolar fractures on the intra-articular load distribution within the ankle joint has been studied in several biomechanical cadaver studies during the last decades. Recently, computed tomography osteoabsorptiometry (CT-OAM) has been proposed as a valuable tool to assess intra-articular joint load distribution in vivo. The purpose of this retrospective matched pair analysis was to apply CT-OAM to evaluate in vivo changes of talar load distribution after lateral malleolar fractures in patients treated with open anatomic reduction and internal fixation (ORIF) compared to patients treated non-operatively.MethodsTen matched pairs of patients with isolated lateral malleolar fractures with a maximum fracture dislocation of 3 mm and a median follow-up of 42 month were included into the study. Patients were matched for age, gender, and fracture dislocation. Range of ankle motion (ROM), the AOFAS hindfoot score and the Short Form 36 (SF-36) were evaluated.CT-OAM analysis of the injured and the uninjured contralateral ankles were performed.ResultsPatients treated with ORIF showed a significant lower ROM compared to the uninjured contralateral ankle. No differences were found regarding clinical scores between patients treated by ORIF and those treated non-operatively.CT-OAM analysis showed symmetrical distribution of subchondral bone mineralization in comparison to the uninjured contralateral ankles for both groups of patients.ConclusionsThe data of this study suggest that isolated lateral malleolar fractures with fracture gaps up to 3 mm are not associated with a change of the tibio-talar joint load distribution in vivo. Therefore, patients with isolated minimally displaced lateral malleolar fractures may achieve good clinical long-term outcome following non-operative treatment.Level of Evidence: Level III, retrospective cohort study     

Posterior-Based Approaches to Open Reduction Internal Fixation of Bimalleolar and Trimalleolar Fractures: A Systematic Review and Meta-analysis

Although there is growing evidence supporting posterior-based surgical approaches to open reduction internal fixation (ORIF) of malleolar fractures, the lateral approach still remains the standard of care for this injury. The purpose of this review was to integrate the results of several studies investigating outcomes following posterior-based approaches to the ORIF of malleolar fractures. The literature search was undertaken using PubMed, the Cochrane Library, and Embase. Crude event rates for fracture healing and postoperative complications were calculated. When possible, meta-analyses were conducted to estimate the relative risk of these outcomes between patients treated by posterior-based approaches versus other approaches to ORIF of malleolar fractures. Twenty-two studies were eligible, and 4 studies were included in the meta-analyses. The healing rate was 100% in all patients, regardless of the surgical approach. Overall, 1.26% of patients developed an infection, 0.63% required reoperation, 1.13% experienced aseptic loosening, 5.53% experienced pain after treatment, and 2.52% experienced symptomatic hardware. No malunion or heterotopic ossification was reported in any study. Among patients treated with a posterior-based approach, the most frequently reported complication was infection (2.50%), with lower rates of reoperation and postoperative pain. Patients with trimalleolar fractures experienced slightly poorer outcomes. Patients treated by posterior-based approaches had a significantly increased risk of infection (p = .010) relative to those treated by the lateral approach; patients treated by the lateral approach had a significantly increased risk of pain after surgery (p = .004) and symptomatic hardware (p = .007). This study brought together evidence that posterior-based surgical approaches and non–posterior-based approaches to ORIF are effective in healing malleolar fractures, with significant differences in specific postoperative complications that need to be further explored.     

Incidence and risk factors for surgical site infection after open reduction and internal fixation of intra‐articular fractures of distal femur: A multicentre study

There remains a lack of data on the epidemiological characteristics of surgical site infection (SSI) following the open reduction and internal fixation (ORIF) of intra‐articular fractures of distal femur, and the aim of this study was to solve this key clinical issue. The electronic medical records (EMRs) of patients who underwent ORIF for distal femoral fracture from January 2013 to December 2017 were reviewed to identify those who developed a SSI. Then, we conducted univariate Chi‐square analyses and used a multivariate logistic regression analysis model to determine the adjusted risk factors associated with SSI. A total of 724 patients who underwent ORIF of intra‐articular fractures of the distal femur were studied retrospectively, and 29 patients had postoperative SSIs. The overall incidence of SSIs was 4.0% (29/724), with deep SSIs being 1.5% (11/724), and superficial SSIs being 2.5% (18/724). Staphylococcus aureus was the most common causative pathogen (8, 42.1%), followed by mixed bacterial pathogens (5, 26.3%). Open fracture, obesity, smoking, and diabetes mellitus were identified as the adjusted risk factors associated with SSIs. Although modification of these risk factors may be difficult, patients and families should be counselled regarding their increased risk of SSI because these patients potentially benefit from focused perioperative medical optimisation.     

Predisposing factors for chronic syndesmotic instability following syndesmotic fixation in ankle fracture: Minimum 5-year follow-up outcomes

BackgroundThis study aimed to identify risk factors for chronic syndesmotic instability following syndesmotic fixation.MethodsWe performed a retrospective review of consecutive patients who had sustained ankle fractures requiring syndesmotic fixation. Patients available for a minimum 5 years of follow-up were classified into 2 groups according to the presence of syndesmotic instability. Statistical binary logistic regression analyses were performed to investigate the significance of various risk factors. Functional outcomes were assessed using the FAOS.ResultsIn total, 166 patients who met the study inclusion criteria underwent analysis. The overall postoperative instability rate was 20.5%, which was significantly affected due to BMI (p = 0.018; OR 6.72), and concomitant posterior malleolar fracture (p = 0.032, OR 2.77). The mean scores in the syndesmotic instability (SI) group were significantly lower than those in the no syndesmotic instability (NSI) group (p = 0.021).ConclusionsObesity and concomitant posterior malleolar fracture were significant risk factors for postoperative syndesmotic instability.     

Radiographic effects observed in the coronal view after medial malleolar osteotomy at total ankle arthroplasty in rheumatoid arthritis cases

BackgroundWhen soft tissue balance is not acceptable at total ankle arthroplasty (TAA) for rheumatoid varus deformity, medial malleolar osteotomy has been performed. At the same time, the shape of the ankle joint changes after soft tissue balancing with such an osteotomy, however there is few information for the radiographic findings after the osteotomy. Thus, radiographic changes in the coronal view of such cases were investigated.MethodsJSSF-RA foot and ankle scale and SAFE-Q scores were determined along with pre/postoperative radiographic parameters of the ankle joint in 70 ankles (65 patients) with rheumatoid arthritis followed for a mean of 7.9 years (range, 2–16 years) after TAA. Seven ankles were excluded because those underwent lateral or lateral/medial malleolar osteotomy. Twenty-seven ankles underwent medial malleolar osteotomy, and compared with 36 ankles without osteotomy.ResultsAll ankles achieved bone union after medial malleolar osteotomy, and the tibial medial malleolus (TMM) angle was significantly decreased [30.3°–19.1°] following significant valgus correction [TC angle: −2.7° to 0.5°]. The gap due to medial soft tissue tightness was significantly improved by medial malleolar osteotomy [4.95° to 0.7°]. Lateral malleolar fractures sometimes occurred (19%: 5/27 ankles) at valgus correction, but they healed completely without any internal fixation.ConclusionMedial malleolar osteotomy was useful in rheumatoid varus ankle for not only controlling the soft tissue balance, but also providing a stabilized shape of the ankle joint. Lateral malleolar fractures were caused by valgus correction following medial malleolar osteotomy in some cases, but all fractures were completely healed without any internal fixation.     

骨折间隙直视下复位固定后踝移位骨折

[目的]介绍骨折断端间隙直视法下三踝骨折中后踝移位骨折复位固定的手术技术与临床效果。[方法]选择2014年1月~2017年12月手足外科收治的三踝骨折中后踝移位骨折患者42例,采用骨折断端间隙直视法复位固定后踝骨折,采用骨骼肌肉功能评分(SMFA)评定患者术后恢复情况。[结果]所有患者均达到骨性愈合,术后未出现需要进行翻修手术或感染的病例,踝关节背伸跖屈功能良好。患者骨骼肌肉功能评分(SMFA)功能障碍指数平均为(8.01±1.73)分,SMFA困扰指数平均为(2.22±1.31)分。所有患者术后平均3个月进行正常的日常生活活动。[结论]对于三踝骨折中后踝移位骨折的治疗,采用后外侧入路骨折断端直视下复位固定方法可能是一种更好的选择。     

Pre-and postoperative factors associated with functional outcomes in patients with posterior malleolar fractures

IntroductionRecent studies on posterior malleolar fractures mainly focus on the reduction quality and fixation of the posterior fragment since it contributes to ankle stability and articular congruency. However, the association of pre-and postoperative factors considering the whole ankle joint in postoperative functional outcomes remains unclear. Therefore, this study aimed to examine the association between pre-and postoperative variables for postoperative functional outcomes in patients with posterior malleolar fragments (classified as Haraguchi type I or II) and considered the association between reduction and fixation for small posterior malleolar fragments of less than 25% of the intra-articular surface.MethodsThis multicenter retrospective cohort study included 110 adult patients who underwent internal fixation for ankle fractures with posterior malleolar fragments. The primary outcome was the American Orthopaedic Foot and Ankle Society (AOFAS) score 12-months postoperatively. As pre-and postoperative variables, the preoperative demographic data, radiographic findings, operative method, postoperative radiographic findings, and complications were evaluated. In addition, univariable and multivariable logistic regression analyses were conducted to examine the association between pre-and postoperative variables and AOFAS scores.ResultsTwenty-four (21.8%) cases had postoperative complications. Univariate analysis showed that age was significantly according to AOFAS score-stratified groups in patients with Haraguchi type II fractures. Multivariable logistic regression analysis using bootstrapping in the Haraguchi type II group showed that postoperative complications were significantly associated with low AOFAS scores, indicating poor functionality. In both fracture types, postoperative complications had the highest odds ratio among the explanatory variables. In patients with small posterior malleolar fragments, fragment reduction, fixation, and ankle stability were not associated with AOFAS scores.ConclusionsOur results suggest that postoperative complications were associated with AOFAS scores at postoperative 12 months in patients with ankle fractures with posterior malleolar fragments. In patients with small posterior malleolar fragments, reduction and fixation were not associated with AOFAS scores. Therefore, clinical decisions for posterior fragment fixation should be made based on the possible risk of complications related to the surgical procedures in addition to the posterior malleolar fragment size.     

后外侧入路在踝关节骨折中的应用

目的 评价后外侧入路在踝关节骨折中的应用价值. 方法 2005年3月至2007年8月对23例踝关节骨折采用后外侧入路,其中按照Lauge-Hansen分型:旋后外旋型Ⅲ度4例,旋后外旋型Ⅳ度12例,旋前外旋型Ⅳ度7例.所有患者均同时有腓骨远段和后踝的骨折,其中17例存在内踝骨折,2例为单纯三角韧带损伤.同时对后外踝行切开复位内固定,外踝骨折处钢板放置于腓骨远端后侧,后踝骨折直接行螺钉或钢板固定.观察术后伤口愈合、骨折愈合及内固定情况,同时按Olerud和Molander踝关节骨折术后评分系统对踝关节功能进行评估. 结果 所有患者获得6～23个月(平均15个月)随访.伤口无裂开、坏死,除1例术后10 d出现浅表感染,经积极换药及适量抗生素处理后愈合外,其余均愈合良好.1例术后出现腓肠外侧皮神绛损伤症状,末做特殊处理,3个月后自行缓解.1例出现症状轻微的腓骨肌腱炎,骨折愈合取出钢板后症状消失.术后4～6个月X线片示骨折均愈合,无内固定松动,断裂.踝关节骨折术后功能评分平均为91分,优良率为95.6%. 结论 后外侧入路可同时完成后、外踝骨折的治疗,能在直视下对后踝进行有效复位及可靠固定.     

A reliable method for intraoperative detection of lateral malleolar malrotation using conventional fluoroscopy

ObjectiveTo introduce a new method for intraoperative detection of rotational malreduction of the lateral malleolus using conventional fluoroscopy.Material and methodsFrom January 2014 to December 2017, 56 Weber type C unstable lateral malleolar fractures with syndesmosis injury were identified. The fibular fracture patterns were simple oblique or transverse in 20, comminuted in 25, and Maisonneuve injury with fibular neck fractures in 11 cases. 47 cases were operated with ORIF, and 9 cases of Maisonneuve fractures were operated with CRIF. The mortise view of the contralateral uninjured ankle was used for intraoperative comparison. Two indexes were applied for fluoroscopic detection of distal fibula malrotation, i.e. the contour profile change in lateral malleolar shape, and the intrinsic structure appearance of lateral malleolar fossa cortex. Postoperative talofibular joint congruency was measured on axial CT scan to confirm the reduction quality.ResultsUsing the two radiographic parameters for intraoperative fluoroscopic evaluation, we finally achieved satisfying reduction and fixation of the lateral malleolus in all 56 cases. A more spoon-shaped fibula profile and disappearance of the lateral fossa cortex shadow indicates an internal rotation, while a more pointed blade-shaped fibula profile and disappearance of lateral fossa cortex shadow indicates an external rotation. Postoperative CT scanning identified distal fibular no rotation in 44 cases (78.6%), mild rotation less than 5° in 12 cases (21.4%), with 7 cases internal rotation (mean 3.1°) and 5 cases external rotation (mean 2.8°).ConclusionUsing conventional intraoperative fluoroscopy on mortise view, new radiographic parameters can provide reliable method to detect rotational malreduction of the lateral malleolus.     

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.     

Comparison of routine computed tomography and plain X-ray imaging for malleolar fractures—How much do we miss?

PurposeMost patients with ankle arthrosis have a history of ankle fracture. Evaluation of malleolar fractures solely on X-ray may be insufficient to identify many pathologies that potentially contribute to ankle arthrosis, with a consequent poor prognosis. We investigated the pathologies that may be overlooked in malleolar fractures evaluated solely on plain X-ray.MethodsDuring 2012–2019, 65,479 patients attended our Emergency Department, of which 6508 complained of an ankle joint problem. X-rays indicated a fracture in 454 of these patients. Patients with isolated, simple fracture of the lateral or medial malleolus, or talus, or a history of surgery to this area were excluded; finally, 67 patients were enrolled (31 males, 36 females; mean age: 51,2 years (range: 9–83 years). Patients underwent X-ray imaging of both ankles in anterio-posterior, lateral, and Mortise views, as well as CT scans. Three independent observers with varied experience in diagnostic imaging (orthopaedic resident, experienced orthopaedic surgeon, and musculoskeletal radiologist) evaluated X-ray images blinded to CT scans. Their diagnoses were subsequently compared with CT findings.ResultsModeling results indicated that about 40% [95% CI: 32%, 50%] of pathologies may be overlooked based on X-ray evaluation, regardless of evaluator experience. The most frequently overlooked injuries were: Tillaux fracture, Pillon fracture, loose bodies and syndesmosis injury. All of that missed pathologies required dedicated treatment and could be easily missed with standard surgical approach.ConclusionEvaluation of malleolar fractures by X-ray only inevitably results in overlooking of many pathologies, despite the clinician’s experience. Routine CT scan can help to improve the accuracy of diagnosis, and thereby reduce the risk of ankle osteoarthrosis.     

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.     

Operative costs associated with arthroscopic assisted open reduction and internal fixation of acute ankle fractures

BackgroundAnkle fractures are a common orthopedic injury that frequently involves associated cartilage lesions, soft tissue damage, and a significant inflammatory burden. Despite studies revealing intra-articular pathology in up to 79% of ankle fractures, only 1% of open reduction and internal fixation (ORIF) procedures undergo arthroscopic evaluation. The primary purpose of this study was to determine the cost effectiveness of ankle arthroscopy performed at time of ORIF for ankle fracture.MethodsAn IRB approved retrospective review of patients who sustained ankle fractures and underwent ORIF with and without concomitant arthroscopic surgery between 2015 and 2020 were investigated. Patient demographics, fracture characteristics, outcomes, and cost data were collected and analyzed.ResultsThere were 567 total ORIF and 28 ORIF and scope included for cost analysis purposes. Total surgical costs averaged $6,537.62 and $6,886.46 for the ORIF only and ORIF and scope procedures respectively. Total direct costs, including operating room time, for the same procedures were found to average $6,212.34 and $7,312.10 for the ORIF only and ORIF and scope procedures respectively. The cost difference between the ORIF only and with arthroscopy was not statistically significant (p = 0.1174). Twelve of the 28 arthroscopic patients (42.86%) had grade 3 or full thickness chondral lesions, and 11/28 (39.28%) arthroscopic patients were found to have grade 1–2 cartilage changes.ConclusionIn the acute treatment of ankle fractures, concurrent arthroscopic evaluation does not add a significant cost to the procedure and may result in improved short and long term benefits for the patient. With improved arthroscopic efficiency, the cost differential can be further reduced.LOEIV.     

后外侧入路在老年性踝关节骨折中的应用

[目的]评价后外侧入路在老年踝关节骨折中的临床应用.[方法]2005年3月-2007年8月对13例老年踝关节骨折采取后外侧入路行外后踝骨折切开复位内固定,同一切口中外踝骨折钢板内固定放置于腓骨远端后侧、后踝骨折行螺钉或钢板固定.观察术后伤口愈合、骨折恢复及内固定情况,同时按Olerud和Molander踝关节骨折术后评分系统对踝关节功能进行评估.[结果] 13例均获随访,随访时间6～23个月,平均15个月.伤口无裂开、坏死,1例出现症状不甚严重的腓骨肌腱炎,骨折愈合后取出钢板后症状消失.术后4～6个月X线片显示骨折均愈合,无内固定松动、断裂.踝关节骨折术后功能评分平均为91分,其中优9例,良3例,可1例,优良率为92.3％.[结论]后外侧入路能同时完成后外踝骨折的治疗,可减少老年患者的手术创伤、创面感染及坏死等并发症,对伴骨质疏松老年患者的外踝骨折能进行牢靠安全固定.     

Posterior Malleolus Fracture Displacement Is Associated with Rotational Ankle Fracture Stability in Patients Without Medial Malleolar Fractures

Background

The optimal method for the determination of ankle stability remains controversial in rotational ankle fractures without medial bony injury.

Questions/Purposes

The purposes of this study were to (1) evaluate whether posterior malleolar (PM) fracture displacement is associated with deltoid ligament injury in supination-external rotation (SER) ankle fractures and (2) compare the diagnostic accuracy of PM displacement and magnetic resonance imaging (MRI) evaluation of the deep deltoid ligament in identifying fractures with deltoid ligament incompetence.

Methods

Patients with rotational bimalleolar injuries containing lateral malleolar and PM fractures without bony medial injury were included. After operative lateral and PM fixation, an external rotation stress test was performed to evaluate deltoid ligament stability. Operative dictations were reviewed to confirm injury pattern, stability on stress test, and visual inspection of the deltoid ligament. Maximum PM displacement was assessed on lateral X-ray. Pre-operative MRI of the ankle was performed following closed reduction and splinting.

Results

The final cohort consisted of 13 trimalleolar equivalent fractures (torn deltoid ligament) and 20 bimalleolar fractures (medial malleolus and deltoid ligament intact). Average PM displacement was significantly higher for SER trimalleolar equivalent patterns when measured on lateral X-ray. The sensitivity of detecting trimalleolar equivalent fracture was higher on all reported X-ray findings than the sensitivity obtained by the reported MRI findings of deltoid ligament injury.

Conclusion

PM displacement on X-ray is a useful adjuvant along with external rotation stress radiography and MRI evaluation of deep deltoid integrity to distinguish between stable and unstable fracture patterns and thus helps facilitate treatment decisions.

     

Comparison of risk factors for postoperative complications across age groups in patients undergoing ORIF of the ankle

IntroductionRisk factors associated with various adverse outcomes for patients undergoing open reduction and internal fixation (ORIF) of the ankle, and how these risks differ between younger and older patient populations, has not been clearly established. Objective quantitative data may aid physicians in surgical decision making, individualizing postoperative management, and targeting interventions for reducing postoperative comorbidity. The purpose of this study is to compare the incidence of and risk factors for adverse postoperative outcomes following ORIF of ankle fractures across patient age groups.Materials and methodsCharts of patients age 18 years and older who underwent open reduction and internal fixation (ORIF) for any closed, non-polytraumatic, non-pilon ankle fracture at a single institution between the years 2008 and 2018 were reviewed. Demographic information, comorbidities, and postoperative outcomes were collected. Relative risks for adverse outcomes were calculated and compared between patients younger than 50 and patients 50 years and older.ResultsA total of 886 patients were included, 375 (42.3%) of which were over age 50. In both age groups, risk of infection was significantly increased among patients with hypertension, although risk among older patients (RR = 3.52, p = 0.004) was greater than that among younger patients (RR = 2.46, p = 0.017). In patients younger than 50, significant risk of wound dehiscence was associated with tobacco use (RR = 3.39, p = 0.022), substance use (RR = 3.07, p = 0.020), and CHF (RR = 12.77, p < 0.001). Risk of implant failure was significantly increased among younger patients with HIV (RR = 4.33, p = 0.026), CHF (RR = 10.54, p < 0.001), and CKD (RR = 10.54, p < 0.001), and among older patients with HTN (RR = 4.51, p = 0.006), CHF (RR = 5.83, p < 0.001), and tobacco use (RR = 3.82, P = 0.001).ConclusionPatients undergoing ORIF of the ankle should be well-informed of the potential risks of surgery as they pertain to specific comorbidities. Multidisciplinary approaches are warranted for appropriate management of patients with multiple comorbidities.     

Risk factors for post-traumatic osteoarthritis of the ankle: an eighteen year follow-up study

Purpose

Long-term studies evaluating risk factors for development of ankle osteoarthritis (OA) following malleolar fractures are sparse.

Methods

We conducted a retrospective cohort study including consecutive patients treated by open reduction and internal fixation for malleolar fracture between January 1988 and December 1997. Perioperative information was obtained retrospectively. Patients were evaluated clinically and radiographically 12–22 years postoperatively. Radiographic ankle OA was determined on standardised radiographs using the Kellgren and Lawrence scale (grade 3–4 = advanced OA). Uni- and multivariate regression analyses were performed to determine risk factors for OA.

Results

During the inclusion period, 373 fractures (372 patients; 9% Weber A, 58% Weber B, 33% Weber C) were operated upon. The mean age at operation was 42.9 years. There were 102 patients seen at follow-up (mean follow-up 17.9 years). Those not available did not differ in demographics and fracture type from those seen. Advanced radiographic OA was present in 37 patients (36.3%). Significant risk factors were: Weber C fracture, associated medial malleolar fracture, fracture-dislocation, increasing body mass index, age 30 years or more and length of time since surgery.

Conclusions

Advanced radiographic OA was common 12–22 years after malleolar fracture. The probability of developing post-traumatic OA among patients having three or more risk factors was 60–70%.     

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.     

Comparison study of patient demographics and risk factors for infections following primary total elbow arthroplasty

BackgroundInfections are a feared complication following primary total elbow arthroplasty (TEA). Studies comparing baseline demographic profiles and identifying risk factors associated with developing surgical site infections (SSIs) or peri-prosthetic joint infections (PJIs), following primary TEA are limited. This study was therefore aimed to: (1) compare patient demographics; and (2) identify patient-related risk factors for the development of infections following a primary TEA.MethodsPatients who underwent primary TEA from January 1, 2005 to March 31, 2014 were identified in an administrative claims database. The study group consisted of all patients who developed either SSIs within 90-days or PJIs within 2-years following the index procedure, respectively. A total of 23,134 primary TEAs were identified between 2005 and 2014, of which 757 (3.3%) were coded as being infected. Primary outcomes that were assessed included comparing baseline patient demographics and identifying patient-related risk factors for developing PJIs. Pearson's chi-square analyses were used to compare study group demographics to their counterparts. Welch's t-test was used to compare mean Elixhauser-Comorbidity Index scores between the cohorts. Multivariate binomial logistics regression was used to calculate odds-ratios (OR) for patient-related risk factors. A P value less than .05 was considered statistically significant.ResultsPatients who developed infections were significantly different compared to their counterparts with respect to the variables analyzed. Patients developing infections were found to have a higher prevalence of comorbidities as measured by mean Elixhauser-Comorbidity Index scores in patients who developed SSIs (7 vs. 5, P < .0001) or PJIs (7 vs. 5, P < .0001) compared to their respective counterparts. The greatest risk factors for SSIs within 90-days following primary TEA were rheumatoid arthritis (OR: 1.80, P < .0001), being male (OR: 1.53, P = .009), and depressive disorders (OR: 1.52, P = .004), whereas iron deficiency anemia (OR: 2.04, P < .0001), rheumatoid arthritis (OR: 1.78, P < .0001), and pathologic weight loss (OR: 1.73, P < .0001) were associated with an increased odd of PJIs.ConclusionThis study demonstrated statistically significant differences between patients who developed and did not develop infections following primary TEA and identified a myriad of risk factors associated with these adverse events. The results from this study can help identify high risk patients by orthopedic surgeon in order to potentially mitigate the incidence of either SSIs or PJIs in patients undergoing TEA.Level of EvidenceLevel III; Database Study, Retrospective Case-Control Prognosis Study     

Functional outcome after operative treatment for ankle fractures in young athletes: a retrospective case series

BACKGROUND: No reports describe the outcome for distal fibula and tibia fractures in athletes, although 10 to 15% of all athletic injuries occur around the ankle joint. MATERIALS AND METHODS: Forty-seven competitive or recreational athletes with ankle fractures underwent open reduction and internal fixation (ORIF). Thirty-six met the inclusion criteria, of which 27 returned for clinical and radiographic exams and also completed validated surveys and a subjective questionnaire. RESULTS: Nineteen of the 27 were male. The average age of all patients was 18.1 +/- 5.9 years. The final evaluations occurred 12 months to 3.7 years after surgery. Injuries occurred in 13 different sports, of which football had the most (n = 10). Bimalleolar fractures were the most prevalent (n = 10) followed by isolated lateral malleolar fractures (n = 6), syndesmosis injury (n = 4), Salter-Harris (n = 4), medial malleolar fracture (n = 2) and pilon fracture (n = 1). The patients with isolated lateral malleolar fractures returned to competition soonest (6.8 +/- 2.4 weeks) while patients with isolated medial malleolus fractures took the longest to return at a mean of 17.0 +/- 9.9 weeks. Scores for function and pain on the Lower Limb Core Module and for pain on the Foot and Ankle module were all greater than 90. CONCLUSION: Athletes who undergo ORIF followed by early motion and early weightbearing are able to return to their pre-injury level of competition within 2 to 4 months with minimal functional morbidity or pain.