Involvement of the inner malleolus and deltoid ligament in supination trauma of the ankle joint

Additional ligament ruptures or fractures of the medial side of the ankle joint accompanying the lateral ligament rupture are rare. These injuries are more often in traumas with pronation-eversion movements of the foot. In cases of lateral ligaments ruptures we only found in 2.8% and in 5.9% additional medial injuries. This is confirmed by different biomechanical experiments. Experimentally the delta ligament rupture could mostly be caused by pronation-eversion movements or by forced plantar flexion of the foot. The diagnosis of bony lesions of the medial malleolus might be easy by X-ray, but ligament lesions of the medial ankle joint can be diagnosed easily too be using the stress X-ray controlling the medial talar tilt as a sign of medial instability. Because the necessity of surgical treatment is less important than of the lateral ligaments we recommend this procedure in cases of bilateral instability or if dislocation is obvious.     

Sprunggelenkfrakturen

Ankle fractures belong to the most frequent injuries to the human skeleton. Correct treatment requires knowledge of the trauma mechanism and thorough analysis of the injured bony and ligamentous components. Isolated, non-displaced fractures of the medial or lateral malleolus are subject to non-operative, functional treatment with favorable long-term results provided that instability of the ankle mortise has been definitely ruled out. Fracture-dislocations have to be reduced as an emergency under sufficient analgesia to avoid severe soft-tissue complications. The most important prognostic factors after operative treatment are exact reconstruction of the articular surfaces and correct position of the distal fibula within the tibial incision after a mechanically relevant syndesmosis rupture. Besides malalignment, negative prognostic factors include delayed reduction, injury of several ankle components and hereditary or acquired neuropathy.     

Examination of the pathologic anatomy of ankle fractures.

A prospective study of the translational and rotational displacement of the lateral malleolus in ankle fractures was carried out utilizing roentgenographic techniques. Twenty-six ankle fractures in 25 patients were studied using both routine plain films and CT scanning with two- and three-dimensional multiplanar reconstruction. Eighty-one percent were Lauge-Hansen supination-external rotation type injuries. Overall, 21 fractures did not involve the medial malleolus. Initial talar shift was less than or equal to 2 mm in 15 fractures. Although all patients exhibited external rotation deformities of the lateral malleolus on plain films, only one fracture was found to possess any degree of external rotation relative to the talus. The proximal fibula was seen on CT scans to have increased internal rotation with respect to the tibia in 19 cases. One patient had a slightly externally rotated proximal fibula; the remainder appeared normally aligned. The displacements measured by the CT scans at the talofibular articulation were compared with the standard plain film measurements. The displacements at the distal lateral malleolus were consistently overestimated by the plain roentgenograms, presumably because the capsular and ligamentous attachments to the distal fibula limit malleolar displacement. The talocrural angle, determined on both plain films and CT scans, was also not found to be a sensitive measure of fibular shortening nor of the severity of the fracture. The results of this study suggest that, in an isolated lateral malleolar ankle fracture, the apparent external rotation of the fracture fragment is relative only to the proximal fibula and is not associated with derangement of the talofibular articulation. Based on these mechanical considerations, surgical intervention for such fractures may not be necessary. This hypothesis is consistent with previous long-term clinical studies.     

The deltoid ligament. An evaluation of need for surgical repair

Forty-two patients were treated surgically for ankle injuries, including complete disruption or incompetency of the deltoid ligament, without any surgical repair as part of the initial operation. In a retrospective study, 36 patients were followed for one year or longer. The functional results appeared satisfactory provided surgical reductions of the medial joint space and lateral malleolus were accurate and maintained until bone repair was complete. No evidence of ligamentous instability of the foot or ankle was noted.     

微创经皮内固定治疗复杂踝部骨折53例

目的：探讨微创内固定治疗复杂踝部骨折的手术方法和临床疗效。方法：自2007年1月至2011年12月,采用微创经皮内固定治疗53例复杂踝部骨折患者,男31例,女22例;年龄18-65岁,平均38．2岁。按Lauge-Hansen分型：旋后外旋型Ⅳ度32例,旋前外旋型Ⅲ、Ⅳ度13例,旋前外展型Ⅲ度5例,因腓骨骨折严重粉碎无法分类3例。Denis—Weber分类：A型4例,B型34例,C型15例。受伤至手术时间2h-14d,平均5d。骨折复位固定顺序为后踝、内踝、外踝和下胫腓联合。后踝骨折采用踝前切口间接复位固定,内外踝骨折采用经皮螺钉、接骨板或张力带固定,必要时螺钉固定下胫腓联合。术后采用Baird-Jackson评价系统进行疗效评价。结果：48例获随访,时间10-36个月,平均13个月。骨折全部愈合,愈合时间10-18周,平均12周。根据Baird-Jackson评价系统进行疗效评定,术后踝关节功能平均（94．7±4．2）分,其中优28例,良15例,可3例,差2例。1例发生皮肤浅表性感染,经换药治愈;2例发生下胫腓联合固定螺钉断裂。结论：采用微创经皮内固定治疗复杂踝部骨折可保证踝关节获得解剖复位,保护骨折端血运及软组织覆盖,最大限度地恢复踝关节功能,获得满意的临床疗效。     

Competence of the deltoid ligament in bimalleolar ankle fractures after medial malleolar fixation

BACKGROUND: The stability of the ankle joint is provided by the medial and lateral malleoli and ligaments. Recent studies of cadaveric ankles have demonstrated that injury to the medial structures of the ankle is necessary to allow lateral subluxation of the talus after fracture. However, cadaveric models are limited by the fracture pattern chosen for the model. We sought to investigate the competency of the deltoid ligament in vivo in patients with an operatively treated bimalleolar ankle fracture. METHODS: Twenty-seven patients with a bimalleolar ankle fracture were evaluated. In each patient, the medial malleolus was anatomically reduced and fixed. A radiograph of the ankle was then made with application of an external rotation load to the joint. All lateral malleolar injuries were then reduced and fixed. The radiographs were evaluated for restoration of the competence of the deltoid ligament according to established criteria. RESULTS: Seven (26 percent) of the twenty-seven patients had radiographically evident incompetence of the deltoid ligament after medial malleolar fixation. This finding was associated with a small medial malleolar fragment. CONCLUSIONS: In bimalleolar fractures, the medial injury may be an osseous avulsion, leaving the deltoid intact on the displaced fragment, or it may be a combination of ligamentous and osseous injury with disruption of the deep portion of the deltoid ligament.     

踝关节三角韧带损伤的手术治疗及效果

目的：探讨踝关节三角韧带损伤手术治疗的重要性。方法：2002年至2008年治疗伴有三角韧带损伤的踝关节骨折61例,男39例,女22例;年龄14～71岁,平均41岁。均采用切开复位和坚强内固定,并修复重建三角韧带,恢复踝关节内外侧结构的稳定性。结果：61例中59例切口Ⅰ期愈合;2例术后外踝伤口浅表感染,经换药于术后3周愈合,内踝伤口全部Ⅰ期愈合。全部病例获得随访,时间5～30个月。平均17个月。按疗效评定标准,本组优35例,良13例,可13例。结论：强调踝关节骨折切开解剖复位、坚强内固定的同时,应充分重视修复重建三角韧带。     

Achilles tendon rupture. Occurrence with a closed ankle fracture

A 61-year-old man, involved in an automobile accident, sustained a complete Achilles tendon rupture with an ipsilateral, closed slightly displaced medial malleolus ankle fracture. The tendon rupture was not diagnosed before operation but was recognized at the time of open reduction of the ankle. This rare combination of injuries was apparently secondary to hyperdorsiflexion of the foot. The tendon rupture would have been missed had surgical treatment not been required. Unrecognized tendon ruptures associated with closed ankle fractures may be a cause of residual ankle-foot weakness, pain, loss of motion, or a combination thereof.     

Ankle Fracture Associated With Rupture of the Achilles Tendon: Case Report and Review of the Literature

Solitary ankle fracture or Achilles Tendon (AT) rupture might not be an uncommon injury. However, concomitant ipsilateral ankle fracture with AT rupture is rare. The present report discusses this rare combination. A 30-year-old female had fallen while rock climbing and sustained a closed fracture of the medial malleolus with an ipsilateral complete AT rupture. Most of the reported cases had similar patterns, not only in terms of history, but also in terms of a similar fracture pattern. This rare combination of orthopedic injuries tends to occur when an abrupt excessive force is applied to the forefoot, with subsequent ankle hyperextension or hindfoot inversion. Imaging studies are useful both for confirming the injuries and for medicolegal and research purposes. Definitive treatment of the AT rupture is usually surgical in young active patients. Concomitant malleolar fractures can be managed conservatively or surgically, depending on the fracture configuration and degree of displacement. The importance of a thorough clinical examination in assessing the musculoskeletal and neurovascular structures in ankle injuries cannot be overemphasized. Knowledge of these injury patterns is crucial to reducing the incidence of residual morbidity such as ankle and foot weakness and loss of motion.     

Stable ankle joint fractures. Indications for operative or conservative treatment?

In German literature, ankle joint fractures are mostly classified in three groups according to Weber. In cases of the type A, the fracture line runs below, in cases of type B at height of the syndesmotic ligaments. C-type fractures are typically seen above this region. However, this practical and simple classification allows no inferences at accompanying injuries which in turn influence the functional outcome. We observed isolated fractures of the lateral malleolus in more than 60% of all type B-fractures, as soon as in the majority the type A-fractures. Since isolated medial ankle fractures occur very rarely, careful exclusion of further injuries is advisable here. In order to differentiate stable ones from unstable type B ankle injuries, we carry out a manual stress test, if there is less than 2 mm fracture dislocation and a congruent ankle mortise. In this manner we could find that stable lateral ankle fractures are characterized with a combination of an intact dorsal syndesmotic and medial ligament. Stable type B and undisplaced type A fractures were treated conservatively with an ankle brace (Aircast?). Unstable ankle injuries were treated by ORIF. Conservative treatment for undisplaced medial malleolar fractures is recommended, if x-rays showed less than 2 mm dislocation which allows a tibio-talare impingement. Biomechanical investigations could prove a significant increase in ankle joint stability, when an axial load of 300 N was applied to various horizontal loads. The talus does not follow automatically a displaced fibular fracture. The dorsal syndesmotic and the medial deltoid ligaments control ankle joint stability.     

Stress fractures of the foot and ankle

Stress fractures occur as a result of microscopic injuries sustained when bone is subjected to repeated submaximal stresses. Overtime, with repeated cycles of loading, accumulation of such injuries can lead to macro-structural failure and frank fracture.There are numerous stress fractures about the foot and ankle of which a trauma and orthopaedic surgeon should be aware. These include: metatarsal, tibia, calcaneus, navicular, fibula, talus, medial malleolus, sesamoid, cuneiform and cuboid.Awareness of these fractures is important as the diagnosis is frequently missed and appropriate treatment delayed. Late identification can be associated with protracted pain and disability, and may predispose to non-union and therefore necessitate operative intervention.This article outlines the epidemiology and risk factors, aetiology, presentation and management of the range of stress fractures in the foot and ankle.     

Crescentic transmalleolar osteotomy for optimal exposure of the medial talar dome

A review of the literature suggests that surgical treatment of transchondral talar dome fractures affords superior results over lengthy conservative therapy. Medial lesions have been reported most often. The authors perform stress views in acute and chronic ankle injuries, as there are often associated ligament ruptures with suspected talar dome fractures, and routinely use an air-contrast radiographic technique for visualization of the continuity of the articular cartilage. An arthrogram is performed for definitive diagnosis of ligamentous injury. A new osseous surgical approach to the medial talar dome has been presented, entailing a crescentic osteotomy of the medial malleolus. The distinct advantage has proven to be enhanced exposure to the middle and posterior aspects of the medial margin of the talus. The configuration of the crescentic osteotomy is also amenable to internal fixation and tension band wiring has been recommended. Unrestricted access to the site of a medial transchondral talar dome fracture through this osteotomy is the benefit of a technically well-performed procedure.     

Ankle fracture following hip arthroscopy

This article describes a case of an ankle fracture following hip arthroscopy. A 58-year-old woman underwent hip arthroscopy for a labral tear. She was placed in a lateral decubitus position with her foot in a padded boot. Traction was maintained for approximately 30 minutes. She was instructed to bear weight as tolerated with crutches postoperatively. At 2-week follow-up, she reported ipsilateral ankle pain. Radiographs revealed a minimally displaced medial malleolus fracture. She was treated with a cast followed by a cam walker boot and successfully went on to complete union and resolution of her symptoms.The following risk factors exist for ankle fracture after hip arthroscopy: history of ankle sprains, ligamentous laxity (more common in women), and small feet with large calves (more likely to become plantarflexed during traction). Distraction performed with the ankle rotated is also likely to place added stress on the medial or lateral ligamentous structures.It is important to counsel patients preoperatively about the risk of ankle pain after hip arthroscopy, to be aware of the possibility of ankle pathology postoperatively, and to have a low threshold for ordering radiographs. Radiographs are warranted if patients continue to have ankle pain after 72 hours postoperatively.     

Reconciliation Between Lateral X-ray and Axial Computed Tomography Regarding Posterior Malleolus Fracture Anatomy and Medial Malleolus Involvement: A Pilot Study

Configuration of a posterior malleolus fracture has significant variation based on mechanism of injury and concomitant ankle injuries. Radiographs obtained during early workup of ankle trauma play a pivotal role in closed reduction, surgical planning and preoperative management. Preoperative computed tomography helps distinguish fracture pathoanatomy. The purpose of this study is to relate measurements from traditional lateral radiographs with measurements on axial computed tomography. Imaging from a total of 22 patients treated at our institution from January 2008 to 2018 were evaluated. Two raters measured posterior malleolus fracture height and articular surface length on lateral radiographs, as well as medial-lateral width and anterior-posterior depth on axial computed tomography using calibrated imaging software. Posterior malleolar fractures with medial extension were recorded. Pearson correlations were calculated for all pairwise combinations of measurements. Lateral height and axial width were positively correlated. There was found to be an association between taller lateral height, and separately, wider axial width with presence of medial extension. Based on the correlations found between the measurements as well as the independent associations found with presence of medial extension, we suggest posterior-medial incision be evaluated as a potential approach in taller fractures as noted on lateral radiograph.     

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.     

Isolated posterior malleolus fracture: a rare injury mechanism

Isolated posterior malleolus fractures of the ankle are very rare, especially those without any associated ligamentous injury. The mechanism of injury is unique, and treatment depends on the displacement of the fracture and associated injuries. We present the case of a 46-year-old female car driver who sustained this injury. Axial loading of the plantar flexed foot most likely caused this fracture pattern. The fracture healed in 6 weeks with non-operative treatment in a below-knee plaster cast.The authors declare that this case study complies with the current laws in the United Kingdom.     

踝关节镜在踝关节骨折治疗中的价值

目的探讨踝关节镜在踝关节骨折治疗中的价值。方法 2009年12月～2011年7月26例踝关节骨折在踝关节镜下探查踝关节腔,清理撕裂韧带、水肿滑膜、损伤软骨,在踝关节镜辅助下复位、固定骨折,修复、重建损伤的韧带。结果软骨损伤部位同时累及胫骨远端关节面及距骨上关节面6例;累及距骨内侧面12例,其中5例同时合并内踝损伤,1例同时合并内、外踝损伤;同时合并外踝及距骨外侧面损伤8例,其中1例同时合并内踝及距骨体部损伤。关节镜下软骨碎片取出术11例,软骨复位固定9例,关节面修整、微骨折术6例;距下关节镜检查示软骨损伤及韧带松弛5例,距跟韧带断裂3例,均在关节镜辅助下行修复重建术。手术时间40～160 min,平均90 min;术中出血量10～300 ml,平均100 ml。术中均无神经、血管损伤,术后无感染病例,切口一期愈合。术后3个月采用改良McGuire评分系统评定临床疗效：优15例（81～100分）,良9例（71～80分）,可2例（65～70分）。26例随访3～24个月,平均9个月,骨折全部愈合。结论踝关节镜辅助治疗踝关节骨折能够精确解剖复位关节面,及时发现、处理软骨、韧带等合并损伤,创伤小,治疗效果满意。     

Assessment of the lateral ligaments of the ankle after healed fractures

BACKGROUND: Lateral ligament complex injuries are difficult to diagnose immediately after ankle fracture, and treatment is focused on the fracture. This study examines the prevalence of ligamentous injuries after severe ankle fractures. METHODS: Lateral ligament instability can be revealed by inversion and anterior stress views after fracture healing. The results of 54 inversion and anterior stress examinations of the ankle after fracture healing, using a Telos stress device at 15 kPa force, were compared with uninjured ankles. RESULTS: No patient had 5 degrees or more of talar tilt or 6 mm or more of anterior displacement of the talus in uninjured ankles; however, in ankles with fractures, we found abnormal talar tilt angle in 12 and excessive anterior displacement in five. An abnormal inversion stress test was found to be considerably more common in the fractured ankles. CONCLUSION: Our study revealed that lateral ligament injuries may occur simultaneously with ankle fractures, with the most frequently injured being the calcaneofibular ligament.     

Delayed reconstruction of lateral complex structures of the ankle

Lateral ankle instability is one of the most common and well-recognized conditions presenting to foot and ankle surgeons. It may exist as an isolated entity or in conjunction with other concomitant pathology, making it important to appropriately diagnose and identify other conditions that may need to be addressed as part of treatment. These associated conditions may be a source of chronic pain, even when the instability has been appropriately treated, or may lead to failure of treatment by predisposing the patient to ankle inversion injuries. The primary goal of this editorial is to provide a brief summary of the common techniques used in the delayed reconstruction of lateral ankle ligamentous injuries and present a method we have successfully employed for over 15 years. We will also briefly discuss the diagnosis and treatment of the more common associated conditions, which are important to identify to achieve satisfactory results for the patient. We present the outcomes of 250 consecutive reconstructions performed over the last 10 years and describe our operative technique for addressing lateral ankle ligamentous injuries.     

Subtalar dislocation: management and prognosis for an uncommon orthopaedic condition

Subtalar dislocations were first described in 1811 as the simultaneous dislocation of the talo-calcaneal and talo-navicular joints without any tibio-talar or talar neck associated fractures. They were classified in 1853 as: medial, lateral, posterior and anterior based on the displacement of the foot in relationship to the talus. These are uncommon injuries, representing approximately 1 % of all traumatic injuries of the foot and 1–2 % of all dislocations, being associated with high energy trauma.Closed reduction of these dislocations should be performed as early as possible to avoid further damage to the skin and neurovascular structures. If this is not possible, then open reduction without further delay is recommended. Irreducible injuries have been reported in 0 to 47 % of cases. Open dislocations represent between 46 and 83 % of all cases, and have been associated with poor prognosis. Associated fractures have a high incidence, the most frequent ones are the posterior process of the talus, talar head, external malleolus, medial malleolus and the tubercle of the fifth metatarsal.These types of injuries are not faced by orthopaedic surgeons on a daily basis and having a source of information on how to manage and what to expect is important. We present an up-to-date literature review on the epidemiology, clinical presentation, radiologic assessment, treatment options and prognostic factors of these uncommon injuries.