Comparison of functional outcomes of total elbow arthroplasty vs plate fixation for distal humerus fractures in osteoporotic elbows

Treating intra-articular fractures about the osteoporotic distal humerus poses a significant challenge. The purpose of this retrospective study was to evaluate functional outcomes for distal humeral fractures treated with total elbow arthroplasty (TEA) or open reduction and internal fixation (ORIF) in a nonarthritic elderly population with osteoporosis. We reviewed the records of all women older than age 60 who had undergone surgical treatment for intraarticular distal humerus fractures (Orthopaedic Trauma Association types 13B and 13C) by 1 of 2 surgeons. Demographic and operative data were obtained, charts were reviewed, and patients were asked to have their outcomes evaluated with the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and the Mayo Elbow Performance Index (MEPI). Twenty-two patients (23 elbows) were identified, and 2 of these (3 elbows) were excluded. Of the remaining 20 patients, 9 had undergone cemented, semiconstrained TEA as initial treatment, and 11 had undergone ORIF. These 2 groups were compared. Mean follow-up was 14.8 months (range, 6-38 months). There were no significant differences between the TEA and ORIF groups with respect to demographic factors. Final elbow range of motion was 92° flexion-extension arc (arthroplasty group) and 98° (fixation group). Two patients in the arthroplasty group and 2 in the fixation group died. For the remaining patients, mean DASH scores were 30.2 (arthroplasty) and 32.1 (fixation), and mean MEPI scores were 79 (arthroplasty) and 85 (fixation). These differences were not statistically significant. Four TEAs developed radiographic loosening by a mean of 15 months, and 1 of these underwent revision with good outcome. Ten of the 11 fractures in the fixation group healed radiographically; the 1 nonunion with collapse continued to be asymptomatic. Two patients in the fixation group underwent contracture release after union for limited elbow range of motion. Many factors come into play in the treatment of intra-articular distal humerus fractures in patients with osteoporosis. Implant selection must be based on bone quality, expected outcome, and surgeon experience. For these injuries, good outcomes may be obtained with either TEA or ORIF.     

A multicenter, prospective, randomized, controlled trial of open reduction--internal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients

We conducted a prospective, randomized, controlled trial to compare functional outcomes, complications, and reoperation rates in elderly patients with displaced intra-articular, distal humeral fractures treated with open reduction-internal fixation (ORIF) or primary semiconstrained total elbow arthroplasty (TEA). Forty-two patients were randomized by sealed envelope. Inclusion criteria were age greater than 65 years; displaced, comminuted, intra-articular fractures of the distal humerus (Orthopaedic Trauma Association type 13C); and closed or Gustilo grade I open fractures treated within 12 hours of injury. Both ORIF and TEA were performed following a standardized protocol. The Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder and Hand (DASH) score were determined at 6 weeks, 3 months, 6 months, 12 months, and 2 years. Complication type, duration, management, and treatment requiring reoperation were recorded. An intention-to-treat analysis and an on-treatment analysis were conducted to address patients randomized to ORIF but converted to TEA intraoperatively. Twenty-one patients were randomized to each treatment group. Two died before follow-up and were excluded from the study. Five patients randomized to ORIF were converted to TEA intraoperatively because of extensive comminution and inability to obtain fixation stable enough to allow early range of motion. This resulted in 15 patients (3 men and 12 women) with a mean age of 77 years in the ORIF group and 25 patients (2 men and 23 women) with a mean age of 78 years in the TEA group. Baseline demographics for mechanism, classification, comorbidities, fracture type, activity level, and ipsilateral injuries were similar between the 2 groups. Operative time averaged 32 minutes less in the TEA group (P = .001). Patients who underwent TEA had significantly better MEPSs at 3 months (83 vs 65, P = .01), 6 months (86 vs 68, P = .003), 12 months (88 vs 72, P = .007), and 2 years (86 vs 73, P = .015) compared with the ORIF group. Patients who underwent TEA had significantly better DASH scores at 6 weeks (43 vs 77, P = .02) and 6 months (31 vs 50, P = .01) but not at 12 months (32 vs 47, P = .1) or 2 years (34 vs 38, P = .6). The mean flexion-extension arc was 107 degrees (range, 42 degrees -145 degrees) in the TEA group and 95 degrees (range, 30 degrees -140 degrees) in the ORIF group (P = .19). Reoperation rates for TEA (3/25 [12%]) and ORIF (4/15 [27%]) were not statistically different (P = .2). TEA for the treatment of comminuted intra-articular distal humeral fractures resulted in more predictable and improved 2-year functional outcomes compared with ORIF, based on the MEPS. DASH scores were better in the TEA group in the short term but were not statistically different at 2 years' follow-up. TEA may result in decreased reoperation rates, considering that 25% of fractures randomized to ORIF were not amenable to internal fixation. TEA is a preferred alternative for ORIF in elderly patients with complex distal humeral fractures that are not amenable to stable fixation. Elderly patients have an increased baseline DASH score and appear to accommodate to objective limitations in function with time.     

Arthroskopisch assistierte Frakturversorgung am oberen Sprunggelenk

Acute ankle fractures are one of the most common fractures in adults with an incidence of 0.1–0.2?% per year. Operative treatment by open reduction and internal fixation (ORIF) is the standard method of treatment for unstable or dislocated fractures. The main goal of the operation is the anatomical realignment of the joint and restoration of ankle stability; nevertheless, anatomical reduction does not automatically lead to favorable clinical results. According to several studies the mid-term and in particular the long-term outcome following operative treatment is often poor with residual symptoms including chronic pain, stiffness, recurrent swelling and ankle instability. There is growing evidence that this poor outcome might be related to occult intra-articular injuries involving cartilage and soft tissues. In recent studies the frequency of fracture-related osteochondral lesions was reported to be approximately 64?%. By physical examination, standard radiography or even computed tomography (CT), these intra-articular pathologies cannot be reliably diagnosed; therefore, many authors emphasize the value of ankle arthroscopy in acute fracture treatment as it has become a safe and effective diagnostic and therapeutic procedure. Arthroscopically assisted open reduction and internal fixation (AORIF) allows control of the reduction as well examination of all intra-articular structures. If necessary, intra-articular pathologies can be addressed by removing ruptured ligaments and loose bodies, performing chondroplasty or microfracturing. So far there is no evidence that supplementary ankle arthroscopy increases the complication rate. On the other hand, the positive effect of AORIF has also not been clearly documented; nevertheless, there are clear indications that arthroscopically assisted fracture treatment is beneficial, especially in complex fractures.     

Functional outcome of unstable distal radius fractures: ORIF with a volar fixed-angle tine plate versus external fixation

PURPOSE: The purpose of this study was to compare the outcomes of 2 treatments for unstable distal radius fractures: open reduction internal fixation (ORIF) through a volar approach with a fixed-angle implant and a standard external fixation (EF) method. METHODS: This study included patients with comminuted unstable intra-articular and extra-articular distal radius fractures treated by a single surgeon. Data were gathered retrospectively on 11 patients treated with EF who had been followed up for an average of 47 months (range, 12-84 mo). Prospective data were gathered on 21 patients who were treated with ORIF through a volar approach with a fixed-angle implant. Follow-up evaluation for this group averaged 17 months (range, 12-24 mo). The 2 groups were compared for range of motion (ROM), strength, and functional outcome as measured by the Patient Rated Wrist Evaluation (PRWE) and the Disability of the Arm, Shoulder, and Hand Questionnaire (DASH). Fracture reduction was evaluated from radiographs taken at the last follow-up visit and compared between groups. RESULTS: The mean passive wrist ROM at the final follow-up evaluation in EF patients was 59 degrees extension and 57 degrees flexion, compared with 63 degrees extension and 64 degrees flexion in patients treated with ORIF. Passive pronation/supination arc of motion was similar for the 2 groups, as were the DASH and PRWE scores. Grip strength as a percentage of the opposite wrist was significantly greater in the external fixation group, a possible consequence of longer follow-up evaluation. Final radiographic measurements for the EF group averaged 5 degrees volar tilt and 25 degrees radial inclination, with 2.2-mm ulnar-positive variance. The ORIF with volar plating group averaged 10 degrees volar tilt and 22 degrees radial inclination, with .5-mm ulnar-negative variance. Radial length and volar tilt were significantly greater for the ORIF group. The average final intra-articular step-off was significantly different, with 1.4-mm step-off in the EF group and .4 mm in the ORIF group. CONCLUSIONS: The use of ORIF with a volar fixed-angle implant resulted in stable fixation of the distal articular fragments, allowing early postsurgical wrist motion. The PRWE and DASH scores for the groups were equivalent, whereas intra-articular step-off, volar tilt, and radial length were better in the ORIF group. There were few complications, implant removal was not necessary, and early postsurgical wrist ROM was initiated without loss of reduction.     

Calcaneus fractures. Open reduction and internal fixation

AIM OF THIS STUDY: Critical analysis of the medium-term results of open reduction and internal fixation (ORIF) of displaced intra-articular calcaneus fractures with a standardized protocol in a greater patient cohort. METHODS: From October 1993 to December 1999 314 patients (mean age 42.3 years) with 348 calcaneus fractures were seen at the Dresden University Hospital. 41 fractures were open, 4 with 1st degree, 28 with 2nd and 9 with 3rd degree soft tissue damage. 275 displaced intra-articular fractures were treated with ORIF, 262 (95.3 %) with plate osteosynthesis via an extended lateral approach. 169 patients could be evaluated at a mean of 18 months (range 10-47 months) postoperatively with an extended protocol of questionnaire, physical and radiographic examination. RESULTS: The Maryland Foot Score after 18 months follow-up averaged 80.8/100, the mean Zwipp score averaged 146.4/200. The functional result with the Merle d'Aubigné score was judged good to excellent in 86% of cases. Rates of deep infection and superficial wound edge necrosis increased significantly with open fractures and delay in surgery of more than 2 weeks after injury in closed fractures. Clinical results were adversely affected by even minor residual steps in the posterior facet (1-2 mm) as judged by CT or Brodén views (p < 0.001). B?hler's tuberosity-joint-angle had an impact on the final result when falling short compared to the unaffected contralateral side by more than 30% (p < 0.001). CONCLUSIONS: Management of intra-articular calcaneus fractures with a standardized protocol of ORIF and early mobilization leads to reproducible good or excellent clinical results in a majority of patients. New approaches like an interlocking calcaneus plate, the use of subtalar arthroscopy, early soft tissue coverage for complex open injuries and percutaneous screw fixation for selected fractures should further improve prognosis.     

青少年胫骨远端三平面骨折的诊治

目的 探讨青少年胫骨远端三平面骨折的诊断、治疗和预后. 方法 2005年2月至2008年10月收治胫骨远端三平面骨折11例,男8例,女3例;年龄12.5～15.3岁,平均13.8岁.右踝9例,左踝2例.X线片示11例患者均为外侧二部分关节内三平面骨折,其中2例伴腓骨骨折.采用闭合复位石膏固定6例,切开复位内固定5例. 结果 11例患者获平均24个月(6～36个月)随访.踝关节功能采用美国足踝外科协会(AOFAS)踝与后足功能评分标准进行评估:优6例,良3例,一般2例.手术患者中2例(预后一般的病例)出现感染及伤口周围皮肤局部坏死. 结论 胫骨远端三平面骨折是青少年踝关节所特有的复杂骨折,其骨折形态由损伤时骨骺骨化的程度和所受暴力的大小所决定.术前CT多维重建是获得准确诊断,选择合理入路的前提.如果骨折移位 >2 mm或保守治疗不能达到解剖复位或复位无法维持,建议切开复位内固定.理想预后的基础是解剖复位.     

踝关节骨折切开复位内固定术后踝关节镜手术的临床结果

目的研究踝关节骨折切开复位内固定(ORIF)手术后再次踝关节镜的疗效。 方法回顾性分析2011年1月至2014年12月在解放军第81集团军医院骨科因踝关节骨折ORIF手术后各种原因行踝关节镜手术66例患者，平均年龄(40±13)岁。纳入踝关节骨折ORIF术后因残余痛及其他各种原因行踝关节镜手术的患者，排除炎症性关节炎及下肢神经病变、合并精神疾病者。记录术前、术后4周、6月的疼痛视觉模拟评分(VAS)及美国足踝骨科协会踝－后足(AOFAS)评分，记录并发症及处理方法。组间比较采用单因素ANOVA方差分析。 结果术后早期无关节镜相关并发症发生。术后4周、6月VAS评分比术前显著改善(t＝2.783, P<0.05), AOFAS评分与术前相比明显升高(t＝6.271, P <0.01)。术后4年再次手术率为19.7%。 结论踝关节骨折ORIF手术后因各种原因行踝关节镜手术早期可以减轻疼痛、改善功能，但中期再手术率高。     

Management of distal femoral periprosthetic fractures by distal femoral locking plate: A retrospective study.

Background:

Management of periprosthetic supracondylar femoral fractures is difficult. Osteoporosis, comminution and bone loss, compromise stability with delayed mobility and poor functional outcomes. Open reduction and internal fixation (ORIF) with anatomic distal femoral (DF) locking plate permits early mobilization. However, this usually necessitates bone grafting (BG). Biological fixation using minimally invasive techniques minimizes periosteal stripping and morbidity.

Materials and Methods:

31 patients with comminuted periprosthetic DF fractures were reviewed retrospectively from October 2006 to September 2012. All patients underwent fixation using a DF locking compression plate (Synthes). 17 patients underwent ORIF with primary BG, whereas 14 were treated by closed reduction (CR) and internal fixation using biological minimally invasive techniques. Clinical and radiological followup were recorded for an average 36 months.

Results:

Mean time to union for the entire group was 5.6 months (range 3-9 months). Patients of ORIF group took longer (Mean 6.4 months, range 4.5-9 months) than the CR group (mean 4.6 months, range 3-7 months). Three patients of ORIF and one in CR group had poor results. Mean knee society scores were higher for CR group at 6 months, but nearly identical at 12 months, with similar eventual range of motion.

Discussion:

Locked plating of comminuted periprosthetic DF fractures permits stable rigid fixation and early mobilization. Fixation using minimally invasive biological techniques minimizes morbidity and may obviate the need for primary BG.     

Incidence of hardware-related pain and its effect on functional outcomes after open reduction and internal fixation of ankle fractures

OBJECTIVES: To document the incidence of late pain and hardware removal after open reduction and internal fixation (ORIF) of ankle fractures. To test the hypothesis that late pain overlying the distal tibial and fibular hardware is associated with poorer functional outcomes. DESIGN: Retrospective review. SETTING: Level II trauma center. PATIENTS: One hundred twenty-six skeletally mature patients undergoing ORIF of unstable malleolar fractures who were followed up for at least six months from injury were included. MAIN OUTCOME MEASUREMENTS: Analog pain score, Short Form-36 Health Survey (SF-36), and Short Form Musculoskeletal Functional Assessment (SMFA). RESULTS: Thirty-nine (31 percent) of the 126 patients had lateral pain overlying their fracture hardware. Twenty-nine patients (23 percent) had had their hardware removed or desired to have it removed. Of the twenty-two patients with hardware-related pain who had undergone hardware removal, only eleven had improvement in their lateral ankle pain; the mean analog pain score decreased from 6 +/- 3.16 (mean +/- standard deviation) before hardware removal to 3 +/- 2.9 after hardware removal (p = 0.008). In general, SF-36 and SMFA scores at final follow-up were significantly lower for patients who had pain overlying their lateral hardware than for those who had no pain. For the group of patients who had lateral ankle pain, no significant difference was noted in SMFA or SF-36 scores for patients who had and who had not had their lateral hardware removed (p > 0.5). CONCLUSION: The incidence of late pain overlying the distal tibial and fibular plate or screws is not insignificant. Although pain is generally decreased after hardware removal, nearly half of patients continue to have pain even after hardware removal. Functional outcome scores are poorer for patients with pain overlying lateral ankle hardware than in those with no pain at this location; this poorer outcome seems to be independent of whether the hardware was removed. Although the results of this study do not support or condemn the routine removal of fracture hardware after healing of unstable ankle fractures, they give orthopaedic surgeons some information that may assist them in counseling patients as to the expected functional outcome after ORIF of ankle fractures and the likelihood of relief of pain after removal of fracture hardware from the distal tibia and fibula.     

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.     

腓骨钩状钢板在腓骨远端不稳定骨折中的应用

目的 探讨应用腓骨钩状钢板治疗腓骨远端不稳定骨折的经验及临床疗效.方法 2006年1月至2009年1月,对28例伴有腓骨远端粉碎性骨折的踝部骨折行切开复位内固定术,其中19例得到完整随访,男12例,女7例;年龄18～72岁,平均36岁;单纯外踝骨折4例,双踝骨折9例,三踝骨折6例.按Danis-Weber分类,A型8例,B型11例,均为腓骨远端不稳定粉碎性骨折.受伤至接受手术的时间为6h至16d,平均6d.手术顺序为外踝、后踝和内踝.外踝骨折使用腓骨钩状钢板固定,内踝骨折使用松质骨螺钉,后踝骨折根据骨折块大小及形态采用螺钉或钢板固定.结果 术后随访6～32个月,平均18.8个月.术后4～6周X线片均可见骨折线模糊;10例患者于术后12周达到临床愈合,9例于术后20周达到临床愈合.伤口均一期愈合,无一例发生感染、局部不良反应及踝关节不稳.Mazur评分为67～92分,平均86.3分,其中优12例,良4例,可2例,差1例,优良率为84.2%.结论 运用腓骨钩状钢板固定外踝骨折能更好恢复外踝正常外翻角及长度等解剖结构,并有效固定,为早期活动提供稳定性,利于踝关节功能恢复.     

腓骨钩状钢板在腓骨远端不稳定骨折中的应用

目的 探讨应用腓骨钩状钢板治疗腓骨远端不稳定骨折的经验及临床疗效.方法 2006年1月至2009年1月,对28例伴有腓骨远端粉碎性骨折的踝部骨折行切开复位内固定术,其中19例得到完整随访,男12例,女7例;年龄18～72岁,平均36岁;单纯外踝骨折4例,双踝骨折9例,三踝骨折6例.按Danis-Weber分类,A型8例,B型11例,均为腓骨远端不稳定粉碎性骨折.受伤至接受手术的时间为6h至16d,平均6d.手术顺序为外踝、后踝和内踝.外踝骨折使用腓骨钩状钢板固定,内踝骨折使用松质骨螺钉,后踝骨折根据骨折块大小及形态采用螺钉或钢板固定.结果 术后随访6～32个月,平均18.8个月.术后4～6周X线片均可见骨折线模糊;10例患者于术后12周达到临床愈合,9例于术后20周达到临床愈合.伤口均一期愈合,无一例发生感染、局部不良反应及踝关节不稳.Mazur评分为67～92分,平均86.3分,其中优12例,良4例,可2例,差1例,优良率为84.2%.结论 运用腓骨钩状钢板固定外踝骨折能更好恢复外踝正常外翻角及长度等解剖结构,并有效固定,为早期活动提供稳定性,利于踝关节功能恢复.     

Maisonneuve骨折诊治的临床特点

 目的 探讨Maisonneuve骨折诊断和治疗的临床特点。
方法 2005年8月至2009年8月,收治23例Maisonneuve骨折患者,男16例,女7例;年龄25~43岁,平均35.3岁;摔倒伤10例,运动相关损伤8例,车祸伤4例,高处坠落伤1例。所有骨折均为闭合性损伤;其中内踝骨折16例,后踝骨折6例,三角韧带撕裂7例;所有患者均有下胫腓联合分离和腓骨上1/4螺旋型骨折。手术采用固定内踝及后踝骨折、修复内侧三角韧带及固定修复下胫腓联合的方法进行治疗。术后采用Baird-Jackson踝关节功能评定标准对患者踝关节功能进行评价。结果23例患者中有9例在入院前发生漏诊,漏诊率为39.13%（9/23）,入院后经详细查体而明确诊断。22例患者获得随访,随访时间为12~25个月,平均16.8个月。术后患者踝关节均无疼痛、压痛及明显肿胀,踝关节活动度与对侧基本相同。术后4~7个月,平均5.3个月X线片示腓骨骨折及踝部骨折均骨性愈合,踝穴正常,腓骨长度恢复,无下胫腓螺钉断裂及创伤性关节炎发生。末次随访Baird-Jackson踝关节功能评分为85~100分,其中优11例、良8例、可3例,优良率为86.4%。22例患者中有19例已经恢复到伤前的活动水平。
结论 Maisonneuve骨折是容易产生漏诊的踝关节损伤,仅注意到受伤的局部情况和缺乏对这种少见骨折的认识是造成漏诊的主要原因;可采用固定内踝及后踝骨折、修复内侧三角韧带及固定下胫腓联合的方法进行治疗。     

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.     

Syndesmotic Stabilization in Pronation External Rotation Ankle Fractures

Boden et al. suggested syndesmosis fixation was not necessary in distal pronation external rotation (PER) ankle fractures if rigid bimalleolar fracture fixation is achieved and was not necessary with deltoid ligament injury if the fibular fracture is no higher than 4.5 cm of the tibiotalar joint. We asked whether height of the fibular fracture with or without medial stability predicted syndesmotic instability as compared with intraoperative hook testing in these fractures. We reviewed 62 patients (35 male, 27 female) with a mean age of 45.6 years (range, 19–80 years). Using a bone hook applied to the distal fibula with lateral force to the distal fibula in the coronal plane, we fluoroscopically assessed the degree of syndesmosis diastasis in all patients. The mean height of the fibular fracture in patients with a positive hook test was higher than in patients with a negative hook test (54.2 mm; standard deviation [SD], 29.3 versus 34.8 mm; SD, 21.4, respectively). The height of the fibular fracture showed a positive predictive value of 0.93 and a negative predictive value of 0.53 in predicting syndesmotic instability; specificity of the criteria of Boden et al. was high (0.96). However, sensitivity was low (0.39) using the hook test as the gold standard. The criteria of Boden et al. may be helpful in planning, but may have some limitations as a predictor of syndesmotic instability in distal PER ankle fractures.     

Investigation of incidence of superficial peroneal nerve injury following ankle fracture

The aim of this study was to investigate the incidence of superficial peroneal nerve (SPN) injury following ankle fracture and to establish whether this differed between those treated by open reduction and internal fixation (ORIF) and those treated nonoperatively in a cast. Two hundred eighty patients who had been treated for an ankle fracture either surgically (ORIF group) or nonoperatively (cast group) were identified. Patients were invited for review, assessed using the AOFAS scoring system, and examined for any evidence of SPN injury. The surgical approach was documented and all fractures were classified according to the Weber classification. A total of 120 patients returned for review; 56 patients from the ORIF group and 64 patients from the cast group. The mean time from injury to review was 2 years (range, 12-36 months). Overall, 18 patients (15%) had a symptomatic SPN injury and these patients had a significantly lower AOFAS score. In the cast group, 9% of patients had painful symptoms from an SPN injury, compared to 21% of patients in the ORIF group (p < .05). No evidence of SPN injury was found in those who had a posterolateral approach to the ankle. Surgeons should be aware that the SPN is at risk during lateral approach to the fibula and that injury to this nerve can frequently be identified as a cause of chronic ankle pain.     

The role of arthroscopy in the management of fractures about the ankle

Anatomic restoration of the joint is the goal of management in fractures about the ankle. Open reduction and internal fixation (ORIF) is the standard of care for unstable ankle fractures; however, arthroscopic management has been proposed. The use of arthroscopic reduction and internal fixation (ARIF) is surgeon-dependent. Reported indications for ARIF include transchondral talar dome fracture, talar fracture, low-grade fracture of the distal tibia, syndesmotic disruption, malleolar fracture, and chronic pain following definitive management of fracture about the ankle. Among the potential benefits are less extensive exposure, preservation of blood supply, and improved visualization of the pathology. Although arthroscopy is increasingly used in the setting of trauma, the effectiveness of ARIF compared with ORIF for management of fractures of the distal tibia, malleolus, displaced talar neck, and talar body has yet to be determined. Most of these fractures are effectively managed with open procedures.     

Radiological assessments and clinical results of intra-articular osteotomy for traumatic osteoarthritis of the ankle

IntroductionTraumatic osteoarthritis of the ankle joint caused after malleolar fractures of the ankle and tibial plafond fractures are frequently observed in comparatively young and highly active patients. Since the ankle movement in these patients is in general, comparatively favorable, orthopedists may sometimes have difficulty in deciding on a treatment policy. In our department, when treating traumatic osteoarthritis patients having a movable range within their ankle joints, we proactively applied distal tibial oblique osteotomy (DTOO) developed by Dr. Teramoto in 1994 or intra-articular osteotomy developed based on DTOO concepts such as distal tibial intra-articular osteotomy (DTIO) and distal fibular oblique osteotomy (DFOO).The objectives of the current study are to radiologically assess the ankle joint after intra-articular osteotomy for traumatic ankle osteoarthritis and evaluate the change in configuration of the ankle joint. This study summarizes the clinical results of intra-articular osteotomy obtained through the above-mentioned study.Patients and methodsThe subjects of this study were 20 patients diagnosed with traumatic osteoarthritis who were surgically treated for a total of 20 ankles. All patients underwent treatment with intra-articular osteotomy and were evaluated retrospectively for the following parameters: surgical procedure, fixation devices, clinical results based on the Japanese Society for Surgery of the Foot ankle/hindfoot scale (hereafter, JSSF scale) and post-operative adverse events. They were also assessed radiologically with pre- and post-operative anterior-posterior (AP) and lateral weight-bearing ankle radiographs.ResultsThe 20 patients consisted of 12 males and 8 females. The median age at surgery was 49 years old (range 14 - 87 years old) and the average follow-up period was 42 months (range 19 to 121 months). DTOO was applied to 10 cases, DFOO to 2 cases, DTOO and DFOO to 2 cases, medial-distal tibial intra-articular osteotomy (M-DTIO) and DFOO to 1 case, lateral-distal tibial intra-articular osteotomy (L-DTIO) and DFOO to 3 cases, M-DTIO followed by DTOO and DFOO to 1 case, and DTOO followed by low tibial osteotomy (LTO) to 1 case. Fixation devices utilized included circular external fixator for 15 cases, locking compression plate (LCP) to 3 cases, LCP and Kirschner-wire (K-wire) to 1 case, and screw and K-wire to 1 case. Radiological assessment revealed significant changes in the following parameters after surgery: tibial ankle surface angle (TAS, P= 0.0203), tibiotalar surface angle (TTS, P= 0.0021), medial malleolar angle (MMA, P= 0.0217), empirical axis (EA, P= 0.0019), fibular angle (FA, P= 0.0002), talar tilt angle (TTA, P= 0.0374), and tibial lateral surface angle (TLS, P= 0.0279). The JSSF scale also improved significantly after surgery (pre-operative JSSF scale: 51.1±11.0, post-operative JSSF scale: 89.2±8.2), p=0.0001.ConclusionIntra-articular osteotomy may change the radiological configuration of the ankle in a weight-bearing state. The present study showed very good short-term clinical results. Intra-articular osteotomy can prove a viable surgical option applicable for treatment of patients with traumatic ankle osteoarthritis having a reasonable range of motion within their ankle joints.     

Triceps-sparing versus olecranon osteotomy for ORIF: analysis of 67 cases of intercondylar fractures of the distal humerus

The purpose of this study was to compare the triceps-sparing approach with olecranon osteotomy regarding their effects on the functional outcomes of intercondylar fractures of the distal humerus managed with open reduction and internal fixation (ORIF), by reviewing 67 cases of intercondylar distal humerus fractures surgically managed with either of the approaches during 2001-2009. The medical records and radiographs of 30 male and 37 female patients, with a mean age of 44.5 years (range, 16-77) and a mean follow-up time of 34.3 months (range, 6-89), were retrospectively reviewed. Flexion, extension, arc of flexion/extension, pronation, supination, arc of pronation/supination and the Mayo Elbow Performance Score (MEPS) were used to assess the functional outcomes of intercondylar distal humerus fractures treated with ORIF through the triceps-sparing approach or olecranon osteotomy. According to the AO Foundation (AO) classification, there were 10 cases of C1, 28 cases of C2 and 29 cases of C3 fractures. At the time of review, all fractures had united. Although there was no overall statistically significant difference in the average flexion, extension, arc of flexion/extension, pronation, supination and arc of pronation/supination between the triceps-sparing group (n = 34) and the olecranon osteotomy group (n = 33), patients above 60 years of age tended to have more extension loss (mean 22.9°, range 0-55°) after ORIF via the triceps-sparing approach, compared with any other surgical approach/age combination group. In the triceps-sparing group, although only 37.5% of patients over the age of 60 years obtained excellent/good MEPS, the rate increased to 100% in patients aged less than 40 years of age (P < 0.05). By contrast, the rate of excellent/good MEPS remained above 80% in all age groups of patients treated with ORIF via olecranon osteotomy. In conclusion, ORIF via the triceps-sparing approach confers inferior functional outcomes for intercondylar distal humerus fractures in patients over the age of 60 years, for whom the olecranon osteotomy approach may be a better choice. However, for patients less than 60 years of age, especially those less than 40 years of age, either approach confers satisfactory outcomes.     

腓骨钩状钢板在腓骨远端不稳定骨折中的应用

目的 探讨应用腓骨钩状钢板治疗腓骨远端不稳定骨折的经验及临床疗效.方法 2006年1月至2009年1月,对28例伴有腓骨远端粉碎性骨折的踝部骨折行切开复位内固定术,其中19例得到完整随访,男12例,女7例;年龄18～72岁,平均36岁;单纯外踝骨折4例,双踝骨折9例,三踝骨折6例.按Danis-Weber分类,A型8例,B型11例,均为腓骨远端不稳定粉碎性骨折.受伤至接受手术的时间为6h至16d,平均6d.手术顺序为外踝、后踝和内踝.外踝骨折使用腓骨钩状钢板固定,内踝骨折使用松质骨螺钉,后踝骨折根据骨折块大小及形态采用螺钉或钢板固定.结果 术后随访6～32个月,平均18.8个月.术后4～6周X线片均可见骨折线模糊;10例患者于术后12周达到临床愈合,9例于术后20周达到临床愈合.伤口均一期愈合,无一例发生感染、局部不良反应及踝关节不稳.Mazur评分为67～92分,平均86.3分,其中优12例,良4例,可2例,差1例,优良率为84.2%.结论 运用腓骨钩状钢板固定外踝骨折能更好恢复外踝正常外翻角及长度等解剖结构,并有效固定,为早期活动提供稳定性,利于踝关节功能恢复.