Second-look arthroscopic findings and clinical outcomes after management of intra-articular lesions in acute ankle fractures with arthroscopy

BackgroundAnatomically surgical reduction of ankle fractures does not always result in a clinically favorable outcome. Arthroscopic examination combined with treatment of intra-articular lesion may related to clinical outcomesObjectivesThe purpose of the present study was to review initial and second look arthroscopic finding of acute ankle fracture and to evaluate clinical outcomes.ResultsLauge-Hansen classification system of ankle fractures included supination-external rotation type (n = 24), supination-adduction type (n = 3), pronation-external rotation type (n = 7), and pronation-abduction type (n = 6), total 40 ankles. Osteochondral lesions were found in 25 ankles (62%) with an initial arthroscopic finding of acute ankle fracture. Newly discovered chondral lesions in secondary arthroscopy were found in 17 cases. According to the Ferkel and Cheng staging at secondary arthroscopy, 4 of 25 ankles with osteochondral lesions of the talus were deteriorating (more than stage D). In terms of ICRS overall repair grades, 5 ankles (20%) were abnormal (grade III). Diffuse synovitis and arthrofibrosis were found in 12 and 7 ankles, respectively, in secondary arthroscopy, and correlations were found between AOFAS scores, VAS and intra-articular lesions.ConclusionSecond-look arthroscopic examination combined with treatment of intra-articular lesion such as arthrofibrosis and osteochondral lesion arising from ankle fracture surgery may consider to improve clinical outcomes.     

Arthroscopic Assessment of Intra-Articular Lesion after Surgery for Rotational Ankle Fracture

Background

The purpose of this study was to report findings of exploratory arthroscopic assessment performed in conjunction with removal of internal fixation device placed in the initial surgery for rotational ankle fracture.

Methods

A total of 53 patients (33 male, 20 female) who underwent surgery for rotational ankle fracture between November 2002 and February 2008 were retrospectively reviewed. All patients gave consent to the exploratory arthroscopic surgery for the removal of internal fixation devices placed in the initial surgery. Lauge-Hansen classification system of ankle fractures was assessed for all patients. Intra-articular lesions (osteochondral lesion, loose body, and fibrosis) were evaluated via ankle arthroscopy. Comparative analysis was then performed between radiological classification of ankle fracture/patient''s symptoms and arthroscopic findings.

Results

Lauge-Hansen classification system of ankle fractures included supination-external rotation type (n = 35), pronation-external rotation type (n = 9), and pronation-abduction type (n = 9). A total of 33 patients exhibited symptoms of pain or discomfort while walking whereas 20 exhibited no symptoms. Arthroscopic findings included abnormal findings around the syndesmosis area (n = 35), intra-articular fibrosis (n = 51), osteochondral lesions of the talus (n = 33), loose bodies (n = 6), synovitis (n = 13), and anterior bony impingement syndrome (n = 3). Intra-articular fibrosis was seen in 31 of symptomatic patients (93.9%). Pain or discomfort with activity caused by soft tissue impingement with meniscus-like intra-articular fibrosis were found in 19 patients. There was statistical significance (p = 0.02) between symptoms (pain and discomfort) and the findings of meniscus-like fibrosis compared to the group without any symptom.

Conclusions

Arthroscopic examination combined with treatment of intra-articular fibrosis arising from ankle fracture surgery may help improve surgical outcomes.     

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。     

累及后踝的踝关节骨折的手术治疗

目的探讨累及后踝的踝关节骨折的损伤机制、手术方法和治疗效果。方法自2008年7月至2012年3月间,手术治疗累及后踝的踝关节骨折共42例,男30例,女12例,应用Lauge-Hansen分类,旋后外旋型21例,旋前外旋型12例,旋前外展型9例。后踝骨折根据CT分类,Ⅰ型22例,Ⅱ型12例,Ⅲ型8例。后踝骨折根据骨块大小和关节面的塌陷情况,采用后侧支撑钢板或多枚拉力螺钉固定。结果 42例均获随访,随访时间12~24个月,骨折愈合时间10~18周。根据美国足与踝关节协会(American orthopaedic foot and ankle society,AOFAS)评分,优21例,良15例,可6例,优良率为85.7%。结论累及后踝的踝关节骨折,常伴有胫骨远端关节面塌陷和踝关节后脱位或半脱位,根据骨折类型选择手术方式和固定方法,可保证踝关节获得解剖复位,最大限度恢复踝关节功能。     

踝关节镜检在治疗急性踝关节骨折中的作用

目的探讨应用关节镜探查急性踝关节骨折时关节内合并病变,并辅助进行踝关节骨折的复位及固定的可能性及优缺点。 方法回顾性分析中山大学孙逸仙纪念医院骨科2016年3月至2017年11月诊断为"急性踝关节骨折"的患者,共78例。所有患者在行踝关节镜检＋切开复位内固定,记录关节镜下软骨损伤、三角韧带损伤、下胫腓联合损伤及游离碎片,采用卡方检验分析关节内病变与骨折类型的相关性。 结果在所有患者中,Weber A型骨折6例,Weber B型骨折45例,Weber C型骨折27例。骨软骨损伤共51例,其中Weber A/B/C分别0/33/18例;胫腓联合损伤39例,其中Weber A/B/C分别0/18/21例;三角韧带损伤27例,其中Weber A/B/C分别0/21/6例;关节腔游离碎片7例,其中Weber A/B/C分别0/4/3例。Weber B型骨折与Weber C骨折距骨软骨损伤发生无统计学差异(χ²＝0.363,P >0.05),但软骨损伤程度,Weber B型骨折更重(Fisher确切检验,P ＝0.007)。胫腓联合损伤,Weber B型骨折与Weber C骨折两组之间相比无统计学差异(χ²＝ 2.4 ,P >0.05);在Weber C骨折中,后踝骨折与胫腓联合不稳明显相关(Fisher确切检验,P ＝0.02)。三角韧带损伤,Weber B型骨折与Weber C骨折两组之间相比有统计学差异(χ²＝4.302, P<0.05);但当将内踝骨折与三角韧带损伤定义为内侧不稳时,两组之间无统计学差异(Fisher确切检验,P ＝0.07)。 结论在急性踝关节骨折时,关节镜探查可同时发现并处理合并的踝关节内病变,并辅助进行踝关节骨折的复位及固定,是提高切开内固定手术疗效的有益辅助工具。     

Incidence of chondral lesions of talar dome in ankle fracture types

BACKGROUND: Although the surgical treatment of ankle fractures is well known, a paucity of literature exists correlating chondral lesions with ankle fracture types. MATERIALS AND METHODS: This study is a retrospective review of patients with absence or presence of chondral lesions that underwent arthroscopically assisted open reduction and internal fixation between June 2002 and April 2005. There were 38 female and 48 male patients (mean age, 41.4 years; mean followup, 33.9 months), and all had an Ankle-Hindfoot Scale score. The relationship between fracture types and presence of lesions was evaluated. RESULTS: Four of 27 fractures with chondral lesions consisted of the bimalleolar type, 6 of 15 fractures with chondral lesions consisted of the trimalleolar type, and 14 of 20 distal fibula fractures had chondral lesions. There was significant greater incidence of chondral lesions associated with distal fibula fractures. The mean AOFAS score was 95.6 among all fractures. CONCLUSION: There is clear evidence that despite anatomic reduction, postoperative results of ankle fracture repair are not free of complications. We believe inspection of the talar dome should be routinely considered in the surgical repair ankle fractures.     

Leg Anterior Compartment Syndrome Following Ankle Arthroscopy After Maisonneuve Fracture

We report a case of leg anterior compartment syndrome following ankle arthroscopy after Maisonneuve fracture. A 21-year-old football player sprained his left ankle. Plain radiography of his left ankle showed a lateral dislocation of the talus without obvious fractures. Plain radiography of his left lower extremity showed a spiral fracture of the proximal fibula approximately one third distal to the fibular head. According to these findings, we diagnosed this fracture as a Maisonneuve fracture and treated it by ankle arthroscopy and drilling of the talar osteochondral injury followed by arthroscopic ankle visualization during syndesmosis screw fixation. Six hours after surgery, the patient complained of pain in the lower extremity. We diagnosed acute compartment syndrome and performed emergent fasciotomy. One year after surgery, he was able to fully participate in athletic activities. We consider ankle arthroscopy to be available for the treatment of ankle fracture with the suspected complication of an intra-articular disorder such as a Maisonneuve fracture. However, with this type of ankle fracture, there is a higher potential risk of acute compartment syndrome developing than with other types of ankle fractures. Therefore we suggest that surgeons guard against this complication.     

后外侧入路治疗后踝骨折的疗效分析

目的探讨后外侧入路治疗后踝骨折的临床疗效。方法随访分析2007年1月至2012年6月运用后外侧入路治疗的54例移位大于25％的后踝骨折,按Lauge—Hansen分类,旋后外旋型Ⅲ度2例,旋后外旋型Ⅳ度40例,旋前外旋型Ⅳ度12例。后踝骨折采用螺钉或支撑钢板固定。外踝骨折采用钢板固定,52例合并内踝骨折用螺钉固定。结果本组病例均获随访,时间6～36个月,平均（15．2±6．0）个月。骨折愈合时间12～24周,平均（14．5±3．6）周。2例患者出现腓肠神经损伤症状,口服营养神经药物治疗,3个月后症状消失。踝关节活动范围：背屈15°～30°,平均（20．5±4．6）。;跖屈25°-50°,平均（38．7±7．9）°。根据Olerud—Molander评分系统进行疗效评价,优32例,良18例,可4例,优良率92．6％。结论后外侧人路是治疗后踝骨折的一个有效入路。     

Arthroskopie des oberen Sprunggelenks zur Therapie des posttraumatischen Impingementsyndroms Grad I–III nach Scranton

Posttraumatic impingement of the ankle is caused by intra-articular fibrous scars due to an ankle sprain, i.e. inversion or eversion injury, in some cases in combination with an ankle fracture. Pain results typically from dorsiflexion. Either open or arthroscopic treatment of the anterior ankle impingement is possible if conservative treatment remains without success over a period of 3 months. In a retrospective study, the outcome after arthroscopic treatment should be evaluated. Thirty-one patients suffering from an ankle impingement grade I–III (rating according to Scranton and McDermott) were included with arthroscopic treatment on average 49 months ago. The results were good or excellent in 25 cases, fair in five, and poor in one case according to the West Point Ankle Score. The results of our study show that ankle arthroscopy with resection of hypertrophic synovium and fibrous bands in type I or tibial spurs in type II and III injuries after an ankle sprain has proven to be the method of choice for the therapy of chronic impingement syndrome of the ankle. The fair and the poor results were associated with severe ankle sprain leading to ligamentous ruptures or fractures where severe chondral lesions could be found with arthroscopy. The outcome of arthroscopic treatment was, thus, related to the extent of chondral lesions.     

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.     

Ankle injuries in distal tibial spiral shaft fractures: results from an institutional change in imaging protocol

Introduction

Posterior malleolus and other articular ankle injuries are known to concomitantly occur with tibial shaft fractures, especially spiral fractures of the distal one-third diaphysis. Due to our heightened awareness of this combined injury, our department instituted a new preoperative ankle imaging protocol for all distal one-third spiral tibia shaft fractures. The purpose of this study was to evaluate the effectiveness of an imaging protocol involving radiographs, CT and magnetic resonance imaging (MRI) in a distal one-third spiral tibia fracture cohort.

Materials and methods

All operatively treated patients with a spiral distal one-third tibial shaft fracture from February 2012 to March 2013 underwent a standardized ankle imaging protocol. Patients had preoperative orthogonal ankle radiographs as well as a CT scan of the tibia that included the ankle. All ankle imaging was scrutinized for evidence of an ankle injury. If no ankle fracture was identified, patients would then undergo an ankle MRI.

Results

Twenty-five patients met the inclusion and exclusion criteria for this study. Concomitant osseous ankle injuries were identified by radiograph and CT in 56 % (14/25) of cases. The remaining 44 % (11/25) of patients had no evidence of a combined injury by radiograph or CT and therefore underwent an MRI. Of the MRI cohort, 64 % (7/11) were found to have an occult ankle fracture. The overall incidence of a combined injury using our protocol was 84 % (21/25). Identification of an occult injury led to a change in management for all of these patients.

Conclusions

Concomitant ipsilateral ankle and distal one-third spiral tibial shaft fractures are more common than previously reported. Utilizing a new imaging protocol, we found that the incidence of this combined injury was 84 %. Recognition of the ankle fracture component in this tibial shaft cohort can be important as it may alter the surgical plan and postoperative management.     

Incidence of Talar Osteochondral Lesions After Acute Ankle Fracture: A Retrospective Analysis

Recent literature suggests the majority of osteochondral lesions occur in the ankle joint. Previous studies have suggested that varying incidences of talar osteochondral lesions (OCLT) are associated with ankle fractures. The primary aim of our study was to investigate the incidence of osteochondral lesions associated with acute ankle fractures as observed on computed tomographic (CT) imaging. We also compared the rates of talar osteochondral lesions in patients who had ankle fractures with dislocation and closed manual reduction (CMR) prior to open reduction with internal fixation, to those who did not suffer from ankle joint dislocation. Additionally, a correlation between the location of talar dome lesions with type of ankle fracture as classified by Lauge-Hansen was investigated. Preoperative CT imaging was retrospectively reviewed in 108 patients with acute ankle fractures. A CT-modified version of Berndt Hardy's classification of osteochondral lesions, as previously described by Loomer et al, was used for diagnosis of lesions in our study. The incidence of lesions was calculated across all subjects, and retrospective comparison was performed in those who did and did not undergo closed manual reduction. Supplementary data on location of lesion and its association with ankle fracture type was also recorded. We found an overall incidence of 50.9% OCLT in patients with acute ankle fractures. This number did not significantly differ from those who underwent closed manual reduction (49%). Although a majority of lesions did occur posteriorly, we saw no statistically significant information was seen between either type of fractures or OCLT locations. Careful consideration and thorough evaluation of preoperative CT imaging should be assessed by the performing surgeon, as this could guide both diagnostic and therapeutic treatments for patients with possible osteochondral lesions of the talus undergoing surgical repair of a fractured ankle.     

Arthroscopic findings in acute fractures of the ankle

We have evaluated prospectively the arthroscopic findings in acute fractures of the ankle in 288 consecutive patients (148 men and 140 women) with a mean age of 45.6 years. According to the AO-Danis-Weber classification there were 14 type-A fractures, 198 type B and 76 type C. Lesions of the cartilage were found in 228 ankles (79.2%), more often on the talus (69.4%) than on the distal tibia (45.8%), the fibula (45.1%), or the medial malleolus (41.3%). There were more lesions in men than in women and in general they were more severe in men (p < 0.05). They also tended to be worse in patients under 30 years and in those over 60 years of age. The frequency and severity of the lesions increased from type-B to type-C fractures (p < 0.05). Within each type of fracture the lesions increased from subgroups 1 to 3 (p < 0.05). The anterior tibiofibular ligament was injured with increased frequency from type-B.1 to type-C3 fractures (p < 0.05), but it was not torn in all cases. While lateral ligamentous injuries were seen more often in type-B than in type-C fractures (p < 0.05), no difference was noted in the frequency of deltoid ligamentous lesions. Our findings show that arthroscopy is useful in identifying associated intra-articular lesions in acute fractures of the ankle.     

Arthroscopically Assisted Treatment of Complex Ankle Fractures: Intra-articular Findings and 1-Year Follow-Up

Especially after complex ankle fractures, patients regularly suffer from residual symptoms, presumably due to occult intra-articular injuries. The aim of this study was to evaluate the intra-articular lesions, identify fractures specifically at risk for these, and assess the results after arthroscopically assisted open reduction and internal fixation of complex ankle fractures after 1 year. The primary outcome was the American Orthopedic Foot and Ankle Society (AOFAS) hindfoot score. Secondary outcome parameters were the Olerud and Molander Ankle Score (OMAS), Tegner activity scale, arthroscopic findings, functional assessment, and complications. Thirty-two patients (56% female) were enrolled. Chondral lesions were detected in 91%. Full-thickness lesions treated by microfracturing were observed in 0% of unimalleolar, 43% of bimalleolar, and 40% of trimalleolar fractures. After 1 year, the median (interquartile range) AOFAS was 94 (9) and OMAS was 90 (10) for all patients. When analyzing factors possibly influencing the outcome, age, sex, smoking, grading for surgical procedures according to the American Society of Anesthesiologists, fracture type (uni-, bi-, or trimalleolar), severity of chondral lesions graded according to the International Cartilage Repair Society (grade <4 versus grade 4), and syndesmotic instability had no significant influence on the outcome. The only variable significantly influencing the AOFAS (p = .004) and OMAS (p < .001) was body mass index (BMI; r_s = –0.522 and –0.606, respectively), with a higher BMI resulting in inferior outcome scores. Complications were observed in 3 patients, 2 with superficial skin necrosis at the posterolateral incision and 1 nonunion of the medial malleolus. Taken together, these data show that intra-articular injuries were common in ankle fractures. Bi- and trimalleolar fractures were particularly at risk for full-thickness lesions. A higher BMI tended to result in inferior outcome scores. Arthroscopically assisted open reduction and internal fixation led to good to excellent results in all but 1 patient.     

Chronic pain after ankle fracture: an arthroscopic assessment case series

BACKGROUND: The purpose of this study was to document findings of ankle arthroscopy in patients with residual complaints after an appropriately treated ankle fracture. METHODS: Patients who had ankle arthroscopy at the Alpine Orthosports Clinic between 1998 and 2000 were identified by a retrospective review of the ankle arthroscopy database. Fifty patients were identified who had arthroscopy for complaints after ankle fracture. The mean duration from injury to arthroscopy was 20.5 +/- 33.5 months, with a range of 2 to 184.6 months. RESULTS: There were 37 isolated fractures and 13 combination fractures. The Danis-Weber classification was used for lateral malleolar fractures. There were five type A, 14 type B, and 11 type C lateral malleolar fractures. RESULTS: Synovitis was present in 46 ankles and was located anterolaterally in 36. Synovitis was noted in 26 of the 30 ankles that had a lateral malleolar fracture. Arthrofibrosis was found in 20 ankles, with anterolateral joint involvement in 16. There was chondral damage noted in 45 ankles, 30 located on the talus and 15 on the tibia. Spurs were found in 15 ankles, and nine had loose bodies or debris. There were two postoperative complications: one patient had bleeding from a portal and the other had an area of paresthesia at the anterolateral portal site. CONCLUSION: Synovitis and chondral damage were more frequent than arthrofibrosis and spurs. Synovitis and arthrofibrosis were found most frequently in the anterolateral aspect of the joint. Also, the higher the lateral malleolar fracture was in relation to the syndesmosis, the higher was the occurrence of talar chondral damage.     

Paratrooper's Ankle Fracture: Posterior Malleolar Fracture

BackgroundWe assessed the frequency and types of ankle fractures that frequently occur during parachute landings of special operation unit personnel and analyzed the causes.MethodsFifty-six members of the special force brigade of the military who had sustained ankle fractures during parachute landings between January 2005 and April 2010 were retrospectively analyzed. The injury sites and fracture sites were identified and the fracture types were categorized by the Lauge-Hansen and Weber classifications. Follow-up surveys were performed with respect to the American Orthopedic Foot and Ankle Society ankle-hindfoot score, patient satisfaction, and return to preinjury activity.ResultsThe patients were all males with a mean age of 23.6 years. There were 28 right and 28 left ankle fractures. Twenty-two patients had simple fractures and 34 patients had comminuted fractures. The average number of injury and fractures sites per person was 2.07 (116 injuries including a syndesmosis injury and a deltoid injury) and 1.75 (98 fracture sites), respectively. Twenty-three cases (41.07%) were accompanied by posterior malleolar fractures. Fifty-five patients underwent surgery; of these, 30 had plate internal fixations. Weber type A, B, and C fractures were found in 4, 38, and 14 cases, respectively. Based on the Lauge-Hansen classification, supination-external rotation injuries were found in 20 cases, supination-adduction injuries in 22 cases, pronation-external rotation injuries in 11 cases, tibiofibular fractures in 2 cases, and simple medial malleolar fractures in 2 cases. The mean follow-up period was 23.8 months, and the average follow-up American Orthopedic Foot and Ankle Society ankle-hindfoot score was 85.42. Forty-five patients (80.36%) reported excellent or good satisfaction with the outcome.ConclusionsPosterior malleolar fractures occurred in 41.07% of ankle fractures sustained in parachute landings. Because most of the ankle fractures in parachute injuries were compound fractures, most cases had to undergo surgical repairs.     

The Hyperplantarflexion Ankle Fracture Variant

Various patterns of ankle fractures that are not accounted for by common classification systems have been the subject of case reports. The first difficulty with these variant patterns is recognizing all associated pathology, followed by the successful application of stable fixation. The purpose of this study was to describe the common morphologic features and ligamentous injuries of a unique variant fracture pattern, as well as the surgical treatment technique and the short-term functional and radiographic outcomes. Of 121 consecutive unstable ankle fractures over a 2-year period, 7 patients were found to have a similar constellation of injuries around the ankle. A vertical shear fracture of the posteromedial tibial rim was the main feature. Six of the 7 also had a fracture of the posterior malleolus. On magnetic resonance imaging, the deltoid and posterior tibiofibular ligaments were intact in all cases. Fractures were treated with open anatomic reduction of the posteromedial and posterior fragments with antiglide plate fixation. All fractures healed at 2 months without loss of reduction, fixation failure, or surgical complications. The average American Academy of Orthopaedic Surgeons lower extremity score was 79 at an average of 8 months' follow-up. The common radiographic and morphologic features associated with this posteromedial fracture indicate that it likely occurs through a common mechanism that involves hyperplantarflexion. The characteristics of this fracture pattern have not been fully described previously, but this ankle fracture variant may occur in up to 6% of cases. Unstable ankle fractures should be evaluated carefully for evidence of posteromedial involvement so appropriate treatment may proceed.     

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.

     

Fracture of the tibia with additional injury of the ankle joint. A frequent and undervalued combination

Summary There are 2 types of a combined tibia fracture and ankle injury: in Type I the tibia fracture extends directly into the ankle joint, in Type II the tibia fracture goes along with a fracture of the fibula and disruption of the fibular-tibial syndesmosis. This type of fracture must be distinguished from a pilon tibiale fracture. The typical mechanism for this combined tibia and ankle injury is the indirect torsional trauma with pronation-eversion. From 1995 to 1997 188 patients with fractures of the tibia were treated by internal fixation in our Trauma Department. 27 of these patients (13.6 %) had a combined tibia and ankle injury. Most of the tibia fractures were located in the distal third, a spiral fracture (16 patients) or a comminuted fracture (6 patients), and another group extending directly into the ankle (5 patients). The ankle lesion was a distal fibular fracture (Weber Typ B + C) in 14 patients, a proximal fibular fracture (Type maisoneuve) in 6 patients, a postero-lateral fragment in 11 cases and a fracture of the medial melleolus in 10 cases. A disrupture of the anterior tibio-fibular syndesmosis was seen in 18 patients, 3 times as an isolated lesion of the ankle joint without fracture of the fibula. The osteosynthesis of the tibia fracture was performed with an unreamed tibia nail in 20 patients, with elastic-biologic plate fixation in 6 and with external fixation in 1 patient. The fibula fractures were stabilized by small fragment titaneum plates, the dorsolateral fragment and the medial malleolus were stabilized by lag-screws, the tibio-fibular ligament was sutured and, in a few cases only, held in place by a positioning screw. The outcome was controlled after 20,7 month according to the Phillip's Score (1996). We found not more than one pour results. It must be considered, that most of the combined injuries of the tibia and the ankle joint concerning 13,6 % of all tibia shaft fractures are usually not recognized and may result in an arthrosis of the ankle joint. The attention should be focused to the ankle joint in any spiral fractures of the distal tibia after indirect trauma, especially with a proximal fibular fracture or an intact fibula. Additional X-ray examination of the ankle joint is recommended during internal fixation of the tibia. Posttraumatic arthrosis of the ankle joint can be prevented by diagnosis and adequate anatomical reconstruction of the additional ankle joint injury.