Home therapy pathway – Safe and streamlined method of initial management of ankle fractures

BackgroundAnkle fractures requiring operative fixation often swell up after 24 h and surgery during this period is not feasible as there are several associated risks including infection and wound breakdown. The affected limb is kept elevated usually in hospital and once the swelling has sufficiently subsided then the operation takes place. We conducted a study looking at the impact of a home therapy ankle pathway on the length of stay and safety of patients with ankle fractures requiring surgical fixation.MethodsThe length of stay of a control group was studied from December 2009 to March 2010. The home therapy ankle pathway was then introduced in August 2010. If patients could not have their operation within 24 h then they were placed in a Plaster of Paris back slab in casualty with the ankle reduced, limb care advice given – elevation, cooling and DVT thromboprophylaxis – and the patient was discharged home on crutches after a slot was determined on the trauma list typically six days later. The patient was also given an emergency contact number in case an untoward event occurred, and they were called at least once during their home stay by hospital staff to ensure all was well. Patients who were unsafe to be discharged on home therapy were admitted. This cohort of patients was studied between August 2010 and December 2011ResultsIn the control group, 49 ankle fractures required operative intervention. The mean pre-operative length of stay was 2.88 days and the mean post op length of stay was 5 days. Between August 2010 and December 2011, after implementation of the pathway, 176 ankle fractures requiring operative treatment presented to the orthopaedic department. Of these, 105 were eligible for home therapy on the ankle pathway prior to surgery. The average pre-operative length of stay on the pathway was 0.17 days. The average post op length of stay was 1.72 days (P < 0.001 in all modalities). Home therapy was carried out for an average of 6.63 days. Challenges of home therapy included persistent swelling and blistering (11), loss of reduction (4), poor pain management whilst at home (4) and cancellation due to lack of availability of a theatre slot (6).ConclusionWith patients in whom it is indicated, the home therapy ankle pathway has proved to be a safe and resource sparing method of managing ankle fractures prior to surgery.     

The use of foot pumps compression devices in the perioperative management of ankle fractures: Systematic review of the current literature

BackgroundAnkle fractures account for 9% of all fractures seen in the United Kingdom. 15,000 of these fractures undergo operative fixation each year. Soft tissue swelling impacts on timing of fixation due to fears of infection and wound dehiscence. The use of arterio-venous foot pumps (AVFP) is increasing in this population although the evidence for their efficacy is unclear. In order to address this, we present an overview of the evidence for AVFP device use following ankle fracture.MethodsIn September 2015 an electronic literature search was undertaken of studies comparing two or more methods of swelling reduction in patients with ankle fractures. Of 326 screened, 5 papers ultimately were included.ResultsTwo studies reported a statistically significant reduction in swelling (p = 0.03) and (p = 0.03 at 24 hours, p = 0.05 at 48 hours) after using AVFP devices compared to the controls (leg elevation +/ ice therapy). Stockle et al. reported a greater reduction in the preoperative ankle, midfoot and forefoot circumference at 24 hours in their AVFP group (53% versus 32% and 10% in their continuous cryotherapy and cool pack cryotherapy groups respectively). Whereas, Rohner-Spengler et al. observed improved preoperative swelling reduction in patients treated with a multilayer compression bandage when compared to their AVFP group. Keehan et al. reported that time to surgery was considerably reduced in patients treated with an AVFP device, (2.3 days) compared to those treated with leg elevation (4.6 days) (p = 0.02). Length of stay (LOS) was not influenced by any of the tested interventions.ConclusionsAVFP devices have been shown to reduce time to surgery and degree of swelling before operative intervention better than other methods but the strength of evidence to support this remains poor.     

Fragility fractures of the ankle in the elderly: Open reduction and internal fixation versus tibio-talo-calcaneal nailing: Short-term results of a prospective randomized-controlled study

IntroductionThe management of ankle fractures in the elderly remains unpredictable, secondary to their various co-morbidities. Although tibiotalocalcaneal (TTC) nailing has been an effective option for ankle arthrodesis due to ankle arthritis or Charcot arthropathy there are few reports regarding the use of TTC nail for the treatment of ankle fractures.PurposeAim of this study was to compare the results of ORIF versus TTC nailing for the treatment of unstable ankle fractures in the elderly. We hypothesized that the elderly may benefit from TTC nailing, as it allows the patient to be mobilized immediately after surgery and minimizes the risk of wound or bone problems.Patients and methodsThis was a prospective, randomized-controlled, comparative study. Between 2009 and 2015, 43 patients were treated with a TTC nail (Group A) and 44 with ORIF (Group B). The Olerud-Molander ankle score was obtained and intraoperative-postoperative complications, length of hospital stay, mobility status and reoperation rate were recorded. The nail fixation was performed with the TrigenR hindfoot nail after closed reduction. ORIF was performed, using a 1/3 tubular plate and 3.5 mm screws for the lateral malleolus and two 4.0 mm cannulated screws for the medial.ResultsMortality rate at one year was 13.9% for Group A and 18.1% for Group B. Mean follow-up was 14 months (12–18 m). There were no intraoperative complications. Three complications in Group A (8.1%) and twelve (33.3%) in Group B were encountered postoperatively (p < 0.05). There was significant shorter hospital stay in Group A (5.2 ± 3.1d) than in Group B (8.4 ± 5.2d). In Group A, 28 patients returned to their pre-injury mobility status (75.6%) while 9 declined one level of the mobility scale (24.3%). In Group B, 26 patients remained at the same mobility level (72.2%) and 10 declined one level (27.7%). There was no significant difference between the postoperative OMAS scores in the two Groups (56.9 ± 9.85 and 56.6 ± 9.3 respectively).ConclusionsWe believe that TTC nailing is a safe and effective method of treatment of unstable ankle fractures in the elderly because it has a low risk of complications and restores function and mobility allowing an immediate return to full weight-bearing.     

High incidence of osteochondral lesions after open reduction and internal fixation of displaced ankle fractures: Medium-term follow-up of 100 cases

BackgroundThe incidence of osteochondral lesions (OCLs) in association with displaced ankle fractures has only been examined in two previous studies. In both studies magnetic resonance imaging (MRI) was performed prior to open reduction and internal fixation (ORIF). Because MRI may overdiagnose or overestimate the extent of OCLs in an acute trauma setting the aim of this study was to determine the incidence of OCLs after ORIF of displaced ankle fractures using MRI at medium-term follow-up, and to analyse if the severity of fracture or the clinical outcome correlates with the incidence of OCLs.Patients and methodsFollowing institutional review board approval a total of 100 patients (mean age, 41.3 years; range, 17.9–64.3 years) with a displaced ankle fracture who had undergone ORIF according to the AO principles were included in this study. The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was used to quantify the clinical outcome and MR images were evaluated for OCLs of the talus and distal tibia after a mean of 34.5 months (range, 17.5–54.1 months).ResultsOCLs were found in 40.4% of the patients. Logistic regression revealed a significant correlation between the severity of fracture and the incidence of OCLs. Patients with a trimalleolar fracture (p = 0.04) or an ankle fracture dislocation (p = 0.003) had a significantly higher risk for developing an OCL compared to those with a type B fracture. Logistic regression also demonstrated a significant correlation between the clinical outcome (AOFAS score) and the incidence of OCLs (p = 0.01). The risk for developing an OCL increases up to 5.6% when the AOFAS score decreases by one point.ConclusionOCLs were frequently found in association with acute ankle fractures at medium-term follow-up, and the severity of fracture was associated with an increased number of OCLs. Considering the disadvantages of MRI including the high cost and limited availability, the results of this study may help to explain why anatomic surgical realignment of displaced ankle fractures may still be associated with poor clinical outcomes.     

Factors Influencing patient experience and satisfaction following surgical management of ankle fractures

BackgroundPatient feedback is increasingly important to inform and develop effective healthcare within the United Kingdom. In order to optimise patient experience of ankle fracture care in our unit, we sought to identify elements of practice associated with poor patient experience and low levels of satisfaction.MethodsAdult patients with closed ankle fractures requiring fixation over a ten month period were prospectively identified. Prior to discharge all patients completed the Picker Patient Experience Questionnaire (PPE-15), satisfaction visual analogue scale (VAS: 0–10) and a demographic questionnaire. Operative delay and cancellation episodes were similarly noted. PPE-15 and satisfaction VAS data were collected concurrently from a control group of elective hip and knee arthroplasty patients.Results52 patients (23 males) of average age 47 years (17–86) underwent ankle fracture fixation. Median pre-operative length of stay (LOS) was 3 days (IQR 1–6). Ankle fracture patients had significantly worse experiences compared to arthroplasty patients (p < 0.05 across all 15 PPE domains). Once pre-operative length of stay exceeded 3 days patients reported more areas of concerns (6 of 15) than those waiting 3 days or less (4 of 15) (p = 0.02). Cancelled patients reported significantly worse experiences, with satisfaction VAS of 7 (versus 9 in those not cancelled [p = 0.005]), and median of 6 PPE-15 domains of concern (versus 3.5 [p = 0.03]).ConclusionsEfforts to improve the healthcare experience of patients with ankle fractures should be focused on improving processes that minimise cancellation of surgery and the communication around delay management.     

External versus internal fixation for arthrodesis of chronic ankle joint infections — A comparative retrospective study

BackgroundArthrodesis of the ankle is a salvage procedure in case of chronic ankle joint infection. External fixation still is the gold standard.We compared the outcome of external fixator versus intramedullary nailing for arthrodesis of the infected ankle joint.MethodsAll patients with ankle joint infection who received arthrodesis with either external fixator or intramedullary nail between 08/2009 and 09/2017 were retrospectively analyzed. Endpoints were the successful control of infection, osseous fusion, and mobilization with full weightbearing.ResultsSeventy-one patients were included. Nineteen patients (27%) suffered reinfection. Patients with intramedullary nailing showed significantly fewer reinfections (p = 0.019), achieved full weightbearing significantly more often (p = 0.042) and faster and developed significantly fewer complications (p < 0.001). Forty-three patients showed bone fusion without significant differences between the groups.ConclusionsAnkle arthrodesis with intramedullary nailing appears to be a successful alternative to the established procedure of external fixation in cases of chronic ankle joint infection.     

Risk factors for symptomatic venous thromboembolism following surgery for closed ankle fractures: A case-control study

BackgroundWe analyzed risk factors for venous thromboembolism (VTE) within 6 months after surgery for closed ankle fractures.MethodsThis was a case-control study based on data from chart review in a cohort of patients having open reduction and internal fixation (ORIF) for closed ankle fractures in two large general hospitals 2009–2011. Cases with symptomatic VTE (pulmonary embolism or deep venous thrombosis) were identified in the cohort, and additional cases of VTE were identified by computerized search of discharge diagnoses in the same hospitals in 2004–2008 and 2012–2016. In total, we identified 60 cases with VTE and compared with 240 randomly selected controls among 998 patients without VTE in the cohort. Risk factors were assessed using logistic regression analysis.ResultsAmong cases, 27 (45%) had pulmonary embolism, 33 (55%) deep venous thrombosis. Those with VTE were older, had higher BMI, had more often a family history of VTE, and more often had antibiotic prophylaxis during surgery than controls. In multivariable logistic regression analysis age/10 (OR 25.75, 95%CI 3.52–188.44, p = 0.001), (age/10)² (OR 0.77, 95%CI 0.65–0.93, p = 0.005), BMI (1.15 per kg/m², 95%CI 1.07–1.24, p < 0.001) and Charlson comorbidity index ≥2 vs.0 (OR 0.27, 95%CI 0.08–0.92, p = 0.036) and 1 vs. 0 (OR 0.27, 95%CI 0.09–0.86, p = 0.026) were associated with VTE within 6 months of surgery.ConclusionsThe odds of symptomatic VTE within 6 months of ORIF increased with increasing age and BMI, but were lower with increasing comorbidity.     

Clinical outcomes comparing arthroscopic vs open ankle arthrodesis

BackgroundOver the last twenty years, minimally invasive ankle arthrodesis has evolved into a well-tolerated and safe procedure. It has grown in favor to open ankle arthrodesis due to shorter length of stay and fewer complications recorded. This paper aims to compare the clinical outcomes of arthroscopic vs open ankle arthrodesis at 24-months followup.MethodsFrom 2004 to 2015, we reviewed a prospectively collected database in a tertiary hospital foot and ankle registry. 28 feet that underwent arthroscopic ankle arthrodesis were matched to 56 feet that underwent open ankle arthrodesis for age, sex and body mass index (BMI). Visual analogue scale (VAS) scores, American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-hindfoot Scores and Short Form Health Survey (SF-36) were obtained to assess clinical outcomes. These parameters were collected before surgery, at 6 months and 24 months after surgery.ResultsThe arthroscopic group demonstrated significant less pain in the perioperative period (arthroscopic: 1.9 ± 1.2, open: 3.8 ± 1.1, p < 0.001) and shorter length of hospitalization stay (arthroscopic: 2.1 ± 0.7 open: 3.5 ± 1.7, p < 0.001). Patients who underwent arthroscopic ankle arthrodesis also reported a higher SF-36 score on physical functioning at 6 months (arthroscopic: 58.4 ± 27.1, open: 47.1 ± 24.0, p < 0.05) and higher AOFAS Ankle-hindfoot Scale score at 24-months (arthroscopic: 78.9 ± 18.9, open: 68.9 ± 24.7, p < 0.05). There were no postoperative complications in the arthroscopic group but 11 in the open group, including 9 which required followup operations. There was no significant difference in length of operative procedure between both groups.ConclusionsWe conclude that the arthroscopic group displayed better clinical outcomes compared to the open group at the 24 months followup. The advantages of arthroscopic ankle arthrodesis include significantly less perioperative pain, higher AOFAS Ankle-hindfoot scores at 24 months, shorter length of stay, fewer postoperative complications and followup operations.Level of evidenceLevel III, retrospective comparative series.     

There is a difference in functional ankle stability between different types of footwear in male athletes: A cross-sectional study

ContextLateral ankle sprains (LAS) are among the most common injuries in sports, with a poor long – term prognosis due to high chronicity and recurrence rates. Chronic ankle instability (CAI) results up to 40% of people that endured a first – time LAS.ObjectiveThe aim of this study was to compare ankle stability between groups characterised by the use of different types of footwear during their sport activities.DesignCross-sectional study.SettingFirm training surface, local sport clubs.ParticipantsFifty - one male subjects were recruited, distributed in four groups based on the type of footwear they use during their sport activities.Main outcome measuresAll subjects performed four clinical ankle stability tests, and completed the Dutch version of the Cumberland Ankle Instability Tool (CAIT) and Profile of Mood States (POMS). All clinical ankle stability tests were performed barefoot.ResultsSubjects performing their sport activities barefoot scored better than subjects performing their sport with shoes at the multiple hop test (p = .002 to .047) and executed the figure–of–8 hop test significantly faster than subjects with submalleolar ankle support (AS) (p = .019). Subjects with submalleolar AS and studs showed significantly better results than subjects with supramalleolar AS on the CAIT– score (p = .024, p = .030) and the side– hop test (p = .050, p = .045). They also scored significantly better than subjects with submalleolar AS for the side – hop test (p = .032), foot – lift test (p = .019) and figure–of 8 hop test (p = .011).ConclusionBarefoot sports performing subjects appear to have better ankle stability compared to subjects performing their sports with shoe support. Subjects performing sports with high AS appear to have worst ankle stability.Level of evidence: Level III, Cross–sectional study.     

Kinematic analysis of ankle stiffness in subjects with and without flat foot

BackgroundAlthough the magnitude of ankle motion is influenced by joint congruence and ligament elasticity, there is a lack of understanding on ankle stiffness between subjects with and without flat foot.ObjectiveThis study investigated a quantified ankle stiffness difference between subjects with and without flat foot.MethodsThere were forty-five age- and gender-matched subjects who participated in the study. Each subject was seated upright with the tested foot held firmly onto a footplate that was attached to a torque sensor by the joint-driving device.ResultsThe flat foot group (mean ± standard deviation) demonstrated increased stiffness during ankle dorsiflexion (0.37 ± 0.16 for flat foot group, 0.28 ± 0.10 for control group; t = −2.11, p = 0.04). However, there was no significant group difference during plantar flexion (0.35 ± 0.15 for flat foot group, 0.33 ± 0.07 for control group; t = 0.64, p = 0.06).ConclusionThe results of this study indicated that the flat foot group demonstrated increased ankle stiffness during dorsiflexion regardless of demographic factors. This study highlights the need for kinematic analyses and joint stiffness measures during ankle dorsiflexion in subjects with flat foot.     

Doctor,when can I drive? — Range of functional ankle motion during driving

BackgroundDriving a motor vehicle needs a specific joint mobility and yet only limited knowledge exists regarding the necessary ankle range of motion. The goal of this study is to characterize the sequence and range of ankle motion.MethodsThe arc of plantarflexion/dorsiflexion and supination/pronation was recorded in the right and left ankle using electrogoniometers while thirty laps were driven by fifteen healthy participants around a course in a manual transmission car with a left sided steering wheel. The driver was required to perform the following maneuvers during each lap: (I) Vehicle acceleration and gear change, (II) Sudden evasion, (III) Routine turning, (IV) Rapid turning, (V) Vehicle acceleration followed by emergency braking.ResultsDriving required the right ankle to plantarflex 13 ± 9 and dorsiflex 22 ± 7 while supinating 15 ± 7 degrees and pronating minimally. The left ankle plantarflexed 19 ± 10and dorsiflexed 17 ± 10 while supinating 15 ± 7 degrees and pronating minimally. The right ankle dorsiflexed significantly more (p = 0.00), and yet the left ankle had a significantly higher maximum plantarflexion and range of plantarflexion/dorsiflexion (p = 0.00). Emergency braking resulted in a significantly higher maximum plantarflexion as well as plantarflexion/dorsiflexion range when compared to other maneuvers.ConclusionThis study describes the range of ankle motion identified to drive a car with a manual transmission and a left-sided steering wheel. The right and left ankle exhibit different arcs of motion during driving. This knowledge may assist when evaluating a patient’s driving capability. Further studies are needed to investigate whether movement restrictions impair driving.Level of evidenceBasic science study.     

Effectiveness of arthroscopically assisted surgery for ankle fractures: A meta-analysis

IntroductionThis meta-analysis was performed to determine whether the arthroscopically assisted open reduction and internal fixation (ORIF) for ankle fractures is more beneficial than the conventional ORIF.MethodsArticles in electronic medial databases were searched between March 1983 and August 2016, including Pubmed and SCOPUS. We included the studies with comparative design comparing the surgical outcomes between the arthroscopically assisted ORIF for ankle fractures and the conventional ORIF. Finally, two RCTs and two retrospective comparative studies were included for analysis. Mean and standard deviation (SD) of postoperative functional scores, number of subjects, and P-values were extracted from the studies. In addition, postoperative follow-up period, fracture type, and study quality were collected.ResultsThe pooled effect size of the four studies 0.535 (95% CI, 0.247–0.823) in Hedges’s g, which favored the arthroscopically assisted ORIF over conventional ORIF. There was no evidence of publication bias in funnel plot and in Egger’s test (p = 0.534).ConclusionThe arthroscopically assisted ORIF for ankle fractures were more beneficial than the conventional ORIF in the current evidences. However, since it needs more medical cost and longer operation time, possible additional complications and cost effectiveness are to be validated in future studies.     

Tibial torsion correlates with talar morphology

BackgroundThere is limited literature on axial rotation of the ankle or variations in anatomy of the talus. We aim to evaluate the rotational profile of the distal tibia and its relationship to talus morphology, radiographic foot-type, and tibiotalar tilt in arthritic ankles.MethodsPreoperative imaging was reviewed in 173 consecutive patients with ankle arthritis. CT measurements were used to calculate tibial torsion and the talar neck-body angle (TNBA). Tibiotalar tilt and foot-type were measured on weightbearing plain radiographs.ResultsMeasurements indicated mean external tibial torsion of 29.2 ± 9.1? and TNBA of 35.2 ± 7.5? medial. Tibiotalar tilt ranged from 48? varus to 23.5? valgus. A moderate association between increasing external tibial torsion and decreasing TNBA was found (ρ = ?0.576, p < .0001). Weak relationships were found between external tibial torsion and varus tibiotalar tilt (ρ = ?0.239, p = .014) and plantarflexion of the talo-first metatarsal angle (ρ = ?0.218, p < .025).ConclusionWe observed a statistically significant correlation between tibial torsion and morphology of the talus, tibiotalar tilt, and first ray plantarflexion. This previously unreported association may provide information regarding the development of foot and ankle deformity and pathology.Level of evidenceLevel III.     

Overtightening of the syndesmosis revisited and the effect of syndesmotic malreduction on ankle dorsiflexion

BackgroundAnkle syndesmotic injuries are a significant source of morbidity and require anatomic reduction to optimize outcomes. Although a previous study concluded that maximal dorsiflexion during syndesmotic fixation was not required, methodologic weaknesses existed and several studies have demonstrated improved ankle dorsiflexion after removal of syndesmotic screws.The purposes of the current investigation are: (1) To assess the effect of compressive syndesmotic screw fixation on ankle dorsiflexion utilizing a controlled load and instrumentation allowing for precise measurement of motion. (2) To assess the effect of anterior & posterior syndesmotic malreduction after compressive syndesmotic screw fixation on ankle dorsiflexion.Material and methodsFifteen lower limb cadaveric leg specimens were utilized for the study. Ankle dorsiflexion was measured utilizing a precise micro-sensor system after application of a consistent load in the (1) intact state, (2) after compression fixation with a syndesmotic screw and (3) after anterior & (4) posterior malreduction of the syndesmosis.ResultsFollowing screw compression of the nondisplaced syndesmosis, dorsiflexion ROM was 99.7 ± 0.87% (mean ± standard error) of baseline ankle ROM. Anterior and posterior malreduction of the syndesmosis resulted in dorsiflexion ROM that was 99.1 ± 1.75% and 98.6 ± 1.56% of baseline ankle ROM, respectively. One-way ANOVA was performed showing no statistical significance between groups (p-value = 0.88).Two-way ANOVA comparing the groups with respect to both the reduction condition (intact, anatomic reduction, anterior displacement, posterior displacement) and the displacement order (anterior first, posterior first) did not demonstrate a statistically significant effect (p-value = 0.99).ConclusionMaximal dorsiflexion of the ankle is not required prior to syndesmotic fixation as no loss of motion was seen with compressive fixation in our cadaver model. Anterior or posterior syndesmotic malreduction following syndesmotic screw fixation had no effect on ankle dorsiflexion. Poor patient outcomes after syndesmotic malreduction may be due to other factors and not loss of dorsiflexion motion.Level of Evidence: IV     

Bone mass and anthropometry in patients with osteoarthritis of the foot and ankle

BackgroundPatients with hip and knee osteoarthritis (OA) have high bone mineral density (BMD) and high BMI. If the same accounts for patients with foot or ankle OA is unknown.MethodsWe measured BMD and femoral neck (FN) width by dual-energy X-ray absorptiometry in 42 women and 19 men with idiopathic OA in the foot or ankle, and in 99 women and 82 men as controls.ResultsWomen with OA had significant higher BMI than controls. Women with OA had higher BMI-adjusted BMD (p < 0.01) and smaller BMI-adjusted FN width (p < 0.01) than controls. Men with OA had higher BMI adjusted-BMD (p < 0.05) and smaller BMI-adjusted FN width (p < 0.01) than controls.ConclusionPatients with OA in the foot or ankle have higher BMD and smaller bone size than being expected by their BMI. This phenotype may provide unfavourable forces across the joint and is hypothetically important for development of OA.     

Indirect signs of blunt duodenal injury on computed tomography: Is non-operative management safe?

IntroductionClear signs of duodenal injury (DI) such as pneumoperitoneum and/or oral contrast extravasation mandate laparotomy. Management when computed tomography (CT) reveals indirect evidence of DI namely duodenal hematoma or periduodenal fluid is unclear. We evaluated the utility of indirect signs to identify DI and the success of expected management, hypothesizing patients with indirect evidence of DI on CT can be safely managed non-operatively.MethodsWe retrospectively reviewed patients with a computed tomography (CT) scan with periduodenal hematoma or periduodenal fluid treated between January 2003 and January 2013 at a level 1 Trauma Center. Demographics, injury characteristics, laboratory values, injury severity scores (ISS), and outcome measures were recorded. Patients having immediate laparotomy were compared to those initially managed nonoperatively.ResultsWe identified 74 patients with indirect signs of DI, with 35 patients (47%) undergoing immediate operative exploration and 39 (53%) initially managed non-operatively. Lactate (4.5 mg/dL, standard deviation (SD) 2.1 vs 3.1 mg/dL, SD 1.4, p < 0.001), ISS (median (IQR) 34 (27–44) vs. 24 (17–34), p = 0.002) and abdominal AIS (3 (3–4) vs 2 (2–3), p < 0.001) were higher in those with immediate operation. The incidence of DI requiring operative repair was 11% (8 of 74). Six of 35 (17%) explored urgently had a DI requiring repair while 29 of 35 (83%) had no DI or minor injury not requiring surgical therapy. Of those managed non-operatively, 7 of 39 (18%) failed observation but only two (5%) required duodenal repair. There was no significant difference in intensive care unit (ICU) (10.2 days, standard error [SE] 2.1 vs 9.7 days, SE 4.8, p = 0.93) or hospital (22.5 days, SE 3.8 vs 23.6 days, SE 8.5, p = 0.91) length of stay between those operated on immediately and those that failed non-operative management when adjusted for age, sex, and ISS. There was no mortality in the non-operative group related to an intra-abdominal injury.ConclusionObservation of patients with indirect sign of DI fails in about 20% of patients, but failure rate due to DI is low at 5%. Conservative management in appropriately selected patients is reasonable with close observation.     

Splinting vs temporary external fixation in the initial treatment of ankle fracture-dislocations

BackgroundTo compare the efficacy, functional outcome, and complication frequency of splinting and external fixation in the initial treatment of ankle fracture-dislocations.MethodAnkles with poor soft tissue conditions who underwent temporary stabilization due to using a splint or external fixator due to an ankle fracture-dislocation between 2012 and 2019 were retrospectively evaluated. Ankles were divided into two groups as the splint (n = 69) and external fixator (n = 48). The time between the injury to definitive surgery, reduction loss, operation time, functional outcome, pain, and soft-tissue complication frequency before and after definitive surgery were compared.ResultsThe frequency of reduction loss (25% vs. 4%, p = 0.019) and skin necrosis (22% vs. 6%, p = 0.028) were significantly higher in the splint group. Posterior malleolar fracture fragment ratio was calculated by dividing the fracture fragment axial length by the total axial length of the articular surface on computed tomography. Posterior malleolar fracture fragment ratio was found to be significantly higher in ankles with reduction loss in both the splint (25% vs 75%, p = 0.032) and fixator groups (4% vs 96%, p = 0.021). The mean time period between injury and definitive surgery was significantly shorter in the external fixator group (11 ± 5 vs 7 ± 4 days, p = 0.033). Before definitive treatment, pin tract infection was observed in two ankles in the fixator group.ConclusionSplint immobilization of ankle fracture-dislocations may predispose to reduction loss, soft tissue complications, and a longer time period between injury and definitive fixation. The risk of these potential complications can be reduced with the use of an external fixator.     

Bipolar fresh total osteochondral allograft in the ankle: Is it a successful long-term solution?

IntroductionSevere post-traumatic ankle arthritis poses a reconstructive challenge in young and active patients. Although technically demanding and despite unsolved immunological issues, bipolar fresh total osteochondral allograft (BFTOA) represent an intriguing option to arthrodesis and prosthetic replacement. The purpose of this paper is to evaluate the outcomes of a series of 48 ankle BFTOA at 10 years follow up and to investigate the rate of survival long term.Methods58 patients underwent BFTOA, of these 48 were available for follow up. The allograft was prepared with the help of specifically designed jigs and the surgery was performed using either a lateral or a direct anterior approach. Patients were evaluated clinically and radiographically preoperatively, and at a mean 121 ± 18 months of follow-up.ResultsThe AOFAS score improved from 31 ± 11 pre operatively, to 65 ± 25 at the last (p < 0.0005). Fourteen failures occurred, with 70.8% allograft rate of survival. All the surviving allografts showed a reduction of the ankle joint movement, still associated with a satisfactory clinical result.ConclusionThe use of BFTOA represents an intriguing option to arthrodesis or arthroplasty. A satisfactory clinical result associated to a good movement of the transplanted joint is to be expected up to short-mid-term, overtime. Long term, the range of motion (ROM) is progressively decreased up to spontaneous arthrodesis in some cases, still the joint results pain free and patient’s perception is of a well functioning ankle. A deeper knowledge of the immunological behavior of transplanted cartilage is needed in order to improve the durability of this fascinating technique.     

The effect of preoperative foot and ankle physiotherapy group on reducing inpatient stay and improving patient care

BackgroundBenefits of day case foot and ankle surgery include reduced hospital stay, cost savings, high patient satisfaction, quicker recovery with no increased complications. The preoperative foot and ankle group was set up in 2007 to reduce inpatient hospital stays and increase the rate of day case procedures.MethodsWe evaluated length of stay and physiotherapy intervention for all our patients during the first three months of 2007–2011.ResultsMedian length of stay was statistically significant (p < 0.05) in all groups apart from the ankle group. Day case surgery rates increased in all groups apart from hindfoot group but the result was only significant for forefoot and midfoot groups.ConclusionThe results show that the setting up our group has resulted in reduced inpatient stay, increase in day case surgery rates with significant cost savings.     

Anterior-inferior tibiofibular ligament anatomical repair and augmentation versus trans-syndesmosis screw fixation for the syndesmotic instability in external-rotation type ankle fracture with posterior malleolus involvement: A prospective and comparative study

PurposeSyndesmosis injury is common in external-rotation type ankle fractures (ERAF). Trans-syndesmosis screw fixation, the gold-standard treatment, is currently controversial for its complications and biomechanical disadvantages. The purpose of this study was to introduce a new method of anatomically repairing the anterior-inferior tibiofibular ligament (AITFL) and augmentation with anchor rope system to treat the syndesmotic instability in ERAF with posterior malleolus involvement and to compare its clinical outcomes with that of trans-syndesmosis screw fixation.Methods53 ERAFs with posterior malleolus involvement received surgery, and the syndesmosis was still unstable after fracture fixation. They were randomised into screw fixation group and AITFL anatomical repair with augmentation group. Reduction quality, syndesmosis diastasis recurrence, pain (VAS score), time back to work, Olerud–Molander ankle score and range of motion (ROM) of ankle were investigated.ResultsOlerud–Molander score in AITFL repair group and screw group was 90.4 and 85.8 at 12-month follow-up (P > 0.05). Plantar flexion was 31.2° and 34.3° in repair and screw groups (P = 0.04). Mal-reduction happened in 5 cases (19.2%) in screw group while 2 cases (7.4%) in repair group. Postoperative syndesmosis re-diastasis occurred in 3 cases in screw group while zero in repair group (P > 0.05). Pain score was similar between the two groups (P > 0.05). Overall complication rate and back to work time were 26.9% and 3.7% (P = 0.04), 7.15 months and 5.26 months (P = 0.02) in screw group and repair group, respectively.ConclusionsFor syndesmotic instability in ERAF with posterior malleolus involvement, the method of AITFL anatomical repair and augmentation with anchor rope system had an equivalent functional outcome and reduction, earlier rehabilitation and less complication compared with screw fixation. It can be selected as an alternative.