Avulsion fracture of the medial tubercle of the posterior process of the talus: Three-dimensional (3D) computed tomography features

Fractures of the medial tubercle of the posterior talar process are rare avulsion fractures, which commonly remain undetected during the first presentation of the patient in the Emergency Department, simulating a more benign ankle sprain. The diagnostic evaluation using three-dimensional (3D) computed tomography (CT) and the successful conservative treatment of a medial tubercle fracture in a young athlete is presented.     

Is lateral ankle sprain of the child and adolescent a myth or a reality? A systematic review of the literature

BackgroundAnkle trauma in children and adolescents is the most common orthopedic injury encountered in pediatric trauma. It has long been recognized that a lateral ankle injury in this population is often a Salter and Harris type I fracture of the distal fibula (SH1). The purpose of this study is to confirm the existence of a lateral ankle sprain and to report the incidence of each pathology of the lateral ankle compartment: SH1 fracture, ATFL injury, and osteochondral avulsions.MethodsA systematic review of the literature is done using the database provided by PubMed and Embase. All articles reporting the incidence of imaging modality-confirmed lateral ankle injury (SH1, ATFL injury, osteochondral avulsion) in children and adolescents were included. Exclusion criteria were the following: case reports or articles with less than ten subjects, unspecified imaging modality and articles unrelated to lateral ankle lesions. Thus, 237 titles and abstracts were selected, 25 were analyzed thoroughly, and 11 articles were included for final analysis.ResultsSH1 fractures were found in 0–57.5% of the cases in all series and 0–3% in the most recent series. A diagnosis of an ATFL injury was found in 3.2–80% and an osteochondral avulsion of the distal fibula in 6–28.1%. The most recent series report 76–80% and 62% for ATFL injury and osteochondral avulsion respectively.ConclusionsThere is a non-negligible incidence of ATFL sprains and fibular tip avulsions in patients with a suspected SH1 fracture of the distal fibula. According to recent evidence and MRI examinations, the most common injuries of the pediatric ankle are ATFL sprain and osteochondral avulsions. This should be taken into consideration in daily practice when ordering radiological examination and deciding on treatment modalities     

Long-term functional outcomes of all-inside arthroscopic repair of anterior talofibular ligament avulsion fracture

BackgroundThe main purpose of this study was to describe the all-inside arthroscopic technique for repairing anterior talofibular ligament (ATFL) avulsion fractures at the attachment points of the fibula and talus, and to evaluate the functional outcomes during long-term follow-up.MethodsThe data of 78 patients with ATFL avulsion fracture treated in our hospital from August 2013 to November 2016 were analyzed retrospectively. All patients underwent surgery. Patients were divided into two groups according to whether they had undergone all-inside arthroscopic treatment or open treatment. The American Orthopedic Foot and Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (KAFS), Foot and Ankle Outcome Score (FAOS) and a 36-item Short Form Health Survey questionnaire (SF-36) were used to evaluate functional outcomes.ResultsThe postoperative follow-up period was 24–48 months. All patients reported subjective improvements to ankle stability without any nerve, blood vessel or tendon complications. At the final follow-up, there was no significant difference in the AOFAS, SF-36 or sport participation rate between the arthroscopic group and the open group; however, the KAFS and FAOS were significantly higher in the arthroscopic group than in the open group.ConclusionsFor ATFL avulsion fractures, the all-inside ankle arthroscopic procedure produced better outcomes than did the open procedure. The all-inside ankle arthroscopic procedure provides a minimally invasive technique with acceptable long-term functional outcomes.     

Outcome after surgery for Maisonneuve fracture of the fibula

The aim of this study was to assess outcome in patients treated surgically for Maisonneuve fractures and to highlight factors associated with a suboptimal result. The authors present a review of 14 patients with Maisonneuve fractures. The mean age was 35.5 years. The most common injury mechanism was a twist incurred whilst participating in sport. The goal of treatment was the anatomic restoration of the ankle mortice with accurate renewal of fibular length. All patients had one or two suprasyndesmotic screws inserted percutaneously under fluoroscopic guidance. These were successfully removed under local anaesthesia in 13 cases (93%). Patients were reassessed clinically and evaluated both functionally and radiographically. Average follow-up was 25.3 months. Twelve patients (86%) had a satisfactory result. They returned to previous activity levels and had favourable Global Foot and Ankle (mean: 95.57) and Shoe Comfort (mean: 81.66) Raw Scores. Ankle range of motion and radiographs were normal. Two patients had an unsatisfactory result. Surgical intervention is recommended to maintain reduction of the fibula into the notch on the tibia, as shortening results in mandatory lateral talar displacement, predisposing to painful ankle arthrosis. The severity of the initial injury and co-morbid disease may adversely affect outcome.     

Treatment for displaced Tillaux fractures in adolescent age group

BackgroundAround age 11–15 years, a forced external rotation of the foot in a supination or a medial rotation of the leg on the fixed foot usually is responsible for an avulsion injury to the anterolateral epiphysis, known as Tillaux fracture. Ligamentous injuries are rare in children because ligaments are stronger than is the growth plate that frequently is injured.ObjectiveThe aim of this study was to present the clinical outcome until the end of growth after surgical treatment for displaced adolescent Tillaux fractures.Patients and methods13 patients with Tillaux fractures in the adolescent age group. Patient`s age ranged (12–17 years) with an average 13.4 years. Of those 13 patients, there were 9 females and 4 males.ResultsFracture union was obtained in all cases (100%) and was assed radiologically when X-ray check-ups in all projections showed the significant presence of trabeculation crossing the fracture, without pain and functionally using the American Orthopedic Foot and Ankle Society (AOFAS) score of the ankle joint. Overall average score was 97 ranged 95–100. There was no recorded post-operative complication.ConclusionThe plain radiographs of patients with an avulsion injury of anterolateral tubercle (Tillaux fragment) should be carefully examined for evidence of syndesmotic widening. If there is any doubt, CT scans is helpful. If fracture displacement was greater than 2 mm, a surgical intervention is recommended to restore the normal anatomy of the ankle joint. Anatomically reduced Tillaux fractures at adolescent age group either by closed or opened means, followed by post-operative plaster cast immobilization will lead to excellent results.     

Selective fixation of the medial malleolus in unstable ankle fractures

BackgroundWhilst the lateral malleolus appears to be crucial in controlling anatomical reduction of the talus, the role of the medial malleolus is less clear. Medial sided complications including infection, damage to local structures and symptomatic hardware are not without morbidity. This study compares the outcomes of patients with bimalleolar or trimalleolar ankle fractures who underwent fibular nail stabilisation with or without medial malleolar fixation.MethodsFrom a prospective single-centre trauma database, we identified 342 patients over a nine-year period who underwent fibular nail insertion to stabilise a bimalleolar or trimalleolar ankle fracture. Isolated lateral malleolar fractures were excluded. Demographic data, clinical outcomes, radiographic evaluation, return to work and sport, and patient reported outcomes, including Olerud-Molander Ankle Score (OMAS), EuroQol-5D (EQ-5D) and Manchester-Oxford Foot Questionnaire (MOXFQ) were collected.ResultsThis study included 247 patients with a mean age of 66.7 years (range, 25–96 years), of whom 200 were female (81%). Medial malleolar fixation was not performed in 54 cases (22%). There was no significant difference between groups with respect to failure of fixation (p = 0.634) or loss of talar reduction (p = 0.157). No patient required surgery for a symptomatic medial malleolar non-union. Medial sided complications occurred in 32 (16%) of the fixation group, of whom 20 (10%) required further surgery. At a mean mid-term follow-up of 4.8 years (range, 8 months – 9 years) there was no significant difference between the non-fixation and fixation groups with respect to the median OMAS (85 vs 80; p = 0.885) or median EQ-5D (0.80 vs 0.81; p = 0.846). Patient satisfaction was not significantly different between the two groups (85/100 vs 87/100; p = 0.410).ConclusionNon-operative management of the medial malleolar component of an unstable ankle fracture treated with a fibular nail may reduce the rate of post-operative complications without compromising the patient reported outcome.     

Arthroscopic Suture-Bridge Repair Technique for an Avulsion of the Talar Insertion of the Anterior Talofibular Ligament

There are several studies about arthroscopic repair techniques for the lesion of the anterior talofibular ligament. However, the research concentrating on the avulsion of the talar insertion of the anterior talofibular ligament is very rare. Among 122 patients who suffered from recurrent ankle sprain and underwent arthroscopic anterior talofibular ligament repair from October 2016 to January 2019 in our hospital, 11 patients with an avulsion of the talar insertion of this ligament were diagnosed and then treated with the arthroscopic suture-bridge repair technique in the present study. The clinical outcomes were assessed using the Karlsson-Peterson score, Ankle and hindfoot score by American Orthopedic of Foot and Ankle Society, Sefton articular stability scale and Visual Analogue Scale. The complications were recorded at the time of observation. The median value of the follow-up time was 30 (range 18-36) months. At the final follow-up, the median value of the Karlsson-Peterson score, American Orthopedic of Foot and Ankle Society ankle-hindfoot score, and Visual Analogue Scale score was 90, 90, 1, respectively. Based on the Sefton stability scale, 10 cases were in the excellent or good category. No wound infections and no neurovascular injuries were encountered, also no case required revision surgery. Only 1 patient complained about mild local irritation at the knotless anchor site. The arthroscopic suture-bridge technique could be suitable for treatment of an avulsion of the talar insertion of the anterior talofibular ligament due to satisfactory activity recovery and few complications.     

Results of surgically treated talar fractures

Objective：Talar fractures present a great challenge to surgeons due to poor treatment outcome and high incidence of sequelae.The purpose of this study was to report the surgical treatment outcome of displaced talar fractures treated by internal fixation.Methods：Atotal of 30 patients with a mean age of 38 years presenting with talar body or neck fractures were studied retrospectively to assess postoperative outcome based on American Orthopaedic Foot ＆ Ankle Society AnkleHindfoot scale.Results：Postoperatively,malunion was found in 18 cases,infection in 5 cases and avascular necrosis in 12 cases.There were 12 cases with subtalar arthritis and 18 cases with both subtalar and malleolar arthritis.The average score of questionnaire was 64± 12.Functional score was 53± 15 and pain score was 65±13.Range of motion failure was detected as 15±4.Conclusion：Talar injuries can compromise motion of the foot and ankle and result in poor prognosis on longterm evaluation.Late complications subsequent to surgically treated talar body fractures are inevitable,and patients are supposed to be counseled about the adverse outcome.     

Osteochondral lesions of the talar dome. A comprehensive review with retrospective study.

The incidence of osteochondral lesions of the talus is increasing because of a greater awareness of this injury following ankle trauma. The treating physician should view the so-called simple ankle sprain as a potential for fractures of the talar dome, especially in patients who are recalcitrant to treatment. It has been the authors' experience that talar dome lesions respond well to arthrotomy with removal of the fracture fragment and subchondral drilling, and yield generally good results. A high index of suspicion following ankle trauma allows for the early recognition and treatment of talar dome lesions.     

Minimally invasive plate osteosynthesis using posterolateral approach for distal tibial and tibial shaft fractures

ObjectiveThe objective of the study was to evaluate the effectiveness of the posterolateral minimally invasive plate osteosynthesis (MIPO) method for managing distal tibial or tibial shaft fractures with severe anterior and medial soft tissue injuries.Materials and methodsFive consecutive patients with three distal tibial and two tibial shaft fractures (three open fractures) at a level-1 trauma and tertiary referral center were retrospectively reviewed. All patients were definitively treated and followed to bone union. Main outcome was measured by American Orthopaedic Foot and Ankle Society (AOFAS) ankle–hindfoot score, complications, and bone union on radiographs.ResultsThe average follow-up period was 15.8 months (range, 12–24 months). The average AOFAS score was 88.2 (range, 81–90). There were no complications, such as incision breakdown, deep infection, or impingement of the flexor hallucis longus tendon. Bone union was achieved in all cases.ConclusionsPosterolateral MIPO is a feasible option when treating these fractures, especially in cases with severe anterior and medial soft tissue injuries.     

Prognostic factors of acute ankle sprain: Need for ultrasonography to predict prognosis

BackgroundAnkle sprains are one of the most common musculoskeletal injuries. To guide management decisions, a clear insight into the relevant subgroups of patients with a potentially better or worse prognosis is important. This study aimed to evaluate injury severity, using ultrasonography (US), as a prognostic factor of acute ankle sprain and other possible factors including age, sex, body mass index (BMI), level of job activity, and level of sports activity.Materials and methodsWe retrospectively reviewed 28 patients with acute ankle sprain who reported at initial examination with an acutely twisted ankle. All patients had received a standard physical examination, radiography and standard ultrasound, to diagnose specific ligament injuries and their ankle sprain had been treated using standard conservative management. Various data including age, sex, BMI, level of sports activity, level of daily job activity, and final functional score (Foot and Ankle Outcome Scores, FAOS) were obtained. Mean comparison and correlations were used to assess risk factors. Risk factors associated with functional outcomes were evaluated using a multiple linear regression test.ResultsAt final follow-up as 1 year after injury, FAOS differed significantly for injury severity, age, and BMI. There were no significant differences in sex, job activity, and exercise levels. The factor most affecting FAOS for both pain (FAOS-Pain) and symptoms (FAOS-Sx) was the number of completely torn ligaments. Age was the most important factor affecting the FAOS-Daily Living Activity (ADL). BMI was the most important factor for sports activity level (FAOS-Sports). Age and the number of completely torn ligaments were both important to FAOS-Sports and quality of life (FAOS-QOL).ConclusionThe severity of injury, defined using US, was a prognostic factor for long-term outcome following acute ankle sprain. Therefore, US imaging of acute ankle ligament injury may be important to predict prognosis of acute ankle sprain.     

The pattern of ankle fractures sustained by outdoor activities at the Snowdonia National Park,North Wales,United Kingdom

ObjectiveThe aim of this study was to review the pattern of ankle fractures sustained by patients brought to the Emergency Department at Ysbyty Gwynedd from The Snowdonia National Park.Materials and methodsThe study group included all patients with ankle fractures on the mountain medicine database between March 2004 and December 2006. The presence of talar shift and comminution of the medial malleolus was noted. The pattern of fractures were analysed and compared with the literature. Radiographs were obtained for 20 casualties.Results70% of these were injured whilst hill walking. Open fractures represented 12% of injuries. 75% of fractures required operative fixation. Weber B injuries were the commonest followed by Weber C and A. Talar shift was seen in 80% of the cases and 45% showed comminution of the medial malleolus.ConclusionsIn our case series we observed a high proportion of open and unstable ankle fractures, with the majority treated by operative fixation. The high rate of comminution of the medial malleolus has previously not been reported in the literature and has the potential of making operative fixation technically difficult. Encouraging the use of walking poles particularly at the time of descending may help to reduce the incidence of ankle fractures in hill walkers.     

Surgical treatment of atraumatic osteochondrosis dissecans of the immature talus—Clinical results and prevalence of radiographic joint degeneration after a median follow-up of 72.5 months

BackgroundThis study aimed to assess the clinical and radiographic outcomes of different surgical procedures in atraumatic osteochondrosis dissecans (OCD) of the talus in youth and adolescence.Methods32 joints in 30 patients (mean age 14.7 ± 2.2 years) were evaluated. Numeric Rating Scale (NRS), Foot and Functional Index (FFI), American Orthopedic Foot and Ankle Society ankle-hindfoot score (AOFAS), Pediatric Outcome Data Collection Instrument (PODCI), and sport participation were recorded. We compared preoperative and follow-up ankle radiographs to identify specific features in the OCD morphology and any signs of joint degeneration.ResultsAfter a median follow-up period of 72.5 months the drilling group showed significantly better scores than the combined fixation and reconstruction groups (AOFAS, p = 0.024; PODCI, p = 0.003; NRS, p = 0.027). Signs of joint degeneration were observed in 50% of all ankles, especially in those treated by OCD-fixation and reconstruction.ConclusionsAdvanced fixation and reconstruction procedures in unstable and non-salvageable atraumatic talar OCD resulted in inferior clinical scores and a higher prevalence of joint degeneration than drilling procedures in stable OCD in young patients.     

Arthroscopy of the ankle: analysis of results and indications on a series of 75 cases

The purpose of this study was to evaluate the results of arthroscopy of the ankle. Of the 114 arthroscopies of the ankle that we performed between 1991 and 1996, 13 were for diagnosis, 6 were associated with open surgery, and 10 were ankle arthrodeses. We report the results of the remaining 85 therapeutic arthroscopies. We identified five groups according to preoperative indications: (1) anterolateral synovitis after a sprained ankle (33 cases), (2) sequelae of fractured ankles (17 cases), (3) anterior impingement as a result of osteophytes (12 cases), (4) loose foreign bodies as a result of avulsion of fragments of bone (6 cases), and (5) osteochondral lesions of the talar dome (17 cases). In anterolateral synovitis, results were better when the pain followed a single sprain than when after chronic instability. In osteochondral lesions of the talar dome, results were better in anterolateral lesions than in posteromedial lesions.     

关节镜治疗踝关节不稳合并前内侧撞击综合征

目的:探讨关节镜治疗踝关节不稳合并前内侧撞击综合征的手术技巧及疗效.方法:回顾性分析2019年2月至2020年8月收治的13例踝关节不稳合并前内侧撞击综合征患者.男10例,女3例;年龄(40.0±15.1)岁;病程(44.1±33.2)个月.所有患者有明确扭伤史,MRI证实踝关节距腓前韧带损伤,踝关节背伸时存在前内侧疼...     

Fracture dislocation of the talus combined with pilon or bimalleolar fracture: a report of two cases

Talar fractures are uncommon and talar body fracture dislocations are still rare. Simultaneous fractures of the ankle and the talar body are rare and the reported incidence in the literature is fewer than 1% of the ankle fractures. We present two cases of patients, who sustained a simultaneous fracture dislocation of talar body with fracture of medial malleolus and/or tibial pilon. The patients were treated with open reduction and internal fixation of talus through the malleolar fracture. They were evaluated at 1 year (case 1) and 8 years (case 2) of follow-up. The prognosis after this fracture dislocation is poor because of the very high risk of avascular necrosis and arthritis, even after anatomic reduction.     

Avulsion fractures of the medial tubercle of the posterior process of the talus

Avulsion fracture of the medial tubercle of the posterior process of the talus occurs after forceful dorsiflexion-pronation of the ankle. We evaluated five patients who had sustained this fracture while participating in sporting activities. Two patients were correctly diagnosed acutely and treated with immobilization and limited weightbearing. Avulsion fractures in the remaining three patients went undiagnosed acutely. This group was treated with delayed operative excision for persistent posteromedial ankle pain. The patients were evaluated at a mean follow-up of 35 months using the AOFAS Ankle-Hindfoot Scale. The two patients diagnosed and treated acutely achieved excellent results. The three patients with missed fractures did poorly, yet achieved comparable results after late excision. Our results suggest that prompt diagnosis and appropriate management yields reliably good outcomes. Untreated avulsion fractures predictably do poorly. For these patients, late excision can provide significant functional and symptomatic improvement.     

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.     

Sekundäre anatomische Rekonstruktion fehlverheilter zentraler Talusfrakturen

Background

Malunion or nonunion of central talar fractures lead to significant impairment, pain and decreased motion of the foot and ankle. In a 20-year period from 1994 to 2013 at the Trauma Department of the University Hospital“Carl Gustav Carus” of the Technical University of Dresden we treated a total of 25 patients with secondary anatomical reconstruction of the talus.

Method

The mean age of the patients was 39.9 years (range 15-71 years) and only 4 out of the 25 patients were female. Of these patients 11 patients were treated conservatively, 3 minimally invasive with external fixation and were admitted on average 7.6 months (range 1.5-42 months) after the initial fracture. Of the patients 11 had previously been treated in another hospital by open surgery on average 8.4 months (range1–24 months) months before. There were 9 malunions or nonunions of talar fractures of the shaft, 14 of the neck and 2 of the head. Only 3 cases were old fractures ≥ 6 weeks and 22 were malunions or nonunions ≥ 3 months. According to an in-house classification 12 malunions (type I), 5 nonunions (type II), and 8 malunions/nonunions with partial necrosis (type III) were treated.

Results

Of the patients 21 out of 25 needed a bilateral approach and 6 additionally an osteotomy of the medial malleolus.The mean follow-up of 22 out of 25 patients was 5.4 years (range1.0-21.5 years). The preoperative American Orthopedic Foot and Ankle Society (AOFAS) hindfoot score increased on average from 36.6 to 86.7 points (p<0.001) at the time of follow-up.     

Medial malleolar osteotomy for the correction of tibiotalar varus deformity during total ankle arthroplasty: Results in 95 ankles

BackgroundThe importance of deformity correction before or during total ankle replacement (TAR) has been recognized for a long time. Our results of TAR, combined with medial malleolar lengthening osteotomy, for the reconstruction of osteoarthritic ankles with varus deformity are hereby reported.MethodsAll ankles in which a medial malleolar osteotomy was performed during implantation of an ankle prosthesis during the period 1998–2018 were filtered out of our database. Preoperative coronal talar alignment was evaluated by measuring the angle between the tibial shaft and talar dome on the weightbearing mortise ankle radiograph. Patient-reported outcomes were measured with the Foot and Ankle Outcome Score (FAOS) and the Foot and Ankle Ability Measure (FAAM). A Kaplan-Meier survival curve was constructed and the number of revisions per 100 observed component years was calculated for interprosthetic comparison.ResultsA total of 95 TARs were included, consisting of the Alpha Ankle Arthroplasty (n = 22); Buechel-Pappas (n = 14) and the Ceramic Coated Implant Evolution (n = 59) prostheses. The preoperative average talar angle in these ankles was 12.4 degrees varus. In 33% (31/95) corrective procedures, in addition to the medial malleolar osteotomy, were performed. A reoperation rate of 44% (42/95) was found, including 28 revisions (revision rate 29% (4% septic; 25% aseptic) at an average follow-up of 5.9 years, resulting in a survival of 0.69 for the total cohort at 10 years of follow-up.At an average follow-up of 6.6 years the average FAOS scores were: FAOS_symptoms 66, FAOS_pain 73, FAOS_function 78, FAOS_sport 45 and FAOS_{quality of life} 56 respectively. The FAAM_adl score averaged 64.ConclusionThis is the largest cohort of TAR combined with medial malleolar osteotomy to date. A 29% revision rate at 5.9 years of average follow-up compares unfavorably with regular cohort studies and with most other results in varus-deformed ankles. Scores on the FAOS and FAAM are comparable to those obtained in regular cohorts with similar length of follow-up. TAR in varus-deformed ankles necessitating medial malleolar osteotomy has an even higher failure rate than regular TAR. Obtaining a stable prosthesis with a neutrally-aligned hindfoot at the end of the procedure is of paramount importance.Level of evidenceIV.