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European Journal of Orthopaedic Surgery... Aug 2022To determine the interobserver reliability of syndesmosis assessment using intraoperative ankle mortise fluoroscopic images, with and without contralateral images.
Need for syndesmotic fixation and assessment of reduction during ankle fracture fixation, with and without contralateral fluoroscopic images, has poor interobserver reliability.
PURPOSE
To determine the interobserver reliability of syndesmosis assessment using intraoperative ankle mortise fluoroscopic images, with and without contralateral images.
METHODS
A survey of 19 operative ankle fracture cases was administered to 17 orthopedic surgeons. Respondents were presented with fluoroscopic mortise and stress images of the ankle after fracture fixation and asked if they would fix the syndesmosis. Final fluoroscopic mortise images were then shown, and respondents were asked to assess the reduction of the syndesmosis. Six weeks later, the survey was administered again with the addition of contralateral fluoroscopic ankle mortise images. Responses were compared to a standard response agreed upon by fellowship-trained orthopedic trauma surgeons.
RESULTS
Interobserver reliability for syndesmosis fixation and reduction, with and without contralateral images, was considered weak (kappa 0.48 and 0.43; mean difference 0.05, 95% confidence interval (CI) 0.01 to 0.1) and minimal (kappa 0.25 and 0.22; mean difference 0.02, CI - 0.02 to 0.08). With the addition of contralateral mortise images, the number of surgeons who changed their response for syndesmosis fixation and reduction quality ranged from 0% to 41% and 0% to 88%; with the number of responses matching the standard increasing for both fixation (proportional difference (PD) 7%, CI 1% to 14%) and reduction (PD 14%, CI 7% to 21%); CONCLUSIONS: Interobserver reliability of syndesmosis fixation and reduction remained weak to minimal between surgeons, with and without contralateral images. Future studies are necessary to understand the variability in surgeon responses in order to improve the intraoperative assessment and fixation of syndesmotic injuries.
Topics: Ankle; Ankle Fractures; Ankle Injuries; Ankle Joint; Fracture Fixation; Fracture Fixation, Internal; Humans; Reproducibility of Results
PubMed: 34347186
DOI: 10.1007/s00590-021-03084-z -
Journal of the American Podiatric... Jul 2021The Bosworth ankle fracture-dislocation is a rare injury and is often irreducible because of an entrapped proximal fragment of the fibula behind the posterior tibial...
The Bosworth ankle fracture-dislocation is a rare injury and is often irreducible because of an entrapped proximal fragment of the fibula behind the posterior tibial tubercle. Repeated closed reduction or delayed open reduction may result in several complications. Thus, early open reduction and internal fixation enable a better outcome by minimizing soft-tissue damage. We report on a 27-year-old man who underwent open reduction and internal fixation after multiple attempts at failed closed reduction, complicated by severe soft-tissue swelling, rhabdomyolysis, and delayed peroneal nerve palsy around the ankle.
Topics: Adult; Ankle; Ankle Fractures; Ankle Joint; Fibula; Fracture Dislocation; Fracture Fixation, Internal; Humans; Male; Peroneal Neuropathies
PubMed: 34478536
DOI: 10.7547/20-013 -
The Journal of International Medical... Apr 2020We aimed to present the radiographic and functional outcomes of anatomical reduction and fixation of anterior inferior tibiofibular ligament (AITFL) avulsion fracture...
OBJECTIVE
We aimed to present the radiographic and functional outcomes of anatomical reduction and fixation of anterior inferior tibiofibular ligament (AITFL) avulsion fracture without syndesmotic screw fixation in rotational ankle fracture.
METHODS
We retrospectively reviewed 66 consecutive patients with displaced malleolar fracture combined with AITFL avulsion fracture. We performed reduction and fixation for the AITFL avulsion fracture when syndesmotic instability was present after malleolar fracture fixation. A syndesmotic screw was inserted only when residual syndesmotic instability was present even after AITFL avulsion fracture fixation. The radiographic parameters were compared with those of the contralateral uninjured ankles. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores were assessed 1 year postoperatively.
RESULTS
Fifty-four patients showed syndesmotic instability after malleolar fracture fixation and underwent reduction and fixation for AITFL avulsion fracture. Among them, 45 (83.3%) patients achieved syndesmotic stability, while 9 (16.7%) patients with residual syndesmotic instability needed additional syndesmotic screw fixation. The postoperative radiographic parameters were not significantly different from those of the uninjured ankles. The mean AOFAS score was 94.
CONCLUSION
Reduction and fixation of AITFL avulsion fracture obviated the need for syndesmotic screw fixation in more than 80% of patients with AITFL avulsion fracture and syndesmotic instability.
Topics: Ankle Fractures; Bone Screws; Fracture Fixation, Internal; Fractures, Avulsion; Humans; Lateral Ligament, Ankle; Retrospective Studies; Treatment Outcome
PubMed: 31885342
DOI: 10.1177/0300060519882550 -
Foot & Ankle International Dec 2022Although chronic kidney disease (CKD) has been associated with poor outcomes following traumatic fractures, there is a scarcity of literature describing the effect on...
BACKGROUND
Although chronic kidney disease (CKD) has been associated with poor outcomes following traumatic fractures, there is a scarcity of literature describing the effect on outcomes of ankle fractures. We will examine the impact of CKD on clinical outcomes following torsional ankle fracture, including complications and unplanned surgical procedures.
METHODS
A retrospective review of 1981 adult patients with torsional ankle fractures treated at a level 1 trauma center was performed to identify patients with CKD based on glomerular filtration rate. Demographic, injury, and treatment-related characteristics were collected. Outcomes included any unplanned procedure: implant removal, debridement, revision, arthrodesis, and amputation; in addition to complications of superficial infection, deep infection, and implant irritation. Patients with CKD were matched with patients without CKD by propensity score matching. Univariate comparisons between groups were conducted using chi-square and Mann-Whitney tests.
RESULTS
136 patients (68 with CKD and 68 without CKD) were analyzed. Of the 68 patients with CKD, the mean stage of disease was 3.7 with 24% on dialysis for a mean length of 4.1 years. Patients without CKD were more likely to undergo primary ORIF (100% vs 54%, < .001). Thirty-five percent of patients with CKD had surgical complications vs 19% in the cohort without ( = .07). Patients with open fractures, dislocation, and chronic kidney disease were, respectively, 5.19, 3.77, and 3.91 times more likely to have any complication ( = .02, = .05, = .05). Patients with CKD were more likely to undergo unplanned arthrodesis ( = .01). Only dislocation was an independent predictor for unplanned procedure (odds ratio = 5.08, = .026).
CONCLUSION
Following torsional ankle fracture, CKD is associated with increased likelihood of having a complication or an unplanned arthrodesis. Open fractures and dislocation at time of injury are also associated with complications. Our findings encourage caution about surgical treatment of ankle fractures in patients with CKD.
LEVEL OF EVIDENCE
Level III, retrospective, comparative, prognostic.
Topics: Adult; Humans; Ankle Fractures; Retrospective Studies; Fracture Fixation, Internal; Fractures, Open; Renal Insufficiency, Chronic; Treatment Outcome
PubMed: 36254721
DOI: 10.1177/10711007221127026 -
The Journal of Foot and Ankle Surgery :... 2020This study retrospectively evaluated patients with ankle fracture to compare the prognosis between patients who had primary repair of the superficial deltoid ligament...
This study retrospectively evaluated patients with ankle fracture to compare the prognosis between patients who had primary repair of the superficial deltoid ligament and those who did not. A total of 71 patients with ankle fracture and fracture-dislocation combined with deltoid ligament injury were divided into 2 groups: repair of superficial layer group (33 cases) and nonrepair group (38 cases). For the repair group, patients first underwent open reduction and internal fixation of the lateral malleolus and received a stress test. If the syndesmosis was widened, it would undergo fixation of the syndesmosis with screws. If instability of the ankle joint was observed, patients might further undergo repair of the superficial deltoid ligament. Ultimately, postoperative functions were evaluated using the Philips and Schwartz scale. All patients achieved bony union without significant pain. In the repair group, plantar and dorsi flexions were 2.5 ± 4.2° (range 0 to 10) and 7 ± 7.1° (range 0 to 20) less than the normal side, respectively. In the nonrepair group, the plantar and dorsi flexions were 2.8 ± 4.6° (range 0 to 10) and 6.6 ± 5.9° (range 0 to 20) less than the normal side. Meanwhile, the Philips and Schwartz scores of the repair and nonrepair groups were 92.5 ± 4.4 (range 80 to 100) and 93.4 ± 3.8 (range 85 to 100), respectively. But the difference of prognosis between the 2 groups was not statistically significant. In conclusion, for ankle joint fracture combined with deltoid ligament injury, routinely exploring or repairing the deltoid ligament was not recommended, but repair of the deltoid ligament increased stability of the ankle joint in the early postoperative stage.
Topics: Ankle Fractures; Ankle Injuries; Ankle Joint; Fracture Fixation, Internal; Humans; Ligaments; Ligaments, Articular; Retrospective Studies
PubMed: 32600557
DOI: 10.1053/j.jfas.2018.07.005 -
Foot and Ankle Clinics Dec 2020There is no consensus on whether the deltoid ligament must be repaired in ankle fractures. Recent studies have shown better early radiologic results when the deltoid... (Review)
Review
There is no consensus on whether the deltoid ligament must be repaired in ankle fractures. Recent studies have shown better early radiologic results when the deltoid ligament is repaired, but no differences in long term functional outcomes. However, there is evidence suggesting that patients with high fibular fractures or injuries with concomitant syndesmotic instability may benefit from repair. The authors recommend repairing the deltoid ligament complex in bimalleolar equivalent fractures associated with syndesmotic or gross multiligamentous instability as well as in heavier patients with greater mechanical requirements.
Topics: Ankle Fractures; Ankle Joint; Fracture Fixation, Internal; Humans; Ligaments; Ligaments, Articular; Treatment Outcome
PubMed: 33543718
DOI: 10.1016/j.fcl.2020.08.009 -
Journal of Orthopaedic Trauma Aug 2019Syndesmosis sprain is not uncommon in unstable ankle fractures. Surgical stabilization of the syndesmosis can be achieved with either trans-syndesmotic screws or a...
Syndesmosis sprain is not uncommon in unstable ankle fractures. Surgical stabilization of the syndesmosis can be achieved with either trans-syndesmotic screws or a suture-endobutton device. The suture-endobutton provides for potential advantages including more anatomical mobility of the joint, quicker return to weight-bearing, and no need for implant removal. In this article, we describe the indications and surgical technique for management of a bimalleolar ankle fracture requiring repair of the syndesmosis. This technique focuses on methods of intraoperative reduction and assessment using fluoroscopic imaging of the contralateral ankle for reference. We also demonstrate the use of a suture-endobutton for syndesmosis fixation.
Topics: Adult; Ankle Fractures; Ankle Joint; Bone Screws; Female; Fracture Fixation, Internal; Humans; Range of Motion, Articular; Sutures
PubMed: 31290832
DOI: 10.1097/BOT.0000000000001538 -
Foot and Ankle Surgery : Official... Aug 2021Tibialis posterior tendon dislocation, a rare complication in ankle fracture-dislocations, can impede anatomical reduction of the ankle mortise. We report on a...
Tibialis posterior tendon dislocation, a rare complication in ankle fracture-dislocations, can impede anatomical reduction of the ankle mortise. We report on a 59-year-old healthy male with an open fracture-dislocation of the right ankle. Despite multiple attempts under direct vision of the anterior syndesmosis, anatomical reduction of the ankle mortise was not possible. Soft tissue windows in a computed tomography (CT) scan revealed the dislocated tibialis posterior tendon to be the impeding structure. At the level of the fibula fracture the tendon passed through the interosseous membrane anterior to the distal tibia and was then incarcerated in the medial talocrural joint before returning to the flexor retinaculum and its insertion on the navicular bone. Understanding the trauma mechanism and the course of the dislocated tendon as well as correct interpretation of CT and magnetic resonance images of the ankle enable surgeons to early diagnose and correctly treat this condition.
Topics: Ankle; Ankle Fractures; Ankle Joint; Fracture Fixation, Internal; Humans; Joint Dislocations; Male; Middle Aged; Tendons
PubMed: 33011101
DOI: 10.1016/j.fas.2020.09.008 -
Journal of Orthopaedic Trauma Mar 2022To investigate patient demographics, injury characteristics, radiographic outcomes, and identify risk factors for developing posttraumatic arthritis in high-energy...
High-Energy Transsyndesmotic Ankle Fracture Dislocation-Injury Characteristics, Radiographic Outcomes, and Factors Affecting the Rate of Posttraumatic Arthritis in Logsplitter Injuries.
OBJECTIVES
To investigate patient demographics, injury characteristics, radiographic outcomes, and identify risk factors for developing posttraumatic arthritis in high-energy transsyndesmotic ankle fracture dislocations or "logsplitter" injuries.
DESIGN
Retrospective cohort study.
SETTING
Academic level one trauma center.
PATIENTS/PARTICIPANTS
Twenty-seven adult patients with logsplitter injuries.
INTERVENTION
All patients were treated with open reduction internal fixation, with possible addition of syndesmosis screw(s) and deltoid repair.
MAIN OUTCOME MEASUREMENTS
The rate of posttraumatic arthritis at one year along with rate and reasons for reoperation.
RESULTS
Twenty-seven patients were included with a mean follow-up of 14.5 ± 12.5 months. At one-year postoperative, 14 of the 20 patients (70%) demonstrated posttraumatic arthritis. Two patients (7.4%) went onto fusion. The reoperation rate was 51.9%. There was no significant difference in the arthritis rate with the number of syndesmosis screws used, quality of reduction, or addition of deltoid repair.
CONCLUSIONS
The logsplitter injury is one with devastating outcomes and high rates of arthritis; it should be considered separately from conventional ankle fractures. The role of deltoid repair remains unclear. Further study of this injury pattern is required.
LEVEL OF EVIDENCE
Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Topics: Adult; Ankle; Ankle Fractures; Arthritis; Fracture Dislocation; Fracture Fixation, Internal; Humans; Retrospective Studies; Treatment Outcome
PubMed: 34294667
DOI: 10.1097/BOT.0000000000002237 -
JAAPA : Official Journal of the... Feb 2018This study evaluated the accuracy and interrater reliability of US Army physician assistants (PAs) in identifying ankle fracture patterns using existing classification... (Comparative Study)
Comparative Study
PURPOSE
This study evaluated the accuracy and interrater reliability of US Army physician assistants (PAs) in identifying ankle fracture patterns using existing classification schemes.
METHODS
Twenty-eight PAs reviewed criteria for stability, Danis-Weber, and Lauge-Hansen ankle fracture classification systems. Participants reviewed 45 ankle radiographs and independently rated each radiograph using these classification schemes.
RESULTS
Participants were able to successfully identify ankle fracture stability in 82.1% of cases (95% CI, 77.6, 86.6) with established criteria. Using the Danis-Weber classification, accurate classification was achieved in 77.8% of cases (95% CI, 72.8, 82.7). The Lauge-Hansen classification system was least reliable, with accuracy of 54.5% (95% CI, 46, 63).
CONCLUSION
Referring PAs can reliably discern unstable ankle fractures in more than 80% of cases. Lauge-Hansen classification was significantly less accurate than the Danis-Weber system or criteria for stability. Good communication between orthopedic surgeons and PAs and an emphasis on PA orthopedic education can improve patient care.
Topics: Adult; Ankle Fractures; Female; Humans; Male; Middle Aged; Military Medicine; Observer Variation; Physician Assistants; Radiography; Reproducibility of Results; United States
PubMed: 29369927
DOI: 10.1097/01.JAA.0000529773.90897.9f