-
European Journal of Trauma and... Oct 2022Different classification systems have been developed for ankle fractures. In recent years, the posterior malleolus has gained in importance and led to computed...
PURPOSE
Different classification systems have been developed for ankle fractures. In recent years, the posterior malleolus has gained in importance and led to computed tomography (CT)-based classification systems. The aim of the study was to analyse their reliability, fracture patterns and influence on treatment strategy.
METHODS
Patients with a trimalleolar ankle fracture treated between 2011 and 2020 with preoperative radiographs and CT images were included. The blinded images were independently classified by three reviewers according to the AO/OTA, Herscovici, Bartoníček, Mason and Haraguchi classifications. The interobserver reliability was calculated by Fleiss' kappa (κ). CT images were analysed to determine the dimensions of the posterior malleolus fragments. Patient registries were reviewed regarding the treatment data.
RESULTS
A total of 193 patients were included. The AO/OTA classification showed almost perfect inter- and intraobserver reliability (Fleiss' κ = 0.86, 95% CI 0.82-0.90). Regarding the posterior malleolus, the Bartoníček classification demonstrated the highest reliability (Fleiss' κ = 0.78, 95% CI 0.73-0.83). The Herscovici classification only reached moderate reliability for medial malleolus fractures (Fleiss' κ = 0.59, 95% CI 0.54-0.65). There was a trend towards direct fixation of the posterior malleolus in the last 3 years of the observation period (OR: 2.49, 95% CI 1.03-5.99).
CONCLUSION
In trimalleolar ankle fractures, the AO/OTA classification is a reliable system to characterize the type of fracture, but it fails to provide solid information about the posterior malleolus. Nowadays, treatment recommendations for trimalleolar ankle fractures focus on the configuration of the posterior malleolus; therefore, the results of this study advocate the use of the Bartoníček classification as a reliable tool to guide treatment.
Topics: Ankle Fractures; Fracture Fixation, Internal; Humans; Radiography; Reproducibility of Results; Tibia; Tomography, X-Ray Computed
PubMed: 35348840
DOI: 10.1007/s00068-022-01959-2 -
The Journal of Foot and Ankle Surgery :... Jan 2019In unstable ankle fractures, the importance of reducing the lateral malleolus first to obtain an anatomic reduction of the talus is well established. Although this is a...
In unstable ankle fractures, the importance of reducing the lateral malleolus first to obtain an anatomic reduction of the talus is well established. Although this is a time-tested and common surgical approach, current surgical practice does not always follow the established dogma. Medial-first fixation may be a worthwhile alternative to lateral-first fixation in select instances. We performed a retrospective, cohort study in an urban level I trauma center to compare medial malleolus-first fixation of unstable ankle fractures with lateral malleolus-first fixation. Patient demographics, injury characteristics, and radiographic metrics including pre-, intra-, and final postoperative talocrural angles, medial clear space, and tibiofibular overlap were assessed. Complications were also reviewed. A total of 280 adult patients with operative bimalleolar ankle fractures from January 2010 to January 2015 met inclusion criteria. There were more open fractures (23.2% vs 9.4%, p = .01) and less isolated injuries in the medial-first group (59.2% vs 71.0%, p = .02). There were less isolated operative procedures (80.3% vs 89.1%, p = .04) and more intramedullary screw placement of the lateral malleolus (11.2% vs 4.3% p = .02) in the medial-first fixation group. There was also a strong trend in identifying more posterior tibial tendon injuries in the medial-first group compared with the lateral-first group (3.5% vs 0%, p = .06). There were no significant differences in fluoroscopy times or radiographic variables in the preoperative, intraoperative, or most recent postoperative images between either group. This approach demonstrates equivalent radiographic outcomes to lateral-first fixation and may be appropriate in select cases.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Ankle Fractures; Female; Fracture Fixation, Internal; Humans; Male; Middle Aged; Patient Selection; Radiography; Retrospective Studies; Treatment Outcome; Young Adult
PubMed: 30448377
DOI: 10.1053/j.jfas.2018.08.007 -
Journal of Orthopaedic Trauma Oct 2021The incidence of geriatric ankle fractures is increasing in step with the current aging population. Special considerations must be taken into account when treating...
The incidence of geriatric ankle fractures is increasing in step with the current aging population. Special considerations must be taken into account when treating geriatric patients due to increased medical comorbidities, worse soft tissue envelope, poor bone quality, and the needs for early mobilization. The orthopaedic surgeon must have a variety of surgical options to treat fractures in the elderly population based on patient-specific needs. This article uses a case-based approach to discuss relevant considerations when selecting between hindfoot fusion nail and robust open reduction and internal fixation for geriatric ankle fractures.
Topics: Aged; Ankle Fractures; Bone Nails; Fracture Fixation, Internal; Fracture Fixation, Intramedullary; Humans; Open Fracture Reduction; Treatment Outcome
PubMed: 34533502
DOI: 10.1097/BOT.0000000000002232 -
Foot and Ankle Surgery : Official... Jan 2022The use of smartphones and multimedia messaging service (MMS) continues to increase in day to day orthopaedic clinical practice. However, there is limited evidence to...
BACKGROUND
The use of smartphones and multimedia messaging service (MMS) continues to increase in day to day orthopaedic clinical practice. However, there is limited evidence to support the safe utilisation of MMS.
OBJECTIVES
The aim of this study was to correlate the performance of MMS imaging to picture archiving and communication systems (PACS) imaging within the setting of diagnosis and management of ankle fractures.
METHODS
The ankle fracture radiograph series of 82 consecutive patients were evaluated by five orthopaedic consultant specialists. A questionnaire regarding diagnosis and preferred management was completed separately for each patient using smartphone and PACS images. Statistical analysis was performed using Intraclass Correlation Coefficient (ICC).
RESULTS
Ankle fracture diagnosis showed strong to excellent correlation both inter- and intraobserver MMS vs PACS when using the Weber (0.815, 0.988), Anatomical (0.858, 0.988), and AO classification systems (0.855, 0.985). MMS was less reliable than PACS in determining many management options.
CONCLUSION
The reliability of ankle fracture classification using MMS image viewing was not significantly different to interpretation on PACS workstations. Smartphone use in ankle fracture classification is supported by this study. Smartphone use was less accurate than PACS in devising management plans and future use should be limited to making only initial plans that must be corroberated with PACS and intraoperative findings prior to definitive fixation.
Topics: Ankle Fractures; Humans; Multimedia; Radiography; Reproducibility of Results; Smartphone
PubMed: 33500217
DOI: 10.1016/j.fas.2021.01.004 -
Foot and Ankle Clinics Mar 2017Injuries to the posterior malleolus are of prognostic relevance in ankle fracture-dislocations. The three-dimensional outline of the fragments as reflected by computed... (Review)
Review
Injuries to the posterior malleolus are of prognostic relevance in ankle fracture-dislocations. The three-dimensional outline of the fragments as reflected by computed tomography classification, involvement of the fibular notch, and the presence of intercalary fragments seem to be of greater therapeutic relevance than the size of the fragment and amount of the articular surface involved. Operative treatment aims at reconstruction of the posterior tibial plafond, the fibular notch, and the integrity of the posterior inferior tibiofibular syndesmosis. Direct open reduction and fixation of posterior malleolus fragments via posterior approaches is biomechanically more stable than indirect reduction and anteroposterior screw fixation.
Topics: Ankle Fractures; Biomechanical Phenomena; Fracture Dislocation; Fracture Fixation; Humans; Tomography, X-Ray Computed
PubMed: 28167058
DOI: 10.1016/j.fcl.2016.09.009 -
The Journal of Foot and Ankle Surgery :... 2020Ankle fracture dislocations with frustrating attempts at closed reduction are a rare traumatic entity. We present a case of an irreducible ankle fracture due to... (Review)
Review
Irreducible Ankle Fracture Due to Incarceration of the Long Flexor Tendons Together With the Neurovascular Bundle in the Tibial Fibular Interosseous Space: A Case Report and Short Literature Review.
Ankle fracture dislocations with frustrating attempts at closed reduction are a rare traumatic entity. We present a case of an irreducible ankle fracture due to incarceration of all the flexor tendons including the neurovascular bundle in the tibial fibular interosseous space; to date, only one such case has been published in the literature. A computed tomography scan in both bone and soft tissue windows was necessary to clarify the structures that were inhibiting repositioning. The decisive step for surgical treatment was removal of the trapped structures from the tibial fibular interosseous space by a dorsomedial approach. The malleolar joint was then reconstructed anatomically. After 12 weeks, the patient was fully mobile without restrictions in his daily professional activities.
Topics: Ankle Fractures; Fibula; Fracture Dislocation; Humans; Joint Dislocations; Tendons
PubMed: 32345508
DOI: 10.1053/j.jfas.2019.10.012 -
The Journal of Foot and Ankle Surgery :... 2020Current nationwide epidemiological data regarding ankle fractures are scarce. Such information is important towards better quantifying the mortality associated with...
Current nationwide epidemiological data regarding ankle fractures are scarce. Such information is important towards better quantifying the mortality associated with such injuries, financial impact, as well as the implementation of preventative measures. This study evaluated the epidemiology of ankle fractures that occurred during a 5-year period. Specifically, we evaluated demographics, mechanism of injury, and disposition. The National Electronic Injury Surveillance System was queried to identify all patients with ankle fractures that presented to US hospital emergency departments between 2012 and 2016. Census data were used to determine the incidence rates of ankle fractures in terms of age, sex, and race. There was an estimated total of 673,214 ankle fractures that occurred during this period, with an incidence rate of 4.22/10,000 person-years. The mean age of patients with an ankle fracture was 37 ± 22.86 (SD) years; 23.5% of ankle fractures occurred in patients aged 10 to 19 years (7.56/10,000 person-years). In addition, 44% of ankle fractures occurred in men (3.81/10,000 person-years), whereas 56% occurred in women (4.63/10,000 person-years). Data on race/ethnicity were available for 71% of the subjects, with incidence rates of 2.85/10,000 person-years for whites, 3.01/10,000 person-years for blacks, and 4.08/10,000 person-years for others. The most common mechanism of injury was falls (54.83%), followed by sports (20.76%), exercise (16.84%), jumping (4.42%), trauma (2.84%), and other (0.30%). For disposition, 81.84% of patients were treated and released, 1.43% were transferred, 16.01% were admitted, 0.59% were held for observation, and 0.13% left against medical advice. The highest incidence of ankle fractures in men occurred in the 10-to-19-years age group, but women were more commonly affected in all other age groups.
Topics: Accidental Falls; Adolescent; Adult; Age Distribution; Aged; Aged, 80 and over; Ankle Fractures; Athletic Injuries; Child; Child, Preschool; Emergency Service, Hospital; Female; Humans; Incidence; Male; Middle Aged; Risk Factors; Sex Distribution; United States; Young Adult
PubMed: 32354504
DOI: 10.1053/j.jfas.2019.09.016 -
Zeitschrift Fur Orthopadie Und... Jun 2021Even minor residual fragment malpositioning after internal fixation of ankle fractures is associated with a worse prognosis. Frequent causes for non-anatomical reduction...
Even minor residual fragment malpositioning after internal fixation of ankle fractures is associated with a worse prognosis. Frequent causes for non-anatomical reduction are fibular shortening due to comminuted fractures or poor bone quality, translational or rotational malpositioning of the distal fibula within the tibial incisura with unstable syndesmosis injuries, and inadequately addressed bony avulsions of the tibiofibular syndesmosis. After operative treatment of fracture dislocations with syndesmotic fixation, in case of complex fracture pathoanatomy, and with suspected non-anatomic reduction in postoperative radiographs, computed tomography imaging of both ankles should be performed. Correction of relevant malreductions should be performed as early as possible in order to speed up rehabilitation and to avoid late sequelae due to a load shift or instability in a weight-bearing joint.
Topics: Ankle; Ankle Fractures; Ankle Injuries; Ankle Joint; Fibula; Fracture Fixation; Fracture Fixation, Internal; Humans
PubMed: 32040967
DOI: 10.1055/a-1079-6476 -
The Journal of Orthopaedic and Sports... Nov 2014Systematic review and meta-analysis of longitudinal studies. (Meta-Analysis)
Meta-Analysis Review
STUDY DESIGN
Systematic review and meta-analysis of longitudinal studies.
OBJECTIVES
To quantify the prognosis of physical function following ankle fracture.
BACKGROUND
Information about the course of recovery of physical function after ankle fracture is essential for patient care and health care policy. The existing data have not previously been included in a meta-analysis.
METHODS
Studies were identified using searches of electronic databases (Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, PEDro, AMED, SPORTDiscus) and gray literature to September 2012. Studies of people with traumatic ankle fracture were included. Two reviewers independently screened references for inclusion, then extracted data and evaluated risk of bias. The outcome of interest was physical function (physical activity and activity limitation). Outcomes were converted to a common 100-point scale, on which higher scores indicated better outcomes. Meta-regression was conducted using generalized estimating equations.
RESULTS
Thirty-one studies (37 articles) were included. Adults with ankle fracture, present with significant activity limitation in the short term (mean at 1 month, 31.9; 95% confidence interval [CI]: 18.8, 45.1), recovered markedly but incompletely in the short to medium term (mean at 6 months, 78.3; 95% CI: 70.1, 85.1), and showed little further improvement in the long term (mean at 24 months, 86.6; 95% CI: 78.2, 95.0). Studies with older participants and predominantly male participants tended to report worse functional outcomes.
CONCLUSION
Adults typically experience a rapid initial recovery of physical function after ankle fracture (approximately 80% function at 6 months), but, on average, recovery remains incomplete 24 months after injury. PROSPERO registration number: 42012002979.
LEVEL OF EVIDENCE
Prognosis, level 2a.
Topics: Activities of Daily Living; Ankle Fractures; Humans; Longitudinal Studies; Male; Prognosis; Recovery of Function
PubMed: 25269609
DOI: 10.2519/jospt.2014.5199 -
Supination External Rotational Ankle Fracture Injury Pattern Correlation With Regional Bone Density.Foot & Ankle International Apr 2019Rotational ankle fractures can present with an array of possible osseous and ligamentous injury combinations in reliable anatomic locations. What accounts for these...
BACKGROUND:
Rotational ankle fractures can present with an array of possible osseous and ligamentous injury combinations in reliable anatomic locations. What accounts for these different injury patterns and whether specific patient and injury factors underlie the different injury patterns is unclear. The purpose of this study was to determine whether causative factors exist that could account for the various injury patterns seen with rotational ankle fractures.
METHODS:
A registry of operatively treated supination external rotation stage IV (SER IV) ankle fractures was used to identify patients. Computed tomography imaging was used to calculate regional bone density by using average Hounsfield unit measurements on axial images from the distal tibia and fibula. Patients were grouped into those with no posterior or medial malleolar fracture (equivalent group), those with either a posterior or medial malleolus fracture (bimalleolar group), and those with both posterior and medial malleolar fractures (trimalleolar group). Sixty-seven patients met inclusion criteria.
RESULTS:
Regional bone density at the ankle, as measured with Hounsfield units, was significantly higher in the equivalent group (371) than in the bimalleolar group (271, P < .0001) and trimalleolar group (228, P < .0001). Logistic regression analyses identified regional bone density as a significant predictor of a medial malleolus fracture ( P = .002) and of a posterior malleolus fracture ( P = .005).
CONCLUSION:
In our cohort of SER IV ankle fractures, regional bone density at the ankle significantly correlated with the presence and number of malleolar fractures compared with ligamentous ruptures. Treating surgeons can use this information to anticipate bone quality during operative fixation based on ankle fracture injury pattern. In addition, the presence of a trimalleolar ankle fracture was a significant indicator of poor bone quality and may represent the first clinical sign of abnormal bone metabolism in many patients.
LEVEL OF EVIDENCE:
Level III, prognostic retrospective cohort study.
Topics: Ankle Fractures; Bone Density; Female; Humans; Male; Middle Aged; Retrospective Studies; Rotation; Supination; Tomography, X-Ray Computed
PubMed: 30577699
DOI: 10.1177/1071100718816680