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Revista Espanola de Cirugia Ortopedica... Jun 2024Ankle fractures represent up to 9% of all fractures, with an increased incidence in the elderly population. Among these fractures, isolated fractures of the lateral... (Review)
Review
Ankle fractures represent up to 9% of all fractures, with an increased incidence in the elderly population. Among these fractures, isolated fractures of the lateral malleolus are the most common, representing 65-70% of all cases. The therapeutic decision-making primarily relies on the stability of the ankle ring, considering it stable if affected at one point and unstable if two or more points are affected. Surgical treatment focuses on restoring the length of the fibula, joint reconstruction, stabilizing the syndesmosis, and providing a stable fixation. It is crucial to rule out associated injuries that may influence therapeutic management. This article reviews the evaluation and management of lateral malleolus fractures, proposes a decision-making algorithm, and examines several fibular fixation options.
PubMed: 38885878
DOI: 10.1016/j.recot.2024.06.008 -
Cureus May 2024The deltoid ligament plays a key role in ankle stability. Ankle fractures involving the medial ligamentous complex are evaluated on the basis of medial-sided tenderness...
The deltoid ligament plays a key role in ankle stability. Ankle fractures involving the medial ligamentous complex are evaluated on the basis of medial-sided tenderness and the Ottawa ankle rules. Evolution in our understanding of this ligament over the last three decades has shown that, within this medial ligamentous complex, it is the deep deltoid ligament that confers mechanical stability. The latest evolution in this understanding, and the learning point of this report, is that only a distinct component of the deep deltoid ligament - specifically the discreet posterior third - the rear attachment of the deep deltoid ligament (RAD) - confers mechanical value. The RAD is responsible for providing the medial ligamentous component of ankle stability - specifically talar shift, tilt, and importantly rotational stability. This knowledge is of key importance in the assessment and management of ankle fractures with associated deltoid ligament injuries. In this technical report, we highlight the biomechanical contribution of the RAD, which will help surgeons and physiotherapists to accurately manage ankle injuries.
PubMed: 38883087
DOI: 10.7759/cureus.60442 -
Heliyon Jun 2024The present case report is aimed to highlight the difficulty and the reason for the delayed diagnosis of phosphaturic mesenchymal tumors, emphasizing the need of...
The present case report is aimed to highlight the difficulty and the reason for the delayed diagnosis of phosphaturic mesenchymal tumors, emphasizing the need of standardized protocols for diagnosis, surgery and follow-up in high-volume hospitals. The clinical signs and symptoms, diagnostic and therapeutic procedures, immunohistological features were analyzed. Delayed diagnosis of phosphaturic mesenchymal tumor was primarily due to non-specific clinical symptoms such as fatigue, muscular and bone pain, and multiple fractures. This cryptic clinical picture made the diagnosis tricky that led to treatment of patient for non-specific pain and stress fractures before to consider the tumor-induced osteomalacia syndrome. Some well-documented studies were found in the literature in which the history of trauma is a critical trigger of glomus tumors. Extra-subungual tumors most frequently occur in the knee and ankle regions, particularly among young adults, and the diagnosis is typically made approximately 7.2 years after initial symptom onset. The difficult tumor localization represented an additional obstacle to the prompt treatment, leading to delayed curative surgery.
PubMed: 38882375
DOI: 10.1016/j.heliyon.2024.e31949 -
Tibiotalocalcaneal ankle arthrodesis with posterior approach arthroscopic-assisted hindfoot nailing.Journal of Orthopaedic Surgery (Hong... 2024End-stage ankle arthrosis causes severe pain and limited movement. Tibiotalocalcaneal arthrodesis with arthroscopy-assisted hindfoot nailing can be used to achieve a...
PURPOSE
End-stage ankle arthrosis causes severe pain and limited movement. Tibiotalocalcaneal arthrodesis with arthroscopy-assisted hindfoot nailing can be used to achieve a high union rate and low complication rate. We aimed to examine the early- and mid-term results of patients treated with this technique from various perspectives and to evaluate them by comparing them with the current literature.
METHODS
Data were collected from 25 patients who met the established criteria and underwent TTCA with arthroscopic-assisted hindfoot nailing. In addition to the demographic data of the patients, their clinical and pain scores were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) and visual analogue scale (VAS). Additionally, the union time and complication data during the follow-up period were examined.
RESULTS
When the AOFAS and VAS scores of the 25 patients were examined, a significant improvement was observed in the preoperative period and early postoperative period comparisons ( < .001). No significant change was observed between the comparison of the postoperative 12th month and last postoperative control clinical scores. While the union rate of the patients was observed to be 92%, the average union time was 13.1 ± 3.5 weeks. During follow-up, peri-implant fracture, deep infection, and non-union were observed in one patient each (12%).
CONCLUSION
The early- and mid-term postoperative results of patients treated with TTCA surgery with posterior approach arthroscopic-assisted hindfoot nailing show that this technique may be an option with low complication and high union rates for the appropriate group of patients planned for ankle arthrodesis.
Topics: Humans; Arthrodesis; Male; Female; Middle Aged; Ankle Joint; Arthroscopy; Bone Nails; Aged; Adult; Retrospective Studies; Osteoarthritis
PubMed: 38881517
DOI: 10.1177/10225536241264623 -
Journal of the American Academy of... Jun 2024To assess the equatorial talar line (ETL) as a sensitive radiographic parameter to predict Sanders type III and IV fractures and the presence of lateral wall blowout.
OBJECTIVE
To assess the equatorial talar line (ETL) as a sensitive radiographic parameter to predict Sanders type III and IV fractures and the presence of lateral wall blowout.
METHODS
Reliability of the ETL was assessed using the intraclass correlation coefficient (ICC) and receiver operating curve (ROC) to predict sensitivity. Using lateral ankle radiographs, raters determined whether the calcaneal tuberosity was "above" (predicting Sanders type I or II) or "below" (predicting Sanders type III or IV and lateral wall blowout).
RESULTS
In determining the "above" or "below" location of the ETL, the calculated ICC was 1.0 for each session. As a predictor of Sanders fracture classification type, the calculated ICC was 0.93 for the first session and 0.89 for the second session for an overall ICC of 0.91. As a predictor of Sanders fracture type, ROC analysis yielded an overall sensitivity of 0.82. As a predictor of lateral wall blowout, ROC analysis yielded an overall sensitivity of 0.81.
CONCLUSION
The ETL is a reproducible radiographic parameter that can be reliably used to crudely predict between Sanders type I or II (ETL is "above") and Sanders type III or IV (ETL is "below") calcaneus fractures as well as the presence of lateral wall blowout.
Topics: Calcaneus; Humans; Radiography; Fractures, Bone; Talus; Reproducibility of Results; ROC Curve; Predictive Value of Tests; Male; Female; Adult; Sensitivity and Specificity; Middle Aged
PubMed: 38875448
DOI: 10.5435/JAAOSGlobal-D-24-00143 -
European Journal of Trauma and... Jun 2024Tibia plafond or pilon fractures present a high level of complexity, making their surgical management challenging. Three-Dimensional Virtual Planning (3DVP) can assist...
PURPOSE
Tibia plafond or pilon fractures present a high level of complexity, making their surgical management challenging. Three-Dimensional Virtual Planning (3DVP) can assist in preoperative planning to achieve optimal fracture reduction. This study aimed to assess the symmetry of the left and right tibial plafond and whether left-right mirroring can reliably be used.
METHODS
Bilateral CT scans of the lower limbs of 75 patients without ankle problems or prior fractures of the lower limb were included. The CT images were segmented to create 3D surface models of the tibia. Subsequently, the left tibial models were mirrored and superimposed onto the right tibia models using a Coherent Point Drift surface matching algorithm. The tibias were then cut to create bone models of the distal tibia with a height of 30 mm, and correspondence points were established. The Euclidean distance was calculated between correspondence points and visualized in a boxplot and heatmaps. The articulating surface was selected as a region of interest.
RESULTS
The median left-right difference was 0.57 mm (IQR, 0.38 - 0.85 mm) of the entire tibial plafond and 0.53 mm (IQR, 0.37 - 0.76 mm) of the articulating surface. The area with the greatest left-right differences were the medial malleoli and the anterior tubercle of the tibial plafond.
CONCLUSION
The tibial plafond exhibits a high degree of bilateral symmetry. Therefore, the mirrored unfractured tibial plafond may be used as a template to optimize preoperative surgical reduction using 3DVP techniques in patients with pilon fractures.
PubMed: 38874625
DOI: 10.1007/s00068-024-02568-x -
European Journal of Orthopaedic Surgery... Jun 2024The purpose of this study was to investigate the independent effect of open ankle fractures on postoperative mortality and to identify factors leading to open ankle...
The purpose of this study was to investigate the independent effect of open ankle fractures on postoperative mortality and to identify factors leading to open ankle fractures in the elderly population. This is a retrospective case-control study of 1,045 patients aged 65 years and older, with ankle fractures undergoing surgical fixation between 2010 and 2020 at three medical centers (Levels 1-2). A logistic regression analysis was used to identify risk factors for open fractures. Propensity score matching and survival analysis were used to measure the hazard of mortality attributable to open versus closed ankle fractures. There were 128 (12.2%) patients with open ankle fractures. Patients with open ankle fractures were more likely to be older, to be active smokers (OR = 1.7, p = 0.049), and tended to have a higher number of medical comorbidities including hypertension (OR = 2, p = 0.006) and chronic kidney disease (OR = 2.9, p = 0.005). Open ankle fractures were, independently of comorbid conditions and age, associated with higher risk of mortality (HR = 1.7, p = 0.03).
PubMed: 38869627
DOI: 10.1007/s00590-024-04016-3 -
Journal of Pediatric Orthopedics Jun 2024Fractures of the distal tibial epiphysis in children are often accompanied by articular surface disruption. With increased displacement, internal fixation is frequently...
Operative Treatment of Distal Tibial Fractures in Children Managed With Epiphyseal Screws: A Comparison of Outcomes When Screws Are Retained Versus Removed Following Fracture Union.
BACKGROUND
Fractures of the distal tibial epiphysis in children are often accompanied by articular surface disruption. With increased displacement, internal fixation is frequently performed with an epiphyseal screw to close the fracture gap. Despite limited, high-level clinical evidence to support implant removal, epiphyseal screws are commonly removed after fracture healing due to potentially increased contact forces on the tibiotalar joint. The purpose of this study was to investigate and compare outcomes and complications in children that underwent surgical treatment of distal tibial epiphyseal fractures with placement of an epiphyseal screw(s) and had the implant(s) retained versus removed at a minimum of 2-year postoperative follow-up.
METHODS
Children younger than 18 years from two urban tertiary care centers who underwent operative management of distal tibia Salter-Harris III and IV fractures using epiphyseal screws (2013-2020) were divided into two cohorts: retained epiphyseal screws and implant removed. Demographics, intraoperative, postoperative, and radiographic data were collected. Patient-reported outcomes (PROs) using the Foot and Ankle Ability Measure (FAAM) and Single Assessment Numeric Evaluation (SANE) questionnaires were collected at the final follow-up. Statistical analysis, including power analysis, was performed.
RESULTS
Fifty-two children were included (30 males, 22 females) with a mean age of 13.3 years at the time of injury (range, 7.7-16.4 years). Thirty-five children retained the implants; seventeen had implants removed. All completed the FAAM questionnaires at a mean follow-up of 4.4 ± 1.9 years, while 29 completed the SANE questionnaire at a mean follow-up of 4.4 ± 1.7 years. No statistically significant difference in patient demographics, surgical variables, or PROs was observed. Six children experienced complications from the initial surgery, including infections and complex regional pain syndrome, with no difference in complication rates between the cohorts (P=0.08). Furthermore, no complication was observed as a result of implant removal.
CONCLUSIONS
Children with retained epiphyseal implants have similar functional outcomes as compared with those who had implants removed after distal tibial epiphyseal fracture fixation and union.
LEVEL OF EVIDENCE
Level III-Retrospective comparative study.
PubMed: 38869022
DOI: 10.1097/BPO.0000000000002712 -
Journal of Medical Engineering &... Jun 2024Total ankle arthroplasty is the gold standard surgical treatment for severe ankle arthritis and fracture. However, revision surgeries due to the failure of the ankle...
Total ankle arthroplasty is the gold standard surgical treatment for severe ankle arthritis and fracture. However, revision surgeries due to the failure of the ankle implant are a serious concern. Extreme bone density loss due to bone remodelling is one of the main reasons for implant loosening, with aseptic loosening of the talar component being one of the primary reasons for total ankle arthroplasty revisions. This study is aimed at determining the performance and potential causes of failure of the talar component. Herein, we investigated the stress, strain, and bone density changes that take place in the talus bone during the first 6 months of bone remodelling due to the total ankle arthroplasty procedure. Computed tomography scans were used to generate the 3D geometry used in the finite element (FE) model of the Intact and implanted ankle. The Scandinavian Total Ankle Replacement (STAR™) CAD files were generated, and virtual placement within bone models was done following surgical guidelines. The dorsiflexion physiological loading condition was investigated. The cortical region of the talus bone was found to demonstrate the highest values of stress (5.02 MPa). Next, the adaptive bone remodelling theory was used to predict bone density changes over the initial 6-month post-surgery. A significant change in bone density was observed in the talus bone due to bone remodelling. The observed quantitative changes in talus bone density over 6-month period underscore potential implications for implant stability and fracture susceptibility. These findings emphasise the importance of considering such biomechanical factors in ankle implant design and clinical management.
PubMed: 38864409
DOI: 10.1080/03091902.2024.2355319 -
Foot and Ankle Surgery : Official... Jun 2024The Proximal Tibiofibular Joint (PTFJ) is a synovial joint with anatomical variations located between the anteromedial surface of the fibula and the posterolateral facet...
INTRODUCTION
The Proximal Tibiofibular Joint (PTFJ) is a synovial joint with anatomical variations located between the anteromedial surface of the fibula and the posterolateral facet of the tibia. These anatomical variations are believed to contribute to different biomechanical behaviors in both the knee and ankle joint and play a role in both physiological and pathological movements. Therefore, the morphology of the proximal tibiofibular joint may play a decisive role in the characteristics of ankle fractures and syndesmotic ligament injuries.
MATERIALS AND METHODS
In this retrospective comparative our CT database was searched between January 2015 and December 2022. Following inclusion criteria were used: Availability of knee CT scans for the fractured ankle, external rotation-type injuries (pronation external rotation and supination external rotation fractures). After applying the exclusion criteria (Plafond fractures, supination adduction and pronation abduction type fractures, pathological fractures, patients with previous fractures or surgeries around the knee, patients with previous fractures or surgeries around the knee, proximal tibiofibular arthrosis), 44 CT scans (mean age = 42.8 ± 14.1) confirmed eligible for further analysis. On each scan following measurements were performed: Coronal and sagittal PTFJ inclination angle, Joint obliquity, fibula head-tibia joint distance and tibia plateau-fibular axis angle.
RESULTS
The study consisted of 24 (54.5 %) male and 20 (45.5 %) female patients. According to the proximal fibular inclination, 29 cases (65.9 %) were of the oblique type, and 15 cases (34.1 %) were of the horizontal type. The distribution of PTFJ variations was as follows: 17 (38.6 %) concave, 4 (9.1 %) convex, 7 (15.9 %) atypical, and 16 (36.4 %) flat type. Regarding the PTFJ joint contour, the distribution was 13 (29.5 %) type a, 11 (25 %) type b, and 20 (45.5 %) type c. There was no relationship between measurements of PITFJ morphology and the type of ankle fracture and/or syndesmosis injury (p > 0.05).
CONCLUSION
PTFJ morphological features are not associated with rotational ankle fractures and syndesmotic ligament injuries.
PubMed: 38862337
DOI: 10.1016/j.fas.2024.05.017