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Journal of Surgical Case Reports May 2024Osteochondral or, even more rarely, purely chondral fractures of the lateral femoral condyle following patella dislocation in adolescents are relatively infrequent....
Osteochondral or, even more rarely, purely chondral fractures of the lateral femoral condyle following patella dislocation in adolescents are relatively infrequent. Various fixation methods are described in the literature, ranging from traditional screws to bioabsorbable constructs or the use of anchors. Each method possesses its own advantages and limitations. Here, we present a case involving a 13-year-old boy with a large purely chondral fracture of the lateral femoral condyle after patella dislocation, initially overlooked. We introduce a cost-effective suture-bridge technique for the fixation of this fracture, which eliminates the need for a second operation and has yielded favorable outcomes. It is important to know that fractures of this type can be easily overlooked, necessitating a high index of suspicion and the utilization of advanced imaging techniques to prevent potential long-term catastrophic outcomes for the knee joint.
PubMed: 38817797
DOI: 10.1093/jscr/rjae367 -
The Archives of Bone and Joint Surgery 2024Here we present a novel adaptation of the previously described fibula pro-tibial fixation in a case requiring salvage fixation of a bimalleolar ankle fracture in an...
Here we present a novel adaptation of the previously described fibula pro-tibial fixation in a case requiring salvage fixation of a bimalleolar ankle fracture in an osteoporotic patient. Unstable osteoporotic ankle fractures are a challenging injury to manage and typically occur in a frail and comorbid subgroup of patients. Various techniques have been described in the evolution of managing these injuries, e.g. hindfoot nailing and anatomical locking plates, however in this uniquely challenging case a novel strategy was required to mitigate bone loss in the distal fibular fracture fragment. There is some evidence to suggest fibular protibial fixation offers a lower complication profile to its alternatives. The novel use of distal fibula pro-tibial screws offers a new alternative to hindfoot nailing of bimalleolar ankle fracture in osteoporotic bone with compromised distal fibular fragment bone purchase. Further research is required to investigate the compatibility of this technique with early weightbearing.
PubMed: 38817417
DOI: 10.22038/ABJS.2024.76119.3515 -
Foot & Ankle International May 2024Syndesmotic malreduction is common and has been associated to an impaired outcome. Various risk factors for DTFJ malreduction have been postulated. The aims of this...
BACKGROUND
Syndesmotic malreduction is common and has been associated to an impaired outcome. Various risk factors for DTFJ malreduction have been postulated. The aims of this study were to assess the DTFJ malreduction rate based on (1) the severity of the syndesmotic injury, (2) the anatomy of the tibial incisura, and (3) the fixation device used in patients treated with suture-button systems.
METHODS
This retrospective, radiographic study included all adult patients who were treated for an acute, unilateral, and unstable syndesmotic injury with a suture-button system and postoperative bilateral CT imaging. Included were isolated syndesmotic injuries and fracture cases. The number of syndesmotic ligaments injured, that is, 2-ligament (AiTFL+IOL) and 3-ligament (AiTFL+IOL+PiTFL), was rated for each patient. The quality of DTFJ reduction, as well as the anatomy of the tibial incisura, was rated based on the postoperative, bilateral CT images and the intraoperative DTFJ reduction was recalculated based on the drilling-tunnel deviation. The possible influence on the DTFJ malreduction rate was assessed.
RESULTS
A total of 147 patients were included, and 94 and 53 patients had a 2- and 3-ligament syndesmotic injury, respectively. In addition, 113 patients were treated with a single-button system, 26 with a double suture-button system, and 8 with a hybrid fixation (suture-button + screw). Malreduction was significantly higher in 3-ligament compared with 2-ligament injuries, both intraoperatively (51% vs 27%; = .003) and postoperatively (28% vs 11%; = .006). The tibial anatomy had no significant influence on the malreduction rates. No significant differences were seen per the different fixation devices used independent of the number of ligaments injured.
CONCLUSION
This study did not find an influence of the incisura's anatomy on the DTFJ malreduction rate. However, we did find that 3-ligament syndesmotic injuries carried a higher risk of intra- and postoperative malreduction compared with 2-ligament injuries.
LEVEL OF EVIDENCE
Level III, retrospective radiologic study.
PubMed: 38817051
DOI: 10.1177/10711007241238227 -
Journal of the American Academy of... Jun 2024Surgical ankle fractures pose a unique situation because both podiatrists and orthopaedic surgeons manage these injuries. Intraoperative fluoroscopy is routinely used;... (Comparative Study)
Comparative Study
Surgical ankle fractures pose a unique situation because both podiatrists and orthopaedic surgeons manage these injuries. Intraoperative fluoroscopy is routinely used; however, excessive radiation can be harmful to both the patient and the surgical team. The primary goal of this study was to determine whether there is a difference in the amount of intraoperative radiation exposure during ankle fracture open reduction and internal fixation (ORIF) when performed by orthopaedic surgeons versus podiatrists. This is a retrospective review of patients who underwent ankle fracture ORIF at an urban level I trauma center between January 1st, 2018, and April 1st, 2023. The electronic health record was queried using International Classification of Diseases nine and 10 codes associated with ankle fractures. Patients aged older than 18 years with an ankle fracture managed surgically were included. Subjects were then stratified by procedure. The mean total radiation dose (mRad) and mean total fluoroscopic time (seconds) were then compared between those performed by orthopaedic surgeons and podiatrists. Of the 333 included procedures, 186 were done by orthopaedic surgeons and 147 were done by podiatrists. Using multiple linear regression analysis to control for age, sex, race, ethnicity, and body mass index, patients undergoing isolated malleolus ORIF with syndesmosis repair performed by orthopaedic surgery were found to have a significantly lower mean fluoroscopic time compared with those performed by podiatry (68.4 s versus 104.8 s; P = 0.028). In addition, trimalleolar ORIF with syndesmotic repair performed by orthopaedic surgery had a significantly lower mean total radiation dose compared with those performed by podiatry (244.6 mRad v 565.6 mRad; P = 0.009). Patients and surgical teams are exposed to markedly less radiation in isolated malleolar and trimalleolar fracture ORIF with syndesmosis repair when performed by an orthopaedic surgeon as compared with those performed by a podiatrist.
Topics: Humans; Fluoroscopy; Ankle Fractures; Retrospective Studies; Male; Female; Fracture Fixation, Internal; Open Fracture Reduction; Radiation Exposure; Middle Aged; Adult; Podiatry; Aged; Radiation Dosage; Intraoperative Period; Orthopedics
PubMed: 38814258
DOI: 10.5435/JAAOSGlobal-D-24-00131 -
A rare combination of talar neck fracture (Hawkins 3) and bimalleolar ankle fracture: A case report.International Journal of Surgery Case... Jul 2024The combination of talar neck fractures with malleolar fractures is a rare. This rare association accounts for 0.3 % of all bone fractures. We describe a one-of-a-kind...
INTRODUCTION
The combination of talar neck fractures with malleolar fractures is a rare. This rare association accounts for 0.3 % of all bone fractures. We describe a one-of-a-kind ankle dislocation with a talar neck fracture and a bimalleolar fracture.
CASE PRESENTATION
A 24-year-old male patient presented to the emergency department after a traffic accident. A physical examination revealed swelling and tenderness in the left ankle. The radiograph and the CT scan showed a Hawkins type III comminuted talar neck fracture, with an oblique fracture of the medial malleolus and an infra-syndesmotic fracture of the lateral malleolus. The patient underwent open reduction and internal fixation involving screw fixation for talar neck fracture and the medial malleolus and plating for the lateral malleolus. The treatment and post-operative follow-up showed successful healing and functional recovery, with a score of 85 on the American Orthopedic Foot and Ankle Society ankle-hindfoot at the last follow up.
DISCUSSION
The discussion includes insights on the rarity of this fracture combination, treatment challenges, and potential complications such as avascular necrosis. This article emphasizes the importance of achieving anatomical reduction and stable fixation for optimal outcomes in such complex fractures.
CONCLUSION
This case report highlights the successful treatment of a rare combination of talar neck and bimalleolar ankle fractures, emphasizing the importance of anatomical reduction and stable fixation for optimal outcomes in complex fractures.
PubMed: 38805841
DOI: 10.1016/j.ijscr.2024.109782 -
Journal of Surgical Case Reports May 2024Surgical site infections (SSIs) following open reduction and internal fixation (ORIF) of ankle fractures can lead to significant disability. This case report emphasizes...
Surgical site infections (SSIs) following open reduction and internal fixation (ORIF) of ankle fractures can lead to significant disability. This case report emphasizes a unique instance of SSI caused by , following ORIF of a trimalleolar ankle fracture in a 55-year-old female patient. To our knowledge, this is the first reported case of infection after ORIF in the literature. The pathogen was detected after surgical debridement, removal and sonication of the hardware, and identified through matrix assisted laser desorption/ionization-time of flight mass spectrometry (MALDI-TOF MS) and 16S rRNA gene sequencing. Specific intravenous antibiotic regimen was administered for a total duration of 4 weeks. During the 12th month follow-up, the patient presented no signs of infection and an excellent clinical outcome. This case report underscores the need for alertness regarding atypical pathogens in postoperative complications and the critical role of precise microbial diagnosis in managing rare orthopaedic infections.
PubMed: 38803842
DOI: 10.1093/jscr/rjae334 -
Cureus Apr 2024Introduction The calcaneus is the most commonly fractured tarsal bone, accounting for up to 60% of tarsal bone fractures and 2% of all fractures in the body. With the...
Introduction The calcaneus is the most commonly fractured tarsal bone, accounting for up to 60% of tarsal bone fractures and 2% of all fractures in the body. With the calcaneus playing an important role in maintaining a stable and efficient bipedal gait, the sequelae of these injuries have also been associated with potential long-term disability or discomfort, especially if improperly managed. Incorrectly sized implants similarly cause their own set of complications, such as poor fixation, impingement, or implant prominence. This potentially increases the need for revision surgery or implant removal, with increased morbidity for the patient. As such, a thorough understanding of calcaneal morphology is vital to ensure optimal conservative and surgical management of calcaneal pathology. CT imaging has become an indispensable tool in the evaluation of such a complex three-dimensional structure and allows us to accurately map out calcaneal morphology. This study aims to evaluate calcaneal morphology in the Southeast Asian population using CT imaging and to determine if morphological differences exist between male and female patients. Methods Calcaneus measurements were taken from CT scans of 100 patients with intact calcanei, consisting of 34 female and 66 male patients. Patients who have had fractures or previous calcaneus surgery were excluded. IBM SPSS Statistics for Windows, Version 28.0 (Released 2021; IBM Corp., Armonk, NY, USA) was used for statistical calculations. Mean values were calculated, and t-tests were performed to establish any significant differences between measurements taken from male and female patients. Results were deemed to have a significant difference if the p-value was less than 0.05. Results Males had larger calcanei measurements than females in all parameters included. Calcaneal length in females measured on CT axial views was 66.2 mm, compared to 75.2 mm in males (p < 0.001). Calcaneal height, measured at the medial wall, was 28.2 mm in females and 33.9 mm in males (p < 0.001). Calcaneal height measured at the lateral wall was 33.3 mm and 38.1 mm in females and males, respectively (p > 0.001). Calcaneal width was 33.0 mm in females and 36.9 mm in males (p < 0.001). The mean dimensions measured in the total sample were an axial length of 72.1 mm, a medial wall height of 32.0 mm, a lateral wall height of 36.4 mm, and a width of 35.6 mm. Conclusion There is a significant difference in calcaneal morphology on CT imaging between male and female patients in the Southeast Asian population, which is an important consideration for surgical planning and the selection of appropriately sized implants.
PubMed: 38800141
DOI: 10.7759/cureus.58899 -
Foot & Ankle Orthopaedics Apr 2024Overcompression of the distal tibiofibular syndesmosis during open reduction and internal fixation of ankle fracture may affect multidirectional flexibility of the ankle...
BACKGROUND
Overcompression of the distal tibiofibular syndesmosis during open reduction and internal fixation of ankle fracture may affect multidirectional flexibility of the ankle bones.
METHODS
Ten cadaveric lower limbs (78.3±13.0 years, 4 female, 6 male) underwent biomechanical testing in sagittal, coronal, and axial rotation with degrees of motion quantified. The intact force (100%) was the force needed to compress the syndesmosis just beyond the intact position, and overcompression was defined as 150% of the intact force. After intact testing, the anterior inferior tibiofibular ligament (AITFL), interosseus membrane (IOM), and posterior inferior tibiofibular ligament (PITFL) were sectioned and testing was repeated. The IOM and AITFL were reconstructed in sequence and tested at 100% and 150% compression.
RESULTS
Overcompression of the syndesmosis did not significantly reduce ROM of the ankle bones for any loading modality ( > .05). IOM+AITFL reconstruction restored distal tibiofibular axial rotation to the intact condition. Axial rotation motion was significantly lower with AITFL fixation compared with IOM fixation alone ( < .05). The proximal tibiofibular syndesmosis demonstrated significantly higher motion in axial rotation with all distal reconstruction conditions.
CONCLUSION
As assessed by direct visualization, overcompression of the distal tibiofibular syndesmosis did not reduce ROM of the ankle bones. Distal tibiofibular axial rotation was significantly lower with IOM+AITFL fixation compared with IOM augmentation alone. Distal tibiofibular axial rotation did not differ significantly from the intact condition after combined IOM+AITFL fixation. Dynamic fixation of the distal tibiofibular syndesmosis resulted in increased axial rotation at the proximal tibiofibular syndesmosis.
CLINICAL RELEVANCE
These biomechanical data suggest that inadvertent overcompression of the distal tibiofibular syndesmosis when fixing ankle fractures does not restrict subsequent ankle bone ROM. The AITFL is an important stabilizer of the distal tibiofibular syndesmosis in external rotation.
LEVEL OF EVIDENCE
controlled laboratory study.
PubMed: 38798904
DOI: 10.1177/24730114241255356 -
Journal of Orthopaedic Case Reports May 2024The free anterolateral thigh (ALT) flap is commonly used to repair a large loss of soft tissue following a lower-limb injury. An issue to be managed is the choice of...
INTRODUCTION
The free anterolateral thigh (ALT) flap is commonly used to repair a large loss of soft tissue following a lower-limb injury. An issue to be managed is the choice of adequate recipient vessels when the tibial arteries result damaged. In this scenario, vein grafts can be interposed to connect a healthy recipient vessel to the ALT flap pedicle.
CASE REPORT
We present a report of a 19-year-old male who suffered a Gustilo fracture type IIIc after a road injury involving the right lower limb. After a failed first attempt of limb salvage with reconstruction of extensor tendons and a free ALT flap, a second procedure was performed using another ALT flap with interposed vein grafts to reach very proximal recipient vessels.
RESULTS
The patient demonstrated excellent recovery and restored ambulation. The effectiveness of the most complex reconstructive options for a high-demanding patient with no comorbidities is demonstrated in this case.
CONCLUSION
The key to success in even the most complex injury cases is early intervention, meticulous surgical planning, and a multidisciplinary approach.
PubMed: 38784885
DOI: 10.13107/jocr.2024.v14.i05.4450 -
Journal of Orthopaedic Case Reports May 2024The Bosworth fracture-dislocation is a rare injury originally described as an irreducible dislocation of a distal fibula fracture where the proximal fibular fragment...
INTRODUCTION
The Bosworth fracture-dislocation is a rare injury originally described as an irreducible dislocation of a distal fibula fracture where the proximal fibular fragment becomes incarcerated behind the distal tibia. There have since been a few cases described of an intact distal fibula with dislocation and similar difficulties in closed reduction attempts, typically seen with associated injuries to the ankle or proximal fibula. Regardless of the specific fracture or dislocation pattern, closed reduction attempts have consistently failed in the significant majority of these cases, which can lead to complications including soft-tissue compromise, severe post-traumatic arthritis, compartment syndrome, avascular necrosis of the talus, and neurovascular compromise. There is only one case in recent literature that describes an isolated distal fibula dislocation without associated fractures or dislocations of the lower extremity; however, it required an open reduction. Cases where a closed reduction was successful to achieve an anatomic reduction of a Bosworth-type injury are exceedingly rare.
CASE REPORT
We present a rare case of a purely ligamentous, isolated distal fibula dislocation in a 21-year-old male who underwent a successful closed reduction upon initial presentation and later underwent surgical fixation with a syndesmosis repair system. We describe the technique used for a successful closed reduction for this injury and present a 1-year follow-up with excellent outcomes.
CONCLUSION
This is the only known case report of a successful closed reduction in an isolated distal fibula dislocation, as well as demonstrating a minimally invasive technique for definitive treatment with a syndesmosis repair system. Accurate diagnosis, early treatment, and anatomic reduction are imperative for good clinical outcomes and reducing complications for Bosworth injuries. This technique may improve the rates of successful closed reductions of Bosworth injuries upon initial presentation, leading to decreased complications and improved patient outcomes.
PubMed: 38784881
DOI: 10.13107/jocr.2024.v14.i05.4438