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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 Surgical Orthopaedic Advances 2024Common fibular nerve (CFN) injury due to ankle fracture is an underreported complication. The authors have proposed that torsional injury to the ankle can be translated...
Common fibular nerve (CFN) injury due to ankle fracture is an underreported complication. The authors have proposed that torsional injury to the ankle can be translated along the interosseous membrane (IOM), producing tension on the CFN at the fibular neck. A 23-year-old woman presented to our clinic for left foot drop. Three months prior, the patient sustained a fall with left ankle inversion injury while running. She was diagnosed with a minor ankle fracture and placed in an orthopaedic boot. Unfortunately, her swelling worsened and one week later the patient was diagnosed with foot drop, which was further corroborated with EMG studies showing severe CFN injury localizing to the fibular neck. Because of the lack of recovery, she underwent decompression of the CFN. She experienced immediate symptomatic relief. High resolution imaging in this case supports our previous mechanism for indirect trauma to the ankle resulting in CFN injury. (Journal of Surgical Orthopaedic Advances 33(1):053-055, 2024).
Topics: Humans; Female; Young Adult; Magnetic Resonance Imaging; Peroneal Nerve; Ankle Fractures; Ankle Injuries; Decompression, Surgical; Peripheral Nerve Injuries; Fibula
PubMed: 38815080
DOI: No ID Found -
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 -
Foot & Ankle Specialist May 2024Several techniques to treat acute distal tibiofibular instability are described consisting in static and dynamic fixation procedures. The aim of our work is to compare...
Comparative Study for Surgical Treatment of Acute Distal Tibiofibular Syndesmotic Lesions Using the Modified Suture-Button Fixation Versus Static Syndesmotic Screw Fixation.
INTRODUCTION
Several techniques to treat acute distal tibiofibular instability are described consisting in static and dynamic fixation procedures. The aim of our work is to compare the outcomes of acute syndesmotic injury fixation between the modified technique of dynamic fixation using the suture-button principle as an efficient and low-cost method and the classic static fixation.
METHODS
It is a prospective study including patients presenting with acute syndesmotic injury. After fracture fixation, residual syndesmotic instability was managed using syndesmotic screw in group A and dynamic fixation with a double Ethibond suture in group B. Functional results were assessed using the American Orthopaedic Foot and Ankle Society score (AOFAS) score. Radiological evaluation was done by a postoperative computed tomography (CT) scan of both ankles and plain X-rays of the ankle after surgery and at 18 months.
RESULTS
Group A included 20 patients meanwhile 35 patients were in group B. The reduction was satisfactory in the 2 groups according to the postoperative CT scan measurements. The mean healing time in group A was 49.65 days and 51.49 days in group B (P = .45). We did not find any significant difference in terms of loss of reduction in the 2 groups. The return to work was faster in group B (P = .04). Patients in group B had better AOFAS score (P = .03) and ankle range of motion than those in group A. The difference was statistically significant (P = .02 for dorsal flexion and P = .001 for plantar flexion). For group A, we did not note any early complications. Meanwhile, 7 patients developed skin complications in group B (P = .03). However, no significant difference was found in terms of late complications.
CONCLUSIONS
The modified dynamic suture-button fixation remains a therapeutic alternative in low-income countries that could achieve better outcomes than static fixation, with easy postoperative follow-up.
LEVELS OF EVIDENCE
.
PubMed: 38814001
DOI: 10.1177/19386400241256440 -
The Journal of the American Academy of... May 2024There is mounting evidence that, among musculoskeletal patients, variation in capability has more notable associations with variations in mental and social health...
BACKGROUND
There is mounting evidence that, among musculoskeletal patients, variation in capability has more notable associations with variations in mental and social health factors than with variation in pathophysiology severity. This study sought factors that could limit the integration of this evidence into more comprehensive care models.
METHODS
In two scenario-based experiments, surgeon participants in an international collaborative, the Science of Variation Group, reviewed scenarios of (a) nontraumatic (83 participants) and (b) trauma-related (130 participants) pathophysiologies for which tests and treatments were discretionary. The following demographic, mental, and social health elements were varied randomly: sex, age, race/ethnicity, mindsets, social health aspects, and specific pathophysiologies. For each scenario, participants rated their likelihood to offer surgery (continuous) and their sense of presence of an opportunity to address better mental or social health in treatment (yes or no). Factors associated with each rating were sought in multivariable analysis.
RESULTS
Greater likelihood to offer discretionary surgery for nontraumatic pathophysiologies was associated with greater pathophysiology severity, trapeziometacarpal arthritis, and greater distress and unhelpful thoughts regarding symptoms. Lateral elbow enthesopathy was associated with a lower likelihood. For trauma-related pathophysiologies, an ankle fracture with slight articular subluxation was associated with greater likelihood to offer surgery, and several other trauma-related pathophysiologies were associated with a lower likelihood. For both nontraumatic and trauma-related pathophysiologies, surgeons noticed unhelpful thinking, distress, and social issues as reasons to consider addressing mental and social health in treatment, relatively independent of pathophysiology.
CONCLUSION
Surgeons seem to recognize opportunities to address mental and social needs but ultimately base their decision to offer discretionary surgery on pathophysiological factors.
CLINICAL RELEVANCE
Comprehensive, whole-person care for musculoskeletal illness might be supported by strategies for ensuring that aspects of stress and distress that contribute to greater symptom intensity are not misinterpreted as a reflection of greater pathophysiology severity.
PubMed: 38810227
DOI: 10.5435/JAAOS-D-23-00962 -
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 -
Musculoskeletal Surgery May 2024Postoperative care of ankle fractures treated with open reduction and internal fixation (ORIF) is a debated topic. A meta-analysis of Randomized Controlled Trials was... (Review)
Review
Postoperative care of ankle fractures treated with open reduction and internal fixation (ORIF) is a debated topic. A meta-analysis of Randomized Controlled Trials was conducted with the aim of comparing early mobilization and weightbearing to traditional postoperative protocols. A systematic search of electronic databases was conducted according to the PRISMA guidelines. Only randomized clinical trials were included. Data about clinical outcome, time to return to work and complications were extracted and summarized. Meta-analyses were performed. Twenty studies for a total of 1328 patients were included. Early mobilization was compared to immobilization in 724 patients: the two groups did not significantly differ in terms of short- and long-term clinical outcome (p = 0.08 and p = 0.41, respectively). However, early mobilization resulted to be significantly associated with faster return to work (p = 0.047). Early weightbearing was compared to nonweightbearing in 1088 patients. While the clinical difference between the two groups was not significant at short term (p = 0.08), it was significant at long term (p = 0.002). No other significant differences, in particular regarding complications, were highlighted between different groups. Early motion, early weightbearing and traditional postoperative protocols are all safe strategies after ORIF for unstable ankle fractures. Early mobilization is significantly associated with faster return to work and early weightbearing improves long term clinical outcome.Level of evidence: I.
PubMed: 38805165
DOI: 10.1007/s12306-024-00832-2 -
Sports Health May 2024Studies routinely evaluate high ankle sprains in isolation, but recent data suggest that these injuries are often associated with concomitant pathology, potentially...
BACKGROUND
Studies routinely evaluate high ankle sprains in isolation, but recent data suggest that these injuries are often associated with concomitant pathology, potentially influencing return to full participation.
HYPOTHESIS
In National Football League (NFL) players, isolated high ankle sprains are rare and syndesmosis injuries with concomitant pathology will result in increased time to return to full participation.
STUDY DESIGN
Cross-sectional study.
LEVEL OF EVIDENCE
Level 3.
METHODS
Distal tibiofibular syndesmosis injuries sustained by NFL players between 2017 and 2019 were identified through NFL Injury Surveillance Database queries and verified with video analysis. Each injury underwent a comprehensive magnetic resonance imaging (MRI) review. Regression modeling was utilized to explore the influence of numerous imaging findings on time to return to full participation.
RESULTS
There were 83 external rotation ankle injuries involving the syndesmosis. Isolated distal tibiofibular syndesmosis injuries were rare (n = 11; 13%) and more often associated with other ligamentous injury (deltoid ligament and lateral ligamentous complex) and/or fractures. Regression modeling resulted in clustering of 3 injury pattern groups for time to return to full participation across numerous imaging findings: syndesmosis injury-fracture combinations (250 days [interquartile range [IQR,] 142-266 days]), syndesmosis injury with complete deep deltoid tear or acute diastasis (175 days [IQR, 20-248 days]), and all other syndesmosis injuries (27 days [IQR, 18-46 days]).
CONCLUSION
In NFL athletes with external rotation ankle injuries, isolated distal tibiofibular syndesmosis injuries were rare and more often associated with concomitant pathology. Time to return to full participation was affected by an associated fracture and complete deep deltoid ligament tear or diastasis but no other relevant MRI variables such as lateral ligament complex involvement or the presence of osteochondral lesions or bone contusions.
PubMed: 38804171
DOI: 10.1177/19417381241253223 -
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 -
Zhejiang Da Xue Xue Bao. Yi Xue Ban =... May 2024To explore the diagnostic value of ultrasonography for injuries of anterior talofibular ligament (ATFL) and anterior inferior tibiofibular ligament distal fascicle...
Diagnostic value of ultrasonography for injury of anterior talofibular ligament and anterior inferior tibiofibular ligament distal fascicle in patients with ankle fractures.
OBJECTIVES
To explore the diagnostic value of ultrasonography for injuries of anterior talofibular ligament (ATFL) and anterior inferior tibiofibular ligament distal fascicle (ATiFL-DF) in patients with ankle fractures.
METHODS
Clinical data of 51 patients with ankle fractures who were clinically suspected of ligament injuries and underwent ankle ultrasonography examination and arthroscopy in Sir Run Run Shaw Hospital, Zhejiang University School of Medicine from April 2019 to March 2023 were retrospectively analyzed. Using arthroscopic findings as the gold standard, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of ultrasonography in diagnosing ATFL and ATiFL-DF injuries were evaluated; and Kappa consistency test was further performed.
RESULTS
The sensitivity and specificity of ultrasonography in diagnosis of ATFL injury were 100.0% and 92.3%, with the PPV of 92.6% and NPV of 100.0%. Ultrasonography findings exhibited excellent concordance with arthroscopic results (=0.849). The sensitivity and specificity of ultrasonography in diagnosis of ATiFL-DF injury was 86.7% and 33.3%, with the PPV of 90.7% and NPV of 25.0%. But the consistence between ultrasonography and arthroscopic results was poor (=0.168).
CONCLUSIONS
Ultrasonography is a reliable diagnostic modality for assessing injuries to the ATFL in patients with ankle fractures; however, its specificity is limited when evaluating injuries to the ATiFL-DF. Therefore, ankle arthroscopy is necessary for ankle fracture patients with negative findings of ATiFL-DF in ultrasonography.
PubMed: 38803280
DOI: 10.3724/zdxbyxb-2023-0602