Management of anterior cruciate ligament revision in adults: the 2022 ESSKA consensus part III-indications for different clinical scenarios using the RAND/UCLA appropriateness method.

PURPOSE: The aim of the ESSKA 2022 consensus Part III was to develop patient-focused, contemporary, evidence-based, guidelines on the indications for revision anterior cruciate ligament surgery (ACLRev). METHODS: The RAND/UCLA Appropriateness Method (RAM) was used to provide recommendations on the appropriateness of surgical treatment versus conservative treatment in different clinical scenarios based on current scientific evidence in conjunction with expert opinion. A core panel defined the clinical scenarios with a moderator and then guided a panel of 17 voting experts through the RAM tasks. Through a two-step voting process, the panel established a consensus as to the appropriateness of ACLRev for each scenario based on a nine-point Likert scale (in which a score in the range 1-3 was considered 'inappropriate', 4-6 'uncertain', and 7-9 'appropriate'). RESULTS: The criteria used to define the scenarios were: age (18-35 years vs 36-50 years vs 51-60 years), sports activity and expectation (Tegner 0-3 vs 4-6 vs 7-10), instability symptoms (yes vs no), meniscus status (functional vs repairable vs non-functional meniscus), and osteoarthritis (OA) (Kellgren-Lawrence [KL] grade 0-I-II vs grade III). Based on these variables, a set of 108 clinical scenarios was developed. ACLRev was considered appropriate in 58%, inappropriate in 12% (meaning conservative treatment is indicated), and uncertain in 30%. Experts considered ACLRev appropriate for patients with instability symptoms, aged ≤ 50 years, regardless of sports activity level, meniscus status, and OA grade. Results were much more controversial in patients without instability symptoms, while higher inappropriateness was related to scenarios with older age (51-60 years), low sporting expectation, non-functional meniscus, and knee OA (KL III). CONCLUSION: This expert consensus establishes guidelines as to the appropriateness of ACLRev based on defined criteria and provides a useful reference for clinical practice in determining treatment indications. LEVEL OF EVIDENCE: II.

Traumatic Rupture and Herniation of the Peroneus Tertius Muscle Leading to Compartment Syndrome and Entrapment of the Superficial Peroneal Nerve: A Case Report.

We present a patient with compartment syndrome and entrapment of the superficial peroneal nerve due to a direct hit to the lateral part of the right lower extremity. The diagnosis of evolving compartment syndrome was made without delay and the patient was quickly taken to the operating theater. Intraoperatively, the entrapment of the superficial peroneal nerve caused by rupture and herniation of the peroneus tertius muscle was surprisingly observed at the site, where the nerve pierces the anterior compartment. The nerve was successfully released in conjunction with fasciotomies of the anterior and lateral compartments. Meticulous diagnosis of compartment syndrome is critical to prevent ischemic injury to muscles and nerves. Recognition of anatomy and anatomical variations is important to prevent iatrogenic injury in unusual circumstances.

The role of outpatient visit after operative treatment of ankle fractures.

It is a common practice that patients have a scheduled follow-up visit with radiographs following ankle fracture surgery. The aim of this study was to evaluate whether an early outpatient visit (<3 weeks) after ankle fracture surgery resulted in a change in patient management. For this study, 878 consecutive operatively treated ankle fracture patients with an early outpatient clinical-radiological visit were reviewed. The outcome measure was a change in treatment plan defined as any procedure, medication, or surgical intervention that is not typically implemented during the uncomplicated healing process of an acute fracture. A change in treatment plan was observed in 9.8% of operatively treated ankle fracture patients. The mean age of the patients was 48 years and the mean follow-up time was 64 months. Of the changes in treatment plan, 91% were exclusively due to clinical findings such as infection. Only three of 878 patients required a change in their treatment plan based merely on the findings of the radiographs taken at the outpatient visit. Only 37% of the patients requiring a change in their postoperative management had solicited an unanticipated visit before the scheduled outpatient visit due to clinical problems such as infection or a cast-related issue. Our study showed that every tenth operatively treated ankle fracture patient requires a change in their treatment plan due to a clinical problem such as infection or a cast-related issue. Although at hospital discharge all patients are provided with written instructions on where to contact if problems related to the operated ankle emerge, only one third of the patients are aware of the clinically alarming symptoms and seek care when problems present. Our findings do not support obtaining routine radiographs at the early outpatient visit in an ankle fracture patient without clinical signs of a complication.

Predictors of Postoperative Wound Necrosis Following Primary Wound Closure of Open Ankle Fractures.

BACKGROUND: Most open malleolar ankle fracture wounds can be closed primarily after meticulous debridement. However, the development of wound necrosis following operative treatment of open malleolar ankle fractures can have catastrophic consequences. The aim of this study was to identify risk factors predisposing to postoperative wound necrosis following primary wound closure of open malleolar ankle fractures. METHODS: A total of 137 patients with open malleolar ankle fractures were identified. The open fracture wound was primarily closed in 110 of 137 (80%) patients, and postoperative wound necrosis occurred in 18 (16%) of these patients. These patients were compared to the open fracture patients without wound necrosis. Twenty possible risk factors for the development of wound necrosis were studied with logistic regression analysis. RESULTS: The variables that were independently associated with an increased risk for postoperative wound necrosis included ASA class ≥2, Gustilo grade III open injury, and the use of pulsatile lavage at index surgery. CONCLUSIONS: Our study showed that ASA class ≥2, Gustilo grade III open injury, and the use of pulsatile lavage at index surgery were the most important factors predisposing to postoperative wound necrosis following primary wound closure of open malleolar ankle fractures. The findings warrant a further study specifically comparing primary and delayed wound closure in patients with Gustilo grade III open malleolar ankle fractures and different ASA classes. Also, the role of pulsatile lavage should be re-evaluated. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

[Complications in ankle fracture surgery]. / Nilkkamurtuman leikkaushoidon komplikaatiot.

Ankle fractures are among the most frequently encountered surgically treated fractures. The operative treatment can be associated with several complications such as malreduction and infection. Reinforcing the surgical armamentarium with meticulous preoperative planning together with recognition of common surgical errors are valuable adjuncts in reducing these complications. Furthermore, it is crucial to recognize and address modifiable risk factors for infection so as to minimize this potentially devastating complication. When a deep infection does occur, it is best managed by a multidisciplinary musculosceletal infection team.

Contemporary demographics and complications of patients treated for open ankle fractures.

Open ankle fractures are rare injuries with a high likelihood of wound complications and subsequent infections. There is limited information about the complications and outcomes of these injuries in different age groups. The aim of this study was to assess the contemporary demographics and complications related to this injury. We performed a chart review of all the 3030 patients treated for ankle fractures at a Level 1 trauma centre from 2006 to 2011. 137 (4.5%) patients had an open ankle fracture. The demographic data, injury mechanism, comorbidities, and fracture type were collected. Treatment, complications, length of stay and number of outpatient visits were also recorded. The mean age of the patients was 60 years and 56% were women. Most fractures were Weber type B with a medial sided wound (93%). Only 20% of the fractures were the result of high-energy trauma, and 31% were Gustilo grade III injuries. Immediate internal fixation was performed in 82% of patients, and the wound was primarily closed in most cases (80%). The incidence of postoperative wound necrosis and deep infection was 18% and 17%, respectively. There were more deep infections if pulsatile lavage was used during the wound debridement (p=0.029). About 14 (10%) patients required a flap reconstruction to cover the soft-tissue defect. Every other patient (54%) had a complication, and 21 patients (15%) suffered a long-term disability related to the injury. The number complications did not differ for nighttime and daytime operations (p=0.083). High-energy injuries were more common in younger patients (p<0.001) and these patients also had more lateral sided open wounds than older patients (p=0.002). Interestingly, younger patients also had significantly more complications (p=0.024), suffered more often from chronic pain (p=0.003), and required more flap reconstructions (p=0.026), reoperations (p=0.026), and outpatient clinic visits (p=0.006). Open ankle fractures have a high complication rate and often require multiple surgical procedures. In young patients these injuries are more likely to be the consequence of high-energy trauma leading to more complications and subsequently increased healthcare resource utilisation.

Flap reconstruction for soft-tissue defects with exposed hardware following deep infection after internal fixation of ankle fractures.

The aim of the present study was to determine the outcome for patients treated with flap reconstruction following deep ankle fracture infection with exposed hardware. Out of 3041 consecutive ankle fracture operations in 3030 patients from 2006 to 2011, we identified 56 patients requiring flap reconstruction following deep infection. Thirty-two of these patients could be examined at a follow-up visit. Olerud-Molander Ankle (OMA) score, 15D score, Numeric Rating Scale (NRS), and clinical examination were used to assess the outcome. A total of 58 flap reconstructions were performed in 56 patients with a mean age of 57 years (range 25­93 years) and mean follow-up time of 52 months. The most commonly used reconstruction was a distally based peroneus brevis muscle flap with a split-thickness skin graft. A microvascular free flap was required in only one patient. 22 (39%) patients required subsequent surgical interventions because of a flap-related complication. With flap reconstruction, hardware could eventually be salvaged in 53% of patients with a non-consolidated fracture. The mean OMA score was fair or poor in 53% of the patients, and only 56% had recovered their pre-injury level of function. Half of the patients had shoe wear limitations. The 15D score showed a significantly poorer health-related quality of life compared to an age-standardised sample of the general population. The mean pain NRS was 2.1 (range 0­6), and the mean satisfaction NRS was 6.6 (range 0­10). Our study showed that successful treatment of a soft-tissue defect with exposed hardware following ankle fracture infections can be achieved with local flaps. Despite eventual reconstructive success, complications are common. Patients perceive a poorer health-related quality of life, have shoe wear limitations, and only half of them achieve their pre-injury level of function.

A comprehensive analysis of patients with malreduced ankle fractures undergoing re-operation.

PURPOSE: The present study aimed to determine the most common surgical errors resulting in early re-operation following ankle fracture surgery. METHODS: We performed a chart review to determine the most common types of malreductions that led to early re-operation following ankle fracture surgery. From 2002 to 2011, we identified 5,123 consecutive ankle fracture operations in 5,071 patients. Seventy-nine patients (1.6%) which underwent re-operation due to malreduction detected in postoperative radiographs. These patients were compared with an equal number of age- and sex-matched controls which did not need further surgery. RESULTS: The most common indication for re-operation was syndesmotic malreduction (47 of 79 patients, 59%). Four main types of errors related to syndesmotic reduction or fixation were identified, with the most common being fibular malpositioning within the tibiofibular incisura. Other indications for re-operation were fibular shortening and malreduction of the medial malleolus. Fracture dislocation, fracture type, posterior malleolar fracture, associated medial malleolar fracture, duration of index surgery, and fixation of an associated medial malleolar fracture with other than two parallel screws were also associated with re-operation. Correction of the malreduction was successfully achieved in the majority (84%) of cases needing further surgery. CONCLUSION: Early re-operation after ankle fracture surgery was most commonly caused by errors related to syndesmotic reduction or failure to restore fibular length. In the majority of cases, postoperative malreduction was successfully corrected in the acute setting.

Predictors of poor outcomes following deep infection after internal fixation of ankle fractures.

The development of deep infection following operative treatment of ankle fractures can have catastrophic consequences. The aim of this study was to identify factors predisposing to treatment failure of an infected ankle fracture. Out of 1923 consecutive ankle fracture operations we identified 97 patients with deep infection necessitating at least one surgical debridement. The outcome measure was a clinical failure or success of the treatment. Various parameters considered to predict clinical outcome were evaluated. Treatment failure occurred in 27% of patients with deep infection necessitating surgical debridement. The mean age of these patients was 54 years and the mean follow-up time was 22 months. The variables that were independently associated with an increased risk of treatment failure included smoking, postoperative malreduction, hardware removal from an ununited fracture and the need for two or more additional debridements. Other significant risk factors included diabetes, alcohol abuse, high-energy injury, Danis-Weber type C fracture, multibacterial infection and ununited fracture at debridement. Our study showed that smoking, postoperative malreduction and hardware removal prior to fracture union were the most important factors predisposing to a permanent complication following an ankle fracture infection. We recommend that hardware be removed only after fracture union has been confirmed.

Risk factors for deep surgical site infection following operative treatment of ankle fractures.

BACKGROUND: Surgical site infection is one of the most common complications following ankle fracture surgery. These infections are associated with substantial morbidity and lead to increased resource utilization. Identification of risk factors is crucial for developing strategies to prevent these complications. METHODS: We performed an age and sex-matched case-control study to identify patient and surgery-related risk factors for deep surgical site infection following operative ankle fracture treatment. We identified 1923 ankle fracture operations performed in 1915 patients from 2006 through 2009. A total of 131 patients with deep infection were identified and compared with an equal number of uninfected control patients. Risk factors for infection were determined with use of conditional logistic regression analysis. RESULTS: The incidence of deep infection was 6.8%. Univariate analysis showed diabetes (odds ratio [OR] = 2.2, 95% confidence interval [CI] = 1.0, 4.9), alcohol abuse (OR = 3.8, 95% CI = 1.6, 9.4), fracture-dislocation (OR = 2.0, 95% CI = 1.2, 3.5), and soft-tissue injury (a Tscherne grade of ≥1) (OR = 2.6, 95% CI = 1.3, 5.3) to be significant patient-related risk factors for infection. Surgery-related risk factors were suboptimal timing of prophylactic antibiotics (OR = 1.9, 95% CI = 1.0, 3.4), difficulties encountered during surgery, (OR = 2.1, 95% CI = 1.1, 4.0), wound complications (OR = 4.8, 95% CI = 1.6, 14.0), and fracture malreduction (OR = 3.4, 95% CI = 1.3, 9.2). Independent risk factors for infection identified by multivariable analyses were tobacco use (OR = 3.7, 95% CI = 1.6, 8.5) and a duration of surgery of more than ninety minutes (OR = 2.5, 95% CI = 1.1, 5.7). Cast application in the operating room was independently associated with a decreased infection rate (OR = 0.4, 95% CI = 0.2, 0.8). CONCLUSIONS: We identified several modifiable risk factors for deep surgical site infection following operative treatment of ankle fractures.

Dislocation of hip hemiarthroplasty following posterolateral surgical approach: a nested case-control study.

PURPOSE: Hip hemiarthroplasty dislocation is a serious complication in treatment of displaced intracapsular hip fractures. We investigated factors associated with an increased risk of dislocation after cemented hip hemiarthroplasty following the posterolateral approach. METHODS: Between January 2002 and December 2008, 602 hip fractures were treated with cemented unipolar hip hemiarthroplasty. A registry-based analysis was carried out to determine the total number of hemiarthroplasty dislocations in these patients. A control group of 96 patients without dislocation was randomly selected. Logistic regression analysis was performed to evaluate clinical and operative factors associated with dislocation. RESULTS: Thirty-four patients (5.6%) experienced at least one dislocation. Most were the result of a fall and occurred within two months after surgery. There was a trend for increased dislocation in patients who had been operated on more than 48 hours after admission and in patients who had a longer operative time. Smaller centre-edge angle and hip offset were observed in patients with dislocation. Recurrent dislocation was a significant problem, as 18 patients (62%) experienced multiple dislocations. CONCLUSIONS: The risk of hemiarthroplasty dislocation following the posterolateral surgical approach may be reduced by prompt surgical treatment and fall prevention in the early postoperative period. Patients with smaller acetabular coverage seem more predisposed to dislocation after the posterolateral approach and may be more suitable for other surgical approaches.