A systematic review on how to diagnose deltoid ligament injuries-are we missing a uniform standard?

BACKGROUND: Up to now, there is no convincing evidence, that surgical treatment of deltoid ligament injuries, especially in the setting of ankle fractures, does result in improved outcome. One reason could be a missing diagnostic standard. The aim of the current systematic review was to analyze the applied diagnostic strategies for acute deltoid ligament injuries in outcome studies. METHODS: MEDLINE, Scopus, Central, and EMBASE were searched through February 2022 for any original studies addressing diagnostics of acute deltoid injuries. The study was conducted per the PRISMA guidelines. The inclusion criteria were formed according to the PICOS criteria. The data assessed were study type, level of evidence, included fractures, time point and method of diagnosing deltoid ligament layers, differentiation between layers and syndesmotic injuries. RESULTS: 31 studies were included in the final analysis. Most studies (n = 28) based their decision to treat the deltoid ligament injury on radiologic findings only, with stressed radiographs (n = 18) being the most common. The radiographs were applied at one or more time points (preoperative, before ORIF, after ORIF, after ORIF and syndesmotic repair). The most frequently assessed parameter was the Medial Clear Space (MCS, n = 27) with cut-off-values considered pathological ranging between MCS > 1 mm and MCS > 6 mm. CONCLUSION: Comparing the 31 studies shows that a standardized method to diagnose deltoid ligament injuries is missing. Further research is needed to establish evidence-based guidelines on how to diagnose acute deltoid ligament injuries. TRIAL REGISTRATION: Prospero ID: CRD42022307112. CLINICAL TRIAL NUMBER: not applicable.

Early history of posterior malleolus fractures in ankle fractures.

INTRODUCTION: No comprehensive treatise on the early history of fractures of posterior malleolus (PM) has yet been published, and many substantial discoveries have fallen into oblivion-particularly if not having been published in English originally. MATERIALS AND METHODS: Literature search was performed in original publications and historical sources. RESULTS: Early history of PM fractures from their first description up to the beginnings of their operative treatment may be divided into three basic periods, covering the era between 1828 and 1940. In the pre-radiological period (1828-1895), description of PM injuries was based merely on the autopsy findings in deceased patients. The first mentions of this injury were published by the British authors. In the radiologic period (1899-1916), the x-ray examination started a revolution also in diagnostics of ankle fractures, with the first radiographs performed as early as in 1899. Radiographic examination had subsequently become an integral part of the diagnostics of these injuries and initiated a number of significant studies of PM fractures. The first detailed mention of a PM injury may be found in the French and German literature. The period of early operative treatment (1918-1940), i.e., open reduction and internal fixation of PM, was started by the younger post-WWI generation, primarily the French surgeons, represented by Gaston Picot. His operative technique and the first six cases treated operatively between 1918 and 1921 were described in 1921 by Edouard Huc. Picot himself published his technique in great detail in 1923. CONCLUSION: The early history of diagnostics and treatment of PM fractures witnesses the remarkable body of knowledge gathered about that topic by numerous visionary surgeons predominantly French and German surgeons immediately before and after World War I. They substantially contributed to the radiological examination and operative treatment of this injury.

[Lateral malleolar fractures : when to operate ?] / Fractures isolées de la malléole externe : quand opérer.

Ankle fractures account for 10 % of all fractures in adults. The incidence of ankle fractures is rising, particularly as the population ages. Two thirds are isolated malleolar fractures. The most used classifications are anatomical, Weber's and Lauge-Hansen's classifications. The treatment of lateral malleolar fractures may be conservative or surgical, depending on the ankle stability. To test this, a weight-bearing X-ray is required. If this is not possible on the day of trauma, it can be done 7 days later. Conservative treatment consists of a six-week immobilization in a splint or plaster cast, with weight-bearing as tolerated. Surgical treatment is mandatory for unstable fractures.

Les fractures de la cheville représentent 10 % des fractures chez les adultes. Leur incidence est en augmentation, notamment en raison du vieillissement de la population. Les fractures malléolaires isolées en constituent les deux tiers. Les classifications les plus souvent utilisées sont celles anatomiques de Weber et de Lauge-Hansen. Le traitement des fractures de la malléole externe peut être conservateur ou chirurgical, selon la stabilité de la cheville. Pour tester la stabilité, une radiographie en charge est nécessaire. Si ce n'est pas possible le jour de traumatisme, un contrôle à 7 jours peut être organisé. Le traitement conservateur consiste en une immobilisation dans une attelle ou un plâtre en charge totale en fonction des douleurs pour six semaines. Le traitement chirurgical est réservé aux fractures instables.

Locked intramedullary nailing provides superior functional outcomes and lower complication rates than plate fixation of distal fibula fractures. A systematic review and meta-analysis of comparative studies.

PURPOSE: This study aims to provide an updated systematic review and meta-analysis of comparative studies on the outcomes and complications of locked IMNs in comparison to ORIF using plates and screws, while avoiding limitations of similar published reviews. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, two independent team members electronically searched MEDLINE (PubMed), EMBASE, Google Scholar, SCOPUS, and Cochrane databases throughout May 2021 using the following keywords with their synonyms: "Ankle fracture fixation" AND "Open reduction and internal fixation", "locked intramedullary nail", or "complications". The primary outcomes were (1) functional outcomes, (2) complications, and (3) reoperation, while the secondary outcomes were: (1) union rate, and (2) cost. INCLUSION CRITERIA: comparative studies on outcomes and complications of plate open reduction and internal fixation (ORIF) vs. locked intramedullary nailing (IMN) of ankle fractures reporting at least one of the following parameters: functional outcomes, complications (infection, dehiscence, reoperation etc.), union, and cost. Studies reporting on non-locked intramedullary fibular nails were also excluded. RESULTS: After the removal of duplicates, a total of 1461 studies were identified. After screening those records, 63 studies remained for full-text assessment. Out of those, four comparative studies with a total of 262 ankle fractures met the inclusion criteria for this meta-analysis. The mean 12 months postoperative Olerud and Molander Ankle Scores (OMAS) were reported by two studies, with a statistically significant difference in favor of IMNs (MD= 6.72, CI: 3.77-9.67, p<0.001, I2= 94%). In the ORIF group, the overall complication rate was 39/134 (29.1%) vs. 10/128 (7.8%) in the IMN group, with a statistically significant difference in favor of the IMN group (RR=3.23, CI:1.71-6.11, p<0.001, I2=34%). In the ORIF group, the overall infection rate was 11/134 (8.2%), while there were no infections in the IMN group, with a statistically significant difference in favor of the IMN group (RR=8.05, CI:1.51-42.82, p=0.01, I2=0%). In the ORIF group, the overall reoperation rate was 10/134 (7.5%) while the overall reoperation rate was 6/128 (4.7%) in the IMN group, with no statistically significant difference between groups (RR=1.49, CI: 0.60-3.70, p = 0.39, I2=0%). CONCLUSION: Locked intramedullary nail fixation of distal fibula fractures could provide superior functional outcomes and lower complication rates in comparison to open reduction and plate fixation. Despite the high incidence of ankle fractures, the number of high-quality comparative studies remains limited in literature, especially on newer locked fibular nails, and large multicentric clinical trials are required before recommending locked IMNs as the new standard of care in distal fibula fractures.

Peripheral nerve block anaesthesia and postoperative pain in acute ankle fracture surgery: the AnAnkle randomised trial.

BACKGROUND: Peripheral nerve blocks (PNBs) are increasingly popular in acute ankle fracture surgery but rebound pain may outweigh the benefits. The AnAnkle Trial was designed to assess the postoperative pain profile of PNB anaesthesia compared with spinal anaesthesia (SA). METHODS: The AnAnkle Trial was a randomised, two-centre, blinded outcome analysis trial. Eligible adults booked for primary ankle fracture surgery were randomised to PNB or SA. The PNBs were ultrasound-guided popliteal sciatic and saphenous blocks with ropivacaine and SAs were with hyperbaric bupivacaine. Postoperatively, all subjects received paracetamol, ibuprofen, and patient-controlled i.v. morphine for pain. The primary endpoint was 27 h Pain Intensity and Opioid Consumption (PIOC) score. Secondary endpoints included longitudinal pain scores and morphine consumption separately, and questionnaires on quality of recovery. RESULTS: This study enrolled 150 subjects, and the PNB success rate was >94%. PIOC was lower with PNB anaesthesia (median, -26.5% vs +54.3%; P<0.001) and the probability of a better PIOC score with PNB than with SA was 74.8% (95% confidence interval, 67.0-82.6). Pain scores and morphine consumption analysed separately also yielded a clear benefit with PNB, despite substantial rebound pain when PNBs subsided. Quality of recovery scores were similar between groups, but 99% having PNB vs 90% having SA would choose the same anaesthesia form again (P=0.03). CONCLUSIONS: PNB anaesthesia was efficient and provided a superior postoperative pain profile compared with SA for acute ankle fracture surgery, despite potentially intense rebound pain after PNB. CLINICAL TRIAL REGISTRATION: Clinicaltrialsregister.eu, EudraCT number: 2015-001108-76.

[Unstable injuries of the deltoid ligament complex in ankle fractures : How to diagnose, how to treat?] / Instabile Verletzungen des Deltabandkomplexes bei Sprunggelenkfrakturen : Wie erkennen, wie behandeln?

Unstable injuries of the deltoid ligament complex can have a substantial negative effect on the prognosis and treatment of ankle injuries. Lesions of the deltoid ligament are often overlooked at the initial presentation, both as isolated ruptures and in combination with more complex injuries of the ankle. Neglected unstable injuries of medial ankle ligaments may result in chronic instability, especially following correct treatment of fractures and lateral ligament injuries. These are accompanied by reduced ankle mobility, persisting pain, reduced load bearing and osteoarthritis. Despite the possible subsequent damage, the need for surgical repair of the deltoid ligament in patients with ankle fractures is controversially discussed. Although in most cases of ligament injuries of the upper ankle joint conservative treatment leads to very good results, there is increased interest in acute surgical treatment particularly for unstable injuries in order to avoid secondary instability and the associated sequelae. When surgical treatment should be given priority over conservative treatment has not yet been sufficiently clarified. This article gives an overview of the diagnosis and treatment of injuries of the deltoid ligament complex in patients with ankle fractures based on the current literature.

Does the Covid-19 pandemic affect ankle fracture incidence? Moderate decrease in Sweden.

Background and purpose - While many other countries implemented strict regulations and restrictions for their citizens during the 1st wave of the Covid-19 pandemic, Sweden maintained a more restrained approach. The Swedish Public Health Agency emphasized individual responsibility and pushed for behavioral changes. With strict lockdown a 77% decrease in ankle fracture incidence has been reported. We investigated whether there was a change in the incidence of ankle fractures seen at 7 selected hospitals during the Covid-19 pandemic 2020.Patients and methods - Data on all ankle fractures treated at 7 selected departments during March 15 through June 15, 2020, and for the same period in the preceding 3 years (2017-2019), was retrieved from the Swedish Fracture Register. The number of fractures during the whole period and subsequent 30-day periods were compared between 2020 and 2017-2019, including subgroup analyses of age and sex.Results - The monthly rate of ankle fractures was reduced by 14% in 2020 (139 fractures) compared with 2017-2019 (161 fractures). Women had a 16% decrease and patients aged > 70 years had a 29% decrease. During the 1st 30-day period, a 26% decrease in fractures was seen.Interpretation - During the 1st wave of the Covid-19 pandemic, a moderate decline in the number of ankle fractures was seen. Women and patients aged > 70 years displayed the greatest reduction. The greatest reduction in incidence of fractures was seen during the 1st 30-day period. This indicates greater adherence to government recommendations regarding social distancing in these subgroups and during the 1st month of the pandemic. Changes in ankle fracture incidence may be a measure of lockdown extent.

Arthroscopy-Assisted Reduction in the Management of Isolated Medial Malleolar Fracture.

PURPOSE: To evaluate the feasibility of arthroscopic reduction percutaneous fixation (ARPF) in the treatment of isolated medial malleolar fracture and compare the results with those of conventional open reduction internal fixation (ORIF). METHODS: This prospective study enrolled 77 patients with isolated medial malleolar fracture between November 2011 and February 2016. The patients were assigned to the ARPF (n = 34) and ORIF (n = 43) groups. The Olerud-Molander ankle score (OMAS), ankle range of motion (ROM), visual analog scale, and radiographic evaluation were determined at the scheduled follow-up. RESULTS: In the ARPF group, 11 of 34 patients (32.4%) had chondral lesions. Tears of the deltoid ligament and anterior inferior tibiofibular ligament were noted in 3 (8.8%) and 15 (44.1%) patients, respectively. The mean follow-up was 5 years. The mean OMAS was higher in the ARPF group than in the ORIF group. The differences were statistically significant at 6 months (mean ± standard deviation, 80.2 ± 4.0 for ARPF vs 77.2 ± 4.1 for ORIF, P = .005) and 1 year (92.9 ± 4.9 vs 88.1 ± 4.6, P < .001), but not at the latest follow-up (P = .081). Ankle ROM was markedly improved in the ARPF group, unlike in the ORIF group at 6 months (dorsiflexion, P = .025; plantarflexion, P < .001) and 1 year (dorsiflexion and plantarflexion, P < .001). The improvement remained at the latest follow-up in plantarflexion (P = .001) but not in dorsiflexion (P = .354). CONCLUSIONS: Arthroscopy-assisted reduction is a feasible alternative modality with superior short-term outcomes for treating isolated medial malleolar fracture, but its superiority may be attenuated in the intermediate term. LEVEL OF EVIDENCE: Level III, comparative study.

Utility of Ottawa Ankle Rules in an Aging Population: Evidence for Addition of an Age Criterion.

The Ottawa ankle rules (OAR) indicate that any patient with the inability to ambulate up to four steps or with tenderness at either malleoli should receive diagnostic imaging for an acute ankle injury. Current trends indicate that health care providers tend to order more images in practice than necessary according to OAR. The purpose of this study is to analyze OAR in geriatric versus nongeriatric patients. Secondarily, we hope to refine these guidelines for ankle imaging in the hopes that health care providers will be comfortable in adhering to these guidelines more strictly. A retrospective chart review was conducted of 491 adult patients with an average (± standard deviation) age of 54.4 ± 21.6 years (range 18 to 96). Applying the current OAR resulted in a sensitivity of 98.2% and a specificity of 58.6% in this entire cohort. The calculated sensitivities were comparable between the nongeriatric and geriatric cohorts, at 98.60% and 97.99%, respectively. The specificities varied between the nongeriatric and geriatric cohorts, at 60.13% and 33.33%. We propose new guidelines that would mandate imaging studies for any patient ≥65 years of age presenting to the emergency department with ankle pain. When applying these proposed guidelines, the sensitivity of the entire study population was found to be improved to 99.0%, whereas the specificity dropped to 56.7%. The slight decrease in specificity was deemed acceptable because these guidelines are meant to be used as a screening tool and because the risk of OAR not correctly identifying ankle fracture (2% of geriatric fractures) was completely mitigated in the geriatric population.

Ankle Fracture Epidemiology in the United States: Patient-Related Trends and Mechanisms of Injury.

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.

Operative Management of a Pediatric Talar Body and Neck Fracture: A Case Report.

Pediatric talus fractures are rare injuries that generally result from high-energy trauma. The relative elasticity of pediatric bone is thought to contribute to the lower rate of fracture in children. Although these injuries are rare, complications of talar body fractures, including avascular necrosis, collapse of the talar dome, and tibiotalar arthrosis, are well described. In the pediatric patient, these complications can result in poor outcomes and a disabling position for the patient. There is a relative paucity of data given the low incidence of these injuries and lack of consensus on operative versus nonoperative management. The authors present the case of an 11-year-old female with a combined talar neck and body fracture. The patient underwent open reduction internal fixation of her fractures with combined cannulated screw and Kirshner wire fixation. She was followed to 7 years postoperatively with excellent functional outcome and no evidence of avascular necrosis or collapse of the talar body.

Retrospective cohort study of operatively treated ankle fractures involving the posterior malleolus.

BACKGROUND: Direct fixation of the posterior malleolus through a posterolateral approach is increasing in popularity. However, data is limited, and no studies have stratified results by posterior malleolus size. METHODS: A retrospective cohort study of patients with posterior malleolus (PM) fractures undergoing internal fixation over an 18-month period was conducted. Radiographic and patient reported outcomes measures (PROMs) were assessed. 75 patients were included, and 31 returned Manchester-Oxford Foot and Ankle (MOXFQ), EQ-5D-3 L, 5-point Likert satisfaction questionnaires. Mean age was 56.2 years, 68% were female, mean ASA was 1.72, 6.7% were diabetic, and average surgical time was 75.7 min (±40.9). RESULTS: Overall, the MOXFQ summary score was 26.9 (±25.8), with the pain domain showing the most severe score 32.4 (±24.0). The EQ-5D VAS index was 0.75 (±0.24). Larger PM size was associated with more anatomical reduction (58.8%, n = 20 of <10% vs. 90.9%, n = 10 of >30%) and larger sized fragments were more likely to be fixed posteriorly. Best PROMs were observed in PM fragments <10%, and the worst in fragments 10-20%. A tendency towards more secondary surgery was observed with posterior subluxation 21.9% (n = 7) vs. 7.0% (n = 3) (p = 0.06). CONCLUSIONS: Patients with fragments >10% have an intra-articular injury. We recommend direct anatomic reduction and rigid internal fixation. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

A cadaveric study investigating the role of the anterior inferior tibio-fibular ligament and the posterior inferior tibio-fibular ligament in ankle fracture syndesmosis stability.

BACKGROUND: This cadaveric study aimed to investigate the role AITFL and PITFL have on preventing talar shift in ankle fractures, as well as investigating the role of AITFL reconstruction in preventing talar shift. METHODS: Twelve lower limb cadavers were used. Talar shift was measured following: Step 1- no ligaments cut; Step 2- entire deltoid ligament division; Step 3- group A (5 specimens) PITFL cut whilst group B (7 specimens) AITFL cut; Step 4- group A had AITFL divided whilst group B had PITFL cut. Reconstruction of the AITFL was performed using part of the superior extensor retinaculum as a local flap. Measurement of talar shift was then repeated. RESULTS: With no ligaments divided, mean talar shift was 0.8mm for group A and 0.7mm for group B. When the deltoid ligament was divided, mean talar shift for group A was 4.8mm compared to 4.7mm in group B (P=1.00). The mean shift in group A after PITFL division was 6.0mm, increasing the talar shift by an average of 1.2mm. In group B after AITFL division mean talar shift was 8.3mm (P=0.06), increasing talar shift by an average of 3.6mm. After division of the second tibiofibular ligament, mean talar shift in group A measured 10.0mm and in group B was 10.9mm (P=0.29). Three times more talar shift occurred after the AIFTL was divided compared to the PITFL (P=0.06). CONCLUSION: Consequently, repairing the PITFL in isolation (for example by fixation of a posterior malleolus avulsion fracture) may not adequately prevent talar shift; we feel consideration should also be given to reconstruction of the AITFL to augment the syndesmosis fixation, which may provide a stronger restoration of ankle stability. LEVEL OF CLINICAL EVIDENCE: 5.

Characteristics of intercalary fragment in posterior malleolus fractures.

BACKGROUND: The purpose of the study is to investigatethe prevalence of posterior malleolus intercalary fragment (ICF) in adult ankle fractures; to analyze the morphological characteristics of ICF; and its mechanism. METHODS: Retrospectively, 247 cases of posterior malleolus fractures (PMF) were included in 369 cases of adult ankle fractures. The prevalence of ICF, relationship between type of ankle fracture, posterior malleolar fracture and the ICF was studied. RESULTS: Among 369 cases, the ICF was found in 43% of the PMF and 29% of the hospitalized unstable ankle fractures. Position of ICF is posterolateral in 68 (64%), mid posterior in 20 (19%) and posteromedial in 18 (17%) cases. The prevalence of ICF was 70% in Bartonícek classification type III fractures, which was significantly higher than type I, II and IV. CONCLUSIONS: The highest incidence occurs in Bartonícek III type fracture. The study helps in further understanding and treatment of the PMF. LEVEL OF EVIDENCE: Level IV, case series.

Comparative analysis of clinical outcomes of fixed-angle versus variable-angle locking compression plate for the treatment of Lisfranc injuries.

BACKGROUND: Fixed-angle locking compression plate (LCP) and variable-angle LCP are utilized for internal fixation of Lisfranc injuries. However, studies regarding the difference of clinical outcomes of these two plates are limited. The purpose of present study was to compare postoperative outcomes between these two plate types in Lisfranc injuries. METHODS: A total of 45 consecutive patients (22 patients with fixed-angle LCP and 23 patients with variable-angle LCP) who underwent surgical treatment for Lisfranc injury were reviewed for this retrospective study. The Foot Function Index (FFI), numerical rating scale (NRS) for pain, development of complications, operative time, and patient satisfaction for current activity were compared. RESULTS: There were no significant differences in FFI and NRS for pain at three months and 12 months following surgery. Postoperative complication rate was similar between two groups. Patients with variable-angle LCP had an 18 min shorter mean length of operation (p = 0.040). Patient satisfaction for current activity was not differ between two groups. CONCLUSIONS: The use of variable-angle LCP for treatment of Lisfranc injuries did not show superiority in functional outcomes, pain, complication rates, or patient satisfaction to fixed-angle LCP, but operative time was shorter with variable-angle LCP. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Surgical treatment of lateral and posterior process fractures of the talus: Mid-term results of 15 cases after 7 years.

BACKGROUND: We retrospectively evaluated the mid-term results of surgery for talar process fractures (lateral and posterior processes) and exploratively analyzed parameters that potentially impact treatment outcomes. METHODS: Fifteen patients who underwent internal fixation (January 2000 to December 2015) were examined for radiological and clinical functional outcomes. The independent parameters evaluated were age, sex, extent of general injury, soft-tissue damage, surgical latency, and fracture type. RESULTS: All fractures healed completely. Three patients developed osteoarthritis. The American Orthopaedic Foot and Ankle Society Ankle/Hindfoot Scale score was 79.5±18.6, the Functional Foot Index score was 31.1±31.4, and the physical and mental component summary scores of the Short Form 36, version 2, were 46.6±11.8 and 50.3±9.1, respectively. No influence on the above scores was determined. CONCLUSIONS: The clinical outcomes of internal fixation of talar process fractures were good. Delayed surgical treatment (≥14days) did not significantly lead to poorer outcomes in our patients.

Surgical vs non-surgical management of Weber B fractures: A systematic review.

BACKGROUND: The aim of this systematic review was to compare surgical and non-surgical management of Weber B ankle fractures. METHODS: A systematic computer-based search was conducted using the MEDLINE (via OvidSP), EMBASE (via OvidSP) and Central databases. Data were extracted regarding functional outcome, radiological union, range of motion (RoM), infection rate and quality of life (QoL). RESULTS: There were no significant differences identified between surgical and non-surgical management of Weber B fractures with respect to functional outcome. There is a higher rate of complication following surgical management, including infection, reoperation, thromboembolic events and death. With respect to QoL and ankle RoM, this review identified no differences between surgical and non-surgical management. CONCLUSIONS: There is a need for further published literature evaluating the most efficacious management as there is a poverty of high-level research available. Currently, the available literature does not overwhelmingly favour a particular approach to Weber B ankle fractures.

Clinical and patient-reported outcomes following Low Intensity Pulsed Ultrasound (LIPUS, Exogen) for established post-traumatic and post-surgical nonunion in the foot and ankle.

BACKGROUND: Biophysical methods including Low Intensity Pulsed Ultrasound (LIPUS) are emerging as potential alternatives to revision surgery for treating established nonunions. We aim to prospectively review the clinical and patient-reported outcomes of patients treated with LIPUS following post-traumatic and post-surgical nonunions in the foot and ankle. METHODS: Forty-seven consecutive patients underwent Exogen treatment. Patient-reported outcome scores included MOXFQ, EQ-5D and VAS. Patients were divided in to 3 groups: fractures (A), hindfoot procedures (B) and midfoot/forefoot procedures (C). RESULTS: Thirty-seven patients (78.7%) clinically united, 4 patients (8.5%) noticed no significant improvement but did not want further intervention and 6 patients (12.8%) underwent revision surgery. The mean duration of Exogen treatment was 6 months. Union rates of 93%, 67% and 78% were noted in the three groups. Significant improvement in functional outcomes and potential cost savings were observed. CONCLUSIONS: Exogen for established nonunion in the foot and ankle is a safe, valuable and economically viable clinical option as an alternative to revision surgery. We observed better results in the fracture and midfoot/forefoot groups and relatively poorer results in the hindfoot fusion group.

Functional outcome 3-6 years after operative treatment of closed Weber B ankle fractures with or without syndesmotic fixation.

BACKGROUND: To compare the long-term functional outcomes of patients surgically treated for Weber B ankle fractures with or without syndesmotic fixation. METHODS: In total, 959 adult patients with previous treatment with open reduction and internal fixation (ORIF) for closed ankle fractures were eligible for inclusion in a cross-sectional postal survey 3-6 years after surgery; 645 had Weber B fractures. The survey assessed functional outcomes with three validated ankle questionnaires. RESULTS: In total 365 (57%) patients responded at a median of 4.2 years after the trauma. After adjusting for age, sex, education, smoking status, body mass index, diabetes, physical status before surgery, fracture classification, and duration of surgery, patients with a syndesmotic fixation had no different OMAS score (p = 0.98), LEFS score (p = 0.61), and SEFAS score (p = 0.98) than those without a syndesmotic fixation. Trimalleolar fracture was associated with worse functional outcomes than unimalleolar on two of the scales, the OMAS (p = 0.028) and LEFS (p = 0.046). CONCLUSIONS: In multivariable analysis, patients with a syndesmotic fixation had no worse long-term functional outcomes than those without syndesmotic fixation.

Fibular nailing for fixation of ankle fractures in patients at high risk of surgical wound infection.

BACKGROUND: Postoperative infection is a severe complication after operative treatment of ankle fractures, associated with age, comorbidities, and severe soft tissue injuries. We assessed the efficacy of intramedullary fibular nailing for treating ankle fractures in patients at high risk of wound complications. METHODS: 41 high-risk patients were included in the study. We retrospectively reviewed the medical records to assess the risk profile, the treatment data, and possible infections and re-operations. After a minimum of 2 years eight patients had died, three had advanced-staged dementia and two were lost to follow-up. Remaining 28 patients reported the functional outcome and QoL through patient-reported questionnaires. Radiographs and cone-beam computed tomography were performed, as well as range-of-motion was measured. RESULTS: No surgical wound infections were found. The mean Olerud-Molander score was 67 points (SD 28 [20-100]). The osteoarthritis stages and the range-of-motion were significantly different between the injured and uninjured ankles, but we detected no significant effect on the QoL. CONCLUSION: Intramedullary fibular fixation appeared to be a safe treatment choice for ankle fractures in high-risk patients. LEVEL OF EVIDENCE: IV.