Maisonneuve fracture treated with short leg cast: A case report with 41-month follow-up.

RATIONALE: Maisonneuve fracture is a specific type of severe ankle injury. To our current knowledge, once a Maisonneuve fracture is diagnosed, the surgery is always recommended for fear of sequelae from inaccurate joint reconstruction. However, in this case, we treated a Maisonneuve fracture with a short leg cast, and the 41-month follow-up showed a favorable outcome with no post-traumatic osteoarthritis, chronic pain, and instability. Therefore, this case provides evidence for the feasibility of conservative treatment of Maisonneuve fracture. PATIENT CONCERNS: A female patient in her early twenties sprained her left ankle while running, suffering regional pain, swelling, and limited mobility. DIAGNOSES: We diagnosed a Maisonneuve fracture with superior fibular fracture and Volkmann tuberosity fracture, a slight separation of inferior tibiofibular syndesmosis (ITS). INTERVENTIONS: The patient rejected our surgical recommendations in favor of nonsurgical treatment, in addition to refusing immobilization of the knee. Consequently, we had to treat her with a short leg cast for 8 weeks and asked her to return for regular follow-up visits. OUTCOMES: At the final follow-up, the radiography showed complete healing of proximal fibula fracture. The patient reported no discernible subjective differences between her bilateral ankles. The range of motion of the left ankle was measured at 22° of dorsiflexion and 40° of plantarflexion. Functional assessments using Olerud-Molander ankle scale and American Orthopedic Foot and Ankle Society Ankle-Hindfoot scale both scored 100 points. Additionally, the radiographic assessment classified arthritis as stage 0 according to Morrey-Wiedeman classification. LESSONS: To avoid missing and misdiagnosing, the physical examination should always extend to 2 neighboring joints. Secondly, if a Maisonneuve fracture is suspected, further computed tomography scans, radiography, and magnetic resonance imaging can help to determine the stability of the ITS and the integrity of the lateral collateral ligaments before making therapeutic decisions. Finally, considering the lateral collateral ligaments may remain intact, we recommend stabilizing ITS by repairing the medial ligaments, which can be conducted arthroscopically and be more minimally invasive, providing an elastic fixation that aligns better with the biomechanics of the ITS which is characterized as a micro-mobile rather than fully fixed joint.

Reconstruction of the Medial Malleolus With Iliac Crest Autograft After Traumatic Loss: A Case Report.

CASE: A 19-year-old woman sustained an open ankle fracture with complete destruction of the left medial malleolus and significant soft-tissue loss. After temporizing external fixation and coverage with a rotational posterior tibial artery perforator flap, the medial malleolus was reconstructed with an autologous iliac crest bone graft and direct repair of the deltoid ligament. The patient achieved excellent improvement in functional outcomes at 21 months with adequate restoration of ankle motion. CONCLUSION: This case shows reconstruction of the medial malleolus with autologous iliac crest bone graft after traumatic loss can be a viable treatment option for young patients.

Impact of Geko Neuromuscular Stimulator on Preoperative Preparation in Ankle Fractures.

OBJECTIVE: To explore the impact of the Geko neuromuscular stimulator on preoperative preparation in patients with ankle fractures. STUDY DESIGN: Quasi-experiment study. Place and Duration of the Study: Department of Foot and Ankle Surgery and Department of Orthopaedics, Beijing Tongren Hospital, Capital Medical University, Beijing, China, between December 2020 and 2021. METHODOLOGY: This quasi-experiment study included patients with ankle fractures treated with Geko neuromuscular stimulator before surgical fixation. The primary outcome was limb swelling at 24, 48, and 72 hours (h) after admission, and the secondary outcomes were pain according to visual analogue scale (VAS) at 12, 24, and 48 hours after admission, preoperative waiting time, and comfort 4 and 72 h after admission. RESULTS: A total of 60 patients were included in the study; 30 in the conventional treatment group (mean age 41.16 ± 2.01 years) and 30 in the Geko group (mean age 40.22 ± 2.68 years). The limb swelling in patients was significantly different between the Geko and conventional treatment groups (p = 0.004). Besides, the swelling values at 48 (p < 0.001) and 72 (p < 0.001) hours were significantly lower than those at 24 hours. The pain in patients was significantly different between the Geko and conventional treatment groups (p = 0.007). Besides, the swelling values at 24 (p < 0.001) and 48 (p < 0.001) hours are significantly lower than those at 24 hours. Comfort was significantly higher at 4 h (69.54 ± 2.18 vs. 67.22 ± 3.14, p = 0.002) and 72 h [(88.50 (84.00 - 94.00) vs. 82.14 ± 3.08, p < 0.001)] after admission. The preoperative waiting time (3.52 ± 1.8 vs. 5.15 ± 2.1 hours, p = 0.002) was significantly shorter in the Geko group. CONCLUSION: The Geko neuromuscular stimulator is a useful option for preoperative preparation in patients with ankle fractures to reduce local swelling and pain and improve patients' comfort. KEY WORDS: Ankle fractures, Lower extremity, Neuromuscular stimulator, Peroneal nerve, Pain.

[Effectiveness comparison of a new hook-shaped anatomical locking plate and conventional anatomical locking plate in treatment of Danis-Weber type A lateral malleolus fractures].

Objective: To investigate the effectiveness of a new hook-shaped anatomical locking plate in the treatment of Danis-Weber type A lateral malleolus fractures. Methods: A retrospective analysis was performed on the clinical data of 45 patients with Danis-Weber type A lateral malleolus fractures who met the selection criteria between November 2020 and November 2022. According to the surgical methods, they were divided into the observation group (treated with the new hook-shaped anatomical locking plate, 23 cases) and the control group (treated with the conventional lateral malleolus anatomical locking plate, 22 cases). There was no significant difference in baseline data such as gender, age, cause of injury, Danis-Weber type of fracture, time from injury to operation, and combined ligament injury between the two groups ( P>0.05). The operation time, partial weight-bearing time, return to work time, and postoperative complications were recorded and compared between the two groups. The function and pain of ankle joint were evaluated by the range of motion of ankle dorsiflexion, plantarflexion, varus, valgus, and visual analogue scale (VAS) score at 1 and 3 months after operation, and at last follow-up, and the American Orthopaedic Foot and Ankle Society (AOFAS) score at 3 months after operation and at last follow-up. Results: All patients were followed up 10-18 months (mean, 15.1 months). There was no significant difference in operation time between the two groups ( P>0.05); the postoperative partial weight-bearing time and return to work time of the observation group were significantly earlier than those of the control group ( P<0.05). During the follow-up, there was 1 case of joint stiffness in the observation group, and 1 case of joint surface displacement, 1 case of joint stiffness, and 1 case of traumatic arthritis in the control group. There was no significant difference in the incidences of complications between the two groups ( P>0.05). With the extension of time after operation, the range of motion of ankle dorsiflexion, plantarflexion, varus, valgus, and VAS score of the two groups gradually improved, and there were significant differences between different time points ( P<0.05); At 1 and 3 months after operation, the above indexes in the observation group were significantly better than those in the control group ( P<0.05), and there was no significant difference between the two groups at last follow-up ( P>0.05). The difference of AOFAS score between the last follow-up and 3 months after operation in the observation group was significantly better than that in the control group ( P<0.05). Conclusion: Compared with the conventional lateral malleolus anatomical locking plate, the new hook-shaped anatomical locking plate has a more reliable fixation effect in the treatment of Danis-Weber type A lateral malleolus fracture, which is conducive to early functional exercise of the ankle joint, so that patients can bear weight earlier and return to work earlier, and the operation time is not significantly prolonged, and the effectiveness is satisfactory.

Percutaneous intramedullary screw or rush pin fixation of unstable ankle fractures in patients with fragile soft tissue - retrospective study of 80 cases.

INTRODUCTION: The standard surgical procedure for unstable ankle fractures is fixation of the lateral malleolus with a plate and screws. This method has a high risk of complications, especially among patients with fragile skin conditions. The aim of this study was to estimate the re-operation rates and identify complications in patients with an unstable ankle fracture, surgically treated with an intramedullary screw or rush pin. MATERIALS AND METHODS: We identified all patients who were surgically treated with either a 3.5-mm screw or rush pin at Aarhus University Hospital, Denmark, from 2012 to 2018. Major complications were re-operations within three months. We included 80 patients, of which 55 (69%) were treated with a 3.5-mm intramedullary screw and 25 (31%) with a rush pin. The majority of the study population was female (59) and the mean age was 75 (range 24 to 100) years. Of the 80 patients included, 41 patients had more than 2 comorbidities. RESULTS: Three patients underwent re-operation within three months due to either fracture displacement or hardware cutout. Radiographs obtained after six weeks showed that nine patients had loss of reduction. Additionally, four patients had superficial wound infections and six patients had delayed wound healing. CONCLUSIONS: Intramedullary fixation of distal fibula fractures with either a screw or rush pin has low re-operation rates. However, the high proportion of patients with radiological loss of reduction is concerning.

Epidemiology and Characteristics of Ankle and Foot Injuries in Electric Scooter-Related Accidents.

Background: The use of electric scooters (e-scooters) continues to increase as a simple, inexpensive means of transport, resulting in a sharp increase in the incidence of scooter-related accidents. No study to date has closely examined the injury extent to the lower leg, joints, and extremities from e-scooter-related accidents. Here, we investigated the epidemiology and injury patterns of such accidents, focusing on injuries to the ankle and foot. Methods: Based on data from a single tertiary hospital's database, the demographics of 563 patients with scooter-associated injuries were analyzed retrospectively. Among the patients, 229 patients who were injured by e-scooter riding were further investigated. Based on the data, the general demographics of whole scooter-associated injuries and the injury characteristics and fracture cases of the lower leg, ankle, and foot were analyzed. Results: During the 4-year study period, the number of patients injured by e-scooters increased every year. Lower extremities were the most common injury site (67.2%) among riders, whereas injuries to the head and neck (64.3%) were more common in riders of non-electric scooters. Among the lower leg, ankle, and foot injuries of riders (52 cases), the ankle joint (53.8%) was the most commonly injured site, followed by the foot (40.4%) and lower leg (21.2%). The fracture group scored significantly higher on the Abbreviated Injury Scale than the non-fracture group (p < 0.001). Among the fracture group (20 cases), ankle fractures (9 cases) were most common, including pronation external rotation type 4 injuries (4 cases) and pilon fractures (2 cases). Five patients (25%) had open fractures, and 12 patients (60%) underwent surgical treatment. Conclusions: The ankle and foot are the most common injury sites in e-scooter-related accidents. Given the high frequency and severity of e-scooter-related ankle and foot injuries, we suggest that more attention be paid to preventing these types of injuries with greater public awareness of the dangers of using e-scooters.

The efficacy and safety of different does of intravenous tranexamic acid on blood loss in fresh foot and ankle fractures: a prospective, randomized controlled study.

BACKGROUND: There are a few studies on the effectiveness and safety of intravenous administration of tranexamic acid(TXA) in patients who underwent foot and ankle surgery, especially for preoperative hidden blood loss in patients with freshfoot and ankle fractures. Thus, the aim of this study was to investigate whether intravenous administration of different doses of TXA can effectively reduce perioperative blood loss and blood loss before surgery and to determine its safety. METHODS: A total of 150 patients with fresh closed foot and ankle fractures from July 2021 to July 2023 were randomly divided into a control group (placebo controlled [PC]), standard-dose group (low-dose group [LD], 1 g/24 h; medium-dose group [MD], 2 g/24 h), and high-dose group (HD, 3 g/24 h; ultrahigh-dose group [UD], 4 g/24 h). After admission, all patients completed hematological examinations as soon as possible and at multiple other time points postsurgery. RESULTS: There was a significant difference in the incidence of hidden blood loss before the operation between the TXA group and the control group, and the effect was greater in the overdose groups than in the standard-dose groups. There were significant differences in surgical blood loss (intraoperative and postoperative), postoperative HGB changes, and hidden blood loss among the groups. The TXA groups showed a significant decrease in blood loss compared to that of the control group, and the overdose groups had a more significant effect than the standard-dose groups. A total of 9 patients in the control group had early wound infection or poor healing, while only 1 patient in the other groups had this complication, and the difference among the groups was significant. No patients in any group suffered from late deep wound infection, cardiovascular or cerebrovascular events or symptomatic VTE. CONCLUSION: This is the first study on whether TXA can reduce preoperative hidden blood loss in patients with freshfoot and ankle fractures. In our study, on the one hand, intravenous application of TXA after foot and ankle fractures as soon as possible can reduce preoperative blood loss and postoperative blood loss. On the other hand, TXA can also lower wound complications, and over-doses of TXA are more effective than standard doses. Moreover, overdoses of TXA do not increase the incidence of DVT.

Study on the risk factors of postoperative wound complications in patients with ankle fracture.

Wound complications after surgery for ankle fractures can lead to catastrophic consequences. The purpose of this study was to evaluate the risk factors of postoperative wound complications in patients with ankle fracture and to determine their effects on prognosis. 200 patients with ankle fracture treated in our hospital from October 2021 to December 2023 were analysed retrospectively. The total incidence of postoperative wound complications was 19% (38/200). Type of complications: wound edge necrosis 15 cases (39.47%), dehiscence (reopening of wound) 13 cases (34.21%), delayed healing (>30 days) 10 cases (26.32%); Univariate analysis showed that patients' age, body mass index (BMI), current smoking, alcoholism, diabetes mellitus, injury mechanism, open fracture, wound classification, higher American Society of Anesthesiologists (ASA) score and operation time were all associated with postoperative wound complications. Multivariate Logistic regression model shows: age ≥60 years old OR3.671 (1.875-5.937), BMI OR1.198 (1.143-1.324), current smoking OR2.727 (1.251-5.602), alcoholism OR1.143 (1.034-1.267), complicated with diabetes OR2.763 (1.236-4.852), injury mechanism (high vs. low and medium energy) OR2.437 (1.238-4.786), open fracture OR1.943 (1.8262.139), wound classification (II vs. I) OR4.423 (1.73511.674), ASA score (III-IV vs. I-II) OR1.307 (1.113-2.194) was an independent risk factor for postoperative wound complications in patients with ankle fracture. Further, ROC curves showed that these nine independent influences had high accuracy and validity in predicting postoperative wound complications in patients with ankle fractures. In conclusion, independent risk factors for postoperative complications of ankle fracture were age >60 years, BMI, injury mechanism, open fracture, wound classification (II vs. I), ASA score, current smoking, and alcoholism. The wound classification (II vs. I) has the highest diagnostic value.

The effect of early weight-bearing and later weight-bearing rehabilitation interventions on outcomes after ankle fracture surgery: A systematic review and meta-analysis of randomised controlled trials.

OBJECTIVE: This systematic review aimed to analyse the effect of early weight bearing versus late weight bearing on rehabilitation outcomes after ankle fractures, which primarily include ankle function scores, time to return to work/daily life and complication rates. METHODS: The China National Knowledge Infrastructure, Wanfang Data Knowledge Service Platform, China Science and Technology Journal, Web of Science, PubMed, Embase and Cochrane Library databases were searched. The focus was on identifying randomised controlled trials centred on early weight-bearing interventions for post-operative ankle fracture rehabilitation. All databases were searched for eligible studies published within the period from database inception to 20 June 2023. The eligible studies were screened according to the inclusion criteria. Study quality was evaluated using the methodology recommended by the Cochrane Handbook for the Systematic Evaluation of Interventions. Two authors independently performed the literature search and data extraction. Eligible studies were subjected to meta-analyses using Review Manager 5.3. Based on the time points at which post-operative ankle function was reported in the studies included in this paper, we decided to perform a meta-analysis of ankle function scores at 6 weeks post-operatively, 12 weeks post-operatively, 24-26 weeks post-operatively and 1 year post-operatively. RESULTS: A total of 11 papers, comprising 862 patients, were included. Meta-analysis indicated that patients receiving early weight-bearing interventions, which referred to weight-bearing for 6 weeks post-operatively, experienced enhancements in ankle function scores (Olerud-Molander score, AOFAS score or Baird-Jackson score) at various post-operative milestones: 6 weeks (SMD = 0.69, 95% CI: 0.49-0.88 and p < 0.01), 12 weeks (SMD = 0.57, 95% CI: 0.22-0.92 and p < 0.01) and the 24-26 weeks range (SMD = 0.52, 95% CI: 0.20-0.85 and p < 0.01). The results of subgroup analyses revealed that the effects of early weight-bearing interventions were influenced by ankle range-of-motion exercises. Additionally, early weight bearing allows patients to return to daily life and work earlier, which was evaluated by time when they resumed their preinjury activities (MD = -2.74, 95% CI: -3.46 to -2.02 and p < 0.01), with no distinct elevation in the incidence of complications (RR = 1.49, 95% CI: 0.85-2.61 and p > 0.05). CONCLUSION: The results showed that early weight bearing is effective in improving ankle function among post-operative ankle fracture patients and allows patients to return to daily life earlier. Significantly, the safety profile of early weight bearing remains favourable, with no higher risk of complications than late weight bearing.

Three-dimensional Mapping Analysis of Talus Fractures and Demonstration of Different Surgical Approaches for Talus Fractures.

OBJECTIVE: The talus is an important component in the ankle, and its treatment after injury is crucial. However, complications and adverse events due to incomplete traditional classifications may still occur, and these classifications fail to analyze the patterns and distribution of fractures from a three-dimensional perspective. Therefore, in this study, we aimed to analyze the location and distribution of fracture lines in different types of talus fractures using three-dimensional (3D) and heat mapping techniques. Additionally, we aimed to determine the surface area of the talus that can be utilized for different approaches of internal fixation, aiding in the planning of surgical procedures. METHODS: We retrospectively analyzed data from CT scans from 126 patients diagnosed with talus fractures at our two hospitals. We extracted the CT data of a healthy adult and created a standard talus model. We performed 3D reconstruction using patients' CT images and superimposed the fracture model onto the standard model for drawing fracture lines. Subsequently, we converted the fracture lines into a heat map for visualization. Additionally, we measured 20 specimens to determine the boundary for various ligaments attached to the talus. We determined the surface area of the talus available for different surgical approaches by integrating the boundary data with previously reported data on area of exposure. RESULTS: Without considering the displacement distance of the fracture, fracture types were classified as follows, by combining Hawkins and Sneppen classifications: talar neck, 41.3%; posterior talar tubercle, 22.2%; body for the talus and comminuted, 17.5%; lateral talar tubercle, 11.9%; and talar head, 7.1%. We established fracture line and heat maps using this classification. Additionally, we demonstrated the available area for anteromedial, anterolateral, posteromedial, posterolateral, and medial malleolus osteotomy and Chaput osteotomy approaches. CONCLUSION: Fracture line and heat map analyses can aid surgeons in planning a single or combined surgical approach for the reduction and internal fixation of talus fractures. Demonstrating the different surgical approaches can help surgeons choose the most effective technique for individual cases.

Temporary Cast Application in Dislocated Ankle Fractures Leads to High Rates of Secondary Loss of Reduction: Does the Lauge-Hansen Injury Type Matter?

BACKGROUND: For the temporary treatment of ankle fracture dislocations (AFDs), previous studies indicate higher rates of secondary loss of reduction (LOR) with splint immobilization, prompting consideration for expanding indications for external fixation (ExFix). However, these studies did not investigate the influence of fracture morphology to further improve patient selection. The aim of this study was to investigate the influence of Lauge-Hansen injury type on the LOR rate in bimalleolar or trimalleolar AFDs for temporary cast vs ExFix immobilization. METHODS: In this retrospective cohort study, patients with isolated AFD cases treated at our institution from 2011 to 2020 were reviewed. Inclusion criteria required radiographs depicting initial dislocation and appropriate reduction after Cast or ExFix immobilization. Exclusion criteria encompassed concomitant injuries, open fractures, conservative management as well as surgery performed within 48 hours or at a different facility. Patients were grouped by temporary treatment (Cast or ExFix). The primary endpoint was LOR prior to definitive surgery across various Lauge-Hansen types. RESULTS: The LOR rate was significantly higher in the cast group (40/152, 26.3%) compared to the ExFix group (5/191, 2.6%; P < .0001). In the cast group, LOR was associated with an increase in time to definitive surgery by a mean of 3 days (P < .002). During cast treatment, LOR was significantly more likely for pronation abduction (P = .001) and supination external rotation injuries (P < .0001), whereas no significant differences were observed for pronation external rotation (P = .006), supination adduction (P > .99), and fractures not classifiable (P > .99). CONCLUSION: In cases of AFDs resulting from supination external rotation or pronation abduction trauma according to the Lauge-Hansen classification, especially in the setting of an additional posterior malleolar fracture, primary application of external fixation should be considered to reduce the risk for secondary loss of reduction. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Preventing Surgical Site Infections in Geriatric Ankle Fracture Surgery with Closed-Incision Vacuum Therapy: A Pilot Study.

BACKGROUND: Ankle fractures are among the most common fractures in older adult patients that need surgical treatment. The risk of surgical site infections (SSIs) after ankle fracture surgery ranges between 0.5% and 30%; SSI incidence is higher among older adults. Further, SSIs have significant consequences for subjective functional outcomes and create a need for prolonged intravenous antibiotic therapy and wound care. Accordingly, it is critical to determine risk factors for and establish optimal postoperative wound care to prevent SSIs. OBJECTIVE: The aim of the pilot study was to examine the feasibility of closed-incision vacuum therapy (CIVT) to reduce rates of SSI in older adults. METHODS: The authors performed a pilot study of a CIVT system in a population of 10 older adult patients after ankle fracture surgery. RESULTS: Nine patients experienced uncomplicated wound healing of the lateral incision. One patient (10%) developed an SSI after premature removal of the vacuum system because of technical failure. Six weeks postoperation, overall satisfaction with the CIVT was high; none of the participants complained of incapacitating discomfort or disruptive limitations in postsurgical recovery. CONCLUSIONS: The authors conclude that CIVT is a feasible, safe, and generally well-tolerated therapy to prevent SSIs in postoperative wound healing after open reduction and internal fixation in older adult patients after ankle fracture.

[Influencing factors of traumatic arthritis after ankle fracture surgery and construction of risk prediction model].

OBJECTIVE: To explore risk factors of post-operative traumatic arthritis in patients with ankle fracture,and to establish risk prediction model. METHODS: Totally 550 patients with ankle fracture treated from May 2020 to May 2022 were selected as research objects and divided into modeling group (385 patients) and verification group (165 patients) according to 7:3. In modeling group,patients were classified as occurrence group (112 patients) and non-occurrence group (273 patients) according to whether traumatic arthritis occurred after opertaion. Age,body mass index(BMI),gender,smoking history,diabetes history,injury type,fracture type,operation time,manual labor,open injury,osteoporosis,poor reduction,postoperative weight-bearing time,vascular injury,and surgical method were recorded; risk factors of traumatic arthritis in ankle fracture patients were analyzed by single factor and multi factor logistic regression analyses; R software was used to build the prediction model of line graph;receiver operating characteristic (ROC) curve and calibration graph were applied to verify the discrimination and consistency of the model. RESULTS: One hundred and twelve of 385 patients with ankle fracture were developed to post-operative traumatic arthritis,and 275 did not. Univariate analysis showed that there were significant differences in age,BMI,fracture type,operation time,physical labor aboveⅡ,open injury,osteoporosis and poor reduction between two groups (P<0.05). Multivariate Logistic regression analysis showed that age (OR=2.887),BMI (OR=4.042),fracture type (OR=4.244),operation time (OR=2.665),physical labor above gradeⅡ(OR=5.099),osteoporosis (OR=10.219),and poor reduction (OR=3.112) were independent risk factors for traumatic arthritis after ankle fracture (P<0.05). Based on the above risk factors,an nomogram model was established to predict the risk of postoperative traumatic arthritis in ankle fracture patients,and internal and external verification was conducted. The results showed calibration curve of modeling group and verification group showed a good fit between correction curve and ideal curve,indicating that the predicted risk of postoperative traumatic arthritis by the model was basically consistent with actual risk. Area runder ROC curve analysis results showed 0.867[(95%CI(0.826,0.908)] and 0.882 [95%CI(0.827,0.938)],respectively,indicating that the prediction model had good prediction ability. CONCLUSION: Age,BMI,fracture type,operation time,physical labor above gradeⅡ,osteoporosis and poor reduction are all risk factors for post-operative traumatic arthritis in patients with ankle fracture. The prediction model based on the above risk factors could effectively evaluate risk of post-operative traumatic arthritis in patients with ankle fracture.

Wound infection and healing in minimally invasive plate osteosynthesis compared with intramedullary nail for distal tibial fractures: A meta-analysis.

To systematically explore the effects of minimally invasive plate osteosynthesis (MIPO) versus intramedullary nail (IMN) on wound infection and wound healing in patients with distal tibia fractures. A computerised search of PubMed, Web of Science, Cochrane Library, Embase, Wanfang, China Biomedical Literature Database (CBM) and China National Knowledge Infrastructure databases was performed, from their inception to October 2023, to identify relevant studies on the application of MIPO and IMN in patients with distal tibial fractures. The quality of the included literature was evaluated by two researchers based on inclusion and exclusion criteria, and basic information of the literature was collected, with wound infection, postoperative complications and wound healing time as the main indicators for analysis. Stata 17.0 software was applied for analysis. Overall, 23 papers and 2099 patients were included, including 1026 patients in the MIPO group and 1073 patients in the IMN group. The results revealed, when compared with IMN treatment, patients with distal tibia fractures who underwent MIPO treatment had a lower incidence of postoperative complications (OR = 0.33, 95% CI: 0.25-0.42, p < 0.001) and a shorter wound healing time (SMD = -1.00, 95% CI: -1.51 to -0.49, p < 0.001), but the incidence of postoperative wound infection was higher (OR = 2.01, 95% CI: 1.35-3.01, p = 0.001). Both MIPO and IMN are excellent treatments for distal tibia fractures. MIPO is effective in reducing the incidence of complications as well as shortening the time of wound healing time but increases the risk of wound infection. In clinical practice, surgeons can make individual choices based on the patient's wishes and proficiency in both techniques.

Validation of anterior ankle soft tissue dynamics and shear modulus for anterior ankle impingement syndrome after ankle fracture surgery.

Anterior ankle impingement syndrome (AAIS) has been reported to account for a high percentage of complications following ankle fracture surgery. The soft tissue etiology of AAIS is thought to be thickening and inflammation of the anterior ankle soft tissues intervening anteriorly at the tibiotalar joint, causing pain and functional limitation during dorsiflexion. However, the effects of anterior ankle soft tissue dynamics and stiffness on AAIS have yet to be clarified. This study aimed to determine the relationship between AAIS and the anterior ankle soft tissue thickness change ratio and shear modulus using ultrasonography (US). The participants were 20 patients with ankle joint fractures (AO classification A, B) who had undergone open reduction and internal fixation and 20 healthy adults. The evaluation periods were 3 months and 6 months postoperatively. US was used to delineate the tibialis anterior tendon, extensor hallucis longus tendon, and the extensor digitorum longus tendon over the talus and tibia on a long-axis image. Anterior ankle soft tissue thickness was measured as the shortest distance from the most convex part of the talus to the tendon directly above it. The Anterior ankle soft tissue thickness change ratio was determined by dividing the value at 0° dorsiflexion by the value at 10° plantarflexion. The same images as for the anterior soft tissue thickness measurement were drawn for the shear modulus measurement, and the average shear modulus (kPa) was calculated using shear-wave elastography. There was no significant difference in the thickness change ratio between the postoperative and healthy groups. Compared with the healthy group, the shear modulus was significantly higher at 3 and 6 months in the postoperative group (p < 0.01). The shear elastic modulus at 6-month postoperative group was significantly lower than at 3-month postoperative group (p < 0.01). Anterior ankle joint soft tissue stiffness may increase after surgery for an ankle fracture.

Homeopathic Ankle Dislocation for Treatment of Unstable Trimalleolar Fractures Involving Posterior Die-Punch Fragment: A Retrospective Cohort Study.

OBJECTIVES: Unstable trimalleolar fractures are relatively complex and more difficult to manage if die-punch fracture is present. We aimed to evaluate the curative effect of homeopathic ankle dislocation on the unstable trimalleolar fractures involving posterior die-punch fragments. METHODS: A total of 124 patients diagnosed with unstable trimalleolar fractures combined with post-die punch fragment between June 2008 and June 2020 were retrospectively included. Patients who received homeopathic ankle dislocation were named as the experimental group, and patients who accepted conventional treatment were control group. The fracture healing time, wound healing, American Orthopedic Foot and Ankle Society ankle-hindfoot scale (AOFAS), visual analogue scale (VAS), the Kellgren-Lawrence arthritis grading scale (KLAGS) and short-form 36 score (SF-36) scores were collected. Student t-test was used for fracture healing time. Wound healing and SF-36 were compared using the Mann-Whitney test. Repeated measurement analysis of variance (ANOVA) was used for AOFAS and VAS. χ2-test was used for KLAGS. RESULTS: AOFAS showed statistically significant differences between the two groups (p = 0.001). In non-weight-bearing and weight-bearing conditions, VAS scores were significant different between the two groups, and there was an interaction between group and time point (p < 0.001). The experimental group was superior to the control group in terms of physical function (p = 0.022), role-physical (p = 0.018), general health (p = 0.001) and social function (p = 0.042).The operation time of experimental group was shorter than that of control group (p < 0.001). CONCLUSION: Homeopathic ankle dislocation is used for the unstable trimalleolar fractures involving posterior die-punch fragment, which can provide better functional outcomes while shortening the operation time and recovery period.

The effect of massage on the plantar flexor muscles during the fixation period in postoperative patients with an ankle fracture.

INTRODUCTION: Ankle fractures are one of the most common lower extremity fractures. After surgery, the ankle joint is often immobilized in a plantar flexion position, and there have been many reported cases of limited ankle joint range of motion. Therefore, the purpose of the present study was to investigate the effect of regular massage interventions on ankle joint range of motion after removal of fixation. METHODS: The massage group comprised 30 patients who had sustained an ankle fracture and had undergone surgical fixation, physical therapy, and massage between November 2020 and March 2022. These subjects received a 3-min massage twice daily, five times a week. The control group consisted of 38 patients who had sustained an ankle fracture between January 2015 and September 2020 and had undergone surgical fixation as well as regular physical therapy. RESULTS: The respective ankle dorsiflexion and plantarflexion ranges of motion after cast removal were 2.50 ± 7.2° and 42.3 ± 7.2° in the massage group and -8.62 ± 2.9° and 34.8 ± 8.3° in the control group. An unpaired t-test showed that the ankle dorsiflexion and plantarflexion ranges of motion in the massage group were significantly greater than those in the control group (p = 0.036 and p < 0.01). CONCLUSIONS: Our results indicate that regular 3-min massage interventions of the plantar flexors could prevent the progression of a range of motion limitations in postoperative patients with an ankle fracture more effectively than regular physical therapy alone.

Primary Ankle Fusion Using an Antegrade Nail Into the Talus for Early Treatment of OTA Type C3 Distal Tibial Plafond Fractures: A Preliminary Report.

BACKGROUND: Type C3 distal tibial plafond fractures consistently show poor outcomes with high complication rates and significant risk of posttraumatic arthritis. We describe a minimally invasive technique of performing a primary ankle fusion using an anterograde tibial nail and compare our early results to traditional methods of fixation. METHODS: During the acute admission, the patient undergoes an arthroscopic preparation of the ankle joint and insertion of an anterograde nail into the talus. This technique is described in detail and presented alongside a retrospective 5-year review of all adult C3 distal tibial plafond fractures from our center. RESULTS: Twenty-six patients (8 open fractures) had been fixed traditionally using open reduction internal fixation (24 patients) and circular frames (2 patients) with an average follow-up of 20 months. Those internally fixed had protected weightbearing for 3 months. Complications included deep infection (12%), nonunion (8%), malunion (4%), severe posttraumatic osteoarthritis (27%), and the secondary conversion to ankle replacement/fusion (12%) requiring an average of 3 reoperations.Six patients underwent primary fusion (3 open fractures) with an average follow-up of 18 months. Patients were allowed to immediately weightbear. There were no reported complications and the primary fusion group demonstrated shorter hospital stays, faster return to work, and higher mean self-reported foot and ankle score (SEFAS) compared to those treated with ORIF. CONCLUSION: C3 distal tibial plafond fractures are difficult to manage and there has not been a satisfactory method of treating them that allows early return to work, has a low risk of complications, and reduces the risk of posttraumatic tibiotalar arthritis.We present our initial results with a method that uses traditional arthroscopic techniques to prepare the tibiotalar joint together with minimally invasive anterograde tibiotalar nailing. In this initial report of a small group of patients, we found that surgery can be performed once the swelling has subsided after injury and that allowing weightbearing as tolerated did not appear to have a negative effect on initial outcomes. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Joint-Preserving Osteotomy of the Lateral Tibial Plafond for Posttraumatic Osteonecrosis: A Prospective Cohort Study.

BACKGROUND: Posttraumatic osteonecrosis (ON) of the lateral distal tibia is a rare but severe complication of malleolar fractures. Treatment options include ankle fusion, arthroplasty, osteotomy, and drilling but clinical data on outcomes are limited to single case reports. The aim of this study was to prospectively evaluate the outcome following joint-preserving reconstruction. METHODS: Over a 10-year period, 10 patients (8 females and 2 males, average age 36 years; range, 27-68 years) with posttraumatic ON were treated with intra-articular osteotomy of the distal tibia and bone grafting. All patients initially sustained a closed pronation injury, 7 with initial tibiotalar subluxation. Chronic syndesmotic instability following initial treatment was present in 4 patients and 5 were smokers. All patients were followed for a median of 68 (range, 12-103) months, 7 returned in person for clinical and radiographic follow-up. RESULTS: No immediate postoperative complications were seen. Secondary ankle fusion was necessary in 1 case (10%) because of progressive osteoarthritis. At the time of follow-up, anterior ankle arthritis leading to impingement and requiring cheilectomy was noted in 4 cases, partial graft necrosis, and secondary syndesmotic instability requiring revision surgery was seen in 1 case each. Compared with the preoperative values, significant improvement in the Olerud-Molander Ankle Score (P = .012), EuroQuol-5 Score (P = .008), and Foot Function Index (FFI-D pain, P = .028; FFI-D restriction, P = .038) was seen. Average range of motion at the ankle was 45 degrees. CONCLUSION: In our limited series of patients with posttraumatic ON of the lateral distal tibia, we found that joint-preserving reconstruction using an intra-articular distal tibial osteotomy with autologous bone grafting usually provided significant functional improvement and pain relief. In our cohort secondary fusions by a median 5.5-year follow-up were rare, but secondary, joint-sparing surgeries were common. LEVEL OF EVIDENCE: Level III, prospective study.

Early posterior column internal fixation: A staged treatment of type C3 tibial pilon fracture.

Pilon fractures represent a challenging subset of tibial fractures. The management of AO/OTA Type C3 fractures remains complex due to associated complications and lack of clear guidelines for surgical timing and methods. A prospective cohort study was conducted to evaluate two staged treatment strategies for AO/OTA Type C3 tibial pilon fractures. The study focused on assessing surgical difficulty, complications, and patient prognosis. One group of patients received early internal fixation of the fibula and tibial posterior column combined with external fixation, while the other group received external fixation alone in the first stage. Patients who received early internal fixation of the fibula and tibial posterior column combined with external fixation had better outcomes, including lower rate of allogeneic bone grafting (67.74 % versus 94.64 %), reduced incidence of wound delay and skin necrosis (3.23 % versus 21.43 %), shorter surgical time (133.06 ± 23.99 min versus 163.04 ± 26.83 min), shorter hospital stay (13.77 ± 2.53 days versus 18.25 ± 3.67 days), and higher AOFAS (83.05 ± 8.68 versus 79.36 ± 8.92). Additionally, avoiding fibular shortening was shown to be crucial in preventing prolonged surgery and improving patient function. The study demonstrated that the staged treatment approach with early internal fixation led to shorter operative times, improved ankle function, and reduced complications, including a lower risk of infection. The findings support the use of this treatment to optimize outcomes in AO/OTA Type C3 pilon fractures.