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.

Weight-bearing or non-weight-bearing after surgical treatment of ankle fractures: a multicenter randomized controlled trial.

PURPOSE: The goal of this study was to assess if unprotected weight-bearing as tolerated is superior to protected weight-bearing and unprotected non-weight-bearing in terms of functional outcome and complications after surgical fixation of Lauge-Hansen supination external rotation stage 2-4 ankle fractures. METHODS: A multicentered randomized controlled trial was conducted in patients ranging from 18 to 65 years of age without severe comorbidities. Patients were randomized to unprotected non-weight-bearing, protected weight-bearing, and unprotected weight-bearing as tolerated. The primary endpoint of the study was the Olerud Molander Ankle Score (OMAS) 12 weeks after randomization. The secondary endpoints were health-related quality of life using the SF-36v2, time to return to work, time to return to sports, and the number of complications. RESULTS: The trial was terminated early as advised by the Data and Safety Monitoring Board after interim analysis. A total of 115 patients were randomized. The O'Brien-Fleming threshold for statistical significance for this interim analysis was 0.008 at 12 weeks. The OMAS was higher in the unprotected weight-bearing group after 6 weeks c(61.2 ± 19.0) compared to the protected weight-bearing (51.8 ± 20.4) and unprotected non-weight-bearing groups (45.8 ± 22.4) (p = 0.011). All other follow-up time points did not show significant differences between the groups. Unprotected weight-bearing showed a significant earlier return to work (p = 0.028) and earlier return to sports (p = 0.005). There were no differences in the quality of life scores or number of complications. CONCLUSIONS: Unprotected weight-bearing and mobilization as tolerated as postoperative care regimen improved short-term functional outcomes and led to earlier return to work and sports, yet did not result in an increase of complications.

Routine Follow-Up Radiographs for Ankle Fractures Seldom Add Value to Clinical Decision-Making: A Retrospective, Observational Study.

Currently, the routine use of radiographs for uncomplicated ankle fractures represents good clinical practice. However, radiographs are associated with waiting time, radiation exposure, and costs. Studies have suggested that radiographs seldom alter the treatment strategy if no clinical indication for the imaging study was present. The objective of the present study was to evaluate the effect of routine radiographs on the treatment strategy during the follow-up period of ankle fractures. All patients aged ≥18 years, who had visited 1 of the participating clinics with an eligible ankle fracture in 2012 and with complete follow-up data were included. The data were retrospectively analyzed. The sociodemographic and clinical characteristics and the number of, and indications for, the radiographs taken were collected from the medical records of the participating clinics. We assessed the changes in treatment strategy according to the radiographic findings. In 528 patients with an ankle fracture, 1174 radiographs were performed during the follow-up period. Of these radiographs, 936 (79.7%) were considered routine. Of the routine radiographs taken during the follow-up period, only 11 (1.2 %) resulted in changes to the treatment strategy. Although it is common practice to take radiographs routinely during the follow-up period for ankle fractures, the results from the present study suggest that routine radiographs seldom alter the treatment strategy. This limited clinical relevance should be weighed against the health care costs and radiation exposure associated with the use of routine radiographs. For a definitive recommendation, however, the results of our study should be confirmed by a prospective trial, which we are currently conducting.

Prospective analytical study of assessment of off loading by Total Contact Cast in treatment of non healing plantar ulcers in anaesthetic foot.

BACKGROUND: Chronic planter ulcer, also known as trophic ulcer, shows no tendency towards healing. It is usually seen in sensory deficient foot. The clinical result of a sensory, motor or autonomic loss of a nerve function is frequently the same--ulceration, although the exact cause may vary. The treatment principle involves dressing and avoiding pressure on the ulcerated site called 'offloading' and patient education for prevention. AIM OF THE STUDY: To determine the outcome of non-healing planter ulcers in an anaesthetic foot treated with offloading, total contact casting (TCC), in terms of rate and duration of healing and percentage of ulcers healed based on improvement of Wagner's grading with respect to the clinical profile of the patient. METHOD: Detailed examination of the patients was done, and neuropathic foot confirmed. Surgical debridement of the ulcer was done to take off all the necrotic tissues, periwound callus, and infected material down to viable tissues. Once the ulcer became clean, a total contact cast was applied with a walking iron for ambulation. TCC was renewed every 2 weeks and rate of healing was assessed. RESULT: 80% of the cases healed within 8 weeks, healing defined by complete re-epithelisation of wound. Average duration of healing of an ulcer was 6.73 ±1.92 weeks. LIMITATIONS OF THE STUDY: Small sample size and the lack of control subjects for comparison. CONCLUSION: Offloading with total contact casts is believed to be the gold standard method with better and faster healing rates.

A rare type of ankle fracture: Syndesmotic rupture combined with a high fibular fracture without medial injury.

High fibular spiral fractures are usually caused by pronation-external rotation mechanism. The foot is in pronation and the talus externally rotates, causing a rupture of the medial ligaments or a fracture of the medial malleolus. With continued rotation the anterior and posterior tibiofibular ligament will rupture, and finally, the energy leaves the fibula by creating a spiral fracture from anterior superior to posterior inferior. In this article we demonstrate a type of ankle fracture with syndesmotic injury and high fibular spiral fractures without a medial component. This type of ankle fractures cannot be explained by the Lauge-Hansen classification, since it lacks injury on the medial side of the ankle, but it does have the fibular fracture pattern matching the pronation external rotation injury (anterior superior to posterior inferior fracture). We investigated the mechanism of this injury illustrated by 3 cases and postulate a theory explaining the biomechanics behind this type of injury.

Weight bearing or non-weight bearing after surgically fixed ankle fractures, the WOW! Study: study protocol for a randomized controlled trial.

BACKGROUND: The optimal post-operative care regimen after surgically fixed Lauge Hansen supination exorotation injuries remains to be established. This study compares whether unprotected weight bearing as tolerated is superior to protected weight bearing and unprotected non-weight bearing in terms of functional outcome and safety. METHODS/DESIGN: The WOW! Study is a prospective multicenter clinical trial. Patients between 18 and 65 years of age with a Lauge Hansen supination exorotation type 2, 3 or 4 ankle fractures requiring surgical treatment are eligible for inclusion. An expert panel validates the classification and inclusion eligibility. After surgery, patients are randomized to either the 1) unprotected non-weight-bearing, 2) protected weight-bearing, or 3) unprotected weight-bearing group. The primary outcome measure is ankle-specific disability measured by the Olerud-Molander ankle score. Secondary outcomes are 1) quality of life (e.g., return to work and resumption of sport), 2) complications, 3) range of motion, 4) calf wasting, and 5) maximum pressure load after 3 months and 1 year. DISCUSSION: This trial is designed to compare the effectiveness and safety of unprotected weight bearing with two commonly used post-operative treatment regimens after internal fixation of specified, intrinsically stable but displaced ankle fractures. An expert panel has been established to evaluate every potential subject, which ensures that every patient is strictly screened according to the inclusion and exclusion criteria and that there is a clear indication for surgical fixation. TRIAL REGISTRATION: The WOW! Study is registered in the Dutch Trial Register ( NTR3727 ). Date of registration: 28-11-2012.

Adult-type bimalleolar ankle fracture in children: report of two cases.

UNLABELLED: Ankle fractures patterns in children may vary depending on the maturity of the distal tibial and fibular physis. Bimalleolar ankle fracture is an exceedingly rare fracture pattern in children and has been reported once in the current English literature. Two further adolescents with bimalleolar ankle fracture are reported. Although these fractures are rare, surgeons should be aware of these atypical fracture patterns. Herein, the underlying physiology and the mechanism of injury of ankle fractures in children are discussed. LEVEL OF EVIDENCE: Therapeutic, Level IV, Case study.

Surgical versus nonsurgical treatment of the SE4-equivalent ankle fracture: a retrospective functional outcome study.

Treatment of Lauge-Hansen supination-eversion (SE)4-equivalent ankle fractures is controversial. This retrospective study conducted at a level-I trauma center compared the clinical outcome of nonsurgical vs open management of these fractures. One thousand eight ankle fractures treated between 1998 and 2003 were reviewed. Forty-three patients who met the criteria for a SE4-equivalent ankle fracture were identified. Average patient age of 23 men and 20 women was 42 years (range, 18-84 years). Olerud Molander ankle scores were recorded. Medical records and radiographs of all patients were reviewed. Average follow-up was 20 months.Twenty-six patients were treated nonsurgically, with an average ankle score of 84 ± 4. Seventeen patients treated surgically had an average ankle score of 63 ± 5. The difference is statistically significant (unpaired t test, P=.0035). There was no difference between open vs closed treatment in maintaining a reduction. To investigate the reason for poor results in the surgical group, we sought an association between functional ankle score and common covariables and found that age and preoperative radiographic grading were important variables for ankle score. Patients younger than 30 years had an average ankle score of 85, whereas those older than 50 years had an average score of 61 (P<.001). Type 1 fractures (medial clear space >5 mm in stress view only) had an average ankle score of 89, type 2 (medial clear space >5 mm but <10 mm) an average score of 76, and type 3 (medial clear space >10 mm or presented with fracture dislocation and/or syndesmosis injury) an average score of 61. Our data support that type 1 and 2 fractures can effectively be treated nonsurgically.

Early active motion versus immobilization after tendon transfer for foot drop deformity: a randomized clinical trial.

BACKGROUND: Immobilization after tendon transfers has been the conventional postoperative management. Several recent studies suggest early mobilization does not increase tendon pullout. QUESTIONS/PURPOSES: To confirm those studies we determined whether when compared with immobilization early active mobilization after a tendon transfer for foot-drop correction would (1) have a similar low rate of tendon insertion pullout, (2) reduce rehabilitation time, and (3) result in similar functional outcomes (active ankle dorsiflexion, plantar flexion, ROM, walking ability, Stanmore score, and resolution of functional problems. METHODS: We randomized 24 patients with surgically corrected foot-drop deformities to postoperative treatment with early mobilization with active motion at 5 days (n = 13) or 4 weeks of immobilization with active motion at 29 days (n = 11). In both groups, the tibialis posterior tendon was transferred to the extensor hallucis longus and extensors digitorum communis for foot-drop correction. Rehabilitation time was defined as the time from surgery until discharge from rehabilitation with independent walking. The minimum followup was 16 months (mean, 19 months; range, 16-38 months) in both groups. RESULTS: We observed no case of tendon pullout in either group. Rehabilitation time in the mobilized group was reduced by an average of 15 days. The various functional outcomes were similar in the two groups. CONCLUSION: In patients with Hansen's disease, an early active mobilization protocol for foot-drop correction has no added risk of tendon pullout and provides similar functional outcomes compared with immobilization. Early mobilization had the advantage of earlier restoration of independent walking. LEVEL OF EVIDENCE: Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

A randomized clinical trial comparing immediate active motion with immobilization after tendon transfer for claw deformity.

PURPOSE: Immobilization after tendon transfers has been the conventional postoperative management. A recent study indicated beneficial effects of an immediate active motion protocol (IAMP) after tendon transfer for claw deformity correction compared with effects in a historical cohort. In this study, we further tested this hypothesis in a randomized clinical trial comparing the effectiveness of the IAMP with that of conventional immobilization. METHODS: Fifty supple claw hand deformities were randomized postoperatively into 2 equal groups for IAMP and immobilization. Therapy began on the second postoperative day for the IAMP group and on the twenty-second postoperative day for the immobilization group. The primary outcome measures were deformity correction, active range of motion of digits, tendon transfer insertion pullout, and time until discharge from rehabilitation. Secondary outcome measures were swelling, pain, hand strength, and dexterity. Both groups were compared at discharge from rehabilitation and at the last clinical follow-up (at least 1 year postoperatively). RESULTS: Assessments were available for all 50 patients at discharge and for 23 patients in each group at follow-up. The average follow-up was 18 months for the IAMP group and 17 months for the immobilization group. Deformity correction, range of motion, swelling, dexterity, and hand strength were similar for both groups at discharge and a follow-up. There was no evidence of tendon insertion pullout in any patient of either group. Relief of pain was achieved significantly earlier with IAMP. Morbidity was reduced by, on average, 22 days with IAMP. CONCLUSIONS: We found that the immediate active motion protocol is safe and has similar outcomes compared with those of immobilization, with the added advantage of earlier pain relief and quicker restoration of hand function. Immediate motion after tendon transfer can significantly reduce morbidity and speed up the rehabilitation of paralytic limbs, and it may save expense for the patients.

Tibialis posterior transfer by interosseous route for the correction of foot drop in leprosy.

This article summarises a prospective study to evaluate the long-term results produced by interosseous transfer of the tibialis posterior tendon for the correction of foot drop due to leprosy neuritis. The study was carried out in 120 feet in 69 patients. All patients had closed elongation of the tendo Achillis (ETA) before transfer of the bifurcated tibialis posterior tendon through the interosseous route to the tendons of tibialis anterior and peroneous tertius or brevis over the dorsum of feet. At final follow-up of average 24 months, all the patients with ETA had a significantly greater range of active dorsiflexion of more than 10 degrees above 90 degrees, which was not merely from the tenodesing effect. The results, in terms of improvement in gait and prevention of trophic changes, remained satisfactory. An interosseous route is preferred with split attachment to the tibialis anterior and to the peroneus brevis or tertius tendons.

Opponens plasty rehabilitation protocol--a case report.

In this case report of opponens plasty, we will attempt to accomplish two objectives: 1) to characterize some innovative modifications to the standard rehabilitation protocol for an opponens plasty and 2) to explain the role and advantages of a new muscle re-education splint in this modified protocol.

Comparison of two conservative methods of treating an isolated fracture of the lateral malleolus.

We compared two conservative methods of treating Weber B1 (Lauge-Hansen supination-eversion 2) isolated fractures of the lateral malleolus in 65 patients. Treatment by immediate weight-bearing and mobilisation resulted in earlier rehabilitation than immobilisation for four weeks in a plaster cast. There was no significant difference in the amount of pain experienced or in the requirement for analgesics and early mobilisation was not associated with any complications. We therefore advocate early mobilisation for these stable ankle fractures.

Healing rates of plantar ulcers in leprosy and diabetes.

Comparison was made of wound healing time in a consecutive series of leprosy and diabetic patients with plantar ulceration. In the leprosy group, 66 of 70 (94%) ulcers healed in a mean time of 42.7 (+/- 36.1) days, and in the diabetic group, 75 of 80 (94%) ulcers healed in a mean time of 39.7 (+/- 32.1) days. Analysis of all healed ulcers using a general linear model found wound depth (p < 0.03), and wound diameter (p < 0.05) significantly related to ulcer healing time. Diagnosis, healing devices (cast, splint and cut-out sandal), age and sex were not significant. In diabetic subjects a regression model including depth, diameter and age explained 36% of the variation in healing time. A meaningful regression model was not found in leprosy patients.

Examination of the pathologic anatomy of ankle fractures.

A prospective study of the translational and rotational displacement of the lateral malleolus in ankle fractures was carried out utilizing roentgenographic techniques. Twenty-six ankle fractures in 25 patients were studied using both routine plain films and CT scanning with two- and three-dimensional multiplanar reconstruction. Eighty-one percent were Lauge-Hansen supination-external rotation type injuries. Overall, 21 fractures did not involve the medial malleolus. Initial talar shift was less than or equal to 2 mm in 15 fractures. Although all patients exhibited external rotation deformities of the lateral malleolus on plain films, only one fracture was found to possess any degree of external rotation relative to the talus. The proximal fibula was seen on CT scans to have increased internal rotation with respect to the tibia in 19 cases. One patient had a slightly externally rotated proximal fibula; the remainder appeared normally aligned. The displacements measured by the CT scans at the talofibular articulation were compared with the standard plain film measurements. The displacements at the distal lateral malleolus were consistently overestimated by the plain roentgenograms, presumably because the capsular and ligamentous attachments to the distal fibula limit malleolar displacement. The talocrural angle, determined on both plain films and CT scans, was also not found to be a sensitive measure of fibular shortening nor of the severity of the fracture. The results of this study suggest that, in an isolated lateral malleolar ankle fracture, the apparent external rotation of the fracture fragment is relative only to the proximal fibula and is not associated with derangement of the talofibular articulation. Based on these mechanical considerations, surgical intervention for such fractures may not be necessary. This hypothesis is consistent with previous long-term clinical studies.

Methods of treating plantar ulcers.

The purpose of this article is to describe the indications, precautions, and fabrication techniques for orthotic devices the authors use to facilitate the healing of plantar ulcers. The methods of fabricating and applying three types of orthotic devices developed by the staff at the Gillis W Long Hansen's Disease Center--walking casts, walking splints, and cutout sandals--are described. Patient examples are given for each of the methods. These techniques, in conjunction with patient education and the use of special footwear, provide clinicians with procedures they can use to aid in the healing of plantar ulcers secondary to leprosy, diabetes, or other neuropathic conditions.

Comparative study of functional bracing and plaster cast treatment of stable lateral malleolar fractures.

In a prospective, randomized study, the use of the Aircast pneumatic air stirrup was compared with a standard below-knee walking cast in the management of Lauge-Hansen supination-eversion, stage II ankle fractures. Forty patients were randomly allocated to the two treatment groups. The use of the air stirrup led to a significant improvement in early patient comfort, post-fracture swelling, range of ankle motion at union, and time to full rehabilitation. We advocate the use of pneumatic air stirrup in the cost-effective management of stable ankle fractures.