Patterns of Anterior Inferior Tibiofibular Ligament Avulsion Fracture Accompanied by Ankle Fracture.

The anterior inferior tibiofibular ligament (AITFL) avulsion fracture accompanying an ankle fracture can compromise ankle stability, necessitating accurate evaluation and a clear understanding of its pathophysiology.. The aim of this study was to investigate the association between AITFL avulsion fracture and Lauge-Hansen, Wagstaffe classification. A retro-prospective study was conducted at a university-affiliated tertiary care medical center. We selected 128 patients who underwent surgery at our institution between January 2013 and July 2017 and analyzed the association between AITFL avulsion fracture and the foot position. According to the modified Wagstaffe classification system, there were 39 cases of type II, followed by 9 cases of type III and 8 cases of type IV. Of the7 pronation-abduction fractures, 3 were AITFL avulsion fracture (43%), while of the 21 pronation-external rotation fractures, 9 were AITFL avulsion fracture (43%). Of the 95 supination-external rotation fractures, there were 56 cases (59%) of AITFL avulsion fractures. Of the pronation fractures, 0% were fibular avulsion fractures and 43% were tibial avulsion fractures. Of the supination fractures, 44% were fibular avulsion fractures and 16% were tibial avulsion fracture. The difference in the ratio of fibular to tibial avulsion fractures between pronation and supination fractures was significant (p < .001). These results suggest that tibial avulsion fractures of type IV in the modified Wagstaffe classification and pronation fractures occur due to collision with the anterolateral corners of the distal bone when the talus externally rotates. Moreover, in cases of pronation fractures, a new type of AITFL avulsion fracture has been observed.

Irreducible Ankle Fracture Dislocation Because of Tibialis Posterior and Flexor Digitorum Longus Tendon Entrapment in the Interosseous Membrane: A Case Report.

CASE: We describe the case of a 63-year-old man with anterior ankle dislocation and fracture confirmed by x-ray. Postreduction x-ray and computed tomography (CT) revealed Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) type 44C3 and Lauge-Hansen pronation-external rotation-type ankle fractures. CONCLUSION: This was a rare case of ankle fracture dislocation because of entrapment of the tibialis posterior and flexor digitorum longus tendons in the interosseous membrane. Tendon entrapment should be suspected in cases of high-energy injuries, Weber type C fractures, Lauge-Hansen pronation-external rotation fractures, syndesmosis widening, and irreducible fractures using manual closed reduction. Fractures and soft tissues should be evaluated by changing the CT settings.

Factors Associated With Successful Closed Reduction of Dislocated Ankle Fractures at a US Level-1 Trauma Center.

Dislocated ankle fractures represent a common presenting pathology at US emergency departments, and several different procedural and anesthetic techniques are employed for attempted closed reduction of these injuries. The objective of this investigation was to evaluate the frequency of and factors associated with success in the closed reduction of dislocated ankle fractures. A diagnostic code search produced 1050 ankle fractures presenting to an urban US level-1 emergency department. These medical records were interrogated and first categorized into whether or not a closed reduction was attempted. Those identified closed reduction attempts were further categorized into whether the attempt was successful. A comparative analysis was subsequently performed of variables associated with procedure success. Of the 1050, 97 (9.2%) required closed reduction and of these, 76 (78.4%) were successfully closed reduced on the first attempt. No differences were observed in initial procedure success with respect to subject age (p = .701), subject gender (p = .623), fracture laterality (p = 1.00), open versus closed injuries (p = .282), fracture mechanism (p = 1.00), utilized anesthetic technique (p value range 0.291-0.616), or the specialty performing the reduction (p-value range 0.402-1.00). A descriptive subanalysis was performed on those fractures with an unsuccessful first closed reduction attempt. It is our hope that this investigation adds to the body of knowledge with respect to a commonly performed procedure by foot and ankle surgeons.

Factors Affecting Hospital Length of Stay in Geriatric Patients With a Surgically Treated Fragility Ankle Fracture.

Fragility ankle fractures in elderly have a rising incidence and hospitalization may be prolonged due to pre-existing comorbidities, compromised soft tissue and postoperative difficulties in the rehabilitation process. The aim of this retrospective cohort study was to investigate risk factors for longer total hospitalization duration in elderly patients with surgically treated fragility (Lauge Hansen supination external rotation type 4) fractures. We included all patients ≥ 70 years with a fragility fracture, who were treated surgically between 2011 and 2019 (n = 97) in a level 1 and 2 trauma center. Data on patient demographics, fracture characteristics, surgical treatment strategies and postoperative complications were retrieved from medical records. Multivariate regression analysis was performed to identify independent risk factors for longer hospitalization duration. The mean age of the included patients was 78.27 (± 6.56) years; 71 patients (73.20%) were female. Ten fractures (10.30%) were classified as open and 49 (50.50%) as a luxation type fracture. Fifty-nine patients (60.80%) were hospitalized after admission to the emergency department. External fixation was performed in 34 patients (35.10%) and served as bridge to definitive fixation in 29 patients (85.30%). The mean total hospital length of stay of all patients was 7.04 (± 6.58) days. Multivariate regression analysis demonstrated that the use of external fixation (p < .001) and the postoperative discharge destination (p < .001) were independently associated with a prolonged hospital stay. External fixation and discharge destination were independent risk factors for a prolonged hospital stay in elderly patients with a fragility fracture.

Reproducibility of the stability-based classification for ankle fractures.

BACKGROUND: Classification of ankle fracture is important when deciding for operative or conservative treatment. This study rates the reproducibility of ankle stability assessment and compares it with the classification by Lauge-Hansen and Arbeitsgemeinschaft für Osteosyntesefragen (AO) in adult patients with primary ankle fractures. METHODS: A total of 496 consecutive ankle fractures were included, and the X-ray images were reviewed 2 times by 2 medical students, 2 residents, and 1 consultant in orthopedic traumatology. The raters were blinded to each other and to their own results. Unweighted Kappa statistics were used to assess reproducibility. RESULTS: Overall mean (95% CI) interrater Kappa results were 0.65 (0.64; 0.68) for Lauge-Hansen, 0.62 (0.60; 0.63) for AO and 0.61 (0.57; 0.62) for the stability assessment. The intrarater results ranged from a mean Kappa of 0.64-0.80 for the medical students, 0.65-0.81 for the residents and 0.82-0.84 for the consultant. CONCLUSION: The stability assessment has substantial to almost-perfect agreement which is comparable to the Lauge-Hansen and AO classifications.

Evaluation of Transsyndesmotic Fixation and Primary Deltoid Ligament Repair in Ankle Fractures With Suspected Combined Deltoid Ligament Injury.

The present prospective study examined the utility of the intraoperative tap test/technique for distal tibiofibular syndesmosis in the diagnosis of deltoid ligament rupture and compared the outcomes of transsyndesmotic fixation to deltoid ligament repair with suture anchor. This diagnostic technique was performed in 59 ankle fractures with suspected deltoid ligament injury. The width of the medial clear space of 59 cases was evaluated to assess the sensitivity and specificity. Those with deltoid ligament rupture were randomly assigned to 2 groups and treated with deltoid ligament repair with a suture anchor or with syndesmosis screw fixation. All the patients were assessed with the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, short-form 36-item questionnaire (SF-36), and visual analog scale (VAS). The tap test was positive in 53 cases. However, surgical exploration demonstrated that 51 cases (86.4%) had a combined deltoid ligament injury and fracture. The sensitivity and specificity of the tap test was 100.0% and 75.0%, respectively. Finally, 26 cases (96.3%) in the syndesmosis screw group and 22 (91.7%) in the deltoid repair group were followed up. No statistically significant differences were found in the AOFAS ankle-hindfoot scale score, SF-36 score, or VAS score between the 2 groups. The malreduction rate in the syndesmosis screw group was 34.6% and that in the deltoid repair group was 9.09%. The tap test is an intraoperative diagnostic method to use to evaluate for deltoid ligament injury. Deltoid ligament repair with a suture anchor had good functional and radiologic outcomes comparable to those with syndesmotic screw fixation but has a lower malreduction rate. We did not encounter the issue of internal fixation failure or implant removal.

Predicting syndesmotic injuries in ankle fractures: a new system based on the medial malleolar focus.

The early establishment of the diagnosis of a syndesmotic injury is essential for treatment selection. However, such injuries may not be apparent radiographically. Previous studies have attempted to describe correlations between medial malleolar fracture geometry and syndesmotic disruption. The main objective of this study was to create predictive models for assessing syndesmotic injuries based on an originally described angle, i.e., the medial crural-focal angle (MCFA). This study included 138 ankle fractures involving the medial malleolus. Any measure from the plain radiograph that could potentially lead to the suspicion of a syndesmotic disruption was recorded, and the newly described MCFA (formed by the main line of the medial malleolus fracture and a line perpendicular to the bearing surface of the tibial plafond) was also recorded. The inter- and intraobserver reliabilities were obtained using Krippendorff's alpha coefficients. To examine the predictive abilities of every parameter, several statistical methods were applied including logistic regression, an ad hoc clinical rule, and discriminant analysis. After variable selection, we obtained the best possible logistic model. The variables that were found to be statistically significant were the MCFA, the tibiofibular clear space (TFCS) and the type of injury in the Lauge-Hansen (L-H) classification. This model was tested by cross validation, which revealed a mean percentage of correctly classified patients of 88%. A simpler and more intuitive alternative model was sought that was based solely on the influences of the MCFA and the TFCS. Our study revealed that an absence of syndesmotic disruptions when the MCFA was under 60°, and there were no uninjured patients with tibiofibular clear space values over 6mm. Cross-validation revealed that the mean percentage of patients who were correctly classified with this model was 86%. The application of discriminant analysis to this combination of variables resulted in a function was able to correctly classify a mean of 84% of patients. In conclusion, three models that can predict syndesmotic injury using parameters from preoperative plain radiographs were obtained and validated. The MCFA measurement was in these models and found to be a reliable technique.

Temporal Variation in Ankle Fractures and Orthopedic Resident Program Planning in an Urban Level 1 Trauma Center.

Previous studies have described the mechanism of ankle fractures, their seasonal variation, and fracture patterns but never in conjunction. In addition, the cohorts previously studied were either not from trauma centers or were often dominated by low-energy mechanisms. The present study aimed to describe the epidemiology of ankle fractures presenting to an urban level 1 trauma center. The records from an urban level 1 trauma center located in the Midwestern United States were retrospectively reviewed, and the injury mechanism and energy, time of injury, day of week, month, and patient characteristics (age, gender, comorbidities, smoking status) were collected. The fractures were classified using the AO (Arbeitsgemeinschaft für Osteosynthesefragen), Lauge-Hansen, and Danis-Weber systems. Of these systems, the Lauge-Hansen classification system resulted in the greatest number of "unclassifiable" cases. Most ankle fractures were due to high-energy mechanisms, with motor vehicle collisions the most common high-energy mechanism. The review found that most ankle fractures were malleolar fractures, regardless of the mechanism of injury. The ankle fracture patients had greater rates of obesity, diabetes, and smoking than present in the region where the hospital is located. The fractures were most likely to occur in the afternoon, with more fractures presenting on the weekend than earlier in the week and more fractures in the fall and winter than in the spring and summer. The temporal variation of these fractures should be considered for health services planning, in particular, in regard to resident physician staffing at urban level 1 trauma centers.

Prospective Computed Tomographic Analysis of Osteochondral Lesions of the Ankle Joint Associated With Ankle Fractures.

BACKGROUND: Osteochondral lesions (OCLs) associated with ankle fracture correlate with unfavorable outcome. The goals of this study were to detect OCLs following ankle fracture, to associate fracture type to OCLs and to investigate whether OCLs affect clinical outcome. METHODS: 100 ankle fractures requiring operative treatment were prospectively included (46 men, 54 women; mean age 44 ± 14 years, range 20-77). All ankle fractures (conventional radiography; 71 Weber B, 22 Weber C, 1 Weber A, 4 isolated medial malleolus and 2 isolated posterior malleolus fractures) were treated by open reduction and internal fixation. Multidetector computed tomography (CT) was performed postoperatively. For each OCL, the location, size, and Loomer OCL classification (CT modified Berndt and Harty classification) were determined. The subjective Foot and Ankle Outcome Scoring (FAOS) was used for clinical outcome at 1 year. RESULTS: OCLs were found in 10/100 ankle fractures (10.0%). All OCLs were solitary talar lesions. Four OCLs were located posteromedial, 4 posterolateral, 1 anterolateral, and 1 anteromedial. There were 2 type I OCLs (subchondral compression), 6 type II OCLs (partial, nondisplaced fracture) and 2 type IV OCLs (displaced fracture). Mean OCL size (largest diameter) was 4.4 ± 1.7 mm (range, 1.7 mm to 6.2 mm). Chi-square analysis showed no significant association between ankle fracture type and occurrence of OCLs. OCLs did occur only in Lauge-Hansen stage III/IV ankle fractures. There were no significant differences in FAOS outcome between patients with or without OCLs. CONCLUSIONS: Ten percent of investigated ankle fractures had associated OCLs on CT. Although no significant association between fracture type and OCL was found, OCLs only occurred in Lauge-Hansen stage III/IV ankle fractures. With the numbers available, OCLs did not significantly affect clinical outcome at 1 year according to FAOS. LEVEL OF EVIDENCE: Level IV, observational study.