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.

Patterns of Ankle Fractures Based on Radiographs and CT Images of 1000 Consecutive Patients.

Objectives: The knowledge of different types of ankle fractures based on plain radiographs and computed tomography (CT) images can help improve patients' management. Methods: This cross-sectional study assessed the plain radiographs and CT images of 1,000 consecutive patients observed in an emergency department between March 2015 and March 2020. Fractures were labeled as uni-, bi-, or trimalleolar. Malleolar fractures were classified into medial, lateral, and posterior ones based on Herscovici, Danis-Weber, and Mason and Molloy classifications, respectively. Bi- and trimalleolar fractures, on the other hand, were categorized according to the Lauge-Hansen classification. Results: This study included 1,000 patients with 1,003 ankle fractures. Of them, 901 were adults (mean±SD age: 41.6±16.7, male: 567 [62.9%]) with 904 fractures. In total, 53% of adult patients were 18 to 39 years old. Considering unilateral ankle fractures, the medial malleolar fracture was the most common unimalleolar fracture (62.6%), with Herscovici C being the most frequent subtype (65.3%). On the other hand, the most common type of lateral malleolar fracture was Danis-Weber type B (65.5%). There were also 209 (23.3%) bimalleolar and 114 (12.7%) trimalleolar fractures, 5.8% (16 fractures) of which could not be classified based on the Lauge-Hansen classification. Unimalleolar fractures were also observed in 87 (87.9%) children, with the medial malleolar fracture being the most common type (89.7%). Conclusion: Medial malleolar fractures were the most frequent malleoli in patients observed in the emergency department under study. Among bi- and trimalleolar ankle fractures, supination-external rotation and pronation-external rotation injuries were the most common patterns. The Lauge-Hansen classification was not applicable in 5.8% of bi- and trimalleolar fractures.

Effect of chronic heavy tobacco smoking on ankle fracture healing.

INTRODUCTION: Tobacco smoking is linked to an elevated risk of osteomyelitis and delayed healing in long bone fractures. However, the impact of smoking on bone union and soft tissue recovery following ankle fractures remains unclear. This study presents a retrospective comparative analysis evaluating the effects of chronic heavy tobacco smoking on the healing process and outcomes of ankle fractures after surgical interventions. MATERIALS AND METHODS: We examined 220 consecutive cases of chronic heavy smokers (CHS) with closed ankle fractures who were referred to our unit for further treatment. A control group, consisting of 220 age- and sex-matched individuals (non-smokers with closed ankle fractures), was identified for comparative analysis. We collected clinical data, including pre-existing comorbidities, Lauge-Hansen fracture classification, necessity for surgery, and the surgical procedures performed. The primary outcomes investigated were the time required for fracture union and wound healing. Secondary outcomes included postoperative complications such as prolonged pain, bleeding, swelling, infection, compartment syndrome, and neurovascular impairment, as well as the incidence of delayed union, non-union, and the need for further intervention. Both cohorts were monitored for a minimum of 24 months. RESULTS: Our analysis revealed that the surgical cohort of chronic heavy smokers exhibited a statistically significant delay in fracture union compared to both the conservatively managed smokers and the control group. Further scrutiny of the surgical cohort of chronic smokers indicated a significant correlation between smoking and extended postoperative pain duration, persistent swelling at the fracture site, and both superficial and deep wound infections. Additionally, these patients experienced delays in both fracture union and wound healing when compared to the control group. Similarly, the conservatively managed chronic smokers showed a marginal increase in the incidence of post-injury pain duration, extended swelling at the fracture site, and delayed union compared to the control group. CONCLUSION: Patients who are chronic heavy smokers and require surgical intervention for ankle fractures should be made aware of their increased risk for delayed fracture union and poor wound healing. Orthopedic surgeons should proactively encourage these patients to participate in smoking cessation programs.

Morphology of Fibular Incisura is a Deciding Factor Between Posterior Malleolus Avulsion Fracture or Syndesmotic Ligament Injury in Ankle Fractures.

The bone anatomy of tibiofibular syndesmosis has been a topic of interest. Fibular incisura morphology has been analyzed on cadaver specimens, plain radiographs, or CT images. The aim of this study is to examine the effects of fibula incisura features and fibula morphology in ankle injuries, especially involving posterior malleolus and posteroinferior tibiofibular ligament injuries. From 2017 through 2022, A total of 59 patients with isolated lateral malleolar fracture, Mason-Malloy type 1 posterior malleolar fracture, syndesmosis injury in those without posterior malleolar fracture, supination external rotation type 3 injuries according to Lauge-Hansen classification, and preoperative bilateral ankle computed tomography images were included in the study. Fibula morphologies and syndesmosis measurements were made from preoperative computed tomography images using axial CT images from 1 cm proximal to the tibial plafond. The diagnosis of posterior malleolar fractures was made using the CT classification system of Mason and Malloy, and the diagnosis of syndesmosis injury was made with a cotton test during surgery. Age, gender, fractured side, incisura type, incisor depth, width, anterior and posterior facet lengths, incisor version (antevert-retrovert), the angle between the anterior and posterior facets, and fibula type were recorded. There was a statistically significant difference between the groups in posterior facet length and incisura width. Morphological features of fibular incisura may be the determinant of PITFL injury or PMA injury in fibular fractures caused by an external rotation mechanism.

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.

[Conservative treatment of supination and external rotation for type â ¢ and â £ankle fracture by bone setting].

OBJECTIVE: To explore curative effect of conservative treatment of supination-lateral rotation (SER) with type Ⅲ and Ⅳ ankle fracture by bone setting technique. METHODS: From January 2017 to December 2019, 64 patients diagnosed with SER with type Ⅲ and Ⅳ ankle fracture were treated with manipulative reduction and conservative treatment (manipulation group) and surgical treatment with open reduction and internal fixation (operation group), 32 patients in each group. In manipulation group, there were 17 males and 15 females, aged from 15 to 79 years old with an average of (51.42±13.68) years old;according to Lauge-Hansen classification, there were 8 patients with supination external rotation type Ⅲ and 24 patients with type Ⅳ. In operation group, there were 13 males and 19 females, aged from 18 to 76 years old with an average of (47.36±15.02) years old;7 patients with type Ⅲ and 25 patients with type Ⅳ. Displacement of ankle fracture was measured by Digimizer software, and compared before treatment, 3 and 12 months after treatment between two groups. Lateral medial malleolus displacement, lateral medial malleolus displacement, lateral malleolus displacement, lateral malleolus displacement, lateral malleolus contraction displacement and posterior malleolus displacement were measured and compared between two groups. Mazur score was used to evaluate ankle joint function. RESULTS: All patients were followed up from 12 to 36 months with an average of (17.16±9.36) months. There were statistical differences in lateral medial malleolus displacement, lateral medial malleolus displacement, lateral malleolus displacement, lateral malleolus displacement, lateral malleolus contraction displacement and posterior malleolus displacement in manipulation group before and after reduction(P<0.05). Compared with operation group, there were no statistically significant differences in lateral malleolus shift, lateral malleolus shift, lateral malleolus contraction shift(P>0.05), while there were statistically significant differences in lateral malleolus shift, posterior malleolus shift up and down (P<0.05). Mazur scores of ankle joint at 3 months after treatment in manipulation group and operation group were 68.84±13.08 and 82.53±7.31, respectively, and had statistical differences(P<0.05), while there was no difference in evaluation of clnical effect(P>0.05). There were no differences in Mazur score and evaluation of clnical effect between two groups at 12 months after treatment (P>0.05). CONCLUSION: Bone setting technique could effectively correct lateral displacement of medial malleolus, lateral displacement of medial malleolus, lateral displacement of lateral malleolus and lateral contraction displacement of lateral malleolus in supination lateral rotation type Ⅲ and Ⅳ ankle fracture, and has good long-term clinical effect, which could avoid operation for some patients and restore ankle function after fracture.

Ligament Ruptures in Ankle Fractures-Was Lauge-Hansen Right?

The contribution of Lauge-Hansen to the understanding and treatment of ankle fractures cannot be underestimated, an unquestionable merit being the analysis of the ligamentous component of these injuries that are considered as equivalent to the respective malleolar fractures. In numerous clinical and biomechanical studies, the lateral ankle ligaments are ruptured either together with or instead of the syndesmotic ligaments, as predicted by the Lauge-Hansen stages. A ligament-based view on malleolar fractures may deepen the understanding of the mechanism of injury and lead to a stability-based evaluation and treatment of the 4 osteoligamentous pillars (malleoli) at the ankle.

Preoperative CT parameters to predict tibiofibular syndesmosis injury associated with ankle fracture: a propensity score-matched analysis.

BACKGROUND: Untreated ankle fractures with concomitant tibiofibular syndesmosis injury often lead to postoperative pain and early traumatic arthritis. CT has advantages in the preoperative diagnosis of combined ankle injuries. However, a few studies have investigated the best preoperative CT parameters to predict tibiofibular syndesmosis injuries associated with ankle fractures. This study aimed to identify and evaluate the optimal preoperative CT parameters for predicting tibiofibular syndesmosis injuries associated with ankle fractures. METHODS: We retrospectively analyzed 129 patients who underwent preoperative CT of an ankle fracture treated between January 2016 and April 2022 at a tertiary A hospital. All patients underwent open reduction and internal fixation and intraoperative stability testing. Based on the Cotton test, the patients were divided into the stable group (n = 83, 64.3%) and unstable group (n = 46, 35.7%). After 1:1 propensity score matching, the general conditions, anterior tibiofibular distance (TFD), posterior TFD, maximum TFD, tibiofibular syndesmosis area, sagittal fracture angle, Angle-A, and Angle-B were compared between the stable and unstable groups. RESULTS: The propensity score-matched cohort comprised 82 patients. There were no significant differences between the stable and unstable groups in sex, age, affected side, operation interval, injury mechanism, Lauge-Hansen classification, sagittal fracture angle, and Angle-A (all P > 0.05). Compared with the stable group, the unstable group had a significantly greater aTFD, pTFD, maxTFD, and area (all P < 0.05). PTFD, maxTFD, and area were positively correlated with joint instability. Angle-B was smaller in the unstable group (57.13°) than the stable group (65.56°). ROC analysis showed that Area (AUC 0.711) and maxTFD (AUC 0.707) had the highest diagnostic efficacy. CONCLUSION: MaxTFD and Area were the best predictive parameters; a larger Area was associated with a higher likelihood of instability of the tibiofibular syndesmosis after ankle fracture fixation.

Risk Factors Associated With Worse Clinical Outcomes of Ankle Fractures Involving the Posterior Malleolus.

Background: Ankle fractures involving the posterior malleolus (PM) tend to result in inferior clinical outcomes compared to other ankle fractures. However, it is unclear which specific risk factors and fracture characteristics are associated with negative outcomes in these fractures. The aim of this study was to identify risk factors for poor postoperative patient-reported outcomes in patients with fractures involving the PM. Methods: This retrospective cohort study included patients who sustained ankle fractures involving the PM between March 2016 and July 2020 and had preoperative computed tomography (CT) scans. In total, 122 patients were included for analysis. One patient (0.8%) had an isolated PM fracture, 19 (15.6%) had bimalleolar ankle fractures involving the PM, and 102 (83.6%) had trimalleolar fractures. Fracture characteristics including the Lauge-Hansen (LH) and Haraguchi classifications and posterior malleolar fragment size were collected from preoperative CT scans. Patient Reported Outcome Measurement Information System (PROMIS) scores were collected preoperatively and at a minimum of 1 year postoperatively. The association between various demographic and fracture characteristics with postoperative PROMIS scores was assessed. Results: Involvement of more malleoli was associated with worse PROMIS Physical Function (P = .04), Global Physical Health (P = .04), and Global Mental Health (P < .001), and Depression scores (P = .001). Elevated BMI was also associated with worse PROMIS Physical Function (P = .0025), Pain Interference (P = .0013), and Global Physical Health (P = .012) scores. Time to surgery, fragment size, Haraguchi classification, and LH classification were not associated with PROMIS scores. Conclusion: In this cohort, we found that trimalleolar ankle fractures were associated with inferior PROMIS outcomes compared with bimalleolar ankle fractures involving the PM in multiple domains. Level of Evidence: Level III, retrospective cohort study.

Posttraumatic checkrein deformity following isolated Lauge-Hansen pronation external rotation stage IV malleolar fracture-a case report and literature review.

The checkrein deformity is characterized by flexion contracture of the interphalangeal joint and extension contracture of the metatarsophalangeal joint. It is a rare condition occurring after lower extremity trauma, especially a malleolar fracture. Little is known about the possible cause and therapeutic strategy. This unique case presents a 20-year-old male patient with a diagnosis of the checkrein deformity secondary to open reduction and internal fixation of a Lauge-Hansen pronation external rotation stage IV malleolar fracture. After performing a detailed physical examination, radiographic evaluation, and ultrasonography, open exploration was performed to remove the hardware and correct the deformity with sole tenolysis of the flexor hallucis longus (FHL). In the 4-month follow-up, no recurrence of the checkrein deformity was observed. This deformity was caused by FHL adhesion. Interosseous membrane injury and fibular fracture together with local hematomas increases the risk of FHL adhesion. Open exploration and tenolysis of the FHL are feasible options to correct the checkrein deformity.

Weber Ankle Fracture Classification System Yields Greatest Interobserver and Intraobserver Reliability Over AO/OTA and Lauge-Hansen Classification Systems Under Time Constraints in an Asian Population.

No previous studies have evaluated the intra- and interobserver reliability between the Weber, Lauge-Hansen and AO Foundation/Orthopaedic Trauma Association (AO/OTA) classification systems under time constraints. This study compares the interobserver and intraobserver reliability of the aforementioned classification systems under simulated time constraints. Anteroposterior and lateral radiographs of ankle malleolar fractures from 80 consecutive patients from 2015 to 2016 were classified by 2 independent observers according to Weber, Lauge-Hansen and AO/OTA. Classifications were conducted over 4 successive weeks under timed (25-seconds) and untimed conditions, with 1-week gaps between each classification. Cohen's kappa and percentage agreement were calculated. Cohen's kappa for interobserver agreement ranged 0.67 to 0.67 and 0.59 to 0.73 for untimed and timed classifications for Weber; 0.38 to 0.47 and 0.44 to 0.50 for Lauge-Hansen; 0.28 to 0.49 and 0.13 to 0.37 for AO/OTA. Intraobserver agreement ranged from 0.83 to 0.85 and 0.78 to 0.79 for untimed and timed classifications for Weber; 0.46 to 0.65 and 0.59 to 0.73 for Lauge-Hansen; 0.42 to 0.63 and 0.40 to 0.51 for AO/OTA. Based on the Landis and Koch's benchmark scale, there was substantial agreement in the inter- and intraobserver variables for Weber; moderate agreement in inter- and intraobserver variables for Lauge-Hansen; fair and moderate agreement in inter- and intraobserver variables respectively for AO/OTA. Interobserver and intraobserver reliability was the most substantial for Weber, followed by Lauge-Hansen and AO/OTA. Time constraint did not have a statistically significant effect on the reliability of classifications. We recommend concurrent usage of the Weber and Lauge-Hansen system, since they demonstrate the greatest reliability and reproducibility, and confer better understanding of the fracture type, respectively.

Cast versus removable orthosis for the management of stable type B ankle fractures: a systematic review and meta-analysis.

PURPOSE: There is currently no consensus on nonoperative management in adult patients after a stable type B ankle fracture. The aim of this review is to compare a removable orthosis versus a cast regarding safety and functional outcome in the NOM of stable type B ankle fractures. METHODS: A systematic review and meta-analysis were performed using randomized clinical trials and observational studies. The methodological quality of the included studies was assessed with the methodological index for non-randomized studies instrument. Nonoperative management was compared using the number of complications and functional outcome measured using the Olerud and Molander Score (OMAS) or the American Academy of Orthopaedic Surgeons Ankle Score. RESULTS: Five studies were included. Two were randomized clinical trials, and three were observational studies, including a total of 516 patients. A meta-analysis showed statistically significant higher odds of developing complications in the cast group [odds ratio (OR), 4.67 (95% confidence interval (CI) 1.52-14.35)]. Functional outcome in OMAS did not vary significantly at 6 weeks, mean difference (MD) - 6.64 (95% CI - 13.72 to + 0.45), and at 12 weeks, MD - 6.91 (95% CI - 18.73 to + 4.91). The mean difference of functional outcome in OMAS at 26 weeks or longer was significantly better in the removable orthosis group; MD - 2.63 (95% CI - 5.01 to - 0.25). CONCLUSION: Results of this systematic review and meta-analysis show that a removable orthosis is a safe alternative type of NOM, as complication numbers are significantly lower in the orthosis group. In addition, no statistically significant differences were found in terms of functional outcome between a removable orthosis and a cast at 6 and 12 weeks. The 6-week and the 26-week OMAS results show that in patients with stable type B ankle fractures, a removable orthosis is non-inferior to a cast in terms of functional outcome.

Identifying the Potential Role of Regional Bone Mineral Density on the Degree of Malleolar Involvement in Acute Ankle Fractures.

Ankle fractures are a common traumatic lower extremity injury and are generally classified and characterized by the rotational mechanism of injury. At each malleolus (i.e., posterior, medial, and lateral) a fracture can occur or a ligamentous injury may be sustained. The purpose of this retrospective study was to determine if bone mineral density is a contributing factor on the number of fractured malleoli versus soft tissue injury in adult ankle fractures. Data was obtained from a registry of ankle fractures that were operatively treated by the foot and ankle team throughout our institutional facilities, from July 2017 to August 2019, and in which a preoperative computerized tomography scan was performed. Regional bone mineral density (BMD) was measured by calculating the average Hounsfield Unit (HU) on axial computerized tomography images of the distal fibula and tibia. The average HU was then compared to the number of fractured malleoli. One hundred eight patients met the study criteria. We identified statistically significant relationships between decreased BMD with increasing age (p < .01) and the male gender (p < .01). After adjusting for the covariates age and gender, no statistically significant relationship was identified between BMD and the number of malleoli involved in a given ankle fracture (p = .11). These findings suggest that while more investigation is required for ankle fracture patterns and BMD evaluation, increased age and biologic female gender is significantly related to decreased BMD as identified via HU.

Cicatrização e prognóstico no longo prazo de fraturas radiculares transversais pós-traumáticas: estudo clínico longitudinal / Healing and long-term prognosis of root fractured permanent teeth: a retrospective longitudinal study

Fraturas radiculares são lesões traumáticas dento-alveiolares (LTDA) complexas que afetam dentina, cemento, polpa e o ligamento periodontal, sendo frequente a ocorrência de lesões concomitantes ao fragmento coronário. São lesões relativamente raras com frequências relatadas variando entre 1,2% e 7% das LTDA na dentição permanente, sendo mais comuns em dentes com completo desenvolvimento radicular. O presente estudo consistiu em um levantamento clínico longitudinal retrospectivo para avaliar dados de 87 pacientes, portadores de 104 dentes permanentes com fraturas radiculares transversais, atendidos na Clínica de Traumatismos Dentários da Faculdade de Odontologia da UFMG, durante o período de 1995 a 2022. Com base na análise dos prontuários, avaliou-se o padrão radiográfico de cicatrização na linha de fratura, seguindo os critérios estabelecidos por Andreasen e Hjorting-Hansen (1967), em dois momentos: no período inicial após o trauma e ao final do período de acompanhamento. Uma análise de sobrevivência de risco competitivo foi realizada para estimar as taxas dos eventos de cicatrização no período inicial após o trauma, bem como o efeito das variáveis demográficas, clínicas e relacionadas ao tratamento. Os resultados demonstraram um percentual de 51,9% de cicatrização no curto prazo, diagnosticada em até 5 meses após o trauma. A não cicatrização com interposição de tecido de granulação na linha de fratura foi fortemente influenciada pela presença e tipo de lesão concomitante no fragmento coronário. Dentes com fraturas de esmalte e dentina (sHR 24,38, IC 95% [3,16 - 188,3], p = 0,0022), luxações com deslocamentos (sHR 10,58, IC 95% [1,37 - 81,9], p = 0,0240) e subluxações (HR 9,66, IC 95% [1,14 - 81,7], p = 0,0370) apresentaram as maiores taxas de não cicatrização das fraturas radiculares no curto prazo. A taxa de cicatrização no longo prazo foi de 70,1%, a maioria delas com interposição de osso e tecido conjuntivo. A estatística Kappa demonstrou uma concordância global de 67,1% entre as modalidades de cicatrização no período inicial e no longo prazo, especialmente para os padrões tecido mineralizado e tecido conjuntivo/osso.

Root fractures are complex traumatic dental injuries (TDI) affecting dentin, cementum, pulp and supporting tissues, generally associated to concurrent injuries to the coronal fragment. They are uncommon injuries with reported frequencies varying between 1.2% and 7% of all TDI in permanent teeth, being more frequent in teeth with complete root development. In the present study we retrospectively evaluated data from 87 patients with104 root-fractured permanent teeth treated at the Dental Trauma Clinic from the Federal University of Minas Gerais, during the period from 1995 to 2022. Clinical dan radiographic data was collected from patient's records to establish healing patterns in the fracture line, following the criteria established by Andreasen & Hjorting-Hansen (1967), at two moments: in the initial period after the trauma and at the end of the follow-up period. A competing risk survival analysis was performed to estimate rates of healing events in the early period after trauma as well as the effect of demographic, clinical, and treatment-related variables. The results showed a rate of 51.9% of healing in the short term, diagnosed in a maximum median period of 5 months after trauma. Non-healing with interposition of granulation tissue at the fracture line was strongly influenced by the presence and type of concomitant lesion in the coronal fragment. Teeth with associated enamel -dentin fractures (sHR 24.38, 95% CI [3.16 - 188.3], p = 0.0022), luxations with dislocations (sHR 10.58, 95% CI [1.37 - 81.9], p = 0.0240) and subluxations (HR 9.66, 95% CI [1.14 - 81.7], p = 0.0370) had the highest rates of non-healing of root fractures in the short term. The long-term healing rate was 70.1%, most of them with interposition of bone and connective tissue. Kappa statistics demonstrated an overall agreement of 67.1% between short and long-term healing patterns, in special HT and CT+ Bone modalities.

A systematic review of ankle fracture-dislocations: Recent update and future prospects.

Background: Ankle fracture-dislocations are one of the most severe types of ankle injuries. Compared to the simple ankle fractures, ankle fracture-dislocations are usually more severely traumatized and can cause worse functional outcomes. The purpose of this study was to review the previous literatures to understand the anatomy, mechanisms, treatment, and functional outcomes associated with ankle fracture-dislocations. Methods: The available literatures from January 1985 to December 2021 in three main medical databases were searched and analyzed. The detailed information was extracted for each article, such as researchers, age, gender, groups, type of study, type of center research, level of evidence, significant findings, study aim, cause of injury, time from injury to surgery, type of fracture, direction of dislocation, follow-up, postoperative complications and functional evaluation scores. Results: A total of 15 studies (1,089 patients) met the inclusion criteria. Only one study was a prospective randomized trial. The top-ranked cause of injury was high-energy injury (21.3%). Moreover, the most frequent type of fracture in ankle dislocations was supination-external rotation (SER) ankle fracture (43.8%), while the most common directions of dislocation were lateral (50%) and posterior (38.9%). Conclusions: Collectively, most ankle fracture-dislocations are caused by high-energy injuries and usually have poor functional outcomes. The mechanism of injury can be dissected by the ankle anatomy and Lauge-Hansen's classification. The treatment of ankle fracture-dislocations still requires more detailed and rational solutions due to the urgency of occurrence, the severity of injury, and the postoperative complications.

Early Unprotected Weight Bearing and Pre-Scheduled Supervised Rehabilitation Program after Surgical Treatment of Ankle Fractures.

Background: Ankle fractures represent one of the most common orthopedic injuries in the lower extremity. Weight-bearing and rehabilitation protocols after surgical treatment of ankle fracture have recently evolved from traditional methods to full weight-bearing protocols. However, more evidence is needed on unprotected immediate weight-bearing along with a standardized rehabilitation program. The purpose of this study was to evaluate effects of unprotected immediate weight-bearing as tolerated and an eight-week prescheduled supervised rehabilitation program on the mid-term clinical and functional outcomes of surgically treated ankle fractures, and to compare functional results with the unaffected side. Methods: Eighty patients (24F and 56M) who underwent rigid fixation of bimalleolar ankle fractures were included (mean age 41.57±13.22 years). Preoperative radiographs and computed tomography scans were used to evaluate and classify the fractures. The fractures were classified using Lauge-Hansen classification system. Ankle ROMs, Pain Disability Index (PDI), American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scores, and Short Form-36 scores were evaluated. Patients were allowed unprotected weight-bearing on the immediate postoperative period and a standardized supervised prescheduled rehabilitation program was undertaken following surgery. Results: The mean follow-up period was 30.32±6.91 months. Based on Lauge-Hansen classification, supination-external rotation injuries were found in 32(40%) patients, supination adduction injuries in 14(17.4%) patients, pronation-external rotation injuries in 28(35%) patients, and pronation-abduction fractures in 6(7.6%) patients. The solid union was achieved in all patients at the final follow-up. The mean PDI score was 12.78±14.78, and the AOFAS score was 80.93±17.24. Although patients' health-related quality of life was at a good level, the injured-side ankle ROM was lower than the healthy side (p ≤ 0.05). Conclusion: Satisfactory clinical and functional outcome can be achieved at mid-term with unprotected weight-bearing as tolerated and pre-scheduled supervised eight-week rehabilitation program following rigid internal fixation of ankle fractures. However, this protocol is not studied in patients with associated comorbidities.

Rare pattern of Maisonneuve fracture: A case report.

BACKGROUND: Maisonneuve fracture is a special type of ankle fracture that consists of proximal fibular fracture, a lesion of the inferior tibiofibular syndesmotic complex (interosseous ligament, anterior inferior tibiofibular ligament and posterior inferior tibiofibular ligament), and injury of the medial structure of the ankle (deltoid ligament tear or medial malleolar fracture). The accepted mechanism of Maisonneuve fracture is pronation external rotation according to the Lauge-Hansen classification. In this paper, we report a rare pattern of Maisonneuve fracture, which has the characteristics of both pronation external rotation ankle fracture and supination adduction ankle fracture. CASE SUMMARY: A 31-year-old female patient accidentally sprained her right ankle while walking 5 d before hospitalization in our hospital. The patient was initially missed in other hospitals and later rediagnosed in our outpatient department. Full-length radiographs of the lower leg revealed proximal fibula fracture, inferior tibiofibular joint separation, and medial malleolar fracture involving the posterior malleolus, which was also revealed on computed tomography scans. Magnetic resonance imaging revealed rupture of the anterior inferior tibiofibular ligament and anterior talofibular ligament. We diagnosed a rare pattern of Maisonneuve fracture with proximal fibular fracture, inferior tibiofibular joint separation, medial malleolar fracture and ruptures of the anterior inferior tibiofibular ligament and anterior talofibular ligament. The patient underwent open reduction and internal fixation in our hospital. A 6-mo postoperative follow-up confirmed a good clinical outcome. CONCLUSION: To our knowledge, this rare pattern of Maisonneuve fracture has not been previously described. The possible mechanism of injury is supination adduction combined with pronation external rotation. Careful analysis of the injury mechanism of Maisonneuve fracture is of great clinical significance and can better guide clinical treatment.

Evaluation of Ankle Fractures in 228 Patients From a Single Center Using Three-Dimensional Computed Tomography Mapping.

Purpose: The ankle joint has a complex anatomy structure with many causative factors and various injury mechanisms, and the clinical presentation of ankle fractures is diverse. This study aimed to analyze the characteristics of ankle fractures by applicating three-dimensional fracture line mapping technique. Methods: A retrospective study was conducted on 228 patients with ankle fractures. Three-dimensional reconstruction was performed by CT images and the fracture reconstruction model was superimposed onto a standard model of the tibiofibula for fracture line drawing. Then the fracture lines were converted into a three-dimensional coordinate point data set. And the fracture line maps as well as the fracture line heat maps were generated in 3-Matic software and Unigraphics NX software, respectively. Results: The dense area of the fibular fracture lines was located above the tibiofibular joint ligament and wrapped obliquely around the distal fibula from the anterior edge of the fibular neck. The fibular fracture line could be divided into three categories according to the degree of denseness. The dense area of the tibial fracture line is located within the anterior tibial fornix, the anterolateral corner, and the fibular notch. The tibial fracture lines can be classified into four categories according to the density of the fracture lines. The combined medial malleolus + posterior malleolar fracture line situation was found to be not encompassed by the existing AO and Lauge-Hansen (LH) classification systems according to this classification. Conclusion: The 3D fracture line mapping technique can better reflect the distribution of ankle fracture lines and could help to establish a new ankle fracture typing system in the future.

Does the Lauge-Hansen Injury Mechanism Predict Posterior Malleolar Fracture Morphology?

The Lauge-Hansen ankle fracture classification system is widely accepted and is utilized to describe and predict ankle fracture patterns based on the mechanism of injury. Multiple studies have shown inconsistencies in the Lauge-Hansen's ability to predict fracture patterns based on the mechanism of injury. We set out to determine if the posterior malleolar fracture pattern is associated with the fracture types described by Lauge-Hansen. In this retrospective cohort study, we reviewed 153 patients with trimalleolar ankle fractures as diagnosed using computed tomography scans. Timing of injury was from February 2013 to August 2017. Patient ages ranged between 18 and 89 years old. Each patient had a complete clinical and radiographic workup including a preoperative computed tomographic scan following initial fracture reduction in the emergency room. We classified each ankle fracture based on plain film radiographs using the Lauge-Hansen classification scheme. Each individual posterior malleolar fracture was evaluated on computed tomography imaging and described using both the Haraguchi and Bartonicek-Rammelt classification systems. Of the 153 patients identified with trimalleolar ankle fractures, 70% were female (±20%), the mean age was 51 y (±8 y), and the mean body mass index was 30 kg/m2 (±3 kg/m2). We did not observe a significant association between the Lauge-Hansen injury mechanism and either the Bartonicek-Rammelt or the Haraguchi trimalleolar ankle fracture classification systems (chi-square correlation tests p > .05).

Ultrasonography for the diagnosis of deltoid injury in supination external rotation ankle fractures - A scoping review.

BACKGROUND: Lauge-Hansen supination external rotation (SER)-type ankle fractures are very common and account for up to 75% of all ankle fractures. Assessing deltoid integrity is key for surgical decision making. Ultrasound has been used recently to assess the integrity of the deltoid ligament and differentiate between SER II and SER IV fractures. The aim of this article is to review the literature for studies assessing the diagnostic accuracy of ultrasound in this group of patients. METHODS: After registering the protocol with PROSPERO, Embase, Ovid MEDLINE, Web of Science Core Collection, and Google Scholar were systematically searched. Studies that satisfied the following inclusion criteria were assessed: (1) Adult patients (>16 years), (2) Acute SER-type ankle fractures assessed within 2 weeks of the injury, (3) Diagnostic accuracy studies. Risk of bias assessment was conducted and a narrative synthesis of the results presented. RESULTS: A total of five studies satisfied our inclusion criteria and were included for review. These had a total of 175 patients studied. All studies showed a sensitivity of 100% and specificity of 90-100% for detecting a complete tear of the deltoid. All papers had a significant risk of bias inherent to the design. Only patients undergoing surgery were exposed to the gold standard of operative intervention. CONCLUSION: Ultrasound scan has shown excellent diagnostic accuracy for detecting complete deltoid ruptures in SER ankle fractures. These results however should be interpreted with caution. Perhaps a different approach is needed to assess the efficacy of ultrasound scans in patient with SER type fractures.