Syndesmotic fixation in supination-external rotation ankle fractures: a prospective randomized study.

BACKGROUND: This study compared mid-term functional and radiologic results of syndesmotic transfixation with no fixation in supination external rotation (SER) ankle fractures with intraoperatively confirmed syndesmosis disruption. Our hypothesis was that early-stage good functional results would remain and unfixed syndesmosis disruption in SER IV ankle fractures would not lead to an increased incidence of osteoarthritis. METHODS: A prospective study of 140 operatively treated patients with Lauge-Hansen SER IV (Weber B) ankle fractures was performed. After bony fixation, the 7.5-Nm standardized external rotation stress test for both ankles was performed under fluoroscopy. A positive stress examination was defined as a difference of more than 2 mm side-to-side in the tibiotalar or tibiofibular clear spaces on mortise radiographs. The patients were randomized to either syndesmotic screw fixation (13 patients) or no syndesmotic fixation (11 patients). After a minimum of 4 years of follow-up (mean, 58 months), ankle function and pain (Olerud-Molander, a 100-mm visual analogue scale [VAS] for ankle function and pain) and quality of life (RAND-36) of all 24 patients were assessed. Ankle joint congruity and osteoarthritis were assessed using mortise and lateral projection plain weight-bearing radiographs and magnetic resonance imaging (MRI; 3T) scans. RESULTS: Improvement in Olerud-Molander score, VAS, and RAND-36 showed no significant difference between groups during the follow-up. In the syndesmotic transfixation group, improvements in all functional parameters and pain measurements were not significant, whereas in the group without syndesmotic fixation, the Olerud-Molander score improved from 84 to 93 (P = .007) and the pain (VAS) score improved from 11 to 4 (P = .038) from 1 year to last follow-up. X-ray or MRI imaging showed no difference between groups at the last follow-up visit. CONCLUSION: With the numbers available, no significant difference in functional outcome or radiologic findings could be detected between syndesmosis transfixation and no-fixation patients with SER IV ankle fracture after a minimum of 4 years of follow-up. LEVEL OF EVIDENCE: Level II, prospective comparative study.

[Epidemiological, morphological and clinical aspects of ankle fractures]. / Epidemiologické, morfologické a klinické aspekty zlomenin v oblasti hlezna.

PURPOSE OF THE STUDY: The study presents the evaluation and comparison of two groups of patients surgically treated for ankle fractures at our department in 2007 and in 2010, respectively. Our analysis included patients' age, the mechanism of injury, fracture morphology and the method of osteosynthesis. The aim of the comparison was to ascertain recent trends in the development of the selected characteristics. MATERIAL AND METHODS: The 2007 group comprised 62 patients, 31 men and 32 women, the 2010 group had 123 patients, 55 men and 68 women. The ankle fractures were classified according to the Weber and Lauge-Hansen systems. The selected characteristics were analysed in each group and the results were compared to obtain information on changes during the interval of 4 years. The data were evaluated using the methods of descriptive statistics; categorical data were analysed by the chi-square test with the level of significance set at 5%. RESULTS: The average age was 44 years in men and 59 in women in the 2007 group and 40 years in men and 56 in women in the 2010 group; in the whole patient group, the average age decreased from 52 years in 2007 to 47 years in 2010. Based on the Weber classification, the incidence of fractures in 2007 and 2010 was as follows; type A, 5% in both years; type B, 68% and 72%; type C, 27% and 23%. There was no significant difference between the groups in the incidence of either type B or type C fractures (p = 0.823 and p = 0.659, respectively). The majority of fractures were caused by low-energy mechanisms. High-energy injuries due to falls from a height or traffic accidents did not exceed 6 %. In men, who sustained sports-related injury more often, fractures were found in 23% and 16% in 2007 and 2010, respectively; this difference approached statistical significance (p = 0.050). Most of the fibular fractures were managed by plate osteosynthesis, often in combination with lag screws. Medial malleolar fractures were usually fixed with two cancellous screws, or with a screw and a K-wire. The number of surgical inspections of the medial structures of an injured ankle with no medial malleolar fracture decreased from 68% in 2007 to 37% in 2010. Osteosynthesis of a fractured posterior margin of the distal tibia was carried out in 7% of the patients in 2007 and in 23% in 2010. DISCUSSION: The morphological and epidemiological characteristics described were selected to obtain a comprehensive notion of the patients studied. Only the patients who had surgery were included. An increase in the number of ankle fractures managed surgically during a four-year period of our study was due to a growing number of patients and the fact that surgery was indicated more frequently because stricter criteria for assessment of post-reduction findings or secondary displacement were adopted. In surgical treatment, the recent trend preferring primary osteosynthesis to transfixation or external fixation has been evident because it allows for early rehabilitation and return to normal activities. CONCLUSIONS: The number of ankle fractures treated by primary osteosynthesis grew between 2007 and 2010. There was also an increase in the number of fractured posterior margins of the distal tibia managed by osteosynthesis. The results of the Weber and Lauge-Hansen classifications were in agreement with the relevant literature data. In the majority of cases the ankle fracture occurred as a single trauma.

Tibiofibular syndesmosis in acute ankle fractures: additional value of an oblique MR image plane.

OBJECTIVE: To evaluate the additional value of a 45° oblique MRI scan plane for assessing the anterior and posterior distal tibiofibular syndesmotic ligaments in patients with an acute ankle fracture. MATERIALS AND METHODS: Prospectively, data were collected for 44 consecutive patients with an acute ankle fracture who underwent a radiograph (AP, lateral, and mortise view) as well as an MRI in both the standard three orthogonal planes and in an additional 45° oblique plane. The fractures on the radiographs were classified according to Lauge-Hansen (LH). The anterior (ATIFL) and posterior (PTIFL) distal tibiofibular ligaments, as well as the presence of a bony avulsion in both the axial and oblique planes was evaluated on MRI. MRI findings regarding syndesmotic injury in the axial and oblique planes were compared to syndesmotic injury predicted by LH. Kappa and the agreement score were calculated to determine the interobserver agreement. The Wilcoxon signed rank test and McNemar's test were used to compare the two scan planes. RESULTS: The interobserver agreement (κ) and agreement score [AS (%)] regarding injury of the ATIFL and PTIFL and the presence of a fibular or tibial avulsion fracture were good to excellent in both the axial and oblique image planes (κ 0.61-0.92, AS 84-95%). For both ligaments the oblique image plane indicated significantly less injury than the axial plane (p < 0.001). There was no significant difference in detection of an avulsion fracture in the axial or oblique plane, neither anteriorly (p = 0.50) nor posteriorly (p = 1.00). With syndesmotic injury as predicted by LH as comparison, the specificity in the oblique MR plane increased for both anterior (to 86% from 7%) and posterior (to 86% from 48%) syndesmotic injury when compared to the axial plane. CONCLUSION: Our results show the additional value of an 45° oblique MR image plane for detection of injury of the anterior and posterior distal tibiofibular syndesmoses in acute ankle fractures. Findings of syndesmotic injury in the oblique MRI plane were closer to the diagnosis as assumed by the Lauge-Hansen classification than in the axial plane. With more accurate information, the surgeon can better decide when to stabilize syndesmotic injury in acute ankle fractures.

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.

Arthroscopic assessment of occult intra-articular injury in acute ankle fractures.

PURPOSE: To arthroscopically assess the pattern and extent of intra-articular damage associated with ankle fractures. TYPE OF STUDY: Prospective case series. METHODS: From 1989 to 1998, 48 consecutive patients with acute unstable ankle fractures underwent ankle arthroscopy followed by reduction and internal fixation. In addition, all injuries were categorized by specific osseous, ligamentous, and articular pathology, based on clinical and arthroscopic examination. Whenever possible, the fractures were classified according to Lauge-Hansen and Danis-Weber schemes. RESULTS: Traumatic articular surface lesions (TASLs), including chondral defects and osteochondral lesions measuring greater than 5 mm in diameter, were identified in 30 of the 48 ankles (63%), with 11 lesions localized to the tibia and 19 noted on the talus. The tibial lesions were at the posterior syndesmotic ligament insertion in 6 cases, at the anterior capsule origin in 3 cases, and at the central articular surface in 2 cases. Of the 19 talar lesions, 15 involved the medial dome and 4 involved the lateral articulation. TASLs of the talus in this series were uniformly unstable or displaced and virtually devoid of subchondral bone, precluding satisfactory internal fixation. Of the 10 pronation-external rotation fractures, 7 had articular surface defects with 5 involving the medial and 2 the lateral dome. Ten of the 24 supination-external rotation or Danis-Weber B fractures were found to have TASLs of the talus, 9 medial and 1 lateral. Nine of 12 fractures with syndesmosis disruptions sustained full-thickness damage to the talar chondral surface (P =.01). CONCLUSIONS: Ankle fractures have a high incidence of concomitant intra-articular pathology with syndesmosis disruption portending a particularly high risk of articular surface injury to the talar dome. Arthroscopy is a valuable tool in identifying and treating intra-articular damage that would otherwise remain unrecognized and may provide prognostic information regarding the functional outcome of these injuries.

[The results of surgical treatment in ankle fractures]. / Ayak bilegi kiriklarinda cerrahi tedavi sonuçlarimiz.

OBJECTIVES: We evaluated the results of surgical treatment for ankle fractures and the factors that play a role in these results. METHODS: The study included 31 patients (20 men, 11 women, mean age 38.2 years) who underwent surgical treatment for ankle fractures and had an adequate follow-up. According to the Lauge-Hansen classification, the mechanism of occurrence was supination-external rotation in 13 (42%), pronation-external rotation in two (26%), pronation-abduction in four (13%), and supination-abduction in four patients (13%). In two patients (6%), the fractures could not be classified. Most of the fractures occurred with falling in winter months. The majority of fractures (55%) was of bimalleolar type. The mean follow-up was 26 months. RESULTS: Union was obtained in all fractures. According to the objective criteria, the results were good, moderate, and poor in 18 (58%), eight (26%), and five (16%) patients, respectively. Subjective evaluation yielded good, moderate, and poor results in 17 (55%), eight (26%), and six (19%) patients, respectively. The results were poor especially in pronation-external rotation and fracture-dislocation type fractures. Two patients (6%) developed degenerative arthritis. CONCLUSION: In our opinion, the best anatomical reduction may be achieved by surgical treatment of ankle fractures that present with a talar tilt, fibular shortening, and injury to the syndesmosis.

Ankle fractures involving the fibula proximal to the distal tibiofibular syndesmosis.

Thirty-two cases of ankle fractures associated with fibular fractures above the distal tibiofibular syndesmosis were studied. All were treated with open reduction and internal fixation. The average follow-up was 25 months. The results of the postoperative evaluation were rated, based on subjective clinical criteria, as good, fair, and poor. According to the Lauge-Hansen classification, there were 17 (53%) cases of supination-external rotation injury (2 stage 2 and 15 stage 4), 9 (28%) cases of stage 3 pronation-abduction injury, and 6 (19%) cases of pronation-external rotation injury (3 stage 3 and 3 stage 4). All cases could be classified as Weber type C or as suprasyndesmotic, fibular diaphyseal fracture (44-C) according to the Orthopaedic Trauma Association classification. In 18 (56%) cases, the fracture was associated with ankle dislocation. There were seven (22%) open fractures, (two grade I, four grade II, and one grade IIIA). Syndesmotic screws were used in 23 (72%) cases (12 supination-external rotation injury, 6 pronation-external rotation injury, and 5 pronation-abduction injury). The syndesmotic screw was removed after an average of 9 weeks. Four (13%) nonunions and two (6%) delayed unions of the fibula were treated with bone grafting and/or hardware revision and eventually healed. Three of the nonunions had poor clinical results because of degenerative ankle joint arthritis in two (one of them ended in arthrodesis) and deep infection, which was eventually cured, in the third. The fourth nonunion had a fair result. One of the delayed unions had a fair result (an obese patient) and the other had a good result. Two patients developed deep infections; one ended in gangrene and amputation in a diabetic patient, and the other was a patient with fibular nonunion that eventually healed. Three patients had superficial infections that were treated successfully. Of the 32 cases, 23 (72%) showed good results, 4 (13%) showed fair results, and 5 (16%) showed poor results. The cases with poor results included three fibular nonunions, one deep infection, and one recurrent superficial infection and wound dehiscence after hardware removal. A syndesmotic screw is usually needed in cases of fracture-dislocations. Two patients with occult fibular nonunions developed diastasis of the syndesmosis after removal of the syndesmotic screw. It was found that reduction and temporary pinning of the distal tibiofibular joint helps achieve fibular length, which is crucial to restoring the biomechanics of the ankle joint. It seems advisable not to remove the syndesmotic screw until there are signs of healing of fibular fracture to avoid diastasis of the distal tibiofibular joint. Bone grafting should be considered in high energy fractures with comminution. These complex injuries are associated with higher rates of complications. Poor results can be attributed to fracture factors, e.g., open fractures, infections; patient factors, e.g., obesity, lowered immunity as in diabetes, and noncompliance; and iatrogenic factors, e.g., early removal of syndesmotic screws.

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.

Evaluation and treatment of ankle fractures.

The ability to classify ankle fractures allows one to determine which fractures will probably do well with nonoperative treatment and which fractures will fare best with open reduction because of their inherent instability. An understanding of the Lauge-Hansen system also allows one to predict the degree of ligamentous injury on the basis of the osseous pattern of the injury. Operative management of ankle fractures requires a thorough understanding of ASIF technique. Open reduction is best performed with a fracture that is not anatomically reducible or with a fracture type that has been historically proven unstable with closed treatment. Restoration of anatomic alignment of articular surfaces should be the goal of treatment. When anatomic reduction has been achieved, ankle fractures generally do well whether they have been treated with operative or nonoperative techniques. Early motion is helpful if rigid fixation can be achieved, but one should not sacrifice stability in an attempt to begin early movement if rigid fixation has not been obtained. Decisions concerning length of immobilization and early movement should be based upon the principles of bone healing physiology.