Printed 3-Dimensional Computed Tomography Scanned Ankle Fractures as an Educational Instrument.

The evaluation of and treatment protocols for ankle fractures represents an important aspect of the education of podiatric medical students. The objective of this investigation was to examine the feasibility of and student satisfaction with using 3-dimensional (3D) printed bone models representative of the Lauge-Hansen classification. The computed tomography scans of subjects with actual rotational ankle fractures representative of the Lauge-Hansen classification were identified and extracted into a format compatible with a 3D printer. The models were approximately 20 cm in height and made of acrylonitrile butadiene styrene plastic in ivory color. These were subsequently implemented into the curriculum of a traumatology course with third year podiatric medical students in the form of a hands-on workshop. Students expressed high levels of satisfaction with the use of these models, and most recommended their continued implementation within the curriculum. The results of this investigation indicate that 3D technology within podiatric medical education is feasible with high levels of student satisfaction.

Prevalence and associated factors of intra-articular lesions in acute ankle fractures evaluated by arthroscopy and clinical outcomes with minimum 24-month follow-up.

BACKGROUND: Acute ankle fractures can lead to high rate of concomitant intra-articular lesions which may compromise clinical results. The purpose of this study was to evaluate the incidence of concomitant intra-articular lesions in acute ankle fractures with arthroscopy. We also sought to analyze the relationship between intra-articular lesions and the fracture type, as well as the severity of the fracture. METHODS: It was a retrospective cohort study. From April 2014 to December 2015, we have chosen arthroscopy-assisted open reduction and internal fixation (AORIF) for the treatment of unstable acute ankle fractures. All concomitant intra-articular lesions were assessed and documented carefully and prospectively, such as ligament injuries, osteochondral lesions, and tibiofibular syndesmosis injuries. All fractures were classified according to the Lauge-Hansen classification system. The American Orthopedic Foot and Ankle Society's (AOFAS) ankle-hindfoot scale was used to assess post-operative function. Statistical comparisons between the intra-articular lesions, the fracture type, and the severity of the presenting fracture were performed using a Chi-squared analysis. RESULTS: Data of 36 patients were analyzed in the study, including 23 supination-type fractures and 13 pronation-type fractures. The incidence of tibiofibular syndesmosis injuries, chondral lesions, and loose bodies were 92%, 72%, and 39%, respectively. Avulsion fractures of the anterior tibiofibular syndesmosis were more commonly found in supination-type fractures than pronation-type fracture (45% vs. 15%, χ = 5.78, P = 0.02), which would cause mechanical blocking in the anterior portion of the ankle. On the contrary, chondral lesions were more commonly found in the more severe fractures than mild fractures (86% vs. 53%, χ = 4.57, P = 0.03). A mean 41.7 months (range, 33.0-51.0 months) of follow-up was achieved. A mean AOFAS's ankle-hindfoot scale was 96.9, and 97.2% of the patients were satisfied with the procedure. CONCLUSIONS: Acute ankle fractures have a high incidence of concomitant intra-articular lesions. Avulsion fractures of the anterior tibiofibular syndesmosis are more commonly found in supination-type fractures. Chondral lesions are related to the severity of the fractures, but not with the classification of the fractures. AORIF can be one reliable solution in dealing with the associated injuries seen with acute ankle fractures.

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.

[Treatment of ankle fractures].

Fractures of the ankle joint are among the most frequent fractures encountered in any accident and emergency department. The traditional classification systems, i.e. the Lauge-Hansen- and the Weber classifications, have proven inadequate, when it comes to deciding, whether treatment should be surgical or conservative. About ten years ago, a stability-based classification was proposed in view of the fact, that the stabilisation of osteosynthesis depends on the stability of the ankle joint. The literature shows excellent long-term results for conservatively treated stable ankle joint fractures.

Short-Term Outcomes and Influencing Factors After Ankle Fracture Surgery.

The present study investigated the factors influencing the early clinical outcomes after ankle fracture surgery. We included 88 patients, who had undergone implant removal surgery at 1 year after ankle fracture surgery, with ankle computed tomographic (CT) scans obtained before ankle fracture surgery and at implant removal available. We collected demographic information, including age, sex, the presence of diabetes mellitus, level of trauma energy, and fracture classification from the medical records. We also recorded the fracture height using the radiographs and CT images. The medial joint space and articular incongruity were assessed on the follow-up radiographs and CT scans. Bone attenuation was measured by placing a circular region of interest around the ankle joint on the preoperative CT image. The postimplant removal outcomes were assessed using 2 functional questionnaires, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale and Foot and Ankle Outcome Score (FAOS). Significant factors related to the AOFAS ankle-hindfoot scale scores and FAOS were identified through univariate analysis using age, sex, radiographic measurements, and CT findings as explanatory variables, followed by multiple regression analysis. On multiple regression analysis, the total FAOS was independently related to the AO classification (p = .003) and Lauge-Hansen classification (p = .003). The total AOFAS ankle-hindfoot scale score was related to articular incongruity (p = .044). The early clinical outcomes after ankle fracture surgery were affected by involvement of the ankle joint fracture rather than the lateral malleolus fracture height. Female sex and the presence of postoperative articular incongruity correlated with inferior early clinical outcomes.

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.

Correlation Between the Lauge-Hansen Classification and Ligament Injuries in Ankle Fractures.

OBJECTIVE: To evaluate the ability of the Lauge-Hansen classification to predict ligament injuries in ankle fractures using magnetic resonance imaging (MRI) and intraoperative findings. DESIGN: Prospective evaluation in consecutive patients. SETTING: Academic level 1 trauma center. PATIENTS: Three-hundred patients with an operatively treated ankle fracture who met the inclusion and exclusion criteria. INTERVENTION: Injury ankle radiographs were assigned to a Lauge-Hansen classification. MRI scans were obtained to evaluate the syndesmotic and deltoid ligaments. A Lauge-Hansen classification for each patient was recorded based on intraoperative findings. MAIN OUTCOME MEASUREMENTS: Comparisons were made between the predicted ankle ligamentous injuries based on radiographic Lauge-Hansen classifications, preoperative MRI analyses, and intraoperative findings. RESULTS: On the basis of the Lauge-Hansen system and injury radiographs, 77% (231/300) were classified as supination external rotation, 13% (40/300) were pronation external rotation, 4% (11/300) were supination adduction, <1% (1/300) was pronation abduction, and 6% (17/300) were not classifiable. Of the 283 fractures that were classified into Lauge-Hansen classes, 266 (94%) had MRI readings of ligamentous injuries consistent with the Lauge-Hansen predictions. Intraoperative findings also highly correlated with the Lauge-Hansen class of ankle fractures, with nearly complete agreement. Comparing MRI and intraoperative findings revealed discrepancies in 6% (16/283) of ankle fracture classifications. CONCLUSIONS: In our large cohort of patients, comparisons between injury radiographs, preoperative MRI, and intraoperative findings suggest that the Lauge-Hansen system is an accurate predictor of ligamentous injuries. The predictions based on the Lauge-Hansen system can be useful for fracture reduction maneuvers and operative planning. LEVEL OF EVIDENCE: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

[EFFECTIVENESS OF SURGERY IN TREATMENT OF ANKLE FRACTURES ASSOCIATED WITH DELTOID LIGAMENT INJURY].

OBJECTIVE: To evaluate the effectiveness of repairing the deltoid ligament with ankle fracture. METHODS: Between January 2010 and January 2013, 11 patients with ankle fractures associated with deltoid ligament injury were treated. There were 7 males and 4 females, with an average age of 38.2 years (range, 18-72 years). The interval between injury and operation was 6 hours to 7 days (mean, 4 days). According to Lauge-Hansen classification, ankle fracture was rated as pronation-external rotation type in 5 cases, as supination-external rotation type in 4 cases, and as pronation-abduction type in 2 cases. The MRI and color Doppler ultrasound showed deltoid ligament rupture. The results of valgus stress test, talus valgus tilt test, and anterior drawer test after anesthesia were all positive. Fracture was treated by open reduction and internal fixation, and deltoid injury was repaired. RESULTS: All incisions healed primarily. All patients were followed up 12-18 months (mean, 13.3 months). The X-ray films showed anatomical reduction, good position of internal fixation and stable distal tibiofibular syndesmosis. The mean fracture union time was 7.6 weeks (range, 6-8 weeks). MRI at 3 months after operation showed normal shape of the deltoid ligament. According to American Orthopaedic Foot and Ankle Society (AOFAS) score, the results were excellent in 6 cases, good in 3 cases, fair in 1 case, and poor in 1 case, with an excellent and good rate of 81.8%. CONCLUSION: It is an effective method to treat ankle fracture with deltoid ligament injury by open reduction and internal fixation of ankle fracture and repair of the deltoid ligament injury, which can effectively rebuild medial instability and has satisfactory effectiveness.

Evaluating the Reliability and Reproducibility of the AO and Lauge-Hansen Classification Systems for Ankle Injuries.

Ankle injuries are responsible for more than 5 million emergency department visits each year. The AO and Lauge-Hansen classification systems are widely used in the clinical diagnosis of ankle injuries. This study aimed to analyze the intraobserver reliability and interobserver reproducibility of the AO and Lauge-Hansen classification systems. In addition, the authors explored the differences among physicians' classification responses and evaluated the clinical value for diagnosis. Fifty-six patients with an ankle injury with complete clinical and radiologic data were enrolled. The definition of injury type, the index score typing methods, and the specific study criteria were explained in detail. Five observers, who were orthopedic surgeons, determined the classifications according to both the AO and Lauge-Hansen systems. The classification was repeated 1 month later. Cronbach's alpha and Cohen's kappa test were used to determine interobserver reliability and intraobserver reproducibility. The physicians conducted 560 classifications (56 cases × 5 physicians × 2 times per patient). Average inter- and intraobserver kappa values for the AO system were 0.708 and 0.608, respectively. Average inter- and intraobserver kappa values for the Lauge-Hansen system were 0.402 and 0.398, respectively. Cronbach's alpha coefficient was 96.7% for the AO system and 76.0% for the Lauge-Hansen system. The Lauge-Hansen classification system is a comprehensive yet cumbersome system. Comparatively, the AO classification system is easier to understand. This study shows that the AO classification system has more reliability and reproducibility, and thus has more value in clinical practice, than the Lauge-Hansen classification system.

Correlation of visual analogue scale foot and ankle (VAS-FA) to AOFAS score in malleolar fractures using Indian language questionnare.

BACKGROUND: Visual analogue scale foot and ankle (VAS-FA score) is a new score, validated in previous studies, but never compared to AOFAS score. OBJECTIVE: Analysis of the two scores using Indian language questionnaire. METHODS: Fifty patients with Malleolar fractures were assessed for functional outcome, time for calculation of scores, difficulty in correlation and comprehension of the questionnaire, in Malayalam language. The score parameters were compared by SSPSS. RESULTS: There was similarity in pattern of score values in both systems but also a difference between values in each category, with VAS-FA having lower values, reflecting its efficacy. There was significant correlation, similar sensitivity and agreement between the scoring systems. VAS-FA correlated better with patient's outcome and required less time for assessment. CONCLUSION: This study shows that Indian language VAS-FA has a similar pattern of extracting scores as AOFAS and can be an efficient tool in ankle outcome assessment in Indian patients.

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.

[Clinical features in the diagnosis and treatment of ankle fracture with Wagsaffe fragment].

OBJECTIVE: To explore the methods in the diagnosis and treatment of ankle fracture with Wagsaffe fragment. METHODS: Among 1 201 patients, there were 18 cases of concurrent Wagstaffe fractures at our hospital between January 2009 to January 2012. There were 11 males and 7 females with an average of 37.4 (17-54) years. The causes of injuries were fall (n = 10), sports-related injury (n = 4), traffic injury (n = 3) and high-altitude fall (n = 1). All of them had lateral malleolar fracture. Other injuries included internal malleolar fracture (n = 16), posterior malleolar fracture (n = 8) and disruption of medial deltoid ligament (n = 3). According to the Lauge-Hansen system, all fractures were of supination-external rotation type. The fractures of fibula and Wagstaffe were explored through an anterolateral approach. The lateral malleolar fracture was fixed with plate While Wagstaffe fragment secured with lag screw or thread. Disrupted anterior tibiofibular ligament was restored. Other treatments included open reduction and internal fixation of medial and posterior malleolus, repair of medial deltoid ligament and screw fixation of disrupted tibiofibular syndesmosis. Ankle function was evaluated by the Baird-Jackson criteria. RESULTS: Wagstaffe fracture occurred at a rate of 1.5% in ankle fractures. Wagstaffe fracture was found in 4.4% of ankle fracture of supination-external rotation type. Seventeen patients were followed up over an average follow-up period of 16.8 (12-25) months. All radiographs showed union of all fractures and normal mortise. Baird-Jackson ankle functional score was from 81 to 99. In all 17 patients, 9 were rated as excellent, 5 as good and 3 as fair. The excellent and good rate was 87.4%. At the latest follow-up, 14 patients resumed their preinjury activities. CONCLUSION: As an easily misdiagnosed condition, Wagstaffe fracture is associated with ankle diastase and prone to occur in ankle fracture of supination-external rotation type. Accurate reduction and stable fixation facilitate the restoration of stable syndesmosis in the treatment of ankle fracture with concurrent Wagsaffe fragment.