[APPLICATION OF POSTEROLATERAL APPROACH FOR TREATMENT OF BIMALLEOLAR AND TRIMALLEOLAR FRACTURES].

OBJECTIVE: To evaluate the advantage of single posterolateral approach for exposing the fragments of lateral malleolus and posterior malleolus in treating bimalleolar and trimalleolar fractures. METHODS: Between January 2013 and June 2015, 47 patients with ankle fractures were treated. Of 47 cases, 16 were male and 31 were female with an average age of 47.7 years (range, 25-65 years); the locations were the left side in 21 cases and the right side in 26 cases. According to types system of Lauge-Hansen, 11 cases were rated as pronation-external rotation and 36 cases as supination-external rotation. There were 9 cases of bimalleolar fractures and 38 cases trimalleolar fractures. CT examination showed that posterior malleolus fracture involved more than 35% of the joint surface in 11 cases, and 9 cases had comminuted posterior malleolus fracture. Of 47 cases, 44 had fresh fractures with a mean disease course of 4 days (range, 8 hours to 7 days), and 3 had old fracture with the disease course of 43, 58, and 62 days respectively. Posterior malleolus fractures were fixed with T-type plates in 12 cases, one-third tubular plates in 10 cases, and cannulated screws in 25 cases. RESULTS: The operation time was 60-100 minutes (mean, 80 minutes); the bleeding volume was 50-100 mL (mean, 72 mL). Primary healing of incision was obtained in all patients, and no postoperative complications of infection, cutaneous necrosis, deep venous thrombosis, and sural nerve injury occurred. The CT examinations after operation showed anatomical reduction of fractures. All patients were followed up from 12 to 20 months (mean, 16 months). No fixation failure or reduction loss was found at last follow-up. All patients could walk normally. The active dorsiflexion of the affected ankles was within 5° less than normal side in 43 cases (91.5%) and 5-10° less than normal side in 4 cases (8.5%). The passive dorsiflexion of the affected ankles was within 5° less than normal side in 44 cases (93.6%) and 5-10° less than normal side in 3 cases (6.4%). According to the Olerud-Molander scoring system, the results were excellent in 40 cases, good in 5 cases, and fair in 2 cases; and the excellent and good rate was 95.7% at last follow-up. CONCLUSIONS: The single posterolateral approach could simultaneously expose the fragments of lateral malleolus and posterior malleolus, with less complication of the incision, short operation time, and clear exposure of posterior malleolus. The surgery could be performed under direct vision. It especially is suitable for bimalleolar and trimalleolar fractures with lateral malleolus and posterior malleolus.

[CLINICAL FEATURES AND SURGICAL EFFECTIVENESS OF ANKLE FRACTURES INVOLVING Tillaux-Chaput IN ADULTS].

OBJECTIVE: To investigate the clinical features of ankle fractures involving Tillaux-Chaput in adults, and to observe the surgical effectiveness. METHODS: Between May 2009 and May 2013, 15 adult patients with ankle fractures involving Tillaux-Chaput were treated by open reduction and internal fixation. There were 12 males and 3 females, with an average age of 32 years (range, 19-45 years). The causes included sport injury (8 cases), traffic accident injury (5 cases), and falling injury from height (2 cases). The left ankle was involved in 5 cases and the right side in 10 cases. There were 2 open fractures (Gustilo type I) and 13 close fractures. Five patients had single Tillaux-Chaput fractures. The mean time between injury and surgery was 8.5 days (range, 3 hours to 15 days). According to the Lauge-Hansen classification, there were 9 cases of supination-external rotation, 5 cases of pronation-external rotation, and 1 case of pronation-abduction. RESULTS: Primary healing of incisions was obtained in 13 patients without infection and neurovascular injury; 2 patients had superficial infection which was cured after oral antibiotics and dressing change. All cases were followed up for 23 months on average (range, 13-36 months). X-ray films showed complete fracture healing at 10-16 weeks postoperatively (mean, 13 weeks) in all cases. The mean American Orthopaedic Foot and Ankle Society (AOFAS) score was 87 (range, 78-99), with an excellent and good rate of 80% (excellent in 9 cases, good in 3 cases, and fair in 3 cases). CONCLUSION: Open reduction and internal fixation for ankle fractures involving Tillaux-Chaput in adults can achieve excellent effectiveness.

[APPLICATION OF COMPUTER-ASSISTED SURGICAL PLANNING IN SURGICAL TREATMENT OF ANKLE FRACTURES].

OBJECTIVE: To explore the clinical value of computer-assisted surgical planning in the treatment of ankle fractures. METHODS: Between January 2012 and January 2014, open reduction and internal fixation were performed on 42 patients with ankle fractures. There were 22 males and 20 females with an average age of 52 years (range, 19-72 years). The causes were spraining injury (20 cases), traffic accident injury (14 cases), and falling from height injury (8 cases). The time from injury to operation was 5 hours to 12 days (mean, 2.5 days). All fractures were closed trimalleolar fractures. According to Lauge-Hansen classification, 25 cases were rated as supination extorsion type IV, 13 as pronation extorsion type IV, and 4 as pronation abduction type III. The preoperative planning was made by virtual reduction and internal fixation using Superimage software. RESULTS: The mean operation time was 93.7 minutes (range, 76-120 minutes). Delayed wound healing occurred in 1 case, and secondary healing was obtained after treatment; primary healing of incision was achieved in the other patients. Postoperative X-ray films and CT images showed anatomic reduction of fracture and good position of internal fixation. All patients were followed up 14.6 months on average (range, 9-27 months). The range of motion of the affected ankle was close to the normal side at 6-8 weeks. The mean fracture healing time was 13.1 weeks (range, 11-17 weeks). Degenerative change of the ankle joint was observed in 3 cases (7.1%) with manifestation of mild narrowing of joint space on the X-ray films at last follow-up. According to Baird-Jackson score system, the results were excellent in 24 cases, good in 13 cases, and fair in 5 cases, with an excellent and good rate of 88%. CONCLUSION: Computer-assisted surgical planning for ankle fractures can help surgeons identify type of ankle fractures and improve surgical scheme for guiding fracture reduction and selecting and placing implants, so good effectiveness can be obtained.

Peroneal strength as an indicator in selecting route of tibialis posterior transfer for foot drop correction in leprosy.

OBJECTIVES: Tibialis posterior tendon transfer (TPT) technique, using either the Circum-tibial (CT) or Inter-osseus (IO) route is the standard surgical technique to correct foot drop. The selection of the route of transfer is usually dependent on the surgeon's preference. This study aims to identify criteria to help make that selection. SUBJECTS AND METHODS: A study was carried out on 381 feet during the period 1999 to 2010. All the patients operated during this period were included in the study. The CT route was used for those with peronei power 4 or 5, while the IO route was used when peronei power was 3 or less. RESULTS: In this case series the mean effective range of motion (above 90 degrees) was 11 and 12 degrees in CT and IO routes, respectively. The results were comparable in terms of rest position, active dorsiflexion and effective range of motion. All patients had a post-operative heel to toe gait, except for one of the 381 operated feet. Only three of the 381 feet had a reduction in navicular height of more than 2 cm, the medial arch being maintained in the others. CONCLUSIONS: TPT is a standard procedure to correct foot drop deformity in leprosy. Pre-selection for route of transfer, CT or IO, based on peronei strength avoids the complication of iatrogenic inversion. The technique of insertion and routine tendo-achilles lengthening provides a good range of movement. The deep tunnelling has not compromised the results, while giving excellent cosmetic appearance.

Simplified diagnostic algorithm for Lauge-Hansen classification of ankle injuries.

Ankle injuries occur in a predictable sequence, allowing a logical understanding of their classification once the injury mechanism is recognized. The Lauge-Hansen classification system was developed on the basis of the mechanism of trauma and is useful for guiding treatment. Three radiographic views of the ankle (anteroposterior, mortise, and lateral) are necessary to classify an injury with the Lauge-Hansen system. Two additional criteria are also necessary: the position of the foot at the time of injury and the direction of the deforming force. Because understanding the mechanism of trauma is fundamental to classifying the injury, three-dimensional movies were assembled for each classification, showing the sequence of ligament rupture and bone fractures that occurs with each type of traumatic mechanism. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.322115017/-/DC1.

A new interpretation of the mechanism of ankle fracture.

BACKGROUND: Researchers have found it difficult to recreate a Lauge-Hansen supination-external rotation-type ankle fracture in experimental settings. We hypothesized that a pronation-external rotation mechanism could cause both distal, short oblique and high fibular fractures and that the fracture type would be affected by associated, laterally directed forces applied to the foot. Methlods: Twenty-three cadaver ankles were subjected to fracture loading that replicated the Lauge-Hansen pronation-external rotation mechanism with or without applying an external lateral force. In Phase I, an axial load was applied to fifteen specimens mounted on a materials testing machine. Each foot was rotated externally to failure. In Phase II, eight specimens were tested according to the Phase-I protocol, but external forces were applied laterally at the foot to increase the abduction moment at the ankle. Load and position versus time curves were recorded and were correlated with video image data to establish the sequence of failure of specific anatomic structures. RESULTS: Eight specimens tested in Phase I sustained an oblique fracture of the distal end of the fibula with both medial and posterior injuries that occurred after the fibular fracture. Increasing the external lateral force and hence the abduction moment within the ankle (Phase II) resulted in three of eight specimens sustaining a high fibular fracture with a reversed fracture line (anterosuperior to posteroinferior) and/or a comminuted high fibular fracture. The distribution of traditional pronation-external rotation-type fractures differed significantly between Phase I and Phase II (p=0.032). CONCLUSIONS: This study generated counterexamples to the Lauge-Hansen classification system by showing that a short oblique fracture of the distal end of the fibula can occur with the foot in the pronated position. Furthermore, a high fibular fracture was recreated by increasing the abduction moment at the ankle.

[Treatment of syndesmosis diastasis with screw fixation in ankle fractures].

OBJECTIVE: To explore the operative method for the treatment of syndesmosis injury in ankle fractures. METHODS: A retrospective study was done on 21 ankles of 20 patients included male 11 and female 9;the range of age were from 27 to 52 years with an average of 36 years) with syndesmosis injury in closed ankle fractures from September 2005 to December 2007. All patients with ankle fractures and syndesmosis injury were diagnosed by the history, physical examination and radiology, then treated with open reduction, internal fixation, and syndesmotic stabilization with a three-cortices syndesmotic screw according to the Lauge-Hansen classification system. Radiological evaluation comprised tibiofibular overlap, total clear space and medial clear space. The clinical effects were evaluated according to modified Baird-Jackson standard. RESULTS: All patients were followed up from 1.0 to 2.2 years with an average of 1.3 years. Radiographic measurements were detailed as follows: tibiofibular overlap averaged (0.46 +/- 3.56) mm in preoperative and (7.14 +/- 0.62) mm in postoperative; mean total clear space (5.69 +/-0.88) mm in preoperative and (3.28 +/- 0.39) mm in postoperative; medial clear space averaged (5.67 +/- 1.23) mm in preoperative and (3.12 +/- 0.33) mm in postoperative; tibiofibular overlap in mortise view averaged (-0.87 +/- 0.96) mm in preoperative and (2.91 +/- 0.30) mm in postoperative. There was significant difference above data between preoperative and postoperative (P < 0.01). Four cases were confirmed minor tibiofibular diastasis through CT scans during postoperative. The modified Baird-Jackson scoring was from 62 to 98 scores with an average of (86.24 +/- 13.26) score at the final review. Of them, 13 ankles had not pain; 16 ankles reported no instability complaints; 11 ankles gained normal walking ability; 8 ankles could run normally; 11 ankles could return work without any restrictions. Activity of ankle in dorsiflexion, plantar flexion, inversion and eversion were respectively (21.05 +/- 5.00) degrees, (33.57 +/- 5.76) degrees, (19.48 +/- 4.57) degrees and (24.05 +/- 4.86) degrees. Three cases had radiological and clinical manifestations of osteoarthritis, but no breakage of syndesmotic screw in all cases. There were excellent results in 12 cases, good in 2, fair in 4, poor in 3. CONCLUSION: The treatment for the syndesmosis diastasis with a three-cortices screw fixation in ankle fractures is effective. Good functional outcome can be obtained with anatomical restoration of the tibiofibular syndesmosis. The repair of deltoid ligament is important for stability of the lower tibiofibular syndesmosis. Removal of the screw before weight loading should be performed to avoid possible screw breakage.

The role of radiology in nerve function impairment and its musculoskeletal complications in leprosy.

Conventional techniques, such as plain radiography and bone-scintigraphy, were used in the past to evaluate skeletal changes in patients with leprosy. More recent publications focus on radiological imaging of affected nerves, and involve advanced modalities such as Computed Tomography (CT-scan), Ultrasonography (US), and Magnetic Resonance Imaging (MRI). US and MRI can play an especially important role in the evaluation of nerve involvement in newly diagnosed patients, and also during leprosy reactions. This is important, because when nerve involvement is diagnosed in time, it may be reversible with adequate treatment. Radiological modalities can also play an important role during the followup of patients with leprosy with nerve function impairment. Skeletal and soft-tissue abnormalities occur, even after treatment. The so-called neuropathic foot is a well known consequence. Because of nerve function impairment, there is a constant risk of developing ulcers and subsequent osteomyelitis, or neuro-osteoarthropathy (Charcot foot or tarsal disintegration), which can lead to the amputation of the affected limb. Different radiological modalities can be used during the evaluation and follow-up of patients with leprosy with a neuropathic foot. With this up-to-date review, we highlight the importance and potential role of radiological imaging techniques in leprosy.

A clinical and radiological follow-up study in leprosy patients with asymptomatic neuropathic feet.

OBJECTIVES: An MRI study done in 2000 on 10 leprosy patients with neuropathic feet, without clinical complications such as ulcerations, osteomyelitis or Charcot deformities revealed abnormalities in nine patients, with degradation, interruption of subcutaneous fat and effusion/synovitis, all located in the first metatarsophalangeal (MTP) region. Since these MRI abnormalities may precede clinical complications of the foot, a follow-up study was performed. DESIGN: A new evaluation was based on a clinical examination and an MRI of the same patients who participated in the initial study. RESULTS: Four patients were lost to follow-up. Average follow-up period was 4-6 years. MRI abnormalities in the MTP 1 region in the first study were no longer visible in three patients, but were still present in two patients. In six patients new MRI findings were found, without clinical evidence of ulceration, osteomyelitis or Charcot deformity. No relationship was found between MRI findings in the MTP 1 region at the start of the study and the development of foot ulcers, callus or skin fissures in the MTP 1 region during follow-up. CONCLUSION: MRI findings of interruption and infiltration of the subcutaneous fat in leprosy patients with uncomplicated neuropathic feet do not necessarily have any clinical implication for the development of future foot problems.

MR imaging of neuropathic feet in leprosy patients with suspected osteomyelitis.

This study was undertaken to analyze MRI findings in leprosy patients with neuropathic feet, which are suspected of having osteomyelitis. As far as we know, there is no literature concerning osteomyelitis and MRI in neuropathic leprosy feet at present. Therefore, we have included MRI examination of 18 events of suspected osteomyelitis in 12 leprosy patients. All patients with long-standing neuropathic foot problems were clinically suspected of having osteomyelitis. All patients underwent the MRI protocol with the inclusion of Two Point Dixon Chemical Shift Imaging as a fat-suppression sequence. For the MRI evaluation, we used signs that are described in literature for detecting osteomyelitis in diabetic feet. The primary MRI signs were positive in 17 of 18 patients. The secondary MRI signs were positive in 100% of the patients. Our results show that MRI with the use of Two Point Dixon Chemical Shift Imaging is a promising diagnostic modality to detect osteomyelitis in the presence of neurosteoarthropathic changes in patients with leprosy. Whenever available, MRI could play an important role in detecting osteomyelitis in leprosy patients with long-standing neuropathic feet.

Mechanics of tarsal disintegration and plantar ulcers in leprosy by stress analysis in three dimensional foot models.

This paper describes three dimensional two arch models of feet of a normal subject and two leprosy subjects, one in the early stage and the other in the advanced stage of tarsal disintegration, used for analysis of skeletal and plantar soft tissue stresses by finite element technique using NISA software package. The model considered the foot geometry (obtained from X-rays), foot bone, cartilages, ligaments, important muscle forces and sole soft tissue. The stress analysis is carried out for the foot models simulating quasi-static walking phases of heel-strike, mid-stance and push-off. The analysis of the normal foot model shows that highest stresses occur at push-off over the dorsal central part of lateral and medial metatarsals and dorsal junction of calcaneus and cuboid and neck of talus. The skeletal stresses, in early state leprosy with muscle paralysis and in the advanced stage of tarsal distintegration (TD), are higher than those for the normal foot model, by 24% to 65% and 30% to 400%, respectively. The vertical stresses in the soft tissue at the foot-ground interface match well with experimentally measured foot pressures and for the normal and leprosy subjects they are the highest in the push-off phase. In the leprosy subject with advanced TD, the highest soft tissue stresses and shear stresses (about three times the normal value) occur in push-off phase in the scar tissue region. The difference in shear stresses between the sole and the adjacent soft tissue layer in the scar tissue for the same subject is about three times the normal value. It is concluded that the high bone stresses in leprosy may be responsible for tarsal distintegration when the bone mechanical strength decreases due to osteoporosis and the combined effect of high value of footsole vertical stresses, shear stresses and the relative shear stresses between two adjacent soft tissue layers may be responsible for plantar ulcers in the neuropathic leprosy feet.

[Progression towards dislocations of foot bone lesions in leprosy]. / De l'évolution vers la dislocation des lésions osseuses du pied du lépreux.

From a series of 211 tarsal, medio-tarsal and metatarso-phalangeal dislocations, the authors, after having recalled the lesion mechanism, adopted a classification and gave a place to preventive conservative surgery in 52 cases. The early forms can have early limited arthrodesia. The developed lesions present indications of arthrodesia--isolated reconstruction or associated to spongy or cortico-spongy bone grafts. The late forms impose amputation even when the forefoot seems of good bone quality because the metatarsal-phalangial stiffness is the cause for the failure of the Wladimiroff-Mickulicz interventions.

Lauge-Hansen classification of malleolar fractures. An assessment of the reproducibility in 118 cases.

The radiographs of malleolar fractures in 118 consecutive patients were assessed by 4 observers using the Lauge-Hansen classification. The interobserver variation was large; only 51 of the 118 radiographs were classified identically by all 4 observers. With the purpose of assessing intraobserver variation, the same observers classified the same radiographs 6 weeks later. The first and the second classification were identical in 75-97 of 118 radiographs (64-82 percent). These results show that the Lauge-Hansen system is difficult to apply in a reproducible way.

Observations of tarsal disintegration in the cases operated for foot-drop.

Fifty cases operated for foot-drop during the years 1971-82 were called for follow-up. Out of fifty, twenty cases were reported to the hospital. Three cases among the twenty were found to have changes of tarsal disintegration. The changes were found more confined to the talo-navicular junction. X-ray changes both in non-weight and weight bearing were studied. Their line drawings (tracings from actual radiograph) are presented. It is concluded that due attention should be given to the pre-operative evaluation, operative procedure used and post-operative management particularly the weight-bearing and proper footwear.

Tarsal disintegration (T.D.) in leprosy.

Tarsal Disintegration in leprosy has been a challenge as far as its prevention is concerned. It is, no doubt, a complex and less understood phenomenon influenced by many factors. In this study made at Dr. Bandorawalla Leprosy Hospital, Kondhawa, factors like insensitivity, loss of protective reflex, infection, lepromatous infiltration of bones etc. have been taken into consideration, but, more emphasis is laid on the biomechanical factors (i.e. altered muscle pulls due to muscular paralysis resulting in imbalance) and the resulting change in weight bearing areas and weight transmission lines. Sixteen cases of neuropathic feet were examined clinically and radiologically. All were burnt out cases of tuberculoid and borderline tuberculoid variety excepting one which was active being of lepromatous variety. Tracings made from actual radiographs of the patients were studied. It was found that apart from insensitivity, biomechanical factors play a lot of importance in accentuating the process of T.D. The changes are predominantly seen in Tuberculoid variety of Leprosy. Attempts have been made to understand this process more closely by drawing conclusions based on the kinetic and kinematic analysis of the normal human foot and comparing it with neuropathic feet.