Incidence of Talar Osteochondral Lesions After Acute Ankle Fracture: A Retrospective Analysis.

Recent literature suggests the majority of osteochondral lesions occur in the ankle joint. Previous studies have suggested that varying incidences of talar osteochondral lesions (OCLT) are associated with ankle fractures. The primary aim of our study was to investigate the incidence of osteochondral lesions associated with acute ankle fractures as observed on computed tomographic (CT) imaging. We also compared the rates of talar osteochondral lesions in patients who had ankle fractures with dislocation and closed manual reduction (CMR) prior to open reduction with internal fixation, to those who did not suffer from ankle joint dislocation. Additionally, a correlation between the location of talar dome lesions with type of ankle fracture as classified by Lauge-Hansen was investigated. Preoperative CT imaging was retrospectively reviewed in 108 patients with acute ankle fractures. A CT-modified version of Berndt Hardy's classification of osteochondral lesions, as previously described by Loomer et al, was used for diagnosis of lesions in our study. The incidence of lesions was calculated across all subjects, and retrospective comparison was performed in those who did and did not undergo closed manual reduction. Supplementary data on location of lesion and its association with ankle fracture type was also recorded. We found an overall incidence of 50.9% OCLT in patients with acute ankle fractures. This number did not significantly differ from those who underwent closed manual reduction (49%). Although a majority of lesions did occur posteriorly, we saw no statistically significant information was seen between either type of fractures or OCLT locations. Careful consideration and thorough evaluation of preoperative CT imaging should be assessed by the performing surgeon, as this could guide both diagnostic and therapeutic treatments for patients with possible osteochondral lesions of the talus undergoing surgical repair of a fractured ankle.

Second-look arthroscopic findings and clinical outcomes after management of intra-articular lesions in acute ankle fractures with arthroscopy.

BACKGROUND: Anatomically surgical reduction of ankle fractures does not always result in a clinically favorable outcome. Arthroscopic examination combined with treatment of intra-articular lesion may related to clinical outcomes OBJECTIVES: The purpose of the present study was to review initial and second look arthroscopic finding of acute ankle fracture and to evaluate clinical outcomes. RESULTS: Lauge-Hansen classification system of ankle fractures included supination-external rotation type (n = 24), supination-adduction type (n = 3), pronation-external rotation type (n = 7), and pronation-abduction type (n = 6), total 40 ankles. Osteochondral lesions were found in 25 ankles (62%) with an initial arthroscopic finding of acute ankle fracture. Newly discovered chondral lesions in secondary arthroscopy were found in 17 cases. According to the Ferkel and Cheng staging at secondary arthroscopy, 4 of 25 ankles with osteochondral lesions of the talus were deteriorating (more than stage D). In terms of ICRS overall repair grades, 5 ankles (20%) were abnormal (grade III). Diffuse synovitis and arthrofibrosis were found in 12 and 7 ankles, respectively, in secondary arthroscopy, and correlations were found between AOFAS scores, VAS and intra-articular lesions. CONCLUSION: Second-look arthroscopic examination combined with treatment of intra-articular lesion such as arthrofibrosis and osteochondral lesion arising from ankle fracture surgery may consider to improve clinical outcomes.

High incidence of (osteo)chondral lesions in ankle fractures.

PURPOSE: To determine the incidence and location of osteochondral lesions (OCLs) following ankle fractures as well as to determine the association between fracture type and the presence of OCLs. Up to 50% of patients with ankle fractures that receive surgical treatment show suboptimal functional results with residual complaints at a long-term follow-up. This might be due to the presence of intra-articular osteochondral lesions (OCL). METHODS: A literature search was carried out in PubMed (MEDLINE), EMBASE, CDSR, DARE and CENTRAL to identify relevant studies. Two authors separately and independently screened the search results and conducted the quality assessment using the MINORS criteria. Available full-text clinical articles on ankle fractures published in English, Dutch and German were eligible for inclusion. Per fracture classification, the OCL incidence and location were extracted from the included articles. Where possible, OCL incidence per fracture classification (Danis-Weber and/or Lauge-Hansen classification) was calculated and pooled. Two-sided p values of less than 0.05 were considered statistically significant. RESULTS: Twenty articles were included with a total of 1707 ankle fractures in 1707 patients. When focusing on ankle fractures that were assessed directly after the trauma, the OCL incidence was 45% (n = 1404). Furthermore, the most common location of an OCL following an ankle fractures was the talus (43% of all OCLs). A significant difference in OCL incidence was observed among Lauge-Hansen categories (p = 0.049). Post hoc pairwise comparisons between Lauge-Hansen categories (with adjusted significance level of 0.01) revealed no significant difference (n.s.). CONCLUSION: OCLs are frequently seen in patients with ankle fractures when assessed both directly after and at least 12 months after initial trauma (45-47%, respectively). Moreover, the vast majority of post-traumatic OCLs were located in the talus (42.7% of all OCLs). A higher incidence of OCLs was observed with rotational type fractures. The clinical relevance of the present systematic review is that it provides an overview of the incidence and location of OCLs in ankle fractures, hereby raising awareness to surgeons of these treatable concomitant injuries. As a result, this may improve the clinical outcomes when directly addressed during index surgery. LEVEL OF EVIDENCE: IV.

Post-Traumatic Hindfoot Arthritis.

The hindfoot is functionally defined as the articulations between the talus, calcaneus, navicular, and cuboid. It is a biomechanically important peritalar unit for shock absorption and propulsion with the subtalar and talonavicular joint essential to its function. The primary cause of hindfoot arthritis is post-traumatic. Other causes include long-term misalignment such as adult-acquired flatfoot, cavus foot, and inflammatory arthritis. Prevention of post-traumatic hindfoot arthritis is the primary objective. Anatomical reduction and fixation of articular hindfoot fractures is the preferred pathway. This article discusses the principles of treatment of hindfoot arthritis. When post-traumatic changes cannot be managed by nonsurgical means, an anatomical well-aligned arthrodesis is indicated. This article addresses the principles of managing this condition, which have been championed by Professor Sigvard T. Hansen. New approaches and techniques are discussed that achieve the goals of a stable, functional plantigrade foot.

[Anterior dislocation of the fibula resulting from surgical malreduction: a case report].

Ankle joint fracture is one of the most common types of fracture. There are many researches on the injury mechanism, treatment principles and surgical techniques. A type of injury which combines posterior dislocation of fibula, known as the Bosworth injury, is relatively rare. In 1947, Bosworth first described this type of injury as an unusual ankle fracture dislocation with fixed posterior fracture dislocation of the distal part of the fibula. In this type of fracture, the proximal fibular shaft fragment locks behind the tibialis posterior tubercle. This rare ankle fracture variant is often not recognized in initial radiographs and requires a computed tomographic (CT) scan for verification. But there are already many reports, discussing the injury mechanism, treatment principles and surgical techniques. However, there are few reports of anterior dislocation of the fibula, caused by either injury or surgery. The mechanism of the injury is still not clear. This article reports a case of anterior dislocation of the fibula. We report a patient with left ankle open fracture (Lauge-Hansen pronation-external rotation stage III, Gustilo IIIA). Open reduction and internal fixation was done in the initial surgery, but ended up with poor reduction, resulting in fibula anterior dislocation, anterior dislocation of talus and tibia fibular dislocation. The fibula was dislocated anteriorly of the tibia, which rarely happened. The patient suffered severe ankle joint dysfunction. The second operation took out the original internal fixation, reduced the fracture, and reset the internal fixation. The function of ankle joint was improved obviously after operation. But because of the initial injury and the two operations, the soft tissue around the fracture was greatly damaged. 6 months after the second operation, and the fracture still not healed, so the bone graft was carried out in the third surgery. Two months after the third surgery, the function of the ankle was significantly better than before, but the fracture healing was poor, which needed further review. Through this case, we understand the rare type of ankle fracture with anterior dislocation of the fibula, and recognize that the timing and quality of initial surgery has a great impact on the patient's prognosis and rehabilitation period.

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

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

Osteological, biomolecular and geochemical examination of an early anglo-saxon case of lepromatous leprosy.

We have examined a 5th to 6th century inhumation from Great Chesterford, Essex, UK. The incomplete remains are those of a young male, aged around 21-35 years at death. The remains show osteological evidence of lepromatous leprosy (LL) and this was confirmed by lipid biomarker analysis and ancient DNA (aDNA) analysis, which provided evidence for both multi-copy and single copy loci from the Mycobacterium leprae genome. Genotyping showed the strain belonged to the 3I lineage, but the Great Chesterford isolate appeared to be ancestral to 3I strains found in later medieval cases in southern Britain and also continental Europe. While a number of contemporaneous cases exist, at present, this case of leprosy is the earliest radiocarbon dated case in Britain confirmed by both aDNA and lipid biomarkers. Importantly, Strontium and Oxygen isotope analysis suggest that the individual is likely to have originated from outside Britain. This potentially sheds light on the origins of the strain in Britain and its subsequent spread to other parts of the world, including the Americas where the 3I lineage of M. leprae is still found in some southern states of America.