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.

[High complication rate after surgical treatment of ankle fractures]. / Høj komplikationsrate efter kirurgisk behandling af malleolfraktur.

The purpose of this study was to determine the quality and re-operation rate of the surgical treatment of ankle fractures at a large university hospital. X-rays and patient records of 137 patients surgically treated for ankle fractures were analyzed for: 1) correct classification according to Lauge-Hansen, 2) if congruity of the ankle joint was achieved, 3) selection and placement of the hardware, and 4) the surgeon's level of education. Totally 32 of 137 did not receive an optimal treatment, 11 were re-operated. There was no clear correlation between incorrect operation and the surgeon's level of education.

Epidemiology, management, and outcome of sport-related ankle fractures in a standard UK population.

BACKGROUND: The literature on the outcome of sport-related ankle fractures has focused on operatively managed fractures, despite a large proportion being treated nonoperatively. We describe the epidemiology, management, and outcome of acute sport-related ankle fractures in a UK population. METHODS: All sport-related ankle fractures sustained during 2007 to 2008 in the Lothian Population were prospectively collected when patients attended the only adult orthopaedic service in Lothian. Fractures were classified using the Lauge Hansen and the Pott's Classification. The presence of fracture displacement was also recorded. Patients were contacted in February 2011 to ascertain their progress in return to sport. RESULTS: Ninety-six sport-related ankle fractures were recorded in 96 patients. Eighty-four fractures (88%) were followed up at a mean interval of 36 months (range, 30-42). Most common associated sports were soccer (n = 49), rugby (n = 15), running (n = 5), and ice skating (n = 3). The mean time for return to sport was 26 weeks (range, 4-104), the return rate to sport 94%, and the persisting symptom rate 42%. Fifty-two fractures (all nondisplaced) were managed nonoperatively-43 isolated lateral malleolar (30 Weber B, 13 Weber A), 2 isolated medial malleolar, 7 bimalleolar. Forty-four fractures were managed operatively-42 were displaced (2 isolated lateral malleolar, 3 isolated medial malleolar, 18 bimalleolar equivalent, 9 bimalleolar, 3 trimalleolar equivalent, 7 trimalleolar), 2 were un-displaced (2 trimalleolar). The mean times for return to sport were 20 weeks (range, 4-52) for the nonoperative cohort (NOC) and 35 weeks (range, 8-104) for the operative cohort (OC) (P < .001), the return rates to sport were 100% for NOC and 87% for OC (P < .016), and the persisting symptom rates were 17% for NOC and 71% for OC (P < .001). CONCLUSIONS: Nondisplaced ankle fractures in athletes were successfully managed with nonoperative care. They had greater return rates to sport, quicker return times, and lower persisting symptom rates but had less severe injuries. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Evaluation of posterior malleolar fractures and the posterior pilon variant in operatively treated ankle fractures.

BACKGROUND: Substantial attention has recently been placed on fractures of the posterior malleolus. Fracture extension to the posteromedial rim ("posterior pilon variant") may result in articular incongruity and talar subluxation. Current classification systems fail to account for these fractures. The relative frequency of this fracture, its associated patient characteristics, and the reliability of its diagnosis have never been reported in such a large series. METHODS: We retrospectively identified 270 patients who met our inclusion criteria. Basic demographic data were collected. The fractures were classified according to Lauge-Hansen and AO/OTA. Additional radiographic data included whether the fracture involved the posterior malleolus and whether the fracture represented a posterior pilon variant. Univariate statistical methods, chi-square analysis, and interobserver reliability were assessed. RESULTS: The relative frequency of posterior malleolus fracture was 50%. The relative frequency of the posterior pilon variant was 20%. No significant difference was noted with respect to the frequency of posterior malleolar or posterior pilon variant between the subgroups of the AO/OTA and Lauge-Hansen classification systems when compared to the overall fracture distribution. Patients with posterior malleolar fractures and posterior pilon variants were significantly older. Females were significantly more likely than men to sustain posterior malleolar fractures and posterior pilon variants. Patients with diabetes trended toward a greater risk of both types of fractures. Interobserver reliability data revealed substantial agreement for posterior malleolar fractures and posterior pilon variants. CONCLUSION: These data represent the highest reported rate of posterior malleolar involvement in operatively treated ankle fractures and is the first to describe the percentage of the posterior pilon variant in such a large series. The interobserver reliability data demonstrate substantial agreement in identification of posterior malleolar fractures and the posterior pilon variant based on plain radiographs. Certain patient characteristics such as age, sex, and diabetes may be associated with these fractures. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Ankle fracture: radiographic approach according to the Lauge-Hansen classification.

Ankle fractures account for 9 % of fractures (Clare in Foot Ankle Clin 13(4):593-610, 1) representing a significant portion of the trauma workload; proximal femoral fractures are the only lower limb fracture to present more frequently. Ankle fractures have a bimodal age distribution with peaks in younger males and older females (Arimoto and Forrester in AJR Am J Roentgenol 135(5):1057-1063, 2). There has been threefold increase in the incidence among elderly females over the past three decades (Haraguchi and Armiger in J Bone Joint Surg Am 91(4):821-829, 3). In 1950, Lauge-Hansen devised a classification of ankle fractures based on the position of the foot and the deforming force at the time of injury. This has been widely accepted by orthopedists, but is not in general use by radiologists. Identification of the fractures and classification of the type of injury allows diagnosis of the otherwise occult ligamentous injuries. 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.

The effect of inclement weather on ankle fracture management in an Irish trauma unit.

INTRODUCTION: Ireland is unfamiliar with extreme weather conditions. Such conditions occurred in winter 2009-2010 and 2010-2011, with much of the country being affected by snow and ice. We reviewed the effect that these conditions had on the treatment of ankle fractures in our trauma unit. MATERIALS AND METHODS: The study period was from November until February for four consecutive years from 2008-2009 until 2011-2012. We compared two winters with extreme weather with two winters with regular weather conditions. Information from Met Eireann was compared with demographics from patient records to differentiate ice-related injuries from non-ice-related injuries. Ankle fractures were classified using the Lauge-Hansen classification. We compared waiting times in A&E, waiting times for theatre, delays relating to injury severity, and overall length of stay for both groups. RESULTS: We identified 44 ice-related injuries and 67 non-ice-related injuries. Ice-related injuries trended towards more severe fracture configurations using the Lauge-Hansen classification. Patients sustaining ankle injuries during inclement weather were significantly younger than patients sustaining injuries during regular weather conditions. There were no other significant differences between the two groups. DISCUSSION: Ice-related injuries trended towards a greater severity of fracture configuration. We identified no significant increase in the time to treatment or overall length of stay of patients sustaining ankle fractures during these times. Ice-related injuries did not have greater rates of complications. These results are a testament to the trauma staff in this unit who absorbed the increased workload without compromising patient care.

Epidemiology of ankle fractures. A prospective population-based study of 212 cases in Aalborg, Denmark.

We studied the epidemiology of ankle fractures prospectively during 1 year in a population of about 200,000. The overall incidence rate was 107 fractures per 10(5) person-years. Below the age of 50, ankle fractures were commonest in men. After this age, females became predominant and the age-specific incidence rates decreased in both sexes. The main cause of fracture was falls (87%), on the ground, on stairs or from a height. 137 fractures (55%) occurred in sports, play or other leisure activities. Most patients (64%) were walking, running or jumping at the time of injury. Alcohol and slippery surfaces were each involved in nearly a third of the cases. The distribution of the fractures according to both the Lauge-Hansen and the AO Weber classification systems were within the limits of previous series. Nearly half the patients were hospitalized and the fractures were operated on with osteosynthesis. Our findings indicate that ankle fractures are mainly caused by substantial trauma sustained during physical activity. Osteoporosis seems to be of minor importance.