Morphology of Fibular Incisura is a Deciding Factor Between Posterior Malleolus Avulsion Fracture or Syndesmotic Ligament Injury in Ankle Fractures.

The bone anatomy of tibiofibular syndesmosis has been a topic of interest. Fibular incisura morphology has been analyzed on cadaver specimens, plain radiographs, or CT images. The aim of this study is to examine the effects of fibula incisura features and fibula morphology in ankle injuries, especially involving posterior malleolus and posteroinferior tibiofibular ligament injuries. From 2017 through 2022, A total of 59 patients with isolated lateral malleolar fracture, Mason-Malloy type 1 posterior malleolar fracture, syndesmosis injury in those without posterior malleolar fracture, supination external rotation type 3 injuries according to Lauge-Hansen classification, and preoperative bilateral ankle computed tomography images were included in the study. Fibula morphologies and syndesmosis measurements were made from preoperative computed tomography images using axial CT images from 1 cm proximal to the tibial plafond. The diagnosis of posterior malleolar fractures was made using the CT classification system of Mason and Malloy, and the diagnosis of syndesmosis injury was made with a cotton test during surgery. Age, gender, fractured side, incisura type, incisor depth, width, anterior and posterior facet lengths, incisor version (antevert-retrovert), the angle between the anterior and posterior facets, and fibula type were recorded. There was a statistically significant difference between the groups in posterior facet length and incisura width. Morphological features of fibular incisura may be the determinant of PITFL injury or PMA injury in fibular fractures caused by an external rotation mechanism.

Impact of Syndesmotic Screw Removal on Quality of Life, Mobility, and Daily Living Activities in Patients Post Distal Tibiofibular Diastasis Repair.

Background and Objectives: While numerous studies have been conducted on syndesmotic screw management following distal tibiofibular diastasis repair, a clear consensus remains unclear. This research aims to evaluate whether the postoperative removal of syndesmotic screws leads to improved patient outcomes, specifically in quality of life, mobility, and daily living activities, and whether it offers a cost-effective solution. Materials and Methods: Patients with a history of unimalleolar or bimalleolar ankle fractures, classified according to the Danis-Weber and Lauge-Hansen systems, were included. Comprehensive evaluations were made via standardized questionnaires like the SF-36 Health Survey, HADS, and WHOQOL-BREF, distributed approximately 2 months post surgery. A total of 93 patients underwent syndesmotic screw removal while 51 retained the screws (conservative approach). Results: Patients who underwent screw removal reported superior satisfaction in mobility, with a score of 7.8, compared to 6.7 in the conservative approach (p = 0.018). Similarly, their ability to perform daily activities scored 8.1, higher than the 6.5 from the conservative cohort (p < 0.001). Pain levels were also more favorable in the screw removal group, with a score of 5.3 against 6.8 in the conservative group (p = 0.003). On the SF-36 physical domain, the screw removal group achieved a mean score of 55.9 versus 53.3 for the conservative group (p = 0.027). Notably, the HADS anxiety subscale highlighted reduced anxiety levels in the screw removal cohort with a mean score of 5.8 against 7.3 in the conservative group (p = 0.006). However, overall quality of life and recommendations to others showed no significant difference between the groups. Conclusions: Syndesmotic screw removal postoperatively leads to marked improvements in patients' mobility, daily activity abilities, and reduced postoperative pain and anxiety levels. However, overall quality of life was similar between the two approaches. The findings offer valuable insights for orthopedic decision making and patient-centered care concerning the management of syndesmotic screws after distal tibiofibular diastasis repair.

Concomitant Unstable and Stable Gravity Stress Tests on Weight-Bearing Stable Weber B Ankle Fractures Treated Nonoperatively: A 2-Year Outcome Study.

BACKGROUND: Replacing gravity stress tests with weight-bearing radiographs to evaluate the stability of Weber B (also called Lauge-Hansen supination-external rotation [SER]) ankle fractures results in a lower surgery rate, thus avoiding associated risks and complications. Still, nonoperative treatment of weight-bearing stable fractures is controversial because of the scarcity of strong evidence. We investigated the influence of a concomitant unstable gravity stress test compared with a stable gravity stress test on outcomes after nonoperative treatment of weight-bearing stable fractures. METHODS: We performed a prospective, noninferiority study on 149 patients with Weber B ankle fractures and stable weight-bearing radiographs. Gravity stress radiographs classified fractures as stable (SER2 [n = 88]) or partially unstable (SER4a [n = 61]). All were treated with a functional orthosis and weight-bearing was allowed; patients were followed for 2 years. The primary outcome was the Manchester-Oxford Foot and Ankle Questionnaire (MOXFQ), with a range from 0 to 100, in which lower scores indicate fewer symptoms. A noninferiority margin was prospectively defined as 7.5 points. The secondary outcomes included the Olerud-Molander Ankle Score, assessment of ankle congruence, and treatment-related adverse events. RESULTS: The primary outcome data were available for 144 (96.6%) of 149 participants at 2 years. The between-group difference in the MOXFQ score was 1.0 point (95% confidence interval, -1.4 to 3.4 points; p = 0.397) in favor of the SER2 group, consistent with noninferiority. We found no appreciable between-group differences for any other outcome. CONCLUSIONS: In Weber B/SER ankle fractures that are stable on weight-bearing radiographs, are treated with removable orthoses, and are allowed to bear weight, a concomitant unstable gravity stress test (SER4a) was not associated with worse patient-reported or radiographic outcomes compared with a stable gravity stress test (SER2) at the 2-year follow-up. Thus, the identification of stress instability seems redundant, which questions the applicability of stress instability for surgical decision-making. LEVEL OF EVIDENCE: Diagnostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Ligament Ruptures in Ankle Fractures-Was Lauge-Hansen Right?

The contribution of Lauge-Hansen to the understanding and treatment of ankle fractures cannot be underestimated, an unquestionable merit being the analysis of the ligamentous component of these injuries that are considered as equivalent to the respective malleolar fractures. In numerous clinical and biomechanical studies, the lateral ankle ligaments are ruptured either together with or instead of the syndesmotic ligaments, as predicted by the Lauge-Hansen stages. A ligament-based view on malleolar fractures may deepen the understanding of the mechanism of injury and lead to a stability-based evaluation and treatment of the 4 osteoligamentous pillars (malleoli) at the ankle.

Preoperative CT parameters to predict tibiofibular syndesmosis injury associated with ankle fracture: a propensity score-matched analysis.

BACKGROUND: Untreated ankle fractures with concomitant tibiofibular syndesmosis injury often lead to postoperative pain and early traumatic arthritis. CT has advantages in the preoperative diagnosis of combined ankle injuries. However, a few studies have investigated the best preoperative CT parameters to predict tibiofibular syndesmosis injuries associated with ankle fractures. This study aimed to identify and evaluate the optimal preoperative CT parameters for predicting tibiofibular syndesmosis injuries associated with ankle fractures. METHODS: We retrospectively analyzed 129 patients who underwent preoperative CT of an ankle fracture treated between January 2016 and April 2022 at a tertiary A hospital. All patients underwent open reduction and internal fixation and intraoperative stability testing. Based on the Cotton test, the patients were divided into the stable group (n = 83, 64.3%) and unstable group (n = 46, 35.7%). After 1:1 propensity score matching, the general conditions, anterior tibiofibular distance (TFD), posterior TFD, maximum TFD, tibiofibular syndesmosis area, sagittal fracture angle, Angle-A, and Angle-B were compared between the stable and unstable groups. RESULTS: The propensity score-matched cohort comprised 82 patients. There were no significant differences between the stable and unstable groups in sex, age, affected side, operation interval, injury mechanism, Lauge-Hansen classification, sagittal fracture angle, and Angle-A (all P > 0.05). Compared with the stable group, the unstable group had a significantly greater aTFD, pTFD, maxTFD, and area (all P < 0.05). PTFD, maxTFD, and area were positively correlated with joint instability. Angle-B was smaller in the unstable group (57.13°) than the stable group (65.56°). ROC analysis showed that Area (AUC 0.711) and maxTFD (AUC 0.707) had the highest diagnostic efficacy. CONCLUSION: MaxTFD and Area were the best predictive parameters; a larger Area was associated with a higher likelihood of instability of the tibiofibular syndesmosis after ankle fracture fixation.

Factors Associated With Successful Closed Reduction of Dislocated Ankle Fractures at a US Level-1 Trauma Center.

Dislocated ankle fractures represent a common presenting pathology at US emergency departments, and several different procedural and anesthetic techniques are employed for attempted closed reduction of these injuries. The objective of this investigation was to evaluate the frequency of and factors associated with success in the closed reduction of dislocated ankle fractures. A diagnostic code search produced 1050 ankle fractures presenting to an urban US level-1 emergency department. These medical records were interrogated and first categorized into whether or not a closed reduction was attempted. Those identified closed reduction attempts were further categorized into whether the attempt was successful. A comparative analysis was subsequently performed of variables associated with procedure success. Of the 1050, 97 (9.2%) required closed reduction and of these, 76 (78.4%) were successfully closed reduced on the first attempt. No differences were observed in initial procedure success with respect to subject age (p = .701), subject gender (p = .623), fracture laterality (p = 1.00), open versus closed injuries (p = .282), fracture mechanism (p = 1.00), utilized anesthetic technique (p value range 0.291-0.616), or the specialty performing the reduction (p-value range 0.402-1.00). A descriptive subanalysis was performed on those fractures with an unsuccessful first closed reduction attempt. It is our hope that this investigation adds to the body of knowledge with respect to a commonly performed procedure by foot and ankle surgeons.

Cast versus removable orthosis for the management of stable type B ankle fractures: a systematic review and meta-analysis.

PURPOSE: There is currently no consensus on nonoperative management in adult patients after a stable type B ankle fracture. The aim of this review is to compare a removable orthosis versus a cast regarding safety and functional outcome in the NOM of stable type B ankle fractures. METHODS: A systematic review and meta-analysis were performed using randomized clinical trials and observational studies. The methodological quality of the included studies was assessed with the methodological index for non-randomized studies instrument. Nonoperative management was compared using the number of complications and functional outcome measured using the Olerud and Molander Score (OMAS) or the American Academy of Orthopaedic Surgeons Ankle Score. RESULTS: Five studies were included. Two were randomized clinical trials, and three were observational studies, including a total of 516 patients. A meta-analysis showed statistically significant higher odds of developing complications in the cast group [odds ratio (OR), 4.67 (95% confidence interval (CI) 1.52-14.35)]. Functional outcome in OMAS did not vary significantly at 6 weeks, mean difference (MD) - 6.64 (95% CI - 13.72 to + 0.45), and at 12 weeks, MD - 6.91 (95% CI - 18.73 to + 4.91). The mean difference of functional outcome in OMAS at 26 weeks or longer was significantly better in the removable orthosis group; MD - 2.63 (95% CI - 5.01 to - 0.25). CONCLUSION: Results of this systematic review and meta-analysis show that a removable orthosis is a safe alternative type of NOM, as complication numbers are significantly lower in the orthosis group. In addition, no statistically significant differences were found in terms of functional outcome between a removable orthosis and a cast at 6 and 12 weeks. The 6-week and the 26-week OMAS results show that in patients with stable type B ankle fractures, a removable orthosis is non-inferior to a cast in terms of functional outcome.

Identifying the Potential Role of Regional Bone Mineral Density on the Degree of Malleolar Involvement in Acute Ankle Fractures.

Ankle fractures are a common traumatic lower extremity injury and are generally classified and characterized by the rotational mechanism of injury. At each malleolus (i.e., posterior, medial, and lateral) a fracture can occur or a ligamentous injury may be sustained. The purpose of this retrospective study was to determine if bone mineral density is a contributing factor on the number of fractured malleoli versus soft tissue injury in adult ankle fractures. Data was obtained from a registry of ankle fractures that were operatively treated by the foot and ankle team throughout our institutional facilities, from July 2017 to August 2019, and in which a preoperative computerized tomography scan was performed. Regional bone mineral density (BMD) was measured by calculating the average Hounsfield Unit (HU) on axial computerized tomography images of the distal fibula and tibia. The average HU was then compared to the number of fractured malleoli. One hundred eight patients met the study criteria. We identified statistically significant relationships between decreased BMD with increasing age (p < .01) and the male gender (p < .01). After adjusting for the covariates age and gender, no statistically significant relationship was identified between BMD and the number of malleoli involved in a given ankle fracture (p = .11). These findings suggest that while more investigation is required for ankle fracture patterns and BMD evaluation, increased age and biologic female gender is significantly related to decreased BMD as identified via HU.

Syndesmosis Injuries in Lateral Malleolar Fractures Accompanied by a Posterior Malleolar Fracture: A Nonfixed Posterior Fracture Fragment May Not Affect Postoperative Tibiofibular Joint Malreduction Rates.

BACKGROUND: The fact that lateral malleolar fracture is accompanied by posterior malleolar fracture may adversely affect syndesmosis malreduction rates. We aimed to compare syndesmosis malreduction rates determined on postoperative radiographs between isolated lateral malleolar fractures and lateral malleolar fractures accompanied by posterior malleolar fractures. METHODS: We retrospectively examined 128 operative patients: 73 with isolated lateral malleolar fractures (group L) and 55 with lateral + posterior malleolar fractures (group LP). In group LP, no patients received posterior fragment fixation. In both groups, indirect syndesmosis fixation was performed with a single screw after open reduction and internal fixation of the lateral malleolus. Patient age, sex, fracture side, fracture type (Lauge-Hansen and Danis-Weber classifications), Kellgren-Lawrence osteoarthritis classification, syndesmotic incongruency on postoperative radiographs, syndesmotic malreduction of postoperative fibula fracture, fracture union time, complication rates, accompanying injuries, and preoperative and postoperative radiographic syndesmotic measurements (tibiofibular overlap, tibiofibular clear space, medial clear space) were recorded, and the groups were compared. RESULTS: Mean ± SD age was 44.32 ± 15.66 years in group L and 48.93 ± 14.03 years in group LP (P = .087). There were no significant differences in preoperative and postoperative tibiofibular distance, tibiofibular overlap, and medial clear space values between groups (P > .05). The prevalence of grade 2 fractures according to the Kellgren-Lawrence classification was significantly higher in group LP (P = .047). Postoperative syndesmosis malreduction was detected in 12 patients in group L and in nine in group LP (P = .991). CONCLUSIONS: In lateral malleolar fractures accompanied by small-fragment posterolateral or avulsion-type posterior malleolar fractures, closed syndesmotic screw fixation does not cause syndesmosis malreduction.

[Malleolar Fractures - Indication for Nonoperative and Operative Treatment]. / Malleolarfrakturen.

Malleolar Fractures - Indication for Nonoperative and Operative Treatment Abstract. In order to understand the trauma mechanism and the expected pattern of injury, malleolar fractures can be classified according to Lauge-Hansen [1]. For isolated lateral malleolar fractures, the Weber classification is also frequently used [2]. For most Weber A fractures and 80% of Weber B fractures conservative treatment is indicated. In all isolated Weber B fractures a supination-external rotation (SER) injury has to be distinguished from a pronation-abduction (PA) injury according to the Lauge-Hansen classification. In SER fractures, stability should be assessed by a gravity stress and a weightbearing radiograph. If the fracture is stable, it can be treated nonoperatively. We recommend surgical treatment for unstable Weber B SER injuries, Weber B PA injuries, and Weber C fractures.

The concept of ring of injuries: evaluation in ankle trauma.

OBJECTIVE: Radiographs are first-line imaging in ankle trauma but lack sensitivity to detect ligamentous injuries and undisplaced fractures. Our hypothesis was that ankle injuries occur in predefined sequences along two osteoligamentous rings, so that occult injuries non-visible on initial radiographs can be predicted. We, therefore, aimed to validate a ring model of progressive damages in the interpretation of ankle trauma radiographs. METHODS: This study retrospectively enrolled 277 adult patients that presented an acute fibular fracture on ankle radiographs between May and November 2019. Four different types of fibula fracture were differentiated, each being considered to correspond to a different mechanism of injury. Patients were classified into four groups, upon the appearance of their fibular fracture. Then, injuries to the distal tibiofibular syndesmosis, medial malleolus, and deltoid ligament (medial clear space) were assessed in each patient radiographs. Traumatic injuries were independently evaluated by a resident and an experienced MSK radiologist. For each patient, observed features were compared to those predicted by the ring concept. Inter- and intraobserver agreements were calculated. RESULTS: Injuries were observed according to the predictable sequence in 266 of the 277 patients (96%). In the 11 remaining patients, discordances were presumably due to undisplaced injuries to the syndesmosis or deltoid ligament. Agreements were considered very good for each evaluated item. CONCLUSION: The Lauge-Hansen ring concept was found to be highly accurate and reproducible for radiographic assessment of ankle injuries. Discordances to the predicted sequence might reflect occult injuries, especially of the syndesmosis or deltoid ligament.

Comparison of Two Surgical Approaches to Supination-External Rotation-Type Ankle Fractures.

Objective: To compare the clinical outcome and postoperative complications of the treatment of supination-external rotation-type ankle fractures using the posterolateral approach in the prone position and the lateral approach in the supine position. Methods: A retrospective cohort study was conducted in our hospital, including a total of 66 patients ranging from January 2013 to February 2016, regardless of age or sex. All the patients were classified as Lauge-Hansen supination-external rotation (SER)-type ankle fractures and were assigned to receive an open reduction and internal fixation (ORIF) through a posterolateral approach performed in the prone position (the "posterolateral approach group," 32 patients), or a lateral approach performed in the supine position (the "Lateral Approach Group," 34 patients). In the posterolateral approach group, 5 patients had Grade II fractures, 8 had Grade III fractures, and 19 had Grade IV fractures; among whom, 12 underwent fixation of the posterior malleolus with hollow screws and 6 with plates, and none of them had fixation of the distal tibiofibular syndesmosis; in the lateral approach group, 4 patients had Grade II fractures, 12 had Grade III fractures, and 18 had Grade IV fractures; among whom, 21 received fixation of the posterior malleolus, and 5 received fixation of the distal tibiofibular syndesmosis. The postoperative complications and ankle scores were recorded. Results: After 1 year of follow-up, in the posterolateral approach group, the incision healed by primary intention and sutures were removed 2 weeks after the operation in all patients; 1 patient had pain in the region posterior to the fibula, presumably peroneal tendon irritation induced by internal fixation, which disappeared after fracture union and fixation device removal; no loosening or breakage of the internal fixation device was reported; the rate of good to excellent results was 96.8% at 12 months. In the lateral approach group: 1 case of wound infection, 1 case of necrosis of lateral skin flap, and 3 cases of lateral skin irritation were reported; the rate of good to excellent results was 94.6% at 12 months. Conclusion: Compared with the traditional lateral approach, the posterolateral approach for the reduction and internal fixation of supination-external rotation-type ankle fractures performed in the prone position has more satisfactory clinical outcomes, with better reduction, more secure fixation, and smaller wound.

Factors Affecting Hospital Length of Stay in Geriatric Patients With a Surgically Treated Fragility Ankle Fracture.

Fragility ankle fractures in elderly have a rising incidence and hospitalization may be prolonged due to pre-existing comorbidities, compromised soft tissue and postoperative difficulties in the rehabilitation process. The aim of this retrospective cohort study was to investigate risk factors for longer total hospitalization duration in elderly patients with surgically treated fragility (Lauge Hansen supination external rotation type 4) fractures. We included all patients ≥ 70 years with a fragility fracture, who were treated surgically between 2011 and 2019 (n = 97) in a level 1 and 2 trauma center. Data on patient demographics, fracture characteristics, surgical treatment strategies and postoperative complications were retrieved from medical records. Multivariate regression analysis was performed to identify independent risk factors for longer hospitalization duration. The mean age of the included patients was 78.27 (± 6.56) years; 71 patients (73.20%) were female. Ten fractures (10.30%) were classified as open and 49 (50.50%) as a luxation type fracture. Fifty-nine patients (60.80%) were hospitalized after admission to the emergency department. External fixation was performed in 34 patients (35.10%) and served as bridge to definitive fixation in 29 patients (85.30%). The mean total hospital length of stay of all patients was 7.04 (± 6.58) days. Multivariate regression analysis demonstrated that the use of external fixation (p < .001) and the postoperative discharge destination (p < .001) were independently associated with a prolonged hospital stay. External fixation and discharge destination were independent risk factors for a prolonged hospital stay in elderly patients with a fragility fracture.

Lack of Displacement of the Fibula Is Not a Confirmation of Ankle Stability in Supination External Pattern Ankle Fractures.

OBJECTIVES: To evaluate and compare radiographic findings in supination external (SE)2 injuries versus stress (+) SE4 injuries. DESIGN: Retrospective. SETTING: Academic Level 1 trauma center. PATIENTS: The study included 350 skeletally mature patients at a single Level 1 trauma center who presented with an isolated, Lauge-Hansen type supination-external rotation pattern, Weber B lateral malleolar fracture, OTA/AO 44-B. RESULTS: We reviewed 350 patients (185 men and 165 women), 18-95 years of age (avg 45), with isolated SE pattern lateral malleolar fractures. One hundred nine had SE4 injuries [medial clear space (MCS) = 8.3 mm]. Two hundred forty-one ankles were stressed; 164 were unstable and 77 were stable (SE2). Avg MCS at presentation and on stress radiographs was 3.59 mm for the SE2 (no widening) and 3.86 mm and 5.94 mm for the stress (+) SE4 group, respectively. The fibular displacement for the SE2, stress (+) SE4, and SE4 groups was 1.5 (0-4.5), 3.5 (0-6.6), and 4.1 (0-30.5), respectively. Sixteen of the 77 (20%) SE2 and 24 of the 164 (15%) stress (+) SE4 fractures had no displacement of the fibula on the lateral view. Similarly, 53 of the 77 (68%) SE2 and 91 of the 164 (55%) stress (+) SE4 had ≤2 mm of fibular displacement Fibular displacement of ≤2 mm on the lateral radiograph corresponded with 0.69 sensitivity and only 0.37 positive predictive value for stable ankle mortise on stress examination. CONCLUSIONS: Previous work indicated that patients with an isolated SE pattern fibula fracture, a normal MCS, and ≤2 mm of fibular displacement on the lateral radiograph have a high rate of ankle stability, with a positive predictive value of approximately 97%. We were unable to confirm this finding because 15% of unstable ankles had 0 mm and 55% had ≤2 mm of fibular displacement. We conclude that stability may not be inferred from a lack of fibular displacement on the lateral view in this population of patients. If stability is to be determined, it must be tested irrespective of fibular displacement on the lateral radiograph. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Effect of Syndesmotic Screw Level on Postoperative Syndesmosis Malreduction.

Tibiofibular injury repair of ankle fractures may result in over-compression when performed via a partially threaded screw depending on its placed level. We aimed to examine the relationship between the screw level relative to the tibiotalar joint and syndesmosis malreduction in postoperative radiographs of ankle fractures treated with partially threaded screws. We retrospectively analyzed 129 patients who underwent surgery due to lateral malleolar fractures between 2011 and 2019. We measured the distance between the screw and the tibiotalar joint and stratified the patients per their screw level as either trans-syndesmotic or suprasyndesmotic. According to Lauge-Hansen, 83 cases were supination-external rotation type (64.3%), and the remaining were pronation-external rotation type (35.7%) injuries. We found postoperative syndesmosis malreduction in 20 cases (15.5%). Eight (6.2%) cases had medial clear space mismatch. As the distance of the screw to the joint increased, postoperative medial clear space values increased (rho: 0.190, p = .031). The relationship between postoperative syndesmosis mismatch and the level of the syndesmotic screw was statistically significant (p = .044). In syndesmosis repair with a partially threaded screw, as the distance of the screw from the joint increases, the over-compression caused by the screw may cause an increase in postoperative syndesmotic malreduction rates.

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.

[Effectiveness of repairing the deep layer of deltoid ligament by suture anchor repair method in treatment of mixed medial injury associated with ankle fractures].

OBJECTIVE: To explore the necessity of repairing the deep layer of deltoid ligament in the treatment of mixed medial injury associated with ankle fractures. METHODS: Between January 2016 and December 2018, 12 patients with mixed medial injury associated with ankle fractures were treated with the fixation of the lateral malleolus by bone plates, the fixation of the anterior colliculus of medial malleolus by cannulated screws, and the repair of the deltoid ligament by suture anchors. There were 8 males and 4 females, with an average age of 42 years (range, 18-56 years). According to the Lauge-Hansen classification criteria, there were 11 cases of supination-external rotation type and 1 case of pronation-external rotation type. According to the Weber classification criteria, all cases were type B. The time from injury to operation was 3-6 days, with an average of 4.7 days. In each patient, X-ray films of anteroposterior and lateral views and mortise view of ankle were taken postoperatively. The motion range of ankle joints was observed. The function of the ankle and the outcome of the treatment were evaluated according to the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system, Olerud-Molander scoring system, and the visual analogue scale (VAS) score. RESULTS: All cases were followed up 12-42 months (mean, 28 months). The 12 patients returned to their pre-injury jobs. Five patients with sports injury completely recovered to their pre-injury motor function. No patient experienced persistent medial ankle pain or ankle instability. At last follow-up, the ankle range of motion in dorsiflexion was 9°-25° (mean, 17.96°), which was 0°-11° (mean, 4.02°) less than that in normal side; the range of motion in plantar flexion was 38°-50° (mean, 43.90°), which was 0°-7° (mean, 2.53°) less than that in normal side. The AOFAS score was 88-100 (mean, 96.7); the Olerud-Molander score was 90-100 (mean, 96.5); the VAS score was 0-3 (mean, 1.1). CONCLUSION: It is necessary to repair the deep layer of deltoid ligament in the mixed medial injuries associated with ankle fracture, which include anterior colliculus fracture and deep deltoid ligament injury. A better outcome can be achieved by employing the suture anchor repair method.

Ankle Fracture with a Complex Injury Mechanism and Misleading Hook Test Result: A Case Report.

Ankle fractures and their mechanisms of injury can be complex. We report a case of a patient with an uncertain mechanism of injury and an uncommon combination of lower extremity fractures, which fit the criteria for a Lauge-Hansen classification pronation-external-rotation fracture, Maisonneuve fracture, Wagstaffe fracture, and posterior pilon fracture. Plain radiographs and computed tomography scan revealed Chaput tubercle avulsion fractures, an anterior distal fibular fracture fragment, multiple lateral malleolar fractures, a posterior malleolar fracture fragment with proximal displacement, a die-punch fragment between the posterior malleolar fragment and the tibia, a proximal fibular fracture, and possible ankle syndesmotic diastasis. Intraoperative hook test was negative after fixation of the fractures, so syndesmotic fixation was not performed. At 3-month follow-up, plain radiographs showed obvious syndesmotic diastasis. At 1-year follow-up, symptoms persisted and syndesmotic fusion was recommended but declined by the patient. This case demonstrates that both ankle fractures and their mechanisms of injury can be remarkably complex and confusing, posterior pilon fractures can occur along with pronation-external-rotation ankle fractures, syndesmotic fixation should be considered for all patients with Maisonneuve fractures, reliance on the hook test for surgical management decisions may not always be reliable, and there exists a need for a more accurate and reliable intraoperative test to determine the presence of ankle syndesmotic injury.

Contemporary Strategies in Pilon Fixation.

The treatment of tibial pilon fractures has evolved substantially over the past decades due to ever-increasing high-energy injuries. Open reduction and internal fixation of these intra-articular fractures requires an appreciation for a number of basic principles: respect the soft tissues, understand the fracture pattern, use safe surgical approaches, and provide stability that allows for early motion of the ankle. Surgical strategy should be customized based on the fracture pattern, access needed for fracture visualization and reduction, and status of the soft tissues. Given the ability to obtain an accurate stable reduction, smaller implants are typically adequate using multiple small incisions. We view this surgical tactic as continuing the evolution of complex fracture treatment whose origins lie in the influences of pioneers such as Dr Sigvard T. Hansen Jr.

Pediatric ankle injuries: utilizing the Dias-Tachdjian classification.

Pediatric ankle injuries require timely diagnosis due to their involvement of the distal tibial physis and subsequent impact on long bone growth. These injuries occur in a predictable pattern based on ankle position, direction of force, and degree of closure of the distal tibial physis. The Dias-Tachdjian classification describes possible ankle injury patterns for the completely open physis, and we present a simplified algorithm for applying this system in routine radiographic interpretation. Similar to the Lauge-Hansen classification in adults, the Dias-Tachdjian system is based on the position of the foot and direction of force at the time of injury with four major patterns: supination-inversion, pronation-eversion external rotation, supination-plantar flexion, and supination-external rotation. In addition, we examine the effect that the closing distal tibial physis has on adolescent fracture patterns (specifically, Tillaux and triplane fractures). Awareness of these injury patterns helps the radiologist to identify nondisplaced fractures and subtle physeal injuries with implications for surgical and/or conservative management.