Morphological analysis of posterior malleolar fractures with intra-articular impacted fragment in computed tomography scans.

BACKGROUND: Intraarticular impacted fragment (IAIF) of posterior malleolar fractures has been reported by a few studies. However its location, morphology, and the correlation of posterior malleolar fractures have not been described in detail. The aim of this study was to describe the morphology of IAIF in posterior malleolar fractures, to analyze the related factors between IAIF and posterior malleolar fragments, and explore the treatment of IAIF. MATERIALS AND METHODS: Between January 2013 and December 2018, 108 consecutive patients with unilateral posterior malleolar fractures were managed in our hospital. Basic demographic and computed tomography (CT) data were collected and classified by Lauge-Hansen, OTA/AO, Haraguchi, and Mason classification. Additional radiographic data, including the length and area of posterior malleolar fragment, IAIF, and stable tibial plafond were measured. The location of IAIF was described, and involvement of the fibular notch and medial malleolus was also observed. Statistics were analyzed based on univariate analysis (Chi-square test, t-test, Mann-Whitney U test, Fisher's test) and Spearman's correlation test. RESULTS: Among the 108 cases of posterior malleolar fractures, 75 (69.4%) were with IAIF and 33 (30.6%) cases were without. There were 74 (68.5%) females and 34 (31.5%) males, and the average age of the patients was 49 years (18-89 years). The average LIFN/(LIFN + LSFN) [length of involving fibular notch/(length of involving fibular + length of stable notch fibular notch)] was 32.9% (11.6-64.9%). The APMF/(APMF + ASTP + AIAIF) [area of posterior malleolar fragment/(area of posterior malleolar fragment + area of IAIF + area of stable tibial plafond)] and AIAIF/APMF (area of IAIF/area of posterior malleolar fragment) were 13.1% (0.8-39.7%) and 52.6% (1.2-235.4%), respectively. Involvement of medial malleolus (fracture line extended to medial malleolus, P = 0.022), involvement of fibular notch (P = 0.021), LIFN/(LIFN + LSFN) (P = 0.037), LMPMF (P = 0.004), and APMF were significantly related to the occurrence of IAIF. CONCLUSION: Our research indicates a high incidence of IAIF in posterior malleolar fractures. All IAIFs were found in posterior malleolar, and the most common location was within the lateral area A. Posterior malleolar fracture lines that extend to medial malleolus or fibular notch herald the incidence of IAIF. LIFN/(LIFN + LSFN), LMPMF and APMF are also associated with the incidence of IAIF. CT scans are useful for posterior malleolar fractures to determine the occurrence of IAIF and make operational plans. Operation approach selection should be based on the morphology of posterior malleolar fragments and the location of IAIF. LEVEL OF EVIDENCE: Level III, retrospective case analysis.

An Exceptional Avulsion Fracture Above the Medial Malleolus: A Retrospective Case Series.

The Lauge-Hansen classification does not cover all types of ankle injuries. The present report details three cases of exceptional fragment of the medial tibia that differed from the traditional Lauge-Hansen supination-external rotation and pronation-external rotation fracture patterns. The information obtained from this study will be helpful for conducting basic research of this condition and determining appropriate surgical approaches.

The risk of fracture to the tibia from a fragment simulating projectile.

Penetrating injuries due to fragments energised by an explosive event are life threatening and are associated with poor clinical and functional outcomes. The tibia is the long bone most affected in survivors of explosive events, yet the risk of penetrating injury to it has not been quantified. In this study, an injury-risk assessment of penetrating injury to the tibia was conducted using a gas-gun system with a 0.78-g cylindrical fragment simulating projectile. An ovine tibia model was used to generate the injury-risk curves and human cadaveric tests were conducted to validate and scale the results of the ovine model. The impact velocity at 50% risk (±95% confidence intervals) for EF1+, EF2+, EF3+, and EF4+ fractures to the human tibia - using the modified Winquist-Hansen classification - was 271 ± 30, 363 ± 46, 459 ± 102, and 936 ± 182 m/s, respectively. The scaling factor for the impact velocity from cadaveric ovine to human was 2.5. These findings define the protection thresholds to improve the injury outcomes for fragment penetrating injury to the tibia.

[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.

Comminuted long bone fractures in children. Could combined fixation improve the results?

Comminuted diaphyseal fractures in the pediatric age group represent a major orthopedic problem. It is associated with a high incidence of complications and poor outcomes because of the instability and difficulty in treatment. The aim of this study was to evaluate the efficacy of combined external skeletal fixation and flexible intramedullary nails in reconstruction of comminuted diaphyseal fracture in skeletally immature patients. Combined external fixator and elastic stable intramedullary nails were used in the management of 27 pediatric patients (15 males and 12 females) with unstable comminuted diaphyseal fractures of the tibia and femur. There were 19 fractures of the femur and eight fractures of the tibia. The average age of the patients was 8.7 years (range 7-14 years) for the femur and 10.8 years (range 6-15 years) for the tibia. Fractures were classified according to the system of Winquist and Hansen as grade II (five cases), grade III (nine cases), and grade IV (13 cases). All cases were operated within 6 days (range 0-6 days) after injury. The mean follow-up period was 2.8 years (range 2-3.5 years). The average duration of the external fixation was 1.6 months for fractures of the tibia, whereas it was 1.4 months for fractures of the femur. The average time for tibia fracture union was 2.8 months for fractures of the tibia, whereas it was 1.9 months for fractures of the femur. Malalignment in varus less than 5° was noted in one patient. One patient had a limb-length discrepancy of 1.5 cms. There were five cases (18.5%) with pin-tract infection. According to the Association for the Study and Application of the Methods of Ilizarov evaluation system, bone results were excellent in 23 cases (85.2%), good in three cases (11.1%), and poor in one case (3.7%). Functional results were excellent in 22 (81.5%) cases and good in five (18.5%) cases. Combined use of external fixators and elastic intramedullary nails is a good method for the treatment of comminuted long bone fractures in children.

Comparison of radiographic stress tests for syndesmotic instability of supination-external rotation ankle fractures: a cadaveric study.

OBJECTIVE: According to the classification of Lauge-Hansen, supination-external rotation IV (OTA 44-B) injuries should not have syndesmotic instability; yet, several studies have suggested disruption is present in up to 40% of these injuries based on stress tests. In this study, we examine various stress radiographic parameters in a cadaver model of supination-external rotation IV equivalent injury. We hypothesize that external rotation stress testing and widening of the medial clear space do not always represent syndesmotic instability. Rather, the better predictor of syndesmotic instability will be an increased tibia-fibula clear space with the lateral stress test. METHODS: Eleven fresh frozen human lower limbs were each secured into a custom frame. External rotation stress test was performed by applying an external moment of 7.5 Nm, and lateral stress test was performed by applying 100 N lateral pull at the distal fibula. True mortise radiographs were taken of intact ankles and while performing external rotation and lateral stress tests at each stage of sequentially sectioning the ankle ligaments. The deltoid ligament was sectioned first, then anterior-inferior tibiofibular ligament, posterior-inferior tibiofibular ligament, and interosseous membrane. Tibiofibular clear space and medial clear space were measured on each radiograph. RESULTS: External rotation stress test produced significant medial clear space widening when the deltoid ligaments were sectioned (P < 0.05). Lateral stress test produced no significant widening of the tibiofibular clear space until interosseous membranes were sectioned (P < 0.05). CONCLUSIONS: Lateral stress test with widening of the tibiofibular clear space is the preferred indicator of syndesmotic instability. The external rotation stress is a poor indicator of syndesmotic injury in the setting of deltoid ligament injury.

Adult-type bimalleolar ankle fracture in children: report of two cases.

UNLABELLED: Ankle fractures patterns in children may vary depending on the maturity of the distal tibial and fibular physis. Bimalleolar ankle fracture is an exceedingly rare fracture pattern in children and has been reported once in the current English literature. Two further adolescents with bimalleolar ankle fracture are reported. Although these fractures are rare, surgeons should be aware of these atypical fracture patterns. Herein, the underlying physiology and the mechanism of injury of ankle fractures in children are discussed. LEVEL OF EVIDENCE: Therapeutic, Level IV, Case study.

Tibiofibular syndesmosis in acute ankle fractures: additional value of an oblique MR image plane.

OBJECTIVE: To evaluate the additional value of a 45° oblique MRI scan plane for assessing the anterior and posterior distal tibiofibular syndesmotic ligaments in patients with an acute ankle fracture. MATERIALS AND METHODS: Prospectively, data were collected for 44 consecutive patients with an acute ankle fracture who underwent a radiograph (AP, lateral, and mortise view) as well as an MRI in both the standard three orthogonal planes and in an additional 45° oblique plane. The fractures on the radiographs were classified according to Lauge-Hansen (LH). The anterior (ATIFL) and posterior (PTIFL) distal tibiofibular ligaments, as well as the presence of a bony avulsion in both the axial and oblique planes was evaluated on MRI. MRI findings regarding syndesmotic injury in the axial and oblique planes were compared to syndesmotic injury predicted by LH. Kappa and the agreement score were calculated to determine the interobserver agreement. The Wilcoxon signed rank test and McNemar's test were used to compare the two scan planes. RESULTS: The interobserver agreement (κ) and agreement score [AS (%)] regarding injury of the ATIFL and PTIFL and the presence of a fibular or tibial avulsion fracture were good to excellent in both the axial and oblique image planes (κ 0.61-0.92, AS 84-95%). For both ligaments the oblique image plane indicated significantly less injury than the axial plane (p < 0.001). There was no significant difference in detection of an avulsion fracture in the axial or oblique plane, neither anteriorly (p = 0.50) nor posteriorly (p = 1.00). With syndesmotic injury as predicted by LH as comparison, the specificity in the oblique MR plane increased for both anterior (to 86% from 7%) and posterior (to 86% from 48%) syndesmotic injury when compared to the axial plane. CONCLUSION: Our results show the additional value of an 45° oblique MR image plane for detection of injury of the anterior and posterior distal tibiofibular syndesmoses in acute ankle fractures. Findings of syndesmotic injury in the oblique MRI plane were closer to the diagnosis as assumed by the Lauge-Hansen classification than in the axial plane. With more accurate information, the surgeon can better decide when to stabilize syndesmotic injury in acute ankle fractures.

Anatomy of the distal tibiofibular syndesmosis in adults: a pictorial essay with a multimodality approach.

A syndesmosis is defined as a fibrous joint in which two adjacent bones are linked by a strong membrane or ligaments.This definition also applies for the distal tibiofibular syndesmosis, which is a syndesmotic joint formed by two bones and four ligaments. The distal tibia and fibula form the osseous part of the syndesmosis and are linked by the distal anterior tibiofibular ligament, the distal posterior tibiofibular ligament, the transverse ligament and the interosseous ligament. Although the syndesmosis is a joint, in the literature the term syndesmotic injury is used to describe injury of the syndesmotic ligaments. In an estimated 1­11% of all ankle sprains, injury of the distal tibiofibular syndesmosis occurs. Forty percent of patients still have complaints of ankle instability 6 months after an ankle sprain. This could be due to widening of the ankle mortise as a result of increased length of the syndesmotic ligaments after acute ankle sprain. As widening of the ankle mortise by 1 mm decreases the contact area of the tibiotalar joint by 42%, this could lead to instability and hence early osteoarthritis of the tibiotalar joint. In fractures of the ankle, syndesmotic injury occurs in about 50% of type Weber B and in all of type Weber C fractures. However,in discussing syndesmotic injury, it seems the exact proximal and distal boundaries of the distal tibiofibular syndesmosis are not well defined. There is no clear statement in the Ashhurst and Bromer etiological, the Lauge-Hansen genetic or the Danis-Weber topographical fracture classification about the exact extent of the syndesmosis. This joint is also not clearly defined in anatomical textbooks, such as Lanz and Wachsmuth. Kelikian and Kelikian postulate that the distal tibiofibular joint begins at the level of origin of the tibiofibular ligaments from the tibia and ends where these ligaments insert into the fibular malleolus. As the syndesmosis of the ankle plays an important role in the stability of the talocrural joint, understanding of the exact anatomy of both the osseous and ligamentous structures is essential in interpreting plain radiographs, CT and MR images, in ankle arthroscopy and in therapeutic management. With this pictorial essay we try to fill the hiatus in anatomic knowledge and provide a detailed anatomic description of the syndesmotic bones with the incisura fibularis, the syndesmotic recess, synovial fold and tibiofibular contact zone and the four syndesmotic ligaments. Each section describes a separate syndesmotic structure, followed by its clinical relevance and discussion of remaining questions.

Clinical, electrodiagnostic and pedobarographic assessments of leprotic patients with trans-tibial amputation.

The aim of present study was to investigate clinical, electrodiagnostic and pedobarographic findings of non-amputee limb in chronic leprotic patients with unilateral trans-tibial amputation to determine neuropathy and plantar foot pressure in non-amputee limb. During the present prospective cross-sectional study, 10 chronic leprotic patients with unilateral trans-tibial amputation were evaluated. The study was conducted in Tabriz Bababaghi and Imam Reza Hospitals at summer of 2008. Sensory nerve conduction (SNAP) and Compound Motor Action Potentials (CMAP) studies were performed in association with pedobarographic assessment. No reliable response was detected from tested sensory and motor nerves, except a very low amplitude finding in deep preoneal nerve of one patient. In comparing with healthy group, static total plantar area, dynamic total plantar area, static rarefoot peak pressure and dynamic rarefoot peak pressure were lower in leprotic patients (p = 0.047, p = 0.004, p = 0.029 and p < 0.001), while static forefoot peak pressure and dynamic forefoot peak pressure were higher in these patients (p = 0.011 and p = 0.031). All of leprotic patients with unilateral trans-tibial amputation suffered from severe neuropathy. Also, these patients have high plantar pressure under the forefoot. Collectively, severe neuropathy and abnormal plantar foot pressure expose in non-amputee foot expose leprotic patients to the higher risk of secondary amputation.

[Surgical techniques of open reduction and internal fixation for ankle fracture].

OBJECTIVE: To evaluate the surgical techniques of open reduction and internal fixation performed for ankle fracture retrospectively and the corresponding clinical outcomes. METHODS: From March 2001 to January 2006, 242 patients with ankle fracture were treated. A total of 85 patients with complete clinical data were analyzed. According to the Lauge-Hansen classification system, the fractures were classified into pronation-external rotation (grade II) in 12 cases and grade IV in 9 cases, supination-external rotation (grade II) in 34 cases and grade IV in 16 cases, supination-adduction (grade II) in 8 cases, and pronation-abduction in 6 cases. The reduction and internal fixation started with lateral malleolus, then medial malleolus and posterior malleolus, and distal tibiofibular syndesmosis in sequence. Among 10 cases, 5 of the distal tibiofibular syndesmosis were fixed with one screw through 3 layers of bone cortexes. All cases were auxiliarily fixed with plaster pad for 4 to 6 weeks after operation. RESULTS: The follow-up period varied from 6 to 36 months, with an average of 10 months. There were no local complications such as malunion or nonunion of the fractures and deformity of the ankle. The inserted screw to distal tibiofibular syndesmosis was not broken. The patients were evaluated with Baird-Jackson scoring system. The numbers of the patients who had excellent, good, fair and poor results were 53, 23, 6, 3, respectively. The excellent and good rate was 89.4%. CONCLUSION: Operative treatment may provide satisfactory clinnical outcomes for ankle fracture. Proper internal fixation and correct fracture pattern estimation are of importance to achieve and gain better long-term results.

Follow-up of tibialis posterior transfer surgery (TPT) for drop-foot in leprosy.

Prevention of Disability (POD) service needs to be expanded for future reducing the leprosy burden. Tibialis Posterior Transfer Surgery (TPT) is an established procedure and relatively easy to do at district level general hospitals. It can protect further damages of affected foot and consequently reduce patient's social burden as well. Totally 70 TPT surgeries were done during a joint project of JICA on leprosy control and basic health service in Myanmar for training purpose (Jan/2002-Jan/2006). A follow-up assessment was done for exploring the effectiveness of foot drop surgery, in Nov/2006 at 9-selected townships in Mid-Myanmar. 33 cases (Male 22, Female 11) were reviewed and the mean of follow up period was 29.1 months (SD=7.1, 10-48 months). Total results were; good: 25 cases (76%), fair: 4 cases (12%) and poor: 4 cases (12%). In good and fair cases, patients were satisfied with the results and TPT improved the QOL of patients. In almost all cases (32/33, 97%) after TPT, patients are free from plantar ulcer. Most serious complication of operation (4 cases, 12%) identified was inversion deformity due to loosed tension of lateral tail of grafted TP tendon sutured to Extensor Digitorum Longus. From the results of TPT surgery follow-up, it can benefit much to the patients if resources permit to make it as a routine service in more places.

The effect of dietary probiotic supplementation on tibial bone characteristics and strength in broilers.

A 6-wk study with 50 birds was conducted to investigate the effects of a dietary supplemental probiotic on morphometric parameters and yield stress of the tibia. Twenty-five 1-d-old broiler chicks were assigned to a control or an experimental diet containing Bacillus licheniformis and Bacillus subtilis (BioPlus 2B, CHR Hansen BioSystems, Denmark, Ugur Ecza Deposu, Turkiye Distributoru, Adapazari 41400, Turkey; each containing 2.3 x 10(8) cfu/g of spores) supplemented to the starter and finisher diets at 500 g/1000 kg of feed. Each diet was replicated 5 times with 5 birds in each replicate. Tibiotarsi weight, length, and weight/length index, robusticity index, diaphysis diameter, modulus of elasticity, yield stress parameters, and percentage Ca content were not affected by the dietary supplementation of probiotic, whereas thickness of the medial and lateral wall of the tibia, tibiotarsal index, percentage ash, and P content were significantly improved by the probiotic. Medullary canal diameter of the tibia of the birds fed the control diet was significantly greater than that of birds fed the probiotic diet. There was no treatment impact on live performance of the birds throughout the 6-wk feeding trial.

Palsy of the rear limbs in Mycobacterium lepraemurium-infected mice results from bone damage and not from nerve involvement.

A small but relatively constant proportion (3-5%) of mice chronically infected with Mycobacterium lepraemurium (MLM) develops bilateral paralysis of the rear limbs. The aim of the study was to investigate whether or not the bilateral leg palsy results from nerve involvement. Direct bacterial nerve infection or acute/delayed inflammation might possibly affect the nerves. Therefore, palsied animals were investigated for the presence of: (a) histopathological changes in the leg tissues including nerves, bones and annexes, and (b) serum antibodies to M. lepraemurium and M. leprae lipids, including phenolic glycolipid I from M. leprae. Histopathological study of the palsied legs revealed that the paralysis was not the result of direct involvement of the limb nerves, as neither bacilli nor inflammatory cells were observed in the nerve branches studied. Antibodies to brain lipids and cardiolipin were not detected in the serum of the palsied animals, thus ruling out an immune response to self-lipids as the basis for the paralysis. Although high levels of antibodies to MLM lipids were detected in the serum of palsied animals they were not related to limb paralysis, as the nerves of the palsied legs showed no evidence of inflammatory damage. In fact, nerves showed no evidence of damage. Paralysis resulted from severe damage of the leg bones. Within the bones the bone marrow became replaced by extended bacilli-laden granulomas that frequently eroded the bone wall, altering the normal architecture of the bone and its annexes, namely muscle, tendons and connective tissue. Although this study rules out definitively the infectious or inflammatory damage of nerves in murine leprosy, it opens a new avenue of research into the factors that participate in the involvement or the sparing of nerves in human and murine leprosy, respectively.

Posterior tibialis transfer for foot-drop due to leprosy: a case with 40 years follow up.

A 56-year-old male was transferred to our centre because of a relapse of leprosy neuritis in the hands. We found that the patient had received a posterior tibialis tendon transfer for correction of his left dropped foot 40 years previously. On examination active dorsiflexion of the left ankle joint was close to 0 degrees with grade 4 power of dorsiflexion, and the plantar flexion was about 35 degrees. Walking gait was almost normal. There were some scars on the plantar surface of the left metatarsal area; but with the continuous use of a soft dressing pad under the middle part of the sole, plantar ulceration has been avoided for many years even with active daily activities of the patient. The patient is very satisfied with the operative results.

Ankle fractures. The Lauge-Hansen classification revisited.

Rational treatment of ankle fractures requires knowledge of the extent of bone and soft tissue injury. Although the Lauge-Hansen classification attempts to do this by relating specific fracture patterns to injury mechanism, the experimental underpinning for this classification has not been reexamined rigorously using modern experimental methods. This study examines the hypothesis that the clinically occurring supination and external rotation injury pattern does not result from the mechanism described by Lauge-Hansen. Thirty-two anatomic specimen ankles were mounted on an MTS machine for combined axial loading with external rotation to failure testing. A foot plate supinated the foot 25 degrees. Testing was performed with the ankle at neutral, 25 degrees plantar flexed, 10 degrees to 15 degrees dorsiflexed, and in 6 degrees to 8 degrees leg valgus. Pure supination and external rotation with the ankle in neutral did not result in the Lauge-Hansen supination and external rotation type fractures. This outcome was not altered if the ankle specimens initially were placed in plantar flexion or dorsiflexion. The addition of a valgus load, which pushes the talus laterally against the fibula, resulted in the classic Lauge-Hansen supination and external rotation type fracture. All specimens had an isolated lateral injury or a lateral injury that preceded medial injury.

Tibialis posterior transfer in the correction of footdrop due to leprosy.

In the correction of footdrop due to leprosy neuritis the tibialis posterior muscle is re-routed and used to provide dorsiflexion of the foot. This study of tibialis posterior transfer was carried out to compare the results of the circumtibial and interosseous routes. There is no significant difference in the range of motion between either route through the range of the interosseous route is more functional (better dorsiflexion). The interosseous route is preferable as this results in a significantly lower incidence of recurrent inversion deformity of the foot at long-term follow-up when compared with the circumtibial route.

Correction of severe foot deformities.

An arthrodesis between tibia and calcaneus was performed after extirpation of the lateral malleolus and the talus in 65 patients with severe stiff paretic feet in equinovarus position, 44 nonleprosy and 21 with leprosy. Early mobilization with weightbearing was allowed after 1 week. Bony fusion was achieved in 95% in the nonleprosy group and 76% in the leprosy group. The final appearance and function was very satisfying with a good range of motion in the Chopart joint.