Nonoperative treatment of the medial malleolus in bimalleolar and trimalleolar ankle fractures: a randomized controlled trial.

OBJECTIVES: To compare internal fixation with no fixation of the medial malleolus after open reduction and internal fixation of the lateral malleolus and if needed, the posterior malleolus. DESIGN: Randomized prospective trial. SETTING: Level III trauma center in a metropolitan area. PATIENTS: One hundred patients with bimalleolar or trimalleolar Orthopaedic Trauma Association type 44 ankle fractures and displacement of the medial malleolus less than 2 mm after open reduction and internal fixation of the lateral component. INTERVENTION: Internal fixation or nonoperative treatment of the medial malleolus. MAIN OUTCOME MEASUREMENTS: American Orthopaedic Foot and Ankle Society ankle hind foot score (AOFAS), The Olerud Molander Ankle (OMA) score, and visual analogue pain scale (VAS). RESULTS: Median follow-up time was 39 months (range: 24-72). There were no significant differences between the 2 groups with respect to OMA (P = 0.91), AOFAS (P = 0.85), VAS (P = 0.85), or development of osteoarthritis (P = 0.22). Reoperation and complication rates were also comparable, but 4 patients treated nonoperatively developed nonunion of the medial malleolus. These patients reported no functional disabilities and presented OMA, AOFAS, and VAS scores better than average. CONCLUSIONS: Our data indicate that nonoperative treatment of minimally displaced fractures of the medial malleolus after operative fixation of the fibula yields satisfactory results. However, long-term follow-up is needed due to increased risk of nonunion and uncertainty regarding the development of posttraumatic arthritis. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Thrombosis markers in hip versus knee arthroplasty: a pilot study.

PURPOSE: To compare the thrombosis markers for thrombosis and fibrinolysis in patients undergoing hip versus knee arthroplasty. METHODS: Seven women aged 38 to 61 years who underwent total hip arthroplasty (THA) and 7 women aged 57 to 67 years who underwent total knee arthroplasty (TKA) were studied. Thromboprophylaxis was given before and after surgery. In patients undergoing TKA, an automatic pneumatic tourniquet was used. Blood samples were drawn (1) before surgery (control value), (2) at wound closure (immediately before release of the tourniquet in TKA), and (3) 4 hours after surgery. Thrombosis markers (prothrombin fragment 1.2 [F1.2], plasmin/ alpha2-antiplasmin complex [PAP], and D-dimer) of the 2 groups were compared. RESULTS: The F1.2 level increased significantly at wound closure and remained elevated 4 hours after surgery in the THA group, whereas it was unchanged at wound closure but increased significantly 4 hours after surgery in the TKA group. The PAP level was constant peri- and post-operatively in the THA group, whereas it increased significantly 4 hours after surgery in the TKA group. The D-dimer level increased significantly at wound closure and 4 hours after surgery in the THA group, whereas it was unchanged at wound closure but increased significantly 4 hours after surgery in the TKA group. CONCLUSION: Systemic thrombin generation starts perioperatively in THA and after tourniquet deflation in TKA, indicating that wound blood must reach the systemic circulation to activate the relevant mediators.

Time course of thrombosis and fibrinolysis in total knee arthroplasty with tourniquet application. Local versus systemic activations.

BACKGROUND: Venous thrombosis is common in knee surgery, and it has been assumed that vein occlusion by tourniquet in itself may induce thrombogenic and fibrinolytic activity. Prophylactic treatment is used up to 12 h before or after surgery, and recent clinical trials suggest that the timing of initiating prophylaxis significantly influences antithrombotic effectiveness. MATERIALS AND METHODS: We studied the time course of coagulation and fibrinolysis locally and systemically during total knee arthroplasty. Specific markers of thrombosis (prothrombin fragment 1.2 (F1.2)) and fibrinolysis (plasmin-antiplasmin (PAP) and D-dimer) were examined in seven female and two male patients. RESULTS: There were no systemic activations of either F1.2 (P = 0.314), PAP (P = 0.314) or D-dimer (P = 0.600) during surgery or at 10 min postoperatively (P = 0.139, 0.139 and 0.128, respectively) as compared to baseline data. At 4 h postoperatively there were significant increments in levels of F1.2 (P = 0.008), PAP (P = 0.038) and D-dimer (P = 0.046). With tourniquet deflation the values of F1.2, PAP and D-dimer were significantly higher in the tourniquet limb than the in the contra lateral limb (P = 0.025, 0.012 and 0.028, respectively). At 10 min after tourniquet deflation, the differences in F1.2, PAP and D-dimer between the two limbs were not significant. CONCLUSION: The use of tourniquet in total knee arthroplasty causes local thrombogenic and fibrinolytic activity, but without influences in the systemic circulation. Systemic activations in thrombosis and fibrinolysis start when local mediators from the injured limb are released after tourniquet deflation.