Intramedullary Nailing Versus Open Reduction and Plate Fixation for Lateral Malleolar Fractures: A Meta-Analysis.

The fixation for lateral malleolar fracture in ankle fractures is still controversial. The purpose of this meta-analysis is to compare clinical and radiological outcomes between intramedullary nail (IMN) and plate for lateral malleolar fractures in ankle fractures. The PubMed, EMBASE, and Cochrane Library were searched for randomized controlled trials (RCTs) from databases inception to June 2023. Data on outcomes were extracted and the methodological quality of the included studies were assessed. A meta-analysis was performed using RevMan 5.3 software when the data extracted from included studies could be synthesized. Seven RCTs were included. The methodological quality of the included studies was moderate to high. The meta-analysis results showed that the infection rate of the IMN group was significantly lower than that of the plate group (RR = 0.38; 95%CI 0.18-0.82; p = .01). There were no significant differences between the 2 groups in Olerud and Molander Ankle Score (OMAS), union rate, radiological outcomes, nerve injury rate, reoperation rate, loss of reduction, and total complication rate. Our present meta-analysis demonstrated that the IMN might be a better method for the fixation of lateral malleolar fracture in ankle fracture, as the infection rate was significantly lower than a plate.

Three-dimensional morphological study of type B lateral malleolar fractures with special reference to the end-tip location of proximal apexes.

Objective: We aimed to describe the morphological characteristics of Danis-Weber type B lateral malleolar fractures, with special attention given to the end-tip locations of fracture apexes, and to construct a 3D (three-dimensional) fracture line map. Methods: A total of 114 surgically treated cases of type B lateral malleolar fractures were retrospectively reviewed. The baseline data were collected, and computed tomography data were reconstructed in a 3D model. We measured the morphological characteristics and the end-tip location of the fracture apex on the 3D model. All the fracture lines were superimposed on a template fibula to generate a 3D fracture line map. Results: Among these 114 cases, 21 were isolated lateral malleolar fractures, 29 were bimalleolar fractures, and 64 were trimalleolar fractures. All the type B lateral malleolar fractures demonstrated a spiral or oblique fracture line. As measured from the distal tibial articular line, the fracture started at -6.22 ± 4.62 mm anteriorly and terminated at 27.23 ± 12.32 mm posteriorly, and the average fracture height was 33.45 ± 11.89 mm. The fracture line inclination angle was 56.85° ± 9.58°, and the total fracture spiral angle was 269.81° ± 37.09°, with fracture spikes of 156.20° ± 24.04°. The proximal end-tip location of the fracture apex was classified into four zones in the circumferential cortex: zone I (lateral ridge) in seven cases (6.1%), zone II (posterolateral surface) in 65 cases (57%), zone III (posterior ridge) in 39 cases (34.2%), and zone IV (medial surface) in three cases (2.6%). Altogether, 43% (49 cases) of fracture apexes were not distributed on the posterolateral surface of the fibula, as 34.2% (39 cases) were located on the posterior ridge (zone III). The aforementioned morphological parameters in fractures with zone III, sharp spikes, and further broken spikes were greater than those in zone II, blunt spikes, and fractures without further broken spikes. The 3D fracture map suggested that the fracture lines with the zone-III apex were steeper and longer than those with the zone-II apex. Conclusion: Nearly half of type B lateral malleolar fractures had their proximal end-tip of apexes not on the posterolateral surface, which may impair the mechanical application of antiglide plates. A steeper fracture line and longer fracture spike indicate a more posteromedial distribution of the fracture end-tip apex.

Outcome After Treatment of Distal Fibula Fractures Using One-Third Tubular Plate, Locking Compression Plate or Distal Anatomical Locking Compression Plate.

Surgical treatment of lateral distal fibula fractures is associated with high risk of reoperation and complications. The primary aim was to report risks of surgical site infection (SSI) and reoperation ≤1 year after treatment with one-third tubular plate, locking compression plate (LCP) or distal anatomical LCP. Secondary to investigate associations between patient, fracture and operative factors and risk of SSI and reoperation. Retrospectively, we evaluated a consecutive cohort of 588 patients having osteosynthesis of distal fibula with a one-third tubular plate (n = 417), LCP (n = 115) or distal anatomical LCP plate (n = 56) at Bispebjerg Hospital, Denmark from January 2010 to December 2015 with 1-year follow-up. The risk of SSI was 15% (95% confidence interval [CI] 12-18) after treatment with one-third tubular plate, 30% (95% CI 23-39) after LCP and 41% (95% CI 29-54) after distal anatomical LCP. We found a significant association of SSI and LCP (p = .005) and distal anatomical LCP (p < .001). Other factors associated with increased risk of SSI were age>70 years (p < .001), smoking (p = .004), DM (p = .007), surgery time ≥90 minutes (p = .006) and surgery delay of 3-6 days (p = .007). The risk of reoperation ≤1 year was 10% (95% CI 6-11) for one-third tubular plate, 21% (95% CI 14-29) for LCP and 25% (95% CI 16-38) for distal anatomical LCP. We found a significant association between distal anatomical LCP and risk of reoperation (p = .008). The only other risk factor associated with risk of reoperation was surgery delay of more than 7 days (p = .004). We conclude that LCP plate and the distal anatomical LCP plate should only be used after careful considerations.

Treatment Variability and Complications Associated With Pediatric Lateral Ankle Injuries: A POSNA Quality, Safety, and Value Initiative Survey.

Background: Isolated pediatric lateral ankle injuries, including ankle sprain (AS) and nondisplaced Salter-Harris type 1 (SH-1) distal fibular fracture, are common orthopaedic sports-related injuries. Variability in treatment is suspected among pediatric orthopaedic surgeons. Complications from medical treatment or lack thereof have not been reported in this population. Purpose: The purpose of this study was to investigate treatment variability and associated complications after pediatric AS and SH-1 via a survey of members of the Pediatric Orthopaedic Society of North American (POSNA). Study Design: Cross-sectional study. Level of evidence, 5. Methods: A voluntary, anonymous survey was distributed to POSNA membership (approximately 1400 members) via email. Survey questions, specific to both grade 1 or 2 AS and nondisplaced or minimally displaced SH-1 injuries in skeletally immature patients, focused on initial evaluation, immobilization, return to sports, and complications. We analyzed variability both in treatment between AS and SH-1 injury and in respondent characteristics. For statistical analysis, chi-square or Fisher exact test was used for categorical variables, and analysis of variance was used for continuous variables. Results: The survey response rate was 16.4% (229/1400). Of the respondents, 27.7% used examination only to distinguish between AS and SH-1, whereas 18.7% performed serial radiography to aid with diagnosis. A controlled ankle motion boot or walking boot was the most common immobilization technique for both AS (46.3%) and SH-1 (55.6%); the second most common technique was bracing in AS (33.5%) and casting in SH-1 (34.7%). Approximately one-third of all respondents recommended either outpatient or home physical therapy for AS, whereas only 11.4% recommended physical therapy for SH-1 (P < .01). Results showed that 81.2% of respondents reported no complications for SH-1 treatment and 87.8% reported no complications for AS treatment. Cast complications were reported by 9.6% for SH-1 and 5.2% for AS. Rare SH-1 complications included distal fibular growth arrest, infection, nonunion, late fracture displacement, and recurrent fracture. Conclusion: Significant variability was found in primary treatment of pediatric AS and SH-1 injuries. Rare complications from injury, treatment, and neglected treatment after SH-1 and AS were reported.

Lateral Malleolar Fracture.

The authors present the case of a young woman who sustained a lateral malleolar fracture. The Emergency Departement presentation, diagnosis and initial acute treatment is discussed.

Metallosis after using distal fibular locking plate for lateral malleolar fractures: a retrospective study.

INTRODUCTION: Studies regarding the development of metallosis following open reduction and internal fixation (ORIF) of fractures are rarely found in orthopedic literature. The aim of the current study was to assess metallosis following ORIF using distal fibular locking plates to treat distal fibular fractures. MATERIALS AND METHODS: 69 patients who underwent surgery using locking compression plates to treat lateral malleolar fractures, with a minimum 1-year follow-up period and subsequent hardware removal were enrolled in our study. We divided the patients into 2 groups, to compare the complications and demographics: 38 patients, treated with ZPLP plate; 31 patients, treated with other plates. RESULTS: During 1 year of postoperative follow-up, 20 complications developed: 6 superficial infections at the operative site, 1 case of nonunion, 3 cases of osteitis, 4 cases of hypaesthesia, 2 cases of peripheral neuropathy, and 4 cases of metallosis. No statistical difference was found in the rate of complications when comparing the treatment groups (Mann-Whitney U test, p < .05) except for metallosis. All 4 patients who developed metallosis were treated using a ZPLP plate, and metallosis did not develop at all in patients who underwent surgery using other plates. CONCLUSION: In our study, metallosis developed more than was previously known, particularly after using LCPs to treat lateral malleolar fractures. Our findings and those in recent publications support the possibility that metallosis can occur not only in patients with arthroplasties, but also in patients with open reduction and internal fixation with LCPs. Surgeons should be aware of such risk of metallosis and be careful to select proper plates for internal fixation.

Risk of Reoperation in Simple Ankle Fracture Surgery When Comparing Locking Plate With Nonlocking Plate.

Locking plates were initially designed to provide improved stability to ankle fractures with poor bone quality but are currently widely used. The aim of this study was to compare the reoperation risk when using locking plates compared with nonlocking plates in patients with simple ankle fractures. This study was a population-based register study. Data regarding patients with AO type 44A1/2 and 44B1/2 injuries who were treated with either locking or nonlocking plates were obtained from the Danish Fracture Database. The follow-up period was 24 months. Major complications were defined as complications requiring surgical intervention, with the exception of simple hardware removal 6 weeks after primary surgery, which was defined as a minor complication. Multivariate regression analysis was performed to determine relative risk (RR), adjusted for age, sex, American Society of Anesthesiologists physical status classification (ASA)-score, and level of the surgeon's experience. A total of 2177 ankle fractures were included, among which 718 (33%) were treated with locking plates, and 1459 (67%) were treated with nonlocking plates. Data were linked with the Danish National Patient Registry to ensure complete information was obtained regarding reoperations, which were divided into major and minor complications. In both groups, the risks for major and minor complications were 3% and 22%, respectively, resulting in adjusted RRs of 1.00 (0.66; 1.66) for major reoperation comparing locking with nonlocking plates and 0.92 (0.76; 1.11) for minor reoperations. We conclude that no significant association with reoperation exists for locking compared with nonlocking plates among patients with surgically treated simple ankle fractures.

A prospective evaluation of strength and endurance of ankle dorsiflexors-plantar flexors after conservative management of lateral malleolar fractures.

OBJECTIVES: This study aims to evaluate patients with conservatively treated stable lateral malleolar fractures with isokinetic tests. PATIENTS AND METHODS: Between January 2016 and November 2017, a total of 24 patients (12 males, 12 females; mean age 40.8±15.0 years; range, 18 to 68 years) with an isolated stable lateral malleolar fracture treated conservatively with the circular cast were included in this prospective study. Calf circumferences, ankle range of motion (ROM), pain levels, and functional outcomes were recorded. The muscle strengths and endurance of the injured side were compared with the non-injured side. All patients were evaluated by isokinetic test after removal of the cast, and three and six months after the rehabilitation period. RESULTS: The ROM was found to be lower after removal of the plaster cast, compared to the contralateral ankle. During cast removal, we also found that both dorsiflexor and plantar flexor muscle strength decreased by 25.6% and 44.7%, respectively, and decreased to 10.3% and 3.6% at three months post-rehabilitation. At the end of six months, no statistically significant difference was found between the two sides. In the dorsiflexion-plantar flexion endurance values, 37.8% and 54.1% deficit were detected before the rehabilitation protocol, respectively (p<0.05). At three months, these values decreased to 6.1% and 13.6%, respectively and the endurances of the injured sides surpassed the non-injured sides (p<0.05) at six months. CONCLUSION: Conservative management of stable isolated lateral malleolar fractures with circular cast causes atrophy and decreases strength-endurance of the calf muscles due to immobilization. These changes are expected to diminish over time and functional outcomes are excellent with a good rehabilitation program.

Value of Ultrasound for Stability Assessment of Isolated Lateral Malleolar Fractures Compared to Stress Radiography and Arthroscopy.

BACKGROUND: This study was performed to evaluate the value of using ultrasound for stability assessment of isolated lateral malleolar fractures compared to simple X-ray, stress radiography, and arthroscopy. METHODS: This is a prospective cohort study with 25 consecutive patients who underwent an arthroscopic examination and subsequent surgery for isolated lateral malleolar ankle fractures. Before operation, simple and external rotation stress radiographs were obtained. Ultrasound was performed to assess the medial deltoid ligament prior to operation. Arthroscopic findings were used as reference standards. Sensitivity, specificity, and positive and negative predictability were calculated and compared using receiver operating characteristic (ROC) curve analysis for simple radiography, stress radiography, and ultrasound examination. RESULTS: The sensitivity and specificity of ultrasound for tears of the deep deltoid ligament were 94.74% and 66.67%, respectively. But, they were both 100% for complete tears of the ligament. ROC curve analysis showed that the ultrasound examination was significantly more accurate than simple and stress radiography. CONCLUSIONS: Ultrasound could be used to assess the instability of isolated lateral malleolar fractures. Commonly used stress radiography appears to overrate the need for operative treatment.

Isolated Lateral Malleolar Fracture Treated with a Bioabsorbable Magnesium Compression Screw.

Magnesium (Mg) bioabsorbable screws are new biomaterials used in fracture fixation. In the current literature, there is only one case report on the use of magnesium bio-absorbable screws in ankle fractures. Within the present study, a 19-year-old female who sustained an isolated lateral malleolar fracture was treated with open reduction and intramedullary Mg screw fixation and then followed up for two years. Fracture union was achieved without any complication such as failure of fixation, loss of reduction, infection, or any other adverse reaction. Mg bioabsorbable screws are an alternative method of fracture fixation as compared to conventional metallic implants since they eliminate the need for implant removal.

Emergency physician accuracy using ultrasonography to diagnose lateral malleolar fracture.

OBJECTIVE: Many studies in the literature related to the investigation of the sensitivity and specificity of ultrasound examinations in lateral malleolar fractures is limited. The aim of this study is to investigate the sensitivity and specificity of ultrasound examinations performed by emergency physicians in fractures who are presented to the emergency department with blunt lateral malleolar trauma. METHOD: Patients over 18years of age who were admitted to the ED with lateral malleolar tenderness were enrolled to this study with convenience sampling. Ultrasonographic examination was performed by emergency physicians. Following the ultrasound examination, a two-sided X-ray was performed. In the case of inconsistency between the US exam and the X-ray evaluated by the emergency physician, a CT was performed on the patients. The X-ray or CT imaging evaluation of an orthopedic surgeon was accepted as the gold standard. RESULTS: A hundred-twenty patients were included in the study. Fractures in the lateral malleolus were detected in 47 patients. The sensitivity of X-ray in the diagnosis of lateral malleolar fractures was 92.8%, (95% CI, 79.4-98.1) and the specificity was 100% (95% CI, 89.5-100), while the sensitivity of US exam was 100% (95% CI, 94.1-100), and the specificity was 93% (95% CI, 85-97.6). X-ray gave false negative results in 3 patients, whereas US gave false positive results in 5 patients. CONCLUSION: In patients admitted to ED with lateral malleolus tenderness, the sensitivity of the ultrasound examination performed by emergency physicians regarding diagnosis of lateral malleolar fracture is higher than X-ray.

State-of-the-Art in Ankle Fracture Management in Chile.

The ankle represents the most commonly injured weightbearing joint in the human body. They are typically the result of low-energy, rotational injury mechanisms. However, ankle fractures represent a spectrum of injury patterns from simple to very complex, with varying incidence of posttraumatic arthritis. Stable injury patterns can be treated nonoperatively; unstable injury patterns are typically treated operatively given that they could lead to severe arthritis if not properly addressed.

Internal fixation of the fibula in ankle fractures: a prospective, randomized and comparative study: plating versus nailing.

AIM: Open reduction and internal plate fixation of the fibula is the gold standard treatment for ankle fractures. The aim of this study was to perform a prospective randomized study to compare bone union, complications and functional results of two types of internal fixation of the fibula (plating and the Epifisa FH intramedullary nail). MATERIALS AND METHODS: Inclusion criteria were: closed fractures, isolated displaced fractures of the lateral malleolus, inter- and supra-tubercular bimalleolar fractures, and trimalleolar fractures. This study included 71 patients (mean age 53 ± 19): plate fixation group (n=35) and intramedullary nail fixation group (n=36). In seven cases, intramedullary nailing was technically impossible and was converted to plate fixation (the analysis of this sub-group was performed independently). Two patients died and two patients were lost to follow-up. The final comparative series included 32 cases of plate fixation and 28 cases of intramedullary nail fixation. Union, postoperative complications and Kitaoka and Olerud-Molander functional scores were analyzed after one year of follow-up. RESULTS: There was no significant difference in the rate of union (P=0.5605) between the two types of fixation. There were significantly fewer complications (7% versus 56%) and better functional scores (96 versus 82 for the Kitaoka score; 97 versus 83 for the Olerud-Molander score) with intramedullary nailing than with plate fixation. CONCLUSION: Intramedullary nailing of the lateral malleolus in non-comminuted ankle fractures without syndesmotic injury is a reproducible technique with very few complications that provides better functional results than plate fixation. LEVEL OF EVIDENCE: II (randomized prospective study).

Comparison of Antiglide Plate Fixation and Lateral Plate Fixation for Danis-Weber Type B Isolated Lateral Malleolar Fractures / 대한족부족관절학회지

PURPOSE: This study was performed retrospectively and to compare the clinical outcomes of the surgical management using Antiglide plating and lateral plating for Danis-Weber type B isolated lateral malleolar fractures. MATERIALS AND METHODS: Between March 2004 and March 2009, 92 patients were followed up for more than 6 months after surgical treatment. 49 patients were treated with Antiglide plating, whereas the remaining 43 patients underwent lateral plating. The results of the two groups were analyzed both radiographically and clinically using Ankle scoring system. RESULTS: Both groups were comparable for age, sex distribution, time to surgery, and operation time. Bone union was noted at average of 8 weeks in all fractures. The mean ankle score was similar in both groups (94% versus 93%). CONCLUSION: Antiglide plating for Danis-Weber type B isolated lateral malleolar fracture is one of the good methods which has some advantages such as early ankle motion, ambulation and smaller operative incision.

Treatment of Lateral Malleolar Fracture Associated with Disruption of the Deltoid Ligament / 대한정형외과학회잡지

PURPOSE: To evaluate the necessity for repair of associated deltoid ligament rupture in lateral malleolar fracture. MATERIALS AND METHODS: Twenty of twenty-five patients were evaluated. Each received surgical treatment without repair of the ruptured deltoid ligament. We found that the medial clear space was widened more than 5 mm in intraoperative stress tests which had been done between May 2003 and June 2008. We did follow-up on these patients for more than 1 year after surgery. At the final follow-up, radiologic and clinical assessment were evaluated on plain X-ray and according to Olerud Molander ankle scores. RESULTS: Open reduction and internal fixation of the lateral malleolar was done in all cases and an additional transfixation screw was needed in 17 patients who had concurrent syndesmotic disruption. Average medial clear space widening before surgery was 9.28 mm (7.0-17.14 mm), at final follow-up time it was 3.43 mm (2.9-5.28 mm). And there were 8 (40%) good, 10 (50%) fair and 2 (10%) poor ratings on radiologic evaluation, but the mean clinical score was 93.75, with 17 (85%) being excellent, 2 (10%) good and 1 (5%) fair on clinical evaluation. CONCLUSION: In the treatment of lateral malleolus fracture associated with disruption of the deltoid ligament, satisfactory clinical results could be obtained including lateral joint stability, with accurate anatomical reduction and internal fixation of the lateral malleolus and distal tibio-fibular joints. Medial joint stability could be obtained without deltoid ligament repair.

Comparative Study for the Fixation Method in the Danis-Weber Type B Lateral Malleolar Fractures: An Antiglide Plate Fixation versus A Lateral Plate Fixation / 대한족부족관절학회지

PURPOSE: To evaluate the advantages of the antiglide plate fixation procedure for Danis-Weber type B lateral malleolar fractures of ankle compared to other methods of lateral plate fixation. MATERIALS AND METHODS: We reviewed 70 cases that antiglide plate fixation and lateral plate fixation procedures were performed from Mar. 2001 through Mar. 2006. Of the total 70 cases, they were divided into two groups ; 22 cases were treated with the antiglide plate procedure (Group I) and 48 cases were treated with the lateral plate procedure (Group II). The results of the two groups were analyzed both radiographically and clinically using Ankle-Hindfoot scale of the American Orthopedic Foot and Ankle Society (AOFAS). RESULTS: All fractures were healed at average of 8 weeks both radiographically and clinically. According to the Ankle-Hindfoot scale, all cases of Group I and 48 cases of Group II were above 80 points. 2 cases (9%) in Group I complained of peroneal tendinitis, while 19 cases (39%) in Group II showed skin irritation resulting from the screw or the plate. A total of 6 cases (27%) in Group I and 27 cases (55%) in Group II complained cosmetic problems. CONCLUSION: we concluded that the antiglide plate fixation for Danis-Weber type B lateral malleolar fractures is one of the good methods. But, further analysis will be need to find a solution for the peroneal tendinitis.

The Necessity of Deltoid Ligament Repair in Lateral Malleolar Fracture Combined with Medial Clear Space Widening

PURPOSE: To evaluate the necessity of deltoid ligament repair in lateral malleolar fracture associated with medial clear space widening. MATERIALS AND METHODS: The 82 cases of 82 patients received surgical treatment for lateral malleolar fracture with medial clear space widening in our hospital from Jan. 1996 to Feb. 2002. 73 male and 9 female patients were included respectively. Average follow-up period was 13.2 month (12~50). The methods of internal fixation of lateral malleolar fracture were 66 cases by cortical screw, 16 by plate and screws, and 9 by transfixing screw. RESULTS: Satisfactory reduction was obtained in 65 of 73 cases by only internal fixation of lateral malleolar fracture. Transfixing screw was needed in 8 cases. There was no need for repair of deltoid ligament. In clinical evaluation, no cases of limitation of movement in ankle was seen at final follow-up time. In radiologic evaluation, average medial clear space widening before operation was 5.89 mm (4.5~13 mm) and that of last follow-up time was 2.54 mm (1.5~3.5 mm). 95.2% was above good result. CONCLUSION: In treatment of unstable lateral malleolar fracture associated with medial clear space widening due to rupture of deltoid ligament, we obtained satisfactory result by accurate anatomical reduction or internal fixation. In these cases, there were no need for repair of deltoid ligament.

Treatment of Fractures of the Lateral Malleolus using Locking Compression Plate / 대한족부족관절학회지

PURPOSE: The purpose of this study was to investigate usefulness of locking compression plate (LCP) as an open reduction technique by evaluating clinical results obtained from the patients with lateral malleolar fracture treated by internal fixation using LCP after open reduction. MATERIALS AND METHODS: Among the patients with lateral malleolar fracture, the 28 patients who were treated by internal fixation using Locking compression plate after an open reduction and were able to be followed up for more than 6 months were included in this study. Final postoperative evaluation was done based on the Meyer's clinical and radiologic evaluation system. RESULTS: All cases achieved anatomical reduction and fixation of the reduction postoperatively. 28 minutes were taken meaningly from the incision to the fixation of LCP plate after the anatomical reduction. Everage bony union time was 8.2 weaks, and the result was excellent in 23 cases (82%), good in 5 cases (17%) and poor result was abscent according to the criteria of Meyer et al. One case of post traumatic arthritis and one case of superficial infection on the operation site were found, but non-union, delayed union and malunion were not occurred. CONCLUSION: The internal fixation after open reduction using LCP is an effective treatment method in treating lateral malleolar fracture of the ankle since it offers advantages including easy application and a greater stability due to its capability of maintaining exact anatomical reduction even though the screw does not penetrate the medial cortex of fibular to add the stability and rigidity of the fixation.

A Case of Trichoadenoma / 대한피부과학회지

Trichoadenoma is a rare cutaneous tumor that was first described by Nikolowski in 1958. It usually occurs as a single tumor on the face and its size varies from 3 to 50mm in diameter. It may arise any time during adult life. This tumor is less mature than trichofolliculoma and more differentiated than trichoepithelioma, and it is considered as a benign tumor with differentiation toward the infundibular portion of the pilosebaceous canal. In this report, we describe a 61-year-old women who developed trichoadenoma on the left shoulder of 3 years duration. The lesion was asymptomatic and had grown slowly. Histopathological findings showed numurous horn cysts with central keratinous material and solid tumor islands reaching to the deep dermis. Immunohistochemical studies showed negative findings for eccrine differentiation.