Immediate weight bearing without immobilization for operatively treated ankle fractures is safe - A systematic review.

BACKGROUND: This systematic literature review compared weight bearing (WB) vs. partial- / non-weight bearing (NWB) and mobilization (MB) vs. immobilization (IMB) for surgically treated ankle fractures. METHODS: Five databases were searched. Eligible were (quasi-)randomized controlled trials comparing at least two different postoperative treatment protocols. The risk of bias was assessed using the RoB-2 toolkit. The primary outcome was complication rate, secondary outcome Olerud and Molander Ankle Score (OMAS), range of motion (ROM), and return to work (RTW). RESULTS: Out of 10,345 studies, 24 papers were eligible. Thirteen studies (n = 853) compared WB/NWB, 13 studies (n = 706) MB/IMB with a moderate study quality. WB did not increase the risk for complications but resulted in superior short-term outcomes for OMAS, ROM, RTW. 12 studies found no inferior results for MB compared to IMB. CONCLUSION: Early and immediate WB and MB do not increase the complication rates but result in superior short term outcome scores. LEVEL OF EVIDENCE: Level I Systematic Review.

Complete avulsion of the heel pad with talar and calcaneal fracture: salvage with multiple K-wire anchorage, internal fixation and free ALT flap.

BACKGROUND: Degloving of the sole of the foot is a rare and serious injury because the heel pad cannot be replaced by similar tissue. The management is challenging and only a few cases have been reported with different treatment regimens. METHODS: Here, we report on a 46-year-old female patient with complex foot trauma consisting of complete avulsion of the heel pad at the hindfoot and a soft tissue defect at the posterior aspect of the heel accompanied by rupture of the anterior tibial tendon and fractures of the talus, calcaneus and midfoot. The sole of the foot was fixed to the calcaneus with multiple temporary Kirschner wires and moist wound dressings. The anterior tibial tendon was sutured. The soft tissue defect at the posterior heel was treated with a free anterolateral thigh flap. The fractures were fixed in staged procedures. RESULTS: At 2-year follow-up, the patient had a durable soft tissue cover over the heel with full sensation over the sole and a pliable flap over the posterior aspect of the heel. The patient was able to fully bear weight and was pain free during her daily activities in comfortable, custom shoes. All fractures had healed, the talar neck fracture after one revision and bone grafting. The foot was plantigrade and stable with preserved painless but limited range of motion at the ankle, subtalar and mid-tarsal joints. CONCLUSION: The unique tissue at the sole of the foot can be salvaged even in cases of full degloving at the hindfoot with the simple method of anchorage with multiple temporary K-wires. Traumatic defects of the vulnerable skin at the posterior aspect of the heel requires durable coverage with free flap coverage. With staged treatment of all bone and soft tissue injuries, a favorable result can be obtained even in case of a complex foot trauma.

Ankle Arthrodesis - a Review of Current Techniques and Results.

Ankle arthrodesis continues to be the golden standard in the treatment of end-stage ankle arthritis. Meticulous soft tissue handling, correct positioning of the foot, and stable fixation are crucial for obtaining a favorable result. With current techniques, mostly internal fixation with screws or plates, union rates between 87 and 100% are reported. Adjacent joint arthritis remains a concern in long-term follow-up, but does not always become symptomatic. It is pre-existing in a substantial number of cases and associated with fusion in less than optimal position, particularly equinus. With arthroscopic arthrodesis techniques, wound complications and scarring can be further reduced while obtaining similar fusion rates and equivalent, if not better, functional results when compared with open techniques. Key words: ankle, hindfoot, fusion, screws, plate, anterior approach, transfibular.

[The periosteal flap augmentation technique in chronic lateral ankle instability]. / Die Periostlappenplastik bei chronischer Instabilität des oberen Sprunggelenks.

OBJECTIVE: Anatomic repair of the lateral ligament complex of the ankle joint and augmentation with an autologous pedicled periosteal flap of the distal fibula following identification and concomitant treatment of intra-articular pathologies. INDICATIONS: Symptomatic chronic mechanical lateral ankle instability. As a modular step in the treatment of osteochondral lesions in conjunction with lateral ankle instability. CONTRAINDICATIONS: Higher degree osteoarthritis of the ankle joint (>Kellgren/Lawrence 2 and 4 or Outerbridge 3 and 4) and/or hindfoot deformity; mechanical incompetence of both the fibulotalar anterior ligament and the fibulocalcaneal ligament preventing anatomical reinsertion; general risk factors. SURGICAL TECHNIQUE: Diagnostic arthroscopy for identification and treatment of intraarticular pathologies; verification and grading of ligamentous instability (medial, lateral, combined). Open exposure of the distal fibula and the ruptured components of the lateral ankle ligament complex. Anatomic reinsertion of the original ligaments and assessment of their mechanical competence. Apart from the situation in the juvenile patient with a thick periosteal layer a doubled and pedicled periosteal strip of the distal fibular periosteum will suffice for the augmentation in one ligamentous component, only. Fixation in the talus or calcaneus is achieved via suture anchors, screws with a washer or transosseous fixation via interference screw. POSTOPERATIVE MANAGEMENT: Postoperative immobilization in a lower leg split cast or a splint until wound healing (5-8 days), mobilization in a walker or an ankle orthosis with consecutive full weight-bearing for further 4-5 weeks. Proprioceptive and pronator muscle training, optionally insole or lateral wedge at the shoe sole for 6 months postoperatively. Avoidance of contact sports for 4-6 months. RESULTS: Several studies have reported reliable restoration of ligamentous ankle stability with overall success rates >90% and good to excellent total results in >90% of patients with limited minor complications. In view of the heterogeneous data from previous studies, some recent studies have demonstrated that the outcome after periosteal augmentation is comparable to that after techniques employing free tendon graft for anatomic restoration of ligamentous ankle stability. The technique has been applied successfully in cases of poor mechanical properties of the formerly ruptured ligaments and in patients with a high functional demand.

[Syndesmosis injuries at the ankle]. / Syndesmosenverletzungen.

BACKGROUND: Injuries to the distal tibiofibular syndesmosis are frequent and continue to generate controversy due to an extensive range of diagnostic techniques and therapeutic options. OBJECTIVE: The aim of this review is to summarize the current knowledge on syndesmotic instability and to present some recommendations for the clinical practice for acute an chronic injuries. MATERIAL AND METHODS: Analysis of the current literature concerning the anatomy, etiology, diagnostics and treatment of syndesmosis injuries. RESULTS: Purely ligamentous injuries (high ankle sprains) are not associated with a latent or frank tibiofibular diastasis and can be treated with an extended protocol of physiotherapy. Relevant instability of the syndesmosis with diastasis results from rupture of two or more ligaments and requires surgical stabilization. Syndesmotic disruptions are commonly associated with bony avulsions or malleolar fractures. Treatment consists of anatomic reduction of the distal fibula into the corresponding incisura of the distal tibia and stable fixation. The proposed means of fixation are one or more tibiofibular screws or suture button implants. There is no consensus on how long to maintain fixation. Both syndesmotic screws and suture buttons need to be removed if symptomatic. The most frequent complication is syndesmotic malreduction and can be minimized with direct visualization and intraoperative 3D scanning. Other complications include hardware failure, adhesions, heterotopic ossification, tibiofibular synostosis, chronic instability and posttraumatic arthritis. CONCLUSION: The single most important prognostic factor after unstable injury of the distal tibiofibular syndesmosis with or without fracture is the anatomic reduction of the distal fibula and fitting into the tibial incisura.

[Classification of posterior malleolar fractures in ankle fractures]. / Klasifikace zlomenin zadní hrany tibie u zlomenin hlezna.

The study presents an overview of the most common radiography and CT-based classifications of posterior malleolar fractures in ankle fracture-dislocations. Their analysis has shown that posterior malleolar fractures largely vary in size and shape. Evaluation of fractures by plain radiographs is inadequate. A detailed assessment of the fragment shape and course of fracture lines requires CT examination in all three projections, followed by 3D CT reconstructions.Key words: ankle fracture - dislocations trimalleolar fractures posterior malleolar fractures classification.

[Injuries under the influence of alcohol]. / Verletzungen unter Alkoholeinfluss.

BACKGROUND: In Germany, an average of 9.5 L of pure alcohol is consumed per capita per year. Alcohol is known to negatively influence psychomotor abilities. The aim of this study was to evaluate injuries that lead to hospital admission with and without prior intake of alcohol. PATIENTS AND METHODS: Over a 7-month period, all 1317 patients who were admitted to the hospital because of an injury were evaluated with respect to their blood-alcohol level. Patient data of both groups (139 injuries under alcohol influence and 1178 injuries without alcohol influence) were compared with respect to the mechanism and type of injury, patient demographics, and treatment costs. RESULTS: At the time of presentation, 11 % (n = 139) of all admitted patients had detectable blood-alcohol levels of more than 0.1 g/L with an average blood-alcohol level of 2.21 g/L. Female patients had an average of 1.96 g/L and males an average of 2.28 g/L (N.S.). Almost every fifth male patient (109 out of 570, 19 %) had a detectable blood-alcohol level, compared to only 4 % of all admitted female patients. Among the patients admitted between 11:00 p.m. and 5:00 a.m., 35 % had detectable blood-alcohol levels and among the 20- to 30-year-old patients, 24 % had detectable blood-alcohol levels. The leading mechanisms of injury among intoxicated patients were falls (50 %, n = 70) and physical violence (18 %, n = 25). The latter was recorded significantly (p = 0.01) less among sober patients (0.17 %, n = 2). The most frequent diagnosis was a mild concussion in both intoxicated (60%, n = 84) and sober (34 %, n = 402) patients (p = 0.04). The time to discharge averaged 4.3 days for intoxicated and 5.6 days for sober patients. CONCLUSIONS: Injuries that occur while under the influence of alcohol that lead to hospital admission are particularly frequent in male patients aged between 20 and 30 years. They do not necessarily lead to more severe injuries.

Should syndesmotic screws be removed after surgical fixation of unstable ankle fractures? a systematic review.

AIMS: In approximately 20% of patients with ankle fractures, there is an concomitant injury to the syndesmosis which requires stabilisation, usually with one or more syndesmotic screws. The aim of this review is to evaluate whether removal of the syndesmotic screw is required in order for the patient to obtain optimal functional recovery. MATERIALS AND METHODS: A literature search was conducted in Medline, Embase and the Cochrane Library for articles in which the syndesmotic screw was retained. Articles describing both removal and retaining of syndesmotic screws were included. Excluded were biomechanical studies, studies not providing patient related outcome measures, case reports, studies on skeletally immature patients and reviews. No restrictions regarding year of publication and language were applied. RESULTS: A total of 329 studies were identified, of which nine were of interest, and another two articles were added after screening the references. In all, two randomised controlled trials (RCT) and nine case-control series were found. The two RCTs found no difference in functional outcome between routine removal and retaining the syndesmotic screw. All but one of the case-control series found equal or better outcomes when the syndesmotic screw was retained. However, all included studies had substantial methodological flaws. CONCLUSIONS: The currently available literature does not support routine elective removal of syndesmotic screws. However, the literature is of insufficient quality to be able to draw definitive conclusions. Secondary procedures incur a provider and institutional cost and expose the patient to the risk of complications. Therefore, in the absence of high quality evidence there appears to be little justification for routine removal of syndesmotic screws. Cite this article: Bone Joint J 2016;98-B:1497-1504.

[New techniques in the operative treatment of calcaneal fractures]. / Neue Techniken in der operativen Versorgung von Calcaneusfrakturen.

The ideal treatment of displaced intra-articular calcaneal fractures is still controversially discussed. Because of the variable fracture patterns and the vulnerable soft tissue coverage an individual treatment concept is advisable. In order to minimize wound edge necrosis associated with extended lateral approaches, selected fractures may be treated percutaneously or in a less invasive manner while controlling joint reduction via a sinus tarsi approach. Fixation in these cases is achieved with screws, intramedullary locking nails or modified plates that are slid in subcutaneously. A thorough knowledge of the three dimensional calcaneal anatomy and open reduction maneuvers is a prerequisite for good results with less invasive techniques. Early functional follow-up treatment aims at early rehabilitation independent of the kind of fixation. Peripheral fractures of the talus and calcaneus frequently result from subluxation and dislocation at the subtalar and Chopart joints. They are still regularly overlooked and result in painful arthritis if left untreated. If an exact anatomical reduction of these intra-articular fractures is impossible, resection of small fragments is indicated.

Posterior malleolar fractures of the ankle.

Despite an increasing awareness of injuries to PM in ankle fracture-dislocations, there are still many open questions. The mere presence of a posterior fragment leads to significantly poorer outcomes. Adequate diagnosis, classification and treatment require preoperative CT examination, preferably with 3D reconstructions. The indication for surgical treatment is made individually on the basis of comprehensive assessment of the three-dimensional outline of the PM fracture and all associated injuries to the ankle including syndesmotic instability. Anatomic fixation of the avulsed posterior tibiofibular ligament will contribute to syndesmotic stability and restore the integrity of the incisura tibiae thus facilitating anatomic reduction of the distal fibula. A necessary prerequisite is mastering of posterolateral and posteromedial approaches and the technique of direct reduction and internal fixation. Further clinical studies with higher numbers of patients treated by similar methods and evaluation of pre- and postoperative CT scans will be necessary to determine reliable prognostic factors associated with certain types of PM fractures and associated injuries to the ankle.

An update on the evaluation and treatment of syndesmotic injuries.

INTRODUCTION: Injuries to the distal tibiofibular syndesmosis are frequent and continue to generate controversy. METHODS: The majority of purely ligamentous injuries ("high ankle sprains") is not sassociated with a latent or frank tibiofibular diastasis and may be treated with an extended protocol of physical therapy. Relevant instability of the syndesmosis with diastasis results from rupture of two or more ligaments that require surgical stabilization. Syndesmosis disruptions are commonly associated with bony avulsions or malleolar fractures. Treatment consists in anatomic reduction of the distal fibula into the corresponding incisura of the distal tibia and stable fixation. Proposed means of fixation are refixation of bony syndesmotic avulsions, one or two tibiofibular screws and suture button. There is no consensus on how long to maintain fixation. Both syndesmotic screws and suture buttons need to be removed if symptomatic. RESULTS/COMPLICATIONS: The most frequent complication is syndesmotic malreduction and may be minimized with open reduction and intraoperative 3D scanning. Other complications include hardware failure, heterotopic ossification, tibiofibular synostosis, chronic instability and posttraumatic arthritis. CONCLUSION: The single most important prognostic factor is anatomic reduction of the distal fibula into the tibial incisura.

[Hindfoot fusion for Charcot osteoarthropathy with a curved retrograde nail]. / Rückfußarthrodese beim Charcot-Fuß mit retrogradem Nagel.

BACKGROUND: Charcot osteoarthropathy of the hindfoot with considerable dislocation and instability represents a therapeutic dilemma. The treatment goal is a plantigrade, stable foot that is free of infection and ulceration with the ability to ambulate in special footwear. MATERIALS AND METHODS: Over a period of 6 years, we performed 23 hindfoot fusions in 21 patients with manifest Charcot arthropathy with the help of a curved retrograde nail (HAN). All patients suffered from insulin-dependent diabetes mellitus with polyneuropathy; 12 patients had additional peripheral vasculopathy. An average of 3.5 previous surgeries had been performed prior to hindfoot fusion. RESULTS: Complete tibiotalocalcaneal fusion was obtained in 16 of 21 patients (76 %). Of these 21 patients, 18 (86 %) were followed clinically and radiologically for an average of 2 years. Overall, 16 patients (89 %) reported a substantial subjective improvement compared to the preoperative state. Hardware failure occurred in 7 cases (30 %) that could be brought to consolidation with exchange of the locking bolts or the complete nail. In 5 cases (22 %), a postoperative hematoma had to be removed and in 8 cases (35 %) wound edge necrosis was treated with local wound care. In 2 cases (9 %), a secondary or reactivated osteitis occurred that finally required below knee amputation. CONCLUSION: Tibiotalocalcaneal fusion with a curved retrograde intramedullary nail (HAN) is an effective treatment option in highly unstable and deforming Charcot osteoarthropathy of the hindfoot. It is an alternative to external or other internal fixation methods and helps to avoid below knee amputation in more than 90 % of cases.

[Elective and acute procedures in trauma surgery. Complications requiring revision]. / Elektive und akute Eingriffe in der Unfallchirurgie. Revisionspflichtige Komplikationen.

BACKGROUND: Using data between 2010 and 31 March 2012, a cohort study concerning complications of all discharged patients who had undergone surgery was performed. PATIENTS AND METHODS: In our detailed analysis, we defined two groups out of the 5,248 cases: an acute trauma patient group (n = 3,942) and an elective patient group (n = 1,306). Complications were divided into the following groups: (1) technical complications (failure of the implant, poor indication, instability or non-union), (2) local complication (hematoma or delayed wound healing), and (3) infection. RESULTS: In 4.4% of patients (n = 233), treatment was delayed because of a complication. In 2.3% (n = 123), a technical complication was observed, followed by local complications in 1.3% [e.g., hematoma 0.6%, other wound healing disturbance (0.6%)]. In the elective surgery group, the percentage of complications needing revision (3.1%) was significantly lower compared to the trauma surgery group (4.9%). The patient's age for the non-complicated surgery group was significantly lower (54 vs. 63 years) and length of hospital stay (6.7 days longer) was significantly higher in patients with complications. Risk factors such as smoking were significantly more frequent in patients with complications (9% vs. 18.5%). CONCLUSION: Recording and evaluating of complications in surgery plays a major role for quality control. Certain factors (e.g., comorbidity and the age of the patient) cannot be influenced, but complications caused by technical problems could theoretically be avoided. Especially these cases must be analyzed in detail to reduce the percentage of complications requiring revision.

[Secondary anatomical reconstruction of malunited central talus fractures]. / Sekundäre anatomische Rekonstruktion fehlverheilter zentraler Talusfrakturen.

BACKGROUND: Malunion or nonunion of central talar fractures lead to significant impairment, pain and decreased motion of the foot and ankle. In a 20-year period from 1994 to 2013 at the Trauma Department of the University Hospital Carl Gustav Carus of the Technical University of Dresden we treated a total of 25 patients with secondary anatomical reconstruction of the talus. METHOD: The mean age of the patients was 39.9 years (range 15-71 years) and only 4 out of the 25 patients were female. Of these patients 11 patients were treated conservatively, 3 minimally invasive with external fixation and were admitted on average 7.6 months (range 1.5-42 months) after the initial fracture. Of the patients 11 had previously been treated in another hospital by open surgery on average 8.4 months (range 1-24 months) months before. There were 9 malunions or nonunions of talar fractures of the shaft, 14 of the neck and 2 of the head. Only 3 cases were old fractures ≥ 6 weeks and 22 were malunions or nonunions ≥ 3 months. According to an in-house classification 12 malunions (type I), 5 nonunions (type II), and 8 malunions/nonunions with partial necrosis (type III) were treated. RESULTS: Of the patients 21 out of 25 needed a bilateral approach and 6 additionally an osteotomy of the medial malleolus.The mean follow-up of 22 out of 25 patients was 5.4 years (range 1.0-21.5 years). The preoperative American Orthopedic Foot and Ankle Society (AOFAS) hindfoot score increased on average from 36.6 to 86.7 points (p<0.001) at the time of follow-up.

[Joint-preserving osteotomy for calcanean malunions]. / Gelenkerhaltende Korrektur fehlverheilter Kalkaneusfrakturen.

BACKGROUND: Calcaneal malunions lead to a considerable loss of global foot function through the loss of the physiological hindfoot lever arm, bony and soft tissue impingement, and involvement of the subtalar joint. In the majority of cases correction of the malunion has to be combined with subtalar fusion because of a rapid development of posttraumatic subtalar arthritis. METHODS: Joint-preserving corrective osteotomy may be considered in carefully selected patients with intact joint cartilage, sufficient bone quality, and good patient compliance. This is the case in extra-articular malunion and intra-articular malunion with displacement of the complete posterior facet of the subtalar joint. RESULTS: While respecting the criteria for indications, overall good functional results could be achieved in two clinical studies on this subject. Only 1 of the 26 reported patients required a secondary subtalar fusion. In case of development of subtalar arthritis a secondary in situ fusion of the subtalar joint can be performed on a corrected hindfoot with good prospects. CONCLUSION: In carefully selected cases of malunited intra-articular calcaneal fractures, joint-preserving osteotomy is an alternative to corrective subtalar fusion.

[Joint-preserving correction of Chopart joint malunions]. / Gelenkerhaltende Korrekturen bei Fehlheilungen im Chopart-Gelenk.

BACKGROUND: Injuries to the mid-tarsal (Chopart) joint are frequently overlooked or misinterpreted and therefore, not adequately treated at initial presentation. Malunion results in a loss of essential joint function and a three-dimensional malalignment leading to considerable impairment of global foot function and a rapid development of painful posttraumatic arthritis. METHODS: If no symptomatic arthritis is present, joint displacement or non-union may be subject to secondary anatomical reconstruction and internal fixation. Bone grafting becomes necessary in cases of non-union or partial avascular necrosis (AVN) of the navicular bone. In most cases joint destruction will have lead to manifest posttraumatic arthritis requiring fusion of the affected joint. Arthrodesis is always combined with axial realignment. Rebalancing of the medial and lateral foot columns is of utmost importance. RESULTS: We have treated 16 patients with joint-preserving correction of the Chopart joint: 6 of the navicular bone, 3 of the talar head, 3 of the anterior calcaneal process, 2 of the cuboid and 2 with combined malunions. Two female patients aged 50 and 67 years developed AVN of the navicular bone and required talonavicular fusion and one patient with a nonunion of the anterior calcaneal process needed a second revision surgery to achieve union. The average American Orthopaedic Foot and Ankle Society (AOFAS) score of 12 patients increased from 37 preoperatively to 77 at follow-up after an average of 2 years. CONCLUSION: Joint-preserving corrections are generally possible for all four bony components of the Chopart joint in carefully selected cases of malunited fractures and fracture dislocations.