Harnessing ResNet50 and SENet for enhanced ankle fracture identification.

BACKGROUND: Ankle fractures are prevalent injuries that necessitate precise diagnostic tools. Traditional diagnostic methods have limitations that can be addressed using machine learning techniques, with the potential to improve accuracy and expedite diagnoses. METHODS: We trained various deep learning architectures, notably the Adapted ResNet50 with SENet capabilities, to identify ankle fractures using a curated dataset of radiographic images. Model performance was evaluated using common metrics like accuracy, precision, and recall. Additionally, Grad-CAM visualizations were employed to interpret model decisions. RESULTS: The Adapted ResNet50 with SENet capabilities consistently outperformed other models, achieving an accuracy of 93%, AUC of 95%, and recall of 92%. Grad-CAM visualizations provided insights into areas of the radiographs that the model deemed significant in its decisions. CONCLUSIONS: The Adapted ResNet50 model enhanced with SENet capabilities demonstrated superior performance in detecting ankle fractures, offering a promising tool to complement traditional diagnostic methods. However, continuous refinement and expert validation are essential to ensure optimal application in clinical settings.

Historic indications for fixation of posterior malleolus fractures- where did they come from and where are we now?

INTRODUCTION: The indications for reduction and fixation of the posterior malleolus component of rotational ankle fractures have been controversial for nearly a century. This study aims to identify the historical basis for surgical intervention and trace trends in management strategies over time. METHODS: In March 2023, a systematic review of full-text, English-language articles providing indications for surgical fixation of the posterior malleolus component of rotational ankle fractures was performed. Articles underwent title and abstract screening before undergoing full-text review. RESULTS: Historical indications for surgical fixation were size-dependent, with fractures comprising 25 % to 33 % of the plafond recommended for internal fixation. Modern studies suggest that nonoperative management of posterior malleolus fractures below this threshold results in residual malreduction of the articular surface, syndesmotic instability, and an increased need for independent fixation of the syndesmosis. CONCLUSIONS: Size-based indications for posterior malleolus fracture fixation are based on Level V evidence from small retrospective case series published nearly one century ago and should be retired. While the size of the posterior malleolus component cannot be ignored, additional factors like fracture morphology and location within the plafond should guide modern surgical indications. Contemporary studies indicate that reduction and fixation of small posterior malleolus fractures (comprising less than 25 % of the articular surface) are associated with improved articular reductions, tibiotalar contact pressures, syndesmotic stability with decreased need for independent fixation of the syndesmosis, and superior postoperative outcomes.

The efficacy and safety of different does of intravenous tranexamic acid on blood loss in fresh foot and ankle fractures: a prospective, randomized controlled study.

BACKGROUND: There are a few studies on the effectiveness and safety of intravenous administration of tranexamic acid(TXA) in patients who underwent foot and ankle surgery, especially for preoperative hidden blood loss in patients with freshfoot and ankle fractures. Thus, the aim of this study was to investigate whether intravenous administration of different doses of TXA can effectively reduce perioperative blood loss and blood loss before surgery and to determine its safety. METHODS: A total of 150 patients with fresh closed foot and ankle fractures from July 2021 to July 2023 were randomly divided into a control group (placebo controlled [PC]), standard-dose group (low-dose group [LD], 1 g/24 h; medium-dose group [MD], 2 g/24 h), and high-dose group (HD, 3 g/24 h; ultrahigh-dose group [UD], 4 g/24 h). After admission, all patients completed hematological examinations as soon as possible and at multiple other time points postsurgery. RESULTS: There was a significant difference in the incidence of hidden blood loss before the operation between the TXA group and the control group, and the effect was greater in the overdose groups than in the standard-dose groups. There were significant differences in surgical blood loss (intraoperative and postoperative), postoperative HGB changes, and hidden blood loss among the groups. The TXA groups showed a significant decrease in blood loss compared to that of the control group, and the overdose groups had a more significant effect than the standard-dose groups. A total of 9 patients in the control group had early wound infection or poor healing, while only 1 patient in the other groups had this complication, and the difference among the groups was significant. No patients in any group suffered from late deep wound infection, cardiovascular or cerebrovascular events or symptomatic VTE. CONCLUSION: This is the first study on whether TXA can reduce preoperative hidden blood loss in patients with freshfoot and ankle fractures. In our study, on the one hand, intravenous application of TXA after foot and ankle fractures as soon as possible can reduce preoperative blood loss and postoperative blood loss. On the other hand, TXA can also lower wound complications, and over-doses of TXA are more effective than standard doses. Moreover, overdoses of TXA do not increase the incidence of DVT.

The Effect of Prone and Supine Limb Positioning on the Radiographic Evaluation of Posterolateral Plate Fixation of the Posterior Malleolus.

Aim: To facilitate the posterolateral approach to the posterior malleolus patients are often positioned prone initially, then turned supine to complete fixation at the medial malleolus. We sought to define observed differences in the radiographic appearance of implants relative to the joint line, in prone and supine positions. Methods: A 3.5 mm tubular plate and a 3.5 mm posterior distal tibial periarticular plate were applied sequentially to 3 individual cadaveric legs, via a posterolateral approach. The tubular plate was positioned to simulate buttress fixation and the posterolateral plate placed more distally. Each limb was secured on a custom jig and radiographs were taken on a mobile c-arm fluoroscopy machine with a calibration ball. A series of prone AP, supine PA and mortise radiographs were taken. Prone radiographs were also taken in different degrees of caudal tilt to simulate knee flexion which occurs in practice, during intraoperative positioning. Plate tip-joint line distances were measured and Mann-Whitney U tests performed. Results: There was no statistically significant difference in plate tip-joint line distance when comparing equivalent prone and supine views (PA/AP or mortise). However, significant differences in apparent implant position were noted with alterations in caudal tilt. When taking a prone image, when the knee is flexed to 20 degrees, the plate tip will appear 6.5-8.5 mm more proximal than in the equivalent supine image where the knee is extended and the fluoroscopy beam is orthogonal to the anatomic axis of the tibia. Conclusion: Observed differences in radiographic appearance of metalwork in the prone and supine position are most likely due to knee flexion and the resulting variation in the angle of the fluoroscopy beam, rather than projectional differences between supine and prone views. Surgeons should be alert to this when analysing intraoperative images.

Pediatric Ankle Fractures: Successful Remodeling and Restoration Through Comprehensive Diagnosis and Conservative Management in a Diverse Context.

Diagnosing toddler ankle fractures, especially those that affect several bones, can be difficult. The infrequency of such complex injuries, particularly in household environments, emphasizes the importance of increased awareness in diagnosing and managing these types of injuries. We present a compelling case study of a 20-month-old toddler of a low socioeconomic background who sustained fractures in the ankle, calcaneus, tibia, and fibula after being trapped under furniture. The diagnostic process involved trauma guidelines, radiographic assessments, and axial CT scans. Conservative management, including an eight-week plaster cast, was chosen based on the careful consideration of the child's age, the nature of the fracture, and the absence of immediate surgical indications. The follow-up period involved radiographic assessments, as well as repeated regular clinical examinations, revealing consistent alignment and the absence of complications. The successful outcome underscores the importance of a comprehensive diagnostic approach, thoughtful treatment planning, and meticulous follow-up. Individualized care, considering both clinical and socioeconomic factors, proved crucial for optimal outcomes in pediatric orthopedics. The case contributes valuable insights into the evolving landscape of early childhood orthopedics, emphasizing the need for a discerning approach to diagnosing and managing complex fractures in this population. Conservative treatment could significantly assist when absolute surgical indications are lacking both in cases of minimal resources where multiple operations are not plausible and when the patient's social history raises awareness.

Can Anatomical Differences Contribute to the Etiology of Danis-Weber Type B Lateral Malleolus Fractures?

Introduction Lateral malleolus fractures are among the most common ankle fractures, but the anatomical factors that may predispose individuals to this specific type of fracture are not fully understood. This study aims to explore whether distinct anatomical characteristics of the ankle joint contribute to an increased susceptibility to lateral malleolar fractures. Methods A retrospective analysis was conducted on 73 patients diagnosed with isolated lateral malleolar fractures between 2020 and 2023. An array of radiologic parameters, including distal tibial articular surface (DTAS) angle, bimalleolar tilt (BMT), medial malleolar length (MML), lateral malleolar length (LML), medial malleolar relative length (MMRL), lateral malleolar relative length (LMRL), medial malleolar slip angle (MMSA), talocrural angle (TCA), anterior inclination of the tibia (AI), and fibular position (FP), were meticulously measured on anteroposterior and lateral ankle radiographs for each study participant. We also measured the same parameters in 126 individuals who had not experienced an ankle fracture for comparison. Results Statistically significant differences were observed between the fracture group and the control group for DTAS angle, BMT, MML, MMRL, LMRL, TCA, AI, and FP (p<.05). Conversely, LML and MMSA displayed no significant variations between the two groups (p=0.745 and p=0.623). Effect sizes were notably large for DTAS and TCA, medium for MMRL, BMT, and AI, and small for LMRL, MML, and FP. Conclusion Our findings indicate an increased risk of lateral malleolus fractures in individuals with a relatively longer medial malleolus, a valgus-oriented ankle, reduced anterior inclination of the tibia, and an anteriorly positioned fibula. Taking protective measures during risky activities in individuals with these differences may help to prevent fractures.

Computed tomography changes diagnosis, management and surgical planning of ankle fractures.

PURPOSE: To demonstrate how the use of adjunctive Computed Tomography (CT) can modify diagnosis, treatment options, and operative planning of ankle fractures in comparison with conventional radiographs (CR) in isolation. MATERIALS AND METHODS: A total of 53 patients diagnosed with an ankle fracture between 2011 and 2016, were assessed with CT and CR. Evaluations of the fractures using CR in isolation and CR combined with CT were compared using different readers. Fractures were assessed in terms of type, displacement, size, associated injuries, treatment, patient position and surgical planning. RESULTS: The medial malleolus fractures characteristics (posteromedial fragment and anterior colliculus), the presence of posterior malleolus fracture and its characteristics (displacement, size, posteromedial or posterolateral segment) (ps < 0.042), syndesmosis injury (p < 0.001), and the absence of deltoid ligament lesion (p < 0.001), were more evident with the combination of CT and radiographs. There was an increase in operative indication (p = 0.007), prone positioning (p = 0.002), posterior malleolus surgical treatment (p < 0.001), posterolateral approach for the lateral malleolus (p = 0.003), and syndesmosis fixation (p = 0.020) with the association of CT and CR, among all groups of expertise, with a high interobserver reliability (> 0.75). CONCLUSIONS: The CR may fail to demonstrate subtle lesions, such as posterior malleolus fractures and syndesmotic injuries. The CT evaluation increases the diagnostic precision and improves the quality of information the surgeon receives, what might positively affect patient care. LEVEL OF EVIDENCE III: Retrospective Comparative Study.

A unilateral external fixator combined with bone transport and tibio-talar fusion for the treatment of severe postoperative infection of peri-ankle fractures: retrospective analysis of 32 cases.

BACKGROUND: To investigate the clinical effects of a unilateral external fixator combined with bone transport and tibio-talar fusion in the treatment of severe postoperative infection of peri-ankle fractures. METHODS: The clinical data of 32 patients (22 men and 10 women) with severe postoperative infection of peri-ankle fractures were retrospectively analyzed. Patients' age ranged from 26 to 62 (mean, 42 ± 9.5) years old. The types of fractures were distal tibia fracture (25 cases), distal tibia and fibula fracture (5 cases), and talus fracture (2 cases). All patients underwent treatment with unilateral external fixation combined with bone transport and tibio-talar fusion. 6 patients with severe infection received two-stage treatment involving focal debridement and external fixation, osteotomy, and bone transport. The remaining 26 patients underwent debridement, external fixation, and osteotomy simultaneously. The length of bone transport, total fixation time of the external fixator, and postoperative complications were recorded for all patients. The efficacy of the treatment was assessed using the American Association of Foot and Ankle Society (AOFAS) ankle-hindfoot score. RESULTS: Patients were followed up for 16-36 months, with an average follow-up time of 24 months. The length of tibia bone transport ranged from 5 to 15 cm, with a mean length of 8.5 cm. The external fixator was applied for 12-24 months, with an average duration of 16 months. One patient suffered from refracture at tibio-talar fusion site, and one patient had external fixation pin-tract infection. No complications, such as recurrent infections (especially the MRSA infection), poor mineralization, refracture, iatrogenic nerve damage or fusion failure, were found in the remaining patients. The preoperative AOFAS ankle-hindfoot function score was 40.0 ± 3.8 (range, 30-52) points, and it increased to 75.0 ± 3.0 (range, 67-78) points at the last follow-up. CONCLUSION: A unilateral external fixator combined with bone transport and tibio-talar fusion is an effective method for treating severe postoperative infection of peri-ankle fractures. This approach is capable of reconstructing large bone defects that remain after clearing the infected lesion. Additionally, it provides stability to the ankle, enhances ankle-hindfoot function, and improves the patient's quality of life.

The Radiological Anatomy of the Distal Tibiofibular Joint: A Retrospective Computed Tomography Study.

Introduction Distal tibiofibular joint (DTFJ) injuries are commonly encountered in patients with ankle fractures. Achieving optimal fixation is mandatory, but it requires a thorough understanding of the local anatomical relationships. For this reason, we performed a retrospective CT study in healthy ankles to radiologically describe the normal anatomy of the DTFJ and the anatomical relationship of the fibula within the ankle joint. Materials and methods For this study, we retrospectively examined 60 CT scans of healthy, non-injured ankles in a plantigrade position. Patients with prior ankle surgery or systemic diseases with ankle involvement were excluded because we needed to describe the normal anatomy of the joint. The radiological evaluation included the position of the fibula in the fibular notch and the rotational relationship of the fibula with the talus and the medial malleolus. Results Our study included 60 healthy ankles. Thirty-three were right ankles, and 27 were left. The cohort included 36 females and 24 males with a mean age of 48.3 years old. We found that the fibular notch was retroverted on the transverse plane, with the tibiofibular engagement being 0.11 mm (SD=1.57 mm, SE=0.2 mm), at 1 cm proximally to the tibial plafond. Additionally, we observed that the fibula was internally rotated against the lateral talar facet, while the medial and lateral malleolus facets were externally rotated in between. Moreover, we found a strong positive correlation between the incisura retroversion and fibular engagement at 1 cm above the tibial plafond line (Pearson correlation=0.273, p=0.03). Conclusion Our study highlights the importance of gaining a comprehensive understanding of the inherent anatomy of the DTFJ to achieve reduction goals in ankle fractures. According to our results, in ankle fracture treatment, surgeons should aim for anatomical fracture and syndesmotic fixation, with the fibula in internal rotation against the lateral talar facet. Additionally, as normal tibiofibular engagement is borderline, we do not suggest that over-tightening the syndesmotic screws is essential. This study's findings can aid surgeons in reducing the malreduction rates in patients with ankle fractures.

Ankle arthroscopy does not elevate complication rates in ankle fractures.

INTRODUCTION: Ankle fractures rank as the second most common lower limb fractures, and surgical intervention is essential for unstable ankle fractures. The use of ankle arthroscopy in such cases offers several advantages. This study aim is to assess whether arthroscopy influenced on complication rates in 171 ankle fractures treated with arthroscopic assistance. METHODS: This retrospective epidemiological analysis encompassed adult ankle fractures between December 2018 and December 2021. Initially, 173 patients were considered, but two were excluded, leaving a final sample of 171 patients. Postoperative complications were categorized as major or minor. RESULTS: The study included 171 patients with surgically treated ankle fractures assisted by arthroscopy, comprising 76 females and 95 males, with an average age of 41.9 years. Syndesmosis injuries were treated in all diagnosed cases (55.0%), and deltoid ligament injuries received attention when identified (33.7%). Arthroscopic techniques were preferred over open techniques (47.4%). Ten patients experienced complications, consisting of 2 major and 8 minor complications (5.8%). DISCUSSION: Our study's epidemiological findings align with prior literature, demonstrating that intra-articular injuries accompany 63% to 79% of ankle fractures. Arthroscopy allows for both diagnosis and treatment within the same procedure, including joint lavage to reduce inflammation. We diagnosed 57 deltoid injuries and identified a statistical relationship between chondral, syndesmotic, and deltoid ligament injuries. Infection is a common complication in ankle fracture surgery, with rates ranging from 1.44% to 16%. Our study yielded a 5.8% complication rate, comprising 1.2% major and 4.6% minor complications. Patients undergoing ORIF with arthroscopic assistance had a lower prevalence of infection. CONCLUSION: The use of arthroscopic assistance in the surgical treatment of ankle fractures does not increase the overall complication rate. LEVEL OF EVIDENCE: IV.

Arthroscopic assisted percutaneous fixation in ankle pilon fracture: A case report.

INTRODUCTION: Results of operative fixation for ankle fractures had been suboptimal, with cases of posttraumatic osteoarthritis occurring following the surgeries. Intra-articular injuries have been suggested as the cause of this problem. This case report aims to present an ankle pilon fracture Ruedi Allgower type II case treated with percutaneous fixation and arthroscopy evaluation. PRESENTATION OF CASE: Female, 17 years old, complained of pain and swelling at the right ankle. The physical examination revealed swelling, deformity, tenderness, and limited range of motion at the right ankle. The radiological examination showed a Ruedi Allgower type II pilon fracture with right ankle dislocation. The patient underwent closed reduction, arthroscopy to evaluate her right ankle and percutaneous internal fixation. The post-surgery evaluation showed a stable ankle. DISCUSSION: Patients undergoing ankle fracture surgery may benefit from ankle arthroscopy because it may increase visualization of articular reductions, assess and repair cartilage and ligament damage, remove loose bodies, decrease soft tissue exposure, preservative vascularity, and evaluate syndesmosis. Moreover, rapid arthroscopic evaluation has a low complication rate. The ability of arthroscopy to improve syndesmotic instability diagnosis suggests that arthroscopy may play a significant role in managing ankle fractures. CONCLUSION: Arthroscopy-assisted internal fixation provides more benefits and information as a single case report, and more studies are warranted; regarding patients' intra-articular injuries, preventing future complications, such as posttraumatic osteoarthritis.

Cost analysis and clinical outcomes of anatomic pre-contoured locking versus conventional plates for distal fibula ankle fractures.

PURPOSE: To analyze differences in union, complication rates and cost from surgical fixation of distal fibula fractures with fibular plating implants. METHODS: In total, 380 adult patients from 2012 to 2015 treated with 12 fibular plates from 4 different manufacturers utilized by 9 surgeons were retrospectively reviewed. They were stratified into a conventional one-third tubular fibular plate group, pre-contoured anatomic locking plate group, or a heterogeneous group including 3.5-mm reconstruction, one-third tubular locking, composite, and limited compression plates. The outcomes included failure of fixation, deep infection requiring debridement, time to union, anatomic reduction, superficial infection, hardware removal, and post-traumatic arthritis. Plate and screw costs were calculated from hospital billing records. RESULTS: Pre-contoured locking plates were used in older, female patients with a greater number of comorbidities. Open injuries and OTA 44B fractures were more likely to be an indication for pre-contoured plates. There was no difference noted in time to union between the different plating groups. Risk factors for deep infection requiring debridement included a history of tobacco use, open fractures, and pre-contoured locking plates relative to the conventional plating group. The pre-contoured plating group was on average $586 more expensive compared to the conventional group. CONCLUSION: Pre-contoured locking plates achieved similar radiographic outcomes compared to conventional plates with an increased risk of complications and higher cost. Surgeons should consider their choice of implant based on the patient's fracture pattern, underlying comorbidities, and risk for infection.

Results of prophylactic simple fasciocutaneous advancement in the initial management of acute ankle fractures with high risk of operative wound complication.

Ankle fracture is the third most prevalent fracture in older adults. Wound dehiscence is the most frequent complication. Our objective is to determine the operative wound complication rate in patients with unstable ankle fracture in whom a prophylactic simple fasciocutaneous advancement was used. METHODS: Prospective registry of patients with unstable ankle fracture, in whom a prophylactic fasciocutaneous advancement was performed between August 2020 and July 2021. Demographic variables, time spent in performing the flap, cost of osteosynthesis, minor and major complications of the surgical wound, readmission or reoperation were registered. RESULTS: 42 older adults with ankle fracture were included. Median age 69 (60-94). 31% diabetics and 21.5% active smokers. A 40% trimalleolar fracture pattern. There were 7% of superficial complications of the surgical wound. No major complications, no reoperations. CONCLUSIONS: Prophylactic fasciocutaneous advancement at the beginning of traumatological surgery is technically simple, reproducible, cheap and with low complications. LEVEL OF EVIDENCE: Level IV, cross-sectional study.

Safety of early weightbearing after ankle fracture fixation.

PURPOSE: Patients with surgically treated ankle fractures are traditionally kept non-weightbearing for at least six weeks post-operatively; however, recent literature suggests numerous benefits of early weightbearing (EWB) before six weeks without significantly impacting long-term outcomes. This study aims to review the safety of early vs late weightbearing following ankle fracture fixation by assessing the complication rate. METHODS: This was a single-centre retrospective study. Between 2020 and 2023, all ankle fixations that commenced weightbearing at two weeks were added to the EWB group. An equal number of similar patients with six-week non-weightbearing were added to the late weightbearing (LWB) group. Baseline characteristics, risk factors, types of fractures and any complications in the six-month post-operative period were evaluated from these cohorts. RESULTS: In total, 459 ankle fixations were identified of which 87 patients met the criteria for the EWB group, with a further 87 added to the LWB group. There was no significant difference in age between the two groups (51.7 ± 20.1 vs 51.0 ± 15.5, respectively; p = 0.81), but more female patients and diabetics in the EWB group. Fracture types were similar between both cohorts (p = 0.51). Complication rate in the EWB group was not significantly different to the LWB group (5 vs 9, p > 0.05). CONCLUSION: No increase in complication rate was identified by commencing weightbearing early at two weeks after ankle fixation compared to six weeks. We therefore suggest EWB if appropriate, given its associated benefits including restoration of patient independence and improved quality of life. LEVEL OF EVIDENCE: Therapeutic, Level IV.

The Impact of the COVID-19 Pandemic and Lockdown on Adult Foot and Ankle Fractures Presenting to the Largest Trust in the United Kingdom.

Background The COVID-19 pandemic induced unprecedented changes in medical practices, prompting a reassessment of their impact on adult foot and ankle fractures within the National Health Service (NHS). This study employs a retrospective observational approach, leveraging the Pathpoint™ eTrauma platform for a comprehensive analysis of prospectively collected data. Methods Data encompassing weekly fracture incidence, weekly surgical procedures, patient demographics, and mean wait time from injury presentation to surgery were systematically evaluated. The study population included all adults (18+) admitted during five distinct periods: pre-pandemic, national lockdown 1, post-lockdown, national lockdown 2, and national lockdown 3. Results An analysis of 434 foot and ankle fractures revealed that national lockdown 1 exhibited the lowest fracture incidence (4.97 per week) and surgeries performed (4.77 per week), reflecting a notable reduction in trauma cases and elective procedures. Conversely, post-lockdown displayed the highest fracture incidence (7.46 per week) and surgeries performed (6.31 per week), suggesting a resurgence in both trauma and elective surgical activities. The pre-pandemic cohort, characterized by the highest mean age (51.98 years) and mean wait time (8.74 days), served as a temporal baseline. Conclusion While the incidence of fractures decreased during all three national lockdowns compared to pre-pandemic or post-lockdown periods, a gradual increase was observed in subsequent lockdowns. Notably, mean wait times showed a significant reduction, reaching the lowest point (5.79 days) during national lockdown 3. These findings underscore the complex interplay between pandemic-related disruptions, evolving guidelines, and adaptive measures within the healthcare system, influencing the dynamics of foot and ankle fracture management.

Correlation between Ankle Imaging Findings and Self-Reported Outcomes: A Longitudinal Assessment in Patients with Tibiofibular Diastasis.

BACKGROUND AND OBJECTIVES: This longitudinal study investigated the correlation between imaging findings and self-reported questionnaire outcomes in patients with tibiofibular diastasis, exploring the effects of surgical screw removal versus conservative treatment. This study was conducted at "Victor Babes" University of Medicine and Pharmacy in Timisoara between 2018 and 2023. MATERIALS AND METHODS: The study involved 85 patients in the screw removal group and 44 in the conservative group, assessed at 2 and 6 months post-surgery, answering the SF-36, HADS, and WHOQOL questionnaires. RESULTS: Significant differences were observed at 2 months post-surgery, with the screw removal group showing lower shear wave velocities in ankle dorsiflexion (8.9 ± 1.4) and anterior talofibular ligament (2.8 ± 0.9), indicating better mobility compared to the conservative group (ankle dorsiflexion: 10.1 ± 1.8, ATFL: 3.2 ± 1.1). Radiographically, lower tibiofibular overlap (8.1 ± 2.1) in the screw removal group suggested improved joint fixation quality. These physical improvements were mirrored in the quality-of-life assessments, where the screw removal group reported higher physical health scores on the SF-36 survey at 2 months, a trend that continued at 6 months. At 2 months, ankle dorsiflexion demonstrated a strong negative correlation with the SF-36 Physical score (r = -0.417) and WHOQOL Physical domain (r = -0.394), and a positive correlation with HADS Anxiety (r = 0.312). Similarly, ATFL and CFL velocities negatively correlated with the SF-36 Physical score (ATFL: r = -0.251; CFL: r = -0.237). Radiographic tibiofibular overlap and clear space positively correlated with WHOQOL Physical domain (TOL: r = 0.291; TCS: r = 0.276), with TCS also negatively correlating with HADS Anxiety (r = -0.228). At 6 months, these correlations persisted, with notable negative correlations between ultrasound ankle dorsiflexion and both SF-36 Physical score and WHOQOL Physical domain. CONCLUSIONS: These findings underscore the advantages of screw removal in enhancing physical recovery and reducing anxiety in the short term, while indicating similar long-term mental health outcomes between treatment approaches.

Assessing the content validity of the Manchester-Oxford Foot Questionnaire in surgically treated ankle fracture patients: a qualitative study.

BACKGROUND: Roughly 10% of fractures in adults are ankle fractures. These injuries are found in both sexes and present with different fracture characteristics. The treatment varies with the patients' biology and fracture type, and the goals are to restore stability, prevent pain and maintain ankle function. Clinicians generally use outcomes like assessment of radiography, pain level, or function. The use of patient-reported outcome measures is increasing, and the Manchester-Oxford Foot Questionnaire (MOXFQ) has been shown to have good measurement properties when validated in patients with foot and ankle disorders. However, the instrument has not been validated for ankle fracture patients. This study aims to assess the content validity of the items in MOXFQ in surgically treated ankle fracture patients. METHODS: A qualitative deductive design was used to investigate patients' response process of the MOXFQ. Individual interviews were conducted using cognitive interviewing based on the theoretical framework of the 4-step model by Tourangeau. Adult patients that were surgically treated for an ankle fracture between four weeks and 18 months were purposively sampled, and interviews followed a semi-structured interview guide. The predetermined categories were comprehension, retrieval, judgement, and response. RESULTS: Seventeen respondents (65% females) were interviewed. Respondents' age ranged from 27 to 76 years. Some of the respondents in the early recovery phase were limited by post-operative restrictions and did not find the items in the walking/standing domain relevant. Respondents that were allowed weight-bearing as tolerated (WBAT) were able to recall relevant information for most items. Respondents with time since surgery more than 12 months had less pain and remembered fewer relevant episodes in the recall period. Items in the social interaction domain contained ambiguous questions and were generally considered less important by respondents. The summary index score lacked important concepts in measuring overall quality of life. CONCLUSIONS: Pain was a central concept in the post-operative recovery of ankle fracture patients. The MOXFQ-subscales for pain and walking/standing had acceptable content validity in patients that were allowed WBAT. The social interaction-subscale and the summary index score had insufficient content validity for this patient population.

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.

Very early prescription of range of motion exercises in ankle fractures treated with ORIF does not increase the rate of complications and reoperations: A survival risk analysis.

BACKGROUND: Ankle fractures are commonly treated with non-surgical or surgical (preferably ORIF) approaches based on fracture characteristics. The postoperative care regimens vary widely, and the impact of very early mobilization on complications and reoperation rates in ankle fractures treated with ORIF remains unclear. METHODS: A retrospective analysis was conducted on ankle fractures treated between January 2014 and November 2020. Demographic and fracture characteristic data were collected. Very early prescription of range of motion exercises was defined as initiation within the first week after surgery, typically between the second and seventh postoperative day. Complications, reoperations, and time to these events were analyzed. Kaplan Meier survival analysis was performed to assess the risk of complications with very early mobilization. RESULTS: A total of 299 patients met the inclusion criteria. The cohort included 83 unimalleolar, 77 bimalleolar, and 138 trimalleolar fractures. Of the patients, 116 (38.8%) underwent very early range of motion. Complications occurred in 45 events among 39 patients (13%), with 16 events (41%) in the very early range of motion group. Reoperations were required for 23 patients (3.67% of the cohort). No statistically significant differences were found in the analysis of complications, with a hazard ratio (HR) of 1.17, and in the adjusted analysis with an HR of 1.12. Similarly, the reoperation analysis showed no significant differences, with an HR of 0.85 and 0.68 in the adjusted analysis. CONCLUSION: Very early prescription of range of motion exercises in ankle fractures treated with ORIF is a safe approach, as it does not increase the rates of complications or reoperations compared to early or late mobilization. This study supports the use of very early mobilization as a rehabilitation method for ankle fractures.