Maisonneuve fracture treated with short leg cast: A case report with 41-month follow-up.

RATIONALE: Maisonneuve fracture is a specific type of severe ankle injury. To our current knowledge, once a Maisonneuve fracture is diagnosed, the surgery is always recommended for fear of sequelae from inaccurate joint reconstruction. However, in this case, we treated a Maisonneuve fracture with a short leg cast, and the 41-month follow-up showed a favorable outcome with no post-traumatic osteoarthritis, chronic pain, and instability. Therefore, this case provides evidence for the feasibility of conservative treatment of Maisonneuve fracture. PATIENT CONCERNS: A female patient in her early twenties sprained her left ankle while running, suffering regional pain, swelling, and limited mobility. DIAGNOSES: We diagnosed a Maisonneuve fracture with superior fibular fracture and Volkmann tuberosity fracture, a slight separation of inferior tibiofibular syndesmosis (ITS). INTERVENTIONS: The patient rejected our surgical recommendations in favor of nonsurgical treatment, in addition to refusing immobilization of the knee. Consequently, we had to treat her with a short leg cast for 8 weeks and asked her to return for regular follow-up visits. OUTCOMES: At the final follow-up, the radiography showed complete healing of proximal fibula fracture. The patient reported no discernible subjective differences between her bilateral ankles. The range of motion of the left ankle was measured at 22° of dorsiflexion and 40° of plantarflexion. Functional assessments using Olerud-Molander ankle scale and American Orthopedic Foot and Ankle Society Ankle-Hindfoot scale both scored 100 points. Additionally, the radiographic assessment classified arthritis as stage 0 according to Morrey-Wiedeman classification. LESSONS: To avoid missing and misdiagnosing, the physical examination should always extend to 2 neighboring joints. Secondly, if a Maisonneuve fracture is suspected, further computed tomography scans, radiography, and magnetic resonance imaging can help to determine the stability of the ITS and the integrity of the lateral collateral ligaments before making therapeutic decisions. Finally, considering the lateral collateral ligaments may remain intact, we recommend stabilizing ITS by repairing the medial ligaments, which can be conducted arthroscopically and be more minimally invasive, providing an elastic fixation that aligns better with the biomechanics of the ITS which is characterized as a micro-mobile rather than fully fixed joint.

Reconstruction of the Medial Malleolus With Iliac Crest Autograft After Traumatic Loss: A Case Report.

CASE: A 19-year-old woman sustained an open ankle fracture with complete destruction of the left medial malleolus and significant soft-tissue loss. After temporizing external fixation and coverage with a rotational posterior tibial artery perforator flap, the medial malleolus was reconstructed with an autologous iliac crest bone graft and direct repair of the deltoid ligament. The patient achieved excellent improvement in functional outcomes at 21 months with adequate restoration of ankle motion. CONCLUSION: This case shows reconstruction of the medial malleolus with autologous iliac crest bone graft after traumatic loss can be a viable treatment option for young patients.

Probability of Occult Ankle Fracture Based on Radiograph-Measured Swelling.

INTRODUCTION: Pediatric ankle injuries are a common presentation in the emergency department (ED). A quarter of pediatric ankle fractures show no radiographic evidence of a fracture. Physicians often correlate non-weight bearing and tenderness with an occult fracture. We present this study to predict the probability of an occult fracture using radiographic soft-tissue swelling on initial ED radiographs. METHODS: This is a retrospective study at a Level 1 pediatric trauma center from 2021 to 22. Soft-tissue swelling between the lateral malleolus and skin was measured on radiographs, and weight-bearing status was documented. Statistical analysis was conducted using Stata software. DISCUSSION: The study period involved 32 patients with an occult fracture, with 8 (25%) diagnosed with a fracture on follow-up radiographs. The probability of an occult fracture was calculated as a function of the ankle swelling in millimeters (mm) using a computer-generated predictive model. False-negative and false-positive rates were plotted as a function of the degree of ankle swelling. CONCLUSION: Magnitude of ankle soft-tissue swelling as measured on initial ED radiographs is predictive of an occult fracture. Although weight-bearing status was not a sign of occult fracture, it improves the predictive accuracy of soft-tissue swelling.

Patients with more complex ankle fractures are associated with poorer patient-reported outcome: an observational study of 11,733 patients from the Swedish Fracture Register.

BACKGROUND AND PURPOSE: Patient-reported outcome measures (PROMs) following ankle fractures, including all fracture types, have not been reported. It is therefore unclear whether fracture morphology correlates with outcome. We aimed to analyze PROMs in patients with an ankle fracture in relation to the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) fracture classification using population-based register data from the Swedish Fracture Register (SFR). METHODS: All patients aged ≥ 18 years with an ankle fracture (AO/OTA 44A1-C3) registered in the SFR between 2012 and 2019 were retrieved from the register. Patients with completed PROM questionnaires (Short Musculoskeletal Function Assessment and EuroQol-Visual Analogue Scale) on both day 0 (pre-trauma) and 1-year post-trauma were included. The difference in PROMs between day 0 and 1 year was calculated for each patient (delta value) and mean delta values were calculated at group level, based on the AO/OTA fracture classification. RESULTS: 11,733 patients with 11,751 fractures with complete PROMs were included. According to the AO/OTA classification, 21% were A fractures, 67% were B fractures and 12% were C fractures. All groups of patients, regardless of fracture class (A1-C3), displayed an impairment in PROMs after 1 year compared with day 0. Type C fractures displayed a larger impairment in PROMs at group level than type B, which in turn had a greater impairment than type A. The same pattern was seen in groups 3, 2, and 1 for A and B fractures. CONCLUSION: We found that the AO/OTA classification is prognostic, where more complex fractures were associated with poorer PROMs.

Impact of Geko Neuromuscular Stimulator on Preoperative Preparation in Ankle Fractures.

OBJECTIVE: To explore the impact of the Geko neuromuscular stimulator on preoperative preparation in patients with ankle fractures. STUDY DESIGN: Quasi-experiment study. Place and Duration of the Study: Department of Foot and Ankle Surgery and Department of Orthopaedics, Beijing Tongren Hospital, Capital Medical University, Beijing, China, between December 2020 and 2021. METHODOLOGY: This quasi-experiment study included patients with ankle fractures treated with Geko neuromuscular stimulator before surgical fixation. The primary outcome was limb swelling at 24, 48, and 72 hours (h) after admission, and the secondary outcomes were pain according to visual analogue scale (VAS) at 12, 24, and 48 hours after admission, preoperative waiting time, and comfort 4 and 72 h after admission. RESULTS: A total of 60 patients were included in the study; 30 in the conventional treatment group (mean age 41.16 ± 2.01 years) and 30 in the Geko group (mean age 40.22 ± 2.68 years). The limb swelling in patients was significantly different between the Geko and conventional treatment groups (p = 0.004). Besides, the swelling values at 48 (p < 0.001) and 72 (p < 0.001) hours were significantly lower than those at 24 hours. The pain in patients was significantly different between the Geko and conventional treatment groups (p = 0.007). Besides, the swelling values at 24 (p < 0.001) and 48 (p < 0.001) hours are significantly lower than those at 24 hours. Comfort was significantly higher at 4 h (69.54 ± 2.18 vs. 67.22 ± 3.14, p = 0.002) and 72 h [(88.50 (84.00 - 94.00) vs. 82.14 ± 3.08, p < 0.001)] after admission. The preoperative waiting time (3.52 ± 1.8 vs. 5.15 ± 2.1 hours, p = 0.002) was significantly shorter in the Geko group. CONCLUSION: The Geko neuromuscular stimulator is a useful option for preoperative preparation in patients with ankle fractures to reduce local swelling and pain and improve patients' comfort. KEY WORDS: Ankle fractures, Lower extremity, Neuromuscular stimulator, Peroneal nerve, Pain.

[Effectiveness comparison of a new hook-shaped anatomical locking plate and conventional anatomical locking plate in treatment of Danis-Weber type A lateral malleolus fractures].

Objective: To investigate the effectiveness of a new hook-shaped anatomical locking plate in the treatment of Danis-Weber type A lateral malleolus fractures. Methods: A retrospective analysis was performed on the clinical data of 45 patients with Danis-Weber type A lateral malleolus fractures who met the selection criteria between November 2020 and November 2022. According to the surgical methods, they were divided into the observation group (treated with the new hook-shaped anatomical locking plate, 23 cases) and the control group (treated with the conventional lateral malleolus anatomical locking plate, 22 cases). There was no significant difference in baseline data such as gender, age, cause of injury, Danis-Weber type of fracture, time from injury to operation, and combined ligament injury between the two groups ( P>0.05). The operation time, partial weight-bearing time, return to work time, and postoperative complications were recorded and compared between the two groups. The function and pain of ankle joint were evaluated by the range of motion of ankle dorsiflexion, plantarflexion, varus, valgus, and visual analogue scale (VAS) score at 1 and 3 months after operation, and at last follow-up, and the American Orthopaedic Foot and Ankle Society (AOFAS) score at 3 months after operation and at last follow-up. Results: All patients were followed up 10-18 months (mean, 15.1 months). There was no significant difference in operation time between the two groups ( P>0.05); the postoperative partial weight-bearing time and return to work time of the observation group were significantly earlier than those of the control group ( P<0.05). During the follow-up, there was 1 case of joint stiffness in the observation group, and 1 case of joint surface displacement, 1 case of joint stiffness, and 1 case of traumatic arthritis in the control group. There was no significant difference in the incidences of complications between the two groups ( P>0.05). With the extension of time after operation, the range of motion of ankle dorsiflexion, plantarflexion, varus, valgus, and VAS score of the two groups gradually improved, and there were significant differences between different time points ( P<0.05); At 1 and 3 months after operation, the above indexes in the observation group were significantly better than those in the control group ( P<0.05), and there was no significant difference between the two groups at last follow-up ( P>0.05). The difference of AOFAS score between the last follow-up and 3 months after operation in the observation group was significantly better than that in the control group ( P<0.05). Conclusion: Compared with the conventional lateral malleolus anatomical locking plate, the new hook-shaped anatomical locking plate has a more reliable fixation effect in the treatment of Danis-Weber type A lateral malleolus fracture, which is conducive to early functional exercise of the ankle joint, so that patients can bear weight earlier and return to work earlier, and the operation time is not significantly prolonged, and the effectiveness is satisfactory.

Percutaneous intramedullary screw or rush pin fixation of unstable ankle fractures in patients with fragile soft tissue - retrospective study of 80 cases.

INTRODUCTION: The standard surgical procedure for unstable ankle fractures is fixation of the lateral malleolus with a plate and screws. This method has a high risk of complications, especially among patients with fragile skin conditions. The aim of this study was to estimate the re-operation rates and identify complications in patients with an unstable ankle fracture, surgically treated with an intramedullary screw or rush pin. MATERIALS AND METHODS: We identified all patients who were surgically treated with either a 3.5-mm screw or rush pin at Aarhus University Hospital, Denmark, from 2012 to 2018. Major complications were re-operations within three months. We included 80 patients, of which 55 (69%) were treated with a 3.5-mm intramedullary screw and 25 (31%) with a rush pin. The majority of the study population was female (59) and the mean age was 75 (range 24 to 100) years. Of the 80 patients included, 41 patients had more than 2 comorbidities. RESULTS: Three patients underwent re-operation within three months due to either fracture displacement or hardware cutout. Radiographs obtained after six weeks showed that nine patients had loss of reduction. Additionally, four patients had superficial wound infections and six patients had delayed wound healing. CONCLUSIONS: Intramedullary fixation of distal fibula fractures with either a screw or rush pin has low re-operation rates. However, the high proportion of patients with radiological loss of reduction is concerning.

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.

Epidemiology and Characteristics of Ankle and Foot Injuries in Electric Scooter-Related Accidents.

Background: The use of electric scooters (e-scooters) continues to increase as a simple, inexpensive means of transport, resulting in a sharp increase in the incidence of scooter-related accidents. No study to date has closely examined the injury extent to the lower leg, joints, and extremities from e-scooter-related accidents. Here, we investigated the epidemiology and injury patterns of such accidents, focusing on injuries to the ankle and foot. Methods: Based on data from a single tertiary hospital's database, the demographics of 563 patients with scooter-associated injuries were analyzed retrospectively. Among the patients, 229 patients who were injured by e-scooter riding were further investigated. Based on the data, the general demographics of whole scooter-associated injuries and the injury characteristics and fracture cases of the lower leg, ankle, and foot were analyzed. Results: During the 4-year study period, the number of patients injured by e-scooters increased every year. Lower extremities were the most common injury site (67.2%) among riders, whereas injuries to the head and neck (64.3%) were more common in riders of non-electric scooters. Among the lower leg, ankle, and foot injuries of riders (52 cases), the ankle joint (53.8%) was the most commonly injured site, followed by the foot (40.4%) and lower leg (21.2%). The fracture group scored significantly higher on the Abbreviated Injury Scale than the non-fracture group (p < 0.001). Among the fracture group (20 cases), ankle fractures (9 cases) were most common, including pronation external rotation type 4 injuries (4 cases) and pilon fractures (2 cases). Five patients (25%) had open fractures, and 12 patients (60%) underwent surgical treatment. Conclusions: The ankle and foot are the most common injury sites in e-scooter-related accidents. Given the high frequency and severity of e-scooter-related ankle and foot injuries, we suggest that more attention be paid to preventing these types of injuries with greater public awareness of the dangers of using e-scooters.

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.

Study on the risk factors of postoperative wound complications in patients with ankle fracture.

Wound complications after surgery for ankle fractures can lead to catastrophic consequences. The purpose of this study was to evaluate the risk factors of postoperative wound complications in patients with ankle fracture and to determine their effects on prognosis. 200 patients with ankle fracture treated in our hospital from October 2021 to December 2023 were analysed retrospectively. The total incidence of postoperative wound complications was 19% (38/200). Type of complications: wound edge necrosis 15 cases (39.47%), dehiscence (reopening of wound) 13 cases (34.21%), delayed healing (>30 days) 10 cases (26.32%); Univariate analysis showed that patients' age, body mass index (BMI), current smoking, alcoholism, diabetes mellitus, injury mechanism, open fracture, wound classification, higher American Society of Anesthesiologists (ASA) score and operation time were all associated with postoperative wound complications. Multivariate Logistic regression model shows: age ≥60 years old OR3.671 (1.875-5.937), BMI OR1.198 (1.143-1.324), current smoking OR2.727 (1.251-5.602), alcoholism OR1.143 (1.034-1.267), complicated with diabetes OR2.763 (1.236-4.852), injury mechanism (high vs. low and medium energy) OR2.437 (1.238-4.786), open fracture OR1.943 (1.8262.139), wound classification (II vs. I) OR4.423 (1.73511.674), ASA score (III-IV vs. I-II) OR1.307 (1.113-2.194) was an independent risk factor for postoperative wound complications in patients with ankle fracture. Further, ROC curves showed that these nine independent influences had high accuracy and validity in predicting postoperative wound complications in patients with ankle fractures. In conclusion, independent risk factors for postoperative complications of ankle fracture were age >60 years, BMI, injury mechanism, open fracture, wound classification (II vs. I), ASA score, current smoking, and alcoholism. The wound classification (II vs. I) has the highest diagnostic value.

The effect of early weight-bearing and later weight-bearing rehabilitation interventions on outcomes after ankle fracture surgery: A systematic review and meta-analysis of randomised controlled trials.

OBJECTIVE: This systematic review aimed to analyse the effect of early weight bearing versus late weight bearing on rehabilitation outcomes after ankle fractures, which primarily include ankle function scores, time to return to work/daily life and complication rates. METHODS: The China National Knowledge Infrastructure, Wanfang Data Knowledge Service Platform, China Science and Technology Journal, Web of Science, PubMed, Embase and Cochrane Library databases were searched. The focus was on identifying randomised controlled trials centred on early weight-bearing interventions for post-operative ankle fracture rehabilitation. All databases were searched for eligible studies published within the period from database inception to 20 June 2023. The eligible studies were screened according to the inclusion criteria. Study quality was evaluated using the methodology recommended by the Cochrane Handbook for the Systematic Evaluation of Interventions. Two authors independently performed the literature search and data extraction. Eligible studies were subjected to meta-analyses using Review Manager 5.3. Based on the time points at which post-operative ankle function was reported in the studies included in this paper, we decided to perform a meta-analysis of ankle function scores at 6 weeks post-operatively, 12 weeks post-operatively, 24-26 weeks post-operatively and 1 year post-operatively. RESULTS: A total of 11 papers, comprising 862 patients, were included. Meta-analysis indicated that patients receiving early weight-bearing interventions, which referred to weight-bearing for 6 weeks post-operatively, experienced enhancements in ankle function scores (Olerud-Molander score, AOFAS score or Baird-Jackson score) at various post-operative milestones: 6 weeks (SMD = 0.69, 95% CI: 0.49-0.88 and p < 0.01), 12 weeks (SMD = 0.57, 95% CI: 0.22-0.92 and p < 0.01) and the 24-26 weeks range (SMD = 0.52, 95% CI: 0.20-0.85 and p < 0.01). The results of subgroup analyses revealed that the effects of early weight-bearing interventions were influenced by ankle range-of-motion exercises. Additionally, early weight bearing allows patients to return to daily life and work earlier, which was evaluated by time when they resumed their preinjury activities (MD = -2.74, 95% CI: -3.46 to -2.02 and p < 0.01), with no distinct elevation in the incidence of complications (RR = 1.49, 95% CI: 0.85-2.61 and p > 0.05). CONCLUSION: The results showed that early weight bearing is effective in improving ankle function among post-operative ankle fracture patients and allows patients to return to daily life earlier. Significantly, the safety profile of early weight bearing remains favourable, with no higher risk of complications than late weight bearing.

Management of Pediatric Supination-inversion Ankle Injuries Involving Distal Tibia and Intraepiphyseal Distal Fibula Fractures.

Pediatric ankle fractures are prevalent injuries that make up a notable portion of all periphyseal injuries. The Salter-Harris classification is the most popular classification about physeal and periepiphyseal injuries. Ogden expanded on this and described type 7 fractures which are completely intraepiphyseal and include propagation of the fracture from the articular surface through the epiphyseal cartilage and do not involve the physis. These injuries are common about the distal fibula in pediatric patients with supination-inversion type injuries. There are no specific guidelines or recommendations on treatment of these injuries in the literature. We present three cases of this injury pattern and describe our chosen management that leads each patient to full, painless ankle range of motion and return to all prior activities and sports without complication. Supination-inversion type pediatric ankle fractures are common injuries that all orthopaedic surgeons will encounter at some point throughout their practice or training. Recognizing fracture variants and understanding treatment options of pediatric ankle fractures are important for the orthopaedic community as a whole.

Talar Neck Fractures With Associated Ipsilateral Foot and Ankle Fractures Have a Higher Risk of Avascular Necrosis.

OBJECTIVES: To determine if talar neck fractures with concomitant ipsilateral foot and/or ankle fractures (TNIFAFs) are associated with higher rates of avascular necrosis (AVN) compared with isolated talar neck fractures (ITNs). DESIGN: Retrospective cohort. SETTING: Single level I trauma center. PATIENT SELECTION CRITERIA: Skeletally mature patients who sustained talar neck fractures from January 2008 to January 2017 with at least 6-month follow-up. Based on radiographs at the time of injury, fractures were classified as ITN or TNIFAF and by Hawkins classification. OUTCOME MEASURES AND COMPARISONS: The primary outcome was the development of AVN based on follow-up radiographs, with secondary outcomes including nonunion and collapse. RESULTS: There were 115 patients who sustained talar neck fractures, with 63 (55%) in the ITN group and 52 (45%) in the TNIFAF group. In total, 63 patients (54.7%) were female with the mean age of 39 years (range, 17-85), and 111 fractures (96.5%) occurred secondary to high-energy mechanisms of injury. There were no significant differences in demographic or clinical characteristics between groups ( P > 0.05). Twenty-four patients (46%) developed AVN in the TNIFAF group compared with 19 patients (30%) in the ITN group ( P = 0.078). After adjusting for Hawkins classification and other variables, the odds of developing AVN was higher in the TNIFAF group compared with the ITN group [odds ratio, 2.43 (95% confidence interval, 1.01-5.84); ( P = 0.047)]. CONCLUSIONS: This study found a significantly higher likelihood of AVN in patients with talar neck fractures with concomitant ipsilateral foot and/or ankle fractures compared to those with isolated talar neck fractures after adjusting for Hawkins classification and other potential prognostic confounders. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Relationship Between Intra-articular Fracture Energy and a Patient's Inflammatory Response.

OBJECTIVES: Prior studies have demonstrated elevated inflammatory cytokine concentrations in the synovial fluid of articular fracture patients postinjury. Similarly, CT-based fracture energy measurements have been correlated with posttraumatic osteoarthritis risk after pilon fracture. The purpose of this study was to determine the associations between synovial fluid cytokine levels, fracture energy, and overall trauma to the body in articular fracture patients. METHODS: Acute tibial plateau, tibial plafond, and rotational ankle fracture patients were prospectively enrolled from December 2011 through January 1, 2019. Synovial fluid concentrations of interleukin-1 beta, interleukin-1 receptor antagonist, IL-6, IL-8, IL-10, matrix metallopeptidase-1, MMP-3, and MMP-13 were quantified. Patient CT scans were used to calculate fracture energy. The Injury Severity Score (ISS) was used to relate cytokine levels to whole-body injury severity. Spearman rho correlation coefficients were calculated to assess the relationship between injury severity metrics and synovial fluid cytokine, chemokine, and matrix metallopeptidase concentrations. RESULTS: Eighty-seven patients were enrolled with 42 had a tibial plateau fractures (OTA/AO 41B1-2, 41B2-14, 41B3-3, 41C1-3, 41C2-4, 41C3-16), 24 patients had a tibial plafond fracture (OTA/AO 43B1-2, 43B2-4, 43B3-5, 43C1-2, 43C2-3, 43C3-8), and 21 had a rotational ankle fracture (OTA/AO 44B1-3, 44B2-3, 44B3-6, 44C1-4, 44C2-5). Fracture energy significantly differed between fracture patterns, with ankle fractures involving substantially less fracture energy (median = 2.92 J) than plafond (10.85 J, P < 0.001) and plateau fractures (13.05 J, P < 0.001). After adjustment for multiple comparisons, MMP-3 was significantly correlated with transformed fracture energy (r = 0.41, 95% confidence interval [CI], 0.22-0.58, P < 0.001), while IL-1ß was significantly correlated with the Injury Severity Score (Spearman ρ = 0.31, 95% CI, 0.08-0.49, P = 0.004). CONCLUSIONS: Synovial fluid MMP-3 concentration was significantly correlated with CT-quantified fracture energy in intra-articular fracture patients. Given that in clinical practice fracture energy tends to correlate with posttraumatic osteoarthritis risk, MMP-3 may warrant further investigation for its role in posttraumatic osteoarthritis development after articular fracture. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Three-dimensional Mapping Analysis of Talus Fractures and Demonstration of Different Surgical Approaches for Talus Fractures.

OBJECTIVE: The talus is an important component in the ankle, and its treatment after injury is crucial. However, complications and adverse events due to incomplete traditional classifications may still occur, and these classifications fail to analyze the patterns and distribution of fractures from a three-dimensional perspective. Therefore, in this study, we aimed to analyze the location and distribution of fracture lines in different types of talus fractures using three-dimensional (3D) and heat mapping techniques. Additionally, we aimed to determine the surface area of the talus that can be utilized for different approaches of internal fixation, aiding in the planning of surgical procedures. METHODS: We retrospectively analyzed data from CT scans from 126 patients diagnosed with talus fractures at our two hospitals. We extracted the CT data of a healthy adult and created a standard talus model. We performed 3D reconstruction using patients' CT images and superimposed the fracture model onto the standard model for drawing fracture lines. Subsequently, we converted the fracture lines into a heat map for visualization. Additionally, we measured 20 specimens to determine the boundary for various ligaments attached to the talus. We determined the surface area of the talus available for different surgical approaches by integrating the boundary data with previously reported data on area of exposure. RESULTS: Without considering the displacement distance of the fracture, fracture types were classified as follows, by combining Hawkins and Sneppen classifications: talar neck, 41.3%; posterior talar tubercle, 22.2%; body for the talus and comminuted, 17.5%; lateral talar tubercle, 11.9%; and talar head, 7.1%. We established fracture line and heat maps using this classification. Additionally, we demonstrated the available area for anteromedial, anterolateral, posteromedial, posterolateral, and medial malleolus osteotomy and Chaput osteotomy approaches. CONCLUSION: Fracture line and heat map analyses can aid surgeons in planning a single or combined surgical approach for the reduction and internal fixation of talus fractures. Demonstrating the different surgical approaches can help surgeons choose the most effective technique for individual cases.

Temporary Cast Application in Dislocated Ankle Fractures Leads to High Rates of Secondary Loss of Reduction: Does the Lauge-Hansen Injury Type Matter?

BACKGROUND: For the temporary treatment of ankle fracture dislocations (AFDs), previous studies indicate higher rates of secondary loss of reduction (LOR) with splint immobilization, prompting consideration for expanding indications for external fixation (ExFix). However, these studies did not investigate the influence of fracture morphology to further improve patient selection. The aim of this study was to investigate the influence of Lauge-Hansen injury type on the LOR rate in bimalleolar or trimalleolar AFDs for temporary cast vs ExFix immobilization. METHODS: In this retrospective cohort study, patients with isolated AFD cases treated at our institution from 2011 to 2020 were reviewed. Inclusion criteria required radiographs depicting initial dislocation and appropriate reduction after Cast or ExFix immobilization. Exclusion criteria encompassed concomitant injuries, open fractures, conservative management as well as surgery performed within 48 hours or at a different facility. Patients were grouped by temporary treatment (Cast or ExFix). The primary endpoint was LOR prior to definitive surgery across various Lauge-Hansen types. RESULTS: The LOR rate was significantly higher in the cast group (40/152, 26.3%) compared to the ExFix group (5/191, 2.6%; P < .0001). In the cast group, LOR was associated with an increase in time to definitive surgery by a mean of 3 days (P < .002). During cast treatment, LOR was significantly more likely for pronation abduction (P = .001) and supination external rotation injuries (P < .0001), whereas no significant differences were observed for pronation external rotation (P = .006), supination adduction (P > .99), and fractures not classifiable (P > .99). CONCLUSION: In cases of AFDs resulting from supination external rotation or pronation abduction trauma according to the Lauge-Hansen classification, especially in the setting of an additional posterior malleolar fracture, primary application of external fixation should be considered to reduce the risk for secondary loss of reduction. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Preventing Surgical Site Infections in Geriatric Ankle Fracture Surgery with Closed-Incision Vacuum Therapy: A Pilot Study.

BACKGROUND: Ankle fractures are among the most common fractures in older adult patients that need surgical treatment. The risk of surgical site infections (SSIs) after ankle fracture surgery ranges between 0.5% and 30%; SSI incidence is higher among older adults. Further, SSIs have significant consequences for subjective functional outcomes and create a need for prolonged intravenous antibiotic therapy and wound care. Accordingly, it is critical to determine risk factors for and establish optimal postoperative wound care to prevent SSIs. OBJECTIVE: The aim of the pilot study was to examine the feasibility of closed-incision vacuum therapy (CIVT) to reduce rates of SSI in older adults. METHODS: The authors performed a pilot study of a CIVT system in a population of 10 older adult patients after ankle fracture surgery. RESULTS: Nine patients experienced uncomplicated wound healing of the lateral incision. One patient (10%) developed an SSI after premature removal of the vacuum system because of technical failure. Six weeks postoperation, overall satisfaction with the CIVT was high; none of the participants complained of incapacitating discomfort or disruptive limitations in postsurgical recovery. CONCLUSIONS: The authors conclude that CIVT is a feasible, safe, and generally well-tolerated therapy to prevent SSIs in postoperative wound healing after open reduction and internal fixation in older adult patients after ankle fracture.

[Influencing factors of traumatic arthritis after ankle fracture surgery and construction of risk prediction model].

OBJECTIVE: To explore risk factors of post-operative traumatic arthritis in patients with ankle fracture,and to establish risk prediction model. METHODS: Totally 550 patients with ankle fracture treated from May 2020 to May 2022 were selected as research objects and divided into modeling group (385 patients) and verification group (165 patients) according to 7:3. In modeling group,patients were classified as occurrence group (112 patients) and non-occurrence group (273 patients) according to whether traumatic arthritis occurred after opertaion. Age,body mass index(BMI),gender,smoking history,diabetes history,injury type,fracture type,operation time,manual labor,open injury,osteoporosis,poor reduction,postoperative weight-bearing time,vascular injury,and surgical method were recorded; risk factors of traumatic arthritis in ankle fracture patients were analyzed by single factor and multi factor logistic regression analyses; R software was used to build the prediction model of line graph;receiver operating characteristic (ROC) curve and calibration graph were applied to verify the discrimination and consistency of the model. RESULTS: One hundred and twelve of 385 patients with ankle fracture were developed to post-operative traumatic arthritis,and 275 did not. Univariate analysis showed that there were significant differences in age,BMI,fracture type,operation time,physical labor aboveⅡ,open injury,osteoporosis and poor reduction between two groups (P<0.05). Multivariate Logistic regression analysis showed that age (OR=2.887),BMI (OR=4.042),fracture type (OR=4.244),operation time (OR=2.665),physical labor above gradeⅡ(OR=5.099),osteoporosis (OR=10.219),and poor reduction (OR=3.112) were independent risk factors for traumatic arthritis after ankle fracture (P<0.05). Based on the above risk factors,an nomogram model was established to predict the risk of postoperative traumatic arthritis in ankle fracture patients,and internal and external verification was conducted. The results showed calibration curve of modeling group and verification group showed a good fit between correction curve and ideal curve,indicating that the predicted risk of postoperative traumatic arthritis by the model was basically consistent with actual risk. Area runder ROC curve analysis results showed 0.867[(95%CI(0.826,0.908)] and 0.882 [95%CI(0.827,0.938)],respectively,indicating that the prediction model had good prediction ability. CONCLUSION: Age,BMI,fracture type,operation time,physical labor above gradeⅡ,osteoporosis and poor reduction are all risk factors for post-operative traumatic arthritis in patients with ankle fracture. The prediction model based on the above risk factors could effectively evaluate risk of post-operative traumatic arthritis in patients with ankle fracture.

Wound infection and healing in minimally invasive plate osteosynthesis compared with intramedullary nail for distal tibial fractures: A meta-analysis.

To systematically explore the effects of minimally invasive plate osteosynthesis (MIPO) versus intramedullary nail (IMN) on wound infection and wound healing in patients with distal tibia fractures. A computerised search of PubMed, Web of Science, Cochrane Library, Embase, Wanfang, China Biomedical Literature Database (CBM) and China National Knowledge Infrastructure databases was performed, from their inception to October 2023, to identify relevant studies on the application of MIPO and IMN in patients with distal tibial fractures. The quality of the included literature was evaluated by two researchers based on inclusion and exclusion criteria, and basic information of the literature was collected, with wound infection, postoperative complications and wound healing time as the main indicators for analysis. Stata 17.0 software was applied for analysis. Overall, 23 papers and 2099 patients were included, including 1026 patients in the MIPO group and 1073 patients in the IMN group. The results revealed, when compared with IMN treatment, patients with distal tibia fractures who underwent MIPO treatment had a lower incidence of postoperative complications (OR = 0.33, 95% CI: 0.25-0.42, p < 0.001) and a shorter wound healing time (SMD = -1.00, 95% CI: -1.51 to -0.49, p < 0.001), but the incidence of postoperative wound infection was higher (OR = 2.01, 95% CI: 1.35-3.01, p = 0.001). Both MIPO and IMN are excellent treatments for distal tibia fractures. MIPO is effective in reducing the incidence of complications as well as shortening the time of wound healing time but increases the risk of wound infection. In clinical practice, surgeons can make individual choices based on the patient's wishes and proficiency in both techniques.