Comparison of complications of early and delayed open reduction and internal fixation for treating pilon fracture: A protocol of systematic review and meta-analysis.

BACKGROUND: Tibial Pilon fractures are severe fractures accompanied by soft tissue injury. Although open reduction and internal fixation (ORIF) are effective in treating Pilon fractures, there is a controversy over time to surgery due to reported postoperative complications. However, there is no systematic review evaluating the difference of postoperative complications between early and delayed ORIF for treating pilon fractures. METHODS: Relevant literature written in English will be searched through PubMed, Cochrane Library, Embase, MEDLINE, and Web of Science. The study aims to compare the effects and complications of early and delayed ORIF for treating fresh pilon fractures in adult patients. The primary outcome will be infection rate, fracture union time, nonunion and malunion rate. And the secondary outcome will be metalwork removal, amputation, and ankle function grade. Two reviewers will independently assess the eligibility of the studies according to the pre-defined inclusion and exclusion criteria. A meta-analysis for the available data will be conducted using Revman 5.3. To measure effect size, odds ratios (ORs) and mean difference will be used for dichotomous and continuous data, respectively. Statistical heterogeneity will be explored. And a random-effects model or a fixed-effects will be used in pooled data on the basis of the existence or absence of heterogeneity. Subgroup analysis will be conducted to identify sources of heterogeneity and sensitivity analysis to test the results' robustness. We will assess the risk of bias by four different quality assessment tools according to the study design. Publication bias will be evaluated by funnel plot. The study data will be stored in the Open Science Framework website. PROSPERO REGISTRATION NUMBER: CRD42020207465.

Effect of Early Weight Bearing on Outcomes After Open Reduction and Internal Fixation of Trimalleolar Ankle Fractures.

Current practice allows early weight bearing of unstable ankle fractures after fixation. This study offers a unique comparison of early weight bearing (EWB) vs late weight bearing (LWB) in operatively stabilized trimalleolar ankle fractures. The goal of this study was to evaluate union rates, clinical outcomes, and complications for patients who were managed with EWB vs LWB. The authors performed a retrospective review of 185 patients who underwent surgical stabilization for trimalleolar ankle fracture. Fixation of the posterior malleolus and weight bearing status were determined by surgeon preference. For this study, EWB was defined as 3 weeks or less and LWB was defined as greater than 3 weeks. Patients were evaluated for fracture union and implant failure. Complications and clinical outcomes included ambulatory status, infection rate, and return to surgery. The EWB group included 47 (25.4%) patients, and the LWB group included 138 (74.6%) patients. Of the 7 nonunions, 1 (14.3%) occurred in the EWB group and 6 (85.7%) in the LWB group. A total of 72 (38.9%) posterior malleolar fractures were operatively stabilized, and stabilization did not affect union rates. Syndesmotic fixation was required for 12.5% of patients, despite posterior malleolar stabilization. Syndesmotic fixation increased the union rate 2.5 times. Deep infection and open fracture decreased union. No difference was seen between groups in implant failure, union rate, infection, or return to the operating room. No deleterious effect of EWB in operatively treated trimalleolar ankle fractures was found for union, implant failure, infection, or reoperation. Syndesmotic fixation may offer an advantage over posterior malleolar fixation, with improved union rates. [Orthopedics. 2021;44(3):160-165.].

Randomized comparative study between extensile lateral and sinus tarsi approaches for the treatment of Sanders type 2 calcaneal fracture.

AIMS: No randomized comparative study has compared the extensile lateral approach (ELA) and sinus tarsi approach (STA) for Sanders type 2 calcaneal fractures. This randomized comparative study was conducted to confirm whether the STA was prone to fewer wound complications than the ELA. METHODS: Between August 2013 and August 2018, 64 patients with Sanders type 2 calcaneus fractures were randomly assigned to receive surgical treatment by the ELA (32 patients) and STA (32 patients). The primary outcome was development of wound complications. The secondary outcomes were postoperative complications, pain scored of a visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, 36-item Short Form health survey, operative duration, subtalar joint range of motion (ROM), Böhler's angle and calcaneal width, and posterior facet reduction. RESULTS: Although four patients (12.5%) in the ELA groups and none in the STA group experienced complications, the difference was not statistically significant (p = 0.113). VAS and AOFAS score were significantly better in the STA group than in the ELA group at six months (p = 0.017 and p = 0.021), but not at 12 months (p = 0.096 and p = 0.200) after surgery. The operation time was significantly shorter in the STA group than in the ELA group (p < 0.001). The subtalar joint ROM was significantly better in the STA group (p = 0.015). Assessment of the amount of postoperative reduction compared with the uninjured limb showed significant restoration of calcaneal width in the ELA group compared with that in the STA group (p < 0.001). CONCLUSION: The ELA group showed higher frequency of wound complications than the STA group for Sanders type 2 calcaneal fractures even though this was not statistically significant. Cite this article: Bone Joint J 2021;103-B(2):286-293.

Unstable malleolar ankle fractures: evaluation of prognostic factors and sports return.

INTRODUCTION: Ankle malleolar fractures are one of the most common surgical fractures. The literature about ankle fracture sport related is reduced. Severe fractures, fractures-dislocations, syndesmosis lesions, associated osteochondral lesions, postoperative complications, as well as age are associated in several studies with worse functional results and may, therefore, also be associated with a lower rate of sports return. This study aims to retrospectively assess the return to physical activity at the level prior to injury in individuals undergoing surgical treatment of unstable malleolar ankle injuries and to identify risk factors associated with a non-return. MATERIALS AND METHODS: We retrospectively evaluated between January 2008 and December 2017, patients with an unstable malleolar fracture of the ankle surgically treated, recreational or competitive sportsman with a minimum follow-up of one year. Demographic data, fracture classification according to AO classification, presence/absence of osteochondral lesion, presence/absence of unstable syndesmosis lesion, associated dislocation, type of surgery, postoperative complications, functional outcome evaluation with the AOFAS score and sports return. RESULTS: 92 patients met the inclusion criteria. The mean AOFAS score observed was 90.93 (67-100). 69.7% of patients returned without limitations in performing physical activity. 21.75% returned with limitations and 8.7% did not return to physical activity. No association was observed between age, sex, syndesmosis lesion and greater risk of not returning to physical activity. Patients with bimalleolar or trimalleolar fractures, osteochondral injury, or associated dislocation presented an increased risk of inferior functional score and non-return sporting activity. CONCLUSIONS: Bimalleolar and trimalleolar fractures, associated presence of dislocation and osteochondral lesions are associated with worse clinical outcome and lower return onset.

Pathoanatomy and Injury Mechanism of Typical Maisonneuve Fracture.

OBJECTIVE: Maisonneuve fracture is a special type of injury which are rare in clinic. The manifestation of such fractures is variable. The aim of this study is to describe the pathoanatomical features of typical Maisonneuve fracture on the basis of radiographs, computed tomography (CT) scans, magnetic resonance imaging (MRI), and intraoperative exploration findings, and to investigate the injury mechanism of this variety. METHODS: The data of 41 patients with Maisonneuve fracture from April 2014 to September 2019 were retrospectively analyzed. There were 32 males and nine females, the average age was 37.9 years (range, 18 to 61 years), the fractures occurred on the left side in 20 patients and on the right side in 21 patients. The cause of injuries were traffic accident in five patients, sprain injury in 20 patients, and falling injury from height in 16 patients. All patients underwent posteroanterior and lateral X-ray examinations of the ankle and calf. CT scan of the ankle was performed in 38 patients, including three-dimensional reconstruction in 33 patients. MRI examination of the ankle and calf was performed in 28 and five patients, respectively. Forty patients were treated with open reduction and internal fixation. The features of proximal fibular fracture, injuries of the medial and posterior structures of the ankle, injuries of the anterior inferior tibiofibular ligament and the interosseous membrane were recorded and analyzed. RESULTS: Forty-one patients had proximal one-third fractures of the fibula including six patients with fracture involving the fibular neck, 30 with proximal one-third fractures of the fibular shaft, and five with proximal-medial one-third junction fracture of the fibular shaft. Thirty-five patients (35/41, 85.37%) with injury of posterior structures, 34 patients had posterior malleolar fracture (34/41, 82.93%), and one patient had posterior inferior tibiofibular ligament rupture (1/41, 2.44%). There were 20 patients with type I fracture, four patients with type II fracture, and 10 patients with type III fracture according to the Haraguchi classification of posterior malleolus fracture. The fracture of the medial malleolus was in 30 patients (30/41, 73.17%), rupture of the deltoid ligament was in 10 patients (10/41, 24.39%), and medial structures intact were in one patient (1/41, 2.44%). All 41 patients had injury of the anterior inferior tibiofibular ligament. CONCLUSIONS: Maisonneuve fracture is characterized by fractures of the proximal fibula and the complete rupture of the anterior inferior tibiofibular ligament. Pronation-external rotation is the main injury mechanism. The manifestations of typical Maisonneuve fracture including that the fibular fracture located in proximal one-third diaphysis and the fracture line was from anterosuperior to posteroinferior.

Effects of Diabetes Mellitus on Functional Outcomes and Complications After Torsional Ankle Fracture.

INTRODUCTION: It is well known that patients with diabetes mellitus experience higher complication rates after torsional ankle fracture; however, the functional consequences remain less clear. The goal of this study was to determine the effects of diabetes on complications, secondary operations, and functional outcomes after torsional ankle fracture. METHODS: Nine hundred seventy-nine adult patients treated surgically for a torsional ankle injury (Orthopaedic Trauma Association 44B, 44C) over 13 years were retrospectively reviewed. Demographic information, comorbidities, injury characteristics, complications, and secondary procedures were recorded. Patient-reported outcome surveys: Foot Function Index (FFI) and Short Musculoskeletal Function Assessment were obtained after minimum of 12 months. Multivariable analysis was done to account for confounding variables. RESULTS: One hundred thirty-one patients (13.4%) had diabetes. Diabetic patients were older (56.4 versus 43.0 years, P < 0.001), with no difference in sex or race. Body mass index was higher among diabetics (36.0 versus 30.4, P < 0.001) as were most medical comorbidities, including stroke, neuropathy, pulmonary disease, and renal disease (all P < 0.03). There were no differences in rates of dislocations or open injuries. Diabetics experienced more complications (26.0% versus 14.6%, P = 0.001), specifically deep infections (6.9% versus 1.3%, P = 0.001), and had more secondary procedures (18.3% versus 9.1%, P = 0.001), including débridement, arthrodesis, and amputation (all P < 0.02). Diabetes was a significant independent predictor of worse FFI activity limitation scores (P = 0.032), but was not predictive of worse outcomes on any other subscore of the FFI or Short Musculoskeletal Function Assessment. CONCLUSIONS: Diabetes was associated with more complications and secondary operations. However, functional outcomes including pain and dysfunction were not markedly affected by these clinical outcomes, potentially due to diminished sensory function and less baseline physical activity among diabetic patients. LEVEL OF EVIDENCE: Prognostic level III.

Weight-bearing CT Scans in Foot and Ankle Surgery.

Weight-bearing CT (WBCT) scans of the foot and ankle have improved the understanding of deformities that are not easily identified on radiographs and are increasingly being used by orthopaedic surgeons for diagnostic and preoperative planning purposes. In contrast to standard CT scans, WBCT scans better demonstrate the true orientation of the bones and joints during loading. They have been especially useful in investigating the alignment of complex pathologies such as adult-acquired flatfoot deformity in which patients have been found to have a more valgus subtalar joint alignment than in a normal cohort and high rates of subfibular impingement. Studies using WBCT scans have also provided new insight into more common lower extremity conditions such as hallux valgus, ankle fractures, and lateral ankle instability. WBCT scans have allowed researchers to investigate pronation of the first metatarsal in patients with hallux valgus compared with normal feet, and patients with lateral ankle instability have been found to have more heel varus than healthy control subjects. Understanding the application of WBCT scans to clinical practice is becoming more important as surgeons strive for improved outcomes in the treatment of complicated foot and ankle disorders.

Medial tenderness revisited: Is medial ankle tenderness predictive of instability in isolated lateral malleolus fractures?

INTRODUCTION: Determining deltoid ligament incompetence in supination external rotation (SER) injuries commonly relies on stress radiography, given several studies demonstrating low predictive value of physical examination. Stress radiography can be difficult to obtain and may result in suboptimal radiographs with equivocal determination of stability. This study revisits the concept of medial ankle tenderness and its association with mortise instability. METHODS: Patients who presented with an isolated lateral malleolus fracture underwent prospective data collection. VAS scores were recorded with palpation at the lateral malleolar fracture site, anterior deltoid ligament, and posterior deltoid ligament. Three non-weightbearing radiographs of the ankle and a gravity stress view were obtained. Statistical analysis was performed to determine a correlation between tenderness and instability defined as MCS widening > 4 mm on gravity stress x-ray. RESULTS: 51 patients met inclusion criteria. Group I (stable) and Group II (unstable) demonstrated no difference in tenderness over the lateral malleolus (p = 0.94) or anterior deltoid (p = 0.12), but patients in Group II reported significantly more tenderness over the posterior deltoid (p = 0.03). Taking the higher pain score from either anterior or posterior deltoid palpation, patients with unstable ankle fractures reported significantly more tenderness with medial palpation (p = 0.02). The relative risk of having an unstable ankle fracture with any tenderness to palpation over either the anterior or posterior deltoid ligament was 1.77 (95% CI 1.03 - 3.06, P = 0.039). When comparing no pain versus the presence of any pain with palpation medially, the sensitivity for any medial tenderness to detect an unstable ankle fracture was 0.76 (specificity 0.59, PPV 0.79, NPV 0.56). CONCLUSION: Patients with any medial tenderness were at significantly higher risk of having an unstable SER ankle fracture in this study, but strict reliance on the presence or absence of medial tenderness without stress radiographs would lead to an unacceptable number of both false positive and false negative determinations of instability. However, our findings suggest that medial tenderness is associated with instability. The 0.79 PPV of any medial tenderness for instability may be useful to cast doubt on equivocal stress radiography and prompt surgeons to repeat stress radiography or shorten the interval for radiographic follow up. LEVEL OF EVIDENCE: Diagnostic study, Level II-1 (development of diagnostic criteria on basis of consecutive patients [with universally applied reference "gold" standard]).

Syndesmosis Injury From Diagnosis to Repair: Physical Examination, Diagnosis, and Arthroscopic-assisted Reduction.

Injuries to the tibio-fibular syndesmotic ligaments are different than ankle collateral ligament injuries and occur in isolation or combination with malleolar fractures. Syndesmotic ligament injury can lead to prolonged functional limitations and ultimately long-term ankle dysfunction if not identified and treated appropriately. The syndesmosis complex is a relatively simple construct of well-documented ligaments, but the dynamic kinematics and the effects of disruption have been a point of contention in diagnosis and treatment. Syndesmotic ligament injuries are sometimes referred to as "high ankle sprains" because the syndesmotic ligaments are more proximal than the collateral ligaments of the ankle joint. Rotational injuries to the ankle often result in malleolar fractures, which can be combined with ankle joint or syndesmotic ligament injuries. Most of the orthopaedic literature to this point has addressed syndesmosis ligament injuries in combination with fractures and not isolated syndesmotic ligament injuries. Thus, we propose a simplified general video guide to do the diagnostic examinations and arthroscopic-assisted reduction based on current evidence-based medicine.

Ankle torque-related fractures and its echo-fast diagnosis protocol.

Ankle torque is the most frequent injury mechanism encountered in traumatology. It usually develops as an ankle sprain, and often produces an ankle fracture. Signs and symptoms are very unspecific on the differential diagnosis, and conventional radiographs must be obtained to confirm it. This study compares ultrasound and standard X-ray images values found in ankle sprain-related fracture diagnoses. A 3-month prospective study was carried out on 52 patients with ankle torque. First, an ultrasound diagnosis was made by the first researcher at their arrival to the emergency department, usually consisting of a longitudinal section of the fibula, tibia, and V metatarsal. Then, a blinded independent investigator carried out the usual diagnosis protocol using traditional radiographs. When the required number was obtained, a third independent investigator evaluated the results. A Chi-squared test was used to contrast the outcomes between sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) comparing a non-inferiority hypothesis of our protocol against standard X-ray images screening. Echography showed to be at least as good as standard radiographs on the screening of ankle torque-related fractures (p = 0.02). In our series of patients, nearly 8% of fractures are misdiagnosed with plain radiographies, which concurs with the lower limit found in the bibliography. All the false negatives on radiographs were true positives in the first ultrasound assessment. The average time for the ultrasound protocol was 42 s. An ultrasound is at least as effective as conventional X-ray images when used in diagnosing ankle sprain-related fractures, regardless of age or sex and could in fact be better. The use of echography could reduce the number of radiographies performed when diagnosing these kinds of fractures, thereby reducing the amount of radiation exposure and expediting the diagnostic process as well as the "in situ diagnosis".Level of clinical evidence 2 [prospective cohort (N > 30 patients) study].

Surgical vs non-surgical management of Weber B fractures: A systematic review.

BACKGROUND: The aim of this systematic review was to compare surgical and non-surgical management of Weber B ankle fractures. METHODS: A systematic computer-based search was conducted using the MEDLINE (via OvidSP), EMBASE (via OvidSP) and Central databases. Data were extracted regarding functional outcome, radiological union, range of motion (RoM), infection rate and quality of life (QoL). RESULTS: There were no significant differences identified between surgical and non-surgical management of Weber B fractures with respect to functional outcome. There is a higher rate of complication following surgical management, including infection, reoperation, thromboembolic events and death. With respect to QoL and ankle RoM, this review identified no differences between surgical and non-surgical management. CONCLUSIONS: There is a need for further published literature evaluating the most efficacious management as there is a poverty of high-level research available. Currently, the available literature does not overwhelmingly favour a particular approach to Weber B ankle fractures.

The Role of Far Cortical Endosteal Fixation for the Treatment of Medial Malleolus Fractures: A Biomechanical Study.

The traditional method for fixation of medial malleolus fractures has been with partially threaded (PT) lag screws extending beyond the physeal scar. The purpose of this study was to evaluate the biomechanical strength of an innovative method of fixation for medial malleolus fractures using a fully threaded (FT) lag screw that extends to the far endosteal cortex. Medial malleolus fractures were simulated in 12 matched cadaver pairs. A single PT 4.0-mm cancellous lag screw was placed in 1 ankle. The contralateral ankle of the same matched pair received an FT 3.5-mm cortical lag screw that extended to the far lateral tibial cortex and achieved endosteal purchase. Final torque of both screw configurations was recorded, and radiographs were taken to confirm appropriate screw placement. Average torque for the PT cancellous screws was 5.02 ± 2.34 in-lb. Average torque for the FT cortical screw was 7.63 ± 3.86 in-lb (p = .002). Visual and radiographic inspections revealed no displacement of the fracture site with use of the FT endosteal lag screw. Our results indicate superior biomechanical torque with far endosteal fixation with use of an FT cortical lag screw versus a traditional PT cancellous lag screw in a cadaver model. Far endosteal fixation is an alternative surgical option for medial malleolus fractures that provides added strength compared with PT lag screws and may obviate downsides associated with bicortical fixation.

Biomechanical Analysis of a Novel Syndesmotic Plate Compared With Traditional Screw and Suture Button Fixation.

Many lateral malleolus fractures have been found to have syndesmosis injuries after anatomic reduction. The main methods for the treatment of syndesmosis injuries are screw fixation and suture-button flexible fixations. In pursuit of innovation, we have designed a novel syndesmotic plate (NSP) for simultaneous fixation of lateral malleolus fractures and distal tibiofibular syndesmosis injuries. The purpose of this study is to compare the biomechanical characteristics of the NSP to syndesmotic screw and suture-button fixations. Twelve adult cadaveric specimens were used in this experiment. Axial loading as well as rotation torque were applied in 3 different ankle positions: neutral, dorsiflexion, and plantarflexion. After the initial specimens were tested, they were made into a pronation-abduction III fracture model as described by Lauge-Hansen. Subsequently, the specimens were fixed sequentially using a distal fibular anatomic locking plate (DFALP) combined with syndesmotic screws, DFALP combined with suture button, and NSP. Then the above tests were repeated. The syndesmotic displacement and the strain of the tibia and fibula were recorded during the experiment. In most cases, the displacements and strains of the NSP group and the screw group were smaller than the suture button groups and the native (SBGAN) (p < .05), and the displacements and strains of the NSP group were also slightly smaller than the screw group in most cases, and there was no significant difference between the 2 groups. The NSP we developed has a fixed strength no less than the traditional syndesmotic screw fixation. This provides us a new idea for the treatment of distal tibiofibular syndesmosis injuries.

Functional outcome 3-6 years after operative treatment of closed Weber B ankle fractures with or without syndesmotic fixation.

BACKGROUND: To compare the long-term functional outcomes of patients surgically treated for Weber B ankle fractures with or without syndesmotic fixation. METHODS: In total, 959 adult patients with previous treatment with open reduction and internal fixation (ORIF) for closed ankle fractures were eligible for inclusion in a cross-sectional postal survey 3-6 years after surgery; 645 had Weber B fractures. The survey assessed functional outcomes with three validated ankle questionnaires. RESULTS: In total 365 (57%) patients responded at a median of 4.2 years after the trauma. After adjusting for age, sex, education, smoking status, body mass index, diabetes, physical status before surgery, fracture classification, and duration of surgery, patients with a syndesmotic fixation had no different OMAS score (p = 0.98), LEFS score (p = 0.61), and SEFAS score (p = 0.98) than those without a syndesmotic fixation. Trimalleolar fracture was associated with worse functional outcomes than unimalleolar on two of the scales, the OMAS (p = 0.028) and LEFS (p = 0.046). CONCLUSIONS: In multivariable analysis, patients with a syndesmotic fixation had no worse long-term functional outcomes than those without syndesmotic fixation.

Biomechanical effect of anterior talofibular ligament injury in Weber B lateral malleolus fractures after lateral plate fixation: A finite element analysis.

OBJECTIVE: To determine the biomechanical effect of anterior talofibular ligament injury in Weber B lateral malleolus fractures after lateral plate fixation. METHOD: A three-dimensional model was established based on CT images from a healthy volunteer. The simulation of lateral malleolus fracture, and the modeling and assembly of plate were completed by referring to characteristics of Weber B lateral malleolus fractures, as well as the technical characteristics of open reduction and internal fixation of lateral plate. Operating conditions were set up for groups A-D. The proximal end of the model was restrained in all four groups, 200N of upward force and 100N of backward force were applied at anterior of talus head in order to simulate the dorsiflexion of ankle joint. Biomechanical differences of the lateral plate were observed under various conditions of different ligament ruptures. RESULTS: The maximum stress value of group A was the smallest, approximately 78.47N, while that of group C was the largest, approximately 238.83N. The maximum stress value of group B was about 91.69N; and that of group D was about 184.08N. Importantly, location of the maximum stress in group D (CUT ATaF) was displaced from the posterior edge to the anterior edge of the plate, which was different from those of the other three groups. CONCLUSIONS: The anterior talofibular ligament injury may be a major contributing factor to the stress of lateral plate fixation following Weber B lateral malleolus fracture. It should be considered as an essential risk factor for evaluation of the stability in these fractures.

Biomechanics of Osteoporotic Fracture Fixation.

PURPOSE OF REVIEW: Fractures of osteoporotic bone in elderly individuals need special attention. This manuscript reviews the current strategies to provide sufficient fracture fixation stability with a particular focus on fractures that frequently occur in elderly individuals with osteoporosis and require full load-bearing capacity, i.e., pelvis, hip, ankle, and peri-implant fractures. RECENT FINDINGS: Elderly individuals benefit immensely from immediate mobilization after fracture and thus require stable fracture fixation that allows immediate post-operative weight-bearing. However, osteoporotic bone has decreased holding capacity for metallic implants and is thus associated with a considerable fracture fixation failure rate both short term and long term. Modern implant technologies with dedicated modifications provide sufficient mechanical stability to allow immediate weight-bearing for elderly individuals. Depending on fracture location and fracture severity, various options are available to reinforce or augment standard fracture fixation systems. Correct application of the basic principles of fracture fixation and the use of modern implant technologies enables mechanically stable fracture fixation that allows early weight-bearing and results in timely fracture healing even in patients with osteoporosis.

Transarticular external fixation versus deltoid ligament repair in treating SER IV ankle fractures: a comparative study.

BACKGROUND: The topic that whether the injured deltoid ligament should be repaired when associated with ankle joint fractures is still discussed. The objective of this study was to compare the clinical effect of open reduction and internal fixation (ORIF) with deltoid ligament repair (DLR) or transarticular external fixation (TEF) in treating supination-external rotation type IV (SER IV) ankle fractures. METHODS: Between January 2012 and December 2015, 43 patients were diagnosed as SER IV ankle fractures, 20 underwent ORIF and transarticular external fixation (TEF) without DLR (group 1), 23 were treated with ORIF and DLR (group 2). The pre- and post-operative radiographic examination were performed, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, the visual analog scale (VAS), the Medical Outcomes Short Form 36-item questionnaire score (SF-36), and the ankle range of motion (ROM) were used for functional evaluation. RESULTS: In both groups, the three scores improved significantly after surgery, but there was no significant difference between the two groups. At 6 weeks after surgery, patients in group 2 had better ankle ROM than group 1 (29.35 ± 2.033 vs. 40.35 ± 3.550, P <  0.001), but there was no difference at 12 months postoperatively. No cases of bone nonunion or post-traumatic arthritic changes were seen during the follow-up. Patients in group 1 required a shorter time to achieve fracture union than patients in group 2. CONCLUSIONS: ORIF with TIF is an optional strategy to manage SER IV ankle fractures as it achieves comparable functional results to ORIF with DLR. It also allows patients to start relatively earlier weight-bearing and may promote fracture union.

Long-term outcome in operatively and non-operatively treated isolated type B fibula fractures.

PURPOSE: Type B fibula fractures are the most common type of ankle fractures. Generally, surgical repair is advised for unstable fractures and non-operative treatment for stable fractures. However, evidence on long-term functional outcome of both treatment regimens is lacking. Aim of this study is to compare the long-term outcome in function and pain between patients with an isolated type B fibula fracture treated non-operatively and surgically. MATERIAL & METHODS: In this retrospective cohort study, all consecutive patients aged between 18 and 75 years, treated non-operatively or surgically between January 2008 and December 2015 for a distal fibula fracture at the level of the syndesmosis without an additional medial or posterior fracture and with a medial clear space ≤6 mm were included. All eligible patients received a questionnaire, composed of the Olerud-Molander Ankle Score (OMAS), the American Orthopaedic Foot and Ankle Society ankle-hindfoot score (AOFAS), the Euroqol-5D (EQ-5D) for quality of life and the Visual Analogue Scale (VAS) for pain sensation. With a mean follow-up of 5.3 years, 229 patients were included. For all aspects of the questionnaire, there was no significant difference between non-operative and operative treatment in outcome of function and pain: the EQ-5D score was respectively 0.8 vs. 0.9 (p = 0.72), mean VAS score 0.8 vs. 1.3 (p = 0.09), OMA score 84 vs. 84 (p = 0.98) and for the AOFAS 93 vs. 90 (p = 0.28). 33% of the patients who had surgery had revision surgery for implant removal because of persistent pain complaints. In 3% of the surgically treated patients, a wound infection required intravenous antibiotic treatment. In the non-operatively treated cohort, one patient developed a deep venous thrombosis in the fractured leg. CONCLUSION: According to results of this study, in adult patients with an isolated distal fibula and medial clear space ≤6 mm, without proven instability these fractures can safely be treated non-operatively, while avoiding risks and costs of surgery and preserving good long-term outcome in terms of pain and function.

Comparison of risk factors for postoperative complications across age groups in patients undergoing ORIF of the ankle.

INTRODUCTION: Risk factors associated with various adverse outcomes for patients undergoing open reduction and internal fixation (ORIF) of the ankle, and how these risks differ between younger and older patient populations, has not been clearly established. Objective quantitative data may aid physicians in surgical decision making, individualizing postoperative management, and targeting interventions for reducing postoperative comorbidity. The purpose of this study is to compare the incidence of and risk factors for adverse postoperative outcomes following ORIF of ankle fractures across patient age groups. MATERIALS AND METHODS: Charts of patients age 18 years and older who underwent open reduction and internal fixation (ORIF) for any closed, non-polytraumatic, non-pilon ankle fracture at a single institution between the years 2008 and 2018 were reviewed. Demographic information, comorbidities, and postoperative outcomes were collected. Relative risks for adverse outcomes were calculated and compared between patients younger than 50 and patients 50 years and older. RESULTS: A total of 886 patients were included, 375 (42.3%) of which were over age 50. In both age groups, risk of infection was significantly increased among patients with hypertension, although risk among older patients (RR = 3.52, p = 0.004) was greater than that among younger patients (RR = 2.46, p = 0.017). In patients younger than 50, significant risk of wound dehiscence was associated with tobacco use (RR = 3.39, p = 0.022), substance use (RR = 3.07, p = 0.020), and CHF (RR = 12.77, p < 0.001). Risk of implant failure was significantly increased among younger patients with HIV (RR = 4.33, p = 0.026), CHF (RR = 10.54, p < 0.001), and CKD (RR = 10.54, p < 0.001), and among older patients with HTN (RR = 4.51, p = 0.006), CHF (RR = 5.83, p < 0.001), and tobacco use (RR = 3.82, P = 0.001). CONCLUSION: Patients undergoing ORIF of the ankle should be well-informed of the potential risks of surgery as they pertain to specific comorbidities. Multidisciplinary approaches are warranted for appropriate management of patients with multiple comorbidities.

Biomechanical Comparison of Locking Plate and Cancellous Screw Techniques in Medial Malleolar Fractures: A Finite Element Analysis.

As the commonly used fixation strategy of medial malleolar fractures, cancellous screws (CS) have been challenged for instability, bone destruction, and metal prominence. It is still unclear whether a locking compression plate (LCP) is a better choice in such fractures. Our purpose is to compare the mechanical efficacy of LCP with traditional 4.0-mm CS for transverse, oblique, and vertical medial malleolar fractures by using finite element analysis. In this study, 3-dimensional models of the distal tibia were reconstructed from a computed tomography scan of a young healthy male adult. Conditions included 3 fracture lines at 30°, 60°, and 90°; 2 groups of fixation (LCP and CS); and 3 adduction loads of 300, 500, and 700 N applied to the medial malleolar joint surface. The proximal part of the tibia was fixed for all degrees of freedom. The fracture displacements of the LCP were smaller than those of CS (p < .05). The stiffness of the LCP constructs was much higher than that of the CS constructs, especially in the 90° fractures (490.3 versus 163.6 N/mm). The mean stress around the CS was higher than that in LCP for 60° and 90° fractures, but there was no difference for 30°. Maximal bone stress increased (19.84 to 50.86 MPa) and concentrated on cortical bone in LCP, whereas it concentrated on cancellous bone in CS. The results showed that LCP could improve stability, preventing bone destruction in oblique and vertical medial malleolar fractures. However, in transverse fractures, CS provides sufficient stability, with no need to use LCP.