Potential Roles of Inflammation on Post-Traumatic Osteoarthritis of the Ankle.

Post-traumatic osteoarthritis of the ankle (PTOA) is frequently observed following a debilitating consequence of intra-articular ankle fractures. Numerous risk factors contribute to the pathogenesis of PTOA, including articular incongruity, joint malalignment, and concomitant soft tissue damage. Despite attempts to restore joint anatomy and manage soft tissues to avoid long-term complications after intra-articular ankle fractures, the incidence of PTOA remains markedly elevated. Inflammatory processes triggered by intra-articular ankle fractures have emerged as potential instigators that expedite the progression of PTOA. Injury to the articular cartilage and subchondral bone may lead to the release of inflammatory mediators, which can contribute to cartilage degradation and bone resorption. This study provides a narrative review on the current knowledge concerning the association between inflammation and the development of PTOA following intra-articular ankle fractures. We also discuss novel therapeutic agents that target inflammatory pathways to impede the progression of post-traumatic osteoarthritis after intra-articular ankle fractures. These medication and interventions were summarized within this review article.

Incidence of Chondral and Osteochondral Lesions in Ankle Fracture Patients Identified With Ankle Arthroscopy Following Rotational Ankle Fracture: A Systematic Review.

A systematic literature search was performed using the PubMed, MEDLINE, and the Cochrane Library databases according to the Preferred Reporting Items for Systematic review and Meta-Analyses guidelines on May 20, 2019. The keywords used were: ankle, distal tibia, distal fibula, fracture, arthroscopic, cartilage, and chondral. The objective of this study is to systematically review the characterization of intra-articular chondral injuries of the talus, tibial plafond, medial malleolus, and lateral malleolus in patients who undergo ankle arthroscopy following ankle fracture. Studies evaluating the incidence of chondral lesions at the time of arthroscopy for ankle fractures within any timeframe were included. The incidence of intra-articular chondral lesions was recorded, the location within the ankle, ankle fracture type, time of arthroscopy, characterization of chondral injury, complications, and outcome if available. Fifteen studies with 1355 ankle fractures were included. About 738 demonstrated evidence of chondral or osteochondral lesion (54.5%). Statistical analyses were carried out with statistical software package SPSS 24.0 (SPSS, Chicago, IL). We compared incidence rates of chondral injury based on Weber classification, malleolar fracture type, and Lauge-Hansen classification, using Pearson chi-square test. For all analyses, p < .05 was considered statistically significant. We found a high incidence of intra-articular chondral lesion in the setting of ankle fractures as demonstrated by arthroscopy.

Ankle Arthroscopy: Correct Portals and Noninvasive Distraction.

Noninvasive ankle distraction technique is the standard of care for ankle arthroscopic surgery. Noninvasive distraction can be performed safely and with fewer complications when compared side-by-side with the nondistraction dorsiflexion technique. Moreover, distraction techniques allow a single surgeon to operate in the most convenient supine position and in a "hands-free" manner, with adequate space to avoid iatrogenic chondral damage. In addition, distraction allows for dedicated inflow and outflow portals to sufficiently irrigate the joint. Although the nondistraction technique allows excellent visualization of the anterior joint, it fails to provide appropriate visualization of the entire joint, using both anterior and posterior portals. Pathology that is best accessed from the posterior portal includes posterior osteochondral lesions, loose bodies, tears of the transverse ligament, acute ankle fractures, posterior tibial osteophytes, and occasionally an os trigonum. Fortunately, noninvasive distraction techniques plantarflex the ankle, also providing optimal access to the talus through the anterior approach. With the added use of posterolateral and occasionally posteromedial portals, near-universal access to lesions about the ankle can be obtained. In this infographic, the authors present the current indications for noninvasive ankle distraction arthroscopy and illustrate the importance of proper portal placement in obtaining the access and visualization necessary to easily and safely address pathology throughout the entire ankle and subtalar joint.

Inducing pilon fractures in human cadaveric specimens depending on the injury mechanism: a fracture simulation.

BACKGROUND: Operative management of pilon fractures, especially high-energy compression injuries, is a challenge. Operative education is of vital importance to handle these entities. Not rarely, it is cut by economics and staff shortage. As public awareness toward operative competence rises, surgical cadaver courses that provide pre-fractured specimens can improve realism of teaching scenarios. The aim of this study is to introduce a realistic pilon fracture simulation setup regarding the injury mechanism. MATERIALS AND METHODS: 8 cadaveric specimens (two left, six right) were fixed onto a custom drop-test bench in dorsiflexion (20°) and light supination (10°). The proximal part of the lower leg was potted, and the specimen was exposed to a high energetic impulse via an axial impactor. CT imaging was performed after fracture simulation to detect the exact fracture patterns and to classify the achieved fractures by two independent trauma surgeons. (AO/OTA recommendations and the Rüedi/Allgöwer). RESULTS: All cadaveric specimens could be successfully fractured: 6 (75%) were identified as a 43-C fracture and 2 (25%) as 43-B fracture type. Regardless of the identical mechanism two different kinds of fracture types were reported. In five cases (62.5%), the fibula was also fractured and in three specimens, a talus fracture was described. There was no statistically significant correlation found regarding Hounsfield Units (HU) and age as well as HU and required kinetic energy. CONCLUSION: A high energetic axial impulse on a fixed ankle specimen in light dorsiflexion (20°) and supination (10°) induced by a custom-made drop-test bench can successfully simulate realistic pilon fractures in cadaveric specimens with intact soft tissue envelope. Although six out of eight fractures (75%) were classified as a 43-C fracture and despite putting a lot of effort into the mechanical setup, we could not achieve an absolute level of precision. Therefore, we suggest that the injury mechanism is most likely a combination of axial loading, shear and rotation. LEVEL OF EVIDENCE: III.

Pathoanatomy of Maisonneuve fracture based on radiologic and CT examination.

INTRODUCTION: Although Maisonneuve fracture (MF) is a well-known type of ankle fracture-dislocation, there is still a lack of information about the epidemiology and the extent of all associated injuries. The aim of study is to describe MF pathoanatomy on the basis of radiographs, CT scans and intraoperative findings. MATERIALS AND METHODS: The study comprised 54 adult patients. MF was defined as an ankle fracture-dislocation with a fracture of the fibula in its proximal quarter. Ankle radiographs and lower leg radiographs were obtained in all patients. Computed tomography (CT) examination was performed in 43 patients, of these in 34 patients in combination with 3D CT reconstructions. A total of 51 patients were treated operatively, and in 38 of these an open procedure was performed. RESULTS: The fibular fracture-fibular head was involved in four cases, and the subcapital region of the proximal quarter of the fibula was affected in 50 cases. Fractures of the posterior malleolus were identified in 43 of 54 patients (80%). Injury to the deltoid ligament was recorded in 27 cases (50%), a fracture of the medial malleolus in 20 cases (37%) and medial structures were intact in 7 cases (13%). Position fibula in fibular notch-in 9 cases the position changed only minimally, in 11 cases the space between the tibia and the fibula was larger than 2 mm, in 20 cases widening of the tibiofibular space was associated with external rotation of the fibula, in 2 cases fibula was trapped behind the posterior tibial tubercle and in 1 case it was associated with a complete tibiofibular diastasis. CONCLUSION: MF is a variable injury, always associated with rupture of the anterior and interosseous tibiofibular ligaments. CT examination should be employed widely in MF, and MRI should be considered under special circumstances.

Sinomenine Regulates Inflammatory Response and Oxidative Stress via Nuclear Factor kappa B (NF-κB) and NF-E2-Related Factor 2 (Nrf2) Signaling Pathways in Ankle Fractures in Children.

BACKGROUND This study aimed to investigate the effects of SIN on ankle fracture and the underlying mechanisms in MG-63 cells. MATERIAL AND METHODS qRT-PCR and ELISA assay were used to detect the mRNA and protein levels of cytokines in peripheral blood of children with or without ankle fracture. The expression and activity of antioxidant and detoxifying enzymes were detected by ELISA assay. Pretreated MG-63 cells with/without SIN were stimulated with 1 µg/ml bradykinin (BK). A CCK-8 kit was used to detect the cell viability. The cytokines produced from MG-63 cells were detected by Western blotting and qRT-PCR. Moreover, Western blotting was used to detect the levels of p-p38 and p-NF-κB (p65), and the activation level of the Nrf2 signaling pathway was examined by qRT-PCR and Western blotting. RESULTS In this study, we found that compared with the healthy children, the mRNA and protein levels of interleukin (IL)-1ß, IL-6, and tumor necrosis factor-alpha (TNF-α) were significantly upregulated in children with ankle fracture. In addition, the expression and activity of antioxidant and detoxifying enzymes were imbalanced in children with ankle fracture. SIN treatment did not have a cytotoxic effect on MG-63 cells. SIN dose-dependently suppressed BK-induced upregulation of IL-1ß, IL-6, TNF-α, p-p38, and p-NF-κB (p65). Furthermore, SIN dramatically inhibited oxidative stress induced by BK via balancing the expression and activity of antioxidant and detoxifying enzymes and inhibited the activation of Nrf2 signaling. CONCLUSIONS SIN might be a potential agent for the treatment of ankle fracture through reducing inflammatory response and oxidative stress.

Transepiphyseal (Type VII) Ankle Fracture Versus Os Subfibulare in Pediatric Ankle Injuries.

BACKGROUND: Pediatric ankle injuries are common, giving rise to ∼17% of all physeal injuries. An os subfibulare in a child with an ankle sprain may be confused with a type VII transepiphyseal fracture. Here, we evaluate the clinical and radiographic features of type VII transepiphyseal fractures to those of os subfibulare presenting with acute ankle trauma with the hypothesis that radiographs are necessary for final diagnosis and neither clinical history nor examination would be diagnostic. METHODS: We performed an internal review board-approved, retrospective chart review of patients identified with a traumatic os subfibulare or type VII ankle fracture over an 18-month period. Charts were reviewed for demographics, mechanism, and clinical findings on initial presentation. Radiographic measurements of the distal fibular fragment as well as epiphysis were made on presenting ankle series radiographs. RESULTS: A total of 23 patients were identified. Eleven patients had a traumatic type VII ankle fracture and 12 had trauma associated with an os subfibulare on initial radiographs. The history and clinical presentations were similar and were nondiagnostic. The ratio of the width of the fibula at its largest point on the anterior posterior view to the width of the fibular fragment was significantly larger in the type VII ankle fractures (P=0.05). All os subfibulare were located within the inferior third of the epiphysis, whereas all type VII fractures were either at the equator or within the middle third of the fibular epiphysis. CONCLUSIONS: Radiographs, not clinical presentation, can differentiate an os subfibulare from a type VII transepiphyseal fracture. Children with type VII fractures have a long, irregular fracture line within the middle third of the distal fibular epiphysis. Those with an ankle sprain and os subfibulare have a smooth-edged ossicle of relatively short length located within the inferior pole of the epiphysis. Furthermore, the radiographic width of the fragment in the type VII fractures is significantly larger in width than the os subfibulare. LEVEL OF EVIDENCE: Level II.

Anatomic Feasibility of Distal Fibula Bicortical Screw Fixation With Lateral Neutralization Plating for Rotational Ankle Fractures.

A common technique for fixation of rotational fibular fractures is to use an interfragmentary compression screw with a laterally positioned neutralization plate. The objective of the present investigation was to examine the anatomic feasibility of distal fibula bicortical fixation within this plating technique. A specific screw insertion technique was performed through a laterally positioned one-third tubular plate on a consecutive series of 81 intact cadaveric ankle mortises. The most distal plate hole was drilled, aimed 10° posterior to the midline of the fibula. The second-most distal plate hole was drilled, aimed 25° superiorly. The specimens were then dissected, and the screw termini were physically examined for whether they had penetrated the articular cartilage of the ankle mortise. The length of the most distal bicortical screw measured a mean ± standard deviation of 20.44 ± 2.49 (range 14 to 26) mm, with an extra-articular terminus in 95.06% of specimens. The length of the second-most distal bicortical screw measured a mean ± standard deviation of 19.68 ± 3.02 (range 12 to 28) mm, with an extra-articular terminus in 100% of the specimens. The results of the present study provide evidence that bicortical distal fibular fixation in accordance with basic fixation principles is anatomically possible and feasible with a one-third tubular plate. This could potentially obviate the need for more expensive fixation options (i.e., locked plates or anatomically contoured plates) and fixation options that are biomechanically stable but potentially anatomically impeding (i.e., posterior antiglide plating).

[Arthroscopic treatment of chondral lesions of the ankle joint. Evidence-based therapy]. / Arthroskopische Behandlung von Knorpelverletzungen am Sprunggelenk. Evidenzbasierte Therapie.

Ankle sprains are the most relevant injuries of the lower extremities and can lead to damage to ligaments and osteochondral lesions. Up to 50 % of patients with a sprained ankle later develop a lesion of the cartilage in the ankle joint or an osteochondral lesion of the talus. This can lead to osteoarthritis of the injured ankle joint. Spontaneous healing is possible in all age groups in cases of a bone bruise in the subchondral bone but in isolated chondral injuries is only useful in pediatric patients. In many cases chondral and osteochondral injuries lead to increasing demarcation of the affected area and can result in progressive degeneration of the joint if not recognized in time. There also exist a certain number of osteochondral changes of the articular surface of the talus without any history of relevant trauma, which are collectively grouped under the term osteochondrosis dissecans. Perfusion disorders are discussed as one of many possible causes of these alterations. Nowadays, chondral and osteochondral defects can be treated earlier due to detection using very sensitive magnetic resonance imaging (MRI) and computed tomography (CT) techniques. The use of conservative treatment only has a chance of healing in pediatric patients. Conservative measures for adults should only be considered as adjuvant treatment to surgery.Based on a comprehensive analysis of the current literature, this article gives an overview and critical analysis of the current concepts for treatment of chondral and osteochondral injuries and lesions of the talus. With arthroscopic therapy curettage and microfracture of talar lesions are the predominant approaches or retrograde drilling of the defect is another option when the chondral coating is retained. Implantation of autologous chondral cells or homologous juvenile cartilage tissue is also possible with arthroscopic techniques. Osteochondral fractures (flake fracture) are usually performed as a mini-open procedure supported by arthroscopy. The use of the osteochondral autograft transfer system (OATS), implantation of membranes with or without autologous bone marrow transfer and possibly with growth factors or implantation of stem cells are carried out in combination with arthroscopic mini-open procedures. The results from the literature are discussed and compared with own results after arthroscopic treatment of chondral lesions of the talus.

[Arthroscopically assisted treatment of ankle fractures]. / Arthroskopisch assistierte Frakturversorgung am oberen Sprunggelenk.

Acute ankle fractures are one of the most common fractures in adults with an incidence of 0.1-0.2 % per year. Operative treatment by open reduction and internal fixation (ORIF) is the standard method of treatment for unstable or dislocated fractures. The main goal of the operation is the anatomical realignment of the joint and restoration of ankle stability; nevertheless, anatomical reduction does not automatically lead to favorable clinical results. According to several studies the mid-term and in particular the long-term outcome following operative treatment is often poor with residual symptoms including chronic pain, stiffness, recurrent swelling and ankle instability. There is growing evidence that this poor outcome might be related to occult intra-articular injuries involving cartilage and soft tissues. In recent studies the frequency of fracture-related osteochondral lesions was reported to be approximately 64 %. By physical examination, standard radiography or even computed tomography (CT), these intra-articular pathologies cannot be reliably diagnosed; therefore, many authors emphasize the value of ankle arthroscopy in acute fracture treatment as it has become a safe and effective diagnostic and therapeutic procedure. Arthroscopically assisted open reduction and internal fixation (AORIF) allows control of the reduction as well examination of all intra-articular structures. If necessary, intra-articular pathologies can be addressed by removing ruptured ligaments and loose bodies, performing chondroplasty or microfracturing. So far there is no evidence that supplementary ankle arthroscopy increases the complication rate. On the other hand, the positive effect of AORIF has also not been clearly documented; nevertheless, there are clear indications that arthroscopically assisted fracture treatment is beneficial, especially in complex fractures.

Irreducible Ankle Fracture Dislocation Due to Tibialis Posterior Tendon Interposition: A Case Report.

Traumatic ankle fractures and dislocations that fail closed reduction present a challenging set of circumstances that can potentially lead to unnecessary complications and require surgical intervention. Interposition of adjacent tendons occurs rarely and can obstruct the anatomic realignment. Because of the potential for neurovascular compromise and possible skin tension necrosis, an irreducible fracture dislocation must be addressed with open reduction and internal fixation. The present case details an unusual, low-energy, external rotation ankle fracture and dislocation that was incapable of skeletal traction relocation. The present report also details the intraoperative finding of a complex injury pattern.

Manual Stress Ankle Radiography Has Poor Ability to Predict Deep Deltoid Ligament Integrity in a Supination External Rotation Fracture Cohort.

Stress ankle radiographs are routinely performed to determine deep deltoid ligament integrity in supination external rotation (SER) ankle fractures. However, variability is present in the published data regarding what medial clear space (MCS) value constitutes a positive result. The purposes of the present study were to evaluate the diagnostic accuracy of different MCS cutoff values and determine whether this clinical test could accurately discriminate between patients with and without a deep deltoid ligament disruption. MCS measurements were recorded for stress ankle injury radiographs in an SER ankle fracture cohort. Preoperative ankle magnetic resonance imaging studies, obtained for all patients, were then read independently by 2 musculoskeletal attending radiologists to determine deep deltoid ligament integrity. The MCS measurements were compared with the magnetic resonance imaging diagnosis using receiver operating characteristic analyses to determine the sensitivity, specificity, and optimal data-driven cutoff values. SER II-III patients demonstrated a mean stress MCS distance of 4.3 ± 0.98 mm compared with 5.8 ± 1.76 mm in the SER IV cohort (p < .001). An analysis of differing MCS positive cutoff thresholds revealed that a stress MCS of 5.0 mm maximized the combined sensitivity and specificity of the external rotation test: 65.8% sensitive and 76.5% specific. Using the receiver operating characteristic curve analysis of the MCS measurement, the calculated area under the curve was 0.77, indicating inadequate discriminative ability for diagnosing SER pattern fractures with or without a deep deltoid ligament tear. Judicious use of additional diagnostic testing in patients with a stress MCS result between 4.0 mm and 5.5 mm is warranted.

[Restoration of contractile capacity of the muscles after closed malleolar fractures].

According to the literature data incomplete restoration of the muscular strength is observed after malleolar fractures that made us evaluate the contractile capacity of the tibial muscles after treatment of 59 adult patients with these fractures using Ilizarov method. Additionally, late follow-up of 5 cases were examined in complex. Practically, full restoration of the anatomical sizes, electrogenesis and contractile property of the tibial muscles is possible in the interval from 5 to 8 years after treatment that can be explained by fine reduction and reliable fixation of the bone fragments during treatment and increase of neuro-motor apparatus sensitivity to the specific impacts while muscles' work in the conditions of habitual motor activity.

The effect of minimally displaced posterior malleolar fractures on decision making in minimally displaced lateral malleolus fractures.

PURPOSE: Despite the high incidence of cases of minimally displaced lateral or posterior malleolus ankle fractures, treatment guidelines are still an issue of controversy. The purpose of this study was to delineate treatment preferences among orthopaedic surgeons in these fractures with and without concomitant posterior malleolus fractures. We hypothesized that concomitant minimally displaced fractures of the posterior malleolus can shift treatment preference towards operative intervention. METHODS: A questionnaire-based study was conducted among orthopaedic surgeons attending the 2012 European Federation of National Associations of Orthopaedics and Traumatology Conference (EFORT) in Berlin, Germany. Treatment preferences were reported for minimally displaced lateral malleolus fractures seen on radiographs and were then compared with treatment preferences when computed tomography (CT) was added revealing a concomitant minimally displaced posterolateral fracture of the posterior malleolus. RESULTS: The cohort comprised 177 surgeons from all six continents. When radiographs showing a minimally displaced lateral malleolus fracture were presented, nonoperative management was indicated by 35 % (62) of participants, whereas 65 % (115) preferred operative intervention. After CT views were added showing an accompanying minimally displaced posterolateral posterior malleolus fracture, 79 % (140) suggested operative intervention and only 21 % (37) advocated nonoperative management (p = 0.03). CONCLUSIONS: Most surgeons prefer open reduction with internal fixation for minimally displaced lateral malleolar fractures. The presence of concomitant posterior malleolus fractures in these cases shifts treatment preference further towards open reduction with internal fixation. Because the posterior malleolus fragment might not be well delineated on standard ankle radiographs, a high index of suspicion is warranted, and the use of CT should be considered in these cases.

Safety profile of sural nerve in posterolateral approach to the ankle joint: MRI study.

The posterolateral approach to ankle joint is well suited for ORIF of posterior malleolar fractures. There are no major neurovascular structures endangering this approach other than the sural nerve. The sural nerve is often used as an autologous peripheral nerve graft and provides sensation to the lateral aspect of the foot. The aim of this paper is to measure the precise distance of the sural nerve from surrounding soft tissue structures so as to enable safe placement of skin incision in posterolateral approach. This is a retrospective image review study involving 64 MRI scans. All measurements were made from Axial T1 slices. The key findings of the paper is the safety window for the sural nerve from the lateral border of tendoachilles (TA) is 7 mm, 1.3 cm and 2 cm at 3 cm above ankle joint, at the ankle joint and at the distal tip of fibula respectively. Our study demonstrates the close relationship of the nerve in relation to TA and fibula in terms of exact measurements. The safety margins established in this study should enable the surgeon in preventing endangerment of the sural nerve encountered in this approach.

Intra-Articular Synovial Fluid With Hematoma After Ankle Fracture Promotes Cartilage Damage In Vitro Partially Attenuated by Anti-Inflammatory Agents.

BACKGROUND: Intra-articular ankle fracture (IAF) causes posttraumatic osteoarthritis (PTOA), but the exact mechanism is unknown. Proinflammatory mediators have been shown to be present in the synovial fluid fracture hematoma (SFFH) but have not been linked to cartilage damage. The purpose of this study was to determine if the SFFH causes cartilage damage and whether this damage can be attenuated by commercially available therapeutic agents. METHODS: Synovial fluid was obtained from 54 IAFs and cultured with cartilage discs from the dome of fresh allograft human tali and randomly assigned to one of the following groups: (A) control-media only, (B) SFFH from days 0 to 2 after fracture, (C) SFFH from days 3 to 9, (D) SFFH from days 10 to 14, (E) group B + interleukin 1 receptor antagonist (IL-1Ra), and (F) group B + doxycycline. The cartilage discs underwent histological evaluation for cell survival and cartilage matrix components. The spent media were analyzed for inflammatory mediators. RESULTS: Cartilage discs cultured with SFFH in groups B, C, and D demonstrated significantly increased production of cytokines, metalloproteinases (MMPs), and extracellular matrix breakdown products. Safranin O staining was significantly decreased in group B. The negative effects on cartilage were partially attenuated with the addition of either IL-1RA or doxycycline. There was no difference in chondrocyte survival among the groups. CONCLUSION: Exposure of uninjured cartilage to IAF SFFH caused activation of cartilage damage pathways evident through cartilage disc secretion of inflammatory cytokines, MMPs, and cartilage matrix fragments. The addition of IL-1Ra or doxycycline to SFFH culture partially attenuated this response. CLINICAL RELEVANCE: IAFs create an adverse intra-articular environment consisting of significantly increased levels of inflammatory cytokines and MMPs able to damage cartilage throughout the joint. These data suggest that the acute addition of specific inflammatory inhibitors may decrease the levels of these proinflammatory mediators.

The relationship between changes in distal tibiofibular joint congruence and clinical and functional results in the short-term follow-up of patients operated on for ankle fracture.

BACKGROUND: The effects of changes in distal tibiofibular joint (DTFJ) congruence on clinical and functional outcomes are unclear in patients operated on for ankle fractures. The present study aims to evaluate the relationship between changes in DTFJ congruence and clinical and functional outcomes in the short-term follow-up of the patients operated on for ankle fractures. METHODS: In this study, hospital records of patients who were operated on for ankle fractures were retrospectively analyzed. The data of patients who underwent bilateral ankle computed tomography scans at least 18 months after surgery were used. DTFJ congruence was evaluated using four methods. Method 1: the distance between the most prominent anterior points of the tibia and fibula (anterior incisura [AI]) and that between the most prominent posterior points of the tibia and fibula (posterior incisura [PI]) were measured. Method 2: the direct anterior (DA) and direct posterior (DP) distances were measured based on perpendicular lines drawn from the most prominent anterior and posterior points of the longitudinal axis of the fibula to the tibia, respectively, and a direct translation (DT) distance was measured based on a perpendicular line drawn to the DA from the most prominent anterior point of the tibia. Method 3: the angle between a line connecting the most anterior and posterior points of the tibia and a line connecting the most anterior and posterior points of the fibula (rotational angle [RA]) was measured. The differences in distances and angles (dAI, dPI, dDA, dDP, dDT, and dRA) between the injured and non-injured sides were calculated in the first three methods. Method 4: any rotational/translational incongruency on the injured side was subjectively reported. The American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, Olerud-Molander Ankle Score (OMAS), and Visual Analog Scale (VAS) were used for clinical and functional evaluations. RESULTS: Thirty patients (18 males and 12 females; mean age, 43.3 [range, 20-78 years] years) were included in this study. The average follow-up was 37.6 (range, 18-54 months) months. Negative correlations were detected between dDA and the AOFAS-pain subscale (r=-0.37; p=0.04), between dDP and the OMAS (r=-0.57; p=0.01), and between dDT and the AOFAS-pain, AOFAS-function, and OMAS (r=-0.55 p=0.01; r=-0.40; p=0.03; r=-0.39; p=0.04, respectively). CONCLUSION: Changes in dDA, dDP, and dDT values affect the clinical and functional outcomes. These parameters should be provided in accordance with the anatomy of the patient during the reduction of the DTFJ to achieve better outcomes.

Better discrimination of the concomitant peri-ankle fractures in the spiral tibial shaft fractures by thin-slice axial and three-dimensional CT.

ABSTRACT: The objective of this study was to examine the morphologic features of spiral tibial shaft as well as concomitant fibular and peri-ankle fractures on multidetector high-resolution CT and to speculate about the mechanisms underlying these combined fractures.This is a retrospective cohort study. A total of 197 tibial shaft fractures underwent multidetector high-resolution CT before intramedullary nailing. The presence and location of peri-ankle fractures were recorded using thin-slice axial CT. Tibial shaft fractures were classified as spiral or non-spiral. The morphologies of spiral tibial fractures and concomitant lateral malleolar fractures were delineated using three-dimensional CT.Seventy-five spiral and 122 non-spiral fractures were identified. Peri-ankle fractures excluding lateral malleolar fractures were found in 77.3% of spiral fractures and 18.9% of non-spiral fractures. The most frequent location of peri-ankle fractures in the spiral group was the posterior malleolus, followed by the anterolateral distal tibia, while the medial malleolus was the most frequent site in the non-spiral group. Of 75 spiral fractures, 72 showed a fracture morphology attributed to external rotation force. There were 13 lateral malleolar fractures that were defined as within 6 cm from the distal end of the fibula. No lateral malleolar fractures showed the typical morphology of isolated supination/external rotation-type ankle injuries. The displaced syndesmotic injuries commonly coexisting in pronation/external rotation-type ankle injuries were not observed.Most spiral tibial shaft fractures were caused by external rotation force. However, the morphology of concomitant peri-ankle fractures was inconsistent with typical mechanisms of isolated external rotation ankle injuries.

Efficacy of intravenous perioperative parecoxib administration in the surgical fixation of unstable ankle fracture: a prospective, double-blinded, randomized, placebo-controlled trial.

OBJECTIVE: Little is known about the efficacy of perioperative intravenous (IV) non-opioid medication administration in patients undergoing orthopedic surgery. The objective of this study was to determine the efficacy of perioperative parecoxib in patients with unstable ankle fractures who were scheduled to undergo surgery. PATIENTS AND METHODS: In this double-blinded, prospective, randomized controlled trial, 40 patients who underwent open reduction and internal fixation for unstable ankle fractures were randomly allocated to the parecoxib group (parecoxib 40 mg IV 30 min before surgery and then 40 mg IV every 12 h for the initial 48 h postoperatively [n=20]) or the placebo group (saline [n=20]). The efficacy of pain control was assessed according to the total morphine used. Pain intensity (at rest/ambulation) and pain relief (at rest/ambulation) were assessed using the verbal numerical rating score (VNRS) and verbal numerical rating percentage (VNRP), respectively. Subjective rating of medication was performed by each patient. All outcomes were recorded by trained personnel who were blinded to the patient group allocation. RESULTS: The mean patient age was 49.3±18.0 years. There were no significant differences between the two groups in terms of pain intensity, pain relief, patients' subjective ratings of the medication at both the preoperative and postoperative periods, total quantity of morphine used, side effects, and acute complications of surgery (p>0.05). The mean length of hospital stay tended to be shorter in the parecoxib group than in the placebo group (6 vs. 9.9 days; p=0.183). CONCLUSIONS: Although the perioperative administration of parecoxib did not provide significantly better postoperative pain control or reduce the opioid requirement relative to placebo, its use led to a shorter hospital stay.