The additional value of weight-bearing and gravity stress ankle radiographs in determining stability of isolated type B ankle fractures

Aim of study: To investigate the short- and long-term outcome of patients with isolated lateral malleolar fracture type B treated with a single hemicerclage out of metallic wire or PDS cord. Methods: Over an 8-year period 97 patients were treated with a single hemicerclage for lateral malleolar fracture type B and 89 were amenable to a follow-up after mean 39 months, including interview, clinical examination and X-ray controls. Results: The median operation time was 35 minutes (range 15-85 min). X-ray controls within the first two postoperative days revealed an anatomical restoration of the upper ankle joint in all but one patient. The complication rate was 8%: hematoma (2 patients), wound infection (2), Sudeck's dystrophy (2) and deep vein thrombosis (1). Full weight-bearing was tolerated at median 6.0 weeks (range 2-26 weeks). No secondary displacement, delayed union or consecutive arthrosis of the upper ankle joint was observed. All but one patient had restored symmetric joint mobility. Ninety-seven percent of patients were satisfied or very satisfied with the outcome. Following bone healing, hemicerclage removal was necessary in 19% of osteosyntheses with metallic wire and in none with PDS cord. Conclusion: The single hemicerclage is a novel, simple and reliable osteosynthesis technique for isolated lateral type B malleolar fractures and may be considered as an alternative to the osteosynthesis procedures currently in use.

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Is postoperative non-weight-bearing necessary? INWN Study protocol for a pragmatic randomised multicentre trial of operatively treated ankle fracture

Trials ◽

10.1186/s13063-021-05319-0 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Ramy Khojaly ◽

Ruairí Mac Niocaill ◽

Muhammad Shahab ◽

Matthew Nagle ◽

Colm Taylor ◽

...

Keyword(s):

Ankle Fracture ◽

Multicentre Trial ◽

Short Form ◽

Plantar Flexion ◽

Weight Bearing ◽

Ankle Fractures ◽

Hospital Length Of Stay ◽

Complication Rates ◽

Fracture Patterns ◽

Randomised Controlled

Abstract Background Postoperative management regimes vary following open reduction and internal fixation (ORIF) of unstable ankle fractures. There is an evolving understanding that extended periods of immobilisation and weight-bearing limitation may lead to poorer clinical outcomes. Traditional non-weight-bearing cast immobilisation may prevent loss of fixation, and this practice continues in many centres. The purpose of this trial is to investigate the safety and efficacy of immediate weight-bearing (IWB) and range of motion (ROM) exercise regimes following ORIF of unstable ankle fractures with a particular focus on functional outcomes and complication rates. Methods A pragmatic randomised controlled multicentre trial, comparing IWB in a walking boot and ROM within 24 h versus non-weight-bearing (NWB) and immobilisation in a cast for 6 weeks, following ORIF of all types of unstable adult ankle fractures (lateral malleolar, bimalleolar, trimalleolar with or without syndesmotic injury) is proposed. All patients presenting to three trauma units will be included. The exclusion criteria will be skeletal immaturity and tibial plafond fractures. The three institutional review boards have granted ethical approval. The primary outcome measure will be the functional Olerud-Molander Ankle Score (OMAS). Secondary outcomes include wound infection (deep and superficial), displacement of osteosynthesis, the full arc of ankle motion (plantar flexion and dorsal flection), RAND-36 Item Short Form Survey (SF-36) scoring, time to return to work and postoperative hospital length of stay. The trial will be reported in accordance with the CONSORT statement for reporting a pragmatic trial, and this protocol will follow the SPIRIT guidance. Discussion Traditional management of operatively treated ankle fractures includes an extended period of non-weight-bearing. There is emerging evidence that earlier weight-bearing may have equivocal outcomes and favourable patient satisfaction but higher wound-related complications. These studies often preclude more complicated fracture patterns or patient-related factors. To our knowledge, immediate weight-bearing (IWB) following ORIF of all types of unstable ankle fractures has not been investigated in a controlled prospective manner in recent decades. This pragmatic randomised-controlled multicentre trial will investigate immediate weight-bearing following ORIF of all ankle fracture patterns in the usual care condition. It is hoped that these results will contribute to the modern management of ankle fractures. Trial registration ISRCTN Registry ISRCTN76410775. Retrospectively registered on 30 June 2019.

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Possible factors for ankle fractures

Vojnosanitetski pregled ◽

10.2298/vsp1003225t ◽

2010 ◽

Vol 67 (3) ◽

pp. 225-228 ◽

Cited By ~ 2

Author(s):

Dejan Tabakovic ◽

Radovan Manojlovic ◽

Marko Kadija ◽

Mihailo Ille ◽

Goran Turkovic ◽

...

Keyword(s):

Body Weight ◽

Significant Risk ◽

Ankle Fractures ◽

Type B ◽

Physical Exercises ◽

Appropriate Treatment ◽

Fracture Body ◽

Type C ◽

Fracture Types

Background/Aim. Classification of ankle fractures is commonly used for selecting an appropriate treatment and prognosing an outcome of definite management. One of the most used classifications is the Danis-Weber classification. To the best of our knowledge, in the available literature, there are no parameters affecting specific types of ankle fractures according to the Danis-Weber classification. The aim of this study was to analyze the correlation of the following parameters: age, body weight, body mass index (BMI), height, osteoporosis, osteopenia and physical exercises with specific types of ankle fractures using the Danis-Weber classification. Methods. A total of 85 patients grouped by the Danis-Weber classification fracture types were analyzed and the significance of certain parameters for specific types of ankle fractures was established. Results. The proportion of females was significantly higher (p < 0.001) with a significantly higher age (59.9 years, SD ? 14.2) in relation to males (45.1 years, SD ? 12.8) (p < 0.0001). Type A fracture was most frequent in the younger patients (34.2 years, SD ? 8.6), and those with increased physical exercises (p = 0.020). In type B fracture, the risk factor was osteoporosis (p = 0.0180), while in type C fracture, body weight (p = 0.017) and osteoporosis (p = 0.004) were significant parameters. Conclusion. Statistical analysis using the Danis-Weber classification reveals that there are certain parameters suggesting significant risk factors for specific types of ankle fractures.

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The Treatment of Displaced Ankle Fractures with Early Joint Motion and Weight Bearing

The Journal of the Korean Orthopaedic Association ◽

10.4055/jkoa.1990.25.4.1024 ◽

1990 ◽

Vol 25 (4) ◽

pp. 1024

Author(s):

Chang Dong Han ◽

Woo Hyeong Lee ◽

Ho Jung Kang ◽

Nam Hyun Kim

Keyword(s):

Weight Bearing ◽

Ankle Fractures ◽

Joint Motion

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Do weight bearing radiographs estimate the stability of an isolated distal fibula fracture?

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00526 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0052

Author(s):

Sohail Yousaf ◽

Daniel Hay

Keyword(s):

Systematic Review ◽

External Rotation ◽

Weight Bearing ◽

Ankle Fractures ◽

Controlled Trials ◽

Distal Fibula ◽

Fibula Fracture ◽

Stress Radiographs ◽

The Stability ◽

Supination External Rotation

Category: Trauma Introduction/Purpose: Differentiating stable isolated fibula fractures consistent with supination external rotation (SER) II ankle fractures from unstable SER IV fractures is essential in determining the need for surgical stabilisation. Stress radiographs are usually required to assess stability including gravity stress views (GSV) and external rotation views (ER). There is no clear consensus as to which modality is most useful to determine stability in a fracture clinic or emergency setting. In last, few years clinical uncertainty about the reliability has led researcher to focus on weight bearing radiographs (WB) .We aim to review recent literature regarding reliability of WB radiographs to estimate the stability of supination external rotation ankle fractures. Methods: A systematic review of the literature relating to radiological assessment of stability of supination external rotation ankle fractures was conducted according to PRISMA guidelines. The systematic review was prospectively registered with PROSPERO. It involved the following steps: Researching the question-Do weight bearing radiographs estimate the stability of an isolated distal fibula fracture? Setting inclusion and exclusion criteria-All English language articles published in the including any Randomised controlled trials (RCT’s) and cohort studies. Data collection)– A literature search of Medline (PubMed), the Cochrane Bone, Joint, and Muscle Trauma Group trial register, the Cochrane central register of controlled trials, Embase and CINAHL was undertaken. The grey literature was searched. Key terms ‘supination external rotation fracture’, ‘stability’. Other variations to the key words were ‘weight bearing’, “axial load”, ‘stress x-rays’, ‘systematic reviews’ and ‘meta-analysis’. Results: A total of six studies met the inclusion criteria including 601 patients. No previous systematic review on stress radiographs including weight bearing was published. All studies concluded weight bearing radiographs is an easy, pain-free, safe and reliable method to estimate stability of isolated distal fibula fractures. No serious concerns or complications were reported. Conclusion: The evidence base contained many methodological limitations and most of the evidence was either level III or IV, and so any conclusion drawn from the research must be done so with caution. The studies suggest that GSV overestimates the instability which should be assessed with studies should focus on randomized controlled trials with narrow range of clinically useful outcome measures.

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Weight-bearing or non-weight-bearing after surgical treatment of ankle fractures: a multicenter randomized controlled trial

European Journal of Trauma and Emergency Surgery ◽

10.1007/s00068-018-1016-6 ◽

2018 ◽

Vol 46 (1) ◽

pp. 121-130 ◽

Cited By ~ 5

Author(s):

Diederik Pieter Johan Smeeing ◽

Roderick Marijn Houwert ◽

Jan Paul Briet ◽

Rolf Hendrik Herman Groenwold ◽

Koen Willem Wouter Lansink ◽

...

Keyword(s):

Randomized Controlled Trial ◽

Surgical Treatment ◽

Controlled Trial ◽

Weight Bearing ◽

Ankle Fractures ◽

Randomized Controlled ◽

Multicenter Randomized Controlled Trial

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Weight-bearing in ankle fractures: An audit of UK practice

The Foot ◽

10.1016/j.foot.2019.02.005 ◽

2019 ◽

Vol 39 ◽

pp. 28-36

Author(s):

James R. Gill ◽

Emilie Lostis ◽

Sabri S. Bleibleh ◽

Michael S. Hennessy ◽

Femi Thondickal ◽

...

Keyword(s):

Weight Bearing ◽

Ankle Fractures

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Mid Term 5-Year Follow Up of a Novel Algorithm for Non-Operative Weber B Ankle Fractures

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00366 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0036

Author(s):

Edward M Rooney ◽

Fred T Finney ◽

Paul Talusan ◽

James R Holmes ◽

David Walton

Keyword(s):

Pain Score ◽

Visual Analog Scale ◽

Weight Bearing ◽

Ankle Fractures ◽

Ankle Arthritis ◽

Analog Scale ◽

Post Traumatic ◽

Grading Scale ◽

Novel Algorithm

Category: Ankle, Ankle Arthritis, Trauma Introduction/Purpose: It is important to understand which isolated fibular fractures require surgical intervention. Several different radiographic guidelines have been used to interpret and predict stability of the injured ankle. Holmes et al previously described a novel algorithm used to assess stability and the ability to treat the stable injuries non-operatively. The one year results demonstrated favorable outcomes of these non-operative patients, however there is a question about the durability of these results and whether these patients developed post-traumatic degenerative changes over mid to long term follow up. Methods: An observational study based on a previous cohort of 51 patients studied from 2010 to 2013 with isolated Weber B ankle fractures was performed. These were defined as stable at the time of injury when the medial clear space (MCS) was less than 7 mm on the initial gravity stress radiographs along with a normal mortise relationship on weight bearing radiographs. 27 patients that were treated non-surgically, were brought back for a mid-term follow up with a mean of 6.8 years. American Orthopaedic Foot & Ankle Society (AOFAS) Hindfoot scores, Olerud-Molander Ankle (OMA) Score, and visual analog scale (VAS) pain score were collected in accordance with the prior study. Patient Reported Outcome Measurement Information System (PROMIS) scores were also collected including lower extremity, physical function, depression, and pain interference. Standing bilateral ankle radiographs were obtained, and assessed for MCS widening, and ankle arthritis using the Kellgren-Lawrence grading scale. Results: Average functional score results were (in comparison to 1-year outcomes): AOFAS Hindfoot, 95.7 (93.2); OMA Score, 95.2 (91.0); and visual analog scale pain score, 0.24 (0.57). Using a Wilcox Signed Ranks Test, there was a statistically significant increase in 5-year AOFAS Hindfoot scores as compared to 1-year scores in those same patients (p=0.005) There was no evidence of significant post-traumatic osteoarthritis based on the Kellgren-Lawrence grading scale. Conclusion: The previously described, novel at the time, algorithm for assessing stability of isolated Weber B ankle fractures and nonsurgical treatment with protected weight bearing has shown to produce excellent results for mid-term follow up with an average of 6.8 years. Additionally, these patients are not at increased risk for rapid progression of post-traumatic osteoarthritis. This further supports initial weight bearing radiographs as a reasonable assessment of ankle stability and validates the aforementioned algorithm as a safe and cost-effective functional treatment regimen.

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Weight-Bearing Cone-Beam CT Scan Assessment of Stability of Supination External Rotation Ankle Fractures in a Cadaver Model

Foot & Ankle International ◽

10.1177/1071100718761035 ◽

2018 ◽

Vol 39 (7) ◽

pp. 850-857 ◽

Cited By ~ 14

Author(s):

Mark C. Lawlor ◽

Melissa A. Kluczynski ◽

John M. Marzo

Keyword(s):

Ct Scan ◽

Ankle Fracture ◽

External Rotation ◽

Imaging Modality ◽

Cone Beam Ct ◽

Weight Bearing ◽

Ankle Fractures ◽

Cone Beam ◽

Clear Space ◽

Supination External Rotation

Background: The utility of computed tomography (CT) for measuring medial clear space (MCS) for determination of the stability of supination external rotation (SER) ankle fractures and in comparison to standard radiographs is unknown. We compared MCS on gravity stress (GS) radiographs to GS and weight bearing (WB) cone-beam CT (CBCT). Methods: An AO SER 44B3.1 ankle fracture was simulated in 10 human cadavers, also serving as controls. MCS was measured on GS radiographs, GS CBCT, and a simulated WB CBCT scan. Specimens were stable if MCS was <5 mm and unstable if MCS was ≥5 mm. Paired t tests were used to compare MCS from each imaging modality for controls versus SER injuries and stable versus unstable specimens. Results: Compared with controls assessed by GS radiographs, MCS was greater for an SER injury when assessed by GS radiograph and GS CBCT scan within the stable group. Compared with controls assessed by GS radiographs, MCS was greater for SER injuries when assessed by GS radiograph, GS CBCT scan, and WB CBCT within the unstable group. MCS was reduced for stable versus unstable SER injuries assessed by WB CBCT. Conclusion: In a cadaveric model of SER ankle fracture, the medial clear space was statistically significantly greater for the experimental condition when assessed by gravity stress radiograph and gravity stress CBCT scan. Under weight-bearing conditions, the cone-beam CT scanner distinguished between stable and unstable ankles in the experimental condition. Clinical Relevance: This study suggests that a WB cone-beam CT scan may be able to distinguish between stable and unstable SER ankle fractures and influence operative decision making.

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Is post-operative non-weight-bearing necessary? Study protocol for a pragmatic randomised multicentre trial of operatively treated ankle fracture (DoWeCAST?).

10.21203/rs.3.rs-17345/v1 ◽

2020 ◽

Author(s):

Ramy E Khojaly ◽

Ruairí Mac Niocaill ◽

Muhammad Shahab ◽

Danilo Vukanic ◽

Matthew Nagle ◽

...

Keyword(s):

Short Form ◽

Plantar Flexion ◽

Weight Bearing ◽

Pragmatic Trial ◽

Ankle Fractures ◽

Hospital Length Of Stay ◽

Institutional Review Boards ◽

Related Factors ◽

Usual Condition ◽

Randomised Controlled

Abstract Background Post-operative management regimes vary following open reduction and internal fixation (ORIF) of unstable ankle fractures. There is an evolving understanding that extended periods of immobilisation and limitation of weight-bearing may lead to poorer clinical outcomes. Traditional non-weight bearing cast immobilisation may prevent loss of fixation, and this practice continues in many centres. The purpose of this trial is to investigate the safety and efficacy of immediate weight-bearing (IWB) and range of motion (ROM) exercise regimes following ORIF of unstable ankle fractures with a particular focus on functional outcomes and complication rate. Methods A pragmatic randomised controlled multi-centre trial, comparing IWB in a walking boot and ROM within 24 hours versus non-weight bearing (NWB) and immobilisation in a cast for six weeks, following ORIF of all types of unstable adult ankle fractures (lateral malleolar, bimalleolar, trimalleolar with or without syndesmotic injury) is proposed. All patients presenting to three trauma units will be included. Exclusion criteria will be skeletal immaturity and tibial plafond fractures. The three institutional review boards have granted ethical approval. The primary outcome measure will be the functional Olerud-Molander Ankle Score (OMAS). Secondary outcomes include; Wound infection (deep and superficial), displacement of osteosynthesis, total arc of ankle motion (plantar flexion and dorsal-flection), RAND 36-Item Short Form Survey (SF-36) scoring, time to return to work and postoperative hospital length of stay. The trial will be reported in accordance with the CONSORT statement for reporting a pragmatic trial and this protocol follow the SPIRIT guidance. Discussion Traditional management of operatively treated ankle fractures includes an extended period of non-weight bearing. There is emerging evidence that earlier weight-bearing may have equivocal outcomes and favourable patient satisfaction but with higher wound-related complications. These studies often preclude more complicated fracture patterns or patient-related factors. To our knowledge, immediate weight-bearing (IWB) following ORIF of all types of unstable ankle fractures has not been investigated in a controlled prospective manner. This pragmatic randomised-controlled multi-centre trial will investigate immediate weight-bearing following ORIF of all ankle fractures pattern in the usual condition of care. It is hoped that these results will contribute towards the modern management of ankle fractures.

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