A Fibular Notch Approach for the Treatment of Ankle Fractures Involving the Distal Tibial Plafond

Abstract BACKGROUND: Although several approaches have been used for the treatment of complex ankle fractures, there are still some ankle fractures which can not obtain ideal intraoperative exposure with these traditional approaches. The purpose of this study was to present an innovative fibular notch approach in detail for the treatment of ankle fractures involving the distal tibial plafond and to present a series of patients with either functional or radiographic outcomes.METHODS: Between March 2015 and October 2018, 22 patients with distal tibial plafond fractures with concomitant fibular and distal tibiofibular syndesmosis injuries were treated through a fibular notch approach. The details of the surgical technique were reviewed from the operative notes. Relevant data were reviewed from the medical records. The quality of fractures and syndesmosis reduction was examined using CT scans, and lateral stability of the ankle was assessed by physical examination and stress radiographs. The American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS) score was implemented for clinical functional assessment.RESULTS: All surgeries were successfully performed via the fibular notch approach as the primary approach. Postoperative radiography revealed satisfying restoration of all fractures and syndesmosis; however, CT scans showed mild malreduction with a gap of less than 2 mm in 4 fractures and a step-off of less than 2 mm in 1 fracture. No significant soft tissue complications occurred except for one case of delayed wound healing. All fractures healed with an average time of 17.3±3.6 weeks. Mild posttraumatic osteoarthritis (PTOA) was present in 4 patients. All patients achieved lateral stability of the ankle except one patient with distal syndesmosis instability. The average ankle range of motion was 55.0 degrees. The average AOFAS score was 88.8.CONCLUSIONS: The fibular notch approach is a safe and reliable approach for the treatment of specific ankle fractures involving the distal tibial plafond. This approach provides excellent direct visualization of the fragments and articular surface without significantly increasing iatrogenic injuries. Satisfactory radiographic and clinical results were observed, and further clinical and anatomical studies are recommended to ascertain the feasibility of this approach in the treatment of complex distal tibial fractures.

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A Fibular Notch Approach for the Treatment of Ankle Fractures Involving the Distal Tibial Plafond

10.21203/rs.3.rs-129852/v2 ◽

2021 ◽

Author(s):

Tong Liu ◽

Yiheng Cheng ◽

Wenqing Qu

Keyword(s):

Articular Surface ◽

Clinical Results ◽

Ankle Fractures ◽

Aofas Score ◽

Radiographic Outcomes ◽

Tibial Plafond ◽

Operative Notes ◽

Tibial Plafond Fractures ◽

Intraoperative Visualization

Abstract BACKGROUND: Although efficacy is related to many factors, the surgical approach is one of the most important intervention factors for complex ankle fractures. Ankle fractures involving the distal tibial plafond frequently present a surgical challenge in choosing which incisions will be best for surgical treatment. Here we present an innovative fibular notch approach for the treatment of some specific ankle fractures and present a series of patients with either functional or radiographic outcomes.METHODS: Twenty two patients with distal tibial plafond fractures with concomitant fibular and distal tibiofibular syndesmosis injuries were treated through a fibular notch approach in this retrospective study. The details of the surgical technique were reviewed from the operative notes. Relevant data were reviewed from the medical records. The quality of fractures and syndesmosis reduction was examined using CT scans, and lateral stability of the ankle was assessed by physical examination and stress radiographs. The American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS) score was implemented for clinical functional assessment.RESULTS: All surgeries were successfully performed via the fibular notch approach as the primary approach with excellent intraoperative visualization. Postoperative radiography revealed satisfying restoration of all fractures and syndesmosis. All fractures healed with an average time of 17.3±3.6 weeks. Mild posttraumatic osteoarthritis (PTOA) was present in 4 patients. The average AOFAS score was 88.8 at the last followup.CONCLUSIONS: The fibular notch approach is a safe and reliable approach for the treatment of specific ankle fractures involving the distal tibial plafond. This approach provides excellent direct visualization of the fragments and articular surface without significantly increasing iatrogenic injuries. Satisfactory radiographic and clinical results were observed, and further clinical and anatomical studies are recommended to ascertain the feasibility of this approach in the treatment of complex distal tibial fractures.

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A fibular notch approach for the treatment of ankle fractures involving the distal tibial plafond

Journal of Orthopaedic Surgery and Research ◽

10.1186/s13018-021-02270-3 ◽

2021 ◽

Vol 16 (1) ◽

Author(s):

Tong Liu ◽

Yiheng Cheng ◽

Wenqing Qu

Keyword(s):

Articular Surface ◽

Clinical Results ◽

Ankle Fractures ◽

Aofas Score ◽

Radiographic Outcomes ◽

Tibial Plafond ◽

Operative Notes ◽

Tibial Plafond Fractures

Abstract Background Although efficacy is related to many factors, the surgical approach is one of the most important intervention factors for complex ankle fractures. Ankle fractures involving the distal tibial plafond frequently present a surgical challenge in choosing which incisions will be best for surgical treatment. Here, we present an innovative fibular notch approach for the treatment of some specific ankle fractures and present a series of patients with either functional or radiographic outcomes. Methods Twenty-two patients with distal tibial plafond fractures with concomitant fibular and distal tibiofibular syndesmosis injuries were treated through a fibular notch approach in this retrospective study. The details of the surgical technique were reviewed from the operative notes. Relevant data were reviewed from the medical records. The quality of fractures and syndesmosis reduction was examined using CT scans, and lateral stability of the ankle was assessed by physical examination and stress radiographs. The American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS) score was implemented for clinical functional assessment. Results All surgeries were successfully performed via the fibular notch approach as the primary approach with excellent intraoperative visualization. Postoperative radiography revealed satisfying restoration of all fractures and syndesmosis. All fractures healed with an average time of 17.3 ± 3.6 weeks. Mild posttraumatic osteoarthritis (PTOA) was present in 4 patients. The average AOFAS score was 88.8 at the last follow-up. Conclusions The fibular notch approach is a safe and reliable approach for the treatment of specific ankle fractures involving the distal tibial plafond. This approach provides excellent direct visualization of the fragments and articular surface without significantly increasing iatrogenic injuries. Satisfactory radiographic and clinical results were observed, and further clinical and anatomical studies are recommended to ascertain the feasibility of this approach in the treatment of complex distal tibial fractures.

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Outcomes of Posterior Arthroscopic Reduction and Internal Fixation (PARIF) for the Posterior Malleolar Fragment in Trimalleolar Ankle Fractures

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00347 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0034

Author(s):

Kevin D. Martin ◽

Jeannie Huh

Keyword(s):

Internal Fixation ◽

Patient Reported Outcomes ◽

Articular Surface ◽

Ankle Fractures ◽

Ct Scans ◽

Loose Bodies ◽

Arthroscopic Reduction ◽

Malleolar Fractures ◽

Posterior Malleolus ◽

Patient Reported

Category: Arthroscopy; Trauma Introduction/Purpose: The treatment of posterior malleolar fractures within a trimalleolar ankle fracture pattern can be challenging to manage. Due to anatomical constraints that inhibit visualization of the articular surface, reduction of the posterior malleolus relies on cortical read and/or intraoperative fluoroscopy. Posterior ankle arthroscopy is a tool that may address this shortfall by providing a means to assess the intra-articular and syndesmotic reductions, while removing any loose bodies. The purpose of this study was to determine the radiographic and patient reported outcomes of posterior arthroscopic reduction and internal fixation (PARIF) for the posterior malleolar fragment in trimalleolar ankle fractures. Methods: From November 2015 to May 2019, we prospectively enrolled consecutive trimalleolar ankle fractures that underwent PARIF for the posterior malleolar fragment by a single surgeon. Patient demographics, surgical details, and fracture characteristics, as determined by computed tomography (CT) scan, were obtained. At final follow-up the main outcome measures collected were: The Foot and Ankle Disability Index (FADI), American Orthopaedic Foot & Ankle Society (AOFAS) ankle score, Olerud and Molander Ankle Score (OSMA), the Visual Analog Score (VAS), and surgical complications. Preoperative and postoperative CT scans were interpreted and compared by two blinded musculoskeletal radiologists for articular congruity, syndesmosis congruity, and presence of loose bodies. Results: A total of 29 trimalleolar ankle fractures were treated with PARIF, including 15 fracture-dislocations. Mean patient age was 36 (range, 19-69) years. Mean prone tourniquet time was 58 (range, 35-79) minutes. Preoperative CT scans demonstrated intra-articular loose bodies in 53% of fractures and syndesmosis incongruity in 80% of fractures. Postoperative CT scans showed one ankle with a retained loose body and residual syndesmosis incongruity in 17% of fractures. 100% of fractures healed and demonstrated intra-articular reduction within 2mm. There were 2 complications (hardware irritation and sural nerve numbness). 2-year patient reported outcomes were available in 13 patients. These included mean VAS 1 (range 0-4), mean AOFAS score 84 (range, 63-100), mean FADI 85 (range, 59-100), and mean OSMA 76 (range, 40-100). Conclusion: Posterior ankle arthroscopic reduction and internal fixation (PARIF) is a safe and effective option for management of posterior malleolar fractures. The technique results in improved intra-articular and syndesmosis congruity, while removing loose bodies. Future studies are needed that compare this technique with current practices.

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Magnetic Resonance Imaging and Outcomes of Osteochondral Lesions of the Talus Associated With Ankle Fractures

Foot & Ankle International ◽

10.1177/1071100720937243 ◽

2020 ◽

Vol 41 (10) ◽

pp. 1219-1225

Author(s):

Seçkin Özcan ◽

Nizamettin Koçkara ◽

Yalkın Camurcu ◽

Hakan Yurten

Keyword(s):

Magnetic Resonance Imaging ◽

Magnetic Resonance ◽

Clinical Results ◽

Ankle Fractures ◽

Osteochondral Lesions ◽

Resonance Imaging ◽

Aofas Score ◽

Prospective Comparative Study ◽

The Mean ◽

Second Year

Background: Osteochondral lesions of the talus (OCLTs) secondary to ankle fractures have previously been reported in the literature. However, no study has evaluated OCLTs using magnetic resonance imaging (MRI) following ankle fracture treatment. The purpose of our study was to investigate accompanying OCLTs in patients with an ankle fracture and evaluate its relationship with the clinical outcomes. Methods: Fifty-six patients with ankle fractures who were treated with either a nonoperative or operative method at our center between June 2016 and February 2017 were included in this prospective comparative study (37 men and 19 women; mean age, 44.6 ± 13 years; range, 20-65 years). The mean American Orthopaedic Foot & Ankle Society (AOFAS) scores were used to evaluate the clinical results in all patients in the second month and second year. The second-month ankle MR images were evaluated for OCLTs in all patients. Thirty patients were treated operatively and 26 nonoperatively. Results: Accompanying OCLTs were detected in 19 of 56 patients (34%). Our results showed no statistically significant association between OCLT and fracture type, as well as the treatment type. In the second postoperative month, the mean AOFAS scores were 87.2 ± 10.8 and 77.6 ± 12.0 in patients with and without OCLTs, respectively ( P = .005). In the second postoperative year, the mean AOFAS scores were 81.3 ± 6.8 and 86.2 ± 8.4 in patients with and without OCLTs, respectively ( P = .031). The mean AOFAS score significantly decreased in the OCLT group in the second-year control, whereas a significant increase was observed in patients without OCLTs ( P = .026 and P < .001, respectively). Conclusion: According to our results, the accompanying OCLTs were found in one-third of patients treated for ankle fractures. We observed a significant correlation between OCLT presence and the AOFAS score. According to the AOFAS score, OCLTs statistically significantly affected clinical results at 2 years. Level of Evidence: Level II, prospective comparative study.

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The Lateral Trans-Malleolar approach for Posterior Malleolar Fracture of the Ankle: A Clinical and Computed Tomography Evaluation

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00463 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0046

Author(s):

Masanori Taki ◽

Naohiro Hio

Keyword(s):

Computed Tomography ◽

External Rotation ◽

Articular Surface ◽

Clinical Results ◽

Direct Visualization ◽

Malleolar Fracture ◽

Aofas Score ◽

Posterior Malleolar Fracture ◽

Posterior Malleolus

Category: Ankle; Trauma Introduction/Purpose: Posterior malleolar fracture reduction including the articular surface of trimalleolar ankle fracture has been reported to be an important prognostic factor. The lateral trans-malleolar approach (LTA) is a surgical approach that provides direct visualization of the articular surface of the posterior malleolus. We herein report the clinical results and computed tomography (CT) findings for the articular reduction status after LTA for posterior malleolar fracture of the ankle. Methods: Sixteen patients (9 men, 7 women, mean age 52.6+-18.1 years old) who underwent the LTA for posterior malleolar fracture of the ankle and were followed for at least 1 year were evaluated retrospectively. The types of ankle malleolar fracture according to the Lauge-Hansen classification were Supination-External rotation (SER) in 13 patients and Pronation-External rotation (PER) in 3 patients. The CT classifications of posterior malleolus fracture by Haraguchi were Type 1 in 6 cases, Type 2 in 10 cases and Type 3 in 0 cases. The AOFAS score, post-surgical complications and reduction status of the posterior malleolus on CT were investigated. Results: The mean follow-up period was 15.5 months. The AOFAS score was 93.0+-5.2 points. Postoperative complications were seen in one case of superficial infection; however, delayed union, nonunion and fibular necrosis were not observed. The articular step-off in CT improved significantly after surgery (5.9+-2.9 mm preoperatively vs. 0.6+-0.8 mm postoperatively). The 2 patients who showed an articular step-off exceeding 1 mm were both Haraguchi type 2 posterior malleolar fracture. Conclusion: Several approaches for managing posterior malleolus of the ankle have been reported. However, few provide direct visualization to the articular surface. The LTA requires relatively substantial invasion, but it can facilitate surgery in the supine position and thereby reduce the articular surface directly. In our experience, the LTA provided favorable clinical results and fracture reductions. Even when utilizing the LTA, it remains difficult to confirm the fracture reduction of medial articular surface for Haraguchi type 2 medial extension fractures. Therefore, it remains important to also perform appropriate intraoperative X-ray controls.

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Percutaneous Chevron/Akin (PECA) versus open scarf/Akin (SA) osteotomy treatment for hallux valgus: A systematic review and meta-analysis

PLoS ONE ◽

10.1371/journal.pone.0242496 ◽

2021 ◽

Vol 16 (2) ◽

pp. e0242496

Author(s):

Gabriel Ferraz Ferreira ◽

Vinícius Quadros Borges ◽

Leonardo Vinícius de Matos Moraes ◽

Kelly Cristina Stéfani

Keyword(s):

Systematic Review ◽

Hallux Valgus ◽

Meta Analysis ◽

Clinical Results ◽

Pain Scale ◽

Pooled Analysis ◽

Mean Difference ◽

Radiographic Evaluation ◽

Aofas Score ◽

Radiographic Outcomes

Purpose The objective of the study is to compare the radiographic and clinical results of two techniques for the treatment of hallux valgus that have the same indication, the open scarf/Akin (SA) technique and the percutaneous Chevron/Akin (PECA). Methods A meta-analysis was performed with the studies found during a systematic review of articles included in electronic databases until 30 May 2020. The pooled analysis was summarized according to clinical outcomes, such as visual analog pain scale (VAS) and American Orthopaedic Foot & Ankle Society (AOFAS) score, radiographic outcomes and complications, with a 95% confidence interval. Results Three studies comparing the open scarf/Akin (SA) versus the PECA techniques were added to the analysis, corresponding to 235 feet, 102 in the PECA group and 133 in the SA. The final mean difference in the hallux valgus angle was 0.80 degrees and in the intermetatarsal angle 0.53, in the last radiographic evaluation. In the AOFAS score, the final mean difference was 4.97 points and in the VAS 0.14 in relation to the last clinical evaluation. Exposure to radiation during the surgical procedure was higher in the PECA group with a mean of 35.53 seconds. Conclusions The PECA surgical technique for the treatment of hallux valgus when compared with SA demonstrated similar radiographic correction, pain and function after six months of follow-up but with a longer radiation exposure time. Register of systematic review (PROSPERO) CRD42018096613.

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Lateral Trans-Malleolar Approach for Posterior Malleolar Fractures of the Ankle for Articular and Syndesmosis Reduction : A Retrospective Study

10.21203/rs.3.rs-1023233/v1 ◽

2021 ◽

Author(s):

Masanori Taki ◽

Kosuke Suzuki ◽

Naohiro Hio ◽

Atsushi Hasegawa

Keyword(s):

Articular Surface ◽

Clinical Results ◽

Aofas Score ◽

Superficial Infection ◽

Malleolar Fractures ◽

Posterior Malleolus ◽

Fibular Fracture ◽

The Mean

Abstract Background The lateral transmalleolar approach (LTA) is a surgical approach for posterior malleolar fractures (PMFs), providing direct visualization of the articular surface of the posterior malleolus, though temporarily disrupting the syndesmosis. However, it is still unclear whether this fibrous joint can be effectively reconstructed afterward to prevent complications. We report the clinical results and computed tomography (CT) findings for articular and syndesmosis reduction status after surgery with LTA for PMF. Methods Sixteen patients who underwent PMF reduction with LTA and were followed up for at least 1 year were evaluated retrospectively. According to the AO/OTA classification, the fracture type was type 44B in 13 patients and 44C in three patients. The Haraguchi classifications of PMF were type 1 in six cases and type 2 in 10 cases. The American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS) score, post-surgical complications, and reduction status of PMF and syndesmosis on CT were investigated. Results The mean AOFAS score was 93.0 ± 5.2 points. Post-operative complications were observed in one case of superficial infection and one case of delayed fibular union. The articular step-off seen on CT improved significantly after surgery (5.9 ± 2.9 mm preoperatively vs. 0.6 ± 0.8 mm post-operatively). Syndesmosis malreduction was seen in three cases, including two high fibular fractures and one comminuted fibular fracture with osteoporosis. Conclusions The LTA provided favourable clinical results and effective reduction of intra-articular PMFs. However, surgeons should be aware of the possibility of syndesmosis malreduction in cases of high fibular fractures or comminuted fibular fractures.

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The Surgical Outcomes of Unstable Ankle Fractures in Patients Aged >65 Years

Geriatric Orthopaedic Surgery & Rehabilitation ◽

10.1177/2151459321997765 ◽

2021 ◽

Vol 12 ◽

pp. 215145932199776

Author(s):

Adem Sahin ◽

Anıl Agar ◽

Deniz Gulabi ◽

Cemil Erturk

Keyword(s):

Surgical Outcomes ◽

External Rotation ◽

High Energy ◽

Ankle Fractures ◽

Medial Malleolus ◽

Aofas Score ◽

Non Union ◽

The Mean ◽

Medial Malleolus Fracture ◽

Mechanism Of Trauma

Aim: To evaluate the surgical outcomes and complications of patients over 65 years of age, with unstable ankle fractures. Material and Method: The study included 111 patients (73F/38 M) operated on between January 2015 and February 2019 and followed up for a mean of 21.2 months (range, 6-62 months).Demographic characteristics, comorbidities, fracture type, and mechanisms of injury were evaluated. Relationships between postoperative complications and comorbidities were examined. In the postoperative functional evaluations, the AOFAS score was used and pre and postoperative mobilization (eg, use of assistive devices) was assessed. Results: The mean age of the patients was 70.5 ± 6.1 years (range, 65-90 years). The mechanism of trauma was low-energy trauma in 90.1% of the fractures and high-energy trauma in 9.9%. The fractures were formed with a SER injury (supination external rotation) in 83.7% of cases and bimalleolar fractures were seen most frequently (85/111, 76%).Complications developed in 16 (14.4%) patients and a second operation was performed in 11 (9.9%) patients with complications. Plate was removed and debridement was performed in 5 of 6 patients due to wound problems. Nonunion was developed in the medial malleolus in 4 patients. Revision surgery was performed because of implant irritation in 2 patients and early fixation loss in the medial malleolus fracture in one patient. Calcaneotibial arthrodesis was performed in 3 patients because of implant failure and ankle luxation associated with non-union. A correlation was determined between ASA score and DM and complications, but not with osteoporosis. The mean follow-up AOFAS score was 86.7 ± 12.5 (range, 36-100).A total of 94 (84.7%) patients could walk without assistance postoperatively and 92 (82.9%) were able to regain the preoperative level of mobilization. Conclusion: Although surgery can be considered an appropriate treatment option for ankle fractures in patients aged >65 years, care must be taken to prevent potential complications and the necessary precautions must be taken against correctable comorbidities.

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Clinical, functional and radiographic outcomes after revision total hip arthroplasty with tapered fluted modular or non-modular stems: a systematic review

Hip International ◽

10.1177/11207000211004383 ◽

2021 ◽

pp. 112070002110043

Author(s):

Antonios A Koutalos ◽

Sokratis Varitimidis ◽

Konstantinos N Malizos ◽

Theofilos Karachalios

Keyword(s):

Total Hip Arthroplasty ◽

Hip Arthroplasty ◽

Revision Rate ◽

Clinical Results ◽

Fracture Rate ◽

Revision Total Hip Arthroplasty ◽

Term Survival ◽

Total Hip ◽

Radiographic Outcomes

Purpose: The aim of the study was to systematically evaluate clinical outcomes of tapered fluted stems, either monoblock or modular, in revision total hip arthroplasty. Methods: PubMed, EMBASE and Web of Science and Cochrane databases were systematically searched by 2 researchers. Clinical studies reporting primarily on survival and re-revision rates, and secondarily on subsidence, dislocation, intraoperative fractures, periprosthetic fractures and infection were included. 2 investigators assessed the quality of the studies. Results: 46 studies were included in this review, reporting on 4601 stem revisions. The pooled re-revision rate was 5.1% and long-term survival ranged from 75% to 98.5%. No differences were observed between monoblock and modular stems regarding re-revision rate, dislocation rate, periprosthetic fracture rate or infection rates. Monoblock stems exhibited more subsidence and modular stems displayed more intraoperative fractures. Conclusions: Satisfactory results can be obtained with the use of tapered fluted end-bearing stems. Monoblock stems offer the same clinical results as modular stems.

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Predisposing Factors for Posttraumatic Osteoarthritis After Malleolus Fracture Fixation in Patients Younger Than 50 Years

Foot & Ankle International ◽

10.1177/10711007211050039 ◽

2021 ◽

pp. 107110072110500

Author(s):

Jong Seok Beak ◽

Yeong Tae Kim ◽

Sung Hyun Lee

Keyword(s):

Risk Factors ◽

Articular Surface ◽

Binary Logistic Regression ◽

Ankle Fractures ◽

Fracture Dislocation ◽

Posttraumatic Arthritis ◽

Level Of Evidence ◽

Posttraumatic Osteoarthritis ◽

Posterior Malleolus

Background: The purpose of this study was to identify the risk factors for posttraumatic osteoarthritis (OA) after surgery for ankle fractures in patients aged ≤50 years. Methods: We performed a retrospective review of consecutive patients who underwent surgery for ankle fractures and were followed up for a minimum period of 5 years. The patients were assigned to 2 groups according to the presence of advanced OA at the last follow-up. Binary logistic regression was used to model the correlation between risk factors and OA. Functional outcomes were assessed using the Foot and Ankle Outcome Score. Results: The data of 332 patients who met the inclusion criteria were included in the analysis. The overall rate of posttraumatic arthritis was 27.7% (nonarthritis group: 240 patients, arthritis group: 92 patients). The arthritic change was significantly affected by BMI (95% confidence interval [CI] 1.29-19.76; adjusted odds ratio [OR] ≥ 30, 6.56), fracture-dislocation injury (CI 1.66-11.57; adjusted OR, 4.06), posterior malleolus (PM) fracture (CI 1.92-12.73, adjusted OR > 25% of the articular surface, 5.72), and postoperative articular incongruence (CI 1.52-18.10; adjusted OR, 7.21). The mean scores of the arthritis group were lower than those in the nonarthritis group ( P < .05). Conclusion: Obesity, fracture-dislocation injury, concomitant large PM fracture, and articular incongruence were risk factors of posttraumatic OA after surgery for ankle fractures. Surgeons should be aware that accurate reduction is critical in patients with ankle fractures with associated large PM fractures, especially those with obesity or severe initial injuries such as fracture-dislocation. Level of Evidence: Level III, case control study.

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