Tips and Tricks in surgical reduction of the posterior column of AO/OTA C3 pilon fractures

Background Accurate posterior column reduction remains a challenging and controversial topic in the management of complex pilon fractures (AO/OTA C3). We aim to report the outcomes of surgical treatment for 22 AO/OTA C3 pilon fracture cases between January 2015 and May 2017 and highlight some traps and tips. Methods Three patients underwent two-stage early plating on the posterior column through a posterolateral approach. The remaining 19 patients were treated with two-stage delayed plating on the posterior column: 11 patients were treated with a posterolateral approach, five patients with a modified posteromedial approach, and three patients with a single anterior approach. The reduction of the posterior column was evaluated according to the Burwell-Charnley’s radiographic criteria, and functional outcomes were assessed using the American Orthopedic Foot and Ankle Society (AOFAS) scores. Results Posterior column malreduction occurred in five cases, including in one case that was re-adjusted immediately and in another case that was re-adjusted during a two-staged delayed operation. According to Burwell-Charnley’s criteria, the satisfactory rate of fracture reduction was 81.8%. After 1 year, the mean AOFAS score was 81.9 (81.9 ± 9.9); the outcome was excellent in three (20.0%), good in nine (60.0%), and fair in three (20.0%). Excellent or good outcomes were noted in 12 patients (80.0%). Conclusions The combined anterior and posterior approach is suggested in the second stage of plating so that the posterior column fragments can be re-adjusted intraoperatively, if necessary. Following these procedures, satisfactory reduction and recovery of good ankle function can be anticipated.

Double Posteromedial Portals for Excision of a Symptomatic Os Trigonum With Ankle Arthroscopy in Supine Position

Background: The existence of abnormal os trigonum often causes posterior ankle impingement syndrome, the commonly used method for excision of symptomatic os trigonum is standard arthroscopic approach when posterior and anterior abnormalities appear in one patient. However, the arthroscopy of posterior and anterior compartement of the ankle joint must be undertaken in one surgical position. In most cases, when adopting the standard arthroscopic approach, the patient has to be firstly positioned supine to perform the anterior procedure, and then re-positioned prone to operate on the posterior compartment. Material and Methods: To simplify this process and shorten operation time, we describe a double posteromedial ankle portals procedure, which provides access to reach both the posterior and anterior compartment without changing position, to exam both symptomatic compartement. Standard operation are conducted by changing position to reach both compartement. Standard operation and double posteromedial ankle portals procedure were conducted to 46 patients (standard approach 23, 2 posteromedial portals 23). Operation time, AOFAS score, KAF score and VAS score were analyzed.Results: It shows operation time reduced from 69.78±5.24 min to 36.61±3.63 min (P<0.05) and postoperative recovery index of novel method including AOFAS score, KAF score and VAS score were better than that in standard way one month after operation, but there was no significance difference after one month. Conclusion: The figures strongly suggest that the double posteromedial portals approach is better than the standard procedures in operation time, short-term postoperative recovery.

Ankle arthrodesis using computer assisted external fixator in patients with end-stage ankle arthrosis

Objective. Ankle arthrosis is an end stage disease for the ankle that happens because of posttraumatic arthropathies or inflammatory diseases. Ankle arthrodesis is the gold standard for ankle arthritis. We present the functional outcome for a mid-term follow up study of the patients who underwent trans fibular ankle arthrodesis fixated with hexapod type external fixator through a distal fibular grafting technique. Materials and Methods. A number of 18 patients with trans fibular ankle arthrodesis were included in this study, out of which 6 were female and 12 were male. The mean age at surgery was 57.6 (ranging from 45 to 73). All the patients underwent follow up for a mean follow up period of 27.5 months (ranging from 24 to 35 months). One of the patients had undergone ankle-related surgery for 9 times. The others had undergone 4 or more ankle-related surgeries. Results. Ankle fusions resulted in bony union within postoperative 4.1 months (ranging from 3 to 6 months). None of our patients had superficial or deep infection, soft tissue problems or problems about the external fixator. The mean preoperative AOFAS score was 52.4, and the postoperative AOFAS score was 78.2. We had 7 excellent (38.8%), and 11 (61.1%) good results. We had two cm shortening in 2 patients, 1.5 cm shortening in 1 patient and 1 cm in 5 patients. Conclusions. We have found this method to be useful to be applied to patients, especially to those who undergo lots of surgeries and for whom amputation is a last option.

Comparison of deltoid ligament repair and non-repair in acute ankle fracture: A meta-analysis of comparative studies

Background Rupture of the deltoid ligament (DL) in acute ankle fracture is very common. However, there is still insufficient evidence on whether to repair the DL in acute ankle fracture. Therefore, a systematic review and meta-analysis of comparative studies was performed to report the outcome of DL repair in acute ankle fracture. Methods The PubMed, Cochrane Library, EMBASE and Web of Science databases were searched from the inception dates to October 31, 2020, for comparative studies. The methodological quality was evaluated based on the risk-of-bias tool of the Cochrane Collaboration for Randomized Controlled Trials (RCTs) or the Risk-of-Bias Assessment Tool for Non-randomized Studies (RoBANS). The post-operative medial clear space (MCS), final MCS, American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, visual analogue scale (VAS) score and incidence of complications were analysed. Results A total of 8 comparative studies involving 388 participants who suffered Weber type B or C ankle fractures were included in this meta-analysis. The results showed that the post-operative MCS, final MCS, AOFAS score and rate of complications were statistically superior in the DL repair group. For the VAS score, there was no significant difference between the DL repair group and the DL non-repair group. Conclusions In this meta-analysis of comparative studies, DL repair offered great advantages in terms of the post-operative MCS, final MCS, AOFAS score and rate of complications compared with non-repair. The repair of the DL in patients with acute ankle fractures might be beneficial to ankle joint stability and assist in improving the quality of ankle reduction. More high-quality and prospective studies with long follow-up durations are needed to further demonstrate the superiority of DL repair over non-repair.

Average 4-Year Outcomes of Distal Oblique First Metatarsal Osteotomy for Stage 1 to 3 Hallux Rigidus

Background: Hallux rigidus is the second most frequent pathology of the first ray. Surgical options for degenerative metatarsophalangeal joint disease are either joint destructive or conservative procedures. The hypothesis was that oblique distal shortening osteotomy of the first metatarsal is an effective conservative technique for the management of stage 1 to 3 hallux rigidus. Methods: We conducted a retrospective cohort study of 87 feet with Coughlin and Shurnas’s stage 1-3 hallux rigidus, operated between 2009 and 2019. The cohort consisted in 72 patients (87 feet) with an average age of 57±9 (30/79) years; 22 of 87 (25.3%) feet had the first metatarsal surgery performed in isolation; 65 of 87 (74.7%) had concomitant forefoot procedures, including 31 of 87 (35.6%) with Akin phalangeal osteotomies and 34 of 87 (39.1%) with Moberg phalangeal osteotomies. We evaluated the American Orthopaedic Foot & Ankle Society (AOFAS) Scale, subjective satisfaction, joint amplitudes, shortening rate, and occurrence of postoperative complications with a mean follow-up of 51 months (16/134). Results: The AOFAS score increased from 54.2±11.3 (25/70) preoperatively to 92.2±7.8 (62/100) postoperatively ( P < .001). Patients reported excellent or good outcome in 95.4% of cases. The 40-point self-reported pain subscale score improved from 19.6 (± 10.0) to 37.4 (± 5.4), P < .001. The overall range of motion increased from 61±21 (20/110) degrees to 69±17 (35/120) degrees ( P < .001). The mean first metatarsal shortening rate (SRpo) was 9.6%. Neither the Coughlin grade, the metatarsal index, or the SRpo influenced the AOFAS score. At 6-month follow-up, 15 patients had transfer metatarsalgia compared with 5 at last follow-up without requiring another surgical procedure. The risk was not significantly different according to Coughlin's stage, preoperative metatarsal index, or SRpo. Conclusion: Oblique distal osteotomy of the first metatarsal for stage 1-3 hallux rigidus, often in combination with other first ray procedures, performed well during our follow-up time period, with a high subjective satisfaction rate and few complications. Level of Evidence: Level III, retrospective cohort study.

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

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.

The effect of a modified chevron osteotomy for hallux valgus patients: A five-year follow-up study

Purpose This study aimed to detect the effect of a modified chevron osteotomy on hallux valgus (HV) deformity at five-year follow up. Methods Twenty patients with symptomatic HV who underwent modified chevron osteotomy between June 2014 and January 2016 were included in the present study. The follow-up duration was more than five years. Each patient was evaluated preoperatively, six weeks postoperatively and five years postoperatively using the visual analog scale (VAS) pain score, the American Orthopaedic Foot & Ankle Society (AOFAS) score and cosmetic and radiological outcomes. Results The AOFAS score improved from 54.40 (± 4.58) preoperatively to 94.30 (± 2.15) six weeks postoperatively (p < 0.001) and 96.95 (± 1.54) five years postoperatively (p < 0.001). The VAS scores decreased from 6.30 (± 1.17)preoperatively to 0.15 (± 0.37) five years postoperatively (p < 0.001). The mean intermetatarsal angle improved from 16.00° (± 2.20°) preoperatively to 4.15° (± 1.22°) six weeks postoperatively (p < 0.001) and 4.40° (± 1.39°) five years postoperatively (p < 0.001). The mean HV angle also improved, from 32.70° (± 5.34°) preoperatively to 4.80° (± 1.40°) six weeks postoperatively (p < 0.001) and 5.20° (± 1.32°) five years postoperatively (p < 0.001). The cosmetic results were either excellent or good in 19 patients (95%). There was no recurrence in this study during the five postoperative years. Conclusion A modified chevron osteotomy can achieve successful correction of moderate-to-severe HV, with excellent outcomes at five-year follow up.

Allograft Versus Autograft Osteochondral Transplant for Chondral Defects of the Talus: Systematic Review and Meta-analysis

Background: It is unclear whether the results of osteochondral transplant using autografts or allografts for talar osteochondral defect are equivalent. Purpose: A systematic review of the literature was conducted to compare allografts and autografts in terms of patient-reported outcome measures (PROMs), MRI findings, and complications. Study Design: Systematic review; Level of evidence, 4. Methods: This study was conducted according to the PRISMA guidelines. The literature search was conducted in February 2021. All studies investigating the outcomes of allograft and/or autograft osteochondral transplant as management for osteochondral defects of the talus were accessed. The outcomes of interest were visual analog scale (VAS) score for pain, American Orthopaedic Foot and Ankle Society (AOFAS) score, and Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score. Data concerning the rates of failure and revision surgery were also collected. Continuous data were analyzed using the mean difference (MD), whereas binary data were evaluated with the odds ratio (OR) effect measure. Results: Data from 40 studies (1174 procedures) with a mean follow-up of 46.5 ± 25 months were retrieved. There was comparability concerning the length of follow-up, male to female ratio, mean age, body mass index, defect size, VAS score, and AOFAS score ( P > .1) between the groups at baseline. At the last follow-up, the MOCART (MD, 10.5; P = .04) and AOFAS (MD, 4.8; P = .04) scores were better in the autograft group. The VAS score was similar between the 2 groups ( P = .4). At the last follow-up, autografts demonstrated lower rate of revision surgery (OR, 7.2; P < .0001) and failure (OR, 5.1; P < .0001). Conclusion: Based on the main findings of the present systematic review, talar osteochondral transplant using allografts was associated with higher rates of failure and revision compared with autografts at midterm follow-up.

Surgical Management of Focal Chondral Defects of the Talus: A Bayesian Network Meta-analysis

Background: No consensus has been reached regarding the optimal surgical treatment for focal chondral defects of the talus. Purpose: A Bayesian network meta-analysis was conducted to compare the clinical scores and complications of mosaicplasty, osteochondral auto- and allograft transplant, microfracture, matrix-assisted autologous chondrocyte transplant, and autologous matrix-induced chondrogenesis (AMIC) for chondral defects of the talus at midterm follow-up. Study Design: Bayesian network meta-analysis; Level of evidence, 4. Methods: This Bayesian network meta-analysis followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions. PubMed, Embase, Google Scholar, and Scopus databases were accessed in February 2021. All clinical trials comparing 2 or more surgical interventions for the management of chondral defects of the talus were accessed. The outcomes of interest were visual analog scale (VAS) score, American Orthopaedic Foot and Ankle Society (AOFAS) score, rate of failure, and rate of revision surgery. The network meta-analysis were performed through the routine for Bayesian hierarchical random-effects model analysis. The log odds ratio (LOR) effect measure was used for dichotomous variables, and the standardized mean difference (SMD) was used for continuous variables. Results: Data from 13 articles (521 procedures) were retrieved. The median length of the follow-up was 47.8 months (range, 31.7-66.8 months). Analysis of variance revealed no difference between the treatment groups at baseline in terms of age, sex, body mass index, AOFAS score, VAS score, and mean number of defects. AMIC demonstrated the greatest AOFAS score (SMD, 11.27) and lowest VAS score (SMD, –2.26) as well as the lowest rates of failure (LOR, 0.94) and revision (LOR, 0.94). The test for overall inconsistency was not significant. Conclusion: At approximately 4 years of follow-up, the AMIC procedure for management of focal chondral defects of the talus produced the best outcome.

537 Open vs Closed Pilon Fractures: Comparison of Management, Outcomes, and Complications

Aim Despite the low incidence of pilon fractures, their high impact nature presents difficulties in surgical management/recovery. Current literature is varied, with no universal treatment algorithm. We aim to highlight differences in treatment, outcomes, complications between open and closed pilon fractures. Method This retrospective study was conducted at a major trauma centre, including patients over 5-year period. 135 patients were included (open:48, closed:87). Primary outcome was AOFAS score at 3-, 6- and 12-months post-injury. Secondary outcomes include time to partial weight-bear (PWB) and full weight-bear (FWB), bone union time, follow-up time. Post-operative complications were collected. Results Open fractures had lower AOFAS score 3 months post-injury, longer bone union time, and time to FWB. For both open and closed fractures, compared to ORIF patients, those treated with fine wire fixator (FWF) had lower AOFAS scores 3- and 6-months post-injury. Closed fracture patients treated with ORIF had shorter bone union time, time to PWB and FWB. Patients with AO/OTA 43A fractures needed shorter time to PWB and FWB than those with 43C fractures. Common complications (closed:open) were superficial infection (22%:54%), post-traumatic arthritis (25%:16%), non-union (11%:24%). Conclusions Open fractures, with more extensive soft tissue damage, were likely more suited for FWF, rather than ORIF (18% of open vs 72% of closed were treated with ORIF). Due to greater associated trauma, more frequent complications, and delayed definitive fixation, open fractures had lower AOFAS scores. Nevertheless, use of staged approach involving temporary external fixation, followed with ORIF or FWF achieved low complication rates and good functional recovery.