Osteochondral Lesions of the Tibial Plafond and Ankle Instability With Ankle Cartilage Lesions: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle

Background: An international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to present the consensus statements on osteochondral lesions of the tibial plafond (OLTP) and on ankle instability with ankle cartilage lesions developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. Methods: Forty-three experts in cartilage repair of the ankle were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 4 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed on in unanimous fashion within the working groups. A final vote was then held. Results: A total of 11 statements on OLTP reached consensus. Four achieved unanimous support and 7 reached strong consensus (greater than 75% agreement). A total of 8 statements on ankle instability with ankle cartilage lesions reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support, and seven reached strong consensus (greater than 75% agreement). Conclusions: These consensus statements may assist clinicians in the management of these difficult clinical pathologies. Level of Evidence: Level V, mechanism-based reasoning.

Morphological analysis of posterior malleolar fractures with intra-articular impacted fragment in computed tomography scans

Background Intraarticular impacted fragment (IAIF) of posterior malleolar fractures has been reported by a few studies. However its location, morphology, and the correlation of posterior malleolar fractures have not been described in detail. The aim of this study was to describe the morphology of IAIF in posterior malleolar fractures, to analyze the related factors between IAIF and posterior malleolar fragments, and explore the treatment of IAIF. Materials and methods Between January 2013 and December 2018, 108 consecutive patients with unilateral posterior malleolar fractures were managed in our hospital. Basic demographic and computed tomography (CT) data were collected and classified by Lauge–Hansen, OTA/AO, Haraguchi, and Mason classification. Additional radiographic data, including the length and area of posterior malleolar fragment, IAIF, and stable tibial plafond were measured. The location of IAIF was described, and involvement of the fibular notch and medial malleolus was also observed. Statistics were analyzed based on univariate analysis (Chi-square test, t-test, Mann–Whitney U test, Fisher’s test) and Spearman’s correlation test. Results Among the 108 cases of posterior malleolar fractures, 75 (69.4%) were with IAIF and 33 (30.6%) cases were without. There were 74 (68.5%) females and 34 (31.5%) males, and the average age of the patients was 49 years (18–89 years). The average LIFN/(LIFN + LSFN) [length of involving fibular notch/(length of involving fibular + length of stable notch fibular notch)] was 32.9% (11.6–64.9%). The APMF/(APMF + ASTP + AIAIF) [area of posterior malleolar fragment/(area of posterior malleolar fragment + area of IAIF + area of stable tibial plafond)] and AIAIF/APMF (area of IAIF/area of posterior malleolar fragment) were 13.1% (0.8–39.7%) and 52.6% (1.2–235.4%), respectively. Involvement of medial malleolus (fracture line extended to medial malleolus, P = 0.022), involvement of fibular notch (P = 0.021), LIFN/(LIFN + LSFN) (P = 0.037), LMPMF (P = 0.004), and APMF were significantly related to the occurrence of IAIF. Conclusion Our research indicates a high incidence of IAIF in posterior malleolar fractures. All IAIFs were found in posterior malleolar, and the most common location was within the lateral area A. Posterior malleolar fracture lines that extend to medial malleolus or fibular notch herald the incidence of IAIF. LIFN/(LIFN + LSFN), LMPMF and APMF are also associated with the incidence of IAIF. CT scans are useful for posterior malleolar fractures to determine the occurrence of IAIF and make operational plans. Operation approach selection should be based on the morphology of posterior malleolar fragments and the location of IAIF. Level of evidence Level III, retrospective case analysis.

Impact of Early Rehabilitation in a Complex Case of Non-union of Tibial Plafond Fracture with Osteosynthesis Associated Infection – A Case Report

Background: Fractures of distal end of tibia associated with soft tissue injuries and fracture of distal fibular end are very complex and forms a total of 1-2% of all fracture of lower limb. These fractures are widely termed as plafond fractures. Case Presentation: A 26- year-old male, a follow up case, gave a history of road traffic accident following which he underwent corticotomy and application of external Ilizarovring fixator. At present due to non-union of the fracture segments patient got readmitted after a year. Further management through a three-step surgical approach was carried out. Rehabilitation program began from post-operative day 1 and was continued for a period of three weeks. Investigations: On the day of examination, the patient’s pain was severe on movement with presence of disuse trophy of lower limb musculature of the affected extremity. Ranges on the right lower limb at all joints were reduced due to pain. The X-ray showed presence of 9-hole recon plate fixed distally over talus and proximally to tibia. Management: Physiotherapeutic intervention began with educating the patient and the caregivers about the condition, the precautions to be taken, the expected time of healing and extent of healing. The exercise program was based on the principles of variability and individuality. The protocol was changed weekly with the observed progression in the patients range, muscles strength and ability to perform more challenging in bed activities. Conclusion: Early rehabilitation in complex cases of tibial plafond fracture facilitates the process of healing as well as maintain the patients level of functioning by maintain muscle properties. Post-operative complications are also reduced.

Articular Cartilage of the Syndesmosis: Avoiding Iatrogenic Cartilage Injury During Syndesmotic Fixation

Background: The optimal surgical management of syndesmosis injuries consists of internal fixation between the distal fibula and tibia. Much of the available data on this joint details the anatomy of the syndesmotic ligaments. Little is published evaluating the distribution of articular cartilage of the syndesmosis, which is of importance to minimize the risk of iatrogenic damage during surgical treatment. The purpose of this study is to describe the articular cartilage of the syndesmosis. Methods: Twenty cadaveric ankles were dissected to identify the cartilage of the syndesmosis. Digital images of the articular cartilage were taken and measured using calibrated digital imaging software. Results: On the tibial side, distinct articular cartilage extending above the plafond was identified in 19/20 (95%) specimens. The tibial cartilage extended a mean of 6 ± 3 (range, 2-13) mm above the plafond. On the fibular side, 6/20 (30%) specimens demonstrated cartilage proximal to the talar facet, which extended a mean of 24 ± 4 (range, 20-31) mm above the tip of the fibula. The superior extent of the syndesmotic recess was a mean of 10 ± 3 (range, 5-17) mm in height. In all specimens, the syndesmosis cartilage did not extend more than 13 mm proximal to the tibial plafond and the syndesmotic recess did not extend more than 17 mm proximal to the tibial plafond. Conclusion: Syndesmosis fixation placed more than 13 mm proximal to the tibial plafond would have safely avoided the articular cartilage in all specimens and the synovial-lined syndesmotic recess in most. Clinical Relevance: This study details the articular anatomy of the distal tibiofibular joint and provides measurements that can guide implant placement during syndesmotic fixation to minimize the risk of iatrogenic cartilage damage.

1343 Post-Operative Outcomes of Circular External Fixation in The Treatment of Tibial Plafond Fractures: A Systematic Review

Introduction Tibial plafond fractures (TPF) are uncommon but potentially devastating injuries to the ankle. Meticulous care of the associated soft tissue injury is imperative in managing these fractures. The reported benefits of circular external fixation (CEF) include the ability to affect fracture reduction and create stable fixation, while limiting further soft tissue insult. This article provides the systematic review of the clinical and functional outcomes of TPF treated definitively with CEF. Method A literature search from inception to 13th November 2020 was performed. Quality and risk of bias was assessed using standardised scoring tools. Results 16 studies were included. 303 patients were analysed. Mean follow-up was 35 months. The mean time in CEF was 18 weeks and mean time to union was 21 weeks. Non-union and malunion occurred in 3.2% and 12.4% respectively. The overall complication rate was 12.3%. The rate of deep infection was 4.8%. No amputations were reported. Minor soft tissue infection (including pin site infections) accounted for 56.7% of complications. Almost two-thirds achieved good-to-anatomic reduction radiologically. Mean range of motion assessments were 11.8 and 24.8 degrees in dorsiflexion and plantarflexion, respectively. Approximately one-third reported excellent functional outcome scores. Quality of the studies was deemed satisfactory. A moderate risk of bias was acknowledged. Conclusions This systematic review provides an evidence-based summary, which highlights CEF as an acceptable treatment option with comparable complication rate and outcome scores to that of internal fixation. However, we acknowledge that high quality evidence is still lacking.