Anatomically Fixed Posterior Malleolar Fractures in Syndesmosis Injuries without Transsyndesmotic Screw Fixation

Background: The stability of the syndesmosis is extremely important in terms of syndesmosis injury, ankle instability, and posttraumatic osteoarthritis development following ankle fractures. The aim of this study is to evaluate 1-year radiographic outcomes after posterior malleolar fixation in lateral and posterior malleolar fractures and trimalleolar fractures without transsyndesmotic screw fixation. Methods: Ninety-four patients who underwent posterior malleolar fixation with posterolateral approach between January 2017 and June 2019 were evaluated retrospectively. The patients were evaluated with parameters such as demographic characteristics, fracture type, injury mechanism, physical examination, and radiographic measurements. The stability of the syndesmosis was evaluated by an intraoperative Cotton test and by measuring the tibiofibular overlap, tibiofibular clear space, and medial clear space parameters preoperatively on the immediate postoperative, first-year weightbearing ankle anteroposterior radiographs. Results: In immediate postoperative measurements on radiographs, although the mean tibiofibular overlap ( P < .001) increased, the mean tibiofibular clear space ( P < .001) and mean medial clear space ( P < .001) decreased compared with preoperative radiographs. Immediate postoperative mean tibiofibular overlap, tibiofibular clear space, and medial clear space compared with postoperative first-year mean tibiofibular overlap ( P = .39), tibiofibular clear space ( P = .23), and medial clear space ( P = .43) were not statistically significant. Bone union was completed radiographically at a median of 3.4 ± 1.8 months after surgery. Conclusion: After posterior malleolar fractures, anatomic reduction of the posterior malleolus and posterior inferior tibiofibular ligament complex provides strong syndesmosis stability as measured radiographically at 1 year. Patients may not need additional transsyndesmotic screw fixation. Level of Evidence: Level IV, case series.

Afterword: Shifting the Terms of the Debate

The afterword discusses how this special issue’s articles work from different angles to unsettle the precepts of “attentional sovereignty” — the socially, politically, and economically valorized virtue that anchors most discussions over attention in its contemporary technological predicament. Whether the attentional sovereign appears in its liberal humanist or its neoliberal behavioral economic guise, sovereignty is valorized and considered under threat. By revealing the contemporary and historical backstories to our investment in this notion, these articles shift the terms of the debate around the attention crisis and clear space for thinking anew about the possibilities and limits of attention today.

Risk Factors for Aseptic Revision of Operatively Treated Ankle Fractures

Background: Early revision rates within 12 months after ankle fracture open reduction internal fixation (AF-ORIF) are fairly low; however, they remain relevant given the volume of ankle fractures occurring annually. Understanding these rates is complex because reoperation due to technical or mechanical complications is typically reported alongside soft tissue–related problems such as symptomatic hardware, wound dehiscence, or infection. There are limited data identifying risk factors specifically for revision of ankle fracture fixation in the absence of soft tissue complications. Understanding variables that predispose to aseptic technical and mechanical failure without this confounder may provide insight and improve patient care. Methods: A retrospective cohort study was performed at 2 large academic medical centers. Research Patient Data Registry (RPDR) data available from 2002 to 2019 were used to identify patients who underwent aseptic revision of AF-ORIF within 12 months (n = 33). A control group (n = 100) was selected by identifying sequential patients who underwent AF-ORIF not requiring revision within 12 months. Multiple factors were recorded for all patients in both cohorts. Each fracture was also evaluated according to the Ankle Reduction Classification System (ARCS) of Chien et al,8 which categorizes biplanar talar displacement in relation to a central tibial plumb line into 1 of 3 grades: A (0-2 mm), B (3-10 mm), and C (>10 mm). Adapted from its original purpose of grading reduction quality, we applied ARCS to pre-reduction radiographs to assess initial fracture displacement. All variables collected were compared in univariate analysis. Variables that achieved significance in univariate comparisons were included as candidates for multivariable analysis. Results: Final multivariable logistic regression modeling demonstrated the following factors to independently predict the need for aseptic revision surgery: documented falls in the early postoperative period (aOR, 298; 95% CI, 15.4, 5759; P < .001), movement-altering disorders (aOR, 81.7; 95% CI, 4.12, 1620; P = .004), a nonanatomic mortise (medial clear space [MCS] > superior clear space [SCS]) on immediate postoperative imaging (aOR, 38.4; 95% CI, 5.53, 267; P < .001), initial coronal plane tibiotalar displacement >10 mm and sagittal plane tibiotalar dislocation (ARCS-C) (aOR vs ARCS-A, 25.8; 95% CI, 2.81, 237; P = .004), substance abuse (aOR, 15.7; 95% CI, 2.66, 92.8; P = .002), and polytrauma (aOR, 12.3; 95% CI, 2.02, 74.8; P = .006). Conclusion: In this investigation we found a notable increase in risk for revision surgery after AF-ORIF for patients who had one of the following: (1) falls in the early postoperative period, (2) movement-altering disorders, (3) a nonanatomic mortise (MCS > SCS) on immediate postoperative imaging, (4) more severe initial fracture displacement, (5) substance abuse, or (6) polytrauma. Identifying these factors may allow surgeons to better understand risk and counsel patients, and may serve as future targets for intervention aimed at improving patient safety and outcomes after ankle fracture ORIF. Level of Evidence: Level III, retrospective cohort study.

Weightbearing Radiographs Reliably Predict Normal Ankle Congruence in Weber B/SER2 and 4a Fractures: A Prospective Case-Control Study

Background: In Weber B/SER2-4 ankle fractures, assessment with weightbearing radiographs to ascertain stability of the ankle mortise has been advised. However, no previous studies report whether this method leads to preservation of normal ankle congruence. The purpose is to evaluate equivalence of ankle congruence of injured ankles after fracture union, vs the uninjured side, for stable SER2 and partially unstable SER4a fracture types. Methods: We conducted a prospective case-control study designed as an equivalence trial to evaluate if weightbearing radiographs predict whether stable/SER2 and partially unstable/SER4a Weber B ankle fractures reach union with preserved normal tibiotalar congruence and without a concomitant increase of treatment failure. A total of 149 patients with a Weber B fracture stable on weightbearing radiographs were recruited into the trial. All participants were treated with a functional orthosis and weightbearing allowed. Results from gravity stress radiographs classified ankles as SER2 or SER4a fracture types. We defined an equivalence margin in medial clear space difference of 1.0 mm. We also evaluated the reliability of obtaining measurements from weightbearing radiographs. Results: No differences in medial clear space between the injured and uninjured ankles were observed after fracture union for the SER2 group (mean difference 0.1 mm, 95% confidence interval [CI] −0.3, 0.0; P = .056), or the SER4a group (mean difference 0.0 mm (95% CI −0.1, 0.1; P = .797). No between-group differences were observed (mean difference 0.0 mm, 95% CI −0.2, 0.2; P = .842). These findings were consistent with equivalence. CIs for the intraclass correlation coefficients indicated excellent reliability. Conclusions: Assessment of stability of Weber B SER2/4a ankle fractures, with weightbearing radiographs, also predicts preservation of normal ankle congruence in those deemed stable, with no difference between SER2 and SER4a fracture types. Further, excellent reproducibility of the method of obtaining medial clear space measurements was demonstrated. Level of Evidence: Level III, case-control.

Follow-up Evaluation of Medial Clear Space and Talar Tilt After Bimalleolar Equivalent Fracture Fixation Without Primary Deltoid Repair

Background We sought first to determine the efficacy of lateral ankle fixation alone in maintenance of medial clear space and talar valgus in bimalleolar equivalent ankle fractures not receiving primary deltoid repair, and second to assess perceived outcomes via the Foot and Ankle Outcome Score. To our knowledge, no study has quantified the reduction of medial clear space and talar valgus in bimalleolar equivalent ankle fractures receiving lateral ankle fixation alone. Methods We compared preoperative, initial postoperative, and greater than 1-year follow-up radiographs of medial clear space and talar valgus in individuals who received lateral ankle fixation alone in bimalleolar equivalent ankle fractures. Subjective outcomes were measured via the Foot and Ankle Outcome Score. Results Thirty-seven patients participated in the study and showed a statistically significant reduction of medial clear space and restoration of talar position, and maintenance with this fixation method during follow-up in patients with bimalleolar equivalent ankle fractures. Adjunctively, patients perceived their outcomes to be satisfactory, as demonstrated by the results of the Foot and Ankle Outcome Score. Conclusions We aimed to assess the efficacy of lateral ankle fixation in the maintenance of medial clear space and talar valgus reduction at midterm follow-up. Although some authors contend that primary deltoid repair in bimalleolar equivalent ankle fractures is warranted, these midterm study results suggest that isolated lateral ankle fixation is adequate for medial ankle stabilization in bimalleolar equivalent fractures, and thus primary deltoid repair is not indicated.

The Value of Additional Gravity Stress Radiographs for Decision Making in the Treatment of Isolated Type B Distal Fibular Fractures

Background: Prior to treatment decisions concerning isolated Weber type B ankle fractures, assessment of the stability of the ankle joint is mandatory. The gravity stress (GS) radiograph is a radiographic tool to determine stability. We hypothesized that this additional GS radiograph would lead to fewer operative treatments by applying the criterion of operative treatment when medial clear space (MCS) > superior clear space (SCS) + 2 mm on the GS radiograph, compared with the nonstressed mortise view criteria of advising operative treatment in case of MCS > SCS + 1 mm. Methods: This retrospective comparative cohort study analyzed 343 patients aged between 18 and 70 years with an isolated Weber type B ankle fracture diagnosed at the emergency department between January 2014 and December 2019. The cohort was divided into 2 groups based on whether an additional GS radiograph was performed. Group I consisted of 151 patients in whom a regular mortise and lateral radiograph were performed. Group II comprised 192 patients, with an additional GS radiograph. Primary outcome was type of treatment (conservative vs operative). Secondary outcomes were patient-reported functional outcomes and pain. Results: Baseline characteristics of both groups did not differ. In group I, surgery was performed in 60 patients (39.7%) compared with 108 patients (56.3%) in group II ( P = .002). In the operatively treated patients, the mean MCS on regular mortise view was significantly smaller in patients in whom an additional GS radiograph was performed compared to patients without an additional GS radiograph (4.1 mm vs 5.2 mm, P < .001). Mean Olerud-Molander Ankle Score and mean visual analog scale (VAS) for pain did not differ significantly between groups I and II. Conclusions: Contrary to what was hypothesized, the introduction of an additional gravity stress radiograph, by which operative treatment was indicated if the MCS was wider than the SCS + 2 mm, did not result in reduced operative treatment of Weber type B ankle fractures when operative treatment was indicated for MCS > SCS + 1 mm on non-gravity stress radiographs. Level of Evidence: Level III: retrospective comparative study.

Radiologic Assessment for Evaluating the Post-operative Reduction of Syndesmosis: A Retrospective Study

Background: Assessing the reduction of syndesmosis is highly recommended due to the complications occurring after the malreduction of the syndesmosis. This study evaluated the post-operative Computed Tomography (CT) scans and standard plain radiographs for assessing the reduction of syndesmosis post-operatively. Objectives: Evaluating the radiologic assessments of post-operative reduction of syndesmosis. Methods: In this retrospective cohort study, 45 patients presented with ankle fractures and syndesmosis failure to the emergency department of our hospital between 2015 and 2019 were evaluated by post-operative CT scans and plain radiographs. Results: Diastasis was demonstrated in 18 patients (40%) in plain radiographs, in 4 patients (8%) by tibial clear space, in 5 patients (11%) by medial clear space, in 10 patients (22%) by AP tibiofibular overlap, and in patients 8 (17%) by mortise tibiofibular overlap. Diastasis was demonstrated in 24 patients (53%) in CT scans, of whom 18 patients had abnormal radiographic parameters, while 6 patients had normal radiographic parameters. Conclusion: We found a post-operative CT scan more useful than standard plain radiographic measurement for assessing the reduction of the syndesmosis. We suggest the use of post-operative CT scan as a routine to evaluate the syndesmosis reduction.

Injury Mechanism Affects the Stability of Suture-Button Syndesmosis Fixation.

Background: Ankle syndesmosis injury is a common condition, and the injury mechanism can be sorted into pure-syndesmosis injury, Weber-B and Weber-C type fractures. This study aims to evaluate the treatment outcomes and stability of suture-button fixation for syndesmosis injury with different injury mechanisms. We hypothesized that injury mechanisms would alter the stability of suture-button fixation.Methods: We retrospectively reviewed 63 patients with ankle syndesmosis injury underwent surgery with TightRope (Arthrex, Naples, FL, USA) from April 2014 to February 2019. The stability of suture-button fixation with TightRope were evaluated by comparing the preoperative, postoperative, and final follow-up measurements of tibiofibular clear space (TFCS), tibiofibular overlap (TFO), and medial clear space (MCS). A subgroup analysis for each demographic group and injury type including pure-syndesmosis injury, Weber-B and Weber-C type fractures were performed.Results: Syndesmosis was effectively reduced using TightRope. After the index surgery, the tibiofibular clear space was reduced from 7.73 mm to 4.04 mm, the tibiofibular overlap was increased from 3.05 mm to 6.44 mm, and the medial clear space was reduced from 8.12 mm to 3.54 mm. However, syndesmosis widening was noted at the final follow-up, especially in Weber-C type fractures (TFCS: 3.82 to 4.45 mm, p < 0.01 and TFO: 6.86 to 6.29 mm, p = 0.04). Though widened, the final follow-up values of tibiofibular clear space and tibiofibular overlap were in the acceptable range. Postoperatively and at the final follow-up, medial clear space was found to be significantly larger in the Weber-C group than in the pure syndesmosis and Weber-B groups (p < 0.05). Conclusions: Suture-button fixation can offer anatomic reduction and dynamic fixation in syndesmosis injuries. However, when using this modality for Weber-C type fractures, more attention should be focused on the accuracy of reduction, especially of medial clear space, and rediastasis should be carefully monitored.Trial registration: This trial was retrospectively approved by TMU-JIRB. Registration number N202004122, and the date of approval was May 06, 2020.Level of evidence: III

Injury mechanism affects the stability of suture-button syndesmosis fixation

Background Ankle syndesmosis injury is a common condition, and the injury mechanism can be sorted into pure syndesmosis injury, Weber-B, and Weber-C type fractures. This study aims to evaluate the treatment outcomes and stability of suture-button fixation for syndesmosis injury with different injury mechanisms. We hypothesized that injury mechanisms would alter the stability of suture-button fixation. Methods We retrospectively reviewed 63 patients with ankle syndesmosis injury who underwent surgery with TightRope (Arthrex, Naples, FL, USA) from April 2014 to February 2019. The stability of suture-button fixation with TightRope was evaluated by comparing the preoperative, postoperative, and final follow-up measurements of tibiofibular clear space (TFCS), tibiofibular overlap (TFO), and medial clear space (MCS). A subgroup analysis for each demographic group and injury type including pure syndesmosis injury, Weber-B, and Weber-C type fractures were performed. Results Syndesmosis was effectively reduced using TightRope. After the index surgery, the tibiofibular clear space was reduced from 7.73 to 4.04 mm, the tibiofibular overlap was increased from 3.05 to 6.44 mm, and the medial clear space was reduced from 8.12 to 3.54 mm. However, syndesmosis widening was noted at the final follow-up, especially in Weber-C type fractures (TFCS 3.82 to 4.45 mm, p < 0.01 and TFO 6.86 to 6.29 mm, p = 0.04). Though widened, the final follow-up values of tibiofibular clear space and tibiofibular overlap were in the acceptable range. Postoperatively and at the final follow-up, medial clear space was found to be significantly larger in the Weber-C group than in the pure syndesmosis and Weber-B groups (p < 0.05). Conclusions Suture-button fixation can offer anatomic reduction and dynamic fixation in syndesmosis injuries. However, when using this modality for Weber-C type fractures, more attention should be focused on the accuracy of reduction, especially of medial clear space, and rediastasis should be carefully monitored. Trial registration This trial was retrospectively approved by TMU-JIRB. Registration number N202004122, and the date of approval was May 06, 2020. Level of evidence III