Does the morphology of the posterior malleolar fragment influence clinical outcomes of trimalleolar fractures after surgical fixation? A systematic review and Meta-analysis

Background: Posterior malleolus (PM) fractures have historically been classified according to the size of the fragment, to study the need for surgical fixation and to assess clinical outcomes. Recent research has suggested that the morphology of the PM fragment is of more relevance than its size. Objectives: This systematic review aims to determine if the size of the PM fragment influences clinical outcomes of trimalleolar fractures after surgical fixation, and if so, to find out which fracture type has the best outcomes. Methods: This systematic review will be conducted according to the PRISMA guidelines. A literature search will be conducted on the electronic databases of PubMed, Embase, Scopus and Ovid with a pre-determined search strategy. A manual bibliography search of included studies will also be done. Original articles in English that have relevant data on the outcomes of PM fractures and its morphology will be included. Data will be extracted from included studies and analysis carried out with the help of appropriate software.

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.

Midterm Outcomes of Unstable Ankle Fractures in Young Patients Treated by Closed Reduction and Fixation With an Intramedullary Fibular Nail vs Open Reduction Internal Fixation Using a Lateral Locking Plate

Background: We aimed to compare midterm radiological and clinical outcomes between closed reduction and internal fixation (CRIF) using the fibular intramedullary nail (IMN) and open reduction and internal fixation (ORIF) using the locking plate for the treatment of unstable ankle fractures in active young patients. Methods: In this retrospective cohort study, 204 patients treated with CRIF using the fibular IMN (94 patients) or ORIF using the locking plate (110 patients) were included after at least 3 years of follow-up. The mean patient age was 41.4 years. Radiographic evaluation included the quality of reduction assessed by plain radiography and 3-dimensional (3D)–reconstructed computed tomography as well as the development of posttraumatic osteoarthritis (PTOA) of the ankle assessed by weightbearing plain radiography. Clinical evaluation included the American Orthopaedic Foot & Ankle Society hindfoot score, Olerud and Molander Score, the Foot and Ankle Outcome Score, and visual analog scale pain score as well as complications. Results: At median follow-up greater than 4 years, we found no significant differences in measured clinical outcomes between the 2 groups. There were significantly fewer postoperative complications in the IMN group than in the ORIF group (9.5% vs 39%, P < .001). However, we did find a greater proportion of radiographically fair or poor reductions in the IMN group than in the ORIF group ( P < .001). The poor reductions in the IMN group were primarily related to Weber type C, pronation-type injury, and comminuted fibular and trimalleolar fractures ( P < .001). PTOA was also more frequently observed in the IMN group than in the ORIF group (21.3% vs 9.1%, P = .024). Conclusion: Given the current prevailing technologies for fracture fixation, this study suggests that surgeons should consider ORIF for unstable ankle fractures in active young patients with Weber type C, pronation-type injury, and comminuted fibular and trimalleolar fractures. Level of Evidence: Level III, retrospective comparative study.

600 The Use of a Wide-Awake Local Anaesthesia No Tourniquet (WALANT) Technique in Foot and Ankle Procedures - A Randomised Control Trial

Introduction Wide awake local anaesthesia no tourniquet (WALANT) is a widely used technique in upper limb procedures that has gained increasing popularity during the coronavirus pandemic. The benefit of WALANT for foot and ankle surgeries is less clear, especially in patients with multiple comorbities. The primary aim of this study was to compare post-operative pain levels in patients undergoing ankle fracture fixation. Secondary objectives included comparison of intra-operative patient experiences, clinical outcomes, and patient satisfaction 1-year post-procedure. Method 129 patients presenting with ankle fractures were enrolled in a multicenter randomised control trial from February 2016 to January 2020. Patients with medial malleolar, lateral malleolar, bimalleolar or trimalleolar fractures received either WALANT (62 patients) or spinal anaesthesia (67 patients). A 5ml solution of 0.9% saline and 2% lidocaine with 1: 100,000 adrenaline was used for WALANT. Results Compared to patients who received spinal anaesthesia, those in the WALANT group experienced less post-operative discomfort and were more satisfied 1-year post-procedure (p-value = 0.003). Surgical outcomes were similar for both groups. Cost analysis revealed that WALANT is significantly more economical. Conclusions WALANT is an effective and safe anaesthetic for foot and ankle procedures. Without use of a tourniquet, it reduces post-operative pain and so, eases patient recovery.

Minimally invasive plate osteosynthesis using the oblong hole of a locking plate for comminuted distal fibular fractures

Background Nonunion is a rare complication for distal fibular fractures. However, when there is a high degree of comminution, nonunion may occur. In this article, we describe a novel technique that uses the oblong hole of a locking plate to lengthen the fibula for fracture reduction. This technique is straightforward and allows for easy control of the comminuted fracture to restore length and rotation at the time of plate application without opening the fracture site. Methods Thirty-five consecutive patients, who were treated with the minimally invasive plate osteosynthesis (MIPO) technique for comminuted distal fibular fractures were retrospectively studied. The study included 19 men and 16 women, with a mean age of 47.0 years (range, 20 to 72). There were 3 lateral malleolar fractures with deltoid injury, 11 bimalleolar fractures, 7 trimalleolar fractures, and 14 distal tibiofibular fractures. The quality of fracture reduction was assessed by comparing the radiologic parameters (fibular length, talocrural angle, and medial clear space) between the affected ankle and the contralateral uninjured ankle. Results Two patients were not reachable and 5 declined to visit the clinic. For these 7 patients, the latest outcomes that were measured prospectively were used. Postoperative radiographs showed well-aligned ankle mortise, with fibular length restoration. The mean Olerud-Molander ankle score was 82.1 ± 10.7 at a mean of 27.2 months (range, 12 to 58). There was one case of nonunion and one case of superficial peroneal nerve injury. Conclusion The MIPO technique, using the oblong hole of a locking plate, achieved satisfactory restoration of length and rotation, bone union, and clinical outcomes for the comminuted distal fibular fractures.

Operative versus Non-Operative Management of The Medial Malleolus in Bimalleolar and Trimalleolar Fractures – A Systematic Review

Purpose Ankle fractures are the fifth most common fracture worldwide. Some reviews have shown that non-operative management of isolated medial malleolar fractures has satisfactory outcomes, and more recent studies have suggested the same may apply in bimalleolar and trimalleolar fractures (BTMF). Importantly, non-operative management has the added benefits of avoiding complications including wound infection, and protruding metalwork. This systematic review aims to compare operative and non-operative management of medial malleolar fractures in the context of BTMF. Methods A search syntax of MeSH terms was used to search ScienceDirect, Scopus, Cochrane Library, and PubMed databases. The methodological quality of the included studies was assessed according to the MINORS criteria. Data extracted included patient demographics, operative techniques, functional outcome scores (EQ-5D, OMAS, MOXFQ, VAS, AOFAS return to work/sports) and complication rates Results A total of four studies were included: one randomised-controlled and three prospective study. Two of these directly compared operative and non-operative approaches, while the remaining two reported solely an operative cohort. Of 373 total fractures, 274 were managed operatively and 99 non-operatively. There was no significant difference across all functional scores between operative and non-operative approaches to medial malleolar fractures in the comparative studies. However, there was an association for higher rates of mal/non-union in the non-operative groups (10.5% vs 5.0%). Conclusion Although there is existing belief that operative approach to BTMF would lead to better outcomes, there is currently no evidence that shows operative is superior to non-operative management. Orthopaedic surgeons should consider the morbidity of post-operative complications when deciding the treatment for medial malleolar fractures in BTMF, particularly in the elderly. Further studies need to be performed on this topic before a definitive conclusion can be made.

Trimalleolar fracture: The endless posterior malleolus fracture debate, to repair or not to repair?

Ankle fracture is one of the most common fractures presenting in the emergency department. The fracture varies from unimalleolar, bimalleolar or trimalleolar. Involvement of the posterior malleolus is common and ranges from small avulsions to large intraarticular fragments causing subluxation of the talus. If left untreated, the resulting step-off, comminution or posterior talar subluxation may lead to osteoarthritis and further disability. To date, no consensus exists regarding the management of posterior malleolus fractures in the set-up of trimalleolar fractures. In this review we provide an overview of the literature on the available treatment options for posterior malleolar fracture in the set-up of trimalleolar fractures.

Operatively treated ankle fractures in Switzerland, 2002–2012: epidemiology and associations between baseline characteristics and fracture types

Background Ankle fractures are common, and their incidence has been increasing. Previous epidemiological studies have been conducted in the US, Scandinavia, and Scotland. Our objectives were to provide a current epidemiological overview of operatively treated ankle fractures and to evaluate the influence of age, sex, lifestyle factors, and comorbidities on fracture types. Methods We performed a population-based epidemiological study of all ankle fractures treated operatively in a 10- year period from 2002 to 2012. Results Two thousand forty-five ankle fractures were operated upon. Men and women differed significantly in age (median 41 vs. 57 years old), obesity (16% vs. 23%), diabetes (5% vs. 10%), smoking (45% vs. 24%), and accident type (daily activities 48% vs. 79%, transportation 24% vs. 9%, sports 21% vs. 8%) respectively. Overall, there were 2% Weber A, 77% Weber B, and 21% Weber C fractures; 54% were uni-, 25% bi-, and 21% trimalleolar; 7.5% of all fractures were open. Weber C fractures were much more frequent among men and with higher BMI (lowest vs. highest category: 14% vs. 32%), but slightly less frequent with older age and among current smokers. Trimalleolar fractures were twice as frequent in women and increased with age. Conclusion Men and women differed substantially in age, lifestyle factors, comorbidities, accident type, and type of ankle fracture. Male sex and higher BMI were more frequently associated with Weber C fractures, whereas female sex and older age were associated with trimalleolar fracture. The risk for severe fracture increased linearly with the degree of obesity.