Migratory Loose Bodies from the Ankle Joint into the Flexor Hallucis Longus Tendon Sheath

Objective: Loose bodies resulting from any form of osteochondral insult can migrate out of their intra-articular position to adjacent compartments. This retrospective study aims to illustrate the phenomenon of loose bodies migration from the ankle joint into the flexor hallucis longus (FHL) tendon sheath. Materials and Methods: Cases of loose bodies in the FHL tendon sheath were identified from the authors' radiological database by way of keyword interrogation, covering the modalities of CT, MRI, and ultrasound over a period of 11 years. The imaging features of the loose bodies were recorded, together with the presence of ankle instability and osteoarthritis. Patient demographics and relevant history, including trauma and surgery, were collected. Results: Thirty-four cases including 33 patients, with a total of 125 loose bodies in the FHL tendon sheath, were identified. There were 58 loose bodies (46.4%) in Zone 1 of the FHL tendon sheath, 65 loose bodies (52%) in Zone 2, and 2 loose bodies (1.6%) in Zone 3. All patients had features of ankle osteoarthritis on imaging, 14 of which had imaging features of ankle instability, and 19 patients had previous ankle trauma. Conclusion: Osteochondral loose bodies originating from the ankle joint can migrate into the FHL tendon sheath. It is important to recognise this phenomenon as a distinct entity, different from primary tenosynovial chondromatosis of the FHL tendon sheath, which may have a different surgical management and clinical outcome. Detection of FHL tendon sheath loose bodies should also prompt closer examination for articular disease in the ankle joint.

Association between joint effusions and concomitant structural injuries (tendinitis and structural injury) on MRI in ankle trauma without fracture

Background The evaluation of correlations among joint effusion, ligament injuries, tenosynovitis and osteochondral lesion of talus (OLT) in the ankle joint is important for developing a treatment plan and predicting prognosis. Purpose To evaluate correlations among tibiotalar (anterior) and talocalcaneal (posterior) joint effusion, tenosynovitis of major flexor tendons, ligaments, and OLT in a group of patients with ankle trauma. Material and Methods This retrospective study included 101 patients with ankle trauma who underwent magnetic resonance imaging. Two radiologists assessed the presence and amount of effusion in the tibiotalar and talocalcaneal joints from grade 0 to 2, according to the amount of capsular distension. Concomitant structural injuries were assessed in the tibialis posterior (TP), flexor digitorum longus, flexor hallucis longus, and peroneus tendons, and the anterior talofibular ligament, calcaneofibular ligament, anteroinferior tibiofibular ligament, posteroinferior tibiofibular ligament, and OLT. Results The proportion of anterior and posterior joint effusion according to grade was 67.3% for anterior joint effusion grade 0, 22.8% for grade 1, and 9.9% for grade 2; for posterior joint effusion, grade 0 was 74.2%, grade 1 was 22.8%, and grade 2 was 3.0%. We found statistically significant correlations between posterior joint effusion and tenosynovitis of TP ( P < 0.05) and between posterior joint effusion and OLT ( P < 0.05). Conclusion Posterior joint effusion is correlated with TP injury and OLT; however, tendon injuries have no correlation with other structural injuries of the ankle joint in a general population with ankle trauma.

P134 Under the weather: The Meteorological correlation in Orthopaedic Trauma and within Hertfordshire

Background The paper aims to understand the effect of meteorological factors on the number of referrals and volume of trauma operating cases within our local area. Method Trauma data was analysed in our database: (eTrauma), a digital clinical platform that co-ordinates all admissions and: trauma theatre activity. Data consisted of number of referrals per day, patient: age, mechanism of injury and type of orthopaedic injury. Weather data was: gathered from a local weather station which: records daily weather observations. Results 1160 consultations wereanalysed, 779 required an operative intervention. Neck of femur fractures: and ankle trauma were the two most common cause of trauma, accounting for 27% and 15% respectively. Neck of femur fracture pathology were not significantly correlated with any meteorological factor studied. On the contrary, ankle trauma were the only injuries significantly correlating with temperature (p &lt; 0.03) and due point (p &lt; 0.04). Conclusion Weather has no effect on neck of femur fractures, the most common trauma pathology treated in our department. In all seasons allocated specific trauma lists for the latter should be arranged irrelevant of the weather conditions. We identified the days receiving highest referral rate, using this data to shape the future on call trauma service.

Efficacy of the Glidepath Technique for Ankle Syndesmosis Reduction

Category: Ankle; Trauma Introduction/Purpose: Syndesmotic screw fixation is frequently required in rotational ankle injuries. Fibular malreduction after syndesmotic screw fixation occurs in as many as 52% of cases, which has been shown to detrimentally affect subjective outcomes and increase the probability of developing arthritis. The glidepath technique has been proposed as a useful technique to prevent malreduction. We hypothesize that the glidepath technique reduces the occurrence of fibular malreduction and results in improved outcomes compared to clamping. Methods: A retrospective cohort study comparing 25 patients reduced with a clamp compared to 18 patient using the glidepath technique. The glidepath technique, described by Needleman, the fibula is manually reduced and a Kirschner wire is placed through the fibula and tibia along the transmalleolar axis, parallel to the superior border of the ankle mortise. CT scans of the injured and contralateral ankles were obtained postoperatively to assess reduction. Malreduction is defined as >2mm difference between the anterior or posterior incisura-fibular distance of the injured ankle compared to the contralateral side. Prospective outcomes were assessed using the AOFAS and VR-12 scores at preoperative, 3 month, 6 month and 1 year followup of the glidepath cohort only. Results: We found a statistically significant reduction in malreduced syndesmoses using the glidepath technique when compared with the clamping technique. In our study, 17% (3/18) were malreduced using the glidepath technique, compared with 48% (12/25 patients) with clamping (p=0.005). The three malreductions seen in our study were anterior, we had no posterior malreductions. Compared with the clamping cohort that had 10/25 posterior malreductions and 2/25 anterior malreductions. Mean outcomes at 3,6 and 1 year scores were AOFAS 76, 86,86; VR-12 46,53,50/ 42,44,47 (physical/mental) respectively. Conclusion: Historically, malreduction for syndesmotic fixation is as high as 52%. The glidepath technique is a viable reduction maneuver that has lower rates of malreduction compared to clamping in our study. This is the first ever CT confirmed study measuring syndesmosis reduction utilizing manual reduction. The value of this technique is that is does not require an open reduction, arthroscopic visualization/reduction or CT guidance to achieve syndesmotic reduction.

BMI and Comorbidities in Patients with Syndesmosis Screw Breakage

Category: Ankle; Trauma Introduction/Purpose: Syndesmosis screw fixation remains a common standard of care in patients with syndesmosis injuries. Post-operative screw breakage is a common occurrence in these patients. The purpose of this is study is to compare BMI, comorbidities, and characteristics of patients who had a syndesmosis injury repaired with screw fixation resulting in screw failure. Numerous studies (21) have examined patients with syndesmosis screw fracture, focusing primarily on screw characteristics such as width, length, and screw material. Of those studies, only six considered BMI, while only one of the six differentiated BMI between patients with a broken screw and those without. Only three of the studies collected patient comorbidity data. Methods: This study examined all tibia procedures at a level 1 trauma center from 2008 to 2019. Only patients treated with syndesmosis screw fixation that resulted in a screw fracture were included for further analysis. In total, 14 patients satisfied this criterion. A comprehensive analysis of each patients BMI, comorbidities, and characteristics was then performed. Age, gender, height, weight, BMI, smoking status, diabetes, hypertension, alcohol abuse, and soft tissue conditions were all analyzed. Further examination of conditions with potential to impact bone quality such as osteoporosis, osteoarthritis, and rheumatoid arthritis were also included. Results: Eight females and 6 males with an average age of 42.43±13.90(20-43) were included in the analysis. The average number of comorbidities was 2.93±(0-6). BMI average was 38.92±(22.05-56.34) indicating Grade II obesity for the entire patient cohort. Six patients had a BMI > 40 or Grade III (morbidly obese) while only two patients had a satisfactory BMI < 25. All patients in the syndesmosis fracture group had more than one comorbidity apart from a single patient (case 3). Six patients had at least 2 comorbidities, 3 patients had 3, 2 patients had 2, and 2 patients had 6. Eight (57%) of 14 had post-operative complications including: Symptomatic hardware + removal (6), revision surgery (4), and compartment syndrome (1). Five patients retained their broken screw without complication. Conclusion: Patients with syndesmosis screw breakage are a highly comorbid population. Patients in this study, on average, had a significantly elevated BMI potentially predisposing them to screw failure. In conclusion, future analysis of syndesmosis injuries should include BMI and comorbidities. Future studies should pay special attention to BMI as potential confounding variable when attempting to determine reasons for syndesmosis screw breakage. [Table: see text]

Bilateral Comparison of the Three-dimensional Configuration in the Normal Ankle Syndesmosis: A non-Weightbearing and Weightbearing CT-analysis

Category: Ankle Introduction/Purpose: Syndesmotic ankle injuries can be present in up to one-fifth of all ankle trauma and may lead to syndesmotic instability or posttraumatic ankle osteoarthirtis on the long term. It remains challenging to distinguish syndesmotic ankle injuries from other types of ankle trauma. Currently, diagnosis is based on plain radiographs by comparing 2D measurements of the injured to the non-injured side. However, it is unclear to what extent the 3D configuration of the normal ankle syndesmosis is symmetrical during non- or weightbearing conditions. Therefore, our aim was two-fold (1) to establish reference values based on three-dimensional side-to-side comparison of the normal ankle syndesmosis imaged by a non-weightbearing (NWBCT) and weightbearing CT (WBCT) (2) to compare measurements obtained from a NWBCT with those of a WBCT. Methods: In this retrospective comparative cohort study, patients with a NWBCT (N=38; Mean age=51+-17.4 years) and WBCT (N=43; Mean age=48+-14.3 years) were analyzed. Inclusion criteria were a bilateral NWBCT or WBCT of the foot and ankle between January 2016 and December 2018. Exclusion criteria consisted of hindfoot pathology and an age <18 years or >75 years. CT images were segmented to obtain 3D models. Computer Aided Design (CAD) operations were used to mirror the left ankle and superimpose it over the right ankle (Fig. 1A). The apex of the lateral malleolus (AML), anterior tubercle (ATF) and posterior tubercle (PTF) were determined. The difference in the coordinates attached to these anatomical landmarks of the left distal fibula in the ankle syndesmosis with respect to the right were used to establish reference values within two standard deviations. The Mann-Whitney U-test was used to compare measurements from a NWBCT with a WBCT. Results: Reference values within two standard deviations are given for each 3D measurement derived from a NWBCT and WBCT-scan (Fig 1B). The highest difference in translation was detected in the anterior-posterior direction (Mean APNWBCT= 0.161mm; 2SD=3.212/ Mean APWBCT= -0.082mm; 2SD=2.374). The highest difference in rotation was detected in the external- internal direction (Mean EINWBCT= -0.484°; 2SD=8.720/ Mean EIWBCT= -0,326°; 2SD=5.370). None of these differences were statistically significant in the normal ankle syndesmosis when obtained from a NWBCT scan compared to a WBCT scan (P>0.05). Conclusion: This study provides reference values of the three-dimensional configuration in the normal ankle syndesmosis based on side-to-side comparison. It did not demonstrate significant differences in the normal ankle syndesmosis between NWBT and WBCT scans. These novel 3D data contribute relevantly to previously established bilateral 2D radiographic reference values. In clinical practice, they will aid in distinguishing if a patient with a syndesmotic ankle lesion differs from normal variance in syndesmotic ankle symmetry.

Impact of Early Weight Bearing on Outcomes after Open Reduction and Internal Fixation of Trimalleolar Ankle Fractures

Category: Ankle; Trauma Introduction/Purpose: There is a current trend to allow earlier weight-bearing of unstable ankle fractures after fixation. This study offers a unique comparison of early (EWB) versus late weight-bearing (LWB) in operatively stabilized trimalleolar ankle fractures. The purpose of this study was to evaluate union rates, clinical outcomes and complications in patients managed with EWB versus LWB. Methods: We performed a retrospective review of 185 patients with trimalleolar ankle fractures who underwent surgical stabilization. Fixation of the posterior malleolus and weight-bearing status were determined by surgeon preference. EWB was defined as ≥3 weeks and LWB was defined as >3 weeks. Patients were evaluated for fracture union and implant failure. Complications and clinical outcomes included ambulatory status, infection rate and return to surgery. Results: There were 47 (25.4%) patients in the EWB group and 138 (74.6%) in the LWB group. There were 7 nonunions, 1 (14.3%) in the EWB and 6 (85.7%) in the LWB group. Seventy-two (38.9%) posterior malleolar fractures were operatively stabilized which did not affect union rates. Syndesmotic fixation was required in 12.5% of patients despite posterior malleolar stabilization. Syndesmotic fixation increased union rate 2.5 times. Deep infection and open fracture decreased union. There was no difference in implant failure, union rate, infection or return to surgery between groups. Conclusion: No deleterious effect of EWB of operatively treated trimalleolar ankle fractures were found with regards to union, implant failure, infection or reoperation. Syndesmotic fixation may offer an advantage to posterior malleolar fixation with improved union rates.