Reference radiologic measurements for the assessment of tibial pilon fractures

Objectives: The management of pilon fractures is a challenge and the outcome depends on multiple factors, one of which is the quality of reduction. In the literature, there is no assessment of anatomical reduction in pilon fractures. We also lack standard radiological parameters in large patient groups to measure the reduction. The main aim of this analysis was to define normal standard radiological values and identify potential specific types of ankle joint morphology (morphotypes) that might deserve special attention intraoperatively. Methods: We analyzed data of 103 healthy contralateral ankles collected within an observational and prospective multicenter study about tibial pilon fractures. We divided the patients according to their height into two groups, measured 11 radiological parameters, and compared them with each other and the literature. In addition, using cluster analysis, we could identify three morphotypes. Results: There is a statistically significant difference between the two groups in the lengths of three parameters: Mortise width, medial clear space, and length of the lateral malleolus, but not in the angles. The three morphotypes differ only in body mass index and the length of the lateral malleolus. Conclusion: Reference values from the literature are insufficient to assess a reduction after open reduction and internal fixation of tibial pilon fractures because they depend on the height. This does not apply to angles because they are independent of height. For clinical practice, a radiological control of the contralateral healthy ankle gives the best information about the reduction quality and should always be done, especially in normal weight males.

An Anatomic Study of the Sural Nerve Using 3-Tesla MRI: A Comparison to Cadaveric Data With Surgical Applications

Background: The sural nerve (SN) is a sensory cutaneous nerve that is at risk of iatrogenic injury during surgery at the lateral ankle. Prior anatomic studies of the SN are limited primarily to cadaveric studies with small sample sizes. Our study analyzed a large cohort of magnetic resonance images (MRIs) of the ankle to obtain a more generalizable, in vivo sample of distal SN course. Methods: A total of 204 3-tesla MRI studies of the ankle were analyzed. Three reviewers measured the distance from the SN to various landmarks including the distal tip of the lateral malleolus (DTLM) and the lateral border of the Achilles tendon (LBA). Results: Mean vertical distance from SN to DTLM was 2.2 cm (range, 0.9-3.6 cm). Mean horizontal distance from SN to DTLM and to LBA at the level of DTLM was 1.7 cm (range, 0.8-3.0 cm) and 1.9 cm (range, 1.0-2.9 cm), respectively. Mean horizontal distance from SN to LBA at the level of superior Achilles tendon insertion onto the calcaneus (SAI) was 2.6 cm (range, 1.4-3.7 cm), and mean horizontal distance from SN to LBA at 5 cm above SAI was 0.9 cm (range, 0.4-1.8 cm). Conclusion: The variation in SN course observed in our study allowed us to propose “safe zones” for several surgical approaches including the extensile lateral approach to the calcaneus (ELAC), the sinus tarsi approach (STA), the direct lateral approach to the lateral malleolus (DLA), and the posterolateral approach to the ankle (PLA), which we hope will minimize iatrogenic injury to the SN. Level of Evidence: Level IV, case series.

Establishment of a Finite Element Model of Supination-external Rotation Ankle Joint Injury and Analysis of Mechanical Changes in the Posterior Malleolar Surface

BackgroundBy establishing a three-dimensional finite element model of supination and external rotation ankle injury, the stress characteristics of the posterior ankle joint surface can be obtained, and complete analysis of the corresponding stress on the lateral ankle can be examined. MethodsThin-layer computed tomography (CT) images of normal ankle joints in the supination and external rotation non-weight-bearing states were selected, a three-dimensional data model of each ankle joint, including the ligament, was established, and whether different degrees of injury were coexistent with lateral ankle fracture was analysed by the finite element method. A load was applied to examine different ankle joint stress values and pressure distributions on the surface of the posterior ankle joint. ResultsWhen a load was applied, the maximum stress was located at the point of attachment of the anterior tibiofibular ligament to the tibia. When the anterior tibiofibular ligament was removed and the lateral malleolus was intact, the maximum stress (271.2 MPa) was located at the attachment point of the posterior tibiofibular ligament to the tibia, and the maximum pressure of the posterior ankle joint surface was 2.626 MPa. When a lateral malleolus fracture was present and the same load was applied, the maximum stress (82 MPa) was located on the fibular fracture surface, and the maximum pressure of the posterior ankle joint surface was 7.787 MPa. The posterior tibiofibular ligament was then removed completely from the lateral malleolus, and the maximum stress (132.7 MPa) was located at the point of attachment of the posterior tibiofibular ligament to the fibula, and the maximum pressure of the posterior ankle joint surface was 4.505 MPa. When a lateral malleolar fracture was present, the maximum stress (82.72 MPa) was located on the fibular fracture surface, and the maximum pressure of the posterior ankle joint surface was 8.022 MPa. ConclusionThis study shows that reconstruction of the lateral malleolus in supination-external rotation ankle injury significantly affects the stress distribution at the posterior malleolar joint surface. When reconstruction of the lateral malleolus is complete, the pressure distribution of the posterior malleolar joint surface can be significantly reduced. The results highlight the significance of reconstruction of posterior malleolar fractures and posterior tibiofibular ligament stability.

Clinical study of intramedullary nailing fixation for the treatment of Danis-Weber B in lateral malleolus fracture

Objective To compare the clinical effects between anatomical locking plates and interlocking intramedullary nails in patients with Danis-Weber B lateral malleolus fractures. Methods This retrospective study enrolled patients with Danis-Weber B fractures of the lateral malleolus. All the operations were completed by the same group of surgeons. The reduction effect, operation time, intraoperative blood loss, hospital stay, fracture healing time and ankle functional outcomes (Olerud-Molander Ankle Score [OMAS]) were compared. Postoperative complications, including incision infections, fixation discomfort and internal fixation loosening, were also compared. Results This study enrolled 73 patients that were treated with either an anatomical locking plate (locking plate group; n = 37) or an interlocking intramedullary nail (intramedullary nail group; n = 36). There was no significant difference between the two groups in terms of reduction effect, hospital stay and OMAS. The intramedullary nail group had significantly lower operation time, intraoperative blood loss and fracture healing time compared with the locking plate group. Postoperative complications in the intramedullary nail group were significantly lower compared with the locking plate group. Conclusion Using intramedullary nails resulted in more satisfactory functional outcomes compared with using locking plates in patients with Danis-Weber B fractures of the lateral malleolus.

Evaluation of in vivo anti-inflammatory activity of Ariflex tablet in comparison with diclofenac and aceclofenac tablet in carrageenan induced rat paw edema model

Background: Osteoarthritis is a major cause of pain and locomotor disability worldwide. Though various pharmacological, mechanical and surgical interventions are used, there is no known cure for OA. The present study was conducted to evaluate anti-inflammatory activity of Ariflex tablet (conceptualized and developed by Ari Healthcare Pvt. Ltd.) in comparison with diclofenac and aceclofenac tablet in carrageenan induced rat paw edema model.Methods: Wistar rats of either sex weighing 150-180 g were taken and divided into 4 groups with 6 animals in each group i.e. group 1 (control group), group 2 (diclofenac tablet), group 3 (aceclofenac tablet) and group 4 (ariflex tablet). The study drugs were orally administered with feeding needle, 30 minutes prior to carrageenan injection. After 30 min 1% w/v of 0.05 ml carrageenan was injected subcutaneously in the rat paw. The paw was marked with ink at the level of lateral malleolus and immersed in mercury up to lateral malleolus mark. The paw volume was measured plethysmographically after injection at 30 minutes, 1 hour, 2 hour, 3 hour, 4 hour and eventually at 5 hour.Results: All the test formulations possess statistically significant (p<0.05) anti-inflammatory activity as compared to control group. The maximum percentage inhibition for Ariflex tablet was 96.97% at the end of 5 hours. When compared to control group, statistically significant reduction of paw edema was observed. The anti-inflammatory activity of Ariflex tablet from 2 hours onwards is comparable to that of diclofenac tablet and aceclofenac tablet.Conclusions: Ariflex tablet possesses significant anti-inflammatory activity.

Operative Fixation of Lateral Malleolus Fractures With Locking Plates vs Nonlocking Plates: A Systematic Review and Meta-analysis

Background: The exact benefit of locking plates over nonlocking plates in patients with lateral malleolus fractures remains unclear. The primary aim of this study was to compare the functional outcome of locking plates vs nonlocking plates in patients with a lateral malleolus fracture. The secondary aims were to compare the number of complications and hardware removals and to compare whether results differed for older patients and for patients treated with anatomical locking plates. Methods: The PubMed/MEDLINE, Embase, Cochrane, and CINAHL databases were searched for studies comparing locking plates with nonlocking plates in patients with fixated lateral malleolus fractures. All included studies were assessed on their methodologic quality using the MINORS. Subgroup analyses were performed on older patients and patients treated with anatomical locking plates. Results: A total of 11 studies were included. The meta-analysis showed that functional outcome did not differ between patients treated with locking plates and nonlocking plates (MD 2.38, 95% CI −2.71 to 7.46). No difference in both complication rate (OR 1.10, 95% CI 0.74-1.63) and the amount of hardware removals (OR 0.77, 95% CI 0.52-1.14) was found. Even after analyzing older patients and patients treated with anatomical locking plates, no benefit was shown. Conclusion: This meta-analysis demonstrates no clear benefit in selecting locking plates over nonlocking plates in the treatment of lateral malleolus fractures. Clinical Relevance: Locking plates are increasingly being used in the treatment of lateral malleolus fractures. Biomechanical studies have shown an increased stability with use of locking vs nonlocking plates. This clinical review does not support a benefit of use of locking plates for these fractures.

Distal fibular periosteal flap for superior peroneal retinaculum reconstruction

Peroneal tendon instability is a common injury that occurs in physically active individuals, often as a result of trauma and in the context of an anatomically shallow distal fibular groove. Subluxation of these tendons over the lateral malleolus is accompanied by superior peroneal retinaculum injury. Several techniques have been described in the literature, including fibular groove deepening and retinaculum repair, but few reconstruction techniques are available for cases with insufficient residual retinaculum. We report the case of a 53-year-old man, without a history of trauma, who presented with chronic peroneal instability with a completely obliterated, unsalvageable retinaculum which we treated with a combination of fibular groove deepening and fibular periosteal flap to reconstruct the superior peroneal retinaculum. Level of Evidence V; Case Report; Expert Opinion.