Short-term results of gait analysis with the Heidelberg foot measurement method and functional outcome after operative treatment of ankle fractures

Background Ankle fractures are common fractures in trauma surgery. Several studies have compared gait patterns between affected patients and control groups. However, no one used the Heidelberg Foot Measurement Method in combination with statistical parametric mapping of the entire gait cycle in this patient cohort. We sought to identify possible mobility deficits in the tibio-talar joint and medial arch in patients after ankle fractures as a sign of stiffness and pain that could result in a pathological gait pattern. We focused on the tibio-talar flexion as it is the main movement in the tibio-talar joint. Moreover, we examined the healing progress over time. Methods Fourteen patients with isolated ankle fractures were included prospectively. A gait analysis using the Heidelberg Foot Measurement Method was performed 9 and 26 weeks after surgery to analyse the tibio-talar dorsal flexion, the foot tibia dorsal flexion, the subtalar inversion and the medial arch as well as the cadence, the walking speed and the ground reaction force. The American Orthopedic Foot & Ankle Society ankle hindfoot score was used to obtain clinical data. Results were compared to those from 20 healthy participants. Furthermore, correlations between the American Orthopedic Foot & Ankle Society hindfoot score and the results of the gait analysis were evaluated. Results Statistical parametric mapping showed significant differences for the Foot Tibia Dorsal Flexion for patients after 9 weeks (53–75%: p = 0.001) and patients after 26 weeks (58–70%: p = 0.011) compared to healthy participants, respectively. Furthermore, significant differences regarding the tibio-talar dorsal flexion for patients 9 weeks after surgery (15–40%: p < 0.001; 56,5–70%: p = 0.007; 82–88%: p = 0.033; 97–98,5%: p = 0.048) as well as patients after 26 weeks (62,5–65%: p = 0.049) compared to healthy participants, respectively. There were no significant differences looking at the medial arch and the subtalar inversion. Moreover, significant differences regarding the ground reaction force were found for patients after 9 weeks (0–17%: p < 0.001; 21–37%: p < 0.001; 41–54%: p < 0.001; 60–64%: p = 0.013) as well as patients after 26 weeks (0–1,5%: p = 0.046; 5–15%: p < 0.001; 27–33%: p = 0.001; 45–49%: p = 0.005; 57–59%: p = 0.049) compared to healthy participants, respectively. In total, the range of motion in the tibio-talar joint and the medial arch was reduced in affected patients compared to healthy participants. Patients showed significant increase of the range of motion between 9 and 26 weeks. Conclusions This study shows, that patients affected by ankle fractures show limited mobility in the tibio-talar joint and the medial arch when compared to healthy participants. Even though the limitation of motion remains at least over a period of 26 weeks, a significant increase can be recognized over time. Furthermore, if we look at the absolute values, the patients’ values tend to get closer to those of the control group. Trial registration This study is registered at the German Clinical Trials Register (DRKS00023379).

Talus Visualization in Ankle Fractures: How Much Are We Really Seeing?

Background: Despite appropriate care, a subset of patients with ankle fractures has persistent pain. This condition may be associated with intra-articular pathology, which is present up to 65% of the time. Purpose: To quantify how much of the talus is visible through an open approach to a standard supination external rotation bimalleolar ankle fracture as a percentage of the entire weightbearing surface of the talus. Study Design: Descriptive laboratory study. Methods: Standard ankle approaches to lateral and medial malleolar fractures were performed in 4 cadaveric ankles from 2 cadavers. Osteotomies were made to simulate a supination external rotation bimalleolar ankle fracture based on the Lauge-Hansen classification. The visible segments of talar cartilage were removed. The tali were then exhumed, and the entire weightbearing superior portion of the talus was assessed and compared with the amount of cartilage removed by an open approach. The mean of the data points as well as the 95% confidence interval were calculated. Results: Four ankle specimens from 2 cadavers were used for these measurements. The mean surface area of the talus was 14.0 cm2 (95% CI, 13.3-14.7 cm2), while the mean area visible via an open approach was 2.1 cm2 (95% CI, 0.5-3.6 cm2). The mean proportion of the talus visualized via an open approach was 14.8% (95% CI, 3.6-26.1%). Conclusion: These findings indicate that the true area of weightbearing talar surface visible during an open exposure may be less than what many surgeons postulate. Clinical Relevance: Only a small fracture of the talus is visible via an open approach to the talus during fracture fixation. This could warrant arthroscopic evaluation of these injuries to evaluate and treat osteocondral lesions resulting from ankle fractures.

COVID-positive ankle fracture patients are at increased odds of perioperative surgical complications following open reduction internal fixation surgery

Introduction Ankle fractures have continued to occur through the COVID pandemic and, regardless of patient COVID status, often need operative intervention for optimizing long-term outcomes. For healthcare optimization, patient counseling, and care planning, understanding if COVID-positive patients undergoing ankle fracture surgery are at increased risk for perioperative adverse outcomes is of interest. Methods The COVID-19 Research Database contains recent United States aggregated insurance claims. Patients who underwent ankle fracture surgery from April 1st, 2020 to June 15th, 2020 were identified. COVID status was identified by ICD coding. Demographics, comorbidities, and postoperative complications were extracted based on administrative data. COVID-positive versus negative patients were compared with univariate analyses. Propensity-score matching was done on the basis of age, sex, and comorbidities. Multivariate regression was then performed to identify risk factors independently associated with the occurrence of 30-day postoperative adverse events. Results In total, 9,835 patients undergoing ankle fracture surgery were identified, of which 57 (0.58%) were COVID-positive. COVID-positive ankle fracture patients demonstrated a higher prevalence of comorbidities, including: chronic kidney disease, diabetes, hypertension, and obesity (p<0.05 for each). After propensity matching and controlling for all preoperative variables, multivariate analysis found that COVID-positive patients were at increased risk of any adverse event (odds ratio [OR] = 3.89, p = 0.002), a serious adverse event (OR = 5.48, p = 0.002), and a minor adverse event (OR = 3.10, p = 0.021). Discussion COVID-positive patients will continue to present with ankle fractures requiring operative intervention. Even after propensity matching and controlling for patient factors, COVID-positive patients were found to be at increased risk of 30-day perioperative adverse events. Not only do treatment teams need to be protected from the transmission of COVID in such situations, but the increased incidence of perioperative adverse events needs to be considered.

Incidence and Predictive Factors of Tibial Fracture with Occult Posterior Ankle Fractures

Background. Few studies exist on the predictive factors of tibial fractures with hidden posterior ankle fractures. Objective. To study the incidence and predictive factors of tibial fractures with occult posterior ankle fractures. Methods. Tibial fracture patients were prospectively selected who were admitted to our hospital from January 2016 to May 2021 and their general clinical data, X-ray images, CT images, and other imaging data were collected and then divided them into posterior malleolus fracture group and nonposterior malleolus fracture group according to the presence or absence of posterior malleolus fractures. Multivariate regression analysis and receiver operating curves (ROC) were performed to analyze the influencing factors of tibial fracture with occult posterior ankle fracture. Results. CT showed that 25 (13.44%) patients had occult posterior ankle fractures among 186 patients with tibial fracture. There was no significant difference in gender, age, and locations of tibial fracture between the two groups ( P > 0.05 ). There were statistical differences in the types, locations, and lengths of patients with tibial fracture but without posterior malleolus fractures. The length of the tibia fracture group was significantly lower than the tibia with posterior ankle fracture group ( P < 0.05 ). Logistics regression analysis showed that tibial fracture with occult posterior ankle fracture was not significantly correlated with gender, age, and location of tibial fracture ( P > 0.05 ), but was significantly correlated with tibial fracture type, location, and length (HR = 1.830, P = 0.035 ; HR = 5.161, P = 0.004 ; HR = 1.126, P = 0.030 ). The ROC curve showed that the AUC of length of tibial fracture with occult posterior ankle fracture was 0.599. The YD index suggested that the best cut point for the prediction of tibial fracture with occult posterior ankle fracture was above 13.18%. The sensitivity and specificity of spiral tibial fracture and distal 1/3 tibial fracture for prediction were 88.00% and 63.35%, 92.00%, and 58.39%, respectively, which was significantly higher than that of tibial fracture length ( P < 0.05 ). Conclusion. Patients with tibial fractures have a higher incidence of occult posterior ankle fractures. Spiral tibial fractures and distal 1/3 tibial fractures have a higher predictive value for tibial fracture with occult posterior ankle fractures and can help clinical detection as soon as possible, which is a more accurate and appropriate treatment.

Can Reducing Implant Costs Increase Revenue for Surgically Treated Ankle Fractures: Time-Driven Activity-Based Costing for 1-Year Episode of Care

Background: The purpose of this study was to investigate whether decision-making regarding implant selection affects the reimbursement margins for the surgical fixation of ankle fractures. Methods: All ankle fractures treated between 2010 and 2017 within a single-insurer database were identified via Current Procedural Terminology codes by review of electronic medical record. Implant cost was determined via the implant record cross-referenced with the single contract institutional charge master database. The Time-Driven Activity-Based Costing (TDABC) technique was used to determine the costs of care during all activities throughout the 1-year episode of care. Statistical analysis consisted of multiple linear regression and goodness-of-fit analyses. Results: In all, 249 patients met inclusion criteria. Implant costs ranged from $173 to $3944, averaging $1342 ± $751. The TDABC-estimated cost of care ranged from $1416 to $9185, averaging $3869 ± $1384. Finally, the total reimbursed cost of care ranged between $1335 and $65 645, averaging $13 954 ± $9445. The implant costs occupied an estimated 34.7% of the TDABC-estimated cost of care per surgical encounter. Implant cost, as a percentage of the overall TDABC, was estimated as 36.2% in the inpatient setting and 33% in the outpatient setting, which was the second highest percentage behind surgical costs in both settings. We found a significant increase in net revenue of $1.93 for each dollar saved on implants in the outpatient setting, whereas the increase in net revenue per dollar saved of $1.03 approached significance in the inpatient setting. Conclusion: There is a direct relationship between intraoperative decision-making, as evidenced by implant choices, and the revenue generated by surgical fixation of ankle fractures. Intraoperative decision-making that is cognitive of implant cost can facilitate adoption of institutional cost containment measures and prompt increased healthcare value. Level of Evidence: Level III: Retrospective cohort study

TREATMENT OF TRIPLANE FRACTURE ANKLE FRACTURES ASSOCIATED WITH IPSILATERAL TIBIAL FRACTURES USING A NOVEL APPROACH

ABSTRACT Objective: The aim of this study is to purpose a novel approach to the concomitant triplanar and tibial shaft fracture. Methods: Retrospective study between 2001 and 2019. We collected the patients’ general information, clinical and radiographic data, and complications after the following three-step treatment: (1) fixation of the Salter-Harris II fracture of the triplane fracture, (2) fixation of the Salter-Harris II/IV fracture with cannulated screws, and (3) fixation of the tibial fracture with flexible titanium nails. Results: The study included seven patients (six males) with a mean age of 14 years and a mean follow-up of 6.4 years (minimum two years). Five triplane fractures had two fragments and two had three fragments. Five fractures were classified as Salter-Harris II and two as Salter-Harris IV. Three tibial fractures were long oblique, three were spiral, and one had a third fragment. Six fractures affected the middle third and one affected the distal third of the tibia. All triplane and tibial fractures consolidated without significant displacement. No physeal damage was identified. Conclusions: This study described the association of tibial fractures with triplane ankle fractures managed by our proposed treatment, which proved to be effective for this fracture association. Level of Evidence IV, Case Series.