Aims.
The most important determinant in the treatment of malleolar fractures is stability. Stable fractures have an intact deep deltoid ligament and do not displace with functional treatment. If the deep deltoid/medial malleolar complex is disrupted, the talus is at risk of displacement. Weber (2010) showed that weightbearing radiographs predicted stability in patients with undisplaced ankle fractures. We developed clinical criteria for potential instability and applied them to a prospective series of patients. Criteria included: medial clear space of < 4mm; medial tenderness, bruising or swelling; a fibular fracture above the syndesmosis; a bimalleolar or trimalleolar fracture; an open fracture; a high-energy fracture mechanism. A consecutive, prospectively documented series of 37 patients chose functional brace treatment of potentially unstable fractures.
Ankle fractures in the elderly are common and have a mortality rate of 12% within the first year. Treatment is challenging due to osteoporotic bone and patient co-morbidities. Many patients struggle with non-weight-bearing (NWB) and presently there is no consensus in the literature regarding optimum management of these injuries. We hypothesised that early weight-bearing in frail patients, Clinical Frailty scale (CFS) score of 4 or more will reduce morbidity and allow patients to return to their usual place of residence faster without jeopardising clinical outcome. We conducted a retrospective analysis of 80 patients aged over 65 years managed at Fiona Stanley Hospital for ankle fractures between January 2016 and 2018. Patients were divided into two cohorts: 40 patients managed NWB and 40 who were permitted to weight-bear as tolerated (WBAT). Patients were stratified as fit (CFS 1–3) or frail (CFS 4+). Primary outcomes were one-year mortality, return to primary residence at six weeks and complications. Secondary outcomes included length of acute hospital stay and rehab stay. For frail patients, those managed NWB stayed in rehab for 19 days longer (p=0.03) and had 28% more complications (p=0.03). By 6 weeks, fewer patients returned to full weight-bearing (p=0.03) and fewer patients had returned home (p=0.01). For fit patients, there were no significant differences in primary outcomes between NWB and WBAT. Our novel study categorising patients by CSF demonstrates that early mobilisation in frail patients results in improved outcomes. Currently there is no formal treatment protocol for the management of ankle fractures in the elderly, and we hope that our proposed algorithm will assist surgeons at our institution and elsewhere. Our study suggests that WBAT may benefit frail patients. We propose a protocol to assist in the management of geriatric ankle fracture patients based on clinical frailty scores.
To systematically review the literature regarding post-surgical treatment regimens on ankle fractures, specifically whether there is a benefit to early weightbearing or early mobilization (6 weeks form surgery). The PubMed, MEDLINE and Embase databases were searched from inception to May 24, 2020. All randomized controlled trials that analyzed the effects of early weightbearing and mobilization following an ankle surgery were included. The primary outcome measure was the Olerud Molander Ankle Score (OMAS). Secondary outcomes included return to work (RTW) and complications. Logistic regression models with random intercepts were used to pool complication data by protocol clustered by study. Twelve RCT's were included, with a total of 1177 patients (41.8 ± 8.4 years). In total, 413 patients underwent early weightbearing and early mobilization (35%), 338 patients underwent early weightbearing and delayed mobilization (29%), 287 patients underwent delayed weightbearing and early mobilization (24%), and 139 patients underwent delayed weightbearing and delayed mobilization (12%). In total, 81 patients had a complication (7%), including 53 wound complications (5%), 11 deep vein thromboses (1%), and 2 failures/nonunions (0%). Early ankle mobilization resulted in statistically significant increases in OMAS scores compared to delayed mobilization (3 studies [222 patients], 12.65; 95% CI, 7.07-18.22; P < 0.00001, I2 = 49%). No significant differences were found between early and delayed weightbearing at a minimum of one-year follow-up (3 studies [377 patients], 1.91; 95% CI, −0.73-4.55, P = 0.16, I2 = 0%). Patients treated with early weightbearing and early mobilization were at higher odds of facing any complication (OR 3.6, 95%CI 1.05-12.1, p=0.041) or wound complications (OR 4.9, 95%CI 1.3-18.8, p=0.022) compared to those with delayed weightbearing and delayed mobilization. Early mobilization following surgical treatment for an ankle fracture resulted in improved ankle function scores compared to delayed mobilization regimens. There were no significant differences between early and delayed weightbearing with respect to patient reported outcomes. Patients who were treated with early mobilization and early weightbearing had an increased odds of postoperative complications.
Pixel Value Ratio (PVR) is a radiographic measure of the relative density of the regenerate to the adjacent bone. This has been reported as an objective criterion for regenerate healing and a guide for when to allow full weight bearing (FWB) in lengthening with intramedullary telescopic nails. The threshold for which magnitude of PVR is adequate to allow bearing full weight is not yet agreed. The aim of this study was to identify from our cohort of adult limb lengthening patients the time to FWB following lengthening, the PVR at this point, and how this compared with the recommended values in the literature. A retrospective database review identified 30 adult patients treated with the PRECICE femoral nail by two senior authors. Time from completion of lengthening to instruction to fully weight bear was noted. The PVR was calculated for each cortex on plain radiographs taken at each postoperative visit following completion of lengthening. Significance was set at Introduction
Materials and Methods
This paper presents a methodology for measuring the femoro-pelvic joint angle based on We scanned a healthy subject in a lying position in a 3T MRI scanner to obtain high resolution (HR) images including two transverse T1-weighted TSE sequence scans at the pelvis and knee and a sagittal T1-weighted dual sense scan at the hip joint. We then scanned the same subject in a weight-bearing configuration in a 0.5T open MRI scanner to obtain related low resolution (LR) images of the femur and acetabulum. Four scan cycles were obtained with the subject being removed and reinserted between cycles in the Open MRI scanner. In each cycle, a block was inserted (up position) and removed (down position) under the subject's foot. The femur and acetabulum bone models were manually segmented and the models from the LR (sitting) images were registered to the HR (supine) images. The femoroacetabular angles relative to the LR scanning plane for four cycles were calculated. The femoral angle relative to the scanner were quite repeatable (SD < 0.9°), the pelvic angles less so (SD ∼2.6–4.3°). The hip flexion angle ranged from 23°–34° in the down and up positions, respectively, so the block induced a mean angle change in the flexion direction of approximately 11° (SD = 1.7°). We found that the femoral position could be accurately re-acquired upon repositioning, while the pelvic position was notably more variable. Limb position changes induced by inserting a block under the subject's foot were consistent (standard deviations in the relative attitude angles under 2°). Overall, our measurement method produces plausible measures of both the femoroacetabular angles and the changes induced by the block, and the reproducibility of relative joint changes is good. ACKNOWLEDGMENTS: Dr. Kang was supported by the National Science and Engineering Research Council of Canada (NSERC) through a Postdoctoral Fellowship and conducted her research at the Centre for Hip Health and Mobility at Vancouver General Hospital, Canada.
Introduction. Open fragility ankle fractures involve complex decision making. There is no consensus on the method of surgical management. Our aim in this study was to analyse current management of these patients in a major trauma centre (MTC). Materials & Methods. This cohort study evaluates the management of geriatric (≥65years) open ankle fractures in a MTC (November 2020–November 2022). The method, timing(s) and personnel involved in surgical care were assessed.
Purpose. Coronal plane malalignment at the level of the tibiotalar joint is not uncommon in advanced ankle joint arthritis. It has been stated that preoperative varus or valgus deformity beyond 15 degrees is a relative contraindication and deformity beyond 20 degrees is an absolute contraindication to ankle joint replacement. There is limited evidence in the current literature to support these figures. The current study is a prospective clinical and radiographic comparative study between patients who underwent total ankle arthroplasty with coronal plane varus tibiotalar deformities greater than 10 degrees and patients with neutral alignment, less than 10 degrees of deformity. Method. Thirty-six ankles with greater than 10 degrees of varus alignment were compared to thirty-six ankles which were matched for implant type, age, gender, and year of surgery. Patients completed preoperative and yearly postoperative functional outcome scores including the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scores, the Ankle Osteoarthritis Scale (AOS) and the Short Form-36 Standard Version 2.0 Health Survey.
The timing of when to remove a circular frame is crucial; early removal results in refracture or deformity, while late removal increases the patient morbidity and delay in return to work. This study was designed to assess the effectiveness of a staged reloading protocol. We report the incidence of mechanical failure following both single-stage and two stage reloading protocols and analyze the associated risk factors. We identified consecutive patients from our departmental database. Both trauma and elective cases were included, of all ages, frame types, and pathologies who underwent circular frame treatment. Our protocol is either a single-stage or two-stage process implemented by defunctioning the frame, in order to progressively increase the weightbearing load through the bone, and promote full loading prior to frame removal. Before progression, through the process we monitor patients for any increase in pain and assess radiographs for deformity or refracture.Aims
Methods
The Precice intramedullary limb-lengthening system has demonstrated significant benefits over external fixation lengthening methods, leading to a paradigm shift in limb lengthening. This study compares outcomes following antegrade and retrograde femoral lengthening in both adolescent and adult patients. A retrospective review of prospectively collected data was undertaken of a consecutive series of 107 femoral lengthening operations in 92 patients. In total, 73 antegrade nails and 34 retrograde nails were inserted. Outcome was assessed by the regenerate healing index (HI), hip and knee range of movement (ROM), and the presence of any complications.Aims
Patients and Methods