The December 2024 Trauma Roundup360 looks at: Percutaneous lumbopelvic fixation is effective in the management of unstable transverse sacral fractures; A systematic review on autologous matrix-induced chondrogenesis (AMIC) for chondral knee defects; Stable clinical and radiological outcomes at medium and over five-year follow-up of calcaneus fracture open reduction internal fixation using a sinus tarsi approach; Right or left? It might make a difference; Suprapatellar versus infrapatellar tibial nailing – is there a difference in anterior knee pain and function?; Can patients safely weightbear following ankle fracture fixation?; Anterior-to-posterior or a plate fixation for posterior malleous fractures?; Audio distraction for traction pin insertion: a prospective randomized controlled study; Is intramedullary nailing of femoral diaphyseal fractures in the lateral decubitus position as safe and effective as on a traction table?
Paediatric triplane fractures and adult trimalleolar ankle fractures both arise from a supination external rotation injury. By relating the experience of adult to paediatric fractures, clarification has been sought on the sequence of injury, ligament involvement, and fracture pattern of triplane fractures. This study explores the similarities between triplane and trimalleolar fractures for each stage of the Lauge-Hansen classification, with the aim of aiding reduction and fixation techniques. Imaging data of 83 paediatric patients with triplane fractures and 100 adult patients with trimalleolar fractures were collected, and their fracture morphology was compared using fracture maps. Visual fracture maps were assessed, classified, and compared with each other, to establish the progression of injury according to the Lauge-Hansen classification.Aims
Methods
Aims.
Aims. The optimal management of
Machine-learning (ML) prediction models in orthopaedic trauma hold great promise in assisting clinicians in various tasks, such as personalized risk stratification. However, an overview of current applications and critical appraisal to peer-reviewed guidelines is lacking. The objectives of this study are to 1) provide an overview of current ML prediction models in orthopaedic trauma; 2) evaluate the completeness of reporting following the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) statement; and 3) assess the risk of bias following the Prediction model Risk Of Bias Assessment Tool (PROBAST) tool. A systematic search screening 3,252 studies identified 45 ML-based prediction models in orthopaedic trauma up to January 2023. The TRIPOD statement assessed transparent reporting and the PROBAST tool the risk of bias.Aims
Methods
Triplane ankle fractures are complex injuries typically occurring in children aged between 12 and 15 years. Classic teaching that closure of the physis dictates the overall fracture pattern, based on studies in the 1960s, has not been challenged. The aim of this paper is to analyze whether these injuries correlate with the advancing closure of the physis with age. A fracture mapping study was performed in 83 paediatric patients with a triplane ankle fracture treated in three trauma centres between January 2010 and June 2020. Patients aged younger than 18 years who had CT scans available were included. An independent Paediatric Orthopaedic Trauma Surgeon assessed all CT scans and classified the injuries as n-part triplane fractures. Qualitative analysis of the fracture pattern was performed using the modified Cole fracture mapping technique. The maps were assessed for both patterns and correlation with the closing of the physis until consensus was reached by a panel of six surgeons.Aims
Methods
The aim of this study was to compare the functional and radiological outcomes and the complication rate after nail and plate fixation of unstable fractures of the ankle in elderly patients. In this multicentre study, 120 patients aged ≥ 60 years with an acute unstable AO/OTA type 44-B fracture of the ankle were randomized to fixation with either a nail or a plate and followed for 24 months after surgery. The primary outcome measure was the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score. Secondary outcome measures were the Manchester-Oxford Foot Questionnaire, the Olerud and Molander Ankle score, the EuroQol five-dimension questionnaire, a visual analogue score for pain, complications, the quality of reduction of the fracture, nonunion, and the development of osteoarthritis.Aims
Methods
Aims. The rationale for exacting restoration of skeletal anatomy after unstable ankle fracture is to improve outcomes by reducing complications from malunion; however, current definitions of malunion lack confirmatory clinical evidence. Methods. Radiological (absolute radiological measurements aided by computer software) and clinical (clinical interpretation of radiographs) definitions of malunion were compared within the Ankle Injury Management (AIM) trial cohort, including people aged ≥ 60 years with an unstable ankle fracture. Linear regressions were used to explore the relationship between radiological malunion (RM) at six months and changes in function at three years. Function was assessed with the Olerud-Molander Ankle Score (OMAS), with a minimal clinically important difference set as six points, as per the AIM trial. Piecewise linear models were used to investigate new radiological thresholds which better explain symptom impact on ankle function. Results. Previously described measures of RM and surgeon opinion of clinically significant malunion (CSM) were shown to be related but with important differences. CSM was more strongly related to outcome (-13.9 points on the OMAS; 95% confidence interval (CI) -21.9 to -5.4) than RM (-5.5 points; 95% CI -9.8 to -1.2). Existing malunion thresholds for talar tilt and tibiofibular clear space were shown to be slightly conservative; new thresholds which better explain function were identified (talar tilt > 2.4°; tibiofibular clear space > 6 mm). Based on this new definition the presence of RM had an impact on function, which was statistically significant, but the clinical significance was uncertain (-9.1 points; 95% CI -13.8 to -4.4). In subsequent analysis, RM of a
The morphology of medial malleolar fracture is highly variable and difficult to characterize without 3D reconstruction. There is also no universally accepeted classification system. Thus, we aimed to characterize fracture patterns of the medial malleolus and propose a classification scheme based on 3D CT reconstruction. We retrospectively reviewed 537 consecutive cases of ankle fractures involving the medial malleolus treated in our institution. 3D fracture maps were produced by superimposing all the fracture lines onto a standard template. We sliced fracture fragments and the standard template based on selected sagittal and coronal planes to create 2D fracture maps, where angles α and β were measured. Angles α and β were defined as the acute angles formed by the fracture line and the horizontal line on the selected planes.Aims
Methods
Aims. The primary aim of this study was to address the hypothesis that fracture morphology might be more important than posterior malleolar fragment size in rotational type
In a randomized controlled trial with two-year follow-up, patients treated with suture button (SB) for acute syndesmotic injury had better outcomes than patients treated with syndesmotic screw (SS). The aim of this study was to compare clinical and radiological outcomes for these treatment groups after five years. A total of 97 patients with acute syndesmotic injury were randomized to SS or SB. The five-year follow-up rate was 81 patients (84%). The primary outcome was the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle Hindfoot Scale. Secondary outcome measures included Olerud-Molander Ankle (OMA) score, visual analogue scale (VAS), EuroQol five-dimension questionnaire (EQ-5D), range of movement, complications, reoperations, and radiological results. CT scans of both ankles were obtained after surgery, and after one, two, and five years.Aims
Methods
The posterior malleolus of the ankle is the object
of increasing attention, with considerable enthusiasm for CT scanning
and surgical fixation, as expressed in a recent annotation in Cite this article:
There has been an evolution recently in the management of unstable
fractures of the ankle with a trend towards direct fixation of a
posterior malleolar fragment. Within these fractures, Haraguchi
type 2 fractures extend medially and often cannot be fixed using
a standard posterolateral approach. Our aim was to describe the
posteromedial approach to address these fractures and to assess
its efficacy and safety. We performed a review of 15 patients with a Haraguchi type 2
posterior malleolar fracture which was fixed using a posteromedial
approach. Five patients underwent initial temporary spanning external
fixation. The outcome was assessed at a median follow-up of 29 months (interquartile
range (IQR) 17 to 36) using the Olerud and Molander score and radiographs were
assessed for the quality of the reduction.Aims
Patients and Methods
Stable fractures of the ankle can be safely treated
non-operatively. It is also gradually being recognised that the integrity
of the ‘medial column’ is essential for the stability of the fracture.
It is generally thought that bi- and tri-malleolar fractures are
unstable, as are pronation external rotation injuries resulting
in an isolated high fibular fracture (Weber type-C), where the deltoid
ligament is damaged or the medial malleolus fractured. However,
how best to identify unstable, isolated, trans-syndesmotic Weber
type-B supination external rotation (SER) fractures of the lateral
malleolus remains controversial. We provide a rationale as to how to classify SER distal fibular
fractures using weight-bearing radiographs, and how this can help
guide the management of these common injuries. Cite this article:
Involvement of the posterior malleolus in fractures of the ankle
probably adversely affects the functional outcome and may be associated
with the development of post-traumatic osteoarthritis. Anatomical
reduction is a predictor of a successful outcome. The purpose of this study was to describe the technique and short-term
outcome of patients with trimalleolar fractures, who were treated
surgically using a posterolateral approach in our hospital between
2010 and 2014. The study involved 52 patients. Their mean age was 49 years (22
to 79). There were 41 (79%) AO 44B-type and 11 (21%) 44C-type fractures.
The mean size of the posterior fragment was 27% (10% to 52%) of
the tibiotalar joint surface.Aims
Patients and Methods
The August 2015 Foot &
Ankle Roundup. 360 . looks at: Is orthosis more important than physio in tibialis posterior deficiency?; Radiographic evaluation of ankle injury; Sciatic catheter quite enough!; A fresh look at avascular necrosis of the talus; Total ankle and VTE; Outcomes of
Our aim was to compare the one-year post-operative
outcomes following retention or removal of syndesmotic screws in
adult patients with a fracture of the ankle that was treated surgically.
A total of 51 patients (35 males, 16 females), with a mean age of
33.5 years (16 to 62), undergoing fibular osteosynthesis and syndesmotic
screw fixation, were randomly allocated to retention of the syndesmotic
screw or removal at three months post-operatively. The two groups
were comparable at baseline. One year post-operatively, there was no significant difference
in the mean Olerud–Molander ankle score (82.4 retention We conclude that removal of a syndesmotic screw produces no significant
functional, clinical or radiological benefit in adult patients who
are treated surgically for a fracture of the ankle. Cite this article:
Most posterior hindfoot procedures have been
described with the patient positioned prone. This affords excellent access
to posterior hindfoot structures but has several disadvantages for
the management of the airway, the requirement for an endotracheal
tube in all patients, difficulty with ventilation and an increased
risk of pressure injuries, especially with regard to reduced ocular
perfusion. We describe use of the ‘recovery position’, which affords equivalent
access to the posterior aspect of the ankle and hindfoot without
the morbidity associated with the prone position. A laryngeal mask
rather than endotracheal tube may be used in most patients. In this
annotation we describe this technique, which offers a safe and simple alternative
method of positioning patients for posterior hindfoot and ankle
surgery. Cite this article:
It has previously been suggested that among unstable
ankle fractures, the presence of a malleolar fracture is associated
with a worse outcome than a corresponding ligamentous injury. However,
previous studies have included heterogeneous groups of injury. The
purpose of this study was to determine whether any specific pattern of
bony and/or ligamentous injury among a series of supination-external
rotation type IV (SER IV) ankle fractures treated with anatomical
fixation was associated with a worse outcome. We analysed a prospective cohort of 108 SER IV ankle fractures
with a follow-up of one year. Pre-operative radiographs and MRIs
were undertaken to characterise precisely the pattern of injury.
Operative treatment included fixation of all malleolar fractures.
Post-operative CT was used to assess reduction. The primary and
secondary outcome measures were the Foot and Ankle Outcome Score
(FAOS) and the range of movement of the ankle. There were no clinically relevant differences between the four
possible SER IV fracture pattern groups with regard to the FAOS
or range of movement. In this population of strictly defined SER
IV ankle injuries, the presence of a malleolar fracture was not
associated with a significantly worse clinical outcome than its
ligamentous injury counterpart. Other factors inherent to the injury
and treatment may play a more important role in predicting outcome.
Techniques for fixation of fractures of the lateral
malleolus have remained essentially unchanged since the 1960s, but
are associated with complication rates of up to 30%. The fibular
nail is an alternative method of fixation requiring a minimal incision
and tissue dissection, and has the potential to reduce the incidence
of complications. We reviewed the results of 105 patients with unstable fractures
of the ankle that were fixed between 2002 and 2010 using the Acumed
fibular nail. The mean age of the patients was 64.8 years (22 to
95), and 80 (76%) had significant systemic medical comorbidities.
Various different configurations of locking screw were assessed
over the study period as experience was gained with the device.
Nailing without the use of locking screws gave satisfactory stability
in only 66% of cases (4 of 6). Initial locking screw constructs
rendered between 91% (10 of 11) and 96% (23 of 24) of ankles stable.
Overall, seven patients had loss of fixation of the fracture and
there were five post-operative wound infections related to the distal
fibula. This lead to the development of the current technique with
a screw across the syndesmosis in addition to a distal locking screw.
In 21 patients treated with this technique there have been no significant
complications and only one superficial wound infection. Good fracture
reduction was achieved in all of these patients. The mean physical
component Short-Form 12, Olerud and Molander score, and American Academy
of Orthopaedic Surgeons Foot and Ankle outcome scores at a mean
of six years post-injury were 46 (28 to 61), 65 (35 to 100) and
83 (52 to 99), respectively. There have been no cases of fibular
nonunion. Nailing of the fibula using our current technique gives good
radiological and functional outcomes with minimal complications,
and should be considered in the management of patients with an unstable
ankle fracture.
The April 2012 Trauma Roundup. 360 . looks at fibula-pro-tibia plating, galeazzi fractures, distal radial fractures in the over 65s, transverse sacral fractures, acute dislocation of the knee,
We assessed the long-term (20 years) outcome
of closed reduction and immobilisation in 19 patients with an isolated
fracture of the posterior malleolus of the ankle treated at a single
hospital between 1985 and 1990. The assessments used were an Olerud
functional questionnaire score, physical examination using a loaded
dorsal and plantar range of movement measurement, radiological analysis
of medial joint space widening, the Cedell score for anatomical
alignment of all three malleoli, and the radiological presence of
osteoarthritic change. . There were excellent or good results in 14 patients (74%) according
to the Olerud score, in 18 patients (95%) according to loaded dorsal
and plantar range of movement assessment, in 16 patients (84%) as
judged by the Cedell score, and for osteoarthritis 18 patients (95%)
had an excellent or good score. There were no poor outcomes. There was
no correlation between the size of the fracture gap and the proportion
of the tibiotalar contact area when compared with the clinical results
(gap size: rho values -0.16 to 0.04, p ≥ 0.51; tibiotalar contact
area: rho values -0.20 to -0.03, p ≥ 0.4). Conservative treatment
of ‘isolated’
1. A method of treatment of