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Saengsin J, Sornsakrin P, Atthakomol P, Sato G, Lubberts B, Waryasz G, DiGiovanni CW, Guss D. Ultrasonography for diagnosing medial sided ankle instability in supination external rotation ankle fracture. J Orthop Surg Res 2025; 20:254. [PMID: 40059169 PMCID: PMC11892171 DOI: 10.1186/s13018-025-05645-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2025] [Accepted: 02/24/2025] [Indexed: 05/13/2025] Open
Abstract
BACKGROUND Destabilizing injuries to the deltoid ligament have relied on radiographic stress examination for diagnosis, with a focus on medial clear space widening. Increasingly, Portable ultrasound has also been used in the clinical setting, allowing dynamic and non-invasive evaluation at the point of care. The aim of this study was to determine whether portable ultrasound can detect medial sided instability associated with supination-external rotation type ankle injuries during the gravity stress, weightbearing, and external rotation stress. METHODS Ten fresh-frozen cadaveric ankles were used in this study. Assessment of medial clear space distances with portable ultrasound was first performed with all structures intact, and later with sequential transection of the anterior inferior tibiofibular ligament (Stage I), Weber B fibular fracture (Stage II), posterior inferior tibiofibular ligament (Stage III), superficial deltoid ligament (Stage IVa), and the deep deltoid ligament (Stage IVb). In all scenarios, four loading conditions were considered; (1) a gravity stress test with the ankle positioned in a neutral position; (2) a gravity stress test with the ankle positioned in a plantarflexed position; (3) an external rotation stress test; and (4) simulated weightbearing condition. RESULTS Among all four loading conditions, all medial clear space values increased as the supination-external rotation ankle injury stage progressed (Spearman's rank correlation ranged from 0.43 to 0.90, P <.001). The medial clear space values measured with the portable ultrasound during; (1) gravity stress test in neutral ankle position, (2) gravity stress test in plantarflexed ankle position, (3) weightbearing, and (4) external rotation stress test were significantly increased between intact stage vs. stage IVb (P =.036), as well as between stage III vs. IVb (P ranged from 0.015 to 0.047). CONCLUSIONS Portable ultrasonography is a feasible tool for diagnosing medial ankle instability in supination-external rotation ankle injury. The medial clear space measurements assessed with portable ultrasound during the gravity stress test, weightbearing, and the external rotation stress test well correlated with the supination-external rotation ankle injury staging. Besides, the portable ultrasound method can differentiate the supination-external rotation ankle injury stage IVb from the intact stage, as well as differentiating the supination-external rotation ankle fracture without deltoid ligament injury (III) from the supination-external rotation stage with complete deltoid ligament injury (IVb).
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Affiliation(s)
- Jirawat Saengsin
- Foot and Ankle Research and Innovation Lab, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
| | - Pongpanot Sornsakrin
- Foot and Ankle Research and Innovation Lab, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Pichitchai Atthakomol
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Go Sato
- Foot and Ankle Research and Innovation Lab, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Orthopedic, Asahikawa medical university, Asahikawa, Hokkaido, Japan
| | - Bart Lubberts
- Foot and Ankle Research and Innovation Lab, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Foot & Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital Harvard Medical School, Boston, MA, USA
| | - Gregory Waryasz
- Foot and Ankle Research and Innovation Lab, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Foot & Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital Harvard Medical School, Boston, MA, USA
| | - Christopher W DiGiovanni
- Foot & Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital Harvard Medical School, Boston, MA, USA
- Newton-Wellesley Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel Guss
- Foot & Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital Harvard Medical School, Boston, MA, USA
- Newton-Wellesley Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Koris J, Calder JDF, Dalmau‐Pastor M, Fernandez MA, Ramasamy A. Deltoid ligament injuries: A review of the anatomy, diagnosis and treatments. Knee Surg Sports Traumatol Arthrosc 2024; 32:3052-3064. [PMID: 38796726 PMCID: PMC11605033 DOI: 10.1002/ksa.12274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 04/28/2024] [Accepted: 05/07/2024] [Indexed: 05/28/2024]
Abstract
PURPOSE Ankle sprains remain the most common soft tissue injury presenting to Emergency Departments. Recently, there has been increased awareness and reporting of deltoid ligament injuries in association with injuries to the lateral ligament complex as well as with fibula fractures. This article reviews the currently available literature on the anatomy of the deltoid ligament, clinical and radiological diagnosis of injuries to the deltoid ligament and treatment recommendations. METHODS A literature review was conducted for keywords associated with deltoid ligament injuries. MEDLINE, PubMed and Embase databases were utilised for this search. Articles were included if involving an adult population, were English-language, were related to deltoid ligament injuries (with or without associated injuries) and reported on patho-anatomy, clinical or radiological diagnosis or treatment methods. RESULTS A total of 93 articles were assessed for relevance from the database search, and 47 were included after the removal of irrelevant articles and duplicates. Several studies reported on the clinical findings of deltoid ligament injury, as well as the radiographic analysis. Arthroscopy was considered the gold standard of diagnosis, with authors reporting on the potential benefit of performing arthroscopic repair or reconstruction at the same time. There were no studies that provided a system for the classification of deltoid ligament injury or larger studies of treatment pathways. Long-term studies of the incidence of instability in deltoid ligament injuries were not available. CONCLUSION There is limited evidence available regarding deltoid ligament injuries, particularly in terms of treatment options, either in isolation or with concomitant injuries. Long-term follow-up studies are needed to obtain more accurate data on the number of complications. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Jacob Koris
- Trauma & Orthopaedic Specialty Registrar, John Radcliffe HospitalOxfordUK
| | - James D. F. Calder
- Department of BioengineeringImperial College LondonLondonUK
- Fortius ClinicLondonUK
| | - Miki Dalmau‐Pastor
- Human Anatomy and Embryology Unit, Department of Pathology and Experimental Therapeutics, School of Medicine and Health SciencesUniversity of BarcelonaBarcelonaSpain
- MIFAS by GRECMIP (Minimally Invasive Foot and Ankle Society)MerignacFrance
| | | | - Arul Ramasamy
- Department of BioengineeringImperial College LondonLondonUK
- Academic Department of Military Trauma and OrthopaedicsRoyal Centre for Defence Medicine, EdgbastonBirminghamUK
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Romsom J, Hoogendoorn JM. The additional value of weight-bearing radiographs in assessing stability of isolated type B fibular fractures. Injury 2024; 55:111348. [PMID: 38290382 DOI: 10.1016/j.injury.2024.111348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 12/11/2023] [Accepted: 01/13/2024] [Indexed: 02/01/2024]
Abstract
INTRODUCTION In isolated type B fibular fractures, the decision whether to operate or treat conservatively is principally based on congruency and stability of the ankle joint. The purpose of the current study is to examine the additional diagnostic value of the weight-bearing radiograph (WBR) in assessing stability of potentially unstable type B fibular fractures. MATERIALS AND METHODS In this retrospective cohort study, patients were selected based on who presented an isolated type B fracture of the fibula. Unstable fractures were directly planned for surgery. Other patients underwent additional weight-bearing imaging 4-7 days after initial trauma, on which definitive treatment was based. The medial clear space (MCS) was compared between the WBR and the conventional radiograph. RESULTS A total of 70 patients were included in the period January 2018-December 2021. The average MCS on conventional mortise radiograph was 3.56 mm compared to 3.02 mm on the WBR(p<0.05). The superior clear space (SCS) was equal between both groups (respectively 3.12 mm and 3.08 mm, p = 0.44). All 70 patients were initially treated conservatively with immediate weight-bearing in a brace or soft cast. One patient had the need for open repair and internal fixation due to non-union. DISCUSSION Different techniques for the assessment of deep deltoid ligament integrity exist, such as the MRI, the ultrasonography and different kinds of stress test radiographs. As fractured ankles don't need direct fixation and operative treatment can be postponed, a stepped approach for the assessment of deep deltoid ligament (DDL) integrity can be of assistance in assessing ankle stability. In isolated type B fibular fractures a stepped approach, using the weight-bearing radiograph can be of additional value in assessing the stability. It is a low cost, prevents unnecessary surgery and contributes to a quick weight-bearing non-operative treatment.
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Affiliation(s)
- Jesse Romsom
- Haaglanden Medical Centre, Lijnbaan 32, The Hague, VA 2512 Netherlands.
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Laurence G, Perdue AM, Hake ME, Talusan PG, Holmes JR, Walton DM. Comparison of Outcomes at Midterm Follow-up of Operatively and Nonoperatively Treated Isolated Weber B Ankle Fractures. J Orthop Trauma 2024; 38:115-120. [PMID: 38031297 DOI: 10.1097/bot.0000000000002735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 11/17/2023] [Indexed: 12/01/2023]
Abstract
OBJECTIVES A novel protocol was previously presented for nonoperative management of Weber B (OTA/AO 44B) ankle fractures with criteria of medial clear space <7 mm on gravity stress (GS) radiographs and ipsilateral superior clear space and contralateral GS medial clear space within 2 mm. This study recruited an operative cohort for comparison of outcomes. METHODS DESIGN Retrospective cohort study. SETTING Level 1 academic center. PATIENT SELECTION CRITERIA The recruited operative cohort consisted of patients who may have been considered for the nonoperative protocol, but underwent surgery instead. OUTCOME MEASURES AND COMPARISONS Kellgren-Lawrence scale for evaluation of arthritis, American Orthopedic Foot and Ankle Society Hindfoot, Olerud Molander Ankle, Lower Extremity Functional Scale (LEFS), and PROMIS (physical function, depression, pain interference) scores for the current operative cohort were compared with that of the original nonoperative cohort. RESULTS There were 20 patients in the operative cohort and 29 in the original nonoperative cohort. Mean follow-up was 6.9 and 6.7 years, respectively. The following outcome scores were better for the nonoperative cohort compared with the operative, respectively: LEFS, 75.2 and 68.1 ( P = 0.009); Olerud Molander Ankle, 94.1 and 89.0 ( P = 0.05); American Orthopedic Foot and Ankle Society, 98.5 and 91.7 ( P = 0.0003); PROMIS Physical Function, 58.2 and 50.4 ( P = 0.01); PROMIS Pain Interference, 42.2 and 49.7 ( P = 0.004). The PROMIS Depression, 42.8 and 45.4 ( P = 0.29), was not different between groups. All patients achieved union of their fracture. Surgical complications included implant removal (15%), SPN neurapraxia (5%), and delayed wound healing (5%). CONCLUSIONS In carefully selected patients with isolated Weber B fractures, nonoperative management may be considered because it can lead to equivalent or superior outcomes with none of the risks typically associated with surgical intervention. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ge Laurence
- Department of Orthopedic Surgery, University of Michigan Health System, Ann Arbor, MI
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Stockwell E, Thomas P, Grossman L, Lyden E, Mormino M, Siebler J, Putnam S. Successful Outcomes With Nonoperative Treatment and Immediate Weightbearing Despite Stress-Positive Radiographs in Isolated Distal Fibula (OTA/AO 44B) Fractures. J Orthop Trauma 2024; 38:e20-e27. [PMID: 37853554 DOI: 10.1097/bot.0000000000002719] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/12/2023] [Indexed: 10/20/2023]
Abstract
OBJECTIVES To determine whether a nonoperative management protocol results in equivalent outcomes in isolated OTA/AO 44B (Weber B) fractures without initial medial clear space (MCS) widening regardless of stress radiography findings. METHODS DESIGN Prospective cohort. SETTING Level 1 academic trauma center. PATIENT SELECTION CRITERIA Nonoperatively managed patients with isolated OTA/AO 44B fractures and MCS ≤4 mm on initial non-weightbearing injury radiographs between from January 2018 and January 2022 were included. All patients underwent emergency department gravity stress radiographs and those with widening were considered the widening cohort and those without the non-widening cohort. OUTCOME MEASURE AND COMPARISONS MCS measurements on weightbearing radiographs were obtained at first follow-up, 6 weeks, 12 weeks, and 6 months postinjury, were considered indicative of instability if >4 mm and were compared between cohorts.; American Orthopaedic Foot and Ankle Society ankle-hindfoot scores were also compared between cohorts. RESULTS Sixty-nine patients were studied. None of the 38 patients (55%) with widening on gravity stress radiographs demonstrated widening with weightbearing radiographs at any time point. Mean MCS measurement differences between the 2 cohorts were statistically significant for all time points ( P = 0.012); however, with a model adjusted mean MCS value of 2.7 mm for the nonwidening cohort and 2.9 mm for the widening cohort, these are not clinically significant. There was no statistically significant difference in overall final American Orthopaedic Foot and Ankle Society scores between the 2 groups ( P = 0.451). In addition, statistical equivalence using Schuirmann 2 one-sided tests was achieved between the 2 groups. Both cohorts had mean American Orthopaedic Foot and Ankle Society scores representing excellent outcomes at the final follow-up. CONCLUSIONS Patients with isolated OTA/AO 44B fractures without MCS widening on initial injury radiographs did not demonstrate instability on subsequent weightbearing radiographs and had equivalent outcomes regardless of gravity stress radiography findings when treated nonoperatively. Weightbearing radiographs at the initial follow-up appear to be a reliable assessment of ankle stability in these injuries and are an appropriate alternative to painful and time-consuming stress radiography. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Erin Stockwell
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha, NE
| | | | | | - Elizabeth Lyden
- University of Nebraska Medical Center College of Public Health, Omaha, NE
| | - Matthew Mormino
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha, NE
| | - Justin Siebler
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha, NE
| | - Sara Putnam
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha, NE
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Lehtovirta S, Casula V, Haapea M, Nortunen S, Lepojärvi S, Pakarinen H, Nieminen MT, Lammentausta E, Niinimäki J. Assessment of articular cartilage of ankle joint in stable and unstable unilateral weber type-B/SER-type ankle fractures shortly after trauma using T2 relaxation time. Acta Radiol Open 2023; 12:20584601231202033. [PMID: 37779823 PMCID: PMC10540593 DOI: 10.1177/20584601231202033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 09/01/2023] [Indexed: 10/03/2023] Open
Abstract
Background Early detection of post-traumatic cartilage damage in the ankle joint in magnetic resonance images can be difficult due to disturbances to structures usually appearing over time. Purpose To study the articular cartilage of unilateral Weber type-B/SER-type ankle fractures shortly post-trauma using T2 relaxation time. Material and Methods Fifty one fractured ankles were gathered from consecutively screened patients, compiled initially for RCT studies, and treated at Oulu University Hospital and classified as stable (n = 28) and unstable fractures (n = 23) based on external-rotation stress test: medial clear space of ≥5 mm was interpreted as unstable. A control group of healthy young individuals (n = 19) was also gathered. All ankles were imaged on average 9 (range: 1 to 25) days after injury on a 3.0T MRI unit for T2 relaxation time assessment, and the cartilage was divided into sub-regions for comparison. Results Control group displayed significantly higher T2 values in tibial cartilage compared to stable (six out of nine regions, p-values = .003-.043) and unstable (six out of nine regions, p-values = .001-.037) ankle fractures. No differences were detected in talar cartilage. Also, no differences were observed between stable and unstable fractures in tibial or talar cartilage. Conclusions Lower T2 relaxation times of tibial cartilage in fractured ankles suggest intact extra cellular matrix (ECM) of the cartilage. Severity of the ankle fracture, measured by ankle stability, does not seem to increase ECM degradation immediately after trauma.
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Affiliation(s)
- Sami Lehtovirta
- Research Unit of Health Sciences and Technology, University of Oulu, Oulu, Finland
- Medical Research Center, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Victor Casula
- Research Unit of Health Sciences and Technology, University of Oulu, Oulu, Finland
- Medical Research Center, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Marianne Haapea
- Department of Diagnostic Radiology, Oulu University Hospital, Oulu, Finland
| | | | | | | | - Miika T. Nieminen
- Research Unit of Health Sciences and Technology, University of Oulu, Oulu, Finland
- Medical Research Center, Oulu University Hospital, University of Oulu, Oulu, Finland
- Department of Diagnostic Radiology, Oulu University Hospital, Oulu, Finland
| | - Eveliina Lammentausta
- Medical Research Center, Oulu University Hospital, University of Oulu, Oulu, Finland
- Department of Diagnostic Radiology, Oulu University Hospital, Oulu, Finland
| | - Jaakko Niinimäki
- Research Unit of Health Sciences and Technology, University of Oulu, Oulu, Finland
- Medical Research Center, Oulu University Hospital, University of Oulu, Oulu, Finland
- Department of Diagnostic Radiology, Oulu University Hospital, Oulu, Finland
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Zeni F, Cavazos DR, Bouffard JA, Vaidya R. Indications and Interpretation of Stress Radiographs in Supination External Rotation Ankle Fractures. Cureus 2023; 15:e38092. [PMID: 37252532 PMCID: PMC10209918 DOI: 10.7759/cureus.38092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2023] [Indexed: 05/31/2023] Open
Abstract
Introduction In supination external rotation (SER) ankle fractures with an intact medial malleolus, stability hinges upon the competence of the deltoid ligament. The purpose of this study is to define the indications and establish criteria for a positive stress radiograph. Methods This is a prospective study of 27 isolated SER lateral malleolar fractures with a reduced ankle mortise. Pain and swelling were noted about the medial ankle, followed by an ultrasound to evaluate the integrity of the deltoid ligament. Static and stress radiographs were performed on both the fractured and contralateral ankles. Results Fourteen patients were normal on ultrasound examination, eight had partial tears, and five had full-thickness tears. The difference in the level of pain to palpation postero-medially between the complete tear (7 +/- 1) and the partial tear (1.3 +/- 2.4) group was significant (p < .001). The negative predictive values for medial swelling and tenderness were 93% and 100%, respectively. Sensitivity and specificity for medial clear space on stress radiograph (fracture (fx)) > 5.0 mm were both 100% while a 2.5 mm or greater change to the contralateral side yielded a sensitivity of 100% and specificity of 95%. Conclusion The lack of significant medial pain, as well as swelling, implies the absence of a complete ligament tear and eliminates the need for stress examination. Conversely, the presence of medial signs of injury is suggestive, but not pathognomonic for a complete deltoid tear. Medial clear space (MCS) variability prompts to recommend a minimum of 2.5 mm on stress radiographs compared to the contralateral side as indirect evidence for a complete tear of the deltoid ligament.
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Affiliation(s)
| | - Daniel R Cavazos
- Orthopaedic Surgery, Wayne State University School of Medicine, Detroit, USA
- Orthopaedic Surgery, Detroit Medical Center, Detroit, USA
| | - José A Bouffard
- Orthopaedic Surgery, Wayne State University School of Medicine, Detroit, USA
| | - Rahul Vaidya
- Orthopaedic Surgery, Wayne State University School of Medicine, Detroit, USA
- Orthopaedic Surgery, Detroit Medical Center, Detroit, USA
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Haupt ET, Sebro R, Iturregui JM, Stanborough R, Siddiqui A, Shi GG. Measuring Deltoid Insufficiency After Supination-External Rotation Ankle Fracture With Lateral Talar Subluxation on Gravity Stress View. Foot Ankle Int 2022; 43:1525-1531. [PMID: 36082428 DOI: 10.1177/10711007221119162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Stress-view radiographs are frequently obtained to evaluate supination-external rotation (SER) variant ankle fractures. Measurement of the ankle medial clear space (MCS) is a surrogate of medial structure integrity as part of overall ankle stability. Measurement of the lateral talus displacement with respect to the incisura may be a sensitive and specific method to assess joint subluxation. METHODS Retrospective review of acute SER-variant isolated lateral malleolar fractures with gravity stress views (GSVs) were performed for 103 patients. GSV analysis was performed with standardized measurements of the MCS, superior clear space (SCS), and 2 new novel measurements of lateral talus subluxation (LTS). Decision for surgery was obtained by surgeons who reviewed masked injury radiographs for predictive performance analysis of the LTS vs MCS. RESULTS MCS, SCS, and LTS measurements were performed on 103 patients. Mean MCS, SCS, and LTS within the operative group was increased. MCS ≥5 mm and LTS >4 mm had equal sensitivity (95%), with higher specificity for LTS (75% vs 60%). Receiver operating characteristic analysis demonstrates an area under the curve of 0.786 for MCS ≥5 mm vs 0.918 for LTS >4 mm. CONCLUSION We found LTS to be superior to MCS for medial ankle structure stability on gravity stress views of SER-variant ankle fractures. We propose this as a useful tool for clinicians to consider when evaluating SER-variant ankle fractures. LEVEL OF EVIDENCE Level II, prospective comparative study of radiographs.
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McCormack DJ, Solan M, Aziz S, Faroug R, Kirmani S, Wright G, Mangwani J. Role of the posterior deep deltoid ligament in ankle fracture stability: A biomechanical cadaver study. World J Orthop 2022; 13:969-977. [PMID: 36439368 PMCID: PMC9685633 DOI: 10.5312/wjo.v13.i11.969] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 09/01/2022] [Accepted: 10/28/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The deltoid ligament is a key component of ankle fracture stability. Clinical tests to assess deltoid ligament injury have low specificity. In supination external-rotation (SER) type-IV ankle fractures, there is either a medial malleolus fracture or deltoid ligament injury. These injuries are often considered unstable, requiring surgical stabilisation. We look to identify the anatomical basis for this instability. This study investigates the anatomical basis for such instability by re-creating SER type ankle fractures in a standardised cadaveric study model, investigating the anatomical basis for such instability.
AIM To investigate the anatomical basis for fracture instability in SER type ankle fractures.
METHODS Four matched pairs of cadaveric limbs were tested for stability both when axially loaded and under external rotation stress. Four matched pairs of cadaveric limbs (8 specimens) were tested for stability when axially loaded to 750 N with a custom rig. Specimens were tested through increasing stages of SER injury in a stepwise fashion before restoring the lateral side with open reduction and internal fixation (ORIF). Clinical photographs and radiographs were recorded at each step. We defined instability in accordance with well accepted radiological parameters: > 4 mm medial clear space opening on a mortise-view radiograph or > 7 degrees of talar tilt.
RESULTS All specimens with an intact posterior deep deltoid ligament were stable. Once the posterior deep deltoid ligament was sectioned there was instability in all specimens. Stabilisation of the lateral side prevented talar shift, but not talar tilt.
CONCLUSION If the posterior deep deltoid ligament is intact then SER fractures can be managed without surgery. If the posterior deep deltoid is incompetent, ORIF and cautious rehabilitation is recommended because the talus can still tilt in the mortise.
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Affiliation(s)
- Daniel James McCormack
- Department of Trauma and Orthopaedics, University Hospitals of Leicester, Leicester LE1 5WW, United Kingdom
| | - Matthew Solan
- Department of Trauma and Orthopaedic Surgery, Royal Surrey City Hospital NHS Trust, University of Surrey, Guilford GU2 7XX, United Kingdom
| | - Sheweidin Aziz
- Department of Trauma and Orthopaedics, University Hospitals of Leicester, Leicester LE1 5WW, United Kingdom
| | - Radwane Faroug
- Department of Trauma and Orthopaedics, Stoke Mandeville Hospital, Aylesbury HP21 8AL, Buckinghampshire, United Kingdom
| | - Sayyied Kirmani
- Department of Trauma and Orthopaedics, University Hospitals of Leicester, Leicester LE1 5WW, United Kingdom
| | - Georgina Wright
- Department of Trauma and Orthopaedics, University Hospitals of Leicester, Leicester LE1 5WW, United Kingdom
| | - Jitendra Mangwani
- Department of Trauma and Orthopaedics, University Hospitals of Leicester, Leicester LE1 5WW, United Kingdom
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Fibular displacement does not predict instability in type B ankle fractures. Arch Orthop Trauma Surg 2022; 142:3285-3291. [PMID: 34533600 DOI: 10.1007/s00402-021-04169-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 09/01/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Despite the wide prevalence of ankle fractures, no consensus exists on the most accurate radiologic diagnostic tool to indicate medial ligament injury in isolated type B distal fibular fractures. The aim of this study was to evaluate the value of the fibular fracture displacement in predicting medial clear space widening on the gravity stress radiographs, as a parameter of fracture instability. METHODS This retrospective cohort study included 192 patients with an isolated type B fibular fracture, for which a regular mortise and gravity stress radiograph were made in our hospital between January 2014 and December 2019. On the regular mortise and lateral radiographs, the medial clear space (MCS), superior clear space (SCS), anteroposterior and lateral fibular displacement were measured. On the gravity stress radiograph, the MCS and SCS were measured. Instability was defined as MCS ≥ SCS + 3.0 mm on the gravity stress radiograph. A receiver operating characteristic (ROC) curve was constructed to evaluate the predictive value of the fibular displacement. RESULTS Of the 192 included patients, 55 (29%) patients had instable ankle fractures. In predicting instability, fibular displacement demonstrated an area under the curve (AUC) of 0.68 (95% confidence interval 0.60-0.77) and a correlation coefficient of 0.41 with MCS. CONCLUSION Fibular displacement on regular mortise view is a poor predictor of instability in type B fibular fractures. It should not be advised to use the fracture displacement as parameter for medial injury and thus for operative treatment.
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Black JDJ, Dhillon G, Tadros BJ, Malik-Tabassum K, Southgate C, Dhinsa B. Ultrasonography for the diagnosis of deltoid injury in supination external rotation ankle fractures - A scoping review. Foot (Edinb) 2022; 51:101897. [PMID: 35255405 DOI: 10.1016/j.foot.2021.101897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 10/19/2021] [Accepted: 12/21/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Lauge-Hansen supination external rotation (SER)-type ankle fractures are very common and account for up to 75% of all ankle fractures. Assessing deltoid integrity is key for surgical decision making. Ultrasound has been used recently to assess the integrity of the deltoid ligament and differentiate between SER II and SER IV fractures. The aim of this article is to review the literature for studies assessing the diagnostic accuracy of ultrasound in this group of patients. METHODS After registering the protocol with PROSPERO, Embase, Ovid MEDLINE, Web of Science Core Collection, and Google Scholar were systematically searched. Studies that satisfied the following inclusion criteria were assessed: (1) Adult patients (>16 years), (2) Acute SER-type ankle fractures assessed within 2 weeks of the injury, (3) Diagnostic accuracy studies. Risk of bias assessment was conducted and a narrative synthesis of the results presented. RESULTS A total of five studies satisfied our inclusion criteria and were included for review. These had a total of 175 patients studied. All studies showed a sensitivity of 100% and specificity of 90-100% for detecting a complete tear of the deltoid. All papers had a significant risk of bias inherent to the design. Only patients undergoing surgery were exposed to the gold standard of operative intervention. CONCLUSION Ultrasound scan has shown excellent diagnostic accuracy for detecting complete deltoid ruptures in SER ankle fractures. These results however should be interpreted with caution. Perhaps a different approach is needed to assess the efficacy of ultrasound scans in patient with SER type fractures.
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Affiliation(s)
| | - Govind Dhillon
- Lister Hospital, East and North Hertfordshire NHS Trust, Coreys Mill Lane, Stevenage, Hertfordshire, SG1 4AB, UK.
| | - Baha John Tadros
- William Harvey Hospital, East Kent Hospitals NHS Trust, Kennington Rd, Willesborough, Ashford, TN24 0LZ, UK.
| | - Khalid Malik-Tabassum
- Royal Surrey County Hospital, Royal Surrey NHS Foundation Trust, Egerton Road, Guildford, Surrey, GU2 7XX, UK.
| | - Crispin Southgate
- William Harvey Hospital, East Kent Hospitals NHS Trust, Kennington Rd, Willesborough, Ashford, TN24 0LZ, UK.
| | - Baljinder Dhinsa
- William Harvey Hospital, East Kent Hospitals NHS Trust, Kennington Rd, Willesborough, Ashford, TN24 0LZ, UK.
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12
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DeKeyser GJ, Campbell ML, Kellam PJ, Haller JM, Rothberg DL, Higgins TF, Marchand LS. True antiglide fixation of Danis-Weber B fibula fractures has lower rates of removal of hardware. Injury 2022; 53:1289-1293. [PMID: 34627627 DOI: 10.1016/j.injury.2021.09.051] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/18/2021] [Accepted: 09/26/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Plating of unstable OTA/AO 44-B2 equivalent lateral malleolus (Danis-Weber B) fractures has been associated with pain, peroneal irritation, and the need for subsequent hardware removal (ROH). The purpose of this study is to retrospectively compare the rates of ROH in unstable Weber B fractures fixed with a posterior, true antiglide plate with no screws in the distal segment versus those that were fixed with a similarly placed posterior, neutralization construct that included screws in the distal fragment. Thus, evaluating the role of the distal screws in rates of ROH. METHODS Skeletally mature patients that were treated for an unstable, isolated Weber B fracture at a single level-1 trauma center over a ten-year period were reviewed. Fractures treated with a single posterior plate with at least six months of follow-up were included and those fixed with a direct lateral plate were excluded. The primary outcome of this study was hardware removal defined as entire plate removal; isolated syndesmotic screw removal was not included. RESULTS Ninety-six patients were included in the study with average age of 46 years (range 17-83) and mean length of follow-up of 24.5 months (range 6.1-140.3). There were 33 patients in the antiglide group (mean follow-up 25.5 months) and 63 in the neutralization plate group (mean follow-up 24 months, p=0.81). Fractures fixed with or without distal screws had equivalent excellent results related to bony union and alignment. However, there was a statistically significant decrease in ROH rates in the antiglide group (antiglide ROH rate 15.2%; neutralization ROH rate 38.1%; p=0.02). Relative risk of ROH with antiglide plate was 0.4 (95% CI 0.17 - 0.95; p=0.04). CONCLUSIONS Antiglide plating shows a significant risk reduction in the rate of ROH when compared to posterior based neutralization plating. A true antiglide plating construct should be considered as a safe and effective way of managing Weber B fractures with a lower relative risk of a second operation for hardware removal. LEVEL OF EVIDENCE Therapeutic level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Graham J DeKeyser
- University of Utah, Department of Orthopaedic Surgery, Salt Lake City, UT, USA.
| | - Megan L Campbell
- University of Utah, Department of Orthopaedic Surgery, Salt Lake City, UT, USA
| | - Patrick J Kellam
- University of Utah, Department of Orthopaedic Surgery, Salt Lake City, UT, USA
| | - Justin M Haller
- University of Utah, Department of Orthopaedic Surgery, Salt Lake City, UT, USA
| | - David L Rothberg
- University of Utah, Department of Orthopaedic Surgery, Salt Lake City, UT, USA
| | - Thomas F Higgins
- University of Utah, Department of Orthopaedic Surgery, Salt Lake City, UT, USA
| | - Lucas S Marchand
- University of Utah, Department of Orthopaedic Surgery, Salt Lake City, UT, USA
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13
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Superficial Deltoid Ligament and Deep Deltoid Ligament Play Equally Important Roles in the Stability of Isolated Lateral Malleolus (OTA/AO 44-B1) Fractures: A Biomechanical Study. J Orthop Trauma 2022; 36:73-79. [PMID: 35061655 DOI: 10.1097/bot.0000000000002216] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/15/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the individual contributions to stability of the superficial and deep deltoid ligaments in the setting of SER IV ankle fractures. METHODS Nineteen total cadaveric specimens were used. SER IV injuries were created with the rupture of either the superficial (SER IV-S) (n = 9) or deep deltoid (SER IV-D) (n = 10). These were tested by applying an external rotation force (1 Nm, 2 Nm, 3 Nm, and 4 Nm). Changes in the position of the talus were recorded with a 3D motion tracker. Injury conditions were compared with a 4-step general linear model with repeated measures. Injury condition was also compared with the intact state and to each other using 2-tailed t tests. RESULTS The general linear model showed that increased loading had a significant effect with axial rotation (P = 0.02) and sagittal translation (P = 0.003). SER IV-S and SER IV-D showed significantly greater instability compared with the intact state in axial rotation (1 Nm, 2 Nm, and 3 Nm). SER IV-S and SER IV-D did not significantly differ from each other. CONCLUSIONS SER IV fracture patterns can be unstable with isolated injury to either the superficial or deep deltoid. This challenges the notion that deep deltoid rupture is necessary. Further clinical studies would help quantify the consequences of this instability.
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14
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de Krom MA, Kalmet PH, Jagtenberg EM, Hermus JP, van Vugt R, Seelen HA, Poeze M. Diagnostic tools to evaluate ankle instability caused by a deltoid ligament rupture in patients with supination-external rotation ankle fractures: A systematic review and meta-analysis. Injury 2022; 53:724-731. [PMID: 34602247 DOI: 10.1016/j.injury.2021.09.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 08/08/2021] [Accepted: 09/17/2021] [Indexed: 02/02/2023]
Abstract
AIM Supination-external rotation (SER) ankle fractures account for the majority of ankle fractures and can be divided into stable or unstable fractures, based on the state of the deltoid ligament. The objective of this review was to appraise the available literature concerning diagnostic tools to evaluate deltoid ligament integrity in patients with SER-type ankle fractures. METHODS A comprehensive literature search of Pubmed and Embase was performed up to December 2020. The outcome measures were sensitivity, specificity and positive and negative predictive value of the diagnostic tools. A meta-analysis was performed to obtain an overview of sensitivity, specificity and area under the curve (AUC). The methodological quality of the articles was evaluated using Quality Assessment of Diagnostic Accuracy Studies. RESULTS A total of 12 studies investigating tools for deltoid ligament rupture in patients with SER-type ankle fractures were included. The present study found sensitivity (and specificity) ranges of 0.20-0.90 (and 0.38-0.97) for clinical features, Magnetic Resonance Imaging (MRI) 0.57-0.85 (and 0.81-1.00), ultrasonography 1.00 (and 0.89-1.00), Malleolar Medial Fleck Sign (MMFS) 0.25 (and 0.99), conventional ankle mortise radiography 0.33-0.57 (and 0.60-0.94), gravity stress radiography 0.71-1.00 (and 0.72-0.88) and manual stress ankle radiography 0.65-1.00 (and 0.00-0.77). The largest AUC was found for ultrasonography, followed by MMFS, gravity stress radiography and MRI. CONCLUSION Ultrasonography and gravity stress radiography seem the most accurate diagnostic tools to evaluate deltoid ligament integrity. To strengthen this conclusion, future research should use an identical reference test to ensure comparability of results. Nevertheless, present study is of high value to close the knowledge gap about which presently available diagnostic tool is to be preferred to evaluate deltoid ligament integrity in patients with SER-type ankle fractures.
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Affiliation(s)
- Maartje Ap de Krom
- Maastricht University Medical Centre+, Dept. of Trauma Surgery, Maastricht, The Netherlands.
| | - Pishtiwan Hs Kalmet
- Maastricht University Medical Centre+, Dept. of Trauma Surgery, Maastricht, The Netherlands
| | - Eline M Jagtenberg
- Maastricht University Medical Centre+, Dept. of Trauma Surgery, Maastricht, The Netherlands
| | - Joris Ps Hermus
- Maastricht University Medical Centre+, Dept. of Orthopedic Surgery, Maastricht, The Netherlands
| | - Raoul van Vugt
- Zuyderland Medical Centre, Dept. of Surgery, Heerlen, The Netherlands
| | - Henk Am Seelen
- Adelante Center of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands; Research School CAPHRI, Dept. of Rehabilitation Medicine, Maastricht University, Maastricht, The Netherlands
| | - Martijn Poeze
- Maastricht University Medical Centre+, Dept. of Trauma Surgery, Maastricht, The Netherlands; Nutrim School for Nutrition, Toxicology and Metabolism, Maastricht University, Maastricht, The Netherlands
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15
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Lack of Displacement of the Fibula Is Not a Confirmation of Ankle Stability in Supination External Pattern Ankle Fractures. J Orthop Trauma 2022; 36:e1-e5. [PMID: 33878070 DOI: 10.1097/bot.0000000000002139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/01/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate and compare radiographic findings in supination external (SE)2 injuries versus stress (+) SE4 injuries. DESIGN Retrospective. SETTING Academic Level 1 trauma center. PATIENTS The study included 350 skeletally mature patients at a single Level 1 trauma center who presented with an isolated, Lauge-Hansen type supination-external rotation pattern, Weber B lateral malleolar fracture, OTA/AO 44-B. RESULTS We reviewed 350 patients (185 men and 165 women), 18-95 years of age (avg 45), with isolated SE pattern lateral malleolar fractures. One hundred nine had SE4 injuries [medial clear space (MCS) = 8.3 mm]. Two hundred forty-one ankles were stressed; 164 were unstable and 77 were stable (SE2). Avg MCS at presentation and on stress radiographs was 3.59 mm for the SE2 (no widening) and 3.86 mm and 5.94 mm for the stress (+) SE4 group, respectively. The fibular displacement for the SE2, stress (+) SE4, and SE4 groups was 1.5 (0-4.5), 3.5 (0-6.6), and 4.1 (0-30.5), respectively. Sixteen of the 77 (20%) SE2 and 24 of the 164 (15%) stress (+) SE4 fractures had no displacement of the fibula on the lateral view. Similarly, 53 of the 77 (68%) SE2 and 91 of the 164 (55%) stress (+) SE4 had ≤2 mm of fibular displacement Fibular displacement of ≤2 mm on the lateral radiograph corresponded with 0.69 sensitivity and only 0.37 positive predictive value for stable ankle mortise on stress examination. CONCLUSIONS Previous work indicated that patients with an isolated SE pattern fibula fracture, a normal MCS, and ≤2 mm of fibular displacement on the lateral radiograph have a high rate of ankle stability, with a positive predictive value of approximately 97%. We were unable to confirm this finding because 15% of unstable ankles had 0 mm and 55% had ≤2 mm of fibular displacement. We conclude that stability may not be inferred from a lack of fibular displacement on the lateral view in this population of patients. If stability is to be determined, it must be tested irrespective of fibular displacement on the lateral radiograph. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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16
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Kellam PJ, Dekeyser GJ, Haller JM, Rothberg DL, Higgins TF, Marchand LS. Predicting Syndesmotic Injury in OTA/AO 44-B2.1 (Danis-Weber B) Fractures. J Orthop Trauma 2021; 35:473-478. [PMID: 33395177 DOI: 10.1097/bot.0000000000002052] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/22/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To establish if preoperative radiographs could predict the rate of syndesmotic injury. SETTING Level 1 trauma center. DESIGN Retrospective cohort study. PATIENTS/PARTICIPANTS There were 548 OTA/AO 44-B2.1 fractures that were reviewed, and 287 patients were included in the study. MAIN OUTCOME MEASUREMENTS Ankle radiographs were used to determine the zone of distal extent of the proximal fracture fragment. Syndesmotic injury was defined as positive intraoperative stress examination that required syndesmotic fixation. RESULTS There were 191 zone 1 (ending below the plafond) injuries, 57 zone 2 (ending between the physeal scar and the plafond) injuries, and 39 zone 3 (ending above the physeal scar) injuries. Of these, 17% (33 patients) of zone 1, 42% (24) of zone 2, and 74% (29) of zone 3 fractures had syndesmotic injuries. The relative risk of syndesmotic injury of zone 1 compared with zone 2 was 2.4 (P < 0.001), zone 1 to zone 3 was 4.3 (P < 0.001), and zone 2 to zone 3 was 1.8 (P = 0.002). The interobserver and intraobserver reliability was excellent (κ = 0.86, 0.94). CONCLUSION OTA/AO 44-B2.1 fractures have a varying rate of syndesmotic injury. Weber B fractures that end between the level of the plafond and the physeal scar (zone 2) are 2.4 times more likely to have a syndesmotic injury compared with those that end below the plafond (zone 1). This is magnified in those injuries ending above the scar (zone 3). This simple classification of OTA/AO 44-B2.1 fractures is predictive of syndesmotic injury and may aid in preoperative counseling and planning. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Patrick J Kellam
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT
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17
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Medial Ankle Stability Evaluation With Dynamic Ultrasound: Establishing Natural Variations in the Healthy Cohort. J Am Acad Orthop Surg 2021; 29:703-713. [PMID: 34270497 DOI: 10.5435/jaaos-d-20-00597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 10/02/2020] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Destabilizing injuries to the deltoid ligament have relied on radiographic stress examination for diagnosis, with a focus on medial clear space (MCS) widening. Recently, studies have demonstrated the use of ultrasonography to assess deltoid ligament injury, but not the medial ankle stability. The purpose of this study was to assess the MCS via ultrasonography while weight-bearing and with a gravity stress test (GST) in the uninjured ankle as a means of establishing normative values for future comparison. METHODS Twenty-six participants with no reported ankle injury in their premedical history were included. The MCS was examined using ultrasonography with the patient lying in a lateral decubitus position to replicate a GST with the ankle held in a neutral and plantarflexed position as well as while weight-bearing. The MCS was assessed in mm at the anteromedial and inferomedial aspect of the ankle joint. RESULTS With weight-bearing, the average anterior MCS and inferior MCS were 3.6 and 3.3 mm, respectively. During the GST in neutral ankle position, the average anterior MCS was 4.1 mm, whereas the average inferior MCS was 4.0 mm. When measured during the GST in plantarflexed ankle position, the averages anterior MCS and inferior MCS increased to 4.4 mm. MCS values were notably higher with GST than with weight-bearing measurements (P < 0.001). MCS values were notably higher with the foot in a plantarflexed compared with a neutral position when doing GST (P < 0.001). No notable differences in MCS distance were found when comparing laterality (P > 0.05). Height had a notable effect on all MCS values (P < 0.05). Inter- and intra-rater reliabilities for ultrasonographic MCS measurements were all excellent (interclass correlation coefficient >0.75). DISCUSSION Ultrasound can reliably measure the MCS of the ankle while doing dynamic stress manoeuvres. With the deltoid ligament intact, a GST increases MCS widening more than weight-bearing, and holding the ankle in plantarflexion while doing a gravity stress view, further increases this difference. LEVELS OF EVIDENCE Diagnostic studies-investigating a diagnostic test: Level III.
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18
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Gourbault LJ, Fennelly JT, Stedman T, Price MJ, Ward AE. The Current UK Consensus on the Management of Weber B and Posterior Ankle Fractures: A Questionnaire Study as Part of the Acute Management of Ankle Fractures (AUGMENT) Audit. J Foot Ankle Surg 2021; 60:669-675. [PMID: 33573901 DOI: 10.1053/j.jfas.2020.04.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 03/31/2020] [Accepted: 04/18/2020] [Indexed: 02/03/2023]
Abstract
Ankle fractures are common conditions which are associated with significant morbidity when managed incorrectly. With the incidence due to triple by 2030, standards of practice were created by the British Orthopaedic Association and the British Orthopaedic Foot and Ankle Society to ensure optimal treatment. In spite of this, anecdotally there is still a variation in practice and therefore a questionnaire study was designed to explore clinician decision-making around Weber B and Posterior Malleolus ankle fractures. Five scenarios explored management regarding minimally and grossly displaced injuries, as well as the use of further imaging. The questionnaires were distributed via AUGMENT collaborators at their sites and at the British Orthopaedic Foot and Ankle Society congress 2018. About 315 questionnaires were completed and included in analysis. For Weber B injuries, overall there was a consensus across all respondents with minimally displaced and grossly displaced fractures being treated conservatively and operatively respectively. For Posterior Malleolus injuries, there was variation in practice between Foot and Ankle specialists and their non-Foot and Ankle colleagues. Computed tomography (CT) was more likely to be used to assess these injuries by specialists (97.50 vs 69.79%) and these injuries were more likely to be treated operatively across the board. This study identified key variation in practice of the management of Posterior Malleolar ankle fractures, including the use of imaging to further define the anatomy and the decision to operate. Foot and Ankle surgeons were more likely to organize CT scans and to surgically manage these injures.
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Affiliation(s)
| | | | - Tobias Stedman
- Registrar, Doncaster Royal Infirmary, Doncaster, United Kingdom
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19
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Abstract
Whereas tenderness, ecchymosis, and swelling over the deltoid ligament have relatively poor sensitivity, resulting valgus and pronation deformity that is seen to disappear when the patient is asked to activate the posterior tibial muscle or to go in tiptoe position is the hallmark for the presence of medial ankle instability. A pain on palpation at anteromedial edge of the ankle confirms the diagnosis. Various stress tests permit to confirm and specify the injury pattern. A pseudo hallux rigidus is the consequence of a hyperactivity of flexor hallucis longus muscle to protect the foot against the valgus and pronation deformity.
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Affiliation(s)
- Roxa Ruiz
- Center of Excellence for Foot and Ankle Surgery, Kantonsspital Baselland, Rheinstrasse 26, CH-4410 Liestal, Switzerland.
| | - Beat Hintermann
- Center of Excellence for Foot and Ankle Surgery, Kantonsspital Baselland, Rheinstrasse 26, CH-4410 Liestal, Switzerland
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20
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Canton G, Sborgia A, Maritan G, Fattori R, Roman F, Tomic M, Morandi MM, Murena L. Fibula fractures management. World J Orthop 2021; 12:254-269. [PMID: 34055584 PMCID: PMC8152440 DOI: 10.5312/wjo.v12.i5.254] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 02/01/2021] [Accepted: 04/05/2021] [Indexed: 02/06/2023] Open
Abstract
Isolated distal fibula fractures represent the majority of ankle fractures. These fractures are often the result of a low-energy trauma with external rotation and supination mechanism. Diagnosis is based on clinical signs and radiographic exam. Stress X-rays have a role in detecting associated mortise instability. Management depends on fracture type, displacement and associated ankle instability. For simple, minimally displaced fractures without ankle instability, conservative treatment leads to excellent results. Conservative treatment must also be considered in overaged unhealthy patients, even in unstable fractures. Surgical treatment is indicated when fracture or ankle instability are present, with several techniques described. Outcome is excellent in most cases. Complications regarding wound healing are frequent, especially with plate fixation, whereas other complications are uncommon.
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Affiliation(s)
- Gianluca Canton
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
| | - Andrea Sborgia
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
| | - Guido Maritan
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
| | - Roberto Fattori
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
| | - Federico Roman
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
| | - Marko Tomic
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
| | - Massimo Max Morandi
- Department of Orthopaedic Surgery, Louisiana State University Health Science Center, Shreveport, LA 71103, United States
| | - Luigi Murena
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
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21
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Karkkola S, Kortekangas T, Pakarinen H, Flinkkilä T, Niinimäki J, Leskelä HV. Stability-Based Classification of Ankle Fractures-The Long-Term Outcome After 11-13 Years of Follow-up. J Orthop Trauma 2021; 35:227-233. [PMID: 32925451 DOI: 10.1097/bot.0000000000001959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/01/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To assess the long-term functional and radiological outcome, as well as complications and reoperations of ankle fracture patients treated based on stability classification. DESIGN Retrospective. SETTING Main Trauma Center, University Hospital. PATIENTS AND INTERVENTIONS One hundred sixty patients were treated based on stability classification. After a mean follow-up of 12 years, 102 patients were assessed; 67 visited the outpatient clinic, and standard standing ankle radiographs were taken; osteoarthritis (OA) was graded according to Kellgren-Lawrence classification. The remaining patients (n = 35) were followed up via mail or telephone. The complications and reoperations of all 160 patients were collected from electronic patient records. MAIN OUTCOME MEASURES Olerud-Molander ankle score, foot and ankle outcome score, visual analog scale, RAND-36 item health survey, range-of-motion measurements, and Kellgren-Lawrence OA classification. RESULTS Very good to excellent ankle functional outcome was reported by 96% of the stable fracture group [mean Olerud-Molander ankle score (OMAS), 92; range, 20-100] and 82% of the unstable group (mean OMAS, 86; range, 30-100). For patients with an unstable fracture, OMAS and VAS pain scores significantly improved from 2 to 12 years, even though higher grades of radiologic OA were found. No patients with fractures deemed stable needed operative intervention even in the long-term follow-up. Instead, 30% of the operatively treated patients underwent reoperation during the long follow-up. CONCLUSIONS The treatment of ankle fractures based on stability-based classification led to predictable, functionally good outcomes even during long-term follow-up. Ankle fractures can reliably be deemed stable based on this classification and treated without failures in the long term. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Sini Karkkola
- Division of Orthopedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
- Medical Research Center, University of Oulu, Oulu, Finland
| | - Tero Kortekangas
- Division of Orthopedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
- Medical Research Center, University of Oulu, Oulu, Finland
| | - Harri Pakarinen
- Division of Orthopedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Tapio Flinkkilä
- Division of Orthopedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Jaakko Niinimäki
- Department of Diagnostic Radiology, Oulu University Hospital, Oulu, Finland; and
| | - Hannu-Ville Leskelä
- Division of Orthopedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
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22
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Nasrallah K, Haim S, Einal B. Therapeutic approach to combined deltoid ligament disruption with lateral malleolus fracture: Current evidence and literature review. Orthop Rev (Pavia) 2021; 13:8987. [PMID: 33936572 PMCID: PMC8082171 DOI: 10.4081/or.2021.8987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 11/29/2020] [Indexed: 11/23/2022] Open
Abstract
Ankle fractures are among the most common injuries treated by orthopaedic traumatologists. These fractures range from stable, simple injuries to complex, multi-planar unstable ones. Osseo-ligamentous structures play a paramount role in maintaining the stability of the ankle joint. The deltoid ligament is among the most important ankle static stabilizers. Rupture of this ligament along with a lateral malleolar fracture is considered by many as an unstable type of injury and usually requires surgical treatment (bi-malleolar equivalent). Left untreated, it may lead to chronic pain, loss of function and secondary arthritis. Due to lack of high-quality evidence, there are no welldefined, well-accepted criteria for the diagnosis and treatment for treating this type of injury.
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Affiliation(s)
- Khalil Nasrallah
- Galilee Medical Center, Department of Orthopedics, Nahariya, Israel
| | - Shtarker Haim
- Galilee Medical Center, Department of Orthopedics, Nahariya, Israel
| | - Bathish Einal
- Galilee Medical Center, Department of Orthopedics, Nahariya, Israel
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23
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Schlickewei C, Krähenbühl N, Dekeyser GJ, Mills M, Priemel M, Rammelt S, Frosch KH, Barg A. [Unstable injuries of the deltoid ligament complex in ankle fractures : How to diagnose, how to treat?]. Unfallchirurg 2021; 124:190-199. [PMID: 33616680 DOI: 10.1007/s00113-021-00970-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2021] [Indexed: 11/28/2022]
Abstract
Unstable injuries of the deltoid ligament complex can have a substantial negative effect on the prognosis and treatment of ankle injuries. Lesions of the deltoid ligament are often overlooked at the initial presentation, both as isolated ruptures and in combination with more complex injuries of the ankle. Neglected unstable injuries of medial ankle ligaments may result in chronic instability, especially following correct treatment of fractures and lateral ligament injuries. These are accompanied by reduced ankle mobility, persisting pain, reduced load bearing and osteoarthritis. Despite the possible subsequent damage, the need for surgical repair of the deltoid ligament in patients with ankle fractures is controversially discussed. Although in most cases of ligament injuries of the upper ankle joint conservative treatment leads to very good results, there is increased interest in acute surgical treatment particularly for unstable injuries in order to avoid secondary instability and the associated sequelae. When surgical treatment should be given priority over conservative treatment has not yet been sufficiently clarified. This article gives an overview of the diagnosis and treatment of injuries of the deltoid ligament complex in patients with ankle fractures based on the current literature.
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Affiliation(s)
- Carsten Schlickewei
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | | | | | - Megan Mills
- Radiologische Universitätsklinik, Universität von Utah, Salt Lake City, UT, USA
| | - Matthias Priemel
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Stefan Rammelt
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, Dresden, Deutschland
| | - Karl-Heinz Frosch
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Alexej Barg
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland. .,Orthopädische Universitätsklinik, Universität von Utah, Salt Lake City, UT, USA.
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24
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[Nonoperative treatment of isolated fractures of the distal fibula]. Unfallchirurg 2021; 124:175-180. [PMID: 33570673 DOI: 10.1007/s00113-021-00960-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2021] [Indexed: 10/22/2022]
Abstract
Stable ankle fractures can be successfully managed nonoperatively. Unstable fractures on the other hand should be treated surgically as operative management consistently leads to better outcomes. How to define stability in ankle fractures continues to be a controversial issue. Better understanding of the mechanism of injury as well as improved knowledge of ankle biomechanics now enables surgeons to define stability after isolated fractures of the distal fibula with high accuracy. The following article describes commonly used methods to assess ankle stability after isolated fractures of the lateral malleolus, including stress tests and the use of weight-bearing radiographs. By adhering to the described criteria more than 90% of all isolated nondisplaced fractures of the distal fibula can be managed nonoperatively with excellent results.
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25
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Levack AE, Gausden EB, Dvorzhinskiy A, Wellman DS, Lorich DG. Posterior Malleolus Fracture Displacement Is Associated with Rotational Ankle Fracture Stability in Patients Without Medial Malleolar Fractures. HSS J 2020; 16:238-244. [PMID: 33380953 PMCID: PMC7749903 DOI: 10.1007/s11420-019-09697-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 05/14/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND The optimal method for the determination of ankle stability remains controversial in rotational ankle fractures without medial bony injury. QUESTIONS/PURPOSES The purposes of this study were to (1) evaluate whether posterior malleolar (PM) fracture displacement is associated with deltoid ligament injury in supination-external rotation (SER) ankle fractures and (2) compare the diagnostic accuracy of PM displacement and magnetic resonance imaging (MRI) evaluation of the deep deltoid ligament in identifying fractures with deltoid ligament incompetence. METHODS Patients with rotational bimalleolar injuries containing lateral malleolar and PM fractures without bony medial injury were included. After operative lateral and PM fixation, an external rotation stress test was performed to evaluate deltoid ligament stability. Operative dictations were reviewed to confirm injury pattern, stability on stress test, and visual inspection of the deltoid ligament. Maximum PM displacement was assessed on lateral X-ray. Pre-operative MRI of the ankle was performed following closed reduction and splinting. RESULTS The final cohort consisted of 13 trimalleolar equivalent fractures (torn deltoid ligament) and 20 bimalleolar fractures (medial malleolus and deltoid ligament intact). Average PM displacement was significantly higher for SER trimalleolar equivalent patterns when measured on lateral X-ray. The sensitivity of detecting trimalleolar equivalent fracture was higher on all reported X-ray findings than the sensitivity obtained by the reported MRI findings of deltoid ligament injury. CONCLUSION PM displacement on X-ray is a useful adjuvant along with external rotation stress radiography and MRI evaluation of deep deltoid integrity to distinguish between stable and unstable fracture patterns and thus helps facilitate treatment decisions.
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Affiliation(s)
- Ashley E. Levack
- Orthopaedic Trauma Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA ,Orthopaedic Trauma Service, Weill Cornell Medical College, 525 East 68th Street, New York, NY 10065 USA
| | - Elizabeth B. Gausden
- Orthopaedic Trauma Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA ,Orthopaedic Trauma Service, Weill Cornell Medical College, 525 East 68th Street, New York, NY 10065 USA
| | - Aleksey Dvorzhinskiy
- Orthopaedic Trauma Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA ,Orthopaedic Trauma Service, Weill Cornell Medical College, 525 East 68th Street, New York, NY 10065 USA
| | - David S. Wellman
- Orthopaedic Trauma Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA ,Orthopaedic Trauma Service, Weill Cornell Medical College, 525 East 68th Street, New York, NY 10065 USA
| | - Dean G. Lorich
- Orthopaedic Trauma Service, Weill Cornell Medical College, 525 East 68th Street, New York, NY 10065 USA
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26
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Kim HN, Jeong S, Park YU. Value of Ultrasound for Stability Assessment of Isolated Lateral Malleolar Fractures Compared to Stress Radiography and Arthroscopy. Clin Orthop Surg 2020; 12:535-541. [PMID: 33274032 PMCID: PMC7683184 DOI: 10.4055/cios20020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 04/27/2020] [Indexed: 11/29/2022] Open
Abstract
Background This study was performed to evaluate the value of using ultrasound for stability assessment of isolated lateral malleolar fractures compared to simple X-ray, stress radiography, and arthroscopy. Methods This is a prospective cohort study with 25 consecutive patients who underwent an arthroscopic examination and subsequent surgery for isolated lateral malleolar ankle fractures. Before operation, simple and external rotation stress radiographs were obtained. Ultrasound was performed to assess the medial deltoid ligament prior to operation. Arthroscopic findings were used as reference standards. Sensitivity, specificity, and positive and negative predictability were calculated and compared using receiver operating characteristic (ROC) curve analysis for simple radiography, stress radiography, and ultrasound examination. Results The sensitivity and specificity of ultrasound for tears of the deep deltoid ligament were 94.74% and 66.67%, respectively. But, they were both 100% for complete tears of the ligament. ROC curve analysis showed that the ultrasound examination was significantly more accurate than simple and stress radiography. Conclusions Ultrasound could be used to assess the instability of isolated lateral malleolar fractures. Commonly used stress radiography appears to overrate the need for operative treatment.
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Affiliation(s)
- Hyong Nyun Kim
- Department of Orthopedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Seungmin Jeong
- Department of Orthopedic Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Young Uk Park
- Department of Orthopedic Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
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Broughton KK, Williams C, Miller CP, Stupay K, Kwon JY. Effect of Muscle Activation on the Gravity Stress View in Unstable Weber B Ankle Fractures. Foot Ankle Int 2020; 41:1342-1346. [PMID: 32660259 DOI: 10.1177/1071100720938668] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND In the setting of apparently isolated distal fibula fractures, the gravity stress view (GSV) is a validated method to determine mortise stability. There is currently no published data evaluating whether dynamic muscle activation can reduce an unstable mortise. If patients with instability can overcome gravity, resultant images could yield false-negative results. The goal of this investigation was to determine if patient effort can influence medial clear space (MCS) measurements in proven unstable bimalleolar-equivalent ankle fractures. METHODS Patients presenting with Weber B fibula fractures were assessed for mortise stability using the GSV. If the GSV demonstrated instability based on MCS widening >4 mm, 3 additional views were performed: GSV with an assistant maintaining the ankle in a neutral position; GSV with the patient actively dorsiflexing to neutral; and GSV with the patient actively dorsiflexing and supinating the foot. Twenty-four consecutive patients met inclusion criteria, with a mean age of 48.7 (range, 22-85) years. Fifteen patients (62.5%) were female and 9 (37.5%) were male. The laterality was evenly divided. RESULTS The mean MCS was 5.8 ± 2.0 6.0 ± 2.6, and 6.2 ± 2.7 mm for the manual assist, active dorsiflexion, and active supination radiograph measurement groups, respectively (P = .434). Only 5 of 24 subjects had any measurable decrease in their MCS with active supination, with a maximum change of 1.2 mm. The remainder of the patients had an increase in MCS ranging from 0.1 to 4.0 mm. CONCLUSION There was no significant difference between measurement states indicating that muscle activation is unlikely to yield a false-negative result on GSV. Mortise instability, secondary to deep deltoid injury in the presence of gravity stress, is unlikely to be actively overcome by dynamic stabilizers, supporting the validity and specificity of the GSV. LEVEL OF EVIDENCE Level III, prospective study.
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Affiliation(s)
- Kimberly K Broughton
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Caroline Williams
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Christopher P Miller
- Orthopaedic Foot & Ankle Service, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Kristen Stupay
- Harvard Combined Orthopaedic Residency Program, Massachusetts General Hospital, Boston, MA, USA
| | - John Y Kwon
- Orthopaedic Foot & Ankle Service, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Marazzi C, Wittauer M, Hirschmann MT, Testa EA. Minimally invasive plate osteosynthesis (MIPO) versus open reduction and internal fixation (ORIF) in the treatment of distal fibula Danis-Weber types B and C fractures. J Orthop Surg Res 2020; 15:491. [PMID: 33092616 PMCID: PMC7583231 DOI: 10.1186/s13018-020-02018-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/14/2020] [Indexed: 12/02/2022] Open
Abstract
Background Minimally invasive plate osteosynthesis (MIPO) has been reported to be superior to open reduction and internal fixation (ORIF) in the treatment of different long bone fractures. Nevertheless, in distal fibula fractures, the evidence of MIPO remains scarce. The aim of this retrospective study was to compare the clinical and radiological outcomes of the minimally invasive techniques applied to the distal fibula with open reduction and internal fixation within a 12 months follow-up. Methods A consecutive series of patients who underwent surgery using either ORIF or MIPO for the treatment of distal fibula fractures between 2010 and 2014 were retrospectively analyzed. All distal fibular fractures requiring an operative treatment (Danis-Weber type B ≙ AO type 44 B1, 2, 3 and Danis-Weber type C ≙ AO type 44 C1, 2) were included (ORIF n = 35, MIPO n = 35). Patients were assessed for postoperative pain using a visual analog scale (VAS) for pain (ranging from 0 to 10) and classified into 4 groups: “no pain” for VAS = 0, “low” for VAS = 1–3, “moderate” for VAS = 3–5, and “severe” for VAS = 5–10. In addition, complications of postoperative fracture-related infection, wound healing disorders, vascular and nerve injury and development of nonunion were evaluated and analyzed. Radiologic outcome measures assessing the talocrural angle, lateral and medial clear space, tibiofibular overlap, and talar tilt angle were evaluated postoperatively. Results The overall complication rate showed to be lower in the MIPO group compared to the ORIF group (14% vs. 37%, p = 0.029). Even though not statistically significant, specific surgery-related complications such as skin necrosis (3% vs. 9%, p = 0.275), nonunion (0% vs. 6%, p = 0.139), infections and wound healing disorders (9% vs. 20%, p = 0.141), as well as postoperative pain (17% vs. 26%, p = 0.5) were found more frequently in the ORIF group. The tibiofibular overlap demonstrated to be significantly lower in the ORIF group (3.3 mm vs. 2.7 mm, p = 0.033). The talocrural angle, talar tilt angle, and lateral and medial clear space showed to be equivalent in both groups. Conclusion In this retrospective single-center consecutive series, MIPO was superior to ORIF in the surgical treatment of distal fibula fractures with respect to the overall complication rate. Trial registration EKNZ Project-ID: 2019-02310, registered on the 20th of December 2019 with swissethics
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Affiliation(s)
- Cesare Marazzi
- Department of General Surgery, Hospital Oberengadin, Samedan, Switzerland.,University of Basel, Basel, Switzerland
| | - Matthias Wittauer
- University of Basel, Basel, Switzerland. .,Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland.
| | - Michael T Hirschmann
- University of Basel, Basel, Switzerland.,Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), Bruderholz, Switzerland
| | - Enrique A Testa
- Department of Orthopaedic and Trauma Surgery, Hospital Lugano, Lugano, Switzerland
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Mansur H, Danilo da Silva S, Maranho DA. Reconstruction of tibiofibular syndesmosis using autologous semitendinosus graft and lengthening derotational osteotomy of the distal fibula. J Clin Orthop Trauma 2020; 14:80-84. [PMID: 33717900 PMCID: PMC7920134 DOI: 10.1016/j.jcot.2020.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 08/18/2020] [Accepted: 09/10/2020] [Indexed: 11/16/2022] Open
Abstract
Distal tibiofibular syndesmosis is a complex anatomical structure that is essential for the stability and function of the ankle. Ankle fractures are a common source of chronic syndesmosis instability with associated functional impairments and early development of osteoarthritis. Case presentation: we described a case of a 28-year-old patient who presented with symptomatic ankle subluxation and chronic syndesmosis instability. Eight months earlier, the patient sustained a minimally displaced ankle fracture that had been treated conservatively elsewhere. The surgical approach included the anatomical realignment of the distal fibula with a lengthening derotational osteotomy and tibiofibular syndesmosis reconstruction using an autologous semitendinosus tendon graft. One year after surgery, the ankle function was restored, and the patient was asymptomatic. Conclusion: The instability of ankle fractures should be carefully evaluated during the treatment decision-making. Surgical treatment of syndesmosis instability should be performed even in chronic cases to restore function. The reconstruction of syndesmosis with semitendinous tendon graft associated with fibular length and realignment improves the ankle stability and function.
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Affiliation(s)
- Henrique Mansur
- Department of Orthopaedics Surgery, Hospital Regional Do Gama, Brasilia, Distrito Federal, Brazil,Corresponding author. Hospital de Força Aérea de Brasília – HFAB, Área Militar do Aeroporto Internacional de Brasília, Brasília, DF, Brazil.
| | - Sandro Danilo da Silva
- Department of Orthopaedics Surgery, Hospital Regional Do Gama, Brasilia, Distrito Federal, Brazil
| | - Daniel Augusto Maranho
- Department of Orthopaedics Surgery, Hospital Sírio-Libanês, Brasilia, Distrito Federal, Brazil
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Stenquist DS, Miller C, Velasco B, Cronin P, Kwon JY. Medial tenderness revisited: Is medial ankle tenderness predictive of instability in isolated lateral malleolus fractures? Injury 2020; 51:1392-1396. [PMID: 32268964 DOI: 10.1016/j.injury.2020.03.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 03/09/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Determining deltoid ligament incompetence in supination external rotation (SER) injuries commonly relies on stress radiography, given several studies demonstrating low predictive value of physical examination. Stress radiography can be difficult to obtain and may result in suboptimal radiographs with equivocal determination of stability. This study revisits the concept of medial ankle tenderness and its association with mortise instability. METHODS Patients who presented with an isolated lateral malleolus fracture underwent prospective data collection. VAS scores were recorded with palpation at the lateral malleolar fracture site, anterior deltoid ligament, and posterior deltoid ligament. Three non-weightbearing radiographs of the ankle and a gravity stress view were obtained. Statistical analysis was performed to determine a correlation between tenderness and instability defined as MCS widening > 4 mm on gravity stress x-ray. RESULTS 51 patients met inclusion criteria. Group I (stable) and Group II (unstable) demonstrated no difference in tenderness over the lateral malleolus (p = 0.94) or anterior deltoid (p = 0.12), but patients in Group II reported significantly more tenderness over the posterior deltoid (p = 0.03). Taking the higher pain score from either anterior or posterior deltoid palpation, patients with unstable ankle fractures reported significantly more tenderness with medial palpation (p = 0.02). The relative risk of having an unstable ankle fracture with any tenderness to palpation over either the anterior or posterior deltoid ligament was 1.77 (95% CI 1.03 - 3.06, P = 0.039). When comparing no pain versus the presence of any pain with palpation medially, the sensitivity for any medial tenderness to detect an unstable ankle fracture was 0.76 (specificity 0.59, PPV 0.79, NPV 0.56). CONCLUSION Patients with any medial tenderness were at significantly higher risk of having an unstable SER ankle fracture in this study, but strict reliance on the presence or absence of medial tenderness without stress radiographs would lead to an unacceptable number of both false positive and false negative determinations of instability. However, our findings suggest that medial tenderness is associated with instability. The 0.79 PPV of any medial tenderness for instability may be useful to cast doubt on equivocal stress radiography and prompt surgeons to repeat stress radiography or shorten the interval for radiographic follow up. LEVEL OF EVIDENCE Diagnostic study, Level II-1 (development of diagnostic criteria on basis of consecutive patients [with universally applied reference "gold" standard]).
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Affiliation(s)
- Derek S Stenquist
- Harvard Combined Orthopaedic Surgery Residency Program, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Christopher Miller
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Brian Velasco
- Chief, Orthopaedic Foot & Ankle Service, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, United States.
| | - Patrick Cronin
- Harvard Combined Orthopaedic Surgery Residency Program, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - John Y Kwon
- Harvard Combined Orthopaedic Surgery Residency Program, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States; Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
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Rosa I, Rodeia J, Fernandes PX, Teixeira R, Saldanha T, Consciência JG. Ultrasonographic Assessment of Deltoid Ligament Integrity in Ankle Fractures. Foot Ankle Int 2020; 41:147-153. [PMID: 31597464 DOI: 10.1177/1071100719882679] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Regardless of fibular status, the presence of a superficial deltoid ligament disruption or a combination of deep and superficial deltoid ligament disruption is central to the decision-making process in treating ankle fractures. The aims of the present study were to test whether ultrasonography can assess deltoid ligament integrity and to determine its validity and reliability by comparing it with gravity stress radiography. METHODS A consecutive series of 81 eligible patients with a nondisplaced or minimally displaced fibula fracture identified on a standard radiograph were prospectively enrolled. All patients underwent gravity stress radiography and ultrasonography. Image analysis included the layer type, integrity, and tear site of the deltoid ligament. Ultrasound validity and intra- and interobserver reliability were assessed by the interpretations of the first author and an independent observer who were blinded to the results. RESULTS Of all patients, 64 (79.0%) had a deltoid ligament disruption; most of the tears were of both the superficial and deep layers, partial and proximal attachment tears, and only 8 (12.5%) were complete tears. Patients with an intact deltoid ligament had a mean medial clear space (MCS) value of 2.7 ± 0.5 mm, and those with deltoid ligament tears had a mean MCS value of 5.9 ± 3.4 mm (P < .001). In a comparison between ultrasonography and gravity radiography, we found a sensitivity of 100% versus 97%, a specificity of 90% versus 100%, a positive predictive value of 97% versus 100%, and a negative predictive value of 100% versus 90%, respectively. The intra- and interobserver reliability was evaluated as almost perfect in all conditions. In a comparison between ultrasonography and gravity radiography, we found a sensitivity of 100% versus 97%, a specificity of 90% versus 100%, a positive predictive value of 97% versus 100%, and a negative predictive value of 100% versus 90%, respectively. CONCLUSION Ultrasonography proved to be an accurate tool, allowing the identification of deltoid ligament disruption and the involved components in a more dynamic fashion. Its relative ease of use and lack of ionizing radiation make it a useful and confident technique that can be performed by an orthopedist. LEVEL OF EVIDENCE Level II, prospective comparative study.
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Affiliation(s)
- Isabel Rosa
- Hospital de São Francisco Xavier, CHLO, Lisbon, Portugal.,NOVA Medical School/Faculty of Medical Sciences, Lisbon, Portugal
| | - Joaquim Rodeia
- Hospital de São Francisco Xavier, CHLO, Lisbon, Portugal
| | | | | | | | - José Guimarães Consciência
- Hospital de São Francisco Xavier, CHLO, Lisbon, Portugal.,NOVA Medical School/Faculty of Medical Sciences, Lisbon, Portugal
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Kamin K, Notov D, Al-Sadi O, Kleber C, Rammelt S. Versorgung der Sprunggelenkfraktur. Unfallchirurg 2020; 123:43-56. [DOI: 10.1007/s00113-019-00753-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Dobbe A, Beaupre LA, Almansoori KA, Fung TS, Scharfenberger AV. Functional Outcomes of Isolated Infrasyndesmotic Fibula Fractures. FOOT & ANKLE ORTHOPAEDICS 2020; 5:2473011419892227. [PMID: 35097357 PMCID: PMC8564941 DOI: 10.1177/2473011419892227] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background: Ankle fractures are among the most common injuries encountered by orthopedic surgeons, with an incidence ranging from 71 to 187 per 100 000 people. Few studies have reliably investigated injuries involving isolated fractures of the distal fibula below the level of the ankle syndesmosis. Therefore, this study details on the patient-reported outcomes of nonoperatively managed isolated infrasyndesmotic fibula (ISF) fractures with a minimum 3-year follow-up. Methods: A retrospective population-based cohort study was undertaken across all emergency departments serving a major urban population. Among 159 consecutive patients meeting inclusion criteria, 108 agreed to participate. Clinical information, functional outcomes, and radiographic measurements were collected from electronic medical records and 3 validated outcome measures: the American Academy of Orthopaedic Surgeons (AAOS) Foot & Ankle Scale (FAS), the AAOS Shoe-Comfort Scale (SCS), and a general questionnaire. Results: An incidence of 22 ISF fractures per 100 000 people/year was found with FAS (91.2 ± 12.9) and SCS scores (76.8 ± 27.7), similar to reported population norms. Approximately 40% of patients (n = 43) reported continuing symptoms including pain (81.8%), stiffness (68.1%), and/or instability (39.0%). Less than 13% (n = 14) reported “severe” disabilities, and no patients required operative intervention within the follow-up period. Less-favorable outcomes were reported among work-related injuries, female patients, and “avulsion-type” fractures less than 10 mm in height (P < .01). No relationships were identified between age, degree of articular-incongruity, fracture-displacement, and self-reported outcomes. Conclusions: The majority of patients with nonoperatively managed ISF fractures reported good-to-excellent early functional outcomes. Less-favorable outcomes were reported among work-related injuries, female patients, and “avulsion-type” fractures. Level of Evidence: Level III, comparative series.
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Affiliation(s)
- Ashlee Dobbe
- Department of Orthopedic Surgery, University of British Columbia, Kelowna, British Columbia, Canada
| | - Lauren A. Beaupre
- Department of Physical Therapy, University of Alberta, Edmonton, Alberta, Canada
| | | | - Tak-Shing Fung
- Department of Information Technology, University of Calgary, Calgary, Canada
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Lambert LA, Falconer L, Mason L. Ankle stability in ankle fracture. J Clin Orthop Trauma 2020; 11:375-379. [PMID: 32405195 PMCID: PMC7211817 DOI: 10.1016/j.jcot.2020.03.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 03/17/2020] [Indexed: 12/16/2022] Open
Abstract
Restoration of normal ankle kinematics should be the all-encompassing ethos in the approach to management of ankle fractures. To do this, the ligamentous stabilisers must also form part of its assessment and definitive management and be considered during index fracture fixation surgery. This article is a review of the anatomy, mechanics and clinical testing of instability in ankle fractures.
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35
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Pitakveerakul A, Kungwan S, Arunakul P, Arunakul M. Radiographic parameters in gravity stress view of the ankle: Normative data. Foot Ankle Surg 2019; 25:819-825. [PMID: 30803817 DOI: 10.1016/j.fas.2018.10.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 09/23/2018] [Accepted: 10/22/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND In rotational ankle injury with isolated fibular fracture, deltoid integrity is important for determining stability of ankle. Medial clear space and superior clear space in gravity stress view are parameters widely used to predict deltoid ligament tear. The purpose of this study is to report radiographic parameters in gravity stress view in normal population. METHODS 120 persons were enrolled. Non weight-bearing ankle mortise and gravity stress view were obtained. Radiographic measurements were made by 2 investigators, including medial clear space (MCS), superior clear space (SCS), tibiofibular overlaps, tibiofibular clear space and talocrural angle. Statistical analysis included mean, mean difference, SD, 95%CI, paired T-test were calculated and subgroup analysis by foot length. Intraclass correlation coefficients were used to determine intra/interobserver reliability of measurement. RESULTS Mean MCS in gravity stress view was 3.19mm (95%CI 3.1-3.31). This compared to mean MCS of 3.01mm (95%CI 2.9-3.12) in mortise view which was statistically significant (P=0.02). Mean difference was 0.18mm (95%CI 0.07-0.3). SCS in gravity stress view was 3.29mm (95%CI 3.19-3.39) and when compared to MCS in gravity stress view, no statistical significance was found (P=0.158). Mean difference was 0.1mm (95%CI 0.03-0.21). In subgroup analysis by foot length, no significant difference was found in any parameters. CONCLUSIONS This study provides normative radiographic data for a gravity stress radiograph and supports that if measurable MCS >4mm on gravity stress view, it should be aware of an unstable ankle in supination-external rotation injury.
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Affiliation(s)
- Akaradech Pitakveerakul
- Department of Orthopaedic Surgery, Sirindhorn Hospital, 20 Onnuch 90, Prawet, Bangkok 10250, Thailand.
| | - Supoj Kungwan
- Department of Orthopaedic Surgery, Faculty of Medicine, Thammasat University, 99 Moo 18 Paholyothin Road, Klong Luang, Pathumthani 12121, Thailand
| | - Preeyaphan Arunakul
- Department of Anesthesia, Faculty of Medicine, Thammasat University, 99 Moo 18 Paholyothin Road, Klong Luang, Pathumthani 12121, Thailand
| | - Marut Arunakul
- Department of Orthopaedic Surgery, Faculty of Medicine, Thammasat University, 99 Moo 18 Paholyothin Road, Klong Luang, Pathumthani 12121, Thailand.
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Velasco BT, Miller CP, Ye MY, Kwon JY. Does fracture obliquity in Weber B fibula fractures correlate with mortise instability? Injury 2019; 50:2113-2115. [PMID: 31371168 DOI: 10.1016/j.injury.2019.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 07/20/2019] [Accepted: 07/23/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND The diagnosis of instability in the apparent, isolated distal fibula fracture can be challenging and often necessitates stress radiography. Danis & Weber classified lateral malleolar fractures based on the level of the fracture in relation to the syndesmosis. While Weber B fractures occur at the level of the syndesmosis, some such injuries present with a long, oblique pattern extending well above the syndesmosis. Given the well-established literature demonstrating that fractures above the syndesmosis correlate with a higher level of concomitant syndesmotic and deltoid ligament injury, we hypothesize that increased fracture obliquity, length and height of Weber B fibula fractures similarly correlates with increased mortise instability. METHODS All patients with isolated Weber B fibula fractures who underwent gravity stress radiography met inclusion criteria. Fracture height was measured on mortise radiographs as: (1) the distance from the distal tip of the fibula to fracture apex, (2) the distance to the fracture apex as measured on a line drawn perpendicular to a line parallel to the plafond, (3) an angle subtended by a line drawn parallel to the plafond and a line drawn to the fracture apex and (4) a ratio of the absolute length as compared to fibular width. RESULTS 51 patients were included in the study. The group of 39 patients with stable ankles had a mean medial clear space of 3.12 ± 0.65 mm (range, 1.5 mm to 4.0 mm). The group of 12 patients with unstable ankles had a mean medial clear space of 6.29 ± 3.11 mm (range, 4.1 mm to 14.0 mm). These groups showed no significant difference in fracture angle (p = 0.93), fracture height from plafond (p = 0.49), fracture height from tip of fibula (p = 0.42), and as a ratio of absolute length to fibular width (p = 0.85). CONCLUSION Increased fracture obliquity, length and height of Weber B fibula fractures did not correlate with a higher incidence of mortise instability. Despite the lack of positive correlation, future studies should continue to investigate and identify radiographic parameters of distal fibula fractures that are most predictive of instability.
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Affiliation(s)
- Brian T Velasco
- Beth Israel Deaconess Medical Center, Boston, MA, United States; Geisinger Commonwealth School of Medicine, Scranton, MA, United States.
| | | | - Michael Y Ye
- Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - John Y Kwon
- Beth Israel Deaconess Medical Center, Boston, MA, United States.
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Gibson PD, Ippolito JA, Hwang JS, Didesch J, Koury KL, Reilly MC, Adams M, Sirkin M. Physiologic widening of the medial clear space: What's normal? J Clin Orthop Trauma 2019; 10:S62-S64. [PMID: 31695262 PMCID: PMC6823741 DOI: 10.1016/j.jcot.2019.04.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 04/20/2019] [Accepted: 04/22/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Literature has validated the use of stress radiographs for evaluation of ankle stability. However, to our knowledge no study has reported the amount of physiological widening that occurs with manual external rotation stress test in uninjured ankles. The purpose of this study was to assess the amount of medial clear space widening that occurs with a manual external rotation stress test in uninjured ankles. METHODS A cohort of adult patients undergoing operative fixation of unstable ankle fractures were prospectively enrolled to have their contralateral ankle undergo manual external rotation stress examination. Fluoroscopic images of the unaffected ankle were performed in the OR. A non-stressed mortise view and manual external rotation stress view were obtained with a standardized marker to correct for magnification differences. The images were de-identified, presented in a randomized order and reviewers who were blinded. Each reviewer measured the medial clear space. RESULTS Thirty fluoroscopic images on fifteen patients were obtained. The mean medial clear space on the non-stressed mortise view was 3.1 mm (SD-0.69; Range 1.9 to 4.2, 95% CI [2.75, 3.45]) versus a mean of 3.2 mm (SD-0.71; Range 2.0 to 4.7, 95% CI [2.94, 3.66]) in the stressed mortise view group. Inter-rater reliability was excellent between all observers for medial clear space (ICC-0.88; CI [0.78, 0.94]). CONCLUSIONS Our results support the previous literature and allow us to advocate for ankle fractures with >5 mm medial clear space after external rotational stress to be considered unstable. Additionally, ankles with a medial clear space between 4 and 5 mm, instability should be considered only if lateral shift is > 2 mm on stress examination. Our data shows that no physiologically healthy ankles widened beyond these established cut-offs before or after the manual external rotation stress.
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Affiliation(s)
| | - Joseph A. Ippolito
- Corresponding author. Department of Orthopaedics, Rutgers New Jersey Medical School, 140 Bergen Street, ACC Building, Suite D1610, Newark, NJ, 07103, USA.
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Yousaf S, Saleh A, Ahluwalia A, Haleem S, Hayat Z, Ramesh P. Systematic Review of Stress Radiographic Modalities Stability Assessment in Supination External Rotation Ankle Fractures. FOOT & ANKLE ORTHOPAEDICS 2019; 4:2473011419890861. [PMID: 35097353 PMCID: PMC8697262 DOI: 10.1177/2473011419890861] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Isolated distal fibular fractures resulting from supination external rotation (SER) injuries without evidence of obvious talar shift on standard radiographs present a diagnostic dilemma for clinicians. The status of the deep deltoid ligament, the main stabilizer of the ankle joint, is assessed by an increase in medial clear space (MCS) on radiographs. Therefore, these injuries can be either stable or unstable. In recent years, considerable clinical and research efforts have been made to determine ankle stability following SER fracture. The purpose of this systematic review was to evaluate and compare the role of different stress radiograph modalities in assessing stability of the ankle with SER fractures with no obvious talar subluxation on standard radiographs. Methods: The electronic databases MEDLINE, EMBASE, Ovid, Cochrane Central, CINAHL, and Google Scholar were searched from January 2000 to January 2018 to identify literature relating to radiologic assessment of stability of SER ankle fractures. Results: Our literature search revealed 10 peer-reviewed articles that fulfilled inclusion criteria. This yielded a total of 698 patients. The systematic review found 3 broad categories of radiographic investigations in the assessment of ankle joint stability: external rotation (ER) stress radiographs, gravity stress views (GSV), and weightbearing (WB) radiographs. Proponents of WB radiographs have demonstrated how axial load can normalize ankle joint alignment in cases of proven instability. There was a consistently high grade of evidence for using a medial clear space (MCS) value of more than 4 to 5 mm to indicate an unstable ankle following SER fracture. Conclusion: In conclusion, the results of this systematic review support an MCS value of less than 4 to 5 mm as a good indicator of stability, regardless of choice of stress imaging modality. These patients can be allowed early weightbearing with expected good functional outcomes. Recent published literature favors WB stress radiographs as a reliable and safe technique for assessing stability in SER ankle fractures. However, it should be kept in mind that this is based on studies with relatively low grades of evidence. Level of Evidence: Level II, systematic review of variable quality studies.
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Affiliation(s)
- Sohail Yousaf
- Epsom and St Helier University Hospitals NHS Trust, Surrey, United Kingdom
| | - Alan Saleh
- Kingston Hospital NHS Foundation Trust, Kingston Upon Thames, United Kingdom
| | - Aashish Ahluwalia
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Shahnawaz Haleem
- St. George’s University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Zara Hayat
- Kingston Hospital NHS Foundation Trust, Kingston Upon Thames, United Kingdom
| | - Palanisamy Ramesh
- Kingston Hospital NHS Foundation Trust, Kingston Upon Thames, United Kingdom
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Biomechanical Analysis of Instability in Rotational Distal Fibula Fractures (OTA/AO 44-B1) With an Intact Deltoid Ligament. J Orthop Trauma 2019; 33:411-416. [PMID: 31335566 DOI: 10.1097/bot.0000000000001487] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To biomechanically analyze instability in supination external rotation (SER) II/III patterns. METHODS Nineteen cadaver legs were tested in a mechanical jig. One, 2, 3, and 4 Nm of external rotation were applied to intact ankles, SER II injuries, and SER III injuries. The talar position relative to the tibia was recorded using 3D motion tracking. Change from the unloaded state in each condition and the torque level was calculated. Results were analyzed using analysis of variance with post hoc paired t tests. RESULTS SER II showed statistically significant differences from the intact state with coronal translation (2, 3, and 4 Nm), sagittal translation (1 and 2 Nm), axial rotation (1, 2, 3, and 4 Nm), and coronal rotation (3 and 4 Nm). SER III showed statistically significant differences from the intact state with coronal translation (2, 3, and 4 Nm), sagittal translation (1, 2, and 3 Nm), axial rotation (1, 2, 3, and 4 Nm), and coronal rotation (3 and 4 Nm). SER II and SER III differed significantly from each other with coronal translation (1, 2, and 3 Nm), axial rotation (2, 3, and 4 Nm), and coronal rotation (1, 3, and 4 Nm). CONCLUSION Instability in SER injuries has only been described with coronal translation and suggests that deltoid rupture is necessary. Our data demonstrate instability in SER II/III in sagittal translation and axial rotation as well as subtle instability in coronal translation. The clinical impact is unclear, but better understanding of long-term sequelae of this instability is needed.
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Warner SJ, Garner MR, Fabricant PD, Schottel PC, Loftus ML, Hentel KD, Helfet DL, Lorich DG. The Diagnostic Accuracy of Radiographs and Magnetic Resonance Imaging in Predicting Deltoid Ligament Ruptures in Ankle Fractures. HSS J 2019; 15:115-121. [PMID: 31327941 PMCID: PMC6609669 DOI: 10.1007/s11420-018-09655-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 11/19/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Operative indications for supination-external rotation (SER) ankle fractures depend on the integrity of the medial structures. Despite the importance of assessing deep deltoid ligament injuries, the accuracy of common diagnostic tests has not been established. QUESTIONS/PURPOSES The objective of this study was to compare the ability of injury (non-stress) and stress radiographs and magnetic resonance imaging (MRI) to diagnose deep deltoid ligament ruptures in operative SER ankle fractures. METHODS Patients were included who underwent surgical fixation of SER ankle fractures and had appropriate injury and manual stress test radiographs, pre-operative ankle MRI, and intra-operative assessment of deep deltoid integrity by direct visualization. The medial clear space (MCS) was considered positive for all values over 5 mm on the injury or stress mortise radiographs. MRI analysis of the deep deltoid ligament injury was performed by blinded fellowship-trained musculoskeletal radiologists. Intra-operative direct visualization and assessment of the deltoid was performed using a direct medial ankle approach at the time of operative fracture fixation. RESULTS Using intra-operative visualization as the gold standard, MCS measurements and MRI had differing abilities to diagnose a deep deltoid rupture. In cases where the MCS was less than 5 mm on injury radiographs and stress tests were performed, MCS measurements were much less accurate than MRI in predicting deltoid ruptures (46% versus 79%, respectively) with a high false positive rate (80%). In contrast, an MCS measurement of greater than 5 mm on injury radiographs was a strong predictor of deep deltoid rupture (accuracy of 95%). CONCLUSION Compared with direct visualization of the deltoid ligament intra-operatively, these data support proceeding with surgery when the MCS on injury radiographs is greater than 5 mm without any additional stress tests or advanced imaging. When the MCS is less than 5 mm, we recommend MRI analysis because of its increased accuracy and decreased false positive rate. Improving our ability to diagnose deltoid ruptures will contribute to more effective management of patients with SER ankle fractures.
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Affiliation(s)
- Stephen J. Warner
- University of Texas Health Science Center at Houston, 6400 Fannin Street, Suite 1700, Houston, TX 70030 USA
| | | | | | | | - Michael L. Loftus
- Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY USA
| | - Keith D. Hentel
- Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY USA
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Weight-bearing in ankle fractures: An audit of UK practice. Foot (Edinb) 2019; 39:28-36. [PMID: 30933870 DOI: 10.1016/j.foot.2019.02.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 01/21/2019] [Accepted: 02/10/2019] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The purpose of this national study was to audit the weight-bearing practice of orthopaedic services in the National Health Service (NHS) in the treatment of operatively and non-operatively treated ankle fractures. METHODS A multicentre prospective two-week audit of all adult ankle fractures was conducted between July 3rd 2017 and July 17th 2017. Fractures were classified using the AO/OTA classification. Fractures fixed with syndesmosis screws or unstable fractures (>1 malleolus fractured or talar shift present) treated conservatively were excluded. No outcome data were collected. In line with NICE (The National Institute for Health and Care Excellence) criteria, "early" weight-bearing was defined as unrestricted weight-bearing on the affected leg within 3 weeks of injury or surgery and "delayed" weight-bearing as unrestricted weight-bearing permitted after 3 weeks. RESULTS 251 collaborators from 81 NHS hospitals collected data: 531 patients were managed non-operatively and 276 operatively. The mean age was 52.6 years and 50.5 respectively. 81% of non-operatively managed patients were instructed for early weight-bearing as recommended by NICE. In contrast, only 21% of operatively managed patients were instructed for early weight-bearing. DISCUSSION The majority of patients with uni-malleolar ankle fractures which are managed non-operatively are treated in accordance with NICE guidance. There is notable variability amongst and within NHS hospitals in the weight-bearing instructions given to patients with operatively managed ankle fractures. CONCLUSION This study demonstrates community equipoise and suggests that the randomized study to determine the most effective strategy for postoperative weight-bearing in ankle fractures described in the NICE research recommendation is feasible.
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Abstract
The ankle gravity stress view (GSV) is often utilized to elucidate instability in patients with an apparent, isolated lateral malleolus fracture. While this has been demonstrated to have advantages over the manual external rotation stress test, positioning in the lateral decubitus position can be difficult, uncomfortable and time-intensive. We report a simple and safe technique that allows one to obtain a gravity stress view of the ankle with the patient seated.
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Naguib SL, Meyr AJ. Reliability, Surgeon Preferences, and Eye-Tracking Assessment of the Stress Examination of the Ankle Syndesmosis. J Foot Ankle Surg 2019; 57:1148-1153. [PMID: 30253965 DOI: 10.1053/j.jfas.2018.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Indexed: 02/03/2023]
Abstract
The diagnosis and stabilization of ankle syndesmotic injuries after acute injury remains an area of controversy in the foot and ankle surgical literature, seemingly without universal consensus. The primary objective of this investigation was to determine the frequency of agreement and reliability of the stress examination of the ankle syndesmosis. Secondary objectives were to determine surgeon preferences and protocols with respect to the ankle syndesmosis and to use gaze recognition software to perform an eye-tracking assessment during performance of stress examinations. Twelve foot and ankle surgeons, 12 residents, and 12 students were shown 5 intraoperative fluoroscopic still images and videos of the stress examination of the ankle syndesmosis. They were asked to evaluate the result as being "positive" or "negative" for syndesmotic stability. The overall reliability of the interpretation of the stress examination of the ankle syndesmosis was a kappa of 0.123 (surgeons 0.087; residents 0.019; students 0.237), indicating "slight" agreement. Survey results indicated wide variability in the perioperative preferences and protocols of surgeons dealing with the evaluation and treatment of the ankle syndesmosis. Eye-tracking results also demonstrated variability in the anatomic structures of interest focused on during performance of this testing. The results of this investigation provide evidence of reliability well below what would be expected of a gold standard test during stress examination of the ankle syndesmosis. These results indicate that future scientific endeavors are required to standardize the performance and interpretation of this testing.
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Affiliation(s)
- Sara L Naguib
- Resident, Temple University Hospital Podiatric Surgical Residency Program, Philadelphia, PA
| | - Andrew J Meyr
- Clinical Associate Professor, Department of Podiatric Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA.
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van Leeuwen CAT, Hoffman RPC, Donken CCMA, van der Plaat LW, Schepers T, Hoogendoorn JM. The diagnosis and treatment of isolated type B fibular fractures: Results of a nationwide survey. Injury 2019; 50:579-589. [PMID: 30630597 DOI: 10.1016/j.injury.2018.12.038] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 12/30/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION In isolated Weber B fractures (type B fibular fractures), ruling out instability is critical for safe conservative treatment. In fractures without evident medial injury, additional diagnostics like MRI scan or gravity stress test should be done to differentiate between a stable and unstable fracture. The aim of the current study is to gain more insight in current practice and treatment of type B fractures by Dutch trauma- and orthopaedic surgeons. MATERIALS & METHODS In December 2017 and January 2018, 559 trauma surgeons were invited by email to join an online survey. This survey consisted of questions regarding diagnostics and treatment of isolated distal fibula fractures. Also, respondents were asked to state their preferred treatment of eight separate cases. RESULTS In total, 161 surgeons participated, covering 68 different hospitals in the Netherlands. Of them, 32.0% treat more than 30 ankle fractures a year. Based on regular mortise radiographs, 13.6% of the respondents chose surgical treatment in case of a medial clear space (MCS) > 4 mm, 33.8% in case of a MCS > 6 mm and 45.5% in case of a MCS > 4 mm in addition to the MCS ≥ superior clear space + 1 mm. Moreover, 18.2% make use of additional diagnostics (43.9% repeat mortise view after a week, 16.6% weight bearing radiograph, 8.6% gravity stress view, 7.9% exorotation radiograph, 6.5% MRI scan, 0.7% ultrasound, 16.8% other) and 8% establishes their decision not based on the mortise radiograph. Fibular dislocation of ≥ 2 mm was used as an indication for surgical treatment by 69%. Of them, 56% decides to treat surgically in these cases, even with proven medial stability. CONCLUSION Many surgeons treat type B fibular fractures with a MCS > 4 mm at mortise view surgically, even without proven medial injury. Rarely, additional diagnostics as MRI or gravity stress test are performed in cases with a MCS 4-6 mm. Consequently many stable ankle fractures are treated operatively unnecessarily.
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Affiliation(s)
- C A T van Leeuwen
- Department of Trauma Surgery, Haaglanden Medical Centre, The Hague, the Netherlands.
| | - R P C Hoffman
- Department of Trauma Surgery, Haaglanden Medical Centre, The Hague, the Netherlands
| | - C C M A Donken
- Department of Orthopaedic Surgery, Sint Maartenskliniek, Ubbergen, the Netherlands
| | - L W van der Plaat
- Department of Orthopaedic Surgery, Sint Maartenskliniek, Ubbergen, the Netherlands
| | - T Schepers
- Department of Trauma Surgery, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - J M Hoogendoorn
- Department of Trauma Surgery, Haaglanden Medical Centre, The Hague, the Netherlands
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Abstract
Isolated lateral malleolus fractures represent one of the most common injuries encountered by orthopaedic surgeons. Nevertheless, appropriate diagnosis and management of these injuries are not clearly understood. Ankle stability is maintained by ligamentous and bony anatomy. The deep deltoid ligament is considered the primary stabilizer of the ankle. In the setting of an isolated lateral malleolus fracture, identifying injury to this ligament and associated ankle instability influences management. The most effective methods for assessing tibiotalar instability include stress and weight-bearing radiographs. Clinical examination findings are important but less reliable. Advanced imaging may not be accurate for guiding management. If the ankle is stable, nonsurgical management produces excellent outcomes. In the case that clinical/radiographic findings are indicative of ankle instability, surgical fixation options include lateral or posterolateral plating or intramedullary fixation. Locking plates and small or minifragment fixation are important adjuncts for the surgeon to consider based on individual patient needs.
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Sun X, Li T, Sun Z, Li Y, Yang M, Li S, Lv Z, Jiang X, Yong W, Wu X, Wang M. Does routinely repairing deltoid ligament injuries in type B ankle joint fractures influence long term outcomes? Injury 2018; 49:2312-2317. [PMID: 30526926 DOI: 10.1016/j.injury.2018.11.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Deltoid ligament reconstruction following type B ankle fractures continues to generate a vivid discussion amongst trauma surgeons. There is a difference of opinion as to whether operative or non operative treatment should prevail. We therefore conducted a prospective comparative cohort study to determine whether it is necessary to routinely repair the injured deltoid ligaments. 41 Type B ankle joint fracture patients were enrolled, all the patients were associated with deltoid ligament ruptures and lateral/posterior-lateral dislocation of talus. After fixation of the lateral malleolus fracture, 12 patients were treated by superficial deltoid ligaments repairing, 16 patients with deep components augmentation, 13 patients had no direct surgical intervention. In the deep components group, the planter and the dorsi flexion was 3.2° (0-10°) and 8.8° (0-15°) less than the normal side. In the superficial components group, plantar and dorsi flexion was 0.8° (0-5°) and 4.2° (0-15°) less than the normal side. In the non-repairing group, the plantar and dorsi flexion was 2.4° (0-10°) and 5.6° (0-20°) less than the normal side. Overall, no significant statistical difference was observed comparing the 3 groups. In addition, no statistically significant inter-group differences were evident in terms of measurement of the ankle medial clear space and the clinical and functional outcomes recorded. In conclusion, the results of this study do not support routine exposure and repairing of the injured deltoid ligaments.
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Affiliation(s)
- Xu Sun
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, 100035 China
| | - Ting Li
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, 100035 China
| | - Zhijian Sun
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, 100035 China
| | - Yuneng Li
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, 100035 China
| | - Minghui Yang
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, 100035 China
| | - Shaoliang Li
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, 100035 China
| | - Zhenbang Lv
- Department of Orthopaedics, Tsinghua University First Hospital, Beijing, China
| | - Xieyuan Jiang
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, 100035 China
| | - Wu Yong
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, 100035 China
| | - Xinbao Wu
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, 100035 China.
| | - Manyi Wang
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, 100035 China
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Immediate Weight-Bearing Protocol for the Determination of Ankle Stability in Patients With Isolated Distal Fibular Fractures. J Orthop Trauma 2018; 32:534-537. [PMID: 30086033 DOI: 10.1097/bot.0000000000001268] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate an alternative protocol for allowing immediate weight-bearing (WB) as tolerated in a functional walking boot in patients with a medial clear space (MCS) of less than 4 mm on nonstressed initial radiographs with subsequent WB radiographs at 1-week follow-up to determine if this can differentiate stable from unstable distal fibular fractures. DESIGN Retrospective case series. SETTING Level 1 trauma center. PATIENTS Seventy-nine patients who sustained an isolated distal fibular fracture with an MCS less than 4 mm on initial non-weight-bearing radiographs during a 6-year period. INTERVENTION Patients with MCS less than 4 mm on 1-week radiographs were treated nonoperatively. Patients with MCS greater than or equal to 4 mm were treated operatively. MAIN OUTCOME MEASUREMENTS Medial clear space measurements on WB ankle radiographs at the time of radiographic bony union. RESULTS Two of the 79 (2.5%) patients had an MCS greater than 4 mm at 1-week follow-up with WB radiographs and underwent operative fixation. The remaining 77 patients were treated nonoperatively. All 77 patients had an MCS less than 4 mm on WB radiographs at the time of radiographic healing. CONCLUSION These results suggest that our immediate weight-bearing protocol may be an effective method for determination of functional ankle stability only in the setting of an isolated distal fibula fracture with MCS less than 4 mm. However, it should be cautioned that careful evaluation of WB radiographs for joint asymmetry and/or MCS widening is mandatory to avoid poor outcomes. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Jeong BO, Kim TY, Baek JH, Song SH, Park JS. Assessment of Ankle Mortise Instability After Isolated Supination-External Rotation Lateral Malleolar Fractures. J Bone Joint Surg Am 2018; 100:1557-1562. [PMID: 30234620 DOI: 10.2106/jbjs.17.00993] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The diagnosis of clinically important instability following isolated supination-external rotation (SER) distal fibular fractures is a challenge. The purpose of this study was to investigate the accuracy of clinical findings including medial tenderness, swelling, and ecchymosis, combined with the gravity stress test and magnetic resonance imaging (MRI), in the assessment of ankle mortise stability in association with isolated SER-type lateral malleolar fractures. The external rotation (ER) stress test was used as the reference with which the methods of assessment were compared. METHODS Thirty-seven patients were enrolled prospectively. Using the ER stress test as a reference, we evaluated the sensitivity, specificity, likelihood ratio (LR), and post-test probability of instability when using clinical examination, the gravity stress test, and MRI for diagnosing ankle mortise instability after an isolated SER lateral malleolar fracture. RESULTS The positive LR for clinical findings ranged from 1.45 to 2.54, and the negative LR ranged from 0.25 to 0.70, shifting the pre-test probability to a rarely important degree. In contrast, the positive LR for the gravity stress test was 5.71 with a 95% confidence interval (CI) of 1.52 to 21.48, a moderate shift from the pre-test probability, and the negative LR was 0.33 (95% CI = 0.16 to 0.66), indicating a small shift. In cases with a deep deltoid ligament disruption identified on MRI, the positive LR was 3.05 (95% CI = 1.03 to 9.02) and the negative LR was 0.53 (95% CI = 0.31 to 0.91), demonstrating a small but sometimes important shift. CONCLUSIONS The gravity stress test is a reliable method for diagnosing ankle mortise instability in patients with an isolated SER lateral malleolar fracture. Nevertheless, this test alone would not qualify as a replacement for the ER stress test. However, when the gravity stress test result is consistent with the clinical or MRI findings, its diagnostic value is almost equivalent to that of the ER stress test. LEVEL OF EVIDENCE Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Bi O Jeong
- Departments of Orthopaedic Surgery (B.O.J., T.Y.K., J.H.B., and S.H.S.) and Radiology (J.S.P.), College of Medicine, Kyung Hee University, Seoul, South Korea
| | - Tae Yong Kim
- Departments of Orthopaedic Surgery (B.O.J., T.Y.K., J.H.B., and S.H.S.) and Radiology (J.S.P.), College of Medicine, Kyung Hee University, Seoul, South Korea
| | - Jong Hun Baek
- Departments of Orthopaedic Surgery (B.O.J., T.Y.K., J.H.B., and S.H.S.) and Radiology (J.S.P.), College of Medicine, Kyung Hee University, Seoul, South Korea
| | - Seung Hyun Song
- Departments of Orthopaedic Surgery (B.O.J., T.Y.K., J.H.B., and S.H.S.) and Radiology (J.S.P.), College of Medicine, Kyung Hee University, Seoul, South Korea
| | - Ji Seon Park
- Departments of Orthopaedic Surgery (B.O.J., T.Y.K., J.H.B., and S.H.S.) and Radiology (J.S.P.), College of Medicine, Kyung Hee University, Seoul, South Korea
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Lawlor MC, Kluczynski MA, Marzo JM. Weight-Bearing Cone-Beam CT Scan Assessment of Stability of Supination External Rotation Ankle Fractures in a Cadaver Model. Foot Ankle Int 2018. [PMID: 29532701 DOI: 10.1177/1071100718761035] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The utility of computed tomography (CT) for measuring medial clear space (MCS) for determination of the stability of supination external rotation (SER) ankle fractures and in comparison to standard radiographs is unknown. We compared MCS on gravity stress (GS) radiographs to GS and weight bearing (WB) cone-beam CT (CBCT). METHODS An AO SER 44B3.1 ankle fracture was simulated in 10 human cadavers, also serving as controls. MCS was measured on GS radiographs, GS CBCT, and a simulated WB CBCT scan. Specimens were stable if MCS was <5 mm and unstable if MCS was ≥5 mm. Paired t tests were used to compare MCS from each imaging modality for controls versus SER injuries and stable versus unstable specimens. RESULTS Compared with controls assessed by GS radiographs, MCS was greater for an SER injury when assessed by GS radiograph and GS CBCT scan within the stable group. Compared with controls assessed by GS radiographs, MCS was greater for SER injuries when assessed by GS radiograph, GS CBCT scan, and WB CBCT within the unstable group. MCS was reduced for stable versus unstable SER injuries assessed by WB CBCT. CONCLUSION In a cadaveric model of SER ankle fracture, the medial clear space was statistically significantly greater for the experimental condition when assessed by gravity stress radiograph and gravity stress CBCT scan. Under weight-bearing conditions, the cone-beam CT scanner distinguished between stable and unstable ankles in the experimental condition. CLINICAL RELEVANCE This study suggests that a WB cone-beam CT scan may be able to distinguish between stable and unstable SER ankle fractures and influence operative decision making.
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Affiliation(s)
- Mark C Lawlor
- 1 The Jacobs School of Medicine and Biomedical Sciences, The State University of New York, University at Buffalo, Amherst, NY, USA
| | - Melissa A Kluczynski
- 1 The Jacobs School of Medicine and Biomedical Sciences, The State University of New York, University at Buffalo, Amherst, NY, USA
| | - John M Marzo
- 1 The Jacobs School of Medicine and Biomedical Sciences, The State University of New York, University at Buffalo, Amherst, NY, USA
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Kwon JY, Cronin P, Velasco B, Chiodo C. Evaluation and Significance of Mortise Instability in Supination External Rotation Fibula Fractures: A Review Article. Foot Ankle Int 2018; 39:865-873. [PMID: 29652191 DOI: 10.1177/1071100718768509] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
UNLABELLED Evaluation and management of ankle fractures has progressed in parallel to an evolving understanding of ankle stability. While stability of the mortise had historically been attributed to the lateral malleolus, Lauge-Hansen's contributions followed by multiple other investigations increased the emphasis on the significance of medial-sided injury in destabilizing the mortise. As the importance of the deltoid ligament has been elucidated, the means of assessing ligamentous incompetence and the prognostic significance of an unstable mortise continue to be defined. LEVEL OF EVIDENCE Level V, expert opinion.
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Affiliation(s)
- John Y Kwon
- 1 Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Patrick Cronin
- 2 Harvard Combined Orthopaedic Residency Program, Boston, MA, USA
| | - Brian Velasco
- 1 Beth Israel Deaconess Medical Center, Boston, MA, USA
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