Performance after surgical treatment of patients with ankle fractures--14-month follow-up

Arthroscopy for Traumatic Ankle Injuries

Using ankle arthroscopy in conjunction to open reduction internal fixation of traumatic ankle injuries can play an important role in the management of these injuries by way of treating intra-articular pathologies, leading to improved patient outcomes. While a majority of these injuries are not treated with concurrent arthroscopy, its addition may lead to more prognostic information to dictate the patient's course. This article has illustrated its use in managing malleolar fractures, syndesmotic injuries, pilon fractures and pediatric ankle fractures. While additional studies may be needed to further support AORIF, it may prove to play a vital role in the future.

Analysis of Dynamic Plantar Pressure and Influence of Clinical-Functional Measures on Their Performance in Subjects with Bimalleolar Ankle Fracture at 6 and 12 Months Post-Surgery

Recovery after ankle fracture surgery can be slow and even present functional deficits in the long term, so it is essential to monitor the rehabilitation process objectively and detect which parameters are recovered earlier or later. The aim of this study was (1) to evaluate dynamic plantar pressure and functional status in patients with bimalleolar ankle fracture 6 and 12 months after surgery, and (2) to study their degree of correlation with previously collected clinical variables. Twenty-two subjects with bimalleolar ankle fractures and eleven healthy subjects were included in the study. Data collection was performed at 6 and 12 months after surgery and included clinical measurements (ankle dorsiflexion range of motion and bimalleolar/calf circumference), functional scales (AOFAS and OMAS), and dynamic plantar pressure analysis. The main results found in plantar pressure were a lower mean/peak plantar pressure, as well as a lower contact time at 6 and 12 months with respect to the healthy leg and control group and only the control group, respectively (effect size 0.63 ≤ d ≤ 0.97). Furthermore, in the ankle fracture group there is a moderate negative correlation (-0.435 ≤ r ≤ 0.674) between plantar pressures (average and peak) with bimalleolar and calf circumference. The AOFAS and OMAS scale scores increased at 12 months to 84.4 and 80.0 points, respectively. Despite the evident improvement one year after surgery, data collected using the pressure platform and functional scales suggest that recovery is not yet complete.

Assessing the functional outcomes of ankle fracture and its predictive factors following surgical treatment at Addis Ababa burn, emergency, and trauma (AaBET) hospital, Addis Ababa, Ethiopia, 2021: A 5-year retrospective cross-sectional study

BACKGROUND

Ankle fracture is a common injury that is treated at Addis Ababa Burn, Emergency, and Trauma Hospital. Previous studies show that there are mixed functional outcomes after surgically treated ankle fractures.

METHODS

After Ethical clearance was obtained from the ethical review committee of St. Paul Millennium Medical College, a retrospective cross-sectional study was conducted on 122 patients from September to October 2021. Patients fulfilling the inclusion criteria were called through phone and verbal consent was obtained, and the patients' responses were recorded with Olerud and Molander ankle outcome score (OMAS). For those study subjects who were unanswered to phone calls or non-functioning cell phones were repeated at least two times per week during the data collection period. The collected data were coded, entered, checked for its completeness, cleaned, and analyzed using SPSS Version 22. Descriptive statistics were presented with frequency, percentage, text, and graphs. Finally, the strength of association between  functional outcome of ankle fracture and independent variables were evaluated using the Chi-square test, and a P-value < 0.05 was declared to be statistically significant.

RESULTS

Out of the total 122 patients, 72.1% of study subjects were males, and the mean OMAS for males and females was 76.79, and 75.65, respectively. Among all ankle fractures, nearly two-thirds (63.1%) of them were closed fractures, which are initially stabilized with splinting, open reduction, and internal fixation (ORIF), and external fixation were 77%, 13.9%, and 9%, respectively, whereas 83.3% definitive management of operatively treated ankle fracture was open reduction and internal fixation. In this study, the score of Olerud and Molander was 82.9% patients 'good' or 'excellent,' whereas 10.5% and 4.5% were fair and poor, respectively. In the present study patients with 40 years and younger (p-value, 0.022) and early surgical treatment (p-value 0.02) were strongly associated with the positive functional outcome of ankle surgery.

CONCLUSION

Even though the surgical treatment of ankle fracture results in good postoperative functional outcomes, restores ankle function, and allows good mobility of the ankle joint, still some patients experience few restrictions in functional activities of 2-5-year post-surgical treatment.

Effect of acute ankle experimental pain on lower limb motor control assessed by the modified star excursion balance test

Introduction

Following most musculoskeletal injuries, motor control is often altered. Acute pain has been identified as a potential contributing factor. However, there is little evidence of this interaction for acute pain following ankle sprains. As pain is generally present following this type of injury, it would be important to study the impact of acute pain on ankle motor control. To do so, a valid and reliable motor control test frequently used in clinical settings should be used. Therefore, the objective of this study was therefore to assess the effect of acute ankle pain on the modified Star Excursion Balance Test reach distance.

Methods

Using a cross-sectional design, 48 healthy participants completed the modified Star Excursion Balance Test twice (mSEBT1 and mSEBT2). Following the first assessment, they were randomly assigned to one of three experimental groups: Control (no stimulation), Painless (non-nociceptive stimulation) and Painful (nociceptive stimulation). Electrodes were placed on the right lateral malleolus to deliver an electrical stimulation during the second assessment for the Painful and Painless groups. A generalized estimating equations model was used to compare the reach distance between the groups/conditions and assessments.

Results

Post-hoc test results: anterior (7.06 ± 1.54%; p < 0.0001) and posteromedial (6.53 ± 1.66%; p < 0.001) directions showed a significant reach distance reduction when compared to baseline values only for the Painful group. Regarding the anterior direction, this reduction was larger than the minimal detectable change (5.87%).

Conclusion

The presence of acute pain during the modified Star Excursion Balance Test can affect performance and thus might interfere with the participant's lower limb motor control. As none of the participants had actual musculoskeletal injury, this suggests that pain and not only musculoskeletal impairments could contribute to the acute alteration in motor control.

Measuring Recovery and Understanding Long-Term Deficits in Balance, Ankle Mobility and Hip Strength in People after an Open Reduction and Internal Fixation of Bimalleolar Fracture and Their Impact on Functionality: A 12-Month Longitudinal Study

To analyze how balance and other physical capacities evolved after surgery in patients with a bimalleolar fracture and how these capacities and clinical variables (immobilization or unloading time) contribute to restoring patients’ functionality, 22 patients and 10 healthy people (HC) were assessed for static and dynamic balance (Y-Balance test, YBT), dorsiflexion ankle mobility (ADFROM) and hip strength at 6 and 12 months after surgery. Patients’ functional status was assessed through the Olerud Molander Ankle Score (OMAS) and the American Orthopaedic Foot and Ankle Society (AOFAS) score. Twenty-one patients with ankle fractures who completed the study showed a worse static and dynamic balance at 6 months. The YBT in the anterior direction (YBTA) revealed balance deficits in the operated limb at 12 months compared to the non-operated limb (−5.6%) and the HC (−6.7%). They also showed a decreased ADFROM compared to the non-operated limb (−7.4°) and the HC (−11°). In addition, medium-term (6 months) deficits in abductor strength hip but no hip strength deficits were found at 12 months after surgery. Relative weight analyses showed that ADFROM and hip strength explained 35–63% of the YBTA variance and AOFAS/OMAS scores. Balance, hip strength and ADFROM seem to be reliable indexes for assessing the functional status of these patients. These results could help to understand the relationship between these physical capacities and the patients’ perceived functional status.

Clinical-Functional Evaluation and Test-Retest Reliability of the G-WALK Sensor in Subjects with Bimalleolar Ankle Fractures 6 Months after Surgery

Ankle fractures can cause significant functional impairment in the short and long term. In recent years, gait analysis using inertial sensors has gained special relevance as a reliable measurement system. This study aimed to evaluate the differences in spatiotemporal gait parameters and clinical−functional measurements in patients with bimalleolar ankle fracture and healthy subjects, to study the correlation between the different variables, and to analyze the test−retest reliability of a single inertial sensor in our study population. Twenty-two subjects with bimalleolar ankle fracture six months after surgery and eleven healthy subjects were included in the study. Spatiotemporal parameters were analyzed with the G-WALK sensor. Functional scales and clinical measures were collected beforehand. In the ankle fracture group, the main differences were obtained in bilateral parameters (effect size: 0.61 ≤ d ≤ 0.80). Between-group differences were found in cadence, speed, stride length, and stride time (effect size: 1.61 ≤ d ≤ 1.82). Correlation was moderate (0.436 < r < 0.554) between spatiotemporal parameters and clinical−functional measures, explaining up to 46% of gait performance. Test−retest reliability scores were high to excellent (0.84 ≤ ICC ≤ 0.98), with the worst results in the gait phases. Our study population presents evident clinical−functional impairments 6 months after surgery. The G-WALK can be considered a reliable tool for clinical use in this population.

Does musculoskeletal pain interfere with motor learning in a gait adaptation task? A proof-of-concept study

BACKGROUND

Experimental pain during gait has been shown to interfere with learning a new locomotor task. However, very few studies have investigated the impact of clinical pain on motor learning due to the challenges associated with clinical populations.

OBJECTIVE

The first objective of this proof-of-concept study was to determine the feasibility to obtain two groups of participants with chronic ankle pathology with or without residual pain while walking. The second objective was to evaluate the impact of clinical musculoskeletal pain on motor learning during gait.

METHODS

Participants with chronic isolated ankle pathology were recruited and their personal and clinical characteristics were collected (functional performance, dorsiflexion maximal strength, range of motion). To assess motor acquisition (Day 1) and retention (Day 2), participants performed an adaptation task on two consecutive days that consisted of walking while experiencing a perturbing force applied to the ankle. The level of pain during the task was measured, and participants who reported pain were attributed to the Pain group and participants without pain to the No Pain group. Learning performance was assessed by measuring ankle kinematics (Mean plantarflexion absolute error) and learning strategy was assessed by measuring the Relative timing of error and the tibialis anterior (TA) electromyographic activity.

RESULTS

Twenty-five participants took part in the experiment. Eight (32%) were excluded because they could not be included in either the Pain or No Pain group due to the intermittent pain, leaving eight participants in the Pain group and nine in the No Pain group. Both groups were similar in terms of baseline characteristics. Musculoskeletal pain had no influence on learning performance, but the learning strategy were different between the two groups. The No Pain group showed a TA activity reduction before perturbation between the days, while the Pain group did not.

CONCLUSION

Some barriers were identified in studying musculoskeletal pain including the high rates of participants' exclusion, leading to a small sample size. However, we showed that it is feasible to investigate clinical pain and motor learning. From the results of this study, musculoskeletal pain has no influence on motor learning performance but influences the learning strategy.

Determinants of functional outcome following ankle fracture

Objectives:

To assess the patient and injury characteristics that impact functional outcomes after ankle fracture.

Design:

Retrospective study.

Setting:

Urban level I trauma center.

Patients/Participants:

One thousand patients underwent fixation of ankle fracture (AO/OTA 44) between 2006 and 2015. Four hundred sixteen completed functional outcome surveys by telephone or mail at a mean of 5.9 years after injury.

Intervention:

Open reduction internal fixation.

Main outcome measure:

Foot Function Index (FFI) and Short Musculoskeletal Function Assessment (SMFA).

Results:

Mean age was 46.7 years, with 46.2% male. Higher (worse) FFI scores were seen in tobacco users (38.9 vs 30.1), recreational drug users (45.9 vs 32.7), and the morbidly obese (52.0 vs 30.6), all P < .005. Higher (worse) SMFA dysfunction and bothersome scores were also seen in these groups, and in females and alcohol users. Multiple regression analysis identified female gender, obesity, tobacco and alcohol use, complications, secondary procedures, and multiple additional injuries as independent predictors of higher scores (all P < .04). Fracture patterns, open fracture, and development of arthritis had no impact on FFI or SMFA scores.

Conclusion:

Patient characteristics, not under surgeon-control, such as female sex, obesity, and substance use, appear to contribute to patient-reported functional outcome scores more than injury characteristics.

Level of Evidence:

Level 3, prognostic

Quality of life and complications in elderly patients after pronation rotation type III ankle fractures treated with a cast and early weight-bearing

Background

Early weight-bearing is becoming increasingly common because it can positively affect the quality of life of patients. Therefore, the efficacy and safety of this conservative treatment should be assessed for different types of ankle fractures. The goal of this study was to compare early weight-bearing and non-weight-bearing in terms of effectiveness and safety in patients with pronation rotation type III ankle fractures treated nonsurgically.

Methods

A prospective multicenter cohort study was conducted over two years. Elderly patients with a nondisplaced pronation rotation type III ankle fracture were included. The main variables were the Barthel Index and SF-12 scores. The patients completed the questionnaires at six weeks, one year and two years. We also compared the complications associated with the two interventions.

Results

30 patients were included in the weight-bearing group, while 32 patients were included in the non-weight-bearing (WB) group. The mean ages were 82.6 ± 2.6 years and 83.1 ± 2.6 years, respectively. Quality of life, measured with the SF-12 scale, increased significantly in both the short and long term in the WB group (53.5 ± 5.8 points vs 65.2 ± 4.4 points at 6 weeks and 70.1 ± 4.2 points vs. 80.9 ± 3.7 points at 2 years; p<0.001). The WB group also showed a higher quality of life, as measured by the Barthel Index (54.5 ± 5.2 points vs. 64.3 ± 4.0 points at 6 weeks and 71.0 ± 4.3 points vs. 80.7 ± 3.4 points at 2 years; p<0.001).

Conclusions

Elderly patients with pronation rotation type III fractures could benefit from an early weight-bearing protocol in terms of quality of life and functionality.

Second-look arthroscopic findings and clinical outcomes after management of intra-articular lesions in acute ankle fractures with arthroscopy

BACKGROUND

Anatomically surgical reduction of ankle fractures does not always result in a clinically favorable outcome. Arthroscopic examination combined with treatment of intra-articular lesion may related to clinical outcomes OBJECTIVES: The purpose of the present study was to review initial and second look arthroscopic finding of acute ankle fracture and to evaluate clinical outcomes.

RESULTS

Lauge-Hansen classification system of ankle fractures included supination-external rotation type (n = 24), supination-adduction type (n = 3), pronation-external rotation type (n = 7), and pronation-abduction type (n = 6), total 40 ankles. Osteochondral lesions were found in 25 ankles (62%) with an initial arthroscopic finding of acute ankle fracture. Newly discovered chondral lesions in secondary arthroscopy were found in 17 cases. According to the Ferkel and Cheng staging at secondary arthroscopy, 4 of 25 ankles with osteochondral lesions of the talus were deteriorating (more than stage D). In terms of ICRS overall repair grades, 5 ankles (20%) were abnormal (grade III). Diffuse synovitis and arthrofibrosis were found in 12 and 7 ankles, respectively, in secondary arthroscopy, and correlations were found between AOFAS scores, VAS and intra-articular lesions.

CONCLUSION

Second-look arthroscopic examination combined with treatment of intra-articular lesion such as arthrofibrosis and osteochondral lesion arising from ankle fracture surgery may consider to improve clinical outcomes.

Functional Evaluation of Ankle Joint After 1-Stage Secondary Debulking Procedure After Flap Reconstruction

OBJECTIVE

Free or local flaps that are used to reconstruct the lower limb often result in poor functional outcome because of bulkiness of the flap and scar contracture over ankle joint region. The aim of this study was to evaluate the functional results of ankle joint after 1-stage secondary debulking procedure for lower limb trauma.

MATERIAL AND METHODS

From January of 2002 to October of 2018, debulking procedures were performed for 66 patients after flap reconstructions of the lower limb. Thirty-eight patients (group 1) of foot injury without ankle joint involvement and 20 patients (group 2) with ankle joint involvement were included. Range of motion (ROM) of ankle joint before and after debulking procedure was measured after 6 months of follow-up.

RESULTS

After debulking procedure, all the patients were able to dress in their preinjury shoes without any difficulty and with ease of ambulation. For all patients, with or without ankle involvement, the postdebulking ROM versus predebulking ROM improved significantly (P < 0.01). The ROM improvements for patients with ankle involvement were significantly better then patients without ankle involvement (P = 0.032).

CONCLUSIONS

One-stage debulking procedure can provide long-term constant, reliable, thin skin coverage for the lower limb after flap reconstruction with improved ankle ROM. This allows better functional results, especially for lower limb trauma patients with initial ankle involvement.

Promoting endogenous repair of skeletal muscle using regenerative biomaterials

Skeletal muscles normally have a remarkable ability to repair themselves; however, large muscle injuries and several myopathies diminish this ability leading to permanent loss of function. No clinical therapy yet exists that reliably restores muscle integrity and function following severe injury. Consequently, numerous tissue engineering techniques, both acellular and with cells, are being investigated to enhance muscle regeneration. Biomaterials are an essential part of these techniques as they can present physical and biochemical signals that augment the repair process. Successful tissue engineering strategies require regenerative biomaterials that either actively promote endogenous muscle repair or create an environment supportive of regeneration. This review will discuss several acellular biomaterial strategies for skeletal muscle regeneration with a focus on those under investigation in vivo. This includes materials that release bioactive molecules, biomimetic materials and immunomodulatory materials.

Functional evaluation of triceps surae during heel rise test: from EMG frequency analysis to machine learning approach

Soleus muscle flap as coverage tissue is a possible surgical solution adopted to cover the wounds due to open fractures. Despite this procedure presents many clinical advantages, relatively poor information is available about the loss of functionality of triceps surae of the treated leg. In this study, a group of patients who underwent a soleus muscle flap surgical procedure has been analyzed through the heel rise test (HRT), in order to explore the triceps surae residual functionalities. A frequency band analysis was performed in order to assess whether the residual heads of triceps surae exhibit different characteristics with respect to both the non-treated lower limb and an age-matched control group. Then, an in-depth analysis based on a machine learning approach was proposed for discriminating between groups by generalizing across new unseen subjects. Experimental results showed the reliability of the proposed analyses for discriminating between-group at a specific time epoch and the high interpretability of the proposed machine learning algorithm allowed the temporal localization of the most discriminative frequency bands. Findings of this study highlighted that significant differences can be recognized in the myoelectric spectral characteristics between the treated and contralateral leg in patients who underwent soleus flap surgery. These experimental results may support the clinical decision-making for assessing triceps surae performance and for supporting the choice of treatment in plastic and reconstructive surgery. Graphical Abstract The Graphical abstract presents the scope of the proposed analysis of myoelectric signals of soleus and gastrocnemius muscles of patiens groups during Hell Rise Test, highlighting the applied methods and the obtained results.

Differences in gait and trunk movement between patients after ankle fracture and healthy subjects

Background

Studies have shown that gait asymmetry and activity limitation can persist several months or years after ankle fracture. However, evidence of gait and trunk movement patterns following ankle fracture during the early rehabilitation period is scarce. Thus, we compared gait patterns and trunk movement during the early phase of rehabilitation between patients with ankle fracture and matched controls.

Methods

Ten patients with ankle fractures, and ten age- and sex-matched healthy controls were prospectively enrolled. An automated infrared-assisted, trunk accelerometer-based gait analysis system was used to measure walking speed, step length, and cadence. The median time of the evaluation following ankle fracture was 4.0 months. Trunk movement intensity was evaluated as acceleration root mean square. Trunk movement symmetry and regularity were analysed using the autocorrelation method. Differences in gait characteristics between the patient and control groups were analysed using the Mann–Whitney U test. Follow-up assessment of falls was performed 24 months after the fracture. The correlations between Lower Extremity Functional Scale (LEFS) scores/falls and gait parameters were evaluated using Spearman’s rank correlation coefficient.

Results

Walking speed (p = 0.019), step length (p = 0.023), cadence (p = 0.003), and trunk movement intensity in anterior–posterior and vertical axis (p = 0.001, p = 0.003, respectively) were all significantly lower in the ankle fracture group than in the control group. Trunk movement symmetry in vertical direction (p = 0.019) decreased significantly in patients with ankle fractures, whereas between-strides regularity did not differ between groups. LEFS scores were moderately correlated with walking speed (r = 0.60, p = 0.044) and step length (r = 0.68, p = 0.021). During the 24 months after the fracture, 3 falls were reported by 3 patients. Trunk acceleration root mean square ratio in mediolateral axis (r = 0.72, p = 0.018) was highly correlated with future falls.

Conclusion

During early rehabilitation, patients with ankle fracture may develop trunk movement asymmetry in the vertical direction accompanied with slower walking speed and cadence, and smaller step lengths, which can contribute to muscular imbalances and potential injury. Thus, proper rehabilitation strategies should be employed for these patients.

Use of 18F-sodium fluoride bone PET for disability evaluation in ankle trauma: a pilot study

Background

There are no objective and accurate rating tools for permanent impairment of traumatized ankles. The purpose of this study is to assess the role of 18F-Sodium fluoride (18F-NaF) positron emission tomography-computed tomography (PET/CT) bone scans in evaluating patients with limited ankle range of motion (ROM) after trauma.

Methods

18F-NaF PET/CT was performed in 121 patients (75 men, 46 women; mean age: 45.8) who had ROM < 70% of normal after trauma affecting ankles. Metabolic target volume (MTV), the sum of voxels with standardized uptake value (SUV) > 2.5 was automatically obtained from the 3D volume that included the ankle joint. The maximum & mean SUV (SUVmax & SUVmean), and the total lesion activity (TLA) were measured.

Results

The median period from injury to performing 18F-NaF PET/CT was 290 days. The causes of injury were as follows: fracture (N = 95), Achilles tendon rupture (N = 12), and ligament injury (N = 12). Hot uptake in the ankle was seen in 113 of 121 patients. The fracture group had higher SUVmax, SUVmean, and TLA values than the non-fracture group. More limited ROM correlated with higher hot-uptake parameters (SUVmax, SUVmean, TLA). In subgroup analysis, the same correlations were present in the fracture, but not in the non-fracture group.

Conclusions

18F-NaF PET/CT can provide considerable information in impairment evaluations of limited ankle ROM, particularly in fracture around the ankle. Thus, 18F-NaF bone PET/CT may provide an additional option as an objective imaging tool in disability assessment after ankle injury.

Therapeutic effect of microcurrent on calf muscle atrophy in immobilized rabbit

INTRODUCTION

Immobilization causes significant muscle loss. In this study we assessed the regenerative effect of microcurrent electrical stimulation (MES) on gastrocnemius muscle (GCM) atrophy induced by immobilization by cast (IC) in rabbits.

METHODS

Fifteen rabbits were divided into 3 groups: IC (group 1); IC and free re-ambulation for 2 weeks after cast removal (CR) (group 2); and IC and MES for 2 weeks after CR (group 3). We evaluated clinical parameters (calf circumference, compound muscle action potential of tibial nerve, and thickness of GCM by ultrasound), histomorphometric data (muscle composition and cross-sectional area), and immunohistochemistry.

RESULTS

Mean atrophic changes in clinical parameters in group 3 were significantly less than those in groups 1 and 2 (P < 0.05). Histomophometric and immunohistochemical parameters in group 3 were significantly greater than those in groups 1 and 2, respectively (P < 0.05).

DISCUSSION

MES prevents muscle atrophy and facilitates regeneration of muscle. Muscle Nerve 58: 270-276, 2018.

Cross-Sectional Study to Assess the Functional Outcome of Neglected Bimalleolar Fracture

INTRODUCTION

Ankle fracture is the most common intra-articular fracture of a weight-bearing joint and accounts for 9% of all fractures. Ankle fractures are classified into 3 subgroups: unimalleolar, bimalleolar, and trimalleolar fractures. Accurate reduction and stable internal fixation is necessary in bimalleolar fractures; otherwise, it may lead to posttraumatic painful restriction of movements or osteoarthritis. The purpose of this study is to assess the functional outcome and results of treatment of neglected bimalleolar fracture.

MATERIALS AND METHODS

Seventeen neglected bimalleolar fracture patients were treated with open reduction and internal fixation. Patients were followed-up at 1, 2, and 5 years and functional ability was assessed by using the modified Weber Rating Scale.

RESULTS

The mean age of patients was 41.4 ± 13.28 years. After 2 year of surgery, 13 out of 17 patients showed excellent results and 4 patients had fair results.

CONCLUSION

Good to excellent functional results were observed after long-term follow-up in neglected bimalleolar fracture treated with open reduction and internal fixation, and we advise surgical intervention in all such patients.

LEVELS OF EVIDENCE

Therapeutic, Level III: Retrospective Cohort study.

Relationships Between Radiographic Pre- and Postoperative Alignment and Patient Perceived Outcomes Following Weber B and C Ankle Fractures

BACKGROUND

Anatomic reduction of ankle fractures may influence outcomes but the relationships between these 2 variables are still unknown and require further investigation. The purpose of this study was to investigate the relationships between radiologic alignment of surgically treated ankle fractures and functional outcomes.

METHODS

This retrospective study included patients who were surgically treated for Weber B and C ankle fractures. The outcome measures consisted of the Olerud and Molander Ankle Score (OMAS) and the foot and ankle disability measure. Standard radiographs included anteroposterior, lateral, and mortise views of the ankle, both on pre- and postoperatively. Between June 2011 and December 2013, a total of 152 patients were treated for ankle fractures and 76 patients with a mean age of 41.3 ± 17.1 years and a mean follow-up of 39.6 ± 8.9 months were included. There were 45 Weber type B fractures (mean age 43.4 ± 17.8, 28 females, 17 males) and 31 Weber type C fractures (mean age 40.7 ± 17.3, 12 females, 19 males).

RESULTS

Linear regression did not reveal any significant relationships with the exception of age. There was a moderate correlation between the OMAS outcome score and age ( r² = 0.46, P = .01).

CONCLUSION

We found that younger age was a moderate predictor of functional outcome following surgical treatment of ankle fractures. Radiographic alignment using standard non-weight-bearing radiographs and fracture severity did not predict functional outcomes at 24 months postoperatively.

LEVEL OF EVIDENCE

Level III, prognostic, retrospective cohort study.

Translation, cross-cultural adaptation, reliability and validity of the Turkish version of the Olerud-Molander Ankle Score (OMAS)

Objective

The aim of this study was to translate and culturally adapt the Olerud-Molander Ankle Score (OMAS) into Turkish and to assess its reliability and validity.

Methods

The Turkish version of the OMAS (OMAS-Tr) was developed after the translation and back-translation, which included the stages recommended by Beaton. The OMAS-Tr was administered to one hundred patients (49 females, 51 males; average age: 42.3 ± 17.7; range 16–81 years) with malleolar fractures. The OMAS-Tr was completed twice by each participant at 7- to 10-days intervals to assess test-retest reliability based on the interrater correlation coefficient, whereas Cronbach's alpha evaluated internal consistency. The external validity was evaluated with correlations between the Turkish version of the Foot and Ankle Ability Measure (FAAM) and the Turkish version of the SF-12 questionnaire. The distribution of floor and ceiling effects was also analyzed.

Results

The internal consistency (Cronbach's α = 0.84) and the test-retest reliability (ICC = 0.98) were excellent. The mean interval between the two tests was 8.6 ± 1.4 days. The mean and standard deviation of the first and second assessments of the OMAS-Tr were 74.1 ± 23.7 and 75.7 ± 23.9, respectively. There was a strong correlation between the OMAS-Tr and the FAAM subscales on activities of daily living and sports (r = 0.86, r = 0.83; p < 0.001, respectively). The OMAS-Tr displayed very good to good correlation with the SF-12 physical component score and the SF-12 mental component score (r = 0.72, r = 0.60, p < 0.001, respectively).

Conclusion

OMAS-Tr was a valid and reliable tool to assess ankle fracture-related problems. Nonetheless, further studies are needed to assess its responsiveness.

Level of evidence

Level III, diagnostic study.

Trends of Concurrent Ankle Arthroscopy at the Time of Operative Treatment of Ankle Fracture: A National Database Review

BACKGROUND

The purpose of this study was to report trends associated with concurrent ankle arthroscopy at the time of operative treatment of ankle fracture.

METHOD

The current procedural terminology (CPT) billing codes were used to search the PearlDiver Patient Record Database and identify all patients who were treated for acute ankle fracture in the United States. The Medicare Standard Analytic Files were searchable between 2005 and 2011 and the United Healthcare Orthopedic Dataset from 2007 to 2011. Annual trends were expressed only between 2007 and 2011, as it was the common time period among both databases. Demographic factors were identified for all procedures as well as the cost aspect using the Medicare data set.

RESULTS

In total, 32 307 patients underwent open reduction internal fixation (ORIF) of an ankle fracture, of whom 313 (1.0%) had an ankle arthroscopy performed simultaneously. Of those 313 cases, 70 (22.4%) patients received microfracture treatment. Between 2005 and 2011, 85 203 patients were treated for an ankle fracture whether via ORIF or closed treatment. Of these, a total of 566 patients underwent arthroscopic treatment within 7 years. The prevalence of arthroscopy after ankle fracture decreased significantly by 45% from 2007 to 2011 (P< .0001). When ORIF and microfracture were performed concurrently, the total average charge for both procedures drops to $4253.00 and average reimbursement to $818.00 compared with approximately $4964.00 and $1069.00, respectively, when they were performed subsequently.

CONCLUSION

Despite good evidence in favor of arthroscopy at the time of ankle fracture treatment, it appears that only a small proportion of surgeons in the United States perform these procedures concurrently.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Retrospective.

Manual Physical Therapy Following Immobilization for Stable Ankle Fracture: A Case Series

STUDY DESIGN

Case series.

BACKGROUND

Ankle fractures commonly result in persistent pain, stiffness, and functional impairments. There is insufficient evidence to favor any particular rehabilitation approach after ankle fracture. The purpose of this case series was to describe an impairment-based manual physical therapy approach to treating patients with conservatively managed ankle fractures.

CASE DESCRIPTION

Patients with stable ankle fractures postimmobilization were treated with manual physical therapy and exercise targeted at associated impairments in the lower limb. The primary outcome measure was the Lower Extremity Functional Scale. Secondary outcome measures included the ankle lunge test, numeric pain-rating scale, and global rating of change. Outcome measures were collected at baseline (performed within 7 days of immobilization removal) and at 4 and 12 weeks postbaseline.

OUTCOMES

Eleven patients (mean age, 39.6 years; range, 18-64 years; 2 male), after ankle fracture-related immobilization (mean duration, 48 days; range, 21-75 days), were treated for an average of 6.6 sessions (range, 3-10 sessions) over a mean of 46.1 days (range, 13-81 days). Compared to baseline, statistically significant and clinically meaningful improvements were observed in Lower Extremity Functional Scale score (P = .001; mean change, 21.9 points; 95% confidence interval: 10.4, 33.4) and in the ankle lunge test (P = .001; mean change, 7.8 cm; 95% confidence interval: 3.9, 11.7) at 4 weeks. These changes persisted at 12 weeks.

DISCUSSION

Statistically significant and clinically meaningful improvements in self-reported function and ankle range of motion were observed at 4 and 12 weeks following treatment with impairment-based manual physical therapy. All patients tolerated treatment well. Results suggest that this approach may have efficacy in this population.

LEVEL OF EVIDENCE

Therapy, level 4.

Weight-bearing ankle dorsiflexion range of motion-can side-to-side symmetry be assumed?

CONTEXT

In clinical practice, the range of motion (ROM) of the non involved side often serves as the reference for comparison with the injured side. Previous investigations of non-weight-bearing (NWB) ankle dorsiflexion (DF) ROM measurements have indicated bilateral symmetry for the most part. Less is known about ankle DF measured under weight-bearing (WB) conditions. Because WB and NWB ankle DF are not strongly correlated, there is a need to determine whether WB ankle DF is also symmetrical in a healthy population.

OBJECTIVE

To determine whether WB ankle DF is bilaterally symmetrical. A secondary goal was to further explore the correlation between WB and NWB ankle DF ROM.

DESIGN

Cross-sectional study.

SETTING

Training facility of the Israeli Defense Forces.

PATIENTS OR OTHER PARTICIPANTS

A total of 64 healthy males (age = 19.6 ± 1.0 years, height = 175.0 ± 6.4 cm, and body mass = 71.4 ± 7.7 kg).

MAIN OUTCOME MEASURE(S)

Dorsiflexion ROM in WB was measured with an inclinometer and DF ROM in NWB was measured with a universal goniometer. All measurements were taken bilaterally by a single examiner.

RESULTS

Weight-bearing ankle DF was greater on the nondominant side compared with the dominant side (P < .001). Non-weight-bearing ankle DF was not different between sides (P = .64). The correlation between WB and NWB DF was moderate, with the NWB DF measurement accounting for 30% to 37% of the variance of the WB measurement.

CONCLUSIONS

Weight-bearing ankle DF ROM should not be assumed to be bilaterally symmetrical. These findings suggest that side-to-side differences in WB DF may need to be interpreted while considering which side is dominant. The difference in bilateral symmetry between the WB and NWB measurements, as well as the only moderate level of correlation between them, suggests that both measurements should be performed routinely.

Development and validation of the ankle fracture outcome of rehabilitation measure (A-FORM)

STUDY DESIGN

Delphi panel and cohort study.

OBJECTIVE

To develop and refine a condition-specific, patient-reported outcome measure, the Ankle Fracture Outcome of Rehabilitation Measure (A-FORM), and to examine its psychometric properties, including factor structure, reliability, and validity, by assessing item fit with the Rasch model.

BACKGROUND

To our knowledge, there is no patient-reported outcome measure specific to ankle fracture with a robust content foundation.

METHODS

A 2-stage research design was implemented. First, a Delphi panel that included patients and health professionals developed the items and refined the item wording. Second, a cohort study (n = 45) with 2 assessment points was conducted to permit preliminary maximum-likelihood exploratory factor analysis and Rasch analysis.

RESULTS

The Delphi panel reached consensus on 53 potential items that were carried forward to the cohort phase. From the 2 time points, 81 questionnaires were completed and analyzed; 38 potential items were eliminated on account of greater than 10% missing data, factor loadings, and uniqueness. The 15 unidimensional items retained in the scale demonstrated appropriate person and item reliability after (and before) removal of 1 item (anxious about footwear) that had a higher-than-ideal outfit statistic (1.75). The "anxious about footwear" item was retained in the instrument, but only the 14 items with acceptable infit and outfit statistics (range, 0.5-1.5) were included in the summary score.

CONCLUSION

This investigation developed and refined the A-FORM (Version 1.0). The A-FORM items demonstrated favorable psychometric properties and are suitable for conversion to a single summary score. Further studies utilizing the A-FORM instrument are warranted. J Orthop Sports Phys Ther 2014;44(7):488-499. Epub 22 May 2014. doi:10.2519/jospt.2014.4980.

Health status, health-related quality of life, and quality of life following ankle fractures: a systematic review

INTRODUCTION

The number of disabling short- and long-term consequences after ankle fracture (AF) is high. Therefore, it is important to consider the health status (HS), health-related quality of life (HRQOL), and quality of life (QOL) of these patients. The aim of this study was to provide a systematic overview of studies on HS, HRQOL, and QOL in patients with AF. In addition, the conceptualisation of HS, HRQOL, and QOL in these studies was evaluated.

METHODS

A systematic literature search was conducted in Pubmed, Embase, The Cochrane Library, and PsycINFO (January 1976 to April 2012).

RESULTS

Twenty-three studies were included of which almost half had a cross-sectional design. The assessment of HRQOL or QOL was an explicit objective in 17.4% of the studies. The SF-36 and SMFA were the instruments most often used and measure respectively HS and a combination of HS and HRQOL. However, they had been labelled as functional status. Inconclusive results were reported regarding the predictive value of age, sex, education level, alcohol use, smoking, fracture type, and the role of syndesmotic reduction with regard to HS and HRQOL. Also, inconclusive results were found comparing HS and HRQOL scores of patients with AF with norm population scores and regarding the course of HS and HRQOL over time. The additional value of early mobilisation after AF was not confirmed.

CONCLUSIONS

There are few quality studies on HS and HRQOL following AF and results are inconclusive. Future studies should measure these important patient-reported outcomes, including QOL. The concepts HS and HRQOL are not applied in agreement with the content of the instruments and instruments are downgraded to assess functional status. The correct terminology should be used to warrant clear communication in the field.

Factors associated with mobility outcomes in older people post-ankle fracture: an observational cohort study focussing on peripheral vessel function

INTRODUCTION

There are increasing numbers of older persons sustaining ankle fractures. This injury often results in a degree of functional limitation, particularly in older patients. There is currently limited research into factors associated with mobility outcomes.

DESIGN

Observational cohort study.

SETTING

Hospital Trauma Department, UK.

PARTICIPANTS

Persons aged 60 years or over who sustained an unstable ankle fracture with no established peripheral arterial disease pre-injury.

METHODS

This study investigated the association between ankle-brachial pressure index (ABPI) and extended timed 'up and go' (TUG) measures. Associations between TUG outcomes and age, pre-morbid functional mobility (Olerud-Molander Ankle Score) and fracture severity (number of malleoli injured) were also explored.

ANALYSIS

Complete cases (n=76; 84% of cohort) were entered into univariate and multivariate linear regression.

RESULTS

No association was found between ABPI and TUG at 6 months in unadjusted and adjusted analyses. Pre-morbid functional mobility (B=-0.34, 95% confidence interval (CI) -0.45 to -0.23, p<0.001) and age (B=0.46, 95% CI 0.25-0.66, p<0.001) were associated with extended TUG values (r2=0.53, p<0.001). Fracture severity was not a significant independent predictor variable.

CONCLUSIONS

Peripheral vessel function and fracture severity may have a limited independent influence on mobility outcome after ankle fracture in those patients who do not have established pre-injury peripheral arterial disease. Age and pre-morbid mobility gave an indication of mobility outcome, but a substantial amount of variance remains unexplained. Limitations of this study, including missing data and potential residual confounding, indicate the need for caution in generalising these results. The study provides a basis on which to plan larger studies of the factors associated with mobility outcome after ankle fracture in older populations.

The Swedish version of OMAS is a reliable and valid outcome measure for patients with ankle fractures

Background

The aim of this study was to evaluate the test-retest reliability and the validity of the self-reported questionnaire Olerud-Molander Ankle Score (OMAS) in subjects after an ankle fracture.

Methods

When evaluating the test-retest reliability of the OMAS, 42 subjects surgically treated due to an ankle fracture participated 12 months after injury. OMAS was completed by the patients on two occasions at one to two weeks’ interval. Concurrent criterion validity was evaluated using the five subscales of the Foot and Ankle Outcome Score (FAOS) and global self-rating function (GSRF), which is a five-grade Likert scale with the alternatives: “very good”, “good”, “fair”, “poor”, “very poor”. Forty-six patients participated in the validation against FAOS, and for GSRF 105 patients participated at 6 months and 99 at 12 months. Uni-, bi- and trimalleolar fractures were all included and both non-rigid and rigid surgical techniques were used. All fractures healed without complications. Before analysis of the results the five groups according to GSRF were reduced to three: “good”, “fair” and “poor”. Test-retest reliability was assessed using Spearman’s rank correlation, the intraclass correlation coefficient (ICC), the standard error of measurement (SEM and SEM%) and the smallest real difference (SRD and SRD%). The Cronbach’s alpha score and validity versus FAOS was assessed using Spearman’s rank correlation and validity versus GSRF using the Kruskal-Wallis Test and the Mann–Whitney U-Test as ad hoc analyses.

Results

The test-retest reliability correlation coefficient obtained was rho = 0.95 and ICC = 0.94. The SEM was 4.4 points and SEM% 5.8% and should be interpreted as the smallest change that indicates a real change of clinical interest for a group of subjects. The SRD was 12 points and SRD% 15.8% and should be interpreted as the smallest change that indicates a real change of clinical interest for a single subject. The correlation coefficients versus the five subscales of FAOS ranged from rho = 0.80 to 0.86. There were significant differences between GSRF groups “good”, “fair” and “poor” (p < 0.001) at both the six-month and the 12-month follow-up. The internal consistency for the OMAS was 0.76. The effect size between results from 6-month and 12-month follow-up turned out be 0.44 and should be considered as medium.

Conclusion

The results showed that the test-retest reliability of the Swedish version of OMAS was very high in subjects after an ankle fracture and the standard error of measurement was low. Furthermore the OMAS was found to be valid using both the five subscales of FAOS and the GSRF. The OMAS can thus be used as an outcome measure after an ankle fracture.

Weightbearing and nonweightbearing ankle dorsiflexion range of motion: are we measuring the same thing?

BACKGROUND

Ankle dorsiflexion range of motion has been measured in weightbearing and nonweightbearing conditions. The different measurement conditions may contribute to inconsistent conclusions regarding the role of ankle dorsiflexion in several pathologic conditions. The purpose of this study was to examine the relationship between ankle dorsiflexion range of motion as measured in weightbearing and nonweightbearing conditions.

METHODS

We compared ankle dorsiflexion range of motion as measured in a weightbearing versus a nonweightbearing position in 43 healthy volunteers. Measurements were taken separately by two examiners.

RESULTS

Weightbearing and nonweightbearing ankle dorsiflexion measurements produced significantly different results (P < .0001). The two measurements correlated moderately (r = 0.6 and r = 0.64 for examiners 1 and 2, respectively; P < .001).

CONCLUSIONS

Weightbearing and nonweightbearing ankle dorsiflexion measurements produce significantly different results and only a moderate correlation, suggesting that these two measurements should not be used interchangeably as measures of ankle dorsiflexion range of motion.

Overexpression of insulin-like growth factor-1 attenuates skeletal muscle damage and accelerates muscle regeneration and functional recovery after disuse

Skeletal muscle is a highly dynamic tissue that responds to endogenous and external stimuli, including alterations in mechanical loading and growth factors. In particular, the antigravity soleus muscle experiences significant muscle atrophy during disuse and extensive muscle damage upon reloading. Given that insulin-like growth factor-1 (IGF-1) has been implicated as a central regulator of muscle repair and modulation of muscle size, we examined the effect of virally mediated overexpression of IGF-1 on the soleus muscle following hindlimb cast immobilization and upon reloading. Recombinant IGF-1 cDNA virus was injected into one of the posterior hindlimbs of the mice, while the contralateral limb was injected with saline (control). At 20 weeks of age, both hindlimbs were immobilized for 2 weeks to induce muscle atrophy in the soleus and ankle plantarflexor muscle group. Subsequently, the mice were allowed to reambulate, and muscle damage and recovery were monitored over a period of 2-21 days. The primary finding of this study was that IGF-1 overexpression attenuated reloading-induced muscle damage in the soleus muscle, and accelerated muscle regeneration and force recovery. Muscle T2 assessed by magnetic resonance imaging, a non-specific marker of muscle damage, was significantly lower in IGF-1-injected compared with contralateral soleus muscles at 2 and 5 days reambulation (P<0.05). The reduced prevalence of muscle damage in IGF-1-injected soleus muscles was confirmed on histology, with a lower fractional area of abnormal muscle tissue in IGF-1-injected muscles at 2 days reambulation (33.2±3.3 versus 54.1±3.6%, P<0.05). Evidence of the effect of IGF-1 on muscle regeneration included timely increases in the number of central nuclei (21% at 5 days reambulation), paired-box transcription factor 7 (36% at 5 days), embryonic myosin (37% at 10 days) and elevated MyoD mRNA (7-fold at 2 days) in IGF-1-injected limbs (P<0.05). These findings demonstrate a potential role of IGF-1 in protecting unloaded skeletal muscles from damage and accelerating muscle repair and regeneration.

Life impact of ankle fractures: qualitative analysis of patient and clinician experiences

BACKGROUND

Ankle fractures are one of the more commonly occurring forms of trauma managed by orthopaedic teams worldwide. The impacts of these injuries are not restricted to pain and disability caused at the time of the incident, but may also result in long term physical, psychological, and social consequences. There are currently no ankle fracture specific patient-reported outcome measures with a robust content foundation. This investigation aimed to develop a thematic conceptual framework of life impacts following ankle fracture from the experiences of people who have suffered ankle fractures as well as the health professionals who treat them.

METHODS

A qualitative investigation was undertaken using in-depth semi-structured interviews with people (n=12) who had previously sustained an ankle fracture (patients) and health professionals (n=6) that treat people with ankle fractures. Interviews were audio-recorded and transcribed. Each phrase was individually coded and grouped in categories and aligned under emerging themes by two independent researchers.

RESULTS

Saturation occurred after 10 in-depth patient interviews. Time since injury for patients ranged from 6 weeks to more than 2 years. Experience of health professionals ranged from 1 year to 16 years working with people with ankle fractures. Health professionals included an Orthopaedic surgeon (1), physiotherapists (3), a podiatrist (1) and an occupational therapist (1). The emerging framework derived from patient data included eight themes (Physical, Psychological, Daily Living, Social, Occupational and Domestic, Financial, Aesthetic and Medication Taking). Health professional responses did not reveal any additional themes, but tended to focus on physical and occupational themes.

CONCLUSIONS

The nature of life impact following ankle fractures can extend beyond short term pain and discomfort into many areas of life. The findings from this research have provided an empirically derived framework from which a condition-specific patient-reported outcome measure can be developed.

Rehabilitation for ankle fractures in adults

BACKGROUND

Rehabilitation after ankle fracture can begin soon after the fracture has been treated, either surgically or non-surgically, by the use of different types of immobilisation that allow early commencement of weight-bearing or exercise. Alternatively, rehabilitation, including the use of physical or manual therapies, may start following the period of immobilisation. This is an update of a Cochrane review first published in 2008.

OBJECTIVES

To assess the effects of rehabilitation interventions following conservative or surgical treatment of ankle fractures in adults.

SEARCH METHODS

We searched the Specialised Registers of the Cochrane Bone, Joint and Muscle Trauma Group and the Cochrane Rehabilitation and Related Therapies Field, CENTRAL via The Cochrane Library (2011 Issue 7), MEDLINE via PubMed, EMBASE, CINAHL, PEDro, AMED, SPORTDiscus and clinical trials registers up to July 2011. In addition, we searched reference lists of included studies and relevant systematic reviews.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials with adults undergoing any interventions for rehabilitation after ankle fracture were considered. The primary outcome was activity limitation. Secondary outcomes included quality of life, patient satisfaction, impairments and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results, assessed risk of bias and extracted data. Risk ratios and 95% confidence intervals (95% CIs) were calculated for dichotomous variables, and mean differences or standardised mean differences and 95% CIs were calculated for continuous variables. End of treatment and end of follow-up data were presented separately. For end of follow-up data, short term follow-up was defined as up to three months after randomisation, and long-term follow-up as greater than six months after randomisation. Meta-analysis was performed where appropriate.

MAIN RESULTS

Thirty-eight studies with a total of 1896 participants were included. Only one study was judged at low risk of bias. Eight studies were judged at high risk of selection bias because of lack of allocation concealment and over half the of the studies were at high risk of selective reporting bias.Three small studies investigated rehabilitation interventions during the immobilisation period after conservative orthopaedic management. There was limited evidence from two studies (106 participants in total) of short-term benefit of using an air-stirrup versus an orthosis or a walking cast. One study (12 participants) found 12 weeks of hypnosis did not reduce activity or improve other outcomes.Thirty studies investigated rehabilitation interventions during the immobilisation period after surgical fixation. In 10 studies, the use of a removable type of immobilisation combined with exercise was compared with cast immobilisation alone. Using a removable type of immobilisation to enable controlled exercise significantly reduced activity limitation in five of the eight studies reporting this outcome, reduced pain (number of participants with pain at the long term follow-up: 10/35 versus 25/34; risk ratio (RR) 0.39, 95% confidence interval (CI) 0.22 to 0.68; 2 studies) and improved ankle dorsiflexion range of motion. However, it also led to a higher rate of mainly minor adverse events (49/201 versus 20/197; RR 2.30, 95% CI 1.49 to 3.56; 7 studies).During the immobilisation period after surgical fixation, commencing weight-bearing made a small improvement in ankle dorsiflexion range of motion (mean difference in the difference in range of motion compared with the non-fractured side at the long term follow-up 6.17%, 95% CI 0.14 to 12.20; 2 studies). Evidence from one small but potentially biased study (60 participants) showed that neurostimulation, an electrotherapy modality, may be beneficial in the short-term. There was little and inconclusive evidence on what type of support or immobilisation was the best. One study found no immobilisation improved ankle dorsiflexion and plantarflexion range of motion compared with cast immobilisation, but another showed using a backslab improved ankle dorsiflexion range of motion compared with using a bandage.Five studies investigated different rehabilitation interventions following the immobilisation period after either conservative or surgical orthopaedic management. There was no evidence of effect for stretching or manual therapy in addition to exercise, or exercise compared with usual care. One small study (14 participants) at a high risk of bias found reduced ankle swelling after non-thermal compared with thermal pulsed shortwave diathermy.

AUTHORS' CONCLUSIONS

There is limited evidence supporting early commencement of weight-bearing and the use of a removable type of immobilisation to allow exercise during the immobilisation period after surgical fixation. Because of the potential increased risk of adverse events, the patient's ability to comply with the use of a removable type of immobilisation to enable controlled exercise is essential. There is little evidence for rehabilitation interventions during the immobilisation period after conservative orthopaedic management and no evidence for stretching, manual therapy or exercise compared to usual care following the immobilisation period. Small, single studies showed that some electrotherapy modalities may be beneficial. More clinical trials that are well-designed and adequately-powered are required to strengthen current evidence.

Effect of multilayer high-compression bandaging on ankle range of motion and oxygen cost of walking

OBJECTIVE

To evaluate the effects of multilayer high-compression bandaging on ankle range of motion, oxygen consumption and subjective walking ability in healthy subjects.

METHOD

A volunteer sample of 22 healthy subjects (10 women and 12 men; aged 67 [63-83] years) were studied. The intervention included treadmill-walking at self-selected speed with and without multilayer high-compression bandaging (Proforeº), randomly selected. The primary outcome variables were ankle range of motion, oxygen consumption and subjective walking ability.

RESULTS

Total ankle range of motion decreased 4% with compression. No change in oxygen cost of walking was observed. Less than half the subjects reported that walking-shoe comfort or walking distance was negatively affected.

CONCLUSION

Ankle range of motion decreased with compression but could probably be counteracted with a regular exercise programme. There were no indications that walking with compression was more exhausting than walking without. Appropriate walking shoes could seem important to secure gait efficiency when using compression garments.

A clinical pathway for management of fractured ankles can be used to identify course of recovery and resource use

Carolyn Page, Kim Brock, Susan Black

Aims: This article describes a study investigating the use of a clinical pathway for the management of fractured ankles and seeking to identify the usual course of recovery for patients treated according to the pathway for both conservative and surgical management.

Methods: The study was a prospective, observational cohort study The participants were 63 patients who had sustained a fractured ankle and could weight bear The outcome measures were the Ankle Lunge Test (ALT), Lower Extremity Functional Scale, swelling, and 10m walk test.

Findings: Compliance in documenting key items of assessment on the pathway ranged between 52% and 91%. Adherence to recommended interventions was above 60% for most recommendations.

The number of weeks attending physiotherapy had a mean of 6.6 (SD 3.3). There was a correlation of r = 0.44 between ALT at week 1 and week of discharge (p > 0.01), with those having poor ALT results more likely to have prolonged treatment. The surgically treated group had a significantly poorer ALT at week one (p < 0.01), continued to make slower recovery at week three (p < 0.001) and, overall, had a significantly longer period of physiotherapy.

Conclusions: A structured clinical pathway for fractured ankles is an effective and efficient way to collect data on this population and has the capacity to detect patients that fail to progress as normal.

Impact of viral-mediated IGF-I gene transfer on skeletal muscle following cast immobilization

Insulin-like growth factor I (IGF-I) is a potent myogenic factor that plays a critical role in muscle regeneration and muscle hypertrophy. The purpose of this study was to evaluate the effect of IGF-I overexpression on the recovery of muscle size and function during reloading/reambulation after a period of cast immobilization in predominantly fast twitch muscles. In addition, we investigated concomitant molecular responses in IGF-I receptor and binding proteins (BPs). Recombinant adeno-associated virus vector for IGF-I (rAAV-IGF-IA) was injected into the anterior compartment of one of the hindlimbs of young (3 wk) C57BL6 female mice. At 20 wk of age, both hindlimbs were cast immobilized in a shortened position for 2 wk to unload the tibialis anterior (TA) and extensor longus digitorum (EDL) muscles. The TA and EDL muscles were removed bilaterally after 2 wk of cast immobilization and after 1 and 3 wk of free cage reambulation. Increases in IGF-I mRNA and protein levels with IGF-I overexpression were associated with significant increases in muscle wet weight, fiber size, and tetanic force, although overexpression did not protect against cast immobilization-induced muscle atrophy. After 1 wk of reambulation, evidence of enhanced muscle regeneration was noted in IGF-I-overexpressing muscles with an increased prevalence of central nuclei, embryonic myosin, and Pax7 positive fibers. We also observed larger relative gains in muscle size (wet weight and fiber area), but not force, during the 3-wk reambulation period in hindlimb muscles overexpressing IGF-I compared with contralateral control legs. Changes in IGFBP-5 mRNA expression during cast immobilization and reambulation paralleled those of IGF-I, whereas IGFBP-3 expression changed inversely to IGFBP-5.

One year follow-up after operative ankle fractures: a prospective gait analysis study with a multi-segment foot model

Ankle fractures are one of the most common lower limb traumas. Several studies reported short- and long-term post-operative results, mainly determined by radiographic and subjective functional evaluations. Three-dimensional gait analysis with a multi-segment foot model was used in the current study to quantify the inter-segment foot motions in 18 patients 1 year after surgically treated ankle fractures. Data were compared to that from gender- and age-matched healthy controls. The correlations between Olerud/Molander ankle score and kinematics were also evaluated. Patients with ankle fractures showed less plantarflexion and smaller range of motion in the injured talocrural joint, which were believed to be a sign of residual joint stiffness after surgery and immobilization. Moreover, the forefoot segment had smaller sagittal and transverse ranges of motion, less plantarflexion and the hallux segment had less dorsiflexion and smaller sagittal range of motion. The deviations found in the forefoot segment may contribute to the compensation mechanisms of the injured ankle joint. Findings of our study show that gait analysis with a multi-segment foot model provides a quantitative and objective way to perform the dynamic assessment of post-operative ankle fractures, and makes it possible to better understand not only how the injured joint is affected, but also the surrounding joints.

Pain and dorsiflexion range of motion predict short- and medium-term activity limitation in people receiving physiotherapy intervention after ankle fracture: an observational study

QUESTION

What predicts short - and medium term activity limitation in people after ankle fracture?

DESIGN

Inception cohort observational study.

PARTICIPANT

Adults with ankle fracture recruited within days following cast removal from physiotherapy departments of teaching hospital in Sydney, Australia.

OUTCOME MEASURES

The predictive value of variables that were injury-related (fracture management, fracture severity, angle of the ankle during cast immobilisation, and time from cast removal to baseline) and performance-related (activity limitation, pain, mobility and dorsiflexion range of motion measured soon after cast removal) were examined in one dataset (n = 150) using univariate linear regression. Significant variables (p <or = 0.20) were further examined with a multivariate linear model. A clinical prediction rule was derived then validated using data from an independent dataset (n = 94).

RESULTS

Fracture management, fracture severity, baseline activity limitation, pain, mobility and dorsiflexion had significant but weak univariate associations with activity limitation. Only pain and dorsiflexion range of motion contributed independently to the clinical prediction rule. When applied to the validation data, the rule explained 12% of the short-term and 9% of the medium-term variance in activity limitation.

CONCLUSION

Performance-related variables were stronger predictors than injury-related variables. A clinical prediction rule consisting of pain and dorsiflexion range of motion explained a small amount of variance in short- and medium-term activity limitation, suggesting that it may be appropriate to identify people with high levels of pain and restricted dorsiflexion after ankle fracture and target intervention accordingly.

Effects of a training program after surgically treated ankle fracture: a prospective randomised controlled trial

BACKGROUND

Despite conflicting results after surgically treated ankle fractures few studies have evaluated the effects of different types of training programs performed after plaster removal. The aim of this study was to evaluate the effects of a 12-week standardised but individually suited training program (training group) versus usual care (control group) after plaster removal in adults with surgically treated ankle fractures.

METHODS

In total, 110 men and women, 18-64 years of age, with surgically treated ankle fracture were included and randomised to either a 12-week training program or to a control group. Six and twelve months after the injury the subjects were examined by the same physiotherapist who was blinded to the treatment group. The main outcome measure was the Olerud-Molander Ankle Score (OMAS) which rates symptoms and subjectively scored function. Secondary outcome measures were: quality of life (SF-36), timed walking tests, ankle mobility tests, muscle strength tests and radiological status.

RESULTS

52 patients were randomised to the training group and 58 to the control group. Five patients dropped out before the six-month follow-up resulting in 50 patients in the training group and 55 in the control group. Nine patients dropped out between the six- and twelve-month follow-up resulting in 48 patients in both groups. When analysing the results in a mixed model analysis on repeated measures including interaction between age-group and treatment effect the training group demonstrated significantly improved results compared to the control group in subjects younger than 40 years of age regarding OMAS (p = 0.028), muscle strength in the plantar flexors (p = 0.029) and dorsiflexors (p = 0.030).

CONCLUSION

The results of this study suggest that when adjusting for interaction between age-group and treatment effect the training model employed in this study was superior to usual care in patients under the age of 40. However, as only three out of nine outcome measures showed a difference, the beneficial effect from an additional standardised individually suited training program can be expected to be limited. There is need for further studies to elucidate how a training program should be designed to increase and optimise function in patients middle-aged or older.

TRIAL REGISTRATION

Current Controlled Trials ACTRN12609000327280.

The lower extremity functional scale has good clinimetric properties in people with ankle fracture

BACKGROUND

There is limited information on the clinimetric properties of questionnaires of activity limitation in people after ankle fracture.

OBJECTIVE

The purpose of this study was to investigate the clinimetric properties of the Lower Extremity Functional Scale, an activity limitation questionnaire, in people with ankle fracture.

DESIGN

This was a measurement study using data collected from 2 previous randomized controlled trials and 1 inception cohort study.

METHODS

Participants with ankle fracture (N=306) were recruited within 7 days of cast removal. Data were collected at baseline and at short- and medium-term follow-ups. Internal consistency and construct validity were assessed using Rasch analysis. Concurrent validity, responsiveness, and floor and ceiling effects were evaluated.

RESULTS

The Lower Extremity Functional Scale demonstrated high internal consistency (alpha > .90). The variance in activity limitation explained by the items was high (98.3%). Each item had a positive correlation with the overall scale, and most items supported the unidimensionality of the scale. These findings suggest that the scale has high internal consistency and construct validity. The scale also demonstrated high concurrent validity and responsiveness in the short term and no floor or ceiling effects. However, the scale would benefit from more-challenging items, as evident at the medium-term follow-up.

LIMITATIONS

This was a secondary analysis of existing data sets.

CONCLUSION

The Lower Extremity Functional Scale is a useful tool to monitor activity limitation in people with ankle fracture up to the short-term follow-up. More- difficult items may need to be added to improve the responsiveness of the scale for longer-term follow-up.

Raising the standards of the calf-raise test: a systematic review

The calf-raise test is used by clinicians and researchers in sports medicine to assess properties of the calf muscle-tendon unit. The test generally involves repetitive concentric-eccentric muscle action of the plantar-flexors in unipedal stance and is quantified by the number of raises performed. Although the calf-raise test appears to have acceptable reliability and face validity, and is commonly used for medical assessment and rehabilitation of injuries, no universally acceptable test parameters have been published to date. A systematic review of the existing literature was conducted to investigate the consistency as well as universal acceptance of the evaluation purposes, test parameters, outcome measurements and psychometric properties of the calf-raise test. Nine electronic databases were searched during the period May 30th to September 21st 2008. Forty-nine articles met the inclusion criteria and were quality assessed. Information on study characteristics and calf-raise test parameters, as well as quantitative data, were extracted; tabulated; and statistically analysed. The average quality score of the reviewed articles was 70.4+/-12.2% (range 44-90%). Articles provided various test parameters; however, a consensus was not ascertained. Key testing parameters varied, were often unstated, and few studies reported reliability or validity values, including sensitivity and specificity. No definitive normative values could be established and the utility of the test in subjects with pathologies remained unclear. Although adapted for use in several disciplines and traditionally recommended for clinical assessment, there is no uniform description of the calf-raise test in the literature. Further investigation is recommended to ensure consistent use and interpretation of the test by researchers and clinicians.

Arthroscopically detected intra-articular lesions associated with acute ankle fractures

BACKGROUND

Anatomic surgical realignment of ankle fractures may still be associated with poor clinical outcomes, possibly as a result of occult intra-articular injury. The aim of this study was to determine if the severity of an acute ankle fracture is correlated with an increased number of arthroscopically detected intra-articular chondral lesions.

METHODS

We conducted a retrospective review of the medical charts on 283 ankle fractures that had been treated with open reduction and internal fixation and for which ankle arthroscopy had been routinely performed. The severity of the ankle fractures was categorized, with use of the arthroscopic findings derived from the operative reports as well as the findings on preoperative radiographs, according to the Lauge-Hansen criteria.

RESULTS

Of the 283 patients, eighty-four (forty-four female and forty male) met our inclusion criteria. Chondral lesions were found in sixty-one patients (73%). Of seventeen fractures graded as pronation-external rotation or supination-external rotation type I according to the Lauge-Hansen classification, fifteen were associated with one or no chondral lesion and two, with two or more chondral lesions. Of ten fractures graded as pronation-external rotation or supination-external rotation type II, nine were associated with one or no chondral lesion and one, with two or more chondral lesions. Of fifty-six fractures graded as pronation-external rotation or supination-external rotation type IV, twenty-seven were associated with one or no chondral lesion and twenty-nine, with two or more chondral lesions. Type-IV pronation-external rotation and supination-external rotation ankle fractures were more likely to be associated with two or more chondral lesions than type-I fractures (odds ratio = 8.1, 95% confidence interval = 1.7 to 38.6; p = 0.0044) or type-II fractures (odds ratio = 9.7, 95% confidence interval = 1.1 to 81.5; p = 0.0172).

CONCLUSIONS

Chondral lesions are commonly found after an acute ankle fracture. This retrospective study demonstrated that the number of intra-articular chondral lesions associated with the more severe ankle fracture patterns (pronation-external rotation and supination-external rotation type-IV fractures) was greater than the number associated with the less severe ankle fracture patterns.

Rehabilitation for ankle fractures in adults

BACKGROUND

Rehabilitation after ankle fracture can begin soon after the fracture has been treated by the use of different types of immobilisation which allow early commencement of weight-bearing or exercise. Alternatively, rehabilitation may start following the period of immobilisation, with physical or manual therapies.

OBJECTIVES

To compare the effectiveness of rehabilitation interventions following ankle fracture in adults.

SEARCH STRATEGY

We searched two Specialised Registers of The Cochrane Collaboration, electronic databases (including MEDLINE, EMBASE and CINAHL), reference lists of included studies and relevant systematic reviews, and clinical trials registers to September 2007.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials with adults undergoing any interventions for rehabilitation after ankle fracture were considered. The primary outcome was activity limitation. Secondary outcomes included impairments and adverse events.

DATA COLLECTION AND ANALYSIS

Two reviewers independently screened search results, assessed methodological quality, and extracted data. Relative risk and 95% confidence intervals (95% CI) were calculated for dichotomous variables, and weighted or standardised mean difference and 95% CI were calculated for continuous variables. A meta-analysis was performed where appropriate.

MAIN RESULTS

Thirty-one studies were included. Clinical and statistical heterogeneity prevented meta-analyses in most instances. After surgical fixation, commencing exercise in a removable brace or splint significantly improved activity limitation, pain and ankle range of motion, but also led to a higher rate of adverse events. Early commencement of weight-bearing during the immobilisation period improved ankle range of motion after surgical fixation. Where it was possible to avoid ankle range of motion after surgical fixation, the use of no immobilisation compared to cast immobilisation also improved ankle range of motion. After the immobilisation period, manual therapy was beneficial in increasing ankle range of motion. There was no evidence of effect for electrotherapy, hypnosis, or stretching.

AUTHORS' CONCLUSIONS

There is limited evidence supporting the use of a removable type of immobilisation and exercise during the immobilisation period, early commencement of weight-bearing during the immobilisation period, and no immobilisation after surgical fixation of ankle fracture. There is also limited evidence for manual therapy after the immobilisation period. Because of the potential increased risk, the patient's ability to comply with the use of a removable type of immobilisation and exercise is essential. More clinical trials that are well-designed and adequately-powered are required to strengthen current evidence.

Outcome and quality of life after surgically treated ankle fractures in patients 65 years or older

Background

Despite high incidence of ankle fractures in the elderly, studies evaluating outcome and impact of quality of life in this age group specifically are sparse. The aim of this study was to evaluate outcome and quality of life 6 and 12 months after injury in patients 65 years or older who had been operated on due to an ankle fracture.

Methods

Sixty patients 65 years or older were invited to participate in the study. 6 and 12 months after the injury a questionnaire including inquiry to participate, the Olerud-Molander Ankle Score (OMAS), Short-Form 36 (SF-36), Linear Analogue Scale (LAS), Self-rated Ankle Function and some supplementary questions was sent home to the patients. The supplementary questions concerned subjective experience of ankle instability, sporting and physical activity level before injury and recaptured activity level at follow-ups, need of walking aid before injury, state of living before injury and at follow-ups and co-morbidities. After the 12-month follow-up the patients were also called for a radiological examination.

Results

Fifty patients (83%) answered the questionnaire at 6-month and 46 (77%) at the 12-month follow-up. Although, 45 (90%) fractures were low-energy trauma 44 (88%) were bi- or trimalleolar and post-operative reduction results were complete in 23 (46%) ankles. The median OMAS improved from 60 (Interquartile range (IQR) 36) at 6-month to 70 (IQR 35) at 12-month (p = 0.002), but at 12-month still sixty percent or more of the patients reported pain, swelling, problems when stair-climbing and reduced activities of daily life. Twenty (40%) rated their ankle function as 'good' or 'very good' at 6-month and 30 (60%) at 12-month. Forty-one (82%) were physically active before injury but still one year after only 18/41 had returned to their pre-injury physical activity level. According to SF-36 four dimensions differed from the age- and gender matched normative data of the Swedish population, 'physical function', 'role physical' and 'role emotional' were below norms at 6-month for women (p = 0.010, p = 0.024 and 0.031) and 'general health' was above norms at 12-month for men (p = 0.044).

Conclusion

One year after surgically treated ankle fractures a majority of patients continue to have symptoms and reported functional limitations. However, SF-36 scores indicate that only females had functional status below the age- and gender matched normative data of the Swedish population.

Five-year functional outcome analysis of ankle fracture fixation

This study examines retrospectively the functional outcome of patients at 5 years following their ankle fracture surgery using the Olerud-Molander Ankle Score (OMAS) and SF-12 questionnaire. Of 69 patients, 43 were females and 26 males. The mean age was 50.7 years. There were 74 and 26% of Weber 'B' and 'C' fractures, respectively. The mean OMAS was 75.2. About 63% of the patients were still complaining of stiffness, around 45% patients were still complaining of ankle swelling, 50% of patients still had some sort of pain, 39% still thought that they had not fully recovered and 38% did not return to their pre-injury sporting activity. Apart from the age, no significant difference was seen in the OMAS due to gender, fracture type or timing of surgery. Our findings show that many patients who have had surgery for ankle fractures will still have some functional limitations even 5 years after the injury.

Intra-articular fibrous tissue formation following ankle fracture: the significance of arthroscopic debridement of fibrous tissue

PURPOSE

The purposes of this study were to understand the clinical consequences of arthrofibrosis following surgical reduction of ankle fractures and to examine the effectiveness of arthroscopic debridement.

METHODS

Subjects included 33 patients (26 males, 7 females) aged 14 to 78 years (mean, 40.2 years) who had undergone open reduction and internal fixation of ankle fractures between May 2000 and May 2003. Arthroscopic examination was performed at the time of implant removal after an average of 12.4 months (range, 6 to 43 months), and abnormal fibrous tissue, when present, was removed through arthroscopy. The mean follow-up period after arthroscopy was 43.7 months (range, 22 to 68 months). Clinical outcomes before and after arthroscopy were evaluated with the American Orthopaedic Foot and Ankle Society scale and our own functional evaluation method. Arthroscopic findings, including the degree of articular cartilage damage and the quantity of fibrous tissue, were scored on a 3-point scale.

RESULTS

Functional deterioration of the ankle joint was observed in 27% of subjects. Arthroscopy showed articular cartilage damage in 33% of patients and arthrofibrosis in 73%. In patients with functional deterioration, the rate of articular cartilage damage was 78%, and arthrofibrosis was present in all cases. Furthermore, when extensive fibrosis and impingement on the articular surface were present, 88% of patients showed impaired articular function. Arthroscopic debridement of fibrous tissue resulted in improved articular function in 89% of patients with functional deterioration of the ankle joint before arthroscopy.

CONCLUSIONS

Arthrofibrosis following ankle fracture causes an unfavorable surgical outcome, and arthroscopic debridement of fibrous tissue is an effective means of improving articular function.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Effectiveness of joint mobilisation after cast immobilisation for ankle fracture: a protocol for a randomised controlled trial [ACTRN012605000143628]

Background

Passive joint mobilisation is a technique frequently used by physiotherapists to reduce pain, improve joint movement and facilitate a return to activities after injury, but its use after ankle fracture is currently based on limited evidence. The primary aim of this trial is to determine if adding joint mobilisation to a standard exercise programme is effective and cost-effective after cast immobilisation for ankle fracture in adults.

Methods/Design

Ninety participants will be recruited from the physiotherapy departments of three teaching hospitals and randomly allocated to treatment or control groups using a concealed procedure. All participants will perform an exercise programme. Participants in the treatment group will also receive joint mobilisation twice a week for four weeks. Blinded follow-up assessments will be conducted four, 12 and 24 weeks after randomisation. The primary outcome measures will be the Lower Extremity Functional Scale and the Assessment of Quality of Life. Secondary outcomes will include measures of impairments, activity limitation and participation. Data on the use of physiotherapy services and participants' out-of-pocket costs will be collected for the cost-effective and cost-utility analyses. To test the effects of treatment, between-group differences will be examined with analysis of covariance using a regression approach. The primary conclusions will be based on the four-week follow-up data.

Discussion

This trial incorporates features known to minimise bias. It uses a pragmatic design to reflect clinical practice and maximise generalisability. Results from this trial will contribute to an evidence-based approach for rehabilitation after ankle fracture.

Balance in single-limb stance after surgically treated ankle fractures: a 14-month follow-up

Background

The maintenance of postural control is fundamental for different types of physical activity. This can be measured by having subjects stand on one leg on a force plate. Many studies assessing standing balance have previously been carried out in patients with ankle ligament injuries but not in patients with ankle fractures. The aim of this study was to evaluate whether patients operated on because of an ankle fracture had impaired postural control compared to an uninjured age- and gender-matched control group.

Methods

Fifty-four individuals (patients) operated on because of an ankle fracture were examined 14 months postoperatively. Muscle strength, ankle mobility, and single-limb stance on a force-platform were measured. Average speed of centre of pressure movements and number of movements exceeding 10 mm from the mean value of centre of pressure were registered in the frontal and sagittal planes on a force-platform. Fifty-four age- and gender-matched uninjured individuals (controls) were examined in the single-limb stance test only. The paired Student t-test was used for comparisons between patients' injured and uninjured legs and between side-matched legs within the controls. The independent Student t-test was used for comparisons between patients and controls. The Chi-square test, and when applicable, Fisher's exact test were used for comparisons between groups. Multiple logistic regression was performed to identify factors associated with belonging to the group unable to complete the single-limb stance test on the force-platform.

Results

Fourteen of the 54 patients (26%) did not manage to complete the single-limb stance test on the force-platform, whereas all controls managed this (p < 0.001). Age over 45 years was the only factor significantly associated with not managing the test. When not adjusted for age, decreased strength in the ankle plantar flexors and dorsiflexors was significantly associated with not managing the test. In the 40 patients who managed to complete the single-limb stance test no differences were found between the results of patients' injured leg and the side-matched leg of the controls regarding average speed and the number of centre of pressure movements.

Conclusion

One in four patients operated on because of an ankle fracture had impaired postural control compared to an age- and gender-matched control group. Age over 45 years and decreased strength in the ankle plantar flexors and dorsiflexors were found to be associated with decreased balance performance. Further, longitudinal studies are required to evaluate whether muscle and balance training in the rehabilitation phase may improve postural control.

Prediction of outcome after ankle fracture

STUDY DESIGN

Prospective inception cohort study of 62 consecutive patients seen in 2 orthopaedic clinics following ankle fracture.

OBJECTIVES

To investigate 4 putative predictors (age, fracture classification, acute management [surgical or nonsurgical], and ankle dorsiflexion range of motion measured at the time of cast removal) of outcome after ankle fracture and to develop simple predictive models of outcome after ankle fracture.

BACKGROUND

Ankle fracture is a common condition. However, few studies have investigated factors that predict outcome after ankle fracture.

METHODS AND MEASURES

Sixty-two consecutive subjects aged 17 or older with ankle fractures were recruited from 2 hospital orthopaedic clinics. Outcome measures recorded at 6 weeks and 6 months after cast removal included 2 functional questionnaires, patients' ratings of global improvement, and a measure of ankle dorsiflexion. The predictive value of 4 variables selected a priori was analyzed using bivariate and stepwise multiple linear regression.

RESULTS

Ankle dorsiflexion and fracture classification predicted outcome 6 weeks and 6 months after cast removal for all outcome measures used (P < .05, r2 = 0.09-0.47). Fracture management (surgical or nonsurgical) inconsistently predicted outcome at both 6 weeks and 6 months, and age did not predict outcome at either 6 weeks or 6 months after cast removal. The predictive models explain between 19% and 58% of the variance in outcomes 6 weeks after cast removal and 19% to 52% of the variance in outcomes 6 months after cast removal.

CONCLUSION

Ankle dorsiflexion measured at the time of cast removal and fracture classification are clinically significant predictors of outcome after ankle fracture; however, much unexplained variation in outcomes still exists.

[Treatment results after primary management of severely dislocated ankle fractures with external fixation and subsequent internal osteosynthesis]

BACKGROUND

Between 1 January 2001 and 30 June 2003, 31 patients with dislocated ankle fractures were primarily treated with an external fixator in our clinic. The aim of the present study was to investigate whether such a concept would determine the overall outcome or influence single parameters such as mobility, dystrophy, pain, arthritis, and complications.

METHODS

Of the 31 patients, 25 aged 18-84 years at the time of the accident were followed up for 6-23 months to assess range of motion, clinical scores, radiological findings, and complications. An isolated injury was present in 23 patients and 3 were open injuries of second to third degree. Between two and five operations were necessary 4-27 days after trauma. The duration of primary hospital care required ranged from 10 to 43 days.

RESULTS

The Olerud and Molander score (9 criteria with 100 max points) was 80 points at the follow-up investigation (rated "good"). "Excellent" results (>90 points) were observed in four cases. In the range of motion there was only an average loss in plantar flexion of 12.4 degrees compared to the healthy side in the patients followed up.

CONCLUSIONS

The treatment result in the study population was compared to the results of prospective studies investigating dislocated ankle joint fractures as well as with our own random sample (n=7) of patients with secondarily treated ankle joint fractures that were initially treated with a cast. Initial external fixation seems to be justified and leads to acceptable results. The main functional lesions are not correlated to the specific treatment selected.

Muscle Adaptations with Immobilization and Rehabilitation after Ankle Fracture

INTRODUCTION/ PURPOSE: The widespread occurrence of muscular atrophy during immobilization and its reversal presents an important challenge to rehabilitation medicine. We used 3D-magnetic resonance imaging (MRI) in patients with surgically-stabilized ankle mortise fractures to quantify changes in plantarflexor and dorsiflexor muscle size during immobilization and rehabilitation, as well as to evaluate changes in force generating capacity (specific torque).

METHODS

Twenty-individuals participated in a 10 wk rehabilitation program after 7 wk of immobilization. MRIs were acquired at baseline, 2, and 7 wk of immobilization, and at 5 and 10 wk of rehabilitation. Isometric plantarflexor muscle strength testing was performed at 0, 5, and 10 wk of rehabilitation.

RESULTS

Dorsiflexors and plantarflexors atrophied 18.9% and 24.4% respectively, the majority of which occurred during the first 2 wk of immobilization (dorsiflexors: 9.6%; plantarflexors: 14.1%). Likewise, more than 50% of hypertrophy during rehabilitation occurred within the first 5 wk of rehabilitation for both the dorsiflexors (12.9%) and plantarflexors (13.2%), when compared to the total amount of hypertrophy over 10 wk of rehabilitation (dorsiflexors: 17.6%, plantarflexors: 22.5%). There were no significant differences in hypertrophy or atrophy of the dorsiflexor or plantarflexor muscles, despite a rehabilitation emphasis on the plantarflexors. Patients had significantly lower plantarflexor specific torque (torque/CSA) than healthy, control subjects immediately after cast immobilization, which did not return to normal after 10 wk of rehabilitation (P < 0.05).

CONCLUSION

Our investigation of the consequences of limb immobilization on rehabilitation outcomes in patients can be applied directly to optimizing rehabilitation programs. Although muscle hypertrophy occurred early during rehabilitation, plantarflexor muscle function (specific torque) should remain the focus of rehabilitation programs because although CSA recovered quickly, specific torque still lagged behind that of control subjects.