Locking versus non-locking neutralization plates for treatment of lateral malleolar fractures: a randomized controlled trial

Lateral Locking Plate Fixation of Simple Weber B Fibula Fractures Without a Lag Screw Yields Excellent Radiographic Results

BACKGROUND

The most common first-line fixation technique for simple Weber B fibula fractures is a lag screw with lateral neutralization plate. The most common surgical technique for unstable Weber B fibula fracture is one-third semi-tubular plate and cortical screws, implemented with lag screw when appropriate. However, the lag technique can be technically challenging in osteoporotic bone or within fibulas of smaller diameter, and in some cases can result in fragmentation at the fracture site, malreduction, or peroneal irritation. The purpose of this study is to examine an alternative first-line method for routine treatment of simple Weber B fibula fractures.

METHODS

Fifty-two consecutive patients undergoing open reduction internal fixation (ORIF) of a Weber B fibula fracture by a single surgeon were included in this retrospective study. After reduction, a lateral locking plate was applied with cortical screws proximally and locking screws distally. No screw crossed the fracture in any case. Per published precedent, nonunion was defined as either a gap of >3 mm between fracture surfaces >6 months postoperatively or a fracture line >2 to 3 mm wide and sclerosing of the fracture surfaces. Similarly, malunion was defined as one or more of the following: talar tilt >2º, talar subluxation >2 mm, or tibiofibular clear space ≥5 mm.

RESULTS

The mean (± standard deviation) age of the 52 included patients was 44.2 ± 16.2 years, the mean body mass index was 27.7 ± 6.6 kg/m2, and 63.5% of patients identified themselves as female sex. The mean follow-up was 6.2 (range: 1.5-15) months. In addition to undergoing fixation of the lateral malleolus, 21 patients also underwent fixation of the posterior malleolus, 27 underwent fixation of the medial malleolus, 29 underwent fixation across the syndesmosis, and 7 underwent repair of the deltoid. In all patients, bony anatomic union of the fibula and congruence of the mortise were achieved with no cases of malunion or nonunion.

CONCLUSIONS

The Arbeitsgemeinschaft für Osteosynthesefragen (AO) fixation technique for simple Weber B fractures with a lag screw and lateral neutralization plating has provided good outcomes for decades. We present an alternative technique for ORIF of these fractures with a lateral locking plate and no lag screw. In our series, we evaluated radiographic union and alignment as our primary outcome measures and found no cases of nonunion or malunion. Prospective cohort testing of lateral locking plates versus traditional fixation in the context of patient-centered value is warranted.Level of Evidence: Level III.

A comparison of outcomes of locking versus non-locking plate fixation for the distal fibula fractures: a systematic review and meta-analysis

PURPOSE

A locking plate (LP) or non-locking plate (NLP) can be used for distal fibula fracture fixation. However, the advantages of LP over NLP in patients with distal fibula fractures are not clear. In terms of indications, the role of the two plates probably differs; however, to draw comparative conclusions, we conceptualized this systematic review and meta-analysis of studies that directly compared the two plates, wherein both groups' indications and baseline parameters were similar.

METHODS

An electronic literature search was performed using PubMed/Medline, Embase, Scopus, and Cochrane Library databases for studies comparing the LP versus NLP fixation for the lateral malleolus fracture. A total of 18 studies were included in qualitative and quantitative analysis. A subgroup analysis was performed for patients aged < 55 years and patients aged > 55 years. The statistical analysis was performed by Review Manager Software version 5.4.1.

RESULTS

A meta-analysis of 4243 fractures was performed across 18 studies. The rate of fracture union and overall complication rates did not differ between the two fixation groups with an OR of 0.71 (95% CI 0.26, 1.96, p = 0.51 and 1.11 (95% CI 0.84, 1.47, p = 0.47, respectively. There is no difference in the reoperation rate due to minor or major complications between the two groups. There was no difference in functional outcome (MD -0.85, with 95% CI -5.63, 3.93, p = 0.73), but NLP has a shorter surgical duration (MD 3.0, with 95% CI 0.26, 5.75, p = 0.03). A leave-one-out sensitivity analysis performed for overall complications affected the final outcome of the meta-analysis.

CONCLUSION

This meta-analysis demonstrates no clear benefit in selecting LP over NLP for the fixation of lateral malleolus fractures.

Locking plates for distal fibula fractures in young and elderly patients: A retrospective study

BACKGROUND

Ankle fractures are common injuries in the young and elderly populations. To prevent post-traumatic arthritis, an anatomic reconstruction of the ankle structure is mandatory. Open reduction and internal fixation is the treatment of choice among orthopaedics. Conventional plates allow stability of the fracture if bone quality is present. Locking plates might offer an advantage for the treatment of lateral malleolar fracture in patients with comminution, severe instability, distal fractures, or osteoporotic bone. Our hospital introduced a new locking plate for fracture of the distal fibula.

AIM

To evaluate locking plates in terms of outcomes and complications in young and elderly patients.

METHODS

We retrospectively reviewed a total of 67 patients treated for displaced distal fibula fractures. Demographic data, number of comorbidities, use of inter fragmentary screw, complication, time of fracture healing, partial or full weight bearing, and reoperation were recorded for all patients. Clinical outcome was assessed by the American Orthopedic Foot and Ankle Society clinical scoring system. Radiographs were obtained at 4, 8, 12, 16, 20, and 24 wk until radiographic union was obtained.

RESULTS

All patients displayed complete bony union on radiographic assessment, and no patients developed any serious complications. We observed two superficial infections, one delayed wound healing, and two plate intolerances. Significant differences were observed between the two age groups in terms of radiographic healing (11.9 wk in younger patients vs 13.7 wk in older patients; P = 0.011) and in the American Orthopedic Foot and Ankle Society score at 6 mo after surgery (88.2 in younger patients vs 86.0 in older patients; P = 0.001) and at 12 mo after surgery (92.6 in younger patients vs 90.0 in older patients; P = 0.000).

CONCLUSION

Locking plates provide a stable and rigid fixation in multifragmentary and comminuted fractures or in the presence of poor bone quality.

The Effectiveness of Three-Dimensional Osteosynthesis Plates versus Conventional Plates for the Treatment of Skeletal Fractures: A Systematic Review and Meta-Analysis

PURPOSE

To assess the difference between preformed anatomically shaped osteosynthesis plates and patient-specific implants versus conventional flat plates for the treatment of skeletal fractures in terms of anatomical reduction, operation time, approach, patient outcomes, and complications.

MATERIAL AND METHODS

MEDLINE (1950 to February 2023), EMBASE (1966 to February 2023), and the Cochrane Central Register of Controlled Trials (inception to February 2023) databases were searched. Eligible studies were randomised clinical trials, prospective controlled clinical trials, and prospective and retrospective cohort studies (n ≥ 10). Inclusion criteria were studies reporting the outcomes of preformed anatomically shaped osteosynthesis plates and patient-specific implants versus conventional flat plates after treating skeletal fractures. Outcome measures included anatomical reduction, stability, operation time, hospitalisation days, patients' outcomes, and complications. Two independent reviewers assessed the abstracts and analysed the complete texts and methodologies of the included studies.

RESULTS

In total, 21 out of the 5181 primarily selected articles matched the inclusion criteria. A meta-analysis revealed a significant difference in operation time in favour of the preformed anatomical plates and patient-specific implants versus conventional plates. Significant differences in operation time were found for the orbital (95% CI: -50.70-7.49, p = 0.008), upper limb (95% CI: -17.91-6.13, p < 0.0001), and lower limb extremity groups (95% CI: -20.40-15.11, p < 0.00001). The mean difference in the rate of anatomical reduction in the lower limb extremity group (95% CI: 1.04-7.62, p = 0.04) was also in favour of using preformed anatomical plates and patient-specific implants versus conventional plates.

CONCLUSIONS

This systematic review showed a significant mean difference in surgery time favouring the use of preformed anatomical plates and patient-specific implants for orbital, upper, and lower limb extremity fractures. Additionally, preformed anatomical plates and patient-specific implants in the lower limb group result in a significantly higher rate of anatomical reduction versus conventional flat plates.

Patient-specific miniplates versus patient-specific reconstruction plate: A biomechanical comparison with 3D-printed plates in mandibular reconstruction

BACKGROUND

Patient-specific 3D-printed miniplates for free flap fixation in mandibular reconstruction were recently associated with enhanced osseous union. Higher mechanical strains resulting from these plates are discussed as reasons, but biomechanical studies are missing. This study aims to examine, whether patient-specific 3D-printed miniplates provide an increased interosteotomy movement (IOM) and lower stiffness compared with reconstruction plates.

METHODS

Polyurethane (PU) mandible and fibula models (Synbone AG, Malans, Schweiz) were used to simulate mandibular reconstruction with a one segment fibula flap equivalent. Osteosynthesis was performed using either four patient-specific 3D-printed miniplates (3D-Mini) or one patient-specific 3D-printed reconstruction plate (3D-Recon). Mastication was simulated using cyclic dynamic loading with increasing loads until material failure or a maximum load of 1000 N. Continuous IOM recording was carried out using a 3D optical tracking system (ARAMIS, Carl Zeiss GOM Metrology, Braunschweig, Germany).

FINDINGS

The averaged stiffness at a load of 100-300 N load did not differ between the groups (p = 0.296). There was a faster 1.0 mm vertical displacement in the 3D-Mini group (26 376 ± 14 190 cycles versus 44 817 ± 30 430 cycles, p = 0.018). The IOM were higher with miniplate fixation in the distal gap (p = 0.040). In the mesial gap, there was no significant difference between the groups (p = 0.160).

INTERPRETATION

Fixation with patient-specific 3D-printed miniplates results in higher mechanical strains. Lower rates of pseudarthrosis, as seen in clinical studies, might be caused by this phenomenon. Surgeons should evaluate the primary use of 3D-printed miniplates in mandibular reconstruction due to advantages of intraoral plate removal alongside safe osteosynthesis.

Comparison of Complications, Metalwork Removal and Cost Between Locking and Tubular Plates for Lateral Malleolus Fractures Fixation

Introduction Ankle fractures are common injuries in orthopaedic practice. Open reduction with internal fixation is the main line of management of displaced ankle fractures in fit patients. The study aims to analyse the complications, re-operation rate and cost difference between one-third tubular and locking plates which are the most frequently used constructs in lateral malleolus fractures. Materials and methods The total number of presented ankle fractures from April to August during the years 2015, 2017 and 2019 to our Tertiary Hospital in the United Kingdom were screened. Data including operative fixation, plate used, complication rates, the need for revision surgery and metalwork removal were collected from the hospital's electronic Virtual Trauma Board. Patients who had less than one-year follow-up were excluded. Results A total of 174 patients were included which represents more than half of presented ankle fractures (56%) with a decline in the mean age of operated patients from 56.4 in 2015 to 46.2 in 2019. The majority of fixation used tubular plates (n=122) versus (n=52) for locking plates. Locking plate fixation doubled from 10 in 2015 to 23 in 2019. However, they only contributed to 27% of the total operated ankle fractures. Despite the initial higher complications and removal rates of locking plates in 2015 (P<0.042 and P<0.038 respectively), there was no significant difference in overall complications, revision rates, and metalwork removal between locking plates and tubular plates (p=0.084, FEp= 0.158 and p=0.096 respectively). There was an estimated extra cost of £15938.60 for the use of locking plates during the study timeline. Conclusion There was no significant difference in overall complications, revision surgery and metalwork removal between tubular and locking plates in treating lateral malleolus fractures despite the significantly higher cost of locking constructs. Further studies are needed to illustrate the trend and cost-effective analysis of the tubular and locking plates in treating ankle fractures.

A Prospective Randomized Study Comparing Functional Outcome in Distal Fibula Fractures between Conventional AO Semitubular Plating and Minimal Invasive Intramedullary "Photodynamic Bone Stabilisation"

(1) Background: As age in western populations is rising, so too are fractures, e.g., of the distal fibula. The aim of this study was to find out whether a novel, minimally invasive intramedullary osteosynthesis technique for the treatment of distal fibula fractures in elderly patients results in not only a reduction of postoperative complications, but also a shorter hospitalization time, an improved clinical outcome, and preserved autonomy in geriatric trauma patients. (2) Methods: In this prospective study, the results following surgical treatment for distal fibula fractures in geriatric patients after using DePuy Synthes^® one-third semitubular plate (Group I) or a minimally invasive intramedullary photodynamic Bone StabilizationSystem (IlluminOss^®) (Group II) were compared at 6 weeks, 12 weeks, 6 months, and 1 year after initial treatment. (3) Results: Significant improvement regarding clinical outcome was shown in Group II 6 and 12 weeks after surgery. (4) Conclusions: Our study results demonstrate that the use of this new intramedullary stabilization system in combination with an immediate postoperative weight bearing seems to be a safe and stable treatment option for ankle fractures in geriatric patients, especially in the early stages of recovery.

Characteristics and Effectiveness of Postoperative Rehabilitation Strategies in Ankle Fractures: A Systematic Review

OBJECTIVES

To explore the characteristics and to report on the effectiveness of postoperative rehabilitation strategies for people with an ankle fracture.

DATA SOURCES

PubMed, Cochrane Library, EMBASE, Web of Science, and CINAHL were searched to identify studies published from January 2010 to November 2021.

STUDY SELECTION

Studies that described or evaluated postoperative rehabilitation strategies for surgically repaired ankle fractures were included.

DATA EXTRACTION

Data on postoperative rehabilitation were extracted in accordance with the Template for Intervention Description and Replication guide. Quality was assessed using the National Heart, Lung, and Blood Institute's Study Quality Assessment Tools.

DATA SYNTHESIS

Meta-analysis was planned to look at the effectiveness of postoperative rehabilitation strategies. Forty studies described postoperative rehabilitation strategies without evaluating effectiveness, whereas 15 studies focused on evaluating effectiveness. Because of the large variety in postoperative strategies and outcomes, narrative synthesis was deemed most suitable to answer our aims. Characteristics of postoperative rehabilitation strategies varied widely and were poorly described in a way that could not be replicated. Most of the studies (48%) used a late weight-bearing approach, although definitions and details around weight-bearing were unclear.

CONCLUSIONS

Late weight-bearing has been the most common postoperative approach reported in the past 10 years. The variety of definitions around weight-bearing and the lack of details of rehabilitation regimens limit replication and affect current clinical practice. The authors propose to adopt consistent definitions and terminology around postoperative practices such as weight-bearing to improve evidence for effectiveness and ultimately patient outcomes.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Similar Clinical Outcome in Locking and Conventional Plate Osteosynthesis for the Treatment of AO 44-B2 Ankle Fractures

INTRODUCTION

Biomechanical studies have proved that locking plates have better primary stability besides versatility regarding fracture pattern while reducing bone contact and bridging the gap, whereas conventional nonlocking plates (plus lag screw) depend on bone-plate compression. The clinical benefit of locking plates over nonlocking plates remains unanswered, however. Therefore, this retrospective cohort study was set up to test the hypothesis that the use of locking plates for unstable ankle fractures will result in fewer re-displacements, superior bony healing, and functional and clinical outcomes better than observed in the nonlocking cohort.

METHODS

Bimalleolar ankle fractures (AO 44-B2) without syndesmotic injury treated with either a locking or a nonlocking plate were included. Groups were compared for complications, bone healing, secondary dislocation, progressions of osteoarthritis, and clinical outcome using patient-reported outcome measures.

RESULTS

Data revealed no clinical outcome differences (Olerud-Molander Ankle Score: nonlocking 88.2 ± 14.4, locking 88.8 ± 12.3, P = .69, robust two 1-sided test for equality (RTOST): P = .03; American Orthopaedic Foot and Ankle Score: nonlocking 91.2 ± 12.9, locking 91.8 ± 11.3, P = .96, RTOST: P = .04). Nevertheless, a significant postoperative progression of osteoarthritis was detected in both groups (P = .04). This was independent of implant (P = .16). Although difference was not significant, locking plates were preferred in older (P = .78) and sicker patients (P = .63) and in cases with severer osteoarthritis (P = .16), and were associated with a higher complication rate (P = .42) and secondary dislocation (nonlocking 9.4%, locking 18.2%; P = .42). Re-displacement, however, was not a compelling reason for revision.

CONCLUSIONS

The present study shows statistically significant equality of both types of implants. Contrary to our expectation, locking plates seemed to be associated with a higher risk for re-displacement. Overall, the use of either locking or nonlocking plates for unstable AO 44-B2 fractures is safe and successful despite significant progression of osteoarthritis.

LEVEL OF EVIDENCE

III, Retrospective observational cohort study.

Indications for retrograde intramedullary screw fixation of the distal fibula: a retrospective cohort series

Introduction

Ankle fractures are a common orthopaedic injury that often require surgical fixation. Because the comorbid population in the United States continues to survive longer, it has become routine to treat comorbid patients with unstable ankle fractures. The literature has identified comorbidities known to increase the risk of ankle fracture complications to include age 55 years or older, body mass index >29.9, polytrauma, open fractures, diabetes mellitus, smoking, peripheral neuropathy, and alcohol use.

Methods

We retrospectively reviewed 37 patients who received retrograde intramedullary screw fixation of the distal fibula, all of whom had preexisting conditions known to increase the rate of postoperative complications.

Results

Thirty-seven patients were included in this study, of whom 36 (97.3%) went on to union. Six of 37 patients (16.2%) had complications although only one (2.7%) was due to inadequate fixation. The average time to weight-bearing as tolerated was 57.2 days (15-115 days). Two patients (5.4%) had symptomatic instrumentation requiring removal after union. Two patients (5.4%) had delayed union of the distal fibula, which responded to the use of a bone stimulator. One patient (2.7%) developed a nonunion which led to chronic subluxation of the ankle joint. One patient (2.7%) had a minor medial ankle wound complication that was treated with oral antibiotics and local wound care.

Conclusions

Retrograde intramedullary screw fixation of the distal fibula is a viable alternative to plate and screw fixation in patients with unstable ankle fractures who have known risk factors for increased complications. However, not all distal fibula fractures are amenable to this fixation method.

Level of Evidence

Level III retrospective cohort study.

Operative Fixation of Lateral Malleolus Fractures With Locking Plates vs Nonlocking Plates: A Systematic Review and Meta-analysis

BACKGROUND

The exact benefit of locking plates over nonlocking plates in patients with lateral malleolus fractures remains unclear. The primary aim of this study was to compare the functional outcome of locking plates vs nonlocking plates in patients with a lateral malleolus fracture. The secondary aims were to compare the number of complications and hardware removals and to compare whether results differed for older patients and for patients treated with anatomical locking plates.

METHODS

The PubMed/MEDLINE, Embase, Cochrane, and CINAHL databases were searched for studies comparing locking plates with nonlocking plates in patients with fixated lateral malleolus fractures. All included studies were assessed on their methodologic quality using the MINORS. Subgroup analyses were performed on older patients and patients treated with anatomical locking plates.

RESULTS

A total of 11 studies were included. The meta-analysis showed that functional outcome did not differ between patients treated with locking plates and nonlocking plates (MD 2.38, 95% CI -2.71 to 7.46). No difference in both complication rate (OR 1.10, 95% CI 0.74-1.63) and the amount of hardware removals (OR 0.77, 95% CI 0.52-1.14) was found. Even after analyzing older patients and patients treated with anatomical locking plates, no benefit was shown.

CONCLUSION

This meta-analysis demonstrates no clear benefit in selecting locking plates over nonlocking plates in the treatment of lateral malleolus fractures.

CLINICAL RELEVANCE

Locking plates are increasingly being used in the treatment of lateral malleolus fractures. Biomechanical studies have shown an increased stability with use of locking vs nonlocking plates. This clinical review does not support a benefit of use of locking plates for these fractures.

Treatment of bimalleolar fractures in elderly

Geriatrics continues to evolve as a specialty by adapting itself to increasingly older patients. Musculoskeletal injuries are common in these patients, who can maintain their physical capacities and autonomy for a long time, but whose bone solidness is frequently reduced by osteoporosis. Falls increase with age and because of certain medical conditions. Trauma in the geriatric population involves specific risks; thus, the treatment must be adapted not only to the fracture, but to the local conditions and the patient. Ankle injuries are particularly frequent in general traumatology but even more in geriatric traumatology. They can lead to complete loss of autonomy if the treatment is delayed and/or not adapted to the local conditions or the patient. The functional prognosis is brought into play, along with the patient's life due to loss of autonomy and general complications occurring in patients who are bed-ridden. The treatment of bimalleolar ankle fractures in older adults requires rigorous analysis at all points, which starts by evaluating the cutaneous status and viability of the soft tissues upon admission. The benefit-risk balance of the various treatment options will be assessed with the main goal being that patients recover their autonomy. This article will review this topic by answering 7 questions: 1) What are the distinctive features of elderly? Dependence on others, comorbidities, bone and soft tissue fragility are the main ones, explaining these high-risk situations and frequent complications. 2) When should a bimalleolar ankle fracture be treated surgically? The surgery must be done early, preferably within 8hours of the injury occurring, once the comorbidities have been controlled. The local conditions (skin and soft tissue damage) must be evaluated carefully as they determine the treatment. Errors are not allowed in these patients, who are often fragile and in precarious health. Definitive fixation is preferred if the skin status allows it, but one must keep temporary external fixation in mind as an option. 3) Is there still a role for conservative treatment of displaced fractures? This will produce good results when it is well done; however, the indications are rare and must be selected carefully. The main risks are secondary displacement and skin lesions inside the cast, which are sources of infection. 4) Is fixation with anatomical locking plates an advance? This is definitely an advance for these fragility fractures, which are often comminuted, as it allows return to weight bearing in certain conditions. However, the implantation rules must be followed exactly, and it is preferable to use thinner plates. 5) Does transplantar Steinmann pin fixation still have a role? It has few indications, limited to salvage situations (catastrophic local conditions, very poor general condition). External tibiocalcaneal fixation, alone or in combination, is a better option. 6) Is immediate transarticular fixation with a retrograde or antegrade locked nail a reasonable option? Fixation can be done by retrograde nailing or antegrade nailing. It is proposed to patients who are not very autonomous with a poor cutaneous status and/or severe osteoporosis. It is preferable to transplantar nailing. 7) Is immediate protected weight bearing, with or without fixation, possible? This can be considered on a case-by-case basis depending on the extent of the trauma, patient compliance and treatment carried out. LEVEL OF EVIDENCE: V, Expert opinion.

One-Third Tubular Plate Remains a Clinically Good Option in Danis-Weber Type B Distal Fibular Fracture Fixation

OBJECTIVE

To compare the clinical outcomes of locking plate (LP) and non-locking one-third tubular plate (TP) fixation, and to provide guidance on plate selection for Danis-Weber type B distal fibular fracture treatment.

METHODS

In total, 83 patients who underwent plate fixation for Danis-Weber type B distal fibular fractures between March 2013 and July 2018 were retrospectively reviewed: 41 (49.0%) received LPs and 42 (51.0%) received TPs. Patients' demographic data, follow-up durations, the proportion of comminuted fractures, and ankle range of motion were investigated. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, Karlsson scale, Foot and Ankle Ability Measure (FAAM), and Lower Extremity Functional Scale (LEFS) scores were assessed. The radiographic union progression and implant removal time were evaluated, along with postoperative complications. Data from the LP and TP groups were compared statistically.

RESULTS

The mean patient ages were 53.3 ± 17.5 years (range, 16-80 years) and 47.6 ± 17.0 years (range, 14-68 years) in the LP and TP groups, respectively (P > 0.05). The gender distribution did not differ significantly between groups (P > 0.05). Other demographic data also did not differ significantly between groups (P > 0.05). The mean follow-up durations were 16.8 ± 7.7 months (range, 13.0-19.0 months) in the LP group and 16.1 ± 6.2 months (range, 12.0-20.0 months) in the TP group (P > 0.05). Comminuted fractures were observed in 18 of 41 (43.9%) patients with LP and 10 of 42 (23.8%) patients with TP (P > 0.05). Forward bending ankle dorsiflexion was possible at the final follow-up in 82.9% and 85.7% of LP and TP patients, respectively (P > 0.05). The AOFAS ankle-hindfoot scale, Karlsson scale, FAAM, and LEFS scores did not differ significantly between groups at the final follow-up (P > 0.05). The pre-fracture and final postoperative scores on these four instruments did not differ significantly in the LP or TP group (P > 0.05). The mean times to radiographic union progression were 13.5 ± 7.1 weeks and 15.1 ± 10.2 weeks in the LP and TP groups, respectively (P > 0.05). The mean times to implant removal surgery reaffirming solid union were 15.6 ± 5.5 months and 14.8 ± 4.9 months in the LP and TP groups, respectively (P > 0.05). Hardware irritation was detected in five patients in the LP group (12.2%) and three in the TP group (7.1%) (P > 0.05). One patient in the LP group and two in the TP group developed superficial wound infections, which resolved without further surgical intervention.

CONCLUSION

Conventional TP remains a good option for the fixation of Danis-Weber type B distal fibular fractures, regardless of the biomechanical properties.

Current management of trimalleolar ankle fractures

A trimalleolar ankle fracture is considered unstable and treatment is generally performed operatively. Computed tomography is important for the operative planning by providing an elaborated view of the posterior malleolus.

Trimalleolar ankle fractures have a rising incidence in the last decade with up to 40 per 100,000 people per year. With a growing number of elderly patients, trimalleolar ankle injuries will become more relevant in the form of fragility fractures, posing a particular challenge for trauma surgeons.

In patients with osteoporotic trimalleolar ankle fractures and relevant concomitant conditions, further evidence is awaited to specify indications for open reduction and internal fixation or primary transfixation of the ankle joint.

In younger, more demanding patients, arthroscopic-assisted surgery might improve the outcome, but future research is required to identify patients who will benefit from assisted surgical care.

This review considers current scientific findings regarding all three malleoli to understand the complexity of trimalleolar ankle injuries and provide the reader with an overview of treatment strategies and research, as well as future perspectives.

Cite this article: EFORT Open Rev 2021;6:692-703. DOI: 10.1302/2058-5241.6.200138

Fibula fractures management

Isolated distal fibula fractures represent the majority of ankle fractures. These fractures are often the result of a low-energy trauma with external rotation and supination mechanism. Diagnosis is based on clinical signs and radiographic exam. Stress X-rays have a role in detecting associated mortise instability. Management depends on fracture type, displacement and associated ankle instability. For simple, minimally displaced fractures without ankle instability, conservative treatment leads to excellent results. Conservative treatment must also be considered in overaged unhealthy patients, even in unstable fractures. Surgical treatment is indicated when fracture or ankle instability are present, with several techniques described. Outcome is excellent in most cases. Complications regarding wound healing are frequent, especially with plate fixation, whereas other complications are uncommon.

Early full weight-bearing in patients with isolated displaced lateral malleolar fracture after rigid internal fixation with locking plates

BACKGROUND

The timing of post-operative full weight-bearing in patients of isolated displaced lateral malleolar fractures remains controversial. The aim of this study was to evaluate the outcomes of early full weight-bearing after rigid internal fixation of such fractures with locking plates.

METHODS

From 2012 to 2018, 46 patients who had closed isolated displaced lateral malleolar fractures were included in the study. All fractures were managed with open reduction and internal fixation with locking plates. The patients were allowed to walk bearing their full weight 2 weeks after the operation. The follow-up period was 41.5 months on average (range: 12-70 months). The patients were available to evaluate union conditions, functional results, and complications.

RESULTS

The fractures united smoothly with an average union time of 10.5 weeks (range: 8-16). At the final follow-up, the average American Orthopaedic Foot and Ankle Score Ankle-Hindfoot Score was 91 (range: 85-98). No complications were observed.

CONCLUSION

For patients with isolated displaced lateral malleolar fractures, full weight-bearing is safe and effective, without an increase in the rate of complications, 2 weeks after open reduction and rigid fixation with locking plates.

Is early full weight bearing safe following locking plate ORIF of distal fibula fractures?

Background

In the modern western world appraisal of economical points such as treatment and disability after trauma present a financial burden. In this context open reduction internal fixation techniques allowing for early full weight bearing might not only improve the clinical outcome but also shorten the period of disability in working life. The aim of the study was to analyze whether ORIF of ankle fractures using either a standard semitubular plate or a new polyaxial locking plate system result in a better clinical outcome.

Methods

In this prospective study, all patients with distal fibula fractures (AO 44 B1.1, B1.2, B1.3), with indication for surgery were included. Patients were randomized to either the DePuy Synthes® one-third semitubular plate (Group I) or NEWCLIP TECHNICS, Active Ankle® polyaxial locking plate (Group II). Primary outcome parameter was function of the ankle joint, assessed by the Olerud and Molander ankle score, Foot and Ankle outcome score and Karlsson and Peterson Scoring System for Ankle function. Secondary outcome parameter were postoperative complications. Superficial wound infection, delayed wound healing, mechanically prominent implant, skin irritations were considered as minor and deep wound infection, material loosening, loss of reduction were regarded as major complications requiring revision surgery. Clinical and radiological follow-up were performed 6 and 12 weeks, 6 months and 1 year postoperatively.

Results

Fifty-two patients (31 W/21 M) with a mean age of 43 yrs. (range 22–64 yrs.) were enrolled. Seven patients (13.5%) were excluded, so that 45 patients were available for follow up. Twenty-five patients were treated with DePuy Synthes® one-third semitubular plate (55.6%; group I) while 20 patients received an anatomically preformed polyaxial locking plate (44.4%, group II). Four minor complications occurred in Group I (16%) compared to two minor complications in group II (10%). Significant better clinical results regarding OMAS (p < 0.02, < 0.04), KPSS (p < 0.04) and FAOS (p < 0.02, < 0.03) were observed 6 and 12 weeks after surgery in group II.

Conclusions

The results of the presented study demonstrate a significant better clinical functional outcome in the early postoperative follow-up in patients treated with a polyaxial locking plate. Furthermore, our data show that ORIF using polyaxial locking plates in combination with an early postoperative weight bearing presents a safe, stable treatment option for ankle fractures so that patients benefit especially in the early stages of recovery.

Trial registration

Registered 20 April 2020, retrospectively on ClinicalTrails.gov (NCT04370561).

Surgical vs non-surgical management of Weber B fractures: A systematic review

BACKGROUND

The aim of this systematic review was to compare surgical and non-surgical management of Weber B ankle fractures.

METHODS

A systematic computer-based search was conducted using the MEDLINE (via OvidSP), EMBASE (via OvidSP) and Central databases. Data were extracted regarding functional outcome, radiological union, range of motion (RoM), infection rate and quality of life (QoL).

RESULTS

There were no significant differences identified between surgical and non-surgical management of Weber B fractures with respect to functional outcome. There is a higher rate of complication following surgical management, including infection, reoperation, thromboembolic events and death. With respect to QoL and ankle RoM, this review identified no differences between surgical and non-surgical management.

CONCLUSIONS

There is a need for further published literature evaluating the most efficacious management as there is a poverty of high-level research available. Currently, the available literature does not overwhelmingly favour a particular approach to Weber B ankle fractures.

Necessity of Interfragmentary Lag Screws in Precontoured Lateral Locking Plate Fixation for Supination-External Rotation Lateral Malleolar Fractures

BACKGROUND

Interfragmentary lag screws, protected by a plate, have been applied for many years in the treatment of supination-external rotation (SER) ankle fractures. Recently, similar biomechanical stability was found between fixation completed with a plate and lag screw and a plate alone. The aim of this study was to determine whether interfragmentary lag screws are necessary during precontoured lateral locking plate fixation for SER lateral malleolar fractures.

METHODS

A prospective randomized controlled trial of 76 patients with unilateral Lauge-Hansen SER lateral malleolar fractures was conducted. The patients were randomly treated either with or without the use of interfragmentary lag screws with precontoured lateral locking plate fixation. Clinical outcomes were assessed using the Olerud-Molander Ankle Score and a visual analog scale for pain. Radiologic outcomes were assessed based on the Kellgren and Lawrence scale score, incongruity of the ankle joint, and type of fracture healing. Sixty-nine patients completed 12 months of follow-up.

RESULTS

There was no significant difference between the 2 groups with regard to clinical outcomes at 3 and 12 months after surgery and radiologic outcomes at 12 months after surgery. All patients in both groups achieved primary bone healing.

CONCLUSION

The results of this study suggest that with precontoured lateral locking plate fixation, the use of interfragmentary lag screw is not essential in the treatment SER lateral malleolar fractures.

LEVEL OF EVIDENCE

Level I, prospective randomized study.

Osteoporotic ankle fractures: A narrative review of management options

The management of Osteoporotic ankle fractures is still considered to be a challenge by many surgeons. One of the issues seems to be a lack of data focused on this special subgroup, with very little evidence of good quality. We did a narrative review of the literature in an attempt to identify the magnitude of the problem and to evaluate the evidence in support of management options.The current review of the literature has brought to light some interesting facts. Despite limited data there seems to be an in increase in the incidence of these fractures. Although we could not demonstrate any clear distinction between geriatric and osteoporotic ankle fractures from the available literature; it is clear that all geriatric fractures are not necessarily osteoporotic and neither is the reverse true. The evidence to associate osteoporotic ankle fractures with poor outcomes is weak, and factors other than osteoporosis may have a stronger influence. From this analysis, we could not establish a higher incidence of implant failure for this specific fracture group, although many modifications in technique have been proposed due to the fear of fixation failure. Hook plating and Tibia-pro fibula fixation have weak evidence in support, but posterior fibular plating is preferred due to soft tissue protection. There is weak evidence in support of Locking plates for these fractures, as publications focused on this are limited; nevertheless some advantages have been documented. Augmentation by calcium based bone graft substitutes has been reported to improve pull out strengths of screws, but again the evidence of its role in Osteoportic fractures is limited. Fibular nailing has been proposed with specific advantages in osteoporotic fibular fractures, but the concept is new and it is indicated only in a select a subgroup of cases. Some evidence exists for the use of trans-articular nails in geriatric subgroups with limited pre-injury mobility, but the technique has to be used with caution to prevent other complications.

INFERENCE

More data needs to be accumulated before clear guidelines for management of osteoporotic ankle factures are defined; however the current literature supports the need for modifications in standard ankle facture fixation methods to improve outcomes.

Treating AO/OTA 44B lateral malleolar fracture in patients over 50 years of age: periarticular locking plate versus non-locking plate

Background

The role of locking plate in lateral malleolar fracture fixation for the elderly remains unclear. The aim of our study is to compare radiological and functional outcomes in older patients (> 50 years) with AO/OTA 44B lateral malleolar fractures after locking plate (PLP) or one-third non-locking tubular plate (TP) lateral fixation.

Methods

We retrospectively reviewed the medical records of 72 patients (PLP group, 34 patients; TP group, 38 patients; mean age, 61.9 ± 7.6 years; range, 51–80 years; follow-up, 1 year). Patients with open fractures, syndesmosis injuries, and a previous ankle trauma or surgery were excluded. Demographic data, union rate, complications, radiographic outcomes, visual analog scale (VAS) scores, and foot and ankle outcome scores (FAOSs) between the groups were recorded and compared. We also investigated the association of clinical features with pain and function. Statistically, the Fisher’s exact test was used for categorical variables and the Mann-Whitney U test for the continuous variables. The final model for the multiple regression analysis was used to predict factors related to functional outcomes.

Results

There were no significant between-group differences in demographic data, complication rates, immediately postoperative distal fibula lengths, ankle osteoarthritis (OA) grades, talar tilt angles (TTAs) ≥ 2°, or reduction accuracy. All fractures achieved union. The PLP group had significantly lower rates of distal screw loosening, fibula shortening > 2 mm, OA grade progression, and TTAs ≥ 2°, and better FAOSs and VAS scores than was the case for the TP group after 1 year of follow-up (all p < 0.05). The severity of OA, TTA ≥ 2°, and distal screw loosening were positively associated with VAS scores, and negatively associated with FAOSs.

Conclusions

When treating AO/OTA 44B fractures in patients over 50 years of age, PLPs provided better VAS scores, FAOSs, and radiological outcomes, including less fibula shortening > 2 mm, less osteoarthritic (OA) ankle progression, less implant removal rate, and fewer TTAs ≥ 2° than was the case for TPs after a 1-year follow-up.

Level of evidence

Therapeutic level III

Twisted Plating - A Method of Distal Fibula Fixation

Objective  The literature entails various intramedullary and extramedullary methods for distal fibula fracture fixation; with no consensus yet over the ideal method of fixation. We have retrospectively analyzed the results of using a twisted and contoured 3.5 mm locking compression plate (LCP) as a posterior buttress plate. Methods  Of the 62 cases with ankle fractures managed at our institute by the senior author from 1 ^st January 2012 to 31 ^st December 2015, 41 patients met our inclusion criteria (Danis-Weber types B and C). Results  All 41 distal fibular fractures healed uneventfully, at a mean of 10.4 weeks (8-14 weeks) (Figs. 6, 7, 8 to 9) with no complications. The mean American Orthopaedic Foot & Ankle Society (AOFAS) score was 92.6 (86-100) at a mean follow-up of 31.5 months (14-61 months). Conclusions  We have achieved excellent clinical and radiological outcomes using a twisted 3.5 mm LCP as a posterior buttress by combining the advantages of posterior antiglide plating and lateral LCP.

Operative treatment of geriatric ankle fractures with conventional or locking plates. A retrospective case-control study

BACKGROUND

The incidence of geriatric ankle fractures continues to rise due to demographic changes. While locking plates have become standard implants for injuries of other body regions, clinical studies on their use for geriatric ankle fractures are rare.

METHODS

Therefore, a retrospective case-control study, including 333 patients with a mean age of 73.5 years was performed. 263 patients underwent operative fixation with one- third tubular plates and 70 were treated with locking plates. Early outcomes and complication rates of locking plates as compared with conventional one- third tubular plates are described.

RESULTS

In the present study, patients treated with locking plates were older and suffered from more severe fracture patterns. In addition, these patients had more severe comorbidities. Treatment with conventional or locking plate fixation resulted in a comparable complication and revision rate. A matched pair analysis showed significantly more complications and required revision surgeries and a trend towards more implant failures in the group that underwent conventional plating.

CONCLUSIONS

Therefore, we conclude that precontoured locking plates represent an appropriate treatment option for severe ankle fractures in patients suffering from relevant co-morbidities. Prospective randomized trials are warranted to prove superiority of locking plates for treatment of geriatric ankle fractures. Level 3: Retrospective case- control study.

Does the Use of Locking Screws Decrease the Rate of Hardware Removal in Ankle Fractures?

Background. While biomechanical characteristics of locking screw fixation versus traditional plating has been studied extensively in orthopaedic literature, clinical outcome studies are lacking. The goal of this study was to evaluate the efficacy and complications rate of locking versus traditional nonlocking screws in complex ankle fractures employing distal fibula internal fixation with 1/3 semitubular small fragment plates. Methods. A retrospective review was performed between January 2010 and June 2013 of all patients in whom internal fixation of the fibula in an ankle fracture (open or closed) was performed using only 1/3 semitubular small fragment fibular plates. Patient characteristics, fracture patterns, specific screw choice that were placed in the most distal 2 fibular plate holes (either locking or nonlocking), infectious wound complications, and concomitant syndesmotic injury and the need and corresponding purpose for hardware removal were recorded. Results. A total of 135 patients were found to meet inclusion criteria and were analyzed for this study. Of the patients with locking screws, 25 of 98 (25%) elected to have hardware removed, while 13 of 37 (35%) of those with nonlocking screws elected hardware removal. This did not reach statistical significance (P = .30). There was no statistically significant difference between the groups with regards to age, smoking status, body mass index, diabetes, or use of syndesmotic screw fixation. There was no significant difference in loss of fixation, infection, or other surgical complications in between the groups. Conclusions. There was no significant decrease in the rate of hardware removal with the use of 1/3 tubular locking versus nonlocking plates in the treatment of distal fibula fractures. Despite these screws locking flush to the plate, the hardware is equally symptomatic in both groups. There was no significant difference in the rate of complications between the 2 groups and our data suggest that the added expense of using locking screws routinely when fixing lateral malleolar fractures should be carefully considered, especially if the fracture pattern does not warrant locking technology. Levels of Evidence: Prognostic, Level III.

A comparison of bone union and complication rates between locking and non-locking plates in distal fibular fracture: Retrospective study of 106 cases

BACKGROUND

Ankle fractures represents the third most frequent fracture in elderly patients. There is a current tendency to fix long bones fractures with locking plates. However, we rarely find published accounts about the use of locking plates in distal fibula fractures, except for biomechanical ones, studying human cadaveric fibula.

OBJECTIVES

The main objective was to compare radiographic bone union rates at 6 and 12 weeks of follow up, then wound complications and hardware removal rates, and construct cost.

STUDY DESIGN & METHODS

We retrospectively analyzed 105 patients who underwent surgery with locking plates or non-locking plates over a two-year period, out of which 42 patients were treated with non-locking plates (VIVES™ - Stryker^Ⓡ) and 63 with locking plates (VariAx™ - Stryker^Ⓡ,). We analyzed bone union on anterior posterior and lateral X-rays of the ankle. We collected data of wound complications and hardware removal from patient records. Multiple linear regression techniques were performed after identifying dependent variables.

RESULTS

There was no significant difference between non-locking and locking plates in the radiographic bone union rate of distal fibula, respectively at 6 and 12 post-operative weeks (85.71% vs. 81%; p = 0.525 and 97.62% vs. 96.83%; p = 1). No significant difference was found in the wound complication rate between the two groups (11.9% vs. 11.12%; p = 0.9). No significant differences were found in the hardware removal rate, either with or without operative site's infection (respectively: 30.95% vs. 39.68%; p = 0.361 and 21.42% vs. 38.09%; p = 0.071). Cost efficiency is in the favor of non-locking plates.

CONCLUSION

Non-locking constructs are as effective as locking constructs in the treatment of displaced distal fibula fractures at a substantially lower cost. High-quality randomized controlled trials are needed in the future to verify the finding of this study.

Cannulated Intramedullary Screw Fixation of Distal Fibular Fractures

Background: Open reduction and internal fixation (ORIF) methods, primarily plates and screws, remain the standard of treatment for distal fibular fractures. This study evaluates the use of a cannulated intramedullary screw as a minimally invasive treatment method for distal fibular fractures, which has not been reported in the current literature. Methods: This retrospective study included 45 patients with distal fibular fractures treated with cannulated intramedullary screw fixation. All patients included in the cohort had a soft-tissue condition and/or comorbidity. The mean age was 54 years. The Weber classification system was used to assess the type of fracture. Average time to union, average time to weight bearing, and complications were monitored. Results: Reduction quality criteria were collected using previously published guidelines. Accordingly, reduction was determined to be good in 25 cases, fair in 15, and poor in 5. A low complication rate of 4% was reported. Average time to union was 10 weeks (range = 8-36 weeks), whereas average time to weight bearing was 14 weeks (range = 8-40 weeks). Conclusion: Cannulated intramedullary screw fixation can serve as a minimally invasive, safe, and satisfactory treatment for distal fibular fractures with resulting high union rates and low complication rates. Levels of Evidence: Level IV: Retrospective, case series.

Comparison of different locking plate fixation methods in lateral malleolus fractures

BACKGROUND

Several fixation methods may be used for displaced lateral malleolar fractures. We aimed to compare clinical and radiologic outcomes associated with use of locking one third tubular plate vs. anatomical distal fibula locking plate in lateral malleolar fractures.

METHODS

A total of 62 orthopedic patients operated for lateral malleolus fracture were included in this retrospective study. Patients were divided into two groups regarding the plate used for fixation as locking one third tubular plate (group I; n=37) and locking anatomical distal fibula plate (group II; n=25). Data on Danis-Weber ankle fracture classification (Type A, Type B), duration of follow up, clinical outcome [ankle range of motion (ROM), American Orthopaedic Foot & Ankle Society (AOFAS) score], radiological outcomes (adequacy of reduction, loss of alignment), time to fracture healing and complications were recorded in study groups.

RESULTS

No significant difference was noted between groups in terms of AOFAS score [87.0 (73-100) vs. 85.0 (71-100), respectively (p=0.339)] and no patients had severe restriction in sagittal and hindfoot motion in both groups. The two groups showed similar healing time [9.0 (7-13) weeks vs. 10.0 (8-13) weeks, respectively (p=0.355)] and complication rate [0.0% vs. 4.0%, respectively (p=0.403)].

CONCLUSIONS

This study revealed no significant difference between use of locking one third tubular plate and locking anatomical distal fibula plate in lateral malleolar fixation, in terms of clinical and radiological outcomes, complication rates and fracture healing time.

Application of a Ni-Ti arched shape-memory connector in unstable lateral malleolus fractures: A retrospective study

PURPOSE

To compare the outcomes of the arched shape-memory connector (ASC) only fixation and the lateral one-third tubular plate fixation in managing unstable Type A or B lateral malleolus fractures according to the Weber (AO) classification, and to evaluate the feasibility and reliability of ASC only fixation in treating these fractures.

METHODS

From January 2010 to January 2015, 148 patients with Type A or B (Weber (AO) classification) lateral malleolus fractures treated with the arched shape-memory connector (ASC) only fixation or lateral plate fixation were included. There were 66 patients in the ASC only fixation group and 82 patients in the lateral plate group. Intergroup differences were absent regarding patient and fracture characteristics. The incision length, complete-union time, major complications and complaints, incidence of hardware removal, and final radiographic and functional evaluations were compared.

RESULTS

The follow-up time averaged 18.2 months in the ASC fixation group and 17.2 months in the lateral plate group. The ASC only fixation group had significantly decreased wound infection (4.55% versus 14.63%) and skin necrosis (none versus 7.32%). Of patients who underwent ASC only fixation 3.03% reported lateral ankle pain, 7.58% received palpable hardware, and 3.03% reported hardware irritation, while the corresponding observations in the lateral plate group were 19.51%, 54.88%, and 14.63%, respectively, representing a statistical difference. Furthermore, compared with the lateral plate group, the incidence of hardware removal was markedly lower in the ASC fixation group (12.12% versus 30.49%). In terms of reduction accuracy, complete-union time, and AOFAS scores, no appreciable differences were observed.

CONCLUSIONS

ASC only fixation is a reliable alternative for managing Type A or B lateral malleolus fractures, leading to fewer soft tissue complications, fewer hardware complaints, and a reduced need for hardware removal, and a reduced need for hardware removal. In addition, ASC can be used for augmented plate fixation in certain comminuted fracture patterns.

Comparison of Locking Versus Nonlocking Plates for Distal Fibula Fractures

Locking plates might offer a biomechanical fixation advantage for distal fibula fractures with comminution or osteoporotic bone. In January 2011, our unit introduced a bone-specific locking plate for the distal fibula. The aim of the present study was to compare it against more conventional plating system implants for lateral malleolar fixation in terms of outcomes, crude costs, and complications. We retrospectively reviewed a consecutive cohort of patients with closed ankle fractures who presented within a 24-month period. The clinical and radiographic outcomes were compared among conventional plating using a one-third semitubular plate, a 3.5-mm limited-contact dynamic compression plate, and a 2.7-mm/3.5-mm locking compression distal fibula plate. A total of 145 patients with ankle fractures underwent surgical fixation: 87 (60.0%) with the semitubular plate, 22 (15.2%) with the limited-contact dynamic compression plate, and 36 (24.8%) with the locking compression distal fibula plate. A greater proportion of patients with established osteoporosis or osteoporosis risk factors were in the locking compression distal fibula plate group (27.8% versus 2.3% and 0%). Four patients (2.8%) required washout for infection. No significant differences were found between the sex distribution within the 3 groups (p = .432). No significant difference was found in the complication rate (p = .914) or the reoperation rate (p = .291) among the 3 groups. Although costing >6 times more than a standard fibula fixation construct (implant cost), bone-specific locking compression distal fibula plates add to the portfolio of implants available, especially for unstable fractures with poor bone quality.

Tubular vs Profile Plate in Peroneal or Bimalleolar Fractures: is There a Real Difference in Skin Complication? A Retrospective Study in Three Level I Trauma Center

Introduction:

Not enough literature is available to evalute the wound complication rate of plates type in distal fibular fractures.

Aim:

The aim of our study was to compare wound complications of using a third tubular plate compared to LCP distal fibula plate.

Material and Methods:

This study is a retrospective single-centre study in which was performed plating of fibula in closed ankle fractures. 93 patients were included in our study and assigned in two groups, based on using of different implant : in group A 48 patients were treated with one-third tubular and in group B 45 patients were treated with LCP distal fibula plate. There were no significant differences in the baseline characterisctics. Patients received the same surgical procedure and the same post-operative care, then they were radiologically evalueted at 1-3-12 months and clinical examination was made at 12 months using AOFAS clinical rating system. Categorical data, grouped into distinct categories, were evalueted using Chi-square test. We considered a p value < 0.05 as statistically significant.

Results:

The wound complications rate of the overall study group was 7.6%. There were no statistical differences in the rate of wound complications between the two groups. There were no differences between both group in percentage of hardware removal at follow-up (overall 5.4%); plate removal was performed earlier in the locking plate because of wound complications.

Conclusions:

Our study has shown no difference in radiographic bone union rate, no significant differences in terms of clinical outcomes, in time of bone reduction and wound complication rate between the LCP distal fibula plate and conventional one-third tubular plate. Controversy still exists about the best method for the fracture reduction.

Costs and Radiographic Outcomes of Rotational Ankle Fractures Treated by Orthopaedic Surgeons With or Without Trauma Fellowship Training

INTRODUCTION

We evaluated the radiographic outcomes and surgical costs of surgically treated rotational ankle fractures in our health system between providers who had completed a trauma fellowship and those who had not.

METHODS

We grouped patients into those treated by trauma-trained orthopaedic surgeons (TTOS) and non-trauma-trained orthopaedic surgeons (NTTOS). We graded the quality of fracture reductions and calculated implant-related costs of treatment.

RESULTS

A total of 208 fractures met the inclusion criteria, with 119 in the TTOS group and 89 in the NTTOS group. Five patients lost reduction during the follow-up period. The adequacy of fracture reduction at final follow-up did not differ (P = 0.29). The median surgical cost was $2,940 for the NTTOS group and $1,233 for the TTOS group (P < 0.001).

DISCUSSION

We found no notable differences in radiographic outcomes between the TTOS and NTTOS groups. Cost analysis demonstrated markedly higher implant-related costs for the NTTOS group, with the median surgical cost being more than twice that for the TTOS group.

LEVEL OF EVIDENCE

Level III.

Percutaneous Intramedullary Screw Fixation of Distal Fibula Fractures: A Case Series and Systematic Review

The current reference standard for unstable ankle fractures is open reduction and internal fixation using a plate and lag screws. This approach requires extensive dissection and wound complications are not uncommon. The use of intramedullary screw fixation might overcome these issues. The aim of our study was to provide an overview of the published data regarding intramedullary screw fixation of fibula fractures combined with a small consecutive case series. We performed a search of published studies to identify the studies in which fibula fractures were treated with percutaneous intramedullary screw fixation. Additionally, all consecutive patients treated for an unstable ankle fracture in a level 1 trauma center using an intramedullary screw were retrospectively included. The literature search identified 6 studies with a total of 180 patients. Wound infection was seen in 1 patient (0.6%), anatomic reduction was achieved in 168 patients (93.3%), and a loss of reduction was seen in 2 patients (1.1%). Implant removal was deemed necessary in 3 patients (1.7%) and nonunion was seen is 2 patients (1.1%). A total of 11 patients, in whom no wound complications occurred, were included in our study. The follow-up duration was a minimum of 12 months. A secondary dislocation was seen in 1 patient, and delayed union was observed after 7.5 months in 1 other patient. In conclusion, intramedullary screw fixation is a safe and adequate method to use for fibula fractures, with a low risk of wound complications. Additional research regarding functional outcome is warranted.

Definition of infection after fracture fixation: A systematic review of randomized controlled trials to evaluate current practice

INTRODUCTION

One of the most challenging musculoskeletal complications in modern trauma surgery is infection after fracture fixation (IAFF). Although infections are clinically obvious in many cases, a clear definition of the term IAFF is crucial, not only for the evaluation of published research data but also for the establishment of uniform treatment concepts. The aim of this systematic review was to identify the definitions used in the scientific literature to describe infectious complications after internal fixation of fractures. The hypothesis of this study was that the majority of fracture-related literature do not define IAFF.

MATERIAL AND METHODS

A comprehensive search was performed in Embase, Cochrane, Google Scholar, Medline (OvidSP), PubMed publisher and Web-of-Science for randomized controlled trials (RCTs) on fracture fixation. Data were collected on the definition of infectious complications after fracture fixation used in each study. Study selection was accomplished through two phases. During the first phase, titles and abstracts were reviewed for relevance, and the full texts of relevant articles were obtained. During the second phase, full-text articles were reviewed. All definitions were literally extracted and collected in a database. Then, a classification was designed to rate the quality of the description of IAFF.

RESULTS

A total of 100 RCT's were identified in the search. Of 100 studies, only two (2%) cited a validated definition to describe IAFF. In 28 (28%) RCTs, the authors used a self-designed definition. In the other 70 RCTs, (70%) there was no description of a definition in the Methods section, although all of the articles described infections as an outcome parameter in the Results section.

CONCLUSION

This systematic review shows that IAFF is not defined in a large majority of the fracture-related literature. To our knowledge, this is the first study conducted with the objective to explore this important issue. The lack of a consensus definition remains a problem in current orthopedic trauma research and treatment and this void should be addressed in the near future.

Locking versus non-locking one-third tubular plates for treating osteoporotic distal fibula fractures: a comparative study

INTRODUCTION

Ankle fractures represent the third most common fracture in elderly patients, after hip and wrist fractures. Distal fibula fractures in this population are closely related to osteoporosis, which renders commonly used methods of internal fixation technically demanding and prone to failure. Currently there is a tendency to fix osteoporotic metaphyseal and epiphyseal fractures with locking plates. However, published accounts about the use of this technology in osteoporotic distal fibula fractures are scarce. In this study we compare the results of two groups of patients who underwent surgery for these types of fracture, one group received locking and the other non-locking screws, both using one-third tubular plates.

METHODS

Sixty-two patients, aged over 64 years, underwent surgery for osteoporotic distal fibula fractures between 2011 and 2014. Forty-five of them were stabilized with a non-locking plate and the remaining 17 with a locking plate fixation. Follow-up was performed at 4, 8, 12, 26, and 52 weeks. Results were assessed according to the AOFAS Ankle-Hindfoot Score and radiological criteria for consolidation.

RESULTS

Average time to union and AOFAS scores at 6 and 12 months were similar in both groups, including for the individual categories: function, pain, mobility, and alignment. Only time until partial weight bearing was significantly lower in the locking plate group (4.69 ± 2.63 vs 7.77 ± 4.30, p = 0.03). The most common complications were wound dehiscence and superficial infection (two cases of both).

CONCLUSIONS

Both locking and conventional non-locking plates achieved similar treatment outcomes in this group of osteoporotic patients aged over 64. However, locking plates may offer more benefits in cases that have to take into account immobilization time and concomitant soft-tissue damage.

Implant Failure Rates and Cost Analysis of Contoured Locking Versus Conventional Plate Fixation of Distal Fibula Fractures

The authors analyzed 330 consecutive Weber B distal fibula fractures that occurred during a 3-year period and were treated with either a contoured locking plate or a conventional one-third tubular plate to compare the cost and failure rates of the 2 constructs. The primary outcomes were failure of the distal fibular implant and loss of reduction. Secondary outcomes were surgical wound infection requiring surgical debridement and/or removal of the fibular implant, and removal of the fibular plate for persistent implant-related symptoms. No failure of the fibular plates or distal fibular fixation occurred in either group. A total of 5 patients required surgical revision of syndesmotic fixation within 4 weeks of the index surgery. Of these patients, 1 was in the contoured locking plate group and 4 were in the one-third tubular plate group (P=.610). The rate of deep infection requiring surgical debridement and/or implant removal was 6.2% in the contoured locking plate group and 1.4% in the one-third tubular plate group (P=.017). The rate of lateral implant removal for either infection or symptomatic implant was 9.3% in the contoured locking plate group and 2.3% in the one-third tubular plate group (P=.005). A typical contoured locking plate construct costs $800 more than a comparable one-third tubular plate construct. Based on a calculated estimate of 60,000 locking plates used annually in the United States, this difference translates to a potential avoided annual cost of $50 million nationally. This study demonstrates that it is possible to treat Weber B distal fibula fractures with one-third tubular plates at a substantially lower cost than that of contoured locking plates without increasing complications. [Orthopedics. 2017; 40(6):e1024-e1029.].

Locking versus Non-locking Neutralization Plates with Limited Excision and Internal Fixation for Treatment of Extra-articular Type a Distal Tibial Fractures

Purpose:

This study aimed to compare the clinical, radiologic, and cost-effectiveness results between locking and non-locking plates for the treatment of extra-articular type A distal tibial fractures.

Methods:

We performed a retrospective review of AO/OTA 42-A1, A2 distal tibial fractures treated by plates from January 2011 to June 2013. Patients were divided to the locking plate group or the non-locking plate group. Clinical outcomes, radiographic outcomes, and hospitalization fee were compared between the two plates groups.

Results:

28 patients were treated with a locking plate and 23 patients were treated with a non-locking plate. The mean follow-up was 18.8 months (12-23 months). There were no significant differences between the groups in surgical time, bleeding, bone union time, or AOFAS scores. The cost of the locking plate was ¥24,648.41 ± 6,812.95 and the cost of the non-locking plate was ¥11,642 ± 3,162.57, p < 0.001. Each group had one patient that experienced superficial infection these wounds were readily healed by oral antibiotics and dressing changes. To date, five patients in the locking group and ten patients in the non-locking group had sensations of metal stimulation or other discomfort (X² = 3.99, p < 0.05) Until the last follow-up, 14 patients in the locking plate group and 18 patients in the non-locking plate group had their plates removed or wanted to remove their plates (X² = 4.31, p < 0.05).

Conclusion:

The use of locking or non-locking plates provides a similar outcome in the treatment of distal fractures. However the locking plate is much more expensive than the non-locking plate.

Interventions for treating ankle fractures in children

BACKGROUND

Ankle fractures, which usually occur after a twisting incident, are a diverse collection of injuries with different levels of complexity and severity. They have an incidence of 1 in 1000 a year in children. Treatment generally involves splints and casts for minor fractures and surgical fixation with screws, plates and pins followed by immobilisation for more serious fractures.

OBJECTIVES

To assess the effects (benefits and harms) of different interventions for treating ankle fractures in children.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (22 September 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 8), MEDLINE (1946 to September Week 2 2015), MEDLINE In-Process & Other Non-Indexed Citations (21 September 2015), EMBASE (1980 to 2015 Week 38), CINAHL (1937 to 22 September 2015), trial registers (17 February 2015), conference proceedings and reference lists of articles.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials evaluating interventions for treating ankle fractures in children.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles, abstracts and full articles for inclusion, assessed risk of bias and collected data. We undertook no meta-analysis.

MAIN RESULTS

We included three randomised controlled trials reporting results for 189 children, all of whom had a clinical diagnosis of a "low risk" ankle fracture. These were predominantly classified as undisplaced Salter-Harris type I fractures of the distal fibula. All three trials compared non-surgical management options. The three trials were at high risk of bias, primarily relating to the impracticality of blinding participants and treating clinicians to the allocated interventions.Two trials compared the Aircast Air-Stirrup ankle brace versus a rigid cast, which was a removable fibreglass posterior splint in one trial (trial A) and a below-knee fibreglass walking cast in the other trial (trial B). In trial A, both devices were removed at around two weeks. In trial B, removal of the brace was optional after five days, while the walking cast was removed after three weeks. There was low-quality evidence of clinically important differences in function scores at four weeks in favour of the brace groups of both trials. Function was measured using the Activities Scale for Kids-performance (ASKp; score range 0 to 100, higher scores mean better function) in trial A and using a modified version of the ASKp score (range 0 to 100%, higher percentages mean better function) in trial B. The results for trial A (40 participants) were median 91.9 in the brace group versus 84.2 in the splint group. The results for trial B (104 participants) were 91.3% versus 85.3%; mean difference (MD) 6.00% favouring brace (95% confidence interval (CI) 1.38% to 10.62%). Trial B indicated that 5% amounted to a clinically relevant difference in the modified ASKp score. Neither trial reported on unacceptable anatomy or related outcomes or long-term follow-up. There was very low-quality evidence relating to adverse events, none of which were serious. Trial A found twice as many children with pressure-related complications in the brace group (10 of 20 versus 5 of 20). In contrast, trial B found four times as many children in the cast group had adverse outcomes assessed in terms of an unscheduled visit to a healthcare provider (4 of 54 versus 16 of 50). Both trials linked some of the adverse events in the brace group with the failure to wear a protective sock. There was very low-quality evidence indicating an earlier return to pre-injury activity in the brace groups in both trials. Trial B provided low-quality evidence that children much prefer five days or more wearing an ankle brace than three weeks immobilised in a walking ankle cast. There was moderate-quality evidence of a lack of difference between the two groups in pain at four weeks.The third trial compared the Tubigrip bandage plus crutches and advice versus a plaster of Paris walking cast for two weeks and reported results at four weeks' follow-up for 45 children with an inversion injury of the ankle. The trial found very low-quality evidence of little difference in pain and function between the two groups, measured using a non-validated pain and function score at four weeks. The trial did not report on adverse effects. There was very low-quality evidence of an earlier return to normal activities, averaging six days, in children treated with Tubigrip (mean 14.17 days for Tubigrip versus 20.19 days for cast; MD -6.02 days, 95% CI -8.92 to -3.12 days).Recent evidence from magnetic resonance imaging studies of the main category of injury evaluated in these three trials suggests that most of the injuries in these trials were sprains or bone bruises rather than fractures of the distal fibular growth plate.

AUTHORS' CONCLUSIONS

There is low-quality evidence of a quicker recovery of self reported function at four weeks in children with clinically diagnosed low-risk ankle fractures who are treated with an ankle brace compared with those treated with a rigid cast, especially a non-removable walking cast. There is otherwise a lack of evidence from randomised controlled trials to inform clinical practice for children with ankle fractures. Research to identify and address priority questions on the treatment of these common fractures is needed.

Preliminary biomechanical study of different acetabular reinforcement devices for acetabular reconstruction

Background

Acetabular reinforcement devices (ARDs) are frequently used as load-sharing devices to allow allograft incorporation in revision hip arthroplasty with massive acetabular bone loss. The key to a successful reconstruction is robust fixation of the device to the host acetabulum. Interlocking fixation is expected to improve the initial stability of the postoperative construct. However, all commercially available ARDs are designed with non-locking fixation. This study investigates the efficacy of standard ARDs modified with locking screw mechanisms for improving stability in acetabular reconstruction.

Methods

Three types of ARDs were examined to evaluate the postoperative compression and angular stability: i) standard commercial ARDs, ii) standard ARDs modified with monoaxial and iii) standard ARDs modified with polyaxial locking screw mechanisms. All ARDs were implanted into osteomized synthetic pelvis with pelvic discontinuity. Axial compression and torsion tests were then performed using a servohydraulic material testing machine that measured load (angle) versus displacement (torque). Initial stability was compared among the groups.

Results

Equipping ARDs with interlocking mechanisms effectively improved the initial stability at the device/bone interface compared to standard non-locked ARDs. In both compression and torsion experiments, the monoaxial interlocking construct demonstrated the highest construct stiffness (672.6 ± 84.1 N/mm in compression and 13.3 ± 1.0 N·m/degree in torsion), whereas the non-locked construct had the lowest construct stiffness (381.4 ± 117.2 N/mm in compression and 6.9 ± 2.1 N·m/degree in torsion) (P < 0.05).

Conclusions

Our study demonstrates the potential benefit of adding a locking mechanism to an ARD. Polyaxial ARDs provide the surgeon with more flexibility in placing the screws at the cost of reduced mechanical performance. This in vitro study provides a preliminary evaluation of biomechanical performance for ARDs with or without interlocking mechanisms, actual clinical trial deserves to be further investigated in future studies.

Fixation of distal fibula fractures: an update

Level of Evidence:

Level V, expert opinion.