Unstable malleolar ankle fractures: evaluation of prognostic factors and sports return

Predictive factors to return to sport after surgical management of ankle fractures

Achieving Return to Sport (RTS) is crucial in managing ankle fractures for athletes. This study aimed to identify RTS factors post-surgical fixation of ankle fractures. A retrospective analysis was conducted on 93 active patients with surgically treated displaced or unstable ankle fractures from January 2020 to January 2021. The median follow-up was 2.12 years. Clinical, functional, and radiographic aspects were evaluated. Among the athletes, 82.8 % resumed sports post-surgery, with 26.9 % returning within 3 months and 75.3 % at 1 year. At 1 year, 40.9 % regained their pre-injury activity level. There was a significant association between RTS and AO/OTA fracture subtype (p = 0.038). Unimalleolar fractures had the best outcomes, with 100 % achieving RTS in a median of 4 months. Bimalleolar fractures had 80.77 % RTS in 6 months, and trimalleolar fractures had 65.22 % RTS in 8 months. AO/OTA subtypes B and C predicted lower RTS to pre-injury levels, with delayed recovery for bimalleolar and trimalleolar fractures. These findings underscore the impact of fracture severity on RTS, with more complex fractures leading to poorer and delayed recovery outcomes.

Treatment Strategy for Posterior Malleolar Fractures: Different Operative Strategies Are Needed for Each Morphological Type

Background: The operative indication for posterior malleolar fracture (PMF) remains controversial. This study aimed to assess the midterm outcomes of PMF treatment for developing a treatment strategy for each morphological type. Methods: In this retrospective analysis, patients undergoing operative treatment for an unstable ankle fracture involving PMF were included after at least 3 years of follow-up. PMFs were classified by fracture morphology according to the Haraguchi classification. This study divided the entire cohort into three independent populations based on the types of PMF. For each population, patients were further categorized into two groups depending on whether PMF was surgically fixed or not, and comparisons were made between these two groups. Demographic data, functional and radiographical outcomes were compared between two groups in each of the three populations. Results: With a total of 472 patients, the mean patient age was 45.8 years, and the mean follow-up was 51 months. For type 1 fracture, a total of 237 cases were found. Quality of reduction by CT (QRC) was mostly good in both groups (83.6% vs. 83.3% in the non-fixation vs. fixation group, respectively, p = 0.269). Functional and radiological outcomes between both groups showed no significant difference. For type 2 PMFs, a total of 199 cases were found, and QRC was significantly different between the two groups (good grade, 5.4% vs. 60.7% in the non-fixation vs. fixation group, respectively, p < 0.001). The radiological and clinical outcomes of the PMF fixation group were statistically superior to those of the non-fixation group (both p < 0.001). For type 3 fractures, a total of 36 cases were found. In all the cases in this group, surgical fixation of PMF was not performed. Only the syndesmosis instability was analyzed as a viable factor to be considered for achieving favorable surgical outcomes. PMF fixation group showed significantly more postoperative complications (24.4% vs. 40.4%, non-fixation vs. fixation, respectively, p < 0.001). Major complications in the fixation group were deep wound infection (6.8%), superficial peroneal nerve injury (6.8%), and hallux flexion deficit (5.0%). Conclusions: Different treatment strategies seem to be required for each PMF morphological subtype. Further studies with more detailed designs for each PMFs are warranted for more clinically related results that are helpful for making practical surgical decisions.

Clinical, functional and radiological outcome after osteosynthesis of ankle fractures using a specific provocation test

BACKGROUND

Ankle fractures are frequent, and despite numerous publications on their treatment and outcome, there is a lack of precise data on the functional results in young, healthy and physically active patients. We hypothesized that patients who underwent open reduction and internal fixation (ORIF) for simple ankle fractures would have similar function compared to a healthy control group, whereas patients with complex fractures will have significant functional deficits. Furthermore, we postulate that there is a discrepancy between the radiological and the functional outcomes.

METHODS

A set of specific provocation tests was developed to evaluate the postoperative possibility of weight bearing, stop-and-go activities and range of motion. In combination with three questionnaires and a radiographic evaluation, the true functional outcome and the possibility of participating in sporting activities were investigated and compared with those of an age- and sex-matched control group.

RESULTS

A significant impairment was found in unilateral and simple ankle fractures. This impairment increased in tests including stop-and-go activities in combination with load bearing and with the complexity of the fractures. Concerning the subjective outcome, there was a significant adverse effect for daily activities without any difference in preoperative or postoperative sporting activity between the groups. No difference was found in the radiological assessment.

CONCLUSIONS

Both simple and complex ankle fractures treated with ORIF have a significant and long-lasting impact on functional outcome in young and active patients. The radiological result is not associated with a good functional outcome.

TRIAL REGISTRATION

BASEC-Nr. 2018 - 01124.

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.

Temporizing cast immobilization is a safe alternative to external fixation in ankle fracture-dislocation while posterior malleolar fragment size predicts loss of reduction: a case control study

Background

To determine if temporizing cast immobilization is a safe alternative to external fixator (ex-fix) in ankle fracture-dislocations with delayed surgery or moderate soft-tissue injury, we analysed the early complications and re-dislocation rates of cast immobilization in relation to ex-fix in patients sustaining these injuries.

Methods

All skeletally mature patients with a closed ankle fracture-dislocation and a minimum 6-months follow-up treated between 2007 and 2017 were included. Baseline demographics, comorbidities, injury description, treatment history and complications were assessed.

Results

In 160 patients (94 female; mean age 50 years) with 162 ankle fracture-dislocations, 35 underwent primary ex-fix and 127 temporizing cast immobilizations. Loss of reduction (LOR) was observed in 25 cases (19.7%) and 19 (15.0%) were converted to ex-fix. The rate of surgical site infections (ex-fix: 11.1% vs cast: 4.6%) and skin necrosis (ex-fix: 7.4% vs cast: 6.5%) did not differ significantly between groups (p = 0.122 and p = 0.825). Temporizing cast immobilization led to an on average 2.7 days earlier definite surgery and 5.0 days shorter hospitalization when compared to ex-fix (p < 0.001). Posterior malleolus fragment (PMF) size predicted LOR with ≥ 22.5% being the threshold for critical PMF-size (p < 0.001).

Conclusion

Temporizing cast immobilization was a safe option for those ankle fracture-dislocations in which immediate definite treatment was not possible. Those temporized in a cast underwent definite fixation earlier than those with a fix-ex and had a complication rate no worse than the ex-fix patients. PMF-size was an important predictor for LOR. Primary ex-fix seems appropriate for those with ≥ 22.5% PMF-size.

Trial registration

The study does not meet the criteria of a prospective, clinical trial. There was no registration.

Fibular displacement does not predict instability in type B ankle fractures

INTRODUCTION

Despite the wide prevalence of ankle fractures, no consensus exists on the most accurate radiologic diagnostic tool to indicate medial ligament injury in isolated type B distal fibular fractures. The aim of this study was to evaluate the value of the fibular fracture displacement in predicting medial clear space widening on the gravity stress radiographs, as a parameter of fracture instability.

METHODS

This retrospective cohort study included 192 patients with an isolated type B fibular fracture, for which a regular mortise and gravity stress radiograph were made in our hospital between January 2014 and December 2019. On the regular mortise and lateral radiographs, the medial clear space (MCS), superior clear space (SCS), anteroposterior and lateral fibular displacement were measured. On the gravity stress radiograph, the MCS and SCS were measured. Instability was defined as MCS ≥ SCS + 3.0 mm on the gravity stress radiograph. A receiver operating characteristic (ROC) curve was constructed to evaluate the predictive value of the fibular displacement.

RESULTS

Of the 192 included patients, 55 (29%) patients had instable ankle fractures. In predicting instability, fibular displacement demonstrated an area under the curve (AUC) of 0.68 (95% confidence interval 0.60-0.77) and a correlation coefficient of 0.41 with MCS.

CONCLUSION

Fibular displacement on regular mortise view is a poor predictor of instability in type B fibular fractures. It should not be advised to use the fracture displacement as parameter for medial injury and thus for operative treatment.

Efficacy of hook-type locking plate and partially threaded cancellous lag screw in the treatment of displaced medial malleolar fractures in elderly patients

INTRODUCTION

Traditionally, partially threaded cancellous lag screws (PTCS) are used for most medial malleolar fractures but are often challenging to execute in elderly patients because of the high risk of postoperative complications. Limited literature explores whether hook-type locking compression plates (LCPs) reliably offer better outcomes than PTCS in elderly patients. We aimed to compare the midterm radiologic and clinical outcomes between hook-type LCP and PTCS for medial malleolar fractures in an elderly population.

METHODS

We included 258 patients, aged 65 years and above, treated with either a hook-type locking plate (hook LCP group: 121 patients) or PTCS (screw group: 137 patients), and with follow-ups of at least 36 months in this retrospective study. Radiographic assessments included the union rate and interval to fracture union. Clinical assessment included the postoperative complications and revision procedures.

RESULTS

Although a significantly higher rate of comminuted fractures was observed in the hook LCP group than in the screw group (p < .001), no significant difference in the union rate was observed between the two groups (hook LCP group: 93.4% vs. screw group: 89.8%, p = .151), and a significantly shorter interval to union was observed in the hook LCP group (10.2 ± 7.0 vs. 12.3 ± 6.7 weeks, p = .015). There was a trend toward a lower rate of complications, including revision procedures, in the hook LCP group than in the screw group (19.9% vs. 28.5%, p = .107 and 6.6% vs. 13.8%, p = .074).

CONCLUSION

Hook-type LCP may be an alternative option for treating medial malleolar fractures with comminution in elderly patients.

Doctor, I fractured my ankle. When can I return to play? An updated systematic review

INTRODUCTION

Ankle fractures in sport are common. Their optimal management is unclear, as is when patients can return to their sports activities. This systematic review provides a contemporary assessment of the literature on return to sports following acute traumatic ankle fractures managed both operatively and non-operatively.

SOURCES OF DATA

We systematically searched Pubmed, Google Scholar, the Cochrane Library, EMBASE and CINAHL using the terms 'ankle fractures', 'ankle injuries', 'athletes', 'sports', 'return to sport', 'return to activity', 'operative management', 'non-operative management'.

AREAS OF AGREEMENT

Thirteen retrospective studies fulfilled the inclusion criteria. The methodological quality of the studies was generally poor. The proportion of patients returning to sporting activity was high. In some studies, a quicker return to sporting activity was demonstrated in patients managed non-operatively.

AREAS OF CONTROVERSY

The time to return to sporting activity and level of performance post-treatment are not universally recorded, and the optimal time to return to sport remains to be confirmed.

GROWING POINTS

Conservative management for stable or undisplaced fracture may result in a higher proportion of patients returning to sport more quickly.

AREAS TIMELY FOR DEVELOPING RESEARCH

Randomized controlled trials should compare conservative to surgical treatment for appropriately chosen fracture patterns. Future studies should routinely report the timing of return to sport, the level of performance reached, and the time to achieve this.

Evaluation Method of Public Physical Training Quality Based on Global Topology Optimization Deep Learning Model

In the quality evaluation of public sports training, the selected indicators are not comprehensive, resulting in some errors in the results of quality evaluation. Therefore, this paper designs a public sports training quality evaluation method based on the deep learning model of global topology optimization. Determine the basic principles of public sports training quality evaluation, determine the human coordinate points of public sports training by determining the basic section and basic axis of human training, and extract the data of public sports training quality evaluation. On this basis, quantify the public sports training quality evaluation index, construct the evaluation matrix, calculate the weight of the evaluation index, and determine the importance of the public sports training quality evaluation index. Preprocess the public sports training quality evaluation index set, search the optimal fitness value in the global topology optimization depth learning model, introduce the global topology optimization depth learning model, input the evaluation index and output the evaluation quality results, and realize the quality evaluation of public sports training. The experimental results show that the evaluation method in this paper can improve the accuracy of the evaluation results and is feasible.

A systematic review of ankle fracture-dislocations: Recent update and future prospects

BACKGROUND

Ankle fracture-dislocations are one of the most severe types of ankle injuries. Compared to the simple ankle fractures, ankle fracture-dislocations are usually more severely traumatized and can cause worse functional outcomes. The purpose of this study was to review the previous literatures to understand the anatomy, mechanisms, treatment, and functional outcomes associated with ankle fracture-dislocations.

METHODS

The available literatures from January 1985 to December 2021 in three main medical databases were searched and analyzed. The detailed information was extracted for each article, such as researchers, age, gender, groups, type of study, type of center research, level of evidence, significant findings, study aim, cause of injury, time from injury to surgery, type of fracture, direction of dislocation, follow-up, postoperative complications and functional evaluation scores.

RESULTS

A total of 15 studies (1,089 patients) met the inclusion criteria. Only one study was a prospective randomized trial. The top-ranked cause of injury was high-energy injury (21.3%). Moreover, the most frequent type of fracture in ankle dislocations was supination-external rotation (SER) ankle fracture (43.8%), while the most common directions of dislocation were lateral (50%) and posterior (38.9%).

CONCLUSIONS

Collectively, most ankle fracture-dislocations are caused by high-energy injuries and usually have poor functional outcomes. The mechanism of injury can be dissected by the ankle anatomy and Lauge-Hansen's classification. The treatment of ankle fracture-dislocations still requires more detailed and rational solutions due to the urgency of occurrence, the severity of injury, and the postoperative complications.

Complications following surgical treatment of posterior malleolar fractures: an analysis of 300 cases

AIMS

The treatment of ankle fractures and fracture-dislocations involving the posterior malleolus (PM) has undergone considerable changes over the past decade. The aim of our study was to identify risk factors related to the occurrence of complications in surgically treated ankle fractures with PM involvement.

PATIENTS AND METHODS

We retrospectively analyzed 300 patients at a mean age of 57 years with 300 ankle fractures involving the PM treated surgically at our institution over a 12-year period. The following relevant comorbidities were noted: arterial hypertension (43.7%; n = 131), diabetes mellitus (DM) (14.0%; n = 42), thereof insulin-dependent (3.7%; n = 11), peripheral vascular disease (0.7%; n = 2), osteoporosis (12.0%; n = 36), dementia (1.0%; n = 3), and rheumatoid arthritis (2.0%; n = 6). Furthermore, nicotine consumption was recorded in 7.3% (n = 22) and alcohol abuse in 4.0% (n = 12).

RESULTS

Complications occurred in 41 patients (13.7%). A total of 20 (6.7%) revision surgeries had to be performed. Patients with DM (p < 0.001), peripheral vascular disease (p = 0.003) and arterial hypertension (p = 0.001) had a significantly increased risk of delayed wound healing. Alcohol abuse was associated with a significantly higher overall complication rate (OR 3.40; 95% CI 0.97-11.83; p = 0.043), increased rates of wound healing problems (OR 11.32; 95% CI 1.94-65.60; p = 0.001) and malalignment requiring revision (p = 0.033). The presence of an open fracture was associated with an increased rate of infection and wound necrosis requiring revision (OR 14.25; 95% CI 2.39-84.84; p < 0.001). Multivariate analysis identified BMI (p = 0.028), insulin-dependent DM (p = 0.003), and staged fixation (p = 0.043) as independent risk factors for delayed wound healing. Compared to the traditional lateral approach, using the posterolateral approach for fibular fixation did not lead to increased complication rates.

CONCLUSIONS

Significant risk factors for the occurrence of complications following PM fracture treatment were identified. An individually tailored treatment regimen that incorporates all risk factors is important for a good outcome.

Comparison of results of three different patient-based assessment scales in surgically treated adult ankle fractures

Purpose: The aim of this study was to evaluate the post-operative clinical and radiological results of ankle fractures, using three different patient-reported outcome measurements (PROM) and to analyze the results and compatibility of the PROMs. Materials and Methods: A total of 77 patients were followed up prospectively. Demographic data, fracture side, trauma mechanisms, fracture types, post-operative splint times, initiation of full weight bearing time, and complications were recorded. All patients were evaluated according to the AOFAS, Ankle-Hindfoot Rating Scale, Weber Scoring and Freiburg Scale, at the first-year follow-ups. Results: The results were good in 57 patients (74%) and poor in 20 patients (26%), according to the AOFAS Scale; excellent in 51 patients (66.2%), good in 12 patients (15.6%) and poor in 14 patients (18.2%) according to the Weber Scoring, and excellent in 50 patients (64.9%), good in 12 patients (15.6%) and poor in 15 patients (19.5%) according to the Freiburg Scale. The results of the PROMs were found to be compatible with each other. Significant relationship was found between the development of complications and the AOFAS Scale and Weber Scoring, and between older age and Weber Scoring. Conclusion: The results of the AOFAS Scale, Weber Score and Freiburg Scales are compatible with each other and can be safely used in the evaluation of ankle fractures. Development of complications and older age are associated with poor clinical outcomes.

Ankle fractures involving the posterior malleolus: patient characteristics and 7-year results in 100 cases

INTRODUCTION

The presence of a posterior malleolar (PM) fragment has a negative prognostic impact in ankle fractures. The best treatment is still subject to debate. The aim of this study was to assess the medium-to-long-term clinical and functional outcome of ankle fractures with a PM fragment in a larger patient population.

MATERIALS AND METHODS

One hundred patients (69 women, 31 men, average age 60 years) with ankle fractures including the PM were evaluated clinically and radiographically. Patients with Bartoníček-Rammelt type 3 and 4 fracture displayed a significant female preponderance. Fixation of the PM was performed in 63% and tailored to the individual fracture pattern.

RESULTS

Internal fixation of the PM fragment was negatively correlated with the need for syndesmotic screw placement at the time of surgery (p = 0.010). At an average follow-up of 7.0 years, the mean Foot Function Index (FFI) was 16.5 (SD: 21.5), the Olerud Molander Ankle Score (OMAS) averaged 80.2 (SD: 24) and the American Orthopedic Foot & Ankle Society (AOFAS) ankle/hindfoot score averaged 87.5 (SD: 19.1). The maximum score of 100 was achieved by 44% of patients. The physical (PCS) and mental health component summary (MCS) scores of the SF-36 averaged 47.7 (SD: 12.51) and 50.5 (SD: 9.36), respectively. Range of motion was within 3.4 (SD: 6.63) degrees of the uninjured side. The size of the PM fragment had no prognostic value. There was a trend to lower outcome scores with slight anterior or posterior shift of the distal fibula within the tibial incisura. Patients who underwent primary internal fixation had significantly superior SF-36 MCS than patients who underwent staged internal fixation (p = 0.031).

CONCLUSIONS

With an individualized treatment protocol, tailored to the CT-based assessment of PM fractures, favorable medium and long-term results can be expected.