Marginal impaction associated with posterior malleolar fracture in rotational ankle injury

Computed Tomography Scans and Fixation Rates for Trimalleolar Ankle Fractures Over 10 Years at a Level 1 Trauma Center

Background

The posterior malleolus component of the trimalleolar ankle fracture has posed a controversial topic for diagnostic imaging and surgical management. Preoperative computed tomography (CT) scans are used to better appreciate fracture morphology and may affect management techniques. No prior study has investigated the trend in preoperative CT scan use and the rates of posterior and syndesmotic fixation for trimalleolar injuries.

Methods

This retrospective cohort study evaluated the use of preoperative CT scans and the rates of posterior and syndesmotic fixation for trimalleolar ankle fractures over a 10-year period at an adult level 1 trauma center. Patients surgically managed for ankle fractures with OTA/AO classifications of 44B3, 44C3.3, 44C1.3, 44C2.3, and 44A3 were identified and included using Current Procedural Terminology codes and a prospectively collected fracture registry. Demographic information, comorbidities, fixation methods, and use of preoperative CT scan were recorded. Comparative analyses were performed to assess for yearly differences in demographic characteristics along with changes in trends of preoperative CT scans and posterior and syndesmotic fixation.

Results

A total of 1191 patients were included in the analyses. OTA/AO 44B3.2 fractures were the most common injuries (yearly range of 59.4%-80.1%). The rate of posterior fixation did not significantly increase during the study interval (1.4% growth per year [95% CI -0.27, 3.07]). However, the rate of preoperative CT scan use significantly increased by 2.76% (95% CI 1.99, 3.52) per year and the rate of syndesmotic fixation increased by 2.58% (95% CI 1.17, 3.99) per year. Fixation methods for both the syndesmosis and posterior malleolus changed during the study timeline.

Conclusion

Despite a relatively stable rate of posterior fixation, the frequency of preoperative CT scans and use of syndesmotic fixation increased significantly over a 10-year study period.

Level of Evidence

Level IV, descriptive pilot study.

Importance of computed tomography in posterior malleolar fractures: Added information to preoperative X-ray studies

BACKGROUND

Ankle fractures are common lesions of the lower limbs. Approximately 40% of ankle fractures affect the posterior malleolus (PM). Historically, PM osteosynthesis was recommended when PM size in X-ray images was greater than 25% of the joint. Currently, computed tomography (CT) has been gaining traction in the preoperative evaluation of ankle fractures.

AIM

To elucidate the similarity in dimensions and to correlate PM size in X-ray images with the articular surface of the affected tibial plafond in the axial view on CT (AXCT) of a PM fracture.

METHODS

Eighty-one patients (mean age: 39.4 ± 13.5 years) were evaluated (54.3% were male). Two independent examiners measured PM size in profile X-ray images (PMXR) and sagittal CT (SAGCT) slices. The correlation of the measurements between the examiners and the difference in the PM fragment sizes between the two images were compared. Next, the PM size in PMXR was compared with the surface of the tibial plafond involved in the fracture in AXCT according to the Haraguchi classification.

RESULTS

The correlation rates between the examiners were 0.93 and 0.94 for PMXR and SAGCT, respectively (P < 0.001). Fragments were 2.12% larger in SAGCT than in PMXR (P = 0.018). In PMXR, there were 56 cases < 25% and 25 cases ≥ 25%. When PMXR was < 25%, AXCT corresponded to 10.13% of the tibial plafond. When PMXR was ≥ 25%, AXCT was 24.52% (P < 0.001). According to the Haraguchi classification, fracture types I and II had similar PMXR measurements that were greater than those of type III. When analyzing AXCT, a significant difference was found between the three types, with II > I > III (P < 0.001).

CONCLUSION

PM fractures show different sizes using X-ray or CT images. CT showed a larger PM in the sagittal plane and allowed the visualization of the real dimensions of the tibial plafond surface.

Classifications of posterior malleolar fractures: a systematic literature review

INTRODUCTION

Complex ankle fractures frequently involve the posterior malleolus. Many classifications describing posterior malleolar fractures (PMF) exist. The aim of this study was to provide a systematic literature review to outline existing PMF classifications and estimate their accuracy.

METHODS

The databases PubMed and Scopus were searched without time limits. Only specific PMF classifications were included; general ankle and/or pilon fracture classifications were excluded. Selection and data extraction was performed by three independent observers. The systematic literature search was performed according to the current criteria of Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). The methodological quality of the included studies was quantified using the modified Coleman score.

RESULTS

A total of 110 studies with a total of 12.614 patients were included. Four main classifications were identified: Those describing the size of the posterior malleolar fracture (n = 66), Haraguchi (n = 44), Bartoníček/Rammelt (n = 21) and Mason (n = 12). The quality of the studies was moderate to good with a median Coleman-score of 43.5 (14-79) and a weighted median Coleman-score of 42.5 points. All classifications achieved a substantial to perfect score regarding the inter- and intraobserver reliability, with Mason scoring the lowest in comparison.

CONCLUSIONS

None of the reviewed PMF classifications has been able to establish itself decisively in the literature. Most of the classifications are insufficient in terms of a derivable treatment algorithm or a prognosis with regard to outcome. However, as the Bartoníček/Rammelt classification has the greatest potential due to its treatment algorithm, its reliability in combination with consistent predictive values, its usage in clinical practice and research appears advisable.

Evaluation of Application Effect of Self-Made Compression Cold Therapy in Postoperative Rehabilitation of Patients with Orthopedic Dyskinesia

With the accelerated aging of the population, orthopedic injuries have become more collective. Among them, the incidence of ankle fractures remains high. Surgery is an effective way to treat ankle fractures by utilizing special surgical site, complex anatomical structure, and specific surgical methods. With surgical approach, it is easy for basis postoperative blood loss, pain, swelling, and other problems. After surgery, most patients suffer from symptoms of fear, increased pain sensitivity, and excessive irrational concerns about physical movement or activity. Compression cold therapy combines cold therapy with air pressure therapy to ease local exudation, constrict blood vessels, improve circulation, relieve pain, and control inflammation through the effects of low temperature and pressure. Application during the rehabilitation period can prevent joint swelling, reduce muscle soreness, and promote the functional recovery of limbs, which provides an effective guarantee for postoperative rehabilitation of patients with orthopedic dyskinesia. Based on this, it is very important to evaluate the application and effect of self-made compression cold therapy in postoperative rehabilitation of patients with orthopedic dyskinesia. This work proposes a one-dimensional deep convolutional neural network-based method; DenseNet for analyzing the rehabilitation effect of patients with orthopedic dyskinesia after ankle fracture surgery. The approach is to evaluate the rehabilitation effect of self-made compression cold therapy from the perspectives of feature reuse, attention mechanism, and feature decoupling. Experiments on the dataset show that the proposed neural network has better efficacy evaluation performance. The proposed systematic assessment based on the emerging deep learning network has great significance in healthcare domain, particularly in assessing applicability, side effects, and noninvasiveness of treatment methods.