Two-Stage Surgery for the Malleolar Fracture-Dislocation With Severe Soft Tissue Injuries Does Not Affect the Functional Results

Internal fixation vs manual reduction in the treatment of ankle fracture healing and inflammation: A case-control study

Ankle fractures are among the most common bone injuries, which are often accompanied by soft tissue injuries. Proper management of these fractures is crucial to promote healing and minimize complications. This study explores the effects of 2 treatment methods for ankle fractures: open reduction and internal fixation and manual reduction followed by plaster external fixation. A retrospective analysis was conducted on 124 patients with ankle fractures admitted between March 2020 and September 2022. Patients were divided into 2 groups: 62 received internal fixation and 62 received manual reduction with plaster external fixation. The study evaluated various clinical outcomes, including treatment effectiveness, recovery times, the incidence of nonunion, ankle joint function and inflammatory factors, and complication rates. The internal fixation group showed a significantly higher effective treatment rate (96.77%) compared to the non-internal fixation group (85.48%). After treatment, the internal fixation group had significantly lower medial malleolus space and talus tilt angles, indicating better fracture alignment. The internal fixation group also had shorter treatment, postoperative recovery, and functional recovery times. Furthermore, the incidence of nonunion and complications was lower in the internal fixation group. Inflammatory markers such as interleukin-6 (IL-6), C-reactive protein (CRP), and interleukin-8 (IL-8) decreased significantly in the internal fixation group compared to the non-internal fixation group. Internal fixation is more effective than manual reduction and plaster external fixation for treating ankle fractures. It leads to better fracture healing, shorter recovery times, and fewer complications, including nonunion. Manual reduction with external fixation remains a viable option but may be associated with a higher risk of nonunion and delayed healing. Early and effective management of soft tissue injuries is crucial for improving treatment outcomes in ankle fractures.

Timing of Fracture Fixation in Ankle Fracture-Dislocations

Ankle fracture-dislocations may require delayed internal fixation. Our aim was to compare acute open reduction and internal fixation (ORIF) with delayed ORIF, using external fixation or cast splint in ankle fracture-dislocations. Factors that affect the rates of re-operation and Surgical site infection (SSI) were identified. In this retrospective cohort study, patients were included with open and closed ankle fracture-dislocations treated with ORIF from two large peripheral hospitals and one academic center in the Netherlands. This study included 447 patients with an ankle fracture-dislocation. In the multivariate analysis, the difference between surgery <48 hours compared to bridging with cast or external fixation had no significant influence on unscheduled re-operation or SSI. Higher body mass index (BMI) and open fractures had a significant positive correlation with re-operation while diabetes mellitus (DM) and open fractures correlated with SSI. In patients with open fractures, there was also no significant difference in outcome between acute or delayed internal fixation. We suggest that it is safe to perform primary ORIF on all dislocated ankle fractures if the soft tissue injury allows surgery within 48 hours. When significant swelling is present, patients with well-reduced fractures and with no soft tissue injury could be treated safely with a cast until delayed ORIF is possible.Level of Evidence: Therapeutic level 2B (retrospective cohort study).

Comparison of temporary external and percutaneous k-wire fixations for treatment of ankle fracture-dislocations

PURPOSE

Ankle fracture-dislocations are among the most severe injuries, and the use of an external fixator as a recommended fixation method has some disadvantages. The aim of this study was to compare the clinical outcomes and complication rates of external and K-wire fixations in the treatment of ankle fracture dislocations.

METHODS

A total of 67 patients with ankle fracture-dislocations requiring temporary external or percutaneous K-wire fixation were included. The exclusion criteria were pilon fractures, open fractures, and those who required acute open reduction internal fixation (ORIF). The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, a 10-point visual analog scale (VAS) score (range 0-10), and complications before and after the definitive surgery were recorded.

RESULTS

A significant difference between the two groups was not observed for age, sex, affected side, fracture type, smoking status, or diabetes. The average AOFAS scores were 83.2 and 83.3, the median VAS scores were 3 and 3, and the complication rates were 32.4% and 6.7% in the external and K-wire fixation groups, respectively (p = 0.010). However, skin necrosis, re-dislocation of the ankle, surgical wound infection, and posttraumatic ankle osteoarthritis frequency were not significantly different between the groups, except for pin-sites infection (p = 0.036).

CONCLUSION

Ankle fracture-dislocations using percutaneous k-wire fixation showed a low rate of complications and favorable clinical outcomes. This method could be a good alternative treatment option for ankle fracture-dislocations.

Intramedullary Fibular Fixation in One-Stage Ankle Fracture Surgery With Soft Tissue Damage: A Study of 19 Cases

This study investigates the efficacy of one-stage surgical intramedullary fibular fixation in managing ankle fractures with associated soft tissue damage. Ankle fractures, often encountered, can lead to complications when coupled with soft tissue injury. Traditional plate and screw fixation can exacerbate infection risks and reduce wound healing. To address this, a minimally invasive approach employing intramedullary fixation of the fibula has been proposed. This retrospective analysis, conducted between 2019 and 2021, explores cases of intramedullary fibular fixation for ankle fractures with stage 2-3 soft tissue injuries. A total of 19 patients were included in the study. The procedure involved either ulna intramedullary nails or locking screws. Results indicate that the approach led to successful union (100%), one superficial infection (5.26%), and no complication was observed. While limitations include the retrospective nature and small sample size, this study contributes valuable insights into the use of intramedullary fibular fixation in one-stage surgery for ankle fractures with concurrent soft tissue damage.

Percutaneous Reduction and Provisional Pinning of the Distal Fibula: A Novel Way to Maintain Fibular Length in Temporary Stabilization

Ankle fractures are commonly observed by orthopaedic trauma surgeons, foot and ankle surgeons, and general orthopaedists with more than 135,000 fractures surgically treated every year in the United States. 1 The soft tissue envelope surrounding the osseous anatomy of the ankle is limited and many injuries, including those that result from higher injury mechanisms and/or those occurring in hosts with vascular and metabolic comorbidities may benefit from a delay in definitive fixation; this may minimize risks of wound healing issues and fracture-related infection. 2,3 Open fractures may benefit from temporizing fixation after debridement and irrigation for the same reasons. 4-6 The benefits of temporizing external fixation in pilon fractures has been recognized for decades. 7 The use of ankle-spanning external fixation for ankle fractures and dislocations has become more frequently used to maintain coronal and sagittal alignment of the ankle mortise as a bridge to definitive fixation. 8-10 However, standard ankle-spanning external fixation techniques do not always directly restore fibular length and rotation, especially in fracture patterns with syndesmotic disruption and/or segmental fibular comminution. Some authors have advocated for limited internal fixation of fibula fractures at time of external fixation application to address this problem, 7 but this still necessitates a surgical approach through a traumatized soft tissue envelope and potentially compromises posterolateral and anterolateral approaches that could be used to address associated Volkman or Chaput fragments. Delayed distal fibular open reduction and internal fixation of shortened fractures has frustrated orthopaedic surgeons for decades and techniques such as "push-pull" screws 11 and extensive soft tissue dissection 12 are often necessary to restore anatomic fibular reduction of length and rotation. Given these challenges, the senior author began to use a technique of percutaneous reduction and buried provisional pinning of the distal fibula to the talus for fibula fractures with persistent shortening after ankle-spanning external fixation of injuries not deemed appropriate for immediate open reduction and internal fixation. We aim to report early results and describe this novel, low-cost surgical technique.

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.

Clinical assessments and gait analysis for patients with Trimalleolar fractures in the early postoperative period

Background

Trimalleolar fracture is a common ankle fracture with serious complications and costly healthcare problem. Most studies used clinical assessments to evaluate the functional status of the patients. Although clinical assessments are valid, they are static and subjective. Dynamic, objective and precise evaluations such as gait analysis are needed. Ankle biomechanics studies on gait in patients with trimalleolar fractures are still rare. This study aimed to investigate the clinical outcomes and gait biomechanics in patients with trimalleolar fractures in the early postoperative period and compared to healthy controls.

Methods

This was a cross-sectional study. 12 patients with trimalleolar fractures were recruited, and 12 healthy people served as controls. All patients underwent clinical assessments: Olerud and Molander ankle score (OMAS), ankle swelling and passive range of motion (ROM) of ankle, and completed gait biomechanical analysis when weight-bearing was allowed: temporal-spatial parameters, plantar pressure distributions, and surface electromyography (sEMG). The control group only performed gait test.

Results

Patients had poor outcomes of clinical assessments in the short-term. During gait analysis, patients presented compromised gait patterns: shorter step length, larger step width, slower walking speed and shorter single support compared to healthy controls (P < 0.001), and patients showed asymmetrical gait. Symmetry index of step width and walking speed were mainly correlated with the difference of ankle inversion ROM between two sides (R = -0.750, P = 0.005; R = -0.700, P = 0.011). During walking, patients showed abnormal dynamic plantar pressure features (mainly in the hindfoot and forefoot regions), and the IEMG (integrated electromyography) of tibial anterior muscle (TA) and peroneal longus muscle (PL) were larger than healthy controls (P = 0.002, 0.050).

Conclusions

Patients with trimalleolar fractures showed physical impairments of the ankle, and presented altered gait parameters compared to healthy subjects in the short-term. The ankle stability of patients declined, and deficits in TA and PL muscle ability might contribute to it. Restoring complete muscle functions and improving passive ankle ROM are significant to promote the recovery of a normal gait pattern.

OUTCOMES AFTER UNSTABLE FRACTURES OF THE ANKLE: WHAT'S NEW? A SYSTEMATIC REVIEW

BACKGROUND

Unstable ankle fractures are very frequent. Given the instability, they often require surgical treatment, but literature scarcely reports on the outcomes of their management.

QUESTIONS/PURPOSES

For this systematic review we asked: (1) What are the outcomes in treatment of unstable ankle fractures? (2) What about complications of treatment in unstable fractures? (3) What factors influence the outcomes? (4) What about the role of the posterior malleolus?

METHODS

The electronic databases PubMed, Scopus, and Embase were interrogated using the search terms "bimalleolar" or "trimalleolar" and "fracture". Studies were included if they reported on: (1) bimalleolar or trimalleolar fracture in adults; (2) treatment; (3) outcomes reported by scales; (4) follow-up. The final review included 33 studies. The quality of the studies was evaluated with the Methodological Index for Non-randomized Studies (MINORS) questionnaire.

RESULTS

All the outcomes of the thirty-three selected studies were analyzed.

DISCUSSION

Surgical fixation of unstable ankle fractures should always be performed within the first 48 hours from the trauma, preventing instability and post-traumatic osteoarthritis. Surgeon should consider factor may influence functional outcomes. Posterior malleolar fractures should be fixed regardless the size, considering some individual factors.

Fracture blisters: pathophysiology and management

Open fractures are considered an orthopaedic emergency due to the severe soft tissue disruption that might potentially lead to devastating complications. On the other hand, closed fractures, and especially those resulting from high-energy mechanisms, are also often accompanied by severe soft tissue trauma. Soft tissue envelope compromise can have a detrimental effect on the final outcome of the patients. Fracture blisters in particular, develop as a sign of significant local tissue trauma and appear in a time period between 6 to 72 hours post-injury. They can delay the definitive fracture treatment for a considerable amount of time and at the same time they also increase the risk for post-operative wound complications. Awareness of fracture blisters pathophysiology and their management options are crucial for orthopaedic surgeons, in order to achieve a favorable clinical outcome. In the herein study we present a concise synopsis of the pathophysiology pathways and management options of fracture blisters.