Functional Outcomes Following Operative and Nonoperative Management of Weber C Ankle Fractures: A Systematic Review

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.

Inducing a Closed Ankle Fracture in a Cadaveric Model to Create Interdisciplinary Teaching Models for Preclinical Medical Students

This paper describes a cost-effective fracture simulation that aids in preclinical learning of fracture identification. This project establishes feasibility of inducing closed fractures in a donated cadaver. The study team made an identified Weber C ankle fracture in this donor, maintaining the soft tissue envelope surrounding the fracture, using minimal materials in a stepwise process that will be reproducible across educational programs regardless of access to highly specialized equipment. The resulting fracture can be used to help students identify fractures during their preclinical education and has demonstrated educational potential for future use and adaptation.

Tibio-Talar-Calcaneal Nail Fixation for Ankle Fractures: A Systematic Review and Meta-Analysis

Unstable ankle fractures are traditionally treated with open reduction and internal fixation. An alternative surgical option is primary tibio-talar-calcaneal fusion. Our aims were to determine the indication, complication rates, and functional outcomes, of tibio-talar-calcaneal nailing when used as the primary treatment of ankle fractures. A multidatabase literature search was performed on December 14, 2019 according to PRISMA guidelines. All studies in the English language reporting complications and outcomes involving tibio-talar-calcaneal nailing for primary treatment of ankle fractures were included. Ten studies with 252 ankle fractures were included. Mean age of patients was 75.5 (32-101) years. Mean follow-up duration was 79 weeks (36-104 weeks). Surgical site infection occurred in 11.2% (95% confidence interval [CI] 6.3%-19%) of patients, implant failure occurred in 8.1% (95% CI 5%-12.8%) of patients, and unplanned return to operating room occurred in 10.1% (95% CI 6.1%-16.2%) of patients. There were no cases of wound dehiscence. All-cause mortality rate at the end of follow-up was 26.6% (95% CI 19.7%-34.9%). Average reduction in Olerud-Molander Ankle Score after surgery was 7.9 points (5.0-11.8). Eighty-one point five percent (95% CI: 67.4%-90.4%) of patients were able to return to similar preoperative mobility aid after surgery. Tibio-talar-calcaneal nailing is an alternative procedure for patients who have sustained fractures unsuitable for nonoperative management, but have low functional demands and at increased risks of complications after open reduction and internal fixation. About 81.5% (95% CI 67.4%-90.4%) of patients were able to return to a similar preinjury mobility status after tibio-talar-calcaneal nailing.

Tourniquet Use During Open Reduction and Internal Fixation of Ankle Fractures - A Systematic Review and Meta-Analysis

The intra-operative use of tourniquet in open reduction and internal fixation (ORIF) of ankle fractures remains a topic of debate. The purpose of this study was to perform a systematic review and meta-analysis of randomized control trials (RCTs) comparing clinical outcomes of patients undergoing ankle ORIF with tourniquet use versus a control group where no tourniquet was used. A systematic review was performed with reference to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines of the Pubmed, Scopus, Embase, and Cochrane Library databases. Studies were included if they were an RCT comparing tourniquet and no-tourniquet in ankle ORIF. Meta-analysis was performed using RevMan, and p-value <.05 was considered to be statistically significant. On completion of the literature search, a total of 4 RCTs including 350 ankles (52.6% males), with a mean age of 47.1 ± 5.7 years were included. There were 173 patients in the tourniquet group (T), versus 177 patients in the no tourniquet control group (NT), with nonsignificant differences between the groups for age, gender and body mass index demographics (all p > .05). There were significantly shorter duration of surgery, with significantly higher patient-reported rates of pain levels at day 2 postoperatively (both p < .001) in the T group. Additionally, there were significantly greater ranges of ankle motion at 6 weeks postoperatively (p = .03), with nonsignificant differences reported incidence of wound infections and deep vein thrombosis (p = .056 and p = .130 respectively) between the groups. In conclusion, current evidence suggests that although intraoperative tourniquet usage in cases of ankle ORIF results in significant reductions in duration of surgery, this may be at the expense of higher patient-reported pain scores and reduced range of motion postoperatively.

Complication rates in operatively managed ankle fracture/dislocations: The effect of pre-reduction imaging and compliance with British orthopaedic association standards for trauma 12 guidance

Introduction

The British Orthopaedic Association Standards for Trauma (BOAST 12) guidelines for the management of ankle fractures aims to optimize recovery and reduce complications. Within the emergency department (ED), they advised urgent reduction of clinically deformed ankles, with radiographs prior only if this would not cause an unacceptable delay. The primary aim of this study was to assess the effect of time to acceptable reduction on the risk of complications and time to definitive reduction.

Methods

This was a retrospective observational study of patients presenting with ankle fracture dislocations between 2013 and 2017. Patients were divided into two groups with and without radiographs prior to reduction of their injury.

Results

A total of 242 patients were identified. The time taken from arrival to achieving an acceptable reduction was significantly longer in patients who received pre-reduction radiographs versus patients who did not (184.5 min vs 82, p < .00). The key finding of this follow-up study was that the overall risk of complications and soft tissue complications was not associated with an increased time to reduction ( p = .62). Time to definitive operative management was similar between the two sub-groups (immediate reduction 1 day vs 2, p = .72).

Conclusion

This study has shown that the use of pre-reduction radiographs in the management of ankle fracture dislocations significantly increases the time to reduction. However, this is not associated with an increased risk of complications or a longer time to definitive management. Further research is needed into the prognostic effect of prolonged ankle dislocation on soft tissues and long-term functional outcome.

Patient reported outcomes following non-operatively managed Weber Type A distal fibula fractures

INTRODUCTION

The outcomes of "Weber A" type fibula fractures treated non-operatively are not well studied. The aims of this study were to investigate patient reported outcomes (PROMs) from such injuries and investigate if different radiological features of the fracture affects such outcomes.

METHODS

Patients with conservatively managed Weber A fractures were contacted retrospectively (minimum 11 months) to measure PROMs. PROMs included the use of the Chertsey Outcome Score for Trauma (COST) as well as the time to return to work, physical activity and time to become symptom free. The effect of fracture features such as fracture height and intra-articular extension were analysed for their effect on PROMs.

RESULTS

Data was collected from 72 patients from a total of 211 patients presenting with Weber A fractures. The mean COST scores were 83 (range 30-100). Patients reported on average 3.1 weeks (desk based) and 5.7 weeks (labour intensive) to return to work, 10.8 weeks to return to physical activity and 14.8 weeks to become symptom free with 21% of patients still symptomatic at follow-up. Fracture height and fractures with comminution, displacement, intra-articular extension did not appear to be associated with poorer PROMs.

CONCLUSION

The outcomes are generally excellent; however, most patients do not return to their baseline before the injury, with a significant proportion of patients remaining symptomatic at follow-up. The reported times to return to work, physical activity and symptom-free are useful to manage patient expectations. Our results dispel any assumption that Weber A type distal fibula fractures are always associated with excellent outcomes.

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.