Mid- to Long-term Outcomes After Weber B-type Ankle Fractures With and Without Syndesmotic Rupture

Operative vs. Nonoperative Management of Isolated Weber B Ankle Fractures

Background and objective Ankle fractures (AFs) are common in orthopedic practice, with Weber B fractures representing a significant proportion. These fractures occur at the syndesmotic level of the fibula and can be treated either operatively or nonoperatively. However, the optimal management approach remains debated, particularly for isolated fractures without medial or syndesmotic involvement. This study aims to compare the operative and nonoperative management outcomes of isolated Weber B AFs in terms of functional recovery, complication rates, and patient satisfaction. Methodology This retrospective cohort study was conducted at the Department of Orthopedics, Hayatabad Medical Complex, Peshawar, from February 3, 2022, to March 2, 2023. A total of 115 patients with isolated Weber B AFs were included. Patients were categorized into operative (n = 65, 56.5%) and nonoperative (n = 50, 43.5%) groups. Outcomes assessed at six months included functional recovery using the Olerud-Molander Ankle Score (OMAS), complication rates (e.g., malunion, nonunion, and infection), and patient satisfaction levels. Statistical analyses were performed to compare outcomes between groups. Results The operative group demonstrated significantly higher OMASs (89.2 ± 6.3) than the nonoperative group (81.4 ± 8.1, P = 0.009). Malunion occurred in 4 patients (8%) in the nonoperative group but was not observed in the operative group (P = 0.034). Surgical site infections were observed in 3 patients (4.6%) in the operative group. Patient satisfaction was higher in the operative group, with 49 patients (75.3%) reporting being very satisfied compared to 32 patients (64%) in the nonoperative group (P = 0.045). Conclusions Operative management of isolated Weber B fractures offers better functional recovery and a lower risk of malunion compared to nonoperative treatment. For stable fractures, nonoperative management remains a valid option. Further long-term studies are required to assess the durability of outcomes for both approaches.

Syndesmotic fixation in Weber B ankle fractures: A systematic review

Weber Type B fractures often arise from external rotation with the foot supinated or pronated. Altered tibiofibular joint kinematics in Weber B fractures are responsible for syndesmotic damage seen in Weber B fractures. Weber B fractures are managed using open reduction and internal fixation if displaced. The syndesmosis is injured in up to 40% of cases resulting in an unstable injury with a syndesmotic diastasis. This systematic review aimed to evaluate the current literature on syndesmotic fixation in Weber B fractures, assess the outcomes and complications of syndesmotic fixation and assess the necessity of syndesmotic fixation in Weber B fractures. A search was carried out on the EMBASE, PubMed and CINAHL databases and eight studies assessing the outcomes of syndesmotic fixations versus no syndesmotic fixation with 292 Weber B ankle fractures were included in this systematic review. Results showed significant heterogeneity so a narrative review was conducted. Results of these studies showed that functional, radiological, and quality-of-life outcomes and incidences of post-traumatic osteoarthritis in patients with syndesmotic screws were similar to those of patients not managed with syndesmotic screws. Only one favoured syndesmotic fixation in all cases of diastasis. As such, syndesmotic fixation with screws may not be necessary in the management of Weber B fractures. Screws are also associated with breakage, loosening, local irritation and infections. Suture button devices and antiglide fixation techniques appear to be valid alternatives to syndesmotic screws. It was found that there was no need for routine hardware removal unless the hardware was causing significant side effects for the patient.

Syndesmosis Injury Contributes a Large Negative Effect on Clinical Outcomes: A Systematic Review

INTRODUCTION

The literature largely addresses questions of diagnostic accuracy and therapeutic accuracy. However, the magnitude of the clinical impact of syndesmosis injury is commonly described in intuitive yet qualitative terms. This systematic review aimed to quantify the impact of syndesmosis injury.

METHODS

Published clinical outcomes data were used to compute an effect size reflecting the impact of syndesmosis injury. This was done within the clinical contexts of isolated syndesmosis injury and syndesmosis injury with concomitant ankle fracture. Clinical outcomes data included Olerud-Molander (OM) and American Orthopaedic Foot and Ankle Society (AOFAS) scores, visual analog scale for pain, and days missed from sport competition. Parametric data were compared with Student t tests. Effect size was computed using Cohen's d.

RESULTS

In ankle fracture patients, syndesmosis injury demonstrated a large effect size for OM (d = 0.96) and AOFAS (d = 0.83) scores. In athletic populations without concomitant ankle fracture, syndesmosis injury demonstrated a large effect size on days missed from competition (d = 2.32).

DISCUSSION

These findings confirm the magnitude of the negative impact of syndesmosis injury in athletic populations with isolated injury and in ankle fracture patients. In ankle fracture patients, this large negative effect remains despite surgery. Thus, syndesmosis repair may not fully mitigate the impact of the injury.

LEVELS OF EVIDENCE

Level III: Systematic review.

Minimum 5-Year Follow-up Results: CROSSBAT (Combined Randomised and Observational Study of Surgery vs No Surgery for Type B Ankle Fracture Treatment)

BACKGROUND

Isolated Weber B, AO (Association for the Study of Internal Fixation) type 44B ankle fractures with no fracture to the medial side are the most common type of ankle fracture and may be treated with internal fixation or without surgery.This study aimed to determine if surgery is superior to nonsurgical management for the treatment of these fractures after a minimum 5-year follow-up.

METHODS

Design: A pragmatic, multicenter, single-masked, randomized controlled trial with minimum 5-year follow-up. Setting/participants/interventions: Participants between 18 and 65 years with AO type 44B ankle fracture and minimal talar shift were recruited from 22 hospitals in Australia and New Zealand. Participants willing to be randomized were randomly allocated to undergo surgical fixation followed by mobilization in a walking boot for 6 weeks. Those treated nonsurgically were managed in a walking boot for 6 weeks. Outcome assessors were masked for the treatment allocation. Primary outcomes: Patient-reported ankle function using the American Academy of Orthopaedic Surgeons Foot and Ankle Outcomes Questionnaire (FAOQ) and the physical component summary (PCS) of the SF-12v2 General Health Survey at 12 months postinjury and at minimum 5 years post injury. Primary analysis was intention-to-treat.

RESULTS

Of the 160 (80 surgical, 80 nonoperative) randomized patients included in the CROSSBAT analysis, 77 (40 surgical, 37 nonoperative) were followed up for repeat analysis at minimum 5-year follow-up (mean 7.3 years, range 5.1-8.9). This cohort demonstrated that surgery was not associated with clinically or statistically significant differences compared to nonoperative management for the FAOQ (51.7 vs 49.6; mean difference 2.1, 95% CI -2.1 to 6.2, P = .95), or the PCS (51.5 vs 49.1; mean difference 2.3, 95% CI -2.0 to 6.7, P = .54). The surgical cohort had a higher rate of any adverse events (odds ratio 3.7, 95% CI 1.2-11.6, P = .04).

CONCLUSION

The results of this study suggest that surgical management is not superior to nonsurgical management in type B ankle (fibula) fractures with minimal talar shift over a 5-year period and is associated with increased adverse events.

LEVEL OF EVIDENCE

Level II, randomized clinical trial.

Lateral Malleolar Fracture

The authors present the case of a young woman who sustained a lateral malleolar fracture. The Emergency Departement presentation, diagnosis and initial acute treatment is discussed.

The prognosis of ankle fractures: a systematic review

The aim of this study was to update the scientific evidence for ankle fracture prognosis by addressing radiographic osteoarthritis, time course and prognostic factors.

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were included if they were randomized controlled trials, controlled trials or observational studies, including case series and case-control studies investigating radiologically confirmed osteoarthritis in adults with a classified ankle fracture, treated with or without surgery, with a minimum follow-up of 1 year. Also included were studies examining prognostic factors predicting radiologically confirmed osteoarthritis. Tibial plafond and talus fractures were excluded.

Thirty-four studies were included examining 3447 patients. Extracted data included study type, inclusion and exclusion criteria, age, number of patients, number of fractures according to the author-reported classification method, radiological osteoarthritis, follow-up period, prognostic factors, and treatment.

Severe heterogeneity was visible in the analyses (I² > 90%), reflecting clinical heterogeneity possibly arising from the presence of osteoarthritis at baseline, the classifications used for the fractures and for osteoarthritis.

The incidence of osteoarthritis was 25% (95% CI: 18–32) and 34% (95% CI: 23–45) for more severe fractures with involvement of the posterior malleolus.

The severity of the trauma, as reflected by the fracture classification, was the most important prognostic factor for the development of radiographic osteoarthritis, but there is also a risk with simpler injuries.

The period within which osteoarthritis develops or becomes symptomatic with an indication for treatment could not be specified.

Comparative CT Study on Syndesmosis Mobility after Static or Dynamic Fixation for Ankle Fractures with Syndesmotic Rupture: A Pilot Study

BACKGROUND

The objective of this prospective randomized pilot study is to compare, by computed tomography (CT), the mobility of syndesmosis after static fixation (SF) or dynamic fixation (DF) in ankle fractures with syndesmotic rupture (AFSR) in adults, and to compare this mobility with that of healthy ankles.

METHODS

Forty-two patients with an AFSR were randomized to 2 groups: SF (N=21) or DF (N=21). Seven patients were lost to follow-up. Ultimately, 35 patients (SF, N=20; DF, N=15) were analyzed. The clinical results were assessed with the American Orthopedic Foot and Ankle Society scale. To assess syndesmosis mobility, CT in 30° of plantar flexion (PFlex) and 20° of dorsal flexion (DFlex) was performed on both ankles one year after the fracture. Four parameters were measured: anterior tibiofibular distance, posterior tibiofibular posterior distance, angle of fibular rotation (AFR), and anteroposterior fibular translation.

RESULTS

The AFR between DFlex and PFlex was more similar to the non-affected side in the DF group. The other three parameters showed no statistical differences between types of fixation. The mean loss of AFR compared with the non-affected side was 1.2° in the SF group and 0.1° in the DF group. No clinical differences between the SF group and the DF group were found. No correlation between clinical and radiological results was observed.

CONCLUSION

The AFR was more similar to the non-affected side in the DF group. However, this finding did not correlate with a better clinical result.

Predictors of Functional Outcome in Unstable Ankle Fractures Treated Surgically - A Prospective Cohort Study

Introduction:

Unstable ankle injuries require anatomical reduction and stabilisation for optimal outcome. In spite of adequate care, a few patients have poor outcome. In this study, we assessed the risk factors that predict the clinical outcomes in surgically treated unstable ankle fractures.

Material and methods:

This prospective cohort study was conducted on 68 patients who underwent surgical management for an unstable ankle injury. Demographic details, fracture type and associated medical comorbidities were recorded. Pre-operative radiographic assessment was done for all patients. At the end of one year follow-up, clinical (American Orthopaedic foot and ankle society-AOFAS and Olerud-Molander ankle - OMAS) scores and radiological parameters were assessed and analysed.

Results:

Fracture dislocation (0.008), diabetes mellitus (0.017), level of alchohol consumption (0.008) and pre-operative talocrural angle (TCA) > 100° (0.03) were significant predictors of poor outcomes as per AOFAS. Fracture dislocation (0.029), diabetes mellitus (0.004), pre-operative TCA > 100° (0.009), female gender (0.001), age more than 60 years (0.002) and open injuries (0.034) had significantly poor outcome as per OMAS. Other parameters (smoking, hypertension, classification, syndesmotic injury, medial clear space and tibiofibular overlap) did not affect the outcome significantly.

Conclusion:

Our study showed that poor outcome predictors in unstable ankle fractures are age >60 years, female gender, diabetes mellitus, alcohol consumption, fracture dislocation, open fractures and pre-op TCA >100°.

Functional outcome 3-6 years after operative treatment of closed Weber B ankle fractures with or without syndesmotic fixation

BACKGROUND

To compare the long-term functional outcomes of patients surgically treated for Weber B ankle fractures with or without syndesmotic fixation.

METHODS

In total, 959 adult patients with previous treatment with open reduction and internal fixation (ORIF) for closed ankle fractures were eligible for inclusion in a cross-sectional postal survey 3-6 years after surgery; 645 had Weber B fractures. The survey assessed functional outcomes with three validated ankle questionnaires.

RESULTS

In total 365 (57%) patients responded at a median of 4.2 years after the trauma. After adjusting for age, sex, education, smoking status, body mass index, diabetes, physical status before surgery, fracture classification, and duration of surgery, patients with a syndesmotic fixation had no different OMAS score (p = 0.98), LEFS score (p = 0.61), and SEFAS score (p = 0.98) than those without a syndesmotic fixation. Trimalleolar fracture was associated with worse functional outcomes than unimalleolar on two of the scales, the OMAS (p = 0.028) and LEFS (p = 0.046).

CONCLUSIONS

In multivariable analysis, patients with a syndesmotic fixation had no worse long-term functional outcomes than those without syndesmotic fixation.