1
|
Hawkins J, Andrews NA, Sankey MT, Sanchez T, Young S, Agarwal A, McGwin G, Shah A. The Impact of Surgical Timing After Ankle Fracture on Clinical and Long-Term Patient Reported Outcomes. J Foot Ankle Surg 2023; 62:701-706. [PMID: 37003858 DOI: 10.1053/j.jfas.2023.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/27/2023] [Accepted: 02/19/2023] [Indexed: 04/03/2023]
Abstract
The goal of this study is to evaluate the effect of time-to-surgery following closed ankle fractures on long-term patient reported outcomes, fracture healing, and wound complications. To date, little research has been done focusing on the impact "time to definitive fixation" has on patient reported outcomes. We performed a retrospective analysis of 215 patient records who underwent open reduction and internal fixation (ORIF) for an ankle fracture from July 2011 to July 2018. A total of 86 patients completed the patient reported outcome measurement information systems (PROMIS) survey at long-term follow-up. Primary outcomes were the rate of delayed union, postoperative wound complications, patient reported outcome measurement information system (PROMIS) pain interference (PI), and physical function (PF) scores. No differences were found when comparing time to surgery on a continuous scale with rates of delayed union, nonunion, or wound complications (p = .84, .47, and .63, respectively). PROMIS scores were collected at a median of 4.5 years (2.0 interquartile range (IQR), range 2.5-12.3) postoperatively. The time from ankle fracture to surgery was independently associated with worse PROMIS PI scores (unstandardized β 0.38, 95% CI 0.07-0.68) but not PROMIS PF scores. Severe Lauge-Hansen injuries were independently associated with decreased PROMIS PF scores (unstandardized β -7.02, 95% CI -12.0 to -2.04). Increased time to surgical intervention and severe Lauge-Hansen injuries were independently associated with worse long-term patient reported outcomes. Surgical timing did not impact union rates or wound complications. Surgeons should be aware that delaying ankle fracture repair beyond 12 days after injury may negatively affect long-term patient reported pain scores.
Collapse
Affiliation(s)
- Jacob Hawkins
- Orthopaedic Resident, Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Nicholas A Andrews
- Orthopaedic Resident, Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Matthew T Sankey
- Orthopaedic Research Fellow, Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Thomas Sanchez
- Orthopaedic Research Fellow, Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Sean Young
- Research Fellow, Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Abhinav Agarwal
- Assistant Professor, Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Gerald McGwin
- Professor, Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL
| | - Ashish Shah
- Associate Professor, Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL.
| |
Collapse
|
2
|
Gerlach R, Toepfer A, Jacxsens M, Zdravkovic V, Potocnik P. 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. BMC Musculoskelet Disord 2022; 23:698. [PMID: 35869482 PMCID: PMC9306170 DOI: 10.1186/s12891-022-05646-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 07/08/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
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.
Collapse
|
3
|
Prijs J, Liao Z, To MS, Verjans J, Jutte PC, Stirler V, Olczak J, Gordon M, Guss D, DiGiovanni CW, Jaarsma RL, IJpma FFA, Doornberg JN. Development and external validation of automated detection, classification, and localization of ankle fractures: inside the black box of a convolutional neural network (CNN). Eur J Trauma Emerg Surg 2022; 49:1057-1069. [PMID: 36374292 PMCID: PMC10175446 DOI: 10.1007/s00068-022-02136-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 10/10/2022] [Indexed: 11/16/2022]
Abstract
Abstract
Purpose
Convolutional neural networks (CNNs) are increasingly being developed for automated fracture detection in orthopaedic trauma surgery. Studies to date, however, are limited to providing classification based on the entire image—and only produce heatmaps for approximate fracture localization instead of delineating exact fracture morphology. Therefore, we aimed to answer (1) what is the performance of a CNN that detects, classifies, localizes, and segments an ankle fracture, and (2) would this be externally valid?
Methods
The training set included 326 isolated fibula fractures and 423 non-fracture radiographs. The Detectron2 implementation of the Mask R-CNN was trained with labelled and annotated radiographs. The internal validation (or ‘test set’) and external validation sets consisted of 300 and 334 radiographs, respectively. Consensus agreement between three experienced fellowship-trained trauma surgeons was defined as the ground truth label. Diagnostic accuracy and area under the receiver operator characteristic curve (AUC) were used to assess classification performance. The Intersection over Union (IoU) was used to quantify accuracy of the segmentation predictions by the CNN, where a value of 0.5 is generally considered an adequate segmentation.
Results
The final CNN was able to classify fibula fractures according to four classes (Danis-Weber A, B, C and No Fracture) with AUC values ranging from 0.93 to 0.99. Diagnostic accuracy was 89% on the test set with average sensitivity of 89% and specificity of 96%. External validity was 89–90% accurate on a set of radiographs from a different hospital. Accuracies/AUCs observed were 100/0.99 for the ‘No Fracture’ class, 92/0.99 for ‘Weber B’, 88/0.93 for ‘Weber C’, and 76/0.97 for ‘Weber A’. For the fracture bounding box prediction by the CNN, a mean IoU of 0.65 (SD ± 0.16) was observed. The fracture segmentation predictions by the CNN resulted in a mean IoU of 0.47 (SD ± 0.17).
Conclusions
This study presents a look into the ‘black box’ of CNNs and represents the first automated delineation (segmentation) of fracture lines on (ankle) radiographs. The AUC values presented in this paper indicate good discriminatory capability of the CNN and substantiate further study of CNNs in detecting and classifying ankle fractures.
Level of evidence
II, Diagnostic imaging study.
Collapse
Affiliation(s)
- Jasper Prijs
- Department of Orthopaedic Surgery, Groningen University Medical Centre, Groningen, The Netherlands.
- Department of Surgery, Groningen University Medical Centre, Groningen, The Netherlands.
- Department of Orthopaedic & Trauma Surgery, Flinders Medical Centre, Flinders University, Adelaide, Australia.
| | - Zhibin Liao
- Australian Institute for Machine Learning, Adelaide, Australia
| | - Minh-Son To
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
- Department of Neurosurgery, Flinders Medical Center, Adelaide, Australia
| | - Johan Verjans
- Australian Institute for Machine Learning, Adelaide, Australia
| | - Paul C Jutte
- Department of Orthopaedic Surgery, Groningen University Medical Centre, Groningen, The Netherlands
| | - Vincent Stirler
- Department of Orthopaedic Surgery, Groningen University Medical Centre, Groningen, The Netherlands
| | - Jakub Olczak
- Institute of Clinical Sciences, Danderyd University Hospital, Karolinska Institute, Solna, Sweden
| | - Max Gordon
- Institute of Clinical Sciences, Danderyd University Hospital, Karolinska Institute, Solna, Sweden
| | - Daniel Guss
- Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, USA
| | | | - Ruurd L Jaarsma
- Department of Orthopaedic & Trauma Surgery, Flinders Medical Centre, Flinders University, Adelaide, Australia
| | - Frank F A IJpma
- Department of Orthopaedic Surgery, Groningen University Medical Centre, Groningen, The Netherlands
| | - Job N Doornberg
- Department of Orthopaedic Surgery, Groningen University Medical Centre, Groningen, The Netherlands
- Department of Orthopaedic & Trauma Surgery, Flinders Medical Centre, Flinders University, Adelaide, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| |
Collapse
|
4
|
Patton BK, Orfield NJ, Clements JR. Does the Lauge-Hansen Injury Mechanism Predict Posterior Malleolar Fracture Morphology? J Foot Ankle Surg 2022; 61:1251-1254. [PMID: 35317945 DOI: 10.1053/j.jfas.2022.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 11/19/2019] [Accepted: 02/16/2022] [Indexed: 02/03/2023]
Abstract
The Lauge-Hansen ankle fracture classification system is widely accepted and is utilized to describe and predict ankle fracture patterns based on the mechanism of injury. Multiple studies have shown inconsistencies in the Lauge-Hansen's ability to predict fracture patterns based on the mechanism of injury. We set out to determine if the posterior malleolar fracture pattern is associated with the fracture types described by Lauge-Hansen. In this retrospective cohort study, we reviewed 153 patients with trimalleolar ankle fractures as diagnosed using computed tomography scans. Timing of injury was from February 2013 to August 2017. Patient ages ranged between 18 and 89 years old. Each patient had a complete clinical and radiographic workup including a preoperative computed tomographic scan following initial fracture reduction in the emergency room. We classified each ankle fracture based on plain film radiographs using the Lauge-Hansen classification scheme. Each individual posterior malleolar fracture was evaluated on computed tomography imaging and described using both the Haraguchi and Bartonicek-Rammelt classification systems. Of the 153 patients identified with trimalleolar ankle fractures, 70% were female (±20%), the mean age was 51 y (±8 y), and the mean body mass index was 30 kg/m2 (±3 kg/m2). We did not observe a significant association between the Lauge-Hansen injury mechanism and either the Bartonicek-Rammelt or the Haraguchi trimalleolar ankle fracture classification systems (chi-square correlation tests p > .05).
Collapse
Affiliation(s)
- Blayne K Patton
- Carilion Clinic Department of Orthopaedic Surgery, Roanoke, VA
| | - Noah J Orfield
- Carilion Clinic Department of Orthopaedic Surgery, Roanoke, VA
| | - John R Clements
- Carilion Clinic Department of Orthopaedic Surgery, Roanoke, VA; Virginia Tech Carilion School of Medicine, Roanoke, VA.
| |
Collapse
|
5
|
Fenelon C, Galbraith JG, Fahey T, Kearns SR. The Operative Treatment of Ankle Fractures: A 10-Year Retrospective Study of 1529 Patients. J Foot Ankle Surg 2021; 60:663-668. [PMID: 33509713 DOI: 10.1053/j.jfas.2020.03.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 03/19/2020] [Accepted: 03/29/2020] [Indexed: 02/03/2023]
Abstract
Ankle fractures are the second most common fracture of the lower limb and account for nearly 10% of all fractures. They range from simple to complex injuries and approximately 40% require surgical intervention. The aim of our study was to provide an up-to-date reference of the epidemiology, fracture, and fixation characteristics of operatively treated ankle fractures. We also sought to determine the number of patients undergoing further surgery through revision, implant removal, or ankle fusion. A retrospective observational study was conducted of 1529 consecutive patients that underwent operative intervention for an unstable ankle fracture between 2007 and 2017. Fractures of the distal tibia and pilon injuries were excluded. The mean age of patients was 41.8 years with 50.7% male. Unimalleolar fixation was performed in 60.1%, while bimalleolar and trimalleolar fixation was performed in 31.2% and 5%, respectively. Isolated syndesmotic fixation was performed in 3.8%. A posterior malleolus fracture was present in 28.6%, of which 31.6% underwent fixation. A further procedure was performed in 234 (15.3%) patients. Revision open reduction internal fixation was required in 1.4% and 0.8% underwent future ankle fusion. Treatment of ankle fractures makes up a sizeable part of orthopedic trauma practice with more than 1 in 7 patients requiring a second procedure. More complex fractures were predominantly seen in older females, while patients who suffered trimalleolar fractures have an increased likelihood of requiring future ankle fusion or revision. Despite this the rate of ankle fusion was <1%.
Collapse
Affiliation(s)
- Christopher Fenelon
- Orthopaedic Registrar, Department of Orthopaedic Surgery, Galway University Hospital, Galway, Ireland.
| | - John G Galbraith
- Consultant Orthopaedic Surgeon, Department of Orthopaedic Surgery, Galway University Hospital, Galway, Ireland
| | - Tom Fahey
- Professor of General Practice, Department of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Stephen R Kearns
- Professor and Consultant Orthopaedic Surgeon, Department of Orthopaedic Surgery, Galway University Hospital, Galway, Ireland
| |
Collapse
|
6
|
Benedick A, Kavanagh M, Audet M, Simske NM, Vallier HA. Supination Adduction Ankle Fractures Are Associated With Arthritis and Poor Outcomes. J Orthop Trauma 2021; 35:e195-e201. [PMID: 33105458 DOI: 10.1097/bot.0000000000001992] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/14/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare complications and functional outcomes between supination adduction type II (SAD) injuries and torsional ankle injuries (TAI). DESIGN Retrospective cohort. SETTING Level 1 trauma center. PATIENTS AND METHODS Patients (n = 1531) treated for ankle fractures (OTA/AO 43B or 44) over 16 years were identified. The most recent 200 consecutive adult patients treated for TAI (OTA/AO 44, not SAD) served as controls. MAIN OUTCOME MEASURES Complications, unplanned secondary procedures, and patient-reported functional outcome scores, as measured by the Foot Function Index and Short Musculoskeletal Function Assessment. RESULTS Sixty-five patients with SAD injuries (4.2%) were included. They were younger (43.2 vs. 47.7 years, P = 0.08) and more commonly involved in a motorized collision, (58.5% vs. 29.0%) and more often multiply injured: other orthopaedic injuries (66.2% vs. 31.0%) and other nonorthopaedic injuries (40.0% vs. 7.5%, all P < 0.001 vs. TAI). Overall complication and unplanned secondary procedure rates were not different between groups. Those with a SAD injury had more posttraumatic arthrosis (80.0% vs. 40.9%, P = 0.004), but no differences were noted in infection, wound healing, malunion, or nonunion. The mean functional outcome scores were worse for SAD patients over 6 years after injury among all the Foot Function Index and Short Musculoskeletal Function Assessment categories; however, these differences were not significant. CONCLUSIONS SAD injuries represented 4.2% of all ankle fractures, occurring in younger patients through higher-energy mechanisms and more often associated with polytrauma. Despite 80% of SAD patients developing posttraumatic arthrosis, secondary procedures were not more common, and functional outcomes after a SAD injury were not different from TAI. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Alex Benedick
- Department of Orthopaedic Surgery, MetroHealth System, Affiliated with Case Reserve University, Cleveland, OH
| | | | | | | | | |
Collapse
|
7
|
Karkkola S, Kortekangas T, Pakarinen H, Flinkkilä T, Niinimäki J, Leskelä HV. Stability-Based Classification of Ankle Fractures-The Long-Term Outcome After 11-13 Years of Follow-up. J Orthop Trauma 2021; 35:227-233. [PMID: 32925451 DOI: 10.1097/bot.0000000000001959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/01/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To assess the long-term functional and radiological outcome, as well as complications and reoperations of ankle fracture patients treated based on stability classification. DESIGN Retrospective. SETTING Main Trauma Center, University Hospital. PATIENTS AND INTERVENTIONS One hundred sixty patients were treated based on stability classification. After a mean follow-up of 12 years, 102 patients were assessed; 67 visited the outpatient clinic, and standard standing ankle radiographs were taken; osteoarthritis (OA) was graded according to Kellgren-Lawrence classification. The remaining patients (n = 35) were followed up via mail or telephone. The complications and reoperations of all 160 patients were collected from electronic patient records. MAIN OUTCOME MEASURES Olerud-Molander ankle score, foot and ankle outcome score, visual analog scale, RAND-36 item health survey, range-of-motion measurements, and Kellgren-Lawrence OA classification. RESULTS Very good to excellent ankle functional outcome was reported by 96% of the stable fracture group [mean Olerud-Molander ankle score (OMAS), 92; range, 20-100] and 82% of the unstable group (mean OMAS, 86; range, 30-100). For patients with an unstable fracture, OMAS and VAS pain scores significantly improved from 2 to 12 years, even though higher grades of radiologic OA were found. No patients with fractures deemed stable needed operative intervention even in the long-term follow-up. Instead, 30% of the operatively treated patients underwent reoperation during the long follow-up. CONCLUSIONS The treatment of ankle fractures based on stability-based classification led to predictable, functionally good outcomes even during long-term follow-up. Ankle fractures can reliably be deemed stable based on this classification and treated without failures in the long term. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Sini Karkkola
- Division of Orthopedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
- Medical Research Center, University of Oulu, Oulu, Finland
| | - Tero Kortekangas
- Division of Orthopedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
- Medical Research Center, University of Oulu, Oulu, Finland
| | - Harri Pakarinen
- Division of Orthopedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Tapio Flinkkilä
- Division of Orthopedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Jaakko Niinimäki
- Department of Diagnostic Radiology, Oulu University Hospital, Oulu, Finland; and
| | - Hannu-Ville Leskelä
- Division of Orthopedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| |
Collapse
|
8
|
Zhang YW, Rui YF. A systematic review of the "Logsplitter" injury: how much do we know? Injury 2021; 52:358-365. [PMID: 33234265 DOI: 10.1016/j.injury.2020.11.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/11/2020] [Accepted: 11/15/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND As an emerging proposed type of ankle joint injury, the concept of logsplitter injury is a unified overview of the high-energy ankle fracture and dislocation accompanied by distal tibiofibular syndesmosis separation and displacement. Since the concept of logsplitter injury is still relatively novel, there is no uniform standard for its clinical classification, diagnosis and treatment currently. Thus, we reviewed previous literatures here to provide certain references for its better clinical diagnosis and treatment in future. METHODS The available literatures from January 1985 to June 2020 in five medical databases were searched and analyzed. The original articles that evaluated the outcomes of patients treated surgically for the logsplitter injury were included. The detailed data were then extracted from each research, including the researchers, type of study, level of evidence, type of center research, groups, number of patients, gender, age, causes of injury, time from injury to surgery, operative time, intraoperative blood loss, length of follow-up, postoperative complications and clinical outcomes. The overall search procedures were performed by the two independent reviewers. RESULTS Seven pieces of researches (199 patients) were eligible for inclusion. All researches were either retrospective or prospective study, and all but one was single center study. Falling from height ranked first in the causes of injury (52.8%), and followed by the traffic accidents (29.6%). Clinical outcomes were all measured using the American Orthopaedic Foot and Ankle Society (AOFAS) score, and the mean AOFAS score at the final follow-up was 77.9 points. CONCLUSIONS None of the definitive consensuses exists on how logsplitter injury should be diagnosed and surgically managed. In light of the novel concept, short presentation time and numerous postoperative complications, the logsplitter injury has not been well understood by most surgeons currently, and its overall situation still needs to be supported by a larger sample size of multicenter research in the future.
Collapse
Affiliation(s)
- Yuan-Wei Zhang
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China.; School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China.; Orthopaedic Trauma Institute, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China.; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
| | - Yun-Feng Rui
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China.; School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China.; Orthopaedic Trauma Institute, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China.; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China.
| |
Collapse
|
9
|
Su QH, Liu J, Zhang Y, Tan J, Yan MJ, Zhu K, Zhang J, Li C. Three-dimensional computed tomography mapping of posterior malleolar fractures. World J Clin Cases 2020; 8:29-37. [PMID: 31970167 PMCID: PMC6962073 DOI: 10.12998/wjcc.v8.i1.29] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 11/28/2019] [Accepted: 11/30/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Posterior malleolar fractures have been reported to occur in < 40% of ankle fractures.
AIM To reveal the recurrent patterns and characteristics of posterior malleolar fractures by creating fracture maps of the posterior malleolar fractures through the use of computed tomography mapping.
METHODS A consecutive series of posterior malleolar fractures was used to create three-dimensional reconstruction images, which were oriented and superimposed to fit an ankle model template by both aligning specific biolandmarks and reducing reconstructed fracture fragments. Fracture lines were found and traced in order to generate an ankle fracture map.
RESULTS This study involved 112 patients with a mean age of 49, comprising 32 pronation-external rotation grade IV fractures and 80 supination-external rotation grade IV fractures according to the Lauge-Hansen classification system. Three-dimensional maps showed that the posterior ankle fracture fragments in the supination-external rotation grade IV group were relatively smaller than those in the pronation-external rotation grade IV group after posterior malleolus fracture. In addition, the distribution analyses on posterior malleolus fracture lines indicated that the supination-external rotation grade IV group tended to have higher linear density but more concentrated and orderly distribution fractures compared to the pronation-external rotation grade IV group.
CONCLUSION Fracture maps revealed the fracture characteristics and recurrent patterns of posterior malleolar fractures, which might help to improve the understanding of ankle fracture as well as increase opportunities for follow-up research and aid clinical decision-making.
Collapse
Affiliation(s)
- Qi-Hang Su
- Department of Orthopedics, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Juan Liu
- Department of the First Clinical Medical School, Shanxi Medical University, Taiyuan 030000, Shanxi Province, China
| | - Yan Zhang
- Department of Orthopedics, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Jun Tan
- Department of Orthopedics, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
- Department of Orthopedics, Pinghu Second People’s Hospital, Pinghu 314200, Zhejiang Province, China
| | - Mei-Jun Yan
- Department of Orthopedics, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Kai Zhu
- Department of Orthopedics, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Jin Zhang
- Department of Orthopedics, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Cong Li
- Department of Trauma Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| |
Collapse
|
10
|
Ankle Fracture Stability-Based Classification: A Study of Reproducibility and Clinical Prognostic Ability. J Orthop Trauma 2019; 33:465-471. [PMID: 31188253 DOI: 10.1097/bot.0000000000001507] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare the reproducibility and prognostic capacity of 2 commonly used ankle fracture classifications to the stability-based classification. METHODS One hundred ninety-three consecutive rotational-type ankle fractures treated during a year at our institution in patients older than 18 years were retrospectively analyzed. Pilon and pathologic fractures were excluded. The fractures were treated by attending physicians who were unaware of the stability-based classification system. Three observers classified injury radiographs using the Lauge-Hansen, Weber/AO, and stability-based classifications systems. Reproducibility (interobserver variation) of each classification system was calculated using kappa statistics. Prognostic values were evaluated by calculating the area under the curve for the receiver-operating characteristic curves (using surgery as the positive outcome). RESULTS The stability-based and Weber/AO classifications showed better reproducibility [kappa 0.938 (95% confidence interval 0.921-0.952), kappa 0.97 (0.961-0.976)], respectively, than the Lauge-Hansen [kappa 0.74 (0.664-0.795); P < 0.05]. The stability-based classification was more accurate (P < 0.001) in predicting surgical treatment [area under the curve 0.883 (95% confidence interval 0.852-0.914)] compared with the other 2 classifications [0.626 (0.576-0.675) and 0.698 (0.641-0.755)], respectively. CONCLUSIONS The stability-based classification was both highly reproducible (kappa 0.938) and had superior prognostic capacity to identify patients who needed surgical intervention compared with both the Lauge-Hansen and AO/Weber classification systems. Importantly, there were no patients who were classified as stable who failed nonoperative treatment. This extends earlier studies by directly demonstrating its prognostic advantage to other classification systems.
Collapse
|
11
|
Weight-bearing in ankle fractures: An audit of UK practice. Foot (Edinb) 2019; 39:28-36. [PMID: 30933870 DOI: 10.1016/j.foot.2019.02.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 01/21/2019] [Accepted: 02/10/2019] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The purpose of this national study was to audit the weight-bearing practice of orthopaedic services in the National Health Service (NHS) in the treatment of operatively and non-operatively treated ankle fractures. METHODS A multicentre prospective two-week audit of all adult ankle fractures was conducted between July 3rd 2017 and July 17th 2017. Fractures were classified using the AO/OTA classification. Fractures fixed with syndesmosis screws or unstable fractures (>1 malleolus fractured or talar shift present) treated conservatively were excluded. No outcome data were collected. In line with NICE (The National Institute for Health and Care Excellence) criteria, "early" weight-bearing was defined as unrestricted weight-bearing on the affected leg within 3 weeks of injury or surgery and "delayed" weight-bearing as unrestricted weight-bearing permitted after 3 weeks. RESULTS 251 collaborators from 81 NHS hospitals collected data: 531 patients were managed non-operatively and 276 operatively. The mean age was 52.6 years and 50.5 respectively. 81% of non-operatively managed patients were instructed for early weight-bearing as recommended by NICE. In contrast, only 21% of operatively managed patients were instructed for early weight-bearing. DISCUSSION The majority of patients with uni-malleolar ankle fractures which are managed non-operatively are treated in accordance with NICE guidance. There is notable variability amongst and within NHS hospitals in the weight-bearing instructions given to patients with operatively managed ankle fractures. CONCLUSION This study demonstrates community equipoise and suggests that the randomized study to determine the most effective strategy for postoperative weight-bearing in ankle fractures described in the NICE research recommendation is feasible.
Collapse
|
12
|
Briet JP, Hietbrink F, Smeeing DP, Dijkgraaf MGW, Verleisdonk EJ, Houwert RM. Ankle Fracture Classification: An Innovative System for Describing Ankle Fractures. J Foot Ankle Surg 2019; 58:492-496. [PMID: 30795890 DOI: 10.1053/j.jfas.2018.09.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Indexed: 02/03/2023]
Abstract
A good classification system is important for clinical handoffs, research, and clinical treatment guidelines. A reliable classification system shows good interobserver and intraobserver agreement. This study analyzed the interobserver and intraobserver agreement of a descriptive system for ankle fractures and the Lauge-Hansen classification. Three groups of observers (experts, semiexperts, and novices) scored a total of 20 ankle radiographs. All ankle radiographs were classified according to the Lauge-Hansen and Danis-Weber classifications. The ankle fractures were subsequently reviewed in a descriptive manner for the following features: number of affected malleoli, type of fracture of the lateral and medial malleolus, and congruence of the ankle joint. After 2 weeks, the same set of radiographs were reviewed. For interobserver and intraobserver variability, the separate groups were used for analysis, and the Fleiss (multirater) κ values were calculated. The interobserver agreement for the Lauge-Hansen classification was moderate for the experts, fair for semiexperts, and slight for novices (κ = 0.45, κ = 0.37, and κ = 0.16). All factors of the descriptive system had better interobserver agreement than the Lauge-Hansen classification, except for the agreement on the type of fracture of the lateral malleolus. The intraobserver agreement of the Lauge-Hansen classification was substantial for the experts, moderate for the semiexperts, and fair for the novice observers (κ = 0.70, κ = 0.49, and κ = 0.26). The intraobserver agreement was better for all factors of the descriptive system compared with the Lauge-Hansen classification. The descriptive system presented in this study shows less variability between observers than the Lauge-Hansen classification. This system has clinical implications and is easy to use for clinicians with mixed levels of experience. It has the potential to improve clinical and research handoffs and overcome the limitations of current classification systems.
Collapse
Affiliation(s)
- Jan Paul Briet
- Surgical Resident, Department of Surgery, Diakonessenhuis Utrecht, Utrecht, the Netherlands.
| | - Falco Hietbrink
- Trauma Surgeon, Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Marcel G W Dijkgraaf
- Statistician, Clinical Research Unit, Academic Medical Center Amsterdam, Amsterdam, the Netherlands
| | - Egbert Jan Verleisdonk
- Trauma Surgeon, Department of Surgery, Diakonessenhuis Utrecht, Utrecht, the Netherlands
| | - R Marijn Houwert
- Trauma Surgeon, Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands; Trauma Surgeon, Utrecht Traumacenter, Utrecht, the Netherlands
| |
Collapse
|
13
|
Smeeing DPJ, Briet JP, van Kessel CS, Segers MM, Verleisdonk EJ, Leenen LPH, Houwert RM, Hietbrink F. Factors Associated With Wound- and Implant-Related Complications After Surgical Treatment of Ankle Fractures. J Foot Ankle Surg 2019; 57:942-947. [PMID: 30005967 DOI: 10.1053/j.jfas.2018.03.050] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Indexed: 02/03/2023]
Abstract
We have described the epidemiology of complications after surgical treatment of ankle fractures and assessed which factors are associated with the most frequent complications. We conducted a retrospective cohort study at 2 level 2 and 1 level 1 trauma center in a single trauma region in the Netherlands. The study variables were collected from the electronic medical patient records; all ankle fractures were classified using the Lauge-Hansen classification, and the complications were recorded. A total of 989 patients were included from 3 hospitals, with 173 complications in 156 patients (15.8%). The most frequent complication was wound related, occurring in 101 patients (10.2%). Implant-related complications occurred in 44 patients (4.4%). Other complications, such as cast pressure spots, posttraumatic dystrophy, nonunion, impingement, and pneumonia occurred in 28 patients (2.8%). The 2 most important complications were further analyzed for risk factors. Multivariate analysis showed the risk factors for wound-related complications were advanced age, increased American Society of Anesthesiologists classification, smoking, right side symptomatic, open fracture, and initial external fixation. Most implant-related complications were caused by malreduction (n = 22) or untreated syndesmotic injury (n = 19). Malreduction was associated with supination eversion fractures (p = .059), and untreated syndesmotic injury occurred more often with pronation external rotation fractures (p < .001). The most frequent complications after ankle fracture surgery were wound- and implant-related complications. Postoperative wound-related complications were multifactorial and dependent on a combination of trauma-, patient-, and treatment-related factors. In contrast, implant-related complications resulted from the interaction between the fracture type and subsequent surgical treatment.
Collapse
Affiliation(s)
- Diederik P J Smeeing
- Surgical Resident, Traumacenter Utrecht, Utrecht, The Netherlands; Surgical Resident, Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Jan P Briet
- Surgical Resident, Department of Surgery, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - Charlotte S van Kessel
- Surgical Resident, Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Michiel M Segers
- Trauma Surgeon, Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Egbert J Verleisdonk
- Trauma Surgeon, Department of Surgery, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - Luke P H Leenen
- Professor in Trauma Surgery, Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Roderick M Houwert
- Trauma Surgeon, Traumacenter Utrecht, Utrecht, The Netherlands; Trauma Surgeon, Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Falco Hietbrink
- Trauma Surgeon, Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| |
Collapse
|
14
|
X-ray features to predict ankle fracture mechanism. Forensic Sci Int 2018; 291:185-192. [DOI: 10.1016/j.forsciint.2018.08.042] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 08/26/2018] [Accepted: 08/28/2018] [Indexed: 12/27/2022]
|
15
|
Yi Y, Chun DI, Won SH, Park S, Lee S, Cho J. Morphological characteristics of the posterior malleolar fragment according to ankle fracture patterns: a computed tomography-based study. BMC Musculoskelet Disord 2018; 19:51. [PMID: 29439685 PMCID: PMC5811968 DOI: 10.1186/s12891-018-1974-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Accepted: 02/08/2018] [Indexed: 12/16/2022] Open
Abstract
Background The posterior malleolar fragment (PMF) of an ankle fracture can have various shapes depending on the injury mechanism. The purpose of this study was to evaluate the morphological characteristics of the PMF according to the ankle fracture pattern described in the Lauge-Hansen classification by using computed tomography (CT) images. Methods We retrospectively analyzed CT data of 107 patients (107 ankles) who underwent surgery for trimalleolar fracture from January 2012 to December 2014. The patients were divided into two groups: 76 ankles in the supination-external rotation (SER) stage IV group and 31 ankles in the pronation-external rotation (PER) stage IV group. The PMF type of the two groups was assessed using the Haraguchi and Jan Bartonicek classification. The cross angle (α), fragment length ratio (FLR), fragment area ratio (FAR), sagittal angle (θ), and fragment height (FH) were measured to assess the morphological characteristics of the PMF. Results The PMF in the SER group mainly had a posterolateral shape, whereas that in the PER group mainly had a posteromedial two-part shape or a large posterolateral triangular shape (P = 0.02). The average cross angle was not significantly different between the two groups (SER group = 19.4°, PER group = 17.6°). The mean FLR and FH were significantly larger in the PER group than in the SER group (P = 0.024, P = 0.006). The mean fragment sagittal angle in the PER group was significantly smaller than that in the SER group (P = 0.017). Conclusions With regard to the articular involvement, volume, and vertical nature, the SER-type fracture tends to have a smaller fragment due to the rotational force, whereas the PER-type fracture tends to have a larger fragment due to the combination of rotational and axial forces.
Collapse
Affiliation(s)
- Young Yi
- Seoul Foot and Ankle Center, Inje University Seoul Paik Hospital, Seoul, Republic of Korea
| | - Dong-Il Chun
- Department of Orthopedic Surgery, Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Sung Hun Won
- Department of Orthopedic Surgery, Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Suyeon Park
- Department of Biostatistics, Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Sanghyeon Lee
- Department of Orthopaedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University, 77, Sakju-ro, Chuncheoni-si, Gangwon-do, 200-704, Republic of Korea
| | - Jaeho Cho
- Department of Orthopaedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University, 77, Sakju-ro, Chuncheoni-si, Gangwon-do, 200-704, Republic of Korea.
| |
Collapse
|
16
|
Boszczyk A, Fudalej M, Kwapisz S, Klimek U, Maksymowicz M, Kordasiewicz B, Rammelt S. Ankle fracture - Correlation of Lauge-Hansen classification and patient reported fracture mechanism. Forensic Sci Int 2017; 282:94-100. [PMID: 29182957 DOI: 10.1016/j.forsciint.2017.11.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 11/12/2017] [Accepted: 11/13/2017] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The genetic Lauge-Hansen classification is used for reconstruction of the mechanism of ankle injury. In this study, we addressed the question of agreement between the mechanism of the fracture as postulated by the Lauge-Hansen classification and mechanism reported by the patient in rotational ankle fractures. MATERIAL AND METHODS Radiographs of 78 patients with acute malleolar fractures were analyzed and compared with fracture mechanisms reported by these patients. RESULTS The patient reported mechanisms were in concordance with the mechanism deducted from the X-rays in 49% of cases. Only 17% of patients who recalled a pronation trauma actually had radiographs classified as pronation fractures while 76% of patients who recalled a supination trauma were also radiographically classified as having sustained supination type fractures. CONCLUSION The Lauge-Hansen classification should be used with caution for determining the actual mechanism of injury as it was able to predict the patient reported fracture mechanism in less than 50% of cases. A substantial percentage of fractures appearing radiographically as supination type injuries may have been actually produced by a pronation fracture mechanism.
Collapse
Affiliation(s)
- Andrzej Boszczyk
- Department of Traumatology and Orthopaedics, Centre of Postgraduate Medical Education, Prof. Adam Gruca Clinical Hospital, Konarskiego Str. 13, 05-400 Otwock, Poland.
| | - Marcin Fudalej
- Forensic Medicine Department, Medical University of Warsaw, Wojciecha Oczki Str. 1, 00-001 Warsaw, Poland.
| | - Sławomir Kwapisz
- Department of Traumatology and Orthopaedics, Centre of Postgraduate Medical Education, Prof. Adam Gruca Clinical Hospital, Konarskiego Str. 13, 05-400 Otwock, Poland.
| | - Urszula Klimek
- Department of Traumatology and Orthopaedics, Centre of Postgraduate Medical Education, Prof. Adam Gruca Clinical Hospital, Konarskiego Str. 13, 05-400 Otwock, Poland.
| | - Marta Maksymowicz
- Department of Traumatology and Orthopaedics, Centre of Postgraduate Medical Education, Prof. Adam Gruca Clinical Hospital, Konarskiego Str. 13, 05-400 Otwock, Poland.
| | - Bartłomiej Kordasiewicz
- Department of Traumatology and Orthopaedics, Centre of Postgraduate Medical Education, Prof. Adam Gruca Clinical Hospital, Konarskiego Str. 13, 05-400 Otwock, Poland.
| | - Stefan Rammelt
- University Center for Orthopaedics & Traumatology, University Hospital, Carl Gustav Carus at the TU Dresden, Fetscherstrasse 74, Dresden 01307, Germany.
| |
Collapse
|
17
|
Weber B Fracture of the Lateral Malleolus with Concomitant Anterior Talofibular Ligament Injury following an Ankle Supination Injury. Case Rep Orthop 2016; 2016:8035029. [PMID: 27313928 PMCID: PMC4903139 DOI: 10.1155/2016/8035029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 04/21/2016] [Indexed: 12/23/2022] Open
Abstract
The Lauge-Hansen (LH) classification attempts to predict patterns of ankle injuries based upon the preceding mechanism of injury. Although it is widely used in clinical practice, it has been criticized mainly due to numerous reports of cases conflicting the prediction system. Here, we report a case of a 32-year-old male who sustained a Weber B fracture of the lateral malleolus following a supination ankle injury, which was treated conservatively, following which the patient presented with ankle instability and was found to have concurrent anterior talofibular ligament tear. Critical review of the LH classification along with its shortcomings is discussed.
Collapse
|