Combined Open and Percutaneous Plating for the Treatment of Pilon Fracture

BACKGROUND

With the advent of percutaneous plating techniques and anatomical locking plates, open plating combined with percutaneous plating may be a feasible option to reduce pilon fracture soft-tissue complications. The purpose of this study was to evaluate the outcomes of a combined open and percutaneous plating approach for the treatment of pilon fracture.

METHODS

Forty-two consecutive patients treated with a combined open and percutaneous plating approach between March of 2010 and February of 2020 for pilon fracture were reviewed retrospectively. The study population consisted of four female patients and 38 male patients with an average age of 47.5 years (range, 15-71 years). The mean follow-up duration was 25.7 months (range, 12-48 months). The combination of a small anterolateral approach and a small anteromedial approach (or a small direct medial approach) was used in all cases. A small posterolateral approach or a small posteromedial approach was added as necessary.

RESULTS

The average ranges of ankle sagittal motion and hindfoot coronal motion at 1 year postoperatively were 43.3° (range, 30°-60°) and 47.7° (range, 40°-55°), respectively. The mean 1-year postoperative visual analogue scale score and American Orthopaedic Foot and Ankle Society score were 0.90 (range, 0-4.0) and 94.5 (range, 78-100), respectively. All patients except one achieved bony union. The mean time to union (except in the one case of nonunion) was 4.5 months (range, 3-8 months). Minor wound breakdown occurred in five cases using combined approaches, but these eventually healed with local wound care. There were no major soft-tissue complications and no instances of deep infection.

CONCLUSIONS

A combined open and percutaneous plating approach is a feasible option for the treatment of pilon fracture. This combined plating technique involving a combination of a small anterolateral approach and a small anteromedial approach (or a small direct medial approach) yielded satisfactory outcomes without major soft-tissue complications.

Evaluation of chronic ankle instability and subtalar instability using the angle between the anterior talofibular ligament and calcaneofibular ligament

PURPOSE

A series of studies have reported a change in the length or thickness of the anterior talofibular (ATFL) and calcaneofibular (CFL) ligaments in patients with chronic ankle instability. However, no study has examined the changes in the angle between the ATFL and CFL in patients diagnosed with chronic ankle instability. Therefore, this study analyzed the change in the angle between the ATFL and CFL in patients diagnosed with chronic ankle instability to confirm its relevance.

METHODS

This retrospective study included 60 patients who had undergone surgery for chronic ankle instability. Stress radiographs comprising the anterior drawer test, varus stress test, Broden's view stress test, and magnetic resonance imaging (MRI) were performed in all patients. The angle between the ATFL and CFL was measured by indicating the vector at the attachment site, as seen on the sagittal plane. Three groups were classified according to the angle between the two ligaments measured by MRI: group I when the angle was > 90°, Group II when the angle was 71-90°, and Group III when the angle was ≤ 70°. The accompanying injuries to the subtalar joint ligament were analyzed via MRI.

RESULTS

A comparison of the angles between the ATFL and CFL measured on MRI in Group I, Group II, and Group III with the angles measured in the operating room revealed a significant correlation. Broden's view stress test revealed a statistically significant difference among the three groups (p < 0.05). The accompanying subtalar joint ligament injuries differed significantly among the three groups (p < 0.05).

CONCLUSION

The ATFL-CFL angle in patients with ankle instability is smaller than the average angle in ordinary people. Therefore, the ATFL-CFL angle might be a reliable and representative measurement tool to assess chronic ankle instability, and subtalar joint instability should be considered if the ATFL-CFL angle is 70° or less.

LEVEL OF EVIDENCE

Level III.

Staged Treatment for Unstable Open Fracture-Dislocation of the Ankle: A Case Report

Unstable fracture-dislocation of the ankle is a common lower-extremity injury. Treatment is challenging when the fracture-dislocation is open and cannot be treated with conventional open reduction and internal fixation (ORIF). Immediate ORIF may not be possible for severe, unstable ankle injuries, such as those with ischemic foot because of a poor blood supply caused by soft-tissue injury, or open fracture-dislocation of the ankle with a deltoid ligament rupture. We describe a staged treatment for unstable open fracture-dislocation of the ankle with a deltoid ligament rupture. The first stage involves temporary vertical transarticular pinning combined with external fixation. The second stage involves delayed definitive plating with autogenous bone graft for the bone defect of the distal fibula. This staged management is useful in select emergency cases of unstable open fracture-dislocations of the ankle combined with deltoid ligament rupture for which conventional ORIF cannot be performed.

Surgical Treatment Approach for Pilon and Talar Dome Fracture

Talar injuries that are associated with pilon fractures include talar body fractures, osteochondral defects, and posterior process talar fractures. Pilon fractures, in combination with talar dome fractures, have not yet been reported in the scientific literature. We report the case of a 15-year-old boy who sustained a pilon fracture with a lateral talar dome fracture. The pilon fracture was initially fixed using a temporary external fixator for soft-tissue care. After the swelling subsided, definitive internal fixation was performed. First, the lateral talar dome fracture was directly reduced and fixed using a small anterolateral approach of the ankle. Then, the intra-articular portion of the pilon fracture was directly reduced using the same anterolateral approach and an additional small anteromedial approach, and the extra-articular metaphyseal portion of the pilon fracture was indirectly reduced. The pilon fracture was finally fixed with an anterolateral distal tibia plate, using a submuscular plating technique through the anterolateral approach and a separate proximal skin incision. A medial distal tibia plate was later added using a subcutaneous plating technique through the anteromedial approach and another proximal skin incision. Both the pilon fracture and the lateral talar dome fracture were addressed simultaneously through a combination of the small anterolateral and anteromedial approaches.

Comparison of Osteochondral Autologous Transplantation and Dorsiflexion Closing Wedge Metatarsal Osteotomy for Late-Stage Freiberg Disease in Adults

BACKGROUND

This study aimed to compare the clinical results between osteochondral autologous transplantation (OAT) and dorsiflexion closing wedge metatarsal osteotomy (DCWMO) in symptomatic adult patients with late-stage Freiberg disease.

METHODS

Between 2012 and 2017, patients with late-stage Freiberg disease surgically treated with OAT (12 patients) or DCWMO (15 patients) were retrospectively identified. The American Orthopaedic Foot & Ankle Society-lesser metatarsophalangeal-interphalangeal (AOFAS-LMI) score, visual analog scale score for subjective pain, and range of motion (ROM) were determined preoperatively and at final follow-up. Postoperative complications were also recorded.

RESULTS

The AOFAS-LMI score at final follow-up was significantly greater in the OAT group than in the DCWMO group (95.7 vs 87.9, P < .001), whereas plantarflexion at final follow-up was significantly lower in the DCWMO group than in the OAT group (30.0 vs 24.0 degrees, P = .037). The DCWMO group reported more postoperative complications including postoperative joint stiffness, deformity, and pain recurrence. In the OAT group, one patient complained of mild knee pain.

CONCLUSION

OAT seemed a better procedure for late-stage Freiberg disease compared with DCWMO in adult patients in terms of postoperative functional score and ROM, with lower complication rates.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Anatomical landmarks for acetabular abduction in adult hips: the teardrop vs. the inferior acetabular rim

PURPOSE

The purpose of this study is to compare the acetabular teardrop (the structure located inferomedially in the acetabulum, just superior to the obturator foramen. The medial lip is the interior, and the lateral lip is the exterior of the acetabular wall) with the inferior acetabular rim as anatomical landmarks to measure the acetabular abduction angle (AAD) using coronal CT images from different levels.

METHODS

Our retrospective study included 120 pelvic CT scans from patients with non-orthopedic pathologies or stress fractures of the proximal femur. The patients included 60 females with a mean age of 48 years (range 40-66) and 60 males with a mean age of 46 years (range 38-65). Each AAD was measured using coronal plane CT slices from five levels: AAD (+ 10) (10 mm anterior to the femoral head center), AAD (+ 5) (5 mm anterior to the femoral head center), AAD (0) (through the femoral head center), AAD (- 5) (5 mm posterior to the femoral head center), and AAD (- 10) (10 mm posterior to the femoral head center). The measurements were then divided into two groups: teardrop-based AADs [AAD (+ 10), AAD (+ 5), and AAD (0)] and rim-based AADs [AAD (- 5) and AAD (- 10)].

RESULTS

There were no mean significant differences in AAD within the groups, whereas the difference between the groups was significant. The mean teardrop-based AAD was quite significantly different from the mean rim-based AAD due to the use of different anatomical landmarks. Teardrop-based AADs are lower than rim-based AADs, leading to measurement differences of more than 10°.

CONCLUSIONS

AAD measurements considering the inferior acetabular rim can be more accurate than those considering the acetabular teardrop because the inferior rim represents the nearly hemispheric acetabulum better than does the teardrop. It is recommended to differentiate between the teardrop and the inferior acetabular rim when measuring AAD to avoid confusion regarding acetabular abduction.

Nail Plate and Bed Reconstruction for Pincer Nail Deformity

Pincer nail deformity is a severe condition in which the nail bed becomes compressed and the nail shows an overcurvature. We retrospectively analyzed 13 pincer nail deformities treated using our nail plate and bed reconstruction technique. Visual analogue scale scores, the width of nail root, width of nail tip, height of nail tip, width index, and height index were assessed before and after surgery. The overcurvature was corrected after detachment of the nail plate. The nail fold was pushed underneath the nail plate and then fixed. The width of nail tip significantly increased after surgery (p < 0.05) and was maintained during follow-up. The height of nail tip decreased after surgery (p < 0.05). This nail plate and bed reconstruction technique is a simple and quick surgical method for correcting deformities and reduces risks of complications such as skin necrosis and infection compared to other existing surgical techniques. We recommend this efficient surgical technique for the treatment of pincer nails.

Diagnostic validity of alternative manual stress radiographic technique detecting subtalar instability with concomitant ankle instability

PURPOSE

To incorporate a diagnostic technique for measuring subtalar motion, namely "talar rotation", into the manual supination-anterior drawer stress radiographs for evaluation of the severity of rotational instability, and to determine its clinical relevance.

METHODS

Sixty-six patients with combined injuries of the anterior talofibular (ATFL) and calcaneofibular ligament (CFL) underwent three bilateral manual stress radiographs, and mean increments of anterior talar translation (mm), talar tilt (°), and talar rotation (%) in the injured ankle compared to the normal opposite side were measured with the technique. Intraobserver and interobserver reliability of each measure was assessed, and the difference in the degree of increments was compared according to the presence of additional cervical ligament insufficiency.

RESULTS

Ankle stress radiographic intraobserver and interobserver agreement was ICC = 0.91 and 0.82 for talar rotation (%), ICC = 0.64 and 0.51 for anterior talar translation, and ICC = 0.78 and 0.71 for talar tilt angle, respectively. In group 2 including patients with combined injuries of the ATFL and CFL along with additional cervical ligament insufficiency, a significantly higher increment of talar rotation, mean 6.4% (SD 3.4%), was observed compared to that of talar rotation, mean 4.1% (SD 2.7 ), in the other group (group 1) with an intact cervical ligament (p < 0.001).

CONCLUSIONS

A new comprehensive stress radiographic technique for diagnosis of chronic lateral ankle instability presented in this study might be a reliable and representable measurement tool to assess additional injury or instability of the subtalar joint.

LEVEL OF EVIDENCE

Prospective cohort study, Level II.

Fixation of a posteromedial osteochondral lesion of the talus using a three-portal posterior arthroscopic technique

Fixation of a large osteochondral fragment on the posteromedial talus can be performed using medial malleolar osteotomy or an arthroscopic technique with a transmalleolar portal. However, osteotomy can be associated with some morbidity, such as longstanding pain and tenderness at the osteotomy site. Also, it requires longer immobilization. However, the transmalleolar portal damages the tibial articular cartilage, which can later cause pain. In young patients, it can injure the epiphyseal plate. We describe a posterior arthroscopic technique using 3 posterior portals that allow access to a posteromedial osteochondral lesion of the talus and fixation of the osteochondral fragment without malleolar osteotomy or transmalleolar drilling.