Trimalleolar Fractures Treated by Open Reduction Internal Fixation Compared With Arthroscopically Assisted Reduction and Minimally Invasive Surgery

BACKGROUND

Currently, the standard of treatment for trimalleolar (TM) fracture is osteosynthesis through open reduction and internal fixation (ORIF). This study assessed whether arthroscopically assisted reduction and minimally invasive surgery (AARMIS) can be an alternative surgical method for TM fractures.

METHODS

This retrospective cohort study included 49 patients with TM that were surgically treated. 27 patients received ORIF and 22 patients underwent AARMIS . At baseline, we recorded the patient's demographic features, fracture pattern (AO-OTA and Haraguchi classification), and surgical method. For postoperative results, we examined the patient's radiographic outcome, including time to union, quality of fracture reduction, as well as functional outcomes (American Orthopaedic Foot & Ankle Society ankle hindfoot score, ankle range of motion, and visual analog scale of pain) and perioperative complications.

RESULTS

At mean follow-up of 46.6±24.6 (ORIF) and 36.4±18.5 months (AARMIS), both groups had comparable radiographic outcomes. No significant difference in rates of early ankle OA were detected. In terms of functional outcome, VAS pain and AOFAS score at postoperative day 3, postoperative month 3, and at final follow-up were not different. In terms of range of motion, we did not find a significant difference in mean range of motion.

CONCLUSION

Patients with TM fractures treated with AARMIS achieved satisfactory results and was not significantly different in radiographic and functional performance compared with ORIF.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Risks Associated With Posterior Ankle Hindfoot Arthroscopy Complications

BACKGROUND

The use of posterior ankle and hindfoot arthroscopy (PAHA) has been expanding over time. Many new indications have been reported in the literature. The primary objective of this study was to report the rate of PAHA complication in a large cohort of patients and describe their potential associations with demographical and surgical variables.

METHODS

In this IRB-approved retrospective comparative study, patients who underwent posterior ankle and/or hindfoot arthroscopy in a single institution from December 2009 to July 2016 were studied. Three fellowship-trained orthopaedic foot and ankle surgeon performed all surgeries. Demographic data, diagnosis, tourniquet use, associated procedures, and complications were recorded. To investigate a priori factors predictive of neurologic complication after PAHA, univariate and multivariable logistic regression was utilized. Where appropriate, sparse events sensitivity analysis was tested by fitting models with Firth log-likelihood approach.

RESULTS

A total of 232 subjects with 251 surgeries were selected. Indications were posterior ankle impingement (37%), flexor hallux longus disorders (14%), subtalar arthritis (8%), and osteochondral lesions (6%). Complications were observed in 6.8% (17/251) of procedures. Neural sensory lesions were noted in 10 patients (3.98%), and wound complications in 4 ankles (1.59%). Seven neurologic lesions resolved spontaneously and 3 required further intervention. In a multivariable regression model controlled for confounders, the use of accessory posterolateral portal was the significant driver for neurologic complications (odds ratio [OR] 32.19, 95% CI 3.53-293.50).

CONCLUSION

The complication rate in this cohort that was treated with posterior ankle and/or hindfoot arthroscopy was 6.8%. Most complications were due to neural sensorial injuries (sural 5, medial plantar nerve 4, medial calcaneal nerve 1 ) and 3 required additional operative treatment. The use of an accessory posterolateral portal was significantly associated with neurologic complications. The provided information may assist surgeons in establishing diagnoses, making therapeutic decisions, and instituting surgical strategies for patients that might benefit from a posterior arthroscopic approach.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Two-Year Outcomes of Posterior Ankle Arthroscopy: A Case Series

The aim of this study was to investigate the outcomes and complications after posterior ankle arthroscopy for the treatment of posterior ankle impingement syndrome, in a local population with a single surgeon series. Two-portal posterior ankle or hindfoot arthroscopy is an alternative option to open surgery in cases of posterior ankle impingement, that showed similar results but with less morbidity and faster recovery. There has been increasing interest in minimally invasive surgical techniques. Indications include extra- and intra-articular conditions and range from bony, cartilaginous to soft tissue pathology. Posterior ankle arthroscopy has been shown to be a good option in cases that are refractory to a period of conservative therapy. Posterior ankle arthroscopy also has known complications of sural nerve damage laterally and neurovascular bundle injury medially and also a steep learning curve that has been studied in the context of os trigonum excision. There have been few or no studies on the local Singaporean population and this article seeks to describe the various indications, results, and complications in the local Singaporean population by a single surgeon.Levels of Evidence: Level IV: Case series.

Outcomes of Posterior Arthroscopic Reduction and Internal Fixation (PARIF) for the Posterior Malleolar Fragment in Trimalleolar Ankle Fractures

BACKGROUND

Posterior malleolar fractures within a trimalleolar ankle fracture pattern are challenging to manage. Posterior ankle arthroscopy provides a means to assess the intra-articular and syndesmotic reductions, while removing loose bodies. The purpose of this study was to determine the radiographic and patient reported outcomes of posterior arthroscopic reduction and internal fixation (PARIF) in trimalleolar ankle fractures.

METHODS

From November 2015 to March 2019, we prospectively enrolled consecutive trimalleolar ankle fractures that underwent PARIF by a single surgeon. Preoperative and postoperative computed tomography (CT) scans were interpreted by 2 blinded musculoskeletal radiologists for articular reduction, syndesmosis congruity, and presence of ossific loose bodies. Patient outcomes were assessed using the Foot and Ankle Disability Index (FADI), American Orthopaedic Foot & Ankle Society (AOFAS) ankle score, Olerud-Molander Ankle Score (OMAS), and visual analog scale (VAS). A total of 28 trimalleolar ankle fractures were treated with PARIF. Mean patient age was 36 years (range, 19-69).

RESULTS

Preoperative CT identified 18 intra-articular loose bodies (range, 0-4) in 36% of ankles and 75% (n = 21) syndesmosis incongruity. Postoperative CT scans demonstrated anatomic intra-articular reduction in all fractures, 41.7% (5/12) syndesmosis incongruity without fixation, and 0% (0/9) with suture-button fixation. At mean 2-year follow-up, the results were good to excellent with mean VAS score 1 (range, 0-4), AOFAS score 84 (range, 63-100), FADI 85 (range, 59-100), and OMAS 76 (range, 40-100).

CONCLUSION

The PARIF technique for displaced posterior malleolar fractures was effective in achieving anatomic intra-articular reduction, syndesmosis congruity, and intra-articular loose body removal, while safely preserving the soft tissues.

LEVEL OF EVIDENCE

Level IV, prospective case series.

Endoscopic repair of posterior ankle impingement syndrome due to os trigonum in soccer players

BACKGROUND

An os trigonum may cause posterior ankle impingement syndrome (PAIS), which may lead to poor sports performance, especially in soccer players. The aim of the present study was to analyze the outcomes of endoscopic repaired posterior ankle impingement (PAI) secondary to os trigonum syndrome within a group of soccer players as well as their return to play time.

METHODS

A retrospective review of 20 soccer players with Tegner activity level 9 was performed. All players were diagnosed of PAIS due to os trigonum. Chief complaint was pain produced with forced plantarflexion when kicking the ball. Conservative treatment was first performed during a 6-week rehabilitation program. When conservative treatment failed, arthroscopic surgical resection of the os trigonum was proposed. Visual analogue scale (VAS) was used to measure pain before and after surgery as well as time until their return to previous sports level.

RESULTS

VAS showed a mean preoperative pain score of 7.5 (SD = 0.9), whereas postoperative VAS at 1 month after surgery decreased to 0.8 (SD = 1.36). Mean symptomatic period was 8.5 months (SD = 4.3), from the beginning of symptoms up to the surgery day. Once patients had undergone surgery, mean time until their return to previous level of sports was 46.9 days (SD = 25.96), reaching the same pre-lesion Tegner level.

CONCLUSIONS

Endoscopic treatment of posterior ankle impingement syndrome due to os trigonum showed excellent results. Hindfoot endoscopy with a posterior approach was an effective treatment and allowed for a prompt return to play in soccer players with a high activity level.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Posterior ankle and subtalar arthroscopy: indications, technique, and results

Over the decades, arthroscopy has grown in popularity for the treatment of many foot and ankle pathologies. While anterior ankle arthroscopy is a widely accepted technique, posterior ankle/subtalar arthroscopy is still a relatively new procedure. The goal of this review is to outline the indications, surgical techniques, and results of posterior ankle/subtalar arthroscopy. The main indications include: 1) osteochondral lesions (of subtalar and posterior ankle joint); 2) posterior soft tissue or bony impingement; 3) os trigonum syndrome; 4) posterior loose bodies; 5) flexor hallucis longus (FHL) tenosynovitis; 6) posterior synovitis; 7) subtalar (or ankle) joint arthritis; 8) posterior tibial, talar, or calcaneal fractures (for arthroscopic reduction and internal fixation). Although posterior ankle/subtalar arthroscopy has shown to be safe and effective in the treatment of many of the above mentioned conditions, thorough knowledge of the anatomy, correct indications, and a precise surgical technique are essential to produce good outcomes.