Talar Neck Fractures With Associated Ipsilateral Foot and Ankle Fractures Have a Higher Risk of Avascular Necrosis

OBJECTIVES

To determine if talar neck fractures with concomitant ipsilateral foot and/or ankle fractures (TNIFAFs) are associated with higher rates of avascular necrosis (AVN) compared with isolated talar neck fractures (ITNs).

METHODS

DESIGN

Retrospective cohort.

SETTING

Single level I trauma center.

PATIENT SELECTION CRITERIA

Skeletally mature patients who sustained talar neck fractures from January 2008 to January 2017 with at least 6-month follow-up. Based on radiographs at the time of injury, fractures were classified as ITN or TNIFAF and by Hawkins classification.

OUTCOME MEASURES AND COMPARISONS

The primary outcome was the development of AVN based on follow-up radiographs, with secondary outcomes including nonunion and collapse.

RESULTS

There were 115 patients who sustained talar neck fractures, with 63 (55%) in the ITN group and 52 (45%) in the TNIFAF group. In total, 63 patients (54.7%) were female with the mean age of 39 years (range, 17-85), and 111 fractures (96.5%) occurred secondary to high-energy mechanisms of injury. There were no significant differences in demographic or clinical characteristics between groups ( P > 0.05). Twenty-four patients (46%) developed AVN in the TNIFAF group compared with 19 patients (30%) in the ITN group ( P = 0.078). After adjusting for Hawkins classification and other variables, the odds of developing AVN was higher in the TNIFAF group compared with the ITN group [odds ratio, 2.43 (95% confidence interval, 1.01-5.84); ( P = 0.047)].

CONCLUSIONS

This study found a significantly higher likelihood of AVN in patients with talar neck fractures with concomitant ipsilateral foot and/or ankle fractures compared to those with isolated talar neck fractures after adjusting for Hawkins classification and other potential prognostic confounders.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Relationship Between Intra-articular Fracture Energy and a Patient's Inflammatory Response

OBJECTIVES

Prior studies have demonstrated elevated inflammatory cytokine concentrations in the synovial fluid of articular fracture patients postinjury. Similarly, CT-based fracture energy measurements have been correlated with posttraumatic osteoarthritis risk after pilon fracture. The purpose of this study was to determine the associations between synovial fluid cytokine levels, fracture energy, and overall trauma to the body in articular fracture patients.

METHODS

Acute tibial plateau, tibial plafond, and rotational ankle fracture patients were prospectively enrolled from December 2011 through January 1, 2019. Synovial fluid concentrations of interleukin-1 beta, interleukin-1 receptor antagonist, IL-6, IL-8, IL-10, matrix metallopeptidase-1, MMP-3, and MMP-13 were quantified. Patient CT scans were used to calculate fracture energy. The Injury Severity Score (ISS) was used to relate cytokine levels to whole-body injury severity. Spearman rho correlation coefficients were calculated to assess the relationship between injury severity metrics and synovial fluid cytokine, chemokine, and matrix metallopeptidase concentrations.

RESULTS

Eighty-seven patients were enrolled with 42 had a tibial plateau fractures (OTA/AO 41B1-2, 41B2-14, 41B3-3, 41C1-3, 41C2-4, 41C3-16), 24 patients had a tibial plafond fracture (OTA/AO 43B1-2, 43B2-4, 43B3-5, 43C1-2, 43C2-3, 43C3-8), and 21 had a rotational ankle fracture (OTA/AO 44B1-3, 44B2-3, 44B3-6, 44C1-4, 44C2-5). Fracture energy significantly differed between fracture patterns, with ankle fractures involving substantially less fracture energy (median = 2.92 J) than plafond (10.85 J, P < 0.001) and plateau fractures (13.05 J, P < 0.001). After adjustment for multiple comparisons, MMP-3 was significantly correlated with transformed fracture energy (r = 0.41, 95% confidence interval [CI], 0.22-0.58, P < 0.001), while IL-1β was significantly correlated with the Injury Severity Score (Spearman ρ = 0.31, 95% CI, 0.08-0.49, P = 0.004).

CONCLUSIONS

Synovial fluid MMP-3 concentration was significantly correlated with CT-quantified fracture energy in intra-articular fracture patients. Given that in clinical practice fracture energy tends to correlate with posttraumatic osteoarthritis risk, MMP-3 may warrant further investigation for its role in posttraumatic osteoarthritis development after articular fracture.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Study on the risk factors of postoperative wound complications in patients with ankle fracture

Wound complications after surgery for ankle fractures can lead to catastrophic consequences. The purpose of this study was to evaluate the risk factors of postoperative wound complications in patients with ankle fracture and to determine their effects on prognosis. 200 patients with ankle fracture treated in our hospital from October 2021 to December 2023 were analysed retrospectively. The total incidence of postoperative wound complications was 19% (38/200). Type of complications: wound edge necrosis 15 cases (39.47%), dehiscence (reopening of wound) 13 cases (34.21%), delayed healing (>30 days) 10 cases (26.32%); Univariate analysis showed that patients' age, body mass index (BMI), current smoking, alcoholism, diabetes mellitus, injury mechanism, open fracture, wound classification, higher American Society of Anesthesiologists (ASA) score and operation time were all associated with postoperative wound complications. Multivariate Logistic regression model shows: age ≥60 years old OR3.671 (1.875-5.937), BMI OR1.198 (1.143-1.324), current smoking OR2.727 (1.251-5.602), alcoholism OR1.143 (1.034-1.267), complicated with diabetes OR2.763 (1.236-4.852), injury mechanism (high vs. low and medium energy) OR2.437 (1.238-4.786), open fracture OR1.943 (1.8262.139), wound classification (II vs. I) OR4.423 (1.73511.674), ASA score (III-IV vs. I-II) OR1.307 (1.113-2.194) was an independent risk factor for postoperative wound complications in patients with ankle fracture. Further, ROC curves showed that these nine independent influences had high accuracy and validity in predicting postoperative wound complications in patients with ankle fractures. In conclusion, independent risk factors for postoperative complications of ankle fracture were age >60 years, BMI, injury mechanism, open fracture, wound classification (II vs. I), ASA score, current smoking, and alcoholism. The wound classification (II vs. I) has the highest diagnostic value.

Risk factors contributing to postoperative surgical site infections in patients undergoing ankle fracture fixation: A systematic review and meta-analysis

Surgical site infections (SSIs) following ankle fracture fixation pose significant challenges in patient recovery and healthcare management. Identifying risk factors contributing to SSIs can aid in developing targeted prevention and treatment strategies. This systematic review and meta-analysis were conducted according to the PRISMA guidelines and the PICO framework. A comprehensive literature search across major databases, including PubMed, Embase, Web of Science and the Cochrane Library, was completed on September 26, 2023. The inclusion criteria encompassed peer-reviewed studies of various designs that investigated risk factors for SSIs post-ankle fracture fixation. Quality assessment was performed using the Newcastle-Ottawa Scale. Statistical analyses assessed heterogeneity and calculated combined effect sizes using fixed- or random-effects models, depending on the heterogeneity observed. The initial search yielded 1250 articles, with seven meeting the inclusion criteria after rigorous screening and full-text review. The included studies, conducted between 2006 and 2019, predominantly utilized case-control designs. The meta-analysis identified diabetes, open fractures, smoking, age, alcohol consumption, ASA score ≥3, high BMI, contaminated incisions, fracture dislocation and heart disease as significant risk factors for postoperative SSIs. Publication bias assessment showed no significant bias across studies. The identification of key risk factors such as diabetes, open fractures, smoking, advanced age, alcohol consumption, high ASA score, elevated BMI, contaminated incisions, fracture dislocation and heart disease is essential in managing SSIs post-ankle fracture fixation. Targeted interventions addressing these risk factors are crucial to reduce the incidence of SSIs and improve overall patient outcomes.

Wound complication risk factors following open reduction and internal fixation of ankle fractures

This study was designed to identify risk factors for wound complications including surgical site infection (SSI) and wound healing issues following open reduction and internal fixation (ORIF) of ankle fractures. A retrospective analysis of individuals with ankle fractures treated with ORIF was undertaken. Study subjects were divided into a wound complications (WC) group and a no wound complication (NWC) group. The WC group was further divided into an SSI group and wound healing issues group. Twenty-one potential risk factors associated with wound complications after ORIF were tracked. Uni- and multivariate binary logistical regression analyses were used to identify risk factors associated with wound complications, ISS and wound healing issues. In total, 613 individuals, who had undergone surgery for ankle fractures formed the study cohort. The incidence of postoperative wound complications was 10.3% (63 cases), including 5.2% of SSI (32 cases) and 5.1% of wound healing issues (31 cases). The independent risk factors for wound complications were age 65 years or older, preoperative serum albumin level below 35 g/L, peripheral neuropathy, open fracture, fewer than seven cases per year in surgical volume, and attending surgeon level. The independent risk factors for SSI were age 65 years or older, preoperative serum albumin level below 35 g/L, open fracture and fewer than seven cases per year in surgical volume. The independent risk factors for wound healing issues were preoperative serum albumin level below 35 g/L, peripheral neuropathy, open fracture and attending surgeon level. Herein we found both factors inherent to the injury and individual and those pertaining to the surgical team affected the frequency of wound complications after ORIF of ankle fractures. Specifically, advanced age and low surgical volume were associated with a greater risk of SSI. Peripheral neuropathy and the low expertise level on the part of the surgeon were associated with a greater risk of wound healing issues. Hypoproteinaemia and open fracture were both associated with a greater risk of both SSI and wound healing issues.

Comparative Clinical Effects and Risk Factors Associated With Vitamin D in Foot and Ankle Fracture and Arthrodesis Healing

Vitamin D deficiency in relation to bone metabolism and healing has been controversial and not well studied. However, hypovitaminosis has been widely identified within the orthopedic patient population. The current best evidence suggests a lack of data on this important topic. The ability to assess patients for optimum bone healing and metabolism is still in question due to lack of a suitable reliable biomarker and multiple other unknown variables affecting bone metabolism. To compound this effect, popular dermatological precautions in the last 20 to 30 years of avoiding sunlight also have the effect of further reducing serum vitamin D production in the skin. As a proof of concept, we performed a preliminary comparative observational retrospective review of orthopedic patients undergoing fracture and arthrodesis osseous healing to determine how serum vitamin D levels are associated with bone healing along with their confounding comorbidities. Based on our review, the current accepted vitamin D levels (≥20 ng/mL) are low and insufficient for fractures and for arthrodesis osseous healing due to observed high rates (>35%) of delayed unions, and an increased (>90%) in the number of multiple confounding comorbidities affecting bone healing process that are often not mentioned or captured in this type of study in previous literature. Obesity and diabetes are significant contributory risks factors, and the preliminary findings suggest that the current accepted adequate levels may not be enough for osseous healing. These low vitamin D levels appear to affect bone healing and prolong treatment, with worsening trends with diabetes and obesity comorbidities.

Patterns of Anterior Inferior Tibiofibular Ligament Avulsion Fracture Accompanied by Ankle Fracture

The anterior inferior tibiofibular ligament (AITFL) avulsion fracture accompanying an ankle fracture can compromise ankle stability, necessitating accurate evaluation and a clear understanding of its pathophysiology.. The aim of this study was to investigate the association between AITFL avulsion fracture and Lauge-Hansen, Wagstaffe classification. A retro-prospective study was conducted at a university-affiliated tertiary care medical center. We selected 128 patients who underwent surgery at our institution between January 2013 and July 2017 and analyzed the association between AITFL avulsion fracture and the foot position. According to the modified Wagstaffe classification system, there were 39 cases of type II, followed by 9 cases of type III and 8 cases of type IV. Of the7 pronation-abduction fractures, 3 were AITFL avulsion fracture (43%), while of the 21 pronation-external rotation fractures, 9 were AITFL avulsion fracture (43%). Of the 95 supination-external rotation fractures, there were 56 cases (59%) of AITFL avulsion fractures. Of the pronation fractures, 0% were fibular avulsion fractures and 43% were tibial avulsion fractures. Of the supination fractures, 44% were fibular avulsion fractures and 16% were tibial avulsion fracture. The difference in the ratio of fibular to tibial avulsion fractures between pronation and supination fractures was significant (p < .001). These results suggest that tibial avulsion fractures of type IV in the modified Wagstaffe classification and pronation fractures occur due to collision with the anterolateral corners of the distal bone when the talus externally rotates. Moreover, in cases of pronation fractures, a new type of AITFL avulsion fracture has been observed.

Using machine learning in the prediction of symptomatic venous thromboembolism following ankle fracture

BACKGROUND

Venous thromboembolism (VTE) is a major cause of morbidity and mortality in the trauma setting, and both prediction and prevention of VTE have long been a concern for healthcare providers in orthopedic surgery. The purpose of this study was to evaluate the use of novel statistical analysis and machine-learning in predicting the risk of VTE and the usefulness of prophylaxis following ankle fractures.

METHODS

The medical profiles of 16,421 patients with ankle fractures were screened retrospectively for symptomatic VTE. In total, 238 patients sustaining either surgical or nonsurgical treatment for ankle fracture with subsequently confirmed VTE within 180 days following the injury were placed in the case group. Alternatively, 937 patients who sustained ankle fractures managed similarly but had no documented evidence of VTE were randomly chosen as the control group. Individuals from both the case and control populations were also divided into those who had received VTE prophylaxis and those who had not. Over 110 variables were included. Conventional statistics and machine learning methods were used for data analysis.

RESULTS

Patients who had a motor vehicle accident, surgical treatment, increased hospital stay, and were on warfarin were shown to have a higher incidence of VTE, whereas patients who were on statins had a lower incidence of VTE. The highest Area Under the Receiver Operating Characteristic Curves (AUROC) showing the performance of our machine learning approach was 0.88 with 0.94 sensitivity and 0.36 specificity. The most balanced performance was seen in a model that was trained using selected variables with 0.86 AUROC, 0.75 sensitivity, and 0.85 specificity.

CONCLUSION

By using machine learning, this study successfully pinpointed several predictive factors linked to the occurrence or absence of VTE in patients who experienced an ankle fracture. Training these algorithms using larger, more granular, and multicentric data will further increase their validity and reliability and should be considered the standard for the development of such algorithms.

LEVEL OF EVIDENCE

Case-Control study - 3.

Patient Characteristics and Outcomes of Geriatric Ankle Fractures: Open Fracture Is the Key Risk Factor for Complications and Functional Decline

OBJECTIVES

To determine whether open (O) or closed (C) geriatric ankle fractures had different patient characteristics or outcomes.

METHODS

.

DESIGN

Retrospective cohort study.

SETTING

Urban Level 1 trauma center.

PATIENT SELECTION CRITERIA

Patients, age 60 years and older, who underwent operative fixation of a rotational ankle fracture (OTA/AO 44A-C) between January 2012 and September 2021.

OUTCOME MEASURES AND COMPARISONS

Morbidity, defined as 90-day reoperation, 90-day readmission, or loss of mobility, as well as 1-year mortality compared between patients with closed and open fractures.

RESULTS

The open cohort was older (75 years vs. 68 years; P = 0.003) but had similar Charlson comorbidity indices (4.6 O vs. 4.0 C; P = 0.323) and preinjury rates of independent ambulation (70.4% O vs. 80.9% C; P = 0.363). There were higher rates of 1-year mortality (11% vs. 0%; P < 0.001), deep infection (14.8% vs. 3.9%; P = 0.019), and loss of mobility (64.7% vs. 23.0%; P < 0.001) in the open cohort. Multivariate regression identified open fracture as an independent predictor of 90-day reoperation (OR: 20.6; P = 0.022) and loss of mobility (OR: 5.1; P = 0.011).

CONCLUSIONS

Despite having comorbidities and preinjury function similar to the closed geriatric ankle fracture cohort, open ankle fracture was independently predictive of greater loss of mobility. Nearly two-thirds of geriatric patients with open ankle fractures experienced a decline in functional independence, compared with 1 in 4 of those with closed fractures. Open fracture was associated with higher rates of deep infection, reoperation, and 1-year mortality.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The effect of tourniquet use on postoperative opioid consumption after ankle fracture surgery - a retrospective cohort study

OBJECTIVES

A pneumatic tourniquet is often used during ankle fracture surgery to reduce bleeding and enhance the visibility of the surgical field. Tourniquet use causes both mechanical and ischemic pain. The main purpose of this study was to evaluate the effect of tourniquet time on postoperative opioid consumption after ankle fracture surgery.

METHODS

We retrospectively reviewed the files of 586 adult patients with surgically treated ankle fractures during the years 2014-2016. We evaluated post hoc the effect of tourniquet time on postoperative opioid consumption during the first 24 h after surgery. The patients were divided into quartiles by the tourniquet time (4-43 min; 44-58 min; 59-82 min; and ≥83 min). Multivariable linear regression analysis was used to evaluate the results.

RESULTS

Tourniquets were used in 486 patients. The use of a tourniquet was associated with an increase in the total postoperative opioid consumption by 5.1 mg (95 % CI 1.6-8.5; p=0.004) during the first 24 postoperative hours. The tourniquet time over 83 min was associated with an increase in the mean postoperative oxycodone consumption by 5.4 mg (95 % CI 1.2 to 9.7; p=0.012) compared to patients with tourniquet time of 4-43 min.

CONCLUSIONS

The use of a tourniquet and prolonged tourniquet time were associated with higher postoperative opioid consumption during the 24 h postoperative follow-up after surgical ankle fracture fixation. The need for ethical approval and informed consent was waived by the Institutional Review Board of Northern Ostrobothnia Health District because of the retrospective nature of the study.

The role of fibula fixation in combined distal-third tibia and fibula fractures: a systematic literature review

OBJECTIVE

The role of concomitant fibula fracture fixation in distal-third tibia fractures regarding alignment, union, and functional outcome is still a topic of debate. In this review, we summarize the available comparative literature regarding fibula fixation in distal third lower leg fractures.

MATERIALS AND METHODS

A systematic literature review of articles published between January 2000 and January 2022 in the PubMed, Cochrane, and EMBASE databases about this topic was performed.

RESULTS

746 unique studies were identified of which four randomized-controlled trials and six retrospective studies were included. Nine studies compared alignment after tibia fixation with or without fibula fixation, six studies reported on tibial union, and three studies reported on functional outcome between groups. Pooling of data was not possible due to varying outcome measures and inclusion criteria. Fibula fixation was associated with less rotational malalignment, while there does not seem to be consensus regarding the effect on sagittal and coronal alignment. Six studies reported on the effect of fibula fixation on tibial union. None of these studies found a significant difference between treatment modalities. Furthermore, one out of three studies reporting functional outcome described a marginal beneficial functional outcome after fibula fixation. Ultimately, no differences in complication rates between treatment modalities were described.

CONCLUSION

Fixation of the fibula in distal-third lower leg fractures does not seem to have a significant effect on coronal and sagittal tibial alignment. Furthermore, fibula fixation is associated with significantly less rotational malalignment, although the clinical importance of this finding is questionable as true differences in rotational alignment between treatment modalities are small. Finally, fibula fixation does not affect union, functional outcome, or complication rate as adjuvant to tibia fixation.

LEVEL OF EVIDENCE

II.

Identifying Risk Factors for Osteonecrosis After Talar Fracture

OBJECTIVE

To identify patient, injury, and treatment factors associated with the development of avascular necrosis (AVN) after talar fractures, with particular interest in modifiable factors.

METHODS

DESIGN

Retrospective chart review.

SETTING

21 US trauma centers and 1 UK trauma center.

PATIENT SELECTION CRITERIA

Patients with talar neck and/or body fractures from 2008 through 2018 were retrospectively reviewed. Only patients who were at least 18 years of age with fractures of the talar neck or body and minimum 12 months follow-up or earlier diagnosis of AVN were included. Further exclusion criteria included non-operatively treated fractures, pathologic fractures, pantalar dislocations, and fractures treated with primary arthrodesis or primary amputation.

OUTCOME MEASUREMENTS AND COMPARISONS

The primary outcome measure was development of AVN. Infection, nonunion, and arthritis were secondary outcomes.

RESULTS

In total, 798 patients (409 men; 389 women; age 18-81 years, average 38.6 years) with 798 (532 right; 264 left) fractures were included and were classified as Hawkins I (51), IIA (71), IIB (113), III (158), IV (40), neck plus body (177), and body (188). In total, 336 of 798 developed AVN (42%), more commonly after any neck fracture (47.0%) versus isolated body fracture (26.1%, P < 0.001). More severe Hawkins classification, combined neck and body fractures, body mass index, tobacco smoking, right-sided fractures, open fracture, dual anteromedial and anterolateral surgical approaches, and associated medial malleolus fracture were associated with AVN ( P < 0.05). After multivariate regression, fracture type, tobacco smoking, open fractures, dual approaches, age, and body mass index remained significant ( P < 0.05). Excluding late cases (>7 days), time to joint reduction for Hawkins type IIB-IV neck injuries was no different for those who developed AVN or not. AVN rates for reduction of dislocations within 6 hours of injury versus >6 hours were 48.8% and 57.5%, respectively. Complications included 60 (7.5%) infections and 70 (8.8%) nonunions.

CONCLUSIONS

Forty-two percent of all talar fracture patients developed AVN, with talar neck fractures, more displaced fractures, and open injuries having higher rates. Injury-related factors are most prognostic of AVN risk. Surgical technique to emphasize anatomic reduction, without iatrogenic damage to remaining blood supply appears to be prudent.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Osteoperiosteal Iliac Autograft Transplantation for Unreconstructable Tibial Plafond After Malunions of Pilon Fractures in Young Patients

BACKGROUND

Malunion of tibial pilon fracture, especially with a large cartilage loss of the tibial plafond, is a tough clinical conundrum. This study describes a joint-preserving technique that mainly involves corrective intraarticular osteotomy and osteoperiosteal iliac autograft transplantation for treating these generally considered unreconstructable tibial plafond.

METHODS

Sixteen patients with an average age of 33.6 years who were treated with this joint-preserving method between 2013 and 2020 were retrospectively analyzed. Ankle distraction was applied in all patients. Additional osteochondral autograft transplantation for talus was performed in 4 patients and supramalleolar osteotomy in 2 patients. The visual analog scale (VAS) score, the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, the 36-Item Short Form Health Survey (SF-36) score, and the ankle range of motion (ROM) were used for outcome analysis. Radiographic assessment was conducted, and the complications were recorded.

RESULTS

At a mean follow-up of 41.1 months, the mean VAS, AOFAS, and SF-36 scores improved from 6.3, 47.6, and 38.0 to 1.7, 84.4, and 70.8, respectively (P < .001 for each). The ankle ROM improved from 27.5 to 32.2 degrees (P = .023). The mean area of ilium blocks was 3.5 cm2, and the mean external fixation time was 94.1 days. Radiographs showed that good osteointegration was found in all patients and no significant progression of osteoarthritis in 15 patients. The major complications included poor incision healing in 2 patients and severe ankle stiffness in 2 patients, with one of them developing considerable varus-type osteoarthritis but reporting no pain. No deep infection, nonunion, or malunion occurred, and no secondary arthrodesis was performed during the final follow-up.

CONCLUSION

Osteoperiosteal iliac autograft transplantation might be an alternative surgical option for reconstructing unreconstructable malunited pilon fractures with a large cartilage loss of the tibial plafond in young patients.

LEVEL OF EVIDENCE

Level IV, case series.

Kirschner Wire Internal Fixation of the Medial Tibiotalar Joint for Indirect Repair of Deltoid Ligament Injury: A Retrospective Comparative Study

OBJECTIVE

Ankle joint fractures are often accompanied by medial deltoid ligament rupture. There is controversy over whether or how to treat deltoid ligament rupture. This study was aimed to explore the feasibility of repairing the medial deltoid ligament using Kirschner wire internal fixation of the medial tibiotalar joint combined with external fixation.

METHODS

Forty-six patients with ankle fractures involving deltoid ligament rupture, treated between October 2012 and February 2021, were retrospectively evaluated. Twenty-five patients were treated with a Kirschner wire to fix the tibiotalar joint and indirectly repair the deltoid ligament as the repaired group. Twenty-one patients underwent reduction and fixation of internal and external malleolus fractures, and the deltoid ligament was not repaired in the unrepaired group. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, visual analog scale (VAS), Medical Outcomes Short Form 36-item questionnaire score (SF-36), and Medial clear space perpendicular (preoperative, postoperative, final follow-up) were used for functional evaluations and reduction assessments. Mann-Whitney test were used to compare the differences between the groups.

RESULTS

The follow-up time was 13-112 months with a mean of 59.32 months for the repaired group and 11-94 months with a mean of 53.43 months for the unrepaired group. There was no significant difference in the operative time or intraoperative blood loss between the two groups (p > 0.05). At the last follow-up, the AOFAS ankle-hindfoot and SF-36 scores of the repaired group were significantly higher than those of the non-repaired group (p < 0.05). Moreover, the VAS pain score was significantly lower and the Medial clear space perpendicular was significantly narrower in the repaired group than that in the unrepaired group.

CONCLUSION

Tibiotalar joint fixation using Kirschner wires is a simple and effective technique that can indirectly reduce and repair the deltoid ligament and stabilize the ankle.

Results of prophylactic simple fasciocutaneous advancement in the initial management of acute ankle fractures with high risk of operative wound complication

Ankle fracture is the third most prevalent fracture in older adults. Wound dehiscence is the most frequent complication. Our objective is to determine the operative wound complication rate in patients with unstable ankle fracture in whom a prophylactic simple fasciocutaneous advancement was used.

METHODS

Prospective registry of patients with unstable ankle fracture, in whom a prophylactic fasciocutaneous advancement was performed between August 2020 and July 2021. Demographic variables, time spent in performing the flap, cost of osteosynthesis, minor and major complications of the surgical wound, readmission or reoperation were registered.

RESULTS

42 older adults with ankle fracture were included. Median age 69 (60-94). 31% diabetics and 21.5% active smokers. A 40% trimalleolar fracture pattern. There were 7% of superficial complications of the surgical wound. No major complications, no reoperations.

CONCLUSIONS

Prophylactic fasciocutaneous advancement at the beginning of traumatological surgery is technically simple, reproducible, cheap and with low complications.

LEVEL OF EVIDENCE

Level IV, cross-sectional study.

Emergency definitive management of a subtalar dislocation with an associated lateral malleolus fracture

Lateral subtalar dislocations are rare injuries with the potential for misdiagnosis and for poor patient outcomes if missed. Prompt reduction and surgical intervention is the consensus and is key to improved patient outcomes.We present a case of a male patient in his 70s who was brought in by ambulance to the emergency department late one afternoon with a lateral subtalar dislocation associated with calcaneal and lateral malleolar fractures. He was operated on that evening, involving cannulated screw fixation of the calcaneus and buttress plating of the lateral malleolus. Non-weight-bearing mobilisation was permitted at 2 weeks and weight-bearing was commenced at 6 weeks postoperatively.The authors could not find any precedent in the literature for same-day definitive fixation and early mobilisation of this rare but significant injury, the combination of which resulted in excellent functional outcomes for the patient.

Biomechanical insights into ankle instability: a finite element analysis of posterior malleolus fractures

BACKGROUND

Posterior malleolus fractures are known to be associated with ankle instability. The complexities involved in obtaining precise laboratory-based spatial pressure measurements of the ankle highlight the significance of exploring the biomechanical implications of these fractures.

METHODS

Finite element analysis was utilized to examine the stress distribution across the contact surface of the ankle joint, both in its natural state and under varied sagittal fracture line angles. The study aimed to identify stress concentration zones and understand the influence of sagittal angles on stress distribution.

RESULTS

Three distinct stress concentration zones were identified on the ankle's contact surface: the anterolateral tibia, the anteromedial tibia, and the fracture line. The most significant stress was observed at the fracture line when a fracture occurs. Stress at the fracture line notably spikes as the sagittal angle decreases, which can potentially compromise ankle stability. Larger sagittal angles exhibited only minor stress variations at the contact surface's three vertices. It was inferred that sagittal angles below 60° might pose risks to ankle stability.

CONCLUSIONS

The research underscores the potential implications of fractures on the stress profile of the ankle joint, emphasizing the role of the contact surface in ensuring stability. The identification of three zones of stress concentration and the influence of sagittal angles on stress distribution offers a valuable reference for therapeutic decision-making. Further, the study reinforces the importance of evaluating sagittal fracture angles, suggesting that angles below 60° may compromise ankle stability.

The hidden impact of neuropathic pain after surgical fixation of wrist, hip, and ankle fractures: A cross-sectional retrospective study evaluating its prevalence and risk factors

BACKGROUND

Dysesthesia, electrical and burning sensations, in addition to allodynia are frequent symptoms of neuropathic pain. Despite the high frequency, scientific data on the development of neuropathic pain after surgery for fracture fixation are scarce. The goal of the present study was to determine the prevalence, risk factors, and evaluate potential associations among neuropathic pain, pain intensity, sociodemographic, and clinical variables after wrist, hip, and ankle fracture fixation.

METHODS

A cross-sectional retrospective study involving a cohort of 166 patients who underwent surgery for distal radius, proximal femur, malleolar fracture fixation was performed. Neuropathic pain was assessed one year after fracture fixation using the Doleur Neuropathique Questionnaire (DN4).

RESULTS

The incidence of neuropathic pain in our sample was 49 (29.5%). Predictors for the development of neuropathic pain included patients with a high body mass index (BMI), female gender, diabetes mellitus, long-term use of analgesics (especially using pain-modulating medication), patients who presented some fracture-related complication during the course of the treatment, who had limitations for daily activity, and who were away from work due to chronic pain.

CONCLUSION

In our study, neuropathic pain after wrist, hip, and ankle fracture fixation was prevalent and associated with higher BMI values and amount of medication, in addition to higher proportions of female sex, absence from work, DM, limitation for daily activities, postoperative complications, and use of pain modulating medications.

Adverse Events After Ankle Fracture Open Reduction Internal Fixation Among Patients With and Without Documented Cannabis and Tobacco Use

BACKGROUND

Ankle fractures are common orthopaedic injuries that may be indicated for open reduction internal fixation (ORIF). Although the negative impact of tobacco use on perioperative outcomes of ankle fracture ORIF has been described, the potential impact of cannabis use on related outcomes is not as well established.

METHODS

Retrospective database study of adult patients undergoing ankle ORIF for closed, isolated, ankle fractures from the 2010-2021 Q1 PearlDiver M151 data set. Subcohorts without and with cannabis and/or tobacco use were identified based on coding and matched based on patient age, sex, and Elixhauser Comorbidity Index (ECI) scores to yield groups of nonusers, tobacco users, tobacco and cannabis users, and cannabis users. Ninety-day adverse events were assessed between matched subcohorts with multivariable logistic regression controlling for age, sex, and ECI.

RESULTS

A total of 149 289 patients met study inclusion criteria for whom tobacco only use was documented for 14 989 (10.0%), tobacco and cannabis use for 2726 (1.8%), and cannabis only use for 867 (0.6%). Matching yielded 823 for each group. On multivariable analyses, isolated tobacco users were at higher odds of 90-day urinary tract infections (UTIs) (odds ratio [OR] 2.64), minor adverse events (OR 2.33), all-cause adverse events (OR 2.17), readmissions (OR 1.85), and severe adverse events (OR 1.84). Tobacco and cannabis comorbid users were at a marginally higher odds of 90-day UTI (OR 2.82), minor adverse events (OR 2.51), readmissions (OR 2.39), and any adverse events (OR 2.22). Cannabis only users were not at greater odds of 90-day adverse events relative to nonusers.

CONCLUSION

Patients with tobacco use (alone or with cannabis) were at greater odds of 90-day adverse events following ankle fracture ORIF, but cannabis only users were not.

LEVEL OF EVIDENCE

Level III, Retrospective database study.

The treatment of a malunited posterior pilon fracture with talar dislocation: A staged surgical treatment protocol

BACKGROUND

Malunited posterior pilon fractures with talus dislocation (mPPFtd) are rare and there are no appropriate treatment strategies. The purpose of this study was to introduce a stepped strategy featuring preliminary soft tissue management according to the Ilizarov principle and delayed open reduction and internal fixation (ORIF) through a modified posteromedial approach to overcome rigid soft tissue contracture.

METHOD

From February 2015 to August 2021, 12 selected patients with mPPFtd who were treated with the staged protocol (Group A) were retrospectively analysed. The clinical and radiographic outcomes were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, the visual analogue scale (VAS) score, and the Burwell-Charnley score. Moreover, this case series was compared with some cases of fresh fracture (Group B) in patients that had the same baseline data from our previous study.

RESULTS

In Group A, the average length of time between the date of injury and the date of surgery was 4.8 ± 3.3 months. The average time to external fixator distraction, as the first-stage treatment, was 13.4 ± 1.0 days. In the second stage of ORIF, the posterosuperior dislocation of the talus was corrected with osteotomy and leverage manoeuvres. According to the Burwell-Charnley score system, the reduction quality was excellent in 9 cases and good in 3 cases. After a mean follow-up of 3.8 ± 2.1 years, there were no infections, wound healing problems, or nerve injuries in our cohort, and union was observed in all fractures without a loss of reduction. The baseline data of the two groups were not significantly different (p>0.05). The mean AOFAS score in Group A was 85.0 ± 10.5 and that in Group B was 95.4 ± 6.1 (p<0.05). The mean VAS score in Group A was 1.7 ± 1.4 and that in Group B was 0.7 ± 0.9 (p<0.05).

CONCLUSION

A staged surgical treatment strategy characterized by soft tissue management will improve the treatment of mPPFtd and produce satisfactory clinical outcomes.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Two-staged management of ankle fracture-dislocations with a posterior fragment: computer-tomography-based classification, treatment and its outcome

INTRODUCTION

Trimalleolar fractures are difficult to treat and malreduction can lead to functional impairment. Involvement of the posterior malleolus has a poor predictive value. Current computed-tomography (CT)-based fracture classifications led to an increase in fixation of the posterior malleolus. The aim of this study was to describe the functional outcome after a two-stage stabilisation with direct fixation of the posterior fragment in trimalleolar dislocation fractures.

MATERIALS AND METHODS

In a retrospective study, all patients presenting with a trimalleolar dislocation fracture, an available CT scan, and a two-stage operative stabilisation including the posterior malleolus by a posterior approach were included. All fractures were treated with initial external fixator and delayed definitive stabilisation including fixation of the posterior malleolus. Next to clinical and radiological follow-up, outcome measures (Foot and Ankle Outcome Score (FAOS), Numeric Rating Scale (NRS), Activity of Daily Living (ADL), Hulsmans implant removal score) and complications were analysed.

RESULTS

Between 2008 and 2019, of 320 trimalleolar dislocation fractures, 39 patients were included. Mean follow-up was 49 months (standard deviation (SD) 29.7, range 16-148). Mean age was 60 years (SD 15.3, 17-84) with 69% female patients. The mean FAOS was 93/100 (SD 9.7, 57-100), NRS 2 (interquartile range (IQR) 0-3) and ADL 2 (IQR 1-2). Four patients showed a postoperative infection, three re-operations had to be performed and implants were removed in 24 individuals.

CONCLUSION

A two-stage procedure of trimalleolar dislocation fractures with in-direct reduction and fixation of the posterior tibial fragment through a posterior approach leads to good functional outcome scores with a low rate of complications.

A More Conservative Approach in the Surgical Management of Pediatric Physeal Ankle Fractures Should be Preferred: Mid to Long-term Functional Outcomes of Three Different Surgical Techniques for Salter-Harris Type II and Triplane Distal Tibial Fractures

BACKGROUND

Pediatric physeal ankle fractures carry a high risk of complications. This study aimed to (1) investigate the effect of anatomic reduction of the physis on mid to long-term functional outcomes in Salter-Harris type II and triplane distal tibial physeal fractures (DTPFs) and (2) compare the outcomes of 3 different surgical techniques applied in these fractures.

METHODS

The database of a single level-I trauma center was retrospectively reviewed for DTPFs between 2012 and 2022. A total of 39 eligible patients with operative Salter-Harris type II and triplane fractures between 2012 and 2022 were included. Surgical treatment methods were closed reduction-percutaneous fixation (CR-PF), open reduction-screw fixation, or open reduction-plate fixation. Patients were further divided into subgroups for fractures reduced anatomically (<1 mm) or nonanatomically (1 to 3 mm). The primary outcome measures were the American Orthopaedic Foot and Ankle Society Score, ankle range of motion, presence of premature physeal closure and angular deformities, and Takakura ankle osteoarthritis grade.

RESULTS

A total of 39 patients were included, with an average age of 12.9 ± 2.2 years. The mean follow-up time was 68.9±38.0 months. The CR-PF group had higher postoperative fracture displacement ( P = 0.011). American Orthopaedic Foot and Ankle Society scores were excellent in all groups, statistically similar between surgical techniques, and similar between anatomic and nonanatomic reduction groups. The CR-PF group ( P =0.030) and nonanatomic reduction ( P = 0.030) provided a significantly lower ankle osteoarthritis rate. All 4 patients with premature physeal closure were observed in patients treated with open techniques.

CONCLUSIONS

CR-PF for the treatment of DTPFs should be preferred in suitable cases as it is less invasive and provides satisfactory mid to long-term functional outcomes without increasing complications compared with anatomic reduction and open techniques.

LEVEL OF EVIDENCE

Level III.

Weight-Bearing CT with Maximum Ankle Dorsiflexion to Identify Impingement and Tibial Plafond Stress Fracture: A Case Report

CASE

A 25-year-old male pole vaulter presented with several months of right ankle pain. Radiographs showed an anterior tibial osteophyte with a small intra-articular body suggesting impingement. Weight-bearing computed tomography (CT) revealed an associated tibial plafond stress fracture. Subsequent arthroscopy with osteophyte resection and loose body removal significantly improved symptoms, and he gradually resumed training.

CONCLUSION

Stress fractures should always be considered in athletes with ankle pain. A unique aspect of this case was the use of weight-bearing CT in diagnosis and surgical planning. To our knowledge, this is the first described case in which weight-bearing CT was used in this fashion.

A Comparison of Ankle Fractures Relative to Other Fragility Fractures: A Review and Analysis of the American Orthopaedic Association's Own the Bone Database

BACKGROUND

Ankle fragility fractures (AFX) continue to increase in the elderly population. There is limited knowledge of AFX characteristics compared to nonankle fragility fractures (NAFX). The American Orthopaedic Association's Own the Bone (OTB) is a fragility fracture initiative. This robust data set was used to examine and compare characteristics of patients presenting with AFX to those with NAFX.

METHODS

The OTB database contained 72,617 fragility fractures between January 2009 and March of 2022 and were reviewed in our secondary cohort comparative analysis. After exclusions, AFX accounted for 3229 patients and 54,772 patients were in the NAFX cohort. Bivariate analysis and logistic regression compared the AFX and NAFX groups concerning demographics, bone health factors, medication use, and prior fragility fracture.

RESULTS

AFX patients were found to have a higher likelihood to be younger (67.6 years old), female (81.4%), non-Caucasian (11.7%) and have a higher BMI (30.6) compared to NAFX. Prior AFX predicted the risk of a future AFX. The probability of an AFX increased with increased age and BMI.

CONCLUSION

A prior AFX is independently predictive of subsequent AFX. Therefore, these fractures should be considered a sentinel event. These patients are more likely to have higher BMI, to be of female gender, non-Caucasian race, and are younger compared to patients with NAFX.

LEVEL OF EVIDENCE

Level III, retrospective cohort.

Postoperative venous thromboembolism risk-prediction in foot and ankle fracture surgery

BACKGROUND

Venous thromboembolism (VTE) are rare but serious complications after foot and ankle fracture surgery. A consensus definition of a high-risk patient has not been reached, leading to significant variability in the use of pharmacologic agents for VTE prophylaxis. The aim of this study was to develop a model for predicting VTE risk in patients undergoing surgery for foot and ankle fractures that is usable and scalable in clinical practice.

METHODS

A retrospective review of 15,342 patients, within the ACS-NSQIP database, who had undergone surgical repair of foot and ankle fractures from 2015 to 2019 was performed. Univariate analysis evaluated differences in demographics and comorbidities. Stepwise multivariate logistic regression was generated based on a 60 % development cohort to evaluate risk factors for VTE. A receiver operator curve based on the 40 % test cohort calculated area under the curve (AUC) to measure the accuracy of the model in predicting VTE within the 30-day postoperative period.

RESULTS

Of the 15,342 patients, 1.2 % patients experienced VTE, and 98.8 % patients did not. Patients who experienced VTE were significantly older and had an overall higher comorbidity burden. Those who had VTE spent on average 10.5 more minutes in the operating room. In the final model, age over 65, diabetes, dyspnea, CHF, dialysis, wound infection and bleeding disorders were all found to be significant predictors of VTE after controlling for all other factors. The model generated an AUC of 0.731, indicating good predictive accuracy. The predictive model is publicly available at https://shinyapps.io/VTE_Prediction/.

CONCLUSIONS

In alignment with previous studies, we identified increased age and bleeding disorders as independent risk factors for VTE after foot and ankle fracture surgery. This is one of the first studies to generate and test a model for identifying patients at risk for VTE in this population. This evidence-based model may help surgeons prospectively identify high-risk patients who may benefit from pharmacologic VTE prophylaxis.

Risk factors and nomogram predictive model of surgical site infection in closed pilon fractures

OBJECTIVES

In this study, we try to investigate the risk factors of postoperative surgical site infection (SSI) in closed pilon fractures and establish a nomogram prediction model.

METHODS

From January 2012 to June 2021, 516 closed pilon fracture patients were included in this study. Of these, 387 patients were randomly assigned to the training group and 129 patients were assigned to the validation group (3:1). By univariate and multivariate Cox analysis, we identified independent risk factors for postoperative SSI after Pilon fracture. We established a nomogram model and used receiver operating characteristic (ROC) and calibration chart to evaluate its discriminant and calibration.

RESULTS

SSI occurred in 71 patients in the training group and 23 patients in the validation group. Ultimately, age, preoperative blood sugar, operative time, Tscherne classification and fracture classification were identified as independent risk factors for SSI. The AUC values for SSI of the training and validation group were 0.898 and 0.880, and the P value of the Hosmer-Lemeshow test was 0.125. We established a nomogram prediction model based on age, preoperative blood sugar, operative time, Tscherne classification and fracture classification.

CONCLUSION

Our nomogram model had good discrimination and calibration power, so it could be used to predict SSI risk in patients with pilon fracture.

Management of High-Energy Tibial Pilon Fractures

➤ Pilon fractures in the younger patient population are frequently high-energy, intra-articular injuries and are associated with devastating, long-term impacts on patient-reported outcomes and health-related quality of life, as well as high rates of persistent disability.➤ Judicious management of associated soft-tissue injury, including open fractures, is essential to minimizing complications. Optimizing medical comorbidities and negative social behaviors (e.g., smoking) should be addressed perioperatively.➤ Delayed internal fixation with interval temporizing external fixation represents the preferred technique for managing most high-energy pilon fractures presenting with characteristically substantial soft-tissue trauma. In some cases, surgeons elect to utilize circular fixation for these scenarios.➤ Although there have been treatment advances, the results have been generally poor, with high rates of posttraumatic arthritis, despite expert care.➤ Primary arthrodesis may be indicated in cases with severe articular cartilage injury that, in the opinion of the treating surgeon, is likely unsalvageable at the time of the index management.➤ The addition of intrawound vancomycin powder at the time of definitive fixation represents a low-cost prophylactic measure that appears to be effective in reducing gram-positive deep surgical site infections.

Tillaux Fracture Associated with Adult Ankle Fracture Injury

Tillaux fractures in adults are rare and, if unrecognized, can lead to ankle fracture healing complications, early progression of arthritis, and limited ankle movement caused by pain and degenerative changes. The Tillaux fracture was first described by Paul Tillaux as an external rotation injury of the ankle, involving an avulsion fracture of the distal anterolateral tibia. This fracture can be easily overlooked on plain radiographs in the adult. A high index of suspicion for this type of fracture pattern along with the use of computed tomographic scanning can help confirm the suspected diagnosis, rule out other tibial injuries, and provide more information on the best course of action. Historically, Tillaux fractures have been more common in adolescents because of the open tibial epiphyseal plate. Once the epiphyseal plate fully closes, skeletal maturity is achieved, thus making it extremely unusual for the anterior tibiofibular ligament to cause an avulsion fragment of the distal anterolateral tibia. Because of how uncommon this type of fracture is in adults, it has rarely been reported in our literature. We reviewed the literature and present a case report of this rare fracture injury.

Surgical outcome of avulsion fractures of the distal fibula: a systematic literature review

PURPOSE

To provide a systematic overview of clinical and radiographic outcomes in patients who underwent surgical treatment of a painful avulsion fragment of the distal fibula also known as posttraumatic os subfibulare.

METHODS

A systematic literature search across two major sources (PubMed and Scopus) was performed. Twenty-seven studies were included and analyzed using the modified Coleman score to assess the methodologic quality.

RESULTS

The surgical treatment of symptomatic os subfibulare, with or without concomitant ankle instability, generally results in substantial improvement in clinical and radiographic outcomes with relative low complication rates. Clinical outcome measures may not be affected by the presence of ankle instability or by the fragment size. The methodological quality of analyzed studies was satisfactory.

CONCLUSION

Posttraumatic os subfibulare may result in chronic pain and ankle instability. If surgery is indicated, ankle instability should be concomitantly addressed when present. Based on available literature, satisfactory postoperative outcomes can be reliably expected following surgical treatment.

LEVEL OF EVIDENCE

Systematic Review of Level III and Level IV Studies, Level IV.

Fracture-related infection: Prevalence and application of the new consensus definition in a cohort of 1004 surgically treated ankle fractures

BACKGROUND

Surgical treatment of ankle fractures comes with a substantial risk of complications, including infection. An unambiguously definition of fracture-related infections (FRI) has been missing. Recently, FRI has been defined by a consensus group with a diagnostic algorithm containing suggestive and confirmatory criteria. The aim of the current study was to report the prevalence of FRI in patients operated for ankle fractures and to assess the applicability of the diagnostic algorithm from the consensus group.

PATIENTS AND METHODS

Records of all patients with surgically treated ankle fractures from 2015 to 2019 were retrospectively reviewed for signs of postoperative infections. Patients with suspected infection were stratified according to confirmatory or suggestive criteria of FRI. Rate of FRI among patients with confirmatory and suggestive criteria were calculated.

RESULTS

Suspected infection was found in 104 (10%) out of 1004 patients. Among those patients, confirmatory criteria were met in 76/104 (73%) patients and suggestive criteria were met in 28/104 (27%) at first evaluation. Patients with clinical confirmatory criteria (N = 76) were diagnosed with FRI. Patients with suggestive criteria were further examined with either bacterial sampling at the outpatient clinic, revision surgery including bacterial sampling, or a wait-and-see approach. Eleven (39%) of the 28 patients had positive cultures and were therefore diagnosed as having FRI at second evaluation. In total 87 (9%) patients were diagnosed with FRI according to the consensus definition. Only 73 (70%) of the 104 patients with suspected FRI had adequate bacterial sampling.

CONCLUSION

The prevalence of FRI, applying the FRI-consensus criteria, for patients with surgically treated ankle fractures was 9%. Twenty-two percent of patients who met the confirmatory criteria had negative bacterial cultures. The current study shows that we did not have a systematic approach to patients with suspected FRI as recommended by the consensus group. A systematic approach to adequate bacterial sampling when FRI is suspected is paramount. The consensus definition of FRI and its diagnostic algorithm facilitates such an approach.

LEVEL OF EVIDENCE

Level III - retrospective cohort study.

Risk factors for venous thromboembolism following fractures isolated to the foot and ankle fracture

OBJECTIVE

Venous thromboembolism (VTE) is an uncommon, but potentially morbid, complication following foot and ankle fractures. Current standard is to not administer thromboprophylaxis to patients with such injuries. Nonetheless, patient and fracture factors might affect this risk/benefit consideration. The goal of this study was to determine what patients are most at risk.

METHODS

The M53Ortho Pearldiver database was used to identify patients with fractures isolated to the foot and ankle that were treated non-operatively or operatively. Patients with pilon, other appendicular fractures remote from the foot and ankle, and other traumatic injuries were excluded. The 90-day occurrence of VTE was identified based on codes for deep vein thrombosis or pulmonary embolism. Characteristics of those patients who did and did not have VTEs were compared using chi-square analyses. Multivariate logistical regression was then performed to determined factors independently associated with VTE. Finally, timing of VTE relative to fracture was analyzed.

RESULTS

A total of 298,886 patients with isolated foot or ankle fractures were identified, of which 1,661 (0.56%) had VTE in the 90 days following fracture. In terms of timing, 27.3% occurred in the first week, and 49.8% occurred in the first three weeks. Independent risk factors for VTE included (in decreasing order):prior VTE (odd ratio [OR] = 25.44), factor V Leiden (OR = 24.34), active cancer (OR = 1.84), specific fracture relative to metatarsal fracture (multiple fractures [OR: 1.51], ankle fracture [OR = 1.51], and calcaneus fracture [OR = 1.24]), surgical treatment (OR = 1.41), male sex (OR = 1.19), greater Elixhauser index (OR = 1.05), and increasing age (OR:1.05 per decade) (p<0.05 for each).

CONCLUSIONS

The present study found that, although only 0.56% of isolated foot and ankle fractures had a VTE within ninety days. Defined risk factors, such as Factor V Leiden, prior VTE, surgical treatment, active cancer, specific fracture patterns, and surgical treatment significantly affected the odds of their occurrence.

Syndesmotic Injury in Tibial Plafond Fractures Is Associated With Worse Patient Outcomes

OBJECTIVES

To present long-term patient-reported outcomes of tibial plafond fractures with and without concomitant ankle syndesmotic injury.

DESIGN

Retrospective cohort study.

SETTING

Academic Level 1 trauma center.

PATIENTS/PARTICIPANTS

One hundred ninety-seven patients with tibial plafond fractures (OTA/AO 43-B and 43-C) treated with definitive surgical fixation were contacted by telephone or email to obtain patient-reported outcome scores at a minimum follow-up of 1 year. Of those contacted, 148 (75%) had an intact syndesmosis, whereas 49 (25%) experienced a syndesmotic injury.

INTERVENTION

The intervention involved open reduction internal fixation of the tibial plafond with syndesmosis repair when indicated.

MAIN OUTCOME MEASUREMENT

The main outcome measurement included patient-reported ankle pain and function using Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference and physical function (PF).

RESULTS

The cohort including patients with syndesmotic injury had significantly more open fractures (syndesmotic injury = 39%, no syndesmotic injury = 16%, P = 0.001), higher rates of end-stage reconstruction (syndesmotic injury = 27%, no syndesmotic injury = 10%, P = 0.004), and worse PROMIS PF (syndesmotic injury = 42.5 [SD = 8.0], no syndesmotic injury = 47.1 [SD = 9.6], P = 0.045) scores at final follow-up when compared with the cohort comprising patients with no syndesmotic injury. Patients with syndesmotic injury trended toward higher rates of postoperative infection, but this association was not statistically significant. There was no difference between the groups in nonunion or PROMIS pain interference scores.

CONCLUSION

Patients with a tibial plafond fracture and concomitant syndesmotic injury had significantly worse PROMIS PF scores, more end-stage ankle reconstructions, and more open fractures. Syndesmotic injury in the setting of tibial plafond fractures portends worse patient outcomes.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

National Evaluation of Social Determinants of Health in Orthopedic Fracture Care: Decreased Social Determinants of Health Is Associated With Increased Adverse Complications After Surgery

OBJECTIVES

To assess the individual impact of social determinants of health disparities (SDHD) on surgical outcomes following orthopaedic trauma surgery.

DESIGN

Retrospective Cohort Study.

SETTING

Mariner Claims Database.

PATIENTS

Inclusion criteria were patients 18-85 years of age, undergoing surgery for hip fractures or ankle fractures from 2010 to 2018.

INTERVENTION

Patients were divided based on SDHD using International Classification of Diseases 9 and International Classification of Diseases 10 codes. Those with SDHD were propensity-score matched with those who did not have any disparities with respect to age, gender, Charlson comorbidity index, tobacco use, and obesity (body mass index >30 kg/m2).

OUTCOMES

Ninety-day major medical complications, infection, readmission, and revisions within 1 year.

RESULTS

Patients with educational deficiencies had increased rates of readmission and major complications compared with those without disparities following hip and ankle fracture management. Moreover, economic disparities were associated with an increased risk of readmission and revision following hip fracture surgery and infection and readmission following ankle fracture surgery.

DISCUSSION/CONCLUSIONS

This study emphasizes the large impact of SDHD on patients' outcomes following surgery and the importance of proper follow-up interventions to optimize patient care.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Better discrimination of the concomitant peri-ankle fractures in the spiral tibial shaft fractures by thin-slice axial and three-dimensional CT

The objective of this study was to examine the morphologic features of spiral tibial shaft as well as concomitant fibular and peri-ankle fractures on multidetector high-resolution CT and to speculate about the mechanisms underlying these combined fractures.This is a retrospective cohort study. A total of 197 tibial shaft fractures underwent multidetector high-resolution CT before intramedullary nailing. The presence and location of peri-ankle fractures were recorded using thin-slice axial CT. Tibial shaft fractures were classified as spiral or non-spiral. The morphologies of spiral tibial fractures and concomitant lateral malleolar fractures were delineated using three-dimensional CT.Seventy-five spiral and 122 non-spiral fractures were identified. Peri-ankle fractures excluding lateral malleolar fractures were found in 77.3% of spiral fractures and 18.9% of non-spiral fractures. The most frequent location of peri-ankle fractures in the spiral group was the posterior malleolus, followed by the anterolateral distal tibia, while the medial malleolus was the most frequent site in the non-spiral group. Of 75 spiral fractures, 72 showed a fracture morphology attributed to external rotation force. There were 13 lateral malleolar fractures that were defined as within 6 cm from the distal end of the fibula. No lateral malleolar fractures showed the typical morphology of isolated supination/external rotation-type ankle injuries. The displaced syndesmotic injuries commonly coexisting in pronation/external rotation-type ankle injuries were not observed.Most spiral tibial shaft fractures were caused by external rotation force. However, the morphology of concomitant peri-ankle fractures was inconsistent with typical mechanisms of isolated external rotation ankle injuries.

Gustilo IIIA Open Bimalleolar Fracture Dislocation of Ankle with Ipsilateral Achilles Tendon Rupture: A Case Report and Review of Literature

CASE

Although rare, a medial malleolus fracture plus ipsilateral Achilles tendon rupture has been described in previous case reports. We present a unique case of an open bimalleolar fracture dislocation with ipsilateral Achilles tendon rupture after a motorcycle crash. His Achilles injury was diagnosed intraoperatively during external fixator placement. He presented in a delayed fashion to our institution, where he underwent open reduction internal fixation and Achilles tendon reconstruction.

CONCLUSION

Although most commonly described with isolated medial malleolus fractures, Achilles tendon injuries can also be associated with bimalleolar ankle fractures. These associated injuries are frequently missed.

Secondary below-knee amputation following open reduction and internal fixation of a closed pilon fracture: A case report and algorithm for management

RATIONALE

Despite significant advances in surgical techniques and implants, the clinical outcome of high-energy pilon fractures remains unsatisfactory, which continues to represent numerous challenges for orthopedic trauma surgeons.

PATIENT CONCERNS

A 62-year-old man injured his right ankle after falling from a 3 m high place. There were no open wounds or other complications.

DIAGNOSES

According to the X-ray and CT scans, the patient was diagnosed with pilon fracture (type AO-43-C2) and lateral malleolus fracture of the right limb.

INTERVENTIONS

The patient was initially treated with calcaneal traction upon admission to a primary hospital. Five days after the injury, the patient underwent open reduction and internal fixation (ORIF) of the fracture and vacuum sealing drainage (VSD) for wound closure.

OUTCOMES

The patient presented to our hospital on the 9th day after the first ORIF operation because of critical ischemia of the affected foot and distal lower leg. Blood circulation did not improve after a series of salvage treatments, and below-knee amputation was ultimately performed.

LESSONS

This is a rare case of complete ischemic necrosis following ORIF surgery of a closed pilon fracture due to iatrogenic damage. Standardized treatment that strictly follows the guidelines, instructions, or expert consensus should be promoted in this kind of complicated pilon fracture.

Biomechanical effect of anterior talofibular ligament injury in Weber B lateral malleolus fractures after lateral plate fixation: A finite element analysis

OBJECTIVE

To determine the biomechanical effect of anterior talofibular ligament injury in Weber B lateral malleolus fractures after lateral plate fixation.

METHOD

A three-dimensional model was established based on CT images from a healthy volunteer. The simulation of lateral malleolus fracture, and the modeling and assembly of plate were completed by referring to characteristics of Weber B lateral malleolus fractures, as well as the technical characteristics of open reduction and internal fixation of lateral plate. Operating conditions were set up for groups A-D. The proximal end of the model was restrained in all four groups, 200N of upward force and 100N of backward force were applied at anterior of talus head in order to simulate the dorsiflexion of ankle joint. Biomechanical differences of the lateral plate were observed under various conditions of different ligament ruptures.

RESULTS

The maximum stress value of group A was the smallest, approximately 78.47N, while that of group C was the largest, approximately 238.83N. The maximum stress value of group B was about 91.69N; and that of group D was about 184.08N. Importantly, location of the maximum stress in group D (CUT ATaF) was displaced from the posterior edge to the anterior edge of the plate, which was different from those of the other three groups.

CONCLUSIONS

The anterior talofibular ligament injury may be a major contributing factor to the stress of lateral plate fixation following Weber B lateral malleolus fracture. It should be considered as an essential risk factor for evaluation of the stability in these fractures.

Posterior Malleolar Fracture Morphology in Tibial Shaft Versus Rotational Ankle Fractures: The Significance of the Computed Tomography Scan

OBJECTIVE

To compare posterior malleolar fracture morphology in ankle fractures compared with those with tibial shaft fractures.

SETTING

Level 1 trauma center.

DESIGN

Retrospective cohort study.

PATIENTS/PARTICIPANTS

Fifty-four patients with tibial shaft fractures and 61 patients with ankle fractures.

MAIN OUTCOME MEASUREMENTS

Posterior malleolar fractures in ankle fractures versus tibial shaft fractures were classified by type and pathomorphology analyzed.

RESULTS

Posterior malleolar fractures were significantly larger when associated with tibial shaft fractures (32% cross-sectional area) as compared to ankle fractures (15% cross-sectional area) (P < 0.001). The distribution of posterior malleolar fracture type differed between tibial shaft fractures and ankle fractures. In addition, 47% of the type II posterior malleolar fractures in tibial shaft fractures had an additional fracture line oriented in the sagittal plane, a fracture pattern unique to these injuries that were not observed in the ankle fracture cohort.

CONCLUSIONS

Posterior malleolar fracture morphology varied significantly between tibial shaft fractures and rotational ankle fractures. Posterior malleolar fractures in tibial shaft fractures were over twice the size of posterior malleolar fractures that occur with rotational ankle fractures and more likely to involved the medial malleolus. This information emphasizes the importance of recognizing that large posterior malleolar fractures are associated with tibial shaft fractures.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Operative Outcome of Bimalleolar Fractures

Background Ankle fractures are common injury occurring due to low energy trauma. Unstable ankle fractures are usually treated with operative management. Objective To find out demographic and the relationship between various clinical variables and outcome of operative treatment in ankle fractures in patient who underwent operative treatment for bimalleolar ankle fractures. Method A retrospective observational study of 32 patients who underwent operative treatment of bimalleolar ankle fracture in between January 2012 and December 2015 at Dhulikhel Hospital, Kathmandu University Hospital was performed. Skeletally mature individual of age greater than 16 years with bimalleolar ankle fractures operated within two weeks of injury were included in the study. Operating surgeon chose the type of surgery and implants required for the patient. Post operatively patients were kept in non-weight bearing for six weeks. Result The average age of the patients was 36.72 ± 19.97 years. The most common cause for the injury was twisted ankle. The mean follow up period of the patients was 20.94 ± 16.32 months. The most common fracture type was Weber B (supination external rotation injury). Most common technique for fixation for medial malleolus fracture was open reduction and modified tension band. Most of the lateral malleolus fractures were treated with open reduction and fixation with reconstruction plate. Six cases were treated with syndesmotic screws. Most of the patients had excellent AOFAS score with mean score of 90.56 ± 10.92 out of maximum 100. Average pain score was 32.81 ± 36.34 out of 40, average function score was 47.81 ± 6.05 out of 50 and average alignment score was 9.94 ± 0.35 out of 10. Conclusion The outcome of surgically treated bimalleolar ankle fractures was excellent for our patients. The fracture patterns and requirement of syndesmotic screw failed to show any significance when comparing the outcome.

Progression to ambulation following lower limb fractures in an individual with a spinal cord injury: a case report

Introduction

Patients with spinal cord injury (SCI) and concomitant lower limb fractures are a challenge to rehabilitate. Conventionally, postural orientation is an important milestone in the rehabilitative process. We propose an alternative strategy in achieving goals in individuals with an SCI with concomitant injuries that preclude weight bearing below the knee.

Case presentation

A 16-year-old girl sustained a burst fracture of L1 in conjunction with bilateral ankle fractures. During rehabilitation, the calcaneal fracture on the left and tibial plafond fracture on the right prevented her progression in conventional rehabilitation. An alternative strategy "K-ing" (Kneel Standing/Kneel Walking) was adopted to facilitate truncal activation without loading the ankle joints. This was found to be helpful in obtaining upright posture stability without hampering her recovery of associated ankle injuries.

Discussion

"K-ing" strategy can be useful and presents a simple alternative in the presence of associated ankle injuries. It also avoids complications associated with bedrest when there is delay in initiation of ambulation.

Ankle joint dislocation treating dislocated trimalleolar fractures accompanied with the complex posterior malleolus fracture without separation of the tibiofibular syndesmosis

To explore the therapy of ankle joint dislocation treating dislocated trimalleolar fractures accompanied with the complex posterior malleolus fracture without separation of the tibiofibular syndesmosis and improve surgical results.Patients who had dislocated trimalleolar fractures accompanied with the complex posterior malleolus fracture without separation of the tibiofibular syndesmosis were retrospectively analyzed and 30 patients were enrolled the study. They were all treated by ankle joint dislocation and the surgical results were evaluated by the Baird-Jackson ankle scoring system. Longitudinal curved incision in medial malleolus was made in ankle joint dislocation and subluxation was automatically formed by appropriate traction of ankle joint. The talus and the distal end of internal and external malleolus were pushed the outside to form the lateral dislocation of the ankle joint. After fully revealed the posterior malleolus and distal articular surface of the tibia, the anatomical reduction of comminuted bones with joint cartilage and posterior malleolus was achieved by fixed with absorbable screw or Kirschner wire. Internal and external malleolus fracture was fixed by the conventional approach.The average follow-up period was 13 months. According to the Baird-Jackson ankle scoring system, the excellent and good result was 28 cases, fair was 2 cases which the excellent and good rate was 93.3% without talar necrosis in any cases.Ankle joint dislocation can achieve the satisfactory results in treating dislocated trimalleolar fractures accompanied with the complex posterior malleolus fracture without separation of the tibiofibular syndesmosis. Ankle joint dislocation can make joint cartilage restore accurately with excellent results.

A higher association of medial collateral ligament injury of the knee in pronation injuries of the ankle

INTRODUCTION

To evaluate the prevalence of medial collateral ligament (MCL) injury of the knee among ankle-fracture patients and to determine the risk factors associated with MCL injury in this patient group.

MATERIALS AND METHODS

303 patients (303 affected ankles) who underwent surgical treatment for an ankle fracture were assessed. Supination versus pronation injury, Danis-Weber classification, age, sex, body mass index (BMI), limb dominance, and mechanism of injury were reviewed to identify factors related to MCL injury.

RESULTS

Prevalence of MCL injury of the knee among the total number of patients with an ankle fracture was 3.96% (12 out of 303 injuries). Multivariable logistic and linear regression analysis with adjustment of possible confounding factors confirmed that female sex and pronation injury were associated significantly (p < 0.05) with MCL injury.

CONCLUSIONS

The prevalence of MCL injury among females and the pronation type of ankle injury was 8.19% (10 out of 122 females) and 10.75% (10 out of 93 pronation injuries), respectively. More careful physical examination of the knee joint is strongly recommended in patients with ankle fractures, especially if the patient is female or the ankle-fracture pattern corresponds to the pronation type of injury.

Establishment of rat ankle post-traumatic osteoarthritis model induced by malleolus fracture

BACKGROUND

Malleolar fracture, which is present in 37-53% of human ankle osteoarthritis (OA), is the most common type of fracture in the ankle joint. In spite of this, no rat animal model has been developed for this type of injury to date. Here, we established a rat ankle post-traumatic OA (PTOA) model induced by malleolar fracture; this model will be useful in ankle OA research.

METHODS

Two-month-old male Sprague Dawley (SD) rats were randomized into 2 groups (n = 19 per group): 1) malleolus articular fracture, dislocation, and immediate reduction on the right joints and 2) malleolus articular fracture on the right ankle. The contralateral ankle joints were used as controls. The fracture and healing processes were confirmed and monitored by radiography. Changes in inflammation were monitored in vivo by fluorescence molecular tomography (FMT). Cartilage damage and changes in expression of OA-related genes were analyzed by histology, immunohistochemistry, Real-time quantitative PCR (qPCR) and enzyme-linked immunosorbent assay (ELISA) at 8 weeks post-surgery.

RESULTS

X-rays showed that all fractures were healed at 8 weeks post-surgery. A reproducible, mild to moderate degree of OA cartilage damage with reduced aggrecan was detected by histology in all animals in both groups but there was no significant difference between the two groups. Decreased Col-II and increased Col-X and MMP-13 levels were detected by qPCR, immunohistochemistry, ELISA and FMT from both groups cartilage.

CONCLUSIONS

Malleolus articular fracture alone induces ankle OA with lesions on the central weight bearing area of the tibiotalar joint in rats. This model will provide a reproducible and useful tool for researchers to study ankle OA.

Effect of Lymphedema Treatment for Management of Acute Pilon Fractures

Pilon fractures are high-energy injuries that often result in considerable edema and compromise of the soft tissue envelope of the ankle. These injuries are typically staged with an external fixator until the soft tissue is amenable for definitive fixation. This study was conducted to determine the effects of lymphedema treatment for the management of pilon fractures. Patients who underwent open reduction and internal fixation of pilon fractures between 2007 and 2014 at the authors' level II trauma center were identified by Current Procedural Terminology codes indicative of placement of an external fixator (20690) and open reduction and internal fixation of a pilon fracture (27826, 27827, or 27828). The primary efficacy endpoint to determine negative outcomes was 90 days after definitive fixation. Eighty-two patients with 84 pilon fractures met inclusion criteria. Forty-eight ankles (57%) received lymphedema treatment. There were no significant differences in population demographics between the control and treatment groups. Median times to internal fixation in the control and treatment groups were 20 days (inter-quartile range, 15.5-30 days) and 11 days (interquartile range, 6-18 days), respectively. This difference was statistically significant (P=.001). Additionally, there was no significant difference in the overall incidence of wound complications between the control and treatment groups (P=.246). Compression wrapping for posttraumatic edema was effective in reducing the time needed for soft tissues to be appropriate for definitive surgical fixation of pilon fractures without increasing the risk of wound complications. These promising results warrant future study. [Orthopedics. 2017; 40(4):e668-e674.].

Irreducible Ankle Fracture from an Interposed Chaput Fragment: A Case Report

CASE

A 23-year-old active-duty military service member sustained an unusual irreducible fracture-dislocation of the ankle joint. Preoperative computed tomography showed an anterolateral tibial (Chaput) fragment entrapped within the distal syndesmosis, preventing adequate reduction. An open reduction of the fragment was performed in the operating room, which allowed near-anatomic reduction and internal fixation of the tibiotalar joint. At the 21-month follow-up visit, the patient remained on active duty in the Navy without limitations.

CONCLUSION

To our knowledge, this rare injury pattern, an interposed Chaput fragment preventing closed reduction of the syndesmosis in a skeletally mature patient, has not previously been described in the literature. An open reduction and internal fixation of the Chaput fragment allowed near-anatomic reduction of the tibiotalar joint.

Relationship of Prolonged Operative Time and Comorbidities With Complications After Geriatric Ankle Fractures

BACKGROUND

The incidence of geriatric ankle fractures has increased during the last few decades. In contrast to younger patients, increased complication rates have been observed. Thus, the goal of the present study was to identify risk factors for perioperative complications following open reduction and internal fixation of geriatric ankle fractures.

METHODS

Two hundred thirty-seven patients over the age of 65 years (mean, 72.5 ± 6.1 years) treated for ankle fractures in our institution between 2004 and 2014 were included. Complications associated with operative treatment as well as complications requiring revision surgery were analyzed. In a multivariate analysis, risk factors were determined.

RESULTS

In 68 patients (28.7%), 74 complications were documented. The most common complications were impaired wound healing and operative site infections. The multivariate analysis revealed that the operative time was the only independent risk factor for the development of a complication. The operative time as well as the presence of an open fracture represented risk factors for needing revision surgery. Comorbidities did not influence the development of complications.

CONCLUSION

The operative management of geriatric ankle fractures was associated with a high complication rate. In the present study, the operative time was the only modifiable factor for the development of a complication that required revision surgery. During preoperative preparation, we believe that perfusion of the affected limb should be optimized to reduce the incidence of wound complications.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Complications of Pediatric Foot and Ankle Fractures

Ankle fractures account for 5% and foot fractures account for approximately 8% of fractures in children. Some complications are evident early in the treatment or natural history of foot and ankle fractures. Other complications do not become apparent until weeks, months, or years after the original fracture. The incidence of long-term sequelae like posttraumatic arthritis from childhood foot and ankle fractures is poorly studied because decades or lifelong follow-up has frequently not been accomplished. This article discusses a variety of complications associated with foot and ankle fractures in children or the treatment of these injuries.

Acute Tibialis Posterior Tendon Rupture With Pronation-Type Ankle Fractures

Tibialis posterior tendon rupture in the setting of pronation-type ankle fractures can lead to long-term debility as a result of chronic tendon dysfunction. This rare injury pattern presents a diagnostic challenge because thorough preoperative examination of the function of the tendon is limited by pain, swelling, and inherent instability of the fracture. As such, a high index of suspicion is necessary in ankle fractures with radiographs showing a medial malleolus fracture with an associated suprasyndesmotic fibula fracture. This report describes 3 cases of tibialis posterior tendon rupture associated with pronation-type ankle fractures treated acutely with open reduction and internal fixation and primary tendon repair. Additionally, common features of this injury pattern are discussed based on the current literature. In accordance with this report, the typical mechanism of injury is high energy and includes forced pronation, external rotation, and dorsiflexion of the ankle, which places maximal stress on the tibialis posterior tendon. Rupture most commonly occurs in a relatively hypovascular area of the tendon located at the posteromedial extent of the medial malleolus fracture. In the operative treatment of pronation-type ankle fractures, direct inspection of the tibialis posterior tendon allows for timely diagnosis and treatment of associated ruptures. [Orthopedics.2016; 39(5):e970-e975.].

Pulmonary embolism and mortality following total ankle replacement: a data linkage study using the NJR data set

OBJECTIVE

To determine the mortality rate following total ankle replacement (TAR) and incidence of 90 day pulmonary embolism (PE) along with the associated risk factors.

DESIGN

Data-linkage study of the UK National Joint Registry (NJR) data and Hospital Episodes Statistics (HES) database. Linkage was performed in a deterministic fashion. HES episodes 90 days after the index procedure were analysed for PE. Mortality data were obtained pertaining to all the index procedures from the NJR for analysis.

PARTICIPANTS

All primary and revision ankle replacement patients captured on the NJR between February 2008 and February 2013.

RESULTS

The 90-day mortality following TAR was 0.13% (95% CI 0.03 to 0.52) and 1-year mortality was 0.72% (95% CI 0.40 to 1.30); no deaths were as a result of PE. The incidence of PE within 90 days following primary TAR was 0.51% (95% CI 0.23 to 1.13). There was only one PE following revision surgery. Patients with an Royal College of Surgeons Charlson score greater than zero were at 13 times greater risk of PE (p=0.003).

CONCLUSIONS

There is low incidence of PE following TAR, but multiple comorbidities are a leading risk factor for its occurrence.

Tibialis Posterior Tendon Entrapment Within Posterior Malleolar Fracture Fragment

Management of posterior malleolus fractures continues to be controversial, with respect to both need for fixation and fixation methods. Fixation methods include an open posterior approach to the ankle as well as percutaneous reduction and fixation with or without arthroscopy for visualization of the articular surface. Plain radiographs are unreliable in identifying fracture pattern and intraoperative reduction, making arthroscopy a valuable adjunct to posterior malleolus fracture management. In this article, we report a case of tibialis posterior tendon entrapment within a posterior malleolus fracture, as identified by arthroscopy and managed with open reduction. Tibialis posterior tendon entrapment within a posterior malleolus has not been previously reported. Ankle arthroscopy for posterior malleolus fractures provides an opportunity to identify soft-tissue or tendinous entrapment, articular surface reduction, and articular cartilage injuries unlikely to be identified with fluoroscopy alone and should be considered in reduction and fixation of posterior malleolus fractures.