Radiographic diagnosis of distal fibula avulsion fractures: Comparison of ankle X-ray and three-dimensional reconstruction of CT / 北京大学学报(医学版)

OBJECTIVE@#To investigate the difference in sensitivity between X-ray and three-dimensional reconstruction of computed tomography (3D-CT) for the diagnosis of distal fibular avulsion fracture, and the radiographic presentation of the ossicle.@*METHODS@#From January to October 2018, 92 patients with distal fibular avulsion fracture were visited for surgical treatment in Department of Sports Medicine, Peking University Third Hospital, and 60 cases were finally enrolled according to the inclusion and exclusion criteria. Intraoperative detection was regarded as the gold standard, and the diagnostic sensitivity of preoperative ankle X-ray and 3D-CT for the distal fibular avulsion fractures was statistically determined. The ossicle maximum diameter as well as the degree of its displacement were also measured. On 3D-CT, the distance from the ossicle center point to the anterior fibular tuberosity (a), the distance to the fibular tip (b), and the a/b value was used to present the ossicle displacement.@*RESULTS@#Among the 60 patients, 36 and the 52 patients were correctly detected by X-ray and 3D-CT, respectively, and the sensitivities was 60.0% and 86.7%, respectively (P=0.004). The mean diameter of the ossicle on X-ray and 3D-CT was (9.2±3.9) mm and (10.5±3.2) mm, respectively. The mean distance from the ossicle center to the anterior fibular tuberosity (a) was (17.5±3.6) mm and the mean distance to the fibular tip (b) was (17.4±4.8) mm, with mean a/b values of 1.1±0.7. The intraclass correlation coefficients (ICC) for each measurement ranged from 0.891-0.998 with a high degree of consistency.@*CONCLUSION@#Compared with X-ray, 3D-CT has higher sensitivity in diagnosing distal fibular avulsion fractures, can help clinicians evaluate ossicle's location and choose surgical methods, and is recommended to be performed in patients with suspected distal fibula avulsion fractures in clinical practice.

Treatment of Distal Tibiofibular Syndesmosis Injury Associated with Ankle Fractures with Suture Button / Tratamento da lesão da sindesmose tibiofibular distal associada às fraturas do tornozelo com suture button

Abstract Objective To evaluate the results obtained from the surgical treatment of malleolar ankle fractures associated with distal tibiofibular syndesmosis (DTFS) injury submitted to conventional surgical procedure for fracture fixation and DTFS fixation by suture button (SB). Methods Forty-nine patients were retrospectively evaluated, with a mean age of 45 years old and a mean follow-up of 34.1 months. Clinical and functional evaluation was based on the visual analogue scale (VAS) and on the American Foot and Ankle Society Score (AOFAS) for ankle and hindfoot, return to routine activities, and return to sport. Results The postoperative mean AOFAS and VAS were, respectively, 97.06 (confidence interval [CI 95%: 95.31-98.81] and 0.16 [CI 95% 0,04 - 0,29]. All patients returned to previous daily activities, and only 12 showed some residual symptom. There was no postoperative instability in any patient. Forty-six patients returned to sports activities and, of these, only 1 did not return to the level prior to the injury. Only two patients presented SB-related alterations. There was no report of dissatisfaction. Conclusion In malleolar fractures of the ankle with DTFS injury, the fixation of syndesmosis with SB demonstrated excellent postoperative results. Level of Evidence IV, retrospective case series.

Resumo Objetivo Avaliar os resultados obtidos do tratamento cirúrgico das fraturas maleolares do tornozelo associadas a lesão da sindesmose tibiofibular distal (STFD) submetidas a procedimento cirúrgico convencional de fixação da fratura e fixação da STFD pelo suture button (SB). Métodos Avaliou-se retrospectivamente 49 pacientes com uma média de idade de 45 anos e seguimento médio de 34,1 meses. A avaliação clínica e funcional foi baseada na escala visual analógica (EVA) e na escala American Foot and Ankle Society Score (AOFAS, na sigla em inglês) para tornozelo e retropé, retorno às atividades da rotina e retorno ao esporte. Resultados As médias pós-operatórias das escalas AOFAS e EVA foram, respectivamente, 97,06 (índice de confiança [IC 95%: 95,31 - 98,81] e 0,16 [IC 95% 0,04 - 0,29]. Todos os pacientes retornaram às atividades prévias do cotidiano, sendo que apenas 12 apresentaram algum sintoma residual. Não se verificou instabilidade pós-operatória em nenhum paciente. Ao todo, 46 pacientes retornaram às atividades desportivas e, destes, apenas 1 não retornou ao nível prévio à lesão. Apenas dois pacientes apresentaram alterações relacionadas ao SB. Não houve relato de insatisfação. Conclusão Em fraturas maleolares do tornozelo com lesão da STFD, a fixação da sindesmose com o SB demonstrou excelentes resultados pós-operatórios. Nível de Evidência IV, série de casos retrospectiva.

Analysis of the efficacy of a modified posteromedial approach for Klammer III posterior Pilon fractures / 中华创伤杂志(英文版)

PURPOSE@#To analyze the curative effect and technical points of a modified posteromedial approach in the treatment of Klammer III posterior Pilon fracture.@*METHODS@#A retrospective analysis of patients with Klammer III posterior Pilon fractures were conducted in our department from January 2018 to December 2019. Before the surgery, the patients were fully relieved of swelling and pain, and a comprehensive examination was carried out. The posteromedial approach exposed the posterior and medial fracture block of the distal tibia. According to the fracture of external malleolus, it is determined whether to combine a lateral incision and protect tendons and vascular nerves by a retractor, and then perform a fracture reduction and internal fixation. Postoperatively, the patients were treated with analgesia, detumescence, anticoagulation and rehabilitation exercise. The American orthopaedic foot and ankle society (AOFAS) score and visual analogue score were recorded at regular follow-up after surgery. A t-test was used for the comparison of the preoperative and final AOFAS score.@*RESULTS@#There were 7 male and 13 female (n = 20) included in the study, aged 22 to 88 years (average age 54.2 years). The injury mechanisms were falling from a height (n = 7), traffic accident (n = 6), walking injury (n = 2) and heavy injury (n = 5). The postoperative follow-up duration was 12-24 months (mean 16.95 months). The AOFAS score of the 20 patients before and after surgery were compared. The preoperative AOFAS score was 38.90 ± 3.91, and the final AOFAS score was 80.55 ± 4.20, (p < 0.001). The mean final visual analogue scores at rest, active and weight-bearing walking were 0.30, 0.85 and 1.70, respectively. One patient reported poor postoperative wound healing and required a return to hospital for debridement and anti-infection treatment.@*CONCLUSION@#In the treatment of Klammer III posterior Pilon fractures, the modified posteromedial approach can fully expose the fracture block and the collapsed articular surface of the medial malleolus, achieve good reduction and internal fixation with limited injury of the tendon and vascular nerves, and have a better prognosis.

Clinical results of modified medial approach in the treatment of Pilon fracture with medial column compression / 中国骨伤

OBJECTIVE@#To explore the clinical results of modified medial incision in the treatment o f Pilon fracture with medial column compression and evaluate its safety.@*METHODS@#Thirty-one patients of Pilon fracture with medial column compressiom accepted surgical treatments in the Department of Foot and Ankle at Honghui Hospital of Xi'an Jiaotong University from January 2015 to January 2019. According to the imaging data at admission, 31 cases were diagnosed as closed Pilon fractures, and both preoperative X-ray and 3D CT scan were shown as medial column compressive fractures. All patients underwent modified medial incision with complete data, including 23 males and 8 females;ranging in age from 22 to 65 years old, with an average of (39.5±16.2) years old. All patients underwent modified medial approach combined with other approaches to expose the broken end of fracture. The time from trauma to operation ranging from 7 to 20 days, with a mean of(9.5±5.5) days. The incision and fracture healing were followed up regularly after operation.@*RESULTS@#All patients were followed up with an average of(15.7±5.5) months(ranged, 13 to 25 months). Preoperative and postoperative routine X-ray and 3D CT examination showed anatomical reduction in 8 cases, and the anatomical reduction rate was 25.81%. Up to the latest follow-up, all 31 fractures had achieved bone healing, and the healing time ranged from 11 to 22 weeks, with a mean of (14.3±4.7) weeks. At the latest follow-up, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scores ranged from 75 to 89, with a mean of 80.5±4.9, 24 patients got a good result, 7 fair.@*CONCLUSION@#The improved medial approach for Pilon fracture can directly expose the posterior medial, medial and anterior medial of the distal tibia. After reduction under direct vision, the medial compressed and collapsed articular surface are fixed. The clinical curative effect is satisfactory and the wound complications are less. It is recommended for Pilon fracture where compression of the medial articular surface is predominant.

Eficiencia de la técnica de Broström-Gould en el tratamiento quirúrgico de la inestabilidad lateral crónica de tobillo / Broström-Gould technique efficiency in chronic lateral ankle instability surgical treatment

Los déficits neuromusculares resultantes de las lesiones que comprometen al tobillo, facilitan la aparición de recidivas, por la afectación estructural que no sólo ocurre en los ligamentos, sino también en los nervios y tejido músculo-tendinoso, pudiendo provocar numerosas alteraciones asociadas que provocan inestabilidad crónica. El objetivo de este trabajo es analizar la eficiencia de la técnica de Broström modificada en pacientes con inestabilidad crónica del tobillo, atendidos en el Hospital Dr. Miguel Pérez Carreño y consulta privada entre noviembre 2016 y enero 2020. El tipo de investigación prospectiva, descriptiva, de campo clínico. La muestra la conformaron 31 pacientes. La edad promedio fue 34,4 años, la mayoría de género masculino, y con predominio en el tobillo derecho. Al aplicar la escala EVA en el pre y post quirúrgico, se observó disminución del grado de dolor postquirúrgico con una escala entre 0 y 4. La escala de Karlsson y Peterson aplicada en el lapso de 1 año después del período postquirúrgico a los pacientes, el 90 % estuvo entre 65 y 90 según escala que significa bueno y excelente. Entre la escala EVA y la de Karlsson y Peterson aplicados al año, se observó una relación entre la disminución del dolor y la buena y excelente evaluación funcional. La técnica de Broström modificada demostró tener muy buenos resultados en el tratamiento quirúrgico de la inestabilidad de tobillo(AU)

The neuromuscular deficits resulting from ankle injuries, make possible the appearance of recurrences, due the structural affectation that not only occurs in the ligaments, but also in nerves and muscle-tendon tissue, and can produce numerous associated alterations that cause ankle chronic instability. The objective is to analyze the efficiency of Broström modified technique in patients with chronic ankle instability, treated at the Dr. Miguel Pérez Carreño Hospital and private practice from November 2016 to January 2020. A prospective, descriptive and clinical study was made. 31 patients were included. The average age was 34,4 years, majority of male patients, and predominance of right ankle. When applying the VAS scale before and after surgery, a decrease in the degree of postoperative pain was observed with a scale between 0 and 4. The Karlsson and Peterson scale applied in the period of 1 year after the postoperative period to the patients, the 90% were between 65 and 90 according to a scale that means good and excellent. Between the VAS scale and the Karlsson and Peterson scale applied after one year, a relationship was observed between pain reduction and good and excellent functional evaluation. The modified Broström technique has shown to have very good results in the surgical treatment of ankle instability(AU)

Ankle Osteoarthritis / Osteoartrite do tornozelo

Abstract Osteoarthritis (OA) is characterized by a chronic, progressive and irreversible degradation of the joint surface associated with joint inflammation. The main etiology of ankle OA is post-traumatic and its prevalence is higher among young and obese people. Despite advances in the treatment of fractures around the ankle, the overall risk of developing posttraumatic ankle OA after 20 years is almost 40%, especially in Weber type B and C bimalleolar fractures and in fractures involving the posterior tibial border. In talus fractures, this prevalence approaches 100%, depending on the severity of the lesion and the time of follow-up. In this context, the current understanding of the molecular signaling pathways involved in senescence and chondrocyte apoptosis is fundamental. The treatment of ankle OA is staged and guided by the classification systems and local and patient conditions. The main problems are the limited ability to regenerate articular cartilage, low blood supply, and a shortage of progenitor stem cells. The present update summarizes recent scientific evidence of post-traumatic ankle OA with a major focus on changes of the synovia, cartilage and synovial fluid; as well as the epidemiology, pathophysiology, clinical implications, treatment options and potential targets for therapeutic agents.

Resumo A osteoartrite (OA) é caracterizada por uma degradação crônica, progressiva e irreversível da superfície articular, associada a inflamação articular. A principal etiologia da OA do tornozelo é pós-traumática e sua prevalência é maior entre os jovens e obesos. Apesar dos avanços no tratamento das fraturas ao redor do tornozelo, o risco geral de desenvolver OA pós-traumática do tornozelo após 20 anos do trauma é de quase 40%; especialmente nas fraturas bimaleolares de Weber tipo B e C e fraturas envolvendo a borda tibial posterior. Nas fraturas do tálus, essa prevalência se aproxima de 100%, dependendo da gravidade da lesão e do tempo de seguimento. Nesse cenário, é fundamental a compreensão atual das vias de sinalização moleculares envolvidas na senescência e apoptose dos condrócitos. O tratamento da OA do tornozelo é estagiado e guiado pelos sistemas de classificação, condições locais e do paciente. Os principais problemas são a limitada capacidade de regeneração da cartilagem articular, o baixo suprimento de sangue e a escassez de células-tronco progenitoras. A presente atualização resume evidências científicas básicas recentes da OA póstraumática do tornozelo, com foco principal nas alterações metabólicas da sinóvia, da cartilagem e do líquido sinovial. Epidemiologia, fisiopatologia, implicações clínicas, e opções de tratamento são também discutidas.

Missed Tillaux Fracture and Syndesmosis Injury in Adult: Arthroscopic Assisted Reduction and Fixation / Fratura de Tillaux não percebida e lesão por sindesmose em adultos: Redução e fixação artroscópica assistida

Abstract Tillaux fractures are fractures of the lateral margin of the distal tibia, usually reported in children between 12 and 14 years old. As intraarticular fractures, they require anatomic reduction and fixation to avoid posttraumatic complications. Since the injury mechanism is external rotation of the foot on the leg, these injuries are commonly associated with other fractures or ligamentous lesions. Currently, arthroscopy is being increasingly used to assist and improve surgical treatment of ankle fractures. The authors describe a 12-month follow-up of a rare case of a missed Tillaux fracture associated with syndesmosis injury in a 76-year-old polytrauma patient, successfully treated by arthroscopically-assisted reduction and internal fixation.

Resumo As fraturas de Tillaux são fraturas da margem lateral da tíbia distal, geralmente relatadas em crianças entre 12 e 14 anos. Como fraturas intra-articulares, requerem redução e fixação anatômica para evitar complicações pós-traumáticas. Como o mecanismo de lesão é a rotação externa do pé na perna, essas lesões são comumente associadas a outras fraturas ou lesões ligamentares. Atualmente, a artroscopia está sendo cada vez mais utilizada para auxiliar e melhorar o tratamento cirúrgico das fraturas do tornozelo. Os autores descrevem um acompanhamento de 12 meses de um caso raro de uma fratura não percebida de Tillaux associada a lesão por sindesmose em um paciente de politrauma com 76 anos de idade, tratado com sucesso por redução e fixação interna assistida por artroscopia.

Evaluation of the Reproducibility of Lauge-Hansen, Danis-Weber, and AO Classifications for Ankle Fractures / Avaliação da reprodutibilidade das classificações Lauge-Hansen, Danis-Weber e AO para fraturas do tornozelo

Abstract Objective The present study aims to analyze the intra- and interobserver reproducibility of the Lauge-Hansen, Danis-Weber, and Arbeitsgemeinschaft für Osteosynthesefragen (AO) classifications for ankle fractures, and the influence of evaluators training stage in these assessments. Methods Anteroposterior (AP), lateral and true AP radiographs from 30 patients with ankle fractures were selected. All images were evaluated by 11 evaluators at different stages of professional training (5 residents and 6 orthopedic surgeons), at 2 different times. Intra- and interobserver agreement was analyzed using the weighted Kappa coefficient. Student t-tests for paired samples were applied to detect significant differences in the degree of interobserver agreement between instruments. Results Intraobserver analysis alone had a significant agreement in all classifications. Moderate to excellent interobserver agreement was highly significant (p ≤ 0.0001) for the Danis-Weber classification. The Danis-Weber classification showed, on average, a significantly higher degree of agreement than the remaining classification systems (p ≤ 0.0001). Conclusion The Danis-Weber classification presented the highest reproducibility among instruments and the evaluator's little experience had no negative influence on the reproducibility of ankle fracture classifications. Level of Evidence II, Diagnostic Studies - Investigating a Diagnostic Test.

Resumo Objetivo Avaliar a reprodutibilidade intra- e interobservador das classificações de Lauge-Hansen, Danis-Weber e Arbeitsgemeinschaft für Osteosynthesefragen (AO) para as fraturas de tornozelo, e a influência do estágio de formação dos participantes na avaliação. Métodos Foram selecionadas radiografias de 30 pacientes com fratura de tornozelo nas incidências anteroposterior (AP), perfil e AP verdadeiro. Todas as imagens foram avaliadas por 11 participantes em diferentes estágios de formação profissional (cinco residentes e seis cirurgiões ortopédicos), em dois momentos distintos. Analisou-se a concordância inter- e intraobservador por meio do coeficiente Kappa ponderado. O teste t de Student para amostras pareadas foi aplicado para verificar se havia diferença significativa no grau de concordância interobservador entre os instrumentos. Resultado Observou-se que existe concordância significativa em todas as classificações quando da análise intraobservador isolada. Existe concordância interobservador altamente significativa de grau moderado a ótimo na classificação de Danis-Weber (p ≤ 0,0001). A classificação de Danis-Weber apresentou, em média, grau de concordância significativamente maior que as outras classificações (p ≤ 0,0001). Conclusão A classificação de Danis-Weber se mostrou a mais reprodutiva entre os instrumentos avaliados, e a pouca experiência do avaliador não influencia negativamente a reprodutibilidade das classificações das fraturas do tornozelo. Nível de Evidência II, Estudos Diagnósticos - Investigação de um Exame para Diagnóstico.

Surgical treatment for adult ankle fracture with Tillaux-Chaput fracture block / 中国骨伤

OBJECTIVE@#To explore clinical effect of adult ankle fracture with Tillaux-Chaput fracture block.@*METHODS@#From January 2014 to December 2018, 15 patients with adult ankle fracture with Tillaux-Chaput fracture block were performed opertaion, including 9 males and 6 females, aged from 27 to 67 years old with an average of (45.6±14.3) years old, 8 patients on the left side and 7 patients on the right side. Fracture healing and complications were observed, American Orthopaedic Foot and Ankle Society(AOFAS) was used to evaluate recovery of ankle joint function.@*RESULTS@#All patients were followed up for 18 to 70 months with an average of (38.1±9.9) months. The incisions healed well at stageⅠ. X-ray reexamination showed all fractures healed well without loosening or breakage of internalfixation. Two patients had symptoms of superficial peroneal nerve injury and recovered gradually after nerve nourishing therapy. Three patients mainfested slightly limits of flexion and extension of ankle joint. AOFAS score of ankle and hind foot at the latest follow up was (85.6±7.9), 9 patients got excellent results, 4 good and 2 fair.@*CONCLUSION@#Fix Tillaux-Chaput fracture block with dentate steel plate has advantages of easy operation, stable fixation, and is beneficial to recovery of ankle function. It is not necessary to fix tibiofibular syndesmosis with screws.

Tratamiento de una fractura-luxación del tobillo mediante la fijación externa RALCA. Seguimiento de cinco años / Treatment of an ankle fracture-dislocation using RALCA external fixation. Five-year monitoring

RESUMEN La fractura luxación del tobillo se presenta con alguna frecuencia en la práctica médica. La asociación de una luxación en las fracturas de tobillo modifica su abordaje terapéutico puesto que la articulación no debe permanecer por más de seis horas en dicha situación y por ende se requerirá del tratamiento quirúrgico de urgencia. Son conocidas las complicaciones relacionadas con la no reducción de una luxación en el periodo de tiempo mencionado anteriormente, dentro de estas, la necrosis avascular del astrágalo representa la más temida debido a la incapacidad que genera. Por tales razones se decidió presentar un caso que muestra el tratamiento de una fractura -luxación del tobillo derecho, en una paciente de 30 años de edad, estabilizada mediante el empleo de un mini fijador RALCA, la cual fue seguida por un periodo de cinco años.

ABSTRACT Ankle fracture dislocation occurs with some frequency in medical practice. The association of a dislocation in ankle fractures modifies its therapeutic approach since the joint should not remain for more than six hours in this situation and therefore emergency surgical treatment will be required. Complications related to the non-reduction of a dislocation in the previously mentioned period of time are known; within these, avascular necrosis of the talus represents the most feared due to the disability it generates. For these reasons, it was decided to present a case that shows the treatment of a fracture -luxation of the right ankle, in a 30-year-old patient, stabilized by using a RALCA mini fixator, which was followed for a period of five years.

Fracturas de tobillo en adultos mayores / Ankle Fracture Treatment in Aged Adults

RESUMEN Introducción: El tratamiento de las fracturas del tobillo tiene importancia en la recuperación de la movilidad e independencia del paciente geriátrico. Objetivo: Evaluar el resultado obtenido al transcurrir un año del tratamiento quirúrgico mediante reducción y fijación de las fracturas inestables en pacientes mayores de 65 años. Métodos: Estudio descriptivo y prospectivo; pacientes mayores de 65 años, atendidos entre enero de 2017 y diciembre de 2018 por fractura de tobillo desplazada, en el Hospital Universitario General Calixto García Íñiguez y el Centro de Investigaciones en Longevidad, Envejecimiento y Salud, que fueron evaluados un año después. Resultados: De un total de 31 pacientes, 6 hombres y 25 mujeres con una edad media de 73,4 ± 3,5 años, 12 presentaban deterioro cognitivo, 18 llevaban terapia anticoagulante y 14 ingerían más de cuatro medicamentos diariamente. Predominaron los grupos con 3 y 4 puntos del índice de Charlson, la mayoría se ubicó en ASA III de riesgo anestésico y fracturas Dannis-Weber tipo C, 29 fracturas fueron cerradas. Las complicaciones fueron escasas; 27 de 31 pacientes se ubicaron como excelente o bueno según la escala AOFAS; 3 ± 2 en la escala visual de dolor; 86 por ciento podían realizar sus actividades de la vida diaria, Conclusiones: El resultado del tratamiento quirúrgico de las fracturas de tobillo en mayores de 65 años fue bueno y con baja incidencia de complicaciones que pueden relacionarse con condiciones mórbidas previas(AU)

ABSTRACT Introduction: The ankle fracture treatment is important in the recovery of mobility and independence of geriatric patients. Objective: To evaluate the results after one year of surgical treatment by reduction and fixation of unstable fractures in patients older than 65 years. Methods: A descriptive and prospective study was carried out in patients older than 65 years, treated from January 2017 to December 2018 due to displaced ankle fracture, at General Calixto García Íñiguez University Hospital and the Research Center for Health, Longevity and Aging. These patients were assessed a year later. Results: Out of a total of 31 patients, 6 men and 25 women with a mean age of 73.4 ± 3.5 years, 12 had cognitive impairment, 18 were on anticoagulant therapy and 14 were taking more than four medications daily. Groups with 3 and 4 points of Charlson index predominated, the majority were located in ASA III of anesthetic risk and Dannis-Weber type C fractures, 29 fractures were closed. Complications were rare and 27 out of 31 patients ranked as excellent or good according to the AOFAS scale, 3 ± 2 on the visual pain scale, 86 percent of performing activities of their daily life. Conclusions: The result of the surgical treatment of ankle fractures in people older than 65 years was good and with a low incidence of complications that may be related to previous morbid conditions(AU)

Twisted Plating - A Method of Distal Fibula Fixation / Uso de placa retorcida - Um método de fixação da fíbula distal

Abstract Objective The literature entails various intramedullary and extramedullary methods for distal fibula fracture fixation; with no consensus yet over the ideal method of fixation. We have retrospectively analyzed the results of using a twisted and contoured 3.5 mm locking compression plate (LCP) as a posterior buttress plate. Methods Of the 62 cases with ankle fractures managed at our institute by the senior author from 1st January 2012 to 31st December 2015, 41 patients met our inclusion criteria (Danis-Weber types B and C). Results All 41 distal fibular fractures healed uneventfully, at a mean of 10.4 weeks (8-14 weeks) (Figs. 6, 7, 8 to 9) with no complications. The mean American Orthopaedic Foot & Ankle Society (AOFAS) score was 92.6 (86-100) at a mean follow-up of 31.5 months (14-61 months). Conclusions We have achieved excellent clinical and radiological outcomes using a twisted 3.5 mm LCP as a posterior buttress by combining the advantages of posterior antiglide plating and lateral LCP.

Resumo Objetivo A literatura discute diversos métodos intramedulares ou extramedulares para fixação de fraturas da fíbula distal, mas não há consenso acerca do método ideal de fixação. Analisamos retrospectivamente os resultados do uso de uma placa bloqueada de compressão (LCP) de 3,5 mm retorcida e com contorno como placa de apoio posterior. Métodos Dos 62 casos de fraturas de tornozelo tratadas em nosso instituto pelo autor sênior entre 1° de janeiro de 2012 e 31 de dezembro de 2015, 41 pacientes atenderam aos critérios de inclusão (tipos B e C de Danis-Weber). Resultados Todas as 41 fraturas fibulares distais cicatrizaram sem intercorrências, em uma média de 10,4 semanas (8-14 semanas) (Figuras 6 a 9) e sem complicações. A pontuação American Orthopaedic Foot & Ankle Society (AOFAS) média foi de 92,6 (86-100) em um período médio de acompanhamento de 31,5 meses (14-61 meses). Conclusões Obtivemos excelentes resultados clínicos e radiológicos com uso de LCP retorcida de 3,5 mm como apoio posterior ao combinar as vantagens da placa antideslizante posterior e a LCP lateral.

Evaluation of ankle conventional x-ray as a gold standard on diagnosis and treatment decisions for ankle weber B fractures. Self-controlled multi-centric experiment / Evaluación Objetiva de las Radiografías de Tobillo como Patrón de Oro en el Diagnóstico y Tratamiento de las Fracturas Webber B. Experimento autocontrolado multicéntrico

Background Ankle fractures are one of the main causes of consultation with emergency services around the world, with an incidence of 187 / 100,000 inhabitants per year. The most common is type B in the Weber-Dannis classification, with a long-term evolution towards osteoarthritis of 14%. Although the diagnosis of distal fibular fracture on an ankle radiograph is very simple, its usefulness has probably been overestimated to provide the necessary insights to decide the appropriate treatment method for the fracture. The objective of the study is to evaluate the diagnostic utility of ankle radiographs and their inter-observer agreement for a treatment decision making in Weber B fractures. Methods A prospective, randomized, double-blind, multicenter trial using three-country surveys of orthopedic surgeons was conducted; orthopedic surgeons and foot and ankle surgeons, were exposed to four Weber B ankle fractures x-ray series where surgery was actually required as the only treatment option. Unilateral and comparative projections, where presented in different time and order to each surgeon, measuring the variability of surgical decisions. Results Fifty-one orthopedic surgeons (72.37%), 24 foot and ankle surgeons (15.79%), 4 surgeons of other orthopedic subspecialties (2.63%) and 14 orthopedic surgery residents (9.21%) were surveyed. An inter-observer agreement of 70.83% (p <0.05) was found in the comparative projections series and 55.31% (p <0.05) in the unilateral ones. When performing linear regression between the training degree, years of experience and the provenance country of the surgeons, no causality was found (power of ß <95%). Nevertheless, 100% of the respondents diagnosed the fracture of the distal fibula as a Weber B fracture. Discussion The unilateral and comparative radiographic series are not recommended for making an adequate surgical decision in Weber B ankle fractures, given their very low inter-observer agreement. For decision making in Weber B ankle fractures it is necessary to take other complementary examinations such as Computed Axial Tomography.

Introducción Las fracturas de tobillo constituyen una de las principales causas de consulta a los servicios de urgencias alrededor del mundo, con una incidencia de 187/100.000 habitantes año. La más frecuente es la tipo B en la clasificación de Weber, con una evolución hacia la artrosis a largo plazo del 14%. Aunque el diagnostico de la fractura del peroné distal en una radiografía de tobillo es muy sencillo, probablemente se ha sobrestimado su utilidad para proporcionar elementos de juicio necesarios para decidir el método de tratamiento adecuado para la fractura. El objetivo del estudio es evaluar la utilidad diagnóstica de las radiografías de tobillo y su concordancia interobservador para la toma de decisiones de tratamiento en fracturas de tobillo Weber B. Materiales y Métodos Se realizó un experimento, prospectivo, aleatorizado, doble ciego, multicéntrico, mediante la aplicación de encuestas en tres países a Ortopedistas, residentes de ortopedia y Cirujanos de pie y Tobillo, en las cuales se les presentaban cuatro casos de fracturas de tobillo Webber B de características quirúrgicas en proyecciones unilaterales y comparativas, midiendo la variabilidad de las decisiones quirúrgicas. Resultados Se recolectaron 152 encuestas que respondieron 110 ortopedistas (72.37%), 24 cirujanos de pie y tobillo (15.79%), 4 cirujanos de otras subespecialidades ortopédicas (2.63%) y 14 residentes de ortopedia (9.21%). Se encontró una concordancia interobservador en las proyecciones comparativas del 70.83% (p<0.05) y en las unilaterales del 55.31%, (p<0.05), al realizar regresión lineal entre la respuesta el grado de entrenamiento, los años de experiencia y el país de procedencia no se encontró causalidad (poder de ?? <95%). El 100% de los encuestados diagnosticó la fractura del peroné distal. Discusión La serie radiográfica unilateral y comparativa no se recomiendan para la toma de una adecuada decisión quirúrgica en las fracturas de tobillo Weber B, dada su muy baja concordancia inter-observador. Para la toma de decisiones en fracturas de tobillo Weber B es necesaria la toma de otros exámenes complementarios como la Tomografía axial Computarizada.

Evaluación Objetiva de las Radiografías de Tobillo como Patrón de Oro en el Diagnóstico y Tratamiento de las Fracturas Webber B. Experimento autocontrolado multicéntrico / Evaluation of ankle conventional x-ray as a gold standard on diagnosis and treatment decisions for ankle weber B fractures. Self-controlled multicentric experiment

Introducción Las fracturas de tobillo constituyen una de las principales causas de consulta a los servicios de urgencias alrededor del mundo, con una incidencia de 187/100.000 habitantes año. La más frecuente es la tipo B en la clasificación de Weber, con una evolución hacia la artrosis a largo plazo del 14%. Aunque el diagnostico de la fractura del peroné distal en una radiografía de tobillo es muy sencillo, probablemente se ha sobrestimado su utilidad para proporcionar elementos de juicio necesarios para decidir el método de tratamiento adecuado para la fractura. El objetivo del estudio es evaluar la utilidad diagnóstica de las radiografías de tobillo y su concordancia interobservador para la toma de decisiones de tratamiento en fracturas de tobillo Weber B. Materiales y Métodos Se realizó un experimento, prospectivo, aleatorizado, doble ciego, multicéntrico, mediante la aplicación de encuestas en tres países a Ortopedistas, residentes de ortopedia y Cirujanos de pie y Tobillo, en las cuales se les presentaban cuatro casos de fracturas de tobillo Webber B de características quirúrgicas en proyecciones unilaterales y comparativas, midiendo la variabilidad de las decisiones quirúrgicas. Resultados Se recolectaron 152 encuestas que respondieron 110 ortopedistas (72.37%), 24 cirujanos de pie y tobillo (15.79%), 4 cirujanos de otras subespecialidades ortopédicas (2.63%) y 14 residentes de ortopedia (9.21%). Se encontró una concordancia interobservador en las proyecciones comparativas del 70.83% (p<0.05) y en las unilaterales del 55.31%, (p<0.05), al realizar regresión lineal entre la respuesta el grado de entrenamiento, los años de experiencia y el país de procedencia no se encontró causalidad (poder de ?? <95%). El 100% de los encuestados diagnosticó la fractura del peroné distal. Discusión La serie radiográfica unilateral y comparativa no se recomiendan para la toma de una adecuada decisión quirúrgica en las fracturas de tobillo Weber B, dada su muy baja concordancia inter-observador. Para la toma de decisiones en fracturas de tobillo Weber B es necesaria la toma de otros exámenes complementarios como la Tomografía axial Computarizada.

Background Ankle fractures are one of the main causes of consultation with emergency services around the world, with an incidence of 187 / 100,000 inhabitants per year. The most common is type B in the Weber classification, with a long-term evolution towards osteoarthritis of 14%. Although the diagnosis of distal fibular fracture on an ankle radiograph is very simple, its usefulness has probably been overestimated to provide the necessary insights to decide the appropriate treatment method for the fracture. The objective of the study is to evaluate the diagnostic utility of ankle radiographs and their inter-observer agreement for the treatment decision making in Weber B fractures. Methods A prospective, randomized, double-blind, multicenter trial using three-country surveys of orthopedic surgeons was conducted; orthopedic surgeons and foot and ankle surgeons, were exposed to four Weber B ankle fractures x-ray series where surgery was actually required as the only treatment option. Unilateral and comparative projections, where presented in different time and order to each surgeon, measuring the variability of surgical decisions. Results Fifty-one orthopedic surgeons (72.37%), 24 foot and ankle surgeons (15.79%), 4 surgeons of other orthopedic subspecialties (2.63%) and 14 orthopedic surgery residents (9.21%) were surveyed. An inter-observer agreement of 70.83% (p <0.05) was found in the comparative projections series and 55.31% (p <0.05) in the unilateral ones. When performing linear regression between the training degree, years of experience and the provenance country of the surgeons, no causality was found (power of ß <95%). Nevertheless, 100% of the respondents diagnosed the fracture of the distal fibula as a Weber B fracture. Discussion The unilateral and comparative radiographic series are not recommended for making an adequate surgical decision in Weber B ankle fractures, given their very low inter-observer agreement. For decision making in Weber B ankle fractures it is necessary to take other complementary examinations such as Computed Axial Tomography.

Manejo terapéutico del maléolo posterior en fracturas trimaleolares de tobillo: revisión bibliográfica / Therapeutic management of the posterior malleolus in trimaleolar ankle fractures: review / Manejo terapêutico do maléolo posterior em fraturas do tornozelo trimaleolar: revisão bibliográfica

Introducción: El manejo terapéutico de las fracturas de maléolo posterior en las fracturas trimaleolares de tobillo continúa en debate. Nuestro objetivo fue realizar una búsqueda de la evidencia científica sobre los aspectos terapéuticos de las fracturas de maléolo posterior en el contexto de las fracturas trimaleolares. Materiales y métodos: Se realizó una revisión de la bibliografía sistematizada por dos revisores, centrados en el manejo terapéutico del maléolo posterior. Resultados: Se obtuvieron 16 artículos clínicos de un total de 1029 pacientes, 8 estudios nivel de evidencia II y 8 de nivel IV. Se sistematizaron las indicaciones quirúrgicas y se analizaron los resultados funcionales y las complicaciones. Conclusiones: La comprensión pato-anatómica de estas fracturas es cada día mayor, principalmente por la utilización habitual de tomografías computarizadas (TC). El tratamiento quirúrgico sobre el maléolo posterior está evidenciando buenos y excelentes resultados funcionales. Para una adecuada decisión terapéutica se debería tener en cuenta ciertos factores: inestabilidad tibiotalar y sindesmótica, congruencia articular y características morfológicas del maléolo posterior. La reducción abierta (RA) y fijación interna con placa de sostén es el tratamiento que ha demostrado mejores resultados a corto y mediano plazo, no encontrando estudios con seguimiento a largo plazo.

Introduction: The therapeutic management of posterior malleolus fractures in trimaleolar ankle fractures continues in debate. Our objective was to conduct a search for scientific evidence on the therapeutic aspects of posterior malleolus fractures in the context of trimaleolar fractures. Materials and methods: A review systematic of the literature was carried out by two reviewers, focusing on the therapeutic management of the posterior malleolus. Results: 16 clinical articles were obtained with a total of 1029 patients, 8 studies level of evidence II and 8 studies level IV. The surgical indications were systematized, and the functional results and complications were analyzed. Conclusions: The patho-anatomical understanding of these fractures is increasing every day, mainly due to the usual use of CT scans. Surgical treatment on the posterior malleolus shows good and excellent functional results. For an adequate therapeutic decision certain factors should be taken into account: tibiotalar and syndesmotic instability, joint congruence and morphological characteristics of the posterior malleolus. Open reduction and internal fixation with support plate is the treatment that has shown better results in the short and medium term, not finding studies with long-term follow-up.

Introdução: O tratamento terapêutico das fraturas do maléolo posterior nas fraturas do tornozelo trimaleolar continua em debate. Nosso objetivo foi realizar uma pesquisa de evidências científicas sobre os aspectos terapêuticos das fraturas do maléolo posterior no contexto das fraturas trimaleolares. Materiais e métodos : Uma revisão sistemática da literatura foi realizada por dois revisores, com foco no manejo terapêutico do maléolo posterior. Resultados: foram obtidos 16 artigos clínicos com um total de 1029 pacientes, 8 estudos com nível de evidência II e 8 estudos com nível IV. As indicações cirúrgicas foram sistematizadas e os resultados e complicações funcionais foram analisados. Conclusões: O entendimento anatomopatológico dessas fraturas está aumentando a cada dia, principalmente devido ao uso habitual de tomografias computadorizadas. O tratamento cirúrgico do maléolo posterior mostra bons e excelentes resultados funcionais. Para uma decisão terapêutica adequada, certos fatores devem ser levados em consideração: instabilidade tibiotalar e sindesmótica, congruência articular e características morfológicas do maléolo posterior. A redução aberta e a fixação interna com placa de suporte é o tratamento que apresenta melhores resultados no curto e médio prazo, não encontrando estudos com acompanhamento a longo prazo.

Haste intramedular de fíbula nas fraturas maleolares do tornozelo - técnica cirúrgica e revisão da literatura / Intramedullary nailing of lateral malleolus in ankle fractures - surgical technique and literature review

RESUMO Nosso objetivo é descrever a técnica de fixação intramedular (IM) da fíbula no tratamento cirúrgico das fraturas maleolares do tornozelo. A redução é realizada sempre de forma percutânea: quando o traço de fratura é oblíquo simples, utilizamos uma pinça de redução de pontas e quando a fratura apresenta padrão multifragmentar, usa-se tração longitudinal e rotação. Isso reduz as complicações relacionadas à redução aberta e fixação interna com placa. A técnica demonstrou ser simples e reprodutível. Além disso, essa forma de fixação permite apoio precoce do peso corporal, o que acelera o processo de reabilitação e potencialmente acelera a cicatrização da fratura. A fixação IM da fíbula mostrou-se uma opção viável para a fixação do maléolo lateral nas fraturas do tornozelo, devendo ser considerada no arsenal do cirurgião.

ABSTRACT Our objective is to describe the technique of intramedullary (IM) nailing of lateral malleolus in the surgical management of ankle fractures. Fracture reduction is performed either percutaneously with a small pointed reduction clamp in simple oblique fractures or using longitudinal traction and rotation for comminuted fractures, thus reducing complications related to open reduction and internal fixation with a plate. The technique has been shown to be simple and reproducible. In addition, the technique allows early weight bearing, which accelerates rehabilitation and potentially fasten fracture healing. IM nailing is a viable option for the fixation of the of lateral malleolus in ankle fractures and should be considered in the surgeon's armamentarium.

Cambios Degenerativos y Evaluación Funcional de Fracturas Intraarticulares de Tobillo en Pacientes Pediatricos / Degenerative Changes and Functional Evaluation of Intraarticular Ankle Fractures in Pediatric Patients

Introducción Las fracturas de tobillo representan el 12% de las fracturas en la edad pediátrica. Planteamos la hipótesis que los pacientes con fracturas intraarticulares de tobillo tendrán un excelente resultado funcional y no presentarán cambios degenerativos articulares a los 6 meses post cirugía. El objetivo del estudio es realizar un analisis del resultado funcional, así como la presencia de cambios radiologicos degenerativos precoces en el seguimiento de pacientes con fracturas intra-articulares de tobillo tratadas en nuestro centro. Materiales y Métodos Estudio de Cohorte retrospectivo, se recolectaron datos de pacientes con fracturas intra-articulares de tobillo entre 2012 y 2016. Se clasificaron y evaluaron mediante score AOFAS y radiografías para clasificar según Van Dijk. Resultados La diferencia promedio de edad entre las fracturas triplanares y tillaux es de 17 meses (p: 0.038). La media de Score AOFAS fue de 85,2%. El 88.8% refiere dolor en relación a actividades cotidianas, a pesar de tener excelentes o buenos resultados funcionales. No hay correlación significativa entre los resultados de AOFAS en pacientes con fracturas transicionales y no transicionales., 43,4% presentaron estadio 0, 43,4% estadio I y 13% estadio II de Van Dijk. Ningún caso presento estadio III. Discusión En base a los hallazgos de este estudio, y al contrario de lo hipotetizado, la mayoría de los pacientes tienen un buen resultado funcional tras el manejo de las fracturas intraarticulares de tobillo y no excelente como se pensaba. Existe un grupo de pacientes que mostró cambios degenerativos precoces demostrables por radiografía.

Background Ankle fractures represent 12% of fractures in pediatric age. We hypothesized that patients with intra-articular ankle fractures will have an excellent functional result and will not present degenerative joint changes 6 months after surgery. The objective of the study is to carry out an analysis of the functional result, as well as the presence of early degenerative radiological changes in the follow-up of patients with intra-articular ankle fractures treated in our center. Methods Retrospective cohort study, data were collected from patients with intra-articular ankle fractures between 2012 and 2016. They were classified and evaluated using AOFAS score and radiographs to classify according to Van Dijk. Results The average age difference between triplanar and tillaux fractures is 17 months (p: 0.038). The mean AOFAS Score was 85.2%. 88.8% reported pain in relation to daily activities, despite having excellent or good functional results. There is no significant correlation between the AOFAS results in patients with transitional and non-transitional fractures. 43.4% had stage 0, 43.4% stage I, and 13% stage II Van Dijk. No case presented stage III. Discussion Based on the findings of this study, and contrary to the hypothesized, most patients have a good functional result after the management of intra-articular ankle fractures and not excellent as previously thought. There is a group of patients who showed early degenerative changes demonstrable by radiography.

Operation-effect analysis of 21 patients with ankle fracture and complete rupture of deltoid ligament / 中国骨伤

OBJECTIVE@#To explore short-term clinical effect of surgical treatment for ankle fracture with complete rupture of deltoid ligament in young and middle-aged patients.@*METHODS@#From January 2016 to March 2019, 21 young and middle-aged patients with ankle joint fracture and complete rupture of the deltoid ligament were treated with internal fixation and repair of the medial deltoid ligament, including 16 males and 5 females, aged from 21 to 52 years old with an average of (38.6±7.3) years old, the time from injury to operation ranged from 1 to 7 days with an average of (3.8±1.5) days. Fracture healing time and complications were observed, changes of medial malleolus clearance before and after operation were compared, American Orthopaedic Foot and Ankle Society (AOFAS) score wasused to evaluate function of ankle joint at 18 months after operation.@*RESULTS@#Twenty-one patients were followed up from 18 to 26 months with an average of (21.7±1.2) months. The incisions were healed at stageⅠ, and fracture healing time ranged from 8 to 12 weeks with an average of (9.5±1.6) weeks. No wound infection, failure of internal fixation, and nerve injury occurred. Medial malleoius space decreased from (5.83±0.32) mm before operation to (2.69±0.25) mm after operation. Postoperative AOFAS score at 18 months was 91.43±4.14, 14 patients got excellent results, 6 good and 1 fair.@*CONCLUSION@#On the basis of stable fixation of fracture, repair of deltoid ligament could help restoring the medial anatomy of ankle joint in young and middle-aged patients, and could achieve good short term clinical effect.

Clinical diagnosis and treatment features of Maisonneuve fracture and analysis of clinical outcome of 15 patients / 中国骨伤

OBJECTIVE@#To explore clinical diagnosis and treatment features of Maisonneuve fractures (maisonneuve fractures of the fibula, MFF), and evaluate its clinical effects.@*METHODS@#From March 2017 to June 2018, 15 patients with MFF were treated with operation, including 9 males and 6 females, aged from 27 to 54 years old with an average of (35.00±7.46) years old, the time from injury to operation ranged from 5 to 8 days with an average of (6.33±1.04) days. All the fractures were fresh and closed injury. The time of bone union and postoperative complications were observed, and AOFAS score was used to evaluate recovery of ankle joint function at 12 months after operation.@*RESULTS@#All patients were followed up from12 to 28 months with an average of (17.00±3.79) months. Four patients were misdiagnosed. All fractures were obtained bone union from 4 to 6 months with an average of (4.80±0.94) months. No postoperative complications such as infection, delayed union or nonunion occurred. Postoperative AOFAS score at 12 months was 90.23±7.27, among which 9 patients got excellent result, 3 good, and 3 fair.@*CONCLUSION@#Maisonneuve fracture is an unstable fracture. High fibular fracture and the separation of the lower tibia and fibula could be easily neglected, which could lead to misdiagnosis and missed care. Surgical treatment could recover anatomical relation of the lower tibia and fibula and ankle mortise, and obtain satisfying clinical effect.

Treatment of Isolated Lateral Malleolar Fractures Using Locking Compression Plate Fixation and Tension Band Wiring Fixation

PURPOSE: The purpose of this study was to compare the clinical and radiological outcomes of locking compression plate (LCP)-screw fixation and tension band wiring (TBW) fixation in isolated lateral malleolar fractures.MATERIALS AND METHODS: From May 2016 to August 2018, 52 patients with isolated lateral malleolar fracture were retrospectively reviewed. They were divided into 30 cases of the LCP fixation group (Group I) and 22 cases of the TBW fixation group (Group II). The clinical and radiological results of those groups were compared. Pearson chi-square tests and independent t-tests were used in the statistical analysis.RESULTS: The mean length of the surgical incision was 8.3 cm in Group I and 4.9 cm in Group II. Radiological union was obtained at a mean of 8.4 weeks in both groups. The mean American Orthopaedic Foot and Ankle Society score was 90 (range, 85–97) and 92 (range, 85–100) in Groups I and II, respectively, at the last follow up.CONCLUSION: Both the LCP-screw and TBW techniques revealed excellent results in isolated lateral malleolar fractures. The tension band technique may be a fine alternative method of fixation in the treatment of isolated lateral malleolar fracture.