Difference in balance measures between patients with chronic ankle instability and patients after an acute ankle inversion trauma.

Neuromuscular control of the ankle is disturbed in patients with chronic ankle instability due to an initial ankle inversion trauma. Static balance is assumed to be a measure for this disturbance. Functional (ankle) scores are another way to evaluate ankle impairment. The hypothesis was that there is a difference in static balance measures between small groups of healthy subjects, patients after an acute ankle inversion trauma and patients with chronic ankle instability and that static balance measures correlate well with functional scores. Static balance in healthy subjects (N = 15), patients after a primary ankle inversion injury (N = 14) and patients with chronic ankle instability (N = 23) was tested with a single leg test on a force plate (Postural Sway test) and on a compliant floor (Simple Balance test). Functional impairment was evaluated with the Karlsson, AOFAS and SF-36 (ankle) scores. There was a statistically significant and clinically relevant difference in functional (ankle) scores, but not a statistically significant difference in balance measures between the groups. Balance measures did not correlate to the functional scores. It was concluded that, despite a clinically relevant difference in functional outcome measures between the groups, static balance measures do not appear to be useful for clinical application in the individual patient.

Clinical evaluation of a dynamic test for lateral ankle ligament laxity.

The dynamic anterior ankle tester (DAAT) has shown a good reliability in testing anterior talar translation in earlier studies. The goal of the present study was first to evaluate the reliability of the DAAT in a clinical setting and second to analyze its ability to detect increased ligament laxity. In 39 patients with unilateral chronic lateral ankle instability, the anterior talar translation of the affected and non-affected side was measured pre and postoperatively using the DAAT, Telos stress radiographs, and the manual anterior drawer test. In contrast to both other tests, the DAAT was not able to accurately detect increased ligament laxity preoperatively or decreased laxity of the affected ankle postoperatively. The DAAT showed a low sensitivity to change (the difference between the mean pre and postoperative value) and a low reliability compared to both other tests. There were no correlations between the three tests. In conclusion, the DAAT showed a low reliability in effectively testing lateral ankle ligament laxity in a clinical setting. This is in contrast to earlier evaluations.

Interventions for treating chronic ankle instability.

BACKGROUND: Chronic lateral ankle instability occurs in 10% to 20% of people after an acute ankle sprain. The initial form of treatment is conservative but if this fails and ligament laxity is present, surgical intervention is considered. OBJECTIVES: To compare different treatments, both conservative and surgical, for chronic lateral ankle instability. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialized Register (to July 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2005, Issue 3), and MEDLINE (1966 to April 2006), EMBASE (1980 to April 2006), CINAHL (1982 to April 2006) and reference lists of articles. SELECTION CRITERIA: All randomised and quasi-randomised controlled trials of interventions for chronic lateral ankle instability were included. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed methodological quality and extracted data. Where appropriate, results of comparable studies were pooled. MAIN RESULTS: Seven randomised trials were included and divided into three groups: surgical interventions; rehabilitation programs after surgical interventions; and conservative interventions. None of the studies were methodologically flawless. Only one study described an adequate randomisation procedure. Only two studies, both about rehabilitation programs after surgery, had a moderate risk of bias; all other studies had a high risk of bias. Due to clinical and methodological diversity, extensive pooling of the data was not possible. Surgical interventions (four studies): one study showed more complications after the Chrisman-Snook procedure compared to an anatomical reconstruction, whereas another study showed greater mean talar tilt after an anatomical reconstruction. Subjective instability and hindfoot inversion was greater after a dynamic than after a static tenodesis in a third study. The fourth study showed that the operating time for anatomical reconstructions was shorter for the reinsertion technique than for the imbrication method. Rehabilitation after surgical interventions (two studies): both studies provided evidence that early functional mobilization leads to an earlier return to work and sports than immobilisation. Conservative interventions: the only study in this group showed better proprioception and functional outcome with the bi-directional than with the uni-directional pedal technique on a cyclo-ergometer. AUTHORS' CONCLUSIONS: In view of the low quality methodology of almost all the studies, this review does not provide sufficient evidence to support any specific surgical or conservative intervention for chronic ankle instability. However, after surgical reconstruction, early functional rehabilitation was shown to be superior to six weeks immobilisation regarding time to return to work and sports.

Long-term results of ankle fractures with a posterior malleolar fragment.

The aim of this study was to evaluate 1) long-term results of ankle fractures with a posterior malleolar fragment, and 2) the need for fixation of fragments smaller than 25%. Forty-five patients with ankle fractures and a posterior malleolar fragment were evaluated. Mean follow-up was 13 years (range, 2-24). The size and fixation of the fragment were registered. Outcome was assessed using an Ankle Fracture Scoring System (maximum: 150 points), a 10-point Numeric Scale for Pain (1 = no pain, 10 = unbearable pain) and an OsteoArthritis Score (0 = no osteoarthritis, 3 = severe osteoarthritis). The mean Ankle Fracture Scoring System, Numeric Scale for Pain and Osteoarthritis-score were 124, 2.5, and 1.2, respectively. The mean size of fixated fragments was significantly larger than that of nonfixated fragments (30% versus 16%). Those patients in which the posterior malleolar fragment was fixated did not have a statistically significant better outcome than those patients in which the fragments were not fixated (Ankle Fracture Scoring System: 119 versus 126, Numeric Scale for Pain: 2.6 versus 2.4, Osteoarthritis-score: 1.0 versus 1.2). There was no significant correlation between outcome and size of unfixated fragments. Fracture-dislocation was seen more often in combination with larger fragments (24% versus 15%) and resulted in statistically significant worse long-term outcome than nondislocated fractures, except for pain (Ankle Fracture Scoring System: 115 versus 134, Osteoarthritis-score: 1.7 versus 0.8). In conclusion, patients showed good results after 13 years follow-up and there was no evidence for the need for fixation of fragments smaller than 25%.

Limb salvage after subtotal supramalleolar amputation by initial shortening followed by tibial lengthening.

BACKGROUND: We present a patient with a subtotal traumatic supramalleolar amputation of the leg, which was initially treated by a vascular reconstruction with deliberate bone and soft-tissue shortening. METHODS: To correct the ensuing complex deformity, which consisted of a varus hindfoot, leg length discrepancy and equinus, a staged reconstruction was planned. Initially, the hindfoot varus, in presence of a stiff ankle, was corrected by a supramalleolar osteotomy, followed by a Wagner distraction and finally a correction of the equinus. RESULTS: After a relatively long period of normal functioning, she regained painful minimal ankle function, which necessitated ankle fusion and correction of a pronation deformity. At the most recent follow-up 13 years after the injury, the patient is fully functional and has near normal leg length. CONCLUSION: Although a mangled lower extremity is often a candidate for primary amputation allowing early rehabilitation, in certain cases a good result can be obtained by a creative strategy.

Choledochal cysts: age of presentation, symptoms, and late complications related to Todani's classification.

PURPOSE: The aim of this study was to compare presentation, complications, diagnosis, and treatment of choledochal cysts in pediatric and adult patients. METHODS: Forty-two patients were analyzed after subdivision into 3 groups: group A, less than 2 years (n = 10); group B, 2 to 16 years (n = 11); group C, greater than 16 years (n = 21). RESULTS: The cysts were classified as extrahepatic (n = 33), intrahepatic (n = 5), and combined (n = 4). Seventy-six percent of patients presented with abdominal pain, (20 of 21 group C), and 57% with jaundice, (10 of 10 group A). Cholangiocarcinoma occurred in 6 patients, 4 of whom had previously undergone internal drainage procedures. Excision of the extrahepatic cyst was performed in 27 of 37 patients. Five patients, of whom, 4 had cholangiocarcinoma, were beyond curative treatment at the time of diagnosis. Six patients had died at the closure of this study, 5 of them had carcinoma. CONCLUSIONS: Presenting symptoms are age dependent with jaundice prevailing in children and abdominal pain in adults. In view of the high risk of cholangiocarcinoma, early resection and not internal drainage is the appropriate treatment of extrahepatic cysts. Patients who had undergone internal drainage in the past still should undergo resection of the cyst.