A Novel Algorithm for Isolated Weber B Ankle Fractures: A Retrospective Review of 51 Nonsurgically Treated Patients.

INTRODUCTION: Stability of isolated Weber B ankle fractures can be difficult to determine. Using weight-bearing radiographs, a reliable method to determine the stability of isolated Weber B ankle fractures is described. METHODS: A retrospective review of prospectively gathered data was performed. Weber B ankle fractures were defined as stable when having a medial clear space (MCS) of <7 mm on initial gravity stress radiographs and a normal mortise relationship on weight-bearing radiographs. Fifty-one patients meeting these criteria were treated nonsurgically with protected weight bearing and serial radiography for 1 year. RESULTS: Average functional score results were: American Orthopaedic Foot and Ankle Society Hindfoot, 93.2; Foot and Ankle Ability Measure for Activities of Daily Living, 93.2; Olerud-Molander Ankle Score, 91.0; and visual analog scale pain score, 0.57. Despite a mean gravity stress MCS of 4.42 mm, no patient demonstrated subsequent MCS widening. Mean MCS on 1-year follow-up weight-bearing radiographs was 2.64 mm. CONCLUSION: Weight-bearing ankle radiographs are predictive of stability in isolated Weber B ankle fractures. Gravity stress radiographs using traditional measurement criteria may overestimate instability in these injuries. Nonsurgical treatment with protected weight bearing shows good early outcomes. LEVEL OF EVIDENCE: IV.

Relationship among radiographic ankle medial clear space, sex, and height.

The ankle medial clear space (MCS) is frequently measured to evaluate ankle stability after an injury. However, controversy exists regarding a threshold size that distinguishes a normal MCS from an abnormal MCS. A retrospective radiographic review of mortise ankle radiographs in the uninjured ankle was performed, with the goal of defining the relationship among patient height, sex, and radiographic ankle MCS. Forty-nine patients with normal mortise radiographs and with information on patient height available in the electronic medical chart were identified for inclusion. For men, mean±standard deviation (in millimeters) was 3.3±0.8 for MCS perpendicular (MCSp), 3.8±0.7 for MCS oblique (MCSo), and 3.8±0.5 for superior clear space (SCS). For women, mean±standard deviation was 2.3±0.6 for MCSp, 2.9±0.5 for MCSo, and 3±0.4 for SCS. Univariate analysis showed that all 3 variables (MCSp, MCSo, and SCS) were statistically different when men were compared with women (P<.0001). Bivariate regression models showed statistically significant (P<.001) positive relationships between each of the measures of clear space and height. In multivariate analysis, female sex alone was associated with a decrease in clear space. When evaluating isolated lateral malleolus fractures, clinicians should consider the patient's height and sex when measuring MCS and SCS to determine deltoid ligament competence. These data suggest that men and people of tall stature are at risk for a false-positive diagnosis of deltoid ligament rupture when previously published threshold MCS and SCS values, such as 4 mm or 5 mm, are used for diagnosis and operative indication.

Cost-effectiveness of MRI to assess for posttraumatic ligamentous cervical spine injury.

Magnetic resonance imaging (MRI) has been shown to be sensitive in identifying ligamentous injury to the cervical spine. The major drawbacks to its routine use are cost and availability. The purpose of this study was to compare the cost of using MRI to rule out ligamentous injury of the cervical spine with the cost of immobilization in a cervical collar and outpatient follow-up. Neurologically intact and nonobtunded patients with neck pain and normal findings on radiographs evaluated for ligamentous injury of the cervical spine were studied. Patients were either evaluated with MRI or immobilized in a cervical collar and followed up for repeat clinical and radiographic evaluation as outpatients. The authors gathered year 2011 fees from their institution and 2011 Medicare reimbursement data and compared the costs of MRI with the costs of cervical collar and outpatient follow-up. In addition, the median income of the local community was used to estimate opportunity costs associated with cervical collar immobilization. After 7 days of lost wages at the median local income, MRI became a less costly option when comparing hospital fees. Alternatively, when considering Medicare reimbursement, MRI became less costly after only 2 days of lost wages at the median local income. On the basis of these findings, MRI of the cervical spine is less costly than other current management strategies when opportunity costs are considered.

Variability in radiographic medial clear space measurement of the normal weight-bearing ankle.

BACKGROUND: Medial clear space (MCS) width on mortise radiographs of the ankle is commonly used by clinicians for determining the competence of the deltoid ligament in the Weber B supination-external rotation ankle fracture. Significant variability exists in the current literature regarding methods of obtaining this measure and definition of a normal measure in comparison with a pathologic state. METHODS: Seventy-three paired bilateral ankle mortise radiographs that were without ankle pathology were retrospectively reviewed. MCS width at two separate locations (oblique and perpendicular) and superior clear space (SCS) were measured on digital radiographs. A Student's t test was used to compare mean values. RESULTS: Mean values (± SD) were 3.2 (± 0.7)~mm for MCS oblique, 2.6 (± 0.7)~mm for MCS perpendicular, and 3.3 (± 0.6)~mm for SCS. A significant difference (p < .001) existed for all three measures between males and females. MCS oblique was statistically different than MCS perpendicular (p < .001) for all patients and for males and females independently. The mean difference between paired bilateral radiographs was 0.3 (± 0.2)~mm for MCS oblique, 0.6 (± 0.6)~mm for MCS perpendicular, and 0.2 (± 0.2)~mm for SCS. CONCLUSIONS: MCS width has variability based on the location chosen for measurement and gender. Contralateral radiographic comparison of MCS should be routinely used to identify pathologic widening versus normal anatomic variation. CLINICAL RELEVANCE: Use of single threshold values for MCS width as an operative indicator may produce a false-positive diagnosis of deltoid incompetence in Weber B supination-external rotation ankle fractures and possibly lead to unnecessary surgery.

Total hip arthroplasty in adolescents with severe hip arthropathy and dysplasia associated with camptodactyly-arthropathy-coxa vara-pericarditis syndrome.

Camptodactyly-arthropathy-coxa vara-pericarditis (CACP) syndrome is a rare disorder. Patients with this syndrome experience early symptomatic arthropathy of the hips. We report a case of adolescent siblings with bilateral arthropathy associated with CACP syndrome in which total hip arthroplasty was performed as treatment of severe associated disability. Postoperative Harris Hip Scores for patient 1 were 86 for the right at 18 months and 96 for the left at 12 months. Postoperative Harris Hip Score at 6 months for patient 2 was 53; however, he had good range of motion and lacked deformity. Based on our limited experience and the limited available clinical data, we feel that total hip arthroplasty is a reasonable treatment option for adolescents with debilitating hip arthropathy associated with CACP syndrome.