Immediate weight bearing without immobilization for operatively treated ankle fractures is safe - A systematic review.

BACKGROUND: This systematic literature review compared weight bearing (WB) vs. partial- / non-weight bearing (NWB) and mobilization (MB) vs. immobilization (IMB) for surgically treated ankle fractures. METHODS: Five databases were searched. Eligible were (quasi-)randomized controlled trials comparing at least two different postoperative treatment protocols. The risk of bias was assessed using the RoB-2 toolkit. The primary outcome was complication rate, secondary outcome Olerud and Molander Ankle Score (OMAS), range of motion (ROM), and return to work (RTW). RESULTS: Out of 10,345 studies, 24 papers were eligible. Thirteen studies (n = 853) compared WB/NWB, 13 studies (n = 706) MB/IMB with a moderate study quality. WB did not increase the risk for complications but resulted in superior short-term outcomes for OMAS, ROM, RTW. 12 studies found no inferior results for MB compared to IMB. CONCLUSION: Early and immediate WB and MB do not increase the complication rates but result in superior short term outcome scores. LEVEL OF EVIDENCE: Level I Systematic Review.

Safe drilling zones for anteriorly, central, and posteriorly angulated syndesmotic stabilization devices.

PURPOSE: The purposes of the study were to (1) analyze the shape of the distal fibula at the location of syndesmotic stabilization and to (2) define safe zones at the distal-lateral fibula for three different drilling tunnel orientations: anteriorly-, posteriorly angulated and center-center. METHODS: Postoperative, bilateral CT images of adult patients that underwent syndesmotic stabilization (suture-button system) for an acute, unilateral ankle injury were analyzed. Manual axial CT reconstructions of the uninjured side were generated. First, the axial shape of the distal fibula was classified. The aspect ratio between the anterio-lateral and the posterior-lateral surfaces of the fibula was calculated to assess symmetry. Second, the same axial planes were used to define the safe zones. Each drilling-tunnel orientation (anterior, central, posterior) comprised a fixed medial tibial anchor point and a safe zone on the lateral fibula. For each of the three orientations, the most anteriorly and posteriorly drilling tunnel location was simulated. Next to a cumulative visual analysis, a quantitative analysis of the most anterior and posterior point on the anterio- and posterior-lateral surfaces was calculated. RESULTS: A total of 96 CT datasets were analyzed. (1) 81% of fibulae revealed a triangular convex-, 10% an irregular-, and 8% a quadrilateral shape. The lateral surface ratio was 1.0 ± 0.2 (range: 0.7-1.5), not differing between the fibula types (n.s.). (2) The safe corridor on the lateral surface of the fibula for an anteriorly angulated drilling tunnel was - 8% to - 41%, for a posteriorly angulated drilling tunnel was 0% to 46%, and for a center-center alignment - 7 ± 11% (range: - 28 to 18%). CONCLUSION: The meta-diaphyseal region of the distal fibula revealed a homogeneous crosssectional shape. The lateral apex of the fibula can serve as a landmark defining safe zones to place the drilling tunnels correctly. Applying these safe zones in clinical practice could help to avoid the misplacement of the syndesmotic fixation device. LEVEL OF EVIDENCE: Level III, retrospective radiographic study.

A systematic review and meta-analysis on the value of the external rotation stress test under fluoroscopy to detect syndesmotic injuries.

Purpose: The aim was to conduct a systematic literature review and meta-anaylsis to analyze the diagnostic accuracy of the external rotation stress test (ERST) for syndesmotic injuries. Methods: The systematic review was conducted according to the PRISMA-P guidelines (Prospero ID: CRD42021282457). Four common databases were searched from inception to September 29, 2021. Eligible were any studies facilitating the ERST under fluoroscopy in a defined state of syndesmotic instability. Syndesmotic ligament-specific rupture must have been proven by MRI, arthroscopy, or controlled dissection (cadaver study). Two reviewers independently conducted each step of the systematic literature review. The risk of bias was assessed by the Quality Appraisal for Cadaveric Studies Score scale. The data analysis was performed qualitatively and quantitatively. Results: Eight studies were eligible for a qualitative analysis, and six studies were eligible for a quantitative analysis. All studies included were cadaver studies. The qualitative analysis comprised 94 specimens and revealed considerable heterogeneity. Six studies allowed for a quantitative analysis of the tibiofibular clear space (TFCS) and five studies for the medial clear space (MCS) during the ERST. The quantitative analysis of the TFCS revealed no significant differences between intact and any stage of syndesmotic injury. The MCS was able to differentiate between intact and 2-ligament- (Z = 2.04, P = 0.02), 3-ligament- (Z = 3.2, P = 0.001), and 3-ligament + deltoid ruptures (Z = 3.35, P < 0.001). Conclusion: The ERST is the only noninvasive test to assess syndesmotic instability and can be conducted bilaterally. The uninjured contralateral side can serve as a baseline reference. Based on the conducted quantitative analysis, the MCS seems to be able to differentiate between stable (intact/1-ligament) and unstable (2-ligament/3-ligament) lesions.

[Salvage options following failed total ankle arthroplasty]. / Revisionsmöglichkeiten nach gescheiterter Sprunggelenkprothese.

The number of patients with osteoarthritis of the ankle, which are treated by arthroplasty, has continuously increased in recent years. The survival time of these implants is far below the results following hip and knee arthroplasty. In some cases a failure rate of approximately 1% per year or a survival rate of 70% after 10 years has been reported. The most frequent reasons for revision of an ankle prosthesis are aseptic loosening, technical implantation errors and persisting pain. For the revision of an ankle prosthesis there are basically two treatment options. For a long time, ankle arthrodesis was considered the gold standard after a failed prosthesis. In recent years, there has been an increasing trend towards re-implantation of an ankle prosthesis, as this preserves the functionality and mobility of the ankle joint as far as possible. Depending on the reason for failure and the size of the bony defect, a decision must be made regarding a one-stage and a two-stage procedure with bone augmentation. This article presents the advantages and disadvantages of arthrodesis and revision arthroplasty after failed primary ankle arthroplasty and highlights the special features of surgery.

[Open reduction and internal fixation of posterior malleolus fractures]. / Offene Reposition und interne Fixation von Frakturen des posterioren Malleolus.

OBJECTIVE: Stabilization of the syndesmotic complex by open reduction and internal fixation (ORIF) of the posterior malleolus, restoration of the tibial articular surface, stability of the ankle, posterior tibiofibular ligament and the incisura tibiae, reduction of the fibula into the incisura tibiae by ligamentotaxis. INDICATIONS: Unstable ankle fractures (OTA/AO type 44-B3, C1.3, C2.3, C3.3) with involvement of the posterior malleolus (type II-IV according to Bartonícek and Rammelt). CONTRAINDICATIONS: Critical general condition, circulatory disorders, severe soft tissue swelling (if necessary, first external fixator), percutaneous treatment the better alternative. SURGICAL TECHNIQUE: Positioning in unstable lateral position, dorsolateral approach dorsally of the peroneal tendons, incision of the superficial and deep fascia, retraction of the flexor hallucis longus tendon medially, visualization of the posterior malleolus, reduction and fixation. To treat the lateral malleolus fracture, preparation of a full-thickness flap above the peroneal tendons on the fibula, treatment according to AO principles. For the treatment of the medial malleolus positioning in supine position without changing the sterile covers, medial approach for the medial malleolus, wound closure. POSTOPERATIVE MANAGEMENT: Six weeks partial weight bearing (20 kg), early functional exercise, exercise of the flexor hallucis longus muscle; transition to full weight bearing after clinical and radiological follow-up after 6 weeks RESULTS: Few clinical results on open ORIF of the posterior malleolus have been published. However, most studies found that ORIF resulted in better reconstruction of the distal articular surface and the tibial incisura, better reduction of the fibula into the tibial incisura, stabilization of the distal tibiofibular joint and better clinical results, regardless of fragment size, when compared to closed reduction or untreated fragments.

[Aftercare following surgical treatment of ankle fractures : What is the current state of knowledge?] / Nachbehandlung von operativ versorgten Sprunggelenkfrakturen : Was ist der aktuelle Wissensstand?

BACKGROUND: Ankle fractures are among the most common fractures in adults but often with unsatisfactory long-term results. In recent years several new surgical treatment approaches have been developed but little has changed regarding the aftercare. The postoperative treatment can be divided into two main components, weight bearing and mobilization. In Germany most patients are still recommended to be immobilized with partial weight bearing for 6 weeks after surgery. OBJECTIVE: The aim of this review is to present the current evidence on postoperative treatment based on an extensive literature search. MATERIAL AND METHODS: A total of seven prospective randomized controlled trials (RCT) compared early and delayed full weight bearing and six RCTs compared ankle mobilization with a form of immobilization. RESULTS: In none of these studies did early full weight bearing lead to an increased complication rate but some studies found a shortened time before return to work and, at least in the short term, better clinical results. Immediate mobilization led to an increased complication rate in only one out of six studies. It also appeared that mobilization led to a reduced time before return to work and, in the short term, to better clinical outcomes. The comparability of the studies was limited as in most cases different clinical scores and parameters were collated. In addition, information on patient age, fracture type, bone quality, comorbidities, and the implants used was often inadequate and post-treatment regimens sometimes differed significantly. CONCLUSION: The early functional therapy following surgically treated ankle fractures increased the rate of wound healing complications in only one of 13 studies, otherwise there were no significant differences in complication rates; however, early functional therapy partly shortened the time to return to work and led to better clinical results in the short term. For future studies, standardization of the parameters assessed would be important to provide clear evidence-based guidelines on follow-up treatment for specific fractures and patient populations.

Evaluation of ankle ligaments with CT: A feasibility study.

PURPOSE: This study aims to systematically investigate if normal ankle ligaments can be assessed with CT imaging, using MRI as reference standard. METHODS: 35 patients (mean age: 47 ±â€¯15 years; female n = 19) with combined CT and MRI exams and without MR-morphologic signs of ankle ligamental injury were retrospectively identified. 3 readers independently evaluated the syndesmotic, the lateral and medial ankle ligaments in terms of visibility on a 4-point Likert scale (0-3 points) in multiplanar MDCT images in standard bone kernel reconstructions. In consensus CT-based ligament density and thickness were measured and the appearance was rated for each ligament. Results were compared and validated with corresponding MRI images. RESULTS: Almost all ankle ligaments identified in MRI images could be adequately depicted in standard multiplanar bone kernel CT images with a mean visual score of 2.7/3 (± 0.2). Difficulties in CT morphological delineation of ankle ligaments occurred in cases of filiform TNL and TCL and in cases of concurrent soft tissue edema. Interreader agreement for the CT-assessment of ankle ligaments was excellent, with Fleiss Kappa values >0.8. Mean density of evaluated medial and lateral ankle ligaments was 68 ±â€¯2.9 HU, with substantially inter- and intraindividual variations. Thickness measurements and assessment of appearance of ankle ligaments showed a good concordance between CT and MRI. CONCLUSIONS: Assessment of normal ankle ligaments via standard CT in bone kernel reconstructions is feasible, with some restrictions concerning the medial collateral ligaments and in the presence of soft tissue edema.

[Unguis incarnatus-conservative or operative treatment? A practical treatment algorithm]. / Unguis incarnatus ­ konservative oder operative Therapie? Ein praktischer Behandlungsalgorithmus.

Unguis incarnatus, an ingrown toenail, is a common condition in primary care, which is encountered by various medical professions. Inconsistent conservative treatment and nonindicated surgical treatment often result in complications and recurrence of the disease. Patients must be thoroughly informed about the complexity of the nail organ. This is a prerequisite to prevent trivialization of the disease and to achieve appropriate patient compliance for treatment. In this article a practical diagnostic and treatment algorithm for unguis incarnatus is presented. In mild cases of acute unguis incarnatus a consistent conservative treatment is the first-line strategy showing promising results. In cases of moderate to severe forms of acute unguis incarnatus, surgical procedures that preserve the nail matrix should be applied. For cases of chronic unguis incarnatus without an acute infection, elective partial matrixectomy can be indicated. Prior to any surgical intervention, detailed informed consent must be obtained from the patients.

[Arthroscopically assisted fracture treatment and open reduction of the posterior malleolus : New strategies for management of complex ankle fractures. Video article]. / Arthroskopisch assistierte Frakturversorgung und offene Reposition des posterioren Malleolus : Neue Strategien zur Versorgung komplexer Sprunggelenksfrakturen. Videobeitrag.

OBJECTIVE: Identification and treatment of intra-articular injuries, stabilization of the syndesmotic complex by open reduction and internal fixation (ORIF) of the posterior malleolus (PM). INDICATIONS: Bimalleolar and trimalleolar fractures, patients with functional demands. CONTRAINDICATIONS: Soft tissue injuries/infections in the area of the surgical approach, higher grade circulatory disorders, diabetes mellitus. SURGICAL TECHNIQUE: The video exemplarily depicts the arthroscopically assisted treatment (AORIF) of a trimalleolar fracture and ORIF of the PM via the dorsolateral approach. Positioning in an unstable lateral position, arthroscopy via standard ventral portals in external rotation, resection of interposing capsular ligamentous structures, removal of loose bodies, diagnosis and treatment of cartilage lesions. Dorsolateral approach dorsal to the peroneal tendons and incision of the fascia of the lateral and deep lower leg compartments, retraction of the flexor hallucis longus muscle medially, visualization of the PM, reduction and fixation with an antiglide plate. Development of a full thickness flap above the superficial fascia to visualize the lateral malleolus, fixation according to AO principles. Repositioning to the supine position without changing the sterile covers, medial approach for fixation of the medial malleolus, stability testing of the distal tibiofibular joint, final arthroscopy, and wound closure. FOLLOW-UP: Cooling and elevation, 6 weeks of partial weight-bearing (20 kg), early functional exercises, full weight-bearing after clinical radiological follow-up at 6 weeks postoperatively. RESULTS: It is known that relevant chondral injuries frequently occur in complex ankle fractures and that ORIF of the PM leads to stabilization of the distal tibiofibular joint. So far only few clinical results have been published regarding AORIF and ORIF of the PM; however, the majority of the studies available found significantly better results for AORIF and ORIF of the posterior malleolus compared to conventional treatment.

Fractures to the anterior process of the calcaneus - Clinical results following functional treatment.

BACKGROUND: Fractures to the anterior process of the calcaneus (APC) have long been considered rare injuries. Although recent studies have reported a higher incidence, these injuries have yet received little attention in clinical research. Only few case reports/series, all suffering multiple methodical shortcomings, exist. The aim of this study was to objectively evaluate the outcome after fractures to the APC treated by full weight bearing and to investigate the influence of fracture characteristics. METHODS: Retrospective register study with prospective follow-up. Adults with acute unilateral fractures to the APC and concomitant injuries limited to the Chopart joint line, treated by full weight-bearing, with a follow-up of ≥ 12 months were included. Fracture characteristics (Degan classification, displacement, intra-articular involvement, comminution) were assessed in CT scans. Return to work (RTW) / sports (RTS), Visual Analogue Scale Foot and Ankle (VAS-FA), Karlsson Score and the 12-Item Short-Form Health Survey (SF-12) were assessed. The influence of age, sex, fracture type/characteristics, and concomitant injuries on the outcome parameters was analyzed. RESULTS: 27 patients (38 years, IQR 29-58), 74% female with a median follow up of 24 months (IQR 16-41) were included. 56% of the fractures were non-displaced and 82% comminuted. 48% were type I, 33% type II and 19% type III according to Degan. 78% of the patients suffered concomitant injuries of the Chopart joint line. Median RTW was 14 days (IQR 10-42), and RTS 90 days (IQR 30-180). The clinical outcome resulted in a median overall VAS-FA of 95 (IQR 89-98), Karlsson Score of 90 (IQR 82-100) and SF-12 PCS of 56 (IQR 53-58) / SF-12 MCS 55 (48-58). CONCLUSION: Functional treatment of fractures to the anterior process of the calcaneus yielded good to excellent results and a fast return to work in the vast majority of patients. Yet, a prolonged return to sports was noted. No significant differences regarding the outcome were observed when comparing the different fracture types or any other fracture characteristic assessed.

[Arthroscopic repair of chronic lateral ankle instability]. / Arthroskopische Außenbandstabilisierung bei chronischer Instabilität des Sprunggelenks.

OBJECTIVE: Repair of the lateral ligament complex of the ankle joint; identification and treatment of intra-articular pathologies. INDICATIONS: Symptomatic chronic lateral ankle instability. Treatment of osteochondral lesions associated with lateral ankle instability. CONTRAINDICATIONS: Osteoarthritis of the ankle joint, risk factors such as peripheral occlusive disease, diabetic foot syndrome, complex regional pain syndrome. SURGICAL TECHNIQUE: Diagnostic arthroscopy of the ankle joint utilizing anterolateral and -medial portals; identification and treatment of intra-articular pathologies; identification and preparation of the distal fibula; insertion of two suture anchors; the sutures are passed inside-out through the joint capsule, the scarred lateral ligaments, the extensor retinaculum using a suture lasso; by tying down the sutures the tissue grasped is then pulled against the distal fibula; this will stabilize the lateral ligament complex. POSTOPERATIVE MANAGEMENT: Partial weight-bearing and short leg cast for 2 weeks, then 4 weeks ankle brace and range of motion exercises, thereafter functional physical therapy, ankle brace only during exercises; no sports for at least 3 months. RESULTS: Currently, one randomized controlled trial is available comparing open to arthroscopic lateral ankle ligament repair. Open repair was always combined with arthroscopy to treat intra-articular pathologies. In all patients, surgery led to a significant increase of the American Orthopaedic Foot and Ankle Score (AOFAS), Karlsson Score and visual analog score (VAS), but no significant differences between the open and arthroscopic procedure after one year with similar complications (arthroscopy group: 3 temporary nerve irritations and 2 patients with pain over the knot; open treated group: 2 temporary nerve irritations and one abscess). Intra-articular pathologies were treated in 68% of the arthroscopically treated patients and 70% of the patients treated by open surgery. One out of two retrospective comparative studies reported a significantly shorter operation time and time to return to daily activity and significantly lower VAS three days postoperatively for arthroscopically treated patients, while the other parameters assessed were comparable.

Open reduction and internal fixation of the posterior malleolus fragment frequently restores syndesmotic stability.

AIM: Comparison of unfixed, CRIF, and ORIF of the posterior malleolus fragment (PMF) regarding the frequency of trans-syndesmotic fixation and quality of reduction in trimalleolar (equivalent) fractures. MATERIAL AND METHODS: Retrospective registry study. Patients with a trimalleolar (equivalent) ankle fractures were identified within the departments' fracture database. General demographics, treatment details, and fracture specific details (CT-scans) were assessed. Patients were grouped per the PMF treatment: not addressed, CRIF, ORIF. RESULTS: 236 patients (53.0 ± 18.3 (range: 18-100) years), 58.1% female were eligible. The mean size of the PMF was 21.4 ± 10.4% (range: 2.7-55.9%), 71.6% were ≤25% of the tibial plafond. PMF fixation: Untreated 48.3%, CRIF 18.6%, ORIF 33.1%. ORIF of the PMF significantly (p < 0.001) reduced the frequency of trans-syndesmotic fixation (25%) compared to CRIF (61%) or untreated PMF (63%) with no significant influence of the PMF size (≤25%/>25%). ORIF resulted in a significantly (p < 0.001) better quality of reduction (1.2 ± 1.1 mm (range: 0-5 mm)) compared to CRIF (2.5 ± 2.1 mm (range: 0-8 mm)) and untreated PMF (2.5 ± 2.3 mm (range: 0-20 mm)). Neither the frequency of trans-syndesmotic fixation nor the quality of reduction differed significantly between untreated PMF and CRIF. CONCLUSION: All posterior malleolus fragments, independent of their size, should be treated by ORIF, as this restores syndesmotic stability significantly more often than untreated PMF or CRIF.

[Fractures of the lateral process of the talus-snowboarder's ankle]. / Frakturen des Processus lateralis tali ­ "snowboarder's ankle".

Fractures of the lateral tubercle of the talus (PLT) are rare. With the increasing popularity of the trend sport snowboarding, the incidence of PLT fractures has increased. The most common classification of PLT fractures is the Hawkins classification. The aim of this review was to raise awareness for the injury and discuss the current evidence. A literature search revealed eight studies, each including at least seven patients. Six out of the eight studies were descriptive, retrospective case series without predefined treatment concepts. These resulted in only moderate treatment outcomes. Due to the low number of patients, the lack of computed tomography (CT) or magnetic resonance imaging (MRI) and inconsistent treatment approaches, these studies do not allow to draw conclusions on a treatment concept for PLT fractures. The other two studies validated existing treatment regimens. Overall, surgical treatment of dislocated fractures and conservative treatment of non-dislocated fractures was carried out with satisfactory results. The outcome of conservative treatment of dislocated factures remains unclear. A reason for the inconsistent treatment results could be the observed concomitant injuries, including dislocation of the tendons of the peroneus muscles (46%), calcaneal chondral injuries (48%) and subluxation of the subtalar joint (7%). Based on the limited evidence available, the authors recommend the application of CT and MRI for PLT fractures to assess concomitant injuries, which are the primary indication for surgery. Dislocated type I and II fractures (>2 mm) should be treated operatively, type III and non-dislocated type I and II fractures can be treated conservatively by immobilization and partial weight-bearing for 6 weeks.

[Fractures of the base of the V metatarsal bone-current concepts revised]. / Frakturen der Metatarsale Fünf Basis ­ eine Neubetrachtung.

Fractures of the base of the fifth metatarsal bone are one of the most frequent fractures to the foot and ankle. Despite the high frequency and although a number of studies are now available, treatment frequently does not follow the available evidence. Among the reasons is the inconsistent terminology used and that the studies available are neglected. The aim of this review is to present the current classifications, the available treatment studies and to derive evidence-based treatment recommendations. The term "Jones fracture" has been used inconsistently for different fracture entities and should, therefore, not be used anymore. Fractures are mostly classified according to Lawrence and Botte into three zones. However, the available studies demonstrate that type I and type II fractures according to Lawrence and Botte do not differ with respect to the prognosis. Both fractures can be successfully healed by functional treatment with weightbearing as tolerated. Consequently, a differentiation between these two zones does not seem to be meaningful. Therefore, they should be summarized as epi-metaphyseal fractures. Even dislocated, intra-articular, and multifragmentary fractures in this region can be functionally treated with good results. Fractures in the meta-diaphyseal region (Lawrence and Botte type III, distal to the IV and V intermetatarsal articulation) demonstrate a high rate of symptomatic non-unions after conservative treatment. Therefore, these fractures should be primarily treated operatively by closed reduction and intramedullary screw fixation.

[Fractures of the anterior process of the calcaneus-frequently overlooked injuries following ankle sprains]. / Frakturen des Processus anterior calcanei ­ häufig übersehene Verletzungen nach Sprunggelenkdistorsion.

Fractures to the anterior process of the calcaneus (PAC) have long been considered rare injuries and have received little attention in clinical research. On the contrary, recent studies have reported a distinct higher incidence, especially following ankle sprains. Decisive reasons are that fractures of the PAC are regularly missed on plain radiographs and that a clinical differentiation from injuries to the lateral ankle ligaments is difficult. With the broad availability of cross-sectional imaging modalities fractures of the PAC are diagnosed more frequently and more reliably. The purpose of this review is to give an overview on the diagnostics, classification and treatment recommendations to this topic and discuss the studies available. To date no evidence-based recommendations are available for the treatment of fractures of the PAC. The few case reports and case series published, predominantly recommend conservative treatment; however, the treatment regimens vary considerably, ranging from immobilization in a lower leg cast (2-10 weeks) to early functional treatment with full weight-bearing. The surgical treatment by open reduction and internal fixation has been described primarily for large dislocated fractures. Surgical excision is considered mainly in cases of persistent pain or symptomatic non-union following non-operative treatment. For both, non-operative and operative treatment, the case reports and case series report satisfactory outcomes for the majority of patients. Nevertheless, comparative studies and patient-rated outcome measures are missing. Therefore, evidence-based recommendations cannot be given.