Risk factors for malunion of distal tibia fractures treated by intramedullary nailing.

BACKGROUND: The treatment of distal tibia fractures (DTF) has historically been a difficult challenge for orthopedic surgeons because of the particular characteristics of this anatomical region. Intra medullary nailing (IMN) remains the best treatment option. However, achieving and maintaining perfect reduction and stable fixation with IMN can be technically challenging due to the large medullary cavity within a short distal fragment. The aim of our study is to determine the risk factors for malunion in DTF treated with IMN. METHODS: It is a retrospective study including DTF treated surgically by IMN in the Orthopedics and Trauma Department at a tertiary hospital over a period of 7 years. The quality of reduction was evaluated by radiological assessment of the antero-posterior (AP) and lateral views of the tibia and ankle at the last follow-up. RESULTS: Our series included 90 patients with an average age of 44.8 years. Sex-ratio was 2.6. Tobacco use was reported in 35.6% of the patients. Diabetes was present in 11.1% of the patients, and 12.2% of them had open fractures. According to the OTA/AO classification, the majority of injuries were classified as type A1 (76.7%). Fibula fractures were present in 86.7% of cases. The mean follow-up was 48 months. Malunion occurred in 13 cases. Based on the univariate analysis, smoking and dynamic fixation were significantly associated with malunion. In the multiple logistic regression analysis, dynamic fixation was found to be a significant factor that increased the risk of malunion by 7.5 times. CONCLUSION: Neither patient demographics nor fracture characteristics were risk factors for malunion. Nevertheless, it should be noted that dynamic nailing must be avoided as it is associated with a higher risk of malunion. Furthermore, one to two medial to lateral distal locking screws provide sufficient stability without the need for additional fibular fixation. TRIAL REGISTRATION: Not applicable.

All-suture fixation of syndesmotic injuries: a case series.

BACKGROUND: To retrospectively evaluate the clinical outcomes of patients treated for syndesmotic injuries with an all-suture construct technique and compare their patient reported outcome scores with historically published outcomes of syndesmotic injuries fixed with suspensory suture buttons. METHODS: This was a retrospective case series of patients treated at a Level 1 Trauma Center from May 1, 2018, to June 30, 2022. Ten patients aged 18 and older with unstable syndesmotic injuries treated with all-suture repair. Patients were excluded if they were treated with trans-osseous screws, had previous failed syndesmotic fixation, or suspensory suture button fixation. Patient-reported outcomes including Visual Analog Scale (VAS) pain scores, American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scores, and complications were recorded. RESULTS: In the patients with 6 weeks or more of radiographic follow-up (N = 9), there was no evidence of nonunion, loss of fixation, hardware complication, or whitling of the fibula by the suture. At final follow-up average VAS pain scores were 1.5 out of 10 (range 0-4; SD 1.2), AOFAS ankle and hindfoot scores averaged 89.6 out of 100 (range 86-100; SD 6.1). The pain subscale of the AOFAS score averaged 37.5 out of 40 (range 35-40; SD 2.5). The functional subscale of the AOFAS score averaged 46 out of 50 (range 44-50; SD 3.0). Stiffness was reported in one patient at their follow-up visits, which resolved with continued physical therapy. There were no superficial or deep infections. CONCLUSIONS: In conclusion, this case series presents the first clinical outcomes of an all-suture fixation technique for treatment of unstable syndesmotic ankle injuries. Our results suggest that the all-suture fixation technique results in similar patient reported outcomes when compared with historically reported patient reported outcomes of suspensory suture button fixation, and low rates of complication or hardware failure.

Cost analysis and clinical outcomes of anatomic pre-contoured locking versus conventional plates for distal fibula ankle fractures.

PURPOSE: To analyze differences in union, complication rates and cost from surgical fixation of distal fibula fractures with fibular plating implants. METHODS: In total, 380 adult patients from 2012 to 2015 treated with 12 fibular plates from 4 different manufacturers utilized by 9 surgeons were retrospectively reviewed. They were stratified into a conventional one-third tubular fibular plate group, pre-contoured anatomic locking plate group, or a heterogeneous group including 3.5-mm reconstruction, one-third tubular locking, composite, and limited compression plates. The outcomes included failure of fixation, deep infection requiring debridement, time to union, anatomic reduction, superficial infection, hardware removal, and post-traumatic arthritis. Plate and screw costs were calculated from hospital billing records. RESULTS: Pre-contoured locking plates were used in older, female patients with a greater number of comorbidities. Open injuries and OTA 44B fractures were more likely to be an indication for pre-contoured plates. There was no difference noted in time to union between the different plating groups. Risk factors for deep infection requiring debridement included a history of tobacco use, open fractures, and pre-contoured locking plates relative to the conventional plating group. The pre-contoured plating group was on average $586 more expensive compared to the conventional group. CONCLUSION: Pre-contoured locking plates achieved similar radiographic outcomes compared to conventional plates with an increased risk of complications and higher cost. Surgeons should consider their choice of implant based on the patient's fracture pattern, underlying comorbidities, and risk for infection.

Safety of early weightbearing after ankle fracture fixation.

PURPOSE: Patients with surgically treated ankle fractures are traditionally kept non-weightbearing for at least six weeks post-operatively; however, recent literature suggests numerous benefits of early weightbearing (EWB) before six weeks without significantly impacting long-term outcomes. This study aims to review the safety of early vs late weightbearing following ankle fracture fixation by assessing the complication rate. METHODS: This was a single-centre retrospective study. Between 2020 and 2023, all ankle fixations that commenced weightbearing at two weeks were added to the EWB group. An equal number of similar patients with six-week non-weightbearing were added to the late weightbearing (LWB) group. Baseline characteristics, risk factors, types of fractures and any complications in the six-month post-operative period were evaluated from these cohorts. RESULTS: In total, 459 ankle fixations were identified of which 87 patients met the criteria for the EWB group, with a further 87 added to the LWB group. There was no significant difference in age between the two groups (51.7 ± 20.1 vs 51.0 ± 15.5, respectively; p = 0.81), but more female patients and diabetics in the EWB group. Fracture types were similar between both cohorts (p = 0.51). Complication rate in the EWB group was not significantly different to the LWB group (5 vs 9, p > 0.05). CONCLUSION: No increase in complication rate was identified by commencing weightbearing early at two weeks after ankle fixation compared to six weeks. We therefore suggest EWB if appropriate, given its associated benefits including restoration of patient independence and improved quality of life. LEVEL OF EVIDENCE: Therapeutic, Level IV.

Immediate Unprotected Weightbearing vs 2 Weeks Nonweightbearing After Open Reduction Internal Fixation of Ankle Fractures.

BACKGROUND: Postoperative care protocols for ankle fracture surgery remain controversial with variability among care providers. This prospective controlled trial compared 12-week postoperative outcomes for immediate unprotected weightbearing (IMWB) vs nonweightbearing (NWB) for 2 weeks in a splint followed by weightbearing as tolerated (WBAT) in a boot after surgical fixation of selected low-energy ankle fractures without superior articular involvement. METHODS: Eighty-seven patients undergoing surgical fixation of ankle fractures at a single level 1 trauma center were recruited according to specific criteria and enrolled by presentation date. The first 43 eligible patients were allocated to the control group, with NWB in a splint for 2 weeks followed by WBAT in a walker boot. The next 44 patients recruited were allocated to the IMWB group. The primary outcome was the Olerud-Molander score (OMAS). Secondary outcome measures included the Euroquol-5D (EQ5D) score and Work Productivity and Activity Impairment: Specific Health Problem (WPAI:SHP) scores, ankle range of motion (ROM), wound complications, time to return to work, radiograph measurements, and fracture reduction loss. In this perioperative-focused study, we collected data on patients until 12 weeks postoperation. RESULTS: The IMWB group had 5 superficial wound complications vs 1 in the control group. At 12 weeks, we found no difference in OMAS, EQ5D, WPAI:SHP scores, ROM, time to return to work, or radiographic measurements. CONCLUSION: In this short-term and relatively small prospective trial, we found more wound complications among patients treated with immediate unprotected weightbearing compared with patients treated with 2 weeks of NWB followed by protected weightbearing. Given the low incidence and small sample size, we do not know if these observed findings are generalizable. However, we also found no difference in functional outcomes at 12 weeks postoperation between these 2 groups. In light of that, we do not recommend IMWB after open reduction internal fixation of low-energy ankle fractures with plate and/or screw fixation. LEVEL OF EVIDENCE: Level II, prospective controlled trial.

Plating Versus Intramedullary Nailing of OTA/AO 43C1 and C2 Intra-articular Distal Tibia Fractures: A Propensity Score and Multivariate Analysis.

OBJECTIVE: To compare rates of reduction loss, nonunion, and infection in intra-articular distal tibia fractures (IADTF) treated with limited open reduction internal fixation and intramedullary nailing (IMN) as compared to open reduction internal fixation with plate and screws (plate fixation [PF]). DESIGN: Retrospective review. SETTING: Level-I academic trauma center. PATIENT SELECTION CRITERIA: Patients age ≥ 18 with OTA/AO 43C1 and C2 IADTF treated with IMN or PF between 2013-2021. OUTCOME MEASURES AND COMPARISONS: Loss of reduction, surgical site infection (SSI), nonunion, and patient-reported outcomes (PROs) were compared for IMN versus PF treatments. RESULTS: One hundred ten patients met the inclusion criteria (IMN 33 and PF 77). There was no loss of reduction found. Seventeen nonunions (15% overall; IMN 4/33 and PF 13/77) and 13 SSIs (12% overall; IMN 2/33 and PF11/77) were identified. Despite several risk factors being identified for nonunion and SSI in bivariate analysis, only open fracture remained significant as a risk factor for both nonunion (odds ratio 0.09 for closed fracture, 95% confidence interval, 0.02-0.56, P = 0.009) and SSI (odds ratio 0.07 for closed fracture, 95% confidence interval, 0.06-0.26, P = 0.012) in the multivariate model. Propensity scoring based on presurgical variables was significantly different between patients who received IMN versus PF ( P = 0.03); however, logistic regression incorporating the propensity score revealed no significant association with nonunion and SSI. Adjusting for the propensity score, there remained no association comparing IMN versus PF with nonunion and SSI ( P = 0.54 and P = 0.17, respectively). There was also no difference in PROs between IMN and PF (physical function: P = 0.25 and pain interference: P = 0.21). CONCLUSIONS: Overall nonunion and SSI prevalence was 15% and 12%, respectively, in operatively treated OTA/AO 43C1 and C2 IADTF. An open fracture was a significant risk factor for nonunion and SSI. Metaphyseal fixation through IMN or PF did not affect loss of reduction, nonunion, SSI, or PROs. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparison of temporary external and percutaneous k-wire fixations for treatment of ankle fracture-dislocations.

PURPOSE: Ankle fracture-dislocations are among the most severe injuries, and the use of an external fixator as a recommended fixation method has some disadvantages. The aim of this study was to compare the clinical outcomes and complication rates of external and K-wire fixations in the treatment of ankle fracture dislocations. METHODS: A total of 67 patients with ankle fracture-dislocations requiring temporary external or percutaneous K-wire fixation were included. The exclusion criteria were pilon fractures, open fractures, and those who required acute open reduction internal fixation (ORIF). The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, a 10-point visual analog scale (VAS) score (range 0-10), and complications before and after the definitive surgery were recorded. RESULTS: A significant difference between the two groups was not observed for age, sex, affected side, fracture type, smoking status, or diabetes. The average AOFAS scores were 83.2 and 83.3, the median VAS scores were 3 and 3, and the complication rates were 32.4% and 6.7% in the external and K-wire fixation groups, respectively (p = 0.010). However, skin necrosis, re-dislocation of the ankle, surgical wound infection, and posttraumatic ankle osteoarthritis frequency were not significantly different between the groups, except for pin-sites infection (p = 0.036). CONCLUSION: Ankle fracture-dislocations using percutaneous k-wire fixation showed a low rate of complications and favorable clinical outcomes. This method could be a good alternative treatment option for ankle fracture-dislocations.

Functional Outcomes After High-Energy Lisfranc Injuries.

BACKGROUND: Midfoot fractures and dislocations are infrequent and functional outcomes following Lisfranc injuries have not been well described. The purpose of this project was to explore functional outcomes following operative treatment of high-energy Lisfranc injury. METHODS: A retrospective cohort of 46 adults with tarsometatarsal fractures and dislocations treated at a single Level 1 trauma center were reviewed. Demographic, medical, social, and injury features of these patients and their injuries were recorded. Foot Function Index (FFI) and Short Musculoskeletal Function Assessment (SMFA) surveys were collected after mean 8.7 years' follow-up. Multiple linear regression was performed to identify independent predictors of outcome. RESULTS: Forty-six patients with mean age 39.7 years completed functional outcome surveys. Mean SMFA scores were 29.3 (dysfunction) and 32.6 (bothersome). Mean FFI scores were 43.1 (pain), 43.0 (disability), and 21.7 (activity), with a mean total score of 35.9. FFI pain scores were worse than published values for fractures of the plafond (33, P = .04), distal tibia (33, P = .04), and talus (25.3, P = .001). Lisfranc injury patients reported worse disability (43.0 vs 29, P = .008) and total FFI scores (35.9 vs 26, P = .02) compared with distal tibia fractures. Tobacco smoking was an independent predictor of worse FFI (P < .05) and SMFA emotion and bothersome scores (P < .04). Chronic renal disease was a predictor of worse FFI disability (P = .04) and SMFA subcategory scores (P < .04). Male sex was associated with better scores in all SMFA categories (P < .04). Age, obesity, or open injury did not affect functional outcomes. CONCLUSION: Patients reported worse pain by FFI after Lisfranc injury compared to other injuries about the foot and ankle. Tobacco smoking, female sex, and preexisting chronic renal disease are predictive of worse functional outcome scores, warranting further study in a larger sample, as well as counseling of long-term consequences of this injury. LEVEL OF EVIDENCE: Level IV, retrospective, prognostic.

Influence of Patient-Reported Outcome Measures by Surgical Versus Conservative Management in Adult Ankle Fractures: A Systematic Review and Meta-Analysis.

Background and Objective: This meta-analysis was performed to compare the effectiveness of surgical treatment and conservative treatment in adult ankle fractures. Methods: Pubmed, Embase, and Cochrane-Library databases were searched to retrieve prospective randomized-controlled studies that compared the efficacy of surgical treatment and conservative treatment in adult ankle fractures. The meta package in R language was used to organize and analyze the obtained data. Results: A total of eight studies involving 2081 patients was considered eligible, including 1029 patients receiving surgical treatment and 1052 receiving conservative treatment. This systematic review and meta-analysis was prospectively registered on PROSPERO, and the registration number is CRD42018520164. Olerud and Molander ankle-fracture scores (OMAS) and the health survey 12-item Short-Form (SF-12) were used as main outcome indicators, and the follow-up outcomes were grouped according to the follow-up time. Meta-analysis results showed significantly higher OMAS scores in patients receiving surgical treatment than those with conservative treatment at six months (MD = 1.50, 95% CI: 1.07; 1.93) and over 24 months (MD = 3.10, 95% CI: 2.46; 3.74), while this statistical significance was absent at 12-24 months (MD = 0.08, 95% CI: -5.80; 5.96). At six months and 12 months after treatment, patients receiving surgical treatment exhibited significantly higher SF12-physical results than those receiving conservative treatment (MD = 2.40, 95% CI: 1.89; 2.91). The MD of SF12-mental data at six months after meta-analysis was -0.81 (95% CI: -1.22; 0.39), and the MD of SF12-mental data at 12+ months was -0.81 (95% CI: -1.22; 0.39). There was no significant difference in SF12-mental results between the two treatment methods after six months, but after 12 months, the SF12-mental results of patients receiving surgical treatment were significantly lower than those of conservative treatment. Conclusions: In the treatment of adult ankle fractures, surgical treatment is more efficacious than conservative treatment in improving early and long-term joint function and physical health of patients, but it is associated with long-term adverse mental health.

Early versus late weight-bearing in operatively treated ankle fractures with syndesmotic injury: A systematic review.

BACKGROUND: Over the past 30 years, several studies have compared early weight-bearing versus late weight-bearing following open reduction and internal fixation of ankle fractures; however, no review strictly including patients with ankle fractures and complete syndesmotic disruption has been performed. OBJECTIVE: The objective of this systematic review was to compare early versus late weight-bearing following surgery for ankle fracture with syndesmotic injury regarding clinical and patient-reported outcomes. METHODS: A comprehensive search strategy was applied to the Cochrane Library, MEDLINE, Embase, CINAHL and PubMed databases from their inception to the 17th of January 2022. The articles were screened independently by two blinded reviewers. Data were extracted by one author, then cross-checked and approved by the other. RESULTS: No comparative studies were found; therefore, studies describing either early or late weight-bearing were included. It was thus not possible to perform a meta-analysis. 11 studies and 751 patients were included. An early partial weight-bearing protocol was used in three studies (253 patients) and late in eight studies (498 patients). Functional outcomes suggested that there were no clear differences between early partial weight-bearing and late weight-bearing. The reoperation rate was 9-31% in the early group and 0-11% in the late. Similar results were seen for loss of syndesmotic reduction, malreduction, infection, and fixation failure. CONCLUSION: Pros and cons were reported for early partial weight-bearing and late weight-bearing, but the evidence was very limited as our results were based on noncomparative studies. In the future, high-quality comparative studies focusing on functional outcomes within 6 months postoperatively are needed. LEVEL OF CLINICAL EVIDENCE: 1.

Talus dislocation and pereonal malleolar fracture after high-energy trauma: a case report.

Talus dislocation is a rare injury and it is usually the consequence of high energy traumas, despite the anatomical features of the talus which predispose to its dissociation (absence of muscle insertions with over 60% of the surface covered by cartilage). It may be associated with malleolar fractures. Standard treatment of closed talar dislocation is a controversial issue. The most common early complications is avascular necrosis. Authors report a case of a complete talar dislocation associated to displaced lateral malleolar fracture in a 18-years-old male following a high energy trauma treated by closed reduction and fixation of the malleolar fracture.

Risks of Immunosuppressive Therapy in Patients Undergoing Open Reduction Internal Fixation for Ankle Fractures.

Chronic steroid and immunosuppressant use have been shown to increase the risk for postoperative complications in orthopedic surgery. Further understanding of the risks of immunosuppression is necessary to aid in risk stratification and patient counseling. However, these risks have not yet been explored in ankle fracture patients. Thus, the purpose of this study is to determine whether patients taking immunosuppressives are at an increased risk for morbidity and mortality following open reduction and internal fixation (ORIF) of ankle fractures. Patients undergoing operative treatment for ankle fractures from 2006 to 2018 were identified in the National Surgical Quality Improvement Program database. Patients were categorized based on their use of immunosuppressive medications. Postoperative outcomes assessed included superficial surgical site infections, deep surgical site infections, organ space infections, wound dehiscence, pneumonia, unplanned intubation, pulmonary embolism, urinary tract infection, renal failure, blood transfusion requirement, deep vein thrombosis, sepsis, cardiac arrest, extended length of hospital stay, readmission, reoperation, and mortality. Univariate and multivariate analyses were performed. In total, 10,331 patients underwent operative treatment for ankle fracture. Total 10,153 patients (98.3%) were not taking immunosuppressants and 178 (1.7%) were taking these medications. In multivariate analysis, patients taking immunosuppressants were at increased risk of pulmonary embolism (odds ratio [OR] 4.382; p = .041) and hospital readmission (OR 2.131; p = .021). Use of immunosuppressive medications is an independent risk factor for pulmonary embolism and readmission following ORIF for ankle fractures. Notably, no association with wound complications, infections, or sepsis was identified.

A Retrospective Analysis of Distal Fibula Fractures Treated With Intramedullary Fibular Nail Fixation.

There is growing literature supporting the use of intramedullary fixation for fracture care because of its smaller incisions, improved biomechanical outcomes, and faster time to weightbearing than traditional internal fixation methods. The aim of this study is to investigate the postoperative outcomes in ankle fractures treated with intramedullary nail fixation in the largest patient cohort to date. From 2015 to 2021, 151 patients were evaluated following surgical treatment of fibular fractures with intramedullary nail fixation. Patients were identified through a medical record database search for appropriate ankle fracture procedure codes. Patient information was reviewed for fracture type, adjunct procedures, time to weightbearing and postoperative complications. Radiographs were assessed for quality and time to radiographic union. The mean time to weightbearing was 4.8 weeks. Minor wound dehiscence was identified in 2 patients (1.3%). Superficial infection was present in 4 patients (2.6%) and a deep infection developed in 2 patients (1.3%). Two patients developed a nonunion (1.5%). There were no DVTs reported, although 1 patient developed a PE postoperatively. Radiographic quality of reduction and time to union is comparable to literature reported plate and screw construct outcomes. Reduction was classified as good in 86.1% of patients and radiographic union was appreciated in 98.5% of patients. This is the largest cohort study evaluating the outcomes of intramedullary nail fixation for ORIF of ankle fractures. These data reinforce that intramedullary nailing provides a minimally invasive approach with accurate anatomic reduction, excellent fracture union rates, low complication rates, and an early return to weightbearing.

Outcomes After Acute Versus Staged Fixation of Complete Articular Tibial Plafond Fractures.

OBJECTIVE: To determine the outcomes after acute versus staged fixation of complete articular tibial plafond fractures. DESIGN: Retrospective cohort study. SETTING: Single Level 1 Trauma center. PARTICIPANTS: 98 skeletally mature patients with OTA/AO 43C type fractures who underwent definitive fixation with plate and screw constructs and had a minimum 6 months of follow-up. INTERVENTION: Acute open reduction internal fixation (aORIF) versus staged (sORIF) definitive fixation. MAIN OUTCOME MEASUREMENT: Rates of wound dehiscence/necrosis and deep infection. RESULTS: Acute (N = 40) versus staged (N = 58) ORIF groups had comparable rates of vascular disease, renal disease, and substance/nicotine use, but aORIF patients had higher rates of diabetes mellitus (10% vs. 0%, P < 0.001), which correlated with higher American Society of Anaesthesiologist scores (>American Society of Anaesthesiologist 3: 37.5% vs. 13.8%, P = 0.02). Both groups achieved anatomic/good reductions, as determined by postoperative CT scans, at rates greater than 90%; however, the sORIF group required modestly longer operative times to achieve this outcome (aORIF vs. sORIF: 121 vs. 146 minutes, P = 0.02). Postoperatively, both groups had similar rates of wound dehiscence (2.5% vs. 6.9%, P = 0.65), superficial infections (10% vs. 17.2%, P = 0.39), and deep infections (10% vs. 8.6%, P = 0.99). While the injury pattern itself required free flap coverage in 1 patient in each group, unplanned free flap coverage occurred in 10.0% and 10.3% of aORIF and sORIF groups, respectively. Overall, rates of unplanned reoperations, excluding ankle arthrodesis, did not differ between groups (aORIF vs. sORIF:12.5% vs. 25.9%, P = 0.13). CONCLUSIONS: In select patients managed by fellowship-trained orthopaedic traumatologists, acute definitive pilon fixation can produce acceptable outcomes. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Fractures of the posterior malleolus: a systematic review and analysis of patient-reported outcome scale selection.

PURPOSE: Despite the extensive use of PROs in ankle fracture research, no study has quantified which PROs are most commonly used for assessing outcomes of patients who sustain fractures of the posterior malleolus. The purpose of this study was therefore to quantify which PROs are most commonly used for outcome research after posterior malleolus fractures. METHODS: A systematic search was performed using the preferred reporting items for systematic reviews and meta-analyses guidelines. Articles were identified through Pubmed, EMBASE, Web of Science, and cochrane central register of controlled trials through May of 2021. Included articles were analyzed for the primary outcome of the most commonly reported PRO. RESULTS: The American orthopedic foot and ankle ankle-hindfoot score (AOFAS) was the most commonly used PRO for assessment of posterior malleolus fracture outcomes, used in 37 of 72 studies (51.4%). The second and third most common were the olerud-molander ankle score (OMAS) (22 studies, 30.6%) and the visual analogue score (VAS) (21 studies, 29.2%). Eleven different PROs were used only once. Quality of evidence was graded as low given the percentage of studies that were observational or case series (68 of 72 studies, 94.4%). CONCLUSION: Investigators have used many different PROs to assess outcomes for posterior malleolus fractures, the most common of which are the AOFAS, OMAS, and VAS. Future investigators should attempt to unify outcome reporting for these injuries.

Clinical outcomes of ankle fractures in sub-Saharan Africa: a systematic review.

PURPOSE: Ankle fractures may cause disability and socioeconomic challenges, even when managed in a high-resource setting. The outcomes of ankle fractures in sub-Saharan Africa are not widely reported. We present a systematic review of the patient-reported outcomes and complications of patients treated for ankle fractures in sub-Saharan Africa. METHODS: Medline, Embase, Google Scholar and the Cochrane Central Register of Controlled Trials were searched, utilising MeSH headings and Boolean search strategies. Ten papers were included. Data included patient demographics, surgical and non-surgical management, patient-reported outcome measures and evidence of complications. RESULTS: A total of 555 patients with ankle fractures were included, 471 of whom were followed up (range 6 weeks-73 months). A heterogenous mix of low-quality observational studies and two methodologically poor-quality randomised trials demonstrated mixed outcomes. A preference for surgical management was found within the published studies with 87% of closed fractures being treated operatively. A total of five different outcome scoring systems were used. Most studies included in this review were published by well-resourced organisations and as such are not representative of the actual clinical practice taking place. CONCLUSION: The literature surrounding the clinical outcomes of ankle fractures in sub-Saharan Africa is sparse. There appears to be a preference for surgical fixation in the published literature and considering the limitations in surgical resources across sub-Saharan Africa this may not be representative of real-life care in the region.

Epidemiology of Ankle Fractures in Korea: A Nationwide Population-Based Study.

BACKGROUND: Although ankle fractures are among the most common fractures, nationwide population-based data on the epidemiology of patients with ankle fractures are scarce. This study aimed to perform an epidemiological analysis of all ankle fractures in Korea from 2010 through 2018. METHODS: We used national registries from the Korean Health Insurance Review and Assessment Service from 2009 to 2018. The annual incidence of the ankle fracture was calculated. The incidence was also calculated according to gender and age. Trends of fracture subtypes were also analyzed. Then, the incidence of ankle fractures by seasonal variation was investigated. RESULTS: A total of 735,073 ankle fractures were identified in 461,497,758 people for 10 years. The annual incidence of ankle fracture was 171.37/100,000 persons in 2018, with a male to female ratio of 0.78. Interesting differences in the ankle fracture trends were observed between gender. Male shows the highest incidence in adolescence, and the even distribution has lasted for the rest of their lives. In females, the incidence of ankle fracture showed an increasing tendency as their age increased. There was a clear difference in the incidence rate of each season according to age. Ankle fractures occurred more in spring and autumn in children and adolescents and most in winter in the elderly. CONCLUSION: Ankle fracture risk was different between sex and exhibited seasonal variations. Our findings can be used for epidemiological awareness and prevention campaigns for ankle fractures.

Prospective Results of the Modified Glide Path Technique for Improved Syndesmotic Reduction During Ankle Fracture Fixation.

BACKGROUND: Malreduction after syndesmotic stabilization occurs in as many as 52% of cases and has been shown to detrimentally affect clinical outcomes. We propose that the modified Glide Path technique reduces the occurrence of syndesmotic malreduction. METHODS: This study is a prospective series comparing 16 patients reduced with the modified Glide Path technique with a retrospectively reviewed series of 25 patients reduced with a traditional technique using fluoroscopy and a clamp. The modified Glide Path technique consists of manual reduction of the fibula and placement of a Kirschner wire through the fibula and tibia along the transmalleolar axis. The syndesmosis can then be reduced along the glide path created by the Kirschner wire to prevent posterior or anterior malreduction. Computed tomographic scans of the repaired and contralateral ankles were obtained postoperatively to assess reduction. RESULTS: We found a statistically significant decrease of syndesmotic malreductions using the modified Glide Path technique when compared with technique that did not use a glide path. In our study, 2 of 16 patients (12.5%) had syndesmotic malreductions using the modified Glide Path technique, compared with 11 of 25 patients (44%) with syndesmotic malreductions in the historical cohort. CONCLUSION: The modified Glide Path technique is a simple method for ankle syndesmotic reduction. The technique has lower rates of malreduction compared with historical methods and may be useful for most operative syndesmotic injuries. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Clinical outcomes in the surgical management of ankle fractures: A systematic review and meta-analysis of fibular intramedullary nail fixation vs. open reduction and internal fixation in randomized controlled trials.

BACKGROUND: What level I evidence exists to support the use of FNF for surgical management of ankle fractures in high risk patients? The purpose of this study was to compare clinical outcomes following fibular intramedullary nail fixation (FNF) and open reduction and internal fixation (ORIF) of ankle fractures. METHODS: A systematic review of the current literature was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Certainty of evidence reported according to GRADE (Grading of Recommendations Assessment, Development, and Evaluation). Our primary hypothesis was that patients undergoing FNF procedures to manage an ankle fracture would have significantly higher patient reported outcome scores (PROs) than patients undergoing ORIF. Primary study outcome measures were validated PROs. Secondary outcome measures included complication rate, secondary surgery rate, and bony union. RESULTS: The primary outcome analysis revealed no evidence of a significant effect difference on Olerud and Molander Ankle Score (OMAS) PRO and no evidence of statistical heterogeneity. Secondary outcome analysis revealed a significant 0.30 (0.12-0.74 95CI) relative risk reduction for complications in FNF (P = 0.008). No evidence of an effect difference for bony union. The GRADE certainty of the evidence was rated as low for bone union. No evidence of reporting bias was appreciated. Sensitivity analyses did not significantly alter effect estimates. CONCLUSION: This systematic review and meta-analysis restricted to evidence derived from RCTs revealed that the quality of evidence is reasonably strong and likely sufficient to conclude: (1) there is likely no clinically important difference between FNF and ORIF up to 12 months post-operatively, as defined by OMS (moderate certainty); (2) surgeons may reasonably expect reduced complications in 14 out of every 100 patients treated with FNF (moderate certainty); (3) there is likely no difference in bony union (low certainty). Future studies should investigate more patient-centered outcomes and if short-term findings are durable over time if these findings apply to lower risk populations. LEVEL OF EVIDENCE: Systematic review and meta-analysis of level I evidence.

Tourniquet Use During Open Reduction and Internal Fixation of Ankle Fractures - A Systematic Review and Meta-Analysis.

The intra-operative use of tourniquet in open reduction and internal fixation (ORIF) of ankle fractures remains a topic of debate. The purpose of this study was to perform a systematic review and meta-analysis of randomized control trials (RCTs) comparing clinical outcomes of patients undergoing ankle ORIF with tourniquet use versus a control group where no tourniquet was used. A systematic review was performed with reference to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines of the Pubmed, Scopus, Embase, and Cochrane Library databases. Studies were included if they were an RCT comparing tourniquet and no-tourniquet in ankle ORIF. Meta-analysis was performed using RevMan, and p-value <.05 was considered to be statistically significant. On completion of the literature search, a total of 4 RCTs including 350 ankles (52.6% males), with a mean age of 47.1 ± 5.7 years were included. There were 173 patients in the tourniquet group (T), versus 177 patients in the no tourniquet control group (NT), with nonsignificant differences between the groups for age, gender and body mass index demographics (all p > .05). There were significantly shorter duration of surgery, with significantly higher patient-reported rates of pain levels at day 2 postoperatively (both p < .001) in the T group. Additionally, there were significantly greater ranges of ankle motion at 6 weeks postoperatively (p = .03), with nonsignificant differences reported incidence of wound infections and deep vein thrombosis (p = .056 and p = .130 respectively) between the groups. In conclusion, current evidence suggests that although intraoperative tourniquet usage in cases of ankle ORIF results in significant reductions in duration of surgery, this may be at the expense of higher patient-reported pain scores and reduced range of motion postoperatively.