ABSTRACTS DE PUBLICACIONES SOBRE TOBILLO

Int Orthop. 2015 Aug 13. [Epub ahead of print]

Biomechanical comparison of bionic, screw and Endobutton fixation in the treatment of tibiofibular syndesmosis injuries.

Wang L1, Wang B, Xu G, Song Z, Cui H, Zhang Y.

Author information

1Department of Anatomy, Hebei Medical University, No.361 Zhongshan East Road, Chang'an District, Shijiazhuang, Hebei, 050011, China.

Abstract

BACKGROUND:

The two prevalent fixation methods in the treatment of syndesmosis injuries, the rigid screw fixation and flexible Endobutton fixation, are not without issues; thus, we have designed a novel bionic fixation method which combines the features of both rigid and flexible fixations. The aim of this study was to compare the biomechanical properties of the bionic fixation to the screw and Endobutton fixations.

METHODS:

Six normal fresh-frozen legs from amputation surgery were used. After initial tests of intact syndesmosis, screw, bionic and Endobutton fixations were performed sequentially for each specimen. Axial loading as well as rotation torque were applied, in five different ankle positions: neutral position, dorsiflexion, plantar flexion, varus, and valgus. The displacement of the syndesmosis and the tibial strain were analysed using a biomechanical testing system.

RESULTS:

Whether receiving axial loading or rotation torque, in most situations (neutral position, dorsiflexion, varus, plantar flexion with low loading, valgus with high loading, internal and external rotation), the bionic group and Endobutton group had comparable displacements, and there was no significant difference among the intact, bionic, and Endobutton groups; whereas the displacements of the screw group were smaller than any of the other three groups. Results of the tibial strain were similar with that of the displacement.

CONCLUSIONS:

The bionic fixation at least equals the performance of Endobutton fixation; it also allows more physiologic movement of the syndesmosis when compared to the screw fixation and may serve as a viable option for the fixation of the tibiofibular syndesmosis.

Int Orthop. 2015 Aug 13. [Epub ahead of print]

Biomechanical comparison of bionic, screw and Endobutton fixation in the treatment of tibiofibular syndesmosis injuries.

Wang L1, Wang B, Xu G, Song Z, Cui H, Zhang Y.

Author information

1Department of Anatomy, Hebei Medical University, No.361 Zhongshan East Road, Chang'an District, Shijiazhuang, Hebei, 050011, China.

Abstract

BACKGROUND:

The two prevalent fixation methods in the treatment of syndesmosis injuries, the rigid screw fixation and flexible Endobutton fixation, are not without issues; thus, we have designed a novel bionic fixation method which combines the features of both rigid and flexible fixations. The aim of this study was to compare the biomechanical properties of the bionic fixation to the screw and Endobutton fixations.

METHODS:

Six normal fresh-frozen legs from amputation surgery were used. After initial tests of intact syndesmosis, screw, bionic and Endobutton fixations were performed sequentially for each specimen. Axial loading as well as rotation torque were applied, in five different ankle positions: neutral position, dorsiflexion, plantar flexion, varus, and valgus. The displacement of the syndesmosis and the tibial strain were analysed using a biomechanical testing system.

RESULTS:

Whether receiving axial loading or rotation torque, in most situations (neutral position, dorsiflexion, varus, plantar flexion with low loading, valgus with high loading, internal and external rotation), the bionic group and Endobutton group had comparable displacements, and there was no significant difference among the intact, bionic, and Endobutton groups; whereas the displacements of the screw group were smaller than any of the other three groups. Results of the tibial strain were similar with that of the displacement.

CONCLUSIONS:

The bionic fixation at least equals the performance of Endobutton fixation; it also allows more physiologic movement of the syndesmosis when compared to the screw fixation and may serve as a viable option for the fixation of the tibiofibular syndesmosis.

Foot Ankle Int. 2000 Sep;21(9):736-41.

Biomechanical comparison of syndesmosis fixation with 3.5- and 4.5-millimeter stainless steel screws.

Thompson MC1, Gesink DS.

Author information

1Department of Orthopaedic Surgery and Rehabilitation University of Nebraska Medical Center, Omaha 68198-1080, USA. MTFemur@aol.com

Abstract

Although most authors recommend either 3.5-mm or 4.5-mm cortical screws for syndesmosis fixation, the optimum screw size has yet to be defined. The present study was designed to biomechanically compare syndesmosis fixation with 3.5-mm and 4.5-mm stainless steel screws. Simulated pronation external rotation ankle injuries were created in twelve paired, fresh-frozen cadaveric leg specimens. One limb from each pair received a 3.5-mm tricortical stainless steel screw for syndesmosis fixation (group I), while the contralateral specimen was stabilized using a 4.5-mm screw (group II). Sub-maximal axial ramp (0 to 1200 N) and external rotation/torsional ramp (0 to 5 N-m) loading was performed on each specimen prior to ligament division, following ligament division and following syndesmosis fixation. Axial fatigue testing was then performed at 1.5 Hz for a total of 100,000 cycles (0 to 900 N), and each specimen was subsequently tested to failure in external rotation. Ligament division resulted in syndesmosis widening (p<0.001) and reduced stiffness (p<0.001) during torsional ramp loading. Subsequent syndesmosis screw placement reduced syndesmosis widening (p<0.05) and increased stiffness (p<0.05). Following screw fixation, however, widening remained greater (p<0.005) and stiffness less (p<0.001) than pre-injury levels. No differences between groups I and II were observed during submaximal testing. In external rotation to failure testing, group I failed at a greater angle (38.9 degrees +/- 4.1 degrees vs. 32.0 degrees +/- 3.8 degrees in group II; p<0.05). Failure torque was slightly higher in group I; however, the difference was not statistically significant (17.8 +/- 2.0 N-m vs. 14.3 +/- 2.6 N-m in group II; p=0.082). Five specimens in group I failed by screw pullout and five specimens in group II failed by fibula fracture (p=0.061). The present results suggest that there is no biomechanical advantage of a 4.5-mm screw over a 3.5-mm in fixation of the syndesmosis.

Foot Ankle Int. 2000 Sep;21(9):736-41.

Biomechanical comparison of syndesmosis fixation with 3.5- and 4.5-millimeter stainless steel screws.

Thompson MC1, Gesink DS.

Author information

1Department of Orthopaedic Surgery and Rehabilitation University of Nebraska Medical Center, Omaha 68198-1080, USA. MTFemur@aol.com

Abstract

Although most authors recommend either 3.5-mm or 4.5-mm cortical screws for syndesmosis fixation, the optimum screw size has yet to be defined. The present study was designed to biomechanically compare syndesmosis fixation with 3.5-mm and 4.5-mm stainless steel screws. Simulated pronation external rotation ankle injuries were created in twelve paired, fresh-frozen cadaveric leg specimens. One limb from each pair received a 3.5-mm tricortical stainless steel

screw for syndesmosis fixation (group I), while the contralateral specimen was stabilized using a 4.5-mm screw (group II). Sub-maximal axial ramp (0 to 1200 N) and external rotation/torsional ramp (0 to 5 N-m) loading was performed on each specimen prior to ligament division, following ligament division and following syndesmosis fixation. Axial fatigue testing was then performed at 1.5 Hz for a total of 100,000 cycles (0 to 900 N), and each specimen was subsequently tested to failure in external rotation. Ligament division resulted in syndesmosis widening (p<0.001) and reduced stiffness (p<0.001) during torsional ramp loading. Subsequent syndesmosis screw placement reduced syndesmosis widening (p<0.05) and increased stiffness (p<0.05). Following screw fixation, however, widening remained greater (p<0.005) and stiffness less (p<0.001) than pre-injury levels. No differences between groups I and II were observed during submaximal testing. In external rotation to failure testing, group I failed at a greater angle (38.9 degrees +/- 4.1 degrees vs. 32.0 degrees +/- 3.8 degrees in group II; p<0.05). Failure torque was slightly higher in group I; however, the difference was not statistically significant (17.8 +/- 2.0 N-m vs. 14.3 +/- 2.6 N-m in group II; p=0.082). Five specimens in group I failed by screw pullout and five specimens in group II failed by fibula fracture (p=0.061). The present results suggest that there is no biomechanical advantage of a 4.5-mm screw over a 3.5-mm in fixation of the syndesmosis.

J Orthop Trauma. 2012 Oct;26(10):602-6.

Lag screw fixation of medial malleolar fractures: a biomechanical, radiographic, and clinical comparison of unicortical partially threaded lag screws and bicortical fully threaded lag screws.

Ricci WM1, Tornetta P, Borrelli J Jr.

Author information

1Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA. ricciw@wudosis.wustl.edu

Abstract

OBJECTIVES:

Bicortical fully threaded (FT) lag screw fixation (lag by method) is a technique for medial malleolar fixation that may provide advantages to partially threaded (PT) cancellous lag screws (lag by screw design). A direct comparison of the biomechanical properties and the clinical outcomes of these 2 methods of medial malleolar lag screw fixation were undertaken. The null hypotheses were that unicortical PT lag screws and bicortical FT lag screws had similar biomechanical and clinical outcomes.

DESIGN:

Biomechanics--Human cadaver biomechanical investigation. Clinical-Retrospective cohort series with control. Settings-Level-1 trauma center.

PATIENTS:

One hundred forty-one consecutive patients with closed medial malleolar fractures (OTA 44) treated with lag screw fixation were identified from a prospective orthopaedic trauma database. Thirty-nine were lost to follow-up and 12 were treated with a single screw leaving 46 in the PT group and 46 in the FT group all treated with 2 screws for their medial malleolar fracture.

INTERVENTION:

Biomechanics--Human cadavers (n = 3) had bilateral oblique medial malleolar fractures (n = 6) created with an osteotome to simulate a typical medial malleolar fracture amenable to lag screw fixation. Fixation of each side was randomly allocated to either two 4.0-mm PT lag screws (length 45 mm) or two 3.5-mm FT threaded screws [length determined by depth gauge after near cortex overdrilled and far cortex (distal lateral tibia) drilled based on core diameter (2.7 mm)]. Clinical-Either 2 traditional PT (n = 46) or 2 FT screws (n = 46) were used for fixation of medial malleolus fractures.

MAIN OUTCOME MEASUREMENTS:

Biomechanics--Peak insertion torque generated during screw insertion. Clinical: Radiographic evidence of screw loosening, clinical non-union, and reoperation.

RESULTS:

Biomechanics--The FT lag screw group (n = 6 screws) showed an average maximum torque of 14.4 in-lbf (range 8.0-20.1, SD = 4.4) before screw stripping. This was over 3 times greater than that seen with the PT lag screws (n = 6) (average maximum torque generation = 4.0 in-lbf, range 2.5-6.6, SD = 1.4), P < 0.0002. Clinical-Radiographic screw loosening was evident in one of the 46 patients (2%) in the FT cohort and in 11 of the 46 patients (24%) in the PT cohort, P < 0.003. Two of the patients with screw loosening in the PT cohort required reoperation for removal of symptomatic hardware, whereas no patient from the LT screw group required removal. All patients in the LT cohort healed after the index procedure although 2 in the PT cohort had nonunions.

CONCLUSIONS:

Screws placed with the lag by method technique that engaged the distal lateral tibial cortex have superior biomechanical, radiographic, and clinical outcomes compared to traditional PT screws for the fixation of medial malleolar fractures.

Sports Health. 2015 May;7(3):267-9. doi: 10.1177/1941738115572984.

Clinician Recommendations and Perceptions of Factors Associated With Ankle Brace Use.

Denton JM1, Waldhelm A1, Hacke JD2, Gross MT3.

Author information

1School of Physical Therapy, University of the Incarnate Word, San Antonio, Texas.

2Division of Physical Therapy at the University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

3Program in Human Movement Science, Division of Physical Therapy at the University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Abstract

BACKGROUND:

Little information is available regarding the ankle braces orthopaedic sports medicine clinicians recommend or clinicians' concerns that may influence their decisions to recommend use of an ankle brace.

HYPOTHESES:

(1) Clinicians most frequently recommend lace-up braces with straps. (2) Clinicians who are concerned about potential adverse side effects from ankle brace use are less likely to recommend an ankle brace to prevent ankle sprain injuries.

STUDY DESIGN:

Descriptive survey study.

LEVEL OF EVIDENCE:

Level 3.

METHODS:

Surveys were sent via e-mail to 1000 randomly selected members of the Orthopaedic Section of the American Physical Therapy Association (APTA) and 1000 randomly selected members of the National Athletic Trainers' Association (NATA). A total of 377 individuals responded to the survey.

RESULTS:

Lace-up braces, specifically lace-up braces with straps, were the most frequently recommended type of ankle brace. Regression analyses indicated that the only perceived adverse side effect significantly related to frequency of ankle brace recommendation was a potential negative influence on ankle strength.

CONCLUSION:

Based on our sample, clinicians recommend lace-up ankle braces with straps most frequently to prevent ankle sprain injuries. Clinicians who are concerned about weakness of ankle musculature may be less likely to recommend use of an ankle brace.

CLINICAL RELEVANCE:

Clinicians may effectively reduce the number of ankle sprain injuries by recommending an ankle brace use after an initial ankle sprain injury.

J Emerg Med. 2015 Jun 2. pii: S0736-4679(15)00271-1. doi: 10.1016/j.jemermed.2015.03.021. [Epub ahead of print]

Double-blind, Randomized, Placebo-controlled Study Evaluating the Use of Platelet-rich Plasma Therapy (PRP) for Acute Ankle Sprains in the Emergency Department.

Rowden A1, Dominici P1, D'Orazio J1, Manur R1, Deitch K1, Simpson S1, Kowalski MJ1, Salzman M2, Ngu D1.

Author information

1Einstein Healthcare Network, Philadelphia, Pennsylvania. 2Cooper Medical School at Rowan University, Camden, New Jersey.

Abstract

BACKGROUND:

Over 23,000 people per day require treatment for ankle sprains. Platelet-rich plasma (PRP) is an autologous concentration of platelets that is thought to improve healing by promoting inflammation through growth factor and cytokine release. Studies to date have shown mixed results, with few randomized trials.

OBJECTIVES:

To determine patient function among patients randomized to receive standard therapy plus PRP, compared to patients who receive standard therapy plus sham injection (placebo).

METHODS:

Prospective, randomized, double-blinded, placebo-controlled trial. Patients with severe ankle sprains were randomized. Severity was graded on degree of swelling, ecchymosis, and ability to bear weight. PRP with lidocaine and bupivacaine was injected at the point of maximum tenderness by a blinded physician under ultrasound guidance. The control group was injected in a similar fashion with sterile 0.9% saline. Both groups had visual analog scale (VAS) pain scores and Lower Extremity Functional Scale (LEFS) on days 0, 3, and 8. LEFS and a numeric pain score were obtained via phone call on day 30. All participants were splinted, given crutches, and instructed to not bear weight for 3 days; at this time patients were reevaluated.

RESULTS:

There were 1156 patients screened and 37 were enrolled. Four withdrew before PRP injection was complete; 18 were randomized to PRP and 15 to placebo. There was no statistically significant difference in VAS and LEFS scores between groups.

CONCLUSION:

In this small study, PRP did not provide benefit in either pain control or function over placebo.

J Foot Ankle Surg. 2015 Jan-Feb;54(1):130-4. doi: 10.1053/j.jfas.2014.09.041. Epub 2014 Oct 31.

Osteomyelitis after TightRope(®) fixation of the ankle syndesmosis: a case report and review of the literature.

Hong CC1, Lee WT2, Tan KJ2.

Author information

1University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Hospital, Singapore, Singapore. Electronic address: choonchiet@gmail.com.

2University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Hospital, Singapore, Singapore.

Abstract

Fixation of ankle syndesmosis injuries using the Ankle TightRope(®) has been gaining popularity. It has been shown to produce good results, facilitate early weightbearing, reduce the need for implant removal, and allow an earlier return to work and, possibly, a more anatomic syndesmotic reduction compared with screw fixation. However, its usage has been associated with complications such as soft tissue irritation, infection and wound breakdown, suture-button subsidence, and pathologic fracture from the screw tract. We describe a case of chronic osteomyelitis and suture-button migration associated with TightRope(®) fixation and a limited contact-dynamic compression plate for ankle syndesmosis disruption and lateral malleolus fracture.

J Bone Joint Surg Am. 2014 Oct 15;96(20):1732-8. doi: 10.2106/JBJS.N.00198.

The effect of suture-button fixation on simulated syndesmotic malreduction: a cadaveric study.

Westermann RW1, Rungprai C1, Goetz JE1, Femino J1, Amendola A1, Phisitkul P1.

Author information

1Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 01008 JPP, Iowa City, IA 52242. E-mail address for R.W. Westermann: Robert-Westermann@uiowa.edu. E-mail address for C. Rungprai: chamnanni-rungprai@uiowa.edu. E-mail address for J. Femino: john-femino@uiowa.edu. E-mail address for A. Amendola: ned-amendola@uiowa.edu. E-mail address for P. Phisitkul: phinit-phisitkul@uiowa.edu. E-mail address: jessica-goetz@uiowa.edu.

Abstract

BACKGROUND:

The accuracy of reduction of distal tibiofibular syndesmosis disruptions has been associated with the clinical outcome. Suture-button fixation of the syndesmosis is a dynamic alternative mode of fixation. We hypothesized that with deliberate clamp-induced malreduction, suture-button fixation of the syndesmosis would allow a more anatomic post-fixation position compared with screw fixation.

METHODS:

Forty-eight syndesmotic fixations were performed on twelve through-knee cadaveric specimens. The syndesmosis was destabilized and off-axis clamping was used to produce both anterior and posterior malreduction patterns. In twelve scenarios (six anterior and six posterior malreductions), syndesmotic screw fixation was used, followed by computed tomography. With tenacula holding the malreduction, the syndesmosis screws were exchanged for a suture-button construct and the specimens underwent a subsequent computed tomography scan. In the other twelve scenarios, the suture-button fixation was achieved first, followed by screw fixation. Standardized measurements of anterior-posterior and medial-lateral fibular displacement were performed by two observers blinded to the method of fixation.

RESULTS:

With anterior off-axis clamping, the mean sagittal malreduction was 2.7 ± 2.0 mm with screw fixation and 1.0 ± 1.0 mm with suture-button fixation (p = 0.02). With posterior off-axis clamping, the sagittal malreduction was 7.2 ± 2.3 mm with screw fixation and 0.5 ± 1.4 mm with suture-button fixation (p < 0.01). No differences were observed between fixation types in the coronal plane (p = 0.20 for anterior malreductions and p = 0.06 for posterior malreductions).

CONCLUSIONS:

With deliberate malreduction in a cadaver model, suture-button fixation of the syndesmosis results in less post-fixation displacement compared with screw fixation. The suture button's ability to allow for natural correction of deliberate malreduction was greatest with posterior off-axis clamping.

CLINICAL RELEVANCE:

Although the clinical relevance is unknown, dynamic syndesmotic fixation may mitigate clamp-induced malreduction.

Foot Ankle Int. 2014 Oct;35(10):1022-30. doi: 10.1177/1071100714540893. Epub 2014 Jun 24.

Comparison of lag screw versus buttress plate fixation of posterior malleolar fractures.

Erdem MN1, Erken HY2, Burc H3, Saka G4, Korkmaz MF5, Aydogan M6.

Author information

1Department of Orthopaedic Surgery, International Kolan Hospital, Istanbul, Turkey.

2Department of Orthopaedic Surgery, Anadolu Medical Center, Istanbul, Turkey yenererken@yahoo.com.

3Department of Orthopaedic Surgery, Suleyman Demirel University School of Medicine, Isparta, Turkey.

4Department of Orthopaedic Surgery, Umraniye Education and Research Hospital, Istanbul, Turkey.

5Department of Orthopaedic Surgery, Inonu University School of Medicine, Malatya, Turkey.

6Department of Orthopaedic Surgery, Bosphorus Spine Center, Istanbul, Turkey.

Abstract

BACKGROUND:

The goal of this study was to report the results of selective open reduction and internal fixation of fractures of the posterior malleolus with a posterolateral approach and to compare the results of the 2 techniques.

METHODS:

We prospectively evaluated 40 patients who underwent posterior malleolar fracture fixation between 2008 and 2012. The patients were treated with a posterolateral approach. We assigned alternating patients to receive plate fixation and the next screw fixation, consecutively, based on the order in which they presented to our institution. Fixation of the posterior malleolus was made with lag screws in 20 patients and a buttress plate in 20 patients. We used American Orthopaedic Foot and Ankle Society (AOFAS) scores, range of motion (ROM) of the ankle, and radiographic evaluations as the main outcome measurements. The mean follow-up was 38.2 (range, 24-51) months.

RESULTS:

Full union without any loss of reduction was obtained in 38 of the 40 patients. We detected a union with a step-off of 3 mm in 1 patient in the screw group and a step-off of 2 mm in 1 patient in the plate group. At the final follow-up, the mean AOFAS score of the patients regardless of fixation type was 94.1 (range, 85-100). The statistical results showed no significant difference between the patients regardless of the fixation type of the posterior malleolus in terms of AOFAS scores and ROM of the ankle (P > .05).

CONCLUSIONS:

Good (AOFAS score of 94/100) and equivalent (within 3 points) results were obtained using the 2 techniques (screws or plate) for fixation after open reduction of posterior malleolar fragments.

LEVEL OF EVIDENCE:

Level II, prospective case series.

Cochrane Database Syst Rev. 2012 Aug 15;8:CD008470. doi: 10.1002/14651858.CD008470.pub2.

Surgical versus conservative interventions for treating ankle fractures in adults.

Donken CC1, Al-Khateeb H, Verhofstad MH, van Laarhoven CJ.

Author information

1Department of General and Trauma Surgery, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands. christiandonken@hotmail.com.

Abstract

BACKGROUND:

The annual incidence of ankle fractures is 122 per 100,000 people. They usually affect young men and older women. The question of whether surgery or conservative treatment should be used for ankle fractures remains controversial.

OBJECTIVES:

To assess the effects of surgical versus conservative interventions for treating ankle fractures in adults.

SEARCH METHODS:

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2012 Issue 1), MEDLINE, EMBASE, CINAHL and the WHO International Clinical Trials Registry Platform and Current Controlled Trials. Date of last search: 6 February 2012.

SELECTION CRITERIA:

Randomised and quasi-randomised controlled clinical studies comparing surgical and conservative treatments for ankle fractures in adults were included.

DATA COLLECTION AND ANALYSIS:

Two review authors independently performed study selection, risk of bias assessment and data extraction. Authors of the included studies were contacted to obtain original data.

MAIN RESULTS:

Three randomised controlled trials and one quasi-randomised controlled trial were included. These involved a total of 292 participants with ankle fractures. All studies were at high risk of bias from lack of blinding. Additionally, loss to follow-up or inappropriate exclusion of participants put two trials at high risk of attrition bias. The trials used different and incompatible outcome measures for assessing function and pain. Only limited meta-analysis was possible for early treatment failure, some adverse events and radiological signs of arthritis.One trial, following up 92 of 111 randomised participants, found no statistically significant differences between surgery and conservative treatment in patient-reported symptoms (self assessed ankle "troubles": 11/43 versus 14/49; risk ratio (RR) 0.90, 95% CI 0.46 to 1.76) or walking difficulties at seven years follow-up. One trial,

reporting data for 31 of 43 randomised participants, found a statistically significantly better mean Olerud score in the surgically treated group but no difference between the two groups in pain scores after a mean follow-up of 27 months. A third trial, reporting data for 49 of 96 randomised participants at 3.5 years follow-up, reported no difference between the two groups in a non-validated clinical score.Early treatment failure, generally reflecting the failure of closed reduction (criteria not reported in two trials) probably or explicitly leading to surgery in patients allocated conservative treatment, was significantly higher in the conservative treatment group (2/116 versus 19/129; RR 0.18, 95% CI 0.06 to 0.54). Otherwise, there were no statistically significant differences between the two groups in any of the reported complications. Pooled results from two trials of participants with radiological signs of osteoarthritis at averages of 3.5 and 7.0 years follow-up showed no between-group differences (44/66 versus 50/75; RR 1.05, 95% CI 0.83 to 1.31).

AUTHORS' CONCLUSIONS:

There is currently insufficient evidence to conclude whether surgical or conservative treatment produces superior long-term outcomes for ankle fractures in adults. The identification of several ongoing randomised trials means that better evidence to inform this question is likely to be available in future.

J Orthop Trauma. 2012 Mar;26(3):129-34. doi: 10.1097/BOT.0b013e3182460837.

Operative versus nonoperative treatment of unstable lateral malleolar fractures: a randomized multicenter trial.

Sanders DW1, Tieszer C, Corbett B; Canadian Orthopedic Trauma Society.

Collaborators (23)

Sanders D, Tieszer C, Leighton R, Coles C, Dobbin G, Trask K, Elizabeth Q 2nd, Gofton W, Borsella V, Buckley R, Duffy P, Carcary K, Korley R, Puloski S, McCormack R, Lemke M, Zomar M, Moon K, Boyer D, Egol K, Wynn C, Spitzer A, Bechtel C.

Author information

1London Health Sciences Centre, Victoria Hospital, London, Canada. david.sanders@lhsc.on.ca

Abstract

OBJECTIVES:

To compare clinical and functional outcomes after operative and nonoperative treatment of undisplaced, unstable, isolated fibula fractures.

DESIGN:

Randomized multicenter clinical trial.

SETTING:

Six level 1 trauma centers.

PATIENTS/PARTICIPANTS:

Eighty-one patients with undisplaced, unstable, isolated fibula fractures as confirmed by an external rotation stress examination demonstrating an increase in medial clear space to 5 mm or greater were followed for 12 months after treatment.

INTERVENTION:

Forty-one patients were treated operatively by open reduction and internal fixation of the fibula. Forty patients underwent nonoperative treatment, which included the use of a short leg cast or brace and protected weight bearing for 6 weeks.

MAIN OUTCOME MEASUREMENTS:

Functional outcomes determined using the Olerud-Molander Ankle Score and the Short Form 36. Radiographic outcomes included measurement of union and displacement at each visit.

RESULTS:

There were no statistically significant differences in functional outcome scores or pace of recovery between the operative and nonoperative groups at any time interval (β = -0.28, 3.49; P = 0.936). Complications in the nonoperative group included 8 patients with a medial clear space ≥5 mm and 8 patients with delayed union or nonunion. In the operative group, 5 patients had a surgical site infection and 5 patients required hardware removal.

CONCLUSIONS:

Patients managed operatively had equivalent functional outcomes compared with nonoperative treatment; however, the risk of displacement and problems with union was substantially lower in patients managed with surgery.

J Orthop Trauma. 2007 Nov-Dec;21(10):710-7.

Bosworth-type fibular entrapment injuries of the ankle: the Bosworth lesion. A report of 6 cases and literature review.

Bartonícek J1, Fric V, Svatos F, Lunácek L.

Author information

1Orthopaedic Department of 3rd Faculty of Medicine, Charles University, Prague-Vinohrady, Czech Republic. bartonic@fnkv.cz

Abstract

OBJECTIVES:

To evaluate patients with Bosworth-type fibular entrapment injuries of the ankle.

DESIGN:

Retrospective clinical study and analysis of the literature.

SETTING:

University hospital.

PATIENTS:

Six cases treated for Bosworth-type fibular entrapment injuries (the Bosworth lesion) in the period 2001 to 2004.

INTERVENTION:

Five patients were treated with open reduction and internal fixation (ORIF), and 1 patient was treated with closed reduction and cast.

RESULTS:

All patients treated by ORIF healed without complications with a good subjective outcome. In 1 case treated nonoperatively, an ankle fusion had to be performed 2 years after injury for severe osteoarthritis. Additionally, we have recorded 3 cases, 2 not previously described in the literature, in which the fracture of the fibula was located at the middle or proximal third of its shaft.In the literature we found another 54 cases with dislocation of the fibula behind the posterior tubercle of the distal tibia. The analysis showed that morphology of the Bosworth lesion, as we prefer to refer to this complex fracture-dislocation, changes with age and may be divided into 3 basic types. In children and adolescents the dislocation of the distal fibula is associated with epiphyseolysis of the distal tibia; in young adults the fibula dislocates without fracture; in middle-aged and older adults, the dislocated fibula fractures, probably because of the decreased elasticity.

CONCLUSIONS:

The Bosworth lesion is a severe injury of the ankle, and its successful treatment requires a correct diagnosis based on careful initial clinical and radiographic evaluation and early surgical treatment.

Foot Ankle Int. 2014 May;35(5):471-7. doi: 10.1177/1071100714524553. Epub 2014 Feb 13.

Comparison of surgical techniques of 111 medial malleolar fractures classified by fracture geometry.

Ebraheim NA1, Ludwig T, Weston JT, Carroll T, Liu J.

Author information

1Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, OH, USA.

Abstract

BACKGROUND:

Evaluation of operative techniques used for medial malleolar fractures by classifying fracture geometry has not been well documented.

METHODS:

One hundred eleven patients with medial malleolar fractures (transverse n = 63, oblique n = 29, vertical n = 7, comminuted n = 12) were included in this study. Seventy-two patients had complicating comorbidities. All patients were treated with buttress plate, lag screw, tension band, or K-wire fixation. Treatment outcomes were evaluated on the basis of radiological outcome (union, malunion, delayed union, or nonunion), need for operative revision, presence of postoperative complications, and AOFAS Ankle-Hindfoot score.

RESULTS:

For transverse fractures, tension band fixation showed the highest rate of union (79%), highest average AOFAS score (86), lowest revision rate (5%), and lowest complication rate (16%). For oblique fractures, lag screws showed the highest rate of union (71%), highest average AOFAS score (80), lowest revision rate (19%), and lowest complication rate (33%) of the commonly used fixation techniques. For vertical fractures, buttress plating was used in every case but 1, achieving union (whether normal or delayed) in all cases with an average AOFAS score of 84, no revisions, and a 17% complication rate. Comminuted fractures had relatively poor outcomes regardless of fixation method.

CONCLUSIONS:

The results of this study suggest that both tension bands and lag screws result in similar rates of union for transverse fractures of the medial malleolus, but that tension band constructs are associated with less need for revision surgery and fewer complications. In addition, our data demonstrate that oblique fractures were most effectively treated with lag screws and that vertical fractures attained superior outcomes with buttress plating.

LEVEL OF EVIDENCE:

Level III, retrospective comparative series.

Bone Joint J. 2013 Dec;95-B(12):1662-6. doi: 10.1302/0301-620X.95B12.30498.

Screw fixation of medial malleolar fractures: a cadaveric biomechanical study challenging the current AO philosophy.

Parker L1, Garlick N, McCarthy I, Grechenig S, Grechenig W, Smitham P.

Author information

1The Royal Free Hospital, Pond Street, London NW3 2QG, UK.

Abstract

The AO Foundation advocates the use of partially threaded lag screws in the fixation of fractures of the medial malleolus. However, their threads often bypass the radiodense physeal scar of the distal tibia, possibly failing to obtain more secure purchase and better compression of the fracture. We therefore hypothesised that the partially threaded screws commonly used to fix a medial malleolar fracture often provide suboptimal compression as a result of bypassing the physeal scar, and proposed that better compression of the fracture may be achieved with shorter partially threaded screws or fully threaded screws whose threads engage the physeal scar. We analysed compression at the fracture site in human cadaver medial malleoli treated with either 30 mm or 45 mm long partially threaded screws or 45 mm fully threaded screws. The median compression at the fracture site achieved with 30 mm partially threaded screws (0.95 kg/cm(2) (interquartile range (IQR) 0.8 to 1.2) and 45 mm fully threaded screws (1.0 kg/cm(2) (IQR 0.7 to 2.8)) was significantly higher than that achieved with 45 mm partially threaded screws (0.6 kg/cm(2) (IQR 0.2 to 0.9)) (p = 0.04 and p < 0.001, respectively). The fully threaded screws and the 30mm partially threaded screws were seen to engage the physeal scar under an image intensifier in each case. The results support the use of 30 mm partially threaded or 45 mm fully threaded screws that engage the physeal scar rather than longer partially threaded screws that do not. A 45 mm fully threaded screw may in practice offer additional benefit over 30 mm partially threaded screws in increasing the thread count in the denser paraphyseal region.

KEYWORDS:

AO; Fracture compression; Internal fixation; Lag-screw; Medial malleolus fracture; Physeal scar