Background:
We present a classification system that progresses in severity, indicates the pathomechanics that cause the fracture and therefore guides the surgeon to what fixation will be necessary by ...which approach.
Methods:
The primary posterior malleolar fracture fragments were characterized into 3 groups. A type 1 fracture was described as a small extra-articular posterior malleolar primary fragment. Type 2 fractures consisted of a primary fragment of the posterolateral triangle of the tibia (Volkmann area). A type 3 primary fragment was characterized by a coronal plane fracture line involving the whole posterior plafond.
Results:
In type 1 fractures, the syndesmosis was disrupted in 100% of cases, although a proportion only involved the posterior syndesmosis. In type 2 posterior malleolar fractures, there was a variable medial injury with mixed avulsion/impaction etiology. In type 3 posterior malleolar fractures, most fibular fractures were either a high fracture or a long oblique fracture in the same fracture alignment as the posterior shear tibia fragment. Most medial injuries were Y-type or posterior oblique fractures. This fracture pattern had a low incidence of syndesmotic injury.
Conclusion:
The value of this approach was that by following the pathomechanism through the ankle, it demonstrated which other structures were likely to be damaged by the path of the kinetic energy. With an understanding of the pattern of associated injuries for each category, a surgeon may be able to avoid some pitfalls in treatment of these injuries.
Level of Evidence:
Level III, retrospective comparative series.
Purpose
The use of percutaneous iliosacral screw fixation as a treatment of sacroiliac joint pain has been reported to be successful. This study was a prospective single surgeon series to evaluate ...the short-term outcomes of patients who underwent percutaneous sacroiliac joint stabilisation.
Methods
Between July 2004 and February 2011, 73 patients underwent percutaneous sacroiliac joint fusion in our unit. All patients completed a short form (SF)-36 questionnaire, visual analogue pain score and Majeed scoring questionnaire prior to treatment and at last follow-up.
Results
55 patients (9 male and 46 female) completed follow-up. The average follow-up period was for 36.18 months (range 12–84). The mean preoperative SF-36 scores were 26.59 for physical health and 40.38 for mental health. The mean postoperative SF-36 scores were 42.93 for physical health and 52.77 for mental health. The mean visual analogue pain scores were 8.1 preoperative and 4.5 postoperative. The mean pelvic specific scoring were 36.9 preoperative and 64.78 postoperative. We noted that patients who had previous instrumented spinal surgery did significantly worse than those who had not. We had two nerve root-related complications.
Conclusion
We conclude that in selected patient group who respond positively to CT-guided injection, a percutaneous SI joint stabilisation is beneficial in effecting pain relief and functional improvement.
Abstract
Sleep posture and movements offer insights into neurophysiological health and correlate with overall well-being and quality of life. Clinical practices utilise polysomnography for sleep ...assessment, which is intrusive, performed in unfamiliar environments, and requires trained personnel. While sensor technologies such as actigraphy are less invasive alternatives, concerns about their reliability and precision in clinical practice persist. Moreover, the field lacks a universally accepted algorithm, with methods ranging from raw signal thresholding to data-intensive classification models that may be unfamiliar to medical staff. This paper proposes a comprehensive framework for objectively detecting sleep posture changes and temporally segmenting postural inactivity using clinically relevant joint kinematics, measured by a custom-made wearable sensor. The framework was evaluated on wrist kinematic data from five healthy participants during simulated sleep. Intuitive three-dimensional visualisations of kinematic time series were achieved through dimension reduction-based preprocessing, providing an out-of-the-box framework explainability that may be useful for clinical monitoring and diagnosis. The proposed framework achieved up to 99.2% F1-score and 0.96 Pearson’s correlation coefficient for posture detection and inactivity segmentation respectively. This work paves the way for reliable home-based sleep movement analysis, serving patient-centred longitudinal care.
Background:
Idiopathic flatfeet are usually caused by attenuation of the medial soft tissues rather than a lateral osseous deficiency. Debate continues on whether spring ligament attenuation or ...posterior tibial tendon (PTT) dysfunction is the initial driver for the deformity. Our comparative prospective study aimed to quantify the radiological and clinical outcomes of 2 techniques for spring ligament reconstruction using a hamstring graft or a synthetic ligament.
Methods:
Seventeen spring ligament reconstructions (SLRs) were performed in 17 patients using synthetic ligament augmentation and 16 SLRs were performed using hamstring allograft in 13 patients. Additional procedures such as gastrocnemius recession, PTT advancement, flexor digitorum longus transfer, and calcaneal osteotomy were performed as required. A minimum of 12 months of follow-up was available for all cases. Radiographic analysis was performed with standardized parameters.
Results:
Following SLR with synthetic ligament augmentation, all radiological parameters significantly improved (P < .05). Hamstring allograft SLR also demonstrated significantly improved radiographic parameters in all but Meary’s line at final follow-up. At 12 months, patient outcome scores were significantly better in the synthetic ligament group.
Conclusion:
Reconstruction of the spring ligament using either hamstring allograft or synthetic ligament augmentation provided significant improvements in radiological alignment; however, superior patient-reported outcomes were found in the synthetic ligament augmentation group.
Levels of Evidence:
Level III, retrospective cohort study.
Background:
To date, there have been no studies describing the characteristics of posteromedial fragment in the posterior malleolus fracture. The aim was to investigate the variability of ...posteromedial fracture fragments to enable better surgical planning.
Methods:
All Mason and Molloy type 2B fractures, defined as fracture of both the posterolateral and the posteromedial fragments of the posterior malleolus, from our database were identified to analyze the preoperative computed tomography scan. The posteromedial fragment was investigated in 47 cases (mean age, 46.6 years; 11 male, 36 female).
Results:
Morphologically, the fracture could be divided into 2 subtypes: (1) a large pilon intra-articular fragment (mean of X axis: 33.0 mm, Y: 30.7 mm, Z: 31.7 mm) presented in 29 cases with mean interfragmentary angle of 32.1 and back of tibia angle of 32.7 degrees (this was seen in 25 of 27 cases with supination injury pattern); and (2) a small extra-articular avulsion fragment (mean of X axis: 9.6 mm, Y: 13.2 mm, Z: 11.5 mm) present in 18 cases with a mean interfragmentary angle of 11.0 and back of tibia angle of 10.1 degrees. It was seen in 80% of pronation injuries.
Conclusion:
The avulsion type of the posteromedial fragment of posterior malleolus fracture was more common in pronation injuries, likely the result of traction by the intermalleolar ligament, and the pilon type was more common in supination injuries, likely the result of the rotating talus impaction. Because of the intra-articular involvement, we believe the pilon type should undergo fixation to achieve articular congruity, unlike the avulsion type which may only function as a secondary syndesmotic stabilizer.
Level of Evidence:
Level III, retrospective comparative series.
Trimalleolar fractures are generally considered to have inferior outcomes among ankle injuries. Historically, emphasis was placed on the size of the posterior malleolar fracture (PMF) to guide ...surgical decision-making and predict outcomes. Recent studies have suggested that the morphology of the PMF fragment is more important than its size. The aim of this systematic review was to determine if the outcomes of trimalleolar fractures depend on the morphology of the PMF as per the Haraguchi classification system after surgical fixation.
A systematic literature search was conducted in the electronic databases of PubMed, Embase, Scopus, and Ovid. Title and abstracts were screened, and data from eligible studies were extracted. Meta-regression and pooled analysis was performed using appropriate computer software.
11 studies with 597 patients were included in the final analysis. Pooled mean AOFAS score was 87.43 (95% CI 84.24–90.62) after a mean follow-up of 31.6 months. Univariate and multivariate meta-regression analysis demonstrated that as the percentage of Haraguchi type 1 patients increased, there was a statistically significant improvement in outcome scores. A similar trend was noted for Haraguchi type 3 fractures, and a reverse trend was observed for Haraguchi type 2 injuries, although neither were statistically significant.
Our review suggests that the outcomes of trimalleolar fractures after surgical fixation may depend on the morphology of the PMF, with Haraguchi type 1 fractures having overall superior functional outcomes than Haraguchi type 2 and 3 injuries. Future studies need to done to conclusively prove or refute these findings.
Introduction
Chopart injuries can be allocated into 4 broad groups, ligamentous injury with or without dislocation and fracture with or without dislocation, which must occur at the talonavicular ...joint (TNJ) and/or calcaneocuboid joint (CCJ). Chopart dislocations are comprised of pure-dislocations and fracture-dislocations. We aim to review the literature, to enable evidence-based recommendations.
Methods
A literature search was conducted to identify relevant articles from the electronic databases, PubMed, Medline and Scopus. The PRISMA flow chart was used to scrutinise the search results. Articles were screened by title, abstract and full text to confirm relevance.
Results
We identified 58 papers for analysis, 36 case reports, 4 cohort studies, 4 case series and 14 other articles related to the epidemiology, diagnosis, treatment and outcomes of Chopart dislocations. Diagnostic recommendations included routine imaging to contain computed tomography (CT) and routine examination for compartment syndrome. Treatment recommendations included early anatomical reduction, with restoration and maintenance of column length and joint congruency. For both pure-dislocations and fracture-dislocations urgent open reduction and internal fixation (ORIF) provided the most favourable long-term outcomes.
Conclusions
Chopart dislocations are a complex heterogenous midfoot injury with historically poor outcomes. There is a relative paucity of research discussing these injuries. We have offered evidence-based recommendations related to the clinical and surgical management of these rare pathologies.
Category:
Ankle; Trauma
Introduction/ Purpose:
Deltoid ligament complex (DLC) injury repair in the presence of an ankle fracture remains a topic of controversy in the current literature. No work in ...the current literature has commented on hindfoot and subtalar instability in the presence DLC injury associated with ankle fracture fixation.
Objective
Our aim was to introduce and validate a new method for assessment of hindfoot instability, when fixing an ankle fracture with associated DLC injury.
Methods:
DLC injury, specifically superficial DLC, controls not only the ankle but the subtalar joint and medial longitudinal arch. Valgus stressing can unmask subtalar instability. It was noted by referencing the hindfoot position to a line parallel with the lateral aspect of the fibula, the lateral fibula line, subtalar instability was proabbale. We used six morphologically normal cadaveric specimens to validate the test.
Results:
Ten cadaveric specimens were used for validation of the hindfoot stability test. Pre-injury, no specimen illustrated bisection5-injury, all specimens showed bisection of the calcaneal tuberosity by the lateral fibular line on hindfoot stability test.
Conclusion:
The hindfoot stability test assesses hindfoot stability on valgus stressing of the hindfoot using the calcaneal tuberosity bisection of the a line drawn from the lateral border of the fibula as a reference point for instability. This was validated using morphologically normal cadavers.
Category:
Ankle; Trauma
Introduction/Purpose:
The tibialis posterior tendon (TPT) entrapment is an uncommon complication associated with posterior malleolar and pilon fractures. If undiagnosed, TPT ...entrapment is associated with significant morbidity.
Our aim was to perform a systematic review of all reported TPT entrapments in the literature to further understand its risks and outcomes.
Methods:
The electronic databases Scopus, PubMed, and Medline was utilised to identify the relevant publications regarding TPT entrapment in pilon and ankle fractures. Inclusion criteria: all adult studies published in English language reporting the outcome of TPT entrapment in patients with ankle injuries. To critically appraise the papers, CASP clinical appraisal tool was used.
Results:
Four retrospective studies and eight case reports were accepted in this review. Collectively there were, 489 Pilon fractures, 77 of which presented with TP entrapment (15.75%). There were 28 Tri-malleolar fractures, 12 of which presented with TP entrapment (42.86%). All the case report studies reported inability to reduce the fracture at initial presentation. The diagnosis of TPT entrapment was made in the early period in 25% of cases and delayed diagnosis in 75% of cases reported. Utilising modified Clavien-Dindo complication classification, 67% of the injuries reported GRADE IIIA complications, and the rest GRADE IIIB complications.
Conclusion:
In conclusion, TPT tendon was the commonest tendon injury associated with Pilon and Tri-malleolar ankle fractures. Early identification, utilising a clinical suspicion and CT imaging, could lead to early management of TP entrapment in these injuries which could potentially lead to better patient outcomes and reduced morbidity.
Background:
Weight-bearing radiographic analysis of pes planus deformities show, with varying degree of severity, a break in the Meary line. The break in the Meary line occurs not only at the ...talonavicular joint but also distal to the spring ligament and reported tibialis posterior insertion. Our aim in this study was to investigate the distal plantar ligaments of the medial longitudinal arch, to try to identify other areas where deformity correction could be affected.
Methods:
We examined 11 cadaveric lower limbs that had been preserved for dissection in a solution of formaldehyde. The lower limbs were carefully dissected to identify the plantar aspect of the medial longitudinal arch.
Results:
In all specimens, the tibialis posterior tendon inserted into the plantar medial aspect of the navicular with separate slips to the intermediate and lateral cuneiform. The navicular cuneiform ligament extended from the navicular to medial cuneiform. This structure was statically inserted between the navicular and medial cuneiform, which would allow the pull of the tibialis posterior to act on the navicular and medial cuneiform in tandem. The average width of the naviculocuneiform ligament was 15.2 mm (range 12.4-18.0) compared to 9.5 mm (range 7.6-11.4) for the tibialis posterior tendon.
Conclusion:
The tibialis posterior tendon inserted into the navicular and continued onto the medial cuneiform to provide a static restraint between 2 bony insertions, thus supporting the distal aspect of the medial longitudinal arch.
Clinical Relevance:
We are confident that it is a structure of importance in maintaining the distal aspect of the medial longitudinal arch and may therefore have significant clinical and surgical implications when treating the pes planus deformity.
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