The supination–external rotation or Weber B type fracture exists as a stable and an unstable type. The unstable type has a medial malleolus fracture or deltoid ligament lesion in addition to a ...fibular fracture. The consensus is the unstable type and best treated by open reduction and internal fixation. The diagnostic process for a medial ligament lesion has been well investigated but there is no consensus as to the best method of assessment. The number of deltoid ruptures as a result of an external rotation mechanism is higher than previously believed. The derivation of the injury mechanism could provide information of the likely ligamentous lesion in several fracture patterns. The use of the Lauge-Hansen classification system in the assessment of the initial X-ray images can be helpful in predicting the involvement of the deltoid ligament but the reliability in terms of sensitivity and specificity is unknown. Clinical examination, stress radiography, magnetic resonance imaging, arthroscopy, and ultrasonography have been used to investigate medial collateral integrity in cases of ankle fractures. None of these has shown to possess the combination of being cost-effective, reliable and easy to use; currently gravity stress radiography is favoured and, in cases of doubt, arthroscopy could be of value. There is a disagreement as to the benefit of repair by suture of the deltoid ligament in cases of an acute rupture in combination with a lateral malleolar fracture. There is no evidence found for suturing but exploration is thought to be beneficial in case of interposition of medial structures.
Abstract We present the case of a 64-year-old female who was referred to us with an unexplained clicking and locking phenomenon of the right ankle. The magnetic resonance imaging findings suggested a ...longitudinal tear of the peroneus brevis tendon. During tendoscopy, not only was a Raikin type B intrasheath tendon subluxation visible, but also a peroneus quartus muscle. The peroneus brevis tear was tubularized and the peroneus quartus muscle resected, which resolved the patient's complaints.
Despite advanced imaging techniques, classic measurements of fracture reduction have not been revisited to date. The purpose of this study was to evaluate the reliability of innovative measurement ...techniques to quantify operative fragment reduction of posterior malleolar fractures by quantification of three-dimensional computed tomography (Q3DCT).
Twenty-eight ankle fractures including a posterior malleolar fragment (AO/OTA type 44) were evaluated using 2DCT and Q3DCT to postoperatively quantify fragment reduction. "Classic" maximum gap and step-off of the posterior fragment were measured on 2DCT and Q3DCT. In addition, 2 innovative Q3DCT parameters were introduced and their reliability was tested using intraclass correlations (ICCs): gap surface (mm) and multidirectional 3D-displacement (mm).
"Classic" measurements showed a median maximum step-off of 1.1 mm interquartile range (IQR) 0.0-1.8 mm on 2DCT versus a median step-off of 0.6 mm (IQR 0.0-1.1) on Q3DCT. Median maximum gap was 1.2 mm (IQR 0.0-3.8) on 2DCT, and its equivalent on Q3DCT showed no median displacement. Q3DCT measurements revealed a median gap surface of 14.5 mm (IQR 4.7-30.0) and a median multidirectional 3D-displacement of 0.7 mm (IQR 0.0-1.1). Interrater reliability of these new Q3DCT parameters of displacement was excellent (ICC 0.92, 95% CI 0.79-0.98) for gap surface and good (ICC 0.64, 95% CI 0.28-0.88) for 3D-displacement.
Q3DCT is a reliable and promising technique for postoperative evaluation of fracture fragment reduction. In addition to "classic" gap and step-off measurements, we propose to explore total gap surface and 3D-displacement as innovative radiographic measurements in future clinical studies.
Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Triple arthrodesis is largely used to restore painful hindfoot deformity. However, the procedure has been connected to several postoperative complications. Therefore, an isolated fusion of the ...talonavicular and the subtalar joint through a single medial approach has gained popularity. This "diple" arthrodesis provides effective correction of deformities and reduces the risk of wound healing problems on the lateral side of the foot.
The Ankle Spacer was developed as a joint-sparing alternative to invasive end-stage surgeries. Currently, there are no clinical studies on the Ankle Spacer.
To describe the operative technique and ...the clinical efficacy of the Ankle Spacer for the treatment of multiple, cystic osteochondral lesions of the talus in patients with failed prior operative treatment.
This is a prospective study during which patients were assessed preoperatively, at 2- and 6 wk, and at 3, 6, 12 and 24 mo postoperatively. Patients with multiple, cystic or large (≥ 15 mm) osteochondral lesions of the talus after failed prior surgery were included. The primary outcome measure was the numeric rating scale (NRS) for pain during walking at 2 years postoperatively. Secondary outcome measures included the NRS in rest and during stair climbing, the American Orthopaedic Foot and Ankle Society Hindfoot Score, the Foot and Ankle Outcome Score, the Short- Form 36 physical and mental component scale, and the Range of Motion (ROM). Radiographic evaluations were conducted to evaluate prosthetic loosening and subsidence. Revision rates and complications were also assessed.
Two patients underwent an Ankle Spacer implantation on the talus. The NRS during walking improved from 6 and 7 preoperatively to 2 and 2 points postoperatively at 2 years, in patient 1 and 2, respectively. The other patient-reported outcome measures also improved substantially. There were no re-operations nor complications. Radiological imaging showed no loosening of the implant and no change of implant position.
The Ankle Spacer showed clinically relevant pain reduction during walking, improvement in clinical outcomes as assessed with PROMs, and no complications or re-operations. This treatment option may evolve as a joint-sparing alternative to invasive end-stage surgeries.
Abstract Background Accurate assessment of articular involvement of the posterior malleolar fracture fragments in ankle fractures is essential, as this is the leading argument for internal fixation. ...The purpose of this study is to assess diagnostic accuracy of measurements on plain lateral radiographs. Methods Quantification of three-dimensional computed tomography (Q-3D-CT) was used as a reference standard for true articular involvement (mm2 ) of posterior malleolar fractures. One-hundred Orthopaedic Trauma surgeons were willing to review 31 trimalleolar ankle fractures to estimate size of posterior malleolus and answer: (1) what is the involved articular surface of the posterior malleolar fracture as a percentage of the tibial plafond? and (2) would you fix the posterior malleolus? Results The average posterior malleolar fragment involved 13.5% (SD 10.8) of the tibial plafond articular surface, as quantified using Q-3D-CT. The average involvement of articular surface of the posterior malleolar fragment, as estimated by 100 observers on plain radiographs was 24.4% (SD 10.0). The factor 1.8 overestimation of articular involvement was statistically significant ( p < 0.001). Diagnostic accuracy of measurements on plain lateral radiographs was 22%. Interobserver agreement (ICC) was 0.61. Agreement on operative fixation, showed an ICC of 0.54 (Haraguchi type I = 0.76, Haraguchi type II = 0.40, Haraguchi type III = 0.25). Conclusions Diagnostic accuracy of measurements on plain lateral radiographs to assess articular involvement of posterior malleolar fractures is poor. There is a tendency to misjudge posteromedial involvement (Haraguchi type II).
Objective
Anatomic reconstruction of clavicle with limited dissection and biomechanically optimal osteosynthesis. Anteroinferior plate placement to minimize patient’s discomfort and need for implant ...removal.
Indications
Midshaft clavicle nonunions.
Midshaft clavicle fractures.
Clavicle malunions for which osteotomy is needed.
Contraindications
Infection.
Compromised skin.
Comorbidities causing unacceptable operative risks.
Surgical Technique
Expose anteroinferior aspect of the clavicle. Remove previous implants with minimal dissection. In atrophic nonunions, remove intervening tissue. Obtain cultures. Open medullary canal using drill. Contour standard or Locking Compression (LCP) 3.5-mm pelvic reconstruction plate (Synthes, Paoli, PA, USA) on anteroinferior aspect of clavicle. Use osteotome to petal/shingle the nonunion and add bone graft. In hypertrophic nonunions, bone graft is generally not needed but excess callus should be removed to prevent impingement on neurovascular structures.
Postoperative Management
Mitella for 10 days to protect wound healing. Start with early pendulum exercises. No active abduction or anteflexion of > 90° or heavy lifting in first 6 weeks.
Results
From December 1993 to February 2007, 52 patients (53 clavicles) were treated with anteroinferior plating of clavicle. There were 38 atrophic nonunions or delayed unions, three hypertrophic nonunions, three infected nonunions, six acute fractures, and one malunion. For two patients initial radiographs could not be located. Average age was 45 years. One patient was lost to follow-up prior to healing. The others were followed up after an average of 35 months. All had consolidation at an average of 3 months (range 2–7 months). Two patients underwent removal of a lag screw that was placed from superior to inferior, whereas three patients underwent plate removal.
The evidence supporting best practice guidelines in the field of cartilage repair of the ankle is based on both low quality and low levels of evidence. Therefore, an international consensus group of ...experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on “terminology for osteochondral lesions of the ankle” developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle.
Forty-three international experts in cartilage repair of the ankle representing 20 countries were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within four working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed, and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed on in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterised as follows: consensus, 51%–74%; strong consensus, 75%–99%; unanimous, 100%.
A total of 11 statements on terminology and classification reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. Definitions are provided for osseous, chondral and osteochondral lesions, as well as bone marrow stimulation and injury chronicity, among others. An osteochondral lesion of the talus can be abbreviated as OLT.
This international consensus derived from leaders in the field will assist clinicians with the appropriate terminology for osteochondral lesions of the ankle.
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