ObjectiveTo explore the clinical value of computer-assisted surgical planning in the treatment of ankle fractures. MethodsBetween January 2012 and January 2014, open reduction and internal fixation were performed on 42 patients with ankle fractures. There were 22 males and 20 females with an average age of 52 years (range, 19-72 years). The causes were spraining injury (20 cases), traffic accident injury (14 cases), and falling from height injury (8 cases). The time from injury to operation was 5 hours to 12 days (mean, 2.5 days). All fractures were closed trimalleolar fractures. According to Lauge-Hansen classification, 25 cases were rated as supination extorsion type IV, 13 as pronation extorsion type IV, and 4 as pronation abduction type Ⅲ. The preoperative planning was made by virtual reduction and internal fixation using Superimage software. ResultsThe mean operation time was 93.7 minutes (range, 76-120 minutes). Delayed wound healing occurred in 1 case, and secondary healing was obtained after treatment; primary healing of incision was achieved in the other patients. Postoperative X-ray films and CT images showed anatomic reduction of fracture and good position of internal fixation. All patients were followed up 14.6 months on average (range, 9-27 months). The range of motion of the affected ankle was close to the normal side at 6-8 weeks. The mean fracture healing time was 13.1 weeks (range, 11-17 weeks). Degenerative change of the ankle joint was observed in 3 cases (7.1%) with manifestation of mild narrowing of joint space on the X-ray films at last follow-up. According to Baird-Jackson score system, the results were excellent in 24 cases, good in 13 cases, and fair in 5 cases, with an excellent and good rate of 88%. ConclusionComputer-assisted surgical planning for ankle fractures can help surgeons identify type of ankle fractures and improve surgical scheme for guiding fracture reduction and selecting and placing implants, so good effectiveness can be obtained.
Objective To evaluate the effectiveness of early internal fixation combined with free anterolateral thigh perforator flap (ALTPF) transplantation in the treatment of open ankle fracture-dislocation. Methods A retrospective analysis was performed on the clinical data of 13 patients with open ankle fracture-dislocation who were admitted and met the inclusion criteria between January 2021 and May 2024. Among them, there were 9 males and 4 females, with the ages ranging from 23 to 61 years (mean, 45.3 years). Fracture types included 5 cases of simple medial or lateral malleolar fracture-dislocation, 7 cases of bimalleolar (medial and lateral) fracture-dislocation, and 1 case of trimalleolar fracture-dislocation. Additionally, 3 cases were complicated with bone defects (1 medial malleolus defect and 2 lateral malleolus defects). All injuries were classified as type ⅢB according to the Gustilo-Anderson classification for open fractures. The size of wound defects ranged from 7 cm×5 cm to 18 cm×12 cm. The time from injury to surgery was 2-20 hours (mean, 4 hours). All patients underwent emergency thorough debridement upon admission. The fracture-dislocation was temporarily stabilized with an external fixator, and the wound was covered with antibiotic-impregnated bone cement sheets or vacuum sealing drainage. Definitive internal fixation of the fracture and free ALTPF transplantation were performed 5-7 days after the initial emergency procedure. Postoperatively, wound healing, flap survival, and fracture union were monitored. At last follow-up, clinical outcomes were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score. Results All 13 patients were followed up 6-24 months (mean, 8.2 months). All flaps survived completely, and all fractures achieved union, with an union time of 3-11 months (mean, 5.5 months). One patient developed a superficial infection at the wound margin, which healed after regular dressing changes and drainage. No internal fixation-related complication (e.g., deep infection, implant loosening, or secondary ankle instability) were observed. At last follow-up, the total AOFAS ankle-hindfoot score was 78.6±13.5, with 3 excellent, 7 good, 2 fair, and 1 poor cases, yielding an excellent and good rate of 76.9%. ConclusionEarly internal fixation combined with ALTPF transplantation for open ankle fracture-dislocation can shorten the treatment course and maximize the recovery of ankle joint function.
Objective To summarize the short-term effectiveness of the surgical treatment for grade III pronation-external rotation ankle fractures. Methods Between October 2011 and May 2015, 36 patients with pronation-external rotation ankle fractures (grade III) were treated with internal fixation and repair of the anterior lower tibiofibular ligament, including 21 males and 15 females with an average age of 45.2 years (range, 21-72 years). Injury was caused by sprain in 19 cases, by traffic accident in 6 cases, and by falling from height in 11 cases. All patients had closed fractures, with no blood vessel and nerve injury. The locations were the left ankle in 13 cases and the right ankle in 23 cases. The time from injury to operation was 3 to 10 days (mean, 6.5 days). At last follow-up, ankle function was evaluated by American Orthopaedic Foot and Ankle Society (AOFAS) ankle-foot score, and the improvement of pain was evaluated by visual analogue scale (VAS). Results Primary healing of incision was obtained in all patients, no incision infection and skin necrosis occurred. Twenty-eight patients were followed up 12-36 months (mean, 17.5 months). X-ray films showed bone union was achieved within 2.6-5 months (mean, 3.2 months). No fracture of internal fixation and disruption of tibiofibular diastasis occurred. At last follow-up, according to AOFAS score for ankle function evaluation, the pain score was 36.3±2.9, the function score was 44.3±3.2, the ligament condition score was 9.2±0.5, and the total score was 89.8±6.6; the results were excellent in 11 cases, good in 15 cases, and fair in 2 cases. VAS score was 1.6±0.5. The range of motion of the ankle was (13±5)° in dorsiflexion and (38±9)° in planteroflexion. Conclusion Repair of anterior tibial ligament is an effective method to treat tibiofibular diastasis injury in the surgical treatment of grade III pronation-external rotation ankle fractures, with convenient operation, and satisfactory short-term effectiveness.
ObjectiveTo evaluate the effectiveness of repairing the deltoid ligament with ankle fracture. MethodsBetween January 2010 and January 2013, 11 patients with ankle fractures associated with deltoid ligament injury were treated. There were 7 males and 4 females, with an average age of 38.2 years (range, 18-72 years). The interval between injury and operation was 6 hours to 7 days (mean, 4 days). According to Lauge-Hansen classification, ankle fracture was rated as pronation-external rotation type in 5 cases, as supination-external rotation type in 4 cases, and as pronation-abduction type in 2 cases. The MRI and color Doppler ultrasound showed deltoid ligament rupture. The results of valgus stress test, talus valgus tilt test, and anterior drawer test after anesthesia were all positive. Fracture was treated by open reduction and internal fixation, and deltoid injury was repaired. ResultsAll incisions healed primarily. All patients were followed up 12-18 months (mean, 13.3 months). The X-ray films showed anatomical reduction, good position of internal fixation and stable distal tibiofibular syndesmosis. The mean fracture union time was 7.6 weeks (range, 6-8 weeks). MRI at 3 months after operation showed normal shape of the deltoid ligament. According to American Orthopaedic Foot and Ankle Society (AOFAS) score, the results were excellent in 6 cases, good in 3 cases, fair in 1 case, and poor in 1 case, with an excellent and good rate of 81.8%. ConclusionIt is an effective method to treat ankle fracture with deltoid ligament injury by open reduction and internal fixation of ankle fracture and repair of the deltoid ligament injury, which can effectively rebuild medial instability and has satisfactory effectiveness.
ObjectiveTo investigate the safety and effectiveness of anatomical approach osteoligaments repair technique in treatment of pronation ankle fractures.MethodsThe clinical data of 53 patients with pronation ankle fractures between April 2015 and October 2016, who were treated with anatomical approach osteoligaments repair technique applied for fracture reduction and internal fixation, were analysed retrospectively. There were 35 males and 18 females with an average age of 33.1 years (range, 18-60 years). The cause of injury included traffic accidents in 27 cases, tumbling in 5 cases, fall from height in 4 cases, twisted injury in 6 cases, sports injuries in 4 cases, and bruises in 7 cases. According to Lauge-Hansen classification, there were 44 cases of pronation external rotation stage Ⅳ and 9 cases of pronation abduction stage Ⅲ. The interval between injury and operation was 4-10 days (mean, 7 days). Postoperative pain and function of ankles were assessed by American Orthopedic Foot and Ankle Score (AOFAS) and visual analogue pain scale (VAS) score. The medial clear space (MCS), tibiofibular clear space (TFCS), distal fibular tip to lateral process of talus (DFTL), the anterior and posterior tibiofibular syndesmosis distance, and the lateral malleolus twist angle were measured by X-ray films and CT of bilateral ankle joints.ResultsThe tourniquet application time was 55-90 minutes (mean, 72.5 minutes); the frequency of fluoroscopy was 5-13 times (mean, 8.9 times). All incisions healed by first intention and no infection, deep vein thrombosis occurred after operation. All patients were followed up 28-48 months (mean, 36 months). There was no significant difference in postoperative MCS, TFCS, DFTL, the anterior and posterior tibiofibular syndesmosis distance, and the lateral malleolus twist angle between bilateral ankle joints (P>0.05). At last follow-up, no ankle instability occurred and the degenerative changes of ankle joints (Kellgren-Lawrence grading Ⅱ) occurred in 5 cases. The average AOFAS score of the ankle joint was 90.84 (range, 85-95); mean VAS score was 1.23 (range, 0-5). The average dorsiflexion and plantar flexion of ankle joints was 20.24° (range, 15-25°) and 42.56° (range, 30-50°), respectively.ConclusionAnatomical approach osteoligaments repair technique in treatment of pronation ankle fractures can expose the talocrural joint and lower tibiofibular syndesmosis clearly, repair the osteoligaments injury directly, and assist the syndesmosis and talocrural joint reduction, and decline the incidence of ankle degeneration.
Objective To evaluate the safety and effectiveness of reducing posterior malleolar fractures via the modified Rammelt transfibular approach. Methods A retrospective analysis was conducted on 26 patients with ankle fractures who met the selection criteria and were admitted between September 2023 and May 2024. There were 13 males and 13 females, aged from 14 to 59 years (median, 43.5 years). Causes of injury included traffic accident (1 case), falls (7 cases), and sprains (18 cases). Time from injury to operation ranged from 1 to 13 days (mean, 3.9 days). According to the Lauge-Hansen classification, there were 5 supination-external rotation type Ⅲ fractures and 21 supination-external rotation type Ⅳ fractures. According to the Bartoníček classification for posterior malleolar fractures, there were 12 type Ⅱ fractures, 10 type Ⅲ fractures, and 4 type Ⅳ fractures. During operation, the fracture was exposed via the modified Rammelt transfibular approach; then, the fracture reduction was achieved under direct vision using techniques such as towel clip traction, posterolateral compression, and lifting with a posterior transverse periosteal elevator; finally, the fracture was fixed using anteroposterior cannulated screws or Kirschner wires. The incision healing was observed after operation. At 4 months after operation, X-ray film and CT were reviewed to evaluate the quality of fracture reduction. The medial clear space, tibiofibular clear space, and the anterior/posterior tibiofibular syndesmotic distances were measured. At last follow-up, the ankle function was assessed using the American Orthopaedic Foot & Ankle Society (AOFAS) score and the range of motion. Results The marginal necrosis occurred in 2 lateral malleolar incisions, and superficial infection occurred in 1 lateral malleolar incision; the remaining incisions healed by first intention. All 26 patients were followed up 13-21 months (mean, 15.6 months). X-ray films showed that fractures in 25 patients achieved clinical union within 3-8 months (mean, 5.4 months); 1 case had delayed union of the lateral malleolus. At 4 months after operation, no significant difference was found between the injured and healthy sides in the medial clear space, tibiofibular clear space, or the anterior/posterior tibiofibular syndesmotic distances (P>0.05). No malreduction of the posterior malleolus or the tibiofibular syndesmosis occurred. At last follow-up, the AOFAS score ranged from 80 to 100 (mean, 91.9). The range of motion ranged from 17° to 22° (mean, 21.0°) in active ankle dorsiflexion and from 40° to 49° (mean, 44.6°) in plantar flexion. Internal fixator was removed in 12 patients at 1 year after operation, with no ankle instability occurring. Ankle joint degeneration was observed in 1 patient at last follow-up. Conclusion The modified Rammelt transfibular approach is a safe and reliable technique. It enables precise reduction under direct vision, improves the quality of reduction for the distal tibial articular surface and the tibiofibular syndesmosis, and provides satisfactory ankle functional recovery in short-term follow-up.
Objective To compare the short-term effectiveness of repairing distal tibiofibular syndesmosis with metal screws and absorbable screws. Methods A retrospective analysis was performed on the clinical data of 63 patients with ankle fracture combined with injury of the distal tibiofibular syndesmosis admitted between January 2017 and January 2020. Among them, 31 patients were treated with absorbable screw fixation of the distal tibiofibular syndesmosis (research group) and 32 patients were treated with metal screw fixation of the distal tibiofibular syndesmosis (control group). There was no significant difference in gender, age, cause of injury, surgical side, time from injury to operation, fracture type, preoperative visual analogue scale (VAS) score, and American Orthopaedic Foot & Ankle Society (AOFAS) score between the two groups (P>0.05). The operation time and fracture healing time were recorded and compared between the two groups. X-ray film was taken to evaluate the effect of ankle joint reduction and fixation. Olerud-Molander ankle fracture efficacy score (short for OM score), AOFAS score, and VAS score were used to evaluate the effectiveness. Results There was no significant difference in operation time between the two groups (t=−0.683, P=0.497). In the control group, 1 case of delayed healing and 1 case of poor healing occurred in the lateral incision after operation, which healed after dressing change; the rest of the patients had primary healing of the incision. Patients in both groups were followed up 12-24 months, with an average of 13.8 months. In the control group, 1 patient with fracture of pronation and external rotation walked with full weight bearing after removing the metal screw of the distal tibiofibular syndesmosis at 8 weeks after operation, the anatomical plate of the lateral malleolus was broken, and the lateral malleolus was fixed again and recovered after 5 months; 1 patient had mild ankle pain after operation, and the pain disappeared after removing the metal screw of the distal tibiofibular syndesmosis at 8 weeks. No complication such as nerve and blood vessel injury occurred in all patients. There was no significant difference in fracture healing time between the two groups (t=−1.128, P=0.264). The AOFAS and VAS scores significantly improved in both groups at 12 months after operation (P<0.05). There was no significant difference between the two groups in the OM scores, and the difference of AOFAS and VAS scores between before and after operation (P>0.05). Conclusion Using absorbable screws to repair the distal tibiofibular syndesmosis can effectively restore the ankle acupoint structure, prevent ankle instability, and restore good ankle function. There is no significant difference in effectiveness between absorbable screws and metal screws, and there is no need for secondary operation to remove screws.
Objective To investigate the feasibility and effectiveness of absorbable screws for the treatment of tibiofibular syndesmotic disruptions by comparing with metallic screws. Methods Between July 2007 and May 2012, 69 patients with tibiofibular syndesmotic disruptions associated with ankle fractures were treated; absorbable screw fixation was used in 38 cases (group A) and metallic screw fixation was used in 31 cases (group B). There was no significant difference in gender, age, injury causes, the type of fracture, the side of fracture, and disease duration between 2 groups (P gt; 0.05). The fracture healing time, weight bearing time, and complications were recorded and compared between 2 groups. According to Baird-Jackson scoring system, the function of the ankle was assessed after 6 months. Results Infection of incision occurred in 3 cases (7.9%) of group A and 2 cases (6.5%) of group B, and skin necrosis of incision in 1 case (2.6%) of group A and 5 cases (16.1%) of group B, showing no significant difference in the incidences of infection and necrosis of incisions between 2 groups (P gt; 0.05); primary healing of incision was obtained in the other patients. The 69 cases were followed up 12-26 months (mean, 18.6 months). The weight bearing time was (2.97 ± 0.59) months in group A and was (3.16 ± 0.74 ) months in group B, showing no significant difference (t=1.175, P=0.244). X-ray films showed that fractures and tibiofibular syndesmotic disruptions healed in 2 groups; the healing time was (5.71 ± 1.01) months in group A and was (5.81 ± 1.08) months in group B, showing no significant difference (t=0.381, P=0.705). No fixation failure, breakage, or loosening occurred in 2 groups. According to Baird-Jackson scoring system, the results were excellent in 29 cases, good in 5 cases, and fair in 4 cases with an excellent and good rate of 89.5% in group A at 6 months after operation; the results were excellent in 20 cases, good in 7 cases, and fair in 4 cases with an excellent and good rate of 87.1% in group B; no significant difference was found in the excellent and good rate between 2 groups (Z= — 0.991, P=0.321). Conclusion Treatment of tibiofibular syndesmotic disruptions with absorbable screws can get good effectiveness and replace metallic screws because of avoiding additional operation for removing the screw.
ObjectiveTo investigate the safety, feasibility, and efficacy of full repair strategy under small incision in the treatment of closed Lauge-Hansen pronation-external rotation type Ⅳ ankle fracture.MethodsThe clinical data of 57 patients with closed Lauge-Hansen pronation-external rotation type Ⅳ ankle fracture treated by full repair strategy (fracture, ligament, and cartilage repair) under small incision between January 2012 and January 2017 were retrospectively analyzed. There were 31 males and 26 females, with an average age of 41.1 years (range, 21-65 years). The causes of injury included traffic accident injury in 33 cases and falling injury in 24 cases. All of them were closed fractures, including 20 cases of medial malleolus fracture, 37 cases of complete medial malleolus but deep and shallow rupture of deltoid ligament. The average time from injury to admission was 9.6 hours (range, 3-34 hours). The quality of reduction of distal tibial articular surface (based on Ketz-Sanders standard), the reduction of tibiofibular syndesmosis (the anterior and posterior distances of distal tibiofibular syndesmosis and the lateral ankle twist angle measured by CT scan at 10 mm above the ankle joint line), and the fracture healing were evaluated. The medial clear space (MCS), tibiofibular clear space (TFCS), and distal fibular tip to lateral process of talus (DFTL) were measured on the X-ray films of ankle points. Before and after operation, the pain and functional improvement of ankle joint were evaluated by visual analogue scale (VAS) score and American Orthopedic Foot and Ankle Association (AOFAS) score, and the activities of ankle dorsiflexion and plantar flexion were measured.ResultsThree cases with osteochondral lesions of the talus were found during operation and all were treated with microfracture techniques. Tournament paralysis occurred in 2 cases after anesthesia. The surgical incisions healed by first intention in all patients. All the 57 patients were followed up 24-84 months, with an average of 38.6 months. All patients achieved bone healing without bone nonunion and malunion at 12 months after operation. The reduction quality of distal tibial articular surface was excellent in 56 cases and good in 1 case at 3 months after operation, the excellent and good rate was 100%. There was no significant difference in the MCS, TFCS, DFTL, anterior distance of distal tibiofibular syndesmosis, posterior distance of distal tibiofibular syndesmosis, and lateral ankle twist angle between the affected and healthy sides at 12 months after operation (P>0.05). At last follow-up, the VAS score, AOFAS score, ankle dorsiflexion and plantar flexion activities of the affected side were significantly improved when compared with preoperative ones (P<0.05). Compared with the healthy side, there was no significant difference in ankle dorsiflexion and plantar flexion activities (P>0.05).ConclusionFull-repair strategy under small incisions for the treatment of Lauge-Hansen pronation-external rotation type Ⅳ ankle fracture is effective and safe. It can not only reduce wound complications, but also improve the quality of joint reduction of the ankle joint and distal tibiofibular syndesmosis. Full repair of ligaments and cartilage can improve the internal fixation strength and joint stability of the ankle joint.