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Introduction: We investigated the biomechanical behaviour of different fixations of the tibial posterior malleolus (TPM), simulating distinct situations of involvement of the tibiotalar articular surface (TTAS) through a finite element model (FEM). Material and methods: A 3D computer-aided design model of the left ankle was obtained. The materials used were divided according to their characteristics into ductile and non-ductile, and all materials were assumed to be linear elastic, isotropic, and homogenous. Three different fracture lines of the TPM were defined, with sagittal angles of 10°, 25°, and 45°. For biomechanical comparison, different constructions using a trans-syndesmotic screw (TSS) only (Group T), a one-third tubular plate only with (Group PT) and without (Group PS) a TSS, and a locked compression plate with (Group LCPT) and without (Group LCPS) a TSS were tested. FEM was used to simulate the boundary conditions of vertical loading. Load application regions were selected in the direction of the 700 N Z-axis, 90% on the tibia and 10% on the fibula. Data on the displacement and stress in the FEM were collected, including the total principal maximum (MaxT) and total principal minimum (MinT) for non-ductile materials, total displacement (desT), localized displacement at the fragment (desL), localized displacement at syndesmosis (desS), and Von Mises equivalent stress for ductile materials. The data were analysed using ANOVA and multiple comparison LSD tests were used. Results: For TPM fractures with sagittal angles 10° and 25°, desL in the PT and LCP groups was significantly lower, as well as Von Mises stress in Group LCPT in 10°, and PT and LCPT groups in 25°. For TPM fractures with a sagittal angle of 45°, desL in the LCP group and Von Mises stress in Group LCPS and LCPT were significantly lower. We found that any TPM fracture may indicate instability of the distal tibiofibular syndesmosis, even when the fragment is small. Conclusion: Our study showed that in fragments involving 10% of the TTAS, the use of a TSS is sufficient, but when the involvement is greater than 25% of the TTAS, either a non-locked or locked plate must be used to buttress the TPM. In posterior fragments affecting 45% or more of the TTAS, the use of a locking plate is recommended.
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BACKGROUND: In unstable ankle fractures, the role of the deltoid and syndesmosis ligaments has been widely studied. However, it is uncertain what the importance of the lateral ankle ligament complex (LALC) is in the vertical stability of the fibula. Given its anatomical position, it should prevent the proximal translation of the fibula. This study aims to evaluate the role of the LALC in stabilizing the fibula in the vertical plane. METHODS: Eleven below-knee cadaveric specimens were used in this study. Proximal traction of the fibula was performed by applying 50 N in the intact state and after sequential transection of the syndesmotic ligaments, anterior talofibular ligament (ATFL), and the calcaneofibular ligament (CFL). At each stage, the proximal displacement of the fibula was measured. One-way repeated measures analysis of variance with post hoc Bonferroni correction was carried out to determine any significant differences between the groups. A P value <.05 was considered statistically significant. RESULTS: The vertical displacement of the fibula in the intact state, and after sequential transection of syndesmotic ligaments, ATFL, and CFL was 1.96 ± 1.19 mm, 3.96 ± 1.33 mm, 5.9 ± 1.73 mm, and 10.22 ± 2.76 mm, respectively. There was no significant difference in the proximal displacement of the fibula between the intact and the syndesmotic ligaments groups (P < .05). However, when the syndesmotic ligaments were transected in conjunction with ATFL ± CFL, a significant difference was observed compared to the intact state (P < .001). CONCLUSION: The complete disruption of syndesmotic ligaments did not significantly increase the proximal displacement of the fibula. However, when the ATFL ± CFL were additionally disrupted, there was a significant increase in the vertical translation of the fibula. CLINICAL RELEVANCE: To our knowledge, this is the first study describing that LALC plays a paramount role in the vertical stability of the fibula. Concomitant syndesmosis and LALC should be suspected in an axially unstable fibular fracture with a significant proximal displacement.
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Instabilidade Articular , Ligamentos Laterais do Tornozelo , Humanos , Fíbula , Tornozelo , Cadáver , Articulação do TornozeloRESUMO
Patients with diabetes mellitus (DM) are at increased risk of complications following ankle fracture surgery. Previous research suggests that patients of low socioeconomic status are at increased risk of amputation following orthopedic complications. The purpose of this research was to determine if low socioeconomic status increases risk of below-knee amputation (BKA) following ankle fractures among patients with DM. The National Inpatient Sample (NIS) was queried from 2010 to 2014 to identify 125 diabetic patients who underwent ankle fracture surgical fixation followed by BKA. Two cohorts (BKA vs no BKA) and a multivariate logistic regression model were created to compare the effects of independent variables, including age, sex, race, primary payer, median household income by ZIP code, hospital location/teaching status, and comorbidities. The most predictive variables for BKA were concomitant peripheral vascular disease (odds ratio [OR] 5.35, 95% confidence interval [CI] 3.51-8.15), history of chronic diabetes-related medical complications (OR 3.29, CI 2.16-5.01), age in the youngest quartile (OR 2.54, CI 1.38-4.67), and male sex (OR 2.28, CI 1.54-3.36). Patient race and median household income were not significantly associated with BKA; however, risk of BKA was greater among patients with Medicaid (OR 2.23, CI 1.09-4.53) or Medicare (OR 1.85, CI 1.03-3.32) compared to privately insured patients. Diabetic inpatients with Medicaid insurance are at over twice the odds of BKA compared to privately insured patients following ankle fracture. Furthermore, peripheral vascular diseases, uncontrolled diabetes, younger age, and male sex each independently increase risk of BKA.
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Fraturas do Tornozelo , Diabetes Mellitus , Doenças Vasculares Periféricas , Humanos , Masculino , Idoso , Estados Unidos/epidemiologia , Fraturas do Tornozelo/cirurgia , Resultado do Tratamento , Fatores de Risco , Medicare , Amputação Cirúrgica/efeitos adversos , Estudos RetrospectivosRESUMO
PURPOSE: The primary aim was to analyse the lateral malleolus morphology with a focus on the shape of the distal fibula for IM fixation of the fibula in infra- and transsyndesmotic fracture patterns. The secondary aim was to propose a treatment algorithm according to the lateral malleolar anatomy. METHODS: 77 healthy, skeletally mature volunteers underwent CT scanning of the ankle. The fibula medullary canal and its cortical thickness were quantitatively analysed at 4 different levels measured from the fibular tip (1.5 cm, 3.0 cm, 4.5 cm, and 6.0 cm). A geometric classification was proposed, and a decision algorithm was developed. Statistical significance was set at a p-value < 0.05. RESULTS: The smallest diameter of the medullary canal of the fibula was at 6.0 cm from the tip of the fibula, in 98.2% of the ankles. The distal fibula can be classified into triangular and rectangular type, according to the cortical thickness index (p < 0.0001). In 16.7% ankles, the internal diameter of the fibula at 6.0 cm was equal or narrower than 3.5 mm (p < 0.05). CONCLUSION: The shape of the distal fibula as evaluated by CT-guided analysis allows for IM osteosynthesis of the lateral malleolus in 83% of individuals. In our study, the smallest diameter of the medullary canal of the fibula was located 6.0 cm from the tip of the lateral malleolus. Coronal CT evaluation is advantageous in indicating which type of IM implant should be used safely for infra- and transsyndesmotic fracture patterns, potentially reducing intraoperative risks.
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Fraturas do Tornozelo , Fraturas da Fíbula , Humanos , Tornozelo , Fíbula/diagnóstico por imagem , Fíbula/cirurgia , Fraturas do Tornozelo/diagnóstico por imagem , Fraturas do Tornozelo/cirurgia , Fixação Interna de Fraturas , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: Ankle fractures are common lesions of the lower limbs. Approximately 40% of ankle fractures affect the posterior malleolus (PM). Historically, PM osteosynthesis was recommended when PM size in X-ray images was greater than 25% of the joint. Currently, computed tomography (CT) has been gaining traction in the preoperative evaluation of ankle fractures. AIM: To elucidate the similarity in dimensions and to correlate PM size in X-ray images with the articular surface of the affected tibial plafond in the axial view on CT (AXCT) of a PM fracture. METHODS: Eighty-one patients (mean age: 39.4 ± 13.5 years) were evaluated (54.3% were male). Two independent examiners measured PM size in profile X-ray images (PMXR) and sagittal CT (SAGCT) slices. The correlation of the measurements between the examiners and the difference in the PM fragment sizes between the two images were compared. Next, the PM size in PMXR was compared with the surface of the tibial plafond involved in the fracture in AXCT according to the Haraguchi classification. RESULTS: The correlation rates between the examiners were 0.93 and 0.94 for PMXR and SAGCT, respectively (P < 0.001). Fragments were 2.12% larger in SAGCT than in PMXR (P = 0.018). In PMXR, there were 56 cases < 25% and 25 cases ≥ 25%. When PMXR was < 25%, AXCT corresponded to 10.13% of the tibial plafond. When PMXR was ≥ 25%, AXCT was 24.52% (P < 0.001). According to the Haraguchi classification, fracture types I and II had similar PMXR measurements that were greater than those of type III. When analyzing AXCT, a significant difference was found between the three types, with II > I > III (P < 0.001). CONCLUSION: PM fractures show different sizes using X-ray or CT images. CT showed a larger PM in the sagittal plane and allowed the visualization of the real dimensions of the tibial plafond surface.
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Introducción: La incidencia de fractura-luxación abierta de tobillo es baja, lo que hace que su combinación con fractura del tercio distal de la tibia sea grave y muy compleja de tratar. Constituye una entidad causada por traumas de alta energía y se asocia a lesiones neurovasculares. Objetivo: Presentar un caso grave y complejo de fractura-luxación abierta de tobillo y fractura del tercio distal de la tibia. Caso clínico: Paciente masculino de 33 años de edad, que ingresó en el servicio de ortopedia y traumatología de urgencia, por haber sufrido trauma directo en el acople de 2 vagones de un tren. Presentó fractura-luxación tibioastragalina abierta III-B, asociado a fractura oblicua del tercio distal de la tibia y el peroné del miembro inferior izquierdo. Fue intervenido quirúrgicamente de urgencia. Se realizó amplio desbridamiento quirúrgico, reducción de la luxación, fijación del maléolo tibial, reparación primaria de las lesiones ligamentosas y estabilización externa para artrodesis precoz. El paciente evolucionó con infección de la herida quirúrgica, para lo cual necesitó de curas secuenciales y oxigenación hiperbárica. Se recuperó a los 8 meses. Conclusiones: La fractura-luxación abierta de tobillo y fractura del tercio distal de la tibia es una combinación poco frecuente, grave y compleja de tratar. Obedece a traumas de altas energías. La cirugía de urgencia, la profilaxis antimicrobiana y la oxigenación hiperbárica, contribuyeron al tratamiento definitivo de este paciente.
Introduction: The incidence of open ankle fracture-dislocation is low, which makes its combination with a fracture of the distal third of the tibia serious and very complex to treat. It is an entity caused by high-energy trauma and is associated with neurovascular injuries. Objective: To present a serious and complex case of open ankle fracture-dislocation and fracture of the distal third of the tibia. Clinical case: A 33-year-old male patient, who was admitted to the emergency orthopedics and traumatology service, for having suffered direct trauma in the coupling of two train cars. He presented an open tibiotalar fracture-dislocation III-B, associated with an oblique fracture of the distal third of the tibia and fibula, of the left lower limb. He underwent emergency surgery; Extensive surgical debridement, reduction of the dislocation, fixation of the tibial malleolus, primary repair of the ligamentous injuries, and external stabilization for early arthrodesis were performed. The patient evolved with infection of the surgical wound, for which he needed sequential dressings and hyperbaric oxygenation. Full recovery at 8 months. Conclusions: Open ankle fracture-dislocation and fracture of the distal third of the tibia is a rare, serious and complex combination to treat. Due to high energy trauma. Emergency surgery, antimicrobial prophylaxis, and hyperbaric oxygenation contributed to the definitive treatment of this patient.
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Las fracturas pueden producir impotencia funcional, deformidad, hematoma, entumecimiento, dolor y cosquilleo. Muchas requieren cirugía y rehabilitación física por personal calificado y equipos adecuados. El objetivo de este estudio fue aplicar la rehabilitación física y el sistema súper inductivo de alta intensidad como tratamiento en fractura postquirúrgica. La paciente de 46 años, sufre caída de propia altura fracturándose la tibia y peroné derechos, confirmado el diagnóstico, se le realiza la reducción abierta más fijación interna, recibe el alta con férula suropédica que se retira seis semanas después, inicia marcha con apoyo parcial progresivo con incremento de dolor eva 6/10, limitación de la movilidad y edema bimaleolar. La radiografía muestra solución de continuidad del maléolo tibial con material de osteosíntesis. Recibe propuesta terapéutica no invasiva, suspensión de la carga, rehabilitación física por cinco semanas más sistema súper inductivo de alta intensidad tres veces por semana. A la valoración radiográfica de tobillo derecho postero anterior, lateral, y oblicua, presenta reducción correcta del maléolo tibial, la flexión, extensión, inversión y eversión son valorables sin dolor ni edema. Se puede concluir que la rehabilitación y el sistema súper inductivo de alta intensidad con campos electromagnéticos de alta potencia, sí bioestimula la reparación ósea, también acelera el plazo de osteosíntesis con reducción del dolor logrando la recuperación funcional en la paciente.
Fractures can cause functional impotence, deformity, bruising, numbness, pain, and tingling. Many require surgery and physical rehabilitation provided by qualified personnel and adequate equipment. The objetive of this study was to apply physical rehabilitation and high intensity super inductive system as a treatment for postsurgical fracture. A 46-year-old woman suffered a fall from her own height, fracturing the right tibia and fibula, and, an open reduction plus internal fixation was performed, afer confirming the diagnosis. She wadischarged with a south-pedic splint, which was removed 6 weeks later the patient, began to walk with progressive partial support with 6/10 increased eva pain, limitation of mobility and bimalleolar edema. îe radiograph shows a solution of continuity of the tibial malleolus with osteosynthesis material. She receives a non-invasive therapeutic proposal, suspension of the load, physical rehabilitation for 5 weeks, and a high intensity super inductive system 3 times a week. Radiographic evaluation of the right ankle anterior, lateral, and oblique shows correct reduction of the tibial malleolus. Flexion, extension, inversion and eversion are assessable without pain or edema. Rehabilitation and high intensity super inductive system with high power electromagnetic fields, biostimulate bone repair and accelerates bone treatment, relieving pain. It can be concluded that the rehabilitation and the high-intensity super-inductive system with high-power electromagnetic fields, biostimulates bone repair, and accelerates the osteosynthesis period with pain reduction, achieving functional recovery of the patient.
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OBJECTIVE: The aim of this study is to purpose a novel approach to the concomitant triplanar and tibial shaft fracture. METHODS: Retrospective study between 2001 and 2019. We collected the patients' general information, clinical and radiographic data, and complications after the following three-step treatment: (1) fixation of the Salter-Harris II fracture of the triplane fracture, (2) fixation of the Salter-Harris II/IV fracture with cannulated screws, and (3) fixation of the tibial fracture with flexible titanium nails. RESULTS: The study included seven patients (six males) with a mean age of 14 years and a mean follow-up of 6.4 years (minimum two years). Five triplane fractures had two fragments and two had three fragments. Five fractures were classified as Salter-Harris II and two as Salter-Harris IV. Three tibial fractures were long oblique, three were spiral, and one had a third fragment. Six fractures affected the middle third and one affected the distal third of the tibia. All triplane and tibial fractures consolidated without significant displacement. No physeal damage was identified. CONCLUSIONS: This study described the association of tibial fractures with triplane ankle fractures managed by our proposed treatment, which proved to be effective for this fracture association. Level of Evidence IV, Case Series.
OBJETIVO: Propor uma nova abordagem para fraturas concomitantes da diáfise da tíbia e triplanares do tornozelo. MÉTODOS: Estudo retrospectivo entre 2001 e 2019. Foram coletadas informações gerais: dados clínicos, radiográficos e complicações. As fraturas seguiram três passos no tratamento: (1) fixação do fragmento Salter-Harris tipo III da fratura triplanar; (2) fixação do fragmento Salter-Harris II/IV com parafuso canulado; e (3) fixação da fratura diafisária da tíbia com hastes flexíveis. RESULTADOS: O estudo incluiu sete pacientes (seis homens) com idade média de 14 anos e seguimento médio de 6.4 anos (mínimo de dois anos). Cinco fraturas triplanares tinham dois fragmentos principais e duas tinham três fragmentos. Cinco fraturas na radiografia em perfil foram classificadas como Salter-Harris II e duas como Salter-Harris IV. Três fraturas diafisárias tibiais tinham traço obliquo longo, três traço espiral e uma fratura com terceiro fragmento. Seis fraturas eram do terço médio e uma fratura do terço distal da tíbia. Todas as fraturas triplanares e tibiais consolidaram sem desvio significativo e não tivemos nenhuma lesão fisária. CONCLUSÃO: O estudo descreveu a associação da fratura da tíbia com a fratura triplanar do tornozelo e nossa proposta de tratamento, que se mostrou uma boa opção no tratamento dessa fratura especial. Nível de Evidência IV, Série de casos.
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ABSTRACT Objective: The aim of this study is to purpose a novel approach to the concomitant triplanar and tibial shaft fracture. Methods: Retrospective study between 2001 and 2019. We collected the patients' general information, clinical and radiographic data, and complications after the following three-step treatment: (1) fixation of the Salter-Harris II fracture of the triplane fracture, (2) fixation of the Salter-Harris II/IV fracture with cannulated screws, and (3) fixation of the tibial fracture with flexible titanium nails. Results: The study included seven patients (six males) with a mean age of 14 years and a mean follow-up of 6.4 years (minimum two years). Five triplane fractures had two fragments and two had three fragments. Five fractures were classified as Salter-Harris II and two as Salter-Harris IV. Three tibial fractures were long oblique, three were spiral, and one had a third fragment. Six fractures affected the middle third and one affected the distal third of the tibia. All triplane and tibial fractures consolidated without significant displacement. No physeal damage was identified. Conclusions: This study described the association of tibial fractures with triplane ankle fractures managed by our proposed treatment, which proved to be effective for this fracture association. Level of Evidence IV, Case Series.
RESUMO Objetivo: Propor uma nova abordagem para fraturas concomitantes da diáfise da tíbia e triplanares do tornozelo. Métodos: Estudo retrospectivo entre 2001 e 2019. Foram coletadas informações gerais: dados clínicos, radiográficos e complicações. As fraturas seguiram três passos no tratamento: (1) fixação do fragmento Salter-Harris tipo III da fratura triplanar; (2) fixação do fragmento Salter-Harris II/IV com parafuso canulado; e (3) fixação da fratura diafisária da tíbia com hastes flexíveis. Resultados: O estudo incluiu sete pacientes (seis homens) com idade média de 14 anos e seguimento médio de 6.4 anos (mínimo de dois anos). Cinco fraturas triplanares tinham dois fragmentos principais e duas tinham três fragmentos. Cinco fraturas na radiografia em perfil foram classificadas como Salter-Harris II e duas como Salter-Harris IV. Três fraturas diafisárias tibiais tinham traço obliquo longo, três traço espiral e uma fratura com terceiro fragmento. Seis fraturas eram do terço médio e uma fratura do terço distal da tíbia. Todas as fraturas triplanares e tibiais consolidaram sem desvio significativo e não tivemos nenhuma lesão fisária. Conclusão: O estudo descreveu a associação da fratura da tíbia com a fratura triplanar do tornozelo e nossa proposta de tratamento, que se mostrou uma boa opção no tratamento dessa fratura especial. Nível de Evidência IV, Série de casos.
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Ankle fractures are common in children, and they have specific implications in that patient population due to frequent involvement of the physis in a bone that has growth potential and unique biomechanical properties.Characteristic patterns are typically evident in relation to the state of osseous development of the segment, and to an extent these are age-dependent.In a specific type known as transitional fractures - which occur in children who are progressing to a mature skeleton -a partial physeal closure is evident, which produces multiplanar fracture patterns.Computed tomography should be routine in injuries with joint involvement, both to assess the level of displacement and to facilitate informed surgical planning.The therapeutic objectives should be to achieve an adequate functional axis of the ankle without articular gaps, and to protect the physis in order to avoid growth alterations.Conservative management can be utilized for non-displaced fractures in conjunction with strict radiological monitoring, but surgery should be considered for fractures involving substantial physeal or joint displacement, in order to achieve the therapeutic goals. Cite this article: EFORT Open Rev 2021;6:593-606. DOI: 10.1302/2058-5241.6.200042.
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PURPOSE: Despite the fact that open reduction and internal fixation with a plate, either non-locked or locked, is the standard of care for managing lateral malleolus fractures, intramedullary (IM) fixation of the fibula has been recently introduced as an alternative, mainly for some potential complicated situations. We hypothesized that almost all patterns of distal fibula fracture can be safely fixed with an IM device, with the potential benefit of providing biomechanical efficiency, but using a soft-tissue friendly implant. Here, we present a multicenter case series based on a proposed algorithm. PATIENTS AND METHODS: Sixty-nine consecutive patients were managed with fibular IM fixation for closed malleolar fractures. Twenty patients were managed by IM screw fixation and 49 by fibular nailing. Outcome was measured both according to the American Orthopaedic Foot and Ankle Society (AOFAS) score for ankle and hindfoot, and the time to bone union. RESULTS: The mean AOFAS for Group I was 99.35 ± 1.95 points and that for Group II was 89.30 ± 16.98 points. There were no significant differences between the fracture pattern, according to the Lauge-Hansen classification, and post-operative levels of pain and functional activity among patients in both groups (p > 0.05). All fractures healed uneventfully in both groups. The mean time to union for Group I was 8.15 weeks and for Group II was 8.25 weeks (p > 0.05). CONCLUSION: In this multicenter case series, intramedullary fixation for the lateral malleolus fracture presented itself as a viable and safe option for the treatment of almost all patterns of fibula fracture in adults. Overall, we were able to demonstrate the potential indications of the proposed algorithm for the choice of IM implant for the lateral malleolus fracture in terms of the Lauge-Hansen staged classification.
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Fraturas do Tornozelo , Fixação Intramedular de Fraturas , Adulto , Fraturas do Tornozelo/diagnóstico por imagem , Fraturas do Tornozelo/cirurgia , Placas Ósseas , Fíbula/diagnóstico por imagem , Fíbula/cirurgia , Fixação Interna de Fraturas , Humanos , Resultado do TratamentoRESUMO
BACKGROUND: Insufficiency fractures occur in bones with low elastic resistance. In contrast to stress fractures, which affect normal bones and have been extensively studied, insufficiency fractures of the foot and ankle have been the subject of little research. The objective of this study was to identify risk factors associated with the development of foot and ankle insufficiency fractures. METHODS: The study included 55 postmenopausal sedentary women with foot and ankle insufficiency fractures and 51 women in the control group. The data collected were the fracture site, body mass index, use of corticosteroids, T scores of the femur and lumbar spine measured by bone densitometry, and serum 25-OH vitamin D level. The calcaneal pitch (CP), talar-first metatarsal, and metatarsus adductus (MA) angles were measured on radiographs. RESULTS: In 49 patients (89%), fractures occurred in the metatarsals. All metatarsals were affected, and the most common fracture site was the base of the fifth metatarsal, with 21 cases (33%). Twenty patients (36%) in the study group reported chronic use of corticosteroids and had lower bone mineral density levels than controls (P < .05). The factors associated with fracture development (P < .05) were the CP and MA angles and low lumbar bone mineral density. CONCLUSION: Insufficiency fractures in this population were associated with low bone mineral density and unfavorable biomechanical characteristics such as pes cavus and metatarsus adductus. LEVEL OF EVIDENCE: Level IIIB, case-control study.
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Fraturas Ósseas , Fraturas de Estresse , Tornozelo , Densidade Óssea , Estudos de Casos e Controles , Feminino , Fraturas de Estresse/etiologia , Humanos , Pós-Menopausa , Fatores de RiscoRESUMO
Background: Surgical management of geriatric ankle fractures requires unique considerations in addressing operative risks. Prior studies have reached varying conclusions regarding optimal treatment strategies. The primary aim of this study was to determine if surgical fixation following a predetermined treatment protocol was safe and effective. The secondary aim was to determine if immediate weight bearing as tolerated (IWBAT) in a subset of patients was safe or conferred any short-term benefits. Methods: This retrospective study included all patients over the age 65 treated surgically for an ankle fracture by a single surgeon over a five-year period. A protocol was used including: augmented fixation techniques, IWBAT for select patients, and specific strategies to minimize soft tissue damage. Complications associated with operative treatment were analyzed. A subgroup analysis of patients with isolated ankle injuries was carried out to compare patients made IWBAT to patients made non-weight bearing (NWB) postoperatively. Results: Thirty-four patients were included in the study. Fracture types were predominantly OTA 44B2 (18/34, 53%) and 44B3 (8/34, 24%). Union rate was 100%. Augmented fixation techniques were used in 14/34, 41% of patients. Twenty-one of 34, 62% of patients were allowed IWBAT. There were 4 complications, 12%: 1 malunion, 1 superficial infection, and 2 wound dehiscence. Two patients returned to the operating room for removal of hardware and irrigation and debridement. In the subgroup analysis, the IWBAT group was discharged to a rehabilitation facility at a significantly lower rate than the NWB group, 25% (4/16) vs 90% (9/10; p=0.0036). There were no differences in the complication rates between the two groups. Conclusion: Acceptable outcomes can be reliably obtained when following a standardized approach to geriatric ankle fracture management. In addition, immediate weight bearing in select patients does not seem to increase complications and may benefit patients by increasing rate of discharge to home.Level of Evidence: IV.
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Fraturas do Tornozelo/cirurgia , Fixação Interna de Fraturas , Serviços de Saúde para Idosos , Complicações Pós-Operatórias/etiologia , Suporte de Carga , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Estudos RetrospectivosRESUMO
PURPOSE: The most common sites of low-energy trauma fractures are the femur, vertebra, humerus, and forearm. Ankle fractures have significant morbidity and high costs for surgical procedure. Forearm fractures are common nonvertebral fractures. Forearm fractures are classified as fragility fractures and predictive for fractures at other sites, although do not allow osteoporosis diagnosis. It is controversial whether ankle fractures are osteoporosis fractures. METHODS: Retrospective observational study, with secular trend analysis, in patients over 50 years old admitted in the Brazilian Public Health System, from 2004 to 2013. We collected hospitalization data according to the ICD-10 for low-trauma ankle and forearm fractures. Fracture rate was calculated according to gender, age, and geographic region, performed linear regression analysis, and estimated fracture rates for 2030. Comparison of ankle and forearm rates was also performed, grouping them in 3-year block. ANOVA test was used to compare each block. RESULTS: Ankle fracture rate was 21.39 fractures per 100,000 inhabitants, 23.98 in females and 18.49 in males. Fracture rates were higher in the South and Southeast regions. In absolute numbers, although ankle fracture rate increased with age, there was a significant decrease in the population over 80 years old. Data showed stabilization in ankle fractures from 2004 to 2013, in women and men. In 3-year block analysis, men had higher ankle fracture rates than forearm. However, in women, forearm rates were higher than ankle. CONCLUSION: Our data suggest that ankle fractures in men would be considered as a sentinel fracture with a similar clinical impact of forearm fracture.
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Fraturas do Tornozelo , Traumatismos do Antebraço , Fraturas Ósseas , Fraturas por Osteoporose , Idoso , Idoso de 80 Anos ou mais , Tornozelo , Fraturas do Tornozelo/epidemiologia , Brasil/epidemiologia , Feminino , Traumatismos do Antebraço/epidemiologia , Fraturas Ósseas/epidemiologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Fraturas por Osteoporose/diagnóstico , Fraturas por Osteoporose/epidemiologia , Estudos RetrospectivosRESUMO
RESUMEN Introducción: El tratamiento de las fracturas del tobillo tiene importancia en la recuperación de la movilidad e independencia del paciente geriátrico. Objetivo: Evaluar el resultado obtenido al transcurrir un año del tratamiento quirúrgico mediante reducción y fijación de las fracturas inestables en pacientes mayores de 65 años. Métodos: Estudio descriptivo y prospectivo; pacientes mayores de 65 años, atendidos entre enero de 2017 y diciembre de 2018 por fractura de tobillo desplazada, en el Hospital Universitario General Calixto García Íñiguez y el Centro de Investigaciones en Longevidad, Envejecimiento y Salud, que fueron evaluados un año después. Resultados: De un total de 31 pacientes, 6 hombres y 25 mujeres con una edad media de 73,4 ± 3,5 años, 12 presentaban deterioro cognitivo, 18 llevaban terapia anticoagulante y 14 ingerían más de cuatro medicamentos diariamente. Predominaron los grupos con 3 y 4 puntos del índice de Charlson, la mayoría se ubicó en ASA III de riesgo anestésico y fracturas Dannis-Weber tipo C, 29 fracturas fueron cerradas. Las complicaciones fueron escasas; 27 de 31 pacientes se ubicaron como excelente o bueno según la escala AOFAS; 3 ± 2 en la escala visual de dolor; 86 por ciento podían realizar sus actividades de la vida diaria, Conclusiones: El resultado del tratamiento quirúrgico de las fracturas de tobillo en mayores de 65 años fue bueno y con baja incidencia de complicaciones que pueden relacionarse con condiciones mórbidas previas(AU)
ABSTRACT Introduction: The ankle fracture treatment is important in the recovery of mobility and independence of geriatric patients. Objective: To evaluate the results after one year of surgical treatment by reduction and fixation of unstable fractures in patients older than 65 years. Methods: A descriptive and prospective study was carried out in patients older than 65 years, treated from January 2017 to December 2018 due to displaced ankle fracture, at General Calixto García Íñiguez University Hospital and the Research Center for Health, Longevity and Aging. These patients were assessed a year later. Results: Out of a total of 31 patients, 6 men and 25 women with a mean age of 73.4 ± 3.5 years, 12 had cognitive impairment, 18 were on anticoagulant therapy and 14 were taking more than four medications daily. Groups with 3 and 4 points of Charlson index predominated, the majority were located in ASA III of anesthetic risk and Dannis-Weber type C fractures, 29 fractures were closed. Complications were rare and 27 out of 31 patients ranked as excellent or good according to the AOFAS scale, 3 ± 2 on the visual pain scale, 86 percent of performing activities of their daily life. Conclusions: The result of the surgical treatment of ankle fractures in people older than 65 years was good and with a low incidence of complications that may be related to previous morbid conditions(AU)
Assuntos
Humanos , Masculino , Feminino , Idoso , Fraturas do Tornozelo/cirurgia , Fixação de Fratura/métodos , Epidemiologia Descritiva , Estudos Prospectivos , Resultado do Tratamento , Estudo ObservacionalRESUMO
There is no consensus on whether the deltoid ligament must be repaired in ankle fractures. Recent studies have shown better early radiologic results when the deltoid ligament is repaired, but no differences in long term functional outcomes. However, there is evidence suggesting that patients with high fibular fractures or injuries with concomitant syndesmotic instability may benefit from repair. The authors recommend repairing the deltoid ligament complex in bimalleolar equivalent fractures associated with syndesmotic or gross multiligamentous instability as well as in heavier patients with greater mechanical requirements.
Assuntos
Fraturas do Tornozelo , Fraturas do Tornozelo/diagnóstico por imagem , Fraturas do Tornozelo/cirurgia , Articulação do Tornozelo/cirurgia , Fixação Interna de Fraturas , Humanos , Ligamentos , Ligamentos Articulares/cirurgia , Resultado do TratamentoRESUMO
RESUMO Nosso objetivo é descrever a técnica de fixação intramedular (IM) da fíbula no tratamento cirúrgico das fraturas maleolares do tornozelo. A redução é realizada sempre de forma percutânea: quando o traço de fratura é oblíquo simples, utilizamos uma pinça de redução de pontas e quando a fratura apresenta padrão multifragmentar, usa-se tração longitudinal e rotação. Isso reduz as complicações relacionadas à redução aberta e fixação interna com placa. A técnica demonstrou ser simples e reprodutível. Além disso, essa forma de fixação permite apoio precoce do peso corporal, o que acelera o processo de reabilitação e potencialmente acelera a cicatrização da fratura. A fixação IM da fíbula mostrou-se uma opção viável para a fixação do maléolo lateral nas fraturas do tornozelo, devendo ser considerada no arsenal do cirurgião.
ABSTRACT Our objective is to describe the technique of intramedullary (IM) nailing of lateral malleolus in the surgical management of ankle fractures. Fracture reduction is performed either percutaneously with a small pointed reduction clamp in simple oblique fractures or using longitudinal traction and rotation for comminuted fractures, thus reducing complications related to open reduction and internal fixation with a plate. The technique has been shown to be simple and reproducible. In addition, the technique allows early weight bearing, which accelerates rehabilitation and potentially fasten fracture healing. IM nailing is a viable option for the fixation of the of lateral malleolus in ankle fractures and should be considered in the surgeon's armamentarium.
Assuntos
Humanos , Fraturas do Tornozelo/cirurgia , Fixação Interna de Fraturas/métodos , Fixação Intramedular de Fraturas/métodos , Fraturas do Tornozelo/diagnóstico por imagemRESUMO
OBJECTIVES: To review a case series of patients with posterior pilon variant fracture using a novel approach, focusing on demographic data, injury pattern, surgical results based on computed tomography (CT) scan, and short-term complications. DESIGN: Consecutive case series. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Twenty-five patients with posterior pilon fracture. INTERVENTION: Posterior pilon fracture open reduction and internal fixation. MAIN OUTCOME MEASUREMENTS: Parameters measured included age, sex, type of fracture, surgical technique, anatomical reduction, and complications. RESULTS: Twenty-five patients sustained a posterior pilon fracture, accounting for 13.4% of all operatively treated ankle fractures with median follow-up of 21.7 months. The average age of patients was 42 years (22-62); 19/25 (76%) were female, and 6/25 (24%) were male. A modified posteromedial approach was used in 18/25 (72%) patients. Persistent syndesmotic instability was present in 11/25 (44%) patients after posterior malleolar stabilization. Quality of reduction was assessed under CT scan in 19 patients, with 15/19 (78.9%) having anatomic reduction. We report 2/25 (8%) patients with early wound problems and 7/25 (20%) with short-term complications during follow-up. CONCLUSION: Posterior pilon variant fracture appears to be less common than previously reported. Most fractures can be satisfactorily treated through a modified posteromedial approach. Albeit obtaining posterior malleolar fracture rigid fixation, syndesmotic instability was more prevalent than expected. The short-term complication rate was low. LEVEL OF EVIDENCE: Therapeutic level IV.
Assuntos
Fraturas do Tornozelo , Traumatismos do Tornozelo , Tornozelo/diagnóstico por imagem , Fíbula , Fixação Interna de Fraturas , Complicações Pós-Operatórias , Adulto , Fraturas do Tornozelo/diagnóstico , Fraturas do Tornozelo/epidemiologia , Fraturas do Tornozelo/cirurgia , Traumatismos do Tornozelo/diagnóstico , Traumatismos do Tornozelo/epidemiologia , Traumatismos do Tornozelo/cirurgia , Chile/epidemiologia , Feminino , Fíbula/diagnóstico por imagem , Fíbula/lesões , Fixação Interna de Fraturas/efeitos adversos , Fixação Interna de Fraturas/métodos , Humanos , Masculino , Avaliação de Processos e Resultados em Cuidados de Saúde , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Tomografia Computadorizada por Raios X/métodosRESUMO
Se sabe que la fractura de Tillaux ocurre en adolescentes una vez que ocurre durante el período de transición cuando la fisis medial y central ha finalizado el cierre, pero la fisis lateral todavía está abierta. El mecanismo de traumatismo es típicamente una lesión de tobillo de rotación externa que resulta en una fractura por avulsión del plafón tibial anterolateral. Esta fractura rara vez se ha informado en adultos, especialmente asociada con otras lesiones. Divulgamos un caso de fractura de Tillaux en un adulto, asociado con una fractura de Volkmann y una fractura de Maisonneuve, que se trataron mediante cirugía con reducción abierta y fijación interna y tuvieron un resultado excelente. Reconocer y tratar apropiadamente cada una de estas lesiones es la clave para prevenir artritis e inestabilidad degenerativas.
Tillaux fracture is known to occur in adolescents once it happens during transition period when the medial and central physis has finished closure, but the lateral physis is still opened. The trauma mechanism is typically external rotation ankle injury resulting in an avulsion fracture of the anterolateral tibial plafond. This fracture has rarely been reported in adults, especially associated with others injuries. We report a case of Tillaux fracture in an adult, associated with a Volkmann fracture and a Maisonneuve fracture, that were surgery treated with open reduction and internal fixation and had an excellent outcome. Recognize and appropriately treat each one of these injuries is the key to prevent further degenerative arthritis and instability.