Evaluation of treatment results for lateral ankle fractures

An analysis was performed of 18 lateral ankle fractures with fracture fissure running from above-back forward and down-ward. In this group, 15 cases were treated conservatively and three cases surgically. In eight patients an evident limitation of pronation movements was found, the remaining movement being limited to a lesser degree. In six patients traces after previous separation of tibiofibular syndesmosis were found. The conservative treatment failed to maintain normal conditions in the talocrural joint.     

Retrospective analysis of operative ankle fractures

A seroprevalence survey to recently proposed adenovirus (AV) serotypes AV 48 and AV 49, isolated primarily from AIDS patients, was conducted among the San Francisco Men's Health Study cohort. This cohort of homosexual, heterosexual, or bisexual HIV-seronegative and -seropositive men from selected San Francisco census tracts has been studied since 1984. The presence or absence of type-specific antibody in 628 serum specimens from 1989 was determined by microneutralization. Thirty of these subjects (26 positive and four negative) were studied longitudinally. Serum specimens taken at 6-month intervals from 1984 to 1993 were tested to characterize antibody response and to document the advent of these new serotypes. Eight subjects were tested against five other AV serotypes for comparison. AV 48 and AV 49 seroprevalence rates were significantly higher in HIV-seropositives, but infection was not limited to the immunocompromised. Sexual preference was not a significant determinant for AV seroprevalence in HIV-seronegatives. However, the extent and duration of the neutralizing antibody response was strikingly different between homosexuals and heterosexuals: an endemic pattern of continuous reexposure over the 9-year period was seen in 90% of 19 homosexuals, while five of six heterosexuals (83%) had an episodic pattern of exposure with antibody decline to undetectable levels. These data suggest that these viruses may be endemic in some part of the homosexual population and that sexual transmission may be the primary source of continuous reexposure.     

Classification of ankle fractures in children

The roentgenograms of 310 children treated for ankle fractures were evaluated for grouping according to the classifications of Ashhurst-Bromer-Weber, Lauge-Hansen, and Salter-Harris. The mean age of the children at the time of injury was 11.1 years (range 2-14 years). Two hundred twenty-one (71.3%) children had malleolar fractures, 71 (22.9%) had tibial epiphyseal fractures, and 18 (5.8%) had syndesmotic lesions. The age distribution of fractures was typical: malleolar fractures predominated among the younger children, epiphyseal fractures among the older. Only the oldest children had avulsion fractures of the syndesmosis. Grouping of the fractures according to Lauge-Hansen and Ashhurst-Bromer-Weber, classifications suited to adults was largely unsuccessful. Epiphyseal fractures, moreover, were easily classified according to Salter-Harris. In spite of their complexity, ankle fractures in children can be roughly divided into avulsional and epiphyseal fractures. Adequately reduced avulsional fractures can be expected to heal well; epiphyseal fractures, however, may five rise to late complications. We propose, therefore, that ankle fractures in children be classified on the basis of roentgenological findings with respect primarily to epiphyseal lesions as well as on an additional simple grouping as to risk for clinical purposes: Group I, low risk, avulsional fractures and epiphyseal separations; Group II, high risk, fractures through the epiphyseal plate.     

Intraoperative radiographic assessment of ankle fractures

This retrospective study was performed to determine whether three or two radiographic views are necessary for intraoperative evaluation of low energy, rotational ankle fracture reduction and fixation. Four orthopaedic surgeons independently reviewed two sets of radiographs of 93 low energy, rotational ankle fractures treated by open reduction and internal fixation. The reviewers judged reduction and fixation, without measurement, as if they had been the operating surgeons. Set 1 consisted of mortise and lateral views and Set 2 consisted of anteroposterior, mortise, and lateral views. There was a 2-month interval between the review of Set 1 and Set 2. Intraobserver consistency for Sets 1 and 2 for reduction ranged from 92% to 98% and consistency for fixation ranged from 85% to 94%. These results underwent statistical testing by calculation of the kappa value. With a 95% confidence interval, the kappa value for reduction ranged from 0.376 to 0.701; the kappa value for fixation ranged from 0.598 to 0.781. The interobserver consistency for Sets 1 and 2 also was calculated. The authors conclude that fracture reduction and fixation can be assessed adequately with lateral and mortise views. The anteroposterior view can be eliminated from the standard radiographic protocol, potentially resulting in cost savings.     

Therapy of ankle joint fractures (author's transl)

Even severely dislocated ankle joint fractures can be fixed in the right position and healed by immediate reposition. Irreponible fractures, ruptures of the syndesmosis, shortening of the fibula and abruptions of tibial edges require timely operative treatment with osteosynthesis, the individual forms of which are demonstrated. The screws fixing the syndesmosis must be removed in time in order to prevent their loosening or breaking. Fixations in hypercorrective position have proved to be unphysiological. Walking plaster, however, are better than training with crutches without the possibility of loading. The combination of osteosynthesis and walking plaster will contribute to the development of an early self-sufficiency on the part of the operated patient.     

Vertical transarticular pin fixation for unstable ankle fractures: impressions after 16 years of experience

The usage of vertical transarticular pin fixation combined with plaster immobilization for severe ankle injuries has been reviewed in 92 consecutive cases over a period of 16 years. Moderately simple in application and without a skin incision, the procedure has been found to provide efficient and reliable short-term stabilization of the ankle and subtalar joints with minimal complications. A new technique is described for accurate placement of the pin and the prevention of its migration. It is a reasonable alternative treatment for certain unstable distal tibial and ankle fractures when open reduction with conventional internal fixation cannot be done. In particular, the method is recommended in treating displaced fractures at the ankle and deltoid ligament ruptures in geriatric patients. It is often useful as a salvage or last-resort procedure in unusually severe ankle injuries with circulatory or neural deficits. In many instances additional trauma to the head, thorax or abdomen may have been sustained. Thus total patient care is essential and priorities must be recognized. The treatment of ankle trauma, furthermore, in a physiologically-aged diabetic patient is often not the same as that for similar injuries in a young healthy adult. The clinical judgement and experience of the operator is the basis for selection of the procedure. The simplest method is often the best. Pin fixation, however, is not for everyone. It should be done only by surgeons qualified to treat bone and joint trauma and even then only for those situations in which its usage is specifically indicated.     

Is surgical treatment of deltoid ligament rupture necessary in ankle fractures?

PURPOSE OF THE STUDY: Fractures of the lateral malleolus associated with rupture of the deltoid ligament are severe fractures types. There is still discussion about wether the ruptured deltoid ligament should be sutured or not. To elucidate further the need for surgical repair of this structure a comparative and retrospective review was conducted at a mean follow-up of 4 years and 8 months. MATERIAL AND METHODS: Twenty nine men and 15 women were included with a mean age of 34 years. Patients were subdivided into two groups according to the attitude regarding the ligament. In the first group (n = 18), an operative repair of the ligament was made and in the second group (n = 17) we leaved it unrepaired. Nine patients were evaluated separately because of an associated osteochondral fracture (n = 7) or a worse reduction of the fibula (n = 2). Subjective and objective clinical assessment were evaluated according to a modified Cedell classification. Roentgenograms including A.P, lateral, mortise view and a external rotation stress view described by Kleiger were obtained in all patients. RESULTS: Subjective and objective analysis showed no significant difference between the two groups, likewise no differences were observed for post operative complications rate. Medial instability was observed in four cases (2 in group 1 and 2 in group II). Roentgenographicaly, more ossifications of the deltoid ligament were founded in group II (p = 0.013), and only one degenerative osteoarthritis of the ankle was seen in group II. Clinical results in the group of patients with osteochondral fracture were statistically worse than in the two previous groups (p = 0.001), with frequent progression to osteoarthritis in four cases. DISCUSSION: In our experience it is impossible to advise surgical repair of the deltoid ligament in accordance to the type of lateral malleolar fracture like other authors have suggested. The existence of a significant widening of the medial space greater than 3 mm was nearly correlated with a deltoid ligament disruption, of the 23 patients treated with a medial approach, the ligament was ruptured in 22 cases. In this study, we may conclude than an untreated rupture of the deltoid ligament does not lead to instability. The advantages of the deltoid repair may be obtained if the fixation of the lateral malleolus allows a perfect congruency of the mortise. The most predictive radiographic factors for a poor outcome were a persistent widening of the medial joint greater than 3 mm, an associated osteochondral fracture and a poor reduction of the lateral malleolus which results in degenerative arthritis of the ankle at long term follow-up. CONCLUSION: Repair of the deltoid ligament is unnecessary if the internal fixation of the fibula achieves an anatomical reconstitution of the mortise. Exploration of the medial side is indicated only with a medial incongruency greater than 3 mm on intra operative roentgenograms.     

Salvage therapy for ovarian cancer

Patients with epithelial ovarian cancer must receive optimal surgical care and state-of-the-art chemotherapy in the primary treatment setting. The salvage treatment of women with recurrent or persistent ovarian cancer remains a difficult task. A very small percentage of patients with platinum-sensitive, small-volume disease appear to achieve prolonged disease-free survival. The treatment of patients with larger-volume disease (> 0.5 cm) or platinum-resistant disease remains largely palliative. The plethora of available new agents has provided the physician with multiple options for salvage chemotherapy. Although cure in the salvage setting is not often achieved currently, palliative treatment allows many patients to live painfree, productive lives. Candidates for salvage therapy may be grouped into one of several categories, which reflect different prognoses for response. These categories include refractory disease (defined as progressive tumor during primary treatment), persistent disease (a partial response to primary therapy followed by elevated tumor markers or clinically evident persistent disease), and recurrent disease (initial complete response to primary therapy with subsequent relapse). Categorizing patients into these categories provides a systematic method for organizing the administration of salvage chemotherapy.     

Salvage surgery for lateral tennis elbow

We undertook a retrospective analysis of 34 patients (35 elbows) who had prior failed surgical intervention for lateral tennis elbow. Revision surgeries were performed between 1979 and 1994. Each patient's non-operative and operative history was recorded before our salvage revision surgery. At revision surgery, findings included residual tendinosis of the extensor carpi radialis brevis tendon in 34 of 35 elbows. In 27 elbows, the pathologic changes in the extensor carpi radialis brevis tendon had not been previously addressed at all, and in 7 elbows the damaged tissue had not been completely excised. Salvage surgery included excision of pathologic tissue in the extensor carpi radialis brevis tendon origin combined with excision of excessive scar tissue and repair of the extensor aponeurosis when necessary. Based on a 40-point functional rating scale proposed here, 83% of the elbows (29 of 35) had good or excellent results at an average followup of 64 months (range, 17 months to 17 years). To prevent failure of surgical treatment for tennis elbow, the pathologic tissue usually present in the extensor carpi radialis brevis tendon should be resected. Release operations, which weaken the extensor aponeurosis but fail to address the pathoanatomic changes, are not recommended.     

Salvage surgery for chemorefractory gestational trophoblastic disease

PURPOSE: To investigate and define better the role of salvage surgery for patients with chemorefractory gestational trophoblastic disease (GTD). PATIENTS AND METHODS: A retrospective review of medical records at The University of Texas M.D. Anderson Cancer Center identified 33 patients with chemorefractory GTD who underwent salvage surgery between 1962 and 1991. The end points selected for analysis were serologic response and survival. RESULTS: Initial salvage procedures consisted of 29 hysterectomies, four thoracotomies, and one nephrectomy (in conjunction with a hysterectomy). Fourteen patients (42%) had a serologic complete response (CR) to surgery (normalization of human chorionic gonadotropin [hCG]), 10 (30%) had a partial response (> 50% decrease in hCG level), and nine had no response (< or = 50% decrease in hCG level). Of 19 patients who received further chemotherapy, eight (42%) attained a CR. Four patients underwent a second salvage surgery: two thoracotomies, one craniotomy, and one partial hepatectomy. All achieved a CR. The probability of achieving a CR was influenced by the time from diagnosis to surgery, number of preoperative disease sites, preoperative World Health Organization (WHO) score, and histologic type. Survival was influenced by the type of antecedent pregnancy, number of preoperative regimens, number of preoperative disease sites, time from diagnosis to surgery, and preoperative WHO score. CONCLUSION: Based on the findings of this study, it appears that a select subset of patients with chemorefractory GTD who have a limited number of clinically detectable tumor foci may benefit from salvage surgery.     

Arthroscopy for problems after ankle fracture

From 1990 to 1994 we undertook arthroscopy of the ankle on 34 consecutive patients with residual complaints following fracture. Two groups were compared prospectively. Group I comprised 18 patients with complaints which could be attributed clinically to anterior bony or soft-tissue impingement. In group II the complaints of the 16 patients were more diffuse and despite extensive investigation the definitive diagnosis was not clear before arthroscopy. At the time of the fracture, some osteophytes were already present in 41% of the patients. These were related to previous supination trauma and participation in soccer. Arthroscopic treatment consisted of removal of the anteriorly located osteophytes and/or scar tissue. After two years, group I showed a significantly better score for patient satisfaction (p = 0.02). There were good or excellent results in group I in 76% and group II in 43%. Patients with residual complaints after an ankle fracture and clinical signs of anterior impingement may benefit from arthroscopic surgery. The place for diagnostic ankle arthroscopy is limited.     

Rotation fasciocutaneous flap for neglected club feet--a new technique

Skin necrosis and wound problems complicate surgical release of severe neglected clubfoot. This is primarily due to excessive tension on the skin edges and a poor understanding of abnormal vascular anatomy in clubfoot. We report a technique of primary skin closure using a local rotation fasciocutaneous flap using the conventional posteromedial skin incision (Turco). Primary uncomplicated wound healing was achieved within 2 weeks in all 16 rigid and neglected clubfeet (1-7 years) operated by this technique. This flap is scientifically logical, technically easy and ensures primary wound healing.