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.     

Salvage operation for neglected ankle fractures

From 1986 to 1993, 49 cases of untreated or poorly treated ankle fractures who received salvage surgery were followed up for an average of 36.4 months. The patients included 31 males & 18 females with an average age of 41.6y/o and the time interval from initial injury to reconstructive surgery average due 17.6 months. They were classified and treated according to their grade of reduction and degree of arthrosis. The surgical methods included arthrotomy & joint debridement, revised open reduction, lower tibial osteotomy and ankle arthrodesis, depending on different individual conditions. After surgery, all cases had symptomatic relief and functional improvement with an average score increased from 26.3 preoperatively to 86.8 at follow up. The goals of ankle fractures is as articular fractures, they are treated by surgical anatomic reduction with rigid fixation as early as possible in order to provide good functional results. Nevertheless they are varied in neglected ankle fractures according to their individual conditions: open reductions were performed on cases with no or little arthritic change even though arthrosis might occur later because, if necessary, future conversion to osteotomy or arthrodesis would be easier. As for late cases with advanced arthritis, ankle arthrodesis were done by compressive arthrodesis with necessary bone graft to secure fusion in an optimal position.     

Retrospective evaluation of graded stress examination of the ankle

Stress radiography of the ankle commonly is used to evaluate talar tilt in patients with a history of inversion ankle sprains. Manual and instrumented procedures have been variously described in the literature. No reports have documented normative talar tilt as measured using the Telos ankle stress device in a large clinical population. In addition, little has been done to examine the value of using graded displacement forces compared with a single displacement force. Bilateral Telos examinations from 113 consecutive patients taken during a 4-year period were evaluated for this study. No measurable talar tilt was observed in 65.8% of the ankles in this study. Talar tilt ranged from 1.7 degrees to 24.9 degrees in injured ankles. In patients with quantifiable talar tilt, all had greater talar tilt at the 15 kPa force than at all other forces. Because of the variability in talar tilt in injured and comparison ankles, clinical conclusions regarding injury severity cannot be made on measured talar tilt alone. The analysis suggests that inversion stress examination is helpful in documenting gross talar instability, but the discriminant value of the procedure to determine the anatomy and severity of lateral ligament injury is tenuous.     

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.     

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.     

Early complications in the operative treatment of patella fractures

In this study two aspects of hybrid functional electrical stimulation (FES) orthoses were investigated: joint motion constraints and FES control strategies. First, the effects of joint motion constraints on the gait of normal subjects were investigated using modern motion analysis systems, including electromyogram (EMG) and heart rate measurements. An orthosis was developed to impose joint motion constraints; the knee and ankle could be fixed or free, and the hip joint could rotate independently or coupled, according to a preset flexion-extension coupling ratio (FECR). Compared with a 1:1 hip FECR, a 2:1 hip FECR was associated with a reduced energy cost and increased speed and step length. The knee flexion during swing significantly reduced energy cost and increased walking speed. Ankle plantar flexion reduced the knee flexing moment during the early stance phase. Second, trials on 3 paraplegic subjects were conducted to implement some of these findings. It appeared that the 2:1 FECR encouraged hip flexion and made leg swing easier. A simple FES strategy increased walking speed and step length and reduced crutch force impulse using fixed orthotic joints.     

Late follow-up results of operative ankle arthroscopy in patients under local anaesthesia

The clinical diagnoses of nodal status (N) and tumor invasion (T) were performed intraoperatively during 1499 consecutive operations for gastric carcinoma and compared with subsequent pathologic diagnoses. An accurate macroscopic diagnosis of N stage was difficult; overall accuracy was only 56.6%. Intraoperative assessment of T stage (particularly of serosal invasion) was correct for 93.2% of early stages of the disease with invasion confined to the mucosa or submucosa (pT1) when the pathologist assessed the T stage in the resected specimen, for 95.6% of advanced tumors invading the serosa (pT3), but for tumors of an intermediate stage with invasion involving the muscularis propria or the subserosa (pT2) in only 41.9% of cases. Macroscopic overestimation occurred in 58.1% of cases with pT2 tumors, which were characterized by carcinomas in the upper third of the stomach, tumors larger than 5 cm, carcinomas of the ulcerating type, differentiated adenocarcinomas, tumors invading the subserosa, and those accompanied by lymph node metastasis or liver metastasis. The overestimated group had a significantly poorer prognosis than the correctly assessed cases (P < 0.05). Since multivariate logistic regression analysis showed that the significant risk factor related to the inaccurate intraoperative assessment of T stage was tumor size, the error in diagnosis may correlate with a greater degree of tumor spread. Surgeons should decide their therapeutic approach at the time of surgery on the basis of their intraoperative assessment of tumor spread. We recommend extensive surgery followed by adequate chemotherapy when serosal invasion is suspected at surgery.     

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.     

Functional recovery after operative treatment of femoral neck fractures in an institutionalized elderly population

Agreement that hip fracture is best treated surgically stems from the fact that early mobilization of the patient reduces morbidity and mortality. This concept was tested in 54 elderly, institutionalized patients with femoral neck fractures who were operatively treated. The patients were reviewed within 12 months after being injured. Their average age was 81.2 years, and 94% of the patients were women. Seventy-five percent of the study population had neurological disease or heart disease and were thus limited in their motivation or ability to participate in a rehabilitation program. Only 16.7% of the patients regained their overall functional ability and only 12.9% returned to their pre-injury, ambulatory status. The therapeutic concept should be reviewed and the conservative approach be given serious consideration.     

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.     

Conservative or operative treatment of fractures of the head of the tibia (author's transl)

Whether fractures of the head of the tibia have to be treated conservatively or surgically in an active way depends on the type of the fracture. In cases with small dislocation conservative treatment should be given priority. Only fractures with badly dislocated fragments should be operated on (osteosythesis).     

Completion pneumonectomy: analysis of operative mortality and survival

BACKGROUND: A single-institution experience with completion pneumonectomy was analyzed to assess operative mortality and late outcome. METHODS: A consecutive series of 138 completion pneumonectomies from 1975 to 1995 was reviewed, and compared with single-stage pneumonectomies performed during the same period. RESULTS: Hospital mortality was 13.8%, including 4 intraoperative and 15 postoperative deaths. Hospital mortality was the same for lung cancer (13.2%) as for benign disease (15.5%). It was 37.5% if an early complication of the primary operation was the indication (p = 0.01). If infection of the pleural space was the indication for completion pneumonectomy, hospital mortality was 23.3% (p > 0.05). In 760 single-stage pneumonectomies hospital mortality was 8.7% (p > 0.05). Five-year actuarial survival after completion pneumonectomy was 42.5% for all patients, 32.3% for those with lung cancer, and 58.8% for those with benign disease. CONCLUSIONS: Hospital mortality for completion pneumonectomy was the same for malignant as for benign indications. It was significantly higher if completion pneumonectomy was done for an early complication of the primary operation. Results at long term of lung cancer patients were the same for single-stage pneumonectomy and completion pneumonectomy.     

Nodular goiter. Retrospective analysis of 608 cases

A retrospective study was carried out on a series of 608 patients, of whom 430 had undergone partial and 178 total thyroidectomy for single or multinodular goitre. Statistical analysis of data for the 532 women (88%) and 76 men (12%), mean age 45 and 39 years respectively, included clinical and operative features, specific morbidity of the exeresis, incidence of cancer on multinodular goitre and the frequency of recurrence of nodular lesions. The men were significantly younger at time of diagnosis (p < 0.0006). Bilateral multinodular forms (n = 577) and hypofixing lesions (n = 515) predominated. The incidence of unsuspected thyroid cancer in the multinodular cases was 3% (15/444). Carcinoma development on single nodules in our series during the same period was 8% (n = 15/195), the difference being statistically significant (p < 0.02). Mortality was nil and non specific morbidity 2% (n = 12/608). No compressive hematoma was reported and tracheotomy was never required. A clinically detectable alteration in the voice was noted in 10% (n = 67/608), this persisting in 0.5% (n = 3) beyond the 6th postoperative month. No significant difference existed between general and vocal morbidity as a function of the type of exeresis. Hypocalcemia was observed in 11% of patients (n = 67/608), 49% (n = 33/67) being asymptomatic and the anomaly spontaneously reversible. Four percent (n = 7/178) were permanent after total thyroidectomy (including 15 cancers on multinodular goitre discovered fortuitously, 8 of which received lymph node dissection) and 3% (n = 2/68) after a "wide" subtotal thyroidectomy.     

Gait analysis of the hemophilic ankle with silicone heel cushion

Shock absorption becomes very important in damaged joints with destroyed cartilage and progressive muscular imbalance as occurs in hemarthropathy. The effects of silicone heel cushioning on the ankle motion of hemophilic patients in different stages of hemarthropathy of the ankle joints was measured using an ultrasound motion analysis system. It is concluded that silicone heel cushioning has no influence on ankles in the late stage of hemarthropathy. Silicone heel cushioning will lead to uncontrolled changes of the ankle joint in the early hemarthropathic ankle, involving the tibiotalar and the subtalar joints. The angular velocity of the ankle is increased producing higher acceleration at the ankle joint. The higher angle acceleration is related to higher joint loading uncontrolled by the muscles. The resulting uncoordinated motion can cause ligamentous overloading, strains, and a higher probability of joint bleeding. Therefore, silicone heel cushioning or other shock absorbing devices that return the energy immediately to the foot are not useful for prevention and treatment of chronic hemophilic synovitis and may cause additional deterioration of the joint.