Abstract:Ankle fractures are one of the most common injuries treated by orthopedic surgeons worldwide. However, operative indications, techniques, and reported outcomes following operative fixation vary widely in the literature. This evidence-based review focuses on recent advances in the operative management of ankle fractures including arthroscopic-assisted surgery, deltoid ligament complex repair, expanded indications for posterior malleolus fixation, fibula intramedullary nailing, and dynamic syndesmosis repair. Le… Show more
“…216–219 A routine use of CT scan of all posterior malleolus fractures is recommended to determine the size, orientation, comminution, and articular impaction. 220 Numerous classifications of PM fracture are suggested in the literature to understand the configuration of the PM fractures as well guide the selection of approach and fixation strategy. 217,221,222 Figure 9.A trimalleolar fracture treated by open reduction and internal fixation of the lateral malleolus, posterior malleolus and medial malleolus.…”
Section: Syndesmotic Injuries With Ankle Fracturesmentioning
The distal tibiofibular syndesmosis (DTFS) is more frequently injured than previously thought. Early diagnosis and appropriate treatment is essential to avoid long term complications like chronic instability, early osteoarthritis and residual pain. Management of these injuries require a complete understanding of the anatomy of DTFS, and the role played by the ligaments stabilizing the DTFS and ankle. High index of suspicion, appreciating the areas of focal tenderness and utilizing the provocative maneuvers help in early diagnosis. In pure ligamentous injuries radiographs with stress of weight bearing help to detect subtle instability. If these images are inconclusive, then further imaging with MRI, CT scan, stress examination under anesthesia, and arthroscopic examination facilitate diagnosis. An injury to syndesmosis frequently accompanies rotational fractures and all ankle fractures need to be stressed intra-operatively under fluoroscopy after fixation of the osseous components to detect syndesmotic instability. Non-operative treatment is appropriate for stable injuries. Unstable injuries should be treated operatively. Anatomic reduction of the syndesmosis is critical, and currently both trans-syndesmotic screws and suture button fixation are commonly used for syndesmotic stabilization. Chronic syndesmotic instability (CSI) requires debridement of syndesmosis, restoration of ankle mortise with or without syndesmotic stabilization. Arthrodesis of ankle is used a last resort in the presence of significant ankle arthritis. This article reviews anatomy and biomechanics of the syndesmosis, the mechanism of pure ligamentous injury and injury associated with ankle fractures, clinical, radiological and arthroscopic diagnosis and surgical treatment.
“…216–219 A routine use of CT scan of all posterior malleolus fractures is recommended to determine the size, orientation, comminution, and articular impaction. 220 Numerous classifications of PM fracture are suggested in the literature to understand the configuration of the PM fractures as well guide the selection of approach and fixation strategy. 217,221,222 Figure 9.A trimalleolar fracture treated by open reduction and internal fixation of the lateral malleolus, posterior malleolus and medial malleolus.…”
Section: Syndesmotic Injuries With Ankle Fracturesmentioning
The distal tibiofibular syndesmosis (DTFS) is more frequently injured than previously thought. Early diagnosis and appropriate treatment is essential to avoid long term complications like chronic instability, early osteoarthritis and residual pain. Management of these injuries require a complete understanding of the anatomy of DTFS, and the role played by the ligaments stabilizing the DTFS and ankle. High index of suspicion, appreciating the areas of focal tenderness and utilizing the provocative maneuvers help in early diagnosis. In pure ligamentous injuries radiographs with stress of weight bearing help to detect subtle instability. If these images are inconclusive, then further imaging with MRI, CT scan, stress examination under anesthesia, and arthroscopic examination facilitate diagnosis. An injury to syndesmosis frequently accompanies rotational fractures and all ankle fractures need to be stressed intra-operatively under fluoroscopy after fixation of the osseous components to detect syndesmotic instability. Non-operative treatment is appropriate for stable injuries. Unstable injuries should be treated operatively. Anatomic reduction of the syndesmosis is critical, and currently both trans-syndesmotic screws and suture button fixation are commonly used for syndesmotic stabilization. Chronic syndesmotic instability (CSI) requires debridement of syndesmosis, restoration of ankle mortise with or without syndesmotic stabilization. Arthrodesis of ankle is used a last resort in the presence of significant ankle arthritis. This article reviews anatomy and biomechanics of the syndesmosis, the mechanism of pure ligamentous injury and injury associated with ankle fractures, clinical, radiological and arthroscopic diagnosis and surgical treatment.
“…Keberhasilan suatu manajemen intervensi terhadap fraktur ankle bimalleolar dapat dievaluasi secara klinis dan radiologis. 5,6,7,8 Capaian status union dan status radiologis merupakan salah satu parameter penting untuk menyatakan kondisi struktural, sedangkan status fungsional dapat dinilai dari kemampuan melakukan aktifitas oleh sendi ankle, range of motion, serta adanya gejala sisa yang penting untuk dinilai pasca dilakukannya intervensi pada pasien. 9 Studi penelitian mengenai evaluasi capaian status struktural, kemampuan fungsional, serta komplikasi yang potensial terjadi pasca intervensi fraktur ankle bimalleolar sudah banyak dilakukan.…”
Fraktur ankle bimalleolar merupakan jenis fraktur yang menyebabkan ketidakstabilan pada struktur anatomis sendi ankleatau sendi talokrural. Fraktur ini berpotensi menimbulkan gejala sisa pada pasien sehingga diperlukan manajemen intervensi adekuat untuk mengembalikan kondisi struktur maupun fungsi optimal. Systematic review ini bertujuan untuk mengetahui hasil evaluasi status struktural, status fungsional, dan komplikasi pasca intervensi fraktur ankle bimalleolar. Protokol PRISMA digunakan untuk menentukan langkah sistematis dan kriteria eligibility (kelayakan) sebagai pedoman menyeleksi artikelpenelitian. Rentangan tahun publikasi artikel penelitian adalah 2015-2020. Penilaian kualitas dan risiko bias dilakukan dengan kriteria OCEBM dan Cochrane. Sejumlah 7 artikel penelitian dari 249 artikel yang berpotensi diinklusi. Total subjek 496 (14-91 tahun) melaporkan hasil evaluasi intervensi operatif dan 1 studi melakukan perbandingan konservatif. Sebanyak 99,6% (n=494) subjek mencapai union, sedangkan non-union ditemukan pada 2 subjek dengan tindakan konservatif. Instabilitas struktural ditemukan pada 6 subjek dengan medial clear space > 4mm. Status fungsional dengan AOFAS, OMA, dan Biard and Jackson didapatkan 98,9% pada rentang sedang-baik, 5 subjek melaporkan skor buruk, dan tidak ada subjek melaporkan restriksi fungsional. Untuk komplikasi, kondisi yang ditemukan paling umum yaitu nyeri sedang 43,1%, osteoarhtitis ankle grade 1, serta infeksi superfisial dan dalam yang sembuh dengan intervensi antibiotik. Capaian status struktural union sangat tinggi (99,6%), namun 2 subjek mengalami non-union pada kelompok intervensi konservatif. Status fungsional pasien tercapai pada kategori sedang-sangat baik (98,9%) dan tanpa adanya restriksi fungsional meskipun terdapat 5 subjek dengan skor buruk. Komplikasi yang muncul pada pasien umumnya adalah nyeri sedang (43,1%), osteoarthritis ankle grade 1, serta infeksi superfisial dan dalam.
Kata kunci : evaluasi pasca intervensi, fraktur ankle bimalleolar
“…Open reduction and internal fixation (ORIF) are typically performed when surgery is indicated. While good clinical outcomes have been extensively reported in the literature [ 10 , 19 , 21 ], minor and major complications (i.e. thromboembolic events, infection, incomplete wound healing, fracture malreduction, malunion, non-union, nerve injury, etc.)…”
Background
Unstable fractures often necessitate open reduction and internal fixation (ORIF), which generally yield favourable outcomes. However, the impact of surgical trainee autonomy on healthcare quality in these procedures remains uncertain. We hypothesized that surgery performed solely by residents, without supervision or participation of an attending surgeon, can provide similar outcomes to surgery performed by trauma or foot and ankle fellowship-trained orthopaedic surgeons.
Methods
A single-center cohort of an academic level-1 trauma center was retrospectively reviewed for all ankle ORIF between 2015 and 2019. Data were compared between surgery performed solely by post-graduate-year 4 to 6 residents, and surgery performed by trauma or foot and ankle fellowship-trained surgeons. Demographics, surgical parameters, preoperative and postoperative radiographs, and primary (mortality, complications, and revision surgery) and secondary outcome variables were collected and analyzed. Univariate analysis was performed to evaluate outcomes.
Results
A total of 460 ankle fractures were included in the study. Nonoperative cases and cases operated by senior orthopaedic surgeons who are not trauma or foot and ankle fellowship-trained orthopaedic surgeons were excluded. The average follow-up time was 58.4 months (SD ± 12.5). Univariate analysis of outcomes demonstrated no significant difference between residents and attendings in complications and reoperations rate (p = 0.690, p = 0.388). Sub-analysis by fracture pattern (Lauge-Hansen classification) and the number of malleoli involved and fixated demonstrated similar outcomes. surgery time was significantly longer in the resident group (p < 0.001).
Conclusion
The current study demonstrates that ankle fracture surgery can be performed by trained orthopaedic surgery residents, with similar results and complication rates as surgery performed by fellowship-trained attendings. These findings provide valuable insights into surgical autonomy in residency and its role in modern clinical training and surgical education.
Level of evidence
Level III – retrospective cohort study.
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