Correlation of Incisura Anatomy With Syndesmotic Malreduction

Background: The anatomy of the syndesmosis is variable, yet little is known on the correlation between differences in anatomy and syndesmosis reduction results. The aim of this study was to analyze the correlation between syndesmotic anatomy and the modes of syndesmotic malreduction. Methods: Bilateral postreduction ankle computed tomography (CT) scans of 72 patients treated for fractures with syndesmotic disruption were analyzed. Incisura depth, fibular engagement into the incisura, and incisura rotation were correlated with degree of syndesmotic malreduction in coronal and sagittal planes as well as rotational malreduction. Results: Clinically relevant malreduction in the coronal plane, sagittal plane, and rotation affected 8.3%, 27.8%, and 19.4% of syndesmoses, respectively. The syndesmoses with a deep incisura and the fibula not engaged into the tibial incisura were at risk of overcompression, anteverted incisuras at risk of anterior fibular translation, and retroverted incisuras at risk of posterior fibular translation. Conclusions: Certain morphologic configurations of the tibial incisura increased the risk of specific syndesmotic malreduction patterns. Level of Evidence: Level III, comparative study

Periprosthetic fractures after shoulder arthroplasty: a systematic review

Purpose: The goal of this study was to review available literature on periprosthetic shoulder fractures to evaluate epidemiology, risk factors and support clinical decision-making regarding diagnostics, preoperative planning, and treatment options. Methods: Two authors cross-checked the PubMed and Web of Science medical databases. The inclusion criteria were as follows: original human studies published in English, with the timeframe not limited, and the following keywords were used: ‘periprosthetic shoulder fracture,’ ‘total shoulder arthroplasty periprosthetic fractures,’ ‘total shoulder arthroplasty fracture,’ and ‘total shoulder replacement periprosthetic fracture.’ Seventy articles were included in the review. All articles were retrieved using the aforementioned criteria. Results: The fracture rate associated with total shoulder arthroplasty varied between 0 and 47.6%. Risk factors for periprosthetic fractures were female gender, body mass index < 25 kg/m2, smoking, rheumatoid arthritis, and Parkinson’s disease. The most commonly used classification is the Wright and Coefield classification. Periprosthetic fractures can be treated both, conservatively and operatively. Conclusion: Periprosthetic fracture frequency after shoulder arthroplasty ranges from 0 to 47.6%. The most common location of the fracture is the humerus and most commonly occurs intraoperatively. The most important factor influencing treatment is stem stability. Fractures with stem instability require revision arthroplasty with stem replacement. Fractures with a stable stem depending on the location, displacement and bone stock quality can be treated both conservatively and operatively. For internal fixation plates with cables and screws are most commonly used

Ankle fracture – correlation of Lauge-Hansen classification and patient reported fracture mechanism

Category: Trauma Introduction/Purpose: The genetic Lauge-Hansen classification is considered to provide a link between mechanism of ankle injury and resulting fracture morphology. In this study, we addressed the question of agreement between the mechanism of the fracture as postulated by the Lauge-Hansen classification and mechanism reported by the patient in rotational ankle fractures. Understanding of the actual mechanisms of ankle fracture may guide treatment decisions. Methods: Of 110 screened patients with acute malleolar fractures, 78 were able to provide information on their fracture mechanism and were included in the study. The study group consisted of 43 women and 35 men with a mean age of 47.8 (range 19.5-88.4) years. Patients were asked to describe the direction of deformation with primary question being pronation and supination as demonstrated by the examiner. As hyperplantarflexion and hyperdorsiflexion has been spontaneously reported by the patients, these directions were added to the analysis. Radiographs were analyzed according to Lauge-Hansen classification and compared with fracture mechanisms reported by the patients. Results: The majority (35/78 = 44.8%) of patients reported pronation as their fracture mechanism, 27 (34.6%) patients reported supination, 15 (19.2%) patients reported hyperplantarflexion (3 pure, one combined with pronation and 11 combined with supination), and 1 patient reported hyperdorsiflexion combined with pronation. Radiographs revealed 61 supination-external rotation (79%), 1 supination-adduction (1.3%), 14 pronation-external rotation (18%), 1 pronation-abduction (1.3%) fractures. One x-ray was unclassifiable with the Lauge-Hansen classification. The patient reported mechanisms were in concordance with the mechanism deducted from the x-rays in 49% of cases. Only 17% of patients who recalled a pronation trauma actually had radiographs classified as pronation fractures while 76% of patients who recalled a supination trauma were also radiographically classified as having sustained supination type fractures. Conclusion: The Lauge-Hansen classification should be used with caution for determining the actual mechanism of injury as it was able to predict the patient reported fracture mechanism in less than 50% of cases. A substantial percentage of fractures appearing radiographically as supination type injuries may have been actually produced by a pronation fracture mechanism

EFAS Score — Multilingual development and validation of a patient-reported outcome measure (PROM) by the score committee of the European Foot and Ankle Society (EFAS)

Background: A scientifically sound validated foot and ankle specific score validated ab initio for different languages is missing. The aim of a project of the European Foot and Ankle Society (EFAS) was to develop, validate, and publish a new score(the EFAS-Score) for different European languages. Methods: The EFAS Score was developed and validated in three stages: (1) item (question) identification, (2) item reduction and scale exploration, (3) confirmatory analyses and responsiveness. The following score specifications were chosen: scale/subscale (Likert 0–4), questionnaire based, outcome measure, patient related outcome measurement. For stage 3, data were collected pre-operatively and at a minimum follow-up of 3 months and mean follow-up of 6 months. Item reduction, scale exploration, confirmatory analyses and responsiveness were executed using analyses from classical test theory and item response theory. Results: Stage 1 resulted in 31 general and 7 sports related questions. In stage 2, a 6-item general EFAS Score was constructed using English, German, French and Swedish language data. In stage 3, internal consistency of the scale was confirmed in seven languages: the original four languages, plus Dutch, Italian and Polish (Cronbach's Alpha >0.86 in all language versions). Responsiveness was good, with moderate to large effect sizes in all languages, and significant positive association between the EFAS Score and patient-reported improvement. No sound EFAS Sports Score could be constructed. Conclusions: The multi-language EFAS Score was successfully validated in the orthopaedic ankle and foot surgery patient population, including a wide variety of foot and ankle pathologies. All score versions are freely available at www.efas.co

Exorotated radiographic views have additional diagnostic value in detecting an osseous impediment in patients with posterior ankle impingement

Objectives A standard lateral radiograph is the first step in the diagnostic workup in patients with posterior ankle pain. Because of overprojection by other structures at suboptimal radiographic projection angle, often an os trigonum is not discovered or erroneously be mistaken for a hypertrophic posterior talar process. The aim of this study was to identify the projection angles at which a radiograph is optimal for detecting bony impediments in patients suffering from posterior ankle impingement. Methods Using ankle CT scans of patients with posterior ankle impingement, digitally reconstructed radiographs (DRRs) simulating 13 different radiographic projection angles were generated. The ankle CT scans served as a reference for the detection of an os trigonum and hypertrophic posterior talar process. Members of the Ankleplatform Study Group were invited to assess the DRRs, for presence or absence of an os trigonum or hypertrophic posterior talar process. Diagnostic accuracy and interobserver reliability were estimated for each projection angle. In addition, the diagnostic accuracy of the standard lateral view in combination with the rotated views was calculated. Results High sensitivity for detecting an os trigonum was found for +15° (90.3%), +20° (81.7%) and +25° (89.7%) degrees of exorotation. Specificity in this range of projection angles was between 89.6% and 97.8%. Regarding the presence of a hypertrophic posterior talar process, increased sensitivity was found for +15° (65.7%), +20° (61.0%), +25° (60.7%), +30° (56.3%) and +35° (54.5%). Specificity ranged from 78.0% to 94.7%. The combination of the standard lateral view in combination with exorotated views showed higher sensitivity. For detecting an os trigonum, a negative predictive value of 94.6% (+15°), 94.1% (+20°) and 96.1% (+25°) was found. Conclusion This study underlines the additional diagnostic value of exorotated views instead of, or in addition to the standard lateral view in detecting an osseous impediment. We recommend to use the 25° exorotated view in combination with the routine standard lateral ankle view in the workup of patients with posterior ankle pain. Level of evidence Level III