Stability-based classification for ankle fracture management and the syndesmosis injury in ankle fractures due to a supination external rotation mechanism of injury.

Harri Pakarinen
{"title":"Stability-based classification for ankle fracture management and the syndesmosis injury in ankle fractures due to a supination external rotation mechanism of injury.","authors":"Harri Pakarinen","doi":"10.3109/17453674.2012.745657","DOIUrl":null,"url":null,"abstract":"<p><p>The aim of this thesis was to confirm the utility of stability-based ankle fracture classification in choosing between non-operative and operative treatment of ankle fractures, to determine how many ankle fractures are amenable to non-operative treatment, to assess the roles of the exploration and anatomical repair of the AITFL in the outcome of patients with SER ankle fractures, to establish the sensitivities, specificities and interobserver reliabilities of the hook and intraoperative stress tests for diagnosing syndesmosis instability in SER ankle fractures, and to determine whether transfixation of unstable syndesmosis is necessary in SER ankle fractures. The utility of stability based fracture classification to choose between non-operative and operative treatment was assessed in a retrospective study (1) of 253 ankle fractures in skeletally mature patients, 160 of whom were included in the study to obtain an epidemiological profile in a population of 130,000. Outcome was assessed after a minimum follow-up of two years. The role of AITFL repairs was assessed in a retrospective study (2) of 288 patients with Lauge-Hansen SE4 ankle fractures; the AITFL was explored and repaired in one group (n=165), and a similar operative method was used but the AITFL was not explored in another group (n=123). Outcome was measured with a minimum follow-up of two years. Interobserver reliability of clinical syndesomosis tests (study 3) and the role of syndesmosis transfixation (study 4) were assessed in a prospective study of 140 patients with Lauge-Hansen SE4 ankle fractures. The stability of the distal tibiofibular joint was evaluated by the hook and ER stress tests. Clinical tests were carried out by the main surgeon and assistant, separately, after which a 7.5-Nm standardized ER stress test for both ankles was performed; if it was positive, the patient was randomized to either syndesmosis transfixation (13 patients) or no fixation (11 patients) treatment groups. The sensitivity and specificity of both clinical tests were calculated using the standard 7.5-Nm external rotation stress test as reference. Outcome was assessed after a minimum of one year of follow-up. Olerud-Molander (OM) scoring system, RAND 36-Item Health Survey, and VAS to measure pain and function were used as outcome measures in all studies. In study 1, 85 (53%) fractures were treated operatively using the stability based fracture classification. Non-operatively treated patients reported less pain and better OM (good or excellent 89% vs. 71%) and VAS functional scores compared to operatively treated patients although they experienced more displacement of the distal fibula (0 mm 30% vs. 69%; 0-2 mm 65% vs. 25%) after treatment. No non-operatively treated patients required operative fracture fixation during follow-up. In study 2, AITFL exploration and suture lead to equal functional outcome (OM mean, 77 vs. 73) to no exploration or fixation. In study 3, the hook test had a sensitivity of 0.25 and a specificity of 0.98. The external rotation stress test had a sensitivity of 0.58 and a specificity of 0.9. Both tests had excellent interobserver reliability; the agreement was 99% for the hook test and 98% for the stress test. There was no statistically significant difference in functional scores (OM mean, 79.6 vs. 83.6) or pain between syndesmosis transfixation and no fixation groups (Study 4). Our results suggest that a simple stability-based fracture classification is useful in choosing between non-operative and operative treatment of ankle fractures; approximately half of the ankle fractures can be treated non-operatively with success. Our observations also suggest that relevant syndesmosis injuries are rare in ankle fractures due to an SER mechanism of injury. According to our research, syndesmotic repair or fixation in SER ankle fracture has no influence on functional outcome or pain after minimum one year compared with no fixation.</p>","PeriodicalId":87168,"journal":{"name":"Acta orthopaedica. Supplementum","volume":"83 347","pages":"1-26"},"PeriodicalIF":0.0000,"publicationDate":"2012-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.3109/17453674.2012.745657","citationCount":"28","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Acta orthopaedica. Supplementum","FirstCategoryId":"1085","ListUrlMain":"https://doi.org/10.3109/17453674.2012.745657","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"","JCRName":"","Score":null,"Total":0}
引用次数: 28

Abstract

The aim of this thesis was to confirm the utility of stability-based ankle fracture classification in choosing between non-operative and operative treatment of ankle fractures, to determine how many ankle fractures are amenable to non-operative treatment, to assess the roles of the exploration and anatomical repair of the AITFL in the outcome of patients with SER ankle fractures, to establish the sensitivities, specificities and interobserver reliabilities of the hook and intraoperative stress tests for diagnosing syndesmosis instability in SER ankle fractures, and to determine whether transfixation of unstable syndesmosis is necessary in SER ankle fractures. The utility of stability based fracture classification to choose between non-operative and operative treatment was assessed in a retrospective study (1) of 253 ankle fractures in skeletally mature patients, 160 of whom were included in the study to obtain an epidemiological profile in a population of 130,000. Outcome was assessed after a minimum follow-up of two years. The role of AITFL repairs was assessed in a retrospective study (2) of 288 patients with Lauge-Hansen SE4 ankle fractures; the AITFL was explored and repaired in one group (n=165), and a similar operative method was used but the AITFL was not explored in another group (n=123). Outcome was measured with a minimum follow-up of two years. Interobserver reliability of clinical syndesomosis tests (study 3) and the role of syndesmosis transfixation (study 4) were assessed in a prospective study of 140 patients with Lauge-Hansen SE4 ankle fractures. The stability of the distal tibiofibular joint was evaluated by the hook and ER stress tests. Clinical tests were carried out by the main surgeon and assistant, separately, after which a 7.5-Nm standardized ER stress test for both ankles was performed; if it was positive, the patient was randomized to either syndesmosis transfixation (13 patients) or no fixation (11 patients) treatment groups. The sensitivity and specificity of both clinical tests were calculated using the standard 7.5-Nm external rotation stress test as reference. Outcome was assessed after a minimum of one year of follow-up. Olerud-Molander (OM) scoring system, RAND 36-Item Health Survey, and VAS to measure pain and function were used as outcome measures in all studies. In study 1, 85 (53%) fractures were treated operatively using the stability based fracture classification. Non-operatively treated patients reported less pain and better OM (good or excellent 89% vs. 71%) and VAS functional scores compared to operatively treated patients although they experienced more displacement of the distal fibula (0 mm 30% vs. 69%; 0-2 mm 65% vs. 25%) after treatment. No non-operatively treated patients required operative fracture fixation during follow-up. In study 2, AITFL exploration and suture lead to equal functional outcome (OM mean, 77 vs. 73) to no exploration or fixation. In study 3, the hook test had a sensitivity of 0.25 and a specificity of 0.98. The external rotation stress test had a sensitivity of 0.58 and a specificity of 0.9. Both tests had excellent interobserver reliability; the agreement was 99% for the hook test and 98% for the stress test. There was no statistically significant difference in functional scores (OM mean, 79.6 vs. 83.6) or pain between syndesmosis transfixation and no fixation groups (Study 4). Our results suggest that a simple stability-based fracture classification is useful in choosing between non-operative and operative treatment of ankle fractures; approximately half of the ankle fractures can be treated non-operatively with success. Our observations also suggest that relevant syndesmosis injuries are rare in ankle fractures due to an SER mechanism of injury. According to our research, syndesmotic repair or fixation in SER ankle fracture has no influence on functional outcome or pain after minimum one year compared with no fixation.

查看原文
分享 分享
微信好友 朋友圈 QQ好友 复制链接
本刊更多论文
踝关节骨折的稳定性分类及旋后外旋机制损伤所致踝关节骨折的联合损伤。
本论文旨在证实基于稳定性的踝关节骨折分类在选择非手术与手术治疗踝关节骨折中的作用,确定有多少踝关节骨折适合非手术治疗,评估骶髂韧带的探查和解剖修复在SER踝关节骨折患者预后中的作用,建立敏感性。钩和术中应力测试诊断SER踝关节骨折联合不稳定的特异性和观察者间可靠性,以及确定SER踝关节骨折不稳定联合的穿固定是否必要。一项回顾性研究(1)评估了基于稳定性的骨折分类在非手术和手术治疗之间选择的效用,该研究纳入了253例骨骼成熟患者的踝关节骨折,其中160例纳入研究,以获得13万人口的流行病学资料。结果是在至少两年的随访后评估的。在288例Lauge-Hansen SE4型踝关节骨折患者的回顾性研究(2)中评估了AITFL修复的作用;其中一组(n=165)探查并修复AITFL,另一组(n=123)采用类似的手术方法,但未探查AITFL。结果以最少两年的随访来衡量。在一项140例Lauge-Hansen SE4踝关节骨折患者的前瞻性研究中,评估了临床联合试验(研究3)和联合内固定(研究4)的观察者间可靠性。通过钩形和ER应力测试评估远端胫腓关节的稳定性。临床试验由主刀医师和助理医师分别进行,试验结束后对双踝行7.5 nm标准化内质网应激试验;如果检测结果为阳性,将患者随机分为韧带联合内固定治疗组(13例)和不内固定治疗组(11例)。以标准7.5 nm外旋应力试验为参考,计算两种临床试验的敏感性和特异性。在至少一年的随访后评估结果。所有研究均采用Olerud-Molander (OM)评分系统、RAND 36项健康调查和VAS来测量疼痛和功能。在研究1中,85例(53%)骨折采用基于稳定性的骨折分类进行手术治疗。与手术治疗的患者相比,非手术治疗的患者报告了更少的疼痛和更好的OM(良好或优秀89%对71%)和VAS功能评分,尽管他们经历了更多的腓骨远端移位(0 mm 30%对69%;治疗后0-2 mm 65% vs. 25%)。随访期间无非手术治疗患者需要手术骨折固定。在研究2中,AITFL探查和缝合导致相同的功能结果(OM平均值,77比73),无需探查或固定。在研究3中,hook试验的敏感性为0.25,特异性为0.98。外旋应力测试灵敏度为0.58,特异性为0.9。两项测试均具有极好的观察者间信度;钩子测试的一致性为99%,压力测试的一致性为98%。在功能评分(OM平均值,79.6 vs. 83.6)或疼痛方面,两组间无统计学差异(研究4)。我们的研究结果表明,简单的基于稳定性的骨折分类有助于选择非手术治疗还是手术治疗踝关节骨折;大约一半的踝关节骨折可以通过非手术治疗并获得成功。我们的观察还表明,由于SER损伤机制,相关的韧带联合损伤在踝关节骨折中很少见。根据我们的研究,与不固定相比,SER踝关节骨折的韧带联合修复或固定至少一年后对功能结局或疼痛没有影响。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
求助全文
约1分钟内获得全文 去求助
来源期刊
自引率
0.00%
发文量
0
期刊最新文献
Internal fixation of fragility fractures of the femoral neck. The young osteoarthritic hip: Clinical outcome of total hip arthroplasty and a cost-effectiveness analysis. Radiostereometric analysis of sacroiliac joint movement and outcomes of pelvic joint fusion. Complications in ankle fracture surgery. Determinants of outcome in lumbar spinal stenosis surgery.
×
引用
GB/T 7714-2015
复制
MLA
复制
APA
复制
导出至
BibTeX EndNote RefMan NoteFirst NoteExpress
×
×
提示
您的信息不完整,为了账户安全,请先补充。
现在去补充
×
提示
您因"违规操作"
具体请查看互助需知
我知道了
×
提示
现在去查看 取消
×
提示
确定
0
微信
客服QQ
Book学术公众号 扫码关注我们
反馈
×
意见反馈
请填写您的意见或建议
请填写您的手机或邮箱
已复制链接
已复制链接
快去分享给好友吧!
我知道了
×
扫码分享
扫码分享
Book学术官方微信
Book学术文献互助
Book学术文献互助群
群 号:481959085
Book学术
文献互助 智能选刊 最新文献 互助须知 联系我们:info@booksci.cn
Book学术提供免费学术资源搜索服务,方便国内外学者检索中英文文献。致力于提供最便捷和优质的服务体验。
Copyright © 2023 Book学术 All rights reserved.
ghs 京公网安备 11010802042870号 京ICP备2023020795号-1