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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 5  |  Issue : 3  |  Page : 157-161

Functional assessment of surgically managed ankle fractures


Department of Orthopaedics, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India

Date of Submission21-Feb-2022
Date of Decision28-Mar-2022
Date of Acceptance12-Apr-2022
Date of Web Publication1-Sep-2022

Correspondence Address:
C Lalithmohan
Associate Professor, Department of Orthopaedics, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad - 500 082, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jodp.jodp_16_22

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  Abstract 


Background: Civilization has made man more prone to injuries. Ankle fractures are one of the most common injuries treated by orthopedic surgeons. Aims and Objectives: The aim of the study is to assess the functional outcome in surgically managed ankle fractures. Materials and Methods: Sixty patients were included in this study with ankle fractures that were surgically treated at NIMS Hospital, Hyderabad. Observations: The study had a male preponderance of 66.6%, with road traffic accidents being the major cause of injury. Supination-external rotation was the most common mechanism of injury and Weber's type B fractures were the most common type of fracture. The associated fractures and injuries noted and the comorbidities seen in these patients have been enumerated. Open reduction and internal fixation under image intensifier control was done in all patients. Postoperatively, patients were immobilized with a plaster splint for a period of 3–6 weeks and were followed up with full weight-bearing walking and active range of movement of ankle exercises. The final outcome as per the Weber's radiological criteria was 66.6% good, 26.6% fair, and 6.8% poor result which showed a good correlation between the immediate postoperative radiological score and the final radiological outcome. The factors that affected the final poor outcome were late presentation, patients with fracture subluxation, post massaging, the presence of long-standing and uncontrolled diabetes, and old age. Conclusion: The present study suggests that anatomical reduction of the ankle fracture and restoration of the joint congruity at the earliest will give a good functional outcome. The postoperative immobilization in a plaster slab up to 3–6 weeks (depending on associated injuries, fracture severity, bone quality, quality of fixation, and patient compliance) does not affect the final outcome with respect to achieving the ankle and subtalar range of movements as most of the patients had achieved full range of motion at the end of 12 weeks.

Keywords: Ankle fracture, open reduction and internal fixation, supination-external rotation


How to cite this article:
Kiran Kumar K K, Lalithmohan C, Pradeep K S, Chandrashekhar P. Functional assessment of surgically managed ankle fractures. J Orthop Dis Traumatol 2022;5:157-61

How to cite this URL:
Kiran Kumar K K, Lalithmohan C, Pradeep K S, Chandrashekhar P. Functional assessment of surgically managed ankle fractures. J Orthop Dis Traumatol [serial online] 2022 [cited 2022 Dec 3];5:157-61. Available from: https://jodt.org/text.asp?2022/5/3/157/355238




  Introduction Top


Injuries around the ankle are more frequent in adults. The mean age at injury is 45 years[1] significantly older than that of patients sustaining isolated ankle sprains.[2] Both injuries have a bimodal distribution, with peak incidences of ankle fractures in younger men and older women and a 50-year gap between peaks.[1],[3] These are typically low-energy injuries, with the majority occurring due to simple falls or sport.[1],[3],[4] Even open ankle fractures are predominantly low-energy injuries caused by simple falls, with the highest incidence in elderly women. As fractures of the ankle have been treated with various modes of internal fixation devices, the best possible implant is determined according to the anatomy of the fracture. In the postoperative period, the protocol of mobilization of the ankle has been a topic of conflict. The final outcome of a fractured ankle is of prime importance, as the treatment should benefit the patient just not in the short term but also in the long term. The treatment of fractures has its challenges in cases where the fracture is complicated by comorbid conditions such as diabetes mellitus, peripheral vascular diseases, and neuropathic conditions which complicates the treatment and influences the overall outcome. A thorough understanding of the ankle anatomy, mechanism of the injury, interpretation of the radiographs, and adherence to basic principles of fracture management are the basis for a good result. Considering all of the above, this study will try to analyze the results of ankle fractures treated at NIMS Hospital, Hyderabad.

Aim of the study

The aim of the study is to assess the functional outcome in surgically managed ankle fractures at our hospital.

Objectives

  1. To analyze and present the outcome in different types of ankle injuries
  2. To assess the time taken for full weight-bearing
  3. To assess complications in the postoperative period of surgically managed ankle fractures
  4. To explore functional outcome and factors related to return to work.



  Materials and Methods Top


A prospective study was undertaken in the field of management of displaced ankle fractures regarding the role of anatomic reduction and internal fixation by various methods in Nizam's Institute of Medical Sciences, Hyderabad. All surgically managed ankle fractures during the period from February 2018 to May 2019 were studied clinically and radiographically, and the data were obtained and analyzed.

Inclusion of cases

All displaced ankle fractures including malleolar and distal fibular fractures in adults were included. Undisplaced fractures and the fractures treated by conservative methods were excluded from the study. Pilon fractures and only ligamentous injuries were excluded from the study.


  Observations and Results Top


This study is done on patients who sustained ankle fractures and admitted in Nizam's Institute of Medical Sciences, Hyderabad. Those ankle fracture patients who were surgically managed with internal fixation between February 2018 and 2019 May and met inclusion criteria are taken into study. Total 60 patients fulfilled our criteria.

Age and sex incidence

Maximum number of patients in our study ranged between 21 and 30 years, and males were predominant [Table 1].
Table 1: Sex incidence in different age groups

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Mechanism of injury as per Lauge-Hansen's classification

Supination-external rotation injury was the most common mechanism of injury in our study as per the Lauge-Hansen's classification comprising up to 47% of the total number [Table 2].
Table 2: Incidence of fractures depending on the mechanism of injury

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Type of fracture as per Weber's classification

Weber's type B fracture was the most common type in our study comprising 58.3% of patients [Table 3].
Table 3: Radiological types depending on Weber's classification

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Side of ankle fracture

Left-sided fractures were more predominant than the right side in our study comprising 51.77% [Table 4].
Table 4: The side of involvement of fractures

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Causes of injury

Road traffic accidents were the most common cause of injury in our study [Table 5].
Table 5: Different causes of injury and their incidence

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Type of fracture

Number of malleoli involved

Only 18% patients had isolated malleolar fracture [Table 6].
Table 6: Number of malleoli involved

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Associated fracture subluxation

There are only 13 patients with subluxation of ankle joint post fracture out of 60 patients.

AO–OTA classification

In our study, majority of the people belong to 44-B3 type of fracture, i.e., trans-syndesmotic fibula fracture with medial side lesion and Volkmann fracture (fracture of posterolateral rim) [Table 7].
Table 7: Depicting type of fracture

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Syndesmotic injury

In our study, 37% of patients got syndesmotic injuries that were managed with syndesmotic screw fixation.

Type of fixation in particular fracture

In [Table 8], among the 54 lateral malleolar (or distal fibular) fixations, 44 (81%) were done with tubular plate and 10 (19%) were done with rush nail. Among the 55 medial malleolar fixation, malleolar or cancellous screw fixation was done in 46 (84%) patients and Kirschner wire fixation in 9 (16%) patients. Among 22 patients with posterior malleolar fracture, 3 patients were fixed with plating and lag screw, while in the rest of 22 patients, no fixation was required as it got reduced with fixation of other malleoli. The syndesmotic screw was applied in 22 fractures. All were placed through fibular plate except one patient.
Table 8: Distribution according to type of fixation in particular fracture

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The cases after discharge were followed up at 2 weeks, 6 weeks, 3 months, and 6 months and at the end of 1 year regularly. The average time for fracture union was 6 months. Progress in functional outcome and complications associated were assessed at each follow-up.

The complications encountered were delayed wound healing in two patients. The wounds of these two patients healed at 3 weeks with regular dressings.

Three patients had ankle stiffness postoperatively; all had delayed presentation to hospital post native massage and are not keen on physiotherapy.

One case had a discharge from the incision site over the medial malleolus after 1 month which showed no evidence of deep infection. The wound healed over a time of 1 month without any further complications.

Three patients developed arthritis. One patient had associated Hawkins' type 2 talus fracture which was also internally fixed. She developed avascular necrosis of the talar dome and osteoarthritis of the ankle. One patient presented to us very late after 3 months with malunited ankle fracture who developed post traumatic osteoarthritis. The third patient also came to us late after 3 months with history of massages with Cotton's fracture and talar subluxation.

Final outcome of our study as per Weber's criteria

All the patients who had good results returned to normal activity and had regained their full ankle movements by the end of 6 months [Table 9].
Table 9: Depicts the percentage of the results based on Weber's criteria

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Those patients with fair results complained of ankle and foot swelling which was noticed toward the end of the day and reduced with rest and elevation. Some pain was related to activity.

Final outcome of our study as per Olerud and Molander Ankle score and American Orthopedic Foot and Ankle Society score

The functional outcome was divided into excellent, good, fair, or poor as per the Olerud and Molander Ankle scale and American Orthopedic Foot and Ankle Society score.

Among the 60 patients, we achieved excellent and good results in 56 (93%) patients whereas poor results seen only in 4 patients.


  Analysis and Discussion Top


The fractures of the ankle are injuries seen in young and middle-aged patients commonly. The mean age in our series was noted to be 39 years, with a male predominance of 66.6%.

Sex distribution in our study showed a male preponderance compared to other studies [Table 10].[5],[6] The most common etiology of fracture in our study is road traffic accidents (23/60). Men are more involved in road accidents, hence male preponderance in our study.
Table 10: Sex distribution in various studies

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The mean age in our study was comparable to other studies [Table 11]. Young people are more involved in road traffic accidents; hence, mean age in our study includes young adults.
Table 11: Mean age distribution in various studies

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The findings were similar to those of Leistal[7] and Freiburg.[8]

The most common mechanism of injury was supination-external rotation injury, with 46% incidence [Table 12].
Table 12: Mechanism of injury

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The findings were similar to observations of Roberts S R[5] and Beris et al.[6]

According to Daly et al.,[4] there was a relationship between the severity of trauma and the nature of the ankle fracture. In our study, most of the supination-external rotation injuries were seen in patients of slip and fall which is a moderate type of trauma. The majority of the patients in our study being in Weber's type B having road traffic accident as mode of injury also reflect the severity of trauma with Weber's type [Table 13].
Table 13: Weber's type of injury

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In this study, left ankle was more affected, i.e., 31 patients (51.7%) [Table 14].
Table 14: Side affected

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The findings were similar to observations of Roberts S R[5] and Beris[6] et al.

The most common mode of injury was road traffic accident. The findings were similar to observations of Lee et al [Table 15].[11]
Table 15: Mode of injury

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In the final score as per the Weber and Krause[12-14]'s criteria, the objective signs and subjective symptoms were noted and compared with the radiological criteria. All the comparisons were made once the fractures united and at later follow-ups.

The results of other studies were compared with our final outcome. This was divided into two groups of excellent and poor results in each of the fracture types. The results when compared showed a comparable result as shown in [Table 16].
Table 16: Functional outcome

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Comparison of complications with other studies

The number of complications noted was nine in six patients, the most common complication being wound healing problems. Arthritis was seen in three cases. This is due to late presentation, fracture subluxation, and post massaging. No major infection was noted [Table 17].
Table 17: Comparison of complications with other studies

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We tried to analyze the association between syndesmotic injury and range of motion, taking the null hypothesis as “presence of syndesmotic injuries will not decrease postoperative range of motion.” The P value came as 0.14 suggesting it as insignificant. Hence, based on our study, we suggest that syndesmotic injuries will have an effect on postoperative range of motion.

Similarly, we tried to analyze the association between fracture subluxation and presence of arthritic changes in ankle postoperatively taking null hypothesis as “presence of ankle fracture subluxation will result in arthritic changes at a later date.” The P value came as 0.9 suggesting it as insignificant. Hence, based on our study, we suggest that not all cases of ankle fracture subluxation will result in postoperative arthritic changes.

Immediate closed reduction and immobilization, careful soft tissue handling during exposure and anatomical reduction, rigid fixation, identification and appropriate treatment of syndesmotic and posterior malleolar fractures and early mobilization have resulted in good ankle scores and functional outcome in nearly all patients.


  Conclusion Top


  1. The fractures of the ankle are commonly seen in the young adult male population, with road traffic accidents being the common cause. They must be properly reconstructed in order to get back to baseline daily routine activities, allowing early range of motion and weight-bearing as tolerated.
  2. Our study used Lauge-Hansen's classification for mechanism of injury and Weber's classification for radiological classification. We recommend the use of Weber's classification for management which is easier for classification and radiological assessment.
  3. In this series, most of the cases are Weber's type B and supination-external rotation injury, which need to be managed operatively.
  4. Tricortical syndesmotic screw fixation gives a superior and stable fixation of syndesmotic ankle injuries. Care should be taken to avoid overcompression of syndesmotic screw as this may affect range of motion and functional outcome.
  5. Restoration of fibular length and normal bend of lateral malleolus can be achieved only by plating.
  6. Internal fixation after reduction of swelling, achieving joint congruity, immobilization until soft-tissue healing, and early ankle rehabilitation achieves good functional results.
  7. In this series, we have operated mainly on closed ankle fractures predominantly young age group, of which the outcome and results are satisfactory. Meta-analysis is required to explore the findings in the current study.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Court-Brown CM, McBirnie J, Wilson G. Adult ankle fractures – An increasing problem? Acta Orthop Scand 1998;69:43-7.  Back to cited text no. 1
    
2.
Wang F, Wera G, Knoblich GO, Chou LB. Pulmonary embolism following operative treatment of ankle fractures: A report of three cases and review of the literature. Foot Ankle Int 2002;23:406-10.  Back to cited text no. 2
    
3.
Jensen SL, Andresen BK, Mencke S, Nielsen PT. Epidemiology of ankle fractures. A prospective population-based study of 212 cases in Aalborg, Denmark. Acta Orthop Scand 1998;69:48-50.  Back to cited text no. 3
    
4.
Daly PJ, Fitzgerald RH Jr., Melton LJ, Ilstrup DM. Epidemiology of ankle fractures in Rochester, Minnesota. Acta Orthop Scand 1987;58:539-44.  Back to cited text no. 4
    
5.
Roberts RS. Surgical treatment of displaced ankle fractures. ClinOrthopRelat Res.1983;172: 164-70.  Back to cited text no. 5
    
6.
Beris AE, Kabbani KT, Xenakis TA, Mitsionis G, Soucacos PK, Soucacos PN. Surgical treatment of malleolar fractures – a review of 144 patients. ClinOrthopRelat Res.1997;341:90-8.  Back to cited text no. 6
    
7.
Liestal. Evaluation of ankle fractures, Non operative and Operative treatment. CORR 1979 No 138, p 111.  Back to cited text no. 7
    
8.
Freiburg. Evaluation of ankle fractures, Non operative and Operative treatment. CORR 1979;No 138:111-9.  Back to cited text no. 8
    
9.
St Gallen. Evaluation of ankle fractures, Non operative and Operative treatment. CORR 1979;No 138:111-9.  Back to cited text no. 9
    
10.
Baird RA, Jackson ST. Fractures of the distal part of the fibula with associated disruption of the deltoid ligament, treatment without repair of the deltoid ligament. J Bone Joint Surg Am 1987;69:1346-52.  Back to cited text no. 10
    
11.
Lee YS, Huang HL, Lo TY, Huang CR. Lateral fixation of AO type-B2 ankle fractures in the elderly: The Knowles pin versus the plate. Int Orthop 2007;31:817-21.  Back to cited text no. 11
    
12.
Weber M, Krause F. Peroneal tendon lesions caused by antiglide plates used for fixation of lateral malleolar fractures: The effect of plate and screw position. Foot Ankle Int 2005;26:281-5.  Back to cited text no. 12
    
13.
Eugene J Carrage. et al. Early complications in the operative treatment of ankle fractures. Influence of delay before operation. JBJS 1991;73 B, p 79.  Back to cited text no. 13
    
14.
Beauchamp.C.G. et al Displaced ankle fractures in patients over 50 yrs of age. JBJS 1983 65B.p 329.  Back to cited text no. 14
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14], [Table 15], [Table 16], [Table 17]



 

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