Michel P. J. van den Bekerom

Biomechanical and Clinical Evaluation of Posterior Malleolar Fractures. A Systematic Review of the Literature

INTRODUCTION Ankle fractures often have involvement of the posterior malleolus. Treatment guidelines exist based on limited biomechanical evidence and still is considered controversial. The objective of this article is to review the biomechanical literature concerning changes in tibiotalar contract area, changes in contact pressures, changes in ankle stability and incongruency of the joint after a posterior malleolar ankle fracture, and to review the clinical literature concerning the outcome of operative and nonoperative treatment of these fractures. Ultimately, the goal is to try to formulate helpful recommendations for clinical practice. MATERIAL The databases Pubmed/Medline, Cochrane Database of Systematic Reviews, Cochrane Clinical Trial Register, and Embase were searched from 1988 to November 2007 to identify studies relating to changes in tibiotalar contact area, contact pressures, ankle stability, clinical outcome, and radiographic osteoarthritis after a posterior malleolar fracture. The search was restricted to articles written in the English, German, and Dutch language. RESULTS Eight biomechanical studies, involving 96 cadaveric ankles were included and 10 clinical studies, involving 447 fractured ankles, were included. DISCUSSION No consensus in the literature was found as to which fragment size of the posterior malleolus (=posterior tibial margin) should be internally fixed. This is partially because of the lack of standardization in examining functional outcomes, making it difficult to compare results. It is not the peak pressure or changes in tibiotalar contact area, but rather the changes in peak pressure distribution that play a large role in posttraumatic arthritis development. It seems important to restore the medial and lateral constraints of the ankle because these, rather than the articular surfaces, provide the majority of ankle stability after an ankle fracture involving the posterior malleolar ankle fracture.

Operative aspects of the syndesmotic screw: Review of current concepts

The distal tibiofibular syndesmosis is important for stability of the ankle mortise and thus for weight transmission and walking. Syndesmotic injuries are most commonly associated with fibular fractures, but they can also occur in isolation or with damage to the lateral ankle ligament after traumatic supination. The need for trans-syndesmotic fixation of the distal tibiofibular joint has been controversial. The goal of this review was to collect evidence on the technical aspects of performing an osteosynthesis using a syndesmotic screw and to formulate some recommendations for clinical practice.

Long-term outcome after 1822 operatively treated ankle fractures: A systematic review of the literature

Abstract The aim of this literature review is to systematically gather the highest level of available evidence on the long-term outcome after operatively treated ankle fractures in the English, German and Dutch literature. A search term with Boolean operators was constructed. The search was limited to humans and adults and the major databases were searched from 1966 to 2008 to identify studies relating to functional outcome, subjective outcome and radiographic evaluation at least 4 years after an operatively treated ankle fracture. Of the 42 initially relevant papers, 18 met our inclusion criteria. A total of 1822 fractures were identified. The mean sample-size weighted follow-up was 5.1 years. The initial number of patients that were included in the studies was 2724, which results in a long-term follow-up success rate of 66.9%. Regarding the fracture reduction we found 4 papers reporting on 106 fractures. Of the fractures that were classified according to Danis–Weber, 736 were eligible for correlation with the long-term outcome. In 442 fractures a comparison was possible between supination–external rotation stage 2 and 4 of the Lauge-Hansen classification. Only one study reported on the influence of initial cartilage lesions on the outcome. Regarding the involvement of the posterior malleolus, two studies reported on the long-term outcome. None of the studies addressed the influence of hindfoot varus or valgus on the long-term outcome after ankle fracture. Only 79.3% of the optimally reduced fractures show good to excellent long-term outcome. The Weber A type fractures do not show a better long-term outcome than Weber B type fractures. Recommendations for future research were formulated.

Methods to diagnose acute anterior cruciate ligament rupture: a meta-analysis of physical examinations with and without anaesthesia.

PurposeThe aims of this meta-analysis were to determine the sensitivity and specificity of the Lachman, pivot shift and anterior drawer test for acutecomplete ACL rupture in the office setting and under anaesthesia. It was hypothesized that the Lachman test is the most sensitive and the pivot shift test the most specific. Secondly, it was hypothesized that the sensitivity and specificity of all three exams increases when the examination is performed under anaesthesia.MethodsAn electronic database search was performed using MEDLINE and EMBASE. All cross-sectional and cohort studies comparing one or more physical examination tests for diagnosing acute complete ACL rupture to an accepted reference standard such as arthroscopy, arthrotomy and MRI were included.ResultsTwenty studies were identified and included. The overall sensitivity of the Lachman test was 0.81 and the specificity 0.81; with anaesthesia, the sensitivity was 0.91 and the specificity 0.78. For the anterior drawer test, the sensitivity was 0.38 and the specificity 0.81; with anaesthesia, the sensitivity was 0.63 and the specificity 0.91. The sensitivity of the pivot shift test was 0.28 and the specificity 0.81; with anaesthesia, the sensitivity was 0.73 and the specificity 0.98.ConclusionIn the office setting, the Lachman test has the highest sensitivity for diagnosing an acute, complete ACL rupture, while all three tests had comparable specificity. When the examination was performed under anaesthesia, the Lachman test still obtained the highest sensitivity, but the pivot shift test was the most specific.Level of evidenceMeta-analysis of diagnostic test accuracy, Level II.

What Is the Evidence for Rest, Ice, Compression, and Elevation Therapy in the Treatment of Ankle Sprains in Adults?

CONTEXT Ankle sprains are common problems in acute medical care. The variation in treatment observed for the acutely injured lateral ankle ligament complex in the first week after the injury suggests a lack of evidence-based management strategies for this problem. OBJECTIVE To analyze the effectiveness of applying rest, ice, compression, and elevation (RICE) therapy begun within 72 hours after trauma for patients in the initial period after ankle sprain. STUDY SELECTION Eligible studies were published original randomized or quasi-randomized controlled trials concerning at least 1 of the 4 subtreatments of RICE therapy in the treatment of acute ankle sprains in adults. DATA SOURCES MEDLINE, Cochrane Clinical Trial Register, CINAHL, and EMBASE. The lists of references of retrieved publications also were checked manually. DATA EXTRACTION We extracted relevant data on treatment outcome (pain, swelling, ankle mobility or range of motion, return to sports, return to work, complications, and patient satisfaction) and assessed the quality of included studies. If feasible, the results of comparable studies were pooled using fixed- or random-effects models. DATA SYNTHESIS After deduction of the overlaps among the different databases, evaluation of the abstracts, and contact with some authors, 24 potentially eligible trials remained. The full texts of these articles were retrieved and thoroughly assessed as described. This resulted in the inclusion of 11 trials involving 868 patients. The main reason for exclusion was that the authors did not describe a well-defined control group without the intervention of interest. CONCLUSIONS Insufficient evidence is available from randomized controlled trials to determine the relative effectiveness of RICE therapy for acute ankle sprains in adults. Treatment decisions must be made on an individual basis, carefully weighing the relative benefits and risks of each option, and must be based on expert opinions and national guidelines.

Surgical treatment of post-traumatic elbow stiffness: a systematic review

BACKGROUND Trauma to the elbow is a common cause of joint stiffness that might require surgical release. Release of the stiff elbow can be done by open or arthroscopic approach. There is no high-level evidence for the best surgical treatment modality for post-traumatic elbow stiffness. The objective of this article was to review current available literature of studies reporting on open or arthroscopic release of post-traumatic elbow stiffness. METHODS A comprehensive literature search was performed. All titles and abstracts of potentially relevant studies were reviewed, with a set of predefined inclusion and exclusion criteria. After the initial assessment for inclusion, 2 authors extracted data independently from the included articles. RESULTS Thirty articles were included, with an overall enrolment of 798 patients. No randomized controlled trials were retrieved. The first article was published in 1989 and the most recent in 2012. There were 4 different kinds of treatment modalities identified from the included studies: 1) open arthrolysis; 2) arthroscopic arthrolysis; 3) open arthrolysis with external fixation; and 4) open arthrolysis with distraction arthroplasty. The gain in range of motion was 51°, 40°, 88°, and 56° for groups 1-4, respectively. The average percentage of complications was 23, 5, 73, and 58 for groups 1-4, respectively. CONCLUSION Current literature is not sufficient enough to draw firm statistically based conclusions. However, as the amount of complications seems to rise with the extent of the surgical procedure, we would advise to treat as less invasive as possible (grade C).

Current Concepts Review: Operative Techniques for Stabilizing the Distal Tibiofibular Syndesmosis

The distal tibiofibular syndesmosis is essential for the stability of the ankle joint that is required for weight transmission and walking.4,9,42 The syndesmosis consists of the anterior-inferior tibiofibular ligament, posterior-inferior tibiofibular ligament, inferior transverse tibiofibular ligament, and interosseous ligament. This complex stabilizes the mortise by securing the fibula in the fibular notch (incisura fibularis tibiae). Syndesmotic injuries most commonly are caused by pronation-external rotation, pronation-abduction and, less frequently, a supination-external rotation mechanism (DanisWeber C injuries).31 These forces cause the talus to abduct or to rotate externally in the mortise, leading to disruption of the syndesmotic ligaments.31,55 Anatomical restoration of the disrupted distal tibiofibular syndesmosis is essential.54 Widening and chronic instability of the distal tibiofibular syndesmosis have been correlated with poor functional outcomes and the development of osteoarthritis.11,16,41,44,52 Because nonoperative treatment cannot effectively stabilize the distal tibiofibular syndesmosis during healing, operative fixation often is recommended. However, the need for transsyndesmotic fixation of the distal tibiofibular joint is controversial, and recommendations for fixation for specific ankle injury patterns are conflicting.6 Other areas of controversy include the optimal number of cortices, the appropriate size of the screws, the position of the ankle joint during screw

Delayed operative treatment of syndesmotic instability. Current concepts review.

OBJECTIVE To review the literature concerning articles evaluating the delayed operative treatment of isolated syndesmotic instability. MATERIAL AND METHODS The main databases Pubmed/Medline, Cochrane Database of Systematic Reviews, Cochrane Clinical Trial Register, Current Controlled Trials and Embase were searched from 1988 to September 2008 to identify studies relating to the late reconstruction of the distal tibiofibular syndesmosis after isolated syndesmotic injury. The level of evidence of the included articles was scored. RESULTS Fifteen articles were identified, involving 94 ankles with a delayed reconstruction for isolated syndesmotic instability. CONCLUSION In subacute (6 weeks to 6 months) total ruptures the focus is to restore the normal anatomy by repair of the ruptured ligament with placement of a syndesmotic screw. On base of the literature in combination with experience in clinical practice some guidelines are formulated. If inadequate remnants of the anterior inferior tibiofibular ligament (AITFL) are present, a tendon graft can be used. The insertion of the AITFL on the tibia can be medialised with a bone block and fixed with a screw. For the treatment of persistent widening and late instability these reconstruction techniques have to be used combined with debridement and placement of a syndesmotic screw to protect the reconstruction. Most adequate treatment for chronic syndesmotic instability (>6 months) is the creation of a synostosis to stabilise the distal tibiofibular joint. Late repairs give satisfactory but less favourable outcome as compared to properly treated acute injuries. It is not easy to regain complete stability by means of these secondary procedures.

The diagnosis and treatment of deltoid ligament lesions in supination-external rotation ankle fractures: a review.

The supination–external rotation or Weber B type fracture exists as a stable and an unstable type. The unstable type has a medial malleolus fracture or deltoid ligament lesion in addition to a fibular fracture. The consensus is the unstable type and best treated by open reduction and internal fixation. The diagnostic process for a medial ligament lesion has been well investigated but there is no consensus as to the best method of assessment. The number of deltoid ruptures as a result of an external rotation mechanism is higher than previously believed. The derivation of the injury mechanism could provide information of the likely ligamentous lesion in several fracture patterns. The use of the Lauge-Hansen classification system in the assessment of the initial X-ray images can be helpful in predicting the involvement of the deltoid ligament but the reliability in terms of sensitivity and specificity is unknown. Clinical examination, stress radiography, magnetic resonance imaging, arthroscopy, and ultrasonography have been used to investigate medial collateral integrity in cases of ankle fractures. None of these has shown to possess the combination of being cost-effective, reliable and easy to use; currently gravity stress radiography is favoured and, in cases of doubt, arthroscopy could be of value. There is a disagreement as to the benefit of repair by suture of the deltoid ligament in cases of an acute rupture in combination with a lateral malleolar fracture. There is no evidence found for suturing but exploration is thought to be beneficial in case of interposition of medial structures.

Evidence for minimally invasive therapies in the management of chronic calcific tendinopathy of the rotator cuff: a systematic review and meta-analysis.

BACKGROUND This meta-analysis assessed the short-term to midterm effectiveness of minimally invasive treatments in the management of calcifying tendinopathy of the shoulder cuff, a common source of chronic shoulder pain that leads to pain, a decreased active range of motion, and loss of muscular strength. When conservative therapies fail, minimally invasive treatment options can be considered before resulting to surgery. MATERIALS AND METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to conduct this review. A systematic literature search was conducted in May 2013 to identify all studies that examined the short-term to midterm effectiveness of minimally invasive treatments for chronic calcifying tendinopathy. The primary end points were identified as function, pain, and total resorption rates. Grades of Recommendation Assessment, Development and Evaluation (GRADE) was used to assess the quality of evidence. RESULTS Included were 20 studies (1544 participants). Common methodological flaws were related to randomization. In general, there is moderate-quality GRADE evidence that high-energy extracorporeal shockwave therapy has a significant effect on pain relief and functional status compared with other interventions. There is variable-quality GRADE evidence on the efficiency of other interventions. CONCLUSION High-energy extracorporeal shockwave therapy is the most thoroughly investigated minimally invasive treatment option in the short-term to midterm and has proven to be a safe and effective treatment. Ultrasound-guided needling is safe but has not been proven to be more effective than an ultrasound-guided subacromial corticosteroid injection in recent level I research, and further research will have to prove its effectiveness.