Dynamic Stress Testing Is Unnecessary for Unimalleolar Supination-External Rotation Ankle Fractures with Minimal Fracture Displacement on Lateral Radiographs

Nortunen, Simo; Leskelä, Hannu-Ville; Haapasalo, Heidi; Flinkkilä, Tapio; Ohtonen, Pasi; Pakarinen, Harri

doi:10.2106/jbjs.16.00450

Cited by 12 publications

(14 citation statements)

References 28 publications

(74 reference statements)

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“…Patients with a supination external rotation type2-4 ankle fracture were included between January 2013 and October 2016 [16,23]. In-and exclusion criteria are shown in Fig.…”

Section: Trial Design and Populationmentioning

confidence: 99%

Weight-bearing or non-weight-bearing after surgical treatment of ankle fractures: a multicenter randomized controlled trial

Smeeing

Houwert

Briët

et al. 2018

Eur J Trauma Emerg Surg

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Purpose The goal of this study was to assess if unprotected weight-bearing as tolerated is superior to protected weightbearing and unprotected non-weight-bearing in terms of functional outcome and complications after surgical fixation of Lauge-Hansen supination external rotation stage 2-4 ankle fractures. Methods A multicentered randomized controlled trial was conducted in patients ranging from 18 to 65 years of age without severe comorbidities. Patients were randomized to unprotected non-weight-bearing, protected weight-bearing, and unprotected weight-bearing as tolerated. The primary endpoint of the study was the Olerud Molander Ankle Score (OMAS) 12 weeks after randomization. The secondary endpoints were health-related quality of life using the SF-36v2, time to return to work, time to return to sports, and the number of complications. Results The trial was terminated early as advised by the Data and Safety Monitoring Board after interim analysis. A total of 115 patients were randomized. The O'Brien-Fleming threshold for statistical significance for this interim analysis was 0.008 at 12 weeks. The OMAS was higher in the unprotected weight-bearing group after 6 weeks c(61.2 ± 19.0) compared to the protected weight-bearing (51.8 ± 20.4) and unprotected non-weight-bearing groups (45.8 ± 22.4) (p = 0.011). All other follow-up time points did not show significant differences between the groups. Unprotected weight-bearing showed a significant earlier return to work (p = 0.028) and earlier return to sports (p = 0.005). There were no differences in the quality of life scores or number of complications. Conclusions Unprotected weight-bearing and mobilization as tolerated as postoperative care regimen improved short-term functional outcomes and led to earlier return to work and sports, yet did not result in an increase of complications.

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“…Patients with a supination external rotation type2-4 ankle fracture were included between January 2013 and October 2016 [16,23]. In-and exclusion criteria are shown in Fig.…”

Section: Trial Design and Populationmentioning

confidence: 99%

Weight-bearing or non-weight-bearing after surgical treatment of ankle fractures: a multicenter randomized controlled trial

Smeeing

Houwert

Briët

et al. 2018

Eur J Trauma Emerg Surg

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“…Nortunen et al 23 assessed morphological factors on standard nonweight-bearing injury radiographs that may indicate stability. The authors evaluated 286 consecutive patients with an isolated lateral malleolus fracture without evidence of incongruity or medial widening on standard injury radiographs.…”

Section: Detecting Tibiotalar Instabilitymentioning

confidence: 99%

Management of Isolated Lateral Malleolus Fractures

Aiyer¹,

Zachwieja

Lawrie³

et al. 2019

J Am Acad Orthop Surg

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Isolated lateral malleolus fractures represent one of the most common injuries encountered by orthopaedic surgeons. Nevertheless, appropriate diagnosis and management of these injuries are not clearly understood. Ankle stability is maintained by ligamentous and bony anatomy. The deep deltoid ligament is considered the primary stabilizer of the ankle. In the setting of an isolated lateral malleolus fracture, identifying injury to this ligament and associated ankle instability influences management. The most effective methods for assessing tibiotalar instability include stress and weight-bearing radiographs. Clinical examination findings are important but less reliable. Advanced imaging may not be accurate for guiding management. If the ankle is stable, nonsurgical management produces excellent outcomes. In the case that clinical/radiographic findings are indicative of ankle instability, surgical fixation options include lateral or posterolateral plating or intramedullary fixation. Locking plates and small or minifragment fixation are important adjuncts for the surgeon to consider based on individual patient needs. AnatomyThe ankle is a complex joint that comprises the talus, medial and lateral malleoli, and tibial plafond. In addition to the osseous architecture of the ankle mortise, three groups of

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“…Increasingly, some have argued that the use of gravity or manual stress views may overestimate the need for surgery by eliciting subtle instability treatable by conservative means and that (1) either weight-bearing radiographs at time of injury and/or (2) a trial of protected weight bearing with repeat x-rays may be a better predictor of mortise stability. 7,10,22,47,55,64,65 A cadaveric study by Stewart and colleagues in 2012 59 sought to elucidate the effect deltoid incompetence has on the integrity of the ankle mortise with an applied axial load. Twelve cadavers were divided into 3 groups: intact ankles, isolated oblique fibular osteotomies, and osteotomized ankles with complete deltoid ligament transection.…”

Section: Physiologic Loading and Instabilitymentioning

confidence: 99%

Section: Physiologic Loading and Instabilitymentioning

confidence: 99%

“…Are stress views or a trial of weight bearing even necessary to predict instability in the patient who presents with an apparent isolated fibula fracture? Recently, Nortunen et al 47 investigated whether radiographic clues could be elicited from initial, non–weight-bearing radiographs to predict stability in a cohort of 286 patients who all underwent subsequent stress testing. The authors demonstrated that lateral malleolar fracture gapping of greater than 2 mm on initial lateral radiographs as well as other associated findings such as fracture comminution could predict instability and potentially obviate the need for additional stress imaging.…”

Section: Physiologic Loading and Instabilitymentioning

confidence: 99%

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Evaluation and Significance of Mortise Instability in Supination External Rotation Fibula Fractures: A Review Article

et al. 2018

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Dynamic Stress Testing Is Unnecessary for Unimalleolar Supination-External Rotation Ankle Fractures with Minimal Fracture Displacement on Lateral Radiographs

Abstract: Background: This study aimed to identify factors from standard radiographs that contributed to the

Cited by 12 publications

References 28 publications

Weight-bearing or non-weight-bearing after surgical treatment of ankle fractures: a multicenter randomized controlled trial

Weight-bearing or non-weight-bearing after surgical treatment of ankle fractures: a multicenter randomized controlled trial

Management of Isolated Lateral Malleolus Fractures

Evaluation and Significance of Mortise Instability in Supination External Rotation Fibula Fractures: A Review Article

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