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Are Outcomes of Bimalleolar Fractures Poorer Than Those of Lateral Malleolar Fractures with Medial Ligamentous Injury?
Nirmal C. Tejwani, MD1; Toni M. McLaurin, MD1; Michael Walsh, PhD1; Siraj Bhadsavle, MD1; Kenneth J. Koval, MD2; Kenneth A. Egol, MD1
1 Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, 550 First Avenue, NBV 21W 37, New York, NY 10016. E-mail address for N.C. Tejwani: Nirmal.tejwani@med.nyu.edu
2 Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, New York, NY

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2007 Jul 01;89(7):1438-1441. doi: 10.2106/JBJS.F.01006
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Abstract

Background: Recommendations for surgical treatment and expected outcomes differ for two unstable patterns of supination-external rotation ankle injuries. We compared the demographic characteristics and functional outcome following surgical stabilization between the two types of supination-external rotation type-4 fractures: distal fibular fracture with a deltoid ligament rupture and bimalleolar fracture.

Methods: Demographic data on 456 patients in whom an unstable fracture of the ankle was treated surgically were entered into a database and the patients were prospectively followed. Two hundred and sixty-six of these patients sustained either a bimalleolar fracture or a lateral malleolar fracture with insufficiency of the deltoid ligament and widening of the medial clear space. No medial fixation was used in the patients with a deltoid ligament injury. All patients followed a similar postoperative protocol. The patients were followed clinically and radiographically at three, six, and twelve months after the surgery. Function was assessed with the Short Musculoskeletal Function Assessment and the American Orthopaedic Foot and Ankle Society score.

Results: Bimalleolar fractures were more commonly seen in female patients, in those older than sixty years of age, and in patients with more comorbidities. There was no significant association between the fracture pattern and either diabetes or the length of the hospital stay. At a minimum of one year postoperatively, the patients with a bimalleolar fracture had significantly worse function, even after we controlled for all other variables. The overall complication rate, including elective hardware removal, was also higher in the group with a bimalleolar fracture (seventeen compared with nine patients).

Conclusions: At one year after surgical stabilization of an unstable ankle fracture, most patients experience little or mild pain and have few restrictions in functional activities. However, the functional outcome for those with a bimalleolar fracture is worse than that for those with a lateral malleolar fracture and disruption of the deltoid ligament, possibly because of the injury pattern and the energy expended.

Level of Evidence: Prognostic Level I. See Instructions to Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Nirmal C Tejwani, M.D.
    Posted on November 12, 2007
    Dr. Tejwani responds to Dr. Mereddy.
    NYU Hospital for Joint Diseases, New York, NY

    Thank you for your interest in our paper.(1) Following are the responses to your queries.

    1. The average time interval between injury and surgery was not looked at for this study. All patients underwent surgery after swelling had decreased as seen by appearance of wrinkles and after resolution of blisters. We are unable to comment on the outcome based on the time to surgery as we do not have this data available.

    2. No patient had post-operative talar shift or loss of reduction necessitating surgery for re-reduction.

    3. We do not remove, nor recommend, routine removal of syndesmotic screws.

    4. The hardware removal rate was higher in the bimalleolar group, 13 versus 8 patients. All of these were at patient request; we are unable to say whether this is because there are more implants, since most hardware removal was requested for lateral plates.

    I hope we have answered your questions. Please feel free to contact us if you have any further questions.

    Reference:

    1. Tejwani NC, McLaurin TM, Walsh M, Bhadsavle S, Koval KJ, Egol KA. Are outcomes of bimalleolar fractures poorer than those of lateral malleolar fractures with medial ligamentous injury? J Bone Joint Surg Am. 2007;89:1438-1441.

    Praveen K R Mereddy
    Posted on October 15, 2007
    Are Bimalleolar Fracture Outcomes Poorer Than Lateral Malleolar Fractures with Medial Lig. Injury?
    Wirral University Teaching Hospital, Upton, Wirral, Merseyside, UK

    To The Editor:

    We read the article, "Are Outcomes of Bimalleolar Fractures Poorer Than Those of Lateral Malleolar Fractures with Medial Ligamentous Injury?"(1) with interest and appreciate the effort involved in conducting this prospective study. However, we have some additional questions:

    What was the average time interval between injury and surgery? Was there a delay in performing surgery on any of the patients because of associated swelling and blisters? If so, does this affect their functional outcome?(2)

    Was there any difficulty in fracture reduction in the group with lateral malleolus fracture and deltoid ligament injury? Did any of these patients have a talar shift post-operatively? At what stage were the syndesmotic screws removed?

    In the complications the authors mention that the implant removal rate was higher in the bimalleolar fracture group. Could this be explained by the fact that the potential for implant related symptoms would be doubled with the implants on both medial and lateral sides?

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    References:

    1. Tejwani NC, McLaurin TM, Walsh M, Bhadsavle S, Koval KJ, Egol KA. Are outcomes of bimalleolar fractures poorer than those of lateral malleolar fractures with medial ligamentous injury? J Bone Joint Surg Am 2007;90:1438-1441.

    2. Høiness P, Strømsøe K. The influence of the timing of surgery on soft tissue complications and hospital stay. A review of 84 closed ankle fractures. Ann Chir Gynaecol. 2000;89(1):6-9.

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