From OT Europe

Weight-bearing radiographs useful to assess stability of isolated lateral malleolar fractures

In patients with isolated lateral malleolar fractures due to a supination-external rotation injury of the ankle, weight-bearing radiographs are a dependable method for assessing fracture stability for nonsurgical treatment, according to a study presented as part of the Free Papers Award Session for Trauma at the 18th EFORT Annual Congress in Vienna.

Fabian Krause
Fabian Krause

In the prospective study, researchers evaluated 104 consecutive patients with closed, isolated, lateral malleolar fractures (presumed AO 44-B1, Lauge-Hansen supination-external rotation [SER] type). Patients were enrolled between September 2008 and August 2015. Researchers excluded patients in whom clear fracture instability (laterally displaced talus) was revealed on initial gravity (g) stress. Between 3 days and 7 days after trauma, all patients underwent a weight-bearing anteroposterior radiograph of the ankle. Fracture instability was defined as a medial clear space more than 4-mm wide or 1-mm wider than the superior clear space. Surgical treatment was recommended for patients with fractures found to be unstable in both radiographs. Patients treated nonsurgically were seen for clinical and radiographic follow-up 1 year to 2 years after trauma.

Researchers found that of the 104 patients with isolated lateral malleolar fractures of the SER type, 14 underwent surgery because of clear instability. Forty-five patients’ fractures showed instability on the gravity stress radiograph, but stability on the weight-bearing radiograph (g-unstable); and 45 patients’ fractures were stable on both radiographs (g-stable). These 90 patients were treated nonoperatively.

At the 20-month average follow-up, the g-stable and the g-unstable groups showed no significant differences in the American Orthopaedic Foot & Ankle Society hindfoot score (92 points in the g-stable group vs. 93 points in the g-unstable group), the foot function index score (11 points vs. 10 points), the SF-36 physical component (86 points vs. 85 points) and the SF-36 mental component (84 points vs. 81 points). Subsequent radiographs revealed all fractures had healed with anatomic congruity of the ankle. These findings suggest that weight-bearing radiographs reflecting the physiological load condition may be a valuable means of preventing unnecessary surgeries.

“Weight-bearing radiographs provide a reliable basis to decide about stability and nonoperative treatment in isolated lateral malleolar fractures of the SER type with excellent clinical and radiographic outcome at short-term follow-up,” study presenter Fabian Krause, MD, chief physician of foot and ankle surgery in the Department of Orthopaedic Surgery at University of Bern Hospital in Bern, Switzerland, told Orthopaedics Today Europe. “Gravity stress radiographs appear to overrate the need for operative treatment or indicate a higher level of presumed instability that is not clinically relevant as indicated by equal outcomes for both types of radiographic assessment. No conversion of nonoperative to operative treatment was required in patients with ‘gravity stress borderline unstable’ but ‘weight-bearing stable’ radiographs,” he said. – by Jennifer Byrne

Disclosure: Krause reports no relevant financial disclosures.

In patients with isolated lateral malleolar fractures due to a supination-external rotation injury of the ankle, weight-bearing radiographs are a dependable method for assessing fracture stability for nonsurgical treatment, according to a study presented as part of the Free Papers Award Session for Trauma at the 18th EFORT Annual Congress in Vienna.

Fabian Krause
Fabian Krause

In the prospective study, researchers evaluated 104 consecutive patients with closed, isolated, lateral malleolar fractures (presumed AO 44-B1, Lauge-Hansen supination-external rotation [SER] type). Patients were enrolled between September 2008 and August 2015. Researchers excluded patients in whom clear fracture instability (laterally displaced talus) was revealed on initial gravity (g) stress. Between 3 days and 7 days after trauma, all patients underwent a weight-bearing anteroposterior radiograph of the ankle. Fracture instability was defined as a medial clear space more than 4-mm wide or 1-mm wider than the superior clear space. Surgical treatment was recommended for patients with fractures found to be unstable in both radiographs. Patients treated nonsurgically were seen for clinical and radiographic follow-up 1 year to 2 years after trauma.

Researchers found that of the 104 patients with isolated lateral malleolar fractures of the SER type, 14 underwent surgery because of clear instability. Forty-five patients’ fractures showed instability on the gravity stress radiograph, but stability on the weight-bearing radiograph (g-unstable); and 45 patients’ fractures were stable on both radiographs (g-stable). These 90 patients were treated nonoperatively.

At the 20-month average follow-up, the g-stable and the g-unstable groups showed no significant differences in the American Orthopaedic Foot & Ankle Society hindfoot score (92 points in the g-stable group vs. 93 points in the g-unstable group), the foot function index score (11 points vs. 10 points), the SF-36 physical component (86 points vs. 85 points) and the SF-36 mental component (84 points vs. 81 points). Subsequent radiographs revealed all fractures had healed with anatomic congruity of the ankle. These findings suggest that weight-bearing radiographs reflecting the physiological load condition may be a valuable means of preventing unnecessary surgeries.

“Weight-bearing radiographs provide a reliable basis to decide about stability and nonoperative treatment in isolated lateral malleolar fractures of the SER type with excellent clinical and radiographic outcome at short-term follow-up,” study presenter Fabian Krause, MD, chief physician of foot and ankle surgery in the Department of Orthopaedic Surgery at University of Bern Hospital in Bern, Switzerland, told Orthopaedics Today Europe. “Gravity stress radiographs appear to overrate the need for operative treatment or indicate a higher level of presumed instability that is not clinically relevant as indicated by equal outcomes for both types of radiographic assessment. No conversion of nonoperative to operative treatment was required in patients with ‘gravity stress borderline unstable’ but ‘weight-bearing stable’ radiographs,” he said. – by Jennifer Byrne

Disclosure: Krause reports no relevant financial disclosures.