Current Issue Volume 4, Number 2 , July-December 2017

EDITORIAL
Rajiv Shah

Ankle Fracture Symposium

[Year:2017] [Month:July-December] [Volumn:4 ] [Number:2] [Pages:51] [Pages No:iv]



Ankle fractures are one of the most commonly treated injuries in day to day practice. Yet the understanding of these complex injuries still remain unclear. Many controversies surrounding ankle fractures are still unresolved. Advances in the field have always been with an attempt to make complexities simpler. With this symposium, based on current literature; we aim to bring out many recent facets of ankle fracture management.


SYMPOSIUM-ORIGINAL ARTICLE
Mandeep S Dhillon, Lokesh Kumar, Siddhartha Sharma, Nikhil Mehta

The Lauge-Hansen Classification for Ankle Fractures: Is it Relevant in 2017?

[Year:2017] [Month:July-December] [Volumn:4 ] [Number:2] [Pages:51] [Pages No:53-56]



Despite being one of the commonest fractures, classifications of ankle injuries are still debated, with modern surgeons decrying the use of the so-called antiquated system based on injury mechanisms. Despite glaring lacunae, especially with lack of reproducibility using modern methods, and an understanding that many fractures which we now see routinely may not fit into this classification, the Lauge-Hansen classification is still worth preserving. It clarifies some, if not most deforming forces, allows us to understand the ankle injury in a three-dimensional concept, both on the medial and lateral sides, and allows an understanding of reduction methods. The limitations in its use are the lack of prognostication ability, the fact that most reductions are now done open, and the recognition of some transitional and posterior malleolar injuries unclassifiable by it. Not being alphanumeric is another disadvantage in the computer age. Nevertheless, it is an important landmark in the history of orthopedics, and in the development of our understanding of ankle fractures. Even in 2017, it is too important a piece of work to be discarded, and modern orthopedic students are encouraged to gain an understanding of this classification system, and to combine it with the newer ones to get an overall picture of the ankle injury.

Keywords: Ankle fractures, Danis-Weber classification, Fracture classification, Lauge-Hansen, Malleoli.

How to cite this article: Dhillon MS, Kumar L, Sharma S, Mehta N. The Lauge-Hansen Classification for Ankle Fractures: Is it Relevant in 2017? J Foot Ankle Surg (Asia-Pacific) 2017;4(2):53-56.

Source of support: Nil

Conflict of interest: None


SYMPOSIUM-INVITED ARTICLE
Jin Su Kim

Anterior Inferior Tibiofibular Ligament Reconstruction with Anchor Sutures compared with Trans-syndesmotic Screw Fixation for Ankle Syndesmotic Injuries

[Year:2017] [Month:July-December] [Volumn:4 ] [Number:2] [Pages:51] [Pages No:57-62]



Background: Acute syndesmotic injuries were usually treated with trans-syndesmotic screw fixation. However, screw fixation is too strong compared with the physiologic ankle joint movement. In addition, it needs removal and leads to delayed rehabilitation. We propose the reconstruction of the anterior inferior tibiofibular ligament (AITFL) using suture anchors to substitute trans-syndesmotic screw fixation.

Materials and methods: We compared the results after transsyndesmotic screw fixation and AITFL suture anchor fixation in syndesmotic injuries with or without ankle fracture. Consecutively, the trans-syndesmotic screw (group I) was conducted between June 2011 and June 2013, and since July 2013, suture anchor fixation was performed (group II). Reductions in quality, the American Orthopedic Foot and Ankle Society (AOFAS) score, and the Olerud-Molander ankle score (OMAS) were evaluated.

Results: The final AOFAS score and OMAS in both groups were not significantly different (p = 0.98, 0.67). Tibiofibular overlapping, tibiofibular space, and tibiofibular overlapping ratio to the tibial width in both groups had satisfactory reduction from the standards. Computed tomographic (CT) evaluation also confirmed that both groups had been anatomically reduced in standard. Anteroposterior axis reduction in CT was more accurate in group II. Nonclinically related complications were three broken screws in final follow-up in group I.

Conclusion: Both trans-syndesmotic screws and suture anchor fixation have satisfactory clinical outcomes. The suture anchor fixation for syndesmotic injury does not need removal and is less complicated compared with the trans-syndesmotic screw fixation.

Keywords: Anchor, Ankle, Screw, Syndesmosis.

How to cite this article: Kim JS. Anterior Inferior Tibiofibular Ligament Reconstruction with Anchor Sutures compared with Trans-syndesmotic Screw Fixation for Ankle Syndesmotic Injuries. J Foot Ankle Surg (Asia-Pacific) 2017;4(2):57-62.

Source of support: Nil

Conflict of interest: None


SYMPOSIUM-INVITED ARTICLE
Mandeep S Dhillon, Kamal Dureja, Sandeep Patel, Tungish Bansal

How We do It. Trimalleolar Fractures: Fixing the Posterior Malleolus by Posterolateral Approach

[Year:2017] [Month:July-December] [Volumn:4 ] [Number:2] [Pages:51] [Pages No:63-68]



The understanding of trimalleolar fractures and, in particular, the posterior malleolus fragment has drastically evolved over the last decade. There has been a tilt in favor of fixing almost all posterior malleolus fragment in contrast to the old school thought of the 20th century. The concept of stability offered by posterior malleolus fixation to the syndesmotic stability is well understood now. Posterolateral approach has almost evolved as a gold standard approach for posterior malleolus fixation.

Keywords: Ankle fracture, Posterior malleolus, Posterolateral approach ankle.

How to cite this article: Dhillon MS, Dureja K, Patel S, Bansal T. How We do It. Trimalleolar Fractures: Fixing the Posterior Malleolus by Posterolateral Approach. J Foot Ankle Surg (Asia- Pacific) 2017;4(2):63-68.

Source of support: Nil

Conflict of interest: None


SYMPOSIUM-REVIEW ARTICLE
Uttam C Saini, Mandeep S Dhillon, Udai Cheema, Rajesh K Rajnish

Open Fractures of the Ankle: Management Options and Factors influencing Outcomes

[Year:2017] [Month:July-December] [Volumn:4 ] [Number:2] [Pages:51] [Pages No:69-76]



Open ankle fractures are rare injuries among all the ankle fractures and commonly occur after high-velocity trauma in road traffic accidents resulting in varying amounts of soft-tissue loss, periosteal stripping, microbial contamination, bone loss, and vascular injury. Management of open ankle fractures remains a daunting task due to the complex osseo-ligamentous complex, relatively thin soft-tissue coverage around the joint, propensity for wound infection and complications, and the risk of impaired functional ability. Management in the emergency trauma room includes initial stabilization of the patient, focused history, and detailed clinical evaluation determining the level and type of injury, extent of wound contamination, soft-tissue and/or bone loss, and neurovascular status of the injured limb followed by radiographic evaluation. Early antibiotics administration and wound assessment, irrigation, aseptic dressing, and temporary splintage form the cornerstone of initial orthopedic stabilization of open fractures. There is a general consensus that all open ankle fractures need early debridement and fixation to restore articular congruity and alignment of fracture fragments although the timing of internal/definitive fixation of open ankle fractures is still debatable. Common complications include superficial and deep infections, marginal skin necrosis, compartment syndrome, nonunion/malunion, and secondary osteoarthritis. Timely interventions improve orthopedic outcomes in these patients.

Keywords: Ankle fractures, Debridement, Flap cover, Foot fractures, Open fractures.

How to cite this article: Saini UC, Dhillon MS, Cheema U, Rajnish RK. Open Fractures of the Ankle: Management Options and Factors influencing Outcomes. J Foot Ankle Surg (Asia- Pacific) 2017;4(2):69-76.

Source of support: Nil

Conflict of interest: None


SYMPOSIUM-CASE REPORT
Rajiv Shah, Shivam R Shah

Diabetic Ankle Fractures: Does Management Differ? A Case-based Presentation

[Year:2017] [Month:July-December] [Volumn:4 ] [Number:2] [Pages:51] [Pages No:77-83]



Fractures in diabetics pose a great management challenge as diabetes mellitus affects fracture healing at the cellular level. With a steep rise in the number of diabetics the world over, there also is a rise in the incidences of ankle fractures. Nonoperative as well as operative management of ankle fractures in diabetics is fraught with a high rate of complications. With the help of history and clinical examination, the clinician must classify the case as either a complicated or an uncomplicated diabetes presentation. Case-based discussion for both these types of diabetic ankle fractures is offered in this article, and we propose a lucid management algorithm.

Keywords: Charcot neuroarthropathy, Complicated diabetes, Diabetic ankle fracture, Tibiotalocalcaneal nail, Uncomplicated diabetes.

How to cite this article: Shah R, Shah SR. Diabetic Ankle Fractures: Does Management Differ? A Case-based Presentation. J Foot Ankle Surg (Asia-Pacific) 2017;4(2):77-83.

Source of support: Nil

Conflict of interest: None


RESEARCH ARTICLE
Gyaneshwar Tank, Rohit Gupta, Amit Gupta, Ravikant Rohila

Comparative Study of Platelet-rich Plasma and Corticosteroid Injection in the Treatment of Plantar Fasciitis

[Year:2017] [Month:July-December] [Volumn:4 ] [Number:2] [Pages:51] [Pages No:84-89]



Introduction: Platelet-rich plasma (PRP) is promoted nowadays as an ideal autologous biological blood-derived product. It enhances wound healing, bone healing, tendon healing and is currently being widely used.

Aims and objectives: A prospective cohort study was done to assess the efficacy of autologous PRP injection and to compare it with corticosteroid injection in treatment of plantar fasciitis (PF).

Materials and methods: Eighty patients were included in the study and divided into two groups. Group I (30 patients) received PRP injection and group II (50 patients) were given steroid injection. Patients were clinically assessed at different intervals. Functional outcome was evaluated on the basis of visual analog scale (VAS) and foot and ankle ability measure (FAAM) scores. Planter fascia thickness was assessed pre- and postinjection by ultrasound.

Results: Platelet-rich plasma and corticosteroid injection groups at the initial visit had VAS score of 8.44 and 8.38 respectively which was reduced to 1.46 and 3.02 at the end of 6 months. The PRP and corticosteroid injection groups at the initial visit had FAAM score of 29.9 and 31.6 respectively which increased to 83.4 and 69.1 at the end of 6 months. After injection, the PRP group had significant reduction (35.90%) in the thickness of plantar fascia as compared to corticosteroid group (28.67%).

Conclusion: Treatment of PF with PRP extract reduces pain and significantly increases function, exceeding the effect of steroid on long-term follow-up.

Keywords: Foot ankle ability measure score, Plantar fasciitis, Platelet-rich plasma, Visual analog scale.

How to cite this article: Tank G, Gupta R, Gupta A, Rohila R. Comparative Study of Platelet-rich Plasma and Corticosteroid Injection in the Treatment of Plantar Fasciitis. J Foot Ankle Surg (Asia-Pacific) 2017;4(2):84-89.

Source of support: Nil

Conflict of interest: None


RESEARCH ARTICLE
Satish R Gawali, Shashikant B Kukale, Pramod V Nirvane, Raman O Toshniwal

Management of Fracture of Posterior Malleolus, Trimalleolar Fracture, Fracture Dislocations, and Syndesmosis Injury of Ankle Joint

[Year:2017] [Month:July-December] [Volumn:4 ] [Number:2] [Pages:51] [Pages No:90-96]



Background: Malleolar fractures of ankle are usually complex injuries, as they are associated with significant ligament and soft tissue injury-injury to syndesmosis and injury to medial and lateral collateral ligaments. The open reduction and internal fixation is not feasible until recovery of significant soft tissue injury and subsidence of edema. Malleolar fractures are articular fractures and have associated subluxation and dislocation of talus. The aims of treatment are to restore normal anatomy and provide sufficient stability for early movements.
Malleolar fractures more often require open reduction. Our study aimed to know efficacy and outcome of operative management of them.

Materials and methods: From January 2013 to March 2015, 35 patients with syndesmotic ankle injury and trimalleolar ankle fractures admitted to the Government Medical College, Latur, India, were operated and followed up prospectively.

Results: Mean age of patients is 35 years (25-60 years). Fracture union was seen radiologically in 3 to 4 months depending on fracture geometry. We achieved good to excellent results of 90%.

Conclusion: We conclude that malleolar fractures encountered in clinical practice need thorough assessment and meticulous surgical intervention, as they are associated with injury to ligament complex, i.e., ligament is a key structure in the stability of ankle mortise. Abduction and external rotation types of injuries are the most common types to be seen. We achieved stable fixation and performed early mobilization of the ankle joint, which limits the complications of mainly ankle stiffness. Each malleolus has got its inherent associated complications and calls for special attention for identifying associated conditions, such as syndesmotic injury, talus dislocation in posterior malleolar fractures, irreducible ankle dislocation with trimalleolar fracture, and entrapped fibula behind tibia with irreducible dislocation.

Keywords: Irreducible fracture dislocations, Malleolar fracture, Syndesmosis injury, Trimalleolar fracture.

How to cite this article: Gawali SR, Kukale SB, Nirvane PV, Toshniwal RO. Management of Fracture of Posterior Malleolus Trimalleolar Fracture, Fracture Dislocations, and Syndesmosis Injury of Ankle Joint. J Foot Ankle Surg (Asia-Pacific) 2017;4(2):90-96.

Source of support: Nil

Conflict of interest: None


RESEARCH ARTICLE
Avadhoot P Kantak

The Metatarsal Axis Deviation Angle: A Novel Angular Measurement for Planning Surgery of Severe Hallux Valgus

[Year:2017] [Month:July-December] [Volumn:4 ] [Number:2] [Pages:51] [Pages No:97-99]



Surgical planning for hallux valgus is a complex procedure. Many angular measurements are described to decide on the correct procedure. Primus metatarsus varus is considered as one of the important factors in the causation and persistence of hallux valgus. Intermetatarsal angle (IMA) has been used to assess the first metatarsal varus. However, we identified a normal IMA in some feet with severe hallux valgus; and these feet had metatarsus adductus. Hence, after further investigations, we propose a new angular measurement to detect axis deviation of the first metatarsal. We have called this the metatarsal axis deviation angle (MADA). We also recommend a basal realignment osteotomy in hallux valgus with the MADA of more than 30°.

Keywords: Hallux valgus, Primus metatarsus varus, Surgery.

How to cite this article: Kantak AP. The Metatarsal Axis Deviation Angle: A Novel Angular Measurement for Planning Surgery of Severe Hallux Valgus. J Foot Ankle Surg (Asia- Pacific) 2017;4(2):97-99.

Source of support: Nil

Conflict of interest: None


CASE REPORT
Rajesh Simon, Atmaram Gadgil, Denis P Jose

Composite Flexor Hallucis Longus and Free Gracillis Flap for Infected Achilles Tendon

[Year:2017] [Month:July-December] [Volumn:4 ] [Number:2] [Pages:51] [Pages No:100-102]



Primary infection of tendo-achilles (TA) is quite uncommon. Here, we are presenting an interesting case of a 42-year-old farmer who developed TA infection following thorn prick injury (3-month-old injury). He presented to us with discharging sinus on posterior aspect of heel. On subsequent debridement, he had 17 cm tendon defect, which was treated with flexor hallucis longus (FHL) tendon and reinforced with free gracillis flap from opposite thigh. However, to the best of our knowledge, combined use of FHL and gracillis tendon has so far not reported.

Keywords: Flexor hallucis longus, Free gracillis flap, Infected tendo-achilles injuries, Open tendo-achilles injuries, Reconstruction of Achilles tendon.

How to cite this article: Simon R, Gadgil A, Jose DP. Composite Flexor Hallucis Longus and Free Gracillis Flap for Infected Achilles Tendon. J Foot Ankle Surg (Asia-Pacific) 2017;4(2):100-102.

Source of support: Nil

Conflict of interest: None


BOOK REVIEW
Rakesh John, Mandeep S Dhillon

The Foot–Arts, Myths, and Secrets

[Year:2017] [Month:July-December] [Volumn:4 ] [Number:2] [Pages:51] [Pages No:103-104]



History, arts, and philosophy are fun subjects! While this topic is debatable, especially among surgeons, Dr Stefan Rammelt and Dr Hans Zwipp have put in an extraordinary effort to compile a unique and one-of-its-kind book about a very unique structure of our body-the foot! As you waft through the pages of this informative as well as entertaining book, you can feel the deep passion that the editors and authors of this book share about the foot. Although orthopedic surgeons are highly knowledgeable about the anatomy, pathomechanics, and surgical treatment of various foot disorders, it is surprising how much we don’t know about the evolution of the foot from prehistorical times to the modern times and the importance of foot in history, language, arts, and folklore!


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