Karl-Friedrich BraunDepartment of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany Department of Traumatology and Reconstructive Surgery including Department of Orthopedic Surgery, Charite Universitätsmedizin Berlin, Berlin, Germany
A trimalleolar ankle fracture is considered unstable and treatment is generally performed operatively. Computed tomography is important for the operative planning by providing an elaborated view of the posterior malleolus.
Trimalleolar ankle fractures have a rising incidence in the last decade with up to 40 per 100,000 people per year. With a growing number of elderly patients, trimalleolar ankle injuries will become more relevant in the form of fragility fractures, posing a particular challenge for trauma surgeons.
In patients with osteoporotic trimalleolar ankle fractures and relevant concomitant conditions, further evidence is awaited to specify indications for open reduction and internal fixation or primary transfixation of the ankle joint.
In younger, more demanding patients, arthroscopic-assisted surgery might improve the outcome, but future research is required to identify patients who will benefit from assisted surgical care.
This review considers current scientific findings regarding all three malleoli to understand the complexity of trimalleolar ankle injuries and provide the reader with an overview of treatment strategies and research, as well as future perspectives.
Cite this article: EFORT Open Rev 2021;6:692-703. DOI: 10.1302/2058-5241.6.200138
Tears of the medial collateral ligament (MCL) are the most common knee ligament injury.
Incomplete tears (grade I, II) and isolated tears (grade III) of the MCL without valgus instability can be treated without surgery, with early functional rehabilitation.
Failure of non-surgical treatment can result in debilitating, persistent medial instability, secondary dysfunction of the anterior cruciate ligament, weakness, and osteoarthritis.
Reconstruction or repair of the MCL is a relatively uncommon procedure, as non-surgical treatment is often successful at returning patients to their prior level of function.
Acute repair is indicated in isolated grade III tears with severe valgus alignment, MCL entrapment over pes anserinus, or intra-articular or bony avulsion. The indication for primary repair is based on the resulting quality of the native ligament and the time since the injury. Primary repair of the MCL is usually performed within 7 to 10 days after the injury.
Augmentation repair for the superficial MCL (sMCL) is a surgical technique that can be used when the resulting quality of the native ligament makes primary repair impossible.
Reconstruction is indicated when MCL injuries fail to heal in neutral or varus alignment. Reconstruction might be advisable to correct chronic instability. Chronic, medial-sided knee injuries with valgus misalignment should be treated with a two-stage approach. A distal femoral osteotomy should be performed first, followed by reconstruction of the medial knee structures.
Cite this article: EFORT Open Rev 2018;3:398-407. DOI: 10.1302/2058-5241.3.170035
Isolated posterior cruciate ligament (PCL) tears are much less frequent than anterior cruciate ligament (ACL) tears.
Abrupt posterior tibial translation (such as dashboard impact), falls in hyperflexion and direct hyperextension trauma are the most frequent mechanisms of production.
The anterolateral bundle represents two-thirds of PCL mass and is reconstructed in single-bundle techniques.
The PCL has an intrinsic capability for healing. This is the reason why, nowadays, the majority of isolated PCL tears are managed non-operatively, with rehabilitation and bracing.
Recent studies have focused on double-bundle reconstruction techniques, as they seem to restore knee kinematics.
No significant clinical differences have been established between single versus double-bundle techniques, autograft versus allograft, transtibial tunnel versus tibial inlay techniques or remnant-preserving versus remnant-release techniques.
Cite this article: EFORT Open Rev 2017;2:89-96. DOI: 10.1302/2058-5241.2.160009
Open fractures of the lower extremity are the most common open long bone injuries, yet their management remains a topic of debate.
This article discusses the basic tenets of management and the subsequent impact on clinical outcome. These include the rationale for initial debridement, antimicrobial cover, addressing the soft-tissue injury and definitive skeletal management.
The classification of injury severity continues to be a useful tool in guiding treatment and predicting outcome and prognosis. The Gustilo-Anderson classification continues to be the mainstay, but the adoption of severity scores such as the Ganga Hospital score may provide additional predictive utility.
Recent literature has challenged the perceived need for rapid debridement within 6 hours and the rationale for prolonged antibiotic therapy in the open fracture. The choice of definitive treatment must be decided against known efficacy and injury severity/type.
Recent data demonstrate better outcomes with internal fixation methods in most open tibial fractures, but external fixation continues to be an appropriate choice in more severe injuries. The incidence of infection and non-union has decreased with new treatment approaches but continues to be a source of significant morbidity and mortality.
Assessment of functional outcome using various measures has been prevalent in the literature, but there is limited consensus regarding the best measures to be used.
Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170072
Acromioclavicular joint (ACJ) injuries are common, but their incidence is probably underestimated. As the treatment of some sub-types is still debated, we reviewed the available literature to obtain an overview of current management.
We analysed the literature using the PubMed search engine.
There is consensus on the treatment of Rockwood type I and type II lesions and for high-grade injuries of types IV, V and VI. The treatment of type III injuries remains controversial, as none of the studies has proven a significant benefit of one procedure when compared with another.
Several approaches can be considered in reaching a valid solution for treating ACJ lesions. The final outcome is affected by both vertical and horizontal post-operative ACJ stability. Synthetic devices, positioned using early open or arthroscopic procedures, are the main choice for young people.
Type III injuries should be managed surgically only in cases with high-demand sporting or working activities.
Cite this article: EFORT Open Rev 2017;2:432–437. DOI: 10.1302/2058-5241.2.160085.
High-energy pilon fractures are challenging injuries. Multiple options are described for the definitive surgical management of these fractures, but there is no level I evidence for optimal management. The current management and recommendations for treatment will be reviewed in this article.
Anatomical reduction of the fracture, restoration of joint congruence and reconstruction of the posterior column with a correct limb axis minimising the soft-tissue insult are the key points to a good outcome when treating pilon fractures.
Even when these goals are achieved, there is no guarantee that results will be acceptable in the mid-term due to the frequent progression to post-traumatic arthritis.
In high-energy fractures with soft-tissue compromise, a staged treatment is generally accepted as the best way to take care of these devastating fractures and is considered a local ‘damage control’ strategy.
The axial cuts from the CT scan images are essential in order to define the location of the main fracture line, the fracture pattern (sagittal or coronal) and the number of fragments. All of this information is crucial for pre-operative planning, incision placement and articular surface reduction.
No single method of fixation is ideal for all pilon fractures, or suitable for all patients. Definitive decision making is mostly dependent on the fracture pattern, condition of the soft-tissues, the patient’s profile and surgical expertise.
Cite this article: Tomás-Hernández J. High-energy pilon fractures management: state of the art. EFORT Open Rev 2016;1:354-361. DOI: 10.1302/2058-5241.1.000016.
clinical evidence, which shows high rates of fracture healing and is associated with an estimated cost saving of £2,407 (~ €2,648) per patient compared with currentmanagement, through avoiding surgery. However, for long bone fractures with delayed healing
significant improvements, the diabetic foot remains a major public health problem and one of the leading causes of hospitalization for diabetic patients.
The currentmanagement of the diabetic foot includes various prevention and treatment options