SLR - December 2019 - Najwah S. Hayman
Reference: Li B, Wang S, Zhang Z, Li J, Li Q, Liu L. Transarticular External Fixation Versus Deltoid Ligament Repair in Treating Ser Iv Ankle Fractures: A Comparative Study. BMC Musculoskeletal Disorders. 2019 Oct. 20:453.Scientific Literature Review
Reviewed By: Najwah S. Hayman, DPM
Residency Program: Cambridge Health Alliance – Cambridge, MA
Podiatric Relevance: Supination External Rotation Type IV (SER IV) ankle fractures are one of the most common unstable fracture patterns encountered in Podiatry, and typically require surgical intervention. Whether primary repair of the ruptured deltoid ligament occurs or not remains a controversial issue. Traditionally, the deltoid ligament has been restored with a suture-anchor technique versus a plaster cast when operating without deltoid ligament repair (DLR). Recent literature suggests that transarticular external fixation (TEF) may replace plaster casts by allowing self healing of the deltoid ligament and possible early weight-bearing. This study seeks to compare ORIF with TEF and no DLR versus ORIF and DLR, with the hypothesis that ORIF with TEF may achieve satisfactory outcomes when treating SER IV ankle fractures.
Methods: A level III retrospective study was performed in a single institution for patients with surgically treated SER IV ankle fractures between January 2012 and December 2015. A total of 43 patients were included: Group 1 (n=20) consisted of patients undergoing ORIF and TEF without DLR, and Group 2 (n=23) having ORIF with DLR. The primary outcomes measured were postoperative complications, fracture healing, and development of post-traumatic arthritis. Functional outcomes were evaluated with the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, Visual Analog Scale (VAS), Medical Outcomes Short Form 36-item questionnaire and ankle range of motion (ROM). Patients were followed for 12 months postoperatively.
Results: Group 1 had an overall postoperative infection rate of 5 percent compared to Group 2 at 8.7 percent, (P =1.000). The average time to achieve fracture healing was 8.95 + 1.986 weeks for Group 1 and 10.70 + 2.548 weeks for Group 2 (P = 0.017). There was no evidence of post-traumatic arthritis observed in either group at the final follow up. Functional outcome scores improved between preoperative and postoperative AOFAS, VAS and SF-36 scores for both groups, although these results were not statistically significant (P > 0.05) between groups. At six weeks postoperatively, patients in Group 2 had better ankle ROM than those of Group 1 (29.35 + 2.033 vs 40.35 + 3.550 degrees, P < 0.001), but by 12 months, both groups had achieved approximately 60 degrees of motion.
Conclusions: The authors conclude that ORIF with TEF produces similar functional outcomes when treating SER IV ankle fractures compared to ORIF with DLR. Although not addressed in this study, other factors to consider when deciding between the two surgical methods include the cost of both procedures and the skill level of the surgeon (more training may be required for external fixation technique). However, regardless of the fixation method, the goal of the physician should be to minimize pain, maximize function, and reduce the chances of postoperative complications. This study is limited by its retrospective design and small sample size. More research is needed before a definitive recommendation can be made on whether or not to repair the deltoid ligament in SER IV ankle fractures.