Homeopathic Ankle Dislocation for Treatment of Unstable Trimalleolar Fractures Involving Posterior Die‐Punch Fragment: A Retrospective Cohort Study

Abstract

Objectives

Unstable trimalleolar fractures are relatively complex and more difficult to manage if die‐punch fracture is present. We aimed to evaluate the curative effect of homeopathic ankle dislocation on the unstable trimalleolar fractures involving posterior die‐punch fragments.

Methods

A total of 124 patients diagnosed with unstable trimalleolar fractures combined with post‐die punch fragment between June 2008 and June 2020 were retrospectively included. Patients who received homeopathic ankle dislocation were named as the experimental group, and patients who accepted conventional treatment were control group. The fracture healing time, wound healing, American Orthopedic Foot and Ankle Society ankle‐hindfoot scale (AOFAS), visual analogue scale (VAS), the Kellgren–Lawrence arthritis grading scale (KLAGS) and short‐form 36 score (SF‐36) scores were collected. Student t‐test was used for fracture healing time. Wound healing and SF‐36 were compared using the Mann–Whitney test. Repeated measurement analysis of variance (ANOVA) was used for AOFAS and VAS. χ ²‐test was used for KLAGS.

Results

AOFAS showed statistically significant differences between the two groups (p = 0.001). In non‐weight‐bearing and weight‐bearing conditions, VAS scores were significant different between the two groups, and there was an interaction between group and time point (p < 0.001). The experimental group was superior to the control group in terms of physical function (p = 0.022), role‐physical (p = 0.018), general health (p = 0.001) and social function (p = 0.042).The operation time of experimental group was shorter than that of control group (p < 0.001).

Conclusion

Homeopathic ankle dislocation is used for the unstable trimalleolar fractures involving posterior die‐punch fragment, which can provide better functional outcomes while shortening the operation time and recovery period.

This study presents a novel homeopathic ankle dislocation approach during surgical treatment and evaluates its effects and safety for patients with unstable trimalleolar fractures involving comminuted posterior malleolar fractures. Homeopathic ankle dislocation is used for the unstable trimalleolar fractures involving posterior die‐punch fragment, which can provide better functional outcomes while shorten the operation time and recovery period.

Introduction

Die‐punch fragment is a depressed type of intra‐articular fracture that formed when a part of articular surface cartilage and subchondral bone embed into cancellous bone due to vertical pressure. ¹ It is more common in distal radius fractures ² , ³ and ankle fractures. ¹ , ⁴ According to the Lauge–Hansen classification, ⁵ posterior ankle fractures are usually caused by talus torsion and impact. ⁶ However, with profound study, the mechanism of ankle fracture is actually more complex, and there are defects in the interpretation of the Lauge–Hansen classification injury mechanism. ⁷ , ⁸ The talus can impact the posterior malleolus under vertical stress, resulting in die‐punch fracture, which was regarded as posterior pilon fracture ⁹ or intercalary fragment (ICF). ¹⁰ Die‐punch fracture is caused by low energy vertical stress, ¹¹ , ¹² with low incidence, and is scarcely studied.

The treatment of posterior malleolus fracture is more complicated than that of medial and lateral malleolus fracture, which is more difficult due to the presence of die‐punch fragment. Posteromedial and posterolateral approaches are the commonly used surgical approaches for treatment of posterior ankle fractures, ¹³ , ¹⁴ both could achieve good clinical efficacy. Bartoníček et al. mentioned that about 70% of B3 fractures are associated with intra‐articular fragment (ICF), ¹⁰ and Sun et al. reported a similar specific die‐punch fragment in B4 fractures. ¹ However, these articles did not provide specific descriptions of the existence and management of ankle joint subluxation. In addition, the common surgical approaches require gentle retraction of the posteromedial neurovascular bundle (posterior tibial artery, vein and tibial nerve) or the posterolateral tendinous tissue with poor elasticity (peroneal tendon), with a small visual window, which makes direct reduction of posterior malleolus fractures difficult, especially for die‐punch fragments in the posterior malleolus. ¹ Based on the status, the aim of this study was to: (i) introduce the novel homeopathic ankle dislocation approach during surgical treatment; (ii) evaluate its effects; and (iii) safety for patients with unstable trimalleolar fractures involving posterior die‐punch fragment.

Methods

Patients

This study was approved by the Ethics Committee of the Third Hospital of Hebei Medical University (No. 2021‐094‐1), and conducted in accordance with the Declaration of Helsinki. Informed consent of patients was waived because of the retrospective study nature. The data of patients with unstable trimalleolar fractures involving posterior die‐punch fragment who were treated from June 2008 to June 2020 were retrospectively collected. Preoperatively, all patients underwent physical examinations, anteroposterior X‐ray, lateral X‐ray and CT examinations of the ankle plain radiographs and CT examinations to determine the diagnosis and type of ankle fracture (Figure 1). According to surgical methods, the patients received homeopathic ankle dislocation were named as the experimental group and patients accepting conventional treatment were the control group.

FIGURE 1.

Preoperative plain radiographs and CT images. (A) Radiographs showed internal, external, and posterior malleolar fractures with lateral ankle subluxation. (B) Posterior malleolus fracture, lateral malleolus fracture dislocation obvious. (C) The yellow arrow refers to the die‐punch fragment.

Inclusion criteria were as following: (i) age ≥ 18 years; (ii) ankle subluxation; (iii) posterior malleolus fracture block ≥25% of distal tibial articular surface or articular surface displacement ≥2 mm; (iv) surgery was performed 7–14 days after the injury; and (v) with complete data. Exclusion criteria were as follows: (i) complicated with open trauma or vascular and nerve injury; (ii) die‐punch fragment did not exist; (iii) combined with other site fractures; (iv) ankle joint could not be dislocated during intraoperative examination; and (v) postoperative incision infection and osteomyelitis.

Surgical Technique

Preoperative Routine Treatment

All operations of the two groups were completed by the same treatment team. All cases were given temporary brace fixation or calcaneal traction before surgery and surgery was performed after sufficient swelling reduction. All cases underwent imaging examinations including anteroposterior and lateral X‐rays of the ankle joint, plain CT scan of the ankle joint and three‐dimensional reconstruction. The comorbidities of all cases, including coronary heart disease, diabetes, and hypertension, were well controlled before surgery.

Homeopathic Ankle Dislocation Approach

The patient was placed in a supine position. A longitudinal incision was made along the inner ankle, approximately 2 cm from the tip of the medial malleolus, between the inner ankle and the Achilles tendon, with the fascia dissected forward to expose the inner ankle fracture (Figure 2A). A periosteal elevator was used to detach the periosteum from the side of the tibia near the fracture site, extending to the posterior ankle. The ankle joint capsule was explored, revealing a complete distal fracture of the tibia from the far end of the tibia. On anterior examination, it was found that there was a significant increase in the anterior–posterior and medial–lateral mobility. Traction was applied to displace the distal tibia, inner ankle, and outer ankle fractures outward, creating a complete lateral dislocation of the ankle joint. This fully exposes the distal tibia joint surface, allowing for the removal of the die‐punch bone fragment and other bone fragments around the posterior ankle joint capsule (Figure 2B). All bone fragments are anatomically reduced under direct visualization (Figure 2C–E). If there was a significant bone compression defect, allograft bone was used for filling, and fixation was achieved using absorbable screws, hollow tension screws, or metal bone pins. When using absorbable screws, they should be inserted from the posterior to increase compression. For hollow tension screws, the guide wire was first inserted from the posterior ankle, passing through the anterior side and then twisted into the screws from the anterior to the posterior. Using metal bone pins, they can be inserted from the posterior, with the tail end aligned with the posterior ankle bone cortex, and the metal bone pins are bent and left in the anterior side of the tibia. The fixation devices should be placed as close to the joint surface as possible to increase stability and compression. The ankle joint was tractioned for reduction, following AO foundation and orthopaedic trauma association (AO/OTA) surgical principles for internal and external ankle fractures. If intraoperative X‐ray fluoroscopy reveals a widened tibiofibular joint space, an elastic fixation device for the lower tibia and fibula was applied for stabilization, and the incision was closed afterward.

FIGURE 2.

Female, 38 years, a sprain caused the left trimalleolar fracture, AO classification type B. The distal articular surface of the tibia was exposure after dislocation. (A) Fracture of the posterior and medial malleolus. The blue arrow indicates the posterior malleolus fragment; White arrow indicates fragment of medial malleolus; The yellow arrow indicates the distal tibia; The green arrow indicates the talus. (B) Dislocation of the ankle and removal of the posterior malleolus comminuted fragment. (C) The removed posterior malleolus fragment and die‐punch fragment. (D): In vitro reduction of the fragment. (E) The reduction of the posterior malleolus under direct vision.

Conventional Surgical Approach

The choice of the posterior medial or posterior lateral surgical approach is determined by the location of the fracture fragment.

For patients with posteromedial approach, ¹⁰ , ¹⁵ surgery was performed using pneumatic tourniquets with the patient lying in a supine position. A longitudinal incision is made between the inner ankle and the Achilles tendon. The posterior tibial artery, posterior tibial nerve are gently pulled forward. Entry is made from the anterior edge of the flexor hallucis longus muscle. The posterior ankle fracture fragment is located and exposed. The die‐punch bone fragment is explored and repositioned. Allograft bone is implanted in the compression zone. Fragments that cannot be repositioned and fixed due to being too small are removed. The remaining comminuted fracture fragments are temporarily fixed with appropriate diameter Kirschner wires. Intraoperative C‐arm X‐ray fluoroscopy in the lateral view of the ankle joint is used to confirm satisfactory reduction of the fracture fragments. Absorbable screws or hollow screws are inserted from posterior to anterior for fixation.

During the posterolateral approach, the patient is placed in a lateral decubitus position with the affected side up. A longitudinal incision is made between the fibula and the Achilles tendon, with careful protection of the sural nerve. Entry is made between the fibularis longus and brevis muscles and the flexor hallucis longus. The peroneal artery is identified. The posterior ankle fracture fragment is located and managed in a similar manner to the posterior medial surgical approach.

If there are two or more fracture fragments in the posterior ankle fracture, with some located on the medial side and others on the lateral side, a combination of both approaches is used for reduction and fixation.

Reduction and fixation of internal and external ankle fractures are performed according to AO/OTA surgical principles. If intraoperative X‐ray fluoroscopy reveals a persistently widened tibiofibular joint space, an elastic fixation device for the lower tibia and fibula is applied for stabilization, and the incision is closed afterward.

Postoperative Management

According to the results of preoperative ultrasound examination, patients who had deep vein thrombosis before surgery were given anticoagulation therapy with low molecular weight heparin 24 h after surgery. If no thrombus exists, prophylactic dose should be given. Lower extremity pressure treatment was given for patients without contraindications as early as possible. Deep venous ultrasound of lower limbs was reviewed 3 and 7 days after surgery, and the treatment plan was adjusted according to the results.

For all patients, ankle joint was fixed with plaster or brace at 90° position for 2–3 weeks after surgery to facilitate the recovery of the wound and soft tissue. One to three days postoperatively, patients were advised to perform functional exercises of the toes and quadriceps contraction. One week postoperatively, patients were advised to perform functional exercises of the active knee extension and flexion. Four to six weeks postoperatively, patients were advised to perform functional exercises of the ankle joint weight‐free dorsiflexion and plantar flexion. Six to twelve weeks postoperatively, patients were advised to perform functional exercises of the complete squatting and partial weight‐bearing walking according to fracture healing. Patients were advised to return to daily activities after 12–15 weeks postoperatively.

Clinical Evaluation

Patients were followed up at 1, 3, 6, 12, and 18 months postoperatively. During follow up period, anteroposterior and lateral plain radiographs radiographs or CT were obtained to assess the status of fracture healing. The observation indicators included AOFAS ankle‐hindfoot scale, ¹⁶ VAS, ¹⁷ KLAGS, ¹⁸ SF‐36, ¹⁹ operation time, fracture healing time (CT scan showed a blurred fracture line, and the bone trabecula passed through the fracture line as standard), wound healing. All patients were reviewed and evaluated by the surgical team doctors. The KLAGS score was determined by at least two attending physicians led by one of the professors in the group, avoiding empirical errors and other human factors. Two statistical methods were used for comparative analysis of KLAGS score: Method 1, 0–4 grade imaging findings; Method 2, definitive presence (2, 3 points), no presence or probable presence (0, 1 points) of post‐traumatic ankle arthritic manifestations.

Statistical Analysis

Statistical analysis was performed using SPSS software (version 26, IBM, Chicago, IL, USA). Quantitative data were expressed as means ± standard deviations (SD), and compared using the student t‐test between two groups. The data not following the normal distribution was described as (M [Q1, Q3]), and compared using the Mann–Whitney test between the two groups. Repeated measurement analysis of variance (ANOVA) was used for AOFAS and VAS measured at different time points. For the indicators with interaction, separate effect analysis was conducted, and Bonferroni correction was used for multiple comparison. For indexes without interaction, main effect analysis was conducted. Student‐Newman‐Keuls (SNK) test was used for pairwise comparison between time points. Qualitative data were expressed as number or percentage and compared with the χ ²‐test. Rank‐sum test was used for rank data. p < 0.05 was considered as significant.

Results

Baseline Data

A total of 332 patients were screened from the database, of those, 208 patients were excluded because they did not meet inclusion criteria. Finally, 124 patients were enrolled in the study, including 74 men and 50 women, with mean age of 41.4 ± 13.4 years (range, 22–68 years). The patients were divided into the experimental group (n = 63) and the control group (n = 61). All fractures were unilateral (left, 61; right, 63). Sprain was the cause fracture in 59 patients (47.6%), traffic injury in 38 patients (30.6%), and fall injury in 27 patients (21.8%). The ankle fractures were categorized using the Lauge–Hansen classification: supination‐external rotation fractures (58/124, 46.8%), pronation‐abduction (40/124, 32.3%) and pronation‐external rotation fractures (26/124, 20.9%). The Danis–Weber (AO/ASIF) classification including type B fractures in 70 patients (56.5%) and type C fractures in 54 patients (43.5%). According to the Haraguchi classification, 72 patients (58.1%) had type I fractures in, 52 patients (41.9%) had type II fractures. Based on the Bartoníček classification, type B3 fractures were in 87 patients (70.2%) and type B4 fractures were in 37 patients (29.8%). There was no significant differences in the general data of the experimental and control groups (Table 1).

TABLE 1.

General information of patients in experiment group and control group.

Characteristics	Experimental group (n = 63)	Control group (n = 61)	χ 2/Z	p‐value
Gender (n, [%])			0.774	0.379
Male	36 (57.1)	38 (62.3)
Female	27 (42.9)	23 (37.7)
Age (years)			0.106	0.916
20 ≤ Age < 30	15 (23.8)	12 (19.7)
30 ≤ Age < 40	20 (31.7)	18 (29.5)
40 ≤ Age < 50	10 (15.9)	16 (26.2)
50 ≤ Age < 60	9 (14.3)	6 (9.8)
Age ≥ 60	9 (14.3)	9 (14.8)
Affected side (n, [%])			0.521	0.471
Left	33 (52.4)	28 (45.9)
Right	30 (47.6)	33 (54.1)
Cause of injury (n, [%])			0.579	0.749
Sprain	28 (50.0)	31 (45.0)
Traffic injury	21 (22.7)	17 (30.0)
Fall injury	14 (27.3)	13 (20.0)
LH classification (n, [%])			0.291	0.865
Supination‐external rotation (IV degree)	30 (47.6)	28 (45.9)
Pronation‐abduction (III degree)	21 (33.3)	19 (31.1)
Pronation‐external rotation (IV degree)	12 (19.1)	14 (23.0)
AO classification (n, [%])			0.270	0.603
Type B	37 (58.7)	33 (54.1)
Type C	26 (41.3)	28 (45.9)
Haraguchi classification 1 (n, [%])			0.331	0.565
Type I	35 (55.5)	37 (60.7)
Type II	28 (44.4)	24 (39.3)
Bartoníček classification 2 (n, [%])			0.098	0.754
Type B3	45 (71.4)	42 (68.9)
Type B4	18 (28.6)	19 (31.1)

AOFAS Score

For AOFAS, the ANOVA showed there were statistically significant differences between the two groups (p = 0.001), the difference among different time points of follow‐up was statistically significant (p < 0.001). Further analysis of the individual effects showed AOFAS scores were significant higher in the experimental group than those in the control group at 6 and 12 months (p < 0.05). In the experimental group, AOFAS score was basically stable at 12 months, there was no statistically significant difference in terms of scores between at 12 and at 18 months (p = 0.28, Table 2).

TABLE 2.

The comparison of AOFAS, VAS between experiment group and control group.

Group	Follow‐up				F‐value	p‐value
	3 months	6 months	12 months	18 months
	AOFAS ‡
Experimental group	54.79 ± 7.38 †	73.24 ± 12.20 * , †	84.35 ± 9.57 *	86.38 ± 8.87 *	15.779	<0.001
Control group	55.26 ± 8.07 †	65.79 ± 10.47 * , †	74.07 ± 11.74 *	82.92 ± 11.89 *	2.817	0.040
F‐value	0.456	12.729	4.677	3.183
p‐value	0.501	0.001	0.033	0.077
	VAS in the static state §
Experimental group	3.03 ± 1.47	2.13 ± 1.19	1.40 ± 0.95	1.11 ± 0.81	70.033	<0.001
Control group	3.10 ± 1.39	2.54 ± 1.25	1.64 ± 1.00	1.38 ± 0.79
F‐value	3.620
p‐value	0.059
	VAS in non‐weight‐bearing condition ‡
Experimental group	3.33 ± 1.59 †	1.98 ± 1.07 * , †	1.48 ± 0.97 *	1.17 ± 1.06 * , †	117.628	<0.001
Control group	3.84 ± 1.68 †	2.98. ± 1.36 * , †	2.18 ± 1.23 *	1.43 ± 1.31 * , †
F‐value	2.946	20.757	12.604	1.392
p‐value	0.089	0.000	0.001	0.240
	VAS in weight‐bearing condition ‡
Experimental group	‐	2.02 ± 1.39 †	1.17 ± 0.77 *	1.24 ± 0.77 *	10.757	<0.001
Control group	‐	3.79. ± 1.33 †	2.44 ± 0.98 *	1.51 ± 0.91 * , †	6.277	0.002
F‐value		52.657	64.586	3.183
p‐value		0.000	0.000	0.077

Abbreviations: AOFAS, American Orthopedic Foot and Ankle Society Ankle‐Hindfoot Scale; VAS, visual analogue scale.

^* Compared with indictor at 3 months follow‐up, p < 0.05.

^† Compared with indictor at 12 month follow‐up, p < 0.05.

^‡ Results were significantly affected by time point and surgical method (p < 0.05), and there was interaction between time point and surgical method (p < 0.05).

^§ The results were only significantly affected by the time point, and the surgical method had no significant effect.

VAS Score

As Table 2 shows, in the static state, there was no significant difference in terms of VAS score between experimental group and control group (p = 0.059), while the VAS scores had statistically significant differences among different time points of follow‐up in the two groups (p < 0.001, Table 2). In the non‐weight‐bearing condition, there were significant differences in terms of VAS score between the two groups, and there was an interaction between group and time point (p < 0.001). The VAS scores in the experimental group at 6 and 12 months were significantly lower than those of the control group (p = 0.001 and p < 0.05). There were significant differences in VAS scores among time points of follow‐up in the two groups (p < 0.05), and the VAS scores decreased gradually. In weight‐bearing condition, there were significant differences in terms of VAS score between the two groups, and there was an interaction between group and time point (p < 0.001). The experimental group had lower VAS scores than those in the control group at 6 and 12 months follow‐up (p < 0.001). There was no statistically significant difference in terms of scores at 12 and 18 months (p = 0.899).

KLAGS Score

For KLAGS, 12 patients (19.1%) of the experimental group and 18 patients (29.5%) of the control group showed suspicious post‐traumatic ankle arthritis at 6 months follow‐up. Six (9.5%) of 12 G1 grade patients in the experimental group and eight (13.1%) of 18 G1 grade patients in the control group developed definite imaging findings of post‐traumatic arthritis at month 12. At the 18th month, the cases of G0 → G1 → G2 → G3 in the experimental group changed to 6‐3‐2, while that in the control group was 10‐7‐1. The results of Method 1 showed statistically significant differences between the two groups (p = 0.042, Table 3).

TABLE 3.

The comparison of the Kellgren–Lawrence arthritis grading scale (KLAGS) between experiment group and control group.

Time	KLAGS	Experimental group (n = 63)	Control group (n = 61)	Z/χ 2	p‐value
3 months	0	63	61	‡	‐
	1	0	0	‐	‐
	2	0	0	‐	‐
	3	0	0	‐	‐
	0/1	22	20	‐	‐
	2/3	0	0
6 months (n, [%])	0	51 (80.9)	43 (70.5)	1.354 †	0.176
	1	12 (19.1)	18 (29.5)
	2	0	0
	3	0	0
	0/1	63	61	‐	‐
	2/3	0	0
12 months (n, [%])	0	46 (73.0)	37 (60.7)	1.460 †	0.144
	1	11 (17.5)	16 (26.2)
	2	6 (9.5)	5 (8.2)
	3	0 (0.0)	3 (4.9)
	0/1	57 (90.5)	53 (86.9)	3.319*	0.068
	2/3	6 (9.5)	8 (13.1)
18 months (n, [%])	0	39 (61.9)	27 (44.3)	2.030 †	0.042
	1	15 (23.8)	19 (31.1)
	2	7 (11.1)	11 (18.0)
	3	2 (3.2)	4 (6.6)
	0/1	54 (85.7)	46 (75.4)	2.108*	0.147
	2/3	9 (14.3)	15 (24.6)

^* χ ²‐value.

^† Z‐value.

^‡ No imaging findings of traumatic arthritis were found in the two groups at 3 months, so no statistical calculation was performed.

SF‐36

The experimental group was superior to the control group in terms of physical function (p = 0.022), role‐physical (p = 0.018), general health (p = 0.001) and social function (p = 0.042), but there was no statistical significance in other aspects (p > 0.05, Table 4). A typical postoperative imaging results was shown in Figure 3.

TABLE 4.

The comparison of SF‐36 at 18 months postoperatively between experiment group and control group.

SF‐36	Experimental group (n = 22)	Control group (n = 20)	Statistical magnitude	p‐value
Physical function (PF)	80 (75, 95)	60 (52.5, 75)	2748	<0.001
Role‐physical (RP)	75 (50, 75)	50 (25, 50)	2779	<0.001
Body pain (BP)	84 (62, 84)	64 (52, 84)	2179.5	0.183
General health (GH)	77 (72, 80)	62 (27.5, 80)	2622.5	<0.001
Vitality (VT)	55 (35, 60)	55 (35, 75)	1654.5	0.178
Social function (SF)	75 (50, 87.5)	50 (25, 75)	2716.5	<0.001
Role emotional (RE)	66.6 (33.3, 100)	66.6 (16.7, 100)	2266.5	0.073
Mental health (MH)	64 (48, 64)	52 (36, 80)	2023.5	0.607

FIGURE 3.

Female, 38 years, a sprain caused the left trimalleolar fracture, AO classification type B. Postoperative plain radiographs and CT images. (A) Postoperative lateral plain radiographs of ankle joint, the posterior ankle was fixed with Kirschner wire, and the corresponding situation of articular surface was good. (B) Postoperative anteroposterior plain radiographs of ankle joint, the medial malleolus was fixed with Kirschner wire, the distal malleolus fibula was fixed with bone plate, fracture alignment was good, the corresponding situation of ankle joint was good. (C) Four months after surgery, the posterior ankle fracture healed well with good joint space. (D) Twenty‐four months after surgery, the fracture healed well and the internal fixation was removed. No obvious osteoarthrosis was observed in the ankle joint.

Operation Time, Fracture Healing Time and Wounding Healing

The operation time of the experimental group was shorter than that of the control group (p < 0.001). Seven patients in the experimental group had delayed wound healing. In four of these seven patients, the incision healed after dressing change. The incisions of two patients were healed after dressing change debridement and suture. One patient did not heal for a long time, but no infection occurred. The incision healed after the internal fixation was removed 18 months after surgery. Delayed wound healing occurred in nine patients in the control group. In one of these nine patients, the incision healed after dressing change debridement and suture. The remaining patients recovered after dressing change. There was no significant difference in wound healing between the two groups (p = 0.545, Table 5).

TABLE 5.

Other observation indicators between experiment group and control group.

Indicators	Experimental group (n = 63)	Control group (n = 61)	Statistical magnitude	p‐value
Operation time (min)	85.49 ± 10.09	98.09 ± 10.04	6.974	<0.001
Healing time (d)	73 (65,81)	76 (70,82)	1538	0.055
Delayed wound healing (n, [%])	7 (11.1)	9 (14.8)	0.366	0.545
No delayed wound healing (n, [%])	56 (88.9)	52 (85.2)

Discussion

Effects and Safety of Novel Homeopathic Ankle Dislocation Approach

Our findings suggest that; (i) the articular surface of the distal tibia can be completely exposed through homeopathic ankle dislocation, which makes it convenient to treat the unstable trimalleolar fractures involving posterior die‐punch fragment; (ii) the method shortened the operation time and the recovery cycle of the patients, reduced the physiological, psychological and economic burden of the patients; and (iii) may reduce the occurrence of traumatic arthritis of the ankle joint.

Current Research Gaps

The majority of fractures involving the posterior malleolus occur as part of trimalleolar fractures and rarely occur in isolation (0.5%–1%). ²⁰ , ²¹ For trimalleolar fractures with associated ankle joint subluxation, the ankle joint is generally considered unstable. ²² Bartoníček et al. mentioned that about 70% of B3 fractures are associated with ICF, ¹⁰ and Sun et al. reported a similar specific die‐punch fragment in B4 fractures. ¹ They achieved good clinical outcomes by using a posterior lateral approach with locking plates for fixation. However, these articles did not provide specific descriptions of the existence and management of ankle joint subluxation. Herein, the unique ankle joint fracture type involves both die‐punch fragments and complete instability of the ankle joint.

Advantages of Novel Homeopathic Ankle Dislocation Approach

Due to the small visual window and small operating space of the posteromedial and posterolateral surgical approaches, we took advantage of the complete instability of the ankle joint and innovatively adjusted the ankle subluxation to dislocation, fully exposing the distal tibial articular surface. Then the die‐punch bone fragments of the posterior malleolus and other posterior malleolus fragments were removed for direct reduction and fixation. For small fragments that could not be adequately fixed or were poorly stabilized, compression of the larger posterior malleolus fragment helped stabilize them, minimizing joint cartilage defects and uneven joint surfaces, thereby reducing the potential for late traumatic arthritis. ²³ Additionally, the bone defect area could easily and securely accommodate the implantation of allograft bone without concern for its dispersal within the ankle joint cavity. With this approach, the surgical time of the experimental group was shorter than that of the control group (p = 0.000), reducing the risk of infection and soft tissue necrosis associated with prolonged operative time. Furthermore, although the homeopathic ankle dislocation method may affect the blood supply of the bone fragment, the difference in fracture healing time between the two groups was not statistically significant (p = 0.055).

At present, there have been reports on the treatment outcomes of patients with ankle fracture through patient‐reported outcome measures, functional examination and radiological manifestations. ²⁴ , ²⁵ In the present study, treatment with the homeopathic ankle dislocation led to the stabilization of AOFAS scores and weight‐bearing VAS scores in the experimental group at 12 months, whereas the control group required a longer recovery period to reach the level of the experimental group. Although the final treatment outcomes were similar at the 18th month, the experimental group was able to achieve faster patient recovery.

Non‐weight‐bearing VAS represents the pain score of the ankle joint during activity in a non‐weight‐bearing state. KLAGS is a descriptive scoring system for post‐traumatic osteoarthritis (PTOA) of the ankle joint, employing a mechanism of assessment by at least three evaluators. In the 18th month, the control group had a higher number of cases classified as KLAGS grade G1, which had a significant proportion in the non‐weight‐bearing VAS scores, possibly contributing to the superior results of the experimental group over the control group. Furthermore, the control group had 29.5% rated as G1 at the 6th month, although this rate decreased to 26.2% at the 12th month, with 13.1% of cases showing clear signs of post‐traumatic arthritis progression, including 4.9% at G3. In contrast, the experimental group had only 9.5% of cases with clear post‐traumatic arthritis at the same period, all at G2 and none at G3. By the 18th month, this difference became more pronounced, with 44.3% in the control group and 61.9% in the experimental group did not have post‐traumatic arthritis. The inter‐group comparison of grade data at the 18th month showed statistical significance, with the experimental group having fewer cases progressing toward severe grades compared to the control group. Therefore, we can infer that homeopathic ankle dislocation would result in a lower potential risk of post‐traumatic arthritis in the ankle joint.

SF‐36 is a commonly used medical outcome assessment scale that evaluates patient treatment outcomes from multiple perspectives. The experimental group outperformed the control group in terms of physical function, role‐physical, general health, and social function. Patients in the control group reported poorer personal lives, work, social activities, and attitudes toward personal health conditions, possibly due to a prolonged recovery period. In contrast, patients in the experimental group, benefiting from a relatively faster recovery, achieved more satisfactory results.

Strengths and Limitations

This study uses homeopathic ankle dislocation to treat unstable trimalleolar fractures involving posterior die‐punch fragment, resulting in better functional outcomes while shortening the operation time and recovery period.

There are several limitations of this study. The successful implementation of homeopathic ankle dislocation requires complete instability of the ankle joint, so the indication range is relatively narrow. With a small sample size and short follow‐up time, patients may have undetected complications or adverse reactions. Another limitation is that we excluded postoperative incision infection and osteomyelitis, which we should take into consideration in future studies.

Prospects of Clinical Application

Our novel homeopathic ankle dislocation approach during surgical treatment can be used in patients with unstable trimalleolar fractures involving posterior die‐punch fragment. It can more conveniently handle the die‐punch bone fragment under direct vision, better ensure the flatness of the distal tibial articular surface, shorten the operation time, and enable the patient to obtain a shorter recovery period and better outcomes. More cases need to be included to improve evaluation criteria and treatment plans. Longer follow‐up will allow for more accurate evaluation of results.

Conclusion

The articular surface of the distal tibia can be completely exposed through homeopathic ankle dislocation, which makes it convenient to treat the unstable trimalleolar fractures involving posterior die‐punch fragment. The method provide better functional outcomes, shorten the operation time and recovery period, reduce the physiological, psychological and economic burden of the patients, and may reduce the occurrence of traumatic arthritis of the ankle joint.

Conflict of Interest Statement

The authors hereby state that they have no financial support or relationships that could potentially create a conflict of interest.

Ethics Statement

This study was approved by the Ethics Committee of the Third Hospital of Hebei Medical University (No. 2021‐094‐1). All participants were informed as to the purpose of this study, and that this study complied with the Declaration of Helsinki. Informed consent was obtained from the all participants.

Author Contributions

LS conceived and designed the study. LS and SQ provided materials and samples. ZP and LS collected and assembled the data. LS, SQ, LS, and WX analyzed and interpreted the data. All authors have made important contributions to drafting the article, revising the article and approved the final manuscript.

Data Availability Statement

All data generated or analyzed during this study are included in this published article.