Abstract
Purpose
To assess the relationship between dislocation and functional outcomes in supination-external rotation (SER) ankle fractures.
Methods
A retrospective case series study was performed on patients with ankle fractures treated surgically at a large trauma center from January 2015 to December 2021. The inclusion criteria were young and middle-aged patients of 18 – 65 years with SER ankle fractures that can be classified by Lauge-Hansen classification and underwent surgery at our trauma center. Exclusion criteria were serious life-threatening diseases, open fractures, fractures delayed for more than 3 weeks, fracture sites ≥ 2, etc. Then patients were divided into dislocation and no-dislocation groups. Patient demographics, injury characteristics, surgery-related outcomes, and postoperative functional outcomes were collected and analyzed. The functional outcomes of SER ankle fractures were assessed postoperatively at 1-year face-to-face follow-up using the foot and ankle outcome score (FAOS) and American Orthopedic Foot and Ankle Society ankle hindfoot score and by 2 experienced orthopedic physicians. Relevant data were analyzed using SPSS version 22.0 by Chi-square or t-test.
Results
During the study period, there were 371 ankle fractures. Among them, 190 (51.2%) were SER patterns with 69 (36.3%) combined with dislocations. Compared with the no-dislocation group, the dislocation group showed no statistically significant differences in gender, age composition, fracture type, diabetes, or smoking history, preoperative waiting time, operation time, and length of hospital stay (all p > 0.05), but a significantly higher Lauge-Hansen injury grade (p < 0.001) and syndesmotic screw fixation rate (p = 0.033). Moreover, the functional recovery was poorer, revealing a significantly lower FAOS in the sport/rec scale (p < 0.001). Subgroup analysis showed that among SER IV ankle fracture patients, FAOS was much lower in pain (p = 0.042) and sport/rec scales (p < 0.001) for those with dislocations. American Orthopedic Foot and Ankle Society ankle hindfoot score revealed no significant difference between dislocation and no-dislocation patients.
Conclusion
Dislocation in SER ankle fractures suggests more severe injury and negatively affects functional recovery, mainly manifested as more pain and poorer motor function, especially in SER IV ankle cases.
Keywords: Ankle fractures, Joint dislocations, Supination-external rotation, Functional outcomes
1. Introduction
Ankle fractures are one of the most common types of fractures, accounting for approximately 9% of all fractures in adults.1,2 As the global population ages, the incidence of ankle fractures is expected to increase dramatically in the next few decades.3 The Lauge-Hansen classification is often used in the clinical diagnosis of ankle fractures, which defines 4 patterns: supination-external rotation (SER), pronation external rotation (PER), supination adduction, and pronation abduction. Several studies have shown that SER ankle fracture is the most common pattern and accounts for approximately 85% of all ankle fractures.4, 5, 6
Ankle dislocation is defined as loss of alignment of the articular surfaces of the tibia and talus, which implies severe damage to the surrounding cartilage and ligaments. It has been reported that 21% – 36% of patients with ankle fractures suffer from dislocation simultaneously.7, 8, 9 With the incremental disruption of the ankle syndesmosis by rotational violence, the stability of the ankle ligament complex is overwhelmed, leading to ankle fracture-dislocation.10 It has been reported that patients with ankle fracture-dislocation are associated with more severe cartilage injury which may be in correlation with poor postoperative prognosis.11 A retrospective study12 found that PER IV ankle fracture-dislocation has a higher rate of malposition and poorer functional outcomes, compared to non-dislocated PER IV ankle fractures. Not coincidentally, another study13 found dislocation to be a risk factor for poor prognosis in SER IV ankle fractures. However, a study based on the Lauge-Hansen classification14 showed that dislocation did not worsen the ankle fracture's functional outcome at mid-term. In general, it is not conclusive whether the dislocation in SER ankle fractures will worsen functional outcomes. Nonetheless, these studies lacked surgery-related outcomes and the strength of evidence is limited by the small sample size. The purpose of this study is to analyze the effect of dislocation on the postoperative functional outcomes in patients with SER ankle fractures and to provide a scientific basis for their postoperative functional rehabilitation.
2. Methods
2.1. Patients and grouping
Between February 2015 and November 2021, a total of 371 consecutive adult patients with ankle fractures at a large university hospital were retrospectively screened (Fig. 1). The inclusion criteria were: (1) age between 18 and 65 years; (2) ankle fractures diagnosed by radiography and can be classified by Lauge-Hansen classification; (3) treated surgically at our center; and (4) preoperative American Society of Anesthesiologists score being I-II. The exclusion criteria were: (1) serious life-threatening diseases of the heart, brain, lungs, kidneys, or other vital organs; (2) open fractures; (3) old fractures delayed for more than 3 weeks; (4) fracture sites ≥2 or bilateral ankle fractures; (5) refuse to sign the informed consent; (6) previous ipsilateral ankle fractures; and (7) incomplete data.
Fig. 1.
Patient flow diagram.
SER: supination-external rotation; PER: pronation external rotation; SAD: supination adduction; PAD: pronation abduction.
All patients who met the eligibility criteria were classified into PER, SER, supination adduction, and pronation abduction according to the Lauge-Hansen classification. Moreover, patients were divided into dislocation and no-dislocation groups. A fracture combined with dislocation or subluxation is diagnosed when radiographs or CT/3D show an ankle fracture and separation of the talus for the tibia in anteroposterior (AP) or lateral views. Based on the literature and clinical experience, dislocation is further defined as a separation of the talus from the tibia of more than 50% in AP or lateral views, whereas subluxation is a separation of less than 50%.11, 12, 13 Subsequently, the dislocations were classified as medial, lateral, posterior, and anterior types according to the direction of dislocation. All patients underwent surgery by the same team. Lateral ankle fractures were fixed with distal fibular steel plates, while medial and posterior ankle fractures were treated with 1 – 2 hollow screws based on the size of the bone block. The syndesmosis injury was diagnosed by the Cotton test and fibular transverse test intraoperatively, and once diagnosed, lower tibiofibular screws were placed. The 2 groups adopt the same rehabilitation plans. Approval from the institutional ethics committee has been obtained before the start of this study.
2.2. Perioperative data and postoperative functional outcomes
The demographics and injury characteristics including gender, age, diabetes mellitus, history of smoking, injury grade by Lauge-Hansen classification, and dislocation directions were recorded in detail at the time of admission. Furthermore, surgery-related outcomes such as time to surgery, operation time, syndesmotic screw fixation, length of hospital stay, and postoperative wound infection were also documented at discharge. Postoperatively, each patient was interviewed and AP and lateral ankle radiography was conducted to assess the quality of fracture repositioning and healing at 1, 2, 3, 6 months, and 1 year after discharge. At 6 weeks postoperatively, patients were required to perform non-weight-bearing ankle range-of-motion exercises. Thereafter, weight-bearing exercises were instructed and adjusted continuously at each interview.
All the included patient was followed up for a minimum of 1 year after discharge. The primary outcome was the foot and ankle outcome score (FAOS) evaluated by 2 experienced orthopedic surgeons. FAOS is a patient self-reported structure-specific questionnaire and includes pain, symptoms, activities of daily living, function in sports and recreation (sport/rec), and foot-and ankle-related quality of life, which ranges from 0 to 100, with 100 indicating no symptoms and 0 indicating extreme symptoms. A recent prospective cohort study15 confirmed the FAOS as a scale with high reliability and validity in the early recovery of ankle fractures. The secondary outcome was the American Orthopedic Foot and Ankle Society ankle hindfoot score (AOFAS),16 which depends mainly on self-reported pain, activity, functional limitations, gait, and motion.
2.3. Statistical analysis
All statistical analyses in the current study were performed in SPSS 22.0 (SPSS Inc., Chicago, USA). Continuous data were presented as mean ± standard deviation (SD) while categorical data were presented using absolute values with percentages. Comparison between the dislocation and no-dislocation groups was achieved by the student's t-test for continuous variables and Chi-square test for categorical variables. All p values were bilateral, and p < 0.05 was considered statistically significant.
3. Results
A total of 371 patients with ankle fractures were screened in this study and 260 patients were included for the Lauge-Hansen classification according to the eligibility criteria. Among these patients, there were 190 (73.1%), 35 (13.5%), 14 (5.4%), and 21 (8.1%) cases of SER, PER, supination adduction, and pronation abduction patterns, respectively. Predictably, the most common injury pattern was SER, among which 69 (36.3%) were combined with dislocation and lateral ones accounted for 76.8%. However, the PER revealed the highest incidence of dislocations (62.9%) among the 4 patterns (Fig. 1).
The 190 cases of SER ankle fractures were divided into dislocation group (n = 69) and no-dislocation group (n = 121). General data, injury conditions, and intraoperative information are shown in Table 1. Comparison between the 2 groups showed no significant difference in demographics, diabetes, smoking history, and surgery-related outcomes of time to surgery, operation time, wound infection, and length of hospital stay (all p > 0.05), but a much higher percent of SER IV cases in the dislocation group (65.2% vs. 26.4%, p < 0.001). In line with our previous findings,10 the rate of syndesmotic screw fixation was also significantly higher in the dislocation group (37.7% vs. 23.1%, p < 0.033).
Table 1.
Demographics, injury characteristics and intraoperative information of 190 patients with supination-external rotation ankle fractures.
| Characteristics | Dislocation group (n = 69) | No-dislocation group (n = 121) | Statistic value | p value |
|---|---|---|---|---|
| Age (year) | 47.3 ± 14.7 | 47.6 ± 14.7 | t = 0.323 | 0.916 |
| Sex | χ2 = 0.015 | 0.902 | ||
| Male | 28 (40.6) | 48 (39.7) | ||
| Female | 41 (59.4) | 73 (60.3) | ||
| Smoking | 18 (26.1) | 34 (28.1) | χ2 = 0.090 | 0.765 |
| Diabetes | 5 (7.3) | 13 (10.7) | χ2 = 0.627 | 0.429 |
| Injury grade by Lauge-Hansen | χ2 = 30.762 | ＜0.001 | ||
| II (n = 55) | 7 (10.2) | 48 (39.7) | ||
| III (n = 58) | 17 (24.6) | 41 (33.9) | ||
| IV (n = 77) | 45 (65.2) | 32 (26.4) | ||
| Dislocation directions | ||||
| Posterior | 4 (5.8) | – | ||
| Lateral | 53 (76.8) | – | ||
| Posterolateral | 12 (17.4) | – | ||
| Time to surgery (day) | 5.97 ± 2.0 | 5.31 ± 2.5 | t = 1.297 | 0.189 |
| Operation time (min) | 95.3 ± 20.5 | 78.6 ± 33.7 | t = 0.625 | 0.537 |
| Syndesmotic screw fixation | 26 (37.7) | 28 (23.1) | χ2 = 4.567 | 0.033 |
| Wound infection | 6 (8.7) | 3 (2.5) | χ2 = 2.511 | 0.113 |
| Length of hospital stay (day) | 14.4 ± 3.30 | 10.5 ± 3.80 | t = 1.746 | 0.073 |
Data are expressed as mean ± SD or n (%).
-: not exist.
After a minimum of 12 months follow-up, the FAOS and AOFAS ankle hindfoot score of the 190 patients with SER ankle fractures were collected. The dislocation group showed both lower FAOS (pain, activities of daily living, sport/rec and quality of life) and AOFAS, ankle hindfoankle hindfoot score especially the sport/rec score, which was much lower in the dislocation group than in the no-dislocation group (31.7 ± 7.5 vs. 46.4 ± 11.8, p < 0.001). Detailed data are shown in Table 2.
Table 2.
Postoperative functional outcome scores of 190 patients with SER ankle fractures (mean ± SD).
| Group | FAOS |
AOFAS ankle hindfoot score | ||||
|---|---|---|---|---|---|---|
| Pain | Symptoms | ADL | Sport/rec | QOL | ||
| Fracture-dislocation (n = 69) | 64.1 ± 5.8 | 49.7 ± 9.4 | 78.1 ± 7.6 | 31.7 ± 7.5 | 44.3 ± 11.8 | 88.6 ± 12.1 |
| No dislocation (n = 121) | 66.1 ± 5.1 | 49.3 ± 9.8 | 72.8 ± 9.7 | 46.4 ± 11.8 | 55.0 ± 11.4 | 91.3 ± 9.8 |
| t value | 0.534 | 0.463 | 0.685 | 5.326 | 1.453 | 1.432 |
| p value | 0.678 | 0.788 | 0.486 | ＜0.001 | 0.132 | 0.136 |
SER: supination-external rotation; FAOS: foot and ankle outcome score; AOFAS: American Orthopedic Foot and Ankle Society; ADL: activities of daily living; QOL: quality of life.
Further analysis was performed on the 77 patients with SER IV ankle fractures, which were also divided into fracture dislocation and no-dislocation groups. It was revealed that dislocation worsened the pain (p = 0.042) and sport/rec (p < 0.001) in SER IV ankle fractures. Other subscale scores and AOFAS were also lower in the dislocation group except for symptoms, though no significant difference was detected (Table 3). Typical cases are shown in Fig. 2, Fig. 3.
Table 3.
Postoperative functional outcome scores of 77 patients with SER IV ankle fractures.
| Group | FAOS |
AOFAS ankle hindfoot score | ||||
|---|---|---|---|---|---|---|
| Pain | Symptoms | ADL | Sport/rec | QOL | ||
| Dislocation (n = 45) | 57.9 ± 8.5 | 47.6 ± 15.1 | 72.3 ± 11.4 | 28.9 ± 9.50 | 38.7 ± 12.9 | 84.3 ± 11.6 |
| No dislocation (n = 32) | 64.9 ± 6.6 | 44.5 ± 12.6 | 75.8 ± 12.7 | 36.2 ± 13.8 | 42.4 ± 15.5 | 87.7 ± 8.3 |
| t value | 1.586 | 0.458 | 0.235 | 3.216 | 0.745 | 1.314 |
| p value | 0.042 | 0.392 | 0.612 | ＜0.001 | 0.209 | 0.097 |
SER: supination-external rotation; FAOS: foot and ankle outcome score; AOFAS: American Orthopedic Foot and Ankle Society; ADL: activities of daily living; QOL: quality of life.
Fig. 2.
A case of SER IV ankle fracture with dislocation. (A) CT/3D reconstructions; (B) Preoperative radiographs; (C) Postoperative radiographs on 1st day showing good reduction of the ankle joint; (D) Postoperative radiographs at 3 months showing good healing of trimalleolar fracture.
SER: supination-external rotation.
Fig. 3.
A case of SER IV ankle fracture without dislocation. (A) CT/3D reconstructions; (B) Preoperative radiographs; (C) Postoperative radiographs on 1st day showing good reduction of the ankle fracture and distal tibiofibular syndesmosis; (D) Postoperative radiographs at 3 months showing that the bone healing is satisfactory without delayed bone union or obvious displacement of fracture segments after surgery.
SER: supination-external rotation.
4. Discussion
This study investigated the clinical characteristics of ankle fracture-dislocations based on the Lauge-Hansen classification and explored the role of dislocation in postoperative functional outcomes of SER ankle fractures. It is shown that PER ankle fractures had the highest proportion of dislocation cases, and the combined dislocation worsens the functional outcomes in SER ankle fractures, especially in daily sports functions. In addition, further analysis showed that patients with SER IV fracture-dislocation had more painful discomfort. These results provide evidence for clinical prognosis and rehabilitation guidance.
SER was the most common ankle fracture pattern (51.2%), though PER is most likely to be combined with dislocations (62.9%). According to a 3D fracture mapping study,17 the fracture line of PER ankle fractures is distributed distal to the fibular stem, which may lead to syndesmotic injuries. A 3D morphological study18 reported that the syndesmosis becomes more unstable for type B ankle fractures when the fracture line is steeper as well as the fracture spike is longer. In our study, there are no significant differences between the dislocation and no-dislocation groups in terms of demographics including age, diabetes, gender, and smoking history. On the contrary, the study of Tantigate et al.19 found that ankle fracture patients of older age or with diabetes are more likely to have dislocations. A systematic review20 speculated that medial malleolus hypoplasia, generalized ligamentous laxity, weakness of the peroneal muscles, and previous ankle sprains are risk factors for pure ankle dislocation. Therefore, among these high-risk populations, vigilance for the occurrence of ankle fracture-dislocation is needed when ankle injury occurs.
In our study, the percentage of SER IV ankle fractures is significantly higher in the dislocation group than in the no-dislocation group (65.2% vs. 26.4%). The dislocation group also showed a higher rate of syndesmotic screw fixation (37.7% vs. 23.1%), which further suggests a more severe syndesmotic injury for the dislocation cases. A systematic review21 summarized that the 3 injury patterns of external rotation of the foot, eversion of the talus, and excessive dorsiflexion in SER ankle fractures can cause syndesmotic injury while pushing the talus outward toward the ankle mortise, which in turn leads to dislocation. Moreover, patients with ankle fracture-dislocation have a 3-time higher rate of wound complications than those without dislocations.22
In addition, we found a relatively higher incidence of wound infection in the dislocation group, but no statistically significant difference was found (8.7% vs. 2.5%, p = 0.113). It is well known that swelling and blisters associated with dislocation increase the risk of postoperative wound complications. Therefore, failure to provide proper management often results in a longer length of hospital stay, increased costs, and worse functional outcomes. However, the study of Tantigate et al.19 showed no significant difference in postoperative wound-related complications including wound erythema, wound dehiscence, and surgical site infection between dislocation and no-dislocation groups. Speculatively, the occurrence of wound complications may be related to individual factors such as diabetes, smoking history, and peripheral vascular diseases.23,24
For our patients, FAOS was used to assess the functional outcomes after ankle surgery. FAOS, a questionnaire with high reliability and validity, reflects the impact of ankle function on the movement of daily life from the subjective view of patients.25 Patients in the dislocation group had significantly worse FAOS in the sport/rec subscale than those in the no-dislocation group (31.7 ± 7.5 vs. 46.4 ± 11.8, p < 0.001). Motor function scores specifically included 5 aspects of running, squatting, jumping, twisting with the injured foot/ankle as a fulcrum, and kneeling. A previous study13 has found that SER IV and PER IV ankle fractures with dislocation have poorer FAOS, mainly in terms of increased pain and reduced activities of daily living. Our study showed similar results. In addition, one study12 showed that PER IV ankle fracture-dislocation has significantly worse FAOS in all 5 subscales. This may be because PER IV ankle fractures are exposed to more severe violence compared to SER IV ankle fractures. The devastating damage to the peri-ankle ligaments from the dislocation would interfere with subsequent functional rehabilitation. A study26 revealed that dislocation is one of the risk factors for reoperation after ankle fractures. Not coincidentally, the incidence of early posttraumatic ankle osteoarthritis in patients with ankle fracture-dislocation is as high as 43.2%.27,28 These clinical evidences further confirmed that dislocation is a risk factor for poor postoperative functional outcomes. Advanced ankle osteoarthritis was even severe enough to require total ankle arthroplasty for treatment.29
Besides FAOS, AOFAS ankle hindfoot score was also used to explore the impact of dislocation on the prognosis of ankle fractures. Although the AOFAS ankle hindfoot score is lower in the dislocation group compared to the no-dislocation group, no statistical difference was revealed. Compared to FAOS, AOFAS ankle hindfoot score requires clinical examination, so enough time is needed to complete an exhaustive and systematic evaluation.16 The lack of sufficient follow-up time might be one of the reasons why the AOFAS ankle hindfoot score failed to detect a significant difference between the 2 groups. To improve the quality of daily life and the motor function of the ankle joint for patients undergoing ankle joint surgery, supervised exercise, and home exercise are important rehabilitation strategies.30,31
There are some limitations in this study. (1) This is a single-center retrospective study, which may have some selection bias. (2) There is no imaging data such as MRI or ultrasound to definitively diagnose ligament injuries. (3) The sample size is relatively small although this is the largest known sample size of studies assessing the functional outcome of dislocation on SER ankle fractures. A further multicenter large-scale study would be conducted to enhance the current level of evidence. (4) It is possible that some of the patients' dislocated ankles achieved reduction on their own after injury, so there is a discrepancy between the imaging data and the extent of injury. Patients are also advised to confirm the extent of the injury by radiographic data before reduction after the injury.
In conclusion, in patients with SER ankle fractures, dislocation is significantly associated with poor postoperative functional outcomes, particularly in patients with SER IV ankle fractures. More pertinent rehabilitation of these patients is important.
CRediT authorship contribution statement
Sheng-Ye Hu: Conceptualization, Investigation, Writing - original draft. Mu-Min Cao: Conceptualization, Investigation, Writing - original draft. Yuan-Wei Zhang: Investigation. Liu Shi: Investigation. Guang-Chun Dai: Investigation. Ya-Kuan Zhao: Investigation. Tian Xie: Investigation. Hui Chen: Conceptualization. Yun-Feng Rui: Conceptualization.
Ethical statement
The research was approved by the Ethics Committee of Southeast University Affiliated Zhongda Hospital (No. 2018ZDSYLL155-P01).
Funding
Nil.
Declaration of competing interest
All authors state that they do not have any declarations of interest.
Footnotes
Peer review under responsibility of Daping Hospital and the Research Institute of Surgery of the Third Military Medical University.
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