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Improved Functional Outcome After Early Reduction in Bosworth Fracture-Dislocation

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Improved Functional Outcome After Early Reduction in Bosworth Fracture-Dislocation Foot and Ankle Surgery 25 (2019) 798–803 Contents lists available at ScienceDirect Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas Improved functional outcome after early reduction in Bosworth fracture-dislocation a,b a, a a a,b Yougun Won , Gi-Soo Lee *, Jung-Mo Hwang , Il-young Park , Jae-Hwang Song , a a Chan Kang , Deuk-Soo Hwang a Department of Orthopaedic Surgery, Chungnam National University School of Medicine, Korea b Department of Orthopedic Surgery, Konyang University College of Medicine, Korea A R T I C L E I N F O A B S T R A C T Article history: Background: Bosworth described an unusual fracture-dislocation of the ankle with fixed posterior Received 23 July 2018 fracture-dislocation of the fibula. Previous epidemiological data on the prevalence and characteristics of Received in revised form 4 October 2018 patients with Bosworth ankle fractures have been limited. Bosworth fracture-dislocations are often Accepted 16 October 2018 missed in patients with ankle fractures. We investigated the outcomes of missed diagnosis and the prevalence of Bosworth fracture-dislocation in patients with ankle fractures. Keywords: Methods: We conducted a retrospective analysis of inpatients aged 15 years and older with an ankle Bosworth fracture, who underwent surgery between 2007 and 2016 in 4 Korean hospitals. The patient Ankle demographics, risk factors, fracture characteristics, treatment data, outcomes, and complications were Posterior malleolus Fracture analyzed. Missed Results: We reviewed 3405 hospital admissions for ankle fractures. During the study period, Bosworth Outcome fracture-dislocations were diagnosed in 51 cases. The prevalence of Bosworth fracture-dislocations Complication (n = 51) was 1.62% among patients with ankle fractures who were enrolled in this study (n = 3140). Emergency surgery was performed within 24 h of injury in 36 cases (group A) and delayed surgery was performed in 15 cases (group B). The mean patient age at admission was 35.97 (standard deviation [SD], 1.643) years in group A and 34.33 (SD, 2.296) years in group B. Men were more commonly affected than women, with a 32:19 ratio. Mostof thepatientswith Bosworth fracture-dislocationswere young adults with high-energy trauma. The most frequent mechanism of trauma was falling down stairs (n = 27, 52.94%), followed by traffic accidents. Patient outcomes were significantly better in group A than in group B. Conclusion: The prevalence of Bosworth fracture-dislocations was higher than expected. If unrecognized, it can result in inappropriate treatment and permanent disability. With accurate diagnosis and prompt treatment, excellent results can usually be obtained. Level of clinical significance: 4. © 2018 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. 1. Introduction recognized early, delaying surgical treatment and reduction [3]. Although this type of dislocation is rare, a few studies have Bosworth fracture is characterized as a pattern of fracture- reported on its prevalence and outcomes. dislocation of the ankle joint in which the proximal part of the We considered that it would be helpful to investigate the actual fibula is entrapped behind the posterior malleolus. Bosworth [1] prevalence of this rare injury and the difference of outcomes first described this fracture in 1947 in a series of 5 patients and between cases with and without early diagnosis and treatment. alerted readers to the poor outcome if the injury is unrecognized. The purpose of this study was to compare the outcomes of patients Bosworth fracture-dislocations have been reported to require who received early diagnosis and treatment and those who did not, urgent surgery because of the associated difficulty encountered and to determine the prevalence of Bosworth fracture-dislocations during closed reduction [2]; however, the injury is often not as part of a multicenter review of 51 cases. 2. Materials and methods * Corresponding author at: Department of Orthopedic Surgery, Chung-Nam We retrospectively reviewed the medical records and radio- National University Hospital, 640 Daesa-dong, Jung-gu, Daejon 35015, Korea. E-mail address: [email protected] (G.-S. Lee). graphic images of 3405 patients with ankle fracture (age 15 years, https://doi.org/10.1016/j.fas.2018.10.007 1268-7731/© 2018 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. Y. Won et al. / Foot and Ankle Surgery 25 (2019) 798–803 799 skeletally mature) who underwent surgery between January 2007 software version 9.4 (SAS Institute, Cary, NC, USA). The Mann– and December 2016 at 4 university hospitals. All patients were found Whitney U-test and Fisher’s exact test were used to compare the 2 to have Bosworth fracture-dislocation based on preoperative plain groups. radiographs including oblique-view or computed tomography (CT) The study has been reviewed and approved by our institutional images; patients without these images were excluded. Moreover, all review board (CNUH 2018-03-069). cases of open ankle fractures were excluded from this study. However, there was no case of Bosworth fracture-dislocation among 3. Results the open ankle fracture cases in this review. All procedures were performed or supervised by an orthopedic surgeon with orthopedic Of the 3405 cases, 485 were assessed and confirmed to have the trauma fellowship training. The minimum follow-up duration of all axilla sign in mortise view or the fibular position in external patients was 12 months or until established treatment failure (Figs.1 oblique radiographs by 1 author (GS Lee). The remaining cases and 2). (n = 2751) were assessed using CT. A total of 169 cases were We assessed the data of patients with Bosworth fracture- excluded because of the absence of the above-mentioned features, dislocations, including age, sex, mechanism of injury, time from and 96 cases were excluded for being open fractures. Finally, 3140 the injury to surgery, surgical method (staged operation), length of patients with ankle fractures were included in this study. The stay, and occurrence of complications. Surgery within 24 h of prevalence of Bosworth fracture-dislocations (n = 51) was 1.62%. injury was defined as urgent surgery (group A). Patients who Fifty-one (1.62%) patients were diagnosed as having Bosworth underwent surgery after 24 h from injury were defined as having fracture-dislocation (mean age, 35.49 years), including 32 men delayed treatment and classified as group B. Patients were (mean age, 35.38 years) and 19 women (mean age, 35.68 years). followed up at approximately 6-week, 3-month, 6-month, and Emergency surgery was performed within 24 h of injury in 36 cases 12-month intervals. The American Orthopedic Foot and Ankle (group A), and delayed surgery was performed in 15 cases (group Society (AOFAS) score was determined at the 12-month visit. B). In group A, 29 of 36 patients were preoperatively diagnosed as All statistical analyses were conducted with SPSS software having Bosworth fracture-dislocations. The remaining 7 patients in version 24.0 for Windows (SPSS Inc., Chicago, IL, USA) or SAS group A were not recognized to have Bosworth fracture-dislocation Fig. 1. Bosworth fracture-dislocation image. (a) The axilla sign is visible on mortise view. (arrow) (b) Posterior subluxation of the talus on lateral radiograph. (c) The fibula is positioned in the middle of the talar body on external oblique radiograph. (d) Axial computed tomography image. 800 Y. Won et al. / Foot and Ankle Surgery 25 (2019) 798–803 Fig. 2. Postoperative radiographs show (a-b) the normal ankle mortise and lateral fibular position following open reduction and internal fixation. (c-d) The mortise and lateral ankle radiographs on 1 year follow-up. Medial joint spaces were slightly widened in the mortise view. before surgery, but underwent emergency surgery (<24 h) because remaining 12 cases were not recognized as Bosworth fracture- of severe dislocation or swelling, and were consequently catego- dislocations during surgery but were diagnosed as Bosworth rized into group A. fracture-dislocations in this review (Table 1). Overall, 29 of 51 (56.86%) patients were diagnosed as having The mean length of stay was 15.75 (standard deviation [SD], Bosworth fracture-dislocation preoperatively, whereas 22 of 51 0.680) days in group A and 21.20 (SD, 1.528) days in group B. The (43.14%) patients did not have such preoperative diagnosis. Some cause of the injury was falling down stairs in 27 (52.94%), a traffic of the cases were misdiagnosed as simple ankle fractures with accident in 14 (27.45%), falling from a height in 6 (11.76%), and instability or fracture-dislocation preoperatively. Of 22 (preopera- other reasons in 4 (7.84%) patients. Thirty-six patients met the tively unrecognized) cases, 10 were diagnosed as Bosworth criterion for inclusion in group A, including 34 (94.44%) who fracture-dislocation during the surgery, when it was observed underwent a 1-staged operation and 2 (5.56%) who underwent a 2- that the dislocated fibula was fixed behind the posterior tibia. The staged operation. Group B consisted of 15 patients, including 5 Table 1 Demographic data of patients groups underwent urgent surgery (Group A) and underwent surgery after 24 h (Group B). Variable Group A Group B P-value No. of patients 36 15 1.000 Age at surgery, years 35.97 Æ 1.643 (Range, 21–55) 34.33 Æ 2.296 (Range, 22–54) .541 Mean body weight 65.7 (57–79) 68.3 (55–83) .365 Sex, male 24 (66.67%) 8 (53.33%) .370 Affected leg, right 17 9 .406 * Time from the injury to surgery, hours 13.78 Æ 5.094 (Range, 5–23) 53.93 Æ 18.626 (Range, 29–92) <.00 * The difference is significant (P < .05). Y. Won et al. / Foot and Ankle Surgery 25 (2019) 798–803 801 (33.33%) who underwent a 1-staged operation and 10 (66.67%) Bosworth fracture-dislocations (n = 51) in only SER-type ankle who underwent a 2-staged operation.
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