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Introduction: The Olerud Molander Ankle Score (OMAS) is a widely used validated Patient Reported Outcome Measure (PROM). For clinical research, it is important to determine the Minimal Clinically Important Difference (MCID). The objective of this study was to determine the MCID of the OMAS at several moments in the follow-up, in a cohort of patients that underwent open reduction and internal fixation of unstable ankle fractures with syndesmotic injury. Materials and methods: Data for this descriptive study were extracted from a prospective randomized controlled trial, the RODEO trial. The Dutch version of the OMAS was completed at 3, 6 and 12-month follow-up and estimated at baseline. The used anchor-based methods were: mean change and ROC curve. The distribution-based methods were: 0.5SD and minimal detectable change (MDC). Results: This cohort included 148 patients. The mean OMAS score in the group with minimal improvement between 3 and 6 months was 15.0 (SD 17.5, 95%CI 9.4–20.6) and between 6 and 12 months 9.5 (SD 17.1, 95% CI 3.1–15.9). The ROC curve between 3 and 6 months resulted in a MCID of 12.5 (AUC 0.72) and between 6 and 12 months, the MCID was 7.5 (AUC 0.78). Using 0.5 SD, the MCID was 10.52 (SD 21.04) at 3 months, 11.37 (SD 22.73) at 6 months and 10.47 (SD 20.94) at 12 months. The MDC was 4.72 at 3 months, 5.20 at 6 months and 4.71 at 12 months. Conclusions: The calculated MCID in patients following surgery for unstable ankle fractures ranges from 10.5 to 15.0 at 3–6-month follow-up and from 7.5 to 11.4 at 6–12-month follow-up, depending on moment and method. [ABSTRACT FROM AUTHOR]

Introduction: Post-operative wound complications remain among the most common complications of orthopedic (trauma) surgery. Recently, studies have suggested environmental factors such as season to be of influence on wound complications. Patients operated in summer are reported to have more wound complications, compared to other seasons. The aim of this study was to identify if "seasonality" was a significant predictor for wound complications in this cohort of trauma-related foot/ankle procedures. Materials and methods: This retrospective cohort study included all patients undergoing trauma-related surgery (e.g. fracture fixation, arthrodesis, implant removal) of the foot, ankle or lower leg. Procedures were performed at a Level 1 Trauma Center between September 2015 until March 2019. Potential risk factors/confounders were identified using univariate analysis. Procedures were divided into two groups: (1) performed in summer (June, July or August), (2) other seasons (September–May). The number of surgical wound complications (FRIs, SSIs or wound dehiscence) was compared between the two groups, corrected for confounders, using multivariate regression. Results: A total of 599 procedures were included, mostly performed in the hindfoot (47.6%). Patients were on average 46 years old, and mostly male (60.8%). The total number of wound complications was 43 (7.2%). Age, alcohol abuse, open fracture and no tourniquet use were independent predicting factors. No difference in wound complications was found between summer and other seasons, neither in univariate analysis [4 (3.2%) vs 39 (8.2%), p = 0.086] nor when corrected for predicting factors as confounders (p = 0.096). Conclusions: No seasonality could be identified in the rate of wound complications after trauma surgery of the lower leg, ankle and foot in this cohort. This lack of effect might result from the temperate climate of this cohort. Larger temperature and precipitation differences may influence wound complications to a larger extent. However, previous studies suggesting seasonality in wound complications might also be based on coincidence. [ABSTRACT FROM AUTHOR]

Background: There is no consensus about the optimal treatment of anterior inferior ligament avulsion fractures of the ankle. The aim of this study is to provide insights regarding the incidence of anterior inferior ligament avulsion fractures, the association with fracture type, and correlation with treatment.Methods: This study is a retrospective analysis in a level-1 trauma center of adult patients with an ankle fracture operated between the dates 01-01-2009 and 01-09-2017 who had a pre- and postoperative CT-scan. Within the study population, the incidence of AITFL avulsion fracture was defined. Primary outcome was the type of avulsion fracture and related treatment. Secondary outcome was additional surgery in relation to the initial treatment.Results: In total, 65 of 252 (25.8%) patients were diagnosed with an anterior inferior ligament avulsion fracture. Zero patients had a Wagstaffe type 1 fracture, 28 (43.1%) had a type 2, 32 (49.2%) had a type 3, and 5 (7.7%) had a type 4. There was a correlation between Wagstaffe type 2 and Weber B fractures, p < 0.0001, and Wagstaffe type 3 avulsions were correlated with a Weber C fracture, p < 0.0001. Thirty-five of the avulsed fragments (53.8%) were smaller than 5 mm. In 13 (20%) of patients with anterior inferior ligament avulsion fracture, the avulsed fragments were directly fixated during initial surgery. Size and direct fixation of the fragment were significantly correlated (p < 0.0001). Within the anterior inferior ligament avulsion fracture group, only a total of four patients (6.2%) underwent a revision.Conclusion: In the current study, an incidence of 25.8% of anterior inferior ligament avulsion fracture in surgically treated ankle fractures is reported. A correlation between the type of Wagstaffe injury and Weber classification was showed. Most fragments smaller than 5 mm were not fixated; however, not all injuries needed syndesmotic screws due to syndesmotic instability.Level Of Evidence: Level IV. [ABSTRACT FROM AUTHOR]

Background: The aim of the current study was to investigate the effect of a footbath in alcohol prior to preoperative disinfection on bacterial flora of the foot and ankle.Methods: Twenty-two volunteers underwent skin preparation mimicking pre-surgical disinfection. One foot was submerged in a bag filled with 70% ethanol containing 10% IPA for 5 min after which it was painted with regular 0.5% chlorhexidine in 70% alcohol. The other foot was only painted with 0.5% chlorhexidine in 70% alcohol. Swabs were taken at four locations: (1) under the nailfold of the first toe, (2) first webspace, (3) sinus tarsi and (4) pre-tibial. A quantitative and qualitative analysis of the cultures was performed.Results: No statistically significant difference between the number of positive cultures between the two methods was observed. The number of colony forming units was statistically significantly lower on two locations in the footbath group (i.e., subungual and the first webspace) (median 1 versus median 92 p =0.03 and median 0 versus median 1 p =0.03, respectively). The number of cultures with heavy growth was lower in the footbath group under the nailfold of the first toe (5 versus 13 p =0.008). Thirty-eight different microorganisms were cultured.Conclusion: A footbath in alcohol prior to regular preoperative skin antisepsis significantly reduces the amount of bacteria under the nailfold and in the first webspace. The number of cultures with heavy growth is lower after a footbath in alcohol.Level Of Evidence: IV. [ABSTRACT FROM AUTHOR]

Background: 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET)/computed tomography (CT) has proven to have a high diagnostic accuracy for the detection of bone infections. In patients with delayed union it may be clinically important to differentiate between aseptic and septic delayed union. The aim of this study was to evaluate the efficacy and to assess the optimal diagnostic accuracy of FDG-PET/CT in differentiating between aseptic and septic delayed union in the lower extremity.Methods: This is a retrospective study of consecutive patients who underwent FDG-PET/CT scanning for suspicion of septic delayed union of the lower extremity. Diagnosis of aseptic delayed union or septic delayed union was made based on surgical deep cultures following PET/CT scanning and information on clinical follow-up. FDG-uptake values were measured at the fractured site by use of the maximum standardized uptake value (SUVmax). Sensitivity, specificity and diagnostic accuracy of FDG-PET/CT were calculated at various SUVmax cut-off points.Results: A total of 30 patients were included; 13 patients with aseptic delayed unions and 17 patients with septic delayed unions. Mean SUVmax in aseptic delayed union patients was 3.23 (SD ± 1.21). Mean SUVmax in septic delayed union patients was 4.77 (SD ± 1.87). A cut-off SUVmax set at 4.0 showed sensitivity, specificity and diagnostic accuracy of FDG-PET/CT were 65, 77 and 70% to differentiate between aseptic and septic delayed union, respectively.Conclusion: Using a semi-quantitative measure (SUVmax) for interpretation of FDG-PET/CT imaging seems to be a promising tool for the discrimination between aseptic and septic delayed union. [ABSTRACT FROM AUTHOR]

Introduction: High rates of postoperative wound infections (POWI) are reported following the operative treatment of calcaneal fractures. This leads to additional therapy, prolonged hospital stay, burden for patients and increased costs. The primary aim of this study is to evaluate the effect of POWI following the extended lateral approach of displaced intra-articular calcaneal fractures on functional outcome. Secondary aims are assessment of health-related quality of life and patient satisfaction. Patients and methods: All consecutive adult patients with a calcaneal fracture treated between 2000 and 2011 with open reduction and internal fixation through an extended lateral approach were retrospectively included and sent a questionnaire. Functional outcome was measured using the Foot Function Index (FFI, best score 0 points) and the American Orthopaedic Foot and Ankle Society (AOFAS, best score 100 points) hindfoot score. The EuroQOL-5D was used for quality of life (QOL) and a Visual Analogue Scale (VAS, best score 10 points) for overall patients satisfaction. Results: Of 135 eligible patients, 94 returned the questionnaire (response rate 70 %). The median FFI was 12 points (IQR 3-33) and AOFAS 79 points (IQR 61-90). The FFI and AOFAS were, respectively, 17 and 9 points higher in favour of patients without POWI ( n = 69) compared to patients with POWI ( n = 25). Albeit large differences, they were not statistically significant given the current number of patients. Patients without POWI scored better on all health-related aspects of QOL in the EQ-5D, but this did not reach statistical significance. However, the VAS on overall patient satisfaction did show a statistically significant difference of 1.3 points (9.0 vs 7.7; p = 0.01) in favour of patients without POWI. Importantly, a clinically relevant difference was found with the FFI as the estimated minimal clinical important difference of the FFI is 10 points. Conclusion: Our results implicate that postoperative wound infection leads lower functional outcome scores following calcaneal fracture surgery, but no statistical significance was reached. In addition, patients do not report significant worse QOL or physical impairment. Overall patient satisfaction measured by a VAS was significantly lower in case of a POWI, reflecting the burden caused by a wound complication. [ABSTRACT FROM AUTHOR]

Extra-articular calcaneal fractures represent 25–40% of all calcaneal fractures and an even higher percentage of up to 60% is seen in children. A disproportionately small part of the literature on calcaneal fractures involves the extra-articular type. The aim of this study was to investigate the incidence of extra-articular calcaneal fractures in a Level 1 trauma centre, define the distribution of the various types of fractures and compare patient demographics between extra- and intra-articular calcaneal fractures. In addition the literature was reviewed for the most common types of extra-articular calcaneal fractures with regard to incidence, treatment and clinical outcome. The radiological records between 2003 and 2005 were reviewed for intra- and extra-articular calcaneal fractures. Patient gender-distribution and age were compared. A literature search was conducted for the treatment of extra-articular calcaneal fractures. In this 3-year study period a total of 49 patients with 50 extra-articular calcaneal fractures and 91 patients with 101 intra-articular fractures were identified. The median age for the first group was 32.7 years, and for the second group 40.3 years; P = 0.04. Male predominance was significantly less pronounced for extra-articular (63%) compared with intra-articular fractures (79%; P = 0.04). One-third of all calcaneal fractures are extra-articular. Significant differences exist between the intra- and extra-articular groups, in terms of lower age and male–female ratio. The literature study shows inconsistencies in treatment options, but most extra-articular fractures are well manageable conservatively. [ABSTRACT FROM AUTHOR]

The long-term follow-up of intra-articular calcaneal fractures is often accompanied by complications. Frequently occurring are arthrosis, arthrofibrosis of the subtalar joint, and malunion. Uncommon is the calcaneal nonunion. A total of three cases is presented in this report, including a review of the literature. The occurrence of a nonunion appears to be more common after conservative treatment, but the pathophysiology remains unclear, however smoking may play a role. [ABSTRACT FROM AUTHOR]

A correction to the article "The Effect of Postoperative Wound Infections on Functional Outcome Following Intra-Articular Calcaneal Fractures" that was published in a previous issue is presented.