Errors and complications in the treatment of complex fractures of the ankle joint

How does a fracture occur?

Ankle fractures, more commonly known as ankle fractures, occur when one or more of the bones that make up the ankle joint are broken. Although an ankle fracture is an injury seen at almost any age, it is more common among older adults and athletes who are physically active.

When the bones are damaged, the ankle becomes unstable. When adding ligament damage, the injury can become a very serious problem, and complications after an ankle fracture are possible.

An ankle fracture can be caused by a sudden, accidental movement, such as twisting the ankle during sports or activity. Car accidents can also cause ankle fractures, especially after hard impacts.

A person can also trip, fall, or twist an ankle, which can cause an ankle fracture. Depending on age and previous health conditions, this problem can develop into a much more serious injury if left untreatedSource: Ankle Injury Analysis. Taylashev M.M., Salatin P.P., Sobolev V.V., Pozikov V.V., Kolesnikov A.S. Acta Biomedica Scientifica, 2008. p. 144-145.

Classification of ankle fractures

The ankle joint itself is formed by three bones - the largest is the tibia, then the fibula (shin bone) and the talus. It is located in the area between the calcaneus, as well as the tibia and fibula. Ankle fractures are classified by the area of ​​the broken bone:

• a fracture in the area of ​​the medial malleolus is the inner surface of the tibia;
• damage to the posterior malleolus is the dorsum of the tibia;
• a fracture in the area of ​​the lateral malleolus is damage to the edge of the fibula.

The stability of the ankle joint is determined by the strength of the ligaments and bones. When fractures occur in the ankle joint, two joints are affected:

• ankle joint - formed by the tibia, talus, fibula;
• The syndesmosis is the area between the tibia and fibula held together by ligaments. Source: Ankle Fractures and Treatment Methods. Cherednik A.A., More Gautam Saherbao, Al-Fakih Abdulaziz. Bulletin of Medical Internet Conferences, 2014. p.432.

Symptoms of an ankle fracture

The main symptoms of an ankle fracture are as follows:

• Severe pain, sharp and burning in open forms and dull, aching in a closed fracture, which increases when trying to move the foot;
• The rapid appearance of edema, which gradually increases and takes on a pronounced character;
• Noticeable deformity in the ankle area;
• Limitation of range of motion in the joint;
• Inability to axial load (inability to stand on the leg with emphasis on it);
• In some cases - the presence of a hematoma (hemorrhage), an increase in local and general body temperature.

Symptoms

Because a sprain can sometimes feel similar to a broken ankle, it is always important to consult a doctor. Assessing the symptoms of an ankle fracture and post-injury pain help in determining how serious the injury is.

An ankle fracture is accompanied by one or all of the following symptoms:

• pain at the fracture site, which in some cases can spread from the foot to the knee;
• significant swelling, which may occur along the length of the leg or be more localized. How long the swelling lasts will depend on the severity of the injury and the volume of damaged tissue;
• a bruise that appears soon after the injury;
• inability to walk while stepping on the entire leg. Therefore, your doctor will tell you how to walk correctly after an injury. However, a person can walk with less severe fractures, so never rely on walking as a test of whether a bone has been broken;
• the appearance of the ankle has been changed - it will be different from the other ankle;
• the bone protrudes from the skin in an open fracture. Fractures that penetrate the skin require immediate attention as they can lead to severe infection and a long recovery time.

Possible causes of fracture

In 90% of cases, the joint is damaged as a result of indirect rather than direct exposure to traumatic force. For example, when the forefoot continues to move while the hindfoot is fixed. This happens when you fall while running or walking.

A displaced fracture can be caused by falling from a ladder, ice skating, roller skating, or doing extreme sports: alpine skiing, skydiving. In any case, you should not endure acute pain, but immediately contact the emergency room to differentiate a possible fracture from a dislocation or sprain, since chronic fractures without appropriate treatment lead to serious complications.

Diagnostics

The doctor will discuss with the patient the medical history (how long the pain has been, what happened before the injury) and symptoms. He will also ask how the injury occurred and examine the affected area. If your trauma surgeon thinks you may have broken your ankle, he or she will order a series of tests to more fully understand the injury.

X-rays : X-rays can show whether the ankle bone has been broken and how many pieces of broken bone are there. They can also determine if there is displacement (a gap between broken bones). The doctor may also take X-rays of other parts of the leg or foot to make sure nothing was damaged as a result of the injury.

Stress test : A stress test is performed to determine whether surgical procedures are necessary to heal the injury. The doctor will apply some pressure to the ankle and take a special x-ray to determine the severity of the injury.

CT scan (computed tomography): If the fracture extends beyond the ankle, a CT scan may be needed to further examine the injury. A CT scan allows you to obtain a series of images in different planes, from which the doctor can determine the severity of the injury. Source: Comprehensive diagnosis of ankle joint injuries. Kim L.I., Dyachkova G.V. Genius of Orthopedics, 2013. p.20-24.

MRI (Magnetic Resonance Imaging) Scan: If your doctor suspects ligament damage has occurred, he or she may order an MRI scan to get a better look at the affected area. MRI can look deeper into bones, soft tissues, and ligaments to create higher-resolution images than most other tests.

First aid for a broken ankle

Treatment for ankle fractures depends on the type and severity of the injury. First aid is necessary to prevent further damage from an ankle fracture and reduce the time it takes for bones to heal.

• Rest : You need to take the weight off the injured ankle. Walking can cause further injury, and only a doctor can determine when it is safe to step on your foot.
• Ice : Apply an ice pack to the injured area, placing a thin towel between the ice and the skin. You should use ice for 20 minutes and then wait at least 40 minutes before applying the cold compress again.
• Compression : An elastic bandage should be used to control swelling.
• Elevation : The ankle should be slightly elevated above the level of the heart to reduce swelling.

First aid

If a person has a sprain or suspected fracture, it is necessary to call an ambulance. It is not recommended to get to the hospital on your own, as there is a risk of dislodging bone fragments. Movement of the injured limb may result in the need for surgery to reconcile the debris.

Without waiting for an ambulance to arrive, you can take several measures to alleviate the condition:

1. Limb immobilization. If there is a fracture or a suspected fracture, the leg must be completely immobilized. To do this, you need to bandage a straight stick to your leg along the outer and inner surfaces. You need to place a flat board on your foot so that it forms an angle of 90°. This position of the leg is anatomical and helps prevent the development of contractures. The video in this article shows how to properly immobilize an injured limb.
   
2. Apply cold. In order to prevent the increase in edema and hematoma, cold must be applied. You should not apply it for a long time, especially in winter, since due to lack of blood supply, tissue trophism may be disrupted.
3. Take a painkiller. If possible, it is recommended to take a tablet analgesic. Before doing this, you need to read the instructions for any contraindications. The instructions for all drugs contain such a clause.

Using an ice pack can significantly reduce swelling.

If the patient has disorders of consciousness, then it is necessary to provide an irritating effect. To do this, you can sprinkle your face with cold water and pinch your face. You can also give ammonia to smell.

Ankle fracture: treatment, clinical recommendations

If the traumatologist determines that the patient has a broken ankle, they need to determine what type of fracture it is and how to treat it. Ankle fractures can be treated with non-surgical methods if the injury is not too severe or unstable.

• Lateral fracture of the fibula. If the ankle is stable, non-surgical healing methods are available. These can range from wearing high tennis shoes to short plaster casts. Your doctor may recommend rest and crutches to keep pressure off the foot and to ensure that the fragments do not become dislodged during healing.
• Fracture of the tibia on the inside of the lower leg. If the fracture is all bones in place or is very minor, it can be healed by keeping your ankle free of stress for 6 weeks. A short bandage on the leg or a removable bandage, as well as a doctor's advice on when you can walk, usually speed up the healing process.
• Fracture of the back of the leg at the level of the ankle joint. In most cases, the fibula also breaks due to the fact that it shares ligaments with the posterior malleolus. If the ankle remains stable, it can be treated without surgery. Treatment may include a short leg bandage or a removable brace. It is important to determine the severity so that arthritis does not develop. The ankle fracture will need to be gradually worked out as it heals.
• A bimalleolar equivalent fracture (two of the three parts of the ankle joint are broken) indicates that the ligaments on the inside of the ankle are also damaged. Because these injuries are usually unstable, surgical treatment is usually recommended. In case of health problems that may interfere with the operation, a splint and short bandage may be applied to the leg. You will need to see your doctor regularly to make sure your ankle remains stable.
• Trimalleolar fracture (all three parts of the ankle are broken). Because this is a very serious situation, surgery is almost always recommended. Rare non-surgical treatment options include a short leg cast, a splint, and ongoing visits to the doctor.

If the joint located between the tibia and fibula is damaged and the ligaments are also affected, the injury may heal like an ankle sprain. The injury can be treated by removing weight from it without surgery.

However, most cases involve sprains and one or more fractures. Recovery from an ankle fracture is rarely complete without surgical treatment. Source: Therapeutic tactics for intra-articular fractures of the ankle joint (literature review). Zedgenidze I.V., Tishkov N.V. Acta Biomedica Scientifica, 2013. pp. 178-182.

Treatment approaches

For a fracture in the ankle area, there are two most common approaches to treatment - conservative and surgical. Each has its own indications and contraindications, features and disadvantages. It all depends on the type of fracture, the degree of displacement, and the presence of fragments. The decision is made by the doctor together with the patient.

Conservative treatment

The technique is indicated in cases where there is a fracture of the ankle joint without displacement or the patient is contraindicated for surgery. In such cases, there are two most common options. In the first case, the doctor may recommend applying a plaster cast, in the second - skeletal traction.

Additionally, non-steroidal anti-inflammatory drugs are used for pain. If swelling is severe, the doctor will prescribe decongestants in the form of tablets or droppers. Calcium preparations will speed up the fusion of bone tissue, and chondroprotectors will make it possible to restore cartilage.

Plaster immobilization

If the case is simple and there is no displacement, then the application of a plaster splint is indicated, which will have to be worn for approximately 4 to 6 weeks. More accurate information depends on each specific case and the x-ray control on the basis of which rehabilitation is carried out.

If there is displacement, a plaster cast is also applied, only the bandage is called a “boot.” In appearance, it really resembles him, only the toes are always left open, and the boot reaches the upper third of the shin. A similar bandage is applied after repositioning the fracture (manipulation is carried out only under anesthesia), after which X-ray control is required. The duration of wearing the bandage is on average 6 to 8 weeks, but may be longer, depending on the rate of fusion.

Skeletal traction

In some cases, the skeletal traction technique can be used. Its disadvantage is that it requires lying for a long time with weights suspended from the limb. However, the silver lining is that a displaced ankle fracture may fall back into place or be easier to realign manually.

Also, such a technique can be a preparation for surgery. Over the course of several days, while the necessary tests are taken and examinations are carried out on the victim, the ligaments and muscles are stretched, making it much easier to compare fragments in the wound. Additional loads or a change in the vector of the traction force of the main load also help eliminate displacement. On average, a person spends about 3 months in traction, after which a cast is applied. The period may vary depending on the type of damage. The disadvantage is the lack of strong fixation of the fragments, and also the fact that the leg must be constantly tightened.

Surgery

If non-surgical treatments don't work or the ankle is too unstable, your doctor may recommend ankle fracture surgery followed by rehabilitation. After surgery, it is important to walk your leg and perform all prescribed procedures in order to reduce rehabilitation time.

Features of the operation: if the fragments are not in their place, the bone fragments must be moved surgically. The fragments had to be returned to their normal position and held together with special screws and metal plates attached to the outer surface of the bone. Surgery may include a bone graft to allow the new bone to actively heal. It is secured with screws and a metal plate. This may reduce the risk of arthritis and speed the return of movement.

Possible complications

After treatment, it is important to follow your surgeon's instructions. Failure to do so can lead to infection, deformity, arthritis, and chronic pain. Source: Mistakes and Complications in the Treatment of Compound Ankle Fractures. Salikhov R.Z., Pankov I.O., Plakseychuk Yu.A., Soloviev V.V. Practical medicine, 2014. p. 128-131.

Article sources:

1. Errors and complications in the treatment of complex fractures of the ankle joint. Salikhov R.Z., Pankov I.O., Plakseychuk Yu.A., Soloviev V.V. Practical medicine, 2014. p. 128-131
2. Analysis of ankle joint injuries. Taylashev M.M., Salatin P.P., Sobolev V.V., Pozikov V.V., Kolesnikov A.S. Acta Biomedica Scientifica, 2008. p. 144-145
3. Comprehensive diagnosis of ankle joint injuries. Kim L.I., Dyachkova G.V. Genius of Orthopedics, 2013. p.20-24
4. Fractures of the ankle joint and treatment methods. Cherednik A.A., More Gautam Saherbao, Al-Fakih Abdulaziz. Bulletin of Medical Internet Conferences, 2014. p.432
5. Therapeutic tactics for intra-articular fractures of the ankle joint (literature review). Zedgenidze I.V., Tishkov N.V. Acta Biomedica Scientifica, 2013. pp. 178-182

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Errors and complications in the treatment of complex fractures of the ankle joint

R.Z. SALIKHOV, I.O. PANKOV, Yu.A. PLAKSEICHUK, V.V. SOLOVIEV

Republican Clinical Hospital of the Ministry of Health of the Republic of Tatarstan, 420064, Kazan, st. Orenburgsky Trakt, 138

Salikhov Ramil Zaudatovich - senior researcher of the scientific department, traumatologist-orthopedist, tel. +7-917-285-28-28, e-mail

Pankov Igor Olegovich - Doctor of Medical Sciences, Professor, Chief Researcher of the Research Department, Head of the Clinic of Traumatology and Orthopedics, tel., e-mail: [email protected]

Plakseychuk Yuri Antonovich - Candidate of Medical Sciences , leading employee of the scientific department, head of the orthopedics department No. 1, tel. +7-917-269-60-01, e-mail

Soloviev Vladislav Vsevolodovich - research fellow of the scientific department, traumatologist-orthopedist, tel. +7-927-672-42-99, e-mail

Errors and complications in the treatment of 116 patients with consequences of injuries to the ankle joint that required repeated surgical treatment were analyzed. The share of errors and complications that arose at the stage of primary diagnosis and treatment was 59.5%. Complications related to the severity of the injury itself amounted to 37.1%; “due to the patient’s fault” 3.4% of complications occurred. The disappointing data obtained highlight the need to improve the training of orthopedic traumatologists and the implementation of standards of care.

Key words : ankle fractures, post-traumatic arthrosis of the ankle joint.

R. _ Z. _ SALIKHOV , I. _ O. _ PANKOV , Y. _ A. _ PLAKSEYCHUK , V. _ V. _ SOLOVYEV

Republican Clinical Hospital of the Ministry of Healthcare of the Republic of Tatarstan, 138 Orenburgskiy Trakt, Kazan, Russian Federation, 420064

Errors and complications in the treatment of complex ankle fractures

Salikhov RZ - Senior Researcher of the Scientific Department, traumatologist-orthopedist, tel. +7-917-285-28-28, e-mail

Pankov IO - D. Med. Sc., Professor, Chief Researcher of Scientific-Research Department, Head of the Clinic of Traumatology and Orthopedics, tel., e-mail: [email protected]

Plakseychuk Yu.A. — Cand. Med. Sc., Leading Researcher of the Scientific Department, Head of the Orthopedic Department No. 1, tel. +7-917-269-60-01, e-mail: [email protected]

Solovyev VV - Researcher of the Scientific Department, orthopedic surgeon, tel. +7-927-672-42-99, e-mail: [email protected]

Errors and complications in the treatment of 116 patients with ankle fractures were analyzed, which required iterated operative treatment. The rate of mistakes and complications encountered at primary diagnosis and treatment was 59.5%. Complications associated with the type of fracture constituted 37.1%. The failure of the patient to adhere to doctors recommendations was revealed in 3.7% of cases. These unsuccessful results highlight the importance of orthopedic surgeons training and the need to follow all necessary procedures.

Key words: ankle fracture, posttraumatic osteoarthritis of ankle.

The frequency of fractures of the ankle joint is 13-20% of all skeletal bone fractures and 30-60% of shin bone fractures, occupying one of the first places in frequency among all injuries of the musculoskeletal system [1, 2]. The frequency of complications and unsatisfactory treatment outcomes is high and reaches 30% or more, depending on the type and type of fractures and the severity of associated tissue damage [3-6].

The purpose of the study is to develop recommendations to reduce unsatisfactory treatment outcomes for patients with complex fractures of the ankle joint.

The objectives of the study are to analyze errors and complications in the treatment of patients with consequences of injuries to the ankle joint.

Materials and methods

Based on anamnesis, physical examination data and radiological research methods (x-ray, computed tomography), errors and complications that led to unsatisfactory treatment results for patients with complex injuries of the ankle joint and required surgical treatment were analyzed and structured. The data of 116 patients who were admitted for surgical treatment in 2003-2013 were studied. Of these, there were 55 men and 61 women. There were 109 patients of working age. The duration of injury ranged from 4 months to 12 years.

The reasons for hospitalization for surgical treatment were: secondary displacement of ankle fragments, relapses of diastasis in the tibiofibular joint, delayed consolidation and pseudarthrosis of ankle fractures, pseudarthrosis and avascular necrosis of the talus, post-traumatic arthrosis and contractures of the ankle joint. All patients underwent appropriate surgical treatment, which included reconstructive operations (transosseous osteosynthesis, corrective osteotomies with restoration of congruence of articular surfaces, arthroscopy of the ankle joint) and stabilizing operations (arthrodesis of the supratalar joint, supra- and subtalar arthrodesis). Errors and complications in the management and treatment of patients with complex injuries to the ankle joint were divided into those that arose at the diagnostic stage, during the treatment process, directly related to the severity of the injury itself, and also into complications “due to the fault of the patients themselves.”

Results and its discussion

The distribution of patients by nosological categories and types of surgical interventions required is presented in Table. 1.

Table 1.

Nosological categories and types of surgical interventions required

Errors and complications that arose at the diagnostic stage included incorrect interpretation of clinical and radiological data - 11 patients, undiagnosed injuries to the distal tibiofibular syndesmosis - 3 patients. There were 14 patients in total, which accounted for 12.1% of the total. To avoid these errors, it is necessary to pay attention to the features of the mechanism of injury, taking into account that all types of complex fractures of the distal articular end of the tibia bones, where suprasyndesmotic or transsyndesmotic fractures of the fibula occur, are accompanied by partial or complete damage to the tibiofibular ligaments; with subsyndesmotic fractures of the fibula, damage to the tibia syndesmosis, as a rule, is not observed (classification by K. Webber, 1966). It is necessary to perform a full clinical and radiological examination (including comparative radiographs of both ankle joints with placement “on syndesmosis” or X-ray computed tomography in doubtful cases).

In Fig. Figure 1 shows radiographs of a patient with a healed fracture of the lateral malleolus, damage to the distal tibiofibular syndesmosis, and outward subluxation of the foot (compared to the uninjured side).

Picture 1.

X-ray of a patient with consequences of damage to the left ankle joint (healed fracture of the lateral malleolus, damage to the distal tibiofibular syndesmosis, subluxation of the left foot outward compared to the uninjured side)

Errors during medical manipulations and surgical procedures: incomplete and inaccurate reduction of the fracture (residual displacement of ankle fragments and incongruity in the supratalar joint), inadequate fixation of fractures - 37 patients, incomplete elimination of tears in the tibiofibular syndesmosis - 10 patients, relapses of displacement of ankle fragments and excessive diastasis in tibiofibular joint - 5 patients, long-term fixation of the foot in a hypercorrection position - 3 patients (in such cases, there is a mutual convergence of muscle attachment points, a weakening of their tone with the subsequent development of combined flatfoot). A total of 55 patients, which accounted for 47.4% of the total. When treating patients with injuries to the ankle joint, one should be guided by the principles of complete restoration of congruence of the articular surfaces, reliable fixation of fragments, and careful implementation of management protocols.

In Fig. Figure 2 shows radiographs of a patient with severe damage to the distal articular part of the leg. The displacement of the fragments was not eliminated, an inadequate method of fixation of the fragments was chosen, and, as a result, the patient developed grade 4 post-traumatic arthrosis. and a sharp impairment in the ability to support the limb.

Figure 2.

Radiographs of a patient with severe damage to the distal articular part of the leg; the displacement of the fragments was not eliminated, an inadequate method of fixation of the fragments was chosen, and, as a result, the patient developed post-traumatic arthrosis of the 4th degree. and a sharp impairment in the ability to support the limb

Complications related to the severity of the injury were identified in 43 patients, which amounted to 37.1% of the total. Severe damage to the capsular-ligamentous apparatus of the ankle joint, extensive destruction of the articular surface of the tibia and talus can cause the development of persistent contractures and deforming arthrosis of the supratalar joint and joints of the foot, even after restoration of congruence of the articular surfaces. Such patients, as a rule, require several courses of rehabilitation treatment and timely referral for repeated surgical treatment. With the development of post-traumatic arthrosis of the 1st–2nd stage. Arthroscopy of the ankle joint can be performed; in case of grade 3–4 arthrosis, formation of a false joint and/or avascular necrotalar bone, arthrodesis remains the operation of choice. Arthroscopy of the ankle joint allows you to clarify the diagnosis, eliminate anterior impingement syndrome, remove loose intra-articular bodies, and increase range of motion. Arthrodesis of the supratalar or supra- and subtalar joints eliminates pain and restores the ability to support the limb.

In Fig. Figures 3 and 4 show radiographs of a patient with severe damage to the distal articular part of the leg. The displacement of the fragments was eliminated, and PCOS was performed using an external fixation device. After 5 years, the patient came to the clinic due to severe pain syndrome, and the development of post-traumatic arthrosis of the 4th degree was diagnosed.

Figure 3.

Radiographs of a patient with severe damage to the distal articular part of the leg. Displacement of fragments was eliminated, PCOS was performed using an external fixation device

Figure 4.

Radiographs of the patient after 5 years. Post-traumatic arthrosis of the 4th degree has developed

Complications due to the “fault of the patients themselves” are conditionally subjective in nature, and they are associated with non-compliance with the prescribed regimen on the part of patients.

Complications of this category: untimely referral of patients for medical help, accidental falls on the operated limb, too early loading of the limb, which can lead to secondary displacement of fragments, fractures of fixators requiring repeated corrective interventions, unjustifiably late loading and function of the limb, which, as a rule, lead to the development of persistent joint contractures and so-called stress osteoporosis, requiring long-term rehabilitation treatment, ignoring full rehabilitation treatment on the part of patients, which leads to significant functional disorders, often leading to permanent disability. We included 4 patients in this group, which accounted for 3.4% of the total.

conclusions

Complex fractures of the ankle joint area are severe intra-articular injuries to the bones of the extremities. The features of this category of fractures include: multiple nature of the damage, a frequent combination of fracture and dislocation with damage to the capsular-ligamentous apparatus of the joint; significant violations of congruence in the ankle joint; a wide variety of types and types of damage; often - difficulties in ensuring reposition and adequate stable fixation of fragments during the period of consolidation; the development of complications in the form of deforming arthrosis and persistent contractures of the ankle and foot joints, combined post-traumatic flatfoot, avascular necrosis of the talus during its fractures, requiring a long period of rehabilitation and often repeated, including reconstructive operations. Among patients with consequences of severe injuries to the ankle joint, a high proportion of errors and complications that arose at the stage of diagnosis and treatment was revealed - 59.5%, which requires improved training of orthopedic traumatologists providing emergency traumatological and orthopedic care, and a wider introduction of diagnostic methods (X-ray computed tomography, magnetic resonance imaging), providing specialized departments of traumatology and orthopedics with power equipment, instruments and modern metal structures.

LITERATURE

1. Oganesyan O.V. Restoring the shape and function of the ankle joint / O.V. Oganesyan, S.V. Ivannikov, A.V. Korshunov // M.: BINOM: Laboratory of Knowledge: Medicine, 2003. - 120 p.

2. Sobhani S. Epidemiology of Ankle and Foot Overuse Injuries in Sports: A Systematic Review / S. Sobhani, R. Dekker, K. Postema, PU Dijkstra // Scand. J. Med. Sci Sports. - 2012. - 12. - P. 32-43.

3. Samoday V.G. Errors and complications in the treatment of ankle fractures / V.G. Samoday, A.N. Letnikov // Materials of the international congress “Modern technologies in traumatology and orthopedics: errors and complications - prevention, treatment.” - M., 2004. - P. 141-142.

4. Khoroshkov S.N. Surgical treatment of patients with adverse consequences in the ankle joint / S.N. Khoroshkov, G.I. Chemyanov, N.G. Doronin, A.Yu. Kostyakov // Abstracts of reports of the I scientific-practical conference “Current issues of orthopedics. Achievements. Prospects." - M., 2012. - P. 130-131.

5. Smith MV Lower Extremity-Specific Measures of Disability and Outcomes in Orthopedic Surgery / MV Smith, SE Klein, JC Clohisy, GR Baca // J. Bone Jt. Surg. - 2012. - 94(A). - No. 5. - P. 468-477.

6. Ovaska MT Risk Factors for Deep Surgical Site Infection Following Operative Treatment of Ankle Fractures / MT Ovaska, TJ Makinen, R. Madanat, K. Huotari // J. Bone Jt. Surg. - 2013. - 95(A). - No. 4. - P. 348-353.

REFERENCES

1. Oganesyan OV, Ivannikov SV, Korshunov AV Vosstanovlenie formy i funktsii golenostopnogo sustava. Moscow: BINOM: Laboratoriya znaniy: Meditsina, 2003. 120 p.

2. Sobhani S. et al. Epidemiology of Ankle and Foot Overuse Injuries in Sports: A Systematic Review. Scand. J. Med. Sci Sports, 2012, 12, pp. 32-43.

3. Samoday VG, Letnikov AN Oshibki i oslozhneniya pri lechenii perelomov lodyzhek. Materialy mezhdunarodnogo kongressa “Modern tekhnologii v travmatologii i ortopedii: oshibki i oslozhneniya - profilaktika, lechenie.” Moscow, 2004. Pp. 141-142.

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5. Smith MV et al. Lower Extremity-Specific Measures of Disability and Outcomes in Orthopedic Surgery. J. Bone Jt. Surg., 2012, 94(A), no. 5, pp. 468-477.

6. Ovaska MT et al. Risk Factors for Deep Surgical Site Infection Following Operative Treatment of Ankle Fractures. J. Bone Jt. Surg., 2013, 95(A), no. 4, pp. 348-353.