Aims. Posterior malleolar (PM) fractures are commonly associated with ankle fractures, pilon fractures, and to a lesser extent tibial shaft fractures. The tibialis posterior (TP) tendon entrapment is a rare complication associated with PM fractures. If undiagnosed, TP entrapment is associated with complications, ranging from reduced range of ankle movement to instability and pes planus deformities, which require further surgeries including radical treatments such as arthrodesis. Methods. The inclusion criteria applied in PubMed, Scopus, and Medline database searches were: all adult studies published between 2012 and 2022; and studies written in English. Outcome of TP entrapment in patients with ankle injuries was assessed by two reviewers independently. Results. Four retrospective studies and eight case reports were accepted in this systematic review. Collectively there were 489 Pilon fractures, 77 of which presented with TP entrapment (15.75%). There were 28 trimalleolar fractures, 12 of which presented with TP entrapment (42.86%). All the case report studies reported inability to reduce the fractures at initial presentation. The diagnosis of TP entrapment was made in the early period in two (25%) cases, and delayed diagnosis in six (75%) cases reported. Using modified Clavien-Dindo complication classification, 60 (67%) of the injuries reported grade IIIa complications and 29 (33%) grade IIIb complications. Conclusion. TP tendon was the commonest tendon injury associated with pilon fracture and, to a lesser extent, trimalleolar ankle fracture. Early identification using a clinical suspicion and CT imaging could lead to early management of TP entrapment in these injuries, which could lead to better patient outcomes and reduced morbidity. Cite this article: Bone Jt Open 2024;5(3):252–259

Aim. Circular frames are used to treat a wide spectrum of acute injuries and deformities. We report on our experience of treating both acute and chronic trimalleolar fracture dislocations with a closed technique, utilizing fine wires and a circular frame. Methods. Data was collected from all patients treated for either acute or chronic trimalleolar fracture dislocations at a single centre between January 2016 and December 2017. A total of 10 patients were identified, 8 with acute injuries and 2 with chronic/delayed injuries. Clinical and radiological outcomes were recorded, as well as patient reported outcome measures (PROMs) using the Chertsey Outcome Score for Trauma (COST score). Results. 8 patients were treated for acute trimalleolar fractures, 2 of which were open medially. One patient had sustained a further break and metalwork failure following fixation for trimalleolar fracture at another hospital and 1 patient presented 6 weeks post injury. Average age was 53.6 years (range 20–86). Average time to surgery following acute injury was 4.3 days (0–12). Average follow up to date was 25 weeks (2–60). All patients had satisfactory alignment and union at completion of treatment. The average COST score (n=8) was 52/100 (30–90). 3 patients had pin site infections managed with antibiotics. One patient died due to unrelated medical complications. Conclusion. Initial use of circular frames for trimalleolar fracture has shown excellent results in terms of radiological, clinical and patient reported outcome measures. Complications have been limited to date

This prospective randomised trial aimed to assess the superiority of internal fixation of well-reduced medial malleolar fractures (displacement □2mm) compared with non-fixation, following fibular stabilisation in patients undergoing surgical management of a closed unstable ankle fracture. A total of 154 adult patients with a bi- or trimalleolar fracture were recruited from a single centre. Open injuries and vertically unstable medial malleolar fractures were excluded. Following fibular stabilisation, patients were randomised intra-operatively on a 1:1 basis to fixation or non-fixation after satisfactory fluoroscopic fracture reduction was confirmed. The primary outcome was the Olerud Molander Ankle Score (OMAS) at 12 months post-randomisation. Complications were documented over the follow-up period. The baseline group demographics and injury characteristics were comparable. There were 144 patients reviewed at the primary outcome point (94%). The median OMAS was 80 (IQR, 60-90) in the fixation group vs. 72.5 (IQR, 55-90) in the non-fixation group (p=0.165). Complication rates were comparable, although significantly more patients (n=13, 20%) in the non-fixation group developed a radiographic non-union (p<0.001). The majority (n=8/13) were asymptomatic, with one patient requiring surgical reintervention. In the non-fixation group, a superior outcome was associated with an anatomical medial malleolar fracture reduction. Internal fixation is not superior to non-fixation of well-reduced medial malleolar fractures when managing unstable ankle fractures. However, one in five patients following non-fixation developed a radiographic non-union and whilst the re-intervention rate to manage this was low, the longer-term consequences of this are unknown. The results of this trial may support selective non-fixation of anatomically reduced fractures

Introduction. Unstable ankle fractures are routinely managed operatively. Due to soft-tissue and implant related complications, there has been recent literature reporting on the non-operative management of well-reduced medial malleolus fractures following fibular stabilisation, but with limited evidence supporting routine application. This trial assessed the superiority of internal fixation of well-reduced (displacement ≤2mm) medial malleolus fractures compared with non-fixation following fibular stabilisation. Methods and participants. Superiority, pragmatic, parallel, prospective randomised clinical trial conducted over a four year period. A total of 154 adult patients with a bi- or trimalleolar fractures were recruited from a single centre. Open injuries and vertical medial malleolar fractures were excluded. Following fibular stabilisation, patients were randomised intra-operatively on a 1:1 basis to fixation or non-fixation after satisfactory fluoroscopic fracture reduction was confirmed. The primary outcome was the Olerud Molander Ankle Score (OMAS) at one-year post-randomisation. Complications and radiographic outcomes were documented over the follow-up period. Results. Among 154 participants (mean age, 56.5 years; 119 women [77%]), 144 [94%] completed the trial. At one-year the median OMAS was 80 (IQR, 60–90) in the fixation group compared with 72.5 (IQR, 55–90) in the non-fixation group (p=0.17). Complication rates were comparable. Significantly more patients in the non-fixation group developed a radiographic non-union (20% vs 0%; p<0.001), with the majority (n=8/13) clinically asymptomatic and one patient required surgical re-intervention for this. Fracture type and reduction quality appeared to influence fracture union and patient outcome. Conclusions. In this randomised clinical trial comparing internal fixation of well-reduced medial malleolus fractures with non-fixation, following fibular stabilisation, fixation was not superior according to the primary outcome. However, 1 in 5 patients following non-fixation developed a radiographic non-union and whilst the re-intervention rate to manage this was low, the future implications require surveillance. These results may support selective non-fixation of anatomically reduced medial malleolus fractures

Aim. The purpose of this study is to analyze the demographic and microbiological variables of acute ankle infections posterior to ankle osteosynthesis and to determine the different characteristics of patients withE. cloacae infection. Method. A multicenter retrospective observational study (4 national hospitals) of acute post osteosynthesis infections of ankle fracture operated between 2015 and 2018 was implemented. The demographic and microbiological variables relating to the surgical intervention and the antibiotic treatment performed were collected. A descriptive assessment of all the variables and a univariate comparison between patients with E. cloacae infection and patients with alternative microorganism infections were performed. The SPSS v25 program for Windows was the choice for statistical analysis. Results. 71 Patients with an average age of 57 years were included, the majority being males (55%). 31% of patients were diabetic, 27% had vascular pathology, and 18.3% had a BMI greater than 35. Trimalleolar fracture was the most common in our study being 52%. 26.8% were open fractures. The microorganisms isolated were: 25% S. aureus, 22.5% E. cloacae and 22.5% polymicrobial. Accounting for polymicrobial infections, the presence of E. cloacae rises to 32%. In the univariate analysis, only significant differences were found in age (patients with E. cloacae infection were older) and the use of VAC therapy. Conclusions. In our series, higher percentages of E. cloacae infection were observed than those described in the literature. There are statistically significant differences in the variables of age and need for VAC therapy. The high incidence of E. cloacae infections suggests the vital importance of adapting antibiotic prophylaxis, ensuring the coverage of this microorganism

Aims

The optimal management of posterior malleolar ankle fractures, a prevalent type of ankle trauma, is essential for improved prognosis. However, there remains a debate over the most effective surgical approach, particularly between screw and plate fixation methods. This study aims to investigate the differences in outcomes associated with these fixation techniques.

Background. There is an increasing acceptance that the clinical outcomes following posterior malleolar fractures are less than satisfactory. In our previous multicenter study (Powell, BOFAS 2016) we showed that the Olerud-Molander Ankle Score (OMAS) was 79 for unimalleolar fractures and 65 for bi malleolar fractures, however it dropped significantly to 54 in trimalleolar fractures. In creating a treatment guiding classification, we report our results in a system change in management of posterior malleolar fractures in our unit. Method. All fractures were classified according to Mason and Molloy classification (BOFAS 2015, FAI 2017) based on CT scans obtained pre-operatively. This dictated the treatment algorithm. Type 1 fractures underwent syndesmotic fixation. Type 2A fractures underwent ORIF through a posterolateral incision, and type 2B and 3 fractures underwent ORIF through a posteromedial incision. The patient remained NWB for 6 weeks postoperative. Data was collected from December 2014 to July 2017. Results. Patient related outcome measures were obtained in 50 patients with at least 6 month follow up (mean 18 months). According to Mason and Molloy classification there were 17 type 1, 12 type 2A, 10 type 2B and 11 type 3. The mean OMAS for type 1 was 75.9 (Range 30–100, SD 18.4), type 2A 75.0 (range 35–100, SD 21.3), type 2B 74.0 (range 55–100, SD 13.7) and type 3 70.5 (Range 35–100, SD 17.1). An increase in OMAS of 4 is clinically significant. Conclusion. We have been able demonstrate an improvement in OMAS for all posterior malleolar fractures with the treatment algorithm applied using the Mason and Molloy classification. Compared to our previous study we have successfully increased our OMAS scores to what would be expected from unimalleolar fractures. Mason and Molloy type 3 fractures have marginally poorer outcomes, which correlates with a more significant injury, however this does not reach statistical significance

The most important determinant in the treatment of malleolar fractures is stability. Stable fractures have an intact deep deltoid ligament and do not displace with functional treatment. If the deep deltoid/medial malleolar complex is disrupted, the talus is at risk of displacement. Weber (2010) showed that weightbearing radiographs predicted stability in patients with undisplaced ankle fractures. We developed clinical criteria for potential instability and applied them to a prospective series of patients. Criteria included: medial clear space of < 4mm; medial tenderness, bruising or swelling; a fibular fracture above the syndesmosis; a bimalleolar or trimalleolar fracture; an open fracture; a high-energy fracture mechanism. A consecutive, prospectively documented series of 37 patients chose functional brace treatment of potentially unstable fractures. Weightbearing radiographs were performed in the brace before treatment, and free of brace at clinical union (6–9 weeks in all patients). Patients were encouraged to bear full weight and actively exercise their ankles in the brace. All fractures healed without displacement. The risk of displacement was 0% (95% CI 0–11.2%). This preliminary series gives support for the use of weightbearing radiographs to guide treatment of undisplaced ankle fractures

Internal fixation of ankle fractures should be undertaken either before or after the period of critical soft tissue swelling. As part of the clinical governance in our unit, an audit was undertaken to examine the interval between admission and surgery and net inpatient stay of patients with ankle fractures over a 6 month period. Thirty four patients fulfilled the inclusion criteria of having an acute closed fracture of the ankle requiring open reduction and internal fixation (ORIF). There were 16 unimalleolar, 10 bimalleolar and 8 trimalleolar fractures. 10 Patients underwent surgery on the day of admission, 9 patients had surgery within 24 hours, 15 patients had surgery after 24 hours of admission. The average in patient stay was 9 days (1–61 days). If surgery was undertaken within 24 hours the average inpatient stay was 9 days (1–14). If surgery was delayed beyond 24 hours the average inpatient stay was 15 days (3–61 days). Delayed surgery of closed ankle fractures increases the risk of soft tissue complications and prolongs hospital stay with profound cost implications. Long-term disability resulting from ankle fractures can be reduced by optimal early management procedures

AIM. To evaluate patient outcomes in surgically managed ankle fractures with respect to fracture pattern, timing of surgery and length of stay. METHOD. A retrospective review was undertaken of all patients admitted with an ankle fracture requiring a surgical procedure to our hospital between 1. st. Jan 2008 – 31. st. Dec 2008. Patient records were reviewed for baseline demographics and dates of admission, surgery and discharge. Radiographs were examined for fracture pattern and any evidence of dislocation. Patients were grouped into either early surgery (<48hours), or delayed surgery (>48hours). Data was analysed for length of stay (total, pre- and post-operative), time to surgery and factors influencing timing of surgery. RESULTS. One hundred and twenty-one patients were identified (12 were excluded for either failed conservative management or pre-op CT required), in all 109 patients were included. Average age was 46.5 years (range 11-83yrs) with a female predominance (ratio 3:1). Average length of stay was 9.13 days, with a mean time to surgery 2.7 days. 44% had early surgery; 56% delayed surgery. Pre-operative bed days in the delayed surgery group totalled 278 (average 4.5days per patient). Total length of stay was, on average, 1.1 days longer in the delayed surgery group, however, post-operative stay was significantly shorter in this group (4.93 versus 6.98 days). Factors associated with delayed surgery were trimalleolar fractures (p=0.06) and failure to reduce dislocation on first radiograph (p=0.27). CONCLUSION. Post-operative stay is shorter when surgery is delayed beyond 48 hours. Patient throughput, total length of inpatient stay, cost and patient satisfaction could be improved with early discharge and semi-elective re-admission for fracture fixation. Tri-malleolar fractures and delays in reduction after dislocation both pre-disposed to delayed surgery, owing to soft tissue swelling, and need to be pre-operatively managed accordingly

The most important determinant of treatment of malleolar fractures is stability. Stable fractures have an intact deep deltoid ligament and do not displace with functional treatment. If the deep deltoid/medial malleolar complex is disrupted, the talus is at risk of displacement. We developed clinical criteria for potential instability and applied them to a prospective series of patients. Criteria included: a medial clear space of < 4mm; medial tenderness, bruising or swelling; a fibular fracture above the syndesmosis; a bimalleolar or trimalleolar fracture; an open fracture; a high-energy fracture mechanism. Patients with a medial clear space of < 4mm and none of these criteria were considered to have stable fractures, while those with a medial clear space of > 4mm were considered to have a displaced fracture. We studied 152 consecutive skeletally mature patients with undisplaced, potentially unstable malleolar fractures treated by the senior author between 1st January 1998 and 31st December 2007. Patients were treated in a below-knee walking cast (136 patients) or a functional ankle brace (16 patients) for six weeks. Weight bearing was encouraged throughout. Weight bearing radiographs were obtained at one week and six weeks. Displacement was defined as talar displacement with a medial clear space > 4mm. Demographic, clinical and radiological data were collected prospectively. There were 88 male and 64 female patients, with a median age of 43 years. Criteria for possible instability were: medial tenderness, 115 patients; proximal fibular fracture, 29 patients; bimalleolar fracture, 17 patients; other criteria, 15 patients. Three fractures displaced (risk of displacement 2.0%, 95% CI 0.4–5.7%). All displaced within the first week and were treated by open reduction and internal fixation. One bimalleolar fracture developed a symptomatic medial malleolar non-union which was treated by percutaneous screw fixation (risk of non-union 5.9%, 95% CI 0.1%–28.7%). All the other fractures achieved clinical union by 8 weeks

Purpose: We report a series of 32 ankle fractures reviewed 15 years after osteosynthesis. Material and methods: The series included 12 fibular fractures, 14 bimalleolar fractures, and six trimalleolar fractures. The Weber classification was: type A four, type B 18, type C ten. Postoperative radiograpphy demonstrated 28 anatomic reductions and four shortened fibulae (3 to 5 cm). The results were assessed using the Harper criteria with a Kitaoka radiographic series. The statistical analysis was done with chi square. Results: At the review 15 years after osteosynthesis, 19 ankles were pain free. Normal mobility was noted in 22 cases, and an absence of oedema in 18. Thirty patients wore normal shoes. Walking was normal in 23 cases; the x-rays revealed tibiotalar narrowing in 12 cases, and lengthenings of the malleolus in 23. Ten cases of tibiotalar narrowings were associated with a long medial malleolus. The objective results were good in 23 cases, fair in eight and poor in one. At fifteen years follow-up, osteoarthritis had developed in 37% of the cases despite anatomic reconstruction in 28. The four fibular shortenings were associated with development of osteoarthritis. Ossification of the medial malleola corresponded to detachment of a non-medial sutured ligament. Ankle osteoarthritis, when present, was particularly well tolerated. Discussion: The long-term results of osteosyntheis for malleolar fractures was good in this series. Success requires perfect restoration of the joint anatomy. Unlike other series reported in the literature, non-surgical treatment of the medial collateral ligament led to medial periarticular ossifications in the very long term and limited joint mobility. We propose surgical suture of the medial collateral ligament

This study seeks to determine the additional cost involved in the management of patients requiring operative fixation of their fractured ankle but whose operation is delayed more than 24 hours. 87 consecutive patients presenting acutely with a fractured ankle that required an operation during a single year were included in the study. All patients with ankle fractures referred from other centres, open fractures and ankle fractures whose non-operative management had failed were excluded from the study. 79 patients presented within 24 hours of their injury and so were eligible for early operative intervention. Of these, 74 presented within 6 hours of injury. Only 47 (60%) of the patients were operated on within 24 hours of their injury. Similarly, 11 (61%) of the 18 patients with trimalleolar fractures were operated on within 24 hours. Patients whose operations were delayed spent an average 4. 4 days more as an inpatient. This was statistically significant (p< 0. 0001, Wilcoxon signed rank test). The postoperative stay of patients having delayed operations was also statistically more than those undergoing early operation, (p< 0. 0001). The cost of the additional stay was calculated at £225/day/patient and equalled £39, 600 for the 40 patients whose operations were delayed. We believe that the operative management of ankle fractures should be given special consideration. These injuries are such that they offer an initial limited window of opportunity for operative intervention (within 24 hours of injury). If this opportunity is missed, then the patient’s operation may have to be delayed for clinical reasons. In our study, only 60% of patients underwent early operative fixation of their fracture; a figure that can surely be improved upon. Therefore, we conclude that significant savings could be accrued by hospitals adopting protocols to fast-track pre-operative interventions to achieve early operation (within 24 hours) unless contraindicated

Aims

This study is a prospective, non-randomized trial for the treatment of fractures of the medial malleolus using lean, bioabsorbable, rare-earth element (REE)-free, magnesium (Mg)-based biodegradable screws in the adult skeleton.