Aims. The purpose of this study was to compare symptomatic treatment of a fracture of the base of the fifth metatarsal with immobilisation in a cast. Our null hypothesis was that immobilisation gave better patient reported outcome measures (PROMs). The alternative hypothesis was that symptomatic treatment was not inferior. Patients and Methods. A total of 60 patients were randomised to receive four weeks of treatment, 36 in a double elasticated bandage (symptomatic treatment group) and 24 in a below-knee walking cast (immobilisation group). The primary outcome measure used was the validated Visual Analogue Scale Foot and Ankle (VAS-FA) Score. Data were analysed by a clinician, blinded to the form of treatment, at presentation and at four weeks, three months and six months after injury. Loss to follow-up was 43% at six months. Multiple imputations missing data analysis was performed. Results. At four weeks and six months, symptomatic treatment proved non-inferior in terms of primary outcome. Take home message: Immobilisation is no better than symptomatic treatment in the management of a fracture of the base of the fifth metatarsal when judged by PROMs. Significant loss to follow-up with this injury could be expected in longer term. Cite this article: Bone Joint J 2016;98-B:806–11

Aims. This study evaluated the effect of treating clinician speciality on management of zone 2 fifth metatarsal fractures. Methods. This was a retrospective cohort study of patients with acute zone 2 fifth metatarsal fractures who presented to a single large, urban, academic medical centre between December 2012 and April 2022. Zone 2 was the region of the fifth metatarsal base bordered by the fourth and fifth metatarsal articulation on the oblique radiograph. The proportion of patients allowed to bear weight as tolerated immediately after injury was compared between patients treated by orthopaedic surgeons and podiatrists. The effects of unrestricted weightbearing and foot and/or ankle immobilization on clinical healing were assessed. A total of 487 patients with zone 2 fractures were included (mean age 53.5 years (SD 16.9), mean BMI 27.2 kg/m. 2. (SD 6.0)) with a mean follow-up duration of 2.57 years (SD 2.64). Results. Overall, 281 patients (57.7%) were treated by orthopaedic surgeons, and 206 patients (42.3%) by podiatrists. When controlling for age, sex, and time between symptom onset and presentation, the likelihood of undergoing operative treatment was significantly greater when treated by a podiatrist (odds ratio (OR) 2.9 (95% CI 1.2 to 8.2); p = 0.029). A greater proportion of patients treated by orthopaedic surgeons were allowed to immediately bear weight on the injured foot (70.9% (178/251) vs 47.3% (71/150); p < 0.001). Patients treated by podiatrists were immobilized for significantly longer (mean 8.4 weeks (SD 5.7) vs 6.8 weeks (SD 4.3); p = 0.002) and experienced a significantly longer mean time to clinical healing (12.1 (SD 10.6) vs 9.0 weeks (SD 7.3), p = 0.003). Conclusion. Although there was considerable heterogeneity among zone 2 fracture management, orthopaedic surgeons were less likely to treat patients operatively and more likely to allow early full weightbearing compared to podiatrists. Cite this article: Bone Joint J 2024;106-B(9):942–948

Objective

The objective of this study was to evaluate the rotation and translation of each joint in the hindfoot and compare the load response in healthy feet with that in stage II posterior tibial tendon dysfunction (PTTD) flatfoot by analysing the reconstructive three-dimensional (3D) computed tomography (CT) image data during simulated weight-bearing.

Objective. To evaluate early mobilization with the ‘STRONG regime’ is safe after lateral ankle ligament repair with suture tape augmentation. Background. The ESSKA-AFAS ankle instability group presented in 2016 evidence-based guidelines for rehabilitation and return to activity after lateral ankle ligament repair. Early mobilization is considered an important element of postoperative rehabilitation. Patients have to be immobilized for approximately six weeks to protect the delicate repair. Lateral ankle ligament repair with suture tape augmentation results in greater strength compared with standard repairs and early mobilization proved to be successful in small sample size studies. Augmented surgery technique is getting increasingly popular. However, it is unknown which rehabilitation regimes are used. It is essential to establish a clear evidence-based guideline for rehabilitation after surgery. Methods. A systematic literature search was performed to obtain the best evidence research regarding this surgery. In cooperation between the orthopaedic- and physical therapy department a post-operative rehabilitation protocol with early mobilization was established. This STRONG protocol (figure 1) is based on milestones and three stages. Results. In February 2016 the first patients were selected for the early mobilization regime. In total 102 patients with a lateral ankle ligament repair were treated with the STRONG protocol. No re-ruptures were observed with a follow up of a year. In a subgroup of athletes hop tests showed a symmetry index of 100,5% for triple hop, 98,6 for side hop and 103,6 for figure of 8 hop. First return to sport was achieved between 9–12 weeks, with full return to competition after a mean of 4 months. Conclusions. An early postoperative mobilization regime based on supervised exercises seems to be a safe intervention after a lateral ankle ligament reconstruction. Clinical implications. Augmented ankle ligament surgery with early mobilization could be an important advancement in treating patients with chronic ankle injuries. For any figures or tables, please contact authors directly

Background. Weightbearing computed tomography scans allow for better understanding of foot alignment in patients with Progressive Collapsing Foot Deformity. However, soft tissue integrity cannot be assessed via WBCT. As performing both WBCT and magnetic resonance imaging is not cost effective, we aimed to assess whether there is an association between specific WBCT and MRI findings. Methods. A cohort of 24 patients of various stages of PCFD (mean age 51±18 years) underwent WBCT scans and MRI. In addition to signs of sinus tarsi impingement, four three-dimensional measurements (talo-calcaneal overlap, talo-navicular coverage, Meary's angle axial/lateral) were obtained using a post processing software (DISIOR 2.1, Finland) on the WBCT datasets. Sinus tarsi obliteration, spring ligament complex and tibiospring ligament integrity, as well as tibialis posterior tendon degeneration were evaluated with MRI. Statistical analysis was performed for significant (P<0.05) correlation between findings. Results. None of the assessed 3D measurements correlated with spring ligament complex or tibiospring ligament tears. Age, body mass index, and TCO were associated with tibialis posterior tendon tears. 75% of patients with sinus tarsi impingement on WBCT also showed signs of sinus tarsi obliteration on MRI. Of the assessed parameters, only age and BMI were associated with sinus tarsi obliteration diagnosed on MRI, while the assessed WBCT based 3D measurements were, with the exception of MA axial, associated with sinus tarsi impingement. Conclusion. While WBCT reflects foot alignment and indicates signs of osseous impingement in PCFD patients, the association between WBCT based 3D measurements and ligament or tendon tears in MRI is limited. Partial or complete tears of the tibialis posterior tendon were only detectable in comparably older and overweight PCFD patients with an increased TCO. WBCT does not replace MRI in diagnostic value. Both imaging options add important information and may impact decision-making in the treatment of PCFD patients

Aims. Osteochondral lesions of the talus (OLT) are a common cause of disability and chronic ankle pain. Many operative treatment strategies have been introduced; however, they have their own disadvantages. Recently lesion repair using autologous cartilage chip has emerged therefore we investigated the efficacy of particulated autologous cartilage transplantation (PACT) in OLT. Methods. We retrospectively analyzed 32 consecutive symptomatic patients with OLT who underwent PACT with minimum one-year follow-up. Standard preoperative radiography and MRI were performed for all patients. Follow-up second-look arthroscopy or MRI was performed with patient consent approximately one-year postoperatively. Magnetic resonance Observation of Cartilage Repair Tissue (MOCART) score and International Cartilage Repair Society (ICRS) grades were used to evaluate the quality of the regenerated cartilage. Clinical outcomes were assessed using the pain visual analogue scale (VAS), Foot Function Index (FFI), and Foot Ankle Outcome Scale (FAOS). Results. All patients had ICRS grade IV cartilage lesions, except for one (ICRS grade III). The paired MOCART scores significantly improved from 42.5 (SD 1.53) to 63.5 (SD 22.60) (p = 0.025) in ten patients. Seven patients agreed to undergo second-look arthroscopy; 5 patients had grade I (normal) ICRS scores and two patients had grade II (nearly normal) ICRS scores. VAS, FFI, and all subscales of FAOS were significantly improved postoperatively (p ≤ 0.003). Conclusion. PACT significantly improved the clinical, radiological, and morphological outcomes of OLT. We consider this to be a safe and effective surgical method based on the short-term clinical results of this study. Cite this article: Bone Jt Open 2023;4(12):942–947

Background. Tenosynovial giant cell tumour (TGCT) is a benign proliferative disease affecting synovial membranes. There are two forms, localised and diffuse, which although histologically similar are managed differently. It is locally invasive and is treated in most cases by operative excision. The aim of this study was to assess outcomes from the largest single-centre experience to date in patients with this condition. Methods. A retrospective analysis of 123 cases was performed in patients treated between 2003 and 2019 with TGCT of the foot and/or ankle. Data was collected on age at presentation, radiological pattern of disease, location of disease, treatment provided and recurrence rates. The minimum follow-up was 2 years with a mean of 7.7 years. Results. 47 male and 76 female patients with a mean age at diagnosis of 39 (range, 11–76) years were identified. 85 (69.1%) cases were categorised as localised and 38 (30.9%) were diffuse. Half of the cases presented in the ankle (62/123, 50.4%). 89% (110) of patients underwent open operative excision of the lesion. Radiotherapy was used in 2 cases for recurrent disease. Pain was the most common postoperative symptom which developed in 20% (22/110) of cases). 13 cases were managed nonoperatively where symptoms were minimal, with one case requiring surgery at a later date. Disease recurrence was 3.5% (3/85) in localised disease and 36.8% (14/38) in diffuse disease giving an overall recurrence rate of 13.8% (17/123). Conclusion. The outcomes of TGCT management are dependent on the type of disease, the extent of preoperative erosive changes and the presence of pre-operative pain. We present a summary of recommended management based on the experience from this single tertiary centre

Background. Surgical intervention for hallux valgus and hallux rigidus is an option for patients presenting with severe pain and deformity. Literature suggest that patients with high Pain Catastrophisation Scores (PCS) have poorer outcomes in spinal and to a lesser extent in arthroplasty surgery. There is however very little evidence pertaining to foot and ankle surgery. Aim. We aimed to study whether catastrophisation as measured by PCS influenced the outcomes following surgery for Hallux valgus and rigidus. Methodology. Ethical approval for this prospective portfolio study was obtained from NRES Committee South Central and Oxford. Approval was granted from the local R&D department prior to data collection. All patients listed for surgery for hallux pathology to the four senior authors were invited to participate. Recruitment into the study started in September 2017 and is ongoing. Pain catastrophising score (PCS), Manchester Oxford Foot Questionnaire (Mox-FQ), Visual analog scale (VAS) for pain and EQ-5D-3L questionnaires were completed Pre-op (baseline), and at 3, 6 and 12- months post-surgery. Results. 93 patients with minimum follow-up of 6 months were analysed using SPSS software. A P-value of less than 0.05 was considered significant. The mean age of the patients was 58.5 years and 83% were women. 70% of the patients had surgery for hallux valgus and rest for rigidus. Both PROMS and PCS improved significantly following surgical intervention. Patients with higher pre-operative PCS had a worse 6-month PROM score and more pain. Conclusion. This study confirms that pre-operative catastrophisation as demonstrated by a high PCS score has an adverse effect on outcomes following hallux surgery. Risk stratifying patients based on their Pre-op PCS scores may be a useful strategy to identify those at risk of poorer outcomes. We recommend that behavioural change interventions should be considered to try to improve outcomes in patients with pre-op PCS

Background. The only existing classification of Müller-Weiss Disease (MWD), based solely on Méary's angle, serves neither as guide for prognosis nor treatment. This accounts for lack of gold standard in its management. Methods. Navicular compression, medial extrusion, Kite's angle and metatarsal lengths were measured on all radiographs of 95 feet with MWD. Joints involved, presence and location of navicular fracture were recorded. Results. We identified three distinct groups. Group 1 comprises 11 “early-onset” MWD feet, aged 9 to 29 years. These had the greatest compression and medial extrusion, and lowest Kite's angles. All except 1 were index minus and had a lateral navicular fracture. None has required surgery to date. Only 1 has moderate talonavicular joint (TNJ) degeneration. Group 2 comprises 23 “Müller-Weissoid” feet with radiologically normal navicular in their fifties and developing MWD, on average, 4.5 years later. These had the lowest compression and extrusion, and highest Kite's angles. None had complete fracture. All had TNJ arthritis, with early changes at lateral naviculocuneiform joint (NCJ) in 43%. Group 3 “late-onset” MWD, presenting in the sixth decade, is subdivided into 3 sub-groups. Only TNJ is involved in group 3A (16). Group 3B denotes affection of TNJ more than NCJ (20). In group 3C “reverse Müller-Weiss disease”, which affects NCJ more than TNJ (25), second metatarsal overlength is highest of all groups. No difference in age, compression, extrusion and Kite's angle exists among the 3 subgroups. No fracture occurred in group 3A compared to 65% and 32% in groups 3B and 3C, respectively. Conclusions. With a need to compare like-for-like pathology, the proposed classification provides a common platform for reporting outcomes of different treatment modalities, operative or nonoperative. We theorize pathogenetic pathways in the different groups and propose systematic surgical approaches for each category

Introduction. Surgical reconstruction of Charcot joint deformity is increasingly being offered to patients. In our centre a hybrid type fixation technique is utilised: internal and external fixation. This combined fixation has better wound management and earlier mobilisation in this deconditioned patient group. The aim of this study was to assess clinical, radiological and patient reported outcomes for all patients who underwent this hybrid technique. Methods. This is a prospective observational case series of all patients who underwent surgical reconstruction of Charcot foot deformity in a single centre between June 2017 and June 2023. Patient demographics, smoking status, diabetic control and BMI were recorded. Outcomes were determined from case notes and included clinical outcomes (complications, return to theatre, amputation and mortality) radiological outcomes and patient reported outcomes. The follow up period was 1–7 years post operatively. Results. 42 reconstructions were included. At the time of surgery the mean age was 59.1 years (29 – 91 years), average HbA1c was 65.2 (33–103); this did not correlate with return to theatre rate. 4 procedures were internal fixation alone (9.5%), 3 external fixation alone (7.1%) and 35 were combined fixation (83.3%). At most recent follow up 7 patients were deceased (16.7%), 2 patients had ipsilateral amputations, 2 had contralateral amputations. 11 patients had issues with recurrent ulcerations. Excluding refreshing of frames and operations on the contralateral side, 17 patients (40%) returned to theatre. We aim to present a detailed analysis of the rate of post-operative complications, return to theatre, radiographic outcomes and patient reported outcomes. Conclusion. This is the largest UK based case series of hybrid type Charcot joint reconstructions and shows that hybrid fixation is a viable option for patients undergoing Charcot joint reconstruction. To best confirm findings and determine which patients have the best post-operative prognosis a larger multi-centre study is required

Introduction. Ankle fractures in the elderly are an increasing problem with our aging population. Options for treatment include non-operative and operative with a range of techniques available. Failure of treatment can lead to significant complications, morbidity and poor function. We compared the outcomes of two operative techniques, intramedullary hindfoot nailing (IMN) and fibular-pro-tibia fixation (FPT). This is the largest analysis of these techniques and there are no comparative studies published. Method. We retrospectively reviewed patients over the age of 60 with ankle fractures who were treated operatively between 2012 and 2017. We identified 1417 cases, including 27 patients treated with IMN and 41 treated with FPT. Age, sex, co-morbidities and injury pattern were collected. Primary outcome was re-operation rate. Secondary outcomes included other complications, length of stay and functional status. Results. The IMN group had a higher average co-morbidity score compared with the FPT group (estimated 10-year survival, 21% vs 53%, p=0.03). Re-operation rate was higher in the IMN group compared with FPT (12 v 1, p< 0.0001). There were more complications in the IMN group compared with the FPT group (23 v 11, p< 0.0001). Length of stay was longer in the IMN group (17 v 29 days, p=0.02). Mobility tended to return to baseline in the FPT patients but decreased in the IMN patients. Conclusion. Outcomes were worse in the IMN group compared with the FPT group in terms of re-operation, complications and length of stay. However, the IMN group tended to have increased comorbidities and poorer soft tissues. We believe that both techniques have a role in the management of elderly ankle fractures, but patient selection is key. We suggest FPT should be the first-choice technique when soft tissues permit. We discuss the indications, risks and benefits of each method based on our experience and literature review

Background. The cavovarus foot is a complex 3-dimensional deformity. Although a multitude of techniques are described for its surgical management, few of these are evidence based or guided by classification systems. Surgical management involves realignment of the hindfoot and soft tissue balancing, followed by forefoot balancing. Our aim was to classify the pattern of residual forefoot deformities once the hindfoot is corrected, to guide forefoot correction. Methods. We included 20 cavovarus feet from adult patients with Charcot-Marie-Tooth who underwent weightbearing CT (mean age 43.4 years, 14 males). Patients included had flexible deformities, with no previous surgery. Previous work established majority of rotational deformity in cavovarus feet occurs at the talonavicular joint, which is often reduced during surgery. Using specialised software (Bonelogic 2.1, Disior) a 3-dimensional, virtual model was created. Using data from normal feet as a guide, the talonavicular joint of the cavovarus feet was digitally reduced to a ‘normal’ position. Models of the corrected position were exported and geometrically analysed using Blender 3.6 to identify anatomical trends. Results. We identified 3 types of cavovarus forefoot morphotypes. Type 1 was seen in 13 cases (65%) and was defined as a foot where only the first metatarsal was relatively plantarflexed to the rest of the foot, with no significant residual adduction after talonavicular correction. Type 2 was seen in 4 cases (20%) and was defined as a foot where the second and first metatarsals were progressively plantarflexed, with no significant adduction. Type 3 was seen in 3 cases (15%) and was defined as a foot where the metatarsals were still adducted after talonavicular de-rotation. Conclusion. We classify 3 forefoot morphotypes in cavovarus feet. It is important to recognise and anticipate the residual forefoot deformities after hindfoot correction as different treatment strategies may be required for different morphotypes to achieve balanced correction

Introduction. Severe, multiplanar, fixed, pantalar deformities present a challenge to orthopaedic surgeons. Surgical options include limb salvage or amputation. This study compares outcomes of patients with such deformities undergoing limb preservation with either pantalar fusion (PTF) or talectomy and tibiocalcaneal fusion (TCF), versus below knee amputation (BKA). Methods. Fifty-one patients undergoing either PTF, TCF and BKA for failed management of severe pantalar deformity were evaluated retrospectively. Twenty-seven patients underwent PTF, 8 TCF and 16 BKA. Median age at surgery was 55.0 years (17 to 72 years) and median follow-up duration was 49.9 months (18.0 to 253.7 months). Patients with chronic regional pain syndrome, tumour, acute trauma or diabetic Charcot arthropathy were excluded. Clinical evaluation was undertaken using the MOxFQ, EQ-5D and Special Interest Group in Amputee Medicine score (SIGAM). Patients were also asked whether they were satisfied with their surgical outcome and whether they would have the same surgery again. Results. There was no statistically significant difference in patient reported outcomes, satisfaction, or complication profile between the groups. Twenty-two patients undergoing PTF (81.5%), 6 patients undergoing TCF (75%), and 15 patients undergoing BKA (93.8%) were satisfied overall (p=0.414). Similarly, there was no difference in the proportion of patients who would opt for the same procedure again (p=0.142): 23 in the PTF group (85.2%), 8 in the TCF group (100%), and 11 in the BKA group (68.8%). Seven patients undergoing PTF (25.9%), 2 patients undergoing TCF (25%) and 6 patients undergoing BKA (37.5%) had major complications (p=0.692). Conclusion. This study has shown that PTF, TCF and BKA can all provide an acceptable outcome in treatment of severe, degenerative deformities of the lower extremity. Therefore, surgical decisions must be based on individual patient considerations. This data may also be useful in counselling patients when considering limb salvage versus amputation for severe deformity

Background. Hallux rigidus is a common condition characterised by first metatarsophalangeal joint (MTPJ) degeneration, pain and limited range of motion (ROM). The gold standard surgical treatment is arthrodesis, providing good pain relief but sacrifices ROM. Recently the Cartiva synthetic cartilage implant (SCI) has been utilised as an interpositional arthroplasty, aiming to reduce pain whilst preserving range of motion. Current evidence for Cartiva SCI is largely based on a single cohort with mixed outcomes. We sought to evaluate the clinical outcomes of Cartiva SCI compared to arthrodesis undertaken in our centre. Methods. Retrospective review of patients undergoing Cartiva SCI or arthrodesis for treating hallux rigidus was conducted. Preoperative arthritis was radiographically graded using the Vanore classification. Patient reported outcomes (PROMs) were assessed using EuroQol 5-dimension score (EQ-5D-5L) and Manchester-Oxford Foot Questionnaire (MOXFQ). Results. Between 2017 and 2020 there were 33 cases (17 Cartiva, 16 arthrodesis, mean age 59.0±9.9 years) with a mean follow up of 2.3 years. For the first MTPJ arthrodesis cohort, the MOXFQ domain scores were: Index 3.9±5.8, Walking/Standing 5.1±7.6, Pain 3.2±5.0, and Social Interaction 2.6±4.0. EQ-5D-5L Index score was 0.828±0.270 and the EQ-VAS was 72.5±23.3. For the Cartiva cohort, the MOXFQ domain scores were: Index 7.7±6.0, Walking/Standing 8.9±7.9, Pain 7.1±5.0, and Social Interaction 6.4±5.4. EQ-5D-5L Index score was 0.631±0.234 and the EQ-VAS was 74.8±20.8. There was no statistically significant difference between any MOXFQ domain or EQ-5D-5L scores. However, a negative trend in MOXFQ domains was identified for the Cartiva group, as well as a reoperation rate of 23.5%. Conclusions. The Cartiva SCI demonstrated no advantage over arthrodesis in PROMs, despite the presumed benefit of preserved ROM. A significant reoperation rate was also observed. Surgeons should be cautious in the use of this novel implant

Introduction. Treatment pathways of 5. th. metatarsal fractures are commonly directed based on fracture classification, with Jones types for example, requiring closer observation and possibly more aggressive management. Primary objective. To investigate the reliability of assessment of subtypes of 5. th. metatarsal fractures by different observers. Methods. Patients were identified from our prospectively collected database. We included all patient referred to our virtual fracture clinic with a suspected or confirmed 5. th. metatarsal fracture. Plain AP radiographs were reviewed by two observers, who were initially trained on the 5. th. metatarsal classification identification. Zones were defined as Zone 1.1, 1.2, 1.3, 2, 3, diaphyseal shaft (DS), distal metaphysis (DM) and head. An inter-observer reliability analysis using Cohen's Kappa coefficient was carried out, and degree of observer agreement described using Landis & Koch's description. All data was analysed using IBM SPSS v.27. Results. 878 patients were identified. The two observers had moderate agreement when identifying fractures in all zones, apart from metatarsal head fractures, which scored substantial agreement (K=.614). Zones 1.1 (K=.582), 2 (K=.536), 3 (K=.601) and DS (K=.544) all tended towards but did not achieve substantial agreement. Whilst DS fractures achieved moderate agreement, there was an apparent difficulty with distal DS, resulting in a lot of cross over with DM (DS 210 vs 109; DM 76 vs 161). Slight agreement with the next highest adjacent zone was found when injuries were thought to be in zones 1.2, 1.3 and 2 (K=0.17, 0.115 and 0.152 respectively). Conclusions. Reliability of sub-categorising 5. th. metatarsal fractures using standardised instructions conveys moderate to substantial agreement in most cases. If the region of the fracture is going to be used in an algorithm to guide a management plan and clinical follow up during a virtual clinic review, defining fractures of zones 1–3 needs careful consideration

Aims. Diabetic foot care is a significant burden on the NHS in England. We have conducted a nationwide survey to determine the current participation of orthopaedic surgeons in diabetic foot care in England. Methods. A questionnaire was sent to all 136 NHS trusts audited in the 2018 National Diabetic Foot Audit (NDFA). The questionnaire asked about the structure of diabetic foot care services. Results. Overall, 123 trusts responded, of which 117 admitted patients with diabetic foot disease and 113 had an orthopaedic foot and ankle surgeon. A total of 90 trusts (77%) stated that the admission involved medicine, with 53 (45%) of these admissions being exclusively under medicine, and 37 (32%) as joint admissions. Of the joint admissions, 16 (14%) were combined with vascular and 12(10%) with orthopaedic surgery. Admission is solely under vascular surgery in 12 trusts (10%) and orthopaedic surgery in 7 (6%). Diabetic foot abscesses were drained by orthopaedic surgeons in 61 trusts (52%) and vascular surgeons in 47 (40%). Conclusion. Orthopaedic surgeons make a significant contribution to both acute and elective diabetic foot care currently in the UK. This contribution is likely to increase with the movement of vascular surgery to a hub and spoke model, and measures should be put in place to increase the team based approach to the diabetic foot, for example with the introduction of a best practice tariff. Cite this article: Bone Jt Open 2022;3(8):618–622

Aims. The morphology of medial malleolar fracture is highly variable and difficult to characterize without 3D reconstruction. There is also no universally accepeted classification system. Thus, we aimed to characterize fracture patterns of the medial malleolus and propose a classification scheme based on 3D CT reconstruction. Methods. We retrospectively reviewed 537 consecutive cases of ankle fractures involving the medial malleolus treated in our institution. 3D fracture maps were produced by superimposing all the fracture lines onto a standard template. We sliced fracture fragments and the standard template based on selected sagittal and coronal planes to create 2D fracture maps, where angles α and β were measured. Angles α and β were defined as the acute angles formed by the fracture line and the horizontal line on the selected planes. Results. A total of 121 ankle fractures were included. We revealed several important fracture features, such as a high correlation between posterior collicular fractures and posteromedial fragments. Moreover, we generalized the fracture geometry into three recurrent patterns on the coronal view of 3D maps (transverse, vertical, and irregular) and five recurrent patterns on the lateral view (transverse, oblique, vertical, Y-shaped, and irregular). According to the fracture geometry on the coronal and lateral view of 3D maps, we subsequently categorized medial malleolar fractures into six types based on the recurrent patterns: anterior collicular fracture (27 type I, 22.3%), posterior collicular fracture (12 type II, 9.9%), concurrent fracture of anterior and posterior colliculus (16 type III, 13.2%), and supra-intercollicular groove fracture (66 type IV, 54.5%). Therewere three variants of type IV fractures: transverse (type IVa), vertical (type IVb), and comminuted fracture (type IVc). The angles α and β varied accordingly. Conclusion. Our findings yield insight into the characteristics and recurrent patterns of medial malleolar fractures. The proposed classification system is helpful in understanding injury mechanisms and guiding diagnosis, as well as surgical strategies. Cite this article: Bone Joint J 2021;103-B(5):931–938

Lisfranc injuries were previously described as fracture-dislocations of the tarsometatarsal joints. With advancements in modern imaging, subtle Lisfranc injuries are now more frequently recognized, revealing that their true incidence is much higher than previously thought. Injury patterns can vary widely in severity and anatomy. Early diagnosis and treatment are essential to achieve good outcomes. The original classification systems were anatomy-based, and limited as tools for guiding treatment. The current review, using the best available evidence, instead introduces a stability-based classification system, with weightbearing radiographs and CT serving as key diagnostic tools. Stable injuries generally have good outcomes with nonoperative management, most reliably treated with immobilization and non-weightbearing for six weeks. Displaced or comminuted injuries require surgical intervention, with open reduction and internal fixation (ORIF) being the most common approach, with a consensus towards bridge plating. While ORIF generally achieves satisfactory results, its effectiveness can vary, particularly in high-energy injuries. Primary arthrodesis remains niche for the treatment of acute injuries, but may offer benefits such as lower rates of post-traumatic arthritis and hardware removal. Novel fixation techniques, including suture button fixation, aim to provide flexible stabilization, which theoretically could improve midfoot biomechanics and reduce complications. Early findings suggest promising functional outcomes, but further studies are required to validate this method compared with established techniques. Future research should focus on refining stability-based classification systems, validation of weightbearing CT, improving rehabilitation protocols, and optimizing surgical techniques for various injury patterns to ultimately enhance patient outcomes.

Cite this article: Bone Joint J 2024;106-B(12):1431–1442.

Aims

Calcaneal osteomyelitis remains a difficult condition to treat with high rates of recurrence and below-knee amputation, particularly in the presence of severe soft-tissue destruction. This study assesses the outcomes of single-stage orthoplastic surgical treatment of calcaneal osteomyelitis with large soft-tissue defects.

Aims

This cross-sectional study aimed to investigate the in vivo ankle kinetic alterations in patients with concomitant chronic ankle instability (CAI) and osteochondral lesion of the talus (OLT), which may offer opportunities for clinician intervention in treatment and rehabilitation.