Introduction. Tibial Pilon fractures are potentially limb threatening, yet standards of care are lacking from BOFAS and the BOA. The mantra of “span, scan, plan” describes staged management with external fixation to allow soft tissue resuscitation, followed by a planning CT-scan. Our aim was to evaluate how Tibial Pilon fractures are acutely managed. Methods. ENFORCE was a multi-centre retrospective observational study of the acute management of partial and complete articular Tibial Pilon fractures over a three-year period. Mechanism, imaging, fracture classification, time to fracture reduction and cast, and soft tissue damage control details were determined. Results. 656 patients (670 fractures) across 27 centres were reported. AO fracture classifications were: partial articular (n=294) and complete articular (n=376). Initial diagnostic imaging mobilities were: plain radiographs (n=602) and CT-scan (n=54), with all but 38 cases having a planning CT-scan. 526 fractures had a cast applied in the Emergency Department (91 before radiological diagnosis), with the times taken to obtain post cast imaging being: mean 2.7 hours, median 2.3 hours, range 28 mins – 14 hours). 35% (102/294) of partial articular and 57% (216/376) of complete articular (length unstable) fractures had an external fixator applied, all of which underwent a planning CT-scan. Definitive management consisted of: open reduction internal fixation (n=495), fine wire frame (n=86), spanning external fixator (n=25), intramedullary nail (n=25), other (n=18). Conclusion. The management of Tibial Pilon fractures is variable, with prolonged delays in obtaining post cast reduction radiographs, and just over half of length unstable complete articular fractures being managed with the gold standard “span, scan, plan” staged soft tissue resuscitation. A BOFAS endorsed BOAST (British Orthopaedic Association Standard for Trauma) for Tibial Pilon fractures is suggested for standardisation of the acute management of these potentially limb threatening injuries, together with setting them apart from more straightforward ankle fractures

Introduction. Achilles tendon rupture (ATR) account for 10.7% of all tendon and ligament injuries and causes lasting muscular deficits and have a profound impact on patients’ quality of life. 1,2. The incidence, characteristics and management of ATR in the United Kingdom is poorly understood. Method. Data was collected prospectively from University Hospitals of Leicester Emergency Department (ED) between January 2016 and December 2020 and analysed retrospectively. The medical records were reviewed to determine management protocols (surgical/non-surgical) and limited mobilisation (VACOped™ boot) duration. Leicestershire population data was taken from Leicestershire County Council demography report. Findings. 277 individuals were diagnosed with an ATR during the 4-year period. The mean (SD) annual incidence was 56 (±6) ATR. An incidence rate of 8.02 per 100,000 people per annum. The average characteristics of those experiencing an ATR is male (78.3%), 46.8yrs old (±14.4), body mass index 29.1 (±6.3). Median (IQR) number of comorbidities 1 (2) and duration to present to ED was 0 days (1). The main mechanism of rupture was sporting activity (62.1%). 97.4% were non-surgically managed using a limited mobilisation boot (VACOped). The boot was worn for an average of 62.6 days (±8.9). 94 participants provided pre-ATR Achilles symptoms data. 16% (n=15/94) of participants reported a previous contralateral ATR. 7.4% reported a re-rupture (n=7/94). 15.4% (n=14/91) reported an Achilles tendinopathy on the ipsilateral side prior to ATR. 7.7% (n=7/91) reported bilateral Achilles tendinopathy and 1.1% (n=1/91) reported contralateral Achilles tendinopathy prior to ATR. Conclusion. The incidence of ATR is 8.02 cases per 100,000 people per annum. This is the first UK data on ATR incidence. Most ATR were managed non-surgically in this cohort. The majority of ruptures occurred during sporting activity. Those that had previous Achilles symptoms (24.2%) indicate tendons are not always asymptomatic prior to ATR

Introduction. Many common fractures are inherently stable, will not displace and do not require plaster casting to achieve union in a good position. Nevertheless, many patients with stable fractures are advised that they need a cast, despite the potential for stiffness, skin problems and thromboembolism. Attempts to challenge this practice often meet the argument that patients prefer a cast for pain relief. We analysed five years of a single consultant's fracture clinic to see how many patients with stable foot and ankle fractures chose a cast after evidence-based counselling. Materials and methods. All patients with stable fractures of the ankle or metatarsals seen between 1st June 2005 and 31st May 2010 were included. Displaced or potentially unstable ankle fractures, Jones fractures and fractures involving the Lisfranc joint were excluded. Patients were advised functional treatment but offered a cast if they wished. Patients were documented prospectively as part of a larger audit, including demographics, diagnosis and treatment in the emergency department and fracture clinic. Results. 93 patients had stable ankle fractures. One (1%) chose a cast, 77 an ankle brace and 14 the RICE regime. One was advised a cast for neurological deformity. 105 patients had fifth metatarsal fractures outside the “non-” zone. 19 (18%) chose casts and 86 followed the RICE regime. 50 patients had other stable metatarsal fractures 15 (30%) chose casts. 86% of patients had casts applied in the emergency department. Discussion. The majority of patients with stable foot and ankle fractures do not wish to wear a cast once they understand it will not affect their outcome. In many cases this decision could have been reached in the emergency department with appropriate guidelines and education, preventing patient inconvenience and possible adverse events. Conclusion. Most patients are happy with evidence-based functional treatment of stable fractures

Introduction:. The treatment of acute rupture of the tendo-achilles remains controversial. There is good evidence to suggest that outcomes are the same for both operative and non-operative treatment when a functional rehabilitation program is utilised. However, debate continues as to whether the radiological gap-size between the proximal and distal remnants of the tendon has an influence on the suitability for non-operative management. Methods:. All adult patients who attended the emergency department with a clinically suspected tendo-achilles rupture were place in a plantarflexed cast, and underwent MRI scanning to confirm the diagnosis. They were then counselled on the risks and benefits of operative versus non-operative treatment. Patients opting for non-operative treatment were asked to take part in the study and treated using a functional rehabilitation programme. Gap sizes were determined using a standardised protocol by a single musculoskeletal radiologist blinded to the clinical outcomes. Results:. A total of 69 patients have been recruited into the study, 40 have complete their one year review. There were two re-ruptures. The average age was 42.4 years (range 19–70). The average gap size recorded by MRI was 40.4mm (range 6–110). The average ATRS score was 80 (range 17–100) and the single limb heel raise percentage of contralateral side was 64.8% (range 4–115). The Spearman rank correlation coefficient comparing gap size and ATRS score was 0.272 (p=0.045) and for gap size and strength was 0.158 (p=0.165). Conclusion:. This study shows a weak positive correlation between MRI measured gap size of the ruptured tendo-achilles and the Achilles tendon Total Rupture Score at one year. No correlation could be demonstrated between gap size and strength at one year. These results suggest that the MRI measured gap size is unimportant in predicting outcome and hence suitability for non-operative treatment of tendo-achilles rupture using functional rehabilitation

Metatarsal fractures are extremely common injuries accounting for 10% of all fractures seen in our accident and emergency departments (3). The vast majority can be treated conservatively. There is no standardised treatment, but it is commahplace to immobilise the foot and ankle joint in a below-knee back-slab, full cast or functional brace for a period of up to 6 weeks, weight-bearing the patient as pain allows. This practice is time-consuming and expensive, not to mention debilitating, and carries a morbidity risk to the patient. We describe a simple, effective and cheap treatment method for metatarsal fracture management using the functional forefoot-offloading shoe (FOS). This is clinically proven to offload pressure on the metatarsals and is commonly used in both elective forefoot surgery and in diabetic patients. Between January and September 2009, we identified 57 patients attending our fracture clinic with new metatarsal fractures. 28 met our inclusion criteria. All patients reported a significant improvement in their pain. At Injury – mean 8.21 out of 10 (range 4-10). After FOS fitting - mean 2.92 out of 10 (range 0-6). The forefoot-offloading shoe is an excellent alternative to plaster casting or functional boot immobilisation, offering high patient satisfaction, an excellent outcome and a considerable cost-saving to the hospital trust

Ankle fractures account for 10% of all fractures. Most deformed looking ankles are manipulated in the emergency departments (ED) on clinical judgement in order to improve the outcome and avoid skin complications. It is accepted that significantly displaced ankle injuries with neurovascular (NV) compromise or critical skin should be reduced prior to imaging. However, is it really possible to understand the injury to an ankle without an x-ray or other imaging? The other possible injuries around the ankle, presenting with swelling and deformity of the ankle region, may include a ligamentous, talar, subtalar, Chopart joint or calcaneal injury. Does the risk of waiting for the imaging outweigh the benefit of manipulation of an undiagnosed injury?. This prospective study involved the analysis of all patients with ankle injuries referred to orthopaedics between November 2009 and February 2010. Results: Over the audited period 100 referrals were identified (43 male, 57 female). The average age was 50.4 years (range 5–89). Only 2% of fractures were open. Manipulation in the ED was performed for 44% of patients. Of these, 39% (17 cases) were manipulated and supported in plaster slab without an initial x-ray; 3 due to vascular deficit, 2 due to critical skin and 12 with no documented reason!. Re-manipulation in the ED as well as definitive open reduction and internal fixation (ORIF) were significantly lower in those patients who had an x-ray prior to manipulation (p < 0.05). ORIF was performed in 68% of all patients. Importantly, 80% of ankles manipulated in ED went on to have ORIF which was significantly higher than the 47% in the non-manipulation cohort (p < 0.05). We conclude that taking ankle injury radiographs prior to any attempt at manipulation, in the absence of NV deficit or critical skin, will constitute best practice

Aims

This study evaluated the effect of treating clinician speciality on management of zone 2 fifth metatarsal fractures.

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

A pilon fracture is a severe ankle joint injury caused by high-energy trauma, typically affecting men of working age. Although relatively uncommon (5% to 7% of all tibial fractures), this injury causes among the worst functional and health outcomes of any skeletal injury, with a high risk of serious complications and long-term disability, and with devastating consequences on patients’ quality of life and financial prospects. Robust evidence to guide treatment is currently lacking. This study aims to evaluate the clinical and cost-effectiveness of two surgical interventions that are most commonly used to treat pilon fractures.

Aims

The primary objective was to determine the incidence of COVID-19 infection and 30-day mortality in patients undergoing foot and ankle surgery during the global pandemic. Secondary objectives were to determine if there was a change in infection and complication profile with changes introduced in practice.

Aims

Functional rehabilitation has become an increasingly popular treatment for Achilles tendon rupture (ATR), providing comparably low re-rupture rates to surgery, while avoiding risks of surgical complications. Limited evidence exists on whether gap size should affect patient selection for this treatment option. The aim of this study was to assess if size of gap between ruptured tendon ends affects patient-reported outcome following ATR treated with functional rehabilitation.

Aims

This study reports the outcomes of a technique of soft-tissue coverage and Chopart amputation for severe crush injuries of the forefoot.

Aims

Arthroscopically controlled fracture reduction in combination with percutaneous screw fixation may be an alternative approach to open surgery to treat talar neck fractures. The purpose of this study was thus to present preliminary results on arthroscopically reduced talar neck fractures.

Aims

The aims of this study were to establish the incidence of acute Achilles tendon rupture (AATR) in a North American population, to select demographic subgroups and to examine trends in the management of this injury in the province of Ontario, Canada.

Aims

To determine whether the findings from a landmark Canadian trial assessing the optimal management of acute rupture of the Achilles tendon influenced the practice patterns of orthopaedic surgeons in Ontario, Canada.

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.

We present a review of litigation claims relating to foot and ankle surgery in the NHS in England during the 17-year period between 1995 and 2012.

A freedom of information request was made to obtain data from the NHS litigation authority (NHSLA) relating to orthopaedic claims, and the foot and ankle claims were reviewed.

During this period of time, a total of 10 273 orthopaedic claims were made, of which 1294 (12.6%) were related to the foot and ankle. 1036 were closed, which comprised of 1104 specific complaints. Analysis was performed using the complaints as the denominator. The cost of settling these claims was more than £36 million.

There were 372 complaints (33.7%) involving the ankle, of which 273 (73.4%) were related to trauma. Conditions affecting the first ray accounted for 236 (21.4%), of which 232 (98.3%) concerned elective practice. Overall, claims due to diagnostic errors accounted for 210 (19.0%) complaints, 208 (18.8%) from alleged incompetent surgery and 149 (13.5%) from alleged mismanagement.

Our findings show that the incorrect, delayed or missed diagnosis of conditions affecting the foot and ankle is a key area for improvement, especially in trauma practice.

Cite this article: Bone Joint J 2014;96-B:1510–14.

A total of 80 patients with an acute rupture of tendo Achillis were randomised to operative repair using an open technique (39 patients) or non-operative treatment in a cast (41 patients). Patients were followed up for one year. Outcome measures included clinical complications, range of movement of the ankle, the Short Musculoskeletal Function Assessment (SMFA), and muscle function dynamometry evaluating dorsiflexion and plantar flexion of the ankle. The primary outcome measure was muscle dynamometry.

Re-rupture occurred in two of 37 patients (5%) in the operative group and four of 39 (10%) in the non-operative group, which was not statistically significant (p = 0.68). There was a slightly greater range of plantar flexion and dorsiflexion of the ankle in the operative group at three months which was not statistically significant, but at four and six months the range of dorsiflexion was better in the non-operative group, although this did not reach statistically significance either. After 12 weeks the peak torque difference of plantar flexion compared with the normal side was less in the operative than the non-operative group (47% vs 61%, respectively, p < 0.005). The difference declined to 26% and 30% at 26 weeks and 20% and 25% at 52 weeks, respectively. The difference in dorsiflexion peak torque from the normal side was less than 10% by 26 weeks in both groups, with no significant differences. The mean SMFA scores were significantly better in the operative group than the non-operative group at three months (15 vs 20, respectively, p < 0.03). No significant differences were observed after this, and at one year the scores were similar in both groups.

We were unable to show a convincing functional benefit from surgery for patients with an acute rupture of the tendo Achillis compared with conservative treatment in plaster.

Supination-external rotation (SER) fractures of the ankle may present with a medial ligamentous injury that is not apparent on the initial radiographs. A cadaver gravity-stress view has been described, but the manual-stress view is considered to be the examination of choice for the diagnosis of medial injuries. We prospectively compared the efficacy of these two examinations.

We undertook both examinations in 29 patients with SER fractures. Of these, 16 (55%) were stress-positive, i.e. and had widening of the medial clear space of > 4 mm with a mean medial clear space of 6.09 mm (4.4 to 8.1) on gravity-stress and 5.81 mm (4.0 to 8.2) on manual-stress examination, and 13 patients (45%) were stress-negative with a mean medial clear space of 3.91 mm (3.3 to 5.1) and 3.61 mm (2.6 to 4.5) on examination of gravity- and manual-stress respectively. The mean absolute visual analgoue scale score for discomfort in the examination of gravity stress was 3.45 (1 to 6) and in the manual-stress procedure 6.14 (3 to 10).

We have shown that examination of gravity-stress is as reliable and perceived as more comfortable than that of manual stress. We recommend using it as the initial diagnostic screening examination for the detection of occult medial ligamentous injuries in SER fractures of the ankle.