Introduction. Different techniques for fixation of lateral malleolus have been described. We report our results of using fibula rod for unstable ankle fractures in level one major trauma centre. Methods. We reviewed the results of 40 ankle fractures (14 open and 26 closed) with significant soft tissue injuries and open fractures that were treated with a fibula rod between 2012 and 2015. The median age of patients was 60 (17–98 years). Results. Satisfactory fracture reduction was achieved in all of these patients Two patients had loss of syndesmosis fixation. All fibula fractures healed but 3 medial malleolus non unions occurred which did not need further surgery. 1 patient developed post-operative deep infection and had removal of metalwork. The median physical component Short-Form 12 (PSF12), Olerud and Molander score (OMS), and American Academy of Orthopaedic Surgeons Foot and Ankle outcome scores (AOFAS) were 40 (19 to 52), 57 (0 to 85) and 75 (20 to 95), respectively. The median PSF12, OMS and AOFAS were 33, 35 and 47 for open fractures and 42, 60 and 78 for closed fractures respectively. Conclusion. Using the fibula rod resulted in good radiological and satisfactory functional outcomes with minimal complications. In spite of lower scores in the open fracture group, only one patient needed removal of metal work for deep infection. We recommend using the fibula rod in unstable ankle fracture in patients with significant soft tissue injuries and consider its use in open injuries

Background

Anatomical reduction of unstable Lisfranc injuries is crucial. Evidence as to the best methods of surgical stabilization remains sparse, with small patient numbers a particular issue. Dorsal bridge plating offers rigid stability and joint preservation.

The primary aim of this study was to assess the medium-term functional outcomes for patients treated with this technique at our centre. Additionally, we review for risk factors that influence outcomes.

Introduction. Positive reports from implant designer centres on the use of fibular nails in the complex ankle fractures has resulted in a marked increase in their use nationally. Our aim in this study was to report on the outcomes of the use of all fibular nails in two major trauma centres. Methods. All patients who underwent ankle fracture fixation using a fibular nail in two major trauma centres, were included for analysis. MTC 1 included patients from April 2013 to May 2015, and MTC 2 included patients February 2015 to March 2018. A minimum follow up of 1 year was achieved for all patients. Radiographic reduction was confirmed by Pettrones criteria at time of operation and at 6 weeks and 1 year post-operatively. Kellgren Lawrence radiographic criteria was used to classify osteoarthritis. All complications and further surgery were recorded. Results. Forty-four patients underwent fibular nail fixation in the two centres. The average age was 59 (range 21–91). Using Pettrones criteria, 86% were malreduced at time of operation. A further 34% deteriorated by at least 1 grade by 6 weeks and an additional 16% (n=7) deteriorated by at least 1 grade by 1 year. 57% had developed radiographic evidence of osteoarthritis by 1 year. Only 4.5% (2ankles) maintained complete reduction by 1 year. Other significant complications were reported in 43% of patients. Conclusion. Both major trauma centres report the same experience in the use of fibular nails for ankle fracture fixation. As previously reported in smaller number studies, initial reduction is challenging. Worryingly, the majority of well-reduced lose position with time. We suggest that the fibula nail is used with caution and as part of an appropriately approved audit

Background. Optimal management of displaced intra-articular calcaneal fractures remains controversial. The aim of this prospective cohort study was to compare the clinical and radiological outcomes of minimally invasive surgery (MIS) versus non-operative treatment in displaced intra-articular calcaneal fracture up to 2-years. Methods. All displaced intra-articular calcaneal fractures between August 2014 and January 2019 that presented to a level 1 trauma centre were considered for inclusion. The decision to treat was made by a multidisciplinary meeting. Operative treatment protocol involved sinus tarsi approach or percutaneous reduction & internal fixation. Non-operative protocol involved symptomatic management with no attempt at closed reduction. All fractures were classified, and the MOXFQ/EQ-5D-5L scores were used to assess foot and ankle and general health-related quality of life outcomes respectively. Results. 101 patients were recruited at a level 1 major trauma centre, between August 2014 and January 2019. Our propensity score matched 44 patients in the surgical cohort to 44 patients in the non-surgical cohort. At 24 months, there was no significant difference in the MOXFQ Index score (p<0.05) however the patients in the surgical cohort had a significantly higher EQ-5D-5L Index score (p<0.05). There was also a higher return to work (91% vs 72%, p<0.05) and physical activity rate (46 vs. 35%, p<0.05) in the surgical cohort despite a higher proportion of more complex fractures in the surgical cohort. The wound complication rate following surgery was 16%. 14% of patients in the non-operative cohort subsequently underwent arthrodesis compared to none of the patients in the surgical cohort. Conclusion. In this study, we found operative treatments were associated with low rates of surgical complication at 2-years and long term pain improvement, facilitating earlier and better functional outcomes for complex injury patterns compared to nonoperative treatment

Introduction. Hindfoot intramedullary nail fixation (HFN) or fibula pro-tibial screw fixation (PTS) are surgical options for ankle fractures in patients with multiple co-morbidities; we compared their outcomes. Methods. A retrospective review of 135 patients who underwent HFN fixation (87 patients) or PTS fixation (48 patients) for ankle fractures (AO/OTA A/B/C) from 5 major trauma centres. Patient demographic data, co-morbidities, Charlson Co-morbidity Index Score (CCIS), weight-bearing, and post-operative complications were recorded. Radiographs were assessed for non-union and anatomical reduction. Results. HFN estimated 10-year survival was 27±31% and was 48±37% for PTS (p<0.001). Average time to full weightbearing (FWB) in the HFN group was 1.7±3.3 weeks compared to 7.8±3.8 weeks in the PTS group (p<0.001). Despite this, HFN fixation carried a greater VTE risk (p=0.02). HFN accompanied by joint preparation had greater risk of infection (p=0.01), metalwork failure (p=0.02) and wound breakdown (p=0.01). The overall complication rate in diabetic patients was 56%, but 76% in HFN patients. In the HFN group 17 (20%) patients died at 1 year. Patients with open fractures(p=0.01), dementia (p<0.05), and a higher CCIS (p=0.04) were more likely to die after HFN surgery. Age and co-morbidity matched data showed a higher rate of complications and mortality in those above 75 years fixed with a HFN, irrespective of CCIS. In those between 60–75 years, there was a greater risk of superficial infection and mortality after HFN, irrespective of CCIS. These complications were not seen after PTS. Conclusion. HFN carries a greater risk of superficial infections, VTE and mortality compared to PTS, independent of age and CCIS. Diabetes leads to a greater comparative risk of deep infections, wound breakdown and non-union in HFN. Alternative methods of fixation (e.g. PTS) should be considered before HFN. HFN may be suitable in selective indications where other methods are not appropriate

Aims. To identify a core outcome set of postoperative radiographic measurements to assess technical skill in ankle fracture open reduction internal fixation (ORIF), and to validate these against Van der Vleuten’s criteria for effective assessment. Methods. An e-Delphi exercise was undertaken at a major trauma centre (n = 39) to identify relevant parameters. Feasibility was tested by two authors. Reliability and validity was tested using postoperative radiographs of ankle fracture operations performed by trainees enrolled in an educational trial (IRCTN 20431944). To determine construct validity, trainees were divided into novice (performed < ten cases at baseline) and intermediate groups (performed ≥ ten cases at baseline). To assess concurrent validity, the procedure-based assessment (PBA) was considered the gold standard. The inter-rater and intrarater reliability was tested using a randomly selected subset of 25 cases. Results. Overall, 235 ankle ORIFs were performed by 24 postgraduate year three to five trainees during ten months at nine NHS hospitals in England, UK. Overall, 42 PBAs were completed. The e-Delphi panel identified five ‘final product analysis’ parameters and defined acceptability thresholds: medial clear space (MCS); medial malleolar displacement (MMD); lateral malleolar displacement (LMD); tibiofibular clear space (TFCS) (all in mm); and talocrural angle (TCA) in degrees. Face validity, content validity, and feasibility were excellent. PBA global rating scale scores in this population showed excellent construct validity as continuous (p < 0.001) and categorical (p = 0.001) variables. Concurrent validity of all metrics was poor against PBA score. Intrarater reliability was substantial for all parameters (intraclass correlation coefficient (ICC) > 0.8), and inter-rater reliability was substantial for LMD, MMD, TCA, and moderate (ICC 0.61 to 0.80) for MCS and TFCS. Assessment was time efficient compared to PBA. Conclusion. Assessment of technical skill in ankle fracture surgery using the first postoperative radiograph satisfies the tested Van der Vleuten’s utility criteria for effective assessment. 'Final product analysis' assessment may be useful to assess skill transfer in the simulation-based research setting. Cite this article: Bone Jt Open 2022;3(6):502–509

Introduction:. In April 2012 National Trauma Networks were introduced in England to optimise the management of major trauma. All patients with an ISS of ≥ 16 should be transferred to the regional Major Trauma Centre (level 1). Our hypothesis was that severe foot and ankle injuries would no longer be managed in Trauma Units (level 2). Methods:. A retrospective analysis of the epidemiology of severe foot and ankle injuries was performed, analysing the Gloucestershire foot and ankle trauma database, from a Trauma Unit, for a catchment population of 750,000 people. The rate of open fractures, mangled feet and requirements for stabilisation with external fixation were reviewed before and after the introduction. This was compared to the foot and ankle injuries triaged to the regional Major Trauma Centre (MTC) using the TARN database information. Results:. The incidence of open foot and ankle injuries was 2.9 per 100,000 per year. There were 5.1% open injuries before the Network and 3.2% after. There was no statistically significant change in the application of external fixators. The frequency of mangled feet was 3.6% before and 6% after the Network commenced, showing no significant fall. Analysis of TARN data from the MTC demonstrated that only 18% of patients had an ISS ≥ 16. The majority of patients brought to the MTC with foot and ankle injuries were either polytrauma patients (43%) or required plastic surgery intervention for open fractures (69%). Only 4.5% of patients had isolated, closed foot and ankle injuries. Conclusion:. We found there to be no decrease in our numbers of mangled ankles, external fixations nor open fractures following the introduction of the Trauma Network. There is still a need for Foot & Ankle Surgeons at Trauma Units to manage complex foot and ankle injuries, because the majority have an ISS < 16

Aims

To compare the cost-utility of removable brace compared with cast in the management of adult patients with ankle fracture.

Introduction:. We report our 10-year experience of post-operative complications of calcaneal fractures treated by internal fixation and attempt to correlate these with previously cited patient risk factors. Methods:. All calcaneal fractures treated by internal fixation in our Major Trauma Centre between September 2002 and September 2012 were identified. Patient indices (age, gender, smoking status and pre-existing co-morbidities), time to surgery and method of surgery (open reduction and internal fixation (ORIF) versus closed reduction and percutaneous fixation) were recorded. Primary outcome was the incidence of wound infection requiring intravenous antibiotics and/or re-operation. Statistical analysis through Mann-Whitney-Wilcoxon testing and relative risk ratio calculations with 95% Confidence Intervals (CI) was performed. Results:. 98 calcaneal fractures in 92 patients were identified. 79 (80.6%) fractures occurred in males, 19 (19.4%) in females. 54 (55.1%) were smokers and 44 (44.9%) non-smokers. 18 (18.4%) were treated by closed reduction and percutaenous fixation and 80 (81.6%) by ORIF. 3 (3.1%) patients (all male) developed post-operative wound infection (RR 0.96, 95% CI 0.92–1.00), of which 1 was a smoker (RR 1.03 95% CI 0.95–1.11). All infections occurred in patients treated percutaneously (RR 6.33, 95% CI 3.99–10.08). There was no significant difference in mean time to surgery (p=0.069) and mean age (p=0.31) for those patients experiencing wound complications and those who did not. Conclusions:. This study reports an overall wound infection rate in keeping with current literature. There was no statistically significant increased risk of wound infection in smokers or male patients. All infections occurred in patients who had percutaneous treatment. These findings support the continued treatment of displaced calcaneal fractures by open reduction and internal fixation through a conventional extended lateral approach. There is no justification in denying surgery to males or smokers although these two factors have been cited as poor prognostic indicators in earlier studies

Charcot osteoarthropathy of the foot is a chronic and progressive disease of bone and joint associated with a risk of amputation. The main problems encountered in this process are osteopenia, fragmentation of the bones of the foot and ankle, joint subluxation or even dislocation, ulceration of the skin and the development of deep sepsis. We report our experience of a series of 20 patients with Charcot osteoarthropathy of the foot and ankle treated with an Ilizarov external fixator. The mean age of the group was 30 years (21 to 50). Diabetes mellitus was the underlying cause in 18 patients. Five had chronic ulcers involving the foot and ankle. Each patient had an open lengthening of the tendo Achillis with excision of all necrotic and loose bone from the ankle, subtalar and midtarsal joints when needed. The resulting defect was packed with corticocancellous bone graft harvested from the iliac crest and an Ilizarov external fixator was applied. Arthrodesis was achieved after a mean of 18 weeks (15 to 20), with healing of the skin ulcers. Pin track infection was not uncommon, but no frame had to be removed before the arthrodesis was sound.

Every patient was able to resume wearing regular shoes after a mean of 26.5 weeks (20 to 45).