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.

Aims. This study aimed to compare the outcomes of two different postoperative management approaches following surgical fixation of ankle fractures: traditional cast immobilization versus the Early Motion and Directed Exercise (EMADE) programme. Methods. A total of 157 patients aged 18 years or older who underwent successful open reduction and internal fixation (ORIF) of Weber B (AO44B) ankle fractures were recruited to this randomized controlled trial. At two weeks post-surgical fixation, participants were randomized to either light-weight cast-immobilization or the EMADE programme, consisting of progressive home exercises and weekly advice and education. Both groups were restricted to non-weightbearing until six weeks post-surgery. The primary outcome was assessed using the Olerud-Molander Ankle Score (OMAS) questionnaire at 12 weeks post-surgery, with secondary measures at two, six, 24, and 52 weeks. Exploratory cost-effectiveness analyses were also performed. Results. Overall, 130 participants returned their 12-week OMAS questionnaires. The mean OMAS was significantly higher in the EMADE group compared with the immobilized group (62.0 (SD 20.9) vs 48.8 (SD 22.5)), with a clinically meaningful mean difference of 13.2 (95% CI 5.66 to 20.73; p < 0.001). These differences were maintained at week 24, with convergence by week 52. No intervention-related adverse events, including instability, were reported. Conclusion. The EMADE programme demonstrated an accelerated recovery compared to traditional six-week cast immobilization for those who have undergone ORIF surgery to stabilize Weber B (AO44B) ankle fractures. The study found the EMADE intervention to be safe. Cite this article: Bone Joint J 2024;106-B(9):949–956

Aims

In approximately 20% of patients with ankle fractures, there is an concomitant injury to the syndesmosis which requires stabilisation, usually with one or more syndesmotic screws. The aim of this review is to evaluate whether removal of the syndesmotic screw is required in order for the patient to obtain optimal functional recovery.

Background. Many approaches to management of medial malleolar fractures are described in the literature however, their morphology is under investigated. The aim of this study was to analyse the morphology of medial malleolar fractures to identify any association with medial malleolar fracture non-union or malunion. Methods. Patients who had undergone surgical fixation of their MMF were identified from 2012 to 2022, using electronic patient records in a single centre. Analysis of their preoperative, intraoperative, and postoperative radiographs was performed to determine their morphology and prevalence of non-union and malunion. Lauge-Hansen classification was used to characterise ankle fracture morphology and Herscovici classification to characterise MMF morphology. Results. A total of 650 patients were identified across a 10-year period which could be included in the study. The overall non-union rate for our cohort was 18.77% (122/650). The overall malunion rate was 6.92% (45/650). There was no significant difference in union rates across the Herscovici classification groups. Herscovici type A fractures were significantly more frequently malreduced at time of surgery as compared to other fracture types (p=.003). Medial wall blowout combined with Hercovici type B fractures showed a significant increase in malunion rate. There is a higher rate of bone union in patients who have been anatomically reduced. Conclusion. The morphology of medial malleolar fractures does have an impact of the radiological outcome following surgical management. Medial wall blowout fractures were most prevalent in adduction-type injuries; however, it should not be ruled out in rotational injuries with medial wall blowouts combined with and Herscovici type B fractures showing a significant increase in malunions. Herscovici type A fractures had significantly higher malreductions however the clinical implications of mal reducing small avulsions is unknown

Background. Ankle fractures are extremely common but unfortunately, over 20% fail to obtain good to excellent recovery. For those requiring surgical fixation, usual-care post-surgery has included six-weeks cast immobilisation and non-weightbearing. Disuse atrophy and joint stiffness are detrimental sequelae of this management. While rehabilitation, starting at two-weeks post-surgery is viewed as safe, the literature contains methodological flaws and a lack of focus on early exercise, perpetuating the controversy over the effectiveness of early exercise interventions. Objectives. Our objectives were to determine if following operative fixation for Weber B fracture, the physiotherapy intervention, early motion and directed exercise (EMADE), applied in the clinical setting, were superior to Usual-care at 12-weeks (primary outcome) and 24-weeks. Design and Methods. We undertook a pragmatic-RCT, recruiting 157 surgically fixed Weber B ankle fracture patients, to establish if EMADE was superior to the Usual-care of 6-weeks immobilisation. The EMADE physiotherapy intervention (between week-2 and 4 post-surgery) utilised a removable cast and combined non-weightbearing progressive home exercises with manual therapy, advice and education. The primary outcome measure was the OMAS at 12-weeks. Results. 130 participants returned their 12-weeks post-surgery data, exceeding the 60/group threshold set by the a-priory power calculation. Group OMAS means were; 62.0 and 48.8 (SD 21, 22.5) EMADE, Usual-care respectively, yielding a clinically meaningful mean difference of 13.2 on the OMAS and a statistical difference (95% CI p< 0.001, 5.66 to 20.73). Both clinically meaningful and statistically significant findings were maintained at week-24. There were no intervention related or unexpected adverse events, including instability. Conclusions. This clinic set pragmatic-RCT yielded both clinical and statistical outcomes at week-12 in favour of the EMADE physiotherapy intervention over the Usual-care of 6-weeks immobilisation, in surgically fixed Weber B ankle fracture patients. These positive findings were maintained at week-24 and justify EMADE physiotherapy as a viable treatment option

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.

Introduction. Injury to the syndesmosis is not always clearly demonstrated on radiographs and different tests have been described to assess for injury. In the presence of a significant injury to the syndesmosis, surgical fixation is often indicated and various fixation methods have been described. If the result of surgery is any mal-reduction of the fibula, this may result in ongoing ankle pain. Assessing how well the fibula has been reduced intra-operatively is currently limited to image intensifier views. We have previously developed a simple assessment, which has been shown to give accurate intra-operative demonstration of an injury to the syndesmosis. Our objective was to ascertain if the same test could demonstrate any malreduction of the fibular after repair of a syndesmosis injury. Methods. Seven fresh frozen cadavers had complete sydesmosis disruption performed before fixation using a well-recognised technique with a single 3.5 mm small fragment screw. Purposeful malreduction was performed in three ankles and standard reduction in the remaining four. 2–5mls of contrast medium was then injected into the ankle joint. Results. When there had been a malreduction, an obvious ‘blush’ of dye leaked superiorly into the surrounding soft tissues, whereas a normal ankle arthrogram was shown when the fibular had been anatomically reduced into the incisura and well fixed. Conclusion. This cadaveric study showed the test to be an easy and reliable adjuct to assess for acute malreduction of a syndesmosis injury

Aims

The rationale for exacting restoration of skeletal anatomy after unstable ankle fracture is to improve outcomes by reducing complications from malunion; however, current definitions of malunion lack confirmatory clinical evidence.

Aims. Patients with diabetes are at increased risk of wound complications after open reduction and internal fixation of unstable ankle fractures. A fibular nail avoids large surgical incisions and allows anatomical reduction of the mortise. Patients and Methods. We retrospectively reviewed the results of fluoroscopy-guided reduction and percutaneous fibular nail fixation for unstable Weber type B or C fractures in 24 adult patients with type 1 or type 2 diabetes. The re-operation rate for wound dehiscence or other indications such as amputation, mortality and functional outcomes was determined. Results. Two patients developed lateral side wound infection, one of whom underwent wound debridement. Three other patients required re-operation for removal of symptomatic hardware. No patient required a below-knee amputation. Six patients died during the study period for unrelated reasons. At a median follow-up of 12 months (7 to 38) the mean Short Form-36 Mental Component Score and Physical Component Score were 53.2 (95% confidence intervals (CI) 48.1 to 58.4) and 39.3 (95% CI 32.1 to 46.4), respectively. The mean Visual Analogue Score for pain was 3.1 (95% 1.4 to 4.9). The mean Ankle Osteoarthritis Scale total score was 32.9 (95% CI 16.0 to 49.7). Conclusion. Fluoroscopy-guided reduction and fibular nail fixation of unstable ankle fractures in patients with diabetes was associated with a low incidence of wound and overall complications, while providing effective surgical fixation. Cite this article: Bone Joint J 2016;98-B:1197–1201

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.

Introduction:. Fibular malreduction is a common and important cause of pain after surgical fixation following a syndesmosis injury, but it is unclear which components of malreduction correspond to clinical outcome. Plain radiographs have been shown to be unreliable at measuring malreduction when compared to CT scans. A number of published methods for measuring fibular position rely on finding the axis of the fibula. Elgafy demonstrated that fibular morphology varies greatly, and some studies have demonstrated difficulty finding the fibular axis. Methods:. We developed a new method of measuring the distal fibular position on CT images. We used CT studies in 16 normal subjects. Two assessors independently measured the ankle syndesmosis using the Davidovitch method, and our new protocol for fibular AP position, diastasis and fibular length. Results:. We demonstrated that after statistical analysis (Pearson Product Moment Correlation) our method showed improved inter-observer reliability (r = 0.99 and 0.95 vs 0.59 and 0.78 respectively) for diastasis and AP translation, and improved intra-observer reliability (r = 0.99 and 0.99 vs 0.91 and 0.97 respectively). We found inter and intra observer reliability of 0.80 and 0.91 respectively for fibular length, but were unable to find a novel, accurate method for measuring fibular rotation. Conclusions:. Our method is a new, simple, accurate and reproducible system for measuring the ankle syndesmosis. We believe that this method could be used to assess fibular reduction after obtaining CT images of the uninjured side for comparison

Aims

The aim of this study was to investigate whether on-demand removal (ODR) is noninferior to routine removal (RR) of syndesmotic screws regarding functional outcome.

Introduction:. Early stabilization has the potential to expedite early return to function and reduce hospital stay thus reducing cost to health care. A clinical audit was performed to test the hypothesis that early surgical stabilization lowers the rate of soft tissue complications and is not influenced by choice of distal fibular implants used for stabilization of ankle fractures. Methods:. All surgically treated adult patients with isolated unstable ankle fracture were included from April 2012 to April 2013 at a MTC in UK. Patients with poly-trauma were excluded. All patients underwent a standard surgical protocol: aim for early definitive surgical fixation (ORIF) within 24 hours however if significantly swollen than temporary stabilization with an external fixation followed by a staged definitive fixation. Results:. In total 172 consecutive unstable ankle fractures were included in one-year study period. Definitive fixation (ORIF) was achieved in 91% patients with only 9% patients required temporary stabilization with external fixation. Fibular locking plates were used in 59(38%) patients compared to conventional one-third tubular plates in 91(60%) patients. In ORIF group 42% (73) patients were operated within 24 hours of admission whilst 58% (83) under went early fixation after 24–72 hours. At one year follow up complications were recorded in 18(11%) patients including metal irritation requiring removal of implant in 6(4%) patients. Wound complications and deep infection leading to a further surgical procedure in 8(5%) patients. There was no statistical difference between complication rates (p=0.016) in early versus delayed fixation groups. Fibular locking plates were associated with higher soft tissue complications (13%) as compared with conventional plates (2%) (p=0.004). Conclusion:. Our study showed that the timing of the surgery has less influence on the complications of the ankle fracture fixation. However choice of implants requires careful consideration and we suggest caution against use of current fibular locking plates

Background. Lisfranc/midfoot injuries are complex injuries with a reported incidence of 1 in 55000 in literature and frequently overlooked. But, recently they are becoming more commonly diagnosed with advent of CT scan and examination under anaesthesias (EUA) for suspicion fractures. Here we present a case series results of a single surgeons experience over the last 6 years. Methods. Retrospective review of 68 patients treated by a single surgeon over the last 6 years. Injuries were diagnosed on plain Xrays, clinic examination. Any suspicious injury were further assessed by a CT scan, all injuries were confirmed by EUA and treated with open reduction and internal fixation within 4 weeks of injury. Post-operative immobilisation in full cast for 6 weeks then a removal boot with non-weight bearing for a total of 3months. They were followed up regularly initially at 3, 6 and 12months. At final review the following data was collected: clinical examination, plain x-ray looking for: late deformity, signs of OA in Lisfranc joint, Auto fusion rate, rate of metal work failure. The x-rays findings were correlated with: (1) type of fixation. (2) The following scores: FAOS, AOFAS-M, specially designed new foot and ankle score. Results. 43 males: 25 females. 37 right: 31 left sided injuries. 90% were fully weight bearing with minimal discomfort after 6months. In 12 months all of them returned to their normal daily life activities. Wound complications: 2 of them had initial wound complications which were treated successfully with 2 weeks of oral antibiotics, 2 had lateral scar tenderness. One had loosened metal work, revised to fusion. Conclusion. Early operative intervention with good anatomical reduction can minimise the potential chronic disability associated with these injuries. This is a largest series of Lis-franc injuries of a single surgeon with good clinical outcome following surgical fixation

Introduction:. Percutaneous fixation of intraarticular calcaneal fractures adequately restore the subtalar joint with lower soft tissue complications and equivalent short-term results compared to open fixation. However, studies have largely focused on less severe fracture types (Sanders types 2/3). We report our initial experience of this relatively new Mini-open Arthroscopic-assisted Calcaneal Osteosynthesis (MACO) technique for more comminuted calcaneal fractures (Sanders types 3/4). Methods:. We prospectively studied consecutive patients with intraarticular calcaneal fractures requiring surgical fixation between April 2012 and June 2013. MACO involves initial subtalar arthroscopic debridement, with subsequent fluoroscopic-assisted, mini-open reduction and fixation of depressed fragments using cannulated screws. Outcome scores (Manchester-Oxford Foot(MOXFQ), AOFAS Hindfoot and SF-36 questionnaires) and radiological parameters were recorded with a mean follow-up of 12 months (7–13). Results:. There were 9 patients (7 M:2 F) with a mean age of 45.4 years (24–70). All had intra-articular joint depression-type fractures: 5 Sanders type 3 and 4 Sanders type 4. Mean time to surgery was 6.6 days (1–13), operating time was 89.4 minutes (66–130) and inpatient stay was 1.7 days (1–4). All wounds healed without complication and one patient required change of a long screw 11 days post-operatively. There were significant post-operative improvements in the mean Bohler's angle (−2°[−27.2–14.8] to 30°[10.2–41.3], p<0.0002) and angle of Gissane (95°[66.2–111.7] to 111°[101.6–120], p=0.004). Mean outcome scores were 60.8(41–86) for MOXFQ and 75.3(55–92) for AOFAS Hindfoot, with 55.9% developing moderate/severe subtalar joint stiffness. Mean physical and mental SF-36 summary scores were 35.5(24.5–41.5) and 51.7(40.8–61.7) respectively. Conclusion:. We describe the MACO technique for Sanders types 3/4 calcaneal fractures. There were no soft tissue complications with good short-term outcomes, despite a reduction in hindfoot mobility. Restoration of the joint and bone stock without infection is desirable in the event of subsequent arthrodesis. We propose MACO is a valuable alternative technique to open fixation

Background. Salvage procedures on the 1st MTPJ following failed arthroplasty, arthrodesis or hallux valgus surgery are difficult and complicated by bone loss. This results in shortened first ray and transfer metatarsalgia. We present our experience of using tri-cortical interposition grafts to manage this challenging problem. Methods. Between 2002 and 2009 our department performed 21, 1st MTPJ arthrodeses using a tri-cortical iliac crest interposition graft. Surgical fixation was achieved with a compact foot plate. We performed a retrospective review from the medical notes and radiographs along with American Foot and Ankle scores which were collected prospectively. We analysed the following parameters: time to radiological, requirement for further surgery, lengthening of 1st ray and any post operative complications. Results. Patient Demographics – Male: Female = 4:16. Mean age – 58 years (38-78 years). Mean follow up – 35 months (4-94 months). Indication for surgery –. Failed arthroplasty 8. Failed fusion 9. Previous Keller's 1. Failed Scarfe Osteotomy 1. Avascular Necrosis 2. Total 21. Arthrodesis achieved – 18 patients (90%) at 4 months post surgery (2-12 months). Mean AOFAS – 45 pre op, 75 post op. Lengthening of 1st Ray achieved – 6 mm average (5mm – 10mm). Complications – 7 (35%). Major – 3 (15%) – 2 non s, 1 varus overcorrection. Minor – 4 (20%) – 2 superficial infection, 2 painful hardware. Conclusions. Using interposition arthrodesis for the salvage of 1st MTPJ surgery we can achieve in 90% of patients. However, the rate of complications is not low and hardware often causes irritation, requiring removal

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 aim of this study was to evaluate the functional outcome in patients undergoing implant removal (IR) after fracture fixation below the level of the knee.

Aims

Total ankle arthroplasty (TAA) surgery is complex and attracts a wide variety of complications. The literature lacks consistency in reporting adverse events and complications. The aim of this article is to provide a comprehensive analysis of each of these complications from a literature review, and to compare them with rates from our Unit, to aid clinicians with the process of informed consent.

Injuries to the foot in athletes are often subtle and can lead to a substantial loss of function if not diagnosed and treated appropriately. For these injuries in general, even after a diagnosis is made, treatment options are controversial and become even more so in high level athletes where limiting the time away from training and competition is a significant consideration.

In this review, we cover some of the common and important sporting injuries affecting the foot including updates on their management and outcomes.

Cite this article: Bone Joint J 2016;98-B:1299–1311.